Perceptions and behaviour among elderly hospital patients: description and explanation of age differences in satisfaction, knowledge, emotions and behaviour

Predictors of Healthcare Workers' Compassionate Care Amid the COVID-19 Pandemic: A Cross-Sectional Study from Patients' Perspective in Kelantan, Malaysia

Background: Compassionate care served by healthcare workers (HCWs) has been recognized as one of the most critical aspects of high-quality care. Unfortunately, there is still an unmet need for the assessment of compassionate care from the patient’s perspective. During the COVID-19 pandemic, many new rules were enacted to tackle the raging pandemic, which raised concerns about its effect on compassionate care. Methods: A cross-sectional study involving 315 patients from three public hospitals was conducted during the conditional movement control order (CMCO). A self-administered Malay version of the Relational Aspect of Care Questionnaire (RAC-QM) was used to assess compassionate care. Multiple linear regression was used to determine the predictors. Results: More than 90% of the patients were Malays, Muslims, and fell under the B40 household income category. Companions were present for 51.7% of the patients, but 75.2% had no visitors. All hospitals received scores of more than 90%. Occupation (student, p = 0.032), dependency level (total dependent, p < 0.001), and household income level (M40, p = 0.027) were the statistically significant predictors for compassionate care. Conclusions: The current study revealed that compassionate care to patients was not compromised during the pandemic. Patients with disabilities or financial constraints are more likely to experience less compassionate care, while students are generally more satisfied. This study may provide clues for hospital administrators and policymakers regarding the vulnerable group of patients. It also provides opportunities for future research to study the perspective of HCWs.

The effect of hospitalization on patients' emotional and psychological well-being among adult patients: An integrative review

OBJECTIVE

Health care providers need to understand how hospitalization impacts patients' emotional statuses, to provide high quality of care. However, an overview of the literature suggests a dearth of research studies that examine and identify the effects of hospitalization on patients' emotional statuses and their well-being. In addition, no research review has synthesized this evidence before. To close this gap, this integrative review examines and synthesizes prior research findings regarding the effects of hospitalization on adult patients' emotional reactions and psychological well-being.

METHOD

This integrative review has been conducted based on the Whittemore and Knafl (2005) outline, which includes four steps: problem identification, literature search, data analysis, and presentation. Seven databases have been systematically searched, including CINAHL, EMBASE, OVID Medline, PsycINFO, SCOPUS, and Cochrane, with no date limitations through January 2021.

RESULTS

The current review synthesizes the findings of 18 publications to identify patients' experiences and factors that evoked emotional reactions during hospitalization. Factors include the effect of admission to a hospital, length of stay, and readmission; these also influence hospitalization experience, the role of health care providers, and patient's characteristics.

CONCLUSION

The current review's findings yield essential information by confirming that hospitalization negatively affects patients' abilities to cope and adjust. Hospitalization demonstrably exacerbates patients' emotions and increases feelings of depression and anxiety. Understanding these findings may help to support patients throughout their hospital stays. Gaps in the evidence and future research recommendations are also explored and discussed to establish a stronger foundation.

Predictors of Client Satisfaction with Outpatient Mental Health Clinic Services in Italy and New York

The aim of this cross-sectional study was to assess factors associated with client satisfaction in two mental health outpatient settings in Italy and the US. Sociodemographic and clinical variables, hope, and personality characteristics were evaluated in 18-65-year-old patients who had been receiving services for at least 2 months in one of two outpatient clinics, in Italy and the US. Patients were administered: the Healthy Days Core Module, the Kessler Screening Scale for Psychological Distress, the Verona Service Satisfaction Survey, the Client Satisfaction Inventory, the Health Service OutPatient Experience questionnaire, the Herth Hope Index, and the NEO Five-Factor Inventory-3. Bivariate tests for differences between the two samples were conducted, a Satisfaction Composite z-score was computed, and a stepwise, backward elimination, multiple linear regression model-including the variables that were significantly associated with Satisfaction Composite Score in bivariate tests-was built. From July 1, 2015 to April 30, 2016, 184 patients (121 in Foligno, 63 in New York City) were enrolled in the study. Predictors of client satisfaction included: receiving services in New York City, being older, having lower educational attainment, having inner positive readiness and expectancy as well as interconnectedness with self and others, and high scores on the agreeableness personality domain. Interestingly, diagnosis and treatment characteristics did not influence satisfaction. Client satisfaction with outpatient mental health services is mainly influenced by sociodemographic characteristics and personality factors more than clinical variables or patterns of care. These findings could have implications regarding trends toward value-based payment models.

An Exploration of Individuals' Expectations of their Stay on an Elderly Care Unit

This article describes the elements of a qualitative cross-sectional study which explored the relationship between the expectations and the experience of 20 individuals with regard to their stay on an elderly care unit. The study data were gathered using semi-structured interviews and analysed using content analysis techniques.

The participants were found to hold a variety of expectations about the tangible and conceptual elements of their experience. Their comments focused primarily on the outcomes experienced rather than on the processes occurring. Their expectations appeared to change in conjunction with both time and experience, with common themes emerging.

The study concluded that the participants' expectations were formed on hunches and/or previous information. They described their situation largely in terms of a mismatch between their expected and actual experience or with regard to unexpected situations. The results suggested that the unit concerned might usefully provide additional information to those admitted. They also raised some broader issues of potential interest to occupational therapists as a whole.

