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Protecting Youth Confidentiality and Privacy: Medication Administration Practices in Camp Settings

Lydia McBride

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Abstract

Teens often experience stigma related to mental illness, including negative attitudes and internalized feelings about psychiatric medications. Group settings, such as school and camp, present challenges regarding confidentiality due to inadvertent disclosure of medication to others in these settings. In camp settings, adolescents meet new people and are trying to form

friendships; however, fear of inadvertent disclosure of mental health diagnosis and treatment may be exacerbated by the need for social acceptance among new peers. Unfortunately, no studies of camp medication administration practices have been conducted.

In order to address this concern and try to determine potential administration policies that would better protect camper confidentiality, a convenience sample of 41 camp nurses completed an anonymous online survey.

Participants described their camp setting, current medication administration practices and shared perceptions of two recommended confidentiality and privacy practices: (1) educating and training counselors to provide certain medications, and (2) allowing campers to request one-on-one medication administration with the nurse if desired. Participants were primarily female, BSN prepared, and had an average of 17.5 years nursing experience and 5 years camp nurse

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Background Adolescents and Mental Health Stigma

Adolescents experience a 46.5% lifetime mental disorder prevalence rate with 20% experiencing a serious disorder (Merikangas et al., 2011; Townsend, Floersch, & Findling, 2009). Chandra and Minkovits (2006) found that adolescents reported high levels of stigma related to mental illness. Adolescents may experience two types of stigma: public stigma and self-stigma. Public stigma is characterized by negative social behaviors and attitudes directed towards people with mental illness. Self-stigma is the internalized effects that result from public stigma (Pattyn, Verhaeghe, Sercu, & Bracke, 2014). Adolescents link their personal value to stereotypes, and this can negatively impact self-esteem, social interaction, and treatment adherence (Kranke, Floersch, Townsend, & Munson, 2010). Because adolescents perceive that “mental health scares people away”, many avoid self-disclosure in order to protect social connections with friends and hopes for the future (Kranke et al., 2010). Further, adolescents worry about negative consequences should school faculty, staff or peers know their diagnosis (Moses, 2010). An early study by Cheng and colleagues (1993) found that more than two-thirds of adolescents kept their diagnosis secret. Other studies found that fear of mental health stigma interfered with school socialization, school attendance, and treatment adherence (Kranke et al., 2010; Sirey et al., 2001). Therefore, reducing inadvertent diagnosis disclosure and protecting adolescent confidentiality to reduce stigma concerns may be an important factor in treatment adherence.

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patient-provider relationship in designated care settings (Berlan ED & Bravender, 2009; Britto,

Tivorsak, & Slap, 2010; Ford, Thomsen, & Compton, 2001; Lehrer et al., 2007). Among school nurses, the primary healthcare provider responsible for administering medications,

confidentiality concerns are focused on communication between nurses and school faculty (Pohlman, Schwab, & Bergren, 2004). Although a number of professional health and school organizations stress the need to protect student confidentiality, studies have not examined contextual factors or medication administration processes that prevent inadvertent disclosure in school settings (AAP, 2004; Hinkson et al., 2017; Zacharski, Kain, Fleming, & Pontius, 2012). As the number of school-administered medications increases, including those related to mental and behavioral disorder treatment, the lack of best practices for confidentiality should be a concern. Maughan and colleagues (2016) note that medication administration in non-healthcare settings present unique challenges, including those related to confidentiality.

Medication Administration and Confidentiality Concerns in Camp Settings

Many adolescents desire to attend camp, but fear related to public and self-stigma may prevent them from pursuing this opportunity. Camp settings, day or overnight, present multiple challenges regarding camper confidentiality. The Association of Camp Nursing lists camper privacy and confidentiality as a requirement (ACN, 2013); however, legal regulations related to medication management vary from state and some states have no regulations in place (Erceg, 2014). With such a range of laws regarding management and administration of medications, there is no streamlined plan and, subsequently, no system set forth to ensure confidentiality is maintained.

In camp settings, campers spend 8 to 24 hours in very close contact where fear of

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for social acceptance among new peers (Kranke et al., 2010). The American Academy of

Pediatrics recommends that camps have someone responsible for safe storage and administration (AAP, 2009). This role is often filled by a registered nurse who is responsible for assessing camper health needs, identifying potential health risks, and administering medications, among other roles.. The recommended ratio of registered nurses to campers is 1:100-120 (Broussard & Meaux, 2007). Unfortunately, providing care in camp settings with larger populations may demand that nurses provide care to a significantly larger number of campers than what is recommended. To optimize efficiency, routine medication may be administered in a common setting, such as a dining hall. In order to comply with the Five Rights of Medication

Administration, medication packaging may be labeled with the name of the medication. As a result, a camper’s medication and related diagnosis can be unintentionally disclosed during administration.

