Relationship-centered care. A constructive reframing

The RCQ Model

As society moves into the age of active knowledge management and sharing, inter-clinician relationships and communities of practice can be directed to support quality improvement efforts within healthcare organizations. It is argued that successful adoption of the processes that are critical to quality improvement is necessary for durable improvements in quality. Knowledge sharing is necessary for supporting the skills in performing activities associated with practice audit, change management and use of the associated technology. This paper introduces the Relationships, Communities, Quality (RCQ) model, which provides a framework for the purpose of conceptualizing how quality improvement in healthcare can be sustained. A variance model is proposed for the evaluation of communities of practice for their value in quality improvement in healthcare.

A conceptual model of the role of communication in surrogate decision making for hospitalized adults

OBJECTIVE

To build a conceptual model of the role of communication in decision making, based on literature from medicine, communication studies and medical ethics.

METHODS

We proposed a model and described each construct in detail. We review what is known about interpersonal and patient-physician communication, described literature about surrogate-clinician communication, and discussed implications for our developing model.

RESULTS

The communication literature proposes two major elements of interpersonal communication: information processing and relationship building. These elements are composed of constructs such as information disclosure and emotional support that are likely to be relevant to decision making. We propose these elements of communication impact decision making, which in turn affects outcomes for both patients and surrogates. Decision making quality may also mediate the relationship between communication and outcomes.

CONCLUSION

Although many elements of the model have been studied in relation to patient-clinician communication, there is limited data about surrogate decision making. There is evidence of high surrogate distress associated with decision making that may be alleviated by communication-focused interventions. More research is needed to test the relationships proposed in the model.

PRACTICE IMPLICATIONS

Good communication with surrogates may improve both the quality of medical decisions and outcomes for the patient and surrogate.

Effect of Practitioner Self-Care and Anxiety on Relationships within the Context of Organizational Change

This paper reviews the literature and suggests a causal model of the relationships between practitioner anxiety and effective caring practitioner – patient and practitioner – practitioner relationships within the context of organizational change through introduction of an electronic healthcare record. In the authors’ model, self-care is introduced as a mediating variable using a conceptual framework of Relationship-centered Care. Engaging in frequent and regular self-care interventions has been shown to be related to practitioner – patient caring ability and caring efficacy. According to a published model of Relationship-centered Care, it is anticipated that self-care will mediate the effect of practitioner anxiety on the ability to engage in effective therapeutic relationships with patients and other practitioners. Through this lens and within the context of organizational changes such as implementation of the electronic health record, a conceptual model for research is proposed, research hypotheses are stated, and methodology for a future stream of research is discussed.

The senses in practice: enhancing the quality of care for residents with dementia in care homes

AIM

The study aimed to develop, deliver, and evaluate a training programme in care homes to enhance the quality of care for people living with dementia based on the principles of relationship-centred care expressed through the Senses Framework.

BACKGROUND

There are increasing numbers of people living with dementia worldwide with a growing proportion requiring residential long-term care. This makes the quest for enhancing the quality of care and quality of life for people with dementia ever more pressing.

DESIGN

A mixed-methods design was used adopting a Practice Development approach. The findings from one care home in the North West of England are reported.

METHODS

Eight facilitated workshops based on the principles of relationship-centred care were completed and evaluated in 2010, using pre- and postintervention design. A focus group was undertaken with staff on completion of the study to gain a more comprehensive understanding of the practice/training context, augmented by case examples of changes in practice identified from the study workshops.

RESULTS

Structured questionnaires were used to profile the care home before and after the training. Following the workshops, staff felt more able to collect and use biographical information. In particular, staff reported how this information supported them to initiate meaningful conversations with the person with dementia as part of everyday care routines, thus improving overall feelings of well-being.

CONCLUSION

Using a biographical approach to care planning structured through the Senses Framework helped staff to develop a greater understanding of the person with dementia.

Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes

Self-appraisal has repeatedly been shown to be inadequate as a mechanism for performance improvement. This has placed greater emphasis on understanding the processes through which self-perception and external feedback interact to influence professional development. As feedback is inevitably interpreted through the lens of one's self-perceptions it is important to understand how learners interpret, accept, and use feedback (or not) and the factors that influence those interpretations. 134 participants from 8 health professional training/continuing competence programs were recruited to participate in focus groups. Analyses were designed to (a) elicit understandings of the processes used by learners and physicians to interpret, accept and use (or not) data to inform their perceptions of their clinical performance, and (b) further understand the factors (internal and external) believed to influence interpretation of feedback. Multiple influences appear to impact upon the interpretation and uptake of feedback. These include confidence, experience, and fear of not appearing knowledgeable. Importantly, however, each could have a paradoxical effect of both increasing and decreasing receptivity. Less prevalent but nonetheless important themes suggested mechanisms through which cognitive reasoning processes might impede growth from formative feedback. Many studies have examined the effectiveness of feedback through variable interventions focused on feedback delivery. This study suggests that it is equally important to consider feedback from the perspective of how it is received. The interplay observed between fear, confidence, and reasoning processes reinforces the notion that there is no simple recipe for the delivery of effective feedback. These factors should be taken into account when trying to understand (a) why self-appraisal can be flawed, (b) why appropriate external feedback is vital (yet can be ineffective), and (c) why we may need to disentangle the goals of performance improvement from the goals of improving self-assessment.

Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes

Self-appraisal has repeatedly been shown to be inadequate as a mechanism for performance improvement. This has placed greater emphasis on understanding the processes through which self-perception and external feedback interact to influence professional development. As feedback is inevitably interpreted through the lens of one's self-perceptions it is important to understand how learners interpret, accept, and use feedback (or not) and the factors that influence those interpretations. 134 participants from 8 health professional training/continuing competence programs were recruited to participate in focus groups. Analyses were designed to (a) elicit understandings of the processes used by learners and physicians to interpret, accept and use (or not) data to inform their perceptions of their clinical performance, and (b) further understand the factors (internal and external) believed to influence interpretation of feedback. Multiple influences appear to impact upon the interpretation and uptake of feedback. These include confidence, experience, and fear of not appearing knowledgeable. Importantly, however, each could have a paradoxical effect of both increasing and decreasing receptivity. Less prevalent but nonetheless important themes suggested mechanisms through which cognitive reasoning processes might impede growth from formative feedback. Many studies have examined the effectiveness of feedback through variable interventions focused on feedback delivery. This study suggests that it is equally important to consider feedback from the perspective of how it is received. The interplay observed between fear, confidence, and reasoning processes reinforces the notion that there is no simple recipe for the delivery of effective feedback. These factors should be taken into account when trying to understand (a) why self-appraisal can be flawed, (b) why appropriate external feedback is vital (yet can be ineffective), and (c) why we may need to disentangle the goals of performance improvement from the goals of improving self-assessment.

Communication skills training increases self-efficacy of health care professionals

INTRODUCTION

Despite the knowledge of good communication as a precondition for optimal care and treatment in health care, serious communication problems are still experienced by patients as well as by health care professionals. An orthopedic surgery department initiated a 3-day communication skills training course for all staff members expecting an increase in patient-centeredness in communication and more respectful intercollegial communication. The aim of this study was to investigate the impact of this training course on participants' self-efficacy with a focus on communication with both colleagues and patients.

METHODS

The study was designed as an effectiveness study with the training course implemented in a real-world context. The staff members attended a 3-day training course in patient-centered communication and communication with colleagues. The effect of the training was evaluated by means of a questionnaire filled out before, immediately after, and 6 months after the course.

RESULTS

Of the 181 participants, 177 answered the questionnaire before, 165 immediately after, and 150 six months after the course. The mean score for self-efficacy in communication with patients increased from 6.68 to 7.88 (p < .001) and in communication with colleagues from 6.85 to 7.84 (p < .001) immediately following the training course. The effect was still present 6 months after the course was completed.

DISCUSSION

Although the study was conducted in a real-world setting with many competing demands, a communication course produced an increase in self-efficacy. This result was observed for doctors, nurses, nursing assistants, and medical secretaries.

Perception of empathy in the therapeutic encounter: effects on the common cold

OBJECTIVE

To evaluate the effects of patient-practitioner interaction on the severity and duration of the common cold.

METHODS

We conducted a randomized controlled trial of 719 patients with new cold onset. Participants were randomized to three groups: no patient-practitioner interaction, "standard" interaction or an "enhanced" interaction. Cold severity was assessed twice daily. Patients randomized to practitioner visits used the Consultation and Relational Empathy (CARE) measure to rate clinician empathy. Interleukin-8 (IL-8) and neutrophil counts were obtained from nasal wash at baseline and 48 h later.

RESULTS

Patients' perceptions of the clinical encounter were associated with reduced cold severity and duration. Encounters rated perfect on the CARE score had reduced severity (perfect: 223, sub-perfect: 271, p=0.04) and duration (perfect: 5.89 days, sub-perfect: 7.00 days, p=0.003). CARE scores were also associated with a more significant change in IL-8 (perfect: mean IL-8 change 1586, sub-perfect: 72, p=0.02) and neutrophil count (perfect: 49, sub-perfect: 12, p=0.09).

CONCLUSIONS

When patients perceive clinicians as empathetic, rating them perfect on the CARE tool, the severity, duration and objective measures (IL-8 and neutrophils) of the common cold significantly change.

PRACTICE IMPLICATIONS

This study helps us to understand the importance of the perception of empathy in a therapeutic encounter.

The association of visit length and measures of patient-centered communication in HIV care: a mixed methods study

OBJECTIVE

Patient centered clinical communication may be associated with longer encounters.

METHODS

We used the General Medical Interaction Analysis System (GMIAS) to code transcripts of routine outpatient visits in HIV care, and create 5 measures of patient-centeredness. We defined visit length as number of utterances. To better understand properties of encounters reflected in these measures, we conducted a qualitative analysis of the 15 longest and 15 shortest visits.

RESULTS

All 5 measures were significantly associated with visit length (p<0.05, rank order correlations 0.21-0.44). In multivariate regressions, association of patient centeredness with visit length was attenuated for 4 measures, and increased for 1; two were no longer statistically significant (p>0.05). Black and Hispanic race were associated with shorter visits compared with White race. Some of the longest visits featured content that could be considered extraneous to appropriate care.

CONCLUSION

Patient centeredness is weakly related to visit length, but may reflect inefficient use of time in long encounters.

PRACTICE IMPLICATIONS

Efforts to make visits more patient centered should focus on improving dialogue quality and efficient use of time, not on making visits longer. Shorter visits for Black and Hispanic patients could contribute to health disparities related to race and ethnicity.

The power of social connection and support in improving health: lessons from social support interventions with childbearing women

Background and objective

Social support interventions have a somewhat chequered history. Despite evidence that social connection is associated with good health, efforts to implement interventions designed to increase social support have produced mixed results. The aim of this paper is to reflect on the relationship between social connectedness and good health, by examining social support interventions with mothers of young children and analysing how support was conceptualised, enacted and valued, in order to advance what we know about providing support to improve health.

Context and approach

First, we provide a brief recent history of social support interventions for mothers with young children and we critically examine what was intended by ‘social support’, who provided it and for which groups of mothers, how support was enacted and what was valued by women. Second, we examine the challenges and promise of lay social support approaches focused explicitly on companionship, and draw on experiences in two cluster randomised trials which aimed to improve the wellbeing of mothers. One trial involved a universal approach, providing befriending opportunities for all mothers in the first year after birth, and the other a targeted approach offering support from a ‘mentor mother’ to childbearing women experiencing intimate partner violence.

