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Patient confidentiality in the emergency department
PATIENT CONFIDENTIALITY IN THE E M E R G E N C Y D E P A R T M E N T ABSTRACT As registered nurses we all owe a duty of confidentiality to those patients we care for. The pure nature of Emergency Departments often makes it difficult to maintain our Mr Mark Wilson
patients' confidentiality. This article outlines
Dip.AppSc (Nursing), Cert. Emergency Nursing, TNCC, ENPC, Clinical Nurse Educator, Liverpool Emergency Department
the principles and laws which relate to patient
I have 6 years emergency nursing experience. I am currently the clinical nurse educator. I completed an emergency nursing certificate at Liverpool 3 years ago and have just completed a Graduate Diploma of clinical practice. I have also completed TNCC, ENPC and an Advanced Resuscitation Course.
confidentiality and how these principles impact on the practice of emergency nurses. This article will provide emergency nurses with the necessary knowledge to uphold their duty of patient confidentiality.
The concept of patient confidentiality is by no means a new concept, its origins go back to the formulation of the Hippocratic Oath, which asks newly qualified doctors to declare that "whatsoever things I see or hear concerning the life of men, in my attendance on the sick or even apart therefrom, which ought not to be noised abroad, I will keep silence thereon, counting such things as sacred secrets. ,,1 Today all health care professionals are obliged to uphold the duty of confidentiality to their patients. The duty of confidentiality is that health care professionals have a duty to keep information disclosed by patients in the course of treatment confidential. This is not just limited to information directly disclosed but also to any information which is obtained through the course of one's professional practice. 1'2 The duty of confidentiality exist primarily for the benefit of the patient so that they are neither hurt nor embarrassed by an unwanted disclosure. The duty of confidentiality exist so that patients can confidently and freely disclose information, which can often be of a personal and highly sensitive nature, necessary for the appropriate medical attention and care. z The duty of confidentiality is not absolute. Generally disclosure is permitted, firstly, when the patient consents to that disclosure. For example when a patient permits or requests that information be given to a spouse or relative. Secondly disclosure is permitted for the patient's benefit. This allows disclosure of information to other health care professionals involved in the treatment of the patient, without the prior expressed consent of the patient. Thirdly, disclosure is permitted when required by law.3 Breaches of patient confidentiality may result in one of several possible outcomes, these are: • The patient may sue in equity (an area of law dealing with fairness) for a breach of confidentiality or seek an injuction to prevent such a disclosure. • The patient may bring about an action for negligence seeking a payment for damages when a disclosure has lead directly to the patient suffering damages. • The patient may sue under contract law, if it were found that a term of the contract imposed a requirement for the maintenance of confidentiality (either stated or implied). • Improper disclosure of confidential information may be considered grounds for charges of professional misconduct and may result in disciplinary action or dismissalY This would be the most likely consequence from a breach of confidentiality.
59
As mentioned previously disclosures are also permitted when they are required by law, this includes:• Notification of infectious diseases - this requires notification of cases of certain infectious diseases to the Department of Health. • Notification of suspected child abuse - this requires notification of suspected cases of child abuse to the appropriate child protection agency. While this is not a mandatory obligation for nurses, they are encouraged to make notification of these cases. • In the course of legal proceedings - During legal proceedings health professionals are required to disclose confidential information if obligated to do so. • In public interest - confidential patient information can be disclosed when disclosure is considered necessary in public interest. The precise nature of information able to be disclosed in the interest of the public is not well defined, however one would require strong reasons to disclose. • In the event of serious criminal activity - Under the NSW crims act there is an obligation for people who have information about a serious offence to notify the police. A serious criminal offence is an offence which attracts a penalty of five years imprisonment or more. 4'5
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® 60
With an understanding of the principles and domain of the laws pertaining to patient confidentiality one can now look at how this impacts on emergency nursing practice. For nurses working in emergency departments the considerations to their patients' confidentiality occurs on numerous occasions every day. It is imperative that emergency nurses have a good understanding of the confidentiality laws and how to apply them as they are often exposed to information of a highly sensitive nature and are exposed to events which often draw attention from the wider community. The following is a list of circumstances where emergency nurses may need to consider their patient's confidentiality and how to apply the law to these circumstances:• Patient enquiries - In general no information should be released without the consent of the patient. If consent is granted information should be given in general terms only. Information regarding diagnosis, treatment or prognosis should be withheld, and a general statement about the condition of the patient should only be given, for example, Satisfactory, Stable, Serious, or Critical. When enquiries are being made about the whereabouts of patients already admitted to wards the information given should in no way reflect the specialty of the ward. The ward should be described by its name, letter or number eg. Ward A, Level 2, East etc. 6 • Patient requests no information to be released Where a patient requires that no information be released to patients wishes should be respected and their name should not appear on any patient list held at enquiry desks. 5
