AWA: Academic Writing at Auckland

The ethical principle of confidentiality is central to the practice of any health care professional. Practitioners have a responsibility to ensure patient information is both respected and used in an appropriate manner. To explore both of these notions further, it is important to examine confidentiality in the New Zealand context. In addition, the importance of this principle in the health care setting and the actions health care professionals must take to maintain it are key points to consider. To properly explore the role of practitioners in maintaining confidentiality, examining the limits of the principle is key. Ultimately, as Winters (2013) suggests, the patient is at the heart of any ethical decision and their welfare should always be the primary consideration.

The current view of confidentiality in New Zealand is clearly defined by the New Zealand Nurses Organisation (NZNO) (2010) as keeping information obtained through privileged access private, whether it be spoken, written or observed. In this definition, the NZNO (2010) also recognizes that confidentiality is not absolute and can differ depending on the legal and contextual situation. There are two vital parts to the definition provided. Firstly, confidentiality usually involves information obtained through privilege. Beauchamp and Childress (2013) state that information given to health care professionals would generally not be given out in an everyday setting and is, often, highly personal. Because this information is being gathered due to a professional role, it is of utmost importance that it is kept confidential, as per the NZNO definition. Secondly, the NZNO (2010) definition highlights that confidential information may be gained not only verbally, but also visually and through written documents. This is a core aspect of confidentiality and where many breaches have arisen. It is important to note that all information gathered from a patient, whether it be through observation, a conversation, or a written chart, is equally sensitive (NZNO, 2010). These two notions are central to the principle of confidentiality.

The maintenance of patient confidentiality is of great importance in the clinical setting for a plethora of reasons. The responsibility of health care professionals to maintain confidentiality can be best examined through exploring the results of a breakdown in this principle. Snider and Hood (2001) argue that the principle of confidentiality closely links to the principle of autonomy and individuals have a right to control who has access to personal information about themselves. Because information provided is often of a sensitive nature, a patient’s perceived control over their information is central to the trust relationship between patient and health care provider. If a patient believes their information is unlikely to be disclosed unnecessarily, they may be more willing to provide details to assist in their care. Snider and Hood (2001) allude to the common situation of health professionals discussing patient cases in hospital elevators. Patients disclose information to a practitioner on the basis that this information will be used only to benefit them. If a patient were to find out they were the victim of a confidentiality breach, it is likely they would be less willing to share crucial information with their health practitioner in the future (Allmark, 2008). This implicates the ability of the health care team to care for the patient. If information cannot be freely shared, a patient’s treatment is significantly more difficult to manage. Because a breach of patient confidentiality can, therefore, significantly affect patient care, it is the duty and responsibility of every health care professional to maintain this ethical principle to the highest possible standard (Clark, 2012).

This same concept can be illustrated on a larger scale. If an HIV positive patient refuses to tell his or her partner of their infection, an ethical dilemma exists. Should the confidential relationship be broken or should the health of the patients’ partner be allowed to be compromised? It has been suggested, that if it was common practice to break the confidentiality agreement in these circumstances, less people would agree to HIV testing for the fear of the information being reported to their partner, thereby creating a public health issue (Allmark, 2008). Although this situation is an ethical dilemma on its own and the partner’s beneficence could be argued for, it does also show the importance of maintaining confidentiality, this time, on a larger scale, for the sake of greater public health and encouraging people to be tested for diseases such as HIV/AIDS, rather than deterring them. Because the results of breaching confidentiality can affect patient safety, the health care professional has a clear responsibility to maintain this principle.

Many laws, codes and professional conduct guides in New Zealand recognise the importance of confidentiality. The first domain in the Nursing Council of New Zealand’s Competencies for Registered Nurses (2012) states that professionals must be responsible and create an environment that, ‘maximises health consumers’ safety, independence, quality of life and health’ (p. 12). Without the maintenance of patient confidentiality, it is difficult to maintain patient safety and health, as has been already examined. Therefore, patient confidentiality plays a large role in meeting this domain. In addition to this, the same document highlights the need for nurses to understand ethical principles such as privacy (Nursing Council of New Zealand, 2012). Again, such a large emphasis is placed on confidentiality because of its necessity in maintaining patient safety. Confidentiality is also enshrined in the Health and Disability Commissioner’s Code of Health and Disability Services Consumers’ Rights (2009). As part of the right to be treated with respect, this document alludes specifically to the consumer’s right to have his or her privacy respected. The Health Information Privacy Code (2008) also specifically states that the principle of confidentiality must be considered when collecting, storing, retaining or using health information. It is clear that there is a large emphasis on the principles of privacy and confidentiality in New Zealand law, largely to ensure patient safety is looked after.

