Screening for partner violence: direct questioning or self-report?

OBJECTIVE

To compare the effectiveness of a self-report checklist with a standard set of direct questions in identifying women who are experiencing domestic partner violence.

METHODS

Medical records were reviewed for evidence of positive partner violence for women attending the Royal Brisbane and Women's Hospital prenatal clinic between August and September 2002.

RESULTS

Records (n = 1,596) were audited, and 937 (58.7%) contained both forms. The self-report check list identified a greater number of "cases" of partner violence (151) than the direct questions (66), with the level of agreement between the two instruments being only "fair" (Kappa coefficient.34). Each of the methods identified 7 cases of major abuse, which would have been missed if only 1 instrument had been used. All cases where women stated that they were afraid of their partner using the direct questions were also identified using the self-report checklist.

CONCLUSION

A self-report checklist is an effective alternative to direct questioning in detecting women who are experiencing partner violence and is acceptable to women.

LEVEL OF EVIDENCE

II-3

[Impact of participatory education on body mass index and blood glucose in obese type-2 diabetics]

Exogenous obesity increases morbidity and mortality risk and has been associated with nutritional habits, which in turn can be affected by health education. Health education aims to promote patient participation in achieving behavior change and healthy lifestyles. The objective of this study is to show the advantages of participatory education in the modification of body mass index (BMI) in obese type-2 diabetics. A quasi-experimental study was performed with random allocation of two patient groups. The educational intervention was organized through a reflection-action process. BMI was measured at baseline and then monthly for 9 months during the intervention. The groups were analyzed by age and sex. Statistical analysis used the Student t test, with the mean difference for related groups. The control group showed a mean BMI of 33.89 + 1.96 and a final BMI of 33.2 +/- 2.15 (t:22.4; p:0.16). The experimental group had an initial value of 33.63 +/- 2.12 and a final BMI of 31.54 +/- 1.71; statistical difference: (t:11.55; p:0.003). The participatory educational intervention thus helped improve the BMI in obese type-2 diabetics.

How the internet affects patients' experience of cancer: a qualitative study

OBJECTIVE

To explore how men and women with cancer talk about using the internet.

DESIGN

Qualitative study using semistructured interviews collected by maximum variation sampling.

SETTING

Respondents recruited throughout the United Kingdom during 2001-2.

PARTICIPANTS

175 men and women aged 19-83 years, with one of five cancers (prostate, testicular, breast, cervical, or bowel) diagnosed since 1992 and selected to include different stages of treatment and follow up.

RESULTS

Internet use, either directly or via friend or family, was widespread and reported by patients at all stages of cancer care, from early investigations to follow up after treatment. Patients used the internet to find second opinions, seek support and experiential information from other patients, interpret symptoms, seek information about tests and treatments, help interpret consultations, identify questions for doctors, make anonymous private inquiries, and raise awareness of the cancer. Patients also used it to check their doctors' advice covertly and to develop an expertise in their cancer. This expertise, reflecting familiarity with computer technology and medical terms, enabled patients to present a new type of "social fitness."

CONCLUSION

Cancer patients used the internet for a wide range of information and support needs, many of which are unlikely to be met through conventional health care. Serious illness often undermines people's self image as a competent member of society. Cancer patients may use the internet to acquire expertise to display competence in the face of serious illness.

Patient-physician communication concerning participation in cancer chemotherapy trials

Cancer patients demand a high level of involvement in decisions concerning treatment. Many patients are informed about experimental trials, and especially the first consultation may be crucial for the future communication and treatment process. Patients with nonresectable non-small-cell lung cancer or colorectal cancer informed about experimental chemotherapy completed a questionnaire on satisfaction with the communication process, general attitude towards experimental treatments, the substance of information, and personal contact with the physician following their first consultation in a medical oncology unit. Physicians completed a questionnaire on their perception of the patients’ satisfaction. Among 68 physician–cancer patient pairs, 29 patients were informed on chemotherapy in randomised trials and 39 in nonrandomised studies. The general attitude towards experimental treatment was positive or very positive in 71% of patients. Information on the treatment was perceived as completely adequate in 93% of patients informed on randomised and in 67% informed on nonrandomised trials. Physicians underestimated the patients’ satisfaction with the overall communication process, the personal contact, the patients’ perceived sufficiency of the specific treatment information and their ability to decide on study entry. In conclusion, considerable differences were observed between patients informed about experimental chemotherapy in randomised and nonrandomised trials, both with respect to their perception of how adequate the information on the specific treatments were, and whether it was sufficient for decisions on study entry. This study type effect should be accounted for in future evaluations of communication and patient satisfaction. The data also support the fact that cancer patients have a desire for and ability to understand rather detailed and comprehensive treatment information.