Results

Interventions providing social support to mothers have most often been directed to women seen as disadvantaged, or ‘at risk’. They have also most often been enacted by health professionals and have included strong elements of health education and/or information, almost always with a focus on improving parenting skills for better child health outcomes. Fewer have involved non-professional ‘supporters’, and only some have aimed explicitly to provide companionship or a listening ear, despite these aspects being what mothers receiving support have said they valued most. Our trial experiences have demonstrated that non-professional support interventions raise myriad challenges. These include achieving adequate reach in a universal approach, identification of those in need of support in any targeted approach; how much training and support to offer befrienders/mentors without ‘professionalising’ the support provided; questions about the length of time support is offered, how ‘closure’ is managed and whether interventions impact on social connectedness into the future. In our two trials what women described as helpful was not feeling so alone, being understood, not being judged, and feeling an increased sense of their own worth.

Conclusion and implications

Examination of how social support has been conceptualised and enacted in interventions to date can be instructive in refining our thinking about the directions to be taken in future research. Despite implementation challenges, further development and evaluation of non-professional models of providing support to improve health is warranted.

When rapport building extends beyond affiliation: communication overaccommodation toward patients with disabilities

INTRODUCTION

Physician rapport with patients is described as a vital component of relationship-centered care, but rapport-building communication behaviors may exceed boundaries and instead indicate patronizing behavior toward patients with disabilities. This paper addresses the types of communication behaviors and contexts for interpreting when rapport building extends beyond boundaries toward patients with disabilities.

METHODS

Videotaped interactions between third- and fourth-year medical students (N = 142) and standardized patient educators with physical disabilities were qualitatively analyzed.

RESULTS

Results suggest six primary themes of exceeding expected rapport boundaries, including baby talk (ie, exaggerated nonverbal gestures and "we" language to indicate "you"), kinesic movement (ie, stiff posture and awkward handshakes), vocalics (ie, volume or pitch that interfered with the flow of conversation), relationship assumptions (ie, communicating assumptions that relationships were grounded in care-receiving), emotional divergence from patient disclosure (ie, minimizing or embellishing disability), and inconsistency with patient emotional cues (ie, responding to negative or neutral disclosure by overly accentuating positive interpretation).

DISCUSSION

This study suggests that communication behaviors generally described as positive, rapport-building behaviors can pose negative implications when they exceed the expected quantity or duration, when they are inconsistent with patient verbal disclosure, or when verbal and nonverbal messages are inconsistent. Identified themes serve as examples to understand when rapport building exceeds beyond affiliation and instead appears to indicate patronizing behavior toward patients with disabilities. Suggestions for interpreting communication behaviors within the context of patient disclosure and building capacity to distinguish attitudes and biases limiting communication are addressed.

Challenges in primary care relationships: seeing it from both sides

OBJECTIVE

This qualitative study explored perspectives of primary care providers and patients in challenging relationships.

METHODS

In 2007, we conducted semi-structured interviews with providers recruited from 12 clinics affiliated with a U.S. academic center. Providers identified patients with whom they had ongoing "challenging relationships," and we interviewed the first consenting patient for each provider. We compared numeric ratings of relationship quality statistically. Using an editing analysis style, ≥2 investigators coded transcripts to identify themes.

RESULTS

Seventeen dyads participated. Providers averaged 14 years in practice. Most were Caucasian (88%) and female (59%). The mean patient age was 49 years, 59% were Caucasian, and 71% female. Relationships averaged 4.6 years. On a 1-10 scale, patients' ratings of the relationship quality (median 9) significantly exceeded providers' ratings (median 5, p=0.002). Three major themes emerged: patients view relationships more positively than providers, the challenges of guarding emotions, and trust matters in challenging relationships.

CONCLUSION

Patients felt more positively about these relationships than providers perceived. Both sought ways to achieve mutual trust, despite barriers arising from guarded emotions.

PRACTICE IMPLICATIONS

Providers in challenging relationships should consider exploring their patients' views, as they may feel reassured that patients appreciate their efforts and have trust in them.

Connectedness in the context of patient-provider relationships: a concept analysis

AIM

This paper is a report of an analysis of the concept of connectedness.

BACKGROUND

Previous attempts to conceptualize patient-provider relationships were limited in explaining how such relationships are fostered and maintained, and how they influence patient outcomes. Connectedness is a concept that may provide insights into the advantages of patient-provider relationships; however, the usefulness of this concept in health care is limited by its conceptual ambiguity. Although connectedness is widely used to describe other social relationships, little consistency exists among its definitions and measures.

DATA SOURCES

Sources identified through CINAHL, OVID, PubMed and PsychINFO databases and references lists of selected articles between 1983 and 2010.

REVIEW METHODS

A hybrid concept analysis approach was used, involving a combination of traditional concept analysis strategies that included: describing historical conceptualizations, identifying attributes, critiquing existing definitions, examining boundaries and identifying antecedents and consequences.

RESULTS

Using five distinct historical perspectives, seven attributes of connectedness were identified: intimacy, sense of belonging, caring, empathy, respect, trust and reciprocity. A broad definition of connectedness, which can be used in the context of patient-provider relationships, was developed. A preliminary theoretical framework of connectedness was derived from the identified antecedents, attributes and consequences.

CONCLUSION

Research efforts to advance the concept of connectedness in patient-provider relationships have been hampered by a lack of conceptual clarity. This concept analysis offers a clearer understanding of connectedness, provides recommendations for future research and suggests practice implications.

Patient reactions to personalized medicine vignettes: an experimental design

PURPOSE

Translational investigation on personalized medicine is in its infancy. Exploratory studies reveal attitudinal barriers to "race-based medicine" and cautious optimism regarding genetically personalized medicine. This study describes patient responses to hypothetical conventional, race-based, or genetically personalized medicine prescriptions.

METHODS

Three hundred eighty-seven participants (mean age = 47 years; 46% white) recruited from a Baltimore outpatient center were randomized to this vignette-based experimental study. They were asked to imagine a doctor diagnosing a condition and prescribing them one of three medications. The outcomes are emotional response to vignette, belief in vignette medication efficacy, experience of respect, trust in the vignette physician, and adherence intention.

