The impact of general practitioners' patient-centredness on patients' post-consultation satisfaction and enablement

Good therapeutic connections and patient psychological safety: A qualitative survey study

BACKGROUND

Therapeutic connections (TCs) between patients and care providers are important for achieving desired patient outcomes. For patients, TC is associated with greater health self-efficacy, better health status, mental health status, and higher satisfaction with providers.

PURPOSE

The aim of the study was to examine patients' descriptions of what signals to them they have a TC with their care provider.

METHODOLOGY

We conducted an online survey of patients with a recent health care visit ( n = 1,766). This study analyzed the results of an open-ended question that asked how patients know they have a good TC with their care provider. Data were analyzed using framework analysis to determine the extent to which patient responses indicated TC dimensions. A thematic content analysis identified emergent themes.

RESULTS

Of the TC dimensions, words associated with Shared Deliberation were mentioned by 60% of respondents. Other dimension mentions ranged between 14% (Shared Mind) and 2% (Bond). Thematic content analysis revealed that patient psychological safety seems to be required for many patients to feel connected.

CONCLUSION

A majority of patients indicated that good TCs happen when they feel seen and heard by providers. However, it appears that prior to feeling a strong TC, patients need to feel safe to be fully welcome into the encounter.

PRACTICE IMPLICATIONS

Health care organizations need to give care providers the uninterrupted time and space they need to fully connect with patients. Training about how to create a psychologically safe environment for patients should be tailored for practicing providers, leaders, and students in health care fields.

What is nursing in advanced nursing practice? Applying theories and models to advanced nursing practice-A discursive review

AIM

This article appraises models and theories related to advanced nursing practice. It argues that while the role of the advanced nurse practitioner builds on and extends beyond traditional nursing, it remains firmly grounded in 'caring'.

BACKGROUND

The stereotype that nurses 'care' and doctors 'cure' is fading. Increasingly, nurses have crossed boundaries and conducted independent assessment, diagnosis, prescribing and consultation, which used to be the doctor's role. Confusion and argument have arisen due to the higher-level practice of the advanced nurse practitioner, as many questions where these 'doctor nurses' stand.

DESIGN

A literature review.

DATA SOURCES

Databases, including CINAHL, Medline and Google Scholar, were searched.

METHOD

Databases were searched, and relevant studies and review articles from 1970 to 2023 were identified using the following keywords: 'advanced nurse practitioner', 'nurse practitioner', 'advanced nursing', 'advance practice', 'nurse practitioner', 'nursing theory' and 'nursing model'.

RESULTS

Although advanced nurse practitioners identify themselves as nurses, there is limited use of nursing theory to conceptualize this new level of practice and to define their contribution to the multi-disciplinary team. It is noted that a holistic approach to personalized patient care, based on therapeutic relationships and effective communication, may help us identify the unique contribution of the advanced nurse practitioner.

CONCLUSIONS

The development of advanced nursing theory needs to capture this holistic approach and its caring element to recognize the value and strengthen the identity allegiance of this hybrid role.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Holistic approach and patient-centred care, effective communication and the therapeutic relationship are strong characteristics relating to ANP practice, the latter of which is yet to be clearly defined and captured in nursing theories. Conceptualizing ANP practice and capturing their valuable nursing care will enable better understanding and clarity for the role to realize its full potential.

Beyond satisfaction in person-centered pharmacy services

Patient self-reported satisfaction is commonly used as an assessment of service experience and quality for community pharmacy services. This commentary discusses alternative foundational approaches to evaluating service experience and quality in patient-centered care. It describes historical and recent literature pertaining to the development and use of satisfaction measures for service design and patient experience assessment. It then highlights potential limitations of patient satisfaction as an assessment tool for patient-centeredness and patient experience identified in the pharmacy literature, which include criticisms that use of patient satisfaction may compromise accuracy in measuring quality due to factors such as patients having poor knowledge of and low expectations for quality and having a predisposition toward rating satisfaction highly when experiencing no-cost and/or unfamiliar services. Moreover, satisfaction measurements may change based on service exposure, with patient preferences for service offerings changing with increased service exposure and variation in patient-specific and environmental factors. After discussing limitations and criticism of patient self-reported satisfaction, we introduce alternative assessments methods which may facilitate more accurate assessments of patient experience and patient-centered pharmacy services such as patient-reported outcomes measures (PROMs), patient-reported experience measures (PREMs), and human-centered design techniques such as journey mapping, prototyping, and user testing to design and assess patient-centered pharmacy services. These alternative assessments are rooted in, or related to preferred implementation science approaches to establishing, evaluating, and sustaining pharmacy services.

Better outcomes through patient - Provider therapeutic connections? An exploratory study of proposed mediating variables

BACKGROUND

Patient-provider therapeutic connections (TCs) have been theorized to enhance patient outcomes as well as care provider job satisfaction and to reduce burnout. High-quality TCs may result in better matching of health care to patient needs, and thus, better care quality and patient outcomes. For care providers, work environments that enable high-quality TCs may make the work more motivating and facilitate resilience.

METHOD

We surveyed patients (n = 346) and care providers (n = 341) about their experiences of TCs, and how TCs related to outcomes. We tested parallel mediation models to examine relations.

RESULTS

TCs predicted better patient health status, mental health status, and satisfaction, and predicted greater care provider job satisfaction and lower burnout. TCs were theorized to operate through two sets of mechanisms (health self-efficacy and activation for patients; meaningfulness of work and psychological safety for providers). Results revealed significant indirect associations between TCs and outcomes for both groups.

CONCLUSIONS

TCs are associated with patient and provider outcomes; however, these relations appear to be explained by several mediating variables. It appears that TCs are associated with better outcomes for patients through health self-efficacy and activation, and TCs are associated with better outcomes for care providers through meaningfulness of work and psychological safety.

Is there equity of patient health outcomes across models of general practice in Aotearoa New Zealand? A national cross-sectional study

BACKGROUND

Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care.

METHODS

We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response.

RESULTS

The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes.

CONCLUSIONS

Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care.

People-centered care and patients' beliefs about medicines and adherence: A cross-sectional study

Introduction

People-centered care (PCC) strategies are believed to improve overall health outcomes. Medicines use is essential for the treatment of many patients with chronic conditions. Non-adherence rates are high and result in poor health outcomes, and increased healthcare utilization and costs. This study aimed to explore the relationship between PCC and adherence to medicines for persons with chronic medicines use, as well as the extent to which patients' beliefs about medicines are influenced by their level of perceived PCC.

Methods

A cross-sectional survey design was performed with adults using at least 3 chronic medicines per day. To measure the degree of medicines adherence, patients' ideas about medication, and PCC, four validated questionnaires were used: The Medication Adherence Report Scale (MARS-5), Beliefs about medicines questionnaire (BMQ), Client-Centered Care Questionnaire (CCCQ) and the Shared Decision Making Questionnaire (SDM-Q-9). Socio-demographics, health status, and drug-related burden were questioned as potential factors to impact the relationship between PCC and adherence.

Results

A sample of 459 persons participated. The mean score on the CCCQ (adjusted to pharmacotherapy) was 52.7 on 75 (sd = 8.83, range [18-70]). The top 20% scored 60 or more, the 20% lowest scores were 46 or less. Adherence levels were high, with a mean score of 22.6 on 25 on the MARS-5, and 88% scoring 20 or more. An increase in PCC corresponded to a higher chance of medicines adherence (OR 1.07, 95%CI [1.02-1.12]), corrected for age, the burden due to chronic diseases, the impact of side effects on daily life, and participants' beliefs about medicines. PCC showed positive correlations with the necessity of medicines use (r = 0.1, p = 0.016) and the balance between necessity and concerns (r = 0.3, p < 0.001); and negative correlations with levels of concerns (r = -0.3, p < 0.001) and scores on harmfulness (r = -0.3, p < 0.001) and overuse of medicines (r = -0.4, p < 0.001).

