Defining information need in health – assimilating complex theories derived from information science

Background Key policy drivers worldwide include optimizing patients’ roles in managing their care; focusing services around patients’ needs and preferences; and providing information to support patients’ contributions and choices. The term information need penetrates many policy documents. Information need is espoused as the foundation from which to develop patient‐centred or patient‐led services. Yet there is no clear definition as to what the term means or how patients’ information needs inform and shape information provision and patient care. Theoretical synthesis The assimilation of complex theories originating from information science has much to offer considerations of patient information need within the context of health care. Health‐related research often focuses on the content of information patients prefer, not why they need information. This paper extends and applies knowledge of information behaviour to considerations of information need in health, exposing a working definition for patient information need that reiterates the importance of considering the patient’s goals and understanding the patient’s context/situation. A patient information need is defined as ‘recognition that their knowledge is inadequate to satisfy a goal, within the context/situation that they find themselves at a specific point in the time’. This typifies the key concepts of national/international health policy, the centrality and importance of the patient. Conclusions The proposed definition of patient information need provides a conceptual framework to guide health‐care practitioners on what to consider and why when meeting the information needs of patients in practice. This creates a solid foundation from which to inform future research.     

“What a nurse suffers”: Care left undone in seventeenth‐century Madrid

Care left undone, interchangeably referred to as missed care, unfinished nursing care and task incompletion, is pervasive in contemporary healthcare systems. Care left undone can result in adverse outcomes for the patient, nurse and organization. The rhetoric that surrounds care left undone infers it is a contemporary nursing phenomenon; however, a seventeenth‐century Spanish nursing treatise, Instruccion de Enfermeros (Instructions for Nurses), challenges this assumption. Instruccion de Enfermeros was an instructional guide that was written for members of the Congregation of Bernardino de Obregon who worked as nurses at the Madrid General Hospital. The treatise provides a historical commentary on the daily roles, responsibilities and working conditions of the Obregonian nurses. Its content and context suggest the Obregonian nursing resource was consistently time poor due to a confluence of internal and external stressors. Consequently, the Obregonians were under considerable role strain resulting in inferior patient care. This article explores the antecedents of care left undone through a historical lens using exemplars from the 1625 edition of Instruccion de Enfermeros. Factors contributing to care left undone in Obregonian nursing will then be examined to offer insights into the similarities between what a nurse suffered 400 years ago and what exists in contemporary nursing practice.     

Needs, closeness and responsibilities. An inquiry into some rival moral considerations in nursing care

Abstract The first part of this paper seeks to clarify how interpersonal relationships are generally rooted in considerations about trust, vulnerability and interpersonal dependence. However, for nurse–patient relationships, and from the point of view of justice and fair rationing, it is essential to investigate their distinct moral nature. Hence, the second part of the paper argues that nurse–patient relationships, as a special kind of interpersonal relationship, raise particular normative issues. I will discuss dilemmas facing nurses and professional care-givers in general who are torn between their obligations to existing patients and more general and impartial considerations regarding the distribution of nursing care. This discussion concerning the normative claims of immediacy and mercy vs. fairness in health care is a pressing issue for nursing care. The claims that arise from particular relationships in nursing care are typically associated with closeness to a person's vulnerabilities. The pressing issue is how considerations of mercy and protection of individual patients can be safeguarded within today's nursing and health-care practices in which distributivist considerations are crucial.     

Advancing nursing practice for improved health outcomes using the principles of perceptual control theory

This article describes how an empirically supported theory of human behaviour, perceptual control theory, can be used to advance nursing practice and improve health outcomes for people who are accessing nursing care. Nursing often takes a pragmatic approach to the delivery of care, with an emphasis on doing what appears to work. This focus on pragmatism can sometimes take precedence over any consideration of the underlying theoretical assumptions that inform decisions to take one particular approach over another or the mechanisms through which nursing interventions have their effects. For nursing to develop as a profession, there needs to be an increased focus on the core principles that underpin the delivery of care. In addition to understanding what works, nurses must develop their understanding of how and why particular approaches work or do not work. Understanding the fundamental principles that underpin nurses’ actions will lead to more efficient and effective approaches to the delivery of nursing care. It will also enable nurses to maximize those elements of their practice that are most beneficial for people and minimize other activities that either have little effect or actually lead to worse outcomes. In this article, we will propose that the phenomenon of control is fundamental to human health. Perceptual control theory provides a coherent theoretical framework that enables us to understand the phenomenon of control through a functional model of human behaviour. People are healthy when their neurochemical, physiological, biological, psychological and social states are all controlled satisfactorily. We will explain the implications of understanding health as control throughout the paper. From this perspective, we will argue that the aim of nurses and nursing should be to support people to maintain or recover control over those aspects of their lives that are important and meaningful to them.     