RESULTS

Race-based medicine vignettes were appraised more negatively than conventional vignettes across the board (Cohen's d = -0.51-0.57-0.64, P < 0.001). Participants rated genetically personalized comparably with conventional medicine (-0.14-0.15-0.17, P = 0.47), with the exception of reduced adherence intention to genetically personalized medicine (Cohen's d = -0.38-0.41-0.44, P = 0.009). This relative reluctance to take genetically personalized medicine was pronounced for racial minorities (Cohen's d = -0.38-0.31-0.25, P = 0.02) and was related to trust in the vignette physician (change in R = 0.23, P < 0.001).

CONCLUSIONS

This study demonstrates a relative reluctance to embrace personalized medicine technology, especially among racial minorities, and highlights enhancement of adherence through improved doctor- patient relationships.

Crossing the patient-centered divide: transforming health care quality through enhanced faculty development

In the report "Crossing the Quality Chasm," the Institute of Medicine asserted that patient-centered care is one of the six domains of quality. In this article, the authors consider how the patient- and relationship-centered components of quality can be achieved in all aspects of medical care. They suggest that faculty development in three key areas-mindful practice, formation, and training in communication skills-is necessary to achieve patient- and relationship-centeredness.The authors first review the philosophical and scientific foundations of patient-centered and relationship-centered care. They next describe and provide concrete examples to illustrate the underlying theory and practices associated with each of the three faculty development areas. They then propose five key areas for faculty development in patient- and relationship-centered care: (1) making it a central competency in all health care interactions, (2) developing a national curriculum framework, (3) requiring performance metrics for professional development, (4) partnering with national health care organizations to disseminate the curriculum framework, and (5) preserving face-to-face educational methods for delivering key elements of the curriculum. Finally, the authors consider the issues faced in faculty development today in light of the medical education issues Abraham Flexner identified more than a century ago.

Research on person-centred clinical care

RATIONALE, AIMS AND OBJECTIVES

To give a selective review of empirical studies on person-centred clinical care, in particular concerning communication patterns between patients and providers.

METHODS

Descriptive and selective review of relevant literature.

RESULTS

Person-centred clinical care may have positive effects on patient satisfaction, patient adherence, health care utilization, malpractice litigation and health outcome. Person-centred communication skills may be promoted by way of communication skills training.

CONCLUSION

The concept of person-centred care is rare in the empirical literature. Future research should operationalize the concept and design studies of the impact of patient-centred clinical care.

Measuring providers' verbal and nonverbal emotion recognition ability: reliability and validity of the Patient Emotion Cue Test (PECT)

OBJECTIVE

To describe the development and validation of the Patient Emotion Cue Test (PECT) as a tool to measure providers' emotion cue recognition ability.

METHODS

The PECT consists of 47 video clips depicting emotion cues that systematically vary in intensity of both verbal and nonverbal contents. The PECT assesses the provider's ability to detect and identify patients' emotion cues accurately. A multi-stage development process produced the PECT. Reliability and validity were assessed in three studies.

RESULTS

Scores on the PECT are normally distributed with significantly above chance responding. Across three studies, the PECT demonstrates convergent validity through significant correlations with standardized tests representing multiple channels of emotion recognition, including the face, body, and voice. The PECT shows adequate inter-item and split-half reliability.

CONCLUSION

The PECT is an easily administered, reliable, and valid test of emotion cue recognition.

PRACTICE IMPLICATIONS

The PECT can be used in future research on providers' emotion recognition ability, for evaluating self-assessment of ability, and as a teaching tool in medical schools.

Initial efforts in community engagement with health care providers: perceptions of barriers to care for cancer patients in Puerto Rico

OBJECTIVE

Cancer health disparities are evident among Puerto Rican Hispanics, both for those on the island and in the mainland United States. Less is known about cancer care services available on the island. Through the Ponce School of Medicine and Moffitt Cancer Center partnership, focus groups with health care providers (HCP) were conducted to explore needs and barriers related to cancer care services with an ultimate goal of developing a cancer control and prevention program for the southern area of Puerto Rico.

METHODS

To engage the community in outreach efforts to identify barriers to cancer care in Ponce, Puerto Rico, we conducted two focus groups with HCPs from a variety of settings, including general hospitals, private clinics, pharmacies, and government agencies. These 90-minute focus groups were conducted in Spanish and moderated using a semi-structured interview guide that explored the needs and barriers related to cancer control and prevention services.

RESULTS

We analyzed content using the emergent material for identifying patterns, themes, and perceptions. Our qualitative analysis indicated that providers had significant concerns about unmet patient needs and system factors, which served as barriers to quality cancer care delivery. Key barriers included unmet practical needs, such as transportation, treatment affordability, lack of resources, and unmet needs for social support and education services.

CONCLUSION

Future research will examine other key informants' (e.g., patients, caregivers) perspectives and identify which issues can be addressed by the partnership grant and which must be addressed by policymakers.

Perspective: Does medical education promote professional alexithymia? A call for attending to the emotions of patients and self in medical training

Emotions--one's own and others'--play a large role in the lives of medical students. Students must deal with their emotional reactions to intellectual and physical stress, the demanding clinical situations to which they are witness, as well as patients' and patients' family members' often intense feelings. Yet, currently few components in formal medical training--in either direct curricular instruction or physician role modeling--focus on the emotional lives of students. In this article, the author examines patients', medical students', and physician role models' emotions in the clinical context, highlighting challenges in all three of these arenas. Next, the author asserts that the preponderance of medical education continues to address the emotional realm through ignoring, detaching from, and distancing from emotions. Finally, she presents not only possible theoretical and conceptual models for developing ways of understanding, attending to, and ultimately "working with" emotions in medical education but also examples of innovative curricular efforts to incorporate emotional awareness into medical student training. The author concludes with the hope that medical educators will consider making a concerted effort to acknowledge emotions and their importance in medicine and medical training.

