The patient-centred interview: the key to biopsychosocial diagnosis and treatment

The article reports on some ideas and experiences gained from a holistic approach to working with patients and introduces a viewpoint that includes opinions on how postmodernism, the biopsychosocial model and a patient-centred interviewing style can change traditional, biomedical-oriented medicine. During the past 10 years, we have been instructing medical students in the use of this patient-centred interviewing model and have trained experienced general practitioners (GPs) in adopting it in 2-year family-oriented continuing medical education courses. We believe that doctors and other health care providers, particularly in primary care settings, need a comprehensive concept of human health and illness, and that skill in patient-centred interviewing is the product of a deep learning process. In conclusion, we have learned that a successful patient-centred interview helps the GP to better understand the patient and helps to explain the data that the patient presents. Patient-centred orientation and interviewing also change the communication between doctor and patient in a direction which supports the patient's and his/her family members' own resources in the healing process.     

Putting the ‘patient’ back into patient-centred care: An education perspective

Patient-centred care is a value espoused by most healthcare systems and a concept taught in nursing education programs as a fundamental concept of patient care. In this study, we focused on the patient's experience of patient-centredness, interviewing eighteen patients and eight family members about their experiences as patients on an in-patient acute care medical unit in a large hospital in Canada. Approximately half of the patients expressed satisfaction with their experiences and their involvement in decisions about their healthcare. The remainder expressed concerns about their care that jeopardized their experiences of patient-centredness. These areas concerned issues of communication with and among healthcare professionals, relationships with these care providers, trust and respect in the professional relationships, and general satisfaction with care. Participants provided advice to professional students about ways to interact more effectively with their patients to establish caring, empathetic, patient-centred relationships as the basis for care. We address patient recommendations to support learner understanding of the patient experience both in classrooms and clinical experiences throughout educational programs as a means to enhance their patient-centredness.     

Professionalising care into compliance: The challenge for personalised care models

One of the most basic understandings of nursing is that a nurse is a caregiver for a patient who helps to prevent illness, treat health conditions, and manage the physical needs of patients. Nursing is often presented as a caring profession, which provides patient care driven by ideals of empathy, compassion and kindness. These ideals of care have further been foregrounded through the development and implementation of stress on patient centred care (PCC) and/or person-centred practice (PCP). Although the idealisation of nursing as a caring profession is common, and one certainly seen as integral by nurses and written into the heart of regulatory documentation, we contend that the actual delivery of care is being undercut by the very regulatory climate that strives to professionalise care. As we outline, with specific reference to the context of Australian Nursing, this transformation delivers a commodified, even McDonaldized, model of patient management rather than care. It seems that even with its explicit stress on PCC and PCP, Australian Nursing cannot live up to its own care ideals. Having outlined this problem, the paper then demonstrates the ways in which PCC is thwarted at the coal face of nursing practice and that there must be an institutionalised change to be able to provide genuine patient-centred care.     

Bridging the gap: Enhancing interprofessional education using simulation

Simulated learning and interprofessional education (IPE) are increasingly becoming more prevalent in health care curriculum. As the focus shifts to patient-centred care, health professionals will need to learn with, from and about one another in real-life settings in order to facilitate teamwork and collaboration. The provision of simulated learning in an interprofessional environment helps replicate these settings thereby providing the traditional medical education model with opportunities for growth and innovation. Learning in context is an essential psychological and cognitive aspect of education. This paper offers a conceptual analysis of the salient issues related to IPE and medical simulation. In addition, the paper argues for the integration of simulation into IPE in order to develop innovative approaches for the delivery of education and improved clinical practice that may benefit students and all members of the health care team.     

Nursing advocacy in an Australian multidisciplinary context: findings on medico-centrism

