Relationship-centered care. A constructive reframing

How to assess experienced quality of care in nursing homes from the client's perspective: results of a qualitative study

BACKGROUND

The culture shift in nursing homes from task-oriented to person-centered care has created a need to assess clients' experienced quality of care (QoC), as this corresponds best with what matters to them. This study aimed to gain insight into how to assess experienced QoC in nursing homes from the client's perspective.

METHOD

A qualitative study was performed consisting of a focus group with client representatives (n = 10), a focus group with nursing home staff (n = 9) and a world café with client representatives and staff recruited from the Living Lab in Ageing & Long-Term Care (n = 24). Three questions about assessing experienced QoC from the client's perspective were addressed during data collection: 1) What content needs to be assessed? 2) What assessment procedures are needed? and, 3) Who needs to be involved in the assessment? Semi-structured questions, photo elicitation and creative writing were used to answer these questions. Conventional content analysis was used to analyze the data.

RESULTS

Participants indicated that experienced QoC mostly occurs within the interactions between clients, family and staff, highlighting the impact of relationships. They suggested assessments should focus on three aspects: 1) knowledge about the client, 2) a responsive approach, and 3) a caring environment. These can be assessed by having conversations with clients, their families and staff, and additionally observing the clients in their living environments. Sufficient time and resources are prerequisites for this. Additionally, the person performing the quality assessments needs to possess certain communication and empathy skills.

CONCLUSION

It is important to include the perspectives of the client, family and staff when assessing experienced QoC, in line with the principles underlying relationship-centered care. In order to be feasible, it is recommended to incorporate quality assessments into the nursing homes' daily routines. Further research with clients, family and staff in nursing homes is needed to develop a feasible, reliable and valid method that assesses experienced QoC from the client's perspective.

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada

Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one's conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.

Relationship continuity and person-centred care in how spouses make sense of challenging care needs

Objectives: Some spouses providing care for a partner with dementia experience continuity in the relationship: Despite the changes that have occurred, the person with dementia and the relationship are felt to be essentially the same as they were before the dementia. Others experience discontinuity: The person and the relationship feel very different. Previous qualitative research has suggested that continuity may be linked with the delivery of more person-centred care. Using a mixed-methods approach, the present study aimed to provide a more robust test of this claim.Method: Twenty-six spousal carers completed the Birmingham Relationship Continuity Measure and the Caregiver Hassles Scale, and took part in an interview about their response to challenging care needs. Attributions about the causes of those needs were extracted from the interviews and coded. Codes referred either to dementia as a cause, or to a range of other causes that reflected a more person-centred focus. A measure of person-centred care was obtained by calculating the percentage of the total number of attributions that fell into these more person-centred categories.Results: Consistent with the hypothesis that continuity and person-centred care are linked, those who reported greater continuity reported a significantly higher percentage of person-centred attributions.Conclusions: Person-centred care is important for the well-being of those giving and those receiving the care. Little is currently known about how to support families to be more person-centred. The possibility of supporting person-centred care through enhancing the experience of continuity merits investigation.

Development of a Community Advance Care Planning Guides Program and the RELATE Model of Communication

OBJECTIVE

Quality communication is an important aspect of advance care planning (ACP). This study evaluates a certification program that trains lay people in communication skills to support community-based ACP conversations.

METHODS

The program was developed with an emphasis on communication skills training. The testing of the program included ACP Guides and conversation partners, who were hospice volunteers, to assess the use of communication skills in ACP conversations. The evaluation used direct observations of conversations between trained ACP Guides and conversation partners as well as semi-structured interviews with those trained to become ACP Guides and those participating in the conversation.

RESULTS

Twenty-two ACP Guides participated in the testing phase with a retention rate of 100% completing all 4 sessions. The RELATE model of communication emerged during program development and testing. Evaluation of 15 ACP Guides having ACP conversations found that trained ACP Guides could use the RELATE model of communication to support ACP conversations.

CONCLUSION

A community-academic partnership developed an ACP Community Guides Program that trained individuals to have community-based ACP conversations. Next steps include additional testing of the program and RELATE in small numbers, especially among minority populations, to evaluate acceptability and usability of this approach.

PRACTICE IMPLICATIONS

Laypersons with concrete communication skills can facilitate effective peer-to-peer ACP conversations.

Use of huddles among frontline staff in clinical settings: a scoping review protocol

OBJECTIVE

This scoping review aims to provide an overview of the current evidence on huddles in healthcare settings involving frontline staff.

INTRODUCTION

Team-based models are gaining prominence as the preferred method for delivering coordinated, cost-effective, high-quality health care. Huddles are a powerful method for building relationships among frontline staff members. Currently, no reviews have described huddles used among frontline staff in clinical settings. There is therefore a need to identify gaps in the literature on evidence informing this practice for a greater understanding of the resources available for frontline staff to implement huddles.

INCLUSION CRITERIA

This scoping review will consider qualitative studies, experimental and quasi-experimental studies, analytic observational studies and descriptive cross-sectional studies that explore the use of frontline staff huddles to improve quality of care in a clinical setting.

METHODS

An initial limited search of PubMed and CINAHL Plus with Full Text will be performed, followed by analysis of the title, abstract and MeSH used to describe the article. Second, searches of PubMed, EBSCOhost and ProQuest will be conducted, followed by searches in reference lists of all articles that meet the inclusion criteria. Studies published in English from inception to the present will be considered. Retrieved papers will be screened for inclusion by at least two reviewers. Data will be extracted and presented in tabular form and a narrative summary that align with the review's objective.

Understanding professional development: Case studies of remedial support

This study reports on work undertaken by the Interactive Studies Unit (ISU), University of Birmingham. A total of 727 doctors were referred to the ISU for one-to-one remedial support in a variety of non-clinical areas between 2010 and 2018. The close-in scrutiny which one-to-one support offers provides an opportunity to study and reflect on such issues as values and professionalism, which are notoriously difficult to define or reach objective judgments about. There are fundamental difficulties, in particular, in inferring underlying values from an individual's behavior. The basic taxonomy of referrals the ISU works with, and which echoes those developed elsewhere, considers problems as being at the level of the self, interactions with others, or working in an institutional or societal context. Six common generic problems are identified, and presented and discussed as generic cases. These are designed to be representative of the complex manner in which behavior and values interact, and problems at the three levels above impinge on each other. All cases are accompanied by details of suggested educational activities.

