Granting and young adults the ability to consent over certain aspects of their health is considered as the foundation of optimal care in adolescent health. Based on this, any information about a minor’s care must not be disclosed to any third-part without their permission. The transition of adolescents into adults needs to be supported by a healthcare provider in order to promote individualization as well as develop autonomy. The fostering of confidentiality of a specific healthcare concern is vital in the development of decision-making skills in adolescents. Promoting confidentiality in adolescent healthcare is a reflection of the clinician's ethical obligation to protects the patient's non-sovereignty, and wellbeing is protected.
Minimizing Confidentiality Breaches in Adolescent Health Care
Relevant State and Federal Laws
State and federal laws are responsible for determining the specific aspects in the health care of a minor or an adolescent that should be protected as well as govern the capacity of adolescents to give consent for medical treatment. Over the past three decades, adolescents have been granted the opportunity to receive protected and confidential health care services, especially when it comes to HIV/AIDs, pregnancy, sexually transmitted diseases, mental health, and substance abuse (Baldridge & Symes, 2018) . Protecting the confidentiality of adolescents is both a clinical and a public policy issue based on the recognition that some adolescents would forego care if they do not receive it confidentially, which would bring about adverse health implications not only to them but the society as well.
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HIPAA ( Health Insurance Portability and Accountability Act ) is a federal confidential legislation that protects the rights of individuals to have access to their medical records and health information. Under HIPAA, the privacy of young adults and adolescents is the same as that of other adults, and they are eligible to access their PHI (protected health information) and, in some circumstances, control the disclosure of that information. When adolescents have been authorized to consent for their own PHI, HIPAA treats them as adults who can exercise their rights over PHI. When parents agree that minors can have a confidential relationship with a health care professional, they are considered as an "individual" under HIPAA, and the parent relinquishes their right to access the minors PHI (Baldridge & Symes, 2018) . Parents are, however, treated as "authorized representatives" under the rule, and they have limited access to the health information of their children in situations that involve endangerment or abuse or when it would not be in the minor's best interest.
State and federal laws in the United States have recognized the importance of confidentiality in the delivery of adolescent-centric care. Although federal laws and policies allow adolescents to provide consent for a range of services, there are variations that exists among states. A majority states allow adolescents to provide consent on the use of contraceptives and the diagnosis and treatment of sexually transmitted disease but some states have imposed age restrictions that only minors over the age of 14 may give consent (Baldridge & Symes, 2018) . In some states, adolescents have been explicitly allowed to consent to contraceptive services but in others, these services may be consented to based on the living situation or status of the minor. In other states, health care providers have the discretion of not disclosing information to parents while in some states they have been given the discretion to inform parents. The above-mentioned variations in federal and state laws and polices function as barriers to health care providers when it comes to the understanding of confidentiality and may hinder how they discuss confidentiality issues with adolescents. Also, based on their personal and professional ethical codes of conduct, health care providers may feel ethically obligated to break the confidentiality agreements with minors when it relates to compromising behaviors such as suicidal behavior, drug use and sexual behavior.
Electronic Health Records (EHR)
The use of EHR is widespread and is gradually replacing the use of paper records. Research has shown that the use of EHRs enhances patient mobility, improves the quality of care, reduces costs, and is an enabling factor in evidence-based medicine. The adoption of EHRs by healthcare institutions in the United States has increased the accessibility and exchange of information (Baldridge & Symes, 2018) . The prevalent use of EHRs has brought about ethical dilemmas when it comes to the protection of adolescent confidential health information. Health care institutions are yet to deploy privacy and security controls for protection of adolescent confidential information . Very few EHRs provide an access point to physicians and clinicians that allows them to isolate or eliminate confidential information from a minor's medical record. Without privacy controls in EHRs, it becomes difficult to determine what constitutes confidential information and hence requires the record to be inspected by trained medical personnel, which is not a guarantee that all confidential information will be identified.