Conclusion

Patients with chronic medicine use perceived an average high level of people-centeredness in the pharmaceutical care they received. This PCC was weakly positively associated with adherence to their medicines. The higher PCC was evaluated, the more patients believed in the necessity of the medicines use and the better the balance between necessity and concerns. The people-centeredness of pharmaceutical care showed several shortcomings and can still be improved. As such, healthcare providers are advised to actively engage in PCC, and not to wait passively for information provided by the patient.

Expert or experiential knowledge? How knowledge informs situated action in childcare practices

The study examines how alternative health information affects the professional authority of doctors. Drawing on in-depth interviews with mothers in Hong Kong and focusing on child-rearing practices, we find that mothers glean expert knowledge from doctors and experiential knowledge from online resources, social networks, and direct observations. Despite the prevalence of information online and traditional Chinese remedies, mothers do not use experiential knowledge to challenge doctors. Instead, they self-interpret medical advice and set self-determined courses of action based on their own practical situations. Generally, they dichotomize child-rearing and caring issues into medical versus non-medical domains to which they apply expert and experiential knowledge, respectively. How a condition is categorized depends on whether their individualized experiential knowledge is adequate to allow them to manage the health of their child. This study concludes that mothers with alternative health information still respect professional authorities in clinical interactions, which accords with previous sociological studies, but mothers often consider expert knowledge overly generic, so they take initiative to translate generic health-related knowledge into individualized knowledge for their child and determine their own course of action. Our theoretical contribution is to bring situational concerns into the debate of professional authority by revealing how the accumulation of experiential knowledge informs situated action.

Patient-centred care and patient autonomy: doctors' views in Chinese hospitals

Background

Patient-centred care and patient autonomy is one of the key factors to better quality of service provision, hence patient outcomes. It enables the development of patients’ trusts which is an important element to a better doctor-patient relationship. Given the increasing number of patient disputes and conflicts between patients and doctors in Chinese public hospital, it is timely to ensure patient-centred care is fully and successfully implemented. However, limited studies have examined the views and practice in different aspects of patient-centred care among doctors in the Chinese public hospitals.

Methods

A quantitative approach was adopted by distributing paper-based questionnaires to doctors and patients in two hospitals (Level III and Level II) in Jinan, Shandong province, China.

Results

In total, 614 doctors from the surgical and internal medicine units of the two hospitals participated in the survey yielding 90% response rates. The study confirmed the inconsistent views among doctors in terms of their perception and practice in various aspects patient-centred care and patient autonomy regardless of the hospital where they work (category II or category III), their unit speciality (surgical or non-surgical), their gender or seniority. The high proportion of doctors (more than 20%) who did not perceive the importance of patient consultation prior to determining diagnostic and treatment procedure is alarming. This in in part due to the belief held by more than half of the doctors that patients were unable to make rational decisions and their involvement in treatment planning process did not necessarily lead to better treatment outcomes.

Conclusion

The study calls for the development of system level policy and organisation wide strategies in encouraging and enabling the practice of patient-centred care and patient autonomy with the purposes of improving the quality of the service provided to patients by Chinese hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00777-w.

Patient-provider therapeutic connections to improve health care: Conceptual development and systematic review of patient measures

BACKGROUND

The Triple Aim (improved population health, improved patient experiences, and lower costs) has influenced U.S. health care since it was introduced in 2008. With it, value-based purchasing has brought unprecedented focus on patient experience measurement. Despite having devoted extensive resources toward improving patient experiences, inconsistent improvements suggest there are some dimensions not yet being widely measured or addressed. Furthermore, a renewed focus on health disparities calls for stronger patient-provider connections in order to reduce health care inequities.

PURPOSE

The aim of this study was to articulate the concept of therapeutic connections (TCs) in health care and examine existing survey measures, from the patient perspective, to learn whether they capture the TC construct.

METHOD

We interviewed subject matter experts (n = 24) and patients (n = 22) about measuring TCs and then conducted a systematic review of quantitative measures from three databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria.

RESULTS

Of 31 unique measures, none captured all of the theorized TC dimensions. Most were measures of collaboration and shared decision-making or caring.

DISCUSSION

Focusing on the nature of patient-provider connections is vital because they are the backbone of most delivery models seeking to achieve the Triple Aim. Further development of the TC concept and measures is warranted to facilitate organizational and financing policies that meaningfully support widespread improvement.

PRACTICE IMPLICATIONS

A focus on barriers and facilitators of TCs is needed. Without advancing our understanding of the role TCs play in care, policymakers and practitioners will be limited in their ability to make impactful changes.

A short scale for measuring attitudes towards the doctor-patient relationship: psychometric properties and measurement invariance of the German Patient-Practitioner-Orientation Scale (PPOS-D6)

Background

The Patient-Practitioner Orientation Scale (PPOS) was originally developed to compare doctor’s and patient’s consensus regarding patient centeredness. Research assumed PPOS measurements to be comparable across different groups of participants, however, without assessing the actual validity of this assumption. In this study, we investigate the psychometric properties and measurement invariance of a short version of the German translation of the PPOS.

Methods

Based on a cross-sectional survey of N = 332 medical students, we present a short version of the German Patient-Practitioner-Orientation Scale (PPOS-D6) and examine its psychometric properties as well as measurement invariance across participants with varying levels of medical experience and gender using multigroup confirmatory factor analyses.

Results

Results indicate that PPOS-D6 provides valid and reliable measurements of patient-centeredness that are invariant across participants with different medical experience. Preliminary results also suggest invariance across gender.

Conclusion

PPOS-D6 is a suitable and efficient measure to compare group-specific attitudes towards the doctor-patient interaction. Additional research on convergent and discriminant validity and divergent study samples is advised.

The effects of organizational climate on adherence to guidelines for COVID-19 prevention

Background

During the current pandemic, it is essential that individuals follow the COVID-19 guidelines (e.g., physical distancing) to slow down the spread of the new coronavirus. Organizations generally affect their employees' behavior in a wide range of areas, but can they also affect how strictly employees adhere to COVID-19 guidelines? To answer this question, the present study examined the impact of an organizational climate for preventing infectious diseases (OCID) on employees' adherence to COVID-19 guidelines both at work and in their private life.

Method

We used a two-wave longitudinal online survey with a final sample of N = 304 UK employees.

Results

Our results show that OCID during the first lockdown in the UK in April 2020 (T1) was positively linked to adherence to COVID-19 guidelines at work one month later (T2). We also found a relationship between OCID (T1) and adherence to guidelines in one's private life (T2) that was mediated through adherence to guidelines at work (T2).

Conclusion

These results highlight the pivotal role organizations play in mitigating the COVID-19 pandemic.