Older Persons 'Medical Encounters and their Outcomes

This article reviews research on older patients and their doctors, with particular attention to the medical encounter between an elderly patient and his or her physician. Major categories of variables affecting the medical encounter include provider and patient characteristics (age, gender, ethnicity, education, values) and the context or setting of the encounter (site, presence of a patient's companion, and whether the visit is an initial one for the physician-patient pair). The process and content of medical encounters are affected by participant characteristics and context variables, and these in turn affect outcome variables such as participant satisfaction, adherence to treatment regimens, and medical outcome. Process issues include transfer of information, medical decision making, and interpersonal relations. Methodological issues are discussed, including problems with theory generation, lack of standardized methodology, gaps in research knowledge, and prior emphasis on descriptive studies as opposed to testing of interventions to improve elderly patient-physician communication.

Racial Differences in Satisfaction with Physicians

This analysis examines the association between race and satisfaction with physicians among a sample of community-dwelling older adults. It is hypothesized that minority elderly will hold more negative attitudes toward physicians than will their White peers due to the difficulty in establishing rapport in the physician-patient relationship. Using data from the Established Populations for Epidemiologic Studies of the Elderly (Duke), we find that African Americans believe that physicians do not display much compassion for, and respect toward, the elderly. However, African Americans report more positive attitudes about the prudence of physicians. These findings are discussed in the context of improving the physician-patient relationship.

[Implementation of a best practice guideline for the prevention of falls: Perception among hospitalized patients and its caregivers]

OBJECTIVE

To analyze the influence that the implementation of a fall prevention Best Practice Guideline (BPG) could have on the perception of patients and their caregivers about the utility of the activities implemented, about the care provided during admission and the adherence (the level of follow-up) to the recommendations received at discharge.

MATERIAL AND METHOD

Design. Quasi-experimental study. Patients >65 years admitted≥48h to the Medical Area of the General Hospital of Albacete.

SAMPLE

104 subjects (consecutive sampling January-March 2013). Experimental group (EG). Patients admitted to BPG implementation units. Control group (CG). Usual care units.

VARIABLES

Sociodemographic characteristics; previous and during admission falls, cognitive status (Pfeiffer); independence in daily life activities (ADLs); satisfaction with care and information provided, utility perceived, adherence to recommendations at discharge.

DATA SOURCES

Interview and clinical history. Statistical analysis (SPSS 15.0). Descriptive and bivariant. Relative Risk. CI95%.

RESULTS

104 patients, EG 46.2% (48) and CG 53.8% (56). Women 51.9%, average age 79.9 years (s.d.=7.8). Pfeiffer 4,3 (s.d.=3.7). Previous falls 31.1%. In process, 1 fall in each group. There were statistically significant differences between EG/CG: age, cognitive status and independence in ADLs. In the EG was higher the percentage of perception about the usefulness of the recommendations to prevent falls (P<.001), greater adherence to them (P=0.0002), and to be very or quite satisfied with the information (P<.00004) and care received (P=.002).

CONCLUSION

To implement recommendations according to an Evidence-based BPG to prevent falls in older people has shown, in users and caregivers, greater satisfaction, better perception of its usefulness and greater adherence to the recommendations.

The comprehensive geriatric assessment guide: an exploratory analysis of a medical trainee performance evaluation tool

PURPOSE

Few opportunities exist for medical students and residents to receive feedback on specific geriatric skills because they are frequently unsupervised when assessing elderly patients. Patients and caregivers are currently an untapped source of clinical content feedback. The purpose of this study was to determine whether patients/caregivers could accurately complete a postassessment evaluation of trainees' clinical performance.

METHOD

The authors developed the Comprehensive Geriatric Assessment Guide (CGAG) consisting of 36 yes/no/don't-remember questions that prompt the patient/caregiver to indicate what topics the trainee discussed during clinical assessment. In 2010, two raters independently listened to audio recordings of 10 trainee-administered clinical assessments, scoring them using the CGAG to determine interrater reliability. Next, 32 patients/caregivers completed a CGAG after a trainee-administered clinical assessment. Then, the authors compared the results with a "gold standard" CGAG of the encounter.

RESULTS

Interrater reliability for the CGAG was high (90.4% agreement), indicating that the patients/caregivers were able to accurately complete the postassessment CGAG. Of 36 CGAG questions, 30 had patient/caregiver and gold standard agreement of over 80%; the remaining 6 had low agreement.

CONCLUSIONS

Patients and caregivers were able to recall sufficient clinical assessment detail to potentially provide constructive feedback to medical trainees on their assessment skills via the CGAG. Six questions with low agreement will be reworded to improve clarity on future versions of the CGAG. Future investigations will help determine whether use of the CGAG during medical education may help trainees improve assessment performance and allow educators to track progress in geriatric competencies.

