Confidentiality is a virtue which is more often than not, taken for granted, among the health care professionals. From their apprenticeship days as students, confidentiality was often touted as one of the most important values of the nursing profession. Most nursing councils further reinforces its importance, with various codes of ethics and professional conduct. It is little wonder, that confidentiality is a culture which is deeply rooted in the nursing profession.
The American Heritage Stedman’s Medical Dictionary defines ‘Confidentiality’ as, the ethical principle or legal right that a physician or other health professional will hold secret all information relating to a patient, unless the patient gives consent permitting disclosure (The American Heritage Stedman’s Medical Dictionary, n.d.).
With this article, the author wishes to explore ‘Confidentiality’ in a multi-perspective fashion; this will include the discussion of the legal obligations of nurses in observing their duty of confidentiality, and also exploration of arguments which endorses the professional divulgence of confidential information under exceptional circumstances.
Importance of Confidentiality
As mentioned by Peate (2009), any information relating to the physical or mental health or condition of a patient, should be deemed confidential; this would apply to records that are manual, electronic or both.
Dimond (2008, p. 784) highlighted that, all healthcare personals, from administrator to clinician, have a duty to protect confidentiality. Much less to say, the nurses.
Patient confidentiality has been, and still is, one of the cornerstones of nursing. It is essential in the preservation of a patient’s dignity, and nurses are obliged to comply, as they owe their patients a duty of confidence, and it is also a key factor in maintaining an efficacious Therapeutic Nurse-Patient Relationship. Clause 4 of Value Statement 7, of the ANMC, code of ethics for nurses, clearly states that nurses should comply with and observe measures which safeguard the confidentiality rights of the patients. While Clause 1 of Value Statement 3, of the SNB, Code of Ethics and Professional Conduct, supports this, by stating that nurses should safeguard the confidentiality of all client-related information.
Unjustifiable Breaching of Confidentiality
Despite a strong awareness of the importance of patient confidentiality, nurses are known to breach patient confidentiality conveniently, over hospital elevator and tea room talks. This poses another area of concern, in nurses whom assumes such nonchalance towards issues and topics, which patients themselves may deem to be of preeminent privacy and sensitivity.
Communication of patient’s information within the professional healthcare team should be deemed as legally permissible. However, nurses should exercise caution with regards to inappropriate sharing of patient information which is not related to the patient’s care (Cornock, 2009). Inappropriate sharing of patient information should in no way, be permitted. As emphasized by BMA (2008), patient confidentiality should continue to be observed, even after a patient has passed on.
In the face of an increasingly cultural-diversed society, nurses may have to anticipate language differences, when communicating with their patients. In the event of a language difference, the nurse should also pay particular attention when employing the assistance of an interpreter. Consent must be obtained from the patient, prior to enlisting the assistance of an interpreter, as a direct breach of confidentiality could result, if an informal interpreter was to be used without proper consent (Carnevale et al., 2009).
When Breaching of Confidentiality is inevitable
In 1985, binded by the Infectious Diseases Act, the notification of HIV infections was made compulsory in Singapore, by the Ministry of Health (Thulaja, 2003).
Hence, a nurse should dutifully report to the appropriate bodies, upon the discovery of an HIV-infected patient. Failure to comply may result in legal implications, as well as disciplinary consequences from the relevant nursing councils.
This is supported by Clause 2 of Value Statement 3, of the SNB, Code of Ethics and Professional Conduct, which states to disclose confidential information only as authorized by the client, unless there is risk of harm to the client or other persons, or when there is a legal obligation to disclose the information.
The nurse should also assess the situation for the most appropriate intervention. Does the confidentiality of the patient outweigh the safety and welfare of the other patients, the rest of the healthcare team, or even the society? Clause 3 of Value Statement 5, of the same code, states to alert the appropriate authority of any situations which may endanger the health or safety of clients or colleagues.