Teaching Shared Decision Making to Undergraduate Medical Students

Despite the wide endorsement of shared decision making (SDM), its integration into clinical practice has been slow. In this paper, we suggest that this integration may be promoted by teaching SDM not only to residents and practicing physicians, but also to undergraduate medical students. The proposed teaching approach assumes that SDM requires effective doctor-patient communication; that such communication requires empathy; and that the doctor's empathy requires an ability to identify the patient's concerns. Therefore, we suggest shifting the focus of teaching SDM from how to convey health-related information to patients, to how to gain an insight into their concerns. In addition, we suggest subdividing SDM training into smaller, sequentially taught units, in order to help learners to elucidate the patient's preferred role in decisions about her/his care, match the patient's preferred involvement in these decisions, present choices, discuss uncertainty, and encourage patients to obtain a second opinion.

Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa

Background

Sexual history taking for risk behavior contributes to improving health outcomes in primary care. Giving the high numbers of people living with AIDS, every patient in South Africa should be offered an HIV test, which implies that a comprehensive sexual history must be taken.

Aim

To describe the optimal consultation process, as well as associated factors and skills required to improve disclosure of sexual health issues during a clinical encounter with a doctor in primary health care settings in North West province, South Africa.

Methods

This qualitative study, based on grounded theory, involved the video-recording of 151 consultations of adult patients living primarily with hypertension and diabetes. This article reports on the 5 consultations where some form of sexual history taking was observed. Patient consultations were analyzed thematically, which entailed open coding, followed by focused and verbatim coding using MaxQDA 2018 software. Confirmability was ensured by 2 generalist doctors, a public health specialist and the study supervisors.

Main Outcome Measure

Sexual history was not taken and patients living with sexual dysfunction were missed. If patients understand how disease and medication contribute to their sexual wellbeing, this may change their perceptions of the illness and adherence patterns.

Results

Sexual history was taken in 5 (3%) out of 151 consultations. Three themes emerged from these 5 consultations. In the patient-doctor relationship theme, patients experienced paternalism and a lack of warmth and respect. The consultation context theme included the seating arrangements, ineffective use of time, and privacy challenges due to interruptions and translators. Theme 3, consultation content, dealt with poor coverage of the components of the sexual health history.

Conclusion

Overall, sexual dysfunction in patients was totally overlooked and risk for HIV was not explored, which had a negative effect on patients’ quality of life and long-term health outcomes. The study provided detailed information on the complexity of sexual history taking during a routine consultation and is relevant to primary health care in a rural setting. Pretorius D, Couper I, Mlambo M. Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa. Sex Med 2021;9:100389.

Validation of the Patient-Centred Care Competency Scale Instrument for Finnish Nurses

Patient-centredness in care is a core healthcare value and an effective healthcare delivery design requiring specific nurse competences. The aim of this study was to assess (1) the reliability, validity, and sensitivity of the Finnish version of the Patient-centred Care Competency (PCC) scale and (2) Finnish nurses' self-assessed level of patient-centred care competency. The PCC was translated to Finnish (PCC-Fin) before data collection and analyses: descriptive statistics; Cronbach's alpha coefficients; item analysis; exploratory and confirmatory factor analyses; inter-scale correlational analysis; and sensitivity. Cronbach's alpha coefficients were acceptable, high for the total scale, and satisfactory for the four sub-scales. Item analysis supported the internal homogeneity of the items-to-total and inter-items within the sub-scales. Explorative factor analysis suggested a three-factor solution, but the confirmatory factor analysis confirmed the four-factor structure (Tucker-Lewis index (TLI) 0.92, goodness-of-fit index (GFI) 0.99, root mean square error of approximation (RMSEA) 0.065, standardized root mean square residual (SRMR) 0.045) with 61.2% explained variance. Analysis of the secondary data detected no differences in nurses' self-evaluations of contextual competence, so the inter-scale correlations were high. The PCC-Fin was found to be a reliable and valid instrument for the measurement of nurses' patient-centred care competence. Rasch model analysis would provide some further information about the item level functioning within the instrument.

Applying empathic communication skills in clinical practice: Medical students' experiences

Background

Studies have demonstrated that empathic communication improves patient outcomes and helps doctors to deliver accurate symptom reports and diagnoses. These benefits emphasise the need for medical students to apply empathic communication skills during their interactions with patients. Focussed empathic communication skill workshops were introduced into the undergraduate medical students’ training at the Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa. This study aimed to explore students’ perceptions of applying these empathic communication skills during their clinical practice. We were interested in determining the factors that might influence the development of empathic communication skills. The findings could help curriculum developers to optimise these workshops for inclusion in a formal medical curriculum.

Methods

This study followed a qualitative, descriptive enquiry, exploring the perceptions of medical students through focus-group discussions. The students (N = 18) were selected using convenience sampling techniques. Recordings were transcribed, and the data were thematically analysed.

Results

The two main themes identified relate to the students and the clinical learning environment. The students valued the knowledge and skills they acquired. However, feelings of emotional vulnerability, a lack of language proficiency and inadequate role modelling were highlighted as challenges when applying empathic communication during clinical practice.

Conclusion

The students reported positively on the workshops as these improved both their patient and personal interactions. However, for students to develop these skills further for clinical practice, they need more intentional and supervised opportunities to practise, reflect and receive constructive feedback. These learning opportunities could help medical schools deliver graduates who can competently communicate with their patients in an empathic manner.

Making the biopsychosocial model more scientific-its general and specific models

Some aver that the biopsychosocial (BPS) model is not fully scientific because it lacks a method to produce BPS information. To resolve this criticism, I propose that we think in terms of general and specific BPS models. What most understand to be the model is the general BPS model. It simply indicates that all patients be understood in biological, psychological, and social terms without specifying a method or sources of BPS information. Its fundamental function is to guide medicine away from the effete, 17^th century disease-only model in clinical care, teaching, and research. Considerable population-based research data also support its scientific status. Less well understood, but of greater relevance to the clinician, is the specific BPS model, which describes the BPS features unique to an individual patient. The specific model, however, requires an interviewing method to achieve this, the method critics believe lacking. In this article, I review how medical communication scholars have established a method to acquire individualized BPS data on each patient. Research identified the patient-centered interviewing (PCI) method to do this. After much progress over several decades, the field was able to test the PCI in several randomized controlled trials-and confirmed it to be evidence-based. Therefore, by definition, because the patient-centered interview defines the specific BPS model in each patient, the model itself is evidence-based. This means we now can, for the first time, identify a scientific BPS model for every individual patient. Joining this scientific support with much existing data for the general model, we now have a fully scientific BPS model.

Implications of a Novel Method for Analyzing Communication in Routine Veterinary Patient Visits for Veterinary Research and Training

The patient-centered clinical method (PCCM), a model developed to characterize communication during patient-physician visits in the 1980s, identifies elements of patient-orientated, physician-orientated, and shared dialogue during the encounter. The model also includes elements that reflect the emotional aspects of these interactions, recognizing expressions of feelings and exchanges related to both personal and medical interests. Fifty-five routine veterinary patient visits in the United Kingdom and United States were analyzed using the novel application of a PCCM adapted for veterinary patient visits. The patient visits were video recorded, transcribed, coded, and analyzed for frequency and proportion of PCCM elements observed. Elements representing the greatest proportion of patient visits were related to gathering information and shared decision making. Those representing the smallest proportion were related to signs of the presenting condition and effects of the condition on the clients' lives. Dialogue during the patient visits flowed iteratively and back and forth between the veterinarian and the client perspective. The findings suggest that patient visits are focused more on gathering information and planning rather than exploring effects of the health problem on the client's life, and that patient visits flow very iteratively and randomly between veterinarian and client perspectives. Both of these topics should be studied further and given emphasis in the way that communication models are developed and taught in order to enhance client-centeredness in veterinary patient visits.

