Case Analysis Demonstration

Allison P. is a charge nurse on a busy medical surgical unit. She is expecting the clinical instructor from the local university at 2 p.m. to review and discuss potential patient assignments for the nursing students the following day. Just as the university professor arrives, one of the patients on the unit develops a crisis requiring Allison's attention. In order to expedite the student nurse assignments for the following day, Allison gives her electronic medical record access password to the instructor.

 

Examine the ethical dilemma

Allison made a commitment to meet with the university instructor to develop student assignments at 2 p.m. The patient emergency that developed prevented Allison from living up to that commitment. Allison had an obligation to provide patient care during the emergency and a competing obligation to the professor. She solved the dilemma of competing obligations by providing her electronic medical record access password to the university professor. By sharing her password, Allison most likely violated hospital policy related to the security of healthcare information. She may also have violated the American Nurses' Association Code of Ethics in that nurses must judiciously protect information of a confidential nature. Since the university professor was also a nurse and had a legitimate interest in the protected healthcare information there may not be a Nurses' Code of Ethics violation.

Thoroughly comprehend the possible alternatives available

  1. Allison could have asked the professor to wait until the patient crisis was solved.
  2. Allison could have delegated another staff member to assist the university professor.
  3. Allison could have logged on to the system for the professor.

Consequences

 

Alternative

Good Consequences

Bad Consequences

Do any rules nullify

Expected Outcome

Potential Benefit > harm

1. Wait until crisis was solved

No policy violation

Patient right safeguarded

Not the best use of the professor's time

No

Best: Crisis will be short

Worst: Crisis may take a long time

Patient right protected

Collegial relationship

Jeopardized

Patient rights may take precedence

2. Delegate to another staff member

No policy violated

Other staff may be equally busy or

May not be as familiar with all patients

No

Best:

Assignments will be completed

Worst:

May not have benefit of 'expert' advice

Confidentiality of record is assured

May

compromise student learning

Patient

rights may take precedence

3. Log onto the system for the professor

Professor can begin making assignments

May still be a violation of policy regarding system access

Rules

regarding access to medical record

Best:

assignments can be completed

Worst: abuse

of access to information

Potential

compromise of records

Patient in

crisis is cared for

 

 

 

Hypothesize ethical arguments

Determine which of the 5 approaches apply to this dilemma.
Utilitarian

1. Identify courses of action available to us

2. Ask who will be affected by each action and what benefits/harms will be derived from each

3. Choose the action that will produce the greatest benefits and the least harm

An ethical action is one that provides the greatest good for the greatest number

Principles: Beneficence & Nonmaleficence

 

Rights

Right of individual to choose for her/himself (Autonomy)

Right to truth (Veracity)

Right of privacy

Right not to be injured

Right to what has been promised (Fidelity)

Does the action respect the moral rights of everyone?

Principles: Autonomy, Veracity & Fidelity

Fairness or Justice

How fair is an action?

Does it treat everyone in the same way, or does it show favoritism and discrimination?

Principles: Justice & Distributive Justice

Common-good

Assumes own good is inextricably linked to good of the community

Community members are bound by pursuit of common values and goals

Ensure that the social policies, social systems, institutions and environments on which we depend are beneficial to all

Examples are affordable healthcare, effective public safety, a just legal system, and unpolluted environment

Principle: Distributive justice

Virtue

Assumes there are certain ideals toward which we should strive which provide for the full development of our humanity

Virtues are attitudes or character traits that enable us to be and to act in ways that develop our highest potential

Examples are honesty, courage, compassion, generosity, fidelity, integrity, fairness, self-control, prudence

Like habits they become a characteristic of the person

The virtuous person is the ethical person

What kind of person should I be?

What will promote the development of character within myself and my community?

Principles: fidelity, veracity, beneficence, nonmaleficence, justice & distributive justice

In this case, there is a clear violation of institutional policy designed to protect the privacy and confidentiality of medical records. However, the professor had a legitimate interest in the information, and a legitimate right to the information. Allison trusted that the professor would not use the system password to obtain information outside the scope of the legitimate interest. However, Allison cannot be sure that the professor would not access inappropriate information. Further, Allison is responsible for how her access to the electronic system is used. Balancing the rights of the professor to the information with the rights of the patient to expect that the information be safeguarded and the right of the patient in crisis to expect the best possible care is the crux of the dilemma. Does the patient care obligation outweigh the obligation to the professor? Yes, probably. Allison did the right thing by caring for the patient in crisis. By giving out her system access password, Allison compromised the rights of the other patients on the unit to expect that the confidentiality and privacy would be safeguarded.
Virtue ethics suggests that individuals use power to bring about human benefit. One must consider the needs of others and the responsibility to meet those needs. Allison has to provide care, prevent harm and maintain professional relationships all at the same time.
Allison may want to effect a long-term change in hospital policy for the common good. It is reasonable to assume that this is not an isolated incident and that the problem may recur in the future. Can institutional policy be amended to include professors in the access to medical records system? As suggested in the HIPAA administrative guidelines, the professor could receive the same staff training regarding appropriate and inappropriate use of access and sign the agreement to safeguard the records. If the institution has tracking software, the access could be monitored to watch for inappropriate use.
Identify the moral principles that can be brought into play to support a conclusion as to what ought to be done ethically in this case or similar cases.
The International Council of Nurses Code of Ethics states that "The nurse holds in confidence personal information and uses judgment in sharing this information." The Code also states, "The nurse uses judgment in relation to individual competence when accepting and delegating responsibilities." Both of these statements apply to the current situation.
Ascertain whether the approaches generate converging or diverging conclusions about what ought to be done
From the analysis, it is clear that the best immediate solution is to delegate assisting the professor with assignments to another nurse on the unit.

Investigate, compare, and evaluate the arguments for each alternative

See table above.

Choose the alternative you would recommend

Best immediate solution is to delegate another staff member to assist the professor.

Best long-tem solution is to change the hospital policy to include access for professors as described above.

Act on your chosen alternative

Allison should delegate another staff member to assist the professor in making assignments.

Look at the ethical dilemma and examine the outcomes while reflecting on the ethical decision.

As already indicated in the alternative analyses, delegation may not be an ideal solution since the staff nurse who is assignment to assist the professor may not possess the same extensive information about all of the patients as the charge nurse. It is however the best immediate solution to the dilemma and certainly safer than compromising computer system integrity. As noted above, Allison may want to pursue a long-term solution to a potentially recurring problem by helping the professor gain legitimate access to the computer system with her own password. This way the system administrator may have the ability to track who used the system and what types of information was accessed during the use.