As a follow-up to a recent study which highlighted the existence of medical dominance in multi-disciplinary team (MDT) meetings, this paper presents research findings from an Australian study which shows that medico-centrism is a key cause of tension within MDTs. The findings are from a 1-year qualitative study in a regional hospital that explored the ethical decision-making of health professionals within an acute care medical unit. This exploration was conducted through an iterative, phenomenological, qualitative research methodology that consisted of open-ended interviews with a multi-disciplinary representation of health professionals and a sample of consumers for whom they care. The paper situates the notion of nursing advocacy within the context of medico-centrism and examines how the nursing profession interfaces with other disciplines. The findings indicate that the professional framework of nursing includes the language of advocacy, whilst the framework of doctors centres around the medical decision-making process. All professional groups made reference to the MDT as the modus operandi for patient-centred care. All participants noted that time and familiarity with patients and their families is essential for patient-centred care and this could be achieved through MDT collaboration. However, doctors who have scant time to spend with patients saw it as their responsibility to direct the decisions of the MDT and viewed the MDT as adding confusion to the decision-making process. Nurses reported that the limited amount of time spent by doctors in patient consultation translated into the need for advocacy. Professional and clinical confidence and experience are noted as necessary to successfully engage in the process of advocacy. The findings of this article indicate that the adoption of an advocacy role by nurses represents an important means through which MDT operation can be enhanced, medico-centrism limited and patient-centred care improved.     

Patientology revisited: Toward tailored care pathways

Background

Concepts such as patient-centred care, patient empowerment and patient participation have challenged our understanding of what it means to be a patient and what role patients play in care pathways. Consequently, patientology as the medical sociological and anthropological study of patients is currently being reconceptualized through perspectives of health as individualized and privatized capital.

Aims

This article explores the potential of such a patientological perspective to enhance our understanding of and tailor care pathways. Particularly, we aim to investigate how such a perspective can contribute to tailoring care pathways to the capacities of individual patients and their relatives.

Materials & Methods

We elaborate on an emerging health capital-theoretic model for patientology and study its potential for optimizing care pathways through two distinct cases of care contexts: communicative challenges in the context of integrative primary care for vulnerable chronically ill multi-morbid patients and the potential of parent involvement in the acute hospitalization of children suspected to be affected by multisystem inflammatory syndrome in children.

Results

Our results shed light on the importance of cultural and social capital of patients and their relatives in the design of effective tailored care pathways. We find that a lack of cultural and social capital presents a significant barrier to effective communication between patients and the healthcare professionals involved in their care pathways. We also find that understanding the cultural and social capital of relatives provides an entry point to their effective involvement in the care pathways of their children.

Discussion & Conclusion

The implications of these findings extend beyond the concrete care contexts studied. This article contributes to our understanding of care pathways through a perspective of health inequalities being based on differences in health capital and demonstrates how the health capital-theoretic patientology model facilitates the systematic development of guidelines for healthcare professionals to assess patients' resources and tailor their care pathways accordingly.     

Developing collaborative person-centred practice: a pilot project on a palliative care unit

Maximizing interprofessional collaborative patient-centred practice holds promise for improving patient care and creating satisfying work roles. In Canada's evolving health care system, there are demands for increased efficiency, cost-effectiveness, and quality improvement. Interprofessional collaboration warrants re-examination because maximizing interprofessional collaboration, especially nurse-physician collaboration, holds promise for improving patient care and creating satisfying work roles. A palliative care team seized the opportunity to pilot a different approach to patient and family care when faced with a reduction in medical staff. Grounded in a collaborative patient-centred practice approach, the Canadian Hospice Palliative Care Association's National Model to Guide Hospice Palliative Care (2002), and outcomes from program retreats and workgroups, a collaborative person-centred model of care was developed for a 12-bed pilot project. Preliminary findings show that the pilot project team perceived some specific benefits in continuity of care and interprofessional collaboration, while the presence of the physician was reduced to an average of 3.82 hours on the pilot wing, compared with 8 hours on the non-pilot wings. This pilot study suggests that a person-centred model, when focused on the physician-nurse dyad, may offer improved efficiency, job satisfaction and continuity of care on a palliative care unit. Incorporating all team members and developing strategies to successfully expand the model across the whole unit are the next challenges. Further research into the impact of these changes on the health care professionals, management and patients and families is essential.     

No identifiable Hb1Ac or lifestyle change after a comprehensive diabetes programme including motivational interviewing: A cluster randomised trial