Healthcare institutions must be aware of the provisions of their EHR settings and effectively advocate for the protection of adolescents in their health care systems. Federal and state governments should make it mandatory for EHR vendors to include customizable that can be adapted by healthcare facilities to meet the privacy standards of adolescents. EHRs also allow information that is stored on a single medical system to be shared between medical facilities (Maslyanskaya & Alderman, 2019) . Additional controls must also be put in place to prevent and protect the release of information to other healthcare institutions unless explicitly directed or approved by the adolescent must be incorporated into the EHR system. Besides, EHR vendors could also develop separate EHR portals for adolescents and their parents, with limited exceptions to adolescents with intellectual abilities or severe medical illnesses. The portals can also be configured to allow adolescents of a specific age and their medical providers to access their PHI while parents can only have access to this information through a proxy (Maslyanskaya & Alderman, 2019) .
Today, a large number of health care providers in the United States have deployed EHRs and considerable resources and time are required to customize their EHR implementations in order to provide confidentiality in adolescent care but this is on case-by-case basis. In adolescent health care, confidentiality concerns are pervasive even in the most harmless patient encounters. Health providers and EHR vendors are yet to address the process deign and functionality considerations that are needed to protect the confidentiality of adolescents. Health care systems and EHR vendors are yet to assume a shared responsibility in providing the key functionalities (proxy access, customizable privacy controls and health information exchange compatibility) that are adequately needed to serve adolescent patients (Maslyanskaya & Alderman, 2019) . To improve care outcomes and serve adolescent patients adequately, health care systems must clarify the applicable adolescent confidentiality policies and processes in order to meet the eccentric needs of this patient population. EHR vendors and health care stakeholders must collaborate in order for adolescent patients to experience the full benefits of health information technology.
Parent-Adolescent Communication
Parent-adolescent communication plays an indispensable role in effective illness management, early identification of issues, health education, and the provision of emotional support for improved health care outcomes. Parents find it reluctant to communicate with their adolescents about embarrassing topics such as reproductive and sexual health, which has been linked to adverse health outcomes. Young adulthood and adolescent stages have been regarded as a vital developed process that prepares and transitions adolescents into adulthood. This period helps adolescents reach essential development milestones as they begin to understand who they are and develop their self-identity. Communication barriers exist between parents and adolescents because a) there is lack trust and emotional safety when adolescents are talking with their parents , b) it is sometimes challenging for adolescents to address sensitive and intimate aspects of their lives and c) adolescents do not feel a sense of inclusion and autonomy when discussing difficult topics with their parents.
To improve health care outcomes, parents need to empathetic and kind when discussing difficult topics with regards to their healthcare as a way of developing a sense of emotional safety when they are feeling vulnerable and uncertain about their health status. This allows parents to have a mutual and engaging interaction with them as an effective method of promoting health behaviors. (Sigman et al., 2013) Although some adolescents communicate with their parents about sensitive health topics, such communication needs to start at earlier stages. Not all parents are willing and available to communicate with adolescents about sensitive issues, and not all adolescents are willing to communicate with their parents about these issues. In this context, healthcare providers play an essential role in improving healthcare outcomes. The communication between health care providers and adolescents should reflect the intricate nature of their health needs during development when preventive health risks can impact their development process.
Maintaining the value of parental involvement in adolescent healthcare revolves around the relationship between the adolescent and their parents in managing their mental and behavioral disorders. A more positive family relationship would result in the successful treatment of an adolescent in the treatment of substance abuse, thus improving their health outcomes. Supportive and caring relationships between adolescents and their parents acts as a strong protective pillar in adolescents' lives as they first turn t o their parents for concerns about their health . A family must act as a strong foundation in the development of healthy children. Productive families are those that stand with the needs and wishes of their children by respecting their right to autonomy, which is a principle that underpins the delivery of confidential medical care to an adolescent.