Medical students on the stage: an experimental performative method for the development of relational skills

BACKGROUND

Development of therapeutic relational skills is a relatively neglected area of medical education. Conventional teaching techniques are mostly unsuitable for the realization of experience-based learning.

AIMS

To develop a training method which enables lived self-experiences of the therapeutic relationship in class. To help students understand that illness and the doctor-patient relationship are integrated in the network of life histories and other relationships.

METHODS

Our Integrated Performative Action Method is based on the elaboration of a short story of an illness in a student group. Through the 5 phases of the process, students write their own version of the story, build up characters, scenarios and enact the play. We have tested the method with 6 groups of students (n = 70) in a 10-week course. Video-recordings and minutes of sessions were analysed by two independent observers.

RESULTS

Through elaborating the characters and playing the roles, students could speak about their own problems and act out feelings in the name of the characters. All groups had strong involvement throughout the process.

CONCLUSIONS

The method helps to experience the ways in which therapeutic relationships and professional identities are constructed, reflected upon and communicated in a group of medical students.

A course for nurses to handle difficult communication situations. A randomized controlled trial of impact on self-efficacy and performance

OBJECTIVE

to evaluate the impact of a communication skills course for nurses on how to handle difficult communication situations in their daily work.

METHODS

a 7-h course was developed using a construct of "Awareness, Feelings, Listen, Solve" (AFLS). A pedagogy of experiential, learner-centered learning was adopted. The course evaluation used a randomized controlled design with pre- and post-measures of self-efficacy and performance.

RESULTS

forty-one nurses volunteered and thirty-three nurses completed all assigned parts of the study. On self-assessment, there was significant improvement for self-efficacy (F=24.43, p<0.001), but not for emotional awareness. On performance, there was no significant improvement between intervention and control groups (F=3.46, p=0.073).

CONCLUSION

a short course for nurses on handling difficult communication situations achieved significant improvements in self-efficacy but not in performance.

PRACTICE IMPLICATIONS

teaching communication skills in community-based settings is important for the safety and effectiveness of patient care. Sponsoring organizations should weigh trade-offs between feasibility and achievement of measurable improvements in performance. One possible approach is to focus on specific communication skills rather than a full suite of skills.

Emancipatory actions displayed by multi-ethnic women: "Regaining control of my health care"

PURPOSE

Despite the recognized importance of patient involvement in primary care interactions, little information describing women's needs and expectations for these interactions is available. This participatory action study was based in Critical Action Theory and designed to describe any emancipatory interests that surfaced when eight ethnically diverse women examined their interactions with primary care nurse practitioners (PCNPs) over the course of five successive focus group meetings.

DATA SOURCES

Focus group meeting transcripts, field notes, interaction notations, seating maps, and first impression summaries.

CONCLUSIONS

Participants wanted to learn how to "stand up" for themselves in primary care interactions. They believed this could be accomplished by developing a positive sense of self-esteem. Ultimately, they identified the right way to "talk back" to clinicians and created a method for regaining control of their own health care and maintaining equality in interactions with primary care clinicians.

IMPLICATIONS FOR PRACTICE

Nurse practitioners working in the primary setting are especially well situated to support self-management and foster patient participation by women as they live with chronic disease, engage in health promotion activities, and deal with common symptomatic problems for themselves and their families.

Adaptive leadership and the practice of medicine: a complexity-based approach to reframing the doctor-patient relationship

RATIONALE, AIMS AND OBJECTIVES

This paper applies the concepts of 'adaptive leadership', as developed by Ron Heifetz, MD, to the practice of medicine.

METHODS

Literature review and theory development.

RESULTS

Patients are complex adaptive systems facing both adaptive and technical health challenges. Technical health challenges are amenable to the simple or complicated expert-mediated technical interventions that are common in modern medicine, but complex adaptive challenges can only be addressed by patients doing the adaptive work to learn new attitudes, beliefs and behaviours. In medicine, we often make the mistake of offering technical interventions in lieu of supporting patients' adaptive work. This error can result in poor clinical outcomes and wasted resources. Expecting simple or complicated technical 'solutions' to resolve complex adaptive health challenges is a failure of adaptive leadership and violates Ashby's law of requisite variety. Adaptive leadership behaviours correspond to and complement doctor practices that have been shown to improve health outcomes and doctor-patient communication.

CONCLUSIONS

Adopting an adaptive leadership framework in the practice of medicine will require adaptive work on our part, but it promises to improve the doctor-patient relationship, increase our effectiveness as healers and reduce unnecessary health care utilization.

Gender bias in patients' perceptions of patient-centered behaviors

OBJECTIVE

This research examines whether patient perceptions are equivalently associated with patient-centered behavior in male and female medical students, and tests the impact of a message emphasizing the importance of patient-centeredness on analogue patients' perceptions of male and female medical students' performance.

METHODS

Sixty-one medical students interacting with standardized patients (SPs) were viewed by 384 analogue patients (APs). APs were randomly assigned to receive a message emphasizing the value of patient-centeredness or of technical competence, or a neutral message, and then evaluated the medical students' competence in the interactions. Students' patient-centeredness was measured using the Four Habits Coding Scheme and Roter Interaction Analysis System.

RESULTS

APs in the neutral and technical competence conditions gave higher competence ratings to more patient-centered male students, but not to more patient-centered female students. However, APs who received the patient-centeredness message gave higher competence ratings to both male and female students who were higher in patient-centeredness.

CONCLUSION

Making it clear that patient-centeredness is a dimension of physician competence eliminated a gender bias in evaluating performance.

PRACTICE IMPLICATIONS

Because patient perceptions are often used in evaluations, gender biases must be understood and reduced so both male and female providers receive appropriate credit for their patient-centered behaviors.

