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Dilemma
Dilemma You shouldn’t have told me that! I was in the final year of my nursing degree and had decided to do a research project on ‘stress amongst staff nurses in A&E’. I had planned my data collection carefully and decided to collection information by interviewing a number of colleagues in my department. I approached the nurse manager and discussed my ideas with her and then asked for colleagues to volunteer to be interviewed. Several staff nurses came forward and I arranged to interview them. I thought that my data collection was going really well until one nurse, in one of the interviews, told me that she had been so stressed on her shift, the previous day, that she thought that she may have made a drug error. I didn’t know what to do, I had promised my colleague that information collected during the interview would be confidential, but she had told me that she might have made a mistake. Should I have kept the information confidential? Should I report her? What should I have done?
Legal reply This situation raises an important issue in relation to the role of the researcher. In what circumstances can a promise of confidentiality of information disclosed during a research project be broken? It is discussed more fully in the author’s chapter in de Raeve (1996).
that patient that this information would have to be made known to the appropriate officer of the Area Child Protection Committee. Other examples of disclosure recognized as being in the public interest would include a situation where a mentally disordered individual had become disturbed and could be seen to pose a threat to himself or others (Dimond 1999).
General principles
Disclosure of professional misconduct
The duty of confidentiality applies to data collected during research, unless the patient has given express approval to the disclosure. The approval of the Local Ethics Committee to the research being conducted will often be subject to safeguards relating to the confidentiality being protected and results anonymised. The research subject may be asked to sign a consent form for participation in the research which will assure the person that information will be kept confidential.
Is it in the public interest to disclose information about possible professional misconduct by a colleague? Would such disclosure come within the duty recognized by the UKCC Code of professional Conduct that the registered practitioner should ‘act always in such a manner as to promote and safeguard the interests and wellbeing of patients and clients’ (UKCC 1992). The probable answer to that question is ‘yes’. The UKCC, through its Professional Conduct Committee and professional misconduct proceedings, ensures that the general public is protected from those registered practitioners who are found unsafe. A practitioner who is too stressed to make competent decisions over the administration of drugs is a dangerous practitioner and information could be passed to the UKCC to enable a referral to the Preliminary Investigating Committee or to the Health Committee.
Disclosure in the public interest If, however, during the conduct of the research, information is learned which could lead to preventing serious harm being caused, then this could be a justification for an exception to the duty of confidentiality. Thus, if a patient were to tell a researcher that he or she had ill-treated a child, then the researcher would be wise to warn
© 2000 Harcourt Publishers Ltd
Accident and Emergency Nursing ( 2 0 0 0 )
8, 31–33
31
Dilemma
Action in a stressful situation
Practical steps
In addition, under Clause 11 of the Code of Professional Conduct, the practitioner has a duty to
It may be that the way out of this dilemma is for the research nurse to notify the nurse she interviewed that in her opinion she should check the drug charts and if an error is confirmed then she herself should inform the appropriate person of this drug error. If the nurse is not prepared to make an honest confession, then the researcher should warn her that the researcher would feel herself to be under a professional duty to make known the error and the dangerous situation to senior management. Hopefully, such a warning would result in the stressed nurse taking the honourable line of action, thereby saving her job and her name on the register.
…report to an appropriate person or authority, having regard to the physical, psychological and social effects on patients and clients, any circumstances in the environment of care which could jeopardise standards of practice.
Under Clause 12, the practitioner must …report to an appropriate person or authority any circumstances in which safe and appropriate care for patients and clients cannot be provided.
It would appear that if nurses are so stressed that they are incapable of fulfilling a reasonable standard of care, then this is of serious concern to management and should be reported even before the research has been completed. The researcher cannot, therefore, ignore the information which has been given to her and under her promise of confidentiality keep it secret. Such a drug error could occur again, with possibly more dangerous consequences.
