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Occupational Medicine 2007 57(5):355-361; doi:10.1093/occmed/kqm033
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© The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Sensitivity towards patient needs in the occupational health consultation

Anne Heikkinen1, Gustav Wickström2, Helena Leino-Kilpi3 and Jouko Katajisto4

1 Department of Nursing Science, University of Turku, Turku 20014 University, Finland
2 Department of Occupational Medicine, University of Turku, Turku 20014 University, Finland
3 Department of Nursing Science, University of Turku, Turku 20014 University, Finland
4 Department of Statistics, University of Turku, Turku 20014 University, Finland

Correspondence to: Anne Heikkinen, Department of Nursing Science, University of Turku, Turku 20014 University, Finland. Tel: +35 850 330 8391; fax: +35 82 333 8400; e-mail: anne.heikkinen{at}pp9.inet.fi


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background Many employers in Finland provide not only preventive health care but also primary care for their employees. This puts occupational health professionals (OHPs) in a dual role, which in turn raises questions about patient privacy.

Aim To investigate occupational health nurses' (n = 140) and physicians' (n = 94) perceptions of privacy in caring relationships.

Methods A self-administered questionnaire was sent to 183 occupational health (OH) physicians and 183 OH nurses. Descriptive statistics and frequency tables were used to characterize the variables. The differences between nurses and physicians were determined with Pearson's chi-square tests and Fisher's exact tests.

Results Both nurses and physicians felt that physical, social, psychological and informational privacy was important in the OH setting. The duration of work experience did affect perceptions of privacy. One-third of respondents considered it good practice to take a full medical history from prospective employees as part of the pre-employment assessment. Over half of the OHPs found the currently valid requirements concerning patients' information privacy too strict in that they may in certain cases complicate the provision of care and treatment.

Conclusions Tact and sensitivity are paramount when dealing with patient privacy. The aim of privacy, however, should not be to conceal information, but rather to prevent any harmful disclosure.

Keywords      Caring relationship; occupational health; privacy


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
All employers in Finland are under a legal obligation to provide preventive occupational health (OH) services to their employees. In addition, most employers also provide primary care to their employees via OH services. This means that occupational health professionals (OHPs) in Finland occupy a dual role. A variety of skills and competencies are needed in order to successfully combine these two roles [1–3]. Patients are often dubious about OHPs' impartiality and confidentiality [4], and even professionals themselves suspect that medical information may be misused [5]. However, patients are prepared to answer even intimate questions if the caring relationship with the health care professional is based on trust and confidence [6,7].

Traditionally, the dissemination of patient information is considered justified on the condition of informed consent [8]. On the other hand, OHPs are under an obligation to pass on even sensitive information about an individual employee, if that particular piece of information is deemed to pose a threat to the health and safety of a large group of employees [9,10]. Consequently, the decision on whether or not to disclose information cannot be based on the employee's consent alone [11,12].

In Finland, 27% of licensed medical practitioners have a specialist degree in occupational health. The basic professional education of public health nurses includes special training in OH, and hence, they are qualified to work as OH nurses. In addition to their basic professional education, >80% of nurses and 75% of physicians involved in OH have completed postgraduate studies in OH. [13].

In Finland, there are four alternative organizational models available for employers to provide OH services for their employees. In terms of ‘external’ OH, the service provider is either a municipal health care centre or a private medical centre. For ‘internal’ OH, a company may have an in-house health service, or the service is jointly provided for several small- and medium-sized enterprises. In the in-house or joint models, the salary payer of OHPs is the company/companies that employ them. Currently, 61% of employers have arranged OH by purchasing services from municipal health care centres and 33% by purchasing services from private medical centres, while 4% of companies have an in-house health service and 2% of employers have resorted to the joint model, i.e. they share OH with other employers. Since the majority of employers have contracted for OH with the local municipal health care centres, availability of OH services is comprehensively ensured in all parts of the country. Over the past decade, however, private medical centres have increased their market share as OH service providers and employers of OH physicians and nurses [13].

Privacy can be divided into four dimensions: informational, physical, social and psychological [14,15]. Informational privacy relates to the individual's right to determine whether and to what extent personal data may be released to others. Physical privacy is the degree to which one is physically accessible by others. Social privacy refers to the individual's ability to control his/her social contacts, while psychological privacy refers to the sense of psycho-emotional coherence and respect experienced as a unique human being [16–18].