Patient-centred care: The patients' perspective - A mixed-methods pilot study

Background

Patient centredness is a broad concept, a moral philosophy. Patient-centred care can be viewed as the actions of patient-centredness. One of the most pertinent actions that a healthcare practitioner can utilise to deliver patient-centred care is empathic communication. Whilst many medical programmes include empathetic communication skills as part of their curricula, the recipients of this care are not asked about the relevance of this teaching.

Aim

We attempted to determine whether the Western constructs of empathy were relevant in our context and also establish whether there were any parts of the medical interview which participants felt were especially important to be communicated to in their home language.

Setting

Two urban communities within the City of Cape Town, Western Cape Province, South Africa.

Methods

This was a mixed-methods pilot study using an explanatory sequential design. Participants who would typically make use of public health care facilities and whose first language was Afrikaans or isiXhosa were conveniently sampled. A subgroup of participants was invited to take part in a follow-up focus group discussion to add clarity to the survey responses.

Results and Conclusion

Western constructs for empathy appeared to be relevant within our multicultural context. Patients wanted to communicate with their doctors and understand the cause of their problems as well as the management plan. Finally, whilst the numbers in this pilot study were too small to be generalisable, it was evident that patient-centred care was not perceived to be implemented in some public healthcare facilities attended by the participants, which resulted in them feeling unseen and disrespected.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres

BACKGROUND

The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility.

RESULTS

The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period.

CONCLUSIONS

The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Contemporaneous patient and health professional views of patient-centred care: a systematic review

OBJECTIVE

To understand the domains of agreement and disagreement, related to person-centred care, between the patient and healthcare professional during a shared episode of care.

DESIGN

A systematic review following the PRISMA protocol searched PubMed (Medline), CINAHL, PsychInfo and Scopus using keywords for health professionals, patients and patient-centred care. A descriptive-interpretive method was used to identify domains described in the person-centred care framework.

SETTING

Research conducted in all healthcare settings (inpatient, outpatient, community) were included.

PARTICIPANTS

Research which presented the contemporaneous perspectives of a health professional and the person they were providing services to were included.

INTERVENTION(S)

Research regarding the delivery of any type of health service was included.

MAIN OUTCOME MEASURE(S)

The person-centred care framework which includes Structure, Process and Outcome as measures for implementing person-centred care was used to interpret and summarize the data.

RESULTS

After title and abstract screening against inclusion and exclusion criteria, 15 of 1,406 studies were critically appraised. High levels of contemporaneous agreement were identified for easily accessible, supportive and accommodating environments, where information sharing occurred. Contemporaneous agreement occurred most often between patients and healthcare professionals in the importance of sharing information across all geographical settings, with greatest disagreement of patient involvement in the European and American hospital environments.

CONCLUSIONS

Greater understanding of the context of information sharing and drivers for management preferences may support shared decision-making and increase satisfaction. More information regarding contemporaneous experiences of healthcare episodes is required to further inform patient-centred care practices and optimize health outcomes.

PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version)

Background: The purpose of our study was to develop and psychometrically test a German-language survey instrument that measures patient enablement generically and in greater detail than previous instruments. Methods: A multidisciplinary team developed 13 items to capture individual aspects of patient enablement (PEN-13). A pre-test with 26 subjects was followed by a random sample survey of N = 1168 subjects. An exploratory factor analysis was conducted in a random split-half sample of the data to explore PEN-13's factor structure; a confirmatory factor analysis was conducted in the validation sample. The internal consistency of the factors was evaluated using Cronbach's alpha, PEN-13's construct validity was checked by means of additional hypothesis testing. Results: The two factors self-management and patient-practitioner interaction, detected in the exploratory analysis, were confirmed with a few modifications in the confirmatory factor analysis, with the comparative fit index (CFI) amounting to 0.903. The Cronbach's alpha values of those two factors amounted to α = 0.90 and α = 0.82, respectively. The correlations of the PEN-13 score with the 'general self-efficacy' and 'health literacy' (HLS-EU-Q16) scores further confirmed its construct validity; the respective correlation coefficients amounted to 0.57 and 0.60. Conclusion: The German version of the survey instrument Patient Enablement Scale-13 items (PEN-13) shows acceptable psychometric properties. Practical implications: PEN-13 seems particularly suitable for health services research purposes. We recommend checking the results in another sample as well as evaluating its responsiveness to enablement-enhancing interventions.

Informing patients on planned consultation time - a randomised controlled intervention study of consultation time in primary care

Objective: To investigate whether patients' pre-consultation knowledge of the time frames for the consultation influences the actual consultation time and/or patient and physician related outcomes; satisfaction and enablement.Design: Randomised controlled blinded intervention study.Setting: Four strategically chosen Primary Health Care Centres (PHCC:s) in Kronoberg county in Sweden participated.Intervention: Pre-consultation information on planned consultation time. During one week in each PHCC consecutive patients were randomised to intervention group or control group, when booking an appointment with a physician.Subjects: Patients >18 years of age.Main outcome measures: Consultation time, patient satisfaction, patient enablement and physician satisfaction.Results: No significant difference in consultation time was found between the intervention group and control group. No differences were seen between intervention group and control group regarding any of the other measures. Stratified data showed significantly shorter consultation time for the intervention group in one of the PHCC:s and for employed physicians. Employed physicians also rated consultations as being easier and were more satisfied with their consultations compared to non-employed physicians.Conclusion: Information on the planned consultation time has a potential to decrease consultation time in certain settings. No negative side effects were found in this study. Key pointsPatients prepare before their consultation but to influence its contents and length is difficult.Informing patients on estimated consultation time can influence actual consultation time.Informing patients on planned consultation time has no adverse effects in this study.

Referrals for uncomplicated lower back pain: a cluster parallel randomised trial of patient-centred communication to improve the management of acute back pain in primary care. A study protocol

INTRODUCTION

Low back pain (LBP) is one of the most frequent encounters in General Practice. Investigation and referral remain common despite the self-limiting character of episodes that are not largely attributable to specific underlying injuries. Identifying patients' ideas, concerns and expectations (ICE) is a well-established element within consultation skills training and has been shown to improve prescribing. It can be a powerful communication tool setting the base for transferring and adjusting adequate clinical information. This study aims to evaluate whether ICE can decrease unnecessary medicine in the management of acute LBP in primary care. METHODS AND ANALYSIS: Research question: Does ICE training intervention have an effect on doctors' referrals of patients suffering from acute LBP? Population: Recruitment to this parallel cluster randomised trial will take place among general practitioners belonging to four independent practice networks in Northern Bavaria/Germany. Intervention: At baseline, 24 out of 48 doctors will be randomly assigned to take part in a 1-day training session covering theoretical background and clinical implementation of patient-centred communication by stimulating ICE. They will also be given access to a web-based supporting tool for reflective practice on their communication skills. Comparison: GPs in the control group will continue consultations as usual. Outcome: Outcome measures are referrals to diagnostic imaging, physiotherapy and specialists obtained from routine practice data, compared between intervention and control group. Time: Referrals of patients consulting their doctors for documented LBP will be monitored up to 3 months after the ICE training intervention.

ETHICS AND DISSEMINATION

Ethical approval for the study was obtained by the Ethics Committee of the University Erlangen-Nuremberg (296_17B). Results will be disseminated by conference presentations and journal publications.

TRIAL REGISTRATION NUMBER

The trial is registered in clinicaltrials.gov (NCT03711071).

