Relationship-centered care. A constructive reframing

Moral Economy and Moral Capital in the Community of Clinical Practice

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

"My Body. My Choice": A Qualitative Study of the Influence of Trust and Locus of Control on Postpartum Contraceptive Choice

Postpartum contraception helps reduce unintended pregnancy and space births to improve maternal and child health. This study explored women's perceptions of contraceptive choice during the postpartum period in the context of locus of control and trust in healthcare providers. Researchers conducted six focus groups with 47 women, ages 18-39, receiving postpartum care at an outpatient clinic. Techniques from grounded theory methodology provided an inductive approach to analysis. HyperRESEARCH 3.5.2 qualitative data analysis software facilitated a constant-comparative coding process to identify emergent themes. Participants expressed a preference for relationship-centered care, in which healthcare providers listened, individualized their approach to care through rapport-building, and engaged women in shared decision-making about contraceptive use through open communication, reciprocity, and mutual influence. Conflicting health messages served as barriers to uptake of effective contraception. While participants trusted their healthcare provider's advice, many women prioritized personal experience and autonomy in decisions about contraception. Providers can promote trust and relationship-centered care to optimize contraceptive uptake by listening, exploring patient beliefs and preferences about contraception and birth spacing, and tailoring their advice to individuals. Results suggest that antenatal contraceptive counseling should incorporate information about effectiveness, dispel misconceptions, and engage patients in shared decision-making.

Experience of Touch in Health Care: A Meta-Ethnography Across the Health Care Professions

Touch mediates health professionals' interactions with patients. Different professionals have reported their practices but what is currently lacking is a well-theorized, interprofessional synthesis. We systematically searched eight databases, identified 41 studies in seven professions-nursing (27), medicine (4), physiotherapy (5), osteopathy (1), counseling (2), psychotherapy (1), dentistry (1)-and completed a meta-ethnographic line-of-argument synthesis. This found that touch is caring, exercises power, and demands safe space. Different professions express care through the medium of touch in different ways. They all, however, expect to initiate touch rather than for patients to do so. Various practices negotiate boundaries that define safe spaces between health care professions and patients. A metaphor-the waltz-integrates the practice of touch. Health care professionals connect physically with patients in ways that form strong relationships between them while "dance steps" help manage the risk that is inherent in such an intimate form of connection.

Supporting Family Involvement in Long-Term Residential Care: Promising Practices for Relational Care

Family members and friends provide significant support for older relatives in long-term residential care (LTRC). Yet, they occupy ambiguous positions in these settings, and their relationships with LTRC staff can involve conflicts and challenges. Based on an ethnographic project carried out in North America and Europe, this article identifies practices that promote meaningful family participation in care home life. We consider instances of rewarding family involvement upon admission to LTRC, throughout the time a relative is living in a care home, and during the final stages of life. Furthermore, we identify working conditions needed to support the well-being of family/friend carers as well as residents and staff. These include greater appreciation of relational care work, time for effective communication, teamwork, and appropriate, inclusive physical spaces. Findings make visible the importance of relational care and have implications for improving living and working conditions in LTRC.

Latent Semantic Analysis: A new measure of patient-physician communication

RATIONALE

Patient-physician communication plays an essential role in a variety of patient outcomes; however, it is often difficult to operationalize positive patient-physician communication objectively, and the existing evaluation tools are generally time-consuming.

OBJECTIVE

This study proposes semantic similarity of the patient's and physician's language in a medical interaction as a measure of patient-physician communication. Latent semantic analysis (LSA), a mathematical method for modeling semantic meaning, was employed to assess similarity in language during clinical interactions between physicians and patients.

METHODS

Participants were 132 Black/African American patients (76% women, Mage = 43.8, range = 18-82) who participated in clinical interactions with 17 physicians (53% women, Mage = 27.1, range = 26-35) in a primary care clinic in a large city in the Midwestern United States.

RESULTS

LSA captured reliable information about patient-physician communication: The mean correlation indicating similarity between the transcripts of a physician and patient in a clinical interaction was 0.142, significantly greater than zero; the mean correlation between a patient's transcript and transcripts of their physician during interactions with other patients was not different from zero. Physicians differed significantly in the semantic similarity between their language and that of their patients, and these differences were related to physician ethnicity and gender. Female patients exhibited greater communication similarity with their physicians than did male patients. Finally, greater communication similarity was predicted by less patient trust in physicians prior to the interaction and greater patient trust after the interaction.

CONCLUSION

LSA is a potentially important tool in patient-physician communication research. Methodological considerations in applying LSA to address research questions in patient-physician communication are discussed.

A review of couple-centred interventions in dementia: Exploring the what and why - Part A

Introduction

Symptoms of dementia bring about challenges to couples’ relationships. Relationship-focused support has been highlighted to be of significant importance for sustained relationship quality and to reduce the negative impact of dementia on the dyadic relationship. This review aimed to explore the ‘what’ and ‘why’ of interventions aimed at couples where one partner has a diagnosis of dementia and in which the couple jointly participate.

Method

Searches were performed in Academic Search Premier, CINAHL, PsycINFO, PubMed, Scopus and Web of Science from January 2000 to August 2017.

