HIPAA Training for Nurses

HIPAA and COVID-19 Vaccination Information

There is no question that HIPAA training for nurses is mandated by the Administrative Requirements of the HIPAA Privacy Rule. However, the content of HIPAA training for nurses should go further than the minimum requirements of the Privacy Rule training standard to ensure compliance.

The Privacy Rule standard relating to training (45 CFR § 164.530 (b)(1)) states, “A Covered Entity must train all members of its workforce on the policies and procedures with respect to Protected Health Information […] as necessary and appropriate for members of the workforce to carry out their functions within the Covered Entity”.

As nurses regularly have access to Protected Health Information (PHI), it is important they adhere to the policies and procedures developed by the Covered Entity to safeguard PHI and prevent unauthorized uses and disclosures. However, HIPAA training for nurses that only focuses on policies and procedures may not be enough for nurses to carry out their functions in compliance with HIPAA.

There are many circumstances in which a nurse could be confronted with a situation not covered by a Covered Entity´s policies and procedures; and, in these circumstances, the nurse needs to be aware of the compliant course of action. Should a violation of HIPAA occur due to a lack of necessary and appropriate training, the Covered Entity – rather than the nurse – will be considered liable.

A Risk Analysis Should Determine the Content of Training

Covered Entities are required to conduct risk analyses under the Security Management Process standard of the HIPAA Security Rule (45 CFR § 164.308 (1)(ii)(A)). Although this standard specifically relates to developing policies and procedures to safeguard electronic PHI (ePHI), the policies and procedures resulting from a Security Rule risk analysis have to be consistent with the Privacy Rule.

Because of the crossover between the Security Management Process standard and the requirement that policies and procedures are consistent with the Privacy Rule, it is recommended Covered Entities conduct a risk assessment to identify situations in which the risk of any unauthorized use or disclosure may occur, and then create further policies to address these potential HIPAA violations.

However, in some situations, it may not be possible to develop a policy or procedure because of the nature of the situation. By alerting nurses to these situations in HIPAA training, it prepares them for taking a compliant course of action if they occur. It also documents the fact that HIPAA training for nurses has been provided to address potential HIPAA violations identified in a risk analysis.

The Importance of Context in HIPAA Training for Nurses

So that nurses can better understand the reasons behind a Covered Entity´s policies and procedures – and to give them a better understanding of what constitutes a compliant course of action in a situation for which no policies nor procedures exist – HIPAA training for nurses should be provided in context inasmuch as training should include a background to the HIPAA Privacy and Security Rules.

This will help nurses better understand policies relating to patients´ rights, the Minimum Necessary Standard, and mitigating threats to patient data. It will also help them determine a compliant course of action when a patient is incapable of giving their consent to disclose PHI, but it is in the patient´s best interests to do so – a circumstance difficult to cover with a standard policy or procedure.

Contextual HIPAA training for nurses will be of benefit in security awareness training required by the Administrative Requirements of the Security Rule, along with any refresher training that is required following a “material change” in policies or procedures. Not only will this help nurses better understand the objectives of HIPAA, but it will also mitigate the risk of unforeseen HIPAA violations.

Training HIPAA Compliance via Modules

HIPAA training for nurses may be more comprehensive than HIPAA training for other members of the workforce, but there are many areas of HIPAA that will need to be included in training for all members of the workforce – for example, the basics of the Privacy Rule, allowable uses and disclosures of PHI, and the Breach Notification Rule.

Preparing separate training courses for different groups of the workforce can be expensive and time-consuming. A suitable solution is to develop or outsource a HIPAA compliance training course using modules so all members of the workforce can be trained simultaneously on common areas of HIPAA, while those who require more advanced training can take their modules separately.

One of the benefits of using training modules is that they can be taken online when nurses have time in their schedules to attend virtual training. It also means large groups of nurses are not simultaneously absent from Covered Entities´ workforces – which could create operational problems. Indeed, it might even be possible in some circumstances to conduct all HIPAA training using outsourced modules.

HIPAA Training for Nurses FAQs

Is there a standard HIPAA training course for nurses?

Although many nurses perform similar roles, the policies and procedures developed by their employers can vary greatly. Consequently, there is no one-size-fits-all HIPAA training course for nurses. Each training course should be developed according to the policies and procedures developed by the Covered Entity and the outcome of a Privacy Rule risk assessment.

If additional training is provided as the result of a Privacy Rule risk assessment, does the training need to be documented?

Although the requirement to document training appears to apply only to training on policies and procedures, if additional training is provided as the result of a Privacy Rule risk assessment, both the risk assessment and the training have to be documented so that, in the event of an HHS inspection, audit, or investigation, it can be shown the Covered Entity identified a risk to the privacy of PHI and took steps to mitigate it.

What should a Privacy Rule risk assessment cover?

Privacy Rule risk assessments and analyses should be relevant to the nature of the Covered Entity´s operations and workforce functions. In respect of HIPAA training for nurses, the most common Privacy Rule violations by healthcare employees include unauthorized disclosures of PHI, leaving devices and paperwork unattended, and providing unauthorized access to medical records.

None of these violations are necessarily malicious. Two nurses discussing a patient´s care within earshot of another patient is an unauthorized disclosure of PHI, leaving devices and paperwork unattended is usually accidental, and providing login credentials to an EHR when a colleague has forgotten theirs helps with productivity, but breaches rules relating to the integrity of audit trails.

Why is HIPAA training on the Breach Notification Rule necessary?

The Privacy Rule standard relating to training stipulates that refresher training is necessary when “functions are affected by material change in the policies and procedures required by this subpart (i.e., the Administrative Requirements) or subpart D of this part”. Subpart D is the Breach Notification Rule, so nurses do need to be trained on this Rule in case it changes.

How might HIPAA training for nurses differ from HIPAA training provided to other members of the workforce?

The best way to answer this question is to start by defining “members of the workforce”. Under HIPAA, “workforce” means employees, volunteers, trainees, “and other persons whose conduct, in the performance of work for a covered entity, is under the direct control of such covered entity, whether or not they are paid by the covered entity”.

Therefore, a Covered Entity´s workforce could consist of public-facing individuals and individuals who have no interaction with the public or limited access to PHI – in which case the content of HIPAA training could vary significantly. Nonetheless, all members of the workforce should be trained on maintaining the privacy of PHI to prevent inadvertent violations of HIPAA.

Couldn´t all members of the workforce receive the same training?

In theory, yes. However, training every member of the workforce on procedures relating to (say) the disclosure of ePHI by certified EHT technology (CEHRT) is only going to be relevant to a small sub-set of the workforce. There is a lot of information for members of the workforce to absorb and retain – regardless of their roles – so it is a best practice to limit HIPAA training to what is relevant.