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Abstract
Study Objective To identify emergency department (ED) predictors of patients' perception of privacy and whether patients' perception of privacy was significantly associated with patient satisfaction, in an urban, university-based hospital ED.
Methods Patients' perceptions of privacy and satisfaction at one urban, university-based hospital ED were assessed. Structured questionnaires were performed, and measures for patients' perception of privacy and satisfaction as well as demographic data were included for data collection for each patient. Ordinal logistic regression model building was conducted for patients' perception of privacy.
Results 364 patients were approached and 313 (86%) on-site questionnaires were completed. 75% of patients agreed and strongly agreed that privacy was very important for their emergency care. Factors that were highly correlated with patients' perception of privacy included personal information overheard by others (OR 0.6273), overhearing others' personal information (OR 0.5521), unintentionally heard inappropriate conversations from healthcare providers (OR 0.5992), being seen by irrelevant persons (OR 0.6337), space provided for privacy when being physically examined (OR 1.6091) and providers' respect for patients' privacy (OR 4.3455). Patient characteristics that significantly predicted lower ratings of perception of privacy included older age, the treatment area in a hallway and longer length of stay. Patient satisfaction was strongly predicted by the perception of privacy (OR 8.4545).
Conclusion These data identify specific factors that are determinants of patients' perception of privacy. It was found that patients' perception of privacy strongly predicts satisfaction. ED improvement efforts should focus on improving ED environmental design and continuing education of healthcare providers to protect patient privacy during their stay in the ED.
- confidentiality
- emergency department
- ethics
- management
- privacy
- quality assurance
- satisfaction
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From ancient times, respect for patient privacy and ensuring patient confidentiality have been regarded as a fundamental obligation of healthcare providers, and are now a cornerstone of contemporary medical practice.1 2 For patients in the emergency department (ED), appropriate privacy and confidentiality are especially critical if a good physician–patient relationship is to be established.1 The ED setting is unique compared with ordinary wards in the hospital; the spaces for patients are usually overcrowded or undersized, and patients are often placed in close proximity to each other, family members, healthcare providers, other staff and the working station. ED patients may have some sensitive problems, for example, drug overuse, domestic violence, sexual assaults, sexually transmitted diseases and sociopsychiatric conditions, etc. Accordingly, severely ill or trauma patients, who may not be capable of protecting their own privacy and confidentiality, can only depend on their healthcare providers to ensure their privacy and confidentiality. This demands ED healthcare providers to be particularly sensitive to issues concerning privacy and confidentiality.3
Moreover, in order to move the equipment easily and facilitate patient observation and examination, ED settings usually placed patients in close proximity to other patients and the working station with a cart surrounded by a curtain. However, patients in the ED may be unwilling to disclose personal information and to be physically examined because their privacy has not been protected and confidentiality may have been jeopardised. It may lead to patients' deep dissatisfaction with their care. Very few studies have investigated these experiences that patients perceive in the ED and the predictors of patients' perception of privacy. Moreover, the relationship between patients' perception of privacy and satisfaction has not previously been studied.
The purpose of this study was to identify predictors of patients' perception of privacy or confidentiality and the relationship between patients' perception of privacy and satisfaction in an urban, university-based hospital ED.
Materials and methods
This study was conducted at an urban, university-based hospital ED. The ED is staffed by resident physicians, who are supervised by attending physicians. This ED only has curtained rooms; the rooms are surrounded by curtains on three sides. Patients are seldom moved from one room to another, unless they are kept for observation or are waiting to be admitted to the ward. Most patients spend most of the time in one room only during their ED stay. Room arrangement for each patient is random and based upon room availability. When a room is not available due to crowding of the ED, patients will be placed in the hallway. This investigation was approved by the institutional review board.
Data were collected from 7 to 25 July 2008. During a 3-week study period in the ED, all patients discharged from the ED were eligible. Exclusion criteria included patients with altered mental status, age younger than 18 years, inability to speak or read Mandarin, refusal to participate.
During study hours, eligible patients were approached and on-site questionnaires were conducted. For logistic reasons, research assistants mainly approached and enrolled patients between 09:00 and 16:00 hours. Eligible patients were approached and informed consent was obtained for the study by a research assistant. Participants were asked to complete a questionnaire concerning their perception of ED privacy and satisfaction. The questionnaire was returned anonymously when the patient completed the questionnaire before leaving the ED. The questionnaire collected information including patient characteristics and other variables. The sociodemographic variables included age, gender, marriage status, self-reported education level and how many times they had ever visited the ED. Other variables related to the patient's visit were collected from the ED computer system, including the speciality, the treatment area and the length of stay.