Patient satisfaction in treatment for cervical pathology

This study aimed to analyse the satisfaction levels of patients treated for cervical dysplasia. At the Orbis Medical Center, all cases of abnormal cervical cytology are referred for colposcopy; however, there are three possible routings for patients: i) Patients are informed by the gynecologist about the colposcopy in a visit to the outpatient clinic, and colposcopy is planned in a second visit; ii) patients are informed by the gynecologist immediately before the colposcopy (a single visit); or iii) patients are called by a nurse practitioner 1-2 weeks prior to the colposcopy. The nurse practitioner informs patients about their Pap smear result, the colposcopy procedure and the follow-up (single visit plus telephone conversation). Patient satisfaction was analysed in the diagnostic and occasionally in the therapeutic colposcopies, with regards to information, treatment, appeasement and number of visits. The issue of whether the introduction of nurse practitioners improved patient satisfaction was also assessed. Patient satisfaction questionnaires were sent to all 593 patients who underwent a colposcopic examination for the first time following an abnormal smear test result. Data were analysed using SPSS 14.0. For statistical analyses, χ(2) tests and the Mann-Whitney U test were used. P<0.05 was considered to be statistically significant. The response rates did not differ significantly among the three groups of patients. In general, patient satisfaction regarding care was high (96%). The role of the nurse practitioner was rated highly (8.0-8.4). Although there were differences in the number of visits and satisfaction regarding the information provided, patient satisfaction did not differ significantly between groups 1 and 3. Patients in group 2 were significantly less satisfied with regard to almost all analysed data. In conclusion, the single visit procedure is extremely efficient. Patient satisfaction did not differ significantly between groups 1 and 3, but group 2 patients were significantly less satisfied. The introduction of nurse practitioners improves patients' knowledge, comfort and satisfaction. Furthermore, it reduces the number of visits required. Efficient treatment strategies were introduced and patient satisfaction was increased.

Social desirability does not confound reports of wellbeing or of socio-demographic attributes by older women

This study assesses the relationship of social desirability response bias with self-reported physical, mental and cognitive health, successful ageing, and socio-demographic attributes among 1,860 older women at the University of California, San Diego's Clinical Center for the Women's Health Initiative and the Sam and Rose Stein Institute for Research on Aging. The women were aged between 57 and 91 years and lived in the San Diego community. Measures included a ten-item Marlowe–Crowne Social Desirability Scale, and self-report scales of physical, mental and cognitive health, successful ageing and wellbeing, as well as standard socio-demographic attributes. Bivariate correlation and multiple regression models indicated that social desirability scores negatively associated with self-reported levels of hostility, anxiety, perceived stress and self-reported cognitive failures, and that they predicted additional variance in multiple regression analyses above models containing socio-demographic predictors alone. On the other hand, even the strongest associations were what are generally considered ‘small effects’ (r<0.30). Overall, while the findings support the general validity of most of the self-report measures in studies of normal and successful ageing, consideration of social desirability response bias in the interpretation of self-reports of low levels of some key constructs (anxiety, hostility, stress, self-perceived cognitive deficits) is warranted.

Providing health information to older adults

Providing information to older adults is essential for informed decision-making and good health. Because there are significant deficits in providing information verbally, health professionals must use written information as well. Most studies have focused on the content and literacy of documents. However, the legibility and formatting are critically important for older adults, who are more likely to suffer with visual impairment. Providing written information that is tested for appropriate reading level and for presentation is necessary to ensure that older adults can use the information given. There are a number of tools available that test these aspects of written information, but not one tool that is universally accepted. Further research regarding the design and presentation of written information for older adults is necessary.

Influence of age and native language on immediate verbal repetition

Objectives of this quasi-experimental study were to assess whether age of listeners and native language of the speaker affected the accurate repetition of words, sentences, and utterances, including medical vocabulary. Two experiments were conducted. In Exp. 1, 20 young adults and 20 older adults repeated 60 words and 30 sentences produced by native and nonnative English speakers. In Exp. 2, 30 young adults and 30 older adults repeated medically oriented utterances spoken by native and nonnative English speakers. Analysis showed that older adults had significantly lower repetition scores (accuracy) than the young adults on all tasks. Both groups had significantly higher repetition scores on items produced by native English speakers than nonnative English speakers. Investigations should focus on strategies which may aid native English speakers in understanding non-native English speakers.

Veterans' decision-making preferences and perceived involvement in care for chronic heart failure

BACKGROUND

Patients with heart failure require a great deal of information about their disease, but it is also important to know about their preferences for involvement in medical decision making and about factors that may influence their preferences so that patients' needs, values, and preferences can be met by clinicians.

OBJECTIVES

We assessed patients' preferred role and perceived level of involvement in medical decision making and tested the effects of patients' age and role preference on perceived involvement in medical decision making.

METHODS

We conducted a telephone survey of 90 adults being treated for heart failure by a Veterans Affairs primary care provider or cardiologist. Patients' preferred role in treatment decisions was assessed using the Control Preferences Scale. Perceptions about their involvement in decision making during the most recent clinic visit was measured using a subscale of the Perceived Involvement in Care Scale. Descriptive, correlational, and generalized linear regression analyses were conducted.

RESULTS

Most patients were elderly (mean = 70.1 years), male (94.4%), and white (85.6%), and had New York Heart Association class II disease (55.6%). Forty-three patients (47.8%) preferred a passive role in decision making, 19 patients (21.1%) preferred an active role, and 28 patients (31.1%) preferred a collaborative role. Most patients believed that their decision-making involvement was relatively passive, as indicated by a mean score of .96 (range, 0-4) on the Perceived Involvement in Care Scale decision-making subscale. Older age was associated with passive role preference (r = .263; P < .05) and less perceived involvement in decision making (r = -.279; P < .01). In addition, less perceived involvement in decision making during the last clinic visit was associated with a preference for a more passive decision-making role (r = rho.355; P < .01). Generalized linear regression analysis indicated that when patients' perceived decision-making involvement was regressed on age and patients' role preferences, age was no longer significantly associated with involvement (beta = -.196; P = .061), but that control preferences continued to exhibit an independent effect on perceived involvement in medical decision making (beta = -.341; P = .003).