Risk factors for patient‐reported medical errors in eleven countries

Objectives The aim of this study was to identify common risk factors for patient‐reported medical errors across countries. In country‐level analyses, differences in risks associated with error between health care systems were investigated. The joint effects of risks on error‐reporting probability were modelled for hypothetical patients with different health care utilization patterns. Design Data from the Commonwealth Fund’s 2010 lnternational Survey of the General Public’s Views of their Health Care System’s Performance in 11 Countries. Setting Representative population samples of 11 countries were surveyed (total sample = 19 738 adults). Utilization of health care, coordination of care problems and reported errors were assessed. Regression analyses were conducted to identify risk factors for patients’ reports of medical, medication and laboratory errors across countries and in country‐specific models. Results Error was reported by 11.2% of patients but with marked differences between countries (range: 5.4–17.0%). Poor coordination of care was reported by 27.3%. The risk of patient‐reported error was determined mainly by health care utilization: Emergency care (OR = 1.7, P < 0.001), hospitalization (OR = 1.6, P < 0.001) and the number of providers involved (OR three doctors = 2.0, P < 0.001) are important predictors. Poor care coordination is the single most important risk factor for reporting error (OR = 3.9, P < 0.001). Country‐specific models yielded common and country‐specific predictors for self‐reported error. For high utilizers of care, the probability that errors are reported rises up to P = 0.68. Conclusions Safety remains a global challenge affecting many patients throughout the world. Large variability exists in the frequency of patient‐reported error across countries. To learn from others’ errors is not only essential within countries but may also prove a promising strategy internationally.     

'We don't have anyone with dementia here': a case for better intersectoral collaboration for remote Indigenous clients with dementia

Objective: This paper reports on findings related to intersectoral collaboration stemming from an evaluation of a dementia awareness resource for use in remote Aboriginal communities * . The resource includes a DVD in English and three (3) Aboriginal languages of the Northern Territory. Design: A qualitative evaluation was conducted in four Northern Territory Aboriginal communities/organisations where the resource had been implemented by external dementia educators. The method included five focus groups with Indigenous aged care workers, community members and aged care service users (n = 26), individual interviews with health care professionals and service coordinators (n = 5), and observation. Data were analysed thematically. Results: Specific findings relating to intersectoral collaboration as a key enabling factor of effective dementia awareness and care are discussed in this paper. In addition to context variables such as understaffing and under‐resourcing, there might be a lack of knowledge or interest on the part of some health practitioners concerning clients with dementia within remote communities. Conclusion: Dementia awareness in remote communities needs to be tackled from a ‘whole system’ perspective and not be the exclusive domain of the aged care services. Strategies that increase the critical mass of informed caregivers as well as health professionals will contribute to better services.     

Nurses,formerly incarcerated adults,and Gadamer: phronesis and the Socratic dialectic

This paper describes the first phase of an ongoing education and research project guided by three main intentions: (1) to create opportunities for phronesis in the classroom; (2) to develop new understandings about phronesis as it relates to nursing care generally and to caring for specific groups, like formerly incarcerated adults; and (3) to provide an opportunity for formerly incarcerated adults and graduate nursing students to participate in a dialectical conversation about ethical knowing. Gadamer's writings on practical philosophy, phronesis, and the Socratic dialectic provide the philosophical foundation and framework for the project. The first phase in the project was a 4‐h class within a graduate‐level health promotion course during which 30 nursing students and three formerly incarcerated panelists engaged in a dialectic conversation about what it means to care for formerly incarcerated adults in a meaningful way. After the class, two focus groups were conducted, one with the students and one with the formerly incarcerated panelists. Findings articulated participants' prejudices and assumptions prior to the class, expanded sense of phronesis, and ability to consider nursing practice within a larger ethical framework. Panelists and students left the class with a deeper understanding of one another and expressed an openness towards continued dialectic conversations together. Use of the Socratic dialectic within nursing curricula reflects a current and critical trend in nursing education to bring non‐epistemologic forms of knowledge into the classroom.     

病人对责任护士满意情况调查分析

为了全面了解责任护士工作中存在的问题,有利于采取改进措施,提高责任护士的整体素质,采用从服务态度、技术水平、专业知识水平、健康教育水平和协调能力5个方面自行设计调查表,对2000年3－4月在该院5个整体护理病房住院的150位病人进行问卷调查。其结果：病人对责任护士的服务态度满意度灰96.94%,技术水平的满意度为95.96%,专业知识水平86.11%,健康教育能力71.81%,协调能力86.11%;而且护士专业知识水平、健康教育水平和协调能力是影响整体护理深入发展的主要原因,应引起管理者的重视。     