The nurse’s failure to admit to the error Even greater evidence of professional misconduct is the nurse’s failure to alert staff to the drug error at the time. Serious consequences can sometimes be avoided following a mistake if immediate action is taken: an antidote could possibly be administered. There are, thus, two serious incidents of professional misconduct: the drug error itself and the failure of the nurse to own up to it. There are, therefore, ample grounds for the researcher to make known the information provided by the nurse, even though that is in breach of the duty of confidentiality. If as a result of that breach, the nurse were to take action against the researcher for an unlawful disclosure, it would probably fail on the grounds of disclosure in the public interest.
32
Accident and Emergency Nursing ( 2 0 0 0 )
8, 31–33
Whistle-blowing This is a whistle-blowing type of situation. Any practitioner could learn of a colleague’s failures, not just a researcher. The Public Interest Disclosure Act of 1998 is aimed at protecting employees who disclose information about certain types of matters from being dismissed or penalized by their employers as a result. The Act applies to disclosures relating to crimes, breaches of a legal obligation, miscarriages of justice, dangers to health and safety or the environment and to the concealing of evidence relating to any of these. It would thus provide protection if the duty of confidentiality is broken as a result of such disclosures. References Dimond B 1996 Legal issues arising in research. In: de Raeve L (ed) Nursing Research: an ethical and legal appraisal. Bailliere Tindall, London Dimond B 1999 confidentiality 2: Disclosure in the public interest. British Journal of Nursing 8(10) UKCC 1992 Code of Professional Conduct for the Nurse, Midwife and Health Visitor. Clause 1. UKCC, London
Bridget Dimond Barrister at Law, Emeritus Professor University of Glamorgan, UK
© 2000 Harcourt Publishers Ltd
Dilemma
Nursing reply In this dilemma, the nurse undertaking the research, has been told by a respondent, who is a colleague, that they might have committed a drug error. In this situation, the researcher’s priority is to act in the best interests of the patient (UKCC 1992). To do this, the nurse needs to support her colleague and encourage her to report her error to the appropriate persons. In doing so the nurse may be seen to be breaching confidentiality, but is she? Many nurses involved in research promise confidentiality without really thinking through what they are able to offer. As more nurses become involved in research there is a need to be very clear about what exactly confidentiality, within the context of research, means. This is important because not only does the researcher need to know what the term means but others involved in the research – colleagues, other health care personnel and patients – need to know its meaning so that they can make choices about their involvement in research in the A&E department. According to the UKCC (1996, p 26) To trust another person with private and personal information about yourself is a significant matter. If the person to whom that information is given is a nurse, midwife or health visitor, the patient or client has the right to believe that this information, given in confidence, will only be used for the purposes for which it was given and will not be released to others without their permission.
This statement, although primarily directed at patient care, is applicable to the care of people invited to take part in research. The nurse undertaking research is trusted with private and personal information about the respondent. Some respondents, when promised that information given for the purposes of research, is confidential, will assume that any information provided will be confined to the researcher and shared with no one else. Therefore the researcher needs to make it very clear just what offering confidentiality means. For example, research findings are often
© 2000 Harcourt Publishers Ltd
published, so this needs to be discussed with potential respondents before they provide data. Ultimately, the researcher has to make clear who will have access to and what will happen to data and not assume that the respondent will know. In addition to this, being a researcher does not absolve the nurse of his/her responsibilities as outlined by the Code of Professional Conduct (1992). Therefore, for A&E nurses undertaking research, the promise of confidentiality will be determined as a result of discussing and clarifying the following, with respondents, as part of the consent process: • Whether or not the research will be published • Who will have access to the data and other information during the time the research is undertaken, e.g. a research supervisor • What action will be taken if bad practice/mistakes are disclosed by respondents In summary, nurses undertaking research have a dual responsibility: to the patient and to the research process. This means taking care, at all times, to ensure that the best interests of patients are promoted as well as making sure that research is undertaken in an appropriate manner. In practice this can be problematic, which makes it of utmost importance to ensure that everyone taking part in research is fully aware of what will happen to their private and personal information once they have decided to share it. References UKCC 1992 The Code of Professional Conduct. UKCC, London UKCC 1996 Guidelines for Professional Practice. UKCC, London
My thanks to everyone who has helped me develop the response to this dilemma. Dr Lynn Sbaih Lecturer, School of Nursing, Midwifery and Health Visiting University of Manchester UK
Accident and Emergency Nursing ( 2 0 0 0 )
8, 31–33
33
Legal reply This situation raises an important issue in relation to the role of the researcher. In what circumstances can a promise of confidentiality of information disclosed during a research project be broken? It is discussed more fully in the author’s chapter in de Raeve (1996).
