Pediatric Emergency Health Care Providers ... - Wiley Online Library

CLINICAL PRACTICE

Pediatric Emergency Health Care Providers’ Knowledge, Attitudes, and Experiences Regarding Emergency Contraception Melissa K. Miller, MD, Diane M. Plantz, MD, MA, M. Denise Dowd, MD, MPH, Cynthia J. Mollen, MD, MSCE, Jennifer Reed, MD, Lisa Vaughn, PhD, and Melanie A. Gold, DO

Abstract Objectives: The objective was to describe knowledge, attitudes, and experiences regarding emergency contraception (EC) among pediatric emergency health care providers (HCPs). Methods: This multicenter, focus group study elicited thoughts and experiences from pediatric emergency HCPs about EC. Participants were physicians, nurse practitioners (NPs), and nurses in one of three urban, geographically distinct, pediatric emergency departments (EDs). A professional moderator used a semistructured format for sessions, which were audiotaped, transcribed, and analyzed for recurrent themes. Participants provided demographic information and completed a written survey evaluating EC knowledge. Results: Eighty-five HCPs (41 physicians, eight NPs, and 36 nurses) participated in 12 focus groups. Overall knowledge about EC was poor. Participants identified barriers including cost, privacy, knowledge, and provider refusal. Provision of EC for adolescents was supported by the majority of physicians and NPs; however, many nurses were not supportive, especially following consensual intercourse. The authors identified use of social judgment by nurses as a novel barrier to EC provision. The majority of HCPs did not support screening for potential EC need. The majority of physicians and NPs felt obligated to provide adolescents with all contraceptive options, while more nurses supported provider refusal to provide EC. Conclusions: This study identified important HCP perceptions and barriers about EC provision in the pediatric ED. These findings may inform future efforts to improve EC provision for adolescents. Specifically, future studies to evaluate the differences in attitudes between nurses, physicians, and NPs, and the use of social judgment in EC provision, are warranted. ACADEMIC EMERGENCY MEDICINE 2011; 18:605–612 ª 2011 by the Society for Academic Emergency Medicine

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nintended adolescent pregnancy remains a major public health concern. Despite the recent 2% decline in the adolescent birth rate, the United States continues to have the highest adolescent pregnancy rate among industrialized nations.1,2 One approach to decreasing the rate of adolescent pregnancy is to improve access to emergency

contraception (EC). Because many high-risk adolescents may not have primary care providers, they often frequent emergency departments (EDs) to seek this care due to ease of access, guaranteed treatment, and anonymity.3,4 Additionally, unintended pregnancy risk may be higher in the ED population than in the general population; 14% of sexually active adolescents in one urban

From the Division of Emergency Medical Services, Children’s Mercy Hospital (MKM, DMP, MDD), Kansas City, MO; the Division of Emergency Medicine, Children’s Hospital of Philadelphia (CJM), Philadelphia, PA; the Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center (JR, LV), Cincinnati, OH; and the Department of Pediatrics, Division of Adolescent Medicine, University of Pittsburgh School of Medicine (MAG), Pittsburgh, PA. Received September 23, 2010; revisions received December 9 and December 14, 2010; accepted December 14, 2010. Presented at the Pediatric Academic Societies annual meeting, Baltimore, MD, May 2009. This study was supported in part by a Katharine B. Richardson grant from the Children’s Mercy Hospitals and Clinics, the Division of Emergency Medicine Small Grant Award from the Cincinnati Children’s Hospital Medical Center, and the Nicholas Crognale Chair for Emergency Medicine at The Children’s Hospital of Philadelphia. The authors have no conflicts of interest to report. Supervising Editor: Marc Gorelick, MD. Address for correspondence and reprints: Melissa K. Miller, MD; e-mail: [email protected].