Community Based Participatory Research (CBPR): A Dynamic Process of Health care, Provider Perceptions and American Indian Patients' Resilience

American Indians are disproportionately affected by factors that lead to health disparities, however many Native people demonstrate resilience when faced with health risks. Study objectives were to use a resilience framework to identify wellness strategies among American Indian people and to assess health care provider perceptions of American Indian wellness. Participants included 39 American Indian adults who self-reported resilient change and 22 health care providers who served American Indian patients. Thematic categories across American Indian and health care provider data were identified: 1) relationships inform resilience; 2) prejudice stymies resilience; and 3) place shapes resilience. Results indicated the salience of relationships in demonstrating resilience. Identified challenges and supporters of resilience are discussed.

Understanding the use of attachment theory applied to the patient-provider relationship in cancer care: Recommendations for future research and clinical practice

Patient attachment styles may inform how patients react differently to the stress of being diagnosed with cancer, as well as how patients may desire to interact and be supported by their provider. The objectives of this study were two-fold: 1) to conduct a systematic scoping review to clarify how attachment theory is utilized and applied within the current body of research on the patient-provider relationship within cancer care, and 2) add to the existing body of literature by introducing an integrated model of patient attachment styles and patient-provider relationships for use in clinical and scholarly work. A systematic search of multiple databases including PubMed, Google Scholar, PsychInfo, and WorldCat was conducted using variations and combinations of keywords related to patient-provider relationship, attachment style, and cancer. The nine studies included in the review were published from 2011 to 2019. The majority of studies had participant samples with multiple cancer diagnoses (n = 5) and examined attachment as an independent or predictor variable (n = 6). Results suggest that a secure attachment was predictive of a better working alliance, more perceived support, less general distress, higher levels of trust and satisfaction with healthcare providers when compared to patients with an insecure attachment style. Data from the current review suggest that using an attachment theory framework can improve the understanding of the patient-provider relationship. We propose a conceptual model that aligns patient attachment style and patient-provider relationship types to be utilized in clinical practice in future research to tailor patient-centered cancer care.

Integrating Family Caregivers of People With Alzheimer's Disease and Dementias into Clinical Appointments: Identifying Potential Best Practices

Family caregiver engagement in clinical encounters can promote relationship-centered care and optimize outcomes for people with Alzheimer's disease and related dementias (ADRD). Little is known, however, about effective ways for health care providers to engage family caregivers in clinical appointments to provide the highest quality care. We describe what caregivers of people with ADRD and people with mild cognitive impairment (MCI) consider potential best practices for engaging caregivers as partners in clinical appointments. Seven online focus groups were convened. Three groups included spousal caregivers (n = 42), three included non-spousal caregivers (n = 36), and one included people with MCI (n = 15). Seven potential best practices were identified, including the following: "acknowledge caregivers' role and assess unmet needs and capacity to care" and "communicate directly with person with ADRD yet provide opportunities for caregivers to have separate interactions with providers." Participants outlined concrete steps for providers and health care systems to improve care delivery quality for people with ADRD.

The seven habits of highly effective aphasia therapists: The perspective of people living with aphasia

Purpose: Influential value-driven approaches to aphasia rehabilitation have been proposed previously, but have emphasised how service providers need to deliver their services. The aim of this article is to extract a set of values or habits that define effective aphasia therapists, from a 16-year programme of research that has sought to capture the perspectives of people with aphasia, their family and speech-language pathologists. Method: The findings of 58 studies published by members of our team which have sought the views of people with aphasia (38 studies), speech-language pathologists (11 studies) and family members (5 studies), and those which compared all stakeholder's perspectives (2 studies), were synthesised into seven themes. Presented as habits, these were subsequently described in the same manner as the popular "Seven Habits of Highly Effective People". Result: The seven habits of highly effective aphasia therapists described by people with aphasia and their family were (1) Prioritise relationships; (2) Find a rope team; (3) Begin with the end in mind; (4) Practise SMARTER therapy; (5) Leave no person behind; (6) Look behind the mask and (7) Find a voice. Conclusion: While there are similarities to other value-based approaches to aphasia rehabilitation, these seven habits are detailed using our published research that has privileged the voices of people with aphasia. The seven habits therefore reflect what people with aphasia view as the features of highly effective aphasia therapists. The next steps are to identify how to evaluate evidence-based practices in these areas and ensure their implementation into practice. Effective aphasia therapists are at the heart of effective aphasia rehabilitation.

Caring for self-harming patients in general practice

INTRODUCTION Intentional self-harm is an international public health issue with high personal, social and financial costs to society. Poor relationship dynamics are known to have a negative influence on the psyche of people who self-harm, and this can increase anxiety and decrease self-esteem, both shown to be significant contributors to self-harm behaviours. Positive and functional social supports have been proposed as a cost-effective and constructive approach in diminishing self-harming behaviours. AIM This qualitative study investigated the aspects of professional, social, familial and romantic relationships that people who have self-harmed identified as having a positive and constructive effect on their self-harm behaviour. METHODS Twelve participants with a history of self-harming behaviours were recruited through free press advertising in primary care and interviewed. The participants ranged in age from 19 to 70 years, and represented New Zealand (NZ) European and Māori from across the Southern region of NZ. RESULTS This study shows that constructive relationships that inhibit self-harm behaviours are characterised by participants' perceptions of authenticity in their relationships, and knowing that other people genuinely care. Feeling cared for within an authentic therapeutic relationship enabled participants to overcome their perception of being damaged selves and gave them the skills and confidence to develop functional relationships within their communities. A relationship-centred care approach may be useful for general practitioners seeking to develop more effective therapeutic relationships with patients who deliberately self-harm.

The patient experience of ambulatory cancer treatment: a descriptive study

Background

Patient experience is often measured quantitatively, but that approach has limitations for understanding the entire experience. Qualitative methods can help to understand more complex issues most important to patients and their families. The purpose of the present work was to use a qualitative analysis examining the patient experience of ambulatory cancer care in Ontario to generate a deeper understanding of the patient experience and to lead to solutions for improvement.

