Evaluating patient education materials about radiation therapy

There is relative consensus about the advantages of patient-centred consultations. However, they have not been easy to realise in clinical praxis. The aim of this study was to investigate whether an intervention focused on health care professionals' understanding of the diabetes-patient encounter could facilitate a patient-centred way to encounter these patients. Two GPs and two nurses participated in the year-long intervention. The intervention focused on the staff's understanding of the encounter. Staff video recorded four to five encounters each and reflected together with a supervisor on their understanding of the encounters and how they were conducted. The encounters were analysed with the Verona-MICS/Dr coding system and patients' comments were analysed separately. The content of the consultations and how they were conducted was also assessed. There was a significant change of two patient-centred items by the staff over time. Two staff seemed to change their educational model. Modern theories of competence development seem to be useful in clinical settings.     

Patients' attitudes to medical and psychosocial aspects of care in fertility clinics: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme

BACKGROUND: The aims were (i) to identify gender differences in motivations to seek assisted reproduction and gender differences in expectations about medical and psychosocial services and (ii) to examine factors that predict the perceived importance of, and intention to use, psychosocial services among infertile people. METHODS: We conducted an epidemiological study based on questionnaires among all new couples attending five fertility clinics with a response rate of 80.0% and a total of 2250 patients. RESULTS: The vast majority of both men and women considered a high level of medical information and patient-centred care as important. Fewer respondents (women 10.0-20.8%, men 4.1-8.9%) felt that professional psychosocial services were important and/or had the intention to use these services. The main predictor of perceived importance of patient-centred care and professional psychosocial services for both men and women was high infertility-related stress in the marital, personal and social domain. CONCLUSIONS: A supportive attitude from medical staff and the provision of both medical and psychosocial information and support should be integral aspects of medical care in fertility clinics. Although only a minority of the participants perceived professional psychosocial services as important, they should be available for patients whose infertility causes them much strain, especially for patients whose marital relationship suffered much because of infertility.     

Patient participation in the medical specialist encounter: does physicians' patient-centred communication matter?

OBJECTIVE: Physicians' patient-centred communication is assumed to stimulate patients' active participation, thus leading to more effective and humane exchange in the medical consultation. We investigated the relationship between physicians' patient-centred communication and patient participation in a medical specialist setting. METHODS: Participants were 30 residents and specialists in internal medicine, and 323 of their patients. Participants completed a questionnaire prior to a (videotaped) follow-up consultation. Physicians' patient-centred communication was assessed by coding behaviours that facilitate or rather inhibit patients to express their perspective. Patient participation was determined by assessing (a) their relative contribution to the conversation, and (b) their active participation behaviour. Analyses accounted for relevant background characteristics. RESULTS: Physicians' facilitating behaviour was found to be positively associated with patients' relative contribution to the conversation as well as patients' active participation behaviour. Physicians' inhibiting behaviour was not related to patients' relative contribution, and was, unexpectedly, positively associated with patients' active participation behaviour. Physicians' behaviour was particularly associated with patients' expression of concerns and cues. CONCLUSIONS: Physicians in internal specialist medicine appear to be able to facilitate patients' active participation in the visit. The findings indicate that inhibiting behaviour may not have the expected blocking effect on patient participation: patients voiced their perspectives just the same and expressed even more concerns. Showing inhibiting behaviour may, alternatively, be a physician's response to the patient's increased participation in the encounter. PRACTICE IMPLICATIONS: The results may give directions for future medical education and specialist training.     

High ratings of satisfaction with fertility treatment are common: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme

BACKGROUND: The aims were: (i). to identify gender differences in evaluation of medical and patient-centred (psychosocial) care in fertility clinics and (ii). to identify predictors of satisfaction. METHODS: An epidemiological prospective study based on questionnaire responses among all new couples attending five fertility clinics. The response rate at the 12 month follow-up was 87.7% and included a total of 1934 patients. RESULTS: During the follow-up period about two-thirds had achieved a pregnancy and about a third became parents. The participants were satisfied with both the medical and patient-centred (psychosocial) services. There were no sex differences in the evaluation of treatment except that women were more satisfied than men with how the staff had performed their medical examinations. Satisfaction with medical and patient-centred services was positively associated with a treatment-related pregnancy/delivery and the report of marital benefits resulting from the infertility experience. Lower social class was a significant predictor for satisfaction. CONCLUSIONS: Both men and women in fertility treatment had high ratings on medical and patient-centred care. It seemed that satisfaction with the psychosocial services was higher than in earlier studies from other countries.     

Qualitative insights into practice time management: does ''patient-centred time'' in practice management offer a portal to improved access?