Supporting patient autonomy: the importance of clinician-patient relationships

Personal autonomy is widely valued. Recognition of its vulnerability in health care contexts led to the inclusion of respect for autonomy as a key concern in biomedical ethics. The principle of respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. In this paper, we suggest that a strong focus on decision situations is problematic, especially when combined with a tendency to stress the importance of patients' independence in choosing. It distracts attention from other important aspects of and challenges to autonomy in health care. Relational understandings of autonomy attempt to explain both the positive and negative implications of social relationships for individuals' autonomy. They suggest that many health care practices can affect autonomy by virtue of their effects not only on patients' treatment preferences and choices, but also on their self-identities, self-evaluations and capabilities for autonomy. Relational understandings de-emphasise independence and facilitate well-nuanced distinctions between forms of clinical communication that support and that undermine patients' autonomy. These understandings support recognition of the value of good patient-professional relationships and can enrich the specification of the principle of respect for autonomy.

Defining and measuring the patient-centered medical home

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Approaches to reducing the most important patient errors in primary health-care: patient and professional perspectives

We have previously reported a preliminary taxonomy of patient error. However, approaches to managing patients' contribution to error have received little attention in the literature. This paper aims to assess how patients and primary care professionals perceive the relative importance of different patient errors as a threat to patient safety. It also attempts to suggest what these groups believe may be done to reduce the errors, and how. It addresses these aims through original research that extends the nominal group analysis used to generate the error taxonomy. Interviews were conducted with 11 purposively selected groups of patients and primary care professionals in Auckland, New Zealand, during late 2007. The total number of participants was 83, including 64 patients. Each group ranked the importance of possible patient errors identified through the nominal group exercise. Approaches to managing the most important errors were then discussed. There was considerable variation among the groups in the importance rankings of the errors. Our general inductive analysis of participants' suggestions revealed the content of four inter-related actions to manage patient error: Grow relationships; Enable patients and professionals to recognise and manage patient error; be Responsive to their shared capacity for change; and Motivate them to act together for patient safety. Cultivation of this GERM of safe care was suggested to benefit from 'individualised community care'. In this approach, primary care professionals individualise, in community spaces, population health messages about patient safety events. This approach may help to reduce patient error and the tension between personal and population health-care.

Community-based disability prevention programs for elders: predictors of program completion

Strategies to foster elder well-being and reduce long-term care costs include efficacious community disability prevention programs. Program completion remains an important barrier to their effectiveness. We examined the association between provider relationships and client variables, and program completion in senior centers. Our mixed methods design used secondary data for 719 clients and primary data through telephone interviews with 20 nurses, 23 social workers, and 18 site managers. Quantitative data showed that higher client baseline self-efficacy positively influenced completion and minority status negatively influenced completion. Qualitative data showed that higher focus on provider-client relationships was associated with high completion.

Therapeutic alliance in pediatric primary care: preliminary evidence for a relationship with physician communication style and mothers' satisfaction

OBJECTIVES

Studies in pediatric primary care suggest that interactions between parents and providers may have therapeutic impact on children's mental health problems. Methods to measure interactions specific to mental health outcomes have been developed in psychotherapy but are only beginning to be applied in primary care. We tested an adaptation of the Vanderbilt Therapeutic Alliance Scale (VTAS) for rating parent-provider interactions in pediatric primary care.

METHODS

Recoding, using the VTAS, of 50 previously collected audiotapes of visits to a pediatric residents' continuity clinic. Concurrent validity of VTAS coding was measured by comparing it to independent coding using the Roter Interaction Analysis System. Predictive validity was tested by comparing VTAS scores to parent ratings of the residents' behavior in the domains of interpersonal sensitivity, partnership, and informativeness.

RESULTS

The VTAS demonstrated a factor structure very similar to the structure observed when it has been used to rate mental health visits. VTAS patient and provider subscale scores correlated with corresponding Roter Interaction Analysis System measures of parent and resident participation. Total VTAS scores correlated most strongly with Roter Interaction Analysis System scores indicating emotion and rapport-building statements from the resident. Total VTAS scores predicted parents' ratings of residents' interpersonal sensitivity but not ratings of partnership or informativeness.

CONCLUSION

It appears possible to use therapeutic alliance to rate interactions in primary care. Measuring alliance may bring greater efficiency to primary care mental health studies because of its potential specificity as a marker of mental health-related outcomes.

Australian women's use of complementary and alternative medicines to enhance fertility: exploring the experiences of women and practitioners

Background

Studies exploring the use of complementary and alternative medicine (CAM) to enhance fertility are limited. While Australian trends indicate that women are using CAM during pregnancy, little is known about women's use of CAM for fertility enhancement. With the rising age of women at first birth, couples are increasingly seeking assisted reproductive technologies (ART) to achieve parenthood. It is likely that CAM use for fertility enhancement will also increase, however this is not known. This paper reports on an exploratory study of women's use of CAM for fertility enhancement.

Methods

Three focus groups were conducted in Melbourne, Australia in 2007; two with women who used CAM to enhance their fertility and one with CAM practitioners. Participants were recruited from five metropolitan Melbourne CAM practices that specialise in women's health. Women were asked to discuss their views and experiences of both CAM and ART, and practitioners were asked about their perceptions of why women consult them for fertility enhancement. Groups were digitally recorded (audio) and transcribed verbatim. The data were analysed thematically.

Results

Focus groups included eight CAM practitioners and seven women. Practitioners reported increasing numbers of women consulting them for fertility enhancement whilst also using ART. Women combined CAM with ART to maintain wellbeing and assist with fertility enhancement. Global themes emerging from the women's focus groups were: women being willing to 'try anything' to achieve a pregnancy; women's negative experiences of ART and a reluctance to inform their medical specialist of their CAM use; and conversely, women's experiences with CAM being affirming and empowering.

Conclusions

The women in our study used CAM to optimise their chances of achieving a pregnancy. Emerging themes suggest the positive relationships achieved with CAM practitioners are not always attained with orthodox medical providers. Women's views and experiences need to be considered in the provision of fertility services, and strategies developed to enhance communication between women, medical practitioners and CAM practitioners. Further research is needed to investigate the extent of CAM use for fertility enhancement in Australia, and to explore the efficacy and safety of CAM use to enhance fertility, in isolation or with ART.