Results

Six studies were included. Objectives for the person with dementia was related to cognitive function and for the care partner the objectives were related to well-being. The majority of the outcomes were mirrored by the objectives and focused on cognitive function for people with dementia and depression and relationship quality for care partners. Our findings indicate that people with dementia should be included in the assessment of the relationship in order to gain an overall picture of relationship dynamics and to increase tailored support in couple-centred interventions.

Conclusions

The findings of this review indicate that joint interventions for people with dementia and care partners are lacking a genuine dyadic approach where both partners’ views of their relationship are valued. In order to identify targets for support and to use the appropriate outcome measures, the quality of the relationship should be recognised and taken into account. Moreover, there is a lack of a salutogenic approach in couple-centred interventions in which couples’ strengths and resources can be identified and supported.

How do healthcare practitioners talk about end-of-life conversations? A poetic inquiry

Despite agreement that end-of-life conversations should happen early on in the illness trajectory, it is widely acknowledged that healthcare practitioners often engage in these conversations when death is imminent or avoid the conversation altogether. Healthcare practitioners’ feelings of distress influence how end-of-life conversations are approached, yet thorough exploration of this emotional experience and its impact are largely missing from the literature. The aims of this preliminary scoping literature review using poetic inquiry were to examine physicians’ and nurses’ emotional distress in their accounts of how they approach end-of-life conversations, and to map key concepts relevant to exploring barriers to these conversations. The poetic findings highlight the differing nature of distress for physicians and nurses. Physicians’ distress appears to stem from adhering to their role of ‘curer’ when communicating with terminally ill adult patients at the end of life, whereas the sources of nurses’ distress appear to be interprofessional hierarchies and conflicts. Future research and training that uses methods to decentre and disrupt hierarchies and ingrained practices will be important to nursing practice and in improving end-of-life conversations. Arts-based approaches are one such method that could be pursued.

VR-CoDES and patient-centeredness. The intersection points between a measure and a concept

OBJECTIVE

The Verona Coding Definitions of Emotional sequences (VR-CoDES) system has been applied in a wide range of studies, in some of these, because of its attention on healthcare provider's ability to respond to patient emotions, it has been used as a proxy of patient-centeredness. The paper aims to discuss how the VR-CoDES can contribute to the broader concept of patient-centeredness and its limitations.

METHODS

VR-CoDES and patient-centeredness concept are briefly described, trying to detect commonalities and distinctions. The VR-CoDES dimensions of Explicit/non explicit responding and Providing or Reducing Space are analysed in relation to relevant aspects of patient-centred communication.

RESULTS

Emotional aspects are encompassed within patient-centeredness model, but they represent only one of the numerous dimensions that contribute to define patient-centeredness as well as Explicit/non explicit responding and Providing or Reducing Space serve different functions during communication.

CONCLUSION

The VR-CoDES can contribute to operationalize the description of emotional aspects emerging in a consultation, by inducing coders to adopt a factual attitude in assessing how health providers react to patient's expression of emotions.

PRACTICE IMPLICATIONS

To better define empirically which measure affective aspects and dimensions of health provider responses are relevant and may contribute to patient-centeredness in different clinical settings.

The institutional logic of integrated care: an ethnography of patient transitions

Purpose The purpose of this paper is to use theories of institutional logics and institutional entrepreneurship to examine how and why macro-, meso-, and micro-level influences inter-relate in the implementation of integrated transitional care out of hospital in the English National Health Service. Design/methodology/approach The authors conducted an ethnographic case study of a hospital and surrounding services within a large urban centre in England. Specific methods included qualitative interviews with patients/caregivers, health/social care providers, and organizational leaders; observations of hospital transition planning meetings, community "hub" meetings, and other instances of transition planning; reviews of patient records; and analysis of key policy documents. Analysis was iterative and informed by theory on institutional logics and institutional entrepreneurship. Findings Organizational leaders at the meso-level of health and social care promoted a partnership logic of integrated care in response to conflicting institutional ideas found within a key macro-level policy enacted in 2003 (The Community Care (Delayed Discharges) Act). Through institutional entrepreneurship at the micro-level, the partnership logic became manifest in the form of relationship work among health and social care providers; they sought to build strong interpersonal relationships to enact more integrated transitional care. Originality/value This study has three key implications. First, efforts to promote integrated care should strategically include institutional entrepreneurs at the organizational and clinical levels. Second, integrated care initiatives should emphasize relationship-building among health and social care providers. Finally, theoretical development on institutional logics should further examine the role of interpersonal relationships in facilitating the "spread" of logics between macro-, meso-, and micro-level influences on inter-organizational change.

Understanding Partnerships With Patients/Clients in a Team Context Through Verbatim Theater

Introduction

Patient partnership has come to the forefront in health care practice and education, influencing professional programs and interprofessional education curricula. While students conceptually understand the idea of partnering with the patient, the practice of doing so is more challenging. Innovative ways to teach this health care approach may be effective in enabling students to apply their learning and promote enhanced patient partnerships. This resource provides an arts-based approach for exploring notions of partnerships with patients in a team context with interprofessional collaboration.

Method

This 2-hour resource features a verbatim reader's theater script and accompanying discussion questions for a small-group reading and debrief activity. The voice of individuals with lived experience is elevated to enhance student learning and connection to the topic. Quotations were taken from interviews with individuals who had experience with the health care system and from health care providers.

