Disclosure of confidential information by mental health nurses,of patients they assess to be a risk of harm to self or others: An integrative review

There is a duty of confidentiality on the part of mental health nurses when they handle confidential patient information. Nonetheless, it may be necessary to disclose confidential information of a patient if the patient is assessed as being a risk to self or others, to protect the patient or others from harm. However, disclosing information inappropriately may constitute a breach of confidentiality. There is a paucity of information on how mental health nurses understand the rules of confidentiality when deciding to withhold or disclose confidential information in these circumstances. An integrative review of the literature was undertaken to explore the disclosure of confidential information by mental health nurses when they assess a patient as being a risk of harm. The findings indicate the rules of confidentiality are not well understood, or are not adhered to by mental health nurses. Risk assessments were found to underpin deliberations to withhold or disclose confidential information of a patient, despite risk being difficult to predict with any certainty. For risk assessment, mental health nurses were noted to prefer their unstructured clinical judgement over actuarial methods; and defer to their clinical intuition over scores of a structured risk assessment instrument, when making structured clinical judgement‐backed decisions in this area of their practice. Gaps in the literature that may be addressed by future empirical research were revealed during this integrative review.     

Cognitive Continuum Theory: Can it contribute to the examination of confidentiality and risk-actuated disclosure decisions of nurses practising in mental health?

Nurses practising in mental health are faced with challenging decisions concerning confidentiality if a patient is deemed a potential risk to self or others, because releasing pertinent information pertaining to the patient may be necessary to circumvent harm. However, decisions to withhold or disclose confidential information that are inappropriately made may lead to adverse outcomes for stakeholders, including nurses and their patients. Nonetheless, there is a dearth of contemporary research literature to advise nurses in these circumstances. Cognitive Continuum Theory presents a single-system intuitive-analytical approach to examining and understanding nurse cognition, analogous to the recommended single-system approach to decision-making in mental health known as structured clinical judgement. Both approaches incorporate cognitive poles of wholly intuition and analysis and a dynamic continuum characterised by a ‘common sense’ blending of intuitive and analytical cognition, whereby cues presented to a decision-maker for judgement tasks are weighed and assessed for relevance. Furthermore, Cognitive Continuum Theory promotes the importance of determining pattern recognition and functional relations strategies, which can be used to understand the operationalisation of nurse cognition.     

Patient decision-making regarding left ventricular assist devices : A multiple case study

ObjectivesTo understand how patients make decisions regarding a left ventricular assist device (LVAD).DesignA qualitative multiple case study design was used to explore the context and influence of individuals regarding patients’ decision-making processes through: 1) detailed, in-depth interviews of those mostly involved in the patient’s decision and 2) pertinent data including observations, medical records, educational information and physical artifacts. Data clusters and patterns of co-occurring codes were examined using thematic analysis.Main outcome measuresThemes were extrapolated from individual case summaries to provide an in-depth analysis of each case and a cross-case analysis across the multiple cases. The predominant theme, consistent with other studies, was the salience of survival.FindingsThis case study approach revealed new themes beyond those of prior studies. Patients considered: 1) self-care management for patients without a caregiver, 2) acceptability and future expectations of the LVAD and 3) the role of nurses in eliciting patients’ fears, values and preferences.ConclusionThe patients’ decision-making processes regarding an LVAD involve a cost-benefit analysis of the anticipated needs and consequences of the LVAD. Acceptability of the device is relevant to clinical practice and public policy. Nurses have a unique role in seeking patients’ concerns, an essential component of shared decision-making.     

Infant removal from birth parents - how does health information impact court decisions? A scoping review

ProblemCourts make complex decisions daily regarding removal of infants from birth parents and placement in out-of-home care. Nurses and other health professionals often take part in such processes, either as court informants, witnesses, or via their role delivering healthcare to infants and/or birth parents involved. To date there has been very little research exploring how health information impacts upon decision-making about infant removal.AimTo explore how health information impacts court decisions about removing infants from birth parents.MethodsUsing Arksey and O'Malley's five-stage method for scoping reviews as a guide, eight electronic databases were searched to identify relevant studies published in peer reviewed journals between 1990 and 2020. After initial screening, 154 articles were assessed for eligibility, resulting in 10 relevant studies.FindingsThree overarching themes emerged: (1) Communication between courts and health professionals; (2) Professional bias; (3) Infant attachment and reunification.DiscussionIn many jurisdictions, children's courts operate as closed courts making scrutiny of decisions difficult. Across jurisdictions there is also a widespread lack of recognition in legislation of infancy as a unique developmental stage. Clarity of communication and understanding between health professionals and courts is needed for health information to be applied in consistent ways in court decision making.ConclusionThe role of health information in court decision-making is unclear and heterogeneous. More research is needed if nurses and other healthcare professionals are to have clarity regarding best practice provision of information, to assist courts with decisions about infant removal.     