Methods

Data from the Ambulatory Oncology Patient Satisfaction Survey (aopss) for 2013-2015 were used to conduct a qualitative content analysis. The aopss is a retrospective paper-based survey, mailed to patients who are currently receiving cancer treatment or who have received cancer treatment within the preceding 6 months, that is designed to capture their experiences. Patients who were surveyed were asked, "Is there anything else you would like to tell us about your cancer care services?" The National Research Corporation Canada's patient-centred care framework was used to guide the analysis.

Results

From the 5391 patients who responded, 7328 coded responses were generated, of which 3658 (49.9%) were related to the patient-centred care framework. New subthemes were identified: diagnosis sensitivity; emotional support resources; care delivery with care, compassion, and comfort; continuity of care between departments and in the community; access to cancer centre personnel; patient-health care provider communication; confidence in the health care provider; wait times; health care provider and treatment coordination; and parking.

Conclusions

The results identify facilitators and barriers to the patient experience in the ambulatory cancer treatment setting from the patient perspective and identify opportunities to improve the patient experience.

Georgia's healthcare system and integration of complementary medicine

BACKGROUND

An increasing number of people in the Republic of Georgia use complementary and alternative medicine (CAM). CAM has long been practiced in the country, but is not currently part of the formal medical system. The aim of this study was to explore patients' CAM use and their perspectives of CAM complementation of existing services in Georgia's health care system.

METHODOLOGY

We conducted a qualitative study exploring patient needs and wants by performing in-depth, contextual interviews with patients using CAM. We recruited participants at CAM clinics and collected data until we reached saturation. A thematic analysis involving line by line coding explored perspectives and allowed us to formulate recommendations of CAM integration in Georgia.

RESULTS

Study participants voiced that they pursued cure beyond symptom relief; their disappointment in that regard with conventional medicine in Georgia directed them towards CAM as a safe and effective care setting. Most sought natural approaches as a sustained approach to their health and perceived CAM as empathetic therapeutic and preventive space. Participants were in favor of integration of CAM with conventional health services through government support and regulation. They saw coverage of payments for CAM visits and treatments as important aspect for an effective and sustainable integration.

CONCLUSION

Patients favor an integration of CAM into Georgia's current healthcare systems to ensure CAM's broad availability as well as effective regulation and financing, including coverage by health insurance.

[What is narrative medicine?]

Narrative medicine first entered China in 2011 and has developed rapidly since then. The patient-centered care, shared decision making and relational medicine in the medical sphere, together with patients narrating their illness and narratology contributed to the rise of narrative medicine. Through listening to patients' narratives, paying attention to their emotions, and representing their stories in various ways, clinicians can connect with patients and empathize with them. In this way, affiliation and mutual trust with patients can be established. Patients will feel good in the doctor-patient encounter because of such humane care, and clinicians may get satisfaction from their work. Narrative medicine courses characterized by close reading of literature and writing should be added to the curriculum of medical education as the major content of medical humanities, so as to train narrative competence for the future doctors.

The influence of mobile health applications on patient - healthcare provider relationships: A systematic, narrative review

OBJECTIVE

To explore the influence of mobile health applications on various dimensions of patient and healthcare provider relationships.

METHODS

A systematic, narrative review of English literature reporting experiences and outcomes of using mobile health applications was performed, evaluating communication and relationships between patients and healthcare professionals. Findings were framed thematically within the four dimensions of relationship-centred care. The methodological quality of included articles was appraised.

RESULTS

Thirty-seven articles were included, all of them meeting tenets of relationship-centred care. After adopting mobile health applications patients perceived an overall positive impact on their relationship with healthcare providers, indicating they are ready to transition from traditional clinical ecounters to a different modality. Use of the applications supported patients in assuming active roles in the management of their health in collaboration with health professionals. Reluctance of providers to using mobile health needs to be acknowledged and addressed when encouraging wider use of applications in clinical practice.

CONCLUSION

The use of mobile health applications can influence communication and relationships between patients and providers positively, facilitating relationship-centered healthcare.

PRACTICE IMPLICATION

Implementation of mobile health can support patients' self-efficacy, improve access to healthcare services and improve relationships between patients and providers in ambulatory and hospital settings.

Effectiveness of a brief training program in relational/communication skills for medical residents

OBJECTIVE

To assess the effectiveness of a brief training program in relational/communication skills (RCS) for medical residents.

METHODS

This longitudinal study enrolled 64 medical residents who participated in a RCS training program in small groups. Teaching was based on interviews with standardized patients and reflective practice. Video-recorded consultations were coded according to the Verona-Coding-Definitions-of-Emotional-Sequences (VR-CoDES) and a coding system developed to assess ten communication skills for breaking bad news. The outcome measures were: independent raters' score in RCS for breaking bad news and the percentage of providing space and empathic responses, by comparing baseline (T1) skills with those after three-days (T2) and three-months (T3).

RESULTS

After the training program residents provided more space for further disclosure of cues and concerns according to VR-CoDES definitions. There were significant improvements in seven of the ten communication skills for breaking bad news. All of these improvements were observed either at T2 or at T3.

CONCLUSION

This study demonstrates the effectiveness of a brief RCS training program designed to improve medical residents' ability to respond appropriately to patients' cues and concerns and to conduct a breaking bad news encounter.

PRACTICE IMPLICATIONS

Brief RCS training programs adopting multiple approaches, should be offered as mandatory during residency programs.

Patient-centered communication in type 2 diabetes: The facilitating and constraining factors in clinical encounters

OBJECTIVE

To explore the perceptions of the constraining and facilitating factors to patient-centered communication in clinical encounters of patients with type 2 diabetes and the providers involved in their care.

DATA SOURCES/STUDY SETTING

Patients (n = 12) and providers (n = 33) involved in diabetes care in northern Portugal.

STUDY DESIGN

Seven focus groups.

DATA COLLECTION/EXTRACTION METHODS

Grounded theory, using open, axial, and selective coding.

PRINCIPAL FINDINGS

Patients focused on the patient-provider relationship, while providers emphasized the constraining factors when exchanging information and the facilitating factors regarding disease and treatment-related behavior. Patients and providers both agreed on some constraints (power imbalance, avoidance of criticism, disease minimization, use of jargon, and insufficient competencies and consistency among providers) and facilitators (seeing patients as persons, providing tailored information in plain language, and recognizing the "wake-up call"). Patients perceived an aggressive attitude as a barrier to communication, but providers perceived it as a facilitator. Patients included issues related to trust, respect, and psychosocial support as important factors to them. Only providers mentioned the influence of macro-level interventions and patients' socioeconomic position as essential factors.

