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The last article considered the duty of confidentiality and the various ways in which health professionals could be held accountable for unjustified breaches of confidentiality. This article considers what those lawfully justified situations cover. The main justifications for disclosure include: consent of the patient; the interests of the patient; court order; statutory requirement; and public interest.
This article revisits the ethical, legal, professional and emotional issues involved with disclosing bad news. The authors examine the push for disclosure that has come from a number of quarters in the UK, including ethical and legal challenges, in particular the Bristol Royal Inquiry Report, professional codes of conduct, health policy and the expectations of the public. The contribution of nurses to breaking bad news is not widely discussed in the literature. With the development of new nursing roles and evidence-based practice it is timely to consider the role of nurses in this process. The article highlights some limitations with current guidelines for breaking bad news, in particular, that these guidelines tend to be constructed from a professional standpoint and lack patient-centred evidence. The issue of emotional labour and how it relates to giving bad news is discussed with respect to professional staff and patients. The article concludes by raising some practice implications, including: the importance of context and continuity; the significance of information and support; the desirable qualities of the professional; and issues to consider in determining patient preferences.
For many mothers living with HIV/AIDS, whether, when, and how to disclose their HIV diagnosis to their children and arranging for future care are important although agonizing issues. Due to the increasing number of children who lose their mothers to AIDS and the dearth of empirical information about them, these issues are increasingly important to research. This study of 188 HIV-positive mothers and their 267 children of minor age in New York City revealed that only half the mothers had disclosed their HIV diagnosis to at least one of their children and only 57% had made formal plans for the children's care. As expected, older children were more likely to be informed than younger children. Contrary to some previous research, maternal disclosure was not related to ethnicity, advanced illness, improved psychological well-being, or greater or more satisfying social support resources. Implications for future research and provision of services to this group of women are discussed.
Although the co-occurrence of woman abuse and child sexual abuse is high little research exists exploring the impact of woman abuse on maternal response to child sexual abuse (CSA). Findings from two qualitative studies indicate the form of woman abuse to have differential impact on maternal response. Mothers who were abused in non-physical ways, psychological, or emotional, displayed more ambivalent, less supportive responses. Mothers who were physically abused by their partners more often acted supportively to their children and displayed less ambivalence about separating from the perpetrator. Some survivors reported non-disclosure as children because of their fear of the perpetrator due to the woman abuse they were exposed to while being sexually abused. Practice and research implications are discussed.
The present review summarizes what is known about reactions of family members to disclosure of homosexual identity, both within the family of origin and in families where the disclosing member is a spouse or parent. It is suggested that the traumatic nature of family member reaction consists of two related processes: (a) the application of negative values about homosexuality to the disclosing member, and (b) a perception that homosexual identity negates or violates previous family roles. Future research in this complex and understudied area could reveal much about the nature of both homosexual identity and family relationships.
This paper examines the assumption that male homosexuality has a natural affinity with femininity and that male heterosexuality has a natural affinity with masculinity. An analysis of the relationship between people's disclosure or concealment of their homosexual practice or identity, particularly as it relates to notions of hegemonic masculinity and femininity provides the focus of this paper. It is argued that everyday understandings of homosexuality tend to be resolved in such as way as to press homosexuality into the service of privileging a male, masculine, and heterosexual subjectivity. This privileging is achieved, in part, as a result of the everyday social practices of homosexually active men's witting and unwitting deference to the hegemonic presumption that masculine men are naturally heterosexual, and its inverse, that feminine men are homosexual and are a perturbation of the natural order. We argue that this correlation is manufactured in everyday life in the world of appearances, but that the appearance of things is not reflected at a level of practice, which is to say, male homosexual practice is not necessarily feminine, just as male heterosexual practice is not necessarily masculine. Realities that conflict with the hegemonic realities are masked in the public world, for a variety of reasons. What we have called closet dynamics are the various discourses through which homosexuality is concealed and disclosed, and the various subject positions people take up in relation to those discourses.