The aim of this paper is to describe OHPs' (nurses and physicians) perceptions of privacy in the OH setting within the framework of the four dimensions of privacy. The research questions are as follows:

(i) How do OHPs perceive privacy in the OH setting?
(ii) Do nurses and physicians differ in their perceptions?
(iii) Which background factors are associated with different perceptions of privacy?


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
A postal questionnaire, followed by a reminder card, was sent randomly to 183 OH physician members of the Finnish Medical Association and 183 OH nurse members of three nurse organizations (the Finnish Association of Occupational Health Nurses, the Finnish Association of Public Health Nurses and the Union of Health and Social Care Professionals).

The first part of the self-administered questionnaire included demographic and background items: these were designed to collect data on the respondents' age, gender, education and work experience, the organization of OH and the breakdown of total working hours between OH and primary care work (Table 1).


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  		Table 1. Demographic data of study population

 
The second part of the questionnaire covered the respondents' knowledge of ethical codes, the legislation and research dealing with privacy and their views on whether the training and education they had received had prepared them for solving ethical problems related to privacy.

In the third part of the questionnaire, the respondents were asked to say to what extent statements describing privacy in caring relationships best corresponded to their views on a five-point Likert scale. Before statistical analyses, this scale was collapsed to a three-point scale: 3 = agree, 2 = neither agree nor disagree, 1 = disagree. A compressed Likert scale increases the sizes of cell frequencies in cross tables and allows for more powerful analysis of statistical dependencies.

The statistical program SPSS 12.0 was used for data analyses. Descriptive statistics and frequency tables were used to characterize the variables. The differences between nurses and physicians were determined with Pearson's chi-square tests and Fisher's exact tests. P-values <0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
The overall response rate was 64%; 140 (77%) nurses and 94 (51%) physicians returned the questionnaire.

Physical privacy
The respondents' views were that patients' privacy must always be respected when they are asked to undress (mean 2.98, SD 0.13). Supervised collection of urine samples for testing for the use of illicit drugs was not considered particularly offensive (mean 1.81, SD 0.86). Forty-nine per cent of the respondents took the view that touching was an acceptable way of showing sympathy to any patient experiencing great grief. Both nurses and physicians generally felt that other staff should not be allowed to enter the room during a patient consultation, although physicians attached less importance to this (Fisher's exact test = 7.32, P < 0.05) (Table 2).


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  		Table 2. OHPs' perceptions of physical privacy

 
Social privacy
The respondents agreed that patients should have the right to choose the person with whom they should discuss personal matters (mean 2.87, SD 0.42). They generally had little reservations about asking personal questions of the patients (mean 2.35, SD 0.82). Both physicians and nurses agreed that tact and sensitivity were important, although physicians attached less importance than nurses to this (Fisher's exact test = 10.93, P < 0.01). Physicians and nurses generally neither agreed nor disagreed with the statement that the patient's whole personal history should be thoroughly clarified as a part of their pre-employment examination (Table 3).


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  		Table 3. OHPs' perceptions of social privacy

 
Psychological privacy
OHPs strongly agreed with the statement ‘Having the patient undress within sight of other clients is to objectify the patient’ (mean 2.85, SD 0.45). Sexuality was regarded as a delicate topic that should be approached discreetly (mean 2.75, SD 0.56). The respondents generally neither agreed nor disagreed with the statement ‘Occupational health care rarely involves situations that might cause detriment to the patient’s sense of self-worth' (mean 2.11, SD 0.89). They generally neither agreed nor disagreed with the statement ‘Occupational health personnel have adequate professional skills for assessing when to dismantle patients’ psychological defence mechanisms' (mean 1.92, 0.79) (Table 4).


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  		Table 4. OHPs' perceptions of psychological privacy

 
Informational privacy
The importance of respecting the patient's will was emphasized in connection with documenting issues concerning their private life (mean 2.90, SD 0.38) and in deciding on the purposes for which patients' medical information was to be used (mean 2.90, SD 0.39). On the other hand, 41% of all respondents thought that the old system might be better where health care personnel had greater independence in deciding on the use of patient information. Two-thirds or 65% were of the opinion that the current requirements on privacy and confidentiality of patient information made patient care more difficult (Table 5).