Abstract

Objective. To study the effectiveness of a comprehensive diabetes programme in general practice that integrates patient-centred lifestyle counselling into structured diabetes care. Design and setting. Cluster randomised trial in general practices. Intervention. Nurse-led structured diabetes care with a protocol, record keeping, reminders, and feedback, plus training in motivational interviewing and agenda setting. Subjects. Primary care nurses in 58 general practices and their 940 type 2 diabetes patients with an HbA1c concentration above 7%, and a body mass index (BMI) above 25 kg/m². Main outcome measures. HbA1c, diet, and physical activity (medical records and patient questionnaires). Results. Multilevel linear and logistic regression analyses adjusted for baseline outcomes showed that despite active nurse participation in the intervention, the comprehensive programme was no more effective than usual care after 14 months, as shown by HbA1c levels (difference between groups = 0.13; CI 20.8–0.35) and diet (fat (difference between groups = 0.19; CI 20.82–1.21); vegetables (difference between groups = 0.10; CI-0.21–0.41); fruit (difference between groups = 20.02; CI 20.26–0.22)), and physical activity (difference between groups = 21.15; CI 212.26–9.97), or any of the other measures of clinical parameters, patient's readiness to change, or quality of life. Conclusion. A comprehensive programme that integrated lifestyle counselling based on motivational interviewing principles integrated into structured diabetes care did not alter HbA1c or the lifestyle related to diet and physical activity. We thus question the impact of motivational interviewing in terms of its ability to improve routine diabetes care in general practice.     

“It goes beyond good camaraderie”: A qualitative study of the process of becoming an interprofessional healthcare “teamlet”

Within the US, the patient-centred medical home has become a predominant model in the delivery of primary care. This model requires a shift from the physician-centric model to an interprofessional team-based approach. Thus, healthcare staff are being reorganized into teams, resulting in having to work and relate to one another in new ways. In 2010, the Veterans Health Administration implemented the patient aligned care team (PACT) model, its version of the patient-centred medical home. The transition to the PACT model involved restructuring primary care staff into “teamlets”, consisting of a registered nurse, licensed practical nurse, and administrative clerk for each full-time-equivalent primary care provider. This qualitative study used observation and semi-structured interviews to understand the factors that affect teamlet functioning as they implement this new model of care and how teams are interacting to address those factors. Findings suggest that role understanding includes understanding how each teamlet member’s tasks are performed in the daily operations of the clinic. In addition, willingness to perform tasks that benefit the teamlet and acceptance of delegation from all teamlet members were found to be important for teamlet functioning and cohesion. In order for healthcare teams to provide patient-centred care, it is important to provide guidance and support about what these new relationships and roles will entail. The building of team relationships is not a static process; ways of working together build over time and, therefore, should be seen as a continuous cycle of quality improvement.     

The patient care team in the hospital ward: the place of the nursing student

Patient care can be regarded as a complex activity, which is the outcome of negotiation amongst a large number of different health care professionals who may, at times, hold conflicting views on goals and priorities. If a high standard of care is to be achieved and limited staff resources are to be used efficiently, a strategy of ‘integrated team working’ should be adopted. For the nurse to play her part in the patient care team, in coordinating ward work, carrying out nursing care, monitoring patients' conditions, helping the patient to make sense of what is happening to him, making the most of the ward's opportunities for learning, and so on, she needs to understand the part played in patient care by other health professionals. The study reported here found that amongst the 46 nursing staff of three wards of different specialties, the majority of trained staff did see themselves as having regular working links with other health care professionals-specifically doctors, physiotherapists and social workers. Only a tiny minority of the 31 student and nursing auxiliaries felt that they had any working links with other health professionals. Most students believed that for the sake of good patient care and effective learning, they should be part of a multidisciplinary team rather than an exclusively nursing team. Whilst the ward manager can do much to foster the development of a multidisciplinary perspective, it is suggested that structuring the workflow along the lines of patient-centred rather than task-centred allocation, automatically builds in face-to-face interactions between nurses of all levels and other health professionals. This facilitates the development of mutual role knowledge and effective integrated team working. The ward manager is in the best position to initiate change in work organization, but, if she is to succeed in this complex endeavour, the active cooperation of others is imperative. In particular, medical staff, nursing management and schools of nursing.     

Facilitating interprofessional education and practice

Collaborative patient-centred care has the potential to address serious issues in the Canadian health-care system such as those related to increasing complexity of care; patient safety and access; and recruitment and retention of health human resources. This approach involves teams of health professionals working together to provide more coordinated and comprehensive care to clients. It places priority on the preferences of the patient and fosters respect for the skills and perspectives of all health-care providers. Interprofessional education at the undergraduate, graduate and practice levels is essential for facilitating the transition to team-based care. The author presents the rationale for collaborative care and describes an interprofessional education project at Memorial University of Newfoundland that is preparing students and health professionals for this groundbreaking change in practice.     

