Confidential Discussions Research Articles

Differences in Receipt of Time Alone with Healthcare Providers Among US Youth Ages 12-17.

Time to meet privately with a health care provider can support optimal adolescent health, but numerous barriers exist to implementing this practice routinely. We examined parent reports on their children aged 12 to 17 from a nationally generalizable sample to quantify the presence of time alone with health care providers at the state and national level, as well as socio-contextual correlates using logistic regression analysis. We estimated that only 1 in 2 adolescents had a confidential discussion at their last medical visit. Certain child, family, and health care factors were associated with lower likelihood for having had confidential discussions. Specifically, adolescents who were Asian; did not have mental, emotional, or behavioral problems; were uninsured; or lived in households with parents who were immigrants, less educated, or did not speak English had significantly lower odds for having had time alone compared with referent groups. Clinical and structural efforts to rectify these gaps may assist a broader share of youth in benefiting from private health care discussions with providers.

After "The Talk": Adolescents' Perspectives Reveal Need for Improvement in Hospital Sexual Health Care Delivery.

To fill access gaps for adolescents, addressing sexual and reproductive health (SRH) is recommended in nontraditional settings. In previous improvement work, we increased documentation of sexual history to >80% of adolescents hospitalized on our pediatric hospital medicine (PHM) service. This study assessed adolescents' perception of SRH conversations with hospital providers and the extent to which they were helpful. Postdischarge survey of patients 13 to 17 years discharged from the PHM service at an academic children's hospital between August 2019 and March 2020. Survey items included demographics; whether confidential discussion of sexual health topics such as contraception, sexually transmitted infection (STI), and sexual orientation occurred; perceptions of these discussions, and sexual history. Eighty-three patients enrolled and 44 (53%) completed the survey after discharge. A total of 68% of respondents were female and median age was 15 years (interquartile range 14-16). A total of 77% reported discussing SRH privately with a PHM provider. A total of 18% recalled discussing condoms, and 63% rated the discussion helpful. A total of 27% of females reported discussing birth control, and 40% rated it helpful. A total of 57% recalled discussing sexual orientation, and 40% rated it helpful. None reported discussions of STI testing with PHM. Of the 23% who were sexually active, none reported being given condoms. Analysis of adolescent patient experiences identified opportunities for continued improvement in the content and quality of SRH discussions, specifically regarding offering STI testing, condom distribution, and sexual orientation conversations. Our work highlights the importance of incorporating patient-reported data into improvement work to ensure providers are addressing targeted gaps in adolescent care.

Improving resident experience during the pediatric intensive care unit rotation

BackgroundIt was recognized through rotation evaluations that residents were dissatisfied with their Pediatric Intensive Care Unit (PICU) experience. It is essential to consistently review resident satisfaction and intervene in a timely manner, as resident dissatisfaction may impact well-being. ObjectiveThrough PICU rotation evaluations and confidential discussion with pediatric residents, key drivers of resident dissatisfaction were identified. A multidisciplinary PICU improvement team was formed, interventions were developed, and a key driver diagram was created. Our aim was to have a minimum of 50% of participating residents agree that implemented interventions were beneficial to their PICU experience upon completion of their PICU rotation. Design/MethodsThe key driver diagram focused on 5 areas: expectation of knowledge, structure of rounds, resolution of conflicts, patient load, and nursing experience. Interventions began in April 2020. The improvement team consistently discussed the status of implementation, as well as met formally on a quarterly basis. Resident satisfaction was evaluated and monitored with three tools: intensivist and PICU rotation evaluations during the study period, pre- and post-mock code surveys during the study period, and a post-intervention satisfaction survey following the study period. ResultsThe post-intervention satisfaction survey revealed that ten of the eleven interventions were reported as either occurring regularly or overall beneficial by 55% to 100% of residents, with an average of 80%. 100% of residents reported the following interventions to be beneficial: being exposed to PICU before their formal rotation, participating in bedside teaching, and completing online modules of core PICU topics. Only 27% of residents agreed that the transport nurse routinely took transport calls during rounds, making this the only intervention that did not regularly occur. Pre- and post-mock code surveys revealed that 67% of residents participated in a mock code and 100% of participating residents agreed that the code was beneficial. Resident evaluations of the PICU rotation revealed that overall resident satisfaction with the rotation improved from 78% to 88%. Resident evaluations of attending intensivists revealed that 75% of intensivists had either sustained or improved resident satisfaction. ConclusionThis study demonstrates that timely and successful creation of an improvement team in response to resident dissatisfaction can be beneficial to residents’ rotation experience and well-being.

