Patient preferences for participation in patient care and safety activities in hospitals

Background

Active patient participation is a patient safety priority for health care. Yet, patients and their preferences are less understood. The aim of the study was to explore hospitalised patients’ preferences on participation in their care and safety activities in Sweden.

Methods

Exploratory qualitative study. Data were collected over a four-month period in 2013 and 2014. Semi-structured interviews were conducted with 20 patients who were admitted to one of four medical wards at a university hospital in Sweden. Data were analysed using thematic analysis.

Results

Nine men and eleven women, whose median age was 72 years (range 22–89), were included in the study. Five themes emerged with the thematic analysis: endorsing participation; understanding enables participation; enacting patient safety by participation; impediments to participation; and the significance of participation. This study demonstrated that patients wanted to be active participants in their care and safety activities by having a voice and being a part of the decision-making process, sharing information and possessing knowledge about their conditions. These factors were all enablers for patient participation. However, a number of barriers hampered participation, such as power imbalances, lack of patient acuity and patient uncertainty. Patients’ participation in care and patient safety activities seemed to determine whether patients were feeling safe or ignored.

Conclusion

This study contributes to the existing literature with fundamental evidence of patients’ willingness to participate in care and safety activities. Promoting patient participation begins by understanding the patients’ unique preferences and needs for care, establishing a good relationship and paying attention to each patient’s ability to participate despite their illness.

     

Patient participation in patient safety still missing: Patient safety experts' views

The aim of this study was to elicit patient safety experts' views of patient participation in promoting patient safety. Data were collected between September and December in 2014 via an electronic semi‐structured questionnaire and interviews with Finnish patient safety experts (n = 21), then analysed using inductive content analysis. Patient safety experts regarded patients as having a crucial role in promoting patient safety. They generally deemed the level of patient safety as ‘acceptable’ in their organizations, but reported that patient participation in their own safety varied, and did not always meet national standards. Management of patient safety incidents differed between organizations. Experts also suggested that patient safety training should be increased in both basic and continuing education programmes for healthcare professionals. Patient participation in patient safety is still lacking in clinical practice and systematic actions are needed to create a safety culture in which patients are seen as equal partners in the promotion of high‐quality and safe care.     

Update on the National Patient Safety Goals--changes for 2005

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EACH YEAR SINCE 2003, the Joint Commission on Accreditation of Healthcare Organizations has established National Patient Safety Goals for accredited health care organizations.

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THE GOALS are developed to promote improvement in patient safety by helping health care organizations address specific safety concerns.

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THIS ARTICLE discusses the current goals and highlights new information for 2005. AORN J 81 (February 2005) 336-341.

     

Patient safety on psychiatric wards: A cross‐sectional,multilevel study of factors influencing nurses' willingness to share power and responsibility with patients

The World Health Organization highlights the need for more patient participation in patient safety. In mental health care, psychiatric nurses are in a frontline position to support this evolution. The aim of the present study was to investigate the demographic and contextual factors that influence the willingness of psychiatric nurses to share power and responsibility with patients concerning patient safety. The patient participation culture tool for inpatient psychiatric wards was completed by 705 nurses employed in 173 psychiatric wards within 37 hospitals. Multilevel modelling was used to analyse the self‐reported data. The acceptance of a role wherein nurses share power and responsibility with patients concerning patient safety is influenced by the nurses' sex, age, perceived competence, perceived support, and type of ward. To support nurses in fulfilling their role in patient participation, patient participation‐specific basic and continuing education should be provided. Managers and supervisors should recognize and fulfil their facilitating role in patient participation by offering support to nurses. Special attention is needed for young nurses and nurses on closed psychiatric wards, because these particular groups report being less willing to accept a new role. Ward characteristics that restrict patient participation should be challenged so that these become more patient participation stimulating. More research is needed to explore the willingness and ability of psychiatric nurses to engage in collaborative safety management with patients who have specific conditions, such as suicidal ideation and emotional harm.     

