Kate Taylor, MPS Clinical Risk Manager, explores the implications for nurses of technology in general practice

Life in the 21st century is dominated by technology – mobile phones, pagers and high-tech devices – we can be interrupted anywhere, at any time. Technology allows us to order shopping online, communicate with friends and family via social networking sites, book holidays, download music, read books and so much more.

So, has technology impacted on general practice? Many practices send patients text messages, offer patients the opportunity to book appointments online, order repeat prescriptions electronically, learn about services provided by the practice via a website, as well as inviting patients to comment on their experience of the services provided via websites, such as NHS Choices. Clinicians use electronic medical records, receive test results electronically and have electronic messaging systems for internal practice communication.

Potential risks

The use of technology comes at a price and there are potential risks in a healthcare setting. Through the Clinical Risk Self Assessment (CRSA) programme, MPS has identified emerging risks that general practice teams need to be mindful of and proactively address.¹

Nurses working within general practice need to be aware of the implications that some of these key risk areas can have on their role and level of responsibility within the practice:

1. Communication

Nurses are increasingly encountering the patients who have done their own research into diseases they have, or think they have, and used the internet to access medical advice.

The web contains a vast spectrum of information: at one end there is controlled and reputable medical information, while at the other end we have uncontrolled websites of a commercial, personal or ideological disposition. Balancing these opposing sources presents medicolegal issues for nurses. This can prove challenging for practice nursing teams as patients are becoming better informed and have raised expectations.

"Nurses are increasingly encountering the patients who have done their own research into diseases they have, or think they have, and used the internet to access medical advice"

The Nursing and Midwifery Council (NMC) state in The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives: “You must listen to the people in your care and respond to their concerns and preferences.”²

Risk management advice:

• Ensure that you have effective communication skills, including listening and empathy, to assist the consultation.
• Warn about the reliability of material from the internet.
• Be receptive about information from the internet.
• Be open to new means of communication, but manage them effectively.
• Remind patients that there are constraints on your time and you can’t read all the printouts that they bring you.
• Work within your competence.
• Keep a record of the consultation in the patient’s record.

2. Email

The use of email has proven to be revolutionary in terms of improving communication; however, although email is an attractive way for patients to communicate with the practice, safeguards are required in order to preserve patient confidentiality. Unless messages are encrypted, patients should be aware that their messages could potentially be read by someone else.

"A standard protocol for email exchanges could prevent emails from patients asking for more complex information about medical symptoms or their proposed treatment"

Risk management advice:

• Seek the patient’s consent before communicating by way of email.
• Only appropriate matters should be dealt with via email exchanges, for example, appointment scheduling, ordering repeat prescriptions and obtaining test results.
• A standard protocol for email exchanges could prevent emails from patients asking for more complex information about medical symptoms or their proposed treatment, which would be difficult for the practice to respond to quickly and appropriately.
• It is important to ensure that all emails to and from the patient are included as part of the patient’s medical record.
• Ensure that there is a protocol for regularly monitoring incoming emails (including during periods of leave).
• Be wary about the workload implications of dealing with incoming emails.
• Take all reasonable steps to ensure that the email is being sent to the correct address.
• Be aware of the limitations of email correspondence (for example, examination findings, body language may be important parts of a clinical assessment).

3. Recording of consultations

It is becoming increasingly common for patients to ask to record a consultation on their phone, to share with a third party. Whilst the nurse may feel that the presence of a recording device may hinder the nurse-patient relationship, the nurse has a duty to assess their condition and advise on any necessary treatment.

"Any concerns about the recording, including managing the security of their confidential information, should be discussed with the patient beforehand"

Risk management advice:

• Explore the patient’s reasons for recording the consultation; in most cases it will be to ensure that they do not forget important information and/or that they may wish to share it with a friend or relative. There may be other ways of communicating this information (for example, by writing down the relevant information or recording a summary of the relevant points at the end).
• Any concerns about the recording, including managing the security of their confidential information, should be discussed with the patient beforehand.
• Consider a copy of the recording being placed in the patient’s medical record.

4. Text messaging

Many practices are signing up to using a text messaging service to inform patients of appointments, flu vaccinations, etc. Text messaging allows practices to target and contact hundreds of patients within minutes. Patients can respond by text with replies automatically forwarded to a specified email address.

Risk management advice:

• Ensure that text messages are as secure as possible and compliant with the relevant legislation and professional guidance.
• Ensure explicit consent is obtained from patients prior to using text messaging as a form of communication.
• Remember that text messaging in this context is a professional communication; hence ‘text speak’ should be avoided.
• Ensure that the patient’s number is correct (and bear in mind that some patients may frequently change their number).
• Do not communicate sensitive information by way of text.

5. Social networking sites

Many practices have embraced some of the social networking sites as an innovative way of communicating with patients; with this growing phenomenon the Nursing and Midwifery Council have developed clear guidance recommending that nurses ensure they use privacy settings when visiting such sites.³

Risk management advice:

• Do not post anything you would not want others to see.
• Do not discuss work-related issues online, including conversations about patients or complaints about colleagues.
• Never post pictures of patients or service users, even if they ask you to do this.
• Social networking sites should not be used for raising and escalating concerns.
• Protect your own privacy.

6. Record keeping and visits

Most nurses recall the days when handwritten clinical notes were the norm; now this is the exception, perhaps only in the context of a home visit or when issuing a handwritten prescription. Particularly within general practice, most nurses will be working with clinical computerised systems.

"Most nurses recall the days when handwritten clinical notes were the norm; now this is the exception, perhaps only in the context of a home visit"

Risk management advice:

• Ensure that you have received appropriate computer training, including the use of the practice clinical system.
• It is easy to overlook making an entry in the records after a home visit; try and ensure that they are written up at the earliest opportunity and if possible create a reminder before you undertake the visit.

Case scenario

Practice nurse Kerry had an extremely bad day at the practice. On returning home she logged onto Facebook and commented on her day; a colleague responded and subsequent exchanges of messages uncovered the identity of a patient who had attended the practice that day. Nurse Kerry had suggested to her colleague that patient X was his usual moaning self.

On returning to work the following day, nurse Kerry was asked to see the practice manager. On arriving at the practice manager’s office it became apparent to Kerry that something serious was going on as one of the senior GP partners was also present. Kerry was questioned by both the practice manager and the GP about the practice policy on confidentiality and was asked to reflect on any activity that she may have been involved in that may have compromised confidentiality.

"Kerry was questioned by both the practice manager and the GP about the practice policy on confidentiality and was asked to reflect on any activity that she may have been involved in that may have compromised confidentiality"

Another staff member had seen the exchange of messages and had alerted the practice manager. Kerry was subsequently managed through the practice’s local disciplinary procedures.

Advice

• Ensure you are familiar with the practice IT policy.
• Ensure you are familiar with the practice confidentiality policy.
• Sign and agree a confidentiality statement that includes the use of social networking sites.

Conclusion

Technological advances will undoubtedly bring further changes and risks will never be eliminated entirely; however, identifying and managing the risks early on will go a long way to provide a safer environment for patients.

References

1. MPS Clinical Risk Assessment
2. Nursing and Midwifery Council (NMC), The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (2008) London
3. Nursing and Midwifery Council (NMC), The Code: Social Networking Advice (2012)

Additional reading:

1. Your Practice (2012) Dilemma: Recording Consultations. A Patient Asks to Record My Consultation – What should I do? Vol 6 No 3
2. MPS factsheet: Communicating with Patients Via Fax and Email
3. MPS factsheet: Making Audio and Visual Recordings of Patients
4. MPS factsheet: Communicating with Patients by Text Message