ª 2011 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2011.01079.x

ISSN 1069-6563 PII ISSN 1069-6563583

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pediatric ED reported unprotected intercourse within the preceding 5 days.5,6 Emergency contraception refers to hormonal medications used within 120 hours after unprotected sex for pregnancy prevention. EC (levonorgestrel, e.g., Plan B) has been available for women aged 18 and older without prescription for years; recently that age was lowered to 17 years. Although EC safety and efficacy are established, and medical organizations have called for improved access to EC, adolescents continue to face many barriers, including the knowledge, attitudes, and beliefs of health care providers (HCPs).7–14 Specific knowledge deficits about EC timing, side effects, and efficacy have repeatedly been found among pediatric HCPs.15–18 Furthermore, knowledge deficits are associated with limiting access and low levels of prescribing EC.15–18 HCP attitudes and beliefs have also been shown to affect EC provision. EC is more frequently prescribed in the ED following alleged sexual assault than after unprotected consensual intercourse.19–23 Additionally, physicians have concerns that EC would discourage other contraception use and increase risk-taking behavior.15,16,18,23 There are little data that describe nurses’ attitudes and knowledge. Some state laws protect HCPs who refuse to participate in services that violate their conscience.24 These ‘‘conscientious objection’’ laws are another barrier to EC, and many refusing HCPs may not feel obligated to provide referrals for patients to obtain services elsewhere.25,26 Because opportunities and barriers to EC are likely significant in the pediatric ED, we aimed to describe the attitudes, beliefs, and experiences regarding EC among these HCPs and to determine HCP selfperceived role in EC provision. METHODS Study Design We conducted a multisite focus group study of HCPs. Participants gave verbal consent and received a $25 gift

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EMERGENCY CONTRACEPTION IN THE PEDIATRIC ED

card. Each site secured institutional review board approval. Study Setting and Population The three participating sites were similar in many ways. EDs were housed within free-standing urban, pediatric, teaching hospitals and staffed by pediatric emergency medicine (PEM) fellowship-trained physicians. Nurse practitioners (NPs) and general pediatricians cared for patients independently, and nurses specialized in pediatric care. None of the hospitals had a religious affiliation or a specific policy about EC. All sites provided HCPs with order sets or pathways that could be used following sexual assault (which contain possible orders for a range of medications including levonorgestrel, as well as orders for various laboratory studies). Most patients at each site were nonwhite and did not have private insurance (Table 1). Also, each site had at least one author with expertise in adolescent health and qualitative research. We also selected sites that were geographically distinct. In 2008–2009, participants were recruited through workplace announcements. Eligible participants were English-speaking physicians, NPs, or nurses employed in U.S. pediatric EDs (two Midwestern and one Northeastern). In the ED, nurses and physicians work closely together to provide patient care, and the nurse often plays an integral role in treatment decisions. Acknowledging this important relationship was paramount to the study design. Also, to increase participant homogeneity and to focus on consistent ED staff, resident physicians and nurses in training were excluded. Study Protocol: Focus Groups A PhD-level psychologist trained in focus group moderation and well versed in adolescent health conducted semistructured sessions using a discussion guide (Data Supplement S1, available as supporting information in the online version of this paper). The white, female moderator had only limited knowledge of the participants

Table 1 Patient Characteristics of Participating EDs

Total patient volume Male Age group (yr) 19 Race ⁄ ethnicity Black or African American White Hispanic Other ⁄ unknown Payer status Governmental Commercial Self-pay Unknown ⁄ other Data are reported as n (%).

Midwestern 1

Midwestern 2

Northeastern

69,930 37,120 (53)

95,755 49,480 (52)

89,044 48,084 (54)

53,395 10,496 5,774 265

(76) (15) (8) (1) (6)

50,755 (57) 34,727 (39) 3,562 (4) 0

(65) (23) (4) (8)

