1. Brazen, Linda BSN, CNOR, MSN

Article Content

Patients in need of operative or other invasive procedures don't lose their right to privacy in the OR or invasive procedure suite (IPS). They're entitled to know who will be present during their case and have the right to refuse the presence of any individual who's not directly related to their care. In terms of privacy, there's no difference between a healthcare industry representative present in an OR and an equipment consultant or a nonemployee nurse who wants to observe a surgery as part of their interview process. What's different is how a healthcare facility addresses these situations and through policies, supports patients' privacy rights in the OR and IPS care settings.


Patient rights and HIPAA law

Over the last decade, technology has created convenience as well as concern. While we enjoy the convenience of paying our bills online, identity theft is a constant threat. As a result, privacy and confidentiality have become important to people, and are even more important to maintain for patients within the healthcare setting.


In 1992, the American Hospital Association (AHA) issued a document called, "A Patient's Bill of Rights." It's not unusual for the patient's Bill of Rights to be posted prominently in public areas of healthcare facilities and to be included in employee orientation programs.


The brochure, The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities, is given to and discussed with the patient as part of the admission process. One of the rights is that the patient has a right to privacy concerning his or her own medical care.1 Indirectly related to the AHA intent of privacy, the Health Insurance Portability and Accountability Act (HIPAA) was passed as a federal mandate to prevent unintentional misuse of patient information. This law supports a patient's autonomy in deciding with whom, when, and where to share health information and it's important for all healthcare providers to protect this autonomy.2


Privacy and confidentiality

The primary goals and values of a profession are explicit in their code of ethics.3 The ethical practices of nurses as healthcare professionals are significant to HIPAA and AHA issues of privacy and confidentiality. An ethical framework of practice means respecting privacy as a personal concept and as a patient's right to keep personal information from being disclosed. At the same time, it also means that if a patient's private information is disclosed with permission, it will be respected as confidential.


In the perioperative setting, the circulating nurse is accountable for managing a safe environment of care and for coordinating safe patient care while the patient is either in an OR or IPS. As the patient's primary caregiver and primary advocate, the nurse is ethically obligated to maintain the patient's privacy as well as to protect confidential information. This task is even more challenging in an environment filled with complex technology such as the OR. A patient's safe and uneventful journey throughout the perioperative experience implies that the nurse achieved all of these objectives successfully on behalf of the patient.


Maintaining the patient's privacy is essential for preserving the trust developed in nurse-patient relationships.2 This trust includes, but is not limited to, mechanisms to protect patients from undue exposure or unwarranted invasions of privacy including verbal, electronic, and written forms of information. The rights to privacy and confidentiality of personal information, well being, and safety are the primary factors to consider when a circulating nurse is an advocate for the patient's privacy.3

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

A breach of confidentiality is a disclosure of information to a third party without the patient's consent or a court order.2 Disclosure includes information the nurse learned within the nurse-patient relationship, related patient care information obtained through a verbal or physical assessment, or information discovered during any phase of the perioperative continuum of care. In an ethical practice framework, perioperative nurses need to consider that despite the HIPAA law, circumstances may still exist that compromise patient privacy or confidentiality. For example, could a healthcare industry representative in the OR or IPS acting as a consultant for new equipment breach confidentiality?


Implementing policies

The laws and rules designed to protect patient privacy are relatively new, and application and implementa tion in healthcare settings are still evolving. To date, there's little evidence of expert opinion in the area of patient privacy for those undergoing an invasive procedure. At best, a policy must be in place to support the ethics of privacy and patient confidentiality. A policy that addresses how to implement these in OR and IPS care settings specifically is essential. The policy should be particularly supportive of nurses in these settings who manage the patient environment and coordinate the patient's care as primary caregivers and primary advocates.


A policy for admitting unauthorized persons into an OR or IPS for any reason must be developed by healthcare facilities and in accordance with federal, local, and state laws and regulations, and accreditation requirements. Each facility should develop a system that addresses informed patient consent regarding the presence of persons in the OR or IPS.4 The consent should include the role of the person who's requesting to be present. Acceptable activities and the conduct of these individuals should be defined. (See Possible visitors.)

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


Policies should also address safety issues from both the patient's standpoint and the visitor's.


The foremost patient safety need is the right to be informed if any visitors will be present during their operative or invasive phase of care. The patient's operative or procedure physician is responsible for informed consent, including obtaining the patient's consent for the presence of unrelated others during a procedure. A patient has the right to refuse to have others present for the intraoperative phase of care. If this privacy is breached, the circulating nurse has an ethical obligation to inform the facility's risk department.


According to one facility, there may be a need to place the following statements in the policy: "Only credentialed and privileged persons may put their hands on a patient during the operative or invasive procedure, or put their hands in a patient's body cavity. Only operating room nurses and surgical technologist employees may perform in the scrub role."5


Patient safety practices also include compliance with traffic patterns, infection control practices, surgical attire, appropriate current immunizations, a confidentiality statement review, and witnessed signature. Another patient safety practice is that visitors wear an identification badge (preferably with a picture), at all times while in the perioperative department, in the OR, or in the IPS. Also, a signed confidentiality form should become part of the patient's record.