Factors affecting patient enablement in an Asian setting: a mixed methods study

INTRODUCTION

Patient-centred medical care has been rising in importance since the turn of the century. It entails treating patients in relation to their biopsychosocial outlook so as to support the management of their conditions. The extent to which a patient is enabled to acquire skills and knowledge can be measured with the Patient Enablement Instrument (PEI) proposed by Howie and colleagues, and it has been noted to be more reflective of a good consultation compared to patient satisfaction scores. This study aimed to determine the level of patient enablement in the Singaporean context and the factors facilitating it.

METHODS

We conducted an embedded mixed method study with primary care patients in two phases: (a) a PEI questionnaire was completed by 150 patients; and (b) a qualitative approach using focused group discussions and individual interviews was used to explore factors associated with high enablement.

RESULTS

The mean PEI score was 4.5 ± 4.4, with significantly higher scores among patients attending specialised primary care clinics. Important physician factors were doctors' advice, attitude and relationship with the patient. Critical system factors included good continuity of care, workload and financial support, while patient factors included their beliefs, preparedness, inquisitiveness and trust, with considerable impact from the influence of community.

CONCLUSION

The PEI score in the Singaporean context is similar to that of other Asian contexts, but slightly higher than that reported in Western studies. Good doctor-patient relationships, efficient systems facilitating continuity of care, and motivated and informed patients all contribute to increased enablement.

What patient involvement means to new patients at two HIV clinics: A longitudinal, qualitative study

OBJECTIVES

This study 1) defines patient involvement from the perspective of patients new to a provider, 2) describes provider communication that patients perceive as promoting involvement, and 3) examines changes in patient definitions of involvement over time.

METHODS

We enrolled 56 patients at two HIV clinics in Houston, Texas, from August 2013 until March 2015. We interviewed patients three times during the first year of care and analyzed interviews using content analysis.

RESULTS

The mean age was 45 years; 54% were men. Patient definitions of involvement ranged from adherence- to decision-oriented. Analysis revealed three provider communication behaviors that patients perceive as promoting involvement: 1) soliciting patient feedback, 2) discussing treatment options and trade-offs, 3) narrating the decision-making process. Definitions of involvement can change over time as providers reframe the patient's illness as manageable and through perceived partnerships with the provider.

CONCLUSION

Provider communication plays a critical role in shaping new patients' perception of involvement and can make patients feel involved even when patients do not actively make medical decisions.

PRACTICAL IMPLICATIONS

Finding strategies to make patients feel involved in their care is important, particularly for new patients, even if those strategies do not necessarily promote more talk from the patient.

Development of the concept of patient-centredness - A systematic review

OBJECTIVE

Patient-centredness is often linked to high-quality patient care, but the concept is not well-defined. This study aims to provide an overview of how patient-centredness has been defined in the literature since Mead and Bower's review in 2000, and to provide an updated definition of the concept.

METHOD & DESIGN

We performed a systematic literature search in PubMed to identify original articles with a sufficient definition of patient-centredness. We analysed extracted data defining patient-centredness.

RESULTS

Eighty articles were included. The dimensions "biopsychosocial", "patient-as-person", "sharing power and responsibility" and "therapeutic alliance" corresponded to four of five dimensions described by Mead and Bower. "Coordinated care" was a new dimension.

CONCLUSION

The identified dimensions are encompassed by three elements: the patient, the doctor-patient relationship and the framework of care i.e. the health care system. The additional focus on coordinated care could reflect increasing complexity of the health care system.

PRACTICE IMPLICATIONS

Narrowing down the understanding of patient-centredness to these three focus areas, viz. 1) understanding of the patients' experience of the illness in their life situation, 2) the professional's relationship with the patient, and 3) coordination of care in the system, could make the operationalisation and implementation of a patient-centred approach more manageable.

Comparison of the Patient Enablement Instrument (PEI) with two single-item measures among Finnish Health care centre patients

Background

The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients.

Methods

Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points.

Results

Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low.

Conclusions

Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

Patient-centered communication, patient satisfaction, and retention in care in assisted reproductive technology visits

PURPOSE

To explore the association between patient-centered communication, patients' satisfaction, and retention in care in assisted reproductive technology (ART) visits.

METHODS

ART visits at eight Italian clinics were videotaped and coded using the Roter Interaction Analysis System, which includes a Patient-Centered Index (PCI), a summary "patient-centered communication" ratio. After the visit, patients completed a satisfaction questionnaire (SATQ). After 3 months, patients were asked about their retention in care. Spearman correlations and Mann-Whitney tests were used to test associations between the study variables; the open-ended item of SATQ was analyzed through content analysis.

RESULTS

Eighty-five visits were videotaped (involving 28 gynecologists and 160 patients). PCI score (μ = 0.51 ± 0.28) revealed a more disease-oriented communication during the visit. Patients reported high levels of satisfaction with the visit and identified in the information provision or in the doctor's humanity or kindness the main reasons of satisfaction. At the follow-up, the majority of the couples declared to have followed the clinicians' recommendations and to have remained related to the ART center. No associations were found among the study variables, except for a lower male satisfaction among couples who declared to have changed ART clinic.

CONCLUSIONS

Contrary to what was expected, the style of physician-patient communication was not found to be associated with patient satisfaction and retention in care. However, patients were highly satisfied and engaged. The actual meaning of a communication that is "patient-centered" in the ART context might be wider, including the couples' need for information, as suggested by qualitative findings.

Measuring empathy in a group of South African undergraduate medical students using the student version of the Jefferson Scale of Empathy

Background

Patient-centred care is a model of care that demands healthcare providers change their focus from the disease to the patient and his or her perceived physical and psycho-social needs. This model requires healthcare workers to listen actively and to have effective communication skills and well-developed levels of empathy.

Aim

The aim of this study was to determine the suitability of the Jefferson Scale for Empathy (JSE-S) as a valid test for empathy in third-year medical students at a South African university and also to determine the baseline level of empathy in this same group of students.

Setting

The study took place at a medical school in the Western Cape, South Africa. This medical degree (MB ChB) is a 6-year programme. Students are first exposed to patients within their second year of training, but it is during their third-year that they start their clinical rotations. We wanted to test whether our empathy training would give students the necessary skills and enable them to establish good empathic communication habits in order to prevent a fall in empathy during this vulnerable period.

Methods

This article explores the suitability of the student version of the JSE-S as a valid test for empathy, within the South African medical school context. We briefly discuss the psychometrics and the scores against what is already known in countries like ours, specifically, developing nations where cultural and language differences exist in the student populations. Furthermore, we explore whether the JSE-S is a valid scale for pre- and post-intervention measurement of medical student empathy within our context and discuss the limitations of self-assessment. We also report on baseline levels of empathy in third-year medical students.

Results

Two hundred and six third-year medical students (69% females) completed the JSE-S prior to the intervention. Females and students aged 25 years and older had significantly higher scores than males and those 22 years old or less. The mean JSE was 109.98 (SD = 12.54), which is lower than most internationally reported scores. The Cronbach’s alpha coefficient was 0.81, indicating scale reliability and consistency, but graded item response testing highlighted variance in three reverse-scored questions.

Conclusion

The JSE-S is an appropriate and valid scale for measuring levels of empathy in undergraduate medical students in South Africa. However, language may need to be clarified in the negatively phrased items.

Adaption, benefit and quality of care associated with primary nursing in an acute inpatient setting: A cross-sectional descriptive study

AIMS

The aim of this study was to investigate the adoption of primary nursing and to determine the quality of primary nurse-led care in an acute inpatient setting.

