"Starting that Conversation Is Even Harder than Having It": Female Patients' Perceptions of Physicians' Communication Competence in Communication about Sexual Behavior.

Female college students demonstrate a persistent lack of knowledge about safe sexual practices and engage in sexual behavior that puts them at risk for sexually transmitted infections and unplanned pregnancy. Physicians have an opportunity to provide accurate and timely information about safe sexual behavior to individuals in their care. However, many young people, and in particular young women, are reticent to talk to their physicians about sexual behavior because they typically consider the information to be private. Exacerbating this issue is the fact that many physicians are also uncomfortable discussing sexual topics with their patients. In this study, Communication Privacy Management (CPM) theory is used to investigate the criteria that female college students employ to negotiate the disclosure and concealment of information about sexual behavior in communication with physicians. Qualitative analysis of semi-structured interviews with female college students was used to explain their perceptions of disclosure of sexual behaviors to their physician. Specifically, the participants' perceptions of physicians' communication competence informed privacy management rules. These findings have the potential to improve communication interventions for both female college students and healthcare professionals.

Conceptualization and operationalization: utility of communication privacy management theory.

Communication Privacy Management (CPM) theory explains one of the most important, yet challenging social processes in everyday life, that is, managing disclosing and protecting private information. The CPM privacy management system offers researchers, students, and the public a comprehensive approach to the complex and fluid character of privacy management in action. Following an overview of Communication Privacy Management framework, this review focuses on recent research utilizing CPM concepts that cross a growing number of contexts and illustrates the way people navigate privacy in action. Researchers operationalize the use of privacy rules and other core concepts that help describe and explain the ups and downs of privacy management people encounter.

Surrogate decision makers and proxy ownership: challenges of privacy management in health care decision making.

This study explored the communicative experiences of surrogates who served as decision makers for patients who were unable to convey health information and choices about treatment options. Drawing on assumptions from communication privacy management theory (Petronio, 2002), 35 surrogates were interviewed to explore how they navigated the role of guardian of patients' private health information while the patient was hospitalized. This research determined that not only are surrogates guardians and thereby co-owners of the patients' private health information, they actually served in a "proxy ownership" role. Surrogates described obstacles to both obtaining and sharing private health information about the patient, suggesting that their rights as legitimate co-owners of the patients' information were not fully acknowledged by the medical teams. Surrogates also described challenges in performing the proxy ownership role when they were not fully aware of the patient's wishes. Theoretical and practical implications of these challenges are discussed.

Making decisions for hospitalized older adults: ethical factors considered by family surrogates.

BACKGROUND: Hospitalized older adults frequently have impaired cognition and must rely on surrogates to make major medical decisions. Ethical standards for surrogate decision making are well delineated, but little is known about what factors surrogates actually consider when making decisions. OBJECTIVES: To determine factors surrogate decision makers consider when making major medical decisions for hospitalized older adults, and whether or not they adhere to established ethical standards. DESIGN: Semi-structured interview study of the experience and process of decision making. SETTING: A public safety-net hospital and a tertiary referral hospital in a large city in the Midwest United States. PARTICIPANTS: The study included 35 surrogates with a recent decision-making experience for an inpatient aged 65 or older. MEASUREMENTS: The key factors that surrogates considered when making decisions. Interview transcripts were coded and analyzed using the grounded theory method of qualitative analysis. RESULTS: Surrogates considered patient-centered factors and surrogate-centered factors. Patient-centered factors included: (1) respecting the patient's input, (2) using past knowledge of the patient to infer the patient's wishes, and (3) considering what is in the patient's best interests. Some surrogates expressed a desire for more information about the patient's prior wishes. Surrogate-centered factors included: (1) surrogate's wishes as a guide, (2) surrogate's religious beliefs and/or spirituality, (3) surrogate's interests, and (4) family consensus. CONCLUSION: Our study indicates that surrogate decision making is more complex than the standard ethical models, which are limited to considerations of the patient's autonomy and beneficence. Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences, models of surrogate decision making must account for these additional considerations. Surrogates' desire for more information about patients' preferences suggests a need for greater advance care planning.