Support Groups

Support groups have become a part of the lives of many people who suffer from illness and injury. Physicians and other healthcare professionals often recommend them to patients and families dealing with medical conditions, and many support groups are diagnosis specific. The members of five support groups were surveyed to determine the factors that influenced their decision to participate. They reported they attended the groups to meet others with the same diagnosis and to gain more information about the diagnosis. The activities they were most likely to attend were those that gave information on the diagnosis, treatment options, and coping strategies. The social aspects of the support groups were more important to those who were married and attended with their spouse. The population of this sample was found to be in close contact with family members. They appeared to view their participation in the group as empowering.

Therapeutic options for patients returning to sexual activity

No head-to-head studies have been conducted with the phosphodiesterase type 5 (PDE5) inhibitors to date. Results of noncomparative studies, however, suggest that tadalafil and vardenafil hydrochloride are at least as effective as sildenafil citrate in improving erections and increasing the number of successful intercourse attempts in men with erectile dysfunction (ED) at all levels of severity. By facilitating a sexual response, PDE5 inhibitors lend naturalness to sexual activity and may permit couples to return to their previous sexual lifestyle. By providing a broader window of opportunity, a longer-acting PDE5 inhibitor such as tadalafil adds to the variety of options currently available in managing ED with PDE5 inhibitors. This option offers increased flexibility by minimizing the need to plan sexual activity; allowing more time for intimacy or romance before sexual intercourse; and reducing the pressure on the patient to perform.

Patients' preferences for involvement in treatment decision making in Japan

BACKGROUND

A number of previous studies have suggested that the Japanese have few opportunities to participate in medical decision-making, as a result both of entrenched physician paternalism and national characteristics of dependency and passivity. The hypothesis that Japanese patients would wish to participate in treatment decision-making if adequate information were provided, and the decision to be made was clearly identified, was tested by interview survey.

METHODS

The subjects were diabetic patients at a single outpatient clinic in Kyoto. One of three case study vignettes (pneumonia, gangrene or cancer) was randomly assigned to each subject and, employing face-to-face interviews, the subjects were asked what their wishes would be as patients, for treatment information, participation in decision-making and family involvement.

RESULTS

134 patients participated in the study, representing a response rate of 90%. The overall proportions of respondents who preferred active, collaborative, and passive roles were 12%, 71%, and 17%, respectively. Respondents to the cancer vignette were less likely to prefer an active role and were more likely to prefer family involvement in decision-making compared to non-cancer vignette respondents. If a physician's recommendation conflicted with their own wishes, 60% of the respondents for each vignette answered that they would choose to respect the physician's opinion, while few respondents would give the family's preference primary importance.

CONCLUSIONS

Our study suggested that a majority of Japanese patients have positive attitudes towards participation in medical decision making if they are fully informed. Physicians will give greater patient satisfaction if they respond to the desire of patients for participation in decision-making.

How breast cancer outpatients perceive mutual participation in patient-physician interactions

This study examines correlations between observable communicative behaviors and patient perceptions of patient-physician interaction in 86 breast cancer outpatient consultations from three patient-centered perspectives: patient participation, physician collaboration, and communicative success. Analysis relied on audio tape recordings and questionnaires, and incorporated non-behavioral factors particular to each physician, patient, and consultation. Results revealed that patient perceptions of self-participation depended on the length of consultation. Physician collaboration depended on the degree to which patients were given the opportunity to speak, while communicative success reflected a patient's level of anxiety at the time of the consultation. Yet patient perceptions of mutual participation reflected observable communicative behaviors only partially. This gap suggests that perceptual and behavioral measures reveal different aspects of participation and that the study of patient-physician interaction benefits from the inclusion of both kinds of measure.