DESIGN

Descriptive cross-sectional study.

METHODS

Participants included inpatients (N = 369) and nurses (N = 381). To assess adoption of primary nursing, patient records were analysed and an online survey of nurses was conducted from May-June 2017. To measure quality of nursing care, a structured questionnaire was administered to inpatients.

RESULTS

Patients reported high quality of individualized, responsive and proficient care, but lower levels of coordinated care. Most nurses agreed that primary nursing is beneficial for person-centred caring. However, only two-thirds found that it was practiced on their unit and only half of care planning activities were attributable to primary nurses.

CONCLUSION

While perceived as beneficial, adoption of primary nursing in clinical practice remains partial. Hence, primary nursing may not be enough to ensure continuity and coordination of acute care.

Medical Students' (Dis)comfort with Assessing Religious and Spiritual Needs in a Standardized Patient Encounter

Most patients want to discuss their religious and spiritual concerns, yet few physicians discuss it. First-year medical students (n = 92) interviewed a standardized patient experiencing spiritual distress. There was a significant difference among the students' reasoning for their (dis)comfort and (mis)matching religion with their patient (X² = 21.0831, p < .05). Most students whose religion matched their patient felt comfortable because of having this in common with their patient. Most students whose religion did not match that of their patient ascribed their comfort to their religious belief to be open and accepting. Discomfort may stem from more individual factors than a (mis)match in religion, as most of the students reported feeling comfortable.

Doctor-patient communication: a review and a rationale for using an assessment framework

PURPOSE

The purpose of this paper is to explore the extent to which improving doctor-patient communication (DPC) can address and alleviate many healthcare delivery inefficiencies.

DESIGN/METHODOLOGY/APPROACH

The authors survey causes and costs of miscommunication including perceptual gaps between how physicians believe they perform their communicative duties vs how patients feel and highlight thresholds such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) used by hospitals to identify health outcomes and improve DPC.

FINDINGS

The authors find that DPC correlates with better and more accurate care as well as with more satisfied patients. The authors utilize an assessment framework, doctor-patient communication assessment (DPCA), empirically measuring the effectiveness of DPC. While patient care is sometimes viewed as purely technical, there is evidence that DPC strongly predicts clinical outcomes as well as patients' overall ratings of hospitals.

RESEARCH LIMITATIONS/IMPLICATIONS

More research is needed to extend our understanding of the impact of the DPC on the overall HCAHPS ratings of hospitals. The authors think that researchers should adopt a qualitative method (e.g. content analysis) for analyzing DPC discourse.

PRACTICAL IMPLICATIONS

When a sufficient amount of DPCA training is initiated, a norming procedure could be developed and a database may be employed to demonstrate training program's efficacy, a critical factor in establishing the credibility of the measurement program and nurturing support for its use.

ORIGINALITY/VALUE

The authors highlight clinical and operational issues as well as costs associated with miscommunication and the need to use metrics such as HCAHPS that allow consumers to see how hospitals differ on specific characteristics.

Prevalence and correlates of patient-centred preparatory information provision to computed tomography and magnetic resonance imaging outpatients: A cross-sectional study

OBJECTIVE

Responsiveness to information preferences is key to high-quality, patient-centred care. This study examined the top ten preparatory information items not delivered in accordance with medical imaging outpatients' preferences, and patient characteristics associated with reporting a greater number of unmet information preferences.

METHODS

Magnetic resonance imaging and computed tomography outpatients were recruited consecutively in one major public hospital waiting room. Participants self-administered a touchscreen computer questionnaire assessing their sociodemographic and scan characteristics, and unmet preferences for 33 guideline-endorsed preparatory information items.

RESULTS

Of 317 eligible patients, 280 (88%) consented to participate. Given equal rankings, the top ten unmet information preferences included 13 items which were endorsed by at least 25% of participants, and commonly related to receiving 'too little' information. One item related to the pre-scan period, seven items to the scan period and five items to the post-scan period. None of the patient characteristics examined were significantly associated with reporting a greater number of unmet information preferences.

CONCLUSION

There is room to improve responsiveness to medical imaging outpatients' preparatory information preferences. Improvements should be targeted at individuals, rather than groups defined by sociodemographic or scan characteristics.

PRACTICE IMPLICATIONS

A standardised approach to addressing individual patient's information preferences is needed.

Enacting person-centredness in integrated care: A qualitative study of practice and perspectives within multidisciplinary groups in the care of older people

Background

Person‐centredness is important in delivering care for long‐term conditions. New models of care aim to co‐ordinate care through integration of health and social care which require new ways of working, often remotely from the patient.

Objective

To describe how person‐centred care is enacted within multidisciplinary groups (MDGs) created as part of a new service, integrating health and social care for older people.

Methods

We followed the implementation of eight neighbourhood MDGs, observing and interviewing staff from three MDGs at different phases of programme implementation using semi‐structured topic guides.

Results

Thirty‐four MDG meetings were observed and 32 staff interviewed. Three core themes were identified which impacted on enactment of person‐centred care: the structural context of MDGs enabling person‐centred care; interaction of staff and knowledge sharing during the MDG meetings; and direct staff involvement of the person outside the MDG discussion.

Conclusions

This study provides new insights into attempts to enact person‐centred care within a new model of service delivery. Teams did what they could to enact person‐centred care in the absence of the “real” patient within MDG meetings. They were successful in delivering and co‐ordinating some aspects of care (eg prompting medication reviews, referring to social worker, health improvement and arranging further multidisciplinary team meetings for complex cases). This “absence of patients” and time pressures within the MDGs led to reliance on the “virtual” record, enhanced by additional “soft” knowledge provided by staff, rather than ensuring the patient's voice was included.

Patients' Interpersonal Communication Experiences in the Context of Type 2 Diabetes Care

The aim of our study is to determine the relational communication characteristics of professional-patient communication situations that have either facilitated or impeded patients' self-management. Conducted from the perspective of Finnish patients in the context of type 2 diabetes care, we used as our research methods an open e-survey and semistructured interviews. Data were analyzed using inductive qualitative content analysis. The critical incident technique was utilized throughout in all these methods. The results show that both positive and negative experiences described by patients were connected to four multidimensional relational communication characteristics: (a) building trust in the other party in the professional-patient relationship, (b) willingness to communicate, (c) emotional presence, and (d) appropriateness. Although the findings support the recommendations of earlier studies concerning individually tailored patient-centered care, acknowledging the characteristics in question can be used as a communication frame for constructing significant care relationships from the perspective of patients' self-management.

A framework for establishing connections in physiotherapy practice

The therapeutic relationship between practitioner and patient is embedded in the clinical interaction. Research using self-report tools has illustrated that positively evaluated therapeutic relationships can have favorable impacts on patient satisfaction with services and clinical outcomes. However, little is known about how physiotherapists develop the connections, or positive attachments, that help establish the therapeutic relationship. This study aimed to identify the various ways that physiotherapists establish meaningful connections with their patients. Interpretive description, a qualitative methodology, was used to structure the inductive and iterative design. Eleven physiotherapists and 7 patients from private practice clinics participated in semi-structured interviews to describe their experiences of the therapeutic relationship. Textual data were analyzed using qualitative content analysis and constant comparison. The iterative data generation and analysis process resulted in a framework composed of three "ways" (i.e. categories) of establishing connections: (1) acknowledging the individual, (2) giving-of-self, and (3) using the body as a pivot point. Findings were supported by various rigor strategies including peer debrief and external audit. This framework demonstrates that establishing connections is a multi-faceted endeavor with personal and professional characteristics. The findings provide practical knowledge that can be used to guide clinicians, educators, and researchers in addressing the therapeutic relationship.

