Violations of patient confidentiality occur all too frequently. Conversations about patients and their care can be heard throughout hospitals. Although these conversations are necessary to manage the care of patients, the breach of confidentiality is of concern because of where the discussions occur and what is being communicated in public places. Healthcare professionals, including nurses, are at risk in matters of patient confidentiality. This article discusses confidentiality and its relationship to privacy and the trust relationship that healthcare professionals have with their patients, and offers some suggestions to uphold confidentiality within the healthcare setting.
During a recent ethics session that I had with a group of third-year medical students, a question was asked about patient confidentiality. The medical student who raised the question was wondering if patient information was ever really held in confidence because of the myriad of conversations about patients and their conditions and treatments that occur throughout the hospital. She said that she believed that healthcare professionals had a responsibility to their patients to not discuss patient issues in public areas. To make her point even more clearly, the student went on to describe the following situation.
I was with some fellow students on the elevator going to the cafeteria. Because it was lunchtime, the elevator was very crowded. I overheard two healthcare providers talk in great detail about a patient for whom they were caring. While neither of the individuals mentioned the patient's name, the amount of information that they were exchanging between themselves seemed to be almost enough to pinpoint the particular patient. They identified the patient's unit and the nature of his health condition.I became alarmed by what I was overhearing and when I exited the elevator, I asked my fellow medical students what they thought about that conversation. All expressed the same concern that I had. Each wondered what might be going through the minds of some of the other people who had been on the elevator who were obviously not healthcare providers or hospital employees. Additionally, we commented about whether these types of conversations should occur even if there are no visitors on the elevator. Quite possibly one of the employees or other healthcare providers could have been a relative or friend of the patients.
This case generated considerable discussion by the members of the medical student group. They commented that they had been taught the importance of respecting patient confidentiality; yet, this case demonstrated what they considered to be an outright abuse of the patient–provider relationship and the implicit promise that is made to hold patient information in confidence.
As a follow-up, I raised this question of “how confidential is confidential” with one of my nursing doctoral students. The student's immediate response to me was “Not very.” We began to discuss how professional communication regarding patient matters often becomes more like the casual conversation that one would have with any other individual.
Nurses have the same ethical responsibilities to patients as other healthcare professionals; nurses are with patients 24 hours a day and 7 days a week. Patients and their families are very open about matters related to the patient's health problem, how they will manage the care once the patient returns home, and possibly other personal issues. Frequently, these discussions occur because patients and their families believe that nurses are there to help them and are trusted confidants.
However, nurses can fall prey to the same situation as described by the medical student; they, too, find themselves in public places discussing confidential matters about their patients. Sometimes these nurses do not realize that they are violating the trust engendered by the nurse–patient relationship. Thus, the purposes of this article are to discuss confidentiality and its relationship to privacy and the trust relationship that healthcare professionals have with their patients, and to offer some suggestions to uphold patient confidentiality within the healthcare setting.
The ethical precept of confidentiality is considered to be a right of patients; thus, it is an entitlement and something that patients are owed by others. These others, in this case healthcare professionals, have a responsibility to uphold and protect the rights of patients. However, “confidentiality is a stringent, but not an absolute obligation” (Jonsen, Siegler, & Winslade, 1998, p. 166).
In 1982, the New England Journal of Medicine published the article, “Confidentiality in Medicine—A Decrepit Concept” by Mark Siegler, a physician and ethicist. Siegler asserted that the traditional understanding of confidentiality no longer exists. Changes in the delivery of healthcare and third-party reimbursement were necessitating the sharing of patient information and, therefore, compromised confidentiality. Siegler argued that attention should focus on those aspects of confidentiality that needed to be retained rather than trying to preserve the historical notion of confidentiality in which physicians kept the “secrets” of their patients.
Changes in healthcare management and reimbursement continue to require the exchange of patient information. Thus, the challenges related to maintaining patient–provider confidentiality persist: who has access to patient information, what information can be disclosed, and when is it critical to share private information for the good of others (Ahronheim, Moreno, & Zuckerman, 2000). Because of the sensitive and private nature of patient information and the increased use of electronic transmission, there is a heightened awareness of confidentiality and the need for additional protections.