News, Equity Action Plan, In Memoriam

News, Equity Action Plan, In Memoriam

Integrating CFIR-ERIC and e-Delphi Methods to Increase Telegeriatrics Uptake.

Participatory implementation methods are needed in geriatric health care to improve care and services for a growing population of older adults. We describe an efficient participatory approach to improve uptake of Geriatric Research Education and Clinical Center (GRECC) Connect, a national geriatrics outpatient consultation service using telehealth technology to connect geriatric specialists to rural, older veterans though community-based clinics. We designed a three-phase participatory method to identify high-priority implementation strategies to support the uptake of GRECC Connect. We used the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) Strategy Matching Tool to derive expert-recommended implementation strategies informed by qualitative interviews with both GRECC Connect staff and clinicians at community-based clinics. We engaged expert panelists in a participatory two-step modified e-Delphi process using confidential surveys and discussion to prioritize strategies nationally. Qualitative interviews revealed barriers, facilitators, and recommendations for program uptake. Many strategies recommended by CFIR-ERIC addressed multiple barriers but needed to be tailored to our specific context. In our two-step e-Delphi process, expert panelists shared previous experience with the strategies presented, views on the importance and feasibility of each, and arrived at a consensus about which strategies to prioritize nationally. We demonstrate the feasibility and benefits of engaging subject matter experts to identify strategies to be tested on a national level. Future considerations include weighting of survey responses, accounting for regional differences, and sensitivity of Likert scales used in the e-Delphi process.

Preferences and experiences of women with epilepsy regarding sexual and reproductive healthcare provision

Rationale: Women with epilepsy (WWE) have unique disease-specific considerations regarding their sexual and reproductive health (SRH), which impact decision-making around pregnancy and contraception. Understanding their perspectives, preferences, and experiences regarding SRH care contributes to optimizing patient-centered clinical practice. MethodsWe conducted individual semi-structured interviews with WWE aged 18–45 years, exploring their SRH care experiences and preferences. We audio-recorded and transcribed all interviews. Two coders used both inductive and deductive strategies to perform thematic analysis and identify key themes and representative quotes. ResultsTwenty WWE completed interviews (median age 23 years; range 18–43 years). Key themes included: 1) SRH counseling from neurologists often did not occur, was limited in scope, or contained misinformation, especially during adolescence and early adulthood. In particular, participants felt that they received poor counseling about contraception, fertility, folic acid, and teratogenic medications, which impacted their reproductive decision-making. 2) WWE report fragmented care between their neurologist and other SRH providers. 3) WWE prefer that their neurologists initiate routine comprehensive discussions about SRH. 4) Conversations about SRH should begin in adolescence and include private confidential discussions between neurologists and WWE. 5) Successful SRH conversations between neurologists and WWE involve detailed information, reassurance, and support for the patient’s reproductive goals. ConclusionWWE desire comprehensive, coordinated counseling and care regarding SRH and epilepsy, and often experience suboptimal SRH care. Better understanding of the SRH needs, preferences, and experiences of WWE will help inform interventions to optimize patient-centered SRH counseling and care by healthcare professionals, especially during adolescence.

Addressing Systemic Racism by Creating a Diversity, Equity, and Inclusion Department Initiative

The ongoing COVID-19 pandemic has underscored the need to optimize care for one of the most affected sectors: older adults in nursing homes and more specifically highly vulnerable populations such as residents with dementia. Research developed in collaboration with stakeholders can optimize impact, relevance, and trustworthiness of study findings thereby informing advances in care. Yet, evidence on stakeholder driven research for enhancing dementia care is limited. This symposium will provide examples of stakeholder-driven research questions that were addressed with stakeholder engagement. First, we will present current evidence about the perspectives of caregivers, including those from communities of color. The second presentation will discuss the perspective of clinical training stakeholders responsible for supporting system-wide clinical program implementation and their experiences with early and later adopter nursing homes within the context of a clinical trial. The third presentation will address the perspective of policy makers and payers via the effect of state-mandated dementia training on resident outcomes. The fourth and final present the findings from a study that examined how nursing home stakeholders responded to a payor requirements for pharmacy services and the relationship between that response and patient outcomes. We will conclude the session with a discussion of stakeholder-engagement methods and recommendations for future nursing home research, which champions stakeholder collaboration.

Effective Screening and Treatment to Reduce Suicide Risk Among Sexual and Gender Minority Youth.

Effective Screening and Treatment to Reduce Suicide Risk Among Sexual and Gender Minority Youth.

