Patient education for the millennium: beyond control and emancipation?

Moving between ideologies in self-management support-A qualitative study

Background

Reforms in current health policy explicitly endorse health promotion through group‐based self‐management support for people with long‐term conditions. Health promotion and traditional medicine are based on different logics. Accordingly, health professionals in health‐promoting settings demand the adoption of new practices and ways of thinking.

Objectives

The objective of our study was to investigate how health professionals perceive the health‐promoting group‐based self‐management support that is politically initiated for people with long‐term conditions.

Design

This study had a qualitative research design that included focus group interviews and was guided by a social constructivist paradigm in which group‐based self‐management was viewed as a social construction. Different logics at play were analysed through the theoretical lens of institutional logic. Discussions among participants show frames of references seen as logics.

Setting and participants

We recruited health professionals from group‐based health‐promoting measures for people with type 2 diabetes in Norway. Two focus groups comprising four and six participants each were invited to discuss the practices and value of health promotion through group‐based self‐management support.

Results

The analysis resulted in three themes of discussion among participants that contained reflections of logics in movement. Health professionals’ discussions moved between different logics based on the importance of expert‐based knowledge on compliance and on individual lifestyle choices.

Discussion and conclusion

The study indicates that health promotion through self‐management support is still a field “in the making” and that professionals strive to establish new logics and practices that are not considered difficult to manage or do not contain incompatible understandings.

Empowering Clients through E-Health in Healthcare Services: Case Brunei

The adoption of Web 2.0 in many business sectors is increasing because it offers the ability for customers to have a greater control in generating contents to their personalized web. Customers are empowered in the sense of controlling the process of interaction(s) between a firm with its customers, and among customers themselves. However, providing empowerment in any state of interaction levels to customers (patients) in a healthcare organization is challenging. Many healthcare organizations have adopted empowerment in their e-health scenario; therefore, it needs a mechanism to measure at which level they have implemented empowerment within their organizations. This article proposes three layers of customers' empowerment in e-health systems based on a reference model called Personal Health Cycle (PHC). The layers of empowerment are personal, social, and medical layers respectively. The modular approach is used to simplify healthcare organizations identifying which modules to be adopted in implementing a strategy for customers' empowerment. The model is derived based on recent studies of empowerment in healthcare organizations. A survey also has been conducted in Brunei Darussalam (Brunei) to verify and improve our initial model and to understand the responses of people regarding empowerment in the e-health services. Questions for the survey are derived from the features of the PHC. The respondents reacted positively to the features of empowerment proposed. We use PHC to define and distinguish electronic health record (EHR) from electronic medical record (EMR).

Patient-practitioner relationships desired by overweight/obese adults

OBJECTIVE

This study investigated the characteristics of the patient-practitioner relationship desired by overweight/obese individuals in weight management. The aim was to identify characteristics of the relationship which empower patients to make lifestyle changes.

METHODS

Grounded theory was used inductively to build a model of the patient-practitioner relationship based on the perspectives of 21 overweight/obese adults.

RESULTS

Emerging from the match between patient and practitioner characteristics, collaboration was the key process explicitly occurring in the patient-practitioner relationship, and was characterised by two subcategories; perceived power dimensions and openness. Trust emerged implicitly from the collaborative process, being fostered by relational, informational, and credible aspects of the interaction. Patient trust in their practitioner consequently led to empowering outcomes including goal ownership and perceiving the utility of changes.

CONCLUSION

An appropriate match between patient and practitioner characteristics facilitates collaboration which leads to trust, both of which appear to precede empowering outcomes for patients such as goal ownership and perceiving the utility of changes. Collaboration is an explicit process and precedes the patient trusting their practitioner.

PRACTICE IMPLICATIONS

Practitioners should be sensitive to patient preferences for collaboration and the opportunity to develop trust with patients relationally, through information provision, and modelling a healthy lifestyle.

Promoting patient empowerment in the healthcare system: highlighting the need for patient-centered drug policy

In recent years the term 'patient empowerment' has increasingly been used among healthcare policy makers; however, discussions have focused on narrow activities that as stand-alone activities would be unlikely to give patients power. This paper presents findings from a systematic review of the medical literature. After offering a new definition of patient empowerment, we review the literature behind the concept, aided by a conceptual model. The model is derived from our review of all papers published in medicine (Medline) between 1980 and 2005, and is focused around issues related to the antecedents, activities and outcomes of patient empowerment, especially as they relate to researchers who may need to formulate or evaluate public policies aimed at the issue. We strive to stimulate more discussion of the linkages between public policy and patient empowerment, identifying a need to take a holistic approach, especially when policies are aimed at empowering patients in the area of personal drug management.

Caught between conduct and free choice--a field study of an empowering programme in lifestyle change for obese patients

The aim of this study was to investigate understandings and strategies of empowerment in Learning and Mastery Centres, in a course in lifestyle change for morbidly obese patients. A field study was conducted with nonparticipant observation, and data analysis was inspired by foucauldian discourse analysis. The analysis revealed powerful discourses underlying the course, and the analysis showed how different discourses were set at play within the teaching strategies in the course. The course leaders balanced powerful aspects that involved directing the participants towards strategies promoting their autonomy. The analysis revealed how strategies to reduce the impression of direction and conduct are powerful actions. From a foucauldian perspective of power, this analysis demonstrates how power is everywhere as a productive force. When creating programmes to empower patients to help them deal with their health, it seems vital that health professionals examine power. By accepting the presence of power, professionals can examine the truth motivation underlying an empowerment programme.