What can I learn from this interaction? A qualitative analysis of medical student self-reflection and learning in a standardized patient exercise about disability

Patients with disabilities receive fewer health services than the general population, yet they have greater health needs. Similarly, physicians report limited training in disability. The current project examines medical students' learning about disability in a project using individuals with disabilities as medical educators. Family medicine clerkship students (N = 138) across an academic year were videotaped during interviews with standardized patient educators with disabilities and during feedback sessions following the interactions. Qualitative analysis of feedback transcripts identifies three primary areas of integrating learning, reflective practice, and disability: (1) learning how disability impacts the treatment plan, (2) self-reflection and recognizing attitudes about disability, and (3) learning about the practice of medicine generally from the disability exercise. Themes are identified within each of the primary learning areas. Medical student reflection provides evidence of learning to connect disability with pain, everyday life, and treatment. Medical students learned to recognize patients' expertise in their own condition and in health care navigation. Medical students also examined how their language implies attitude. The current investigation provided evidence of the ways examining disability can serve as a cornerstone for building relationship-centered patient care and encouraging reflective practice overall.

Psychosocial aspects of women's lives: work and family/personal life and life cycle issues

Beginning in the past century and continuing to evolve into the twenty-first century, there have been dramatic changes in women's work and personal/family lives within the United States. These changes have particularly affected white, middle-class women and women in medicine and other professions. Physicians in fields whose practitioners are predominantly female and/or who treat primarily women and families need to be aware of the scope and nature of these changes and to recognize that their own personal experiences and values might differ from those of women of different generations as well as different socioeconomic and cultural backgrounds.

Reconsidering the team concept: educational implications for patient-centered cancer care

Patient-centered cancer care has become a priority in the oncology field. Increasing efforts to train oncologists in communication skills have led to a growing literature on patient-centered cancer education. In addition, systems approaches have led to an increased emphasis on the concept of teams as an organizing framework for cancer care. In this essay, we examine issues involved in educating teams to provide patient-centered cancer care. In the process, we question the applicability of a tightly coordinated 'team' concept, and suggest the concept of a 'care community' as a more achievable ideal for the way that cancer care is commonly delivered. We discuss the implications that this has for cancer communication education, and propose three principles to guide the development of educational interventions aimed at increasing patient-centeredness in cancer care delivery systems.

The impact of senior medical students' personal difficulties on their communication patterns in breaking bad news

PURPOSE

To evaluate the possible influence of personal difficulties and barriers that are within the news bearer and his or her self-awareness (SA) of them, on the patterns of communication during encounters involving breaking bad news (BBN).

METHOD

Following an intensive BBN course in 2004, 103 senior medical students at the Sackler School of Medicine, Tel Aviv University, were evaluated for BBN competencies by the analysis of their written descriptions of how they visualized their manner of delivering bad news to a patient described in a challenging vignette. The students were further asked to reflect on their own difficulties and barriers that surfaced in response to reading the narrative presented in the vignette and in delivering the bad news. Using an immersion crystallization narrative analysis method, the authors analyzed the relationship between the students' BBN strategies and their self-perceived barriers and difficulties.

RESULTS

Four types of communicators were identified and related to 45 different personal and professional barriers that the students, through self-reflection, found in themselves. These perceived barriers as well as the ability to self-reflect on them influenced their patterns of communication in their envisioned and written-down encounters, including the level of emotional connectedness, information provided, and the chosen focus-of-care paradigm (physician-centered, patient-centered, or relationship-centered).

CONCLUSIONS

These findings empirically demonstrate that intrapersonal difficulties within the communicator and his or her level of SA about them influenced the manner and content of the communication during the encounter. This finding suggests that enhancing SA and addressing personal and professional difficulties could help physicians' capability to cope with challenging communication tasks. The authors propose a working tool (the Preparatory SPIKES) to facilitate the integration of self-reflection (by identifying personal difficulties) into day-by-day planning and delivery of bad news.

The role of patient activation in psychiatric visits

OBJECTIVE

This study identified ways that consumers of mental health services are active participants in psychiatric treatment.

METHODS

Four providers (three psychiatrists and one nurse practitioner) were recruited, and ten consumers with severe mental illness were recruited per provider (40 total). Consumers completed questionnaires on patient activation, illness self-management, and medication attitudes on the day of a psychiatric visit. The visit was audiotaped, transcribed, and thematically analyzed. Providers gave information on diagnosis, substance use disorder, and medication adherence.

RESULTS

Consumer-rated patient activation was positively related to illness self-management and negatively related to substance use disorder. Transcripts of the psychiatric visit showed that consumers were active in partnership building, seeking and displaying competence, and directing treatment; however, the relationship was weak between consumer-reported activation and observed activation behaviors.

CONCLUSIONS

Consumers were found to be active participants in treatment in a variety of ways, but similar to other populations, the relationship between observed patient activation and consumer-reported desire for involvement was not direct.

Commentary: Identifying attitudes towards empathy: an essential feature of professionalism

Preserving and promoting empathy are ethical imperatives in medical education. The authors of this commentary propose that the "hidden curriculum" and mixed messages learners frequently receive during clinical rotations may erode humanistic traits essential to high-quality care. Three articles in this issue focus on assessing attitude towards empathy in the health care setting using the Jefferson Scale of Physician Empathy. The authors discuss salient points from these reports, reinforce the concept of empathy as a cognitive attribute, and offer recommendations for teaching and nurturing empathy in health professionals. In the reports, construct validity and reliability of the instrument were confirmed and were comparable with previous results, thus providing medical educators with a sound instrument to measure empathic attitudes in the context of patient care. The authors agree with the distinctions made in the three studies between empathy (described as a cognitive attribute) and sympathy (described as an emotional attribute) and believe that empathy as a cognitive skill can be role modeled, taught, and assessed. Barriers to empathic practice (lack of sufficient role models, failing to teach empathy as a cognitive skill, negative experiences, time pressures, overreliance on technology) can be remedied in medical education through interprofessional education and practice and institutional promotion of relationship-centered care, which maintains the centrality of the patient-clinician relationship while recognizing the importance of relationships with self and others.