News, Events, Publications, and Awards

News, Events, Publications, and Awards

Reverse techniques as a means of increasing the validity of the cardio-oculometric diagnostics

The article presents empirical data confirming the validity of our assumption that the use of reverse modes in operations with visual stimuli presented on the eyetracker screen allows us effectively assessing the degree of respondents’ honesty in work. It is shown that the combination of modes "authentic view" with the "reverse view" significantly facilitates performing all tests by the respondents, simplifies the procedure of their self-determination in their personal choice and makes their participation in research an interesting and attracting event. It is noted that a comparison of the gaze parameters obtained in these modes can serve as an additional indicator of the degree of subjective significance of various visual stimuli elements for respondents. It is also shown that the use of reverse modes, visual stimuli of personal orientation, active participation of respondents in the discussion of all oculometric and oculographic data obtained therewith increases the motivation of interviewees to validate various types of information content and confidential discussion of even unpopular questions

Opportunities to Improve Sexual and Reproductive Care Among Hospitalized Adolescents.

Improved access to sexual and reproductive care (SRC) improves adverse outcomes among adolescents, yet barriers continue to exist. Although the continued declining rate of adolescent pregnancy over the past decades is encouraging, adolescents in the United States still experience disproportionately high rates of unplanned pregnancy and sexually transmitted infections (STIs) compared with adolescents in other industrialized countries.1–3 Nearly 90% of adolescent pregnancies are unplanned, leading to increased risk for preventable outcomes, including preterm delivery, low birth weight, and neonatal mortality.4,5 In addition, unintended teen-aged pregnancy is associated with reduced education attainment and career earning potential.6 Rates of STIs among adolescents remain high, with nearly 1 in 4 girls testing positive for an STI annually.7 In addition, only half of adolescents are fully vaccinated against the human papillomavirus (HPV), leaving those who are unvaccinated at risk for developing HPV-associated cancers.8 Despite multiple national organizations advocating for provision of comprehensive care for adolescents at every clinical encounter, adolescent reproductive and sexual health needs often go unmet.9,10 In light of recent events, including the COVID-19 pandemic as well as the current administration’s health care reform policies, access to evidence-based SRC is even further decreased, particularly among vulnerable populations, including adolescents; thus, efforts to address these needs are now more critical than ever.11,12 Many adolescents, particularly those at highest risk for unintended pregnancy and STIs, have limited access to SRC because of numerous barriers, including poor access and confidentiality concerns.13–15 Open parent-teenager communication regarding sexual and reproductive health promotes reduced risk behaviors, but most teenagers do not receive these discussions with their parents, guardians, or health care providers.16 Among …

Inappropriate Adults? A Review of the Current Use of Appropriate Adults in the Criminal Justice System

Appropriate Adults (AAs) are an important procedural safeguard for young and vulnerable people in a criminal investigation. The significance of their role is recognised by Parliament in the Police and Criminal Evidence Act 1984 (PACE) and the appending Codes of Practice, most notably Code C. However, the ability of AAs as to perform their role is being impeded by a lack of clarity around their status and the rules that they are governed by. Often at the behest of lawyers, AAs are excluded from the conversations which lawyers have with their clients as a pragmatic solution to the uncertainty in the status of AAs. This means that AAs are rarely able to properly perform their vital role. Consequently, vulnerable people are not receiving the meaningful support they should receive. This represents a missed opportunity to protect the rights and interests of vulnerable people in the criminal justice system. When AAs are deployed effectively and appropriately, they can empower young or vulnerable suspects in an adversarial criminal justice system which, in turn, can help recalibrate the scales of justice to allow for a fairer outcome. This article will examine and critique the state of the current law, clarify the law on Legal Professional Privilege (LPP) and how that relates to Aas and propose a modest incremental extension to the principles of confidentiality to cover confidential discussions between AAs and young or vulnerable people in the criminal justice system.

