Personal & Prefessional Issues in Adult Nursing - Term Paper Example

Confidentiality in Nursing Introduction Whilst on a clinical placement, I experienced a breach of confidentiality, so for the purpose of this assignment I will concentrate on the rules and guidelines associated with confidentiality. Confidentiality is more than keeping a secret. It is being entrusted with the confidence of another and that confidence, in the privacy of the relationship between a patient and a nurse to whom the information is entrusted has serious responsibilities. Without trust and confidentiality the patient, their clinical treatment and progress would be compromised. While the literature for medical and allied studies is dotted with experts opinions regarding confidentiality, there are also examples given by them of how they experienced confidentiality breaches conducted by their peers. An Experience I experienced an incident of such a breach myself. The breach of confidentiality I witnessed came up on my clinical placement. It was undertaken by a qualified staff nurse whom, for the purposes of this assignment (and to maintain confidentiality); will be referred to as “Nurse Jones.” During clinical placement, a patient who was known to both Nurse Jones and myself had been admitted to accident and emergency (A&E) following a horrific road traffic accident (RTA). This patient, whom I will refer to as “Mandy,” had sustained severe head and internal injuries that proved to be fatal. In fact, she died shortly after her arrival at A&E. The following day while I was working in the hospital, a patient called me over and she asked me if I knew anything about Mandy, the accident and the injuries Mandy had sustained. I asked the patient questions to ascertain how she knew Mandy. Was she a member of Mandy’s family? Was she Mandy’s friend? The patient replied that she did not know Mandy well and she was only an acquaintance. I explained to the patient that one of my roles as a nurse is to protect patient confidentiality and that I am governed by the Nursing and Midwifery Council (NMC, 2004) Code of Professional Conduct and my contract of employment to keep information acquired from work confidential and as stated by NMC (2004) Code of Professional Conduct “use it only for the purpose for which it was given”. I also explained that if I did have any information, I was not at liberty to say. Additionally, I asked the patient how she would feel if nurses divulged sensitive information about a member of their family or about one of her friends. The patient seemed to accept my explanation; she apologised for being nosy and we said no more about the subject. Later on that day, I was working along side Nurse Jones and during our conversation I happened to mention the predicament I had found myself in with the patient earlier that morning. I asked Nurse Jones what she would have done given similar circumstances. I was amazed and to some level, annoyed, by Nurse Jones’s total lack of professionalism and sensitivity when she replied, “you do not have to worry too much about confidentiality in that sort of situation. I would have told her what I knew”. Even now I find Nurse Jones’s reply distasteful and very unprofessional as I found it then. I reminded Nurse Jones that doing such a thing would be unprofessional as well as unethical since it would amount to disclosure of patient information. Nurse Jones’s retort shocked me even more when she said, “I would expect that from you because you are still a student, believe me you will be doing the same once you qualify”. I hope and I can say with a high level of certainty that I will disappoint Nurse Jones if she thinks I would betray a patient’s confidence or even divulge information which is prohibited by ethical guidelines. I believe that it is our duty and responsibility as nurses and as professionals to be bound by the NMC Code of Professional Conduct (2004). This states that confidentiality is a basic element of the nurse-patient relationship and a nurse is required to maintain the privacy of all patients under their care with regard to their medical as well as personal information. As my own experience has shown when patients share something with a nurse it is on a more personal and a private level. I feel that the relationship a patient has with a nurse is often intimate and close and this is supported by the evidence provided by the ANA (2001). By not divulging the information I knew about Mandy I felt confident in my ability to restrict flow of information to only those who need to know, and as such is the essence of the patient-nurse relationship. Being trustworthy is an important part of being a nurse and information that is trusted becomes a serious responsibility.  The Need for Confidentiality The assurance of confidentiality encourages and strengthens the integrity of the patient-nurse relationship and thus promotes patient care and recovery (Fowler, 2000). The principle of respect for patient’s autonomy furthers the right of a patient to have control over his or her own life, and this would include the right to decide who should have access to his or her personal information (Horan, 2006). Horan, (2006) goes on to say “that is why, confidentiality is seen as a fundamental ethical principal in health care and a breach of confidentiality by any health care professional could be a reason for disciplinary action” (Horan, 2006). Confidentiality has been given such importance, that even if a patient does not know that his/her information has been disclosed by a healthcare professional to someone, even then it is considered to be a breach of the patient’s confidence. Fundamentally, the relationship between the health care professional and the patient can be seen as having elements of an implied contract and this includes an implied promise which ensures that health