Policies have been implemented within healthcare organizations to protect patients' rights regarding who has access to what aspects of their personal health information (Erlen, 2004). These policies need to be congruent with the regulations written by the Department of Health and Human Services that afforded the implementation of the Health Insurance Portability and Accountability Act of 1996, Public Law 104–191 (Office for Civil Rights, 2003). Patients must give permission with regard to the information that can be disclosed, to whom, and for what purpose.
Yet, these policies are not addressing the more indiscriminate sharing of patient information or indiscretion as Siegler (1982) noted, which is most likely akin to the traditional understanding of the need to protect the patient's confidentiality. There are no policies per se to prevent healthcare providers from talking about their patients in the cafeteria, the hospital's coffee shop, or the hallways. There is considerable carelessness concerning the sharing of confidential information (Jonsen et al., 1998).
Professional codes of ethics as promulgated by the American Nurses Association (2001) and the American Medical Association Council on Ethical and Judicial Affairs (2006) clearly delineate the patient's right to confidentiality within the context of the patient–provider relationship. Any breach of this confidentiality violates the patient's trust and diminishes the healthcare professional's respect for the dignity and worth of the patient. The practice of healthcare professionals should be governed by these ethical codes with their explicit statements and implicit promises to the public. In addition, individual healthcare providers rely upon their own personal values to guide their interactions with their patients.
Privacy is often included in discussions about confidentiality; the terms are frequently used interchangeably. However, privacy refers to the freedom one has from accessibility, interference, intrusion, or observation by others to whom permission has not been granted. Simply stated, privacy can be defined as one's right to be left alone.
Respect for another's privacy is inherent in the principle of respect for autonomy and thus becomes critical in the patient–provider relationship (Beauchamp & Childress, 2001). Within this relationship, the patient can decide how much, as well as what information about himself or herself to share with the healthcare provider. The patient provides access to this personal information and to other intrusions on privacy that are necessary for assessments, diagnoses, and care. However, when patients share personal information, they may have an increased sense of vulnerability (Erlen, 1998). Patients do not know how their personal information will be treated and whether others will inadvertently learn what these patients may perceive to be their secrets.
Healthcare professionals expect that patients are being honest when sharing their personal health information. Likewise, patients need to feel comfortable with and trust their healthcare providers with regard to how they will handle personal information that patients disclose in this therapeutic relationship. Otherwise, patients may be reluctant to share some of the more intimate details of their health history (Ahronheim et al., 2000). Patients expect that what they have disclosed about themselves and what healthcare providers have learned through health assessments and laboratory tests will be held in total confidence or disclosed only to those who need to know because they are involved in their care; they expect this because there is the possibility of some negative consequences should others such as employers, insurance companies, or family members gain access to or learn of that information without the patient having disclosed it to them.
Patient privacy and confidentiality are inextricably linked within the confines of the patient–healthcare provider relationship, which is built on shared trust. However, although this trust is assumed, it also needs to develop. Initially, patients may not fully confide in or trust their healthcare providers. Patients select healthcare professionals using referrals from friends, family, or other healthcare providers or because of these professionals' particular area of expertise. Patients do not have personal knowledge of the providers nor do the providers have knowledge of the patients when they meet for the first time; each comes to the encounter as a stranger to the other. Thus, there is a period of time in which each of the parties comes to know the other; together they build the patient–provider relationship. The bond they establish creates the environment in which the patient feels free to share personal health information.
Consider the helpless infant who must learn to have confidence in and depend on other people to meet his or her basic needs, such as the need for food. Without these other caring individuals, infants would be unable to survive on their own. When their needs are met, infants are quieted. They come to trust and rely upon others for food, comfort, and security. Over time, the relationship grows stronger; the human bond strengthens. However, when an infant's needs are not met or are only partially met, a situation of mistrust occurs. There is anxiety and apprehension; they doubt that someone will come to help them in a timely or caring manner. There is uncertainty. Erikson (1963), a leader in child development and psychoanalysis, described this first developmental stage as “trust vs. mistrust.”
In many respects, the trust relationship that is established between an adult patient and their healthcare provider is not so different. Patients also find themselves in a dependent position; they lack knowledge, have little or no control, and have difficulty with making decisions (Curtin, 1979). Thus, patients learn to depend on others to meet their needs and to help them.