Is it good to express uncertainty to a patient? Correlates and consequences for medical students in a standardized patient visit

OBJECTIVE

To examine the consequences of expressions of uncertainty (EOUs) in medical student interactions, with a particular focus on the gender of the expressor.

METHODS

EOUs were identified in 147 videotaped interactions between third-year medical students and standardized patients enacting four medical scenarios. The encounters were also analyzed using the Roter Interaction Analysis System (RIAS). A subset of these interactions was shown to 244 analogue patients who rated satisfaction, liking, and perceived competence and confidence.

RESULTS

Female medical students used more EOUs but not when adjusted for total number of statements. The EOU rate varied across scenarios. A higher EOU rate was perceived as more affectively negative by both RIAS trained coders and analogue patients. EOU rate was inversely related to analogue patient satisfaction and liking and this relationship was stronger for males than females. Female student use of EOUs was more strongly associated with ratings of anxiety than was male EOU use.

CONCLUSION

There was an overall negative perception of medical students who expressed uncertainty; however, the strength of the associations varied due to medical student gender.

PRACTICE IMPLICATIONS

The implications for medical education are discussed.

Living with skin diseases and topical treatment: Patients' and providers' perspectives and priorities

OBJECTIVES

Relationship-centred care stresses the importance of taking both patients' and health-care providers' values, expectations and preferences into account to improve health outcomes. The aim of this qualitative study was to identify patients' and providers' views and experiences of skin disease and topical treatment.

METHODS

Two types of focus group were used: (i) patients with chronic dermatological diseases and (ii) doctors, nurses and pharmacists working in dermatological care.

RESULTS

Three major categories emerged: (i) problems related to the disease, (ii) problems related to the treatment and (iii) strategies for improving everyday life for patients.

CONCLUSION

Patients and providers made several suggestions for improving everyday life. Future research needs to focus on how to achieve preference-matched shared decision-making, or concordance, between patients and health-care providers, taking different perspectives into account and how to evaluate the effect of the final, clinical, economical and humanistic outcomes of care and treatment. More seamless care and an increasingly shared understanding between patients and providers of their values, expectations and preferences for care and treatment may contribute to better health and better daily lives for patients.

Practitioner empathy and the duration of the common cold

OBJECTIVE

This study's objective was to assess the relationship of empathy in medical office visits to subsequent outcomes of the common cold.

METHODS

A total of 350 subjects ? 12 years of age received either a standard or enhanced physician visit as part of a randomized controlled trial. Enhanced visits emphasized empathy on the part of the physician. The patient-scored Consultation and Relational Empathy (CARE) questionnaire assessed practitioner-patient interaction, especially empathy. Cold severity and duration were assessed from twice-daily symptom reports. Nasal wash was performed to measure the immune cytokine interleukin-8 (IL-8).

RESULTS

Eighty-four individuals reported perfect (score of 50) CARE scores. They tended to be older with less education but reported similar health status, quality of life, and levels of optimism. In those with perfect CARE scores, cold duration was shorter (mean 7.10 days versus 8.01 days), and there was a trend toward reduced severity (mean area under receiver-operator characteristics curve 240.40 versus 284.49). After accounting for possible confounding variables, cold severity and duration were significantly lower in those reporting perfect CARE scores. In these models, a perfect score also correlated with a larger increase in IL-8 levels.

CONCLUSIONS

Clinician empathy, as perceived by patients with the common cold, significantly predicts subsequent duration and severity of illness and is associated with immune system changes.

An examination of adherence strategies and challenges in poison control communication

INTRODUCTION

The principal objective of this study was to characterize how nurses and pharmacists at a poison control center (PCC) determine the likelihood of caller adherence to a health care facility referral.

METHODS

A focus group was conducted with 6 nurses and 4 pharmacists from a regional PCC. Content analysis was used to determine themes within the discussion. All participants were certified as specialists in poison information (SPIs).

RESULTS

Four themes were identified: (1) SPIs' generation of informal "likelihood-of-adherence" assessments as to whether a caller will follow the recommendation to go to a health care facility, (2) SPI communication strategies used to promote adherence, (3) behavior of SPIs during periods of high call volume, and (4) communication training for PCC staff members.

DISCUSSION

This pilot study provides insights in SPIs' current assessment and communication, particularly those related to promoting caller adherence to recommendations.

Provider communication effects medication adherence in hypertensive African Americans

OBJECTIVE

To evaluate the effect of patients' perceptions of providers' communication on medication adherence in hypertensive African Americans.

METHODS

Cross-sectional study of 439 patients with poorly controlled hypertension followed in community-based healthcare practices in the New York metropolitan area. Patients' rating of their providers' communication was assessed with a perceived communication style questionnaire,while medication adherence was assessed with the Morisky self-report measure.

RESULTS

Majority of participants were female, low-income, and had high school level educations, with mean age of 58 years. Fifty-five percent reported being nonadherent with their medications; and 51% rated their provider's communication to be non-collaborative. In multivariate analysis adjusted for patient demographics and covariates (depressive symptoms, provider degree), communication rated as collaborative was associated with better medication adherence (beta=-.11, p=.03). Other significant correlates of medication adherence independent of perceived communication were age (beta=.13, p=.02) and depressive symptoms (beta=-.18, p=.001).

CONCLUSION

Provider communication rated as more collaborative was associated with better adherence to antihypertensive medications in a sample of low-income hypertensive African-American patients.

PRACTICE IMPLICATIONS

The quality of patient-provider communication is a potentially modifiable element of the medical relationship that may affect health outcomes in this high-risk patient population.