A patient-centered model of care for hospital discharge

Patient-centered care is a key characteristic of quality health care in the 21st century. Three patient-driven processes of care, characteristic of patient-centered models of care, may be related to improved readiness for discharge: patients' knowledge of their home-going needs, their relative importance, and their active involvement in the discharge process. Forty-four patients having planned abdominal surgery were interviewed at three time points to determine their information needs and preference for involvement. Patients identified 4.74 needs prior to admission, 5.05 needs prior to discharge, and 5.35 needs after discharge. Using Friedman's ANOVA for ranks, the importance of each need did not change over time. Patients expressed a desire for information and preference to be involved. These findings provide initial evidence for the efficacy of future interventions in designing care as seen through the eyes of the patient.     

Teaching patient-centered holistic care

Nursing education aims to help students understand concepts and gain competencies in holistic care. The purpose of this paper was to present a nursing curriculum that adapted and introduced holistic care into an adult nursing curriculum taught at a university of science and technology. The course framework included both holistic and nursing domains. The holistic aspect addressed client physical psychological-spiritual needs and related factors, health related factors, and the status of Maslow's hierarchy of needs and related factors. The nursing aspect addressed the way in which nursing was applied to identify client problems and provide individualized, integrated and continuous care in hospital, family or community based settings employing primary, secondary, or tertiary prevention. Scenario with problem based learning and concept mapping were used in class to guide students to consider in depth the concepts that underpin holistic care.     

End-of-Life care: guidelines for patient-centered communication

When patients are diagnosed with cancer, primary care physicians often must deliver the bad news, discuss the prognosis, and make appropriate referrals. When delivering bad news, it is important to prioritize the key points that the patient should retain. Physicians should assess the patient's emotional state, readiness to engage in the discussion, and level of understanding about the condition. The discussion should be tailored according to these assessments. Often, multiple visits are needed. When discussing prognosis, physicians should be sensitive to variations in how much information patients want to know. The challenge for physicians is to communicate prognosis accurately without giving false hope. All physicians involved in the patient's care should coordinate their key prognosis points to avoid giving the patient mixed messages. As the disease progresses, physicians must reassess treatment effectiveness and discuss the values, goals, and preferences of the patient and family. It is important to initiate conversations about palliative care early in the disease course when the patient is still feeling well. There are innovative hospice programs that allow for simultaneous curative and palliative care. When physicians discuss the transition from curative to palliative care, they should avoid phrases that may convey to the patient a sense of failure or abandonment. Physicians also must be cognizant of how cultural factors may affect end-of-life discussions. Sensitivity to a patient's cultural and individual preferences will help the physician avoid stereotyping and making incorrect assumptions.     

A rehabilitation framework for patient-focused care

Rehabilitation is an evolving and developing collaborative discipline. The nursing role is pivotal to the success of the government's agenda for service development and modernisation. This article presents a new framework of rehabilitation as a mechanism for clarifying and understanding the value of nursing's all-encompassing, complex role. The framework aims to contribute to the developing body of knowledge relating to the specialty, offering an opportunity for nurses to challenge their practice through a systematic re-evaluation of their approach.     

A hybrid course for the RN-to-baccalaureate curriculum: patient-centered care and quality

Teaching RN-to-baccalaureate nursing students to incorporate patient-centered care and quality concepts into the practice environment presents challenges and opportunities for nurse educators. The authors describe development, deployment, and evaluation of an RN-to-baccalaureate hybrid course focused on patient-centered care and quality improvement. Course teaching strategies and evaluation of student learning and the efficacy of using a hybrid instructional design are discussed.     

A framework for generalizability in palliative care

Palliative medicine has only recently joined the ranks of evidence-based medical subspecialties. Palliative medicine is a rapidly evolving field, which is quickly moving to redress its historical paucity of high-quality research evidence. This burgeoning evidence base can help support the application of evidence-based principles in palliative and hospice clinical care and service delivery. New knowledge is generally taken into practice relatively slowly by established practitioners. At present, the translation of evidence into palliative and hospice care clinical practice lags behind emerging research evidence in palliative care at even greater rates for three critical reasons: 1) the application of research results to specific clinical subpopulations is complicated by the heterogeneity of palliative care study subpopulations and by the lack of a recognized schema for describing populations or services; 2) definitional issues in service provision are, at best, confusing; and 3) fundamental research concepts (e.g., external validity, effect size, generalizability, applicability) are difficult to apply meaningfully in palliative care. This article provides a suggested framework for classifying palliative care research subpopulations and the clinical subpopulations to which the research findings are being applied to improve the ability of clinicians, health planners, and funders to interpret and apply palliative care research in real-world settings. The framework has five domains: patients and caregivers; health professionals; service issues; health and social policy; and research.     

A unifying framework for improving health care

The quality health care around world is suboptimal. To improve the quality of contemporary health care delivery, advocates have proposed a number of scientific and technical initiatives. All these initiatives, however, have arisen and continue to operate in siloes, resulting in confusion and incommensurability among those concerned with health care improvement. Participants in the quality improvement (QI) space typically stress their own, often narrow, perspective, failing to place QI in context or to acknowledge other approaches. In order to improve delivery of health care, the following is required:

1. Provide a unifying framework for improving health care. We argue this is best done under a Health System Science (HSS) framework but with full understanding that the fundamental principles of HSS are rooted in evidence‐based medicine (EBM) and decision sciences.
2. Understand that QI initiatives are fundamentally local activities. Hence, incentivizing bottom‐up, local QI initiatives would improve health care delivery to a far greater extent than the current top‐down initiatives undertaken in a response to various regulatory mandates.
3. Akin to the “Choosing Wisely” initiative, which challenged professional societies, each institution should identify (a) the extent to which its practices are evidence‐based and (b) the top 5 health care practices or interventions that, at a given institution, represent overuse, underuse, or misuse/error or undermine clinicians' efforts to deliver kind and empathic care.

Providing a framework that can unify the current patchwork of the initiatives would help create a common basis to help align all the existing QI efforts. In addition, thinking small (at local level) may lead to health care quality improvements that national initiatives (thinking big), focused on regulation, competition, or legal requirements, have failed to achieve.