Thoughts about confidentiality and respect.

• The design of hospitals means that we frequently overhear private conversations between clinicians and patients.
• What can these overheard conversations teach us about nursing care?

This year marks the 25th year anniversary of the Health Insurance Portability and Accountability Act (HIPAA). When signed into law, HIPAA was lauded as the national health privacy statute. Legalese aside, the ubiquitous proof that confidentiality is taken as seriously as a fatal disease can be seen by anyone riding a hospital elevator with a sign reading: “Do not discuss patient information in public.” HIPAA became a stand-in for considerate and respectful patient care, at least in the elevator. At the bedside (or stretcher side), however, it’s often a different story.

Do you hear what I hear?

Working in an open intensive care unit (ICU) with only a curtain between patients, I became an accidental eaves­dropper. Don’t ask me how, but I have vivid recollections of snippets of conversations between patients and any number of healthcare staff. One particular standout was a young intern asking a 94-year-old patient with a subdural hematoma, as part of the medical history interview, “When was the last time you had sex?” In her worsening lethargy, the patient struggled to reply, “I can’t remember exactly. Eisenhower was president at that time.” My ears perked up, not because of the delicate nature of the question, but because I had no idea when Eisenhower was president (I didn’t learn American history in the Philippines).

Listening to this conversation made me realize that the bedside can be a very public place — susceptible to eavesdropping. Other memorable matter-of-fact utterances heard from behind the gauzy veneer of confidentiality offered by a curtain include

• “Did you know that pain is a sign of life?”
• “How long have you had HIV?”
• “We will just drill a small hole in your skull and cut a tiny piece of your brain.”
• “What drugs did you take?”
• “This pill is for sleep, the other one is for the nightmares.”
• “Just go on the bed, and we’ll clean you after.”

Hearing these conversation fragments made me think that the last frontier of patient confidentiality isn’t the elevator. It’s the bedside. The hospital confines the patient to a room, but privacy may be an illusion. I frequently thought that had I not been on the other side of the curtain, the patient’s confidentiality would have been preserved. My very presence in the same space made me an unwitting accomplice to violating the patient’s privacy. Similar thoughts came back to me recently, this time as a visitor. While visiting a friend who was in a two-bed hospital room, I could clearly hear the not-so-hushed conversation between the patient in the next bed and the neurologist: “When did you start having seizures?” asked the latter.

On the one hand, it’s possible that hearing about your hospital neighbor’s maladies might evoke fear of contagion (finding out the neighbor is HIV positive or had COVID-19) or some other primal negative emotions such as bigotry (having someone of a different race as a roommate). On the other hand, knowing your neighbor’s health misfortunes also may bring out the best in us. Seeing someone in pain or crying can elicit empathy. I think of Mr. Rogers’ oft-quoted advice, “Look for the helpers. You will always find people who are helping.” It’s not unheard of for patients in shared rooms to look after each other. One might alert the nurse to the cries of a roommate who isn’t able to summon help. Another might offer a consoling word to a neighbor who’s preparing for surgery. I once witnessed a patient helping another walk to the bathroom.

Nursing confidential

“And remember every nurse should be one who is to be depended upon, in other words, capable of being a ‘confidential’ nurse… she must be no gossip, no vain talker; she should never answer questions about her sick except to those who have a right to ask them…”

 — Florence Nightingale, 1860

Upholding patient confidentiality goes back to the teachings of Hippocrates, and Nightingale deemed it essential to professional nurses’ comportment. And then the digi­tal age came. Technology is both boon and bane of patient confidentiality. At the height of the pandemic, staff used social media platforms to connect patients with loved ones. However, I’ve also heard that some nurs­ing teams run group chats where patients are discussed and dissed by staff. Although this may not be against the law, it’s a sad commentary on the misplaced belief that what the patients don’t know won’t hurt them. To honor the public’s trust, we must practice in good faith, and just as Nightingale said: “One must be no gossip.”

Now what?

HIPAA protects the patient’s healthcare records, but it doesn’t guarantee respectful care. It would be great if in every patient care unit, an examination room was dedicated to patient interviews (I’ve seen this in a European hospital). In spite of architectural barriers to maintaining patients’ privacy, when interviewing a patient, staff should speak quietly enough for the patient to hear, but not a neighbor or visitors. If a visitor is present, the interviewer can ask the patient’s permission to discuss health matters in their presence. The visitor also could be asked politely to leave the room for a few minutes while the interview takes place.

Overhearing healthcare interactions makes me ponder human folly and frailty. In our seemingly sclerotic world, the crucial conversations I’ve heard somehow soften me in a good way, to be gentler to those around us. I hope I’ve not dishonored any patient’s memory by writing about what I heard. Some of their words repeat in my head, reminding me to value patients as greater than the sum of their comorbidities, and to listen to them well.

Fidelindo Lim is a clinical associate professor at New York University Rory Meyers College of Nursing in New York City and an American Nurse Journal Nurse Influencer.