Enhancing nurse and physician collaboration in clinical decision making through high-fidelity interdisciplinary simulation training

OBJECTIVE: To determine whether interdisciplinary simulation team training can positively affect registered nurse and/or physician perceptions of collaboration in clinical decision making.PARTICIPANTS AND METHODS: Between March 1 and April 21, 2009, a convenience sample of volunteer nurses and physicians was recruited to undergo simulation training consisting of a team response to 3 clinical scenarios. Participants completed the Collaboration and Satisfaction About Care Decisions (CSACD) survey before training and at 2 weeks and 2 months after training. Differences in CSACD summary scores between the time points were assessed with paired t tests.RESULTS: Twenty-eight health care professionals (19 nurses, 9 physicians) underwent simulation training. Nurses were of similar age to physicians (27.3 vs 34.5 years; p=.82), were more likely to be women (95.0% vs 12.5%; p<.001), and were less likely to have undergone prior simulation training (0% vs 37.5%; p=.02). The pretest showed that physicians were more likely to perceive that open communication exists between nurses and physicians (p=.04) and that both medical and nursing concerns influence the decision-making process (p=.02). Pretest CSACD analysis revealed that most participants were dissatisfied with the decision-making process. The CSACD summary score showed significant improvement from baseline to 2 weeks (4.2 to 5.1; p<.002), a trend that persisted at 2 months (p<.002).CONCLUSION: Team training using high-fidelity simulation scenarios promoted collaboration between nurses and physicians and enhanced the patient care decision-making process.AHRQ = Agency for Healthcare Research and Quality; CSACD = Collaboration and Satisfaction About Care DecisionsNearly a decade has passed since the Institute of Medicine released its seminal report To Err is Human: Building a Safer Health System.¹ The report described the US health care system as a decade or more behind other high-risk industries in its attention to ensuring basic safety. One recommendation was that Congress should create a center for patient safety within the Agency for Healthcare Research and Quality (AHRQ). The AHRQ was asked to set standards, communicate with members about safety, and develop training programs that create a culture of safety across disciplines.¹ The AHRQ supports simulation research through its patient safety program, recognizing that “simulation in health care creates a safe learning environment that allows researchers and practitioners to test new clinical processes and to enhance individual and team skills before encountering patients.”²Effective collaboration between registered nurses and physicians has been shown to reduce morbidity and mortality rates, cost of care, and medical errors and to improve job satisfaction and retention of nursing staff.^3-6 The nursing workforce is expected to decrease by 20% by 2020, putting the profession in a critical shortage.⁷ Collaboration between nurses and physicians improves professional job satisfaction and is considered a high priority for retention purposes. The literature has outlined the importance of nurse-physician collaboration but is lacking in strategies that enhance it. The team approach to health care requires that these different professions communicate and collaborate effectively in a rapidly changing and complex environment. Patients are at risk of adverse effects when exchanged information is misunderstood or misinterpreted.The need for improvement in the ability of nurses and physicians to exchange information is well known. Team-training exercises for health care professionals are considered to be a highly effective tool to improve communication and team performance, particularly in crisis situations.^8-10 TeamSTEPPS, developed by the Department of Defense and the AHRQ, is an evidence-based framework to optimize team performance across the health care delivery system.^11,12 The framework comprises 4 teaching and learning skills: (1) leadership, (2) situation monitoring, (3) mutual support, and (4) communication. We have designed a team-training course that incorporates key concepts and principles from TeamSTEPPS and crisis resource management.^11,12High-fidelity simulation training, in a dedicated simulation center, offers a realistic and experiential environment in which learners practice response to clinical scenarios, debrief, and evaluate team performance in the absence of patient risk. Simulation exercises offer a venue for dialogue on and active listening to one another''s perspectives, thoughts, and practices and may be beneficial in general medical-surgical settings as a vehicle to enhance nurse-physician collaboration. Therefore, our aim was to determine if interdisciplinary simulation team training can positively affect perceptions of nurses and/or physicians about collaboration in clinical decision making.     

