ARTICLE IN PRESS
Just between Us: An
Integrative Review of
Confidential Care for
Adolescents
Stacy Baldridge, MSN, RN, CNRN, CCRC, & Lene Symes, PhD, RN
ABSTRACT
Introduction: Confidential care is recommended for all adolescents to facilitate risk behavior screening and discussion
of sensitive topics. Only 40% of adolescents receive confidential care. The purpose of this integrative review is to
describe research related to the practice of confidential care
for adolescents. Evidence was analyzed to identify strategies to increase confidential care and improve risk behavior
screening.
Method: Whittemore and Knafl’s integrative literature review
process was applied.
Results: The 26 research articles included in this review included patients’, parents’, and physicians’ perspectives.
Confidential care practice is inconsistent. Strategies to improve
practice are known.
Conclusions: Four key elements should be considered to
establish a practice culture of confidential care for adolescents. Strategies for implementing the key elements of
confidential care and supporting resources for efficient use
of time alone are provided. J Pediatr Health Care. (2017) ■■,
■■-■■.
KEY WORDS
Adolescent, confidential, confidential care, risk behavior
Stacy Baldridge, PhD Student, Texas Woman’s University, College
of Nursing, Houston, TX.
Lene Symes, Professor, Texas Woman’s University, College of
Nursing, Houston, TX.
Conflicts of interest: None to report.
Correspondence: Stacy Baldridge, MSN, RN, CNRN, CCRC,
College of Nursing, Texas Woman’s University, 6700 Fannin St.,
Houston, TX 77030-2897; e-mail: sbaldridge@twu.edu
0891-5245/$36.00
Copyright © 2017 by the National Association of Pediatric Nurse
Practitioners. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.pedhc.2017.09.009
www.jpedhc.org
INTRODUCTION
All adolescents should receive screening for risk behaviors and preventive counseling. In 2017, Laura Searcy,
President of the National Association of Pediatric Nurse
Practitioners, called for education and universal screening for mental, behavioral, and substance use disorders
(Searcy, 2017). Adolescent participation in risk-taking
behaviors, such as smoking or drug use, is an established problem recognized by parents, consumers, and
health care professionals (Johnston, O’Malley, Miech,
Bachman, & Schulenberg, 2016; National Institute on
Drug Abuse [NIDA], National Institutes of Health [NIH],
& U.S. Department of Health and Human Services
[DHHS], 2017). Annual updates from the University of
Michigan’s Monitoring the Future study with NIDA, NIH,
and USDHHS make clear the extent of risk behaviors
related to alcohol and drug use (Figure 1; National
Institute on Drug Abuse, National Institutes of Health,
& U.S. Department of Health and Human Services, 2017).
In 2015, 27.1 million people aged 12 years or older
had used an illicit drug in the past 30 days, largely
marijuana and prescription pain relievers (Center for
Behavioral Health Statistics and Quality, 2016). If adolescents are afforded the opportunity for confidential
conversations, risk behaviors are more likely to be disclosed (American Academy of Pediatrics, 2016).
However, it is likely that only 40% of adolescents spent
confidential time with providers during preventive care
visits (Irwin, Adams, Park, & Newacheck, 2009). The
proportion of adolescents with chronic diseases who
receive confidential time may be even less. Nash, Britto,
Lovell, Passo, and Rosenthal (1998) found that only
27% of adolescent rheumatology patients (N = 52; n
= 14) had ever been interviewed alone.
Adolescents with chronic medical conditions may
participate in risk behaviors as much or more than their
healthy peers (Miauton, Narring, & Michaud, 2003;
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MARIJUANA
Nylander, Seidel, & Tindberg, 2014; Suris, Michaud, Akre,
& Sawyer, 2008; Suris & Parera, 2005). Borowsky,
Ireland, and Resnick (2009) studied the relationship
of health status to risk behaviors over time in youths
in the United States. They found that of 20,745 youth,
3,018 (14.5%) anticipated a high likelihood of early death.
The possibility of early death was a risk factor for participation in health-jeopardizing behaviors. Suris and
Parera (2005) found that despite the likelihood of more
frequent contact with health care professionals for adolescents with chronic conditions, such contact may not
be associated with a lower rate of risk behavior participation. Disease management is often the priority
during clinic visits, but providers should consider the
potential negative effects of risk behavior participation on the adolescent’s already compromised health
(Louis-Jacques & Samples, 2011; Nylander et al., 2014).
There is a need to understand the practice of confidential care as a potential facilitator of risk behavior
screening and intervention. The purpose of this integrative review is to describe research related to the
practice of confidential care for adolescents and to
answer the following questions.
• What is the current practice of confidential care?
• What are the facilitators of and barriers to confidential care?
• What is the perspective of parents and adolescents?
• What strategies support confidential care for
adolescents?
BACKGROUND
The Center for Medicaid and CHIP Services (2014) describes adolescent and provider time alone as potentially
“the most effective way to help the adolescent develop
engagement and autonomy on health-related issues as
well as to improve delivery of guidance on sensitive
2
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12th Grade
CIGARETTE
12.50%
11.00%
6.20%
4.90%
2.60%
10.50%
14.00%
5.40%
7.30%
ALCOHOL
10th Grade
22.50%
8th Grade
19.90%
33.20%
FIGURE 1. Past month use of alcohol, marijuana, and cigarettes of 8th, 10th, and 12th grade students
(National Institute on Drug Abuse, National Institutes of Health, & U.S. Department of Health and
Human Services, 2017).