Coping better with health problems after a visit to the family physician: associations with patients and physicians characteristics

BACKGROUND

Good patient experience is recognized as an important component of a strong primary care system. Among the dimensions related to experience in family medicine, the ability to cope better with health problems is considered to be a measure of the quality of a consultation with a family physician (FP). The objective is to identify factors related to patients, physicians and practice, associated with patients' ability to cope better with their health problems after a family medicine consultation.

METHODS

The data stemmed from the Swiss part of the Quality and Costs of Primary Care (QUALICOPC) study, an international cross sectional survey aiming to compare quality, cost and equity in primary care. In Switzerland, a random sample of 199 FPs and 1791 patients participated. The negative answer to the question: "After this visit, I feel I can cope better with my health problems" was modeled using multilevel logistic regressions.

RESULTS

Difficulty to cope better with health problems was positively associated with the following: younger age (OR: 1.58, 95% CI [1.03-2.41]), cultural aspects related to the Swiss area of language (French speaking people declared higher inability than German and Italian ones), presence of chronic disease (OR: 1.54 95% CI [1.00-2.39]). Conversely an intermediate number (1-4) of visits during the last 6 months (OR: 0.37 95% CI [0.23-0.62]) and the satisfaction with the physician (OR: 0.18 95% CI [0.08-0.44]) are negative predictors of the patient inability to cope better with his health problems. A self-reported effort-reward imbalance at work (OR: 0.64 95% CI [0.41-1.00]) was the only predictive FP characteristic (negatively associated).

CONCLUSIONS

Although the design of the study does not allow causal inference, this study showed that the predictors of patient difficulties to cope better with health problem are mainly centered on the patients' characteristics. The patient-physician relationship both in terms of quality and frequency of visits is probably also important. Organizational practice characteristics do not seem to play a major role but stress at work among physicians should be further investigated.

A structural equation model of patient-healthcare provider relationships and HIV-infected patient outcomes in Chinese populations

Obtaining maximum antiretroviral therapy (ART) adherence is critical for maintaining a high CD4 count and strong immune function in PLWHA. Key factors for achieving optimum adherence include good medication self-efficacy, decreased medication-taking difficulties, and positive patient-healthcare provider (HCP) relationships. Limited studies have analyzed the correlation of these factors and ART adherence in Chinese population. In this paper, structural equation modeling was performed to assess the proposed model of relations between patient-HCP relationships and adherence. Audio Computer-Assisted Self-Interview (ACASI) software was used to collect data on ART adherence and patient variables among 227 PLWHA in Shanghai and Taipei. Participants completed a one-time 60-minute ACASI survey that consisted of standardized measures to assess demographics, recent CD4 counts, self-efficacy, patient-HCP relationship, adherence, and medication-taking difficulties. The data shown the relationship between patient-HCP relationships and adherence was significantly consistent with mediation by medication self-efficacy. However, patient-HCP interaction did not directly influence medication-taking difficulties, and medication-taking difficulties did not significantly affect CD4 counts. Furthermore, patient-HCP interactions did not directly impact CD4 counts; rather, the relation was consistent with mediation (by either better medication self-efficacy or better adherence) or by improved adherence alone. Future interventions should be designed to enhance self-management and provide better patient-HCP communication. This improved communication will enhance medication self-efficacy and decrease medication-taking difficulties. This in turn will improve medication adherence and immune function among PLWHA.

Patient Enablement After a Single Appointment With a GP: Analysis of Finnish QUALICOPC Data

Background: Patient enablement is described as patient’s ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. Methods: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. Results: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant (P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. Conclusions: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.

The UK Pharmacy Care Plan service: Description, recruitment and initial views on a new community pharmacy intervention

INTRODUCTION

The UK government advocates person-centred healthcare which is ideal for supporting patients to make appropriate lifestyle choices and to address non-adherence. The Community Pharmacy Future group, a collaboration between community pharmacy companies and independents in the UK, introduced a person-centred service for patients with multiple long-term conditions in 50 pharmacies in Northern England.

OBJECTIVE

Describe the initial findings from the set up and delivery of a novel community pharmacy-based person-centred service.

METHOD

Patients over fifty years of age prescribed more than one medicine including at least one for cardiovascular disease or diabetes were enrolled. Medication review and person-centred consultation resulted in agreed health goals and steps towards achieving them. Data were collated and analysed to determine appropriateness of patient recruitment process and quality of outcome data collection. A focus group of seven pharmacists was used to ascertain initial views on the service.

RESULTS

Within 3 months of service initiation, 683 patients had baseline clinical data recorded, of which 86.9% were overweight or obese, 53.7% had hypertension and 80.8% had high cardiovascular risk. 544 (77.2%) patients set at least one goal during the first consultation with 120 (22.1%) setting multiple goals. A majority of patients identified their goals as improvement in condition, activity or quality of life. Pharmacists could see the potential patient benefit and the extended role opportunities the service provided. Allowing patients to set their own goals occasionally identified gaps to be addressed in pharmacist knowledge.

CONCLUSION

Pharmacists successfully recruited a large number of patients who were appropriate for such a service. Patients were willing to identify goals with the pharmacist, the majority of which, if met, may result in improvements in quality of life. While challenges in delivery were acknowledged, allowing patients to identify their own personalised goals was seen as a positive approach to providing patient services.

Patient–Provider Communication and Health Outcomes Among Individuals With Atherosclerotic Cardiovascular Disease in the United States

Background—

Consumer-reported patient–provider communication (PPC) assessed by Consumer Assessment of Health Plans Survey in ambulatory settings is incorporated as a complementary value metric for patient-centered care of chronic conditions in pay-for-performance programs. In this study, we examine the relationship of PPC with select indicators of patient-centered care in a nationally representative US adult population with established atherosclerotic cardiovascular disease.

Methods and Results—

The study population consisted of a nationally representative sample of 6810 individuals (aged ≥18 years), representing 18.3 million adults with established atherosclerotic cardiovascular disease (self-reported or International Classification of Diseases, Ninth Edition diagnosis) reporting a usual source of care in the 2010 to 2013 pooled Medical Expenditure Panel Survey cohort. Participants responded to questions from Consumer Assessment of Health Plans Survey that assessed PPC, and we developed a weighted PPC composite score using their responses, categorized as 1 (poor), 2 (average), and 3 (optimal). Outcomes of interest were (1) patient-reported outcomes: 12-item Short Form physical/mental health status, (2) quality of care measures: statin and ASA use, (3) healthcare resource utilization: emergency room visits and hospital stays, and (4) total annual and out-of-pocket healthcare expenditures. Atherosclerotic cardiovascular disease patients reporting poor versus optimal were over 2-fold more likely to report poor outcomes; 52% and 26% more likely to report that they are not on statin and aspirin, respectively, had a significantly greater utilization of health resources (odds ratio≥2 emergency room visit, 1.41 [95% confidence interval, 1.09–1.81]; odds ratio≥2 hospitalization, 1.36 [95% confidence interval, 1.04–1.79]), as well as an estimated $1243 ($127–$2359) higher annual healthcare expenditure.

Conclusions—

This study reveals a strong relationship between PPC and patient-reported outcomes, utilization of evidence-based therapies, healthcare resource utilization, and expenditures among those with established atherosclerotic cardiovascular disease.