BACKGROUND: Different sets of literature suggest how aspects of practice time management can limit access to general practitioner (GP) care. Researchers have not organised this knowledge into a unified framework that can enhance understanding of barriers to, and opportunities for, improved access. AIM: To suggest a framework conceptualising how differences in professional and cultural understanding of practice time management in Auckland, New Zealand, influence access to GP care for children with chronic asthma. DESIGN OF STUDY: A qualitative study involving selective sampling, semi-structured interviews on barriers to access, and a general inductive approach. SETTING: Twenty-nine key informants and ten mothers of children with chronic, moderate to severe asthma and poor access to GP care in Auckland. METHOD: Development of a framework from themes describing barriers associated with, and needs for, practice time management. The themes were independently identified by two authors from transcribed interviews and confirmed through informant checking. Themes from key informant and patient interviews were triangulated with each other and with published literature. RESULTS: The framework distinguishes 'practice-centred time' from 'patient-centred time.' A predominance of 'practice-centred time' and an unmet opportunity for 'patient-centred time' are suggested by the persistence of five barriers to accessing GP care: limited hours of opening; traditional appointment systems; practice intolerance of missed appointments; long waiting times in the practice; and inadequate consultation lengths. None of the barriers is specific to asthmatic children. CONCLUSION: A unified framework was suggested for understanding how the organisation of practice work time can influence access to GP care by groups including asthmatic children.     

The realisation of patient-centred care during a 3-year proactive telephone counselling self-care intervention for diabetes

Objective

To explore the way that patient-centred care is realised within a tele-carer behavioural change intervention.

Method

In-depth, semi-structured interviews undertaken at years 1 and 3 with a purposively selected sample from the intervention group within a 3-year randomised controlled trial (RCT) of a telephone-based education and support for persons with type 2 diabetes, and interviews with the non-medically trained tele-carers and supervising diabetes specialist nurse.

Results

A four-phased flow of the patient-centred interactions was identified, which evolved over the process of the intervention. Initially, attention centred on building a picture for and of the patient and assessing their knowledge base. Later, focus moved towards understanding diabetes from the patient's perspective and advice-giving became more individualised. Throughout, the interaction dynamics varied for patients.

Conclusion

This study provides insight into the development of patient-centred behaviours over time and the influence of patients on tele-carer communication styles.

Practice implication

When adopting a patient-centred approach, tele-carers need to be flexible and recognise that patients vary in their knowledge, skills and psychological adaption to diabetes. Continuity of care and consistent contact is pivotal to patients being able to move through the various phases of their illness trajectory and make the transition towards improved self-care management.     

Patients' and physicians' understanding of health and biomedical concepts: relationship to the design of EMR systems

OBJECTIVE: The aim of this paper is to examine knowledge organization and reasoning strategies involved in physician-patient communication and to consider how these are affected by the use of computer tools, in particular, electronic medical record (EMR) systems. DESIGN: In the first part of the paper, we summarize results from a study in which patients were interviewed before their interactions with physicians and where physician-patient interactions were recorded and analyzed to evaluate patients' and physicians' understanding of the patient problem. We give a detailed presentation of one of such interaction, with characterizations of physician and patient models. In a second set of studies, the contents of both paper and EMRs were compared and in addition, physician-patient interactions (involving the use of EMR technology) were video recorded and analyzed to assess physicians' information gathering and knowledge organization for medical decision-making. RESULTS: Physicians explained the patient problems in terms of causal pathophysiological knowledge underlying the disease (disease model), whereas patients explained them in terms of narrative structures of illness (illness model). The data-driven nature of the traditional physician-patient interaction allows physicians to capture the temporal flow of events and to document key aspects of the patients' narratives. Use of electronic medical records was found to influence the way patient data were gathered, resulting in information loss and disruption of temporal sequence of events in assessing patient problem. CONCLUSIONS: The physician-patient interview allows physicians to capture crucial aspects of the patient's illness model, which are necessary for understanding the problem from the patients' perspective. Use of computer-based patient record technology may lead to a loss of this relevant information. As a consequence, designers of such systems should take into account information relevant to the patient comprehension of medical problems, which will influence their compliance.     

