Although most Covered Entities fulfil the basic requirements of HIPAA training for nurses, these may not always be enough to prevent avoidable HIPAA violations, data breaches, and patient complaints. Therefore, it is recommended Covered Entities provide annual refresher training to ensure nurses consider HIPAA best practices when carrying out their functions.
The rules relating to HIPAA training for nurses are quite clear. Covered Entities are required to “train all members of its workforce on policies and procedures with respect to PHI […] as necessary and appropriate for members of the workforce to carry out their functions within the Covered Entity” (45 CFR § 164.530) and “implement a security and awareness training program” (45 CFR § 164.308).
It may also be necessary to provide further HIPAA training for nurses when a material change in policies and procedures affects nursing functions, when a risk assessment identifies a need for training, or when training is a requirement of an OCR corrective action plan. However, additional training of this nature happens infrequently – potentially allowing poor practices to creep in.
Why Poor HIPAA Practices Can Creep In
Healthcare professionals have very busy work schedules which make it impractical for Covered Entities to remove nurses from the workplace to attend HIPAA training when it is not mandated. Consequently, many nurses only receive HIPAA training when they first join a Covered Entity´s workforce and periodically thereafter through the security and awareness training program.
Due to the need for healthcare professionals to work as efficiently as possible, it can be the case that shortcuts are taken with HIPAA compliance “to get the job done”. When shortcuts develop into unofficial methods of working, it becomes the cultural norm to abandon HIPAA best practices to the extent that HIPAA violations occur frequently without them being recognized as HIPAA violations.
This was what happened in a case study published by the Journal of Nursing Education and Practice. The case study discusses an event in which a nursing assistant – who was studying for her RN qualification at the same facility she was employed at – disclosed PHI during a coursework presentation. Threatened with termination, the nursing assistant argued that she had only disclosed as much information as other nurses and nursing assistants did during hand-off reports.
After an investigation into the poor HIPAA practices that had crept into the nursing unit, the nursing assistant was suspended from the training course for one term (rather than being expelled from the training course and sacked from her job). On her return to the course, she was required to prepare a 30-minute presentation for newly-admitted nursing students on HIPAA compliance. Ultimately, the nursing assistant graduated from the training course and successfully completed the NCLEX-RN.
The Case for Refresher HIPAA Training for Nurses
The case study demonstrates the volume of work involved in dealing with a relatively minor HIPAA violation. Multiple senior healthcare professionals were involved in responding to the initial violation, investigating the unofficial methods of working in the nursing unit, and retraining nurses and nursing assistants to carry out their functions in compliance with HIPAA.
All this work – and the costs involved – may have been avoided if refresher HIPAA training for nurses had been provided to prevent shortcuts being taken and poor HIPAA practices creeping in. Refresher HIPAA training for nurses fills the gaps between initial policy and procedure training and security awareness training to support HIPAA compliance in all healthcare operations.
Furthermore, compared to the resources required to address the HIPAA violation and its cause (as reported in the case study), refresher HIPAA training for nurses can be provided in online modules that can be taken individually by nurses as time allows. This eliminates workplace disruption and prevents the scenario in which nurses are unable to carry out functions because they are training.
One further advantage of online, modular refresher training is that it is easier to document. In many cases, documentation is provided automatically via an LMS – enabling Covered Entities to comply with the Privacy Rule requirement to document all training to demonstrate compliance with the training requirements in the event of an OCR audit, inspection, or investigation.
How Often Should Refresher Training be Provided?
Compliance experts feel refresher HIPAA training for nurses should be provided at least annually in order to reinforce best practices and keep HIPAA compliance “at top of mind”. However, the frequency of refresher training could also be determined by a risk assessment that identifies poor practices creeping in, or a material change to policies and procedures with respect to PHI.
With regards to how to deliver refresher training, the most important consideration is the ease with which refresher training can accommodate busy work schedules – which is why the online, modular method of providing refresher training is recommended. Online, modular refresher HIPAA training for nurses also gives Covered Entities the option to pick and choose which modules are taught to better address issues identified in risk assessments or required by OCR corrective action plans.