Undergraduate nursing students' experiences in a rural clinical placement

Objective: This paper draws on questionnaire findings and analysis of students' comments to demonstrate the aspects of rural placements that were effective in engaging students in the learning process. It also examined how a primary health care clinical placement in Aboriginal communities can provide nursing students with a rich and varied learning experience and an insight into the complex aspects of rural life including Aboriginal health. Design: A cohort of eight second‐year nursing students from the Australian Catholic University, North Sydney, in partnership with the Broken Hill University Department of Rural Health (BHUDRH), participated in a 4 weeks' rural placement in far western New South Wales. A pre‐test/post‐test questionnaire was used to capture their experiences with the students completing the questionnaires before and after their clinical placements. Such placements offer students opportunities to deepen their understanding of issues related to rural health in clinical, professional, social and community contexts. Results: The results suggest that clinical experience in rural areas can positively influence attitudes, preparedness for practice and engage students on many levels, deepened their understanding of rural communities and issues related to rural health. Conclusion: This group of undergraduate nursing students indicated they all had a positive learning experience in their rural clinical placement. The value of rural placements as a method for increasing nursing student's practical experience should be promoted.     

Pilot study comparing patients’ valuation of health‐care services with Medicare’s relative value units

Background and aims Physician reimbursement for services and thus income are largely determined by the Medicare Resource‐Based Relative Value Scale. Patients’ assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients’ valuation of health‐care services to Medicare’s relative value unit (RVU) assessments and to discover patients’ perceptions about the relative differences in incomes across physician specialties. Design Cross‐sectional survey. Participants and setting Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. Methods Data collection included the use of a visual analog ‘value scale’ wherein participants assigned value to 10 specific physician‐dependent health‐care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the abovementioned services. Comparisons of (i) the ‘patient valuation RVUs’ with actual Medicare RVUs, and (ii) patients’ estimations of physician income with actual income were explored using t‐tests. Outcomes Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P < 0.001) and the range in values assigned by participants was much smaller than Medicare’s (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P < 0.001) and the differential across specialties was thought to be much smaller (estimate: $88 225, actual: $146 769). Conclusion In this pilot study, patients’ estimations of the value health‐care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients’ valuation of services rendered by physicians may be warranted.     

The FIRST2ACT simulation program improves nursing practice in a rural Australian hospital

Objective: To measure the impact of the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST²ACT) simulation program on nursing observations and practice relevant to patient deterioration in a rural Australian hospital. Design: Interrupted time series analysis. Setting: A rural Australian hospital. Participants: All registered nurses (Division 1) employed on an acute medical/surgical ward. Intervention: The FIRST²ACT simulation program. Outcome measures: Appropriate frequency of a range of observations and administration of oxygen therapy. Results: Thirty‐four nurses participated (83% of eligible nurses) in the FIRST²ACT program, and 258 records were audited before the program and 242 records after. There were statistically significant reductions in less than satisfactory frequency of observations (P = 0.009) and pain score charting (P = 0.003). There was no measurable improvement in the administration of oxygen therapy (P = 0.143), while the incidence of inappropriate nursing practice for other measures both before and after the intervention was too low to warrant analysis. Conclusion: FIRST²ACT was associated with measurable improvements in nursing practice.     

Cyborgs,biotechnologies, and informatics in health care – new paradigms in nursing sciences

Nursing Sciences are at a moment of paradigmatic transition. The aim of this paper is to reflect on the new epistemological paradigms of nursing science from a critical approach. In this paper, we identified and analysed some new research lines and trends which anticipate the reorganization of nursing sciences and the paradigms emerging from nursing care: biotechnology‐centred knowledge; the interface between nursing knowledge and new information technologies; body care centred knowledge; the human body as a cyborg body; and the rediscovery of an aesthetic knowledge in nursing care.     

Continuity of care through medical records--an explorative study on GPs' management considerations

BACKGROUND: The growing complexity of care with more professionals involved is a threat to the delivery of coherent and consistent care. Excellent exchange of information between professionals may be a way to maintain continuity of care. Relevant information to be passed over includes thoughts about future management for individual patients. AIM: To explore the nature of GPs' thoughts about future management, and to determine the extent to which such thoughts are actually recorded in medical records. DESIGN OF STUDY: Cross-sectional study of 5741 consultations. SETTING: Thirty GPs from 17 practices in a region in the eastern part of The Netherlands. METHODS: The GPs responded to an electronic questionnaire, directly after 200 successive consultations. The questionnaire included items on management considerations, consultation characteristics and personal continuity. We compared the data from the questionnaire to the actual recording of management considerations in the patient records. RESULTS: The GPs had management considerations in 66.4% of the consultations, involving mainly considerations about additional testing (15.5%), adjustment of medication (22.5%), alternative treatment plans (18.6%), possible referral (11.8%) and coping behaviour (18.0%). These considerations were seldom recorded in the electronic patient record; additional testing (3.0%) adjustment of medication (2.9%) and alternative treatment plans (4.1%). Surprisingly however, GPs rarely found that management considerations from earlier consultations were lacking in the medical record. CONCLUSION: GPs often have thoughts on how to deal with this patient, but hardly ever record such considerations. We recommend the development of tools that facilitate the recording of management considerations in electronic patient records.     