E-CIGARETTE
topics” (p. 10). The
There is a need to
American Academy of
understand the
Pediatrics (2016) in the
practice of
Bright Futures guidelines recommend that
confidential care as
providers spend time
a potential
alone with children as
facilitator of risk
young as 11 years
during well-care visits.
behavior screening
The American Medical
and intervention.
Association’s (1997)
Guidelines for Adolescent Preventive Services recommends time alone with
adolescents during preventive care. The Society for Adolescent Medicine recommends that providers regularly
spend part of each visit alone with patients, beginning when they are in early adolescence (Ford, English,
& Sigman, 2004). Despite these recommendations, Irwin
et al. (2009) found that only 40% of adolescents (N =
3,038) had time alone with the provider at their most
recent preventive care visit.
Adolescents with chronic medical conditions are likely
to have relatively frequent visits with health care professionals, but parents are likely to be present during
the visit, which may inhibit confidential conversations between the provider and adolescent (Suris et al.,
2008). Britto, Rosenthal, Taylor, and Passo (2000) evaluated pediatric rheumatologists’ screening for risk
behaviors (n = 10 physicians and n = 178 patients)
and found that most patients were not screened for
risk behaviors before an educational intervention to
improve screening rates that were very low: fewer than
5% for alcohol, smoking, and marijuana and 12% for
sexual activity. The physicians described limited opportunities for confidential discussions. In an earlier
report, Britto et al. (1999) concluded that the parents
of adolescents with chronic conditions might be unlikely
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to leave adolescents alone with the physician during
a visit. Primary care providers also described parental involvement as a barrier to substance abuse screening
when parents refuse to leave the room (van Hook et al.,
2007). Limited time for visits was also described as a
barrier to provision of time alone (Britto et al., 2000;
McKee, Rubin, Campos, & O’Sullivan, 2011).
Clinician time alone with adolescents facilitates open
and honest conversations and fosters a confidential relationship to allow discussion of sensitive topics (Ford
et al., 2004). In addition to aiding discussion of sensitive topics, confidential care is also a factor in
adolescent decision-making to seek medical care. Adolescents in the United States who forgo medical care
because of concerns with confidentiality are a population at risk and are likely in need of health care
services (Lehrer, Pantell, Tebb, & Shafer, 2007). The
effect of confidential care extends beyond the immediate value of the interaction between provider and
patient to potentially reduce negative outcomes related
to high-risk behaviors and forgone medical care.
METHODS
The integrative literature review process described by
Whittemore and Knafl (2005) was followed for this
review. EBSCOHost (all databases, including CINAHL
and MEDLINE) and Scopus electronic databases were
queried for combinations of search terms of confidential care, confidential, and adolescent. Additional
publications were identified through ancestry search
methods used during the review of previously identified articles. No limitations were placed on country
or publication date. Inclusion criteria were reports of
primary studies regarding practice of confidential care
(specifically time alone) and reports of research related
to patient, provider, or parent perspectives regarding
confidential care or time alone with patients. Exclusion criteria were reports of studies focused on
confidentiality of medical records and studies detailing gynecologic physical examinations or abortions.
Although there may be value to understanding the practice of confidential visits for the purposes of gynecologic
examinations or abortions, those practices are beyond
the scope of this review. State laws and professional
society recommendations guide practice for confidential care of adolescents considering abortion (Braverman
et al., 2017). During the literature search phase, abstracts were reviewed for evaluation of inclusion/
exclusion criteria. Articles meeting inclusion criteria were
retrieved for full-text review. Data collection and evaluation considerations of selected studies included review
of the following criteria: sample population perspective (patient/parent/provider), research method, study
purpose, data collection and analysis, study conclusions, reference to professional guideline or tool, mention
of communication strategy or framework, themes, facilitators or barriers, and limitations.
www.jpedhc.org
The data analysis process followed Whittemore and
Knafl’s (2005) steps of data reduction, display, comparison, and drawing conclusions. A table of study
characteristics was developed, highlighting categories described in the data evaluation phase, such as
purpose, research method, population, variables, results,
and common themes. Quantitative and qualitative studies
were categorized and analyzed based on the study
population, noting patient, provider, and parent perspectives. Facilitators and barriers to confidential care
were highlighted, as were themes that emerged from
the analysis. Results are presented through a descriptive synthesis approach because of the inclusion of
studies incorporating various research methods
(Connelly, 2009). Evidence was evaluated using the
Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal (Newhouse, Dearholt, Poe,
Pugh, & White, 2007). The Johns Hopkins Nursing
Evidence-Based Practice includes evidence ratings for
the strength of research evidence (Levels I-V) and for
the quality of evidence (Grades A, B, and C; Newhouse
et al., 2007).
RESULTS
The initial search identified 507 articles. Titles and
abstracts were reviewed for inclusion/exclusion criteria, and 59 articles were identified for full-text and
ancestry review. Of those, 26 articles met the inclusion criteria for this integrative review (Figure 2).
Publications meeting inclusion criteria included
quantitative (n = 18), qualitative (n = 6), and mixed
methods research reports (n = 2). The excluded
publications included studies that did not describe
time alone, editorials, review articles, position statements, or reports describing legal implications and
practice without research findings.