ACADEMIC EMERGENCY MEDICINE • June 2011, Vol. 18, No. 6

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and EC and no religious or cultural background that strongly influenced personal opinion. The guide was developed by the authors and moderator and included topics from literature and clinical experience. The guide used open-ended questions, and discussion was pursued along each topic until no new themes emerged (thematic saturation). Prior to the close of each group, participants were given an opportunity to contribute additional comments. Participants were grouped by occupation (physician ⁄ NP, or nurse) and sex (numbers permitting), to avoid potential professional or hierarchal dominance. Considering both standard methodologic practice and practical constraints, the authors decided a priori to hold four groups at each site (two physician ⁄ NP groups and two nurse groups), with each group having approximately 10 participants.27 Before the session, participants provided information regarding age, education, sex, parenting experience, religiosity, and spirituality and completed a written survey to evaluate EC knowledge. The survey contained true ⁄ false and multiple choice questions that were adapted from previous studies or developed by study authors.15,17 We piloted the survey among pediatric emergency physicians at the authors’ institution for clarity and ease of use, with minimal revisions to questions. No personal identifiers were collected. The moderator introduced the project, explained the voluntary nature, and described the process. Sessions lasted 60– 90 minutes and were audiotaped and transcribed. Notes were taken during the sessions and were used for reference if needed. Data Analysis Transcripts were entered verbatim (without identifiers) into an electronic spreadsheet. Two authors (including one from that transcript site) worked independently to extract key points and generate themes, without using a predefined classification scheme. Authors identified recurring themes and representative quotes and then developed summaries. A third author and the moderator validated this process by reviewing these summaries for discrepancies, which were reviewed until consensus was reached. Two authors (MKM, DMP) reviewed each site summary to develop overarching themes. Themes were examined for differences by profession and location. Survey analysis was conducted using SPSS (SPSS Inc., Chicago, IL). Means and frequencies were determined for sociodemographic characteristics. Chi-square analyses were used to assess differences between groups (profession, location) for dichotomous outcomes. Test levels for significance were p < 0.05. RESULTS Participants Twelve groups were conducted with 85 total participants. Groups had 3–11 participants (most with about seven) and included 36 nurses (one male), 26 PEM physicians, 13 PEM fellows, two pediatricians, and eight NPs. Group characteristics did not vary by site or profession except for female predominance among nurses (Table 2). Overall participation rates were slightly

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Table 2 Participant Characteristics by Profession

Female Experience (mean years ± SD) Age < 40 yr Parented children Very ⁄ moderately religious Very ⁄ moderately spiritualà

All (n = 85)

Nurses (n = 36)

Physicians and NPs (n = 49)

65 (77) 8.8 ± 8.0

35 (97) 8.8 ± 7.4

30 (61)* 8.7 ± 8.5

50 (59) 49 (58) 49 (58)

22 (66) 21 (58) 20 (56)

28 (57) 28 (58) 29 (59)

75 (88)

33 (91)

42 (86)

Data are reported as n (%). NP = nurse practitioner. *p < 0.05 Answered ‘‘very’’ or ‘‘moderately’’ to question ‘‘To what extent do you consider yourself a religious person?’’ àAnswered ‘‘very’’ or ‘‘moderately’’ to question ‘‘To what extent do you consider yourself a spiritual person?’’

higher at Midwestern site 1, and rates at all sites were higher for physicians and NPs than nurses. Thematic Findings Three major themes emerged: 1) attitudes and beliefs toward adolescent sex and contraception, 2) attitudes and beliefs toward EC, and 3) barriers and opportunities to EC provision (Table 3). There was some overlap in that some subthemes were relevant to more than one general theme. It became clear that geographic location was not as important as occupation when identifying recurrent themes. In fact, one of the most striking findings was the differences between nurses and physicians or NPs. Therefore, the results are presented within each theme mostly according to occupation. Attitudes and Beliefs Toward Adolescents, Sex, and Contraception Most nurses and physicians or NPs supported adolescent contraception, but indicated that it was a complex matter and mentioned the importance of abstinence. One nurse said, ‘‘Some people feel that it gives them a license to have sex.’’ Said one physician ⁄ NP, ‘‘I just have an issue with kids so young starting to use pharmacologic agents in their bodies. So, I still think it ought to be available to them, but I like barrier methods more in teenagers, if they’re not going to be abstinent.’’ Participants identified barriers to reproductive care and contraception in general, including fear, availability, knowledge deficits, side effects, cost, transportation, need for HCP contact and prescription, embarrassment, lack of planning, and privacy issues. Nurses at all sites mentioned societal norms that have become more accepting of teen pregnancy, with generational norms, race or ethnicity, and economic status contributing to change. One said, ‘‘It’s not a social stigma to be pregnant or to have a baby.’’ Another added, ‘‘It’s not just the population we see. I don’t like to hear about this population and that population. This is generational.’’ Some physicians or NPs occasionally mentioned