CONCLUSIONS

Improvements in patient-centered communication depend on fostering the patient-provider relationship, patients' participation and involvement, and training providers' communication skills.

Finding Common Ground: Can Provider-Patient Race Concordance and Self-disclosure Bolster Patient Trust, Perceptions, and Intentions?

BACKGROUND

Improvements in provider-patient relationships may help alleviate health disparities. Provider-patient race concordance and provider self-disclosure are variables that may help improve this relationship.

PURPOSE

This study sought to answer if provider-patient race concordance and provider self-disclosure may improve patient trust, rapport, similarity, likeability, intention to disclose, satisfaction, behavioral intention to keep a provider, and intention to recommend a provider, while using empathy as a covariate.

METHODS

Using 882 White or Black participants, the current research used a 2 × 2 online experimental design. Participants were asked to read a vignette in which they were told they had borderline high cholesterol and needed to eat a healthier diet, by either a Black or White male physician, who either self-disclosed or did not self-disclose regarding their own struggle to eat a healthy diet. After reading this vignette, participants were surveyed regarding the dependent variables of interest.

RESULTS

Participants in a Black concordant dyad reported higher levels of similarity than those in any other dyad. Provider self-disclosure led to higher levels of trust, rapport, similarity, likeability, intention to disclose, satisfaction, behavioral intention to continue using the provider, and intention to recommend the provider. No interaction effects were found.

CONCLUSION

While it is possible, based on past research, that race-concordant pairings may lead to trust via similarity, provider self-disclosure directly increased perceptions of trust as well as providing numerous other benefits. This study supports the importance of trainings for providers on health-related self-disclosure to benefit both parties in provider-patient dyads.

Transforming Preprofessional Health Education Through Relationship-Centered Care and Narrative Medicine

ISSUE

The Institute of Medicine identified health care education reform as a key to improving the error prone, costly, and unsatisfying U.S. health care system. It called for health care education that no longer focuses exclusively on the mastery of technical skills but teaches students the human dimensions of care and develops their ability to collaborate with patients and colleagues to alleviate suffering and improve health. When should this educational reform begin, by what frameworks should it be guided, and which methods should it employ are important questions to explore.

EVIDENCE

There is increasing evidence that practitioners' relational skills, such as empathy and reflection, improve patients' health outcomes. Efforts to shift education toward patient-centered care in interprofessional teams have been made at the professional level, most notably in medical schools. However, reform must begin at the preprofessional level, to start cultivation of the habits that support humane care as early as possible and protect against empathic decline and the development of counterproductive attitudes to collaboration. The conceptual basis for reform is offered by relationship-centered care (RCC), a framework that goes beyond patient-centered care and interprofessional teamwork to focus on the reciprocal human interactions at the micro, mezzo, and macro levels of care. RCC identifies practitioners' relationships with patients, colleagues, community, and self as the critical interpersonal dimensions of healthcare and describes a foundation of values, knowledge, and skills required for teaching each dimension. The teaching of these foundations can be facilitated with techniques from narrative medicine, a compatible care model that conceptualizes health care as a context in which humans exchange stories and thus require narrative competence.

IMPLICATIONS

We suggest beginning the educational reform at the preprofessional level with the implementation of a formal curriculum based on the 4 RCC dimensions with students expected to gain beginner levels of competency on these dimensions in addition to evidence-based principles of health sciences. This requires interprofessional collaboration among health professions, social science, and liberal arts faculty and training of health professions faculty in narrative medicine. Next, we suggest engaging in incremental change in the organizational culture with professional development and team-building activities. Although we need systematic research on the efficacy of the components of the transformation, their impact on students' learning, and their costs, it is important to engage in efforts to prepare professionals who are able to respond to the complex health needs of individuals and society in the 21st century.

The time is now: Fostering relationship-centered discussions about patients' social determinants of health

OBJECTIVE

This paper discusses the importance of developing best practices in communication strategies to identify and act on social determinants of health (SDOH) in care settings in ways that minimizes shame and builds patient trust in the process.

DISCUSSION

We leverage the relationship-centered care framework to provide health care teams guidance in how to foster meaningful discussions about SDOH at three pivotal points in the process: 1) at the initial screening; 2) once an unmet social need has been identified; and 3) when exchanging SDOH data with team members and external organizations.

CONCLUSION

This discussion piece uses a relationship-centered framework to offer several evidence-based recommendations for health care systems on how to help their workforce respectfully listen and collaborate with patients to address SDOH. Additional research into patient and provider perceptions of relationship-centered communication surrounding screening and referral practices can help further adapt and refine best practices to maximize chances for addressing patients' SDOH.

Being Nice Is Not Enough-Exploring Relationship-Centered Veterinary Care With Structural Equation Modeling. A Quantitative Study on German Pet Owners' Perception

During the last years, the philosophy of relationship-centered care gained increasing attention in veterinary medicine. Relationship-centered care is based on a joint venture between pet owner and veterinarians and therefore offers the opportunity to satisfy the pet owners' need for participation in medical decision-making and to provide the best care for the patient. Although research on relationship-centered care in the veterinary consultation is still limited, the available findings suggest that the characteristics of relationship-centered care reflect the pet owners' expectations on satisfactory veterinary care. In this study a quantitative survey was conducted among German pet owners that collected information regarding their perception of the veterinarians' communication during the last appointments. Questionnaires were available online and paper-based. Data were analyzed using exploratory factor analysis and structural equation modeling using SAS. First aim of the study was to explore structural equation modeling (SEM) as an opportunity to evaluate quantitative data in the field of research on relationship-centered care. Further, SEM was used to evaluate associations between the implementation of different characteristics of relationship-centered care in the veterinary practice (empathic communication, partnership-building) and latent outcome variables regarding the pet owners (pet owners' need for further information, consultation of competing health care providers). N = 1,270 valid questionnaires were completed. Participants owned small companion animals (55.6%), horses (7.6%), or both (36.9%) within the last 2 years. Results of SEM suggest that partnership-centered and empathic communication decreased the pet owners' needs for further information (e.g., from online sources) and their need to consult alternative health providers (e.g., homeopaths). Especially addressing the pet owners' worries and fears, discussing pros and cons of diagnostic and therapeutic options as well as providing the required amount of information were shown to be large influence factors within the model. Therefore, veterinarians are recommended to implement the concept of partnership-centered care in their daily practice, for it may increase pet owners' loyalty and satisfaction. Results may motivate future research in this field. Further development of the proposed model assumptions may enable valuable progress in the field of quantitative research on relationship-centered care.