Screening and Brief Intervention for Underage Drinkers

In a 2007 report, the US Surgeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief intervention, and referral to treatment. MEDLINE and published reviews were used to identify relevant literature. Several brief screening methods have been shown to effectively identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the initial intervention typically focuses on education, motivation for change, and consideration of treatment options. Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes in federal and commercial insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances in clinical methods and progress on reimbursement policies have made screening and brief intervention for underage drinking more feasible in general health care practice.ADHD = attention-deficit/hyperactivity disorder; AUDIT = Alcohol Use Disorders Identification Test; AUDIT-C = Alcohol Use Disorders Identification Test–Consumption; AUD = alcohol use disorder; CAGE = Cut down, Annoyed, Guilty, Eye-opener; CRAFFT = Care, Relax, Alone, Family, Friends, Trouble; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision); NIAAA = National Institute on Alcohol Abuse and Alcoholism; SAMHSA = Substance Abuse and Mental Health Services Administration; SBIRT = screening, brief intervention, and referral to treatmentUnderage drinking is a statistically and culturally normative phenomenon in the United States. Alcohol use is typically initiated in middle adolescence, and binge drinking is common in high school students.¹ Initiation of alcohol use in early adolescence increases the risk for alcohol use disorders (AUDs).^2,3 Underage drinking peaks during the college-age years, and alcohol dependence is more common among older adolescents (ie, 18-20 years) than among any adult age group.⁴ More than one-third of college students have alcohol abuse or dependence, and among those with alcohol dependence, only approximately 1 in 20 have sought treatment.⁵ Given the relative infrequency of health care visits among this age group, any available opportunities for health care practitioners to identify and intervene with underage drinkers need to be used. Organizations representing health care professionals and federal health services agencies have agreed that identification of underage drinkers should be routine clinical practice. The US Surgeon General recently called for health care professionals to identify adolescents who use alcohol, provide expanded services for them, and develop treatment referral networks. Despite this consensus, few health care professionals adhere to these recommendations.⁶ Commonly cited barriers include time constraints, inadequate reimbursement, concerns about alienating the patient and family, inadequate training, and lack of intervention resources.^7,8 Health care professional education has been shown to partially overcome these barriers.⁹ This review provides health care practitioners with contemporary information on alcohol-related screening, brief intervention, and referral to treatment (SBIRT) that will facilitate their participation in this national effort to reduce underage drinking.Patients aged 12 through 20 years need to be screened for underage drinking. Adolescents in this age range may be seen by internists, pediatricians, family physicians, specialty physicians, and nonphysician practitioners. Any health care practitioners serving patients in this age group may be called on to identify and intervene with an underage drinker. The methods described in this article may also be implemented in a variety of health care settings, including but not limited to traditional outpatient clinics, emergency departments, and schools. Adolescents tend to have relatively little contact with health care practitioners, making screening and intervention for underage drinking important in virtually any health care setting. Therefore, we targeted this article to any health care professionals who serve individuals in this age range.     

Laboratory safety and the WHO World Alliance for Patient Safety

Laboratory medicine has been a pioneer in the field of patient safety; indeed, the College of American Pathology first called attention to the issue in 1946. Delivering reliable laboratory results has long been considered a priority, as the data produced in laboratory medicine have the potential to critically influence individual patients' diagnosis and management. Until recently, most attention on laboratory safety has focused on the analytic stage of laboratory medicine. Addressing this stage has led to significant and impressive improvements in the areas over which laboratories have direct control. However, recent data demonstrate that pre- and post-analytical phases are at least as vulnerable to errors; to further improve patient safety in laboratory medicine, attention must now be focused on the pre- and post-analytic phases, and the concept of patient safety as a multi-disciplinary, multi-stage and multi-system concept better understood. The World Alliance for Patient Safety (WAPS) supports improvement of patient safety globally and provides a potential framework for considering the total testing process.     

Registered Nurses’ experiences of patient participation in hospital care: supporting and hindering factors patient participation in care

Background

Promoting patient participation in care is an international priority identified by the World Health Organization and various national bodies around the world and an important aspect of person‐centred care.

Aim

The aim of this study was to describe Registered Nurses’ experiences with patient participation in nursing care including their barriers and facilitators for participation.

Method

The study setting was a University Hospital in Sweden. Interviews were conducted with twenty Registered Nurses working at medical wards in 2013. Thematic data analysis was used to analyse the transcribed interview data.

Results

Twenty nurses from four wards in two hospitals were included. Five themes emerged from the analysis including listening to the patient, engaging the patient, relinquishing some responsibility, sharing power and partnering with patients. The core theme ‘partnering with patients’ was enacted when nurses listened to and engaged patients and when they relinquished responsibility and shared power with patients. In addition, hindering and facilitating factors to participation were identified, such as patients wanted to take on a passive role, lack of teamwork which participants understood would enhance interprofessional understanding and improve patient safety. Patient participation was hindered by medical jargon during the ward round, there was a risk of staff talking over patients’ heads but sometimes inevitable having conversations at the patient's bedside. However, nurses preferred important decisions to be made away from bedside.

Conclusions

It all came down to partnering with the patient and participants described how they made an effort to respect the patients’ view and accept patient as a part of the care team. Identified hindering factors for participation were lack of teamwork, patients’ taking on passive roles and communication during ward rounds having conversations at the patient's bedside. Nurses wished for a change but lacked strategies on how. Nurses preferred important decisions to be made away from bedside.