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Table 3 Themes and Subthemes Identified in Focus Groups and Their Frequency

Theme

Nurse

Attitudes and beliefs toward adolescent sex, HCPs support contraception for sexually active adolescents HCPs support abstinence for adolescents Sex without pregnancy protection is irresponsible Attitudes and beliefs toward EC EC is only for use after assault Adolescents who may need EC are irresponsible EC is morally wrong EC terminates a pregnancy Barriers and opportunities to EC provision HCPs support EC following consensual intercourse HCPs support EC following nonconsensual intercourse HCPs use social judgment HCPs support personal role in patient education HCPs support provider refusal HCPs express punitive attitude toward teens HCPs lack EC knowledge

Physician ⁄ NP

contraception F F F

R

F

R

F F

R R

O O

R R

R

F

O

F

F F

R O

F F

R R

O

O

Presented is the frequency each subtheme was discussed by each focus group. EC = emergency contraception; F = frequent; HCP = health care professional; NP = nurse practitioner; O = often; R = rare.

changes in societal norms. One said, ‘‘I think there is more cultural acceptance [but] I think it’s overstating it to say that all these teenagers want to get pregnant.’’ Attitudes and Beliefs Toward EC Many nurses remarked on the complexity surrounding adolescent EC use. Said one, ‘‘We’re not just nursing professionals … we’re maybe Christians, we’re moms, we’re sisters, daughters, we have all these different things that affect our decisions.’’ Several shared personal experiences; as one nurse said, ‘‘That’s why we kicked our niece out, because she got the Plan B.’’ Many nurses indicated that irresponsible behavior led to the need for EC and expressed punitive attitudes. One said, ‘‘Where do we say to them you have to accept personal responsibility? You use condoms or go and get your pills or whatever it is you’re going to use. But for crying out loud, don’t come here and ask for Plan B. That is really supposed to be for acute cases.’’ When discussion led to the possibility that denying EC might result in a future abortion, one replied, ‘‘You know at some stage, if you play the game, don’t you maybe have to pay?’’ While physicians and NPs agreed that EC provision and use is complex, they generally did not express the same attitudes and beliefs as nurses (Table 3). Barriers and Opportunities to EC Provision Social Judgment. Nurses at all sites discussed determining provision of EC based on certain criteria or on