Nurses’ perspectives regarding the disclosure of errors to patients: A qualitative study

BackgroundThere is often a mismatch between patients’ desire to be informed about errors and clinical reality. In closing the “disclosure gap” an understanding of the views of all members of the healthcare team regarding errors and their disclosure to patients is needed. However, international research on nurses’ views regarding this issue is currently limited.ObjectivesExplore nurses’ attitudes and experiences concerning disclosing errors to patients and perceived barriers to disclosure.DesignInductive, exploratory study employing semi-structured interviews with participants, followed by conventional content analysis in which investigators read and discussed transcribed data to identify important themes.SettingsNursing departments from hospitals in two German-speaking cantons in Switzerland.ParticipantsPurposive sample of 18 nurses from a range of fields, positions in organisational hierarchy, work experience, hospitals, and religious perspectives.MethodsData were collected via individual, face-to-face interviews using a researcher–developed semi-structured interview guide. Interviews were transcribed in German and analysed using the qualitative data analysis software package Atlas-Ti (Berlin) and conventional content analysis. The most illustrative quotes were translated into English.ResultsNurses generally thought that patients should be informed about every error, but only a very few nurses actually reported disclosing errors in practice. Indeed, many nurses reported that most errors are not disclosed to the patient. Nurses identified a number of barriers to error disclosure that have already been reported in the literature among all clinicians, such as legal consequences and the fear of losing patients’ trust. However, nurses in this study more frequently reported personal characteristics and a lack of guidance from the organisation as barriers to disclosure. Both issues suggest the need for a systematic institutional approach to error disclosure in which the decision to inform the patient stems from within the organisation and is not shouldered by individual nurses alone.ConclusionsOur study suggests that hospitals need to do more to support and train nurses in relation to error disclosure. Such measures as hospitals establishing a disclosure support system, providing background disclosure education, ensuring that disclosure coaching is available at all times, and providing emotional support for all parties involved, would likely go a long way to address the barriers identified by nurses.     

Parent disclosure of complementary health approaches used for children with autism spectrum disorder: Barriers and facilitators

Background and objectivesComplementary health approaches (CHA) are widely used among children with autism spectrum disorder (ASD). As part of shared treatment decision-making, healthcare providers are encouraged to discuss CHA with parents of children with ASD. Yet prior research suggests that parents often do not disclose CHA used for children, and their reasons for nondisclosure are poorly understood. We, therefore, aimed to identify barriers and facilitators to parent disclosure of CHA used for children with ASD.Design and settingIn-depth interviews were conducted with 31 parents who reported that they were currently using CHA for their child’s ASD in Denver, Colorado or Portland, Oregon.ResultsWe used content analysis to identify six main themes indicating that the following factors play a role in disclosure: parents’ drive to optimize their child’s health, parent self-efficacy discussing CHA with healthcare providers, parent beliefs about the effectiveness of CHA, parent-provider relationship quality, provider attitudes and knowledge regarding CHA and ASD, and visit characteristics.ConclusionsStudy findings suggest that family and health system factors, together, influence parent disclosure of CHA used for children with ASD. Multifaceted intervention concurrently targeting the CHA-related knowledge, beliefs, and self-efficacy of parents whose children have been recently diagnosed with ASD, in addition to the CHA-related attitudes and knowledge of their healthcare providers may promote disclosure and shared treatment decision-making about the use of CHA.     

Clinical decision-making in the intensive care unit: A concept analysis

AimTo operationally define clinical decision-making as it relates to intensive care unit nursing.BackgroundClinical decision-making is an intricate cognitive process that is demanding on intensive care nurses due to the severity of their patients’ illnesses, consistent exposure to high-stakes situations, and prevalent patient mortality. When compromised, it can lead to adverse patient events. However, clinical decision-making specific to the intensive care unit is a concept seldom defined in nursing research.DesignConcept analysis.MethodsUsing Walker and Avant’s eight-step method, nursing databases were searched for studies between 1980 and 2022 describing the antecedents, defining attributes, consequences, and empirical referents of clinical decision-making in the intensive setting.FindingsIntensive care unit clinical decision-making is a complex cognitive process in which nurses recognize a clinical problem in their patient and respond promptly by implementing interventions to improve their patient’s rapidly and frequently changing health status to a more favorable condition in an intensive care setting. The defining attributes are: assessment of the patient situation, prompt recognition of cues, efficient comprehension of patient data abnormalities, prior knowledge and experience, prompt response to the clinical problem(s), colleague collaboration, formulation of interventions to treat clinical problem(s), and appraisal of risks/benefits.ConclusionIntensive care unit clinical decision-making is a skill that is different from traditional clinical decision-making in nursing. Prompt action characterizes this concept due to the unstable health status of these patients. More research on this concept is needed to enhance nurse performance and patient outcomes in intensive care.Implications for clinical practiceA definition of this concept opens doors for potential studies on promoting effective decision-making among intensive care nurses. This can improve the safety and outcomes of critically ill patients. Additionally, it generates new questions regarding how nursing schools and hospital orientation programs can promote and develop competent decision-making skills in future intensive care nurses.     