The questionnaire assessed the patient's overall perception of privacy and satisfaction with emergency care on a five-point Likert scale. Available responses were designated based upon the Likert scale as follows: 1, strongly disagree; 2, disagree; 3, fair; 4, agree and 5, strongly agree. Questions related to other measures of privacy were collected on the five-point Likert scale during their ED visit. These questions (see appendix) were developed based on the framework proposed by Anita Allen and the literature.1 3–6 Anita Allen has proposed four forms of privacy that limited access to the person including physical privacy, informational privacy, decisional privacy and proprietary privacy.4 The internal consistency of these questions assessing measures of privacy for emergency care was evaluated. A high consistency for these ratings was revealed, and a Cronbach's α of 0.72 was noted. Only the overall perception of privacy for emergency care was further evaluated in the following univariate and multivariate analyses.
The univariate correlation of each predictor to ratings of overall perception of privacy was conducted. The Spearman rank sum test was conducted for continuous and ordinal variables, the Wilcoxon rank sum test was conducted for binary variables, and the Kruskal–Wallis test was conducted for categorical variables. Variables significantly correlated with ratings of the overall perception of privacy were included in the regression model building.
By using the proportional odds assumption, a forward stepwise, ordinal logistic regression model was computed. The predictors were retained for model building when the Wald test scores were at values of p less than 0.2. A threshold of p values less than 0.05 was determined for variables whether they were considered to be significant. OR and 95% CI were computed for significant predictors. Potential confounding effects were conducted by observing the changes on β coefficients and SE of the selected predictors when the unselected variable was put back to the model. If the unselected variable changed the β coefficient of one or more selected predictors by 15% or greater, they would be kept in the model and were considered to be a confounder. The likelihood ratio test was conducted for the overall model.
By randomly selecting hypothetical populations from the study sample, a bootstrap procedure was conducted for internal validation of the built model. The coefficients and p values of the model variables were calculated for each hypothetical population, and the size of each hypothetical population was the same as the study sample. The procedure was repeated 250 times, and mean coefficients and SE were obtained for model variables. Finally, the residual analyses of the model were assessed.
The STATA package (version 10.1) was used for all statistical analyses and data management.
Results
During study hours, 364 eligible patients presenting to the ED were approached, and 86% of patients (313) completed questionnaires. There was no statistically significance difference in gender between patients who were willing to participate and those who refused to participate. The baseline characteristics of patients who completed the questionnaires are provided in table 1.
Baseline characteristics
The results of ratings of the overall perception of privacy and ratings of satisfaction are distributed and are presented in table 2. A relatively high percentage of patients perceived that they were satisfied with their emergency care. The ratings of satisfaction and overall perception of privacy were non-normally distributed.
Distribution of ratings of overall perception of privacy and satisfaction
The distributions of withholding information and refusal of examination as a result of infringement of informational and physical privacy are provided in table 3. Twenty-one per cent of patients agreed and strongly agreed that they withheld some information from healthcare providers because they felt that information may be disclosed inappropriately. Nineteen per cent of patients agreed and strongly agreed that they were reluctant to be examined because they felt their bodies may be exposed inappropriately. Seventy-five per cent of patients agreed and strongly agreed that privacy was very important for their emergency care.
Distribution of withholding information and refusal of physical examination
An ordinal logistic regression model was built for ratings of overall perception of privacy and is provided in table 4. This method is appropriate for analysing ordinal values with a non-normal distribution.
Multivariate ordinal logistic regression model for ratings of overall perception of privacy
Significant factors associated with patients' overall perception of privacy included personal information overheard by others, overhearing of others' personal information, unintentionally heard inappropriate conversations from healthcare providers, being seen by irrelevant persons, privacy of space when being physically examined, and providers' respect for privacy. Significant patient characteristics included age, treatment area and length of stay in the ED. Older patients tended to have lower ratings of overall perception of privacy, and patients with longer length of stay tended to have lower ratings of overall perception of privacy. Patient treatment area in the hallway had lower ratings of overall perception of privacy. These factors including patient characteristics were statistically significant with overall perception of privacy at a determined threshold of p less than 0.05.
In another ordinal logistic regression model for patient satisfaction with their emergency care included in table 5, ratings of overall perception of privacy were determined to be highly statistically significant, with an OR of 8.4545, 95% CI for OR of 5.9277 to 12.0584 and p value less than 0.000.