This paper examines the role that interpersonal trust plays in gay and bisexual males' accounts of the factors that led them to decide to reveal or to withhold their sexual identities from their mothers. Fifty men completed a questionnaire about their coming out experiences in the context of their relationships with their mothers. As part of this questionnaire, they indicated whether or not they had disclosed their sexual orientation to their mothers and explained the basis for their decision in this regard. A content analysis of the explanations offered supports findings from previous research which suggest that a considerable range of motivations underlie the decision to disclose (or not to disclose). More importantly, consistent with expectations that the mother's trustworthiness would emerge as a principle concern in participants' responses, several of the classes of explanation identified in disclosers' and non-disclosers' decision accounts suggest that the move toward disclosure is guided in part by the climate of trust existing in individuals' relationships with their mothers.
Past research has found that a stronger secure attachment style, developed in childhood, enhances one's ability to acknowledge negative feelings, cope with negative life events, and develop satisfying social relationships. Because an integral part of the "coming out" process for gay men is the ability to seek support from the gay community in order to reevaluate negative beliefs toward homosexuality, a gay man's attachment style may strongly impact this critical stage of his life. Results demonstrated that men who more strongly endorsed a secure attachment style reported more positive attitudes toward their own homosexuality, and that these more positive attitudes could mediate the relation between more secure attachment style, greater levels of self-disclosure regarding their homosexuality, and greater self-esteem. Implications of these data for internalized homophobia, the coming-out process, and effective social functioning are discussed.
OBJECTIVE: To examine disclosure of sexual orientation and response rates in a pilot study of questions on sexual orientation and gender of sexual partners in the Nurses' Health Study II. METHODS: A pilot questionnaire was mailed to random samples of 350 women from each of three marital status strata: never married, previously married, and currently married. We estimated prevalence of each category of sexual orientation in the pilot study. Response rates to the sexual orientation question for the pilot questionnaire and the 1995 cohort questionnaire were compared. RESULTS: The overall response rate to the pilot study was 78%. In the pilot study, 98% of women reported a sexual orientation of heterosexual, 0.1% bisexual, and 0.9% lesbian, with 0.7% either declining to answer, leaving the question blank, or categorizing themselves as none of the above, weighted for stratified sampling by marital status. The distribution of sexual orientation in the cohort study (N = 91,654) was similar. Asking women to participate in the pilot study of sexual orientation questions did not appear to cause participants to drop out of the cohort. Concordance between reported sexual orientation on the pilot study and the cohort study was high. CONCLUSIONS: Based on our experience, researchers may be encouraged to add questions on sexual orientation to large studies of women.
OBJECTIVE: This paper examined whether written emotional disclosure reduces psychosis-related post-traumatic stress disorder symptoms in a small clinical sample recovering from a first episode of psychosis. METHOD: Approximately 2.5 years after their first episode of psychosis, 22 people completed measures of traumatic symptoms, recovery style, insight, anxiety and depression. Participants then wrote about the most stressful aspects of their illness (N = 12) or about emotionally neutral topics (N = 10) for 15 minutes on three separate occasions. Approximately 5 weeks later, participants re-completed the same dependent measures. RESULTS: Participants who wrote about their psychotic experiences showed less overall severity and avoidance of traumatic symptoms compared with participants who did not write about their psychotic experiences. There were no effects on the other dependent measures. CONCLUSIONS: Preliminary evidence with a small clinical sample suggests that providing people who are recovering from a psychotic episode with an opportunity to disclose the most stressful aspects of their illness and treatment may lessen the traumatic impact of these experiences. However, this finding requires replication with a larger sample.