Utilization of research methodology in designing and developing an interdisciplinary course in ethics

Within health, it is widely acknowledged that a collaborative, team-oriented approach to care is required to ensure patient safety and quality of service delivery. A pre-qualification interprofessional learning experience should provide an ideal opportunity for students to gain the necessary knowledge, skills and attitudes to enable them to work as part of a patient-centred interprofessional team. In this article we report a multidimensional evaluation of a pre-qualification interprofessional learning (IPL) program. The program brings together senior year students from various health care professions on clinical placement in the same service area of a hospital to take part in shared, structured learning experiences centred on interprofessional teamwork. We used a combination of qualitative and quantitative methods to evaluate the IPL program. Results indicate that students' understanding of the roles of other team members was enhanced, and students and supervisors perceived the program to be of value for student learning. Measured changes in attitude were limited. Unexpected findings emerged in relation to role responsibilities within teams and attitudes towards doctors. We conclude that such programs have the potential to expand students' understanding of the contributions made by other professionals/colleagues to effective patient care, although challenges persist in overcoming pre-existing role stereotypes.     

A patient-centred model of care incorporating a palliative approach: A framework to meet the needs of people with advanced COPD?

Abstract

Background

Current models of care for people with advanced chronic obstructive pulmonary disease (COPD) have been demonstrated to be inadequate, particularly in areas such as advance care planning, symptom control and psychosocial and spiritual care.

Aim

This paper aims to explore how a model of patient-centred care can incorporate a palliative approach to form a practical and useful framework for care that meets the needs of people with advanced COPD.

Discussion

There is increasing recognition of the need to provide active disease management at the same time as supportive care for people with chronic disease. A palliative approach can incorporate these two care imperatives but a number of barriers often make implementation problematic. A patient-centred care approach can help to address these barriers and is increasingly being seen as an appropriate framework for all healthcare service provision. Significant changes are required to health systems and service provision for this model of care to be implemented; specialist palliative care services can take a leading role in change management.

Conclusion

Patient-centred care provides an appropriate framework for the development of a model of care for advanced COPD. It allows for a need-based approach to service provision, rather than the current prognosis-based system and brings patient and carer needs and concerns to the forefront of care.     

Patient-centred care and nurses' health: the role of nurses' caring orientation

Title.  Patient-centred care and nurses' health: the role of nurses' caring orientation.
Aim.  This paper is a report of a study of the moderating effect of caring orientation on the relationship of patient-centred care to nurses' physical and mental health.
Background.  Providing effective patient-centred care is well-accepted as an important contributor to a host of patients' health outcomes. Based on two theoretical perspectives – person–environment fit and emotional labour – I suggest that providing patient-centred care per se does not potentially harm nurses' health; the cause is the fit (or non-fit) of a nurse's caring orientation and the displayed patient-centred care behaviours.
Method.  Data were collected in 2007 with a random sample of 325 registered nurses working in the Israeli public healthcare sector in in-patient units. Caring orientation, health and control variables were measured via validated questionnaires. Patient-centred care behaviours were assessed by structured observations.
Results.  The mental health of nurses who exhibited high caring orientation combined with high patient-centred care, or that of nurses who exhibited low caring orientation combined with low patient-centred care, was statistically significantly higher in comparison with the mental health of nurses who exhibited incongruent (low/high or high/low) caring orientation and patient-centred care behaviours. For nurses' physical health, the findings revealed that providing patient-centred care was associated with worsened health, and possessing a caring orientation was associated with better health.
Conclusions.  The findings support the hypotheses that were derived from person–environment fit and emotional labour only with regard to mental health. Separate theory needs to be developed on how to maintain nurses' physical health.     