Ordinal logistic regression model for patient satisfaction
The bootstrapping validation procedures were performed and the results are provided in the footnotes of table 3. Only the variables with an increasing p value above 0.05 after the bootstrapping procedures are shown. A high degree of internal validity for the model of overall perception of privacy was determined. On residual analysis, none of the model was found have improperly influential data points.
Discussion
We identified factors that significantly affected patients' perception of privacy and satisfaction with emergency care. This study is different from previous ED research because of the special focus on specific factors that have an influence on patients' perception of privacy, the high response rate of participants, and the use of proper statistical methodology for determining ratings of patient perceptions of privacy and satisfaction. To our knowledge, this is the first study to analyse the determinants of patient perceptions of privacy with emergency care and the relationship between patient perceptions of privacy and satisfaction in the ED setting. Not surprisingly, ratings of overall privacy with ED care were determined to be a significant predictor of patient satisfaction.
Our findings propose a conceptual model for comprehending patients' perceptions of privacy with emergency care. We recognised adjustable factors that reveal the importance of the ED environment and the attitude of healthcare providers to patients' perception of privacy and satisfaction. Demographic comparisons explain the differences in statistically significant patient characteristics with perceptions of privacy and satisfaction. Other associated factors show the main role of patient expectations and the appropriate ED management for those expectations to be very important. All these results recommend that it is necessary in the ED to maintain efforts to provide competent care as well as the protection of patient privacy and confidentiality.
Patient perceptions of privacy and satisfaction are subjective evaluations, and many factors may have an influence on these evaluations. Our findings suggest that ED environmental redesign and continuing staff education are critical to protect and respect patient privacy and increase satisfaction. For patient privacy in ED care, we identified several factors as significant determinants. Many of them are specific and adjustable variables of the ED environment and staff education, and patients perceived that these have not been accomplished appropriately during their visits. Continuing education of ED staff in how to protect patient privacy during the patient's stay in the ED is important in increasing patient ratings of privacy and satisfaction.
In our study, 21% of patients withheld some information from healthcare providers and 19% of patients were reluctant to be examined because of perceived lack of privacy. These results raised major concerns for diagnostic accuracy and medical error. In the ED (especially crowded ED), some female patients might be reluctant to be examined by male staff even when they were accompanied by female staff. Some patients might be reluctant to be examined because they might perceive privacy is not being well protected as a result of staff and irrelevant persons walking around the curtains, and are worried about the curtains being drawn back unawares. Furthermore, some staff might lack vigilance in coming in and going out for treatment purposes without being sensitive to protect and respect patient privacy.
Limiting staff discussions of patients near the patient care area would obviously decrease privacy and confidentiality breaches.7 Many of the breaches occurred simply in the course of daily work in the ED. Staff members talk to each other through curtains and across the patient care area of the department in normal or even raised voices. Patient information is perhaps inappropriately passed back and forth in these situations. Continuing education of healthcare providers about how to protect patient privacy and confidentiality is very important.7
Patient characteristics suggested that age is statistically significant to patients' perceptions of privacy. Elderly patients tend to have lower ratings of the perception of privacy than do younger patients. This finding might not be consistent with a previous study that found that younger patients have lower ratings of the perception of privacy.8 This might be due to elderly patients receiving a lower level of attention for privacy from the ED healthcare providers in comparison with younger patients. Moreover, our findings suggest that gender is not a significant factor affecting patients' perceptions of privacy, and this may not be consistent with previous research.1 Although patient characteristics are not changeable, it is still important to consider these factors when comparing the protection of privacy in the ED with different patient populations, in particular as ED privacy is increasingly promulgated/complained about by the public. Furthermore, the reasons for these differences suggest the need for further investigation.
Other process of ED care measures suggested that length of stay and the patient treatment area is essential to patient perceptions of privacy. Patients with a longer length of stay had lower ratings of the perception of privacy. This finding is consistent with previous research that found that the longer a patient was in the ED, the more privacy incidents they might experience.1 In addition, patients being cared for in the hallway had lower ratings of the perception of privacy. ED crowding interferes with the protection of privacy and confidentiality. Little or no physical privacy is provided when patients are placed in the hallways and there are limited opportunities for patients to communicate personal information with healthcare providers in confidence.2 Moreover, patients may feel less respect when they are placed in the hallways. Therefore, healthcare providers should also do their best to reduce patient length of stay in the ED, thereby reducing overall patient volumes.