The patient needs assessment in cancer care: identifying barriers and facilitators to implementation in the UK and Canada

PurposePersonalised information and support can be provided to cancer survivors using a structured approach. Needs assessment tools such as the Holistic Needs Assessment (HNA) in the UK and the Comprehensive Problem and Symptom Screening (COMPASS) questionnaire in Canada are recommended for use in practice; however, they are not widely embedded into practice. The study aimed to determine the extent to which nurses working in cancer care in the UK and Manitoba value NA and identify any barriers and facilitators they experience.MethodOncology nurses involved in the care of cancer patients in the UK (n = 110) and Manitoba (n = 221) were emailed a link to an online survey by lead cancer nurses in the participating institutions. A snowball technique was used to increase participation across the UK resulting in 306 oncology nurses completing the survey in the UK and 116 in Canada.ResultsParticipants expressed concerns that these assessments were becoming bureaucratic “tick-box exercises” which did not meet patients’ needs. Barriers to completion were time, staff shortages, lack of confidence, privacy, and resources. Facilitators were privacy for confidential discussions, training, confidence in knowledge and skills, and referral to resources.ConclusionMany busy oncology nurses completed this survey demonstrating the importance they attach to HNAs and COMPASS. The challenges faced with implementing these assessments into everyday practice require training, time, support services, and an appropriate environment. It is vital that the HNA and COMPASS are conducted at optimum times for patients to fully utilise time and resources.

Social relations in late adolescence and incident coronary heart disease: a 38-year follow-up of the Swedish 1969–1970 Conscription Cohort

ObjectivesIncreasing evidence suggests that low social support is associated with an elevated risk of coronary heart disease (CHD). Earlier studies in this field were conducted in predominantly middle-aged or older...

Horizontal Well Frac-Driven Interactions: Types, Consequences, and Damage Mitigation

Management Interactions between fractures in adjacent horizontal wells and development of methods for mitigating their costly negative effects has become the focus of much discussion and debate within the fracturing community. The impetus for this attention has been the impact of these interactions on productivity and mechanical integrity of these wells. Faced with these challenges, a group of 15 subject-matter experts representing different parts of the fracturing community held a 2-day meeting in December 2018 for a very open and confidential discussion of the technical foundation of the various aspects of the subject: what are the root causes of these interactions, their types, consequences, industry experience with various mitigating actions, and what has worked and what has not. At the conclusion of the meeting, the group decided to prepare a report of its deliberations and make it available as a service to the industry. Soon after the start of the discussions, the group recognized the multiplicity of terms used for each of the various aspects of the subject. Furthermore, these terms were viewed to be vague and without a descriptive technical foundation. Having been developed during the early days of discovery of these events, they generically identified them as problems with minimum regard to the technical roots of their occurrence, variations in their types, or cause-and-effect relationships that may exist between the type of events and their impact on well productivity or mechanical integrity. Development of proper technically-based terms and their definitions were the first outcome of the group’s deliberations. The terms defined below are reflective of the relevant applicable technologies and are intended to be descriptive of the physical events that occur during these events that control their behavior. It is the group’s hope that use of these terms will increase clarity and accuracy to the extensive technical content currently devoted to this subject. To start with, the term “frac-driven interaction (FDI)” was recommended for defining the broader overall subject. This term is offered as replacement for “frac hit,” “frac bashing,” “frac intersection,” etc., all of which have a negative connotation. It was argued that a neutral term is more suited for describing these events, since all FDIs do not harm adjacent passive wells. Some of them can in fact provide valuable information about engineering characteristics of the created fractures and detecting their existence and identifying their type can serve a useful purpose by offering the information needed for the next generation of fracturing treatments. Additionally, the term “frac hit” projects an unnecessarily negative impression to the public, environmental groups, and state and federal regulating agencies. The definitions offered to identify the status of wells and fracturing are listed below. Active well. The well where fracturing (or refracturing) operations are currently taking place. Passive wells. Wells offset to the active well. These wells may be shut in and their pressure monitored for diagnostic purposes. In practice, these wells are often already fractured.

Medical Directors: Why Do You Abdicate Your Advocacy With Nursing Homes?

Medical Directors: Why Do You Abdicate Your Advocacy With Nursing Homes?

Abstracts of the British Psychosocial Oncology Society Annual Conference, 8-9 March 2018, Southampton, UK.

Background: Personalised information and support can be provided to cancer survivors using a structured approach. Assessment tools such as the Holistic Needs Assessment (HNA) in the UK and the Comprehensive Problem and Symptom Screening (COMPASS) in Canada have been recommended for use in practice. However, completion of the HNA/COMPASS is not widely embedded into practice and Clinical Nurse Specialists (CNSs) express concern about their ability to respond to issues raised by patients. Aims: To investigate CNS's views on HNAs/COMPASS and identify barriers and facilitators to implementation. Methods: This international on‐line survey using a snowball technique recruited CNSs across the UK and one Canadian province (Manitoba) in 2017. Results: A total of 306 CNSs in the UK and 162 in Canada completed the on‐line survey. In the UK, HNAs were completed primarily prior to and immediately after treatment. In Canada, COMPASS was usually completed at every appointment. Participants expressed concerns that HNAs/COMPASS were becoming “tick‐box exercises” which did not meet patients' needs. Barriers to completion were time, staff shortages, lack of confidence, privacy and signposting of resources. Facilitators were privacy for confidential discussions, training, confidence in knowledge and skills, and signposting of resources. Conclusions: That so many busy CNSs completed this survey demonstrates the importance they attach to HNAs and COMPASS. The challenges faced with implementing these assessments into everyday practice require training, time, support services and an appropriate environment. It is vital that the HNA and COMPASS are conducted at optimum times for patients to make the best use of time and resources.