Results

The script and accompanying small-group discussion questions have been used in the interprofessional education curriculum with approximately 1,100 health profession students. Student response has been positive, indicating a new appreciation for thinking about partnering with patients.

Discussion

Although the script has been used in the context of interprofessional education, it has the potential to be used as part of uniprofessional teaching and in practice environments, since understanding the nature of partnerships between practitioners and patients transcends all settings.

What Patients Value About Reading Visit Notes: A Qualitative Inquiry of Patient Experiences With Their Health Information

Background

Patients are increasingly asking for their health data. Yet, little is known about what motivates patients to engage with the electronic health record (EHR). Furthermore, quality-focused mechanisms for patients to comment about their records are lacking.

Objective

We aimed to learn more about patient experiences with reading and providing feedback on their visit notes.

Methods

We developed a patient feedback tool linked to OpenNotes as part of a pilot quality improvement initiative focused on patient engagement. Patients who had appointments with members of 2 primary care teams piloting the program between August 2014-2015 were eligible to participate. We asked patients what they liked about reading notes and about using a feedback tool and analyzed all patient reports submitted during the pilot period. Two researchers coded the qualitative responses (κ=.74).

Results

Patients and care partners submitted 260 reports. Among these, 98.5% (256/260) of reports indicated that the reporting tool was valuable, and 68.8% (179/260) highlighted what patients liked about reading notes and the OpenNotes patient reporting tool process. We identified 4 themes describing what patients value about note content: confirm and remember next steps, quicker access and results, positive emotions, and sharing information with care partners; and 4 themes about both patients’ use of notes and the feedback tool: accuracy and correcting mistakes, partnership and engagement, bidirectional communication and enhanced education, and importance of feedback.

Conclusions

Patients and care partners who read notes and submitted feedback reported greater engagement and the desire to help clinicians improve note accuracy. Aspects of what patients like about using both notes as well as a feedback tool highlight personal, relational, and safety benefits. Future efforts to engage patients through the EHR may be guided by what patients value, offering opportunities to strengthen care partnerships between patients and clinicians.

The Meanings of Helping: An Analysis of Cystic Fibrosis Patients' Reasons for Participating in Biomedical Research

Research participants often report wanting to help as a reason for participation, but who they want to help and why is rarely explored. We examined meanings associated with helping among 21 adults with cystic fibrosis (CF)-a group with high participation in research. Meanings included helping to advance research, helping others with CF, helping as their job, helping themselves, helping because they are special, and helping to give back. While some meanings were primarily oriented toward helping others, some also involved hoping for benefits for oneself, and some included feelings of responsibility. Despite indicating that they understood that research is not designed to help them directly, participants nevertheless hoped that it might. We discuss implications for research ethics oversight.

Empathic nonverbal behavior increases ratings of both warmth and competence in a medical context

In medicine, it is critical that clinicians demonstrate both empathy (perceived as warmth) and competence. Perceptions of these qualities are often intuitive and are based on nonverbal behavior. Emphasizing both warmth and competence may prove problematic, however, because there is evidence that they are inversely related in other settings. We hypothesize that perceptions of physician competence will instead be positively correlated with perceptions of physician warmth and empathy, potentially due to changing conceptions of the physician’s role. We test this hypothesis in an analog medical context using a large online sample, manipulating physician nonverbal behaviors suggested to communicate empathy (e.g. eye contact) and competence (the physician’s white coat). Participants rated physicians displaying empathic nonverbal behavior as more empathic, warm, and more competent than physicians displaying unempathic nonverbal behavior, adjusting for mood. We found no warmth/competence tradeoff and, additionally, no significant effects of the white coat. Further, compared with male participants, female participants perceived physicians displaying unempathic nonverbal behavior as less empathic. Given the significant consequences of clinician empathy, it is important for clinicians to learn how nonverbal behavior contributes to perceptions of warmth, and use it as another tool to improve their patients’ emotional and physical health.

Validation of SDM-Q-Doc Questionnaire to measure shared decision-making physician's perspective in oncology practice

OBJECTIVE

The aim of this study was to analyze the psychometric properties of the Shared Decision-Making Questionnaire-Physician version (SDM-Q-Doc) in a sample of medical oncologists who provide adjuvant treatment to patients with non-metastatic resected cancer and the correlations between the total SDM-Q-Doc score and physician satisfaction with the information provided.

METHODS

Prospective, observational and multicenter study in which 32 medical oncologists and 520 patients were recruited. The psychometric properties, dimensionality, and factor structure of the SDM-Q-Doc were assessed.

RESULTS

Exploratory factor analyses suggested that the most likely solution was two-dimensional, with two correlated factors: one factor regarding information and another one about treatment. Confirmatory factor analysis based on cross-validation showed that the fitted two-dimensional solution provided the best fit to the data. Reliability analyses revealed good accuracy for the derived scores, both total and sub-scale, with estimates ranging from 0.81 to 0.89. The results revealed significant correlations between the total SDM-Q-Doc score and physician satisfaction with the information provided (p < 0.01); between information sub-scale scores (factor 1) and satisfaction (p < 0.01), and between treatment sub-scale scores (factor 2) and satisfaction (p < 0.01). Medical oncologists of older age and those with more years of experience showed more interest in the patient preferences (p = 0.026 and p = 0.020, respectively). Patient age negatively correlated with SDM information (p < 0.01) and physicians appear to provide more information to young patients.

