Emotional comfort: the patient's perspective of a therapeutic context

BACKGROUND: Comfort is a word that is frequently used to describe both physical and emotional aspects of the hospital experience. A number of definitions exist in the literature and there is a lack of clarity in understanding this concept. OBJECTIVES: This paper describes the therapeutic context of emotional comfort that was identified in a qualitative study that sought to explain the perceived therapeutic effect of interpersonal interactions that were experienced by patients during hospitalisation. DESIGN: Grounded theory. SETTINGS: Public and private hospitals situated in Perth, Western Australia. PARTICIPANTS: 40 patient participants from a variety of settings, and 32 nurse participants. All participants were over the age of 18 and spoke English. METHODS: Formal and informal interviews, field observations. RESULTS: Patients interpreted the interpersonal interactions that they experienced during hospitalisation in terms of their experience of emotional comfort or discomfort. A central feature of emotional comfort was the patient's perception of personal control. CONCLUSIONS: This study provides a greater understanding of the concept of comfort from the perspective of hospitalised patients. It highlights that patients approach their illnesses or injuries perceiving that a connection exists between the mind and the body.     

Medical students’ perceptions of an emergency medicine clerkship: an analysis of self-assessment surveys

Introduction

An effective international response to a disaster requires cooperation and coordination with the existing infrastructure. In some cases, however, international relief efforts can compete with the local work force and affect the balance of health-care systems already in place. This study seeks to evaluate the impact of the international humanitarian response to the 12 January 2010 earthquake on Haitian health-care providers (HHP).

Methods

Fifty-nine HHPs were surveyed in August of 2010 using a modified World Health Organization Quality of Life-Brief questionnaire (WHOQoL-B) that included questions on respondents' workload before the earthquake, immediately after, and presently. The study population consisted of physicians, nurses, and technicians at public hospitals, non-governmental organization (NGO) clinics, and private offices in Port-au-Prince, Haiti.

Results

Following the earthquake, public hospital and NGO providers reported a significant increase in their workload (15 of 17 and 22 of 26 respondents, respectively). Conversely, 12 of 16 private providers reported a significant decrease in workload (p < 0.0001). Although all groups reported working a similar number of hours prior to the earthquake (average 40 h/week), they reported working significantly different amounts following the earthquake. Public hospital and NGO providers averaged more than 50 h/week, and private providers averaged just over 33 h/week of employment (p < 0.001). Health-care providers working at public hospitals and NGOs, however, had significantly lower scores on the WHOQoL-B when answering questions about their environment (p < 0.001), and in open-ended responses often commented about the lack of potable water and poor access to toilets. Providers from all groups expressed dissatisfaction with the scope and quality of care provided at public hospitals and NGO clinics, as well as disappointment with the reduction in patient volume at private practices.

Conclusions

The emergency medical response to the January 2010 earthquake in Haiti had the unintended consequence of poorly distributing work among HHPs. To create a robust health-care system in the long term while meeting short-term needs, humanitarian responses should seek to better integrate existing systems and involve local providers in the design and implementation of an emergency program.     

Public hospitals under contract management. An assessment of operating performance

Numerous changes in their operating environments have caused many public hospitals to experience serious fiscal deterioration. One increasingly common response to this situation is contracting with private organizations for the provision of total management services. This study examines the effects of these contract management arrangements on the operating performance of public hospitals. Three areas of performance are considered: operating efficiency, service structure, and Medicare/Medicaid case load. Eighty short-term public hospitals operating under contract management in 1980 are compared with 122 traditionally managed public hospitals and 74 hospitals 1-2 years prior to entering contract management. Controlling for a series of hospital and environmental variables, contract managed hospitals display several financial and organizational differences vis a vis the comparison groups. These findings are discussed in terms of their implications for policymakers, hospital managers, and researchers.     

Multilevel factors affecting tuberculosis diagnosis and initial treatment

Objectives The study aims to assess provider adherence to national tuberculosis programme guidelines on diagnosis, initial regimens and dosages, and to examine independent effects of factors at patient, staff and hospital levels influencing adherence. Methods A review of 383 medical records of new tuberculosis (TB) patients and interviews with related staff were carried out. The study was conducted in 16 public hospitals of seven provinces of southern Thailand. The outcome variables were provider adherence to the guidelines on diagnostic procedure, initial regimen and dosage. Independent variables consisted of patient, staff and hospital factors. Multilevel logistic regression was used to identify factors associated with adherence. Results The proportions of adherence to the diagnostic procedure, initial regimen and initial dosage prescribed were 70.0%, 100.0% and 57.1%, respectively. Most of diagnosis non‐adherence was anti‐TB drugs being prescribed for smear‐negative patients without prior antibiotic trial (12.5%). The anti‐TB drug with the highest percentages of patients receiving non‐adhered dosage was ethambutol (33.6%). In contrast to single‐level analysis, which showed significant influence of up to five factors, multilevel analysis confirmed only strong effect of male patients receiving better adhered diagnosis and of non‐doctors and TB clinics providing better dosage adherence. Conclusions Adherence to TB diagnostic procedures was not good, and adherence to initial dosage, especially for ethambutol, was poor. TB clinics, the key factor of adherence, should be expanded. Female patients should be reviewed more carefully because they tend to receive poorer diagnosis adherence.     