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  		Table 5. OHPs' perceptions of informational privacy

 
Work experience and education showed some correlation with perceptions of privacy. Physicians with >20 years experience felt more strongly than others that OHPs are adequately prepared to judge when to dismantle patients' psychological defence mechanisms (Fisher's exact test = 9.69, P < 0.05). Less qualified nurses were more reluctant to take into account the individual patient's wishes as to what to document about their private life than nurses with more specialized training in OH (Fisher's exact test = 20.68, P < 0.05).

The model of OH organization was related to nurses' perceptions. Nurses employed in the private sector were keener than other nurses to clarify their clients' whole personal history as a part of their pre-employment examination (Fisher's exact test = 13.70, P < 0.05). Those working in a ‘joint model’ felt more strongly that the right of patients not to disclose confidential information about themselves makes patient care more difficult (Fisher's exact test = 14.5, P < 0.05).

A clear pattern emerged between the respondents' self-reported knowledge of ethical codes, legislation and research dealing with privacy, on the one hand, and perceptions of privacy, on the other. Those who felt they possessed a good knowledge of ethical codes (Fisher's exact test = 16.8, P < 0.01, nurses and physicians) and of research in the field (Fisher's exact test = 18.79, P < 0.01, physicians) took the view that situations potentially causing detriment to a patient's ego and sense of self-worth actually occur in OH. Physicians who felt they possessed a good knowledge of privacy legislation respected the patient's right to decide for what purposes their medical information may be used (Fisher's exact test = 14.61, P < 0.05), and physicians who felt they had a good knowledge of ethical codes respected their patients' wishes with regard to whom they wanted to talk with about their personal matters (Fisher's exact test = 8.15, P < 0.05). Those respondents who reported good knowledge of legislation (Fisher's exact test = 15.24, P < 0.05) and privacy research (Fisher's exact test = 16.04, P < 0.05) were keener than others to clarify their clients' whole personal history as part of a pre-employment examination.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
The occupational health practitioners who took part in this survey generally felt that privacy is important with regards to patients undressing, that other staff should not enter the room during consultations, that individuals should have the right to choose the OHPs that they visit, that tact and sensitivity are important, that recording of personal matters is important when taking histories, that sexuality should be approached in a discreet manner and that an individual's wishes need to be considered with regard to any data that is recorded in the case notes and the use of such data.

Finland was the first country in Europe to implement a constitutional act on patients' rights in 1992 [19]. The act provides for the patient's right to good health care; the right of access to treatment, within resources available; the right to be informed about care and treatment and the right to self-determination. The relevant legislation also established a complaints procedure and a patient ombudsman institution. In Finland, patients are very conscious about their rights, particularly in OH, following the introduction of the new Act on the Protection of Privacy in Working Life in 2004 [20].

Intrusion into a patient's territory (e.g. entering into room without warning) [21], personal space (e.g. coming physically too near) [6] or body zone (e.g. inappropriate touching) [22] refers to the violation of physical privacy. Occupational health nurses might enter the room without warning [21]. As has been shown earlier [21,23], patients do not take kindly to these kinds of interruptions. In this study, we found that physicians had fewer objections than nurses to other staff entering the room during patient consultations. Generally speaking, Finns are rather reserved, so it was somewhat surprising that 49% of respondents found touching an acceptable way to show sympathy to patients experiencing great grief. To prevent interference with samples, drug testing must be conducted under supervision [20]. Respondents to our survey did not find the supervised collection of a urine sample offensive.

Social privacy can be violated by ignoring a patient's will concerning with whom he or she is willing to communicate, and when and how much [17]. Seventy-four per cent of the OHPs (mean 2.65) responding to our survey considered that tact and sensitivity with regard to what the patient is asked cannot be overemphasized. Thirty per cent of the respondents were eager to clarify a patient's whole personal history as part of a pre-employment examination, and 74% considered that the patient's personal matters are information that should be inquired about in the same way as other issues. According to the guide ‘Good Practice in Occupational Health Services’ published by the Ministry of Social Affairs and Health, OHPs are only authorized to seek information relevant to the purpose of the particular health examination. Within OH services, the caring relationships are usually long-standing, and over the years, the OHPs get to know their clients well. The clients may be willing to discuss sensitive personal matters, such as religious beliefs [24], sexual orientation [25] and family problems, including problems in marriage [26] and with children [27], with the familiar OHPs, but usually not at the first contact, as in the pre-employment examination, when they do not yet know the OHPs well.

