Nurses are often confronted by various ethical challenges or dilemma situations during their professional practice. It is therefore important that they be familiar with the ethical codes of conduct and decision-making. As one of the most trusted professions, the nursing ethical codes of conduct were first adopted by the International Council of Nurses in 1953. The codes guide nurses in decision-making whenever they face barriers in executing their professional obligations. One of the difficult situations in which these codes help nurses to navigate through is in maintaining patients’ privacy and confidentiality. This is particularly true for student nurses who train in hospital settings (Matlakala & Mokoena, 2011). The need to ensure confidentiality of patient information is recognized as important in almost all cultures, which is evident in the development of the nursing fraternity world over. In Iran where studies have shown a weakness of nurses with regard to ethical conduct, a task force was formed to compile a set of national nursing ethics code in 2009, which emphasized on nurse conduct particularly the need to maintain confidentiality of patient information (Zahedi et al., 2013).
While nurses have a moral obligation to keep patient information confidential, they often have to involve the patient’s family in the treatment. Nurses could be uncertain about the kind and level of information that can be passed on to family members. Moral conflict begins in cases of HIV/AIDS or terminal illnesses like cancer. Nurses, particularly student nurses might perceive that sharing information about the patient with his or her family is not unethical, as they consider the family as being central to patient welfare. However upon admission to the hospital and the individual becomes a full patient, the medical condition and treatment of the individual become clearer (Matlakala & Mokoena, 2011). The information might be needed to be kept confidential from the family who had brought the patient. Maintaining confidentiality and ensuring privacy of patients has been an obligation of nurses for a longtime. However what type of information and how much information about the patient could be shared and with whom, has been too difficult to determine. Access to information has been determined to be a primary requirement for satisfaction among the patients and their families with regard to intensive care (Mc Cullough & Schell-Chaple, 2013). Confidentiality in medicine involves balancing the protection of confidential information while also soliciting appropriate disclosures. Sharing patient information is necessary for collaboration among the treating physicians, and for better treatment outcomes. However when privacy and confidentiality in medicine are not handled with thought and discretion, the ethical standards are not only compromised, they also create undesired outcomes for both patients and the treating fraternity (Petronio, DiCorcia, & Duggan, 2012).
The communication privacy management (CPM) model suggests that handling privacy and confidentiality involves balancing autonomy and connectedness. The CPM emphasizes that healthcare providers have two privacy boundaries in their relationship with their patients. One is the boundary with regard to their personal opinion or judgments on situations, based on which they make disclosures to the patient. Nurses, like the physicians and are also co-owners of patient’s health information and are within the privacy boundary of the patient. Despite this they need to decide what and how much of information they would share with the patient at a particular treatment stage (Petronio, DiCorcia, & Duggan, 2012). Nurses are trained to keep their feelings under control and within their privacy boundary. They must be able to clearly demarcate what is personal and what is professional to effectively serve the role of a confidant for the patient.
The difficulty in handling patient information became more complicated with the introduction of the Health Insurance Portability and Accountability Act (HIPAA) in 2002. The rules dictated the sharing and accessing of the medical records of a patient and included penalties like fines and reduced job security for the violators. There were soon several situations where diligent thought and action was needed on the part of the nurses. Some of the more tough-to-decide situations include a patient’s friend who is also a nurse, seeks specific answers for medications and treatment plans. Sometimes patient’s relatives might want to know test results over phone too. To tackle such situations, the intensive care unit at the University of California Medical Center, San Francisco came up with a novel idea. The idea involved the use of a code word by the patient permitting the sharing of his or her health information (Mc Cullough & Schell-Chaple, 2013). Here the nurse reviews a code word usage with the patient or the patient’s relative mentioned in the consent form. When information on the patient is requested by anyone either in person or through phone, the nurse requests the code word. When the requesting person is unable to say the code word, then the nurse responds saying that they cannot share any information due to privacy and confidentiality reasons. The pilot program was so successful that the code word program was expanded to the entire hospital.
Technology development and implementation is fundamental in every sphere of life. Mobile communication devices (MCD) have radically transformed the way nurses communicate. Traditionally nurses had to walk about from place to place for assistance or had to contact the unit clerk. MCDs provide nurses with hands-free communication, facilitating instant connection with various other healthcare providers. Several studies have evaluated the effectiveness of communications technology on nursing workflow. MCDs have been determined to also have negative effects on nursing, particularly with regard to privacy and confidentiality (Dumphy et al., 2011). The information communicated can be heard by anyone in the vicinity, given the built-in speaker used in the MCD. Nurses were also apprehensive as to what can be shared without sender being aware of the location and personal at the receiver. Despite improving communication efficiency and reducing work stress, nurses were concerned with breaches in patient confidentiality. Introduction of technology in nursing must be compatible to patient confidentiality and privacy and must be accompanied by guidelines for appropriate use.
