Patient participation in medication safety during an acute care admission

Background

Patient participation in medication management during hospitalization is thought to reduce medication errors and, following discharge, improve adherence and therapeutic use of medications. There is, however, limited understanding of how patients participate in their medication management while hospitalized.

Objective

To explore patient participation in the context of medication management during a hospital admission for a cardiac surgical intervention of patients with cardiovascular disease.

Design

Single institution, case study design. The unit of analysis was a cardiothoracic ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. Multiple methods of data collection were used including pre‐admission and pre‐discharge patient interviews (n = 98), naturalistic observations (n = 48) and focus group interviews (n = 2).

Results

All patients had changes made to their pre‐operative cardiovascular medications as a consequence of surgery. More patients were able to list and state the purpose and side‐effects of their cardiovascular medications at pre‐admission than prior to discharge from hospital. There was very little evidence that nurses used opportunities such as medication administration times to engage patients in medication management during hospital admission.

Discussion and Conclusions

Failure to engage patients in medication management and provide opportunities for patients to learn about changes to their medications has implications for the quality and safety of care patients receive in hospital and when managing their medications once discharged. To increase the opportunity for patients to participate in medication management, a fundamental shift in the way nurses currently provide care is required.     

Having diabetes and having to fast: a qualitative study of British Muslims with diabetes

Background

There are approximately 2.7 million Muslims in the UK, constituting 4.8% of the population. It is estimated that 325 000 UK Muslims have diabetes. Whilst dietary practices of Muslims with diabetes have been explored, little work has described the beliefs and decisions to fast during Ramadan, whereby Muslims with diabetes refrain from eating, drinking and taking medication between sunrise and sunset.

Objective

To explore beliefs and experiences of fasting during Ramadan of Muslim respondents with diabetes and their perceptions of the role played by their general practitioner (GP) and/or practice nurse (PN) in supporting them.

Design

Qualitative study.

Setting

General practices and community groups located in Greater Manchester.

Participants

23 South Asian Muslims.

Methods

Semi‐structured interviews were conducted as part of the Collaboration of Applied Health Research and Care (CLAHRC) programme, Greater Manchester. Respondents were recruited using random and purposive sampling techniques. Interviews were analysed thematically using a constant comparison approach.

Results

Thirteen respondents reported they fasted and altered diabetes medication and diet during Ramadan. The decision to fast was influenced by pressures from the family and the collective social aspect of fasting, and respondents made limited contact with primary care during fasting.

Conclusion

Tensions exist between the respondent''s personal desire to fast or not fast and their family''s opinion on the matter, with a strong reluctance to disclose fasting to GP and/or PN. Future research needs to explore whether GPs or PNs feel competent enough to support patients who wish to fast.     

The impact of concordant and discordant comorbidities on patient‐assessed quality of diabetes care

Objective

To examine the impact of concordant and discordant comorbidities on patients'' assessments of providers'' adherence to diabetes‐specific care guidelines and quality of chronic illness care.

Research design and methods

A population‐based survey of 3761 adults with type 2 diabetes, living in Queensland, Australia was conducted in 2008. Based on self‐reports, participants were grouped into four mutually exclusive comorbid categories: none, concordant only, discordant only and both concordant and discordant. Outcome measures included patient‐reported providers'' adherence to guideline‐recommended care and the Patient Assessment of Chronic Illness Care (PACIC), which measures care according to the Chronic Care Model. Analyses using the former measure included logistic regressions, and the latter measure included univariate analysis of variance, both unadjusted and adjusted for sampling region, gender, age, educational attainment, diabetes duration and treatment status.

Results

Having concordant comorbidities increased the odds of patient‐reported providers'' adherence for 7 of the 11 guideline‐recommended care activities in unadjusted analyses. However, the effect remained significant for only two provider activities (reviews of medication and/or complications and blood pressure examinations) when adjusted. A similar pattern was found for the both concordant and discordant comorbidity category. The presence of discordant comorbidities influenced only one provider activity (blood pressure examinations). No association between comorbidity type and the overall PACIC score was found.

Conclusions

Comorbidity type is associated with diabetes‐specific care, but does not seem to influence broader aspects of chronic illness care directly. Providers need to place more emphasis on care activities which are not comorbidity‐specific and thus transferable across different chronic conditions.     