Differences in triage thresholds for patients presenting with possible acute coronary syndromes: more than meets the eye.

BACKGROUND: Many studies have shown differences in cardiac care by racial/ethnic groups without accounting for institutional factors at the location of care. OBJECTIVE: Exploratory analysis of the effect of hospital funding status (public vs private) on emergency department (ED) triage decision making for patients with symptoms suggestive of acute coronary syndromes (ACSs) and on the likelihood of ED discharge for patients with confirmed ACS. STUDY DESIGN AND SETTING: Secondary analysis of data from a randomized controlled trial of 10,659 ED patients with possible ACS in five urban academic public and five private hospitals. The main outcome measures were the sensitivity and specificity of hospital admission for the presence of ACS at public and private hospitals and the adjusted odds of a patient with ACS not being hospitalized at public versus private hospitals. RESULTS: Of 10,659 ED patients, 1,856 had confirmed ACS. For patients with suspected ACS, triage decisions at private hospitals were considerably more sensitive (99 vs 96%; p<.001) but less specific (30 vs 48%; p<.001) than at public hospitals. The difference between hospital types persisted after adjustment for multiple patient-level and hospital-level characteristics. CONCLUSION: Significant differences in triage for patients with suspected ACS exist between public and private hospital EDs, even after adjustment for multiple patient demographic, clinical, and institutional factors. Further studies are needed to clarify the causes of the differences.     

教育管理体系对佛山市结核病医院公众结核病防治知识的影响

目的探讨我市结核病医院内部人群对大众结核病防治知识知晓率情况,为我市有效开展结核病防控健康工作提供科学依据。方法对研究人群进行分类(医技人员、院内非医技人员、外聘公司人员、患者及家属),采用结核病防治知识调查问卷,分析比较不同人群对结核病防治知识的差异,并分析其影响因素。结果调查人群结核病防治知识的总知晓率为95.34%,其中性别与户籍类型人员对知晓率无统计学意义,不同人群类别特征中总知晓率差异有统计学意义(Z=38.74,P0.05)。结论我市结核病医院内的人群对结核病防治知识知晓率较高,但需进一步提高公众结核病防治知识的知晓率。     

Should alternatives to conventional hospitalisation be promoted in an era of financial constraint?

Background

Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow‐up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded.

Materials and methods

Narrative review.

Results

The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost‐effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital‐at‐home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness.

Conclusions

Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.     

Tensions between medical professionals and patients in mainland China

In China, state investment into public hospitals has radically decreased since the early 1980s and has brought on the dismantling of the healthcare system in most parts of the country, especially in rural areas. As a result of this overhaul, the majority of public hospitals have needed to compete in the so-called socialist market economy. The market economy stimulated public hospitals to modernize, take on highly qualified medical professionals, and dispense new therapies and drugs. At same time, liberalization has clearly affected the attitude and behavior of both medical professionals and the general public. The public has many concerns about the healthcare system for various reasons: there are long hospital waiting lists, patients experience difficulties in obtaining an appointment to see a qualified doctor, and, over the past decades, there has been an increase in out-of-pocket healthcare expenditure. These and other changes in post-reform China have radically reshaped the doctor–patient interaction, which is increasingly eroded by tension and violence.     

Voiceless and vulnerable: An existential phenomenology of the patient experience in 21st century British hospitals

Current health policy, high-profile failures and increased media scrutiny have led to a significant focus on patient experience in Britain's National Health Service (NHS). Patient experience data is typically gathered through surveys of satisfaction. The study aimed to support a better understanding of the patient experience and patients' expression of it through consideration of the aspects of the patient experience on NHS wards which are by their nature impossible to capture through patient satisfaction surveys. Existential phenomenology was used to develop an in-depth exploratory narrative, expressed through the voices of the participants. Data collection involved in-depth face-to-face interviews with 12 purposively sampled participants, with analysis by means of hermeneutics. Though the individuality of each experience was apparent and cannot be overemphasised, common factors emerging from the data included uncertainty and unexpectedness, suffering and finitude, the futility of feedback and bureaucracy and absurdity. Overall, participants demonstrated how their individual personalities and expectations affected their response both to illness or injury and to their hospital admissions, highlighting feelings of vulnerability and voicelessness as a response to hospitalisation. The findings of this study provide useful insight into the patient experience on British hospital wards, and the value of an existential–phenomenological approach is demonstrated.     