Most quantitative studies were conducted using survey
methods. One study used a randomized-controlled research design. Study populations represented the
perspectives of adolescent patients, parents, and physicians, and combinations (Table 1). Most qualitative
studies were conducted with focus groups of parents
and/or adolescents. The mixed methods study evaluated physician practice and experience (McKee et al.,
2011; O’Sullivan, McKee, Rubin, & Campos, 2010).
Studies were synthesized and categorized to address
the questions posed for this review. Studies included
in this review were evaluated as having Levels I through
III strength of evidence, with quality ratings of A or
B. No studies were excluded based on quality, because
each showed value in answering questions relevant to
this review. All selected articles described studies conducted in outpatient settings, with provider specialties
including pediatrics, adolescent medicine, and family
practice. Studies were conducted in the United States,
New Zealand, and Australia. Publication dates ranged
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FIGURE 2. Literature review process.
from 1985 through 2017. A summary table of articles
is presented in Table 1, organized by perspectives of
patients, parents, and providers.
Review of Practice of Confidential Care
Ten studies provided frequency rates of clinician time alone
with patients, with most data based on recall by providers, patients, or parents. Two U.S. studies analyzed data
from the Medical Expenditure Panel Survey to review preventive care visits and time alone with providers (Edman,
Adams, Park, & Irwin, 2010; Irwin et al., 2009). Providers recalled that 34% to 40% of adolescents who had a
preventive care visit in the prior year had time alone with
the clinician. Age was significantly correlated with time
alone with the provider, and time alone was more likely
during a preventive care visit than other types of visits
(Edman et al., 2010). For patients who were not afforded time alone, authors noted the improbability of
screening in the sensitive areas of sexual health or substance abuse (Irwin et al., 2009).
Adolescent reports of time alone with providers to
receive confidential, private health care varied. In a
sample of New Zealand students in grades 8 through
12 (N = 9,107), 27% (n = 1,946) reported time alone
with a provider (Denny et al., 2012). U.S. studies showed
higher rates of time alone with a provider. In a nationally representative sample of U.S. adolescents (5th12th grade, N = 6,748), 58% reported time alone with
their provider (Klein, Wilson, McNulty, Kapphahn, &
Collins, 1999). Gilbert, Rickert, and Aalsma (2014) surveyed parents (n = 500) and adolescent patients (n =
504). Approximately half of adolescent parents
(n = 245) and fewer than half of adolescent patients
(n = 199) reported that the adolescent had some time
alone with a provider at the most recent visit. Across
studies, females and older adolescents were consistently more likely to report time alone with the provider
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(Denny et al., 2012; Gilbert et al., 2014; Klein et al.,
1999). In a survey of pediatricians, internists, and family
practice specialists (n = 1,630), 52% reported consistently spending some time alone with adolescent patients
(Purcell, Hergenroeder, Kozinetz, Smith, & Hill, 1997).
In a study of U.S. pediatric nephrologists (n = 66), 56%
reported routinely (over 90% of the time) interviewing teens alone (Hergenroeder & Brewer, 2001).
Respondents who interviewed patients alone were more
likely to report assessing sexual history. A similar relationship between time alone and assessment of sexual
history was found in a study of primary care physicians (n = 21). Of 144 visits that a parent attended,
physicians reported that 68% of visits included time
alone with the adolescent (O’Sullivan et al., 2010). Time
alone was significantly more likely to be reported for
patients receiving physical examinations and with a
sexual complaint. Overall, physician providers reported providing confidential care for over half of
adolescent visits. Similar results were found when researchers analyzed the transcripts of 49 pediatric and
family practice physicians’ interactions with 166 overweight adolescents during annual visits (Bravender et al.,
2014). Time alone was provided in approximately half
of the visits (n = 85). Physicians providing assurances of confidentiality were more likely to provide
time alone, and pediatricians offered time alone more
frequently than family practice physicians. Specific statements of confidentiality were provided in approximately
31% of visits (Bravender et al., 2014).
The University of Michigan implemented a quality
improvement project to improve delivery of confidential care and risk behavior screening. Participating
physicians (n = 44) reviewed charts for provision of
confidential care and subsequently implemented quality
improvement strategies to address barriers and change
practice. The baseline rate of time alone with patients
Journal of Pediatric Health Care
www.jpedhc.org
TABLE 1. Table of evidence
Perspective
Authors
Research method
N
Significant findings
Only 27% (n = 1,946) of students who had
accessed care in the previous year
reported confidential, private health care,
which was more common among
females and more common for older
adolescents.
Older adolescents noted preference of
confidentiality of information, noting the
risk of forgone care to avoid disclosure
of information.
Level III-A
1,123 boys,
1,315 girls
Adolescents who forgo care because of
confidentiality concerns are at risk and
likely in greater need of health care
services.
Level III-B
6,728 adolescents
Discussion of risks was more likely with
adolescents who had time alone with
providers. For adolescents reporting risk
behaviors, most had not discussed them
with providers.
58% of adolescents reported time alone
with their provider; time alone was more
frequent for females and for older
adolescents. Adolescents missed care in
efforts to hide information from their
parents.
Confidentiality assurances influenced
adolescent willingness to disclose
sensitive information and probability of
future visits.