Multiple conditions: exploring literature from the consumer perspective in Australia

Background

Following a workshop with people with multiple conditions, the Chronic Illness Alliance undertook a literature review to explore current literature about multiple conditions.

Methods

The literature search was performed using Medline, CINAHL, Google Scholar and Cochrane Library employing an extensive list of search terms and limited to English language journals between 1999 and 2009. Inclusion criteria for articles were those articles focussing on issues identified by consumers with more than one chronic illness and the health services working with them.

Results

The results reported in this article are definitions of multiple conditions, safety and quality of services, risks and benefits of treatments for multiple and rare conditions and coordination of services.

Discussion

The impact of multiple conditions or multimorbidities on health services has been researched internationally and identifies the barriers to good health care when multiple conditions are not recognized. While the issues for consumers with more than one condition are not well recognized, the barriers identified by the literature are of great importance to consumers.

Conclusions

This review demonstrates that services and policies in Australia require specific reforms to better meet the needs of people with multiple conditions.     

Impact of clinical and patient‐reported outcomes on patient satisfaction with cataract extraction

Background

To date, factors that influence satisfaction with cataract surgery have not been broadly explored.

Objective

To identify variables related to patient satisfaction after cataract extraction by phacoemulsification and to determine the relationship between satisfaction and visual acuity (VA) and visual function (VF).

Design

Prospective cohort study.

Setting

Five hospitals belonging to the Basque Health Care Service.

Participants

4335 consecutive patients undergoing cataract extraction.

Interventions

Clinical data on vision were collected before the intervention and 6 weeks afterwards. Before cataract extraction, patients answered a global question about their expectations for the procedure, answered three questions related to specific activities (reading, going out and recognizing people, and doing housework) and completed the Visual Function‐14 (VF‐14) and Short‐Form‐36 (SF‐36) instruments. Three months after cataract extraction, they again completed the VF‐14 and SF‐36 along with questions about global satisfaction with the procedure and satisfaction with the three specific activities.

Main outcome measures

Three months after cataract extraction, they again completed the VF‐14 and SF‐36 along with questions about global satisfaction with the procedure and satisfaction with the three specific activities.

Results

Pre‐intervention VA and VF‐14 scores and their post‐intervention changes were associated with both global satisfaction and satisfaction with the ability to perform specific activities. Unresolved ocular complications were related to global satisfaction with cataract extraction (OR _95% = 0.39_{(0.27, 0.55)}, P < 0.001). Both the mental and physical component scales of the SF‐36 were related to global satisfaction. A group of patients were not satisfied with the intervention in spite of achieving similar vision‐related improvements as patients who were quite satisfied with the procedure.

Conclusion

Satisfaction with cataract extraction is related to clinical outcomes and is also associated with patients'' expectations of their improvement in visual function.     

Burden of treatment for chronic illness: a concept analysis and review of the literature

Context

Treatment burden, the burden associated with the treatment and management of chronic illness, has not yet been well articulated.

Objective

Using Rodgers'' (1989, Journal of Advanced Nursing, 14, 330–335) method of concept analysis, this review describes the ways in which treatment burden has been conceptualized to define the concept and to develop a framework for understanding its attributes, antecedents and consequences.

Methods

Leading databases were searched electronically between the years 2002 and 2011. To ensure the review focused on actual observations of the concept of interest, articles that did not measure treatment burden (either qualitatively or quantitatively) were excluded. An inductive approach was used to identify themes related to the concept of treatment burden.

Main results

Thirty articles, identified from 1557 abstracts, were included in the review. The attributes of treatment burden include burden as a dynamic process, as a multidimensional concept, and comprising of both subjective and objective elements. Prominent predisposing factors (antecedents) include the person''s age and gender, their family circumstances, possible comorbidity, high use of medications, characteristics of treatment and their relationship with their health‐care provider. The most dominant consequences are poor health and well‐being, non‐adherence to treatment, ineffective resource use and burden on significant others. Furthermore, many of these consequences can also become antecedents, reflecting the cyclic and dynamic nature of treatment burden.

Conclusion

The findings underscore the need for researchers and health‐care professionals to engage in collaborative discussions and make cooperative efforts to help alleviate treatment burden and tailor treatment regimens to the realities of people''s daily lives.     

