What’s the Deal with the Bathrooms?!?

In my role as a trainer and consultant at health centers and public hospitals for the last twenty years, I have come across a very basic, prevalent, and highly interesting phenomenon in health care organizations across the country. I don’t really get it. Why do staff need to use a separate bathroom from both sick and well patients? Is it as some have explained because patient bathrooms are often less clean and tidy? And, if that is the case, why haven’t we corrected this bad health care practice?

The first time I learned about this trend, my surprised, practical mind went immediately to questions of, “why would we budget to put in double the plumbing and fixtures just to make sure staff have a place, away from patients, to use the toilet and take care of a relatively straightforward human need?” My questioning must have been a mistake…

Flashback to the year 1997 I was working my first job at a community health center. On my first day of employment, I became aware of the staff/patient bathroom hierarchy. The patient bathroom was located off the hallway by the waiting room. The staff bathroom was in the back of the office, and a lab bathroom with a door in the wall where patients could leave samples. This was all interesting, good information. I asked, naively, “Is our staff bathroom different?” “No, it’s just ours so it’s clean and we don’t have patients in it,” was the reply. Baffled, I was acutely aware of the acculturation I was undergoing, and felt pressured by my desire as a new employee to fit in. In the words of Lt. Joe Cable from South Pacific, “You have to be carefully taught.”

Then, one day, I heard it. A homeless patient came out of an exam room that was just around the corner from the staff bathroom–maybe 20 steps–but about 60 steps from the “patient bathroom.” He wasn’t disabled (and the walk would not be onerous), but he was messy physically and what he lacked in olfactory appeal he made up for in street smarts. This patient was observant and had clearly been acquainted with the health center for years, compared to my mere weeks. As he came out of his exam room he said, “I need to use the restroom. Can I use this bathroom?” pointing to the staff bathroom just around the corner to the right. I felt stuck.

Everything human and humane in me wanted to say of course, go for it. No one is going get hurt, and our “staff only” rule doesn’t make sense. But, of course, I looked around first, and caught the eye of my experienced lead who jumped in without invitation to address the patient, stating in a very matter-of-fact manner that this conveniently located pit stop was the staff bathroom, and that the patient bathroom was out in the waiting room. She inquired whether he knew the way back out and reminded him that the doctor would still be a few minutes…he had time.

I thought for a moment and, as a farmer’s daughter, immediately recognized what I was seeing: a posturing similar to animals–a pecking order of sorts–and the patient was being reminded that he was lower down the order than we were. However, we were supposed to be the caregivers, and the patient needed us to care for him; maybe he needed us to care and value him even more than he seemed to value himself these days.

What I want to point out here is the cultural implication of the hierarchies in which we exist. Dr. Brian Goldman’s TED Talk, Doctors Make Mistakes. Can We Talk About That? shouldn’t have been as revolutionary as it was. Likewise, Dr. Atul Gawande’s article Personal Best about why doctors should be comfortable having a coach–just like musicians, athletes, and other great professionals–shouldn’t have been shocking, either. But it was.

I walked away from the experience, filing it away as a moment where I disagreed with the conventional wisdom of my manager, and wondered if I should have challenged her. I also wondered if I was wrong to secretly hope that a patient would never, ever ask me to use the staff bathroom again so that I would never again be put in the position of giving the “right” answer—an answer I didn’t believe in. Mahatma Gandhi is credit for explaining that happiness is when what you do, what you say, and what you believe are in agreement. It was an unhappy moment for me.

Now, as a health care process consultant and trainer, I spend quite a bit of time visiting health centers. I am in a health center more weeks each year than I am not. I love to drop in the waiting room and use the “patient” bathroom when I first arrive. It’s a chance to wash my hands, to be sure I don’t have coffee on my shirt, and be sure I am ready for the day. And, more profoundly, it allows me to see how well the facility is maintained for patients. Is the patient bathroom well stocked? Is it clean? Is there toilet paper on the floor? Is there soap in the soap dispenser? As proponents of good healthcare, should we not always make sure that our bathrooms are 100% clean, serving as small islands of space that reinforce good hygiene and promote health? The answer seems obvious to me.

Since my experience with my homeless patient, I have learned that asking for the bathroom, even when I don’t need to use it, is a great question when I arrive somewhere new. When I visit health centers, I am there to train, coach, or provide help in some way. Sometimes that help comes includes pointing out needed changes that their eyes have grown to accustomed to seeing. Those who have invited me want to “host” me and want to be gracious hosts. And they are. Health center staff are some of the kindest people I have ever met. They provide me with a place to set my bag, and always want to show me where the (staff) bathrooms are located in case I need them during the day. Sometimes I want to provoke the team by posing the question of why, in this day and age, still feel the need for a staff bathroom separate from patients. However, since the question of do whether we need a male AND female gendered bathroom as well as a transgender bathroom remains unresolved, I refrain.

These events have caused me to ask people in other industries about their bathrooms. Given all the posted restaurant signs reminding staff to wash their hands before they return to work (equally as important for health care workers), it is clear that staff in many industries use the same bathrooms as customers. Hotel staff use the restrooms in the lobby, which are also available for guests. So why does health care view itself as unique and does this “uniqueness” point to our need to evolve?

At the core of all this, it doesn’t matter to me if there is a staff bathroom and a patient bathroom. Convenience is a wonderful goal. What matters to me is whether a health center offers different levels of respect and cleanliness. They should not. Sometimes I take note, and if there is an opportunity I’ll mention patient bathrooms being out of soap or toilet paper, if there was paper on the floor, or if the bathroom was just gross. The response is often the same: as much as we clean, patients are messy, so we throw up our hands and leave it as it is. Humans are messy.

Shouldn’t everyone who is being encouraged to practice good health habits and great hygiene have access to clean sinks, clean toilets, plentiful soap, and a clean place to avoid contracting infections? At the heart of it all, is healthcare finally becoming ripe for a cultural overhaul that brings us to a more human place with patients? I think so.