The NZNO Code of Ethics (2010) carefully examines the actions health care professionals must take to ensure client confidentiality is maintained. The nurse must not only protect their client from unwanted intrusion into their physical, emotional and social rights but also ensure confidentiality is maintained in an organisational and societal setting (NZNO, 2010). It is the role and responsibility of the health care professional to ensure systems that are processing large amounts of client information do not breach standards of confidentiality (NZNO, 2010) For example, Saddan (2001) discusses how patient charts are often left scattered around a ward after patient rounds have been completed. Because of this, a large amount of information is left freely accessible to visitors and the general public. This could be classed as a confidentiality breach as due measures are not taken to keep client information out of the public eye. The NZNO Code of Ethics (2010) states that professionals have a duty to be alert to organisational systems that may breach confidentiality and it is a nurses’ role to challenge these systems, as in this case. This role of the healthcare professional is becoming increasingly important with the rise of large amounts of electronic patient data, available to many people at the click of a button (Grace, 2004). If there is concern of a breach of patient privacy as a result of this, it is the duty of the practitioner to critique the system (NZNO, 2010).  It is also important to note, confidentiality does not mean merely excluding a patient’s name from discussion. Vigod, Bell and Bohnen (2003) examine a situation where three professionals discussed a patient’s state in an elevator, without using names. A member of the public was able to identify the patient, based off the medical information provided. This scenario clearly illustrates that it is unacceptable to discuss patient cases in a public setting, even without specifying names. A patient can be easily be identified from other information, and this too, is a breach of confidentiality. It is clear, health care practitioners must ensure they are constantly taking actions to maintain a high level of patient privacy.

Finally, the responsibility of the health care professional in maintaining patient privacy often conflicts with societies need for information (Saddan, 2001). Saddan (2001) claims Israeli health professionals were placed in a difficult ethical situation when asked to disclose all patients with conditions that may affect their driving to the Israeli Ministry of Health. Duncan, Williams and Knowles (2012) state that when a practitioner is asked to break patient confidentiality, the harm to the patient and the potential results of breaking the confidentiality agreement must be weighed against an immediate and specified risk of harm to either the patient or society. In some instances, such as the Tsaroff case, where a patient told his psychiatrist he intended on killing his girlfriend, the risk to society outweighs the harm of breaking confidentiality and it is the practitioner’s responsibility to alert the appropriate authorities (Cochran, 1999). In the Israeli Ministry of Health case, the threat to society does not seem as imminent or severe, and it would be outside of the health care professional’s role to disclose such sensitive information.

To conclude, it is clear all health care professionals have a role and responsibility in protecting patient information. This can be examined through the effects of confidentiality breaking down, and the effect this has on patient safety. In addition, health care professionals must ensure they take actions, such as actively analysing the use of information and taking care not to discuss patient cases, to maintain patient privacy. Confidentiality is, indeed, central to the practice of any health care professional.

References

Allmark, P. (2008). HIV and the boundaries of confidentiality. Journal of Advanced Nursing, 21(1), 158-163. DOI: 10.1046/j.1365-2648.1995.21010158.x

Beauchamp, T.L., & Childress, J.F. (2013). Principles of biomedical ethics (7^th ed.). New York: Oxford University Press.

Clark, J. R. (2012). The smoking gun: Patient confidentiality. Air Medical Journal, 31(1), 13-15. http://dx.doi.org.ezproxy.auckland.ac.nz/10.1016/j.amj.2011.10.007

Cochran, M. (1999). The real meaning of patient-nurse confidentiality. Critical Care Nursing Quarterly, 22(1), 42-51. Retrieved from http://www.ovidsp.tx.ovid.com

Duncan, R.E., Williams, B.J., & Knowles, A. (2012). Adolescents, risk behaviour and confidentiality: When would Australian psychologists breach confidentiality to disclose information to parents? Australian Psychologist, 48(6), 408-419. DOI: 10.1111/ap.12002

Grace, P. J. (2004). Patient safety and the limits of confidentiality: Do you know when you shouldn’t keep patient information confidential? American Journal of Nursing, 104(11), 33-37.  Retrieved from http://www.jstor.org.ezproxy.auckland.ac.nz/stable/29746192

Health and Disability Commissioner. (2009). Code of health and disability services consumers’ rights. Retrieved from http://www.hdc.org.nz/media/24833/leaflet%20code%20of%20rights.pdf

New Zealand Nurses’ Organisation. (2010). Code of ethics. Retrieved from http://www.nzno.org.nz/Portals/0/publications/Code%20of%20Ethics%202010.pdf

Nursing Council of New Zealand. (2012). Competencies for registered nurses. Retrieved from http://nursingcouncil.org.nz/Nurses/Scopes-of-practice/Registered-nurse

Privacy Commissioner. (2008). Health information privacy code. Retrieved from http://privacy.org.nz/the-privacy-act-and-codes/codes-of-practice/health-information-privacy-code/

Sadan, B. (2001). Patient data confidentiality and patient rights. International Journal of Medical Informatics, 62(1), 41-49. http://dx.doi.org.ezproxy.auckland.ac.nz/10.1016/S1386-5056(00)00135-0

Snider, J.M., & Hood, K.M. (2001). Confidentiality: Keeping secrets. Journal of Professional Nursing, 17(5), 213-214. http://dx.doi.org.ezproxy.auckland.ac.nz/10.1053/jpnu.2001.26302

Vigod, S.N., Bell, C.M., & Bohnen, J.M.A. (2003). Privacy of patients’ information in hospital lifts: Observational study. British Medical Journal, 327(7422), 1024-1025. http://dx.doi.org.ezproxy.auckland.ac.nz/10.1136/bmj.327.7422.1024

Winters, N. (2013). Whether to break confidentiality: An ethical dilemma. Journal of Emergency Nursing, 39(3), 233-235. http://dx.doi.org.ezproxy.auckland.ac.nz/10.1016/j.jen.2012.03.003