Provider qualities of confidentiality and
honesty ranked higher than medical
knowledge for adolescents. Most
adolescents noted that providers lacked
in ensuring confidentiality, but parents
reported that providers possessed the
characteristic. Some adolescents
reported lack of trust and withholding
information from providers.
Level III-B
Adolescents
Denny et al.
(2012)
Quantitative
To determine the prevalence of health care
use and private and confidential health
care among a nationally representative
population of high school students
9,107 adolescents
Adolescents
Britto et al. (2010)
Qualitative
54 adolescents
Adolescents
Lehrer et al.
(2007)
Quantitative
Adolescents
Klein and Wilson
(2002)
Quantitative
Adolescents
Klein et al. (1999)
only
Quantitative
To understand adolescents’ preferences
for multidimensional aspects of privacy,
including psychological, social, and
physical, and confidentiality
(informational privacy) in the health care
setting
To examine risk characteristics associated
with citing confidentiality concern as a
reason for forgoing health care among a
sample of U.S. adolescents who
reported having forgone health care they
believed was necessary in the past year
To compare adolescents’ reports of topics
they wanted to discuss with providers
with what was actually discussed and
whether they talked about self-reported
health risks
To examine factors associated with access
to care among adolescents, including
gender, insurance coverage, and having
a regular source of health care
Adolescents
Ford et al. (1997)
Quantitative
562 adolescents
Adolescents/parents
Farrant and
Watson (2004)
Quantitative
To investigate the influence of physicians’
assurances of confidentiality on
adolescents’ willingness to disclose
information and seek future health care
To identify and compare perceptions of
health care service delivery held by
young people with chronic illness and
their parents
6,748 adolescents
53 adolescent
patients, 45
parents
Evidence grade
Level III-B
Level III-A
Level I-B
Level III-B
5
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Purpose
6
TABLE 1. Continued.
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Perspective
Authors
Research method
Gilbert et al.
(2014)
Quantitative
Adolescents/parents
McKee et al.
(2006)
Qualitative
Adolescents/parents
Rubin et al.
(2010)
Qualitative
Parents
Dempsey et al.
(2009)
Parents
Purpose
N
Significant findings
Evidence grade
Journal of Pediatric Health Care
To better understand how confidentiality
affects the delivery of preventive
adolescent health care by examining
adolescent and parent beliefs and the
relationship between confidentiality and
the number and subject matter of health
topics discussed at the last visit
To obtain perspectives of mothers and
daughters on facilitators of and barriers
to adolescent girls’ timely access to riskappropriate reproductive care
To obtain the perspectives of adolescent
males and their mothers about the
health care concerns of the adolescents
and provision of confidential care
504 adolescents,
500 parents
Approximately half of parents and patients
reported confidential care. The split visit
model supports the greatest mean
number of topics discussed.
Level III-A
22 mothers, 18
daughters
Level III-B
Quantitative
To understand parental opinions about
which topics should be discussed during
adolescent preventive health visits and
how best to incorporate adolescent
confidentiality into these visits
1,025 parents
Duncan et al.
(2014)
Quantitative
106 parents
Parents
Duncan et al.
(2011)
Quantitative
Parents
Edman et al.
(2010)
Quantitative
To better understand how tensions
(between guidance about adolescentfriendly care and parental involvement
impact to Type 1 diabetes mellitus
[T1DM] control) are reconciled in clinical
practice by identifying how frequently
adolescents with T1DM are seen alone
and exploring parents’opinions about this.
To document parental views regarding
confidentiality with adolescents, aiming to
identify topics that parents believe they
should be informed about despite an
assurance of confidentiality between their
child and the doctor and to document
harms and benefits that parents
associate with adolescents seeing
doctors alone
To examine rates of time alone with any
type of visit and preventive visit rates/
differences by age, gender
Mothers described their role as protector
and distrust of confidential care.
Daughters worried about violations of
confidentiality.
Adolescents verbalized distrust of the
process of confidential care. Mothers of
sons supported confidential care but
described feeling excluded. Adolescent
males described distrust of the provider
and concerns with confidentiality of
information.
Highlights disparity between parental
desire to be informed and confidentiality:
66% of parents noted the importance of
adolescent time alone with provider, but
almost half preferred full disclosure of
adolescents’ health information.
13% of parents reported adolescent time
alone with physician. Concerns with time
alone included not being informed of
important information or treatment plan.
3 groups with
mothers (n = 22), 2
groups with sons
(n = 20)
Level III-B
Level III-B
Level III-B
86 parents
Parents’ primary concern with confidential
care is a fear of not being informed about
important information. Researchers
describe disparity between parental
desire to be informed and confidentiality
laws and expectations.
Level III-B
4,302 parents/
caregivers
34% of adolescents had time alone with
provider. Time alone was more likely to
occur during a preventive care visit and
more likely for older adolescents.
Level III-A
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Adolescents/parents
www.jpedhc.org
TABLE 1. Continued.
Perspective
Authors
Research method
Purpose
N
Hutchinson and
Stafford (2005)
Quantitative
To explore the prevalence of parents who
have negative attitudes about teen
privacy and whether education can
influence a parent’s attitudes
188 parents
Parents
Irwin et al. (2009)
Quantitative
8,464 adolescents
Parents
Sasse et al.