Managing the pain of labour: factors associated with the use of labour pain management for pregnant Australian women

Background

Despite high rates of women''s use of intrapartum pain management techniques, little is known about the factors that influence such use.

Objective

Examine the determinants associated with women''s use of labour pain management.

Design

Cross‐sectional survey of a substudy of women from the ‘young’ cohort of the Australian Longitudinal Study of Women''s Health (ALSWH).

Setting and participants

Women aged 31–35 years who identified as being pregnant or recently given birth in the 2009 ALSWH survey (n = 2445) were recruited for the substudy. The substudy survey was completed by 1835 women (RR = 79.2%).

Main variables studied

Determinants examined included pregnancy health and maternity care [including complementary and alternative medicine (CAM)] for their most recent pregnancy and any previous pregnancies. Participants'' attitudes and beliefs related to both CAM and maternity care were also included in the analysis.

Main outcome measures

The outcome measures examined were the use of both pharmacological and non‐pharmacological pain management techniques (NPMT).

Results

Differences were seen in the effects of demographics, health service utilization, health status, use of CAM, and attitudes and beliefs upon use of intrapartum pain management techniques across all categories. The only variable that was identified as a determinant for use of all types of pain management techniques was a previous caesarean section (CS).

Discussion and conclusions

The effect of key determinants on women''s use of pain management techniques differs significantly, and, other than CS, no one determinant is clearly influential in the use of all pain management options.     

Barriers for an effective communication around clinical decision making: an analysis of the gaps between doctors' and patients' point of view

Background

There are doubts on whether patients feel that they have sufficient information for actively participating in clinical decisions.

Objective

To describe the type of information that patients receive. To determine whether patients consider this information sufficient, and whether it contributes or not to improve clinical safety. To identify the barriers for patient participation in clinical decision making.

Study Design

Cross‐sectional study with 764 patients and 327 physicians.

Study Setting and participants

Fourteen health centres belonging to three primary care districts and three hospitals in Spain.

Principal Findings

Just 35.1% (268) (95% CI 32.2, 39.1%) of patients preferred to have the last word in clinical decisions. Age (39 vs. 62%, P < 0.001) and severity of illness (38 vs. 46%, P = 0.002) increased the tendency to take a passive role. In 85.1% (650) (95% CI 83.3, 88.3%) of the cases, patients reported having received sufficient information. Lack of consultation time (29.6%, 95% CI 25.8, 32.5%) and patients'' use of Internet or other sources (19.2%, 95% CI 16.4, 22.2%) were identified as new obstacles to doctor–patient communication by the patients. Only 19.6% (64) (95% CI 15.4, 24.2%) of doctors considered that they could intervene to involve patients in the decisions.

Discussions and Conclusions

The majority of patients prefer the decisions to be made by their doctor, especially those with more severe illnesses, and older patients. Patients are not normally informed about medication interactions, precautions and foreseeable complications. The information provided by general practitioners does not seem to contribute enough to the patient involvement in clinical safety.     

‘You don't get told anything,they don't do anything and nothing changes’. Medicine as a resource and constraint in progressive ataxia

Background

Progressive ataxias are neurological disorders affecting balance, co‐ordination of movement and speech.

Objective

A qualitative study was undertaken to discover patients'' experiences of ataxia and its symptoms.

Participants

Thirty‐eight people with ataxia recruited from patient support groups and two hospital outpatients departments.

Design

Cross‐sectional qualitative study with thematic analysis.

Results

These accounts highlight the limits of medicine in the context of a rare, incurable and disabling disorder, and the embodied uncertainties brought by slowly progressive diseases that lie at the boundaries of mainstream medical knowledge. The existential crises faced by people with ataxia are seemingly magnified by sometimes idiopathic aetiologies and the limited number of inherited conditions identifiable by the available genetic tests. Interviewees were drawn into a medical system that was focused mainly on the diagnosis process, with widely varying results. However, when asked, most had rather valued the provision of disability aids and physical therapies. Only one informant reported overcoming the myriad uncertainties of progressive ataxia, and their account supported the notion of ‘biographical repair’ in chronic illness.