Social media and such other electronic communication are being increasingly used today. There are an increasing number of social media outlets and applications including video sites, online chat, blogs, and social network sites. Social media plays a very important role in strengthening professional relationship and addressing consumer concerns and nursing is no exception. Nurses share their workplace experiences using these blogs and forums which serve as venues for expression of their feelings or to seek support from peers, colleagues or anyone using the internet. When nurses use social media inappropriately, they cause immense concern for employers and educators. Such improper use of social media could at times even be a violation of state or federal laws governing patient rights, and subject the violators to criminal proceedings and imprisonment. Given the implications, nursing organizations have already begun implementing guidelines for fair use of social media. The American Nurses Association has also incorporate fair use of social media in its code of ethics (Cronquist & Spector, 2011). The National Council of State Boards of Nursing (NSCBN) conducted a survey in 2010 to determine inappropriate use of social media. About 33 of the 46 respondent boards said that they received complaints about nurses posting photos or patient information in violation of patient’s privacy, forcing them to take disciplinary actions. The board of nursing (BON) investigated inappropriate conduct by nurses under the following grounds (Cronquist & Spector, 2011):
Unethical conduct
Moral turpitude
Mismanagement of patient records
Breach of confidentiality
Unprofessional conduct
The legal consequences of inappropriate conduct by nurses vary between jurisdictions. When investigations confirm the allegations, the offending nurses face disciplinary action like a reprimand, fine, temporary or permanent forfeiture of license. To realize the appropriate use of social media, we must know the relevance of confidentiality and privacy in the context of healthcare. Among the important guidelines formulated by NCSBN to minimize social media risks by nurses are:
Nurses are not allowed to post any information or pictures that can violate patients’ right to confidentiality or could embarrass the patient.
Nurses are prohibited from posting or sharing any patient related information gained during the course of their nurse-patient relationship, unless there is a legal obligation to do so.
Nurses must consult their leaders or employer policies for advice on work-related postings. They must also report any breach of confidentiality they witness.
Nurses need to be sensitized to the implications of revealing patient information through social media. But by being aware and careful, they can enjoy the benefits of social media without any violation.
Social media is just one possible way of compromising the privacy and confidentiality of a patient’s health condition. Maintaining confidentiality and the privacy of the patients is at times challenging for the nurses, particularly student nurses. This may be attributed to the fact that information about patients is shared in several ways in the hospital care settings including record keeping of patient’s progress, taking over of nursing rounds, reporting doctor orders, and referring to other departments. At most occasions International Classification of Diseases (ICD) coding is used to identify patient diagnosis while also maintaining the privacy of the information (Matlakala & Mokoena, 2011). The coding serves as a standard diagnostic tool to classify diseases and other health conditions on health records. These are used by several groups including physicians, nurses, health information managers, policy makers and patient organizations.
The role of nurses is crucial in the treatment of any patient, and they are obviously within the privacy boundaries of the patient. Nurses are fully aware of patient’s privacy and their health information confidentiality. However, in executing their role in the treatment of the patient, they have several opportunities and uncertain situations where they could breach the professional expectations from them. The introduction of technology though brings about immense positive changes, must also ensure that they don’t compromise the interests of the patient. Although ethical codes and law serve as guidelines, nurses must take judgment-based decisions to uphold patient interests, while also being in line with law and morality.
References
Cronquist, R. & Spector, N. (2011). Nurses and social media: Regulatory concerns and guidelines. Journal of Nursing Regulation, 2(3), 37-40.
Dumphy, H., Hinlay, J.L., Lemaire, J., MacNaim, I., Wallace, J.E. (2011) Hands-free communication technology: A benefit for nursing?. The Journal of Nursing Administration, 41(9), 365-368.
Matlakala, M.C & Mokoena, J. D. (2011). Student nurses views regarding disclosure of patients’ confidential information. South African Family Practice, 53(5), 481-487.
Mc Cullough, J. & Schell-Chaple, H. (2013). Maintaining patient’s privacy and confidentiality with family communications in the intensive care unit. Critical Care Nurse, 33(5), 77-79
Petronio, S., DiCorcia, M.J., & Duggan, A. (2012). Navigating ethics of physician-patient confidentiality: A communication privacy management analysis. The Permanente Journal, 16(4), 41-45.
Zahedi, F., Sanjari, M., Aala, M., Peymani, M., Aramesh, K., Parsapour, A., Bagher Maddah, S.S. et al. (2013). The code of ethics for nurses. Iranian Journal of Public Health, 42(1), 1-8.
