Throughout my placement, I have to observe and learn from my mentor as I worked alongside her. This assignment centred on a particular experience during one of my shifts. In accordance with the NMC (2008) The code, Standard of conducts, performance and ethics for nurses and midwifes, confidentiality shall be maintained and all names have been changed to protect identity. I called him Ted, a 75 old man; he was admitted for total hip replacement. I was involved in his pre-admission and post operative care. I learnt about his medical history and his social background and treatment, I needed to have an understanding of all the relevant information about his care. I was also with him when the theatre staff came and collected him from the ward. During this time when the nurse came down and did his pre-operative check something concerned me about the way the nurse undertook the check. Although it was thorough I felt that she was not discreet enough and I was concerned that she could be overheard by the next patient. However, I did not say anything and thought that probably it was the way it always done until now when I was reflecting what happened.
Towards the end of a shift, as expected, a handover had to take place from the morning to afternoon shift. As what happened previously, I was waiting for my mentor to start the handover in respect of Ted. Without prior notice, my mentor informed me that she wished me to give the handover by the bedside. I was quite nervous but as I have mentioned earlier, I felt that I had to do it no matter how I felt. She also said that she was happy that I had enough time to learn about Ted’s medical condition and she believed that I could do the handover. I didn’t argue, but the truth was I did not want to do the handover because I knew I was not ready. However, I felt I had no other option but to do it.
I was so nervous and I was unaware of the patient’s surroundings. I failed to take into account that we were doing handover in a place where I could be overheard by other patients and visitors in the next bed to Ted’s. My action might have put patient confidentiality at risk. McMahon (1990) and Johns (1989) have documented concerns over possible confidentiality breaches while handing over care at the bedside. Ward 1988 excuses the fear of confidentiality by pointing out that doctors have been known to discuss patients in the middle of the ward for all to hear. While the NMC (2008) guidance on confidentiality and accountability must also be considered, the need for patient’s consent to discuss their information in an open ward may result in some patients being included in hand over and others not. Ward 1988 argues that patients can see some of nursing care being carried out and that they discuss this among themselves. Ward also argues that handover is for discussing nursing care and diagnosis. Nursing care, however, should be treated as confidentially as diagnosis, as this is personal to each individual patient.
Upon reflection, I realised that trust is at the heart of the nurse/patient relationship. Implicit within the duty of care owed to the patient is the duty to recognise the right of the patient to have personal information relating to him/her confidential. Although, taking this to the extreme, my patient, Ted could have easily seen what I did, albeit unintentionally, as a breach of his confidentiality. This could have had a negative impact on my conduct as a nurse. This was an experience that made me think deeper about my responsibility regarding patient confidentiality.
Confidentiality is a duty ingrained within the NMC (2008) The code –Standard of conduct, performance and ethics and it is also ingrained within NHS contract of employment of nurses. The Trust where I was allocated for my first placement has a Confidentiality and Disclosure of Personal Information Protocol which I found very helpful. The protocol states that “The processing and disclosing (sharing) of personal identifiable information about patients and staff within the trust is fundamental to the care and well being of patients. Regarding sharing of information with other professionals, the trust’s protocol also states, Information relating to a patient maybe shared with other professionals concerned with patient’s care and treatment. These professionals must abide by the rule of confidentiality.” The Trust protocol l, the NMC code (2008), and the Data Protection Act 1998 had emphasised to me the significance of protecting patient’s information. Protecting patients’ confidentiality is my duty and responsibility as a nurse, professionally, legally and contractually.
Further reflection allowed me to identify other areas of concern regarding lack of confidentiality. This was in relation to the use of handover proforma. This was a sheet that was being used to jot down some relevant patient details during handover. Although the proforma was useful, I felt that it could be a potential risk to breach of confidentiality if it was left hanging around on the ward. It could be dropped accidentally, or could be left anywhere and be lost. It concerned me because should it fall on the wrong hands, patient confidentiality could be breached. However, I found that the use of the proforma was very useful as it help the nurses to remember name of the patients, nursing care given and treatments needed, etc. I have discussed my concern with my mentor and I suggested that the proforma must be shredded at the end of the shift. More importantly, nurses must ensure that they write only the minimum of identifiable information on the sheet and where possible anonymise information written on it. The principles of data protection Act 1998, B. Diamond (1998) emphasised that personal data processed for any purpose or purposes shall not be kept longer than is necessary for that purpose.
