Confidentiality, but not at all costs
Supervisors of midwives sometimes need to disclose information about an individual
midwife’s practice in order to protect the public, says Kath Mannion
Confidentiality is one of the essential elements of midwifery practice and one that every
midwife meets on a daily basis – no matter where or what her sphere of practice. As
midwives, we regard confidentiality as part and parcel of our job. The same ethos applies
to supervisors of midwives and their relationship with the midwives on their caseload.
Many would relate confidentiality to how we store and keep information about women.
Most women now hold their own notes; we stress that this information is confidential to
them, and that if they do not want it revealed to others they must keep the notes in a safe
place.
However, do we really believe that we keep all information relating to women
confidential? Most labour wards have white boards where information relating to each
woman present is recorded to a lesser or greater degree. Could this be seen as revealing
confidential information, albeit in a controlled area which may only be accessed by staff?
The same problems arise within the supervisory relationship. Confidential information
may be imparted by the midwife to her supervisor, but how is this kept and might it be
revealed at any time? All midwives must have a copy of their annual review, and it is up
to the midwife who she discusses this review with.
During an investigation into a critical incident, confidential information is gathered by
the supervisor of midwives – but to whom may it be revealed? When a midwife is on
supervised practice, who knows the details surrounding the decision? Duty rotas reveal,
almost like the white board, confidential information relating to a midwife. For example,
even though a midwife is written on the rota, the fact that she is supernumerary and
working closely with another midwife may signal to others that there may be a problem
with her practice.
Is there a danger that, by maintaining strict confidentiality among limited numbers of
people, repeated incidents might not be linked due to only one or two people knowing the
full history?
The following information forms the guidance given by the Local Supervising
Authorities (LSAs) in England to supervisors of midwives regarding confidentiality
within the supervisory relationship, and will hopefully answer the questions posed above.
Legislation
The Nursing and Midwifery Council (NMC) has set clear guidelines for confidentiality in
The Code of Professional Conduct: Standards for Conduct, Performance and Ethics
(NMC 2004). Confidentiality of healthcare records is also covered by the Data Protection
Act (1998), Caldicott Guardians (NHS Executive 1999), Human Rights Act (1998), NHS
Code of Practice (DoH 2003), the Human Fertilisation and Embryology Act (1990),
Freedom of Information Act (2000) and For the Record: Managing Records in NHS
Trusts and Health Authorities (HSC 1999) .
Clause 5 of the NMC Code (NMC 2004) states:
As a registered nurse or midwife, you must protect confidential information
5.1 You must treat information about patients and clients as confidential and use it only
for the purpose for which it was given. (p.8)
5.4 Where there is an issue of child protection, you must act at all times in accordance
with national and local policies.(p.9)
The code details how confidential information and confidentiality are part of every
midwife’s daily working life. The principles within the code apply equally to
confidentiality and supervision of midwives.
Annual reviews
Confidentiality is one of the basics of the supervisory relationship. As such, interaction
between the supervisor and midwife may be confidential in full or part, depending on the
situation.
Disclosure by the midwife to the supervisor may cause a dilemma, especially if the
practitioner reveals poor practice which requires remedial action. In facilitating supported
or supervised practice, the supervisor is required to maintain a balance between revealing
the case to those working with the midwife and keeping details of the midwife’s failings
confidential. However, the overriding principle of public protection must be preserved.
There is anecdotal evidence that supervisors may have difficulty with confidentiality
within the supervisory relationship. Difficulties can arise in determining when
confidential information relating to a midwife’s practice must be disclosed. Supervisors
have described how, by not sharing confidential information in relation to a midwife’s
practice, the supervisory network has been unaware of problems relating to that
individual. Several supervisors may have been involved with different issues, but because
no one has shared or pooled the information the level of poor practice has not been
sufficiently noted and the practitioner appropriately supported.