Conclusions

Clinical uncertainties in ataxia constrained people''s attempts to deal with their condition. The construction of the proactive, informed, medical consumer who is assumed to be a partner in care is problematic in the context of a rare and difficult‐to‐diagnose disease for which there is usually no cure. Service providers should be mindful of the need to manage patient expectations in relation to diagnosis and cure. More focus might usefully be placed on the provision of physical therapies and disability aids.     

Patients' and clinicians' experiences and perceptions of the primary care management of insomnia: qualitative study

Background

Insomnia is common leading to patients with sleep problems often presenting to primary care services including general practice, community pharmacies and community mental health teams. Little is known about how health professionals in primary care respond to patients with insomnia.

Aim

We aimed to explore health professionals'' and patients'' experiences and perceptions of the management of insomnia in primary care.

Design

We used a qualitative design and thematic approach.

Setting

Primary care in Nottinghamshire and Lincolnshire.

Method

We undertook focus groups and one‐to‐one interviews with a purposive sample of health professionals and adults with insomnia.

Results

We interviewed 28 patients and 23 health professionals. Practitioners focused on treating the cause of insomnia rather than the insomnia itself. They described providing stepped care for insomnia, but this focused on sleep hygiene which patients often disregarded, rather than cognitive behavioural therapy for insomnia (CBT‐I). Practitioners were ambivalent towards hypnotic drugs but often colluded with patients to prescribe to avoid confrontation or express empathy. Patients sometimes took hypnotics in ways that were not intended, for example together with over‐the‐counter medication. Practitioners and patients were sometimes but not always concerned about addiction. Practitioners sometimes prescribed despite these concerns but at other times withdrew hypnotics abruptly without treating insomnia. Both patients and practitioners wanted more options and better training for the management of insomnia in primary care.

Conclusion

A better understanding of the current approaches and difficulties in the management of insomnia will help to inform more therapeutic options and health professional training.     

Patients' expectations of osteopathic care: a qualitative study

Background

Research has shown that patients'' expectations of health care and health‐care practitioners are complex and may have a significant impact on outcomes of care. Little is known about the expectations of osteopathic patients.

Objectives

To explore osteopathic patients'' expectations of private sector care.

Design

Focus groups and individual interviews with purposively selected patients; this was the qualitative phase of a mixed methods study, the final phase being a patient survey.

Setting and participants

A total of 34 adult patients currently attending for treatment at private osteopathic practices across the United Kingdom.

Intervention

Focus group discussions and individual interviews around expectations before, during and after osteopathic care.

Outcome measures

Thematic analysis of text data to identify topics raised by patients and to group these into broad themes.

Results

Many components of expectation were identified. A preliminary conceptual framework describing the way the therapeutic encounter is approached in osteopathy comprised five themes: individual agency, professional expertise, customer experience, therapeutic process and interpersonal relationship.

Discussion and Conclusion

The components of expectation identified in this phase of the study provided potential question topics for the survey questionnaire in the subsequent phase of the investigation. The model developed in this study may add a new perspective to existing evidence on expectations. Further research is recommended to test the findings both within private practice and the National Health Service.     

Supporting public involvement in research design and grant development: a case study of a public involvement award scheme managed by a National Institute for Health Research (NIHR) Research Design Service (RDS)

Background

It is good practice for the public to be involved in developing health research. Resources should be available for researchers to fund the involvement of the public in the development of their grants.

Objective

To describe a funding award scheme to support public involvement in grant development, managed by an NIHR Research Design Service (RDS). Case examples of how the award contributed to successful grant applications and findings from a recent evaluation of the scheme are presented.

Design

A case study of resource provision to support public involvement activities in one region of England.

Participants

University and NHS‐based researchers, and members of the public.

Findings

Between 2009 and 2012, the RDS approved 45 public involvement funding awards (totalling nearly £19 000). These awards contributed to 27 submitted applications at the time of writing, of which 11 were successful (totalling over £7.5 million). The evaluation revealed difficulties encountered by some researchers when involving the public in grant development, which led to suggestions about how the scheme could be improved.

Conclusion

This award scheme represents an efficient method of providing researchers with resources to involve the public in grant development and would appear to represent good value for money.     