IoT/Sensor-Based Infrastructures Promoting a Sense of Home, Independent Living, Comfort and Wellness

This paper presents the results of three interrelated studies concerning the specification and implementation of ambient assisted living (AAL)/Internet of Things (IoT)/sensor-based infrastructures, to support resident wellness and person-centered care delivery, in a residential care context. Overall, the paper reports on the emerging wellness management concept and IoT solution. The three studies adopt a stakeholder evaluation approach to requirements elicitation and solution design. Human factors research combines several qualitative human–machine interaction (HMI) design frameworks/methods, including realist ethnography, process mapping, persona-based design, and participatory design. Software development activities are underpinned by SCRUM/AGILE frameworks. Three structuring principles underpin the resident’s lived experience and the proposed ‘sensing’ framework. This includes (1) resident wellness, (2) the resident’s environment (i.e., room and broader social spaces which constitute ‘home’ for the resident), and (3) care delivery. The promotion of resident wellness, autonomy, quality of life and social participation depends on adequate monitoring and evaluation of information pertaining to (1), (2) and (3). Furthermore, the application of ambient assisted living technology in a residential setting depends on a clear definition of related care delivery processes and allied social and interpersonal communications. It is argued that independence (and quality of life for older adults) is linked to technology that enables interdependence, and specifically technology that supports social communication between key roles including residents, caregivers, and family members.

Perspectives of Patients With Mental Illness on How to Better Teach and Evaluate Diversity Education in the National Health Service

INTRODUCTION

Diversity education is a mandatory requirement for all mental-health practitioners and health care professionals in the UK National Health Service. Wide variability exists in the development, delivery, and evaluation of diversity education across health care settings, with limited evidence to suggest the optimal approach for teaching this subject. This study aimed to explore the perspectives of patients with mental illness on how to better teach and evaluate diversity education in the National Health Service.

METHODS

A participatory research approach was used with five mental-health patient organizations. Forty-two patients with mental illness took part in three participatory workshops. Data were analyzed through template analysis.

RESULTS

The findings indicated that a focus on the nuances and dynamics of clinical relationships would be beneficial. Specifically, the relationship considered most important to examine with respect to diversity education was the "practitioner-self" relationship.

DISCUSSION

Reconstructing the relationship-centered care model with the addition of the practitioner-self relationship may be better suited to theoretically informing future developments in diversity education. Further research is needed to understand what educational approaches contribute toward a relationship-centered care outlook and how relationship building behaviors, particularly those relevant to the practitioner-self relationship are best developed in diverse settings.

Understanding and addressing barriers to communication in the context of neonatal neurologic injury: Exploring the ouR-HOPE approach

Predicting neurologic outcomes for neonates with acute brain injury is essential for guiding the development of treatment goals and appropriate care plans in collaboration with parents and families. Prognostication helps parents imagine their child's possible future and helps them make ongoing treatment decisions in an informed way. However, great uncertainty surrounds neurologic prognostication for neonates, as well as biases and implicit attitudes that can impact clinicians' prognoses, all of which pose significant challenges to evidence-based prognostication in this context. In order to facilitate greater attention to these challenges and guide their navigation, this chapter explores the practice principles captured in the ouR-HOPE approach. This approach proposes the principles of Reflection, Humility, Open-mindedness, Partnership, and Engagement and related self-assessment questions to encourage clinicians to reflect on their practices and to engage with others in responding to challenges. We explore the meaning of each principle through five clinical cases involving neonatal neurologic injury, decision making, and parent-clinician communication. The ouR-HOPE approach should bring more cohesion to the sometimes disparate concerns reported in the literature and encourage clinicians and teams to consider its principles along with other guidelines and practices they find to be particularly helpful in guiding communication with parents and families.

Relationship-Centered Advising in a Medical School Learning Community

BACKGROUND

Medical schools are required to have formal advising structures; however, there are limited data on how to optimally meet that mandate. Learning communities (LC), with their emphasis on longitudinal relationships, offer a unique scaffold for advising.

PROGRAM DESCRIPTION

The Johns Hopkins School of Medicine (JHSOM) LC focuses on curricular and extracurricular longitudinal connections between students and advisors. A core component of the LC is a relationship-centered advising (RCA) model drawing from best practices in physician-patient relationships, life coaching, and social contract theories. The key elements of the model include dyadic and small group advising, while the LC structure allows for faculty development in these domains. Relationship-centered advising approaches the collaborative advising work between students and advisors through explicit valuing of personal experiences, mutual respect, and earned trust. Framing the advising relationship in this way allows it to grow with the student along their medical school journey.

PROGRAM EVALUATION & RESULTS

Student and faculty satisfaction with this model is high. Data from annual, anonymous student evaluations consistently indicate high degree of trust in and satisfaction from these relationships.

DISCUSSION

Relationship-centered advising aims to create a relationally anchored platform on which students can develop their personal and professional identities. This LC-based advising model is adaptable across schools regardless of structure and resources.

When Differing Perspectives Between Health Care Providers and Parents Lead to "Communication Crises": A Conceptual Framework to Support Prevention and Navigation in the Pediatric Hospital Setting

OBJECTIVES

The communication experience and therapeutic relationships between parents and health care providers (HCPs) impacts the quality of patient care. A guiding "communication crisis" description was created to encourage study participants to describe difficult communication encounters between parents and HCPs where their perspectives regarding the recommended patient care conflicted (ie, parent refusal of a lumbar puncture), which created barriers to the provision of optimal care and the development of therapeutic relationships in the pediatric hospital setting. The purpose of this research was to highlight factors that may contribute to communication crises through the characterization of these circumstances.

METHODS

Participants were multidisciplinary HCPs and parents (n = 37) with firsthand experience regarding communication crises. Data were collected through focus groups (7), semistructured interviews (2), and a verification focus group where open-ended questions regarding participants' experiences were used. Data were analyzed by using a constructivist grounded theory approach.

