15 - Barriers and Enablers to Conducting Confidential Conversations with Adolescents in the Emergency Department: A Multi-Center, Qualitative Analysis

Poster Number: 15
Publication Number: 15.405

Lauren S. Chernick, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Mona Bugaighis, Columbia University Irving Medical Center, Hicksville, NY, United States; Laura Britton, Columbia University School of Nursing, New York City, NY, United States; Andrea T. Cruz, Baylor College of Medicine, Houston, TX, United States; Monika Goyal, Children's National Medical Center, Washington, DC, United States; Rakesh MIstry, University of Colorado School of Medicine, Aurora, CO, United States; Jennifer L. Reed, Cincinnati Children's Hospital, Cincinnati, OH, United States; Suzanne Bakken, Columbia University, New York, NY, United States; John Santelli, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Peter Dayan, Columbia University, Hastings on Hudson, NY, United States

Background: The provision of confidential care is essential in delivering adolescent health services. Yet, emergency department (ED) providers frequently forego confidential conversations about sensitive topics such as mental or sexual health or substance use with adolescents. To change ED provider practices, the contextual factors influencing behaviors must be understood.

Objective: To identify the barriers and enablers to conducting confidential conversations with adolescent ED patients.

Design/Methods: We conducted semi-structured, qualitative interviews of ED providers across five tertiary-care academic pediatric EDs representing distinct geographic regions to elicit provider perceptions of barriers and enablers of confidential conversations. Participants were purposively sampled across gender, professional title, and years of professional experience. We used the Theoretical Domains Framework (TDF), a framework for exploring determinants of health, to develop an interview guide to study individual and system-level factors affecting provider behavior. Enrollment continued until saturation of themes. In-person and virtual interviews were recorded, transcribed, and coded by three investigators based on thematic analysis using NVivo 12. After coding, we generated belief statements, which are first-person statements that reflect a shared, underlying perspective.

Results: We conducted 38 interviews with ED providers across 5 sites from 11/2019 to 06/2020. Participants consisted of 18 physicians, 13 registered nurses, 5 nurse practitioners and 4 physician assistants. Table 1 categorizes 17 belief statements as either barriers or enablers to the conduct of confidential adolescent conversations. Each statement and an exemplary quote accompany the relevant TDF domains. Predominate barriers included patient flow, parents, inability to address patient concerns, and wanting to provide focused medical care. Predominant enablers included self-efficacy in talking to adolescents and in excusing parents and identifying as a holistic medical provider. Conclusion(s): We found that barriers and enablers for initiating confidential conversations about sensitive topics in the ED crossed multiple TDF domains, elucidating the multidimensionality of factors that influence whether ED providers address unmet adolescent health needs. Our findings suggest that addressing a singular belief statement is unlikely to create change; rather, collaboration and coordination across multiple domains are crucial to appropriately conduct confidential conversations in the ED.
Table 1. Barriers and enablers to conducting confidential conversations about sensitive topics, with belief statements, their related Transtheoretical Domain Framework domains, and exemplary quotes.