Development of the concept of patient-centredness – A systematic review

ObjectivePatient-centredness is often linked to high-quality patient care, but the concept is not well-defined. This study aims to provide an overview of how patient-centredness has been defined in the literature since Mead and Bower’s review in 2000, and to provide an updated definition of the concept.Method & designWe performed a systematic literature search in PubMed to identify original articles with a sufficient definition of patient-centredness. We analysed extracted data defining patient-centredness.ResultsEighty articles were included. The dimensions “biopsychosocial”, “patient-as-person”, “sharing power and responsibility” and “therapeutic alliance” corresponded to four of five dimensions described by Mead and Bower. “Coordinated care” was a new dimension.ConclusionThe identified dimensions are encompassed by three elements: the patient, the doctor-patient relationship and the framework of care i.e. the health care system. The additional focus on coordinated care could reflect increasing complexity of the health care system.Practice implicationsNarrowing down the understanding of patient-centredness to these three focus areas, viz. 1) understanding of the patients’ experience of the illness in their life situation, 2) the professional’s relationship with the patient, and 3) coordination of care in the system, could make the operationalisation and implementation of a patient-centred approach more manageable.     

Swedish health care professionals' diverse understandings of diabetes care

Knowledge of health care professionals' different understandings of diabetes care is important when preparing such professionals in patient education. For patients to manage illness effectively, the actions of health care professionals are crucial. Patients' understanding of their condition should be taken as the point of departure when creating a learning situation. The professionals' understandings of diabetes care were mapped using a survey including 169 primary care doctors, nurses, assistant nurses and chiropodists in Stockholm, Sweden. The responses were analysed using a phenomenographic approach. Five understandings were identified: the professionals treat the patients, the professionals give information, the professionals focus relation and organisation, the professionals seek the patient's agreement, and the professionals focus the patient's understanding of the situation. Only 20 (12%) of the 169 professional caregivers focused the patient's understanding. Professionals need to develop their understandings of health care and the professional-patient interaction in order to support the patients' learning.     

Patient-centredness in chronic illness: what is it and does it matter?

The evidence as to whether patient-centredness is associated with beneficial physical and psychological outcomes is inconsistent. This review of published research on health care communication in chronic illness investigates whether (i) studies of patient-centred consultations use distinctive concepts, (ii) different concepts are differentially associated with health outcomes. Studies of patients with a chronic illness consulting a health professional were included if they measured health professional-patient interaction and a physical or psychological outcome. Thirty studies were identified, falling into two, reliably distinct, categories. In the first, health professionals took the patient's perspective and in the second, they sought to "activate" the patient. The 10 studies taking the latter approach were more consistently associated with good physical health outcomes than were the 20 studies taking the former approach. The suggestion that different types of patient-centredness have different associations with physical health outcomes should be investigated further in experimental studies.     

Frailty in primary care: a review of its conceptualization and implications for practice

Frail, older patients pose a challenge to the primary care physician who may often feel overwhelmed by their complex presentation and tenuous health status. At the same time, family physicians are ideally suited to incorporate the concept of frailty into their practice. They have the propensity and skill set that lends itself to patient-centred care, taking into account the individual subtleties of the patient's health within their social context. Tools to identify frailty in the primary care setting are still in the preliminary stages of development. Even so, some practical measures can be taken to recognize frailty in clinical practice and begin to address how its recognition may impact clinical care. This review seeks to address how frailty is recognised and managed, especially in the realm of primary care.     

General practitioners and their possible role in providing spiritual care: a qualitative study.

We interviewed the general practitioners (GPs) of 40 patients with life-threatening illnesses over the course of the last year of life. We asked them to identify their patients' holistic needs, and to discuss whether they considered that they had a role in providing 'spiritual care'. The GPs varied greatly in their understanding of their patients' experiences and needs. Most said that they had a role in providing spiritual care, but hesitated to raise spiritual issues with patients, mentioning lack of time, a feeling that they should wait for a cue, or being unprepared or unskilled.     

Participation of family members in ward rounds: Attitude of medical staff, patients and relatives

OBJECTIVE: To assess the attitude of medical staff, patients and their relatives to the presence of FMs in WRs. METHODS: This prospective study was performed in an Internal Medicine Department in Israel. WRs were conducted without (phase 1) and with (phase 2) the presence of FMs. Questionnaires were completed by staff members (N = 26, 23), patients (N = 26, 35) and FMs (N = 32, 40) during phases 1 and 2, respectively. RESULTS: 82.6%, 96% and 96.7% of staff, patients and relatives, respectively, expressed a positive attitude towards the participation of FMs in WRs. Staff members became significantly more positive about the concept after having undergone the experience. Patients believed it contributed to a better understanding of their disease and FMs felt it provided them with an opportunity to participate in medical decision-making. CONCLUSION: Hospitalized patients would like their FMs to participate in WRs. Staff members were reluctant at first, but developed a more positive attitude towards the idea after the experience. PRACTICE IMPLICATIONS: Incorporating FMs into WRs is plausible, though adjustment of WRs' routine to the change will be needed. This move might increase patients' satisfaction from WRs.     