Patient Participation: Current Knowledge and Applicability to Patient Safety

Patient participation is increasingly recognized as a key component in the redesign of health care processes and is advocated as a means to improve patient safety. The concept has been successfully applied to various areas of patient care, such as decision making and the management of chronic diseases. We review the origins of patient participation, discuss the published evidence on its efficacy, and summarize the factors influencing its implementation. Patient-related factors, such as acceptance of the new patient role, lack of medical knowledge, lack of confidence, comorbidity, and various sociodemographic parameters, all affect willingness to participate in the health care process. Among health care workers, the acceptance and promotion of patient participation are influenced by other issues, including the desire to maintain control, lack of time, personal beliefs, type of illness, and training in patient-caregiver relationships. Social status, specialty, ethnic origin, and the stakes involved also influence patient and health care worker acceptance. The London Declaration, endorsed by the World Health Organization World Alliance for Patient Safety, calls for a greater role for patients to improve the safety of health care worldwide. Patient participation in hand hygiene promotion among staff to prevent health care—associated infection is discussed as an illustrative example. A conceptual model including key factors that influence participation and invite patients to contribute to error prevention is proposed. Further research is essential to establish key determinants for the success of patient participation in reducing medical errors and in improving patient safety.Patient participation is a complex concept and arises from the widespread consumer movement of the 1960s that affirmed the consumer''s right to safety, the right to be informed, the right to choose, and the right to be heard.¹ During the past few years, patient participation has been increasingly recognized as a key component in the redesign of health care processes and successfully applied to some aspects of patient care, notably the decision-making process and the treatment of chronic illness. Recently, increasing patient participation has been recommended to improve patient safety. The World Health Organization (WHO) World Alliance for Patient Safety is actively highlighting the role that patients and their families could play in the improvement of health care.² However, this field of patient participation has not been widely researched thus far.We review the underlying principles and the efficacy of patient participation in decision making and self-treatment of chronic illness, as well as the potential obstacles to implementation. Building on these principles, we develop a conceptual framework for patient participation. Finally, we suggest that patient participation could be useful to improve quality of care and prevent medical errors and propose an agenda for research.     

Skills integration in a simulated and interprofessional environment: an innovative undergraduate applied health curriculum

The objective of our study was to propose an innovative applied health undergraduate curriculum model that uses simulation and interprofessional education to facilitate students' integration of both technical and "humanistic" core skills. The model incorporates assessment of student readiness for clinical education and readiness for professional practice in a collaborative, team-based, patient-centred environment. Improving the education of health care professionals is a critical contributor to ultimately improving patient care and outcomes. A review of the current models in health sciences education reveals a scarcity of clinical placements, concerns over students' preparedness for clinical education, and profession-specific delivery of health care education which fundamentally lacks collaboration and communication amongst professions. These educational shortcomings ultimately impact the delivery and efficacy of health care. Construct validation of clinical readiness will continue through primary research at The Michener Institute for Applied Health Sciences. As the new educational model is implemented, its impact will be assessed and documented using specific outcomes measurements. Appropriate modifications to the model will be made to ensure improvement and further applicability to an undergraduate medical curriculum.     

Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward

Aims and objectives. The main aim of this study was to improve the quality of nursing care for older acutely ill hospitalized medical patients through developing, implementing and evaluating a new model of care using a participatory action research process. Background. One of the challenges of nursing today is to meet the health‐care needs of the growing older population. It is important to consider what quality of nursing care means to older patients if nurses are to address gaps between their own perceptions and those of older patients themselves and to consider conceptual models of care appropriate for older patients care in order to improve the quality of care provided. Design. This study is a mixed method triangulated study, involving the use of both quantitative and qualitative methods through participatory action research methodology to establish an evidence‐base for an evolving model of care. Methods. The model was tested on 60 acutely ill patients aged at least 65 years. The medical ward nurses selected a key reference group including the researcher to facilitate the participatory action research process to develop, implement and evaluate a new model of care based on Orem's self‐care model incorporating the Nurses Improving Care to Health System Elders Faculty (Am J Nurs 1994; 94:21) medication protocol to improve the nursing care provided for acutely ill older patients. Results. The participatory action research process resulted in improved heath‐care outcomes for the patients, such as significant improvements in activities of daily living capabilities between admission to discharge, significant improvements in knowledge levels regarding their medication regimes, as well as increased satisfaction with nursing care activities as perceived by older patients and nursing staff. The implementation of educational sessions during the model of care improved the older patient's functional activities and knowledge levels of their medication regime prior to discharge. In addition, by repeatedly explaining procedures, nurses became more involved with their individual patient's care, developing a patient‐centred care relationship based on Orem's self‐care model. Conclusions. This study demonstrates the efficacy of a new model of nursing care in improving the quality of nursing care for older patients in the acute medical ward setting. Relevance to clinical practice. This study is significant because of its evidence‐base and demonstrates how the participatory action research process empowered nurses to make sustainable changes to their practice. The nurses in the study wanted to affect change. The planned change was not dictated by management, but was driven by the clinical nursing staff at the ‘grass roots’ level. Therefore, being involved in the decision‐making process provided an incentive to actively implement change.