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‘‘a case-by-case kind of basis.’’ One suggested monitoring for frequent EC use: ‘‘We can look it up now. We can make it our goal.’’ Another added, ‘‘I mean, if it was truly an accident like the condom broke, or something and there was just one time to use it—not just every single time.’’ Another gave a detailed description of a potential EC candidate, ‘‘What about the straight-A student who’s had the same boyfriend for seven years? She’s 17 years old, she has a scholarship to Stanford, and she religiously takes her birth control pills … to me, there is a responsible person. She’s well informed. She’s smart. She knows that this could ruin the rest of her life, essentially.’’ Rarely, a nurse would argue, ‘‘Doing it on a case-by-case basis becomes very judgmental and that’s all subjective and whose decision is that?’’ EC Provision. There were geographic differences regarding EC support among nurses. While Northeastern nurses supported EC in general, some Midwestern nurses did not support EC regardless of the situation. One said, ‘‘I have issues with it in general. I can’t even give it to the patients who have been sexually abused, because it’s killing in my opinion. I won’t give it.’’ Many Midwestern nurses did not support EC following consensual intercourse. One commented, ‘‘In my mind, an emergency is when you are assaulted. There is no emergency contraception if you’re under 18 and choosing recklessly to have sex.’’ Most nurses felt the ED was an appropriate place to seek EC after assault, but not following consensual intercourse. One said, ‘‘I would not be unhappy or disappointed if the only emergency contraception we provided was when we get a rape kit.’’ Many did not appreciate the importance of timely intervention following unprotected intercourse. Said one, ‘‘It’s not here just for convenience, it should be an emergency.’’ Another allowed for exceptions, such as a ‘‘girl who is absolutely in tears and you can see she has never been here for that and seems to have a good head on her shoulders. But that’s not the majority of the patients, because that patient would be smart enough to go to her doctor or go to the pharmacy. Not the clientele that we get here.’’ Nurses identified additional barriers including adolescent and HCP knowledge deficits, cost, embarrassment, and need for timely access. Most physicians and NPs supported EC availability for teens. One observed, ‘‘Pregnancy is a big price to pay for momentary lapse in teenage judgment.’’ However, many physicians and NPs worried that providing EC would discourage better decision-making. One said, ‘‘I don’t want to enable. But the reality is, our adolescents do things like that. This is a medical treatment that I provide. And I don’t actually have any moral qualms with it.’’ Many physicians and NPs commented about more preferable methods of contraception, such as barrier methods and routine contraception. Identified barriers to EC provision included: shame, timeliness, HCP refusal, transportation, adolescent and HCP knowledge deficits, lack of primary care physician (PCP), cost, availability, family, religion, and stigma. One said, ‘‘It’s a real barrier to have to go to the emergency room to


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see a doctor to get contraception. And you’ve also got to deal with the issue that not every physician feels comfortable or believes that it should be given for consensual sex.’’ EC Knowledge and Experience. Many nurses expressed confusion surrounding EC, including screening requirements, side effects, and legality of health care provision for adolescents. One wondered, ‘‘… Can a 14-year-old come into our ER herself and check herself in and we treat her and do all that—and never, ever contact a parent?’’ Importantly, nurses at one Midwestern location expressed confusion about patient eligibility for EC, stating ‘‘it’s not available to anyone besides sexual assault victims.’’ Physicians and NPs also reported unfamiliarity with EC. One commented, ‘‘I have to say that I would love to prescribe it, but like I’m a little uncomfortable just because I don’t know the logistics of it. I don’t know how you write for it.’’ The majority of physicians and NPs supported EC provision in the ED, although few had experience outside of assault. Said one, ‘‘I don’t think that we bring it up in other circumstances where a teenager might have had unprotected sex or come in with an STD or abdominal pain or something. I don’t think most of the time we even think about it.’’ EC in the ED. Many HCPs felt that there were more preferable locations other than the ED for obtaining EC. Many physicians and NPs felt that a PCP would best provide EC, due to less cost and opportunity for ‘‘more long-term interaction.’’ Most could identify reasons why adolescents use the ED. One said, ‘‘I think in the world of health care it is a stupid place to go. It’s a costly place to go. But if I was 16, that’s where I would go. It’s anonymous; it doesn’t require an appointment or forethought.’’ Another commented, ‘‘And as far as the ED, many adolescents have no place to go for routine health questions anyway, let alone for something as potentially life-altering as this decision.’’ Refusal. The majority of nurses felt HCPs should have the option to refuse to provide EC. There were few nurses who argued against this. One said, ‘‘You can’t do that. It’s not your kid. You’re not in charge of their morality. There should be zero tolerance for that.’’ Nurses endorsed referral in cases of provider refusal. Several shared personal experiences. One stated, ‘‘I can’t ethically give this medicine without knowing what it will do, and so I just got somebody else to do it.’’ The majority of physicians and NPs felt that HCPs had an obligation to provide information about EC. Said one, ‘‘There’s almost a little bit of a breach of that oath if you’re not going to offer your patient everything that’s available for them out there.’’ Another commented, ‘‘I’m not going to impose my values upon you just because you drew the card that said I’m your doctor today.’’ Rarely, a physician or NP supported refusal based on moral conflict, but emphasized need for referral. Education. Most HCPs felt that reproductive education was important, but barriers existed, including time, HCP knowledge deficit, and lack of adolescent interest.