Patient involvement in general practice care: a pragmatic framework

This paper presents a pragmatic framework to guide decisions on involving people in general practice care. Patient involvement may be defined as: enabling patients to take an active role in deciding about and planning their healthcare. It can be located at different levels of care, including the patient-clinician contact or episode of care, and the patient population served by a care provider, or the regional or national population. The involvement of patients depends on considerations that include the aim of patient involvement, the type of health decision, and the type of patient. With respect to the aims, the fundamental question is whether involvement is seen as desirable in itself, or whether it is expected to result in favourable consequences. We suggest that patients' ability and willingness to be involved should determine the level of involvement. The concept of involving patients is relatively new, and new approaches are required to overcome obstacles for its implementation in healthcare.

Decision-making during hospitalization: parents' and children's involvement

BACKGROUND

Ethical duties of health professionals include the obligation to enhance their patients' competence and ability to participate.

AIMS AND OBJECTIVES

To explore what kind of decisions and how these decisions were made during a child's hospitalization.

DESIGN

During a 9-week period 24 children and their parents were followed during the course of events at the hospital. In total 135 hours of observations were made and analysed in two steps.

RESULTS

In most of the situations one or both parents were present with the child. Most decisions were of a medical nature, and commonly decisions were made in consultation with those affected by the decision. Although one or more persons protested in 83 of the 218 described situations, decisions were seldom reconsidered.

CONCLUSIONS

The children and their parents were usually involved in the decision-making process. Children and parents made few decisions themselves and even if they disagreed with the decision made, few decisions were reconsidered.

RELEVANCE TO CLINICAL PRACTICE

Having a voice in decision-making helps the child to develop a sense of himself as a person and gives the parents a feeling that they are part of a team giving their child optimal care during hospitalization. Promoting children's rights is one of the most important roles for the children's nurse.

Women's satisfaction with decision-making related to augmentation of labour

OBJECTIVE

to describe women's experiences of participating in decision-making related to augmentation of labour.

DESIGN

a qualitative approach using modified grounded theory technique. Open-ended interviews were conducted 1-3 days after childbirth.

SETTING

the interviews were performed in the postnatal wards in five hospitals (tertiary level) in Stockholm, Sweden.

PARTICIPANTS

20 newly delivered women who had received oxytocin infusion for augmentation of labour during childbirth. FINDINGS AND KEY CONCLUSIONS: support and guidance from midwives in combination with knowledge and expectations about the intervention seemed to be important for women's satisfaction with decision-making concerning augmentation of labour. Four patterns of decision-making were found. One group of women participated in the decision-making regarding augmentation of labour while a second group was invited, but refrained from participation. These women were satisfied with the decisions made. A third group of women did not participate, but wanted to and they were dissatisfied with the decisions made. The fourth group did not participate in the decision-making-and did not want to. These women accepted the decisions made. The desire for information exceeded the desire for involvement in decision-making and the majority of women had confidence in the midwives' assessment.

Contextualizing medical decisions to individualize care: lessons from the qualitative sciences

Clinical decision making can be described as answering one question: "What is the best next thing for this patient at this time?" In addition to incorporating clinical information, research evidence, and patient preferences, the process requires considering contextual factors that are unique to each patient and relevant to their care. The failure to do so, thereby compromising that care, can be called a "contextual error." Although proponents of evidence-based clinical decision making and many scholars of the medical interview emphasize the importance of individualizing care, no operational definition is provided for the concept, nor is any methodology proposed for the interpretation of clinically relevant patient-specific variables. By conceptualizing the physician-patient encounter as a participant-observer case study with an N of 1, this essay describes how existing approaches to studying social systems can provide clinicians with a systematic approach to individualizing their clinical decision making.

Clinical placements for medical students: factors affecting patients' involvement in medical education

Many medical students now have contact with patients from the very beginning of their course and the increasing numbers of medical students means that more and more patients will be exposed to students during their medical treatment. This paper presents the attitudes of 281 patients towards medical students encountered in a primary or secondary care setting. Particular attention is paid to consent, types of procedures undertaken and the title given to the medical student. The study showed that the likelihood of patients agreeing to be involved in medical education depended on the patient, the student and the procedure being undertaken. Recommendations have been made to the university on the basis of the results with the aim of maximizing patient involvement and satisfaction in order to further medical student education.

Positive self-assessed general health in patients with medical problems. A qualitative study from general practice

BACKGROUND

Patient and doctor do not always agree on the status of the patient's health. By underestimating the patient's strong sides, the doctor may be contributing to disempowerment and bypassing knowledge needed for adequate medical diagnosis and management.

OBJECTIVE

To understand how our patients with medical problems assess their general health as good.