Reducing uncertainty in triaging mental health presentations: Examining triage decision-making

Little is known about how emergency department (ED) nurses make decisions and even less is known about triage nurses’ decision-making. There is compelling motivation to better understand the processes by which triage nurses make decisions, particularly with complex patient populations such as those with frequently emotive mental health and illness issues. While accuracy and reliability of triage decisions generally have been improved through the introduction of standardised triage scales and instruments, other factors such as lack of knowledge or confidence related to mental health issues, past experiences that may elicit transference and countertransference, judgments about individuals based on their behavioural presentations may impact on decisions made at triage. In this paper, we review the current research regarding the effectiveness of triage tools particularly with mental health presentations, present a theoretical framework that may guide research in understanding how triage nurses approach decision-making, and apply that framework to thinking about research in mental health-related triage. Developing a better understanding of how triage nurses make decisions, particularly in situations where issues related to mental health and illness may raise the levels of uncertainty, is crucial to ensure that they have the skills and tools they need to provide the most effective, sensitive, and compassionate care possible.     

Nurses' perspectives on advance directives before the establishment of the new well-dying law in Korea: A mixed methods study

AimThis study explored the attitudes, experiences, and perceptions of Korean nurses toward advance directives (ADs) before the establishment of new Well-Dying Law.MethodsA sequential explanatory mixed method design was applied. We administered a constructed questionnaire on attitudes toward ADs and end-of-life issues and experience related to end-of-life decision-making. A Korean-translated version of the KAESAD [Knowledge-Attitudinal, Experimental Survey on ADs] was administered by 245 nurses. Semi-structured interviews (N = 16) were audio-recorded, transcribed, and coded in a qualitative content analysis.ResultsThe quantitative results revealed the nurses' perspectives on ADs: that valuing patient's autonomy, authority, or rights is vital to the implementation of ADs and end-of-life decision-making. Also, nurses reported that patients should be knowledgeable and informed about ADs. These responses allowed us to generate an interview, which revealed four themes in adopting the Well-Dying Law, including ADs. Themes with ‘benefits’ and ‘roles of health care providers’ mainly supported the quantitative results. Themes with ‘ethical issues,’ such as disagreement between patients and family members on ADs, and ‘preparation,’ regarding adopting the new law, should be importantly considered when implementing ADs in clinical settings.ConclusionsOur study highlights that nurses need to develop sufficient knowledge on the laws, and communication skills to help patients be knowledgeable and make their own decisions regarding ADs. To successfully adopt the Well-Dying Law, our findings suggest that a nationwide public campaign and a continuing education program for nurses to manage ethical issues regarding ADs are required.     

Confidentiality in occupational health care: a matter of advocacy.

Occupational and environmental health nurses play an important role in establishing and maintaining employee confidentiality. Preserving confidentiality transcends simple nondisclosure of private information and consists of an agreement between the employee and the health professional regarding the boundaries of shared secrets. Health professionals must be aware of specific limitations to confidentiality and convey these limits to employees. Occupational and environmental health nurses must restrict employer access to employee medical records. Open and honest communication is necessary to establish the appropriate boundaries of confidentiality and strengthen the employee/employer/health professional relationship.     

Forensic mental health: Perceptions of transition and workforce experiences of nurses

BackgroundWith the growing need for nurses in forensic mental health settings, understanding the experiences of transition and perceptions of the setting is important to support staff retention.AimTo explore registered nurses’ experiences of working in a forensic mental health setting. In particular, to understand their transition experience, perceptions of the practice environment and intention to stay within the setting.MethodsRegistered nurses employed in a high-secure forensic mental health hospital in New South Wales, Australia, completed an online survey including the Revised Professional Practice Environment Scale and Nurse Retention Index.FindingsSixty-nine participants responded to the survey. During the first year of their employment, participants reported feeling isolated, lacking support and being anxious when providing patient care. In terms of the environment, participants perceived ‘internal work motivation’ as positive in the environment when compared to ‘handling disagreement and conflict’. While many intended to continue their nursing careers for the foreseeable future, 45.3% of participants were undecided about whether they would leave the forensic setting.DiscussionDue to the complexity of forensic mental health practice, the reporting of poor experiences of transition and issues regarding support and conflict is concerning. Considering the importance of workplace culture and teamwork in forensic mental health, strategies to enhance positive interpersonal relationships is essential.ConclusionGiven the predicted future workforce shortages, this study highlights a need for appropriate supports for nurses’ transitioning into forensic mental health employment to enhance workplace satisfaction and retention.     