The results concerning informational privacy are interesting. Over half of OHPs took the view that the right of patients to limit access to their medical records complicates the task of care provision, and many of them said they preferred the old system where health care staff had more independence in deciding about the use of patient information (in Finland, the current Personal Data Act is stricter than the preceding one). The purpose of informational privacy should not be to conceal private information, but rather to prevent harmful disclosure [28,29] so that patients can freely confide in their caregivers about even the most private issues [6,7]. It is important therefore to determine reasons behind suspicions about the confidentiality of OH [4,5] in order to minimize any sense of distrust.

Basically, the OHPs are, like most professionals in the health sector, expected to act for the benefit of the patient independently of any financial reward [30]. Our findings indicated that the model of OH did not influence the respondents' views to any significant extent, even though in the in-house model and joint model, the OHPs are paid by the companies for which they are working. This indicates that OH has maintained its independence and impartiality in relation to client companies, even though the employers have become more aggressive in pressuring OHPs to disclose confidential information [5,31,32].

The two professional groups—nurses and physicians—had very similar perceptions of privacy, although their training and education differ. Traditionally, Finnish OH relies very much on teamwork, which may well explain this similarity in thinking. The duration of work experience was associated with the perceptions of privacy. Experienced OHPs felt they were more sensitive towards the patients' needs than their less experienced colleagues. This potential competence may be taken advantage of in mentoring.

There were certain limitations in this study. A postal inquiry is an anonymous way of studying sensitive topics such as privacy, but it does not necessarily give a reliable picture of reality where ethical questions are concerned. Given the structured items, the respondents in this study were not in a position to exercise their own judgement, but were forced to choose the preset response options which best corresponded to their perceptions. This method of recording and the subsequent data analysis methods may have biased the study. Further, the results on the relationship between knowledge of ethical codes, legislation, research and education and the respondents' perceptions of privacy have to be seen as indicative only, as the assessments of knowledge were based on self-report.

The strengths of this study lie in its innovative nature. Patients' values and needs have rarely been in the interest of OH researchers, even though the importance of ethics has been repeatedly emphasized [33–35]. Patients often base their assessment of the quality of health care on how their personal rights and values are respected, and in Finland, for instance, a large proportion of complaints made by patients concern health care personnel's inappropriate behaviour. The present study supports the idea that ethics should be included as an integral part of basic professional training and education [30]. In Finland, for example, confidentiality in the OH is found to be at a satisfactory level only [5].

Future studies should work with larger samples that also include patients' views, so that we can gain a fuller, more in-depth picture of the issues raised. Moreover, international studies are needed in order to investigate whether the patients' needs and rights differ from country to country and to develop the ethical quality of OH in all European Union member states.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
We would like to thank the Turku University Foundation and the Finnish Work Environment Fund for funding this research.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. Rodham K. Manager or medic: the role of the occupational health professional. Occup Med (Lond) (1998) 48:81–84.[CrossRef][Medline]

  2. Koh D, Lee S-M. Good medical practice for occupational physicians. Occup Environ Med (2003) 60:1–2.[Free Full Text]

  3. London L. Dual loyalties and the ethical and human rights obligations of occupational health professionals. Am J Ind Med (2005) 47:322–332.[CrossRef][Web of Science][Medline]

  4. Plomp HN. Workers' attitude toward the occupational physicians. Occup Environ Med (1992) 34:893–901.

  5. Martimo KP, Antti-Poika M, Leino T, Rossi K. Ethical issues among Finnish occupational physicians and nurses. Occup Med (Lond) (1998) 48:375–380.[CrossRef][Medline]

  6. Edwards SC. An anthropological interpretation of nurses' and patients' perceptions of the use of space and touch. J Adv Nurs (1998) 28:809–817.[Web of Science][Medline]

  7. Spees EK. Accidental intimacy in the emergency department. Top Emerg Med (2004) 26:2.

  8. Scott PA, Välimäki M, Leino-Kilpi H, et al. Autonomy, privacy and informed consent 1: concepts and definitions. Br J Nurs (2003) 12:43–47.[Medline]

  9. ICOH. In: International Code of Ethics of Occupational Health Professionals (2002) Rome, Italy: International Commission on Occupational Health.