Contextualizing the findings of a systematic review on patient and carer experiences of dementia diagnosis and treatment: a qualitative study

Background

Involving service users in the systematic review process is seen as increasingly important. As systematic reviews often include studies from diverse settings and covering a time span of several decades, involving service users in consideration of applicability to specific populations or settings might make reviews more useful to practitioners and policymakers.

Objectives

To test and contextualize the findings of a systematic review of qualitative studies looking at patient and carer experiences of diagnosis and treatment of dementia.

Methods

Results from the systematic review were discussed in focus groups and semi‐structured interviews with patient, public and professional participants in the South East of England. Analysis was guided by coding frameworks developed from the results of the systematic review.

Participants

We recruited 27 participants, including three people with dementia, 12 carers, six service providers and five older people without dementia.

Results

Findings from the focus groups and interviews were consistent with those from the systematic review and suggest that our review findings were applicable to the local setting. We found some evidence that access to information and diagnostic services had improved but, as in the systematic review, post‐diagnosis support was still often experienced as inadequate.

Conclusions

Focus groups and interviews with service users and their representatives can provide useful contextual information. However, such strategies can require considerable investment of the part of the researcher in terms of time and resources, and more work is needed to refine strategies and establish the benefits for patients and the organization of services.     

Laypersons' views of material incentives for enhancing colorectal cancer screening

Background

Colorectal cancer (CRC) early detection improves health outcomes; screening programmes invest efforts in initiating invitations to target populations to be tested. Enhanced adherence is essential for reduction of morbidity and mortality. Participation rates in Israel are still relatively low.

Objective

To explore lay views regarding the concept of receiving material incentives in exchange for enhanced adherence to CRC screening.

Research design

Qualitative study. Between November 2009 and February 2010 six focus group discussions were carried out in two urban, middle and low socio‐economic status primary care clinics in a Northern city in Israel. Participants were eligible individuals for CRC screening, aged 50–68 (N = 24). Data analysis followed the principles of grounded theory, supported by qualitative software.

Results

Participants found administering incentives in exchange for CRC screening inappropriate on rational and moral grounds. They valued their relations with the medical team and the health system more than the potential gain expected. Individuals eligible for CRC screening perceived themselves as responsible for their health, admitting difficulties in realizing this responsibility. Incentives were reported unsuitable for solving reported screening difficulties and a potential harm to the doctor–patient relationship.

Conclusions

Focus group participants expressed an unconventional voice towards the use of material incentives. They pointed to the need for focused support of health behaviour change and valued their autonomy. While a proportion of the invitees in the target population see the importance of screening and appreciate the HMO''s initiative to invite them for testing, they also expressed their need for support from the HMO in realizing the recommended health behaviour.     

Parents' experiences of living with a child with hydrocephalus: a cross‐sectional interview‐based study

Background

Shunts, the main treatment for hydrocephalus, are problematic because they frequently malfunction. Detecting shunt malfunction is challenging because symptoms are similar to those of common childhood illnesses, particularly viral infections. Parents are responsible for identifying shunt malfunction and responding accordingly. Understanding parents'' experiences has the potential to improve parent–professional collaboration and the management of the child''s condition.

Aim

To explore parents'' experiences of living with a child with hydrocephalus and their decisions when they suspect shunt malfunction.

Design and methods

A cross‐sectional interview‐based survey using qualitative methods was undertaken. Twenty‐five parents participated in the interviews. Framework approach underpinned data analysis.

Findings

Three concepts, ‘uncertainty’, ‘developing expertise’, and ‘a normal life’, were identified. These concepts were dynamic in nature as parents learned through experience, adapted to changes in their child''s health status and made decisions about their needs. Uncertainty because of the unpredictability and life‐threatening nature of shunt malfunction dominated parents'' accounts. Through experience, parents learned to differentiate between symptoms that suggested a shunt problem and those of other childhood illnesses, but perceived their expertise was not always valued by health professionals or used to inform clinical decisions. Decisions about where or when to seek advice related to prior experiences of health‐care services and minimizing disruption for the whole family.

Conclusion

Parents can recognize illness symptoms suggestive of shunt malfunction and want to collaborate with health professionals about the management of their child''s condition. Collaboration with parents requires health professionals to listen to parents'' concerns and value their experiences.