RESULTS

Three themes and 11 subthemes (communication crisis risk factors) were identified: (1) health care team factors (communication skills, care processes, and interprofessional communication), (2) family and/or parent factors (language or cultural barriers, mental health conditions, socioeconomic factors, and beliefs), (3) patient factors (acute condition, unclear diagnosis, unstable condition, and medical complexity). A core theory emerged: parent trust in their HCP significantly impacts the therapeutic relationship and can mitigate communication crises despite the presence of risk factors.

CONCLUSIONS

We highlight factors that may be predisposing to communication crises in pediatric hospital settings. Awareness of these factors can support timely identification and implementation of relationship care and foster the establishment of trusting relationships.

A systematic review of the methods utilised to measure the relationship between cancer patients and oncologists: Implications for future research and practice

INTRODUCTION

The patient-physician relationship is a critical component of patient-centred health care. The patient-oncologist relationship is particularly important due to the uncertainties that surround treatment of cancer. The goal of the current review was to summarise current methodological approaches to studying the relationship between cancer patients and oncologists.

METHODS

A systematic review using PsychInfo, Ebsco, PubMed and Google Scholar was performed using combinations and variations of the MESH terms: "relationship," "doctor-patient," and "oncology." The included studies explicitly measured the "relationship" as an independent or dependent variable. Data were extracted and analysed.

RESULTS

The 13 studies included in the review were published from 2004 to 2018. There was little agreement between studies on the definition of the patient-oncologist relationship. Trust was most frequently measured, but methods varied. Most studies evaluated the patient perspective (n = 10). The few studies that considered the oncologist perspective did not measure their perception of the relationship.

CONCLUSIONS

The current review demonstrates that current approaches used to assess the patient-oncologist relationship are inconsistent. These differences may limit our understanding of patient needs in current research and practice. Future research should focus on the use of a relational lens as a theoretical framework to assess the patient-oncologist relationship.

Measuring nonverbal behavior in clinical interactions: A pragmatic guide

OBJECTIVE

Understanding nonverbal behavior is key to the research, teaching, and practice of clinical communication. However, the measurement of nonverbal behavior can be complex and time-intensive. There are many decisions to make and factors to consider when coding nonverbal behaviors.

METHODS

Based on our experience conducting nonverbal behavior research in clinical interactions, we developed practical advice and strategies for coding nonverbal behavior in clinical communication, including a checklist of questions to consider for any nonverbal coding project.

RESULTS

We provide suggestions for beginning the nonverbal coding process, operationalizing the coding approach, and conducting the coding.

CONCLUSION

A key to decision-making around nonverbal behavior coding is establishing clear research questions and using these to guide the process.

PRACTICE IMPLICATIONS

The field needs more coding of nonverbal behavior to better describe what happens in clinical interactions, to understand why nonverbal behaviors occur, and to determine the predictors and consequences of nonverbal behaviors in clinical interactions. A larger evidence base can inform better teaching practices and communication interventions.

"Getting the Knowledge Right": Patient Communication, Agency, and Knowledge

In 2013, in accordance with a provision in the Patient Protection and Affordable Care Act (2010), the U.S. government began fining hospitals with "excessive" patient readmission rates. Those working to respond to this issue have identified discharge communication with patients as a critical component. In response to this exigency and to contribute to the conversation in the medical humanities about the field's purview and orientation, this article analyzes studies of and texts about communication in health and medicine, ultimately arguing that the on-going circulation of compliance rhetoric and assumptions has limited efforts to improve patient communication. The article, furthermore, considers that humanist ideals of agentic action, the patient-centered care movement's emphasis on the patient, and biomedicine's tendency to treat evidence-based knowledge as fixed and given may have combined to support a rationale for using patient adherence to treatment guidelines as metrics in measurement studies designed to identify effective communication strategies. Finally, the article proposes that those working in the medical humanities consider the value of interdisciplinary posthumanist scholarship-specifically, its treatment of agency and knowledge as emergent, distributed, and contingent-and its potential to transform or extend in productive ways the conversation about what constitutes effective communication with patients.

Beyond words: What can help first year medical students practice effective empathic communication?

OBJECTIVE

To gain insight into first year medical students' experiences of practicing empathic communication and how patients that train students perceive such communication, in order to inform early communication skills training.

METHODS

Our study consisted of four focus groups, two of year one students who completed a first semester clinical skills course, one of standardized patients, and one of volunteer outpatients. Focus group transcripts were independently coded and iteratively reviewed to identify major themes. Course evaluation data was collected and analyzed.

RESULTS

Themes from student focus groups described significant challenges in striving to convey empathy: coping with anxiety due to multitasking, "buying-in" to learning empathy, and managing vulnerability when engaging emotionally. Patients appreciated students' expression of vulnerability and nonverbal communication.

CONCLUSION

First year medical students encounter challenges in learning empathic communication, and patients may perceive empathy from students in ways other than verbal responses. Early communications curricula should focus on assisting students with anxiety of multi-tasking, sense of vulnerability, buy-in to communications training, and the importance of non-verbal communication.

PRACTICE IMPLICATIONS

A deliberate focus on empathetic responsiveness, especially non-verbal, might lessen anxiety, improve attentional switching, and build confidence in managing vulnerability for early medical students learning communication skills.

A Qualitative Study on the Importance and Value of Doctor-Patient Relationship in Iran: Physicians' Views

BACKGROUND

Doctor-patient relationship [DPR] refers to verbal and non-verbal communication between doctor and patient, which is of great importance in consultation sessions.

AIM

Therefore, the present study attempts to explore the importance and value of DPR in Iran.

MATERIAL AND METHODS

The method used in the study was conventional content analysis. The data were collected from 21 faculty members (FMs) of Shiraz University of Medical Sciences (SUMS), Shiraz, Iran, who participated in three focus group discussions (FGDs). Transcribed data were analysed using Conventional Content Analysis (CCA) which identified condensed meaning units, subthemes, and themes.

RESULTS

Four themes were extracted from 198 meaning units, 87 condensed meaning units, and 17 subthemes. These included gateway [the role of DPR]; nonlinearity [the nature of DPR]; distortion (quality of DPR in the context); and dysfunctional system (weakness in health system). Generally, results showed DPR to be the gateway to consultations based on non-verbal communication and doctor empathy. The study showed distorted DPR which was due to the dysfunctionality of the health care system.