DESIGN AND SETTING

Qualitative observational study based on audiotaped material from general practice consultations in authors' practices (Norway and Denmark). The patients were asked to rate their current state of health on a scale ranging from zero to 100, and then to explain their score.

SUBJECTS

From 41 consecutive consultations we compiled a purposeful sample of 12 patients who reported positive self-assessed general health although medical problems were present. The 7 women and 5 men were aged between 43 and 96 years, and had been diagnosed with musculoskeletal disorders, heart disease, cancer, depression, headache or severe menopausal symptoms.

MAIN OUTCOME MEASURES

Salutogenesis, represented by the authors' Health Resource/Risk Balance Model, and Antonovsky's Sense of Coherence (SOC) concept comprised the theoretical framework. Transcripts from audiotaped consultations were used for qualitative text condensation analysis, inspired by Giorgi's phenomenological method. Analysis was theory-driven, applying comprehensibility, manageability and meaningfulness as entries to elaborate patients' accounts of positive health.

RESULTS

Patients' answers demonstrated how a feeling of logical reasoning related to symptom perception could provide comfort and sometimes lead to advantageous coping strategies. Personal and social resources were mentioned as essential means for tolerating and managing the burden of disease. Even fairly extensive endeavours could be experienced as worthwhile when sometimes providing relief, even only temporarily.

CONCLUSIONS

Patients' accounts of general health can challenge the traditional medical views on assessment of health and disease.

Testing the individualized care model

BACKGROUND

Although there has been some research to identify the dimensions on which individualized care should be measured, the indicators that constitute individualized care remain unclear.

OBJECTIVES

To describe briefly the maintenance of individualized care and to test a hypothetical model of individualized care in a sample of surgical patients.

DESIGN AND METHODS

A correlational survey design was used. Data were collected with questionnaires from adult patients (n = 454) discharged from surgical wards in one Finnish hospital district (response rate 91%). Structural equation modelling LISREL SIMPLIS using maximum likelihood estimation was used to estimate and test the parameters of the hypothesized model derived deductively from the previous literature.

RESULTS

The goodness-of-fit statistics supported the basic solution of the Individualized Care Model, although two additional paths indicating error covariances between the sub-concepts were identified in the revised model. In this model individualized care is defined in terms of patients' views of nursing activities aimed at supporting individuality in care and in terms of perceptions of individuality in their own care.

CONCLUSIONS

The model has been found to capture attributes that characterize individualized care. It can be used as a basis for evaluation in clinical nursing practice from patients' point of view. The study highlights the importance of patients' clinical situation, personal life situation and decisional control as predictors of individualized care. The results also confirm the construct validity of the previously developed Individualized Care Scale.

How can nurses help patients work more effectively with nurses to improve the safety of patient care?

The literature seems quite clear that patients still regard the nurse as the principal link between the technical and interpersonal aspects of their care. The often-discussed medical error crisis tends to create in the patient mistrust of all care providers. The health care industry is driving towards a system that requires patients to be self-reliant in managing their care, without allowing for factual limitations in patient capability, ability, and interest in such an enterprise. Unfortunately for the overworked, understaffed nurse, patients still look to them to provide quality compassionate care without the patient having to police them. Health care providers have been mandated to provide assessment and intervention for pain management. It was mandated because we as health care professionals failed to perform this vital function in a consistent, quality manner. It did add to the workload of the nurse. However, if done properly, it is a valuable communication tool for the nurse and the patient to comfortably discuss pain and its management--the interpersonal part of care.

Different voices: reviewing and revising the politics of working with consumers in mental health

Working with consumers is now a common expectation in contemporary mental health services. Yet health professionals may not entirely understand the difference between patient and consumer roles. Alternatively, they may feel they do not have the skills or resources to deal with people in roles other than patient or carer. Nor may they be able to separate out their personal experiences with particular consumers from the ideals and goals for effective consumer partnerships. This paper reviews a concept known as the politics of difference as well as the rise of the consumer movement in order to explore areas of difference between consumers and providers, to reexamine how power and marginalization practices occur. It reminds professionals that generalizing from one failed experience relating with a consumer is just as invalid as idealizing the current policy of consumer inclusion. Inviting, allowing, amplifying and improving the effectiveness of the consumer voice in mental health services today requires active commitment, educative processes and novel strategies to move beyond superficial relationships so that consumers and professionals work together to make enduring change.