Seeking sexual health information? Professionals' novel experiences of the barriers that prevent female adolescents seeking sexual health information.

Objective Sexual health professionals are key stakeholders in implementing sexual health intervention programmes, yet their views are largely absent from the literature. Sexual health professionals provide a unique perspective on teen sexual health issues as they engage in confidential discussions with a wide range of teenagers. This study aimed to provide an in-depth exploration of professionals' perceptions of teenagers' sexual health information seeking practices and barriers. Furthermore, the research provided a unique re-examination of key predictors of risky sexual behaviours, which have been highlighted by previous research. Methods Nine semi-structured interviews were undertaken with sexual health professionals to explore their perceptions of teenagers' sexual health information seeking practises and barriers. Subsequently the professionals rank ordered the 57 factors identified in previous research in terms of their perceived importance in predicting risky sexual behaviours. Results Four themes emerged: "society and media"; "environment and family"; "peer influences"; and "the self". The rank order task confirmed that 33 of the 57 factors were perceived as highly important by sexual health professionals. Conclusion Society, peers, environment and family are perceived as barriers to teenagers seeking reliable sexual health information, but these are dependent on the individual person. An individual with higher self-esteem is more confident in seeking sexual health information and applying this knowledge appropriately. Self-esteem was also identified as a key perceived predictor of risky sexual behaviours. Therefore, there is scope for intervention programmes targeting self-esteem and knowledge, so teenagers have the confidence to seek out sexual health information and to make their own informed sexual health decisions.

Politics, Security and Early Ideas of ‘Greater Malaysia’, 1945-1961

The formation of the Federation of Malaysia in 1963 remains a source of much debate among historians. The official announcement by the Prime Minister of Malaya, Tunku Abdul Rahman, on 27 May 1961, urging a closer association of Malaya, Singapore and the three British-controlled Borneo territories is viewed by some studies as the trigger that led to the formation of Malaysia on 16 September 1963. While this study recognizes that Tunku’s proposal of May 1961 was a catalyst to the formal negotiations, it shows through a closer scrutiny of Colonial Office documents that the idea of a super-federation or “grand design” had been gradually planted in the minds of the elites in Malaya, Singapore and the Borneo territories, particularly from the early 1950s and that these confidential discussions were crucial to the acceptance of the basic premise of such a grand federation. It argues further that Tunku’s suggestion of a broader federation to Lord Perth in June 1960 merely speeded up the formal discussions for the federation that was already being seriously considered at the time by Colonial Office and British officials in the Borneo territories and Singapore. Thus the new federation was not merely a result of ‘local developments’ in Southeast Asia, but was also a by-product of a concerted effort in the Colonial Office to create a broader entity in Southeast Asia.

Service robots: System design for tracking people through data fusion and initiating interaction with the human group by inferring social situations

In a situation where a robot initiates conversation with a group of people, questions such as “where is the people group?” and “whether the robot should approach them?” should be addressed. This paper develops a new system that enables a robot to determine whether or not it should approach the aforementioned human group and interact with them after identifying what the current social situation is. The system is mainly to fuse depth-related data to track the positions of a group of people, extract social cues of those people by using depth-related data and a decision network (DN) model, and the main challenge lies in understanding the social cues of the group and the current underlying social situation concerning the relation between the robot and the group. The social cues are based on Proxemics and F-formations, whereas the social situations are categorized as individual-to-individual, individual-to-robot, robot-to-individual, group-to-robot, robot-to-group, confidential discussion and group discussion. Our system proceeds as follows : once a group of people are detected and the social cues of that target group of people are extracted, the corresponding social situation is appropriately inferred, and in turn the robot decides whether it should initiate conversation with the group based on rules to be specified later. The conducted experimental results demonstrate the properness of the system design and the efficacy of the proposed method in recognizing the social cues among individuals of the group as well as the nature of the social situations concerning the group and the robot.