professionals keep secure any confidential information about their patients to themselves (Stuttle, 2006). A Contract under Common Law With the implied contract, it becomes reasonable for patients and their families to expect that information they divulge for health related services will be kept confidential. If that trust is breached, the patient may feel let down since an implied promise has been broken (Stuttle, 2006). In fact, a nurse who breaches confidentiality guidelines may jeopardise his/her career as a health care professional. With more extreme cases, such acts may even result in a very expensive and damaging lawsuit. Kloss (2006) states that: The duty of confidence arises whenever there is a relationship between the parties which implies such a duty. So, for example, the common law duty of confidentiality exists between husband and wife, priest and penitent, employee and employer and nurse or patient and client (Kloss, 2006, pg. 13). The laws and ethics guidelines hold health care professionals liable for maintaining confidentiality and see the divulging of patient information as a serious offence (Stuttle, 2006). From my own experience, I found the actions of Nurse Jones to be offensive, but since she did not actually give out any information which I was aware of, a report of the incident could not be made. The simple reason for the existence of such laws is to protect both the nurse and the patient so that only the right information can be given to the right people at the right time (ANA, 2001). At the same time, as suggested by Rankin (2000), the ethics of patient care demands that nurses share information about the patient with those who seek the improvement of health but even there nurses need to be aware of the applicable confidentiality laws. Saving Lives Fallon (2006) suggests confidentiality is important because it lets people accept the fact that any information they divulge will remain with the nurse and proceed no further. Fallon says, “Two thirds of young people would be less likely to seek advice if they thought that information about their sexual activity would be passed on to authorities such as social workers (Fallon, 2006, pg. 3)”. In effect, confidentiality makes it easier for individuals to seek health information and therefore it saves lives for those who might otherwise be not interested in seeking help (Scanlon, 2000). Throughout their training, nurses are constantly reminded of the importance of patient confidentiality. The relationship between the nurse and the patient is one of trust and the nurse has a duty to respect the patient’s confidence at all times. In the initial phase of the relationship, nurses and patients assess each other in an effort to determine if they can get along. Morse (1991) argues that patients will, at times, question the nurse’s motivation to nurse and generally observe and assess the nurse to determine what kind of person he/she is. Nowadays it is becoming common practice for patients to test nurses as to their dependability and their ability to keep something in confidence (Morse, 1991). This personal assessment is not the same as a formal clinical assessment, which is designed to gain information that has direct bearing on patients’ nursing care. If the nurse is in any doubt at all about the confidentiality of any information it must not be disclosed. As Morse (1991) suggests, the patient can test a nurse for confidentiality before confessing something or revealing information which might be helpful in the recovery of health. Information Governance Confidentiality and the privacy of patient information fall under the larger topic of information governance which shows how information must be kept away from those who do not have the right to see it or the need to see it. At the same time, confidentiality and information governance also require allowing full access for individuals with the need to know and the right to know (Hutchinson & Sharples, 2006). While paper records are often the ones which were given high importance in the past, with the advent of modern technology, electronic records have taken the primary position with regard to information governance issues (NHS, 2005). The rules applicable to confidentiality apply to any information about the physical or mental condition of a person which has been recorded or created by or for a medical health professional. However, clinical practice does constrain the health care professional’s obligation to protect patient confidentiality since sharing information about patients is one of the fundamental reasons why computer systems and patient databases are created. In the course of caring for patients, a nurse will find herself exchanging pertinent information about her patients with other health care professionals as and when required (Hutchinson & Sharples, 2006). These discussions are often critical for patient care and are an integral part of the learning experience in a clinical setting. Moreover, they are justifiable so long as precautions are taken to limit the ability of others to hear or see confidential information. Computerised patient records pose a unique challenge to confidentiality and deserve discussion on their own but at a general level, the health care professional should adhere to local trust procedures for computer access and security. Information governance rules, as they apply to both paper and electronic records, are broadly defined by the standards used by NHS called HORUS (NHS, 2005). HORUS These standards are the basic mechanisms for information governance and confidentiality for patient information and they are discussed in the NHS (2005) document, What You Should Know about Information Governance. Using the acronym HORUS, a nurse can follow these standards for both the cases of protecting and sharing information. Held in confidence and