Visitors to the OR or IPS should never compromise the patient due to their own illness or sickness. The health and infection control issues of staff and others who may be present during an operative or invasive phase of care need to be in compliance with traffic patterns, infection control practices, and surgical attire guidelines. Ideally, a review of the visitor's record of immunizations for appropriateness and as a precautionary measure should be performed, including a purified protein derivative (PPD) or tuberculin skin test or declination form. If a record is unavailable, the facility's risk management department should be contacted. Additional considerations may be applied to minor visitors. (See Recommendations for minors.)


Industry representatives

Healthcare industry representatives can provide technical support to the surgical team to expedite the operative or invasive procedure and therefore facilitate patient outcomes.6 Patients still retain the right to be informed if and when representatives will be present during the procedure, and what purpose the representative will serve. Healthcare facilities may choose to separate industry representatives from other categories of visitors in their policies. To assist with this category specifically, HealthStream and the Association of periOperative Registered Nurses (AORN) developed an online protocol to prepare healthcare industry sales representatives for visiting ORs during procedures. This online protocol is available at.


Maintaining ethical responsibility

The perception that visitors are an invasion of privacy or a breach of confidentiality must be discussed within an ethical framework of practice. Although the mission of a teaching hospital may permit a more lenient approach to visitors being present during an operative or invasive procedure, the different categories of visitors must still be defined. Professional nursing associations, specifically AORN and the American Nurses Association, as well as organizations such as the AHA, all support the patient's right to be informed of anyone who may be present during the continuum of care, especially the intraoperative phase. Currently, two states and one district have provisions that pertain to visitors in the OR: Illinois, Arkansas, and District of Columbia.6


As healthcare facilities continue to develop policies regarding visitors in the OR who are unrelated to a patient's care, ensuring compliance by healthcare industry representatives also must be considered.7 An ethical approach will be important and necessary when dealing with the issues involved with visitors. OR


Possible visitors

Examples of persons who may be present in an OR or IPS are:


Healthcare industry representatives - A healthcare industry employee or facility vendor who provides equipment, supplies, or instrumentation service(s) in an OR or an IPS suite.


Authorized visitor - An affiliated school of nursing or school of medicine student, a licensed RN or medical doctor (MD) who's directly involved in the pre- or postoperative care of the patient, a non-OR employee directly related to the care of the patient in the OR, students present for contracted clinical learning activities, and parents present during induction/intubation of children. These visitors should receive an overview of the clinical setting and expectations for their time and activities while present during the procedure.


Guest visitor - A nonemployee RN, MD, or affiliate contracted student invited by the procedure surgeon to be present in the OR during the procedure and who's not directly involved in the pre- or postoperative care of the patient.This category of visitors should receive expectations for their time and activities in the OR or IPS.


Observer - A nonemployee or someone who's not a student with an affiliated contracted facility and isn't involved in a patient's perioperative continuum of care, who requests to be present during an operative procedure for the purpose of interest or career. These visitors will be directed and supervised during the clinical experience by a delegated member of the operative or invasive team so that the circulating nurse may remain attentive to the needs of the patient.


Family presence - The attendance of one or more family members at the patient's resuscitation, invasive procedure, or in the OR as part of the patient's planned end-of-life care.


Recommendations for minors

According to the AORN, "high school students or visitors who are younger than 18 years of age" may not be accommodated in some facilities.4 In one teaching hospital, observers under the age of 21, regardless of curiosity or interest, are discouraged.5 However, if minors are approved, the following requirements should be part of the policy:


* The procedure physician must document the specific reason for observing the operative/invasive procedure.


* The minor must be accompanied to the OR or IPS control desk by a parent or legal guardian who has a picture ID.


* The minor must provide a current immunization record, including a recent PPD test.


* The parent or legal guardian and the minor must participate in the review of the confidentiality statement and both must sign the form.


* The procedure surgeon is solely responsible for the minor's safety throughout the perioperative experience, specifically in the OR or IPS.





1. American Hospital Association. A Patient's Bill of Rights. Available at: Accessed July 7, 2008. [Context Link]


2. Nielsen J. Confidentiality, privacy, and the HIPAA Law. Submitted in partial fulfillment of PL447XH72 Health Care Ethics. Regis University. August 25, 2005. [Context Link]


3. AORN Explications for Perioperative Nursing. Standards, Recommended Practices, and Guidelines. Denver, Colo: AORN, Inc.; 2008:633-660. [Context Link]


4. AORN Clinical Issues Column. AORN J. 2006; 84(2): 266. [Context Link]


5. University of Colorado Hospital. Policy and procedure: Patient privacy in the operating room and invasive procedure suites. University of Colorado Hospital: Denver, Colo: 2007. [Context Link]


6. AORN Guidance Statement. The role of the health care industry representative in the perioperative setting. Standards, Recommended Practices, and Guidelines. Denver, Colo.: AORN Inc.; 2008:180-181. [Context Link]


7. Ecarius K, McCain D, Whitcomb J, et al. Are we ready for healthcare industry representatives to enter the operating room? Poster presentation at AORN 2007 Congress in Orlando, Fla. [Context Link]