Contradictory experiences of safety and shame in inpatient mental health practice – a qualitative study

This study explores the lived experience of hospitalisation from the perspective of people with a mental health disorder. This hermeneutic‐phenomenological study, which forms part of a larger qualitative serial inquiry, uses a participatory research design, with analysis inspired by interpretative phenomenological analysis. Fourteen participants were interviewed twice: first during hospitalisation and then again 3 months following hospital discharge. Findings are reported from the entire interview data set. Our findings suggest that mental health hospitalisation is a contradictory experience for patients. On one hand, our study participants experienced the hospital as a place where it is alright to be vulnerable, while on the other hand participants experienced hospitalisation as a burden of everyday stigma and signs of depersonalisation. We conclude that it is important to recognise that patients in need of inpatient treatment for mental illnesses are, in fact, people first and foremost. More reflective practice can be developed by shifting the focus to recovery‐oriented practices to and open dialogue‐based approaches.     

Suggestions for the reorganization of nurse training and improvement of patient care in a hospital for the mentally handicapped

Traditionally, the service requirements of hospitals and the health service have dominated the educational needs of training nurses. With the impending implementation of the Briggs Report on Nursing, the relationship between service and educational needs, especially the regulation for clinical experience, requires fresh thought. The author argues, taking one mental hospital as an example, that the present regulations for clinical experience, in the existing hospital structure, have negative effects both on the quality of nurse education and on the quality of patient care. He argues that both patient care and nurse education can be improved by a rethinking of the regulation for clinical experience and a change in the structure of mental handicap hospitals.     

‘How do we get the managers we need and the leaders we want?’ A personal view

For most patients and the general public, their most significant interface within the hospital setting occurs at the ward level. Here, the professional abilities of the Ward Sister/Charge Nurse – as well as the ward environment – will have a major impact on the experience and outcome of the patient’s stay in hospital. It will also strongly influence the opinion of relatives and friends about the standards of care being delivered in that hospital. Ward managers are expected to demonstrate not only clinical leadership, but also be competent at dealing with the plethora of organisational issues which arise on their ward on a daily basis. As part of a professional response to the public’s concerns around the environment of care within our hospitals and the perception that nursing leadership is not what it was, Welsh Assembly Government have launched a new strategy to re‐empower Ward Sisters/Charge Nurses and develop and support the nurse managers/leaders of the future.     

某公立医院皮肤科与某民营连锁皮肤病医院就诊患者疾病构成比较

目的了解某公立三级甲等医院皮肤科与某民营连锁皮肤病医院就诊患者疾病构成。方法获取2013年1—6月北京友谊医院皮肤科、北京京城皮肤病医院（医保定点民营专科皮肤病医院）及其连锁医院唐山京城皮肤病医院三家医院皮肤病门诊就诊数据,了解银屑病、白癜风、真菌感染性皮肤病及皮炎湿疹类皮肤病等门诊就诊人次构成,使用SPSS20．0及MicrosoftExcel对相关数据进行整理,使用卡方检验比较分析。结果三家医院皮肤病门诊构成及复诊情况存在显著差异。北京京城皮肤病医院银屑病及白癜风患者构成比及复诊率皆高于北京友谊医院皮肤科,而北京友谊医院皮肤科的真菌感染性皮肤病及皮炎湿疹类皮肤病构成比及复诊率较高。唐山京城皮肤病医院门诊就诊人次构成及复诊率与北京两家医院存在显著差异,其银屑病及白癜风患者构成比明显高于北京两家医院。结论三家医院皮肤病门诊各有特点,在某种程度上可以反映出公立医院与民营医院的差异,分析了解差异存在的原因,有助于优化医院资源配置,更好地为患者服务。     

从劳动关系视角分析公立医院编外护士的离职原因

目前在我国公立医院中,编外护士已成为医院护理工作的重要力量,但编外护士的离职率较高,严重影响了护理质量和患者满意度,并对医院的长远发展造成不良影响。文章从劳动关系的视角分析了编外护士离职的原因,并从签订劳动合同、制定薪酬待遇标准和注重工会集体谈判三个方面提出了意见和建议,以期为卫生行政部门和医院管理部门加强编外护士的管理提供理论依据和政策支持。     

A qualitative investigation of hospital visitors’ experiences using the analytic lens of liminality: Informing nursing practice and policy

This research aimed to inform nursing practice and policy by identifying satisfying and problematic experiences of hospital visitors during the hospitalisation episode of a significant other. An extensive contextual review revealed that healthcare systems in advanced economies face multiple pressures and that in England, the government leaves the determination of hospital visiting rules to individual trusts. The analytic lens of liminality provides rich interpretations of visitors’ accounts and demonstrates the importance to visitors of structure (hospital rules and systems) and communitas (social bonding among liminal personae). Supportive hospital structures reduce the challenges of liminality and increase satisfaction. The data further suggest an extension to current understandings of liminality. Strong structure and successful communitas permit a safe exit from liminality after the hospitalisation episode for visitors with a close emotional bond with the patient.     