Satisfaction Domains Differ between the Patient and Their Family in Adult Intensive Care Units

Background. Patients' and family's satisfaction data from the Asian intensive care units (ICUs) is lacking. Objective. Domains between patient and family satisfaction and contribution of each domain to the general satisfaction were studied. Method. Over 3 months, adult patients across 4 ICUs staying for more than 48 hours with abbreviated mental test score of 7 or above and able to understand English and immediate family members were surveyed by separate validated satisfaction questionnaires. Results. Two hundred patients and 194 families were included in the final analysis. Significant difference in the satisfaction scores was observed between the ICUs. Patients were most and least satisfied in the communication (4.2 out of 5) and decision-making (2.9 out of 5) domains, respectively. Families were most and least satisfied in the relationship with doctors (3.9 out of 5) and family's involvement domains (3.3 out of 5), respectively. Domains contributing most to the general satisfaction were the illness management domain for patients (β coefficient = 0.44) and characteristics of doctors and nurses domain for family (β coefficient = 0.45). Discussion. In an Asian ICU community, patients and families differ in their expectations and valuations of health care processes. Health care providers have difficult tasks in attending to these different domains.

The impact of general practice nursing care on patient satisfaction and enablement in Australia: A mixed methods study

BACKGROUND

The numbers of nurses in general practice in Australia tripled between 2004 and 2012. However, evidence on whether nursing care in general practice improves patient outcomes is scarce. Although patient satisfaction and enablement have been examined extensively as outcomes of general practitioner care, there is little research into these outcomes from nursing care in general practice. The aim of this study was to examine the relationships between specific general practice characteristics and nurse consultation characteristics, and patient satisfaction and enablement METHODS: A mixed methods study examined a cross-section of patients from 21 general practices in the Australian Capital Territory. The Patient Enablement and Satisfaction Survey was distributed to 1665 patients who received nursing care between September 2013 and March 2014. Grounded theory methods were used to analyse interviews with staff and patients from these same practices. An integrated analysis of data from both components was conducted using multilevel mixed effect models.

RESULTS

Data from 678 completed patient surveys (response rate=42%) and 48 interviews with 16 nurses, 23 patients and 9 practice managers were analysed. Patients who had longer nurse consultations were more satisfied (OR=2.50, 95% CI: 1.43-4.35) and more enabled (OR=2.55, 95% CI: 1.45-4.50) than those who had shorter consultations. Patients who had continuity of care with the same general practice nurse were more satisfied (OR=2.31, 95% CI: 1.33-4.00) than those who consulted with a nurse they had never met before. Patients who attended practices where nurses worked with broad scopes of practice and high levels of autonomy were more satisfied (OR=1.76, 95% CI: 1.09-2.82) and more enabled (OR=2.56, 95% CI: 1.40-4.68) than patients who attended practices where nurses worked with narrow scopes of practice and low levels of autonomy. Patients who received nursing care for the management of chronic conditions (OR=2.64, 95% CI: 1.32-5.30) were more enabled than those receiving preventive health care.

CONCLUSIONS

This study provides the first evidence of the importance of continuity of general practice nurse care, adequate time in general practice nurse consultations, and broad scopes of nursing practice and autonomy for patient satisfaction and enablement. The findings of this study provide evidence of the true value of enhanced nursing roles in general practice. They demonstrate that when the vision for improved coordination and multidisciplinary primary health care, including expanded roles of nurses, is implemented, high quality patient outcomes can be achieved.

Engaging Older Adults in Health Care Decision-Making: A Realist Synthesis

BACKGROUND

Engagement in healthcare decision making has been recognized as an important, and often lacking, aspect of care, especially in the care of older adults who are major users of the healthcare system.

OBJECTIVE

We aimed to conduct a review of available knowledge on engagement in healthcare decision making with a focus on older patients and their caregivers.

METHODS

We conducted a realist synthesis focusing on strategies for engagement of older patients and their caregivers in healthcare decision making. The synthesis encompassed theoretical frameworks and both peer-reviewed and grey literature. Expert consultations included interviews (n = 2) with academics and group consultations (n = 3) with older adults and their caregivers. Abstracts that reported description, assessment, or evaluation of strategies for engagement of adult patients, families, or caregivers (i.e., that report on actual experiences of engagement) were included.

RESULTS

The search generated 15,683 articles, 663 of which were pertinent to healthcare decision making. Theoretical and empirical work identified a range of strategies and levels of engagement of older patients and their families in healthcare decision making. The importance of communication emerged as a key recommendation for meaningful engagement among providers and patients and their caregivers. The principles developed in this study should be implemented with consideration of the context in which care is being provided.

CONCLUSIONS

We have developed a framework that promotes the engagement of patients and their caregivers as equal partners in healthcare decision making. Future research should implement and test the framework in various clinical settings.

Preassessment clinic interview and patient anxiety

BACKGROUND

It is widely recognized that patients have increased anxiety before elective surgery, however, previous research investigating the effect of preassessment clinics (PACs) on anxiety levels has been limited specifically to patient information literature or multimedia use, rather than the consultation process itself. The aim was to investigate the effect attendance at PAC had on patients' anxiety levels, associated with their subsequent surgery and anesthetic.

MATERIALS AND METHODS

This survey consisted of a cross-sectional, questionnaire-based, quantitative study investigating patients' anxiety levels before and after attendance at the PAC. The questionnaire consisted of a series of statements concerning the surgery and anesthetic and rated using a Likert-type scale. All adult patients who attended an appointment at the PAC were eligible to participate in the study. Those unable to read and understand the questionnaire were excluded.

RESULTS

Overall 121 participants were included in the study. Participants felt less anxious about their subsequent surgery and anesthetic following consultation at the PAC (P < 0.001). This was true for both gender subgroups (P < 0.05) Concerns about intraoperative complications generated the most anxiety. Postoperatively, male participants were most anxious about pain and females about nausea and vomiting. Participants also reported high satisfaction rates for the service at the PAC.

CONCLUSIONS

This study contributes to a greater understanding of preoperative anxiety and has important implications for PACs. This clinical survey has been able to demonstrate that consultation at the PAC has a statistically significant positive effect on alleviating patients' anxieties in regards to their surgery and anesthetic.

The uses and implications of standards in general practice consultations

Quality standards play an increasingly important role in primary care through their inscription in various technologies for improving professional practice. While 'hard' biomedical standards have been the most common and debated, current quality development initiatives increasingly seek to include standards for the 'softer' aspects of care. This article explores the consequences of both kinds of quality standards for chronic care consultations. The article presents findings from an explorative qualitative field study in Danish general practice where a standardized technology for quality development has been introduced. Data from semi-structured interviews and observations among 17 general practitioners were analysed using an iterative analytical approach, which served to identify important variations in the uses and impacts of the technology. The most pronounced impact of the technology was observed among general practitioners who strictly adhered to the procedural standards on the interactional aspects of care. Thus, when allowed to function as an overall frame for consultations, those standards supported adherence to general recommendations regarding which elements to be included in chronic disease consultations. However, at the same time, adherence to those standards was observed to narrow the focus of doctor-patient dialogues and to divert general practitioners' attention from patients' personal concerns. Similar consequences of quality standards have previously been framed as manifestations of an inherent conflict between principles of patient-centredness and formal biomedical quality standards. However, this study suggests that standards on the 'softer' aspects of care may just as well interfere with a clinical approach relying on situated and attentive interactions with patients.