Information-seeking behaviours and decision-making process of parents of children with cancer

PurposeThis study aimed to explore the information-seeking behaviours, perceptions and decision-making experiences of parents of children with cancer by employing semi-structured interviews.Methods and sampleA qualitative research design was used to assess the information-seeking behaviours, perceptions and decision-making processes used by parents in Turkey whose children have cancer. Interviews were conducted with 15 parents of children with cancer using a semi-structured interview schedule. The interviews were recorded and transcribed verbatim.ResultsSix main issues emerged. Issues were related to parents' information needs, the sources of information, difficulties that the parents encountered when seeking information, the decision-making process, the factors affecting decision-making, and expectations from the health team. Information resources for parents included medical doctors and nurses, the internet, friends and the parents of other children who were staying in the hospital. The parents mostly sought information about their child's illness, prognoses, treatment, side-effects and care giving issues. The parents expressed that they were directed primarily by health care providers during their decision-making process.ConclusionsAdequate and systematic information pertaining to illness, treatment, prognosis and child care must be provided by health care professionals throughout the illness process. In addition, individual guidance and spare time are key components to helping parents make decisions about their children with cancer.     

Return-to-work success despite conflicts: an exploration of decision-making during a work rehabilitation program*

Abstract

Purpose: Collective decision-making by stakeholders appears important to return-to-work success, yet few studies have explored the processes involved. This study aims to explore the influence of decision-making on return-to-work for workers with musculoskeletal or common mental disorders.

Method: This study is a secondary analysis using data from three earlier multiple-case studies that documented decision-making during similar and comparable work rehabilitation programs. Individual interviews were conducted at the end of the program with stakeholders, namely, the disabled workers and representatives of health care professionals, employers, unions and insurers. Verbatims were analysed inductively.

Results: The 28 decision-making processes (cases) led to 115 different decisions-making instances and included the following components: subjects of the decisions, stakeholders’ concerns and powers, and types of decision-making. No differences were found in decision-making processes relative to the workers’ diagnoses or return-to-work status. However, overall analysis of decision-making revealed that stakeholder agreement on a return-to-work goal and acceptance of an intervention plan in which the task demands aligned with the worker’s capacities were essential for return-to-work success.

Conclusion: These results support the possibility of return-to-work success despite conflictual decision-making processes. In addition to facilitating consensual decisions, future studies should be aimed at facilitating negotiated decisions.

• Implications for rehabilitation

• Facilitating decision-making, with the aim of obtaining agreement from all stakeholders on a return-to-work goal and their acceptance of an intervention plan that respects the worker’s capacities, is important for return-to-work success.

• Rehabilitation professionals should constantly be on the lookout for potential conflicts, which may either complicate the reach of an agreement between the stakeholders or constrain return-to-work possibilities.

• Rehabilitation professionals should also be constantly watching for workers’ and employers’ return-to-work concerns, as they may change during work rehabilitation, potentially challenging a reached agreement.

     

Confidential registration in health services: randomised controlled trial

Background

Human rights legislation safeguards the privacy and dignity of patients.

Objective

To assess the effectiveness in terms of patient assessed privacy of confidential registration.

Design

Randomised controlled trial.

Setting

Emergency Department, University Hospital of Wales.

Participants

A total of 302 patients aged over 15 years.

Main outcome measures

Binary choices and ordinal visual analogue scores from a validated questionnaire on self reported measures: patient ability and preference to speak to receptionists and disclose confidential information without being overhead and concern about disclosure of items of confidential personal information.

Results

Patients who registered in a screened area felt significantly more able to tell receptionists things they did not want others to hear. Control patients were significantly more concerned than intervention patients that others heard their name, address, date of birth, reason for emergency department attendance, and telephone number, but not their marital status. Overall, intervention patients were less concerned about disclosure of information and that they had been overheard.

Conclusions

Patients value privacy when they register and are concerned if others can hear them tell receptionists who they are, how to contact them, and why they are there. Confidential registration should be instituted in health services. Confidential registration increased patient privacy and should be instituted in health services.     

Access to confidential sexual health services

The authors conducted one-on-one interviews with adolescent females, aged 13 to 16, concerning their perception of the confidentiality of sexual health services available to them. Participants were selected from an urban school with a youth health centre (YHC) and also from a rural school without access to a YHC. They typically viewed traditional health services as not confidential and reported concern about disclosure to parents. This qualitative study suggests that adolescent females have an absolute need to maintain positive parental regard by preventing disclosure of sexual activity.