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someone else could have access to the medication. Thus, the need to provide safe medication administration processes that reduce inadvertent disclosure of diagnosis is important. Although the Association of Camp Nursing requires ensuring camper privacy and confidentiality during medication administration (ACN, 2013), there are no studies of medication administration in camp settings. Additionally, there are no outlined practices to help ensure these requirements are met.

Recommended Medication Administration Practices for Camp Settings

Maintaining the Five Rights of Medication Administration is important for the safety of campers, and well as the liability of the provider. In school settings, privacy in the clinic is important and effort should be put forth to keep a student’s health needs confidential (Bergren, 2004). Although specifics for medication administration in camp settings are lacking, the American Camp Association addresses several medication management components to include: storage of medications in a controlled area, administration or delegation and subsequent

supervision of administration, and administration documentation (Marugg, 2000). Although no research studies examined strategies to protect camper privacy, two approaches appear in published commentary: delegating administration to camp counselors and allowing adolescents to request private administration.

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administration basics (Marugg, 2000). The implementation of these courses allows nurses to delegate the administration of a medication to a trained individual, such as a camper’s counselor. In this situation, delegation would only include providing the camper with the right medication at the right time, and no decision-making by the counselor would be required. By allowing

counselors to administer specific medications, such as anti-depressants, there is a chance that inadvertent disclosure could be better avoided.

The option for campers to request further privacy should also be considered when determining techniques to maintain privacy and confidentiality. Some school nurses have used signs to inform students of steps they can take to request further privacy (Pohlman, Schwab, & Bergren, 2004). If campers were allowed to request one-on-one meetings with the camp health care personnel for their medication administration, risk for inadvertent disclosure may be greatly reduced. This request could be made during the camp application process, via email or phone call in the time before camp, or during opening day screening. Screening on the opening day of camp should occur for all campers bringing medications, and campers should be assessed regarding their medication knowledge (Marrugg, 2000). This time could be an ideal time to ask the camper if he or she would like to have the medication given during mealtimes, or if it would be more comfortable for administration to occur in a more confidential setting, such as one-on-one in the camp clinic. Because of the lack of best practice evidence, this study aims to describe current camp medication practice and assess camp nurses’ perceptions of two recommended confidentiality and privacy practices.

Method

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distributed through the School’s social media accounts, and a link embedded in the School’s alumni newsletter. Participants we asked to self-screen for age > 18 years and current or past camp nurse experience.

Questionnaire

A Qualtrics survey (Table 1) was created to anonymously gather insight into current medication administration practices in various camp settings. The survey included four

demographic questions (i.e., age, gender, degree, years of practice), nine questions about camp nursing experiences (i.e., camp size and setting, years in camp nurse role, healthcare team), and eight questions about medication administration experiences in camp settings. Respondents were asked to share perceptions of two recommended confidentiality and privacy practices: (1)

educating and training counselors to provide certain medications, and (2) allowing campers to request one-on-one medication administration with the nurse if desired. They scored these recommendations on effectiveness related to maintaining confidentiality and feasibility of implementation. A scale of 1 to 5 was used with 1 being least and 5 being most. They were also invited to provide alternative practices that they believed would help to preserve confidentiality of campers during medication administration. The survey took approximately 20 minutes to complete, and respondents were able to exit the survey at any point.

Table 1.

We're interested in the process of medication administration in camp settings and the standards in place to protect confidentiality of campers, especially related to sensitivities about their medications. We are surveying camp nurses in order to identify the various processes in use in camps, and how these processes factor in confidentiality of the campers. A goal of this study is to develop a set of priorities for administration and identify processes that could be

implemented in the future in order to better protect camper confidentiality and care for their sensitivities.

Degree level

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Years of experience as a camp nurse Average days worked per year Camp setting

- Day camp - Overnight camp - Other

Style of camp nurse job - Weekly

- Monthly

- Full-season (specify) - Other

What is the makeup of the healthcare team at your camp? Do you work alone or are there others who aid in providing care and administering medications?