In Singapore, particularly, in accordance to the Infectious Diseases Act, it is also an offence for an HIV-infected individual to engage in any activity which may cause the infection to spread (Thulaja, 2003). Therefore, it is also in the patient’s best interest, that nurses make the necessary notifications.
Divulging, in the patient’s interest
Nurses, though often regarded as being intellectually inferior to the other members of the healthcare team (Barker, 1997), and also often associated with mundane tasks which does not require much analytical work. The author feels that there is a need for all nurses, to be critical thinkers, in order to advocate in the best interests of the patients under their care. There are instances when patients may be overtly emotional or afflicted to make a sound decision. And nurses are in the best position to advocate, as they are the healthcare workers whom often possess more rapport with patients than the rest of the healthcare team. After all, it is often said, that nurses are the healthcare workers whom knows the patients the best. The author believes that few would object to that saying.
In 2007, a report was done on a fifteen year old girl whom had committed suicide, some three weeks after having confided in a nurse about the fact that she was being raped, the nurse had pledged confidentiality to this sharing of information, and had failed to brought the matter to the attention of the relevant local jurisdiction (Doherty, 2007).
A bold argument by John Wilson (1956), ‘all tragedy is the failure of communication’, entices the importance of proper communication; and in this case, a tragedy could have been prevented, if proper communication of crucial information had taken place.
No doubt issues pertaining to confidentiality can often be complex and in some instances, perplexing (McHale, 2009). The author feels that, as our patients’ advocators, nurses should assess a given situation with professional judgment and act in the best interest of their patients.
Clause 3 of Value Statement 7, of the SNB, Code of Ethics and Professional Conduct, states to defend those clients who may be vulnerable and incapable of protecting their own interests.
Identifying and reporting ill practices
A long-standing problem, in nursing particularly, with regards to patient confidentiality, could well be the breaching of confidentiality over casual ‘small talks’; be it hospital elevator talks, or tea room talks.
Statement 1.1 of the ANMC, national competency standards for the registered nurse, clearly affirms that a prudent nurse, not only handles their patients’ confidentiality issues diligently, but should also be competent in identifying ill practices of their counterparts, which may result in breaches of any patient’s confidentiality.
The author, for one has strong feelings with regards to this matter, and feels that such unprofessional attitudes and behaviours should not be condoned. Besides compelling an intentional and direct breach of confidentiality and trust, such actions, may also effect an indirect damage to the image of nursing, which is just as irreversible as the damage done unto the affected patients.
Ironically, most nurses who feel obliged to raise issues and concerns about care standards, are not coming forward, and not speaking up. This is especially true, in the Asian context, where an invisible ‘closed’ culture is very much in place, and ‘whistle-blowing’ is almost a taboo.
As suggested by Scott (2009), nursing needs to adopt an open culture, one in which nurses whom possess legitimate grounds for complaints may speak out freely.
Conclusion (and implications to nursing practice)
In conclusion, the author feels that even though patient confidentiality is one of the key factors in the foundation of nursing; and no doubt it is a topic which is heavily implicated, legally. Nurses should assess each patient’s situation, as a unique case; and exercise confidentiality, only if it is to the benefit of their patients. They also should not hesitate to communicate valuable information to appropriate personnel or authorities, if it is deemed necessary, and if it is in the best interest of the patients. The author stands by this statement, which was pointed out by Griffith (2007), that nurses should not assume absolution in their duty of confidence.
Lastly, the author believes that, if exercised appropriately and with caution, there can be patient benefits, on both sides of the coin of confidentiality. Be it non-maleficence, by complying with the non-divulgence of confidential information; or beneficence, by divulging when it is deemed necessary. Therefore, it is somewhat incongruous to eradicate any one side of this coin. For as much as nurses should be aware of the existence and significance of the various codes of ethics and desirable conducts. It is, ultimately, the nurses whom are expected to assume full responsibility for their own actions, and be fully accountable for their mistakes. After all, the rules are dead. The nurses’ utmost concern, therefore, should be that of patients’ dignity and interests.