The objective was to identify factors associated with financial discussions and financial disclosure of medical costs within a low-income urban community. The method used was a cross-sectional community-based survey in Allegheny County, Pennsylvania. The survey was conducted door-to-door and at area food pantries. Two hundred and twenty six adults were interviewed. Overall, 76.1% reported having a usual source for care and 73.0% had health insurance. Thirty nine and four tenths percent reported having been asked about their ability to pay for health services; this was more common among African Americans (OR 5.2; 95% CI 1.73-15.84), those with no health insurance (OR 4.3; 95% CI 1.01-17.89), and those less than 45 years old (OR:2.9; 95% CI 1.03-8.28). Only 10.6% reported being told how much a health visit would cost. Overall, 30.1% reported their provider made payment allowances for medical bills, with white respondents 2.5 times more likely and those persons identifying an ambulatory site for care 2.6 times more likely to report this. Overall, 30.5% reported being referred to a collection agency for unpaid medical bills; this was 2.4 times more common among those individuals identifying a non-ambulatory usual site for care. Significant race and socio-economic disparities exist in discussions about and access to financial resources to pay for medical care. Expanding the availability of financial assistance is critical to improving access to health care.
New patient safety standards from JCAHO that require hospitals to disclose to patients all unexpected outcomes of care took effect 1 July 2001. In an early 2002 survey of risk managers at a nationally representative sample of hospitals, the vast majority reported that their hospital's practice was to disclose harm at least some of the time, although only one-third of hospitals actually had board-approved policies in place. More than half of respondents reported that they would always disclose a death or serious injury, but when presented with actual clinical scenarios, respondents were much less likely to disclose preventable harms than to disclose nonpreventable harms of comparable severity. Reluctance to disclose preventable harms was twice as likely to occur at hospitals having major concerns about the malpractice implications of disclosure.
Amid concerns that clinical and basic research is increasingly vulnerable to pressure from industry sponsors, many federal agencies and professional organizations are recommending new or revised policies regardingfinancial disclosure and conflicts of interest. Despite pressure for greater external regulation and common professional standards, little is known about how existing policies are implemented. We analyze the implementation of conflict-of-interest policies within the multicampus University of California system. We show that there is variation among campuses in defining problematic relationships and in determining appropriate remedies to mitigate conflicts of interest. Our study suggests the importance of local culture and context for institutional decision making.
In 2002 Pennsylvania became the first state to impose on hospitals a statutory duty to notify patients in writing of a serious event. If the disclosure conversations are carefully planned, properly executed, and responsive to patients' needs, this new requirement creates possible benefits for both patient safety and litigation risk management. This paper describes a model for accomplishing these goals that encourages health care providers to communicate more effectively with patients following an adverse event or medical error, learn from mistakes, respond to the concerns of patients and families after an adverse event, and arrive at a fair and cost-effective resolution of valid claims.
Many children with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome are surviving to middle childhood and adolescence. Studies suggest that children who know their HIV status have higher self-esteem than children who are unaware of their status. Parents who have disclosed the status to their children experience less depression than those who do not. This statement addresses our current knowledge and recommendations for disclosure of HIV infection status to children and adolescents.
We evaluated disclosure of human immunodeficiency virus (HIV) antibody status to a main sex partner and the impact on the relationship in men who have sex with men and who are enrolled in the Acquired Immunodeficiency Syndrome (AIDS) Community Demonstration Projects cohorts. Eighty-nine percent of both seronegative and seropositive men disclosed the results to their main sex partner. Seventy percent of the seronegative men and 82% of the seropositive men who did so reported that the relationship remained "as strong as ever" after 6 months. Most men who did not disclose their test results to their main partner reported being "single" after 6 months.
To gain some insight as to how people feel about the disclosure of a hidden physical disability to a potential employer, 821 students were queried. The results suggest that about 15 percent would disclose the disability initially, 30 percent would divulge the information only when they felt secure on the job, while 30 percent would not disclose the disability at all.
69 Lonely and 142 Nonlonely undergraduates were compared on self-disclosure to four interpersonal targets, i.e. friend, group of friends, stranger, and group of strangers. The Lonely group were less willing to disclose to all four targets and reported higher frequency and intensity of loneliness-related affects.