CONCLUSION

SDM-Q-Doc showed good psychometric properties and could be a helpful tool that examines physician's perspective of SDM and as an indicator of quality and satisfaction in patients with cancer.

Synthesis maps: visual knowledge translation for the CanIMPACT clinical system and patient cancer journeys

Salient findings and interpretations from the canimpact clinical cancer research study are visually represented in two synthesis maps for the purpose of communicating an integrated presentation of the study to clinical cancer researchers and policymakers. Synthesis maps integrate evidence and expertise into a visual narrative for knowledge translation and communication. A clinical system synthesis map represents the current Canadian primary care and cancer practice systems, proposed as a visual knowledge translation from the mixed-methods canimpact study to inform Canadian clinical research, policy, and practice discourses. Two synthesis maps, drawn together from multiple canimpact investigations and sources, were required to articulate critical differences between the clinical system and patient perspectives. The synthesis map of Canada-wide clinical cancer systems illustrates the relationships between primary care and the full cancer continuum. A patient-centred map was developed to represent the cancer (and primary care) journeys as experienced by breast and colorectal cancer patients.

The 'ouR-HOPE' approach for ethics and communication about neonatal neurological injury

Predicting neurological outcomes of neonates with acute brain injury is an essential component of shared decision-making, in order to guide the development of treatment goals and appropriate care plans. It can aid parents in imagining the child's future, and guide timely and ongoing treatment decisions, including shifting treatment goals and focusing on comfort care. However, numerous challenges have been reported with respect to evidence-based practices for prognostication such as biases about prognosis among clinicians. Additionally, the evaluation or appreciation of living with disability can differ, including the well-known disability paradox where patients self-report a good quality of life in spite of severe disability. Herein, we put forward a set of five practice principles captured in the "ouR-HOPE" approach (Reflection, Humility, Open-mindedness, Partnership, and Engagement) and related questions to encourage clinicians to self-assess their practice and engage with others in responding to these challenges. We hope that this proposal paves the way to greater discussion and attention to ethical aspects of communicating prognosis in the context of neonatal brain injury.

Learning from patients: trainers' use of narratives for learning and teaching

Background

There is a growing interest in how doctors learn from narratives about individual cases, reflected, for example, in the use of e-portfolios.

Aim

This study aimed to evaluate how GP trainers conceptualised ‘learning from patients’, and what use they currently made of narrative recounts in training.

Design & setting

Thematic analysis (TA) and corpus-linguistic (CL) analysis, with data collected from a convenience sample of trainers in the UK, Ireland, and Spain.

Method

GP trainers in the three settings were contacted, and volunteers recruited (22 in UK, 24 in Ireland, and 16 in Spain). Volunteers were interviewed and asked to offer a narrative about ‘a patient you learned from’ and whether they used narratives as a training device.

Results

There were no differences between settings. Trainers described an engaged and personal relationship with patients. They described learning about themselves, the human condition, and about how to live and die well. Their narratives were structured in various ways. At times, they led to precise conclusions: at times, they were perceived as meaningful, but resisting analysis. As regards teaching through narrative, it was reported as commonly used, but present practice appears ad hoc rather than planned.

Discussion

The lack of difference between settings suggests a degree of commonality about how trainers perceive learning and teaching in the areas explored, but cannot be generalised further. The level of personal engagement was more than anticipated, and suggests the label ‘doctor–patient relationship’, as the term is used, may not be adequate to describe the nature of some interactions.

Reconciling Tensions: Needing Formal and Family/Friend Care but Feeling like a Burden

Dans le cadre d’une politique néolibérale qui transfère la responsabilité pour la santé et le bien-être de l’État aux familles et aux individus, les stratégies canadiennes pour soins à domicile ont tendance à présenter les membres de la famille comme « partners in care ». En s’appuyant sur une étude interprétative fondée sur une théorie qui comprenait 34 entrevues qualitatives, cet article examine les expériences des personnes âgées aux intersections des soins à domicile formels et arrangements pour les soins dispensés par la famille et les amis, dans le contexte de politiques mettant l’accent sur les partenariats avec les familles. Le concept fondamental tiré des entrevues était de concilier les tensions entre le besoin de soins et le souci de surcharger les autres, dans le contexte des soins à domicile et communautaires disponibles. Quatre processus sont identifiés, qui illustrent la façon dont l’accès aux ressources financières et sociales peut conduire à des opportunités et des contraintes dans l’expérience de soins. Les résultats mettent en évidence les défis émotionnels et pratiques que les personnes âgées peuvent rencontrer vis-à-vis le discours encourageant les familles à assumer la responsabilité des soins. Les implications pour la politique et la pratique sont discutées.

Teaching Resident Self-Assessment Through Triangulation of Faculty and Patient Feedback

PROBLEM

To accurately determine one's ability in any clinical competency, an individual must be able to self-assess performance and identify personal limitations. Existing research demonstrates that physicians of all levels are unreliable self-assessors. This poses a concern in medical practice, which requires continuous updates to clinical competencies and awareness of personal limitations. Few published studies examine graduate medical education curricula designed to develop self-assessment skills.