Number of campers in a given session - 1-50

- 51-100 - 101-200 - 201-300 - 301-400 - 401-500 - 501-1000 - 1001+

Age group of campers - Pre-K

- Elementary School - Middle School - High School - Other Population of camp

- General, i.e. sports, adventure, religious-based

- Special needs, i.e. disability, specific medical conditions - Other

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How does the process explained above accommodate for the 5 Rights? Are there any barriers or facilitators to completing the 5 Rights in the current process?

A few studies suggest that adolescents worry about stigma related to their medications, especially anti-depressants and other mental health medications. Describe how your current process does or does not protect confidentiality of campers and their medications.

Please rate the following potential proposals for medication administration based on

feasibility on a scale of 1-5, with 1 being not feasible at all and 5 being very feasible and able to be incorporated.

- Training counselors to administer medications as requested by campers - Allowing campers to request special pick-up of medication

Please rate the following potential proposals for medication administration based on potential effectiveness to protect privacy on a scale of 1-5, with 1 being not effective at all and 5 being completely effective.

- Training counselors to administer medications as requested by campers - Allowing campers to request special pick-up of medication

Please list any barriers that you see in any of the above possible options that would impact the ability to implement a new system.

Please list any other recommendations that you may have for ways that medication could be administered in the camp study to protect camper confidentiality while still meeting the 5 Rights criteria.

Thank you for taking the time to fill out this survey and contribute to the betterment of

medication administration in camp settings, as well as the better providing of care for campers.

Results Demographics

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to high school. The total number of campers served in a given session ranged from 1-50 campers up to 1000+ campers (Table 4).

Table 2.

20-29 30-39 40-49 50-59 60-69 70-79 0

5 10 15 20

Age of Respondents

Age Range in Years

N um be r of R es po nd en ts Table 3.

Degree Level of Respondents

BSN ADN MSN

Table 4.

1-50 51-100 101-200 201-300 301-400 401-500 501-1000 1000+ 0 2 4 6 8 10 12

Camp Size by Number of Campers

Total Number of Campers per Session

N um be r o f C am ps

Current Medication Administration Practices Being Used

The medication management practices in place for routine medications varied widely across the camp settings represented in survey responses. Components of this process that varied include: medication packaging and labeling, administration location, and approach to

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Medication packaging and labeling can play a significant role in ensuring the Five Rights are met; however, packaging can be done in a variety of ways. One respondent reported the use of paper pill cups with only the camper’s name labeled. A “tackle box” was used to organize the medications based on administration time and a separate sheet that included information

regarding the medication and its dosage was referenced during administration. Another

respondent described placing medications into miniature envelopes and then labeling them with camper name and cabin number, as well as medication name and dose. A third nurse stated that volunteers from the local CVS created blister packs for each camper’s medication at the

beginning of the session.

Many nurses reported administration of routine medications occurred in the dining hall during meal time. One approach for administration in the dining hall included a cart or box used to travel to camper tables. One nurse respondent described a process that included asking

campers for their name and cabin number, verifying the medication sheet, and then passing them their paper pill cup. Another described a process of seeking out cabins based on information on labeled medication envelopes and then handing this envelope to the camper after he or she self-identified. Designated tables were also used for administration in the dining hall. One practice had campers line up in front of their peers and come one at a time to receive medication. Another allowed campers to come two at a time to a table where medications were laid out alphabetically by camper name. Once a camper received their medication, his or her drug card was turned over.

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process where the camper was identified and then the medication was poured into a medication cup and handed to the camper to avoid disclosure of the medication. Nighttime meds were most commonly administered in the infirmary. Some nurses reported the counselors would accompany the campers, while others reported campers came alone or with a friend prior to bedtime. Two nurses reported traveling to the cabins to administer bedtime medications.

The majority of nurses stated that both prescriptions and over-the-counter medications were required to be turned in. Only one nurse reported the allowance of self-administration in her camp, and she stated that self-disclosure of medication was not mandated.

Recommended Practices Feedback

Participants perceived that one-on-one meetings provided greater privacy when compared to counselor training. Implementation of one-on-one meetings was perceived as more feasible than counselor training as well (Table 5). Respondents were also invited to voice their opinions for each intervention, whether supportive or not.

Table 5.