(2013)
Qualitative
To examine receipt of preventive services,
including disparities in services received,
by using a nationally representative
sample of adolescents
To investigate the beliefs and opinions of
parents about confidential care for
adolescents
Parents
Tebb et al. (2012)
Qualitative
52 parents
Provider
Bravender et al.
(2014)
Quantitative
Provider
Hergenroeder
and Brewer
(2001)
Quantitative
Provider
Purcell et al.
(1997)
Quantitative
Provider
McKee, Rubin,
Campos, &
O’Sullivan
(2011)
Mixed methods
(report of
qualitative)
To explore the knowledge and attitudes
that Latino parents have about
confidential health services for their
teens and to identify factors that may
influence those attitudes
Objective examination of how often
confidentiality is ensured, how often
adolescents are seen alone, and which
physicians are more likely to do either
To determine pediatric nephrologists’
practices of sexual history taking and
diagnosis and treatment of sexually
transmitted infections in their adolescent
patients
To describe primary care physicians’
practices with regard to inviting parent(s)
to leave the room to interview the teen
alone, and the factors associated with
use of this technique
To describe primary care clinicians’
patterns of delivering time alone,
decision making about introducing time
alone to adolescents/parents, and
experiences delivering confidential
services
Evidence grade
Approximately half of parents believed that
doctors should speak with teens alone;
approximately 90% believed that teens
should be able to have time alone if
interested. The percentage of parents
disagreeing with confidential care
decreased after the educational
intervention.
40% met with doctor alone; it is unlikely
that screening or counseling related to
sensitive topics took place.
Level III-B
Parental role and trust in provider inform
opinions about confidentiality. There was
a disparity between parent preference
for information and confidentiality
guidelines for providers.
Wide range of knowledge of confidential
care, trust in clinician is critical. Parents
note desire to be informed.
Level III-B
Half of visits included time alone with
adolescents. Explicit statements of
confidentiality were provided in 31% of
visits.
Only 56% reported routine time alone with
adolescents; 55% consistently asked
females about sexual intercourse.
Level III-B
1,630 physicians
Only 52% of providers almost always/
always spent some time alone with
adolescent patients
Level III-B
20 physicians
(18 interviews)
Physicians describe time constraints as a
barrier to time alone. Scripts facilitate
time alone to include normative
statements and purpose of confidential
care.
Level III-B
17 parents
45 physicians
66 nephrologists
Level III-A
Level III-B
Level III-B
7
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Parents
Significant findings
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TABLE 1. Continued.
Perspective
Authors
Research method
Purpose
Significant findings
Providers reported that 68% of visits where
a parent attended included time alone
with the adolescent (out of 144 visits).
Provision of time alone was significantly
higher for visits with physical
examinations and slightly higher for
teens presenting with sex complaints.
Interventions led to increase in provision of
time alone, effective practice change,
and improved confidential care.
Level III-B
Half of providers often/always provide
opportunities for time alone (half
sometimes/seldom/never), with a larger
proportion of physicians reporting often/
always.
Lack of time was the most common barrier
to substance abuse screening; some
noted parents refusing to leave
adolescent alone as a barrier.
Level III
Provider
O’Sullivan et al.
(2010)
Mixed methods
(report of
quantitative)
To track primary care physicians’ time
alone with adolescent patients and to
identify key factors associated with its
provision
21 providers
Provider
Riley, Ahmed,
Lane, Reed, &
Locke (2017)
Quantitative
54 physicians
Provider
Wadman et al.
(2014)
Quantitative
Provider
van Hook et al.
(2007)
Qualitative
To assess whether a medical board
Maintenance of Certification Part IV
project could improve the delivery of
confidential care to minor adolescent
patients seen in outpatient primary care
practices
To investigate the knowledge and practice
of health care providers at Alberta
Children’s Hospital and to inform
practice about the adolescent’s right to
confidentiality
To identify barriers to adolescent
substance abuse screening in primary
care
389 providers
38 physicians
Evidence grade
Level III-B
Level III-B
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Journal of Pediatric Health Care
N
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was 77.3% (n = 706), and postintervention rates increased to 89.2% and 90.3% after two rounds of practice
intervention with associated increases in risk behavior screening throughout the project (Riley, Ahmed, Lane,
Reed, & Locke, 2017). In sum, the provision of time
alone was more likely for older adolescents or female
patients, or when visits were for preventive care, physical examinations, or evaluation of a sexual complaint.
Significant numbers of adolescents are not afforded time
alone with providers, which may represent a missed
opportunity for risk behavior screening. An intervention designed to increase time alone was effective but
still resulted in fewer than 100% of adolescents having
time alone with physician providers during visits. To
fully explore the practice of confidential care, an understanding of facilitators and barriers to the practice
is necessary. Both are presented below, with consideration given to the perspectives of adolescents and
their parents. Finally, strategies to improve confidential care are presented with evidence-based practice
improvement techniques.
Establishment of Trust Facilitates Confidential
Care
Trust between adolescent patient and provider, adolescent and parent, and parent and provider were
common themes in nine studies of confidential care.
A trusting relationship is developed when provider communication is honest and confidentiality is maintained.