Patient privacy is important and must be considered for good ED design. In our ED, the patient treatment areas are only equipped with curtains. Previous studies have explored the environmental factors that may have an influence on ED patient privacy and ED staff discussing cases in improper circumstances.3 5 Rooms with walls and doors provide the most private and confidential environment. ED patients in one university hospital have reported that in curtained treatment areas, they felt there was a higher possibility of being seen and overheard by irrelevant persons than in rooms with solid walls.5 Noises and smells are also easier to contain within rooms with walls rather than behind curtains. However, curtains might be convenient with the facilitation of patient observation and examination as well as efficient movement of equipment and personnel for patient treatment in major incidents and emergency situations. Moreover, when many family members were injured in an incident, we can provide accommodation and facilitate treatments for the family in one room by using curtains. If ED were equipped with disposable curtains, the environments of the ED might be effectively sterilised and infection might be adequately controlled. Ultimately, taking these factors into consideration would provide a more permanent solution to these problems in the reconstruction and renovation of ED.
Seventy-five per cent of patients agreed and strongly agreed that privacy was very important for their emergency care in our study. Although we have provided a special privacy protection for some patient populations, such as patients who need gynaecological examinations, patients might have to give a psychiatric history, report sexual assaults or domestic violence insults, etc. Most patients in the ED might not have received appropriate privacy protection. Therefore, it is important to face the privacy issue for patient care in the ED. No patient should be examined or treated in a room or hallway without any appropriate privacy protection.
In our opinion, the most important factor influencing patient privacy was lack of vigilance in the ED. Healthcare providers have to be sensitive to and avoid infringements of patient privacy as much as possible to prevent patients withholding their personal information and being reluctant to be physically examined. Therefore, healthcare providers should take important strategies to protect patient privacy, and avoid unnecessary and undesired physical exposure and informational disclosure for their patients. Healthcare providers should also use all possible partitions and available treatment areas appropriately and effectively to separate patients from each other, or at the very least, on discovering that the patient has sensitive issues, move them to a more private location so the patient feels more comfortable about discussing his or her concerns. Furthermore, if procedures and examinations have to be performed for patients in open areas, staff should be aware of and insist on using moveable privacy screens to protect patient privacy.
This study has several limitations. Some limitations of our study include the use of a convenience sample, which may have introduced selection bias. As with any research survey, patient responses may not really reveal their true viewpoints, particularly when the survey raises sensitive issues. Although measures were used to minimise bias, patients may have declined to give unfavourable responses to survey questions.
Moreover, the study site is an urban, university-based teaching hospital ED. In the study population, the percentage of severely ill patients may be higher than for non-urban ED. Moreover, most respondents came from the same geographical area, and they may not be suitable representatives for patients in other areas of the country. Although the general response rate for the study was high, the findings may have been biased as a result of the differences among respondents and non-respondents. Moreover, as our ED is a university-based, teaching hospital with resident physicians and medical students, our patients may perceive differences in their privacy and confidentiality than in a non-teaching hospital.
There were numbers of privacy issues not discussed in this study. For instance, patients may have concerns about the privacy and confidentiality of nursing charts with their medical information and notes. Patients may have a concern about the accessibility for others to their bedside medical records, or their notes being left in an open access area. Patients may also have a concern about the visibility of personal information on the computer screens. These issues may not have been well explored and carefully researched in the study.
In summary, our data suggest the identification of specific factors that are determinants of patient perceptions of privacy and satisfaction. We have found that patients' perception of privacy strongly predicts satisfaction. ED improvement efforts must concentrate on improving ED environmental design and continuing education of healthcare providers to protect patient privacy during their stay in the ED.
Appendix
| Questionnaire questions |
| I feel others will overhear my conversation with healthcare providers |
| I feel personal information will be overheard by others |
| I have overheard others' personal information |
| I have unintentionally heard inappropriate conversations from healthcare providers |
| I feel I was seen by irrelevant persons |
| I feel ED space provided privacy when physical examination was performed |
| I feel healthcare providers respected my privacy |
| I withheld some information from healthcare providers because I felt that information may be disclosed inappropriately |
| I was reluctant to be examined because I felt my body may be exposed inappropriately |
| Privacy is very important for my emergency care |
| Overall, I have had privacy in the ED |
| Overall, I was satisfied with care in the ED |
Footnotes
Funding This study was supported by a grant from the Kaohsiung Medical University Hospital (KMUH96-6G08) awarded to Y-KL.
Competing interests None to declare.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Kaohsiung Medical University Hospital institutional review board.
Provenance and peer review Not commissioned; externally peer reviewed.