Confidentiality in all of health care is important but notably so in psychiatry because of possible discriminatory treatment of those with mental illness. All individuals have a right to privacy, and all client records and communications should be kept confidential.
Dos and Don'ts of Confidentiality
- Do not discuss clients by using their actual names or any identifier that could be linked to a particular client (e.g., name/date of birth on an x-ray/assessment form).
- Do not discuss client particulars outside of a private, professional environment. Do not discuss with family members or friends.
- Be particularly careful in elevators of hospitals or community centers. You never know who might be on the elevator with you.
- Even in educational presentations, protect client identity by changing names (John Doe) and obtaining all (informed consent) permissions.
- Every client has the right to confidential and respectful treatment.
- Accurate, objective record keeping is important, and documentation is significant legally in demonstrating what was actually done for client care. If not documented, treatments are not considered done.
When Confidentiality Must Be Breached
- Confidentiality and Child Abuse – If it is suspected or clear that a child is being abused or in danger of abuse (physical/sexual/emotional) or neglect, the health professional must report such abuse as mandated by the Child Abuse Prevention Treatment Act, originally enacted in 1974 (PL 93–247).
- Confidentiality and Elder Abuse – If suspected or clear that an elder is being abused or in danger of abuse or neglect, then the health professional must also report this abuse.
- Tarasoff Principle/Duty to Warn (Tarasoff v. Regents of the University of California 1976) – Refers to the responsibility of a therapist, health professional, or nurse to warn a potential victim of imminent danger (a threat to harm person) and breach confidentiality. The person in danger and others (able to protect person) must be notified of the intended harm.
The Health Insurance Portability and Accountability Act (HIPAA) (1996)
Enacted on August 21, 1996, HIPAA was established with the goal of assuring that an individual’s health information is properly protected while allowing the flow of health information (US Department of Health and Human Services 2006; HIPAA 2006).
- Voluntary – An individual decides treatment is needed and admits himself/herself to a hospital, leaving of own volition – unless a professional (psychiatrist/other professional) decides that the person is a danger to himself/herself or others.
- Involuntary – Involuntary commitments include: 1) emergency commitments, including those unable to care for self (basic personal needs), and 2) involuntary outpatient commitment (IOC).
- Emergency – Involves imminent danger to self or others; has demonstrated a clear and present danger to self or others. Usually initiated by health professionals, authorities, and sometimes friends or family. Person is threatening to harm self or others. Or evidence that the person is unable to care for herself or himself (nourishment, personal, medical, safety) with reasonable probability that death will result within a month.
- 302 Emergency Involuntary Commitment – If a person is an immediate danger to self or others or is in danger due to a lack of ability to care for self, then an emergency psychiatric evaluation may be filed (section 302). This person must then be evaluated by a psychiatrist and released, or psychiatrist may uphold petition (patient admitted for up to 5 days) (Emergency commitments 2004; Christy et al 2010).
Restraints and Seclusion for an Adult — Behavioral Health Care
The Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) wants to reduce the use of behavioral restraints but has set forth guidelines for safety in the event they are used.
- In an emergency situation, restraints may be applied by an authorized and qualified staff member, but an order must be obtained from a Licensed Independent Practitioner (LIP) within 1 hour of initiation of restraints/seclusion.
- Following application of restraints, the following time frames must be adhered to for reevaluation/reordering:
- Within first hour, physician or LIP must evaluate the patient face to face, after initiation of restraint/seclusion, if hospital uses accreditation for Medicare-deemed status purposes. If not for deemed status, LIP performs face-to-face evaluation within 4 hours of initiation of restraint/seclusion.
- If adult is released prior to expiration of original order, LIP must perform a face-to-face evaluation within 24 hours of initiation of restraint/seclusion.
- LIP reorders restraint every 4 hours until adult is released from restraint/ seclusion. A qualified RN or other authorized staff person reevaluates individual and need to continue restraint/seclusion.
- LIP face-to-face evaluation every 8 hours until patient is released from restraint/seclusion.
- 4-hour RN or other qualified staff reassessment and 8-hour face-to-face evaluation repeated, as long as restraint/seclusion clinically necessary (JCAHO revised 2009).