that patient that this information would have to be made known to the appropriate officer of the Area Child Protection Committee. Other examples of disclosure recognized as being in the public interest would include a situation where a mentally disordered individual had become disturbed and could be seen to pose a threat to himself or others (Dimond 1999).
General principles
Disclosure of professional misconduct
The duty of confidentiality applies to data collected during research, unless the patient has given express approval to the disclosure. The approval of the Local Ethics Committee to the research being conducted will often be subject to safeguards relating to the confidentiality being protected and results anonymised. The research subject may be asked to sign a consent form for participation in the research which will assure the person that information will be kept confidential.
Is it in the public interest to disclose information about possible professional misconduct by a colleague? Would such disclosure come within the duty recognized by the UKCC Code of professional Conduct that the registered practitioner should ‘act always in such a manner as to promote and safeguard the interests and wellbeing of patients and clients’ (UKCC 1992). The probable answer to that question is ‘yes’. The UKCC, through its Professional Conduct Committee and professional misconduct proceedings, ensures that the general public is protected from those registered practitioners who are found unsafe. A practitioner who is too stressed to make competent decisions over the administration of drugs is a dangerous practitioner and information could be passed to the UKCC to enable a referral to the Preliminary Investigating Committee or to the Health Committee.
Disclosure in the public interest If, however, during the conduct of the research, information is learned which could lead to preventing serious harm being caused, then this could be a justification for an exception to the duty of confidentiality. Thus, if a patient were to tell a researcher that he or she had ill-treated a child, then the researcher would be wise to warn
© 2000 Harcourt Publishers Ltd
Accident and Emergency Nursing ( 2 0 0 0 )
8, 31–33
31
Dilemma
Action in a stressful situation
Practical steps
In addition, under Clause 11 of the Code of Professional Conduct, the practitioner has a duty to
It may be that the way out of this dilemma is for the research nurse to notify the nurse she interviewed that in her opinion she should check the drug charts and if an error is confirmed then she herself should inform the appropriate person of this drug error. If the nurse is not prepared to make an honest confession, then the researcher should warn her that the researcher would feel herself to be under a professional duty to make known the error and the dangerous situation to senior management. Hopefully, such a warning would result in the stressed nurse taking the honourable line of action, thereby saving her job and her name on the register.
…report to an appropriate person or authority, having regard to the physical, psychological and social effects on patients and clients, any circumstances in the environment of care which could jeopardise standards of practice.
Under Clause 12, the practitioner must …report to an appropriate person or authority any circumstances in which safe and appropriate care for patients and clients cannot be provided.
It would appear that if nurses are so stressed that they are incapable of fulfilling a reasonable standard of care, then this is of serious concern to management and should be reported even before the research has been completed. The researcher cannot, therefore, ignore the information which has been given to her and under her promise of confidentiality keep it secret. Such a drug error could occur again, with possibly more dangerous consequences.
The nurse’s failure to admit to the error Even greater evidence of professional misconduct is the nurse’s failure to alert staff to the drug error at the time. Serious consequences can sometimes be avoided following a mistake if immediate action is taken: an antidote could possibly be administered. There are, thus, two serious incidents of professional misconduct: the drug error itself and the failure of the nurse to own up to it. There are, therefore, ample grounds for the researcher to make known the information provided by the nurse, even though that is in breach of the duty of confidentiality. If as a result of that breach, the nurse were to take action against the researcher for an unlawful disclosure, it would probably fail on the grounds of disclosure in the public interest.