Public safety may also be compromised in this instance when each supervisor has seen
the incident or poor practice as a ‘one-off’ and has not had the opportunity to see the full
picture. The lessons from the Laming Report (Lord Laming 2003) into the death of
Victoria Climbie can equally be applied to supervision. The report found that information
silos relating to her case were held by different professionals but there was no overview
or sharing of the information. It may be necessary to reveal confidential information to
other professionals to ensure proper support for the midwife and public safety.
Midwives may reveal to their colleagues some if not all of the facts relating to them. The
midwife’s account of her story may be told differently once it has been related to other
colleagues. The supervisor may hear a very different story via the informal networks. On
no account should the supervisor be tempted to correct details since this is also a breach
of confidentiality.
Supervisory records
Supervisory records must be kept separate from employment/personal records. Guidance
on storage of supervisory records is available to all supervisors of midwives and
midwives from the LSA Midwifery Officers.
The Midwives’ Rules and Standards (NMC 2004) state, in Rule 12:
Although these records are confidential between you and your supervisor it is important
for you to understand that in certain circumstances they may be disclosed, for example, in
a local supervising authority or NMC fitness to practice investigation. In other
circumstances, a court order would be required before the disclosure of these records.
(p.27-28)
Disclosure of information regarding a particular midwife should be on a ‘need-to-know’
basis, and the supervisor must ensure that the midwife understands the concept of
confidentiality within supervision.
Supervisors of midwives must share issues both for personal support and to achieve
professionally optimum outcomes. It is also important to utilise issues as learning
experiences and for supervisors to learn from them while maintaining confidentiality
within the supervisory framework. Clearly, the midwife must also be made aware that the
LSA Midwifery Officer and/or the NMC may also need to be made aware of the
information.
Discussion
Many midwives and supervisors will relate to the above guidelines and have found that
confidentiality within the supervisory relationship is maintained even when a serious
incident is being investigated. Supervisors must focus on the balance between
maintaining confidentiality and protection of the public – not an easy task.
Confidential information relating to annual supervisory reviews or investigations may be
revealed by the midwife to her friends and colleagues. The midwife needs to be aware
that this information is confidential to her, and that by revealing it to others there is a risk
that it might be spread among other members of staff to whom she might not wish to
impart this information.
Supervisors report frustration when they overhear other midwives discussing a case
where the information has become skewed, and they are unable to correct this because it
would breach confidentiality in relation to the individuals concerned.
When dealing with women receiving midwifery care, confidential information may need
to be revealed because of overriding concerns – for example, child protection issues.
Similarly, issues relating to an individual midwife’s practice may need to be revealed in
order to protect the public. Both cases require sensitive handling to achieve the best
outcome, and it is essential that supervisors of midwives work alongside their colleagues
and discuss the issues in a safe, confidential environment. Advice and guidance can also
be sought from the LSA Midwifery Officers. TPM
Kath Mannion is Local Supervising Authority Midwifery Officer, Northern Consortium
of Local Supervising Authorities.
A full listing of contact details for LSA Midwifery Officers in England is available at
www.nmc-uk.org
References
Data Protection Act (1998). London: HMSO.
DoH (2003). NHS Code of Practice, London: Department of Health.
Freedom of Information Act (2000). London: HMSO.
HSC 199/053 (1999). For the Record: Managing Records in NHS Trusts and Health
Authorities, London: Public Records Office.
Human Fertilisation and Embryology Act (1990). London: HMSO.
Human Rights Act (1998). London: HMSO.
Lord Laming (2003). The Victoria Climbie Inquiry: the Report of an Inquiry by Lord
Laming, London: HMSO.
NHS Executive (1999). Protecting and Using Patient Information: a Manual for Caldicott
Guardians, London: NHS Executive.
NMC (2004). The Code of Professional Conduct: Standards for Conduct, Performance
and Ethics, London: NMC.
NMC (2004). Midwives’ Rules and Standards, London: NMC.