As a nursing student and an independent practitioner I must consider my actions carefully. It is upon reflection that I realised that during my initial handover I might have breached patient confidentiality. I felt that I might have done this by giving my handover at the patient's bedside without adequate regard to assessing the risk of being overheard. On reflection, I could not remember how loud my voice during the handover was – all I knew I was trembling and I was petrified! I was overwhelmed with ‘nerves’, I was not thinking clear. The NMC (2008) The Code- Standard of conduct, performance and ethics (2008) clearly states that as a nurse you must protect confidential information. Special training is needed to ensure that practice is consistent with policy in any authorized disclosures of personal health information because the risk of a breach is particularly great when information changes hands.
The handover has traditionally taken place in an office where patients do not have the opportunity to overhear what is being said. It is only in recent years that nurses have begun the practice of handing over care at the patient's bedside (Greaves 1999). The current practice has changed from the type of round where the purpose was purely to check standards of care overnight, to today's efforts to involve patients more. This shift in emphasis is a move forward in changing traditional nursing practices and has accompanied efforts by nurses to individualise patient care (Johns 1989). However Webster (1999) wrote that the bedside handover results in better nurse-patient communication and a sense of partnership. On the other hand Smith (1986) suggests that the correct location is somewhere private, away from patients and without distractions.
As a student I would somehow grow in confidence. I would like more practice doing handover in private in the office. Eventually when my confidence is stronger, I would like to gradually venture to the bedside where the patient will be personally involved. I understand that nursing is dynamic and it will continue to change to meet changing demands, for example, to facilitate better patient communication. I have to learn to accept change and to look at the positive effects of change like the practice of handover from office to bedside. I need to understand change and the risks that go with it whilst mindful of my duty to protect patient information and confidentiality at all times. I will continue to use clinical supervision to discuss anything that I felt might affect patient confidentiality. I will continue to be vigilant and assess risks to ensure that I plan my nursing activities
Everyone who becomes a patient is vulnerable to public exposure, as details about his/her personal life, treatment or care are passed around. However how abstract it may appear, patient’s medical history forms a part of who they are. Their ‘story’ belongs to them. To ignore or minimise the precious nature of the person's ‘story’ is to imperil them; exposing the person to anxieties and insecurities of which we may know little, and understand even less. Patient’s medical history belongs to him/her and should be treated with utmost safeguards, respect and confidentiality.
I would still use the proforma because I have found it useful. However, I will anonymise as much as possible information that I write on it. At the end of the shift, I will shred the proforma that I wrote on and discard it safely to ensure that I protect patient confidentiality.
According to Grey et al (2000), the delivery of hand over is the key to the overall delivery of high quality nursing care. I believe that this particular nursing action should always have ‘patient confidentiality’ at the heart of the process.
I have gained a lot of experience from my first placement and have reflected on these and my nursing actions. I have developed professionally and personally as nurse and I have a better understanding of patient confidentiality.
References:
Atkins, S. and Murphy, K. (1994) Reflective Practice. Nursing Standard 8(39) 49-56.
Burns, S. and Bulman, C. (2000) Reflective Book in Nursing, The Growth of the Professional Practitioner, MPG Books Ltd. Bodmin Cornwall.
Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford Brookes University, Oxford.
Jasper M 2006 Professional Development, Reflection and decision-making
Blackwell Publishing Ltd, Oxford
Myers J; ; ; American Journal of Public Health (AM J PUBLIC HEALTH), 2008 May; 98(5): 793-801 Ethics in public health research: privacy and public health at risk: public health confidentiality in the digital age.
Webster: Practitioner centred research: an evaluation of the implementation of bedside handover. J Adv nursing, 1999.
Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives.