INTERVENTION

Conceptual models, such as self-determination theory, suggest that self-assessment is most effectively learned through reflective processes. The Family Medicine Residency Program at Lehigh Valley Health Network developed a learner-centered competency assessment process that integrates advising and performance review. The multisource, observable behavior-based process encourages conversation between resident and advisor. Utilizing feedback from clinical preceptors and patient surveys, advisors guide residents in determining individual learning needs in core competency areas, including relationship-centered care. Development of medical learners' capacity to form relationships is one means to improving the patient experience.

CONTEXT

This retrospective case study evaluates the accuracy of senior residents' self-assessment in relationship-centered care compared with that of junior residents. The study population includes the 34 residents enrolled from AY 2009-2012. Data sets represent specific 6-month periods and have 3 component scores-Self, Faculty, and Patient-which were triangulated to determine concordance rates by postgraduate year level.

OUTCOME

The concordance rate among first-years was 26.7%, whereas third-years saw 60.0% concordance. A discordance analysis found the Patient score most often deviated from the other 2 scores, whereas the Faculty score was never the sole dissenter. When all 3 scores differed, the Self score frequently fell between the other 2 scores.

LESSONS LEARNED

The principles of self-determination theory provide a valuable framework for understanding the development of residents' intrinsic motivation to become lifelong learners. The trend in improved concordance rates among senior residents suggests that prompting learners to triangulate feedback from multiple sources can lead to a shift in perspective about competency. Further study is needed to determine whether our results are generalizable to other competencies and educational settings.

Color-Blind and Multicultural Strategies in Medical Settings

Recently, scholars have called for research that systematically examines the role of race and culture in shaping communication during racially discordant practitioner-patient interactions (i.e., patient and physician from different racial ethnic groups). In this review, we focus on two conceptual frameworks that influence the way people think about race, and subsequently, how they interact with others of a different race: color blindness and multiculturalism. We integrate basic social psychological research on interracial laboratory interactions with research on the markers of successful practitioner-patient communication to discuss how these two strategies shape interactions between Black patients and non-Black practitioners. Given that racial discrimination is often addressed within medical education and training contexts, we also discuss how these two strategies influence how practitioners are trained to talk about race. We conclude by offering practical suggestions as to how medical interactions can be improved by taking into consideration how color-blind and multicultural strategies shape behaviors within medical settings.

The clinically excellent primary care physician: examples from the published literature

Clinical excellence is the ultimate goal in patient care. Exactly what the clinically excellent primary care physician (PCP) looks like and her characteristics have not been explicitly described. This manuscript serves to illustrate clinical excellence in primary care, using primarily case reports exemplifying physicians delivering holistic and patient-centred care to their patients. With an ever increasing demand for accessible and accountable health care, an understanding of the qualities desirable in primary care providers is now especially relevant.A literature review was conducted to identify compelling stories showing how excellent PCPs care for their patients. In the 2397 published works reviewed, we were able to find case reports and studies that exemplified every domain of the description of clinical excellence proposed and published by the Miller Coulson Academy of Clinical Excellence (MCACE). After reviewing these reports, the authors felt that the domains of excellence, as described by the MCACE, are practically applicable and relevant for primary care physicians. It is our hope that this paper prompts readers to reflect on clinical excellence in primary care.

"Let Me Tell You About My…" Provider Self-Disclosure in the Emergency Department Builds Patient Rapport

INTRODUCTION

As patients become increasingly involved in their medical care, physician-patient communication gains importance. A previous study showed that physician self-disclosure (SD) of personal information by primary care providers decreased patient rating of the provider communication skills.

OBJECTIVE

The objective of this study was to explore the incidence and impact of emergency department (ED) provider self-disclosure on patients' rating of provider communication skills.

METHODS

A survey was administered to 520 adult patients or parents of pediatric patients in a large tertiary care ED during the summer of 2014. The instrument asked patients whether the provider self-disclosed and subsequently asked patients to rate providers' communication skills. We compared patients' ratings of communication measurements between encounters where self-disclosure occurred to those where it did not.

RESULTS

Patients reported provider SD in 18.9% of interactions. Provider SD was associated with more positive patient perception of provider communication skills (p<0.05), more positive ratings of provider rapport (p<0.05) and higher satisfaction with provider communication (p<0.05). Patients who noted SD scored their providers' communication skills as "excellent" (63.4%) compared to patients without self-disclosure (47.1%). Patients reported that they would like to hear about their providers' experiences with a similar chief complaint (64.4% of patients), their providers' education (49%), family (33%), personal life (21%) or an injury/ailment unlike their own (18%). Patients responded that providers self-disclose to make patients comfortable/at ease and to build rapport.

CONCLUSION

Provider self-disclosure in the ED is common and is associated with higher ratings of provider communication, rapport, and patient satisfaction.

Transformational leadership in primary care: Clinicians’ patterned approaches to care predict patient satisfaction and health expectations

Clinicians face the complex challenge of motivating their patients to achieve optimal health while also ensuring their satisfaction. Inspired by transformational leadership theory, we proposed that clinicians’ motivational behaviors can be organized into three patient care styles (transformational, transactional, and passive-avoidant) and that these styles differentially predict patient health outcomes. In two studies using patient-reported data and observer ratings, we found that transformational patient care style positively predicted patients’ satisfaction and health expectations above and beyond transactional and passive-avoidant patient care style. These findings provide initial support for the patient care style approach and suggest novel directions for the study of clinicians’ motivational behaviors.