Feasibility of Implementation Effectiveness of Protecting Privacy

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Feedback of Proposed Recommendations

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Counselor Training Feedback

Support for training counselors to administer specific medications to campers was rooted in two main positives. First, by allowing counselors to administer a few designated medications, the workload of the camp nurse would be lessened. With a recommended nurse-to-camper ratio of 1:100-120 (Broussard & Meaux, 2007) and the majority of respondents serving camps with greater than 200 campers (Table 3), many nurses have too great of a workload. A couple of respondents acknowledged that, though some camps have health care teams to help ease the burden, utilizing the already available counselors could be a practical option. One respondent stated that, by allowing counselors to administer select medications, the health care person could take full responsibility for the more serious medications. Second, training camp counselors also capitalized on the camper-counselor relationship. A camper may be more comfortable receiving medication from his or her counselor, and this set-up could allow for more private administration if carried out well.

Respondents identified a variety of concerns related to training counselors to administer medications. The predominant concerns included (1) liability and (2) counselor comfort, raised by six and eight respondents, respectively. Liability becomes a concern when considering the potential for missed doses, incorrect administration, and potential reactions following

administration. Respondents concerned about counselor comfort also noted that counselors have a host of other responsibilities and adding one more, especially one that has legal implications, could be burdensome. Other feedback included the thought that it would not be easier, but rather more difficult to maintain privacy if the counselor were to administer the medication if it

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related to storage of the medications if the counselor had them in the cabin and the increased potential for medication access being compromised.

One-on-One Meetings Feedback

The proposed recommendation to allow campers to request a one-on-one meeting with the camp health care person received higher scores related to effectiveness at maintaining confidentiality and feasibility of implementing this process (Table 5). Despite these higher scores, respondents expressed a greater number of issues associated with this intervention.

Support for this proposal included its effectiveness to protect the camper’s privacy, as well as protecting the camp and preventing chances for there to be stigmatization. Respondents thought this was a good option in situations where only a few campers requested one-on-one meetings. Further, one respondent acknowledged that this option may be requested by relatively few campers, making accommodations to one-on-one requests quite feasible.

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Practices Recommended by Respondents

Survey participants were asked to share any recommendations they had for ways to administer medication that upheld the Five Rights while effectively protecting camper privacy. Some recommendations were based on the nurse’s current practice, while others were envisioned as a result of the individuals participation in the survey.

Three responses reflected current practices in nurse’s camp settings. One nurse described pouring the medication into an unlabeled cup prior to administration. The medication was only poured into the cup after the correct camper and medication were identified and the other rights were verified. Another nurse described labeling a miniature envelope with the camper name and cabin, but did not include the medication information. The nurse acknowledged that this set-up was not conducive to performing a complete third medication check, but did allow her the opportunity to check name and cabin number on her sheet to the information on the envelope and the camper she was giving the medication to. A third respondent described having campers line up near a designated table during the administration period (i.e., meal time), and only allowing one camper to be at the table at a time. However, the respondent noted that the only rights checked upon administration were right name and right dose in order to get campers through the line quickly. The final currently-practiced recommendation included allowing campers to keep their medications with them and have them sign off after taking each dose. One respondent stated that this was the current practice at her camp. Campers were responsible for self-administration and she was never aware of camper medications unless they chose to self-disclose.

Respondents suggested a variety of other potential practices to help address maintaining camper confidentiality during medication administration. A scannable card or bracelet,

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medication name would never be displayed for other campers to see. Another recommendation suggested designating a “med prep” area where campers could come during meal time up until a certain point. If a camper did not come to pick up his or her medication, the nurse would then take the medication to the camper’s table.

Additional Feedback from Respondents

Survey responses included a couple of statements that addressed the proposal of

implementing a new medication administration practice. One respondent stated that camp is “not a private, confidential place”. This should be an understanding when someone signs up for a camp and, therefore, confidentiality during medication administration should not be an

expectation. Further, another participant spoke to the lesser importance of confidentiality, stating that it is “not as important as safety”, and that safety should not be compromised for the sake of confidentiality or privacy.

Discussion

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The biggest barrier identified to implementation of one-on-one meetings was time-consumption. One respondent acknowledged that, if this request was made by a small number of campers, implementation would be reasonably feasible. Another respondent noted that she believed only a few would request this. This practice was deemed to be very effective at protecting privacy if implemented. Therefore, the offering of one-on-one meetings should be considered as an option for camps to improve upon protection of privacy, especially for campers who are prone to experiencing the negative effects of public and self-stigma.

Implications

The suggestions made by respondents warrant investigation and form the basis for a follow-up survey. Through the use of a secondary survey, there is the potential for a singular priority or set of priorities to be identified and a practice to be laid out that would better maintain camper confidentiality. This would help provide guidance to camps and allow them to foster a greater overall camp experience that is not impacted by mental health stigma or any other feelings of discomfort related to medication administration.

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