CONCLUSION

As indicated DPR plays an important role in medical contexts, but if distorted it leads to an unsuccessful outcome. Therefore, to promote DPR, it is necessary to reinforce its structure. Thus, the infrastructure has to be modified and developed at all levels.

Communication Course for Pediatric Providers Improves Self-efficacy

BACKGROUND

Communication is essential to building a trusting, clinician-patient relationship. Multiple studies have demonstrated the effects of experiential communication training on patient experience and provider well-being and resiliency. To date, no studies have described an organization-wide communication training program for pediatric clinicians. The objective of this study was to evaluate the impact of a pediatric-focused communication course on provider satisfaction, self-efficacy, and burnout.

METHODS

Texas Children's Hospital, in collaboration with the Academy on Communication in Healthcare, designed and implemented a pediatric focused communication course entitled Breakthrough Communication. Pre, immediate-post, and 3-month postcourse completion online surveys were sent to participants 1 day before, 1 day after, and 3 months after course completion. Participant demographic information, self-assessment of communication skills, the Maslach Burnout Inventory Human Services Survey, and postcourse satisfaction data were collected.

RESULTS

Participants reported high course satisfaction and improved self-efficacy in all measured skill sets both following and 3 months after course completion. Trends indicating a reduction in provider burnout improved in 2 of the 3 Maslach Burnout Inventory domains; however, statistical significance was not achieved.

CONCLUSIONS

A pediatric-focused communication course was well received by multi-specialty clinicians within a large, academic health care organization. This course enhanced clinician self-efficacy with newly learned pediatric encounter specific communication skills.

How clinicians integrate humanism in their clinical workplace-'Just trying to put myself in their human being shoes'

INTRODUCTION

Humanism has been identified as an important contributor to patient care and physician wellness; however, what humanism means in the context of medicine has been limited by opinion and a focus on personal characteristics. Our aim was to describe attitudes and behaviours that enable clinicians to integrate humanism within the clinical setting.

METHODS

We conducted semi-structured individual interviews with ten clinical faculty to explore how they enact and experience humanism in patient care and clinical teaching. Interpretive description was used to analyze the data qualitatively.

RESULTS

Humanism in medicine was described through five themes representing core attitudes and behaviours: whole person care, valuing, perspective-taking, recognizing universality, and relational focus. Whole person care involved recognizing the multiple dimensions of personhood and sensitivity to others' needs; valuing involved respecting and appreciating others; perspective-taking consisted of considering others' perspectives, suspending judgment, and listening; recognizing universality involved acknowledging the shared human condition, finding common ground, transcending roles, and humility; and relational focus was described through multiple relationships between patients, families, clinicians and learners, becoming part of another's story, reciprocal influence, and accompaniment.

CONCLUSIONS

Whereas previous descriptions of humanism have focused on clinicians' personal qualities, our research describes a number of attitudinal and behavioural foundations of humanistic care and teaching, grounded in the experiences of clinical faculty. In drawing attention to the holistic and relational elements of humanism, our work highlights how these foundational elements can be more explicitly integrated into patient care, workplace culture, and clinical education.

The Complexity of Patients' Health Communication Social Networks: A Broadening of Physician Communication

Phenomenon: Patients have access to a wide variety of sources of information about their health in their day-to-day contexts. This can sometimes result in discordance between a physician's perception of a patient's health issue and a patient's perception of their health issue. Even after the physician has negotiated an understanding and treatment plan with a patient, subsequent interactions outside the physician-patient encounter may modify the patient's understanding of their health issue. A patient's reinterpretation of his or her health issue can then result in nonadherence of the treatment plan or even alternative treatment plans that the physician perceives as being unsatisfactory. Current models of physician-patient communication do not prepare physicians to manage this phenomenon. Approach: Using an ethnographic and a social network analysis research design, participants' patterns of social interaction around health information were investigated over a yearlong period (2012-2013) in a small rural community in Western Canada. Data included (a) individual interviews, (b) focus group interviews, and (c) field notes. Data were analyzed in a three-stage process: (a) item analysis, (b) pattern analysis, and (c) structural analysis. Findings: The findings highlight how physicians are only one nodal point in patients' broad, multilayered networks of communication. Interactions around health topics were not isolated events but rather occurred in various patterns of social interactions that were longitudinal and iterative. Meaning making around health topics was constructed, shared, elaborated, reconstructed, and interpreted in participants' social networks, as information was distributed through a complex temporal system of interpersonal ties. Insights: Issues concerning physician communication have been a long-standing conversation in the field of medical education. Many competency frameworks have attempted to encompass this core competency in their elaboration of the physician communicator. However, most representations and discussions in the field tend to depict physician communicators as experts who translate their knowledge to patients in a simplified way, in a single moment in time. This study suggests that educational initiatives in physician-patient communication would benefit from contextualizing physicians as part of patients' resource-rich, temporally extended, iterative process of meaning making. This alternative framing has the potential to support physicians' continuing engagement with patients as a meaningful and responsive node in patients' meaning-making networks.

How can tomorrow's doctors be more caring? A phenomenological investigation

CONTEXT

Peabody's maxim 'the secret of the care of the patient is in caring for the patient' inspired generations of doctors to relate humanely to patients. Since then, phrases such as 'managed care' have impersonalised caring. The term 'patient-centred' was introduced to re-personalise caring. Ironically, however, such terms have been defined by professionals' preconceptions rather than patients' experiences. Using patients' experiences of doctors being (un)caring to guide doctors' learning could reinvigorate caring. Interpretive phenomenology provides qualitative research tools with which to do this.

METHODS

Ten patients, purposively selected to have broad experiences of primary, secondary and tertiary health care, consented to participate. To stay close to their lived experiences, participants first drew 'Pictor' diagrams to represent relationships between themselves and professionals during remembered experiences of (un)caring. A researcher then used the depictions to structure in-depth, one-to-one explorations of the lived experience of caring. Verbatim transcripts were analysed using template analysis. To remain very close to patients' experiences, the researchers assembled a narrative description of the phenomenon of caring using participants' own words.

