Simulated patients and their reality: An inquiry into theory and method

A mixed-methods pilot examination of Montana, North Dakota nurse practitioner telepresence behaviors through web-camera eye-tracking and qualitative descriptive interviews

BACKGROUND

The use of telehealth for mental health-related encounters has increased exponentially since the COVID-19 pandemic. However, little is known how nurse practitioners (NPs) in rural areas establish connection and presence with patients through telehealth.

PURPOSE

To leverage web-camera eye-tracking technology coupled with qualitative interviews to better understand rural NPs' perceptions, beliefs, experiences, and visual cues of connection and presence during mental health-related telehealth encounters.

METHODS

This mixed-methods study employed web-camera eye-tracking technology to measure eye contact, facial/body movements with microexpressions, and auditory expressions during a simulated mental health-related telehealth visit. A qualitative descriptive methodology was used to conduct semistructured interviews with participants regarding utilization of telehealth in rural mental health care delivery. Sticky software, R, and STATA were used for the quantitative eye-tracking and demographic data analyses. Qualitative findings were analyzed using inductive thematic analysis.

RESULTS

Ten NPs participated in the eye-tracking aspect of the study; among them, three completed semistructured interviews. Eye-tracking areas of interest were significant for the number of fixations ( p = .005); number of visits ( p < .001); time until notice ( p < .001); and time viewed ( p < .001). The category Workflow had the greatest number of thematic units ( n = 21) derived from semistructured interviews.

CONCLUSIONS

Although an accessible means of obtaining data, web-camera eye tracking poses challenges with data usability. This prompts further attention to research, optimizing the telehealth milieu to lessen patient and provider frustrations with technological or environmental issues.

IMPLICATIONS

Nurse practitioners provide a key voice in the design and deployment of telehealth platforms congruent with the comprehensive assessment and presence of remote care delivery.

Reducing (Behavioral) Restraint Use Through Simulation at the Bedside

Hospitals are experiencing an influx of patients in active behavioral crises, leading to restraints as a behavior management strategy. Over 100 staff participated in simulation training designed to manage escalating patient behavior. The training had a direct impact on the reduction of restraint use and increased preparedness and confidence of participants managing escalating patient behavior. Results suggest simulation can be an effective strategy to train medical staff to manage challenging behavior and reduce restraint use.

What drives poor quality of care for child diarrhea? Experimental evidence from India

Most health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades. Using randomized experiments in India, we estimated the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider's financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing, whereas stock-outs and financial incentives explain only 6 and 5%, respectively.

Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study

BACKGROUND

Indonesia has the second highest incidence of tuberculosis in the world. While 74% of people with tuberculosis in Indonesia first accessed the private health sector when seeking care for their symptoms, only 18% of tuberculosis notifications originate in the private sector. Little is known about the impact of the COVID-19 pandemic on the private sector. Using unannounced standardized patient visits to private providers, we aimed to measure quality of tuberculosis care during the COVID-19 pandemic.

METHODS

A cross-sectional study was conducted using standardized patients in Bandung City, West Java, Indonesia. Ten standardized patients completed 292 visits with private providers between 9 July 2021 and 21 January 2022, wherein standardized patients presented a presumptive tuberculosis case. Results were compared to standardized patients surveys conducted in the same geographical area before the onset of COVID-19.

RESULTS

Overall, 35% (95% confidence interval (CI): 29.2-40.4%) of visits were managed correctly according to national tuberculosis guidelines. There were no significant differences in the clinical management of presumptive tuberculosis patients before and during the COVID-19 pandemic, apart from an increase in temperature checks (adjusted odds ratio (aOR): 8.05, 95% CI: 2.96-21.9, p < 0.001) and a decrease in throat examinations (aOR 0.16, 95% CI: 0.06-0.41, p = 0.002) conducted during the pandemic.

CONCLUSIONS

Results indicate that providers successfully identify tuberculosis in their patients yet do not manage them according to national guidelines. There were no major changes found in quality of tuberculosis care due to the COVID-19 pandemic. As tuberculosis notifications have declined in Indonesia due to the COVID-19 pandemic, there remains an urgent need to increase private provider engagement in Indonesia and improve quality of care.

The family doctor: health, kin testing and primary care in Patna, India

Private primary care providers are usually the first site where afflictions come under institutional view. In the context of poverty, the relationship between illness and care is more complex than a simple division of responsibilities between various actors-with care given by kin, and diagnosis and treatment being the purview of providers. Since patients would often visit the provider with family members, providers are attuned to the patients' web of kinship. Providers would take patients' kinship arrangements into account when prescribing diagnostic tests and treatments. This paper terms this aspect of the clinical encounter as 'kin testing' to refer to situations/clinical encounters when providers take into consideration that care provided by kin was conditional. 'Kin testing' allowed providers to manage the episode of illness that had brought the patient to the clinic by relying on clinical judgment rather than confirmed laboratory tests. Furthermore, since complaints of poor health also were an idiom to communicate kin neglect, providers had to also discern how to negotiate diagnoses and treatments. Kinship determined whether the afflicted bodies brought to the clinics were diagnosed, whether medicines reached the body, and adherence maintained. The providers' actions make visible the difference that kinship made in how health is imagined in the clinic and in standardized protocols. Focusing on primary care clinics in Patna, India, we contribute to research that shows that kinship determines care and management of illnesses at home by showing that relatedness of patients gets folded in the clinic by providers as well.

Tuberculosis diagnosis and management in the public versus private sector: a standardised patients study in Mumbai, India

BACKGROUND

There are few rigorous studies comparing quality of tuberculosis (TB) care in public versus private sectors.

METHODS

We used standardised patients (SPs) to measure technical quality and patient experience in a sample of private and public facilities in Mumbai.

RESULTS

SPs presented a 'classic, suspected TB' scenario and a 'recurrence or drug-resistance' scenario. In the private sector, SPs completed 643 interactions. In the public sector, 164 interactions. Outcomes included indicators of correct management, medication use and client experience. Public providers used microbiological testing (typically, microscopy) more frequently, in 123 of 164 (75%; 95% CI 68% to 81%) vs 223 of 644 interactions (35%; 95% CI 31% to 38%) in the private sector. Private providers were more likely to order chest X-rays, in 556 of 639 interactions (86%; 95% CI 84% to 89%). According to national TB guidelines, we found higher proportions of correct management in the public sector (75% vs 35%; (adjusted) difference 35 percentage points (pp); 95% CI 25 to 46). If X-rays were considered acceptable for the first case but drug-susceptibility testing was required for the second case, the private sector correctly managed a slightly higher proportion of interactions (67% vs 51%; adjusted difference 16 pp; 95% CI 7 to 25). Broad-spectrum antibiotics were used in 76% (95% CI 66% to 84%) of the interactions in public hospitals, and 61% (95% CI 58% to 65%) in private facilities. Costs in the private clinics averaged rupees INR 512 (95% CI 485 to 539); public facilities charged INR 10. Private providers spent more time with patients (4.4 min vs 2.4 min; adjusted difference 2.0 min; 95% CI 1.2 to 2.9) and asked a greater share of relevant questions (29% vs 43%; adjusted difference 13.7 pp; 95% CI 8.2 to 19.3).

CONCLUSIONS

While the public providers did a better job of adhering to national TB guidelines (especially microbiological testing) and offered less expensive care, private sector providers did better on client experience.