Who Needs to Know?
                                                     Jacksonville University
                                                           Victoria Filomeo
                                                              June 21, 2016


        Prior to the initiation of the electronic health record, all chart entries were hand-written. Anyone who picked up the chart had access to the entire medical record. This access changed when information was typed into an electronic record.  Contents of the record were limited to those deemed having a need to know.
         The need for privacy has been recognized as far back as Hippocrates whose oath states "What I may see or hear in the course of treatment, or even outside of the treatment, which on no account one must spread abroad, I will keep to myself" (Grzybowski, p53, 2005). Nursing staff in my hospital participate in annual reviews which include privacy and confidentiality. When the entire chart was available to all staff, there was no restriction on what staff was able to learn about a patient. With current restrictions, some staff are severely limited on what they are able to learn, often to the detriment of the patients.
         In my own workplace, the staff who provide the bulk of the hands on care are mental health workers. They may be certified nursing assistants but they do not have any nursing license.  They are only able to view nurse's notes, the cardex and patient belongings records. They are not able to view the psychiatrist's documentation, the social worker's notes, the history and physical, physician orders, lab results nor the RN admission documents. This becomes a  minor issue if a patient is allowed to have caffeine, which is restricted on many psych units.  The RN needs to stop what she is doing and review the physician orders to answer this question. A somewhat more important issue is if a patient is allowed to have second portions at mealtime. To answer this question, the RN must peruse the history and physical to determine if the patient is diabetic or has any dietary restrictions. Regular unit staff are usually aware of such restrictions but nurses and mental health workers who float to another unit will not have this information.
       The much larger issues of who needs to know arise with communicable disease and assaultive behavior. Violence against healthcare workers is not uncommon. California offers some protection for emergency department workers but none for inpatient workers (Hester, Harrelson, Mongo, 2016). In one study of 5,000 nurses, 76% reported being the victim of violence, either verbal or physical. I had a physician friend who was murdered by a patient. Another friend, an RN, was beaten so badly he suffered brain damage and was never able to work again.  I believe all nursing staff have the need and the right to know if a patient has a violent history.  In my hospital, this history is found in the psychiatrist's evaluation and in the social worker's notes; neither is accessible to the staff members giving the hands on care.
        Communicable disease presents a safety risk for the staff as well.  Staff members are protected against blood borne diseases with the use of universal precautions. However, gloves and masks are no defense against assault. Last week, one of the mental health workers was badly bitten by a patient with hepatitis C.  She assaulted a psychiatrist and the mental health worker. The RN staff and medical staff, who have access to the history and physical, were aware she had hepatitis. The mental health worker did not have this information. Would having this information changed anything?  Maybe not but perhaps he would have been more cautious and aware of where his arms were in relation to her mouth. In mental health nursing, we often have patients with IV drug abuse and the diseases associated with it.  Currently, there are two patients with HIV on my unit. This information is not accessible to all of the staff unless I tell them daily.
         The process of changing accessibility to information in my hospital requires the use of a "safe."  Safes are used throughout the hospital system to control access to information. Some safes allow access to incident reports, others to employee evaluations, disciplinary actions and to minutes of confidential meetings, for example. Safes are controlled by the chiefs of departments.  In my hospital, the safe for nursing access is controlled by the director of nurses.
         My plan to improve accessibility is to approach the director of nurses and ask her to extend this safe allowing mental health workers access to the same information accessible to  RN staff.  If access is granted, I would review the changes with the mental health workers.  I would suggest they log on to their computers and review information for patients with whom they are unfamiliar.  I would remind them of confidentiality again as they now have access to sensitive information. Armed with this information, they will be able to accomplish patient care more efficiently and the RN staff will not spend precious time looking up information for others. The mental health workers would be aware of communicable diseases and take measures to protect themselves.
        I anticipate some reluctance to allow mental health workers access to this information.  If the fear is a loss of confidentiality, I will  point out it was not that long ago we had paper charts and everyone could read the contents. Confidentiality was maintained at that time. There may also be the fear that care will be compromised. My argument will be that of staff safety and their right and need to know in order to stay safe. As pointed out by Laura Finney in a discussion board post on June 6,2017, nurses do not need to know a criminal background to perform some nursing functions but when we work intimately close to a patient, we are entitled to the information we need to stay safe. Staff need to be given the knowledge they need to provide care in a safe manner, even if this involves working in pairs or even groups. Having adequate staff caring for patients prevents injury to both patients and staff (CPI, 2014).
         Evaluation of the effectiveness of  this plan would not be difficult.  Asking the mental health workers questions about their patients would evaluate if the workers had the information they needed to do their work.  I would also observe if they are able to follow through with the knowledge they gained.

References

Crisis Prevention Institute (2014). Retrieved from crisisprevention.com

Finney, L. (2017). Laura Finney in response to Victoria Filomeo, discussion board post, Jacksonville
        University, week 7

Grzyboweski, D. (2005). Thought leaders.  Patient privacy:  The right to know versus the need to
         need to access. Health Management Technology, 26(9) 53-54.  Retrieved from
         https://healthmgttech.com

Hester, E, Harrelson, C.& Mongo, T. (2016) Workplace violence against nurses:  Making it safe to
         care. Creative Nursing, 22(3) 204-209.  doi:  10.1891/1078-4535.22.3.204