Beyond patient-centered care: person-centered care for Parkinson's disease

Interest has grown in centering Parkinson's disease (PD) care provision on the welfare of the patient with PD. By putting the welfare of patients first, this patient-centric focus tends to subordinate the welfare of others including clinicians and carers. A possible solution is person-centered care. Rather than remove the spotlight from the patients, it widens that light to illuminate moral interests of all healthcare participants as persons whose welfare is interdependent. It assumes that unwellness among clinicians, for example, can impact the quality of the PD care they provide, such that caring for clinicians may also optimize the welfare of persons with PD. For PD, we suggest how the two models differ and why these differences are important to understand and act on to optimize benefit for participating stakeholders.

The use of protocol in breaking bad news: evidence and ethos

This article discusses health professionals use of protocol in the breaking of bad news, focusing particularly on the well-known SPIKES framework. The evidence of impact on the patient experience is examined and recommendations are made for further outcome-based research. Existing evidence suggests that the model as commonly interpreted may not fully meet the needs of patients or reflect the clinical experience of breaking bad news for some professionals and further guidance may be needed to support them in their practice. The ethos of the step-wise protocol is debated, questioning whether it helps or hinders individualised care and the formation of a genuine relationship between patient and professional. Finally, recommendations for practice are offered.

'It just has to click': Internists' views of: what constitutes productive interactions with chronically ill patients

BACKGROUND

According to the Chronic Care Model, productive interactions are crucial to patient outcomes. Despite productive interactions being at the heart of the Model, however, it is unclear what constitutes such an interaction. The aim of this study was to gain a better understanding of physician views of productive interactions with the chronically ill.

METHOD

We conducted a qualitative study and interviewed 20 internists working in an academic hospital. The data were analyzed using a constructivist approach of grounded theory. To categorize the data, a coding process within which a code list was developed and tested with two other coders was conducted.

RESULTS

The participants engaged in goal-directed reasoning when reflecting on productive interactions. This resulted in the identification of four goal orientations: (a) health outcome; (b) satisfaction; (c) medical process; and (d) collaboration. Collaboration appeared to be conditional for reaching medical process goals and ultimately health outcome and satisfaction goals. Achieving rapport with the patient ('clicking,' in the term of the participants) was found to be a key condition that catalyzed collaboration goals. Clicking appeared to be seen as a somewhat unpredictable phenomenon that might or might not emerge, which one had to accept and work with. Goal orientations were found to be related to the specific medical context (i.e., a participant's subspecialty and the nature of a patient's complaint).

CONCLUSIONS

The participants viewed a productive interaction as essentially goal-directed, catalyzed by the two parties clicking, and dependent on the nature of a patient's complaint. Using the findings, we developed a conceptual process model with the four goal orientations as wheels and with clicking in the center as a flywheel. Because clicking was viewed as important, but somewhat unpredictable, teaching physicians how to click, while taking account of the medical context, may warrant greater attention.

Applicability of the Calgary-Cambridge Guide to Dog and Cat Owners for Teaching Veterinary Clinical Communications

Effective communication in health care benefits patients. Medical and veterinary schools not only have a responsibility to teach communication skills, the American Veterinary Medical Association (AVMA) Council on Education (COE) requires that communication be taught in all accredited colleges of veterinary medicine. However, the best strategy for designing a communications curriculum is unclear. The Calgary-Cambridge Guide (CCG) is one of many models developed in human medicine as an evidence-based approach to structuring the clinical consultation through 71 communication skills. The model has been revised by Radford et al. (2006) for use in veterinary curricula; however, the best approach for veterinary educators to teach communication remains to be determined. This qualitative study investigated if one adaptation of the CCG currently taught at Midwestern University College of Veterinary Medicine (MWU CVM) fulfills client expectations of what constitutes clinically effective communication. Two focus groups (cat owners and dog owners) were conducted with a total of 13 participants to identify common themes in veterinary communication. Participants compared communication skills they valued to those taught by MWU CVM. The results indicated that while the CCG skills that MWU CVM adopted are applicable to cat and dog owners, they are not comprehensive. Participants expressed the need to expand the skillset to include compassionate transparency and unconditional positive regard. Participants also expressed different communication needs that were attributed to the species of companion animal owned.

Lifestyle INtervention for Diabetes prevention After pregnancy (LINDA-Brasil): study protocol for a multicenter randomized controlled trial

BACKGROUND

Gestational diabetes mellitus (GDM), a hyperglycemic state detected during pregnancy, is an established risk factor for diabetes. However, treatment during pregnancy in and of itself is not able to eliminate this risk, and a considerable fraction of women with GDM will develop frank diabetes in the decade following pregnancy. Our aim is to conduct a multicenter randomized controlled trial to investigate the effectiveness of a lifestyle intervention program implemented after a pregnancy complicated by GDM in delaying or preventing the development of type 2 diabetes.