The Role of the Nurse
The primary purpose of clinical practice is to deliver unbiased and patient-centered care to patients, while promoting continuous communication between the minors and their parents without the physician betraying the adolescent’s trust in him/her . Nurses have a responsibility to ensure that confidential healthcare services must be appropriately provided to adolescents. Regardless of the healthcare setting, nurses have the responsibility of initiation meaningful conversations with regards to substance abuse, sexual and reproductive health at every visit and advocate for the delivery of adolescent-friendly services that must include a nurse-adolescent consultation session that is private within the confines of the law (Kim & White, 2017) . Nurses should be on the frontline in advocating for the prioritization adolescent-friendly health care services and must ensure an empathetic nurse-patient corporation It is essential for nurses to remove the obstacles to health care access by young adults and adolescents by advocating for the provision of confidential health services within healthcare facilities and facilitating their enactment . Kim and White (201 7 ) found out that the most effective way for adolescents to seek health care services was to address provider-level barriers that are associated with confidentiality, continuity, privacy and the timelines of preventive care.
In their health care settings, nurse can be instrumental in address ing some of these concerns by performing practice-based evaluations of the services being provided to ensure that adolescents receiving friendly care as well as making the required changes to improve their impressions o n care. Nurse can promote for guideline-based care, confidentiality accessibility to health care through after-school programs or providing convenient clinical locations, and staff friendliness in the delivery of preventive care. Nurses can also advocate for use of technology in promoting the use of adolescent-friendly mobile health applications that allows users to search for preventive healthcare services based on their most immediate needs . In addition, nurses should reassure adolescents that access to their information is confidential which is an essential aspect of health care delivery (Kim & White, 2017) . To maintain confidentiality, nurses can go a step further by establishing meaningful and trusting relationships with minors before they become adolescents, this may be instrumental to help ing parents a s well as other adult caregivers in understanding that privacy is a standard of care for young adults .
There are a lot of inconsistencies among health care providers when it comes to understanding and practicing adolescent confidentiality. There are issues that affects the nurse’s capacity to provide confidential care for adolescents. Before providing care, nurses must determine the adolescent’s capacity to give informed consent. Nurses are then prompted to analyze for situations that may limit their ability to provide confidential care such as if the case is a suspected physical or sexual abuse (Kim & White, 2017) . Nurses also face challenges when it comes to how the records of the minor may be stored and maintained when parents reserve the rights to obtain some but not all of their minors’ health information because of the little control that they have hence complicating the issue further. Many at times, providing adolescent confidentiality is often misunderstood with family-centered care, the legal responsibility and the capacity to consent to medical care and treatment. When an adolescent seeks medical care, many nurses would rather assess whether the adolescent is a mature minor before providing confidential care and this may result to the adolescents right to confidential care not to be fully respected thus affecting the assessment, outcomes and interventions (Sigman et al., 2013) .
References
Baldridge, S., & Symes, L. (2018). Just between Us: An Integrative Review of Confidential Care for Adolescents. Journal Of Pediatric Health Care , 32 (2), e45-e58. https://doi.org/10.1016/j.pedhc.2017.09.009
Butler, P., & Middleman, A. (2018). Protecting Adolescent Confidentiality: A Response to One State's “Parents’ Bill of Rights”. Journal Of Adolescent Health , 63 (3), 357-359. https://doi.org/10.1016/j.jadohealth.2018.03.015
Kim, B., & White, K. (2017). How can health professionals enhance interpersonal communication with adolescents and young adults to improve health care outcomes?: systematic literature review. International Journal Of Adolescence And Youth , 23 (2), 198-218. https://doi.org/10.1080/02673843.2017.1330696
Maslyanskaya, S., & Alderman, E. (2019). Confidentiality and Consent in the Care of the Adolescent Patient. Pediatrics In Review , 40 (10), 508-516. https://doi.org/10.1542/pir.2018-0040
Sigman, G., Silber, T., English, A., & Gansepner, J. ( 2013 ). Confidential health care for adolescents: Position paper of the Society for Adolescent Medicine. Journal Of Adolescent Health , 21 (6), 408-415. https://doi.org/10.1016/s1054-139x(97)00171-7