•
•
•
•
Information requests by police officers - Numerous occasions arise with police seeking information on patients and clients. In the majority of cases it is not for the purpose of laying charges against the patient. Generally the information sought is used in writing reports (say following a motor vehicle collision) occasionally the information sought may be used to determine charges to be brought against another person. The information should be released by a responsible medical officer or senior health professional (Nurse in charge) when they are satisfied that the information is required in the execution of police duty. The information given should consist of a general outline of the patient's condition and injuries, confirmation of the patient's identity and the patient's address. 6 Police interviews of patients - Except in the case of declarations from dying patients, permission to interview a patient should only be given when the patient's medical condition permitsJ Nurses should also remember their duty to disclose information regarding issues of public safety and information relating to serious crime, as discussed previously. Information request by the media - The pure nature of emergency nursing means that we are often exposed to incidents which attract both public and media attention. When a request is made for information from the media nurses should follow their hospital's protocol on regarding such requests. Generally information given to the media is done via the hospital's designated media liaison. However to release information in accordance with the law the following recommendations should be followed. Firstly no information should be given without the consent of the patient. If the patient is not conscious consent must be obtained from his/her next of kin. Information released about victims or incidents should be limited to the number of casualties, sex, appropriate age and whether injuries are critical, serious or minor. 5 Patients Notes - As patients notes (nursing notes in the form of flow sheets or clipboards) are generally kept at the end of the patient's bed this can often present some difficulty in maintaining the patient's confidentiality. Generally information regarding the patient's diagnosis and past medical history are not recorded on these notes, however presenting problem is often recorded. These notes are often visible and accessible to visitors and other unauthorised persons. Recommendations require that unattended documents containing personal information should not be visible to unauthorised people, therefore the information contained in these notes should not contain personal or sensitive information. Furthermore the current practice of leaving notes at the patient's bedside should be reviewed in accordance with the confidentiality laws and recommendations2
•
Visibility of Computer Screens - With the introduction of patient tracking computer systems into emergency departments confidential information is now stored within these systems. To protect confidential information is now stored within these systems.To protect confidential information computer terminals should be placed so that they cannot be seen by others other than the staff member entering the information. If left unattended no information should be left on the screen. The use of screen savers should be used wherever possible to reduce the chance of casual observation? • Casual conversations - It is essential for he health care professional to maintain the confidentiality of their patients during conversations with other health care professionals. Disclosure of information to other health care professionals is only permitted by law when it is directly related to the patient's care. These conversations should not occur in public places such as lifts, corridors or dining rooms. It is the responsibility of all health care professionals to discuss patient inforraation in areas where it is not likely to be overheard. 5 • Training and Education - The anonymity of patients should be maintained during case presentations, research activities, at seminars and conferences. The use of photographs, slides and other visual aids which allow identification of individuals must be done so with the expressed consent of the patient, s • Reception Desk - Often the reception desk is crowded and close to those patients in the waiting area offering no privacy to patients wishing to disclose the nature of their presentation. To maintain confidentiality of patients presenting to the reception desk one may consider introducing a queuing system with rope cordons which only allows one person to be present at the counter at any one time. Consideration should also be given to the installation of a television in the waiting area. The noise produced from the television should be kept at a level so that conversations at the reception desk cannot be overheard by those people in the waiting area. A private triage assessment area should be used so that the patients may disclose information regarding their presentation in private and a physical assessment can be attended to by the triage nurse.1 • Physical Environment - Often the mere design of emergency departments do not consider the confidentiality of patients. The use of curtains to screen off bed spaces do not protect information disclosed during conversations regarding medical history and other conversations of a potentially sensitive nature. Health care professionals working in emergency departments must remain aware that curtains are not soundproof and when conversations with patients are likely to be of a private nature
•
consideration must be given to conducting those conversations in an environment which is able to maintain the confidentiality of the patient. 1 Telephones - Consideration to the placement of telephones within the emergency departments should be made so that they are not within earshot of the general public.