Dutch transmural nurse clinics for chronic patients: a descriptive study

'Transmural care' can be defined as patient-tailored care provided on the basis of close collaboration and joint responsibility between hospitals and home care organizations. One form of transmural care is transmural nurse clinics for chronically ill. This study describes 62 transmural nurse clinics in the Netherlands. It was established that most of these nurse clinics are held by a specialized community nurse at a hospital outpatient clinic. The principal tasks of the specialized nurse at the clinic are providing illness-related information and supporting patients in dealing with the illness. Only a few unpublished evaluations of Dutch transmural nurse clinics have been conducted. Future research has to provide more insight into the impact of transmural nurse clinics on the quality and continuity of care.     

Translating theory into practice: using Action Research to introduce a coordinated approach to emotional care

OBJECTIVE: This paper describes a translational project that explored the feasibility and effect of introducing a coordinated approach to emotional care. METHODS: The project was undertaken using Action Research on one ward at St John of God Hospital Subiaco, Western Australia. A senior Registered Nurse was appointed to provide the leadership and direction to staff regarding emotional care and an education program for staff was provided. The project was evaluated using both quantitative and qualitative data. RESULTS: Data demonstrated an increase in the patient's evaluation of emotional care, although levels were found to fluctuate throughout the project. Factors such as the emotional distress of the staff were hypothesised as impacting on the delivery of emotional care. CONCLUSION: The approach used in this project was found to be a useful method of improving emotional care. However, the data collected in this study revealed the complexity of emotional care delivery and the possible impact of a number of factors within the environment. PRACTICE IMPLICATIONS: Emotional care delivery can be improved by using a coordinated research-based educational approach led by a clinical champion. However, the impact of other factors within the hospital environment needs to be considered and more research is required.     

Measuring the burden of psychiatric illness on the family: an evaluation of some rating scales

The gradual shift towards non-institutional treatment for severe and chronic psychiatric illnesses has been accompanied by a recognition of potentially harmful effects ('burden') upon the patient's caregivers. This paper aims to provide a framework for the development of further research into the burden of 'community care' by offering a clear definition of the burden concept, an exposition of the criteria for evaluating rating scales to measure the concept, a review of major rating scales of burden, and some suggestions for improvements in methodology which are urgently required.     

Factors in decision making following genetic counseling for pre-natal diagnosis of de novo chromosomal rearrangements

A retrospective survey of genetic counselors was conducted in order to identify practice patterns and factors that influence a patient's decision making when a de novo translocation is diagnosed pre-natally. Different variables that influence patients' decisions about pregnancy management were assessed and compared. Specifically, the type of rearrangement and/or knowledge of the breakpoints, risks provided for abnormal outcome, anxiety, fetal ultrasound findings and personal reasons for parental decisions were evaluated. Our findings suggest that patient anxiety level significantly predicts pregnancy management decisions. This information may be of benefit in identifying potential areas of education for genetic counselors as well as other health care providers.     

Can a "good death" be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients

BACKGROUND: Prior studies attempting to improve end-of-life care have focused on specific outcomes deemed important to healthcare providers, with disappointing results. Improvement may be best achieved by identifying concerns important to individual patients, communicating the patients' concerns to the treating medical team, and repeating the process frequently until all concerns are addressed. Our objective was to conduct a preliminary evaluation of this innovative patient-centred quality improvement strategy. METHODS: Initial interviews elicited participants' ideas for improvement, which were then fed back to health care providers by the study investigator. A rapid-cycle change model ensured frequent reassessment and continued feedback. The study involved 36 seriously ill, hospitalized patients on teaching general medical inpatient units of a tertiary care hospital. The main outcome measure was participants' ratings of satisfaction within different domains of care on follow-up interviews. RESULTS: The proportion of participants who rated various aspects of their care as "excellent" or "very good" on initial interview was 72% for overall care, 64% for symptom control, 66% for level of support, and 75% for discussions about life sustaining treatments. Patients and families identified many actionable steps for improvement such as; better control of pain and shortness of breath, better access to physicians and medical information, more help with activities of daily living, improving the patient's environment, and shorter waits for nursing care, diagnosis, and treatment. Following feedback to the clinical team, participants reported improvement in overall care (32%), symptom control (44%), and support (40%). Only a minority had further discussions about life sustaining treatments. CONCLUSION: A patient-centred approach using rapid-cycle change was feasible and shows promise for improving the quality of end-of-life care. It should be evaluated on a larger sample in a controlled trial.