CONCLUSION

The results suggest that the preferences of patients with heart failure for a more passive role in decision making may be a stronger independent predictor of patients' perceived involvement in decision making than patients' age.

Older adults experiences of rehabilitation in acute health care

Rehabilitation is a key component of nursing and allied healthcare professionals' roles in most health and social care settings. This paper reports on stage 2 of an action research project to ascertain older adult's experience of rehabilitation. Twenty postdischarge interviews were conducted and the interview transcripts were analysed using thematic content analysis. All older adults discharged from an acute older acute rehabilitation ward to their own homes in the community were eligible to participate. The only exclusion criterion was older adults who were thought to be unable to give consent to participate by the nurse in charge and the researcher. Whilst 92 older adults were eligible to participate in this research study, only 20 were interviewed. The findings from this study suggest that older adults valued communication with health professionals but were aware of their time constraints that hindered communication. This study suggests that both nurses and allied health professionals are not actively providing rehabilitative services to promote health and well-being, which contradicts the focus of active ageing. Furthermore, there was evidence of unmet needs on discharge, and older adults unable to recall the professions that were involved in their interventions and the rationale for therapy input. It is suggested that further research is needed to explore the effectiveness of allied health rehabilitation in the acute setting. This study highlights the need for further research into older adults' perceptions of the rehabilitation process in the acute setting.

White Coats Meet Grey Power: Students and Seniors Respond to an “Intergenerational Gala”

Research suggests that nonclinical interactions with older people may enhance medical students' traditionally poor attitudes toward this patient group. Although extensive literature has reported on student attitudes, seniors' perspectives of their relationships with younger healthcare professionals (HCPs) are generally unknown. This study explores students' and seniors' perceptions of aging and the influence of these perceptions on medical practice before and after a recreational, intergenerational event. In March 2006, the Schulich Faculty of Medicine and Dentistry at the University of Western Ontario held its second annual "Intergenerational Gala." Approximately 150 seniors and students were invited to complete a brief pre- and postevent questionnaire exploring attitudes toward aging, care of older people, and HCP training. After the event, approximately 60% of students did not feel that their curriculum contained adequate geriatrics content, and more than one-third of seniors did not feel that today's HCPs are adequately trained to address the healthcare needs of older people. Content analysis indicated strongly positive postevent perceptions of the gala but also considerable divergences between students' and seniors' responses to "To me, growing older means. ..." Seniors also offered advice to young HCPs encouraging listening, patience, and not using "age" as a medical diagnosis. The second Intergenerational Gala explored similarities and differences between how seniors and students view aging. Although significant changes in attitudes were not observed, qualitative responses from both groups suggest that similar events hold promise as part of a concerted curricular strategy to encourage and improve intergenerational relations in the context of medical practice.

Doctor and patient perceptions of the level of doctor explanation and quality of patient-doctor communication

BACKGROUND

Several measures, such as the frequency, duration and ratio of quantitative communication behaviours, have been used to evaluate patient-doctor communication; however, these measures have several major problems. Therefore, we examined whether doctors' and patients' perceptions of the level of doctors' explanations provide a better measure for evaluating the quality of patient-doctor communication.

METHODS

The subjects were 630 doctor-patient pairs in Japan. One-way anova and multiple logistic regression analysis were used for the data analysis.

RESULTS

Of 190 doctors and 950 patients selected randomly, 126 doctors and 630 patients returned questionnaires (response rates, both 66.3%). We found the following. (i) With respect to the sufficiency of the doctor explanation, the 'patient-better' situation (i.e. when patients' evaluations were better than doctors' evaluations) had a more positive influence on patients' outcome measures than did other situations. (ii) The 'doctor better' situation (i.e. when doctors' evaluations were better than patients' evaluations) had the most negative influence on patient outcome measures compared with the other situations. (iii) The length of clinical experience, patient gender and guidance concerning a change in lifestyle were predictors of the doctor-better condition in the two types of doctor explanations.

CONCLUSIONS

A measure that classifies patient-doctor pairs into doctor-better and the other situations might be effective for evaluating the quality of patient-doctor communication. As this is a new approach to evaluating patient-doctor communication, more studies are necessary to verify these findings.

Satisfaction with mental health services in older primary care patients

OBJECTIVE

This study examines whether older adult primary care patients are satisfied with two intervention models designed to ameliorate their behavioral health problems.

METHODS

A total of 1,052 primary care patients aged 65 and older with depression, anxiety, or at-risk drinking were randomly assigned to and participated in either integrated care (IC) or enhanced specialty referral (ESR) model and completed the Client Satisfaction Questionnaire (CSQ) administered at three-month follow-up assessment.

RESULTS

Older adult patients' satisfaction with IC (mean: 3.4, standard deviation [SD]: 0.60) was significantly higher than that with ESR (mean: 3.2, SD: 0.78), but the absolute difference was modest. Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction. Stigma toward mental illness was negatively associated with satisfaction with mental health services.

CONCLUSIONS

Older adults are more likely to have greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics.

Is personality a determinant of patient satisfaction with hospital care?

OBJECTIVE

We investigated to what extent personality is associated with patient satisfaction with hospital care. A sizeable association with personality would render patient satisfaction invalid as an indicator of hospital care quality.

DESIGN

Overall satisfaction and satisfaction with aspects of care were regressed on the Big Five dimensions of personality, controlled for patient characteristics as possible explanatory variables of observed associations.

PARTICIPANTS

A total of 237 recently discharged inpatients aged 18-84 years (M = 50, SD = 17 years), 57% female, who were hospitalized for an average of 8 days.