Furthermore, conversations regarding patients which take place via the telephone should be done in a private area which will ensure the confidentiality of the information discussed. 1
CONCLUSION What has been described outlines the legal principles which should be maintained when dealing with patients and the confidential information which nurses are privileged to in their day to day work. These principles must underpin all critical decisions made regarding patient's confidentiality and the disclosure of such information. This will ensure that no legal or professional misconduct proceedings will be brought against any emergency nurse for a breach of patient confidentiality.
EDITORIALCOMMENT The right to privacy is inherent in any democracy. Central to this is the duty of maintaining confidentiality as outlined in this paper. How easy it is for us to forget this important aspect of patient care. How many times have we all been guilty of openly discussing patients around the desk, over coffee or in the corridors. It is always important to try and ask yourself if you would be happy to have this sort of information disclosed about yourself! The author highlights areas for improvement in ED's but how about the calling out of peoples names over the PA when it is their turn to be seen, should not we perhaps consider some sort of numbering system rather than a gross breach of privacy by announcing to the whole waiting room the name of the next patient to be seen! Something to think about perhaps.
REFERENCES 1.
Mortlock, t I994 "Maintaining Confidentiality in A&E" Nursing Times. Vo190. No34 pp 42.43.
2.
Edginton, J., 1995 Law for the Nursing Profession and Allied Health Care Professionals (3rd Ed) North Ryde: CCH Australia
3.
Dix. A. Errington, M. Nicholson, K. and Powe, R, 1988 Law for the Medical Profession Sydney: Butterworths.
4.
McFarlane, EJ.M. 1993 Health Law: Commentary and Materials. Leichhardt: The Federation Press.
5.
NSW Health Department., 1996 Information Privacy: Code of Practice. Sydney: Government Printers.
6.
Staunton, EJ. and Whyburn, B., I989 "Nursing and the Law". (2nd Ed). Sydney: W.B. Saunders.
61
patients' confidentiality. This article outlines
Dip.AppSc (Nursing), Cert. Emergency Nursing, TNCC, ENPC, Clinical Nurse Educator, Liverpool Emergency Department
the principles and laws which relate to patient
I have 6 years emergency nursing experience. I am currently the clinical nurse educator. I completed an emergency nursing certificate at Liverpool 3 years ago and have just completed a Graduate Diploma of clinical practice. I have also completed TNCC, ENPC and an Advanced Resuscitation Course.
confidentiality and how these principles impact on the practice of emergency nurses. This article will provide emergency nurses with the necessary knowledge to uphold their duty of patient confidentiality.
The concept of patient confidentiality is by no means a new concept, its origins go back to the formulation of the Hippocratic Oath, which asks newly qualified doctors to declare that "whatsoever things I see or hear concerning the life of men, in my attendance on the sick or even apart therefrom, which ought not to be noised abroad, I will keep silence thereon, counting such things as sacred secrets. ,,1 Today all health care professionals are obliged to uphold the duty of confidentiality to their patients. The duty of confidentiality is that health care professionals have a duty to keep information disclosed by patients in the course of treatment confidential. This is not just limited to information directly disclosed but also to any information which is obtained through the course of one's professional practice. 1'2 The duty of confidentiality exist primarily for the benefit of the patient so that they are neither hurt nor embarrassed by an unwanted disclosure. The duty of confidentiality exist so that patients can confidently and freely disclose information, which can often be of a personal and highly sensitive nature, necessary for the appropriate medical attention and care. z The duty of confidentiality is not absolute. Generally disclosure is permitted, firstly, when the patient consents to that disclosure. For example when a patient permits or requests that information be given to a spouse or relative. Secondly disclosure is permitted for the patient's benefit. This allows disclosure of information to other health care professionals involved in the treatment of the patient, without the prior expressed consent of the patient. Thirdly, disclosure is permitted when required by law.3 Breaches of patient confidentiality may result in one of several possible outcomes, these are: • The patient may sue in equity (an area of law dealing with fairness) for a breach of confidentiality or seek an injuction to prevent such a disclosure. • The patient may bring about an action for negligence seeking a payment for damages when a disclosure has lead directly to the patient suffering damages. • The patient may sue under contract law, if it were found that a term of the contract imposed a requirement for the maintenance of confidentiality (either stated or implied). • Improper disclosure of confidential information may be considered grounds for charges of professional misconduct and may result in disciplinary action or dismissalY This would be the most likely consequence from a breach of confidentiality.