Disclosing medical mistakes: a communication management plan for physicians.

INTRODUCTION: There is a growing consensus that disclosure of medical mistakes is ethically and legally appropriate, but such disclosures are made difficult by medical traditions of concern about medical malpractice suits and by physicians' own emotional reactions. Because the physician may have compelling reasons both to keep the information private and to disclose it to the patient or family, these situations can be conceptualized as privacy dilemmas. These dilemmas may create barriers to effectively addressing the mistake and its consequences. Although a number of interventions exist to address privacy dilemmas that physicians face, current evidence suggests that physicians tend to be slow to adopt the practice of disclosing medical mistakes. METHODS: This discussion proposes a theoretically based, streamlined, two-step plan that physicians can use as an initial guide for conversations with patients about medical mistakes. The mistake disclosure management plan uses the communication privacy management theory. RESULTS: The steps are 1) physician preparation, such as talking about the physician's emotions and seeking information about the mistake, and 2) use of mistake disclosure strategies that protect the physician-patient relationship. These include the optimal timing, context of disclosure delivery, content of mistake messages, sequencing, and apology. A case study highlighted the disclosure process. CONCLUSION: This Mistake Disclosure Management Plan may help physicians in the early stages after mistake discovery to prepare for the initial disclosure of a medical mistakes. The next step is testing implementation of the procedures suggested.

A case of error disclosure: a communication privacy management analysis.

To better understand the process of disclosing medical errors to patients, this research offers a case analysis using Petronios's theoretical frame of Communication Privacy Management (CPM). Given the resistance clinicians often feel about error disclosure, insights into the way choices are made by the clinicians in telling patients about the mistake has the potential to address reasons for resistance. Applying the evidenced-based CPM theory, developed over the last 35 years and dedicated to studying disclosure phenomenon, to disclosing medical mistakes potentially has the ability to reshape thinking about the error disclosure process. Using a composite case representing a surgical mistake, analysis based on CPM theory is offered to gain insights into conversational routines and disclosure management choices of revealing a medical error. The results of this analysis show that an underlying assumption of health information ownership by the patient and family can be at odds with the way the clinician tends to control disclosure about the error. In addition, the case analysis illustrates that there are embedded patterns of disclosure that emerge out of conversations the clinician has with the patient and the patient's family members. These patterns unfold privacy management decisions on the part of the clinician that impact how the patient is told about the error and the way that patients interpret the meaning of the disclosure. These findings suggest the need for a better understanding of how patients manage their private health information in relationship to their expectations for the way they see the clinician caring for or controlling their health information about errors. Significance for public healthMuch of the mission central to public health sits squarely on the ability to communicate effectively. This case analysis offers an in-depth assessment of how error disclosure is complicated by misunderstandings, assuming ownership and control over information, unwittingly following conversational scripts that convey misleading messages, and the difficulty in regulating privacy boundaries in the stressful circumstances that occur with error disclosures. As a consequence, the potential contribution to public health is the ability to more clearly see the significance of the disclosure process that has implications for many public health issues.

Navigating ethics of physician-patient confidentiality: a communication privacy management analysis.

The ethics of physician-patient confidentiality is often fraught with contradictions. Privacy boundaries are not always clear, and patients can leave an interaction with their physicians feeling uncomfortable about the security of their private medical information. The best way to meet confidentiality and privacy management expectations that patients have may not be readily apparent. Without realizing it, a physician may communicate a patient's information in ways that are inconsistent with that person's perceptions of how his/her medical information should be treated. A proposed model is presented as a tool for physicians to better serve the privacy and confidentiality needs of their patients. This model depends on the communication privacy management (CPM) perspective that emerged from a 35-year research program investigating how people regulate and control information they consider private and confidential. A physician's use of this model enables the ability to establish a confidentiality pledge that can address issues in understanding the best way to communicate about privacy management with patients and more likely overcome potential negative outcomes.