     

Patient safety culture in Norwegian primary care: A study in out-of-hours casualty clinics and GP practices

Objective. This study aimed to investigate patient safety attitudes amongst health care providers in Norwegian primary care by using the Safety Attitudes Questionnaire, in both out-of-hours (OOH) casualty clinics and GP practices. The questionnaire identifies five major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, and Working conditions. Design. Cross-sectional study. Statistical analysis included multiple linear regression and independent samples t-tests. Setting. Seven OOH casualty clinics and 17 GP practices in Norway. Subjects. In October and November 2012, 510 primary health care providers working in OOH casualty clinics and GP practices (316 doctors and 194 nurses) were invited to participate anonymously. Main outcome measures. To study whether patterns in patient safety attitudes were related to professional background, gender, age, and clinical setting. Results. The overall response rate was 52%; 72% of the nurses and 39% of the doctors answered the questionnaire. In the OOH clinics, nurses scored significantly higher than doctors on Safety climate and Job satisfaction. Older health care providers scored significantly higher than younger on Safety climate and Working conditions. In GP practices, male health professionals scored significantly higher than female on Teamwork climate, Safety climate, Perceptions of management and Working conditions. Health care providers in GP practices had significant higher mean scores on the factors Safety climate and Working conditions, compared with those working in the OOH clinics. Conclusion. Our study showed that nurses scored higher than doctors, older health professionals scored higher than younger, male GPs scored higher than female GPs, and health professionals in GP practices scored higher than those in OOH clinics – on several patient safety factors.Key Words: Adverse events, general practice, medical errors, Norway, out-of-hours, patient safety culture, primary care, Safety Attitudes QuestionnairePatient safety culture is how leader and staff interaction, attitudes, routines, and practices in a group setting may protect patients from adverse events.

• In out-of-hours clinics, nurses scored higher than doctors, and older health professionals scored higher than younger on patient safety factors.
• Male professionals in GP practices scored significantly higher than female on four of the patient safety factors.
• Health care providers in GP practices had higher patient safety factor scores than those working in out-of-hours clinics.

     

Patient safety in the developing world: new frontiers

Patient safety is not only a vitally important concept for nurses and doctors in the developed world, but is also essential for those in the developing world. Consequently, the World Health Organization (WHO) has launched the WHO African Partnership for Patient Safety (APPS) project, which brings together nurses, doctors and other health professionals in both UK and African hospitals to enhance patient safety. This article will discuss the APPS project alongside a report (WHO, 2008) from the Regional Director, Regional Office for Africa, which outlines key patient safety challenges and opportunities. Some are particularly relevant to hospitals in the developed world, whereas others can apply to all hospitals.     

Advance Care Planning in Community-Dwelling Patients With Dementia

Context

Little is known about advance care planning (ACP) among community-dwelling patients with dementia.

Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: a qualitative study

Background

Patient safety culture emerges from the shared assumptions, values and norms of members of a health care organization, unit, team or other group with regard to practices that directly or indirectly influence patient safety. It has been argued that organizational culture is an amalgamation of many cultures, and that subcultures should be studied to develop a deeper understanding of an organization’s culture. The aim of this study was to explore subcultures among registered nurses and nurse assistants in Sweden in terms of their assumptions, values and norms with regard to practices associated with patient safety.

Methods

The study employed an exploratory design using a qualitative method, and was conducted at two hospitals in southeast Sweden. Seven focus group interviews and two individual interviews were conducted with registered nurses and seven focus group interviews and one individual interview were conducted with nurse assistants. Manifest content analysis was used for the analysis.

Results

Seven patient safety culture domains (i.e. categories of assumptions, values and norms) that included practices associated with patient safety were found: responsibility, competence, cooperation, communication, work environment, management and routines. The domains corresponded with three system levels: individual, interpersonal and organizational levels. The seven domains consisted of 16 subcategories that expressed different aspects of the registered nurses and assistants nurses’ patient safety culture. Half of these subcategories were shared.

Conclusions

Registered nurses and nurse assistants in Sweden differ considerably with regard to patient safety subcultures. The results imply that, in order to improve patient safety culture, efforts must be tailored to both registered nurses’ and nurse assistants’ patient safety-related assumptions, values and norms. Such efforts must also take into account different system levels. The results of the present study could be useful to facilitate discussions about patient safety within and between different professional groups.