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Said one nurse, ‘‘We are not primary educators. We just don’t have the backgrounds, we don’t have the education. Time is really the main issue. We’re not equipped to have those conversations.’’ One physician said, ‘‘There are a lot of opportunities for education. I know I personally avoided those because I’m not the primary provider and I don’t want to get involved … I’m there to address an acute issue. So I think a lot of times I use that as an excuse to not address bigger issues.’’ Screening. Most HCPs did not support routine screening for EC need. Asked one nurse, ‘‘And what would be the purpose? Just so that everyone out there in the world would know about emergency contraception and whether they needed it or not?’’ Most HCPs were willing to provide information for certain ‘‘high-risk’’ populations. Most obtained sexual history only when relevant to the presenting complaint. Several shared that they did not screen for health problems like obesity or seat belt use. One physician ⁄ NP argued that EC screening may be different: ‘‘There is possibly one distinction between this issue and all the others you mentioned, which is at the exact moment that you’re seeing them, it could be highly relevant.’’ Advance Prescription. Very few nurses, physicians, or NPs supported advance prescription for EC. Said one nurse, ‘‘If you want to write prescriptions for it in the future, it would be the same as you get it over the counter and we don’t allow that.’’ Another added, ‘‘I think its promoting irresponsibility.’’ No physician or NP had provided an advance prescription for EC. Most were uncomfortable doing it, citing lack of knowledge or conflict with their ED role. One said, ‘‘You’re asking me to do too much and more than I’m comfortable doing. I don’t want to enter into that person’s future medical care.’’ EC Knowledge Survey Overall, knowledge about EC was poor (Table 4). Participants from Midwestern sites were more likely to incorrectly answer ‘‘true’’ to the statement ‘‘Emergency contraceptive pills have the potential to disrupt a pregnancy after implantation in the uterine lining’’ (55% vs. 28%, p < 0.05). Nurses overall were more likely to incorrectly answer ‘‘up to 72 hours’’ to the question ‘‘How long after unprotected intercourse have emergency contraceptive pills been shown to prevent pregnancy?’’ (66% vs. 49%, p < 0.05). DISCUSSION This research facilitated an in-depth study of the attitudes, beliefs, and experiences about EC expressed by nurses and physicians who provide care for adolescents in urban, pediatric EDs. The results demonstrate the complexities surrounding EC provision for adolescents. HCPs who provide care for adolescents need to be aware of how these complexities may affect their practice. Several differences between nurses and physicians or NPs were identified. The majority of physicians and NPs supported EC, while nurses were divided. Nurses also differentiated between the patient circumstances, with

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Table 4 Assessment of Participant Knowledge of EC

Question A negative pregnancy test is always required before prescribing EC pills. One way EC pills may prevent pregnancy is through the inhibition of ovulation. EC pills are more effective the sooner after unprotected intercourse it is taken. If a patient had intercourse, indications for EC may include any of the following: leaving the transdermal birth control patch on for more than 9 days straight, last Depo Provera shot greater than 14 weeks ago, or missing two or more combination oral contraceptive pills. EC pills have the potential to disrupt a pregnancy after implantation in the uterine lining. How long after unprotected intercourse have EC pills been shown to prevent pregnancy?