- The American Psychiatric Nurses Association and International Society of Psychiatric-Mental Health Nurses are committed to the reduction of seclusion and restraint and have developed position statements, with a vision of eventually eliminating seclusion and restraint (APNA 2014; ISPN 1999).
- Learn your institutional policies on restraints and seclusion and take advantage of any training available, contacting supervisors/managers if any questions about protocols.
ALERT: The decision to initiate seclusion or restraint is made only after all other less restrictive, nonphysical methods have failed to resolve the behavioral emergency (APNA 2014). Restraint of a patient may be both physical and pharmacological (chemical) and infringes on a patient’s freedom of movement and may result in injury (physical or psychological) and/or death. There must be an evaluation based on benefit: risk consideration and a leaning toward alternative solutions. Restraints may be used when there is dangerous behavior and to protect the patient and others. You need to become familiar with the standards as set forth by TJC and any state regulations and hospital policies. The least restrictive method should be used and considered first, before using more restrictive interventions.
- First adopted in 1973 by the American Hospital Association, A Patient’s Bill of Rights was revised on October 21, 1992.
- Sets forth an expectation of treatment and care that will allow for improved collaboration between patients, health care providers, and institutions resulting in better patient care (American Hospital Association [revised] 1992).
In 2003 “A Patient’s Bill of Rights” was replaced by “The Patient Care Partnership,” in order to emphasize the collaboration between patient and health providers (American Hospital Association 2003).
Quality and Safety Education for Nurses (QSEN)
The Quality and Safety Education for Nurses (QSEN) project (2005), funded by the Robert Wood Johnson Foundation, focused on the promotion of quality and safety in patient care. Teaching strategies include the following core competencies, which are needed to develop student and graduate attitudes and skills for quality patient care and safety: evidence-based practice, safety, teamwork and collaboration, patient-centered care, quality improvement, and informatics (QSEN 2012). Additional information, including QSEN teaching strategies, can be found in Morgan K & Townsend MC, Essentials of Psychiatric Mental Health Nursing, 8th ed., 2019 and other resources.
- Every adult person has the right to decide what can and cannot be done to their own body (Schloendorff v. Society of New York Hospital, 105 NE 92 [NY 1914]).
- Assumes a person is capable of making an informed decision about own health care.
- State regulations vary, but mental illness does not mean that a person is or should be assumed incapable of making decisions related to their own care.
- Patients have a right to:
- Information about their treatment and any procedures to be performed.
- Know the inherent risks and benefits.
Without this information (specific information, risks, and benefits) a person cannot make an informed decision. The above also holds true for those who might participate in research. Videocasts on informed consent can be accessed at: http://videocast.nih.org (National Institutes of Health, Informed Consent: The ideal and the reality, Session 5 November 9, 2005).
Right to Refuse Treatment/Medication
- Just as a person has the right to accept treatment, he or she also has the right to refuse treatment to the extent permitted by the law and to be informed of the medical consequences of his/her actions.
- In some emergency situations, a patient can be medicated or treated against his/her will, but state laws vary, and so it is imperative to become knowledgeable about applicable state laws (American Hospital Association [revised] 1992; American Hospital Association 2003).
Health Care Reform and Behavioral Health
On March 23, 2010, President Barack Obama signed into law a comprehensive health care and reform legislation. Extensive information can be found at: http://mentalhealthcarereform.org. This site explains and summarizes the law, provides timelines for implementation, discusses health reform and parity, and provides excellent links to other relevant organizations. The American Psychiatric Association has approved a Position Statement on Principles for Health Care Reform for Psychiatry (2008). It is important to keep current as to mental health care reform, parity, and reform legislation as it affects mental health care in the years to come.
- Confidentiality
- The Health Insurance Portability and Accountability Act (HIPAA) (1996)
- Types of Commitment
- Restraints and Seclusion for an Adult — Behavioral Health Care
- A Patient's Bill of Rights
- Quality and Safety Education for Nurses (QSEN)
- Informed Consent
- Right to Refuse Treatment/Medication
- Health Care Reform and Behavioral Health