59
As mentioned previously disclosures are also permitted when they are required by law, this includes:• Notification of infectious diseases - this requires notification of cases of certain infectious diseases to the Department of Health. • Notification of suspected child abuse - this requires notification of suspected cases of child abuse to the appropriate child protection agency. While this is not a mandatory obligation for nurses, they are encouraged to make notification of these cases. • In the course of legal proceedings - During legal proceedings health professionals are required to disclose confidential information if obligated to do so. • In public interest - confidential patient information can be disclosed when disclosure is considered necessary in public interest. The precise nature of information able to be disclosed in the interest of the public is not well defined, however one would require strong reasons to disclose. • In the event of serious criminal activity - Under the NSW crims act there is an obligation for people who have information about a serious offence to notify the police. A serious criminal offence is an offence which attracts a penalty of five years imprisonment or more. 4'5
,
{
{{{ 5 1 : { : } .....: ) :
® 60
With an understanding of the principles and domain of the laws pertaining to patient confidentiality one can now look at how this impacts on emergency nursing practice. For nurses working in emergency departments the considerations to their patients' confidentiality occurs on numerous occasions every day. It is imperative that emergency nurses have a good understanding of the confidentiality laws and how to apply them as they are often exposed to information of a highly sensitive nature and are exposed to events which often draw attention from the wider community. The following is a list of circumstances where emergency nurses may need to consider their patient's confidentiality and how to apply the law to these circumstances:• Patient enquiries - In general no information should be released without the consent of the patient. If consent is granted information should be given in general terms only. Information regarding diagnosis, treatment or prognosis should be withheld, and a general statement about the condition of the patient should only be given, for example, Satisfactory, Stable, Serious, or Critical. When enquiries are being made about the whereabouts of patients already admitted to wards the information given should in no way reflect the specialty of the ward. The ward should be described by its name, letter or number eg. Ward A, Level 2, East etc. 6 • Patient requests no information to be released Where a patient requires that no information be released to patients wishes should be respected and their name should not appear on any patient list held at enquiry desks. 5
•
•
•
•
Information requests by police officers - Numerous occasions arise with police seeking information on patients and clients. In the majority of cases it is not for the purpose of laying charges against the patient. Generally the information sought is used in writing reports (say following a motor vehicle collision) occasionally the information sought may be used to determine charges to be brought against another person. The information should be released by a responsible medical officer or senior health professional (Nurse in charge) when they are satisfied that the information is required in the execution of police duty. The information given should consist of a general outline of the patient's condition and injuries, confirmation of the patient's identity and the patient's address. 6 Police interviews of patients - Except in the case of declarations from dying patients, permission to interview a patient should only be given when the patient's medical condition permitsJ Nurses should also remember their duty to disclose information regarding issues of public safety and information relating to serious crime, as discussed previously. Information request by the media - The pure nature of emergency nursing means that we are often exposed to incidents which attract both public and media attention. When a request is made for information from the media nurses should follow their hospital's protocol on regarding such requests. Generally information given to the media is done via the hospital's designated media liaison. However to release information in accordance with the law the following recommendations should be followed. Firstly no information should be given without the consent of the patient. If the patient is not conscious consent must be obtained from his/her next of kin. Information released about victims or incidents should be limited to the number of casualties, sex, appropriate age and whether injuries are critical, serious or minor. 5 Patients Notes - As patients notes (nursing notes in the form of flow sheets or clipboards) are generally kept at the end of the patient's bed this can often present some difficulty in maintaining the patient's confidentiality. Generally information regarding the patient's diagnosis and past medical history are not recorded on these notes, however presenting problem is often recorded. These notes are often visible and accessible to visitors and other unauthorised persons. Recommendations require that unattended documents containing personal information should not be visible to unauthorised people, therefore the information contained in these notes should not contain personal or sensitive information. Furthermore the current practice of leaving notes at the patient's bedside should be reviewed in accordance with the confidentiality laws and recommendations2