Adolescents and parents hold these provider qualities in high regard (Farrant & Watson, 2004). In a survey
of adolescent diabetic patients and their parents (n =
53 patients, n = 45 parents), both ranked honesty higher
than medical knowledge as desirable provider qualities. Adolescents also ranked confidentiality higher than
medical knowledge. Compared with parents, fewer adolescents reported that specialty providers possessed
qualities of honesty and maintaining confidentiality
(Farrant & Watson, 2004). When adolescents have concerns about confidentiality, they may lie about behaviors,
avoid discussing sensitive topics, or forgo health care
altogether (Gilbert et al., 2014; Klein & Wilson, 2002;
Lehrer et al., 2007; Rubin, McKee, Campos, & O’Sullivan,
2010).
Adolescents are more willing to discuss sensitive topics
when they are assured of confidentiality (Bravender
et al., 2014; Ford, Millstein, Halpern-Felsher, & Irwin,
1997; Klein & Wilson, 2002). The only randomized controlled trial included in this review evaluated the impact
of confidentiality assurances on adolescents’ willingness to share health information or to seek health care.
Findings were based on the adolescents’ responses to
audio portrayals of a physician introduction (Ford et al.,
1997). Assurances of confidentiality influenced both adolescents’ willingness to disclose sensitive information
(substance use, sexuality) and their probability of seeking
health care in the future (Ford et al., 1997). The prowww.jpedhc.org
vision of confidential care establishes an environment
of trust that allows the adolescent an opportunity to
discuss risk behaviors they may not willingly share in
front of their parents (Klein & Wilson, 2002).
Adolescents who reported poor communication with
parents were more likely than those who reported better
communication to also report that confidentiality concerns were a barrier to seeking health care (Lehrer et al.,
2007). Parents described trust in the provider as integral to accepting their adolescent child receiving
confidential care (Sasse, Aroni, Sawyer, & Duncan, 2013;
Tebb, Hernandez, Shafer, Chang, & Otero-Sabogal, 2012).
Minority adolescent males (Rubin et al., 2010) and minority mothers of daughters verbalized distrust of the
process of confidential care (McKee, O’Sullivan, &
Weber, 2006). Mothers of daughters described their role
as being to protect their daughters. Exclusion of mothers
during confidential care of their daughters threatened that role, contributing to discomfort and distrust
of providers (McKee et al., 2006). Although many
mothers of sons described similar feelings of exclusion, overall they supported confidential care (Rubin
et al., 2010). Adolescent males described distrust of the
provider and concerns with confidentiality of information. Adolescent girls had similar fears, but they
appreciated the need for confidential care. Parents frequently differ from their children in perceptions of
provider trust and confidentiality, with adolescents
showing an underlying distrust of health care providers (Farrant & Watson, 2004).
Trust is both a facilitator of, and potential barrier
to, confidential care and the discussion of sensitive
topics. To engage in discussions about sensitive issues,
adolescents need providers to provide explicit assurances of confidentiality. Providers should consider the
perspectives of both adolescents and parents when planning and carrying out confidential care.
Parents Support Confidential Care but Want to
be Fully Informed
Findings from eight
To engage in
studies indicate that the
discussions about
three-way relationship
sensitive issues,
between parent, patient,
and provider often
adolescents need
complicates confidenproviders to
tial care for adolescents.
provide explicit
McKee et al. (2011) reported that tensions
assurances of
resulting from the threeconfidentiality.
way relationships may
affect delivery of confidential care when physicians try to honor those
complex relationships. Parents may appreciate the value
of confidential care yet a concurrent desire to be informed about everything that is discussed during the
visit, thereby negating the visit’s value (Dempsey, Singer,
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9
ARTICLE IN PRESS
Clark, & Davis, 2009; Duncan, Jekel, O’Connell, Sanci,
& Sawyer, 2014; Duncan, Vandeleur, Derks, & Sawyer,
2011; Gilbert et al., 2014; Tebb et al., 2012). Awareness of the discrepancy between adolescents and their
parents’ values, perceptions of confidential care, and
trust of providers is important when planning and delivering confidential care (Farrant & Watson, 2004).
Parental negative opinions about adolescent confidential care were successfully reduced using an education
intervention in an adolescent medicine clinical setting
(Hutchinson & Stafford, 2005).
Adolescents with concerns about confidentiality
may be at greater risk
Adolescents consistently report concerns with confidentiality or parental notification as a primary reason
to forgo health care (Britto, Tivorsak, & Slap, 2010; Ford
et al., 1997; Klein et al., 1999; Lehrer et al., 2007). To
further compound the problem, adolescents with concerns about confidentiality are often those with increased
vulnerability because of risk behavior participation
(Lehrer et al., 2007). Multiple studies have shown that
adolescents who do access health care may lie about
behaviors or may limit the topics of discussion, because
they believe that their information will not remain confidential (Gilbert et al., 2014; Klein & Wilson, 2002; Rubin
et al., 2010). Adolescents who are allowed to speak
privately with the provider are more likely to discuss
risk behaviors; they are also more likely to discuss a
greater number of risk behaviors and to provide more
detail about those behaviors (Gilbert et al., 2014; Klein
& Wilson, 2002). Adolescents with confidentiality concerns place themselves at greater risk by avoiding health
care or concealing the truth (Britto et al., 2010; Ford
et al., 1997; Gilbert et al., 2014; Klein & Wilson, 2002;
Klein et al., 1999; Lehrer et al., 2007; Rubin et al., 2010).
Strategies to create a culture of confidential care
Confidential care is frequently practiced in the context
of preventive care, consistent with the focus of those
visits on risk assessment and anticipatory guidance rather
than an acute medical concern (Edman et al., 2010;
Hutchinson & Stafford, 2005; O’Sullivan et al., 2010).