32
Accident and Emergency Nursing ( 2 0 0 0 )
8, 31–33
Whistle-blowing This is a whistle-blowing type of situation. Any practitioner could learn of a colleague’s failures, not just a researcher. The Public Interest Disclosure Act of 1998 is aimed at protecting employees who disclose information about certain types of matters from being dismissed or penalized by their employers as a result. The Act applies to disclosures relating to crimes, breaches of a legal obligation, miscarriages of justice, dangers to health and safety or the environment and to the concealing of evidence relating to any of these. It would thus provide protection if the duty of confidentiality is broken as a result of such disclosures. References Dimond B 1996 Legal issues arising in research. In: de Raeve L (ed) Nursing Research: an ethical and legal appraisal. Bailliere Tindall, London Dimond B 1999 confidentiality 2: Disclosure in the public interest. British Journal of Nursing 8(10) UKCC 1992 Code of Professional Conduct for the Nurse, Midwife and Health Visitor. Clause 1. UKCC, London
Bridget Dimond Barrister at Law, Emeritus Professor University of Glamorgan, UK
© 2000 Harcourt Publishers Ltd
Dilemma
Nursing reply In this dilemma, the nurse undertaking the research, has been told by a respondent, who is a colleague, that they might have committed a drug error. In this situation, the researcher’s priority is to act in the best interests of the patient (UKCC 1992). To do this, the nurse needs to support her colleague and encourage her to report her error to the appropriate persons. In doing so the nurse may be seen to be breaching confidentiality, but is she? Many nurses involved in research promise confidentiality without really thinking through what they are able to offer. As more nurses become involved in research there is a need to be very clear about what exactly confidentiality, within the context of research, means. This is important because not only does the researcher need to know what the term means but others involved in the research – colleagues, other health care personnel and patients – need to know its meaning so that they can make choices about their involvement in research in the A&E department. According to the UKCC (1996, p 26) To trust another person with private and personal information about yourself is a significant matter. If the person to whom that information is given is a nurse, midwife or health visitor, the patient or client has the right to believe that this information, given in confidence, will only be used for the purposes for which it was given and will not be released to others without their permission.
This statement, although primarily directed at patient care, is applicable to the care of people invited to take part in research. The nurse undertaking research is trusted with private and personal information about the respondent. Some respondents, when promised that information given for the purposes of research, is confidential, will assume that any information provided will be confined to the researcher and shared with no one else. Therefore the researcher needs to make it very clear just what offering confidentiality means. For example, research findings are often
© 2000 Harcourt Publishers Ltd
published, so this needs to be discussed with potential respondents before they provide data. Ultimately, the researcher has to make clear who will have access to and what will happen to data and not assume that the respondent will know. In addition to this, being a researcher does not absolve the nurse of his/her responsibilities as outlined by the Code of Professional Conduct (1992). Therefore, for A&E nurses undertaking research, the promise of confidentiality will be determined as a result of discussing and clarifying the following, with respondents, as part of the consent process: • Whether or not the research will be published • Who will have access to the data and other information during the time the research is undertaken, e.g. a research supervisor • What action will be taken if bad practice/mistakes are disclosed by respondents In summary, nurses undertaking research have a dual responsibility: to the patient and to the research process. This means taking care, at all times, to ensure that the best interests of patients are promoted as well as making sure that research is undertaken in an appropriate manner. In practice this can be problematic, which makes it of utmost importance to ensure that everyone taking part in research is fully aware of what will happen to their private and personal information once they have decided to share it. References UKCC 1992 The Code of Professional Conduct. UKCC, London UKCC 1996 Guidelines for Professional Practice. UKCC, London
My thanks to everyone who has helped me develop the response to this dilemma. Dr Lynn Sbaih Lecturer, School of Nursing, Midwifery and Health Visiting University of Manchester UK
Accident and Emergency Nursing ( 2 0 0 0 )
8, 31–33
33