METHODS

Women aged 18 or older identified as having recent GDM are recruited and followed by telephone to assess eligibility for the trial. To be eligible, women must have used insulin during pregnancy or present intermediate hyperglycemia postpartum. Women are encouraged to enter the trial as early as 10 weeks, and are permitted to do so up to 2 years after a pregnancy with GDM. An estimated 740 women will be randomized to either conventional care or to coach-based interventions focused on breastfeeding, weight loss, healthy eating, and increased physical activity, and predominantly delivered by telephone. Women are followed annually to detect new onset diabetes, the primary outcome, and additional secondary outcomes which include reversion to normoglycemia, weight loss, physical activity and fitness, and insulin resistance.

DISCUSSION

Though previous studies have demonstrated that type 2 diabetes can be delayed or prevented, no study has yet demonstrated the feasibility and effectiveness of similar interventions implemented in the postpartum period for women with recent GDM. If shown to be successful, this approach could become an important means of preventing diabetes in primary care settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02327286; Registered 23 December 2014.

Medical students' creative projects on a third year pediatrics clerkship: a qualitative analysis of patient-centeredness and emotional connection

BACKGROUND

Increasingly, medical educators are incorporating reflective writing and original creative work into educational practices with the goals of stimulating student self-awareness, appreciation of multiple perspectives, and comfort with ambiguity and uncertainty. This study investigated students' creative projects to assess the extent to which they adopted a patient/relationship-centered, emotionally connected position toward patients and families.

METHODS

Over a 10 year period, students on a required third year pediatrics clerkship individually or in groups completed either a reflection or an education project using a creative medium. 520 projects (representing 595 students, 74.7 % of total eligible students) were qualitatively analyzed according to various thematic and emotion-based dimensions.

RESULTS

The majority of projects were personal narrative essays and poetry. The largest number of project themes related to the importance of patient/relationship-centered medicine with patients. The next largest number of projects focused on health education of parents, patients, or classmates. In telling their stories, students were more likely to use a personal voice representing either their or the patient's perspective than an objective, impersonal one. In terms of emotional tone, projects were more likely to be serious than humorous. The largest number of students' emotions expressed an empathic tone. Students identified a large number and wide range of both negative and positive feelings in themselves and their patients. The majority of student emotions were positive, while the majority of patient and family emotions were negative.

CONCLUSIONS

Students' preference for patient-centered, relational themes, as well as their tendency to favor the first voice, empathic tone, and willingness to express a range of positive and negative emotions in presenting their projects, suggests that they valued emotional connection with patients and families during the pediatrics clerkship experience.

Limited English proficient Hmong- and Spanish-speaking patients' perceptions of the quality of interpreter services

BACKGROUND

Language barriers are a large and growing problem for patients in the US and around the world. Interpreter services are a standard solution for addressing language barriers and most research has focused on utilization of interpreter services and their effect on health outcomes for patients who do not speak the same language as their healthcare providers including nurses. However, there is limited research on patients' perceptions of these interpreter services.

OBJECTIVE

To examine Hmong- and Spanish-speaking patients' perceptions of interpreter service quality in the context of receiving cancer preventive services.

METHODS

Twenty limited English proficient Hmong (n=10) and Spanish-speaking participants (n=10) ranging in age from 33 to 75 years were interviewed by two bilingual researchers in a Midwestern state. Interviews were audio taped, transcribed verbatim, and translated into English. Analysis was done using conventional content analysis.

RESULTS

The two groups shared perceptions about the quality of interpreter services as variable along three dimensions. Specifically, both groups evaluated quality of interpreters based on the interpreters' ability to provide: (a) literal interpretation, (b) cultural interpretation, and (c) emotional interpretation during the health care encounter. The groups differed, however, on how they described the consequences of poor interpretation quality. Hmong participants described how poor quality interpretation could lead to: (a) poor interpersonal relationships among patients, providers, and interpreters, (b) inability of patients to follow through with treatment plans, and (c) emotional distress for patients.

CONCLUSIONS

Our study highlights the fact that patients are discerning consumers of interpreter services; and could be effective partners in efforts to reform and enhance interpreter services.

The meaning of slow nursing in dementia care

Research literature in the dementia field lacks examples of ‘best-practices’ demonstrating concretely how it is possible to support the sense of coherence in people with dementia. The purpose of this study was to elucidate the nurses’ views concerning a caring approach that may support the sense of coherence in people with dementia. The data were collected through participant observation and focus group interviews during a four-month period in 2011. Sixteen registered nurses recruited from two Norwegian nursing homes participated in this study. The data were interpreted using a phenomenological-hermeneutical method. Three themes were identified: ‘being in the moment’, ‘doing one thing at a time’, and ‘creating joy and contentment’. An overall interpretation of these themes is described by the metaphor ‘slow nursing’, a caring approach that may lead to supporting the sense of coherence in people with dementia.

Social and relational identification as determinants of care workers' motivation and well-being

A growing body of research in the field of health and social care indicates that the quality of the relationship between the person giving care and the person receiving it contributes significantly to the motivation and well-being of both. This paper examines how care workers' motivation is shaped by their social and relational identification at work. Survey findings at two time points (T1, N = 643; T2, N = 1274) show that care workers' motivation increases to the extent that incentives, the working context (of residential vs. domiciliary care), and the professionalization process (of acquiring vs. not acquiring a qualification) serve to build and maintain meaningful identities within the organization. In this context care workers attach greatest importance to their relational identity with clients and the more they perceive this as congruent with their organizational identity the more motivated they are. Implications are discussed with regard to the need to develop and sustain a professional and compassionate workforce that is able to meet the needs of an aging society.