Barriers to confidential care include parent and provider knowledge gaps, providers’ lack of comfort and
lack of consistent practice, and process issues related
to having time for confidential care during visits (Riley
et al., 2017). Consistent practices of confidential care
supported by education and by communication that
confidential care for adolescents is normative and purposeful are effective strategies to introduce confidential
care and develop family trust in confidential care (Lehrer
et al., 2007; McKee et al., 2011). Standard scripts for
providing confidentiality assurances are associated with
an increased likelihood of providers spending time alone
with the patient (Bravender et al., 2014; McKee et al.,
2011; Riley et al., 2017). Providers should consider their
10
Volume ■■ • Number ■■
state’s confidentiality requirements when developing
a script. A simple example as follows.
Everything we discuss with you today is confidential
with three exceptions: if you are at risk of immediate harm; if you are putting someone else at risk of
immediate harm; if someone else is putting you in immediate harm (Wadman et al., 2014, p. e13).
Scripts should include normative statements and
purpose, such as “We do this for all teens … to encourage good communication” (McKee et al., 2011,
p. 39). A split-visit model, where a portion of the visit
is conducted with the provider and the patient and the
remainder of the visit is conducted with parents present,
facilitates confidential care. A greater number of topics
were discussed in the split-visit model compared with
visits with no confidential care or visits that were completely confidential (Gilbert et al., 2014). Motivational
interviewing techniques are associated with assurances of confidentiality and may improve delivery of
confidential care (Bravender et al., 2014).
In addition to educating providers, parents, and patients about state confidentiality laws, the rationales for
confidential care, and scripts to introduce time alone,
documentation reminders, prompts, and role-play activities increase provider comfort with confidential care
(Riley et al., 2017). Once time alone is established, multiple resources are available to guide assessing for risk
behaviors (Table 2). The American Academy of
Pediatrics’s (2016) Bright Futures Recommendations for
Preventive Pediatric Health Care recommend initiation of alcohol and drug screening at 11 years of age.
Extensive resources are available from the organization, including the CRAFFT (Car, Relax, Alone, Forget,
Friends, Trouble) screening tool for alcohol and other
drugs (American Academy of Pediatrics, 2016). The
American Medical Association’s Guidelines for Adolescent Preventive Services addresses health care delivery,
anticipatory guidance, medical and risk behavior screening, and immunizations for patients aged 11 through
21 years (1997). Additional risk behavior screening tools
include the HEEADSSS method of interviewing (Home
environment, Education and employment, Eating, peerrelated Activities, Drugs, Sexuality, Suicide/depression,
and Safety from injury and violence) and the 21question Rapid Assessment for Adolescent Preventive
Services screening tool (Klein, Goldenring, & Adelman,
2014; Salerno, Marshall, & Picken, 2012). A summary
of strategies to develop a practice culture that supports confidential care is presented in Table 3.
DISCUSSION
The aim of this integrative review was to identify facilitators and barriers to confidential care and strategies
to support implementing and providing confidential care.
Many adolescents are not afforded time alone with
Journal of Pediatric Health Care
ARTICLE IN PRESS
TABLE 2. Risk behavior screening tools and resources
Tool/Resource
Description
American Academy of
Pediatrics Bright Futures
Comprehensive guidance for
preventive care screenings
Alcohol and Brief Intervention for
Youth: Practitioners Guide
CRAFFT screening tool
Comprehensive resource
Guideline for Adolescent
Preventive Services (GAPS)
HEADDSSS
National Institute on Drug
Abuse: Evidence-Based
Screening Tools for Adults
and Adolescents
Rapid Assessment for
Adolescent Preventive
Services (RAAPS) tool
Society for Adolescent Health
and Medicine Screening Tools
Substance Abuse and Mental
Health Administration
6 questions, high-risk alcohol/
drug use
Comprehensive guide with
screening tools (61-72
questions for adolescent, 15
questions for parent)
Psychosocial history interview
tool
Resource materials and
evidence-based screening
tools
https://brightfutures.aap.org/Pages/default.aspx
https://brightfutures.aap.org/Bright%20Futures%20Documents/
Screening.pdf
https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/
YouthGuide.pdf
http://www.ceasar-boston.org/CRAFFT/
Elster AB, Kuznets NJ, eds. AMA Guidelines for Adolescent Preventive
Services (GAPS): Recommendations and rationale. Baltimore, MD:
Williams & Wilkins; 1994.