•
Visibility of Computer Screens - With the introduction of patient tracking computer systems into emergency departments confidential information is now stored within these systems. To protect confidential information is now stored within these systems.To protect confidential information computer terminals should be placed so that they cannot be seen by others other than the staff member entering the information. If left unattended no information should be left on the screen. The use of screen savers should be used wherever possible to reduce the chance of casual observation? • Casual conversations - It is essential for he health care professional to maintain the confidentiality of their patients during conversations with other health care professionals. Disclosure of information to other health care professionals is only permitted by law when it is directly related to the patient's care. These conversations should not occur in public places such as lifts, corridors or dining rooms. It is the responsibility of all health care professionals to discuss patient inforraation in areas where it is not likely to be overheard. 5 • Training and Education - The anonymity of patients should be maintained during case presentations, research activities, at seminars and conferences. The use of photographs, slides and other visual aids which allow identification of individuals must be done so with the expressed consent of the patient, s • Reception Desk - Often the reception desk is crowded and close to those patients in the waiting area offering no privacy to patients wishing to disclose the nature of their presentation. To maintain confidentiality of patients presenting to the reception desk one may consider introducing a queuing system with rope cordons which only allows one person to be present at the counter at any one time. Consideration should also be given to the installation of a television in the waiting area. The noise produced from the television should be kept at a level so that conversations at the reception desk cannot be overheard by those people in the waiting area. A private triage assessment area should be used so that the patients may disclose information regarding their presentation in private and a physical assessment can be attended to by the triage nurse.1 • Physical Environment - Often the mere design of emergency departments do not consider the confidentiality of patients. The use of curtains to screen off bed spaces do not protect information disclosed during conversations regarding medical history and other conversations of a potentially sensitive nature. Health care professionals working in emergency departments must remain aware that curtains are not soundproof and when conversations with patients are likely to be of a private nature
•
consideration must be given to conducting those conversations in an environment which is able to maintain the confidentiality of the patient. 1 Telephones - Consideration to the placement of telephones within the emergency departments should be made so that they are not within earshot of the general public.
Furthermore, conversations regarding patients which take place via the telephone should be done in a private area which will ensure the confidentiality of the information discussed. 1
CONCLUSION What has been described outlines the legal principles which should be maintained when dealing with patients and the confidential information which nurses are privileged to in their day to day work. These principles must underpin all critical decisions made regarding patient's confidentiality and the disclosure of such information. This will ensure that no legal or professional misconduct proceedings will be brought against any emergency nurse for a breach of patient confidentiality.
EDITORIALCOMMENT The right to privacy is inherent in any democracy. Central to this is the duty of maintaining confidentiality as outlined in this paper. How easy it is for us to forget this important aspect of patient care. How many times have we all been guilty of openly discussing patients around the desk, over coffee or in the corridors. It is always important to try and ask yourself if you would be happy to have this sort of information disclosed about yourself! The author highlights areas for improvement in ED's but how about the calling out of peoples names over the PA when it is their turn to be seen, should not we perhaps consider some sort of numbering system rather than a gross breach of privacy by announcing to the whole waiting room the name of the next patient to be seen! Something to think about perhaps.
REFERENCES 1.
Mortlock, t I994 "Maintaining Confidentiality in A&E" Nursing Times. Vo190. No34 pp 42.43.
2.
Edginton, J., 1995 Law for the Nursing Profession and Allied Health Care Professionals (3rd Ed) North Ryde: CCH Australia
3.
Dix. A. Errington, M. Nicholson, K. and Powe, R, 1988 Law for the Medical Profession Sydney: Butterworths.
4.
McFarlane, EJ.M. 1993 Health Law: Commentary and Materials. Leichhardt: The Federation Press.
5.
NSW Health Department., 1996 Information Privacy: Code of Practice. Sydney: Government Printers.
6.
Staunton, EJ. and Whyburn, B., I989 "Nursing and the Law". (2nd Ed). Sydney: W.B. Saunders.
61