Everyone's problem but nobody's job: Staff perceptions and explanations for poor nutritional intake in older medical patients

Aim: Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital. Methods: Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape‐recorded, transcribed and analysed thematically. Results: All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient‐level barriers to nutrition care such as non‐compliance to feeding plans and hospital‐level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘extra hands’ would address most barriers but did not consider organisational change. Conclusions: Redesigning the model of care to reprioritise meal‐time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospital‐wide leadership and support to empower staff and increase accountability within a team‐led approach.     

Why are some care homes better than others? An empirical study of the factors associated with quality of care for older people in residential homes in Surrey,England

This paper reports an empirical study that investigated associations between the quality of care received by older people in residential settings and features of the care homes in which they live. Data were gathered from the first announced inspection reports (2002–2003) of all 258 care homes for older people in one county of England (Surrey). The number of inspected standards failed in each home was used as the main indicator of quality of care. Independent variables (for each home) were: size, type, specialist registration, on‐site nursing, ownership, year registered, location, maximum fee, vacancies, resident dependency, whether the home took publicly funded residents, care staff qualifications and managerial quality. Quality of care was modelled using a Poisson count maximum likelihood method based on 245 (91%) of the inspected homes for which relevant data were available. The results showed that quality of care (as defined by failures on national standards) was statistically associated with features of care homes and their residents. A higher probability of failing a standard was significantly associated with being a home that: was a for‐profit small business (adjusted risk ratio (RR) = 1.17); was registered before 2000 (adj. RR = 1.22), accommodated publicly funded residents (adj. RR = 1.12); was registered to provide nursing care (adj. RR = 1.12). Fewer failures were associated with homes that were corporate for‐profit (adj. RR = 0.82); held a specialist registration (adj. RR = 0.91); charged higher maximum fees (adj. RR = 0.98 per 100 pound sterling unit). A secondary analysis revealed a stronger model: higher scores on managerial standards correlated with fewer failures on other standards (r = 0.65, P < 0.001). The results of this study may help inform future policy. They are discussed in the context of alternative approaches to measuring quality of residential care, and in terms of their generalisability.     

Can nursing epistemology embrace p‐values?

The use of correlational probability values (p‐values) as a means of evaluating evidence in nursing and health care has largely been accepted uncritically. There are reasons to be concerned about an uncritical adherence to the use of significance testing, which has been located in the natural science paradigm. p‐values have served in hypothesis and statistical testing, such as in randomized controlled trials and meta‐analyses to support what has been portrayed as the highest levels of evidence in the framework of evidence‐based practice. Nursing has been minimally involved in the rich debate about the controversies of treating significance testing as evidentiary in the health and social sciences. In this paper, we join the dialogue by examining how and why this statistical mechanism has become entrenched as the gold standard for determining what constitutes legitimate scientific knowledge in the postpositivistic paradigm. We argue that nursing needs to critically reflect on the limitations associated with this tool of the evidence‐based movement, given the complexities and contextual factors that are inherent to nursing epistemology. Such reflection will inform our thinking about what constitutes substantive knowledge for the nursing discipline.     

Is primary angioplasty an acceptable alternative to thrombolysis? Quantitative and qualitative study of patient and carer satisfaction

Objective The National Infarct Angioplasty Project assessed the feasibility of establishing a comprehensive primary angioplasty service. We aimed to compare satisfaction at intervention hospitals offering angioplasty‐based care and control hospitals offering thrombolysis‐based care. Design Mixed methods, with postal survey of patients and their carers, supported by semi‐structured interviews. Setting and participants Survey of 682 patients and 486 carers, and interviews with 33 patients and carers, in eight English hospitals. Interventions Primary angioplasty or thrombolysis. Main outcome measures Satisfaction with treatment. Results Responses were received from 595/682 patients (87%) and 418/486 carers (86%). Satisfaction with overall care was high at both intervention and control sites (78% vs. 71% patients rated their care as ‘excellent’, P = 0.074). Patient satisfaction was higher at intervention sites for some aspects of care such as speed of treatment (80% vs. 67%‘excellent’, P = 0.001). Convenience of visiting was rated lower at intervention sites by carers (12% vs. 1%‘poor’, P = 0.001). During interviews, carers reported that they accepted the added inconvenience of visiting primary angioplasty sites in the context of this life‐saving treatment. Patient satisfaction with discharge and aftercare was lower in both treatment groups than for other aspects of care. Conclusions Reorganization of care to offer a primary angioplasty service was acceptable to patients and their carers. Satisfaction levels were high regardless of the type of care received, with the exception of discharge and aftercare.