INSTRUMENTS

The Satisfaction with Hospital Care Questionnaire addressing 12 aspects of care ranging from admission procedures to discharge and aftercare and the Five-Factor Personality Inventory assessing a person's standing on Extraversion, Agreeableness, Conscientiousness, Emotional stability, and Autonomy.

RESULTS

Agreeableness significantly predicted patient satisfaction in about half of the scales. After controlling for shared variance with age and educational level, the unique contribution of Agreeableness shrank to a maximum of 3-5% explained variance. When one outlier was dropped from the analysis, the contribution of Agreeableness was no longer statistically significant.

CONCLUSION

Patient satisfaction seems only marginally associated with personality, at least at the level of the broad Big Five dimensions.

Satisfaction with Medical Care Among Elderly Patients

Research on patient satisfaction has focused predominantly on the mainstream adult population (ages 18-64). Satisfaction in older patients has not been adequately studied. Moreover, a systematic review of the research literature that does exist on this topic has not yet been conducted. The literature search yielded only 17 studies that met the selection criteria established for this review. Key research elements and findings from each of the studies are arrayed in matrix form. The results of the literature review are organized and analyzed in terms of four major categories of variables: background characteristics, predispositional variables, service quality attributes, and contextual factors. Special attention is awarded to identifying the determinants of satisfaction among elderly patients and the ways in which their service quality appraisals may differ in comparison with the general adult population of medical care consumers. Implications for management practice and directions for future research are discussed.

Patient involvement in medical decision-making and pain among elders: physician or patient-driven?

BACKGROUND

Pain is highly prevalent among older adults, but little is known about how patient involvement in medical decision-making may play a role in limiting its occurrence or severity. The purpose of this study was to evaluate whether physician-driven and patient-driven participation in decision-making were associated with the odds of frequent and severe pain.

METHODS

A cross-sectional population-based survey of 3,135 persons age 65 and older was conducted in the 108-county region comprising West Texas. The survey included self-reports of frequent pain and, among those with frequent pain, the severity of pain.

RESULTS

Findings from multivariate logistic regression analyses showed that higher patient-driven participation in decision-making was associated with lower odds (OR, 0.82; 95% CI, 0.75-0.89) of frequent pain, but was not significantly associated with severe pain. Physician-driven participation was not significantly associated with frequent or severe pain.

CONCLUSIONS

The findings suggest that patients may need to initiate involvement in medical decision-making to reduce their chances of experiencing frequent pain. Changes to other modifiable health care characteristics, including access to a personal doctor and health insurance coverage, may be more conducive to limiting the risk of severe pain.

Older women and the internet

This study was designed to explore the effects that training had on older adults' willingness to use the Internet to manage their health care. The most interesting result was that out of 70 self-volunteers, 58 were women. Results show that highly educated women who either own a computer or have access to one, and have low levels of anxiety toward computers, with strong feelings of self-efficacy toward computers and the Internet, and an internal locus of control, are more willing than men to use the Internet to find medical information to manage a chronic health problem.

GPs' views on involvement of older patients: an European qualitative study

Involvement of older patients in general practice care is regarded as important, but is not widespread. To determine specific barriers to the involvement of older patients in general practice care and to identify variations between countries, we performed an international comparative study based on qualitative interviews with 233 general practitioners (GPs) in 11 countries. Most GPs thought that involving older patients had positive outcomes. GPs saw patient involvement as a process taking place solely during consultations. The main barrier for GPs was lack of time. Barriers related to older patients were their feelings of respect for doctors, their lack of experience in being involved and possible mental and physical impairments. To conclude, increasing involvement of older patients is not easy and will only be effective when GPs have adopted a more developed concept of patient involvement and are supported with the different methods for achieving this. The range of appropriate interventions may be similar in all countries.

Patient participation during dental consultations: the influence of patients' characteristics and dentists' behavior

OBJECTIVE

This study examined the influence of the following variables on patients' information-seeking and participating behavior during emergency treatment: patients' preferences for information and participation, patients' coping style, patients' socio-demographic variables, and dentists' communicative behavior.

METHODS

The sample consisted of 83 patients receiving emergency care from 13 different dentists. Consultations were videotaped in order to assess dentists' and patients' behavior. Dentists' communicative behavior was coded by means of the Communication in Dental Settings Scale (CDSS); scores for patients' behavior included the number and nature of questions asked during the consultation, attempts to offer diagnoses, and whether or not patients made the decision to undergo treatment themselves. At home, patients filled out a questionnaire that included scales to measure their preference for information and participation and other background variables.

RESULTS

Results showed that patients' desire for information and participation, together with other variables, was not reflected in their overt behavior. Furthermore, dentists' communicative behavior was unrelated to patients' information-seeking and participating behavior.

CONCLUSIONS

Scores on the CDSS show that still there is a discrepancy between the legal prerequisites of information-giving and emergency dental practice. Therefore, dentists' information-giving behavior should be improved in order to enhance the patients' right to make informed decisions.

Issues concerning the on-going care of patients with comorbidities in acute care and post-discharge in Australia: a literature review

BACKGROUND

Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most western countries. This has resulted in an ageing population with a concomitant growth in the number of people who are living with chronic illnesses. Indeed a significant number of younger people experience more than one chronic illness. Large numbers of these may require repeated admissions to hospital for acute or episodic care that is superimposed upon the needs of their chronic conditions.

AIM

To explore the issues that circumscribe the complexities of caring for people with concurrent chronic illnesses, or comorbidities, in the acute care setting and postdischarge.