Coproduction of healthcare service

Efforts to ensure effective participation of patients in healthcare are called by many names—patient centredness, patient engagement, patient experience. Improvement initiatives in this domain often resemble the efforts of manufacturers to engage consumers in designing and marketing products. Services, however, are fundamentally different than products; unlike goods, services are always ‘coproduced’. Failure to recognise this unique character of a service and its implications may limit our success in partnering with patients to improve health care. We trace a partial history of the coproduction concept, present a model of healthcare service coproduction and explore its application as a design principle in three healthcare service delivery innovations. We use the principle to examine the roles, relationships and aims of this interdependent work. We explore the principle's implications and challenges for health professional development, for service delivery system design and for understanding and measuring benefit in healthcare services.

The ICF, Relationship-Centred Care and Research Outcome Measurement: Carol Frattali's Impact on Aphasia Research

Outcome measurement was a major focus of Carol Frattali's work. This article describes three aphasia research initiatives that have followed from her early publications. The first is the application of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) to aphasia. The Living with Aphasia: A Framework for Outcome Measurement (A-FROM) is a reinterpretation of the ICF specifically as it applies to aphasia. The Assessment for Living with Aphasia (ALA) is an assessment that is derived from the A-FROM. The second initiative is the program of research that has described aphasia and aphasia rehabilitation from the patient perspective. Using qualitative methodologies, this research has highlighted the need for relationship-centred care in aphasia services. Finally, a current project is described that seeks to gain international consensus on a core outcome set for aphasia treatment research. This will help researchers combine data in effectiveness studies. To achieve the best outcomes for people with aphasia, there is a need to realize Carol Frattali's vision and ensure the continued use of unifying frameworks, relationship-centered practice, consumer-focused research, and consistent outcome measurement practices.

No moment wasted: the primary-care visit for adults with diabetes and low socio-economic status

AIM

To better understand the type and range of health issues initiated by patients and providers in 'high-quality' primary-care for adults with diabetes and low socio-economic status (SES).

BACKGROUND

Although quality of care guidelines are straightforward, diabetes visits in primary care are often more complex than adhering to guidelines, especially in adults with low SES who experience many financial and environmental barriers to good care.

METHODS

We conducted a qualitative study using direct observation of primary-care diabetes visits at an exemplar safety net practice in 2009-2010. Findings In a mainly African American (93%) low-income population with fair cardiovascular control (mean A1c 7.5%, BP 134/81 mmHg, and low-density lipoprotein cholesterol 100 mg/dL), visits addressed a variety of bio-psychosocial health issues [median: 25 problems/visit (range 13-32)]. Physicians most frequently initiated discussions about chronic diseases, prevention, and health behavior. Patients most frequently initiated discussions about social environment and acute symptoms followed by prevention and health behavior.

CONCLUSIONS

Primary-care visits by diabetes patients with low SES address a surprising number and diversity of problems. Emerging new models of primary-care delivery and quality measurement should allow adequate time and resources to address the range of tasks necessary for integrating biomedical and psychosocial concerns to improve the health of socio-economically disadvantaged patients.

Mothers' perceptions of primary health-care providers: thematic analysis of responses to open-ended survey questions

General practitioners and maternal, child and family health nurses have a central role in postpartum primary health care for women and their infants. Positive client-provider relationships are particularly important for women experiencing mental health problems or unsettled infant behaviour. However, little is known about their experiences of postnatal primary health care. The study aimed to describe views of postnatal primary health care among women completing a residential early parenting programme and to identify potential strategies to enhance provider-patient interactions. Participants (n=138) were women admitted with their infants to a private or a public early parenting service in Melbourne, Australia. Women completed a detailed self-report survey, including open-ended questions about experiences of primary health-care services, and a structured psychiatric interview to diagnose anxiety and depression. Survey responses were analysed thematically. Womens' experiences of primary health care were influenced by their perceptions of provider competence and the quality of interactions. While similar positive characteristics of doctor and nurse care were valued, medical and nursing practices were judged in different ways. Women described GPs who listened, understood and were thorough as providing good care, and maternal, child and family health nurses were valued for providing support, advice and encouragement. Threats to therapeutic relationships with doctors included feeling rushed during consultations, believing that GPs were not mental health-care providers and the clinician not being 'good' with the infant; with nurses, problems included feeling judged or given advice that was inconsistent or lacked an evidence-base. Postpartum primary health care will be improved by unhurried consultations, empathic recognition, encouragement, evidence-informed guidance and absence of criticism.

Patients' understanding of shared decision making in a mental health setting

Shared decision making is a fundamental component of patient-centered care and has been linked to positive health outcomes. Increasingly, researchers are turning their attention to shared decision making in mental health; however, few studies have explored decision making in these settings from patients' perspectives. We examined patients' accounts and understanding of shared decision making. We analyzed interviews from 54 veterans receiving outpatient mental health care at a Department of Veterans Affairs Medical Center in the United States. Although patients' understanding of shared decision making was consistent with accounts published in the literature, participants reported that shared decision making goes well beyond these components. They identified the patient-provider relationship as the bedrock of shared decision making and highlighted several factors that interfere with shared decision making. Our findings highlight the importance of the patient-provider relationship as a fundamental element of shared decision making and point to areas for potential improvement.