The experiences of adults with cerebral palsy during periods of hospitalisation.

People with cerebral palsy may have a range of disabilities that can result in daily dependence on others to meet some or all of their basic and more complex care needs. The aim of this New South Wales research was to examine the experiences of adults with cerebral palsy during inpatient admission to a number of public hospitals. A self-selected sample of 31 adults with cerebral palsy completed a questionnaire that collected information related to their disability-specific needs and how well these were addressed by nursing staff during admissions to hospitals. Analysis of the data revealed that many respondents felt hospital staff had limited knowledge and skills of caring for people with cerebral palsy, resulting in their basic care needs not being adequately addressed during periods of hospitalisation. Changes in nursing assessment, continuing education and discharge planning are recommended to address these issues.     

Using nursing practice guidelines for the prevention of multidrug‐resistant tuberculosis among hospitalized adult patients in Bangladesh

Multidrug‐resistant tuberculosis (MDR‐TB) is one of the major public health concerns worldwide particularly in developing countries, including Bangladesh. Thus far, there are no well‐validated clinical guidelines for the prevention of MDR‐TB. This study aims to evaluate the improvement in nurses' practice using the newly developed Nursing Practice Guidelines for the Prevention of MDR‐TB (NPG: MDR‐TB) among hospitalized adult patients in Bangladesh. The guidelines were developed, disseminated and evaluated among 64 nurses by assessing nursing practice for the prevention of MDR‐TB during pre‐ and postimplementation of the guidelines. Significant differences between pretest and post‐test mean scores of nursing practice for the prevention of MDR‐TB in case finding and case holding were found in three levels of wards, including Level 0 (non‐TB), Level 1 (TB) and Level 2 (MDR‐TB) (P < 0.001). This indicated that the guidelines might be applicable to reduce the development of MDR‐TB in hospitals. However, this was a preliminary study with a limited time frame. Further evaluation is, therefore, needed.     

Hydration of patients treated with cisplatin: practical investigation and establishment of a protocol

BACKGROUND: Administration of cisplatin requires hyperhydration of the patient to prevent nephrotoxic effects of this molecule. MATERIALS AND METHODS: A survey done in different hospitals - university hospitals, general hospitals and cancer institutes--has shown a large variability in the hydration protocols. A multidisciplinary group was set up in our university hospital comprising oncologists, nephrologists and pharmacists. This group has developed a consensual local protocol from a bibliographic analysis (Medline) and from the personal experience of each member. CONCLUSION: This protocol was approved by our hospital's Committee of Drugs and Medical Devices.     

Using linked hospitalisation data to detect nursing sensitive outcomes: A retrospective cohort study

Background

Nursing sensitive outcomes are adverse patient health outcomes that have been shown to be associated with nursing care. Researchers have developed specific algorithms to identify nursing sensitive outcomes using administrative data sources, although contention still surrounds the ability to adjust for pre-existing conditions. Existing nursing sensitive outcome detection methods could be improved by using look-back periods that incorporate relevant health information from patient's previous hospitalisations.

Design and setting

Retrospective cohort study at three tertiary metropolitan hospitals in Perth, Western Australia.

Objectives

The objective of this research was to explore the effect of using linked hospitalisation data on estimated incidence rates of eleven adverse nursing sensitive outcomes by retrospectively extending the timeframe during which relevant patient disease information may be identified. The research also explored whether patient demographics and/or the characteristics of their hospitalisations were associated with nursing sensitive outcomes.

Results

During the 5 year study period there were 356,948 hospitalisation episodes involving 189,240 patients for a total of 2,493,654 inpatient days at the three tertiary metropolitan hospitals. There was a reduction in estimated rates for all nursing sensitive outcomes when a look-back period was applied to identify relevant health information from earlier hospitalisations within the preceding 2 years. Survival analysis demonstrates that the majority of relevant patient disease information is identified within approximately 2 years of the baseline nursing sensitive outcomes hospitalisation. Compared to patients without, patients with nursing sensitive outcomes were significantly more likely to be older (70 versus 58 years), female, have Charleson comorbidities, be direct transfers from another hospital, have a longer inpatient stay and spend time in intensive care units (p ≤ 0.001).

Conclusions

The results of this research suggest that nursing sensitive outcome rates may be over-estimated using current detection methods. Linked hospitalisation data enables the use of look-back periods to identify clinically relevant diagnosis codes recorded prior to the hospitalisation in which a nursing sensitive outcome is detected. Using linked hospitalisation data to incorporate look-back periods offers an opportunity to increase the accuracy of nursing sensitive outcome detection when using administrative data sources.