METHODS

A literature review to examine the issues that impact upon the provision of comprehensive care to patients with comorbidities in the acute care setting and postdischarge.

FINDINGS

Few studies have investigated this subject. From an Australian perspective, it is evident that the structure of the current health care environment has made it difficult to meet the needs of patients with comorbidities in the acute care setting and postdischarge. This is of major concern for nurses attempting to provide comprehensive care to an increasingly prevalent group of chronically ill people.

CONCLUSION

Further research is necessary to explore how episodic care is integrated into the on-going management of patients with comorbidities and how nurse clinicians can better use an episode of acute illness as an opportunity to review their overall management.

The effects of patient communication skills training on the discourse of older patients during a primary care interview

OBJECTIVES

To test the effects of a communication skills training intervention on older patients' discourse during a primary care interview.

DESIGN

A quasi-experimental design involving two intervention conditions.

SETTING

The Family Practice Center of a university-based clinic.

PARTICIPANTS

Thirty-three patients averaging age 72 and 9 family practice physicians.

INTERVENTION

A communication skills training booklet received approximately 3 days before the scheduled appointment and a 30-minute face-to-face follow-up session before seeing the physician.

MEASUREMENTS

Patients' seeking, providing, and verifying of information were coded from transcripts of the 33 interviews.

RESULTS

Trained patients engaged in significantly more seeking and providing of information than untrained patients. Additionally, trained patients obtained significantly more information from physicians than did untrained patients, both in terms of the number of total information units and the number of units per question asked.

CONCLUSION

Patient communication skills training appears to be an effective means of enhancing patients' participation in the medical interview without increasing the overall length of the interview.

Is gratitude a moral affect?

Gratitude is conceptualized as a moral affect that is analogous to other moral emotions such as empathy and guilt. Gratitude has 3 functions that can be conceptualized as morally relevant: (a) a moral barometer function (i.e., it is a response to the perception that one has been the beneficiary of another person's moral actions); (b) a moral motive function (i.e., it motivates the grateful person to behave prosocially toward the benefactor and other people); and (c) a moral reinforcer function (i.e., when expressed, it encourages benefactors to behave morally in the future). The personality and social factors that are associated with gratitude are also consistent with a conceptualization of gratitude as an affect that is relevant to people's cognitions and behaviors in the moral domain.

Measuring satisfaction with social care amongst older service users: issues from the literature

Issues of quality and accountability in social care for older people are of increasing importance. A key factor in determining quality is the extent to which older people themselves are satisfied with both the assessment of their needs and the services provided. The 1997 White Paper, Modernising Social Services, stated that local authorities will need to establish authority-wide objectives and performance measures to improve the quality and efficiency of services. In measuring quality, the White Paper stipulated that social service departments would need to design and administer satisfaction surveys as one means of capturing user and carer perceptions and experiences of services. This paper attempts to highlight some of the main issues to be considered when designing and conducting such surveys with older users of community care services. Through a review of the British and North American literature on older people's satisfaction with services, current approaches to measuring satisfaction are outlined and the relationship between the characteristics and circumstances of older people and their responses to satisfaction questions is examined. The paper concludes by offering some solutions to overcoming current problems by drawing conclusions about quality from survey findings, so that older people's opinions about the services they receive can begin to be assessed in a more meaningful way.

Qualitative research for the study of cancer and age

Qualitiative research emphasizes identification, illumination, and understanding of phenomena, the meaning and theory behind which are unpresumed by the investigator. Although quantitative techniques are used to test predetermined hypotheses, qualitative techniques are used to generate hypotheses. Qualitative techniques have only begun to be used in medical research in the past decade but are especially useful in exploring content areas about which little is known and in eliciting and understanding the patient's perspective. Despite the aging of the United States population, the cancer illness experience has not been well studied in older patients. Because communication preferences, treatment decision-making styles, psychosocial issues, and the illness experience itself may be significantly different for older persons diagnosed with cancer than for younger persons, qualitative research techniques can be used to identify those differences critical to the effective health care of this burgeoning population.

Communication between the hospitalized older patient and physician

Much research has shown that how physicians communicate with patients can have profound influence on behavioral, psychosocial, and clinical outcomes of the encounter. Communication with older patients, however, is often compromised by some attributes of the aging process. Communication can also be affected by the setting in which it takes place, and the hospital presents some barriers not found in ambulatory sites. These concerns are often compounded in end-of-life decisions for older patients when discussed in hospital settings.

The influence of patient age on primary care resident physician-patient interaction

OBJECTIVES

To explore resident physician-patient interaction in primary care to address issues relevant to quality of care for older people.

DESIGN

A sample of 509 new, adult, nonpregnant patients was assigned to the care of second- and third-year residents in primary care clinics. Care was compared for three subgroups of patients: older patients (65 years or older; n = 45), those aged 18 to 44 years (n = 320), and those aged 45 to 64 years (n = 144).

SETTING

Observations were made at the family medicine and general internal medicine clinics at the University of California, Davis.

MEASUREMENTS

Self-report by means of the Medical Outcomes Study Short Form-36 (MOS SF-36) was used to determine patient demographics and patient health status. Two measures of satisfaction were obtained gauging reaction to medical care in general and to the videotaped visit specifically. Videotapes were coded for content using the Davis Observation Code.