in a secure manner Obtained with fair and efficient means Recorded accurately and with reliability Used effectively as well as ethically Shared in a manner this is appropriate and lawful (NHS 2005) Clearly, both the first and the last standard for information governance are directly connected to the confidentiality contract between a patient and a nurse which highlights the importance of the topic (NHS, 2005). Confidentiality is not only an obligation for the nurse; it is also a right for the patient (Hutchinson & Sharples, 2006). This is supported by the Data Protection Act of 1998 and the Human Rights Act of 1998 under which nurses and other medical care providers are supposed to protect the confidentiality of those who are placed under their care (cited in Kloss, 2006). The patient has the right to know when information about them is noted, how it is created and how it will be employed in helping them get better (Kloss, 2006). Information Disclosure Additionally, information stored about a patient should be given to the patient if s/he demands to see it. There are exceptions to this rule and in certain cases information about the patient can be withheld from him or her. The ability to withhold information from the patient depends on the personal professional judgement of a nurse and if the nurse judges that a particular piece of information could hurt the patient, or others, it may be restricted or withheld altogether (Hutchinson & Sharples, 2006). While the decision to withhold or reduce the amount of information given to the patient belongs to the nurse, it must be remembered that a nurse must have a good reason for it. Such decisions can be challenged by the patient in a court of law. Therefore a nurse should be clear about why s/he is not telling the patient something (Hutchinson & Sharples, 2006). This situation shows that the implications of a contract of confidentiality do not apply in the fullest sense when it comes to the disclosure of information. When a nurse chooses to or has to disclose confidential patient information, it is extremely important to ensure that the patient is made aware of the disclosures that take place in order to provide them with high quality care (Horan, 2006). In particular, clinical governance and clinical audits, which are proper components of healthcare provision, might not be clear to patients and should be clarified in the simplest of terms (Rankin, 2000). From my own experience, most patients are quite reasonable and understand that their medical information needs to be shared between a number of multi-professional teams and even between different organisations involved in healthcare provision. This is particularly important where disclosure extends to non-NHS bodies. Disclosure with Consent As a nurse, I am bound by law and the NMC (2004) Code of Professional Conduct which states that registered nurses, midwives or specialist community public health nurses, must protect all confidential information regarding the patients who are under their care. In addition, Section 5.2 of the NMC code states a nurse should seek and know patients’ and clients’ wishes regarding the sharing of their information with family and other interested parties. The process of knowing the patient’s wishes regarding their disclosure of information is getting their consent. With a patient’s consent, the liability for information disclosure is reduced since a nurse can judge what information can be given to relatives or friends of the patients. However, it does not create a legal obligation on the nurse to disclose information rather it signifies that the patient does not mind information disclosure (NHS, 2005). I feel that even with the consent of the patient, I would exercise my own judgement and try to comfort the family of the patient in ways other than providing them with information about the ailment afflicting the person under my care. I would expect that all information given to me by my patient is given in confidence just as I would expect my information to be taken in confidence if I were ever a patient. Furthermore, the information would only be used for the purpose for which it was given and will not be released to others without the patient’s consent (Horan, 2006). Considering that there are other interests involved in the medical field, a professional who chooses to breach the basic principle of confidentiality, believing it to be necessary for the public interest must consider the matter sufficiently to justify that decision. I feel that the majority of patients trust nurses as professionals and they allow us to gather sensitive information relating to their health and other matters without hesitation as part of them seeking treatment. They do so in confidence and have the legitimate expectation that staff will respect their privacy and act appropriately. Even if some patients do not understand the regulations regarding confidentiality, or in cases where consent can not be given; the confidence has to be maintained from the professional’s perspective if not the patients. The patient nurse relationship might include more time spent together since a patient is given round the clock care by nurses, not doctors. In some circumstances (such as Mandy’s) patients may lack the competence to hold a nurse to the trust between them, or they may be rendered unconscious, but this does not diminish the duty of confidence placed on the nurse. That contract between the health service provider and the patient remains firm even if the patient is no longer living, since it is a valid recourse of legal protection for both the nurse and the patient involved in the process. Secondary Uses of Information Information gathered from patients is valuable since it has many applications in medical research and the further development of the field. According to NHS Code of Practice (2003) many current uses of confidential patient information do not contribute to or support the health care that a patient receives. Very often, these secondary uses are extremely important and provide several benefits to society such as; medical research, protecting the health of the public, health service management and financial audits for hospitals and related bodies. The secondary use of patient information depends on a nurse’s ability to make accurate and detailed records about the patient and it raises particular concerns about confidentiality and security (Castledine, 2006). Norwell (2006) suggests that even the arrangement of the consulting room computer screens can be taken as a confidentiality hazard. To me, this clarifies that the professional community is seriously concerned about confidentiality and secrecy regarding information. Information Insecurity While confidentiality is a fundamental right and it must be protected as much as possible, it should not become the overriding factor for nurses or health care professionals. All that can be done to secure information should be done. Norwell (2006) says that: “While no information system can ever be 100 per cent secure, GPs need to demonstrate they have adequate security in place and they have taken steps to try to prevent accidental disclosure of confidential data (Norwell, 2006, Pg. 60).” To minimise the remaining chance of unauthorised information disclosure, nurses should not leave patients records in any form, i.e. paper or electronic records anywhere that allows them to be seen by others. The ‘others’ in this statement includes other patients, unauthorised staff personnel and the general public who have come to the hospital (Norwell, 2006). Conclusion From the research conducted on the topic as well as my personal experience, it is clear that the majority of the medical profession takes confidentiality very seriously and consider it to be essential. An important part of the confidentiality situation is the legal requirement of the process which has to be met for most situations except when the law itself prohibits information withholding. However, the legal requirement is only a small part of the need for confidentiality since the greatest reason comes from the relationship of trust that a nurse needs to have with his/her patients. Fundamentally, a nurse has to understand that the needs and confidentiality of the patients’ are of paramount importance. With the introduction of the guidelines on patient-identifiable information, the NMC (2004), as well as other ruling bodies for nurses and other medial practitioners, have reinforced the need for medical personnel to understand their responsibilities in relation to the information they have access to in their professional roles. There can be no doubt that the privacy of information about our health is precious to us all. Furthermore, the government and the laws of the land recognise this by treating health information as sensitive personal information and thereby it is certainly worthy of the special protection status it has been given. However, the fact remains that handling personal information is a complex issue which often requires judgements to be made by the practitioner in relation to how the information is important to legal authorities and for the public. Health records and the information they contain are often governed by common and statute law, by contractual and professional obligations as well as the norms which are accepted in the medial profession. Without an awareness of these governing factors a nurse could find it difficult to see where the rules are applied in what shape and how the patient and the nurse can be protected. Word Count: Referneces: American Nurses Association. 2001. ‘Code of Ethics for Nurses with Interpretive Statements’. ANA Publications [Online] Available at: http://nursingworld.org/ethics/code/protected_nwcoe303.htm Castledine, G. 2006, ‘The importance of keeping patient records secure and confidential’, British Journal Of Nursing, vol. 15, no. 8, pp. 466-467. DoBias, M. 2006, ‘Fighting for privacy. Protect patients in rush to health IT coalition’, Modern Healthcare, vol. 36, no. 15, pp. 14-15. Fallon, D. 2006, ‘Bad girls or big brother?’ Paediatric Nursing, vol. 18, no. 1, pp. 3-4. Fowler, M. 2000, ‘A new code of ethics for nurses’, American Journal of Nursing, vol. 100, no. 7, pp. 69-72. GP. 2006, ‘Confidentiality fears over childrens records’, General Practitioner, 5 May, p. 7. Horan, S. 2006, ‘Confidentiality must come first’, Occupational Health, vol. 58, no. 4, pp. 10-11. Hutchinson, C. and Sharples, C. 2006, ‘Information governance: practical implications for record-keeping’, Nursing Standard, vol. 20, no. 36, pp. 59-64. Kloss, D. 2006, ‘Keep it to yourself’, Occupational Health, vol. 58, no. 2, pp. 13-15 Morse, J. 1991, ‘Negotiating commitment and involvement in the nurse-patient relationship’, Journal of advanced nursing, vol. 16, no. 1, pp. 455-468. NHS. 2003, Confidentiality: NHS Code of Practice. The Stationery Office, London. NHS. 2005, What you should know about information governance. The Stationery Office, London. Norwell, N. 2006, ‘Confidentiality risks for electronic patient data’, General Practitioner, 21 Apr., p. 60-61. Nursing & Midwifery Council. 2004. Code of Professional Conduct: standards for conduct, performance and ethics, NMC. Rankin, W. 2000, ‘Ethics of care and the empowerment of nurses’ Journal of Pediatric Nursing, vol. 15, no. 3, pp. 193-194. Rogers, W. 2006, ‘Pressures on confidentiality’, Lancet, vol. 367, no. 9510, pp. 553-4. Scanlon, C. 2000, ‘A professional code of ethics provides guidance for genetic nursing practice’, Nursing Ethics, vol. 7, no. 3, pp. 262-268. Stuttle, B. 2006, ‘Independent Nurse: The wider issues around confidentiality’, General Practitioner, 10 Feb., p. 94. Read More