  10. Occupational Health Care Act 1383/2002. http://www.finlex.fi (12 December 2006, date last accessed).

  11. Dworkin RB. Getting what we should from doctors: rethinking patient autonomy and the doctor-patient relationship. Health Matrix Clevel (2003) 13:235–296.[Medline]

  12. Hodge JG, Gostin KG. Challenging themes in American health information privacy and public's health: historical and modern assessments. J Law Med Ethics (2004) 32:670–679.[CrossRef][Web of Science][Medline]

  13. Räsänen K, ed. Occupational Health Services in Finland in 2000. (Työterveyshuolto Suomessa vuonna 2000 ) (2002) Helsinki, Finland: Työterveyslaitos, Sosiaali- ja terveysministeriö.

  14. Badzek L, Gross L. Confidentiality and privacy: at the forefront for nurses. Am J Nurs (1999) 9:52–54.

  15. Pinch WJE. Confidentiality: concept analysis and clinical application. Nurs Forum (2000) 35:5–15.[Medline]

  16. Burgoon JK. Privacy and communication. Commun Yearb (1982) 6:206–249.

  17. Leino-Kilpi H, Välimäki M, Arndt M, et al. Patient's Autonomy, Privacy and Informed Consent (2000) Amsterdam, The Netherlands: IOS Press, Ohmsha.

  18. Leino-Kilpi H, Välimäki M, Dassen T, et al. Privacy: a review of the literature. Int J Nurs Stud (2001) 38:663–671.[CrossRef][Web of Science][Medline]

  19. The Constitution of Finland 731/ 1999. http://www.finlex.fi (2 February 2007, date last accessed).

  20. Act on the Protection of Privacy in Working Life, 759/ 2004. http://www.finlex.fi (12 December 2006, date last accessed).

  21. Heikkinen A, Wickström G, Leino-Kilpi H. Understanding privacy in occupational health services. Nurs Ethics (2006) 13:515–530.[Abstract/Free Full Text]

  22. Routasalo P, Isola A. The right to touch and be touched. Nurs Ethics (1996) 3:165–176.[Abstract/Free Full Text]

  23. Woogara J. Patients' privacy of the person and human rights. Nurs Ethics (2005) 12:273–287.[Abstract/Free Full Text]

  24. Palm E. The dimensions of privacy. In: The Ethics of Workplace Privacy—Hansson SO, Palm E, eds. (2005) Berlin, Germany: P.I.E.-Peter Lang. 157–174.

  25. Behling D, Guy J. Who's protected? Legal, ethical issues in employing the immunosuppressed. Occup Health Saf (1993) 62:76–79.[Medline]

  26. Heikkinen A, Suominen T, Kiviniemi K. Men, work and the capacity for work: how men experience their working capacity during the divorce process (Mies, työ ja työkyky – miehen kokemuksia työkyvystä avioeroprosessin aikana). Sos Laaketiet Aikak (2005) 42:44–56.

  27. DiGiulio JF. A more humane workplace: responding to child welfare workers' personal losses. Child Welfare (1995) 74:877–888.[Web of Science][Medline]

  28. Tabak N, Ozon M. The influence of nurses' attitudes, subjective norms and perceived behavioral control on maintaining patients' privacy in a hospital setting. Nurs Ethics (2004) 11:366–377.[Abstract/Free Full Text]

  29. Gostin LO. Health information privacy. Cornell Law Rev (1995) 80:451–528.[Web of Science][Medline]

  30. Westerholm P. A changing life at work: ethical ramifications. In: Practical Ethics in Occupational Health—Westerholm P, Nilstun T, Ovretveit J, eds. (2004) Oxford: Radcliffe Medical Press. 1–22.

  31. Feingold E. Your privacy or your health. Nations Health (1994) 24:2.

  32. Verbeek J, Hulshof C. Work disability assessment in the Netherlands. In: Practical Ethics in Occupational Health—Westerholm P, Nilstun T, Ovretveit J, eds. (2004) Oxford: Radcliffe Medical Press. 105–114.

  33. Tilton SH. Right to privacy and confidentiality of medical records. Occup Med (Lond) (1996) 11:17–29.

  34. Emanuel E. Introduction to occupational medical ethics. Occup Med (Lond) (2002) 17:549–558.

  35. Higgins P, Orris P. Providing employer-arranged occupational medical care: conflicting interests. Occup Med (Lond) (2002) 17:601–606.


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