RESULTS

Self-reported health status of older persons was poorer than that of younger groups as measured by the MOS SF-36. Differences in demographics were explored and then controlled, along with physical health status in subsequent analyses. Supporting prior studies, this study found that older patients had more return visits and reported higher levels of satisfaction than did younger comparison groups. Contrary to prior literature, older patients were found to have longer visits than did younger cohorts. The physician-patient interaction was significantly different in many areas between these three groups. Whereas older patients experienced more chatting in their visits, they were given less counseling, asked fewer questions, had less discussion about their families and their use of substances, were asked to change their health behavior habits less often, and were given less health education. For older patients, more of each visit was spent checking on compliance with earlier treatment and developing treatment plans.

CONCLUSIONS

These results provide a new and more detailed view of how resident physician-patient interaction differs between older and younger groups and raise important issues on whether quality of care needs for this population are being adequately addressed, particularly regarding mental health issues.

Prioritising family health needs: a time--space analysis of women's health-related behaviours

Much has been made over the years of the view that health-related geographical research has failed fully to explore the complex and mutually reinforcing impact of social and spatial relations on individual health-related behaviours. At the same time, there is a growing awareness elsewhere in the social sciences and in health services research of the generally inadequate exploration of the role of place particularly at the scale of the local community--in the social construction of health, illness and health care use. This paper aims to contribute to the debate by offering a clear framework within which to analyse the impact of spatially configured social relations at the micro-level. In-depth interview evidence from Liverpool shows that, looking at the problem from the perspective of the opportunity-costs of time-space constraints, is a useful means to understand the distinct ways in which health services are used, when and why, across different social groups and geographical areas. Particular attention is drawn to the different thresholds for decision-making depending upon whose health-related needs are being negotiated within the family. The paper concludes with the latest policy developments in UK primary care which offer professionals the clear opportunity to develop much more sophisticated understandings of what constitutes locally-sensitive health service provision. The argument is that such developments must be based on a firm sense of how individual time-space circumstances interact with conditions in the local area if the best possible use of increasingly scarce and valuable resources is to be achieved--particularly in communities characterised by poverty and social exclusion such as those in Liverpool.

Validating a measure of patient satisfaction with community nursing services

This study describes an attempt to develop and validate a measure of patient satisfaction with a district nursing service in a south-west London inner city borough. The patients were 126 house-bound elderly people living alone and dependent upon district nursing services. The patient satisfaction measure was derived from an earlier North American questionnaire assessing satisfaction with hospital nursing services. The results indicated that the measure chosen reflected multiple dimensions of patient satisfaction that were differentially sensitive to factors such as the degree of personalization of care and the impact of disruptions to the service. Scores on the questionnaire were also related in a systematic way with the number and type of spontaneous comments made about the service. Overall the results suggest that self-report questionnaire measures of satisfaction can be devised that are sensitive to variations in the style and level of community nursing offered to older house-bound people.

Predictors of medication adherence in the elderly

As average life expectancy increases, so do the incidence of chronic diseases and the number of persons receiving long-term drug therapy. Thus elderly patients' noncompliance with medication regimens has the potential for sweeping medical and economic consequences and is likely to become increasingly important in the design of disease-management programs for this population. The author conducted a MEDLINE search of the English-language literature for the years 1962 to 1997 to identify articles concerning predictors of medication compliance in the elderly. A descriptive analysis of this literature indicated that there remains some uncertainty about the reasons for noncompliant medication-taking in the elderly. Clear associations have been established between elderly patients' medication adherence and race, drug and dosage form, number of medications, cost of medications, insurance coverage, and physician-patient communication. However, the findings are inconsistent with regard to the effects of patients' age, sex, socioeconomic status, living arrangement, comorbidities, number of physician visits, and knowledge, attitudes, and beliefs about health. Until the results of further comprehensive studies are available, the current knowledge should be considered when designing and implementing disease-management programs for the elderly.

Deciphering the physician-older patient interaction

OBJECTIVE

The purpose of this article is to provide a commentary on non-verbal communication in the physician-older patient interaction.

METHOD

A literature review of physician-older patient communication yielded several published studies on this topic. Nonverbal behaviors were rarely examined in this body of literature even though the need to adopt a more "biopsychosocial" model of care was mentioned in several of the articles. The nonverbal communication literature was also reviewed to determine whether aging had been a variable of interest with regard to encoding (sending) and decoding communication (receiving) skills.

RESULTS

To date there have been very few studies that have investigated the role of nonverbal communication in the physician-older patient interaction. Selected encoding and decoding characteristics for both physicians and patients are discussed with the context of the aging process. In lieu of direct evidence linking nonverbal behavior and physician-older patient communication, possible implications are offered for the following characteristics: expression of emotion, pain expression, gestures, gaze, touch, hearing, and vocal affect. Three relevant outcomes (satisfaction with care, quality of life, and health status) are also discussed within the nonverbal behavior-aging framework.

CONCLUSION

The connection between nonverbal behavior and how physicians and older patients interact with one another has not been rigorously examined. Identifying and improving nonverbal communication will likely enhance the verbal exchange in the medical encounter and may improve the older patient's quality of care.

Preadmission psychosocial screening of older orthopedic surgery patients: evaluation of a Social Work Service

A preadmission social work intervention was evaluated for impact on length of hospital stay (LOS) and patient satisfaction. Psychosocial issues related to function and post-discharge needs were assessed at an exploratory level. A modified post-test only control group design was used. Study group patients were screened before hospitalization and offered services on admission. Control group patients received standard care. Study group patients were significantly more satisfied with services but impact on length of stay was not demonstrated with one possible exception. Post-operative complications were significantly related to longer LOS; however, unlike control group patients, study group patients with complications did not have significantly longer LOS. Women and those limited in preadmission physical function were most likely to report insufficient help after discharge. A more intensive preadmission intervention is recommended to improve impact on LOS and informal support system involvement, while future outcome studies would clarify the nature of service gaps and high risk groups.