Communicating with clinicians: the experiences of surrogate decision-makers for hospitalized older adults.

OBJECTIVES: To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult. DESIGN: Semistructured interviews about a recent hospitalization. SETTING: Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital. PARTICIPANTS: Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died). MEASUREMENTS: Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory. RESULTS: Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences. CONCLUSION: In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support.

A conceptual model of the role of communication in surrogate decision making for hospitalized adults.

OBJECTIVE: To build a conceptual model of the role of communication in decision making, based on literature from medicine, communication studies and medical ethics. METHODS: We proposed a model and described each construct in detail. We review what is known about interpersonal and patient-physician communication, described literature about surrogate-clinician communication, and discussed implications for our developing model. RESULTS: The communication literature proposes two major elements of interpersonal communication: information processing and relationship building. These elements are composed of constructs such as information disclosure and emotional support that are likely to be relevant to decision making. We propose these elements of communication impact decision making, which in turn affects outcomes for both patients and surrogates. Decision making quality may also mediate the relationship between communication and outcomes. CONCLUSION: Although many elements of the model have been studied in relation to patient-clinician communication, there is limited data about surrogate decision making. There is evidence of high surrogate distress associated with decision making that may be alleviated by communication-focused interventions. More research is needed to test the relationships proposed in the model. PRACTICE IMPLICATIONS: Good communication with surrogates may improve both the quality of medical decisions and outcomes for the patient and surrogate.

Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker.

OBJECTIVES: To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions. DESIGN: Retrospective cohort study. SETTING: Large, urban, public hospital. PARTICIPANTS: Hospitalized adults aged 65 and older over a 3-year period (1/1/2004-12/31/2006) with a DNR order during their hospital stay. MEASUREMENTS: Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders. RESULTS: Of 668 patients, the ordering physician indicated that the DNR decision was made with the patient in 191 cases (28.9%), the surrogate in 389 (58.2%), and both in 88 (13.2%). Patients who required a surrogate were more likely to be in the intensive care unit (62.2% vs 39.8%, P<.001) but did not differ according to demographic characteristics. By hospital Day 3, 77.6% of patient decisions, 61.9% of surrogate decisions, and 58.0% of shared decisions had been made. In multivariable models, the number of days from admission to DNR order was higher for surrogate (odds ratio (OR)=1.97, P<.001) and shared decisions (OR=1.48, P=.009) than for patient decisions. The adjusted hazard ratio for hospital death was higher for patients with surrogate than patient decisions (2.61, 95% confidence interval (CI)=1.56-4.36). Patients whose DNR orders were written on Day 6 or later were twice as likely to die in the hospital (OR=2.20, 95% CI=1.45-3.36) than patients with earlier DNR orders. CONCLUSION: For patients who have a DNR order entered during their hospital stay, order entry occurs later when a surrogate is involved. Surrogate decision-making may take longer because of the greater ethical, emotional, or communication complexity of making decisions with surrogates than with patients.

Disclosure predicaments arising during the course of patient care: nurses' privacy management.

At times, nurses receive patient disclosures that have the potential to create challenges resulting in needs for strategies to manage patient information and expectations. This study examines disclosure predicaments nurses experience in critical care and emergency units at a large urban hospital. Utilizing the constant comparative method to identify disclosure themes guided by the principles of communication privacy management (CPM), the findings show that nurses regulate patient privacy in the role of stakeholder confidants. Second, disclosure predicaments occur in three different contexts: during the course of nurses' professional routine; when the nurses created safe terminals or havens for patients to talk; and when family matters became an inseparable part of caring for the patient. Third, the results indicate that there are several specific strategies that nurses use to manage disclosure predicaments they encounter. The lens of CPM is used to interpret these findings and offers a context in which to better understand the needs of nurses concerning patient disclosive behavior and privacy issues for nurses.