Correct Answer

Answered correctly, N = 85, n (%)

False

20 (24)

True

30 (35)

True

79 (93)

True

51 (60)

False

30 (35)

Up to 120 hours

19 (22)

EC = emergency contraception.

more nurses disapproving of EC following consensual intercourse. Because patient care is very team oriented in the ED, and nurses have extensive contact with patients, this difference between these two groups of HCPs warrants further investigation if improved EC provision in this high-risk setting is desired. The support of EC expressed by physicians and NPs is in contrast to current literature. Many studies have shown EC is infrequently prescribed in the ED and is more frequently prescribed following alleged sexual assault rather than after unprotected consensual intercourse.19–23 In this context, it may be useful to consider a recent study by Sable et al.,23 which applied the theory of reasoned action to explain physician intent to prescribe EC. While positive physician attitudes strongly predicted intention to prescribe EC, the authors pointed out that intention to prescribe may not accurately predict prescribing behavior. This may also apply to our findings: what the physicians and NPs reported in the focus groups may not translate into actual behavior. Nurses were more supportive of refusal to provide EC. Some participants cited ‘‘conscientious objection’’ as their basis. Medical and nursing organizations have guidelines to address conflicts in providing care, including provider refusal. The American Nursing Association addresses conflicts arising from ‘‘personal and professional values’’ and advises the nurse to ‘‘ensure patient safety and guard the patient’s best interest.’’28 The American Academy of Pediatrics recommends ‘‘a balance between the individual physician’s moral integrity and his or her fiduciary obligations to patients,’’ while

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also describing a duty to disclose, inform, and refer patients.29 Claims of conscientious objection are difficult to characterize, and identifying the boundary between conscientious objection and discrimination is problematic. Many nurses based their disapproval of EC provision on social judgment, and some displayed a punitive attitude toward adolescents with reproductive complaints. Our findings indicate that education about social judgment for HCPs is needed. Similar to previous studies, HCPs repeatedly demonstrated poor knowledge about EC, which is important given the link between poor knowledge and low EC usage.11–14 Specific deficits (time frame for use, prescription requirements, mechanism) need to be addressed as improved knowledge may lead to increased access. Nurses often expressed confusion about providing reproductive care to adolescents in general, and nurses at one site were adamant that EC was only available (due to ‘‘policy’’) after assault. These misconceptions may have influenced participant responses and represent a significant need for education. When our findings are examined in the context of the behavioral model of health services use, it seems that some HCPs limit potential access to reproductive care by negatively affecting enabling factors.30 One simple but required enabling factor is the presence of health personnel who are available to provide reproductive care in the adolescents’ community. If HCPs lack EC knowledge or use social judgment to determine EC provision, then access is clearly limited. While most HCPs would not support routine screening for EC need, most endorsed information for high-risk adolescents. Methods for identifying highrisk teens in the ED have not been established. Further, many adolescents in the pediatric ED have had recent unprotected intercourse,5,6 underscoring the question of how best to reach this vulnerable population. Geographic differences were noted, specifically for knowledge and nursing attitudes toward EC provision. This may indicate need for further quantitative evaluation.

LIMITATIONS There are several limitations to this study, some of which are inherent in qualitative methods.31,32 One limitation is potential subject selection bias, as interest may be associated with participation. To reduce this possibility, investigators educated potential participants and were heavily involved with recruitment. Another potential limitation is variation of discussion content among groups, despite moderator and guideline use. Also, while it is anticipated that group size may vary, it is unknown what effect variation in group size may have had, if any. While it may have been useful to solicit the participants’ thoughts about the accuracy of the data analysis, this was not done. Also, although the written survey used to collect information about EC knowledge was not validated, it still provides useful information about the participants. Finally, while we sought to elicit a wide range of responses through this qualitative


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study, these results may not be generalizable to other practice settings. CONCLUSIONS We identified important health care professional perceptions and barriers about emergency contraception provision in the pediatric ED. Our findings may inform future efforts to improve emergency contraception provision for adolescents. Specifically, future studies to evaluate the differences in attitudes between nurses, and physicians ⁄ nurse practitioners, and the use of social judgment in emergency contraception provision are warranted. The authors thank Sara Pyle, PhD, for her work as focus group moderator as well as the research assistants at each institution who assisted with subject recruitment and data entry.

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me care for my patients? Evidence-Based Medicine Working Group. JAMA. 2000; 284:478–82. Supporting Information The following supporting information is available in the online version of this paper: Data Supplement S1. Discussion guide. The document is in DOC format. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.