Promoting autonomy and independence for older people within nursing practice: a literature review

The principles of promoting autonomy and independence underpin many approaches to improving the quality of nursing care for older people in whatever setting, and are in line with wider developments in health care such as the Patient's Charter. However, these concepts require careful definition if nursing practices which might promote autonomy and independence are to be identified. Although the generalizability of the research-based literature in this field is limited by a focus upon older people in continuing-care settings, a review of the literature found a number of indicators associated with attempts to promote patient autonomy and independence. These were grouped into the following categories: systems of care delivery which promote comprehensive individualized assessment and multidisciplinary care planning; attempts to encourage patients/clients to participate in decisions about their care; patterns of communication which avoid exerting power and control over patients/clients and attempts to modify the environment to promote independence and minimize risk. It is suggested that the review identifies a number of principles for nursing practice which can be applied in a range of care settings in order to promote the autonomy and independence of older people.

The emotional experience of hospitalization: its moderators and its role in patient satisfaction with foodservices

OBJECTIVES

To investigate the basic dimensions of patient emotional experience of hospitalization; to identify the moderators of emotional experience in terms of individual characteristics and contextual factors; and to investigate the contribution of the dimensions of the patient emotional experience to satisfaction with foodservices.

DESIGN

Survey questionnaire.

SUBJECTS/SETTING

One hundred two hospitalized patients of a specialized, acute-care, urban hospital in Canada who required one or more overnight stays. Patients with notable physical, cognitive, or emotional limitations were excluded from the study. Patients admitted to the obstetrics department were also excluded because of the unique nature of their emotional experience of hospitalization.

STATISTICAL ANALYSES PERFORMED

Factor analysis followed by orthogonal rotation (varimax), analyses of variance, and multiple regression analyses.

RESULTS

Five dimensions represented the emotional experience of hospitalization: positive emotions, arousal emotions, and three negative dimensions structured on the basis of their possible causes (situation-, other-, or self-attributed negative emotions). Individual characteristics (gender, age, marital status, perceived health status) and contextual factors (perceived control over the situation, complexity of medical diagnosis, and admission procedures) significantly influenced patient emotions. Satisfaction with foodservices was structured in technical and interpersonal dimensions; the largest part of the common variance was accounted for by interpersonal aspects. The relationship between emotions and satisfaction was direct for positive emotions and, surprisingly, for situation-attributed negative emotions and self-attributed negative emotions. Other-attributed negative emotions and arousal emotions were negatively associated with satisfaction with foodservices.

APPLICATIONS

Results suggest that dietitians' interventions should be adapted for subgroups of patients who experience different emotions. Results also provide insights on individual and contextual factors that can be used to identify or better understand the specific characteristics of these subgroups. The pattern of relationships between emotions and satisfaction demonstrates that the fine-tuning of dietitians' interventions as a function of patients' emotional states may be conducive to increased patient satisfaction with foodservices.

Attitudes of medical students and primary care physicians regarding input of older and younger patients in medical decisions

This study was designed to determine whether medical students, residents, and fully trained physicians differ in their attitudes toward decision-making input by older and younger patients, whether they believe that physicians should have greater input than patients in medical decisions, whether physicians grant different decision-making authority to younger versus older patients, and whether physician gender affects attitudes toward patient input in medical decisions. Respondents (n = 818) were first- (n = 311) and third-year (n = 227) medical students and family practice and internal medicine residents (n = 120) and faculty (n = 160) from the University of Kansas Medical Center (n = 367) and The Ohio State University Hospital (n = 451) who completed the Beisecker Locus of Authority: Geriatrics Scale to assess attitudes regarding involvement in medical decision making for either a 25- or 75-year-old patient. Respondents were alternately assigned to one of the two patient age vignettes. Analyses included descriptive statistics, t tests, and four-way analysis of variance. Ninety percent of respondents believed that physicians should have greater input in decisions than patients. Female respondents advocated greater patient input than male respondents. As training and experience increased beyond medical school, there was an increased tendency toward belief in physician-only decision making. For the older patient, residents advocated the most patient input and faculty advocated the least. Level of training influenced belief in patient input when its interaction with patient age and institution were examined.

Responses to the institution among elderly patients in hospital long-stay care

The theory of the 'total institution' argues that institutions deliberately create dependency in individuals who would otherwise be self-determining. We examine the significance of this concept for patients in long-stay geriatric wards. All such patients in the South West Thames Region (808) were located and assessed for levels of physical dependency and mental confusion. 87% were profoundly disabled, 53% were severely confused and 23% were seriously ill or unable to communicate. Those capable of responding (291) were interviewed. Three quarters or more were satisfied with 'staff relations', 'autonomy', 'amenities' and 'privacy' and three fifths were satisfied with the 'social environment'. Results suggest that: (a) patients in long-stay geriatric wards who were not severely confused were able to make realistic assessments of their situation and (b) the majority were not passively institutionalized. In terms of institutionalization theory, it is their physical frailty that appears to differentiate this group from other categories of 'inmates'. We conclude that appropriate policy for the long-term ill necessitates consideration of the actual as well as the attributed needs of patients.