http://contemporarypediatrics.modernmedicine.com/contemporary
-pediatrics/content/tags/adolescent-medicine/heeadsss-30
-psychosocial-interview-adolesce?page=0,0
https://www.drugabuse.gov/nidamed-medical-health-professionals/
tool-resources-your-practice/screening-assessment-drug-testing
-resources/chart-evidence-based-screening-tools-adults
21-question screening tool for
adolescent risk behaviors
https://www.raaps.org/
Clinical care guidelines and
screening tools for alcohol
and drugs
Resource guide and screening
tools, including Screening,
Brief Intervention, and
Referral to Treatment
https://www.adolescenthealth.org/Topics-in-Adolescent-Health/
Substance-Use/Clinical-Care-Guidelines/Screening-Tools.aspx
providers. Based on findings from the U.S. studies, it
seems likely that more than 40% of adolescents do not
receive confidential care or receive it very infrequently (Edman, Adams, Park, & Irwin, 2010; Irwin et al.,
2009). Older adolescents, females, or those with sexual
complaints or the need for a private physical examination are more likely to receive confidential care than
younger adolescents or males or those who do not
present with symptoms suggesting the need for privacy
(Denny et al., 2012; Gilbert et al., 2014; Klein et al.,
1999; O’Sullivan et al., 2010). Trust emerged from the
analysis as both necessary for effective confidential care
and as difficult to establish, influenced by the relationships between adolescent and parent, parent and
provider, and adolescent and provider. Provider assurances of confidentiality emerged as a strategy to
increase adolescents’ trust of the provider, because such
assurances are directly associated with an adolescent’s willingness to divulge sensitive information (Ford
et al., 1997). Providers should be cognizant of the potential negative outcomes related to failure to provide
confidential care. The evidence confirms the value of
confidential care in providing an environment in which
adolescents are more likely to discuss risk behaviors
(Gilbert et al., 2014; Klein & Wilson, 2002).
Practice Implications
Nurse practitioners who provide care to adolescents
should implement confidential care if they are not
www.jpedhc.org
Link
https://www.samhsa.gov/sbirt/resources
already providing it consistently. In the search for literature for this review, no studies were found that
evaluated nurse practitioners’ provision of confidential care to adolescents. Simple techniques of chart
reminders, interview scripts, education for staff and patients, and motivational interviewing strategies can be
implemented to facilitate the practice of confidential
care. Recognizing the risk associated with a lack of confidential care should encourage providers to allow
adolescent patients opportunities for time alone during
clinical encounters. Acknowledgement of, and respect
for, the autonomy of adolescents can serve as the springboard for implementation of patient-centered
communication strategies to simplify confidential care.
Assurances of confidentiality and education for both
patients and parents are integral to the process. When
adolescents are not allowed opportunities for confidential discussion of sensitive topics or high-risk
behaviors, we may be placing them at greater risk.
Limitations
Limitations of this review are in the relatively low level
of evidence of most of the studies, which were primarily survey studies and qualitative focus groups.
Although these methods are appropriate for identifying practice patterns, limitations of self-reporting affects
the results, leaving questions to be answered regarding the true practice of confidential care. In addition,
the focus was on physician care. These limitations set
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11
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TABLE 3. Developing a practice culture that supports confidential care
Strategy
Focus
Educate providers/staff
Confidentiality laws
Best practices
Implications of confidential care
Risk behavior screening tools
Establish practice
policies
Confidential care
Risk behavior screening guidelines
Risk behavior screening tools
Provide parent/
adolescent education
Confidentiality laws
Visit structure/expectations
Implement a
communication plan
Scripts
• Assurance of confidentiality
• Introduction of confidential care
• Purpose of confidential care
normative statements
Define visit structure for parents
Incorporate motivational interviewing
Process of confidential care (include
front desk/support staff)
Documentation
Practice culture
Consistency
Split visit structure
Standardized risk tools
Establish workflow
practices
Methods
Conduct baseline chart review/practice survey to determine current
practice and knowledge/attitudes to inform education initiatives
Develop and provide
• Online education modules
• In services
• Handouts
Develop and disseminate policies for
• Providing confidential care
• Screening for risk behaviors
Review screening tools and decide which screening tools will be
used in the practice
Develop and use
• Handouts for staff, parents, and patients
• Practice welcome letter to parents
• Posters in waiting rooms/examination rooms (state laws)
Written script for various provider/support roles
• Purpose: “to promote effective communication; to take better
care of … ”
• Normative: “We do this for all adolescents,” “It’s our routine”
• Assurance of confidentiality
Role play with scripts for various office staff
Meet patients where they are
Role play scenarios: introducing confidential care to
parents/adolescents
Routine evaluation of individuals and practice to ensure methods for
establishing confidential care are being implemented consistently
Medical record reminder flags and documentation templates
Sources: Bravender et al. (2014); Gilbert et al. (2014); Lehrer et al. (2007); McKee et al. (2011); Riley, Ahmed, Lane, Reed, & Locke
(2017); Rubin et al. (2010).
the stage for future reWhen adolescents
search to address the
are not allowed
gap in studies of nursing
practice. There is a sigopportunities for
nificant opportunity for
confidential
nurses to be a part of
discussion of
the solution for the confidential care problem,
sensitive topics or
through leading confihigh-risk
dential care in advanced
behaviors, we may
practice or supporting
confidential care as a
be placing them at
part of the extended
greater risk.
care team. Although
some studies identified lack of time as a
barrier to the provision of confidential care, none identified strategies for overcoming that barrier. Also largely
missing was attention to the specific issue of confidential care for adolescents with chronic illnesses. The
gap in research regarding practice of confidential care
by nurse practitioners, strategies for managing issues
related to lack of time, and issues of confidential care
for adolescents with chronic illness suggest topics for
future research.
12
Volume ■■ • Number ■■
CONCLUSION
All adolescents should be allowed confidential care at
every encounter with a health care professional. Strategies to implement confidential care exist and should
be implemented in practice. Comprehensive practice
change initiatives are likely required to significantly
improve the rates of confidential care and facilitate effective risk behavior screening.
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