     

Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments

Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia.ANH = artificial nutrition and hydration; PS = palliative sedationPalliative sedation (PS) refers to the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. The practice of PS has gained attention in the literature during the past 20 years. In 1994, Cherny and Portenoy¹ first offered an algorithm for determining appropriate indications for use of PS. During the late 1990s, several important court cases in the United States brought the issue of PS to the forefront and clarified the legality of the right to palliation at end of life.^2,3 Studies have shown that PS is effective, with efficacy rates ranging from 71% to 92%,⁴ usually defined as the patient, family, or physician''s perceived relief of refractory physical symptoms. In many settings, PS is uncommon, although a recent review revealed considerable variability in the prevalence of PS in the United States and other countries.⁴ When PS is used, it is a measure of last resort rather than general care. Although required infrequently, PS is an important palliative tool with which clinicians should be familiar.     

Pilot Study of Providing Online Care in a Primary Care Setting

OBJECTIVE: To study the use of e-visits in a primary care setting.PATIENTS AND METHODS: A pilot study of using the Internet for online care (“e-visits”) was conducted in the Department of Family Medicine at Mayo Clinic in Rochester, MN. Patients in the department preregistered for the service, and then were able to use the online portal for consultations with their primary care physician. Use of the online portal was monitored and data were collected from November 1, 2007, through October 31, 2009.RESULTS: During the 2-year period, 4282 patients were registered for the service. Patients made 2531 online visits, and billings were made for 1159 patients. E-visits were submitted primarily by women during working hours and involved 294 different conditions. Of the 2531 e-visits, 62 (2%) included uploaded photographs, and 411 (16%) replaced nonbillable telephone protocols with billable encounters. The e-visits made office visits unnecessary in 1012 cases (40%); in 324 cases (13%), the patient was asked to schedule an appointment for a face-to-face encounter.CONCLUSION: Although limited in scope, to our knowledge this is the largest study of online visits in primary care using a structured history, allowing the patient to enter any problem, and billing the patient when appropriate. The extent of conditions possible for treatment by online care was far-ranging and was managed with a minimum of message exchanges by using structured histories. Processes previously given as a free service or by nurse triage and subject to malpractice (protocols) were now documented and billed.Some fundamental aspects of transforming primary care include eliminating barriers to access, using technology to communicate with patients, and enhancing financial performance.¹ Currently, it is possible for patients to use the Internet to see laboratory test results, make appointments, pay bills, and review their charts.² Some reports have shown improved patient satisfaction with use of these options.^3-5 Several articles have discussed electronic messaging (e-mails) as a way to improve efficiency by decreasing patient telephone calls to the physician''s office.^6-9 Various reports have described the use of the Internet to manage conditions such as depression,^10,11 diabetes mellitus,¹² hypertension,^13,14 and sexually transmitted diseases¹⁵ and also to assist with breastfeeding support,¹⁶ previsit well child encounters,¹⁷ and communication with patients in safety net practices.¹⁸ Guidelines have been established for providing medical care on the Internet (“e-visits”).¹⁹ Patients in primary care practices also have indicated a willingness to pay for online services.²⁰However, implementation of billable e-visits has been slow. “Reasons for provider hesitation to adopt e-visit technologies include fears of being overburdened by electronic communication, improper use of electronic communication by patients, lack of reimbursement schemes, legal and regulatory issues, and concerns over security, privacy, and confidentiality.”²¹ Also, electronic consultations to date have generally used online forms or secure e-mail. The information in these formats is unstructured and often lacks sufficient information, prompting the clinician to respond to the patient to request further information, which results in delays.²² Furthermore, the lack of organization in an e-mail makes it difficult to code complexity; consequently, the same fee is often charged for all online consultations, regardless of complexity.²³For editorial comment, see page 701Isolated reports of the use of online consultations have been disappointing. For example, despite indications that electronic communication could decrease health care costs²⁴ and provide reimbursement from patients,^25,26 Fairview Health System has reported only 10 e-visits per week in a system with 400 physicians,²⁷ and Blue Cross of Minnesota processed about 30 e-visits per month in July 2008 and 90 e-visits per month in July 2009 (D. Hiza, MD, written communication, February 2010).Studies have not described a portal for online patient consultations that has a structured medical history. Structured computerized histories were first described in the 1960s by Mayne et al²⁸ and Slack et al.²⁹ Their work included using the telephone and teletype with patients from distant locations providing their histories.³⁰ The evidence for using computerized histories to produce more organized histories, detect new symptoms, and provide greater patient satisfaction with improved clinician performance has been reviewed.³¹We conducted a pilot study of online patient visits in a primary care setting using structured histories and the possibility of the patients being billed for the service.