RESULTS

Caring doctors were genuine. They allowed their own individuality to interact with patients' individuality. This made participants feel recognised as individuals, not just diseases. Caring doctors listened and spoke carefully, encouraged expressions of emotion, were accessible and responsive, and formed relationships. These factors empowered participants to be actively involved in their own care. Little things like smiling, shaking hands, admitting uncertainty, asking a colleague for advice and calling a participant unexpectedly at home showed that doctors were prepared to 'go above and beyond'. This was caring.

CONCLUSIONS

These findings provide medical educators with an interpretation of caring that is truly patient-centred. Coupling technical proficiency with human qualities - being genuinely empathic and respectful - within doctor-patient relationships is the essence of caring.

Patient-Centered Pain Management Communication from the Patient Perspective

BACKGROUND

Pain management discussions between patient and provider can be stressful to navigate and greatly impact the care received. Because of the complexity, emotional color, and sensitivity of pain management, such discussions require a high degree of skill.

OBJECTIVE

To identify patients' perspectives of patient-centered care communication within the context of pain management discussions.

DESIGN

We conducted semi-structured interviews (25-65 min) with patients regarding their experiences with pain assessment and management.

PARTICIPANTS

36 patients (29 males, 7 females), from 3 Veteran Affairs healthcare locations. Participant age ranged from 28 to 94 with pain intensity ranging from 0 to 10, based on the "pain now" numeric rating scale report gathered at the time of the interview.

APPROACH

Interview transcript analysis was conducted using the constant comparison method to produce mutually agreed upon themes.

KEY RESULTS

Elements of patient-centered care communication described by participants include judgment, openness, listening, trust, preferences, solution-oriented, customization, and longevity. Patients perceive provider reciprocation in openness and trust as drivers of the patient-provider relationship, thereby enhancing positive, associated themes.

CONCLUSIONS

Findings highlight the importance of the patient-provider relationship in patient-centered care and offer patient-centered care communication tools for practitioners to utilize, such as solution-oriented messages and communicating trust, especially when interacting with patients about pain.

Project on the Good Physician: Further Evidence for the Validity of a Moral Intuitionist Model of Virtuous Caring

THEORY

In the Project on the Good Physician, the authors propose a moral intuitionist model of virtuous caring that places the virtues of Mindfulness, Empathic Compassion, and Generosity at the heart of medical character education.

HYPOTHESES

Hypothesis 1a: The virtues of Mindfulness, Empathic Compassion, and Generosity will be positively associated with one another (convergent validity). Hypothesis 1b: The virtues of Mindfulness and Empathic Compassion will explain variance in the action-related virtue of Generosity beyond that predicted by Big Five personality traits alone (discriminant validity). Hypothesis 1c: Virtuous students will experience greater well-being ("flourishing"), as measured by four indices of well-being: life meaning, life satisfaction, vocational identity, and vocational calling (predictive validity). Hypothesis 1d: Students who self-report higher levels of the virtues will be nominated by their peers for the Gold Humanism Award (predictive validity). Hypothesis 2a-2c: Neuroticism and Burnout will be positively associated with each other and inversely associated with measures of virtue and well-being.

METHOD

The authors used data from a 2011 nationally representative sample of U.S. medical students (n = 499) in which medical virtues (Mindfulness, Empathic Compassion, and Generosity) were measured using scales adapted from existing instruments with validity evidence.

RESULTS

Supporting the predictive validity of the model, virtuous students were recognized by their peers to be exemplary doctors, and they were more likely to have higher ratings on measures of student well-being. Supporting the discriminant validity of the model, virtues predicted prosocial behavior (Generosity) more than personality traits alone, and students higher in the virtue of Mindfulness were less likely to be high in Neuroticism and Burnout.

CONCLUSIONS

Data from this descriptive-correlational study offered additional support for the validity of the moral intuitionist model of virtuous caring. Applied to medical character education, medical school programs should consider designing educational experiences that intentionally emphasize the cultivation of virtue.

Incidental Fetal Ultrasound Findings: Interpretation and Management

Ultrasonography is a common component of prenatal care worldwide and is often used in early pregnancy to determine gestational age, number of fetuses, fetal cardiac activity, and placental location. Patients and their families may also consider ultrasonography a social event, as it provides confirmation and reassurance of a normal pregnancy. Ultrasound screening is typically scheduled in the second trimester to visualize fetal anatomy and confirm gestational age. Most ultrasound examinations are reassuring, but some incidentally identify structural anomalies and soft markers for aneuploidy, making it necessary for health care providers to correctly interpret these findings. The health care provider's ability to prepare patients prior to the ultrasound and deliver the necessary information needed to make informed decisions regarding any follow-up screening or diagnostic testing is critical to reducing parental anxiety. Preparation for the anatomic survey should include counseling for normal and abnormal findings. The ethical concepts of patient autonomy and shared decision making are used as a guide in providing this critical information and enabling informed choices during follow-up for incidental ultrasound findings.

The Clinical Examination and Socially At-Risk Populations: The Examination Matters for Health Disparities

Data from the United States show that persons from low socioeconomic backgrounds, those who are socially isolated, belong to racial or ethnic minority groups, or identify as lesbian, gay, bisexual, or transgender experience health disparities at a higher rate. Clinicians must transition from a biomedical to a biopsychosocial framework within the clinical examination to better address social determinants of health that contribute to health disparities. We review the characteristics of successful patient-clinician interactions. We describe strategies for relationship-centered care within routine encounters. Our goal is to train clinicians to mitigate differences and reduce disparities in health care delivery.

Conscientious objection and person-centered care

Person-centered care offers a promising way to manage clinicians' conscientious objection to providing services they consider morally wrong. Health care centered on persons, rather than patients, recognizes clinicians and patients on the same stratum. The moral interests of clinicians, as persons, thus warrant as much consideration as those of other persons, including patients. Interconnected moral interests of clinicians, patients, and society construct the clinician as a socially embedded and integrated self, transcending the simplistic duality of private conscience versus public role expectations. In this milieu of blurred boundaries, person-centered care offers a constructive way to accommodate conscientious objection by clinicians. The constitutionally social nature of clinicians commits and enables them, through care mechanisms such as self-care, to optimize the quality of health care and protect the welfare of patients. To advance these conditions, it is recommended that the medical profession develop a person-centered culture of care, along with clinician virtues and skills for person-centered communication.