Patients learn that sharing important and relevant healthcare information with their healthcare providers is necessary so that healthcare professionals can manage their patients' health conditions appropriately. Although patient–provider trust is often automatically assumed to be a part of this relationship, trust actually develops more gradually enabling the patient to have increased confidence that it is safe to share private, personal information with the healthcare professional because the provider will keep the information confidential or will use discretion and disclose it only to those who need to have this knowledge.
The medical student who recounted the scenario in the elevator clearly felt uncomfortable by what she overheard and the location in which the information was disclosed. However, did she have any responsibility to intervene and to ask the other parties to discontinue their conversation until they reached a private area once they exited the elevator? She recognized that sharing confidential patient information in a public setting is inappropriate and unprofessional and can erode the trust that patients have in their healthcare providers (Erlen, 2004).
Consider what the possible reactions may have been had the medical student interrupted the conversation she was overhearing. Would she have been rebuffed? Would she have been ignored? Would she have been told to mind her own business? Knowing that these are possible responses can easily make a person hesitant to intervene even though one is becoming increasingly uncomfortable by hearing what seems to be a very private conversation.
Quite possibly, many nurses have encountered similar situations and have felt equally uncomfortable. Although it seems natural to take advantage of an opportunity to discuss patient matters when one encounters a colleague who is involved in the care of a particular patient, not all settings are conducive to these private conversations. Healthcare professionals need to carefully select those areas where they disclose a patient's private information with others rather than taking advantage of an opportunity when one sees a colleague who is also involved in a particular patient's care.
Nurses need to consider the nature of the conversation and move to a location that is out of the earshot of those who do not need to know what is being discussed. If changing the setting is not possible, then other alternatives may be to discontinue the conversation or turn toward the wall and lower one's voice so that others cannot hear what is being said.
Creating an environment that supports patient confidentiality requires the cooperation of the healthcare organization's administration and its employees. All professional and nonprofessional staff need to understand that conversations that they overhear and information that they learn is not for everyone they know. The reason they are privy to specific patient information is that they have some role in the care of the patient. Should there be a need to discuss the care of this patient with others, they need to do so in a manner and place that respect the patient's privacy rights.
However, there are other employees who are not direct patient care providers. These individuals provide essential ancillary or support services such as transport, housekeeping, or dietary. These employees also need to understand the importance of maintaining patient confidentiality and not disclosing patient information that they overhear during the course of their work.
Developing policies will not create an environment that recognizes the importance of privacy and confidentiality. Instead, there need to be discussions during employee orientations, underscoring the patient's right to privacy and confidentiality. Periodically, organizational publications need to publish articles addressing these patient issues, emphasizing that everyone has the responsibility to maintain patient confidentiality and offering ways to handle situations in which patient information is being disclosed indiscriminately.
The organization needs to offer support rather than reprimand employees who call attention to individuals disclosing a patient's personal information in a public place within the facility. The agency needs to establish that the expected behavior or norm for all employees is having these private conversations in areas where others cannot overhear them even when patients' names are not being used. Areas can be designated for discussing patients and their care management.
Respecting the dignity and worth of the patient requires that one consider how he or she would like to be treated if in the same situation. Healthcare providers need to ask themselves “would I want others to be talking about me and my health problems in the cafeteria or on the elevator?”
Indiscriminate disclosure of personal information demonstrates a lack of respect and increases the vulnerability of patients. Healthcare workers should share only with those who need to know the information about the patient and share only that information that these other healthcare providers need to know. When healthcare professionals know with whom they are speaking and their purpose for knowing particular patient information, the likelihood of indiscriminate disclosure lessens. Healthcare professionals need to recognize that upholding the dignity of the patient is paramount.
Protecting the patient's right to privacy and maintaining confidentiality are fundamental to the patient– provider relationship. Changes in the provision of healthcare, third-party reimbursement, and protecting the public well-being may require the disclosure of specific patient information. However, inadvertent, indiscriminant, and unnecessary disclosure of patients' personal information may violate their confidentiality. Healthcare organizations and healthcare professionals need to recognize their significant responsibility to create and maintain an environment that advocates protecting patient confidentiality and upholding patient dignity.
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| Source : | Orthopaedic Nursing November/December 2008 Volume 27 Number 6 Pages 357 - 360 |
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