Patient empowerment in theory and practice: polysemy or cacophony?

OBJECTIVE

This paper examines how the term "empowerment" has been used in relation to the care and education of patients with chronic conditions over the past decade.

METHODS

Fifty-five articles were analysed, using a qualitative method of thematic analysis.

RESULTS

Empowerment is more often defined according to some of its anticipated outcomes rather than to its very nature. However, because they do not respect the principle of self-determination, most anticipated outcomes and most evaluation criteria are not specific to empowerment. Concerning the process of empowerment, our analysis shows that (i) the educational objectives of an empowerment-based approach are not disease-specific, but concern the reinforcement or development of general psychosocial skills instead; (ii) empowering methods of education are necessarily patient-centred and based on experiential learning; and (iii) the provider-patient relationship needs to be continuous and self-involving on both sides.

CONCLUSION

Our analysis did not allow for the unfolding of a well-articulated theory on patient empowerment but revealed a number of guiding principles and values.

PRACTICE IMPLICATIONS

The goals and outcomes of patient empowerment should neither be predefined by the health-care professionals, nor restricted to some disease and treatment-related outcomes, but should be discussed and negotiated with every patient, according to his/her own particular situation and life priorities.

A review of evidence on the conceptual elements informing client-centred practice

BACKGROUND

Client-centred practice is a central concept in occupational therapy in Canada. Since 1980, Canadian occupational therapy publications have discussed the elements of a client-centred practice approach.

PURPOSE

The purpose of this paper is to enhance the understanding of key elements of a client-centred approach and to highlight the implications for practice that arise from this discussion.

METHOD

Literature about client-centred practice in health care from 1990 - 2005 was reviewed regarding thoughts and ideas about client-centred practice. The content was analyzed for thematic focus about client-centred practice conceptual ideas and their influence on practice.

RESULTS

Thematic conceptual elements emerging from the review include an overarching theme of power, with important underpinning themes of listening and communicating, partnership, choice, and hope. Selected definitions of client-centred practice and the link to best practice provide the context for the presentation of the concepts and recommendations for the implementation of client-centred practice.

PRACTICE IMPLICATIONS

The paper concludes with a discussion of practice implications through the presentation of questions for therapists to consider as a quick reference tool and suggestions for further research and dialogue concerning client-centred practice.

Lay perceptions of evidence-based information--a qualitative evaluation of a website for back pain sufferers

Background

In an evidence-informed patient choice the patient has access to research-based information about the effectiveness of health care options and is encouraged to use this information in treatment decisions. This concept has seen growing popularity in recent years. However, we still know relatively little about users' attitudes to the use of research-based information, possibly because people have been unexposed to this type of information. After developing the BackInfo website where the results of Cochrane systematic reviews on the effects of low back pain were adapted and presented to lay users we evaluated how users responded to this information.

Methods

Focus group meetings were held with 18 chronic back pain sufferers, after they had been sent a link to the website before the meetings.

Results

The focus groups suggest that the most important challenges to the use of BackInfo's research-based information are not primarily tied to the comprehension or presentation of the information, but are mainly associated with participants' attitudes towards the credibility of research and researchers, and the applicability of research results to themselves as individuals. Possible explanations for participants' lack of trust in research and their apparent difficulties in applying this research to their own situations include aspects that may be typical for the general public including the media's presentation of research, and a lack of familiarity with and feelings of distance to research evidence. Other aspects may be typical for patient groups with chronic and unclear medical conditions, such as a lack of trust in the health care establishment in general.

Conclusion

In order to enhance the credibility and applicability of research evidence, providers of research-based information could explore a number of possibilities including the use of including personal stories to illustrate the research outcomes.

Making words count: the value of qualitative research

In the current climate of evidence-based practice, physiotherapy is urged to prove its worth via rigorous scientific research. However, there are concerns that limited methodologies are used to explore complex therapeutic issues, and that the profession relies too heavily on quantitative research studies to provide its evidence base. Qualitative research methods are able to explore the complexity of human behaviour and generate deeper understanding of illness behaviours and therapeutic interactions. Nevertheless, there is still a sense of distrust of qualitative research, related to the challenge of evaluating both the quality and usefulness of findings derived through qualitative methods. This discussion paper explores these issues. It examines some of the most frequently used techniques aimed at ensuring quality and value in qualitative research, such as sampling, triangulation, multiple coding, respondent validation and the use of audit trails, as well as addressing reflexivity. Because of the pluralistic and interactive nature of qualitative inquiry, the criteria used to judge quality need to be appropriate to each piece of research and should provide evidence to help readers to evaluate the calibre of the study and its relevance to their own area of work.

Effects of an empowerment-based psychosocial intervention on quality of life and metabolic control in type 2 diabetic patients

This study was aimed at determining impact of an empowerment-based psychosocial intervention on the patients' quality of life and glycemic control as compared to patients in standard care. Consecutively recruited type 2 diabetic patients, scheduled for their regular medical check-ups, were individually acquainted with empowerment-based principles and invited to participate in an empowering psychosocial course. The response rate was 35% giving a number of 73 patients who were treated in eight separate groups. The treated patients reported their quality of life to be improved after the course regarding its psychological and social aspects. Their glycemic control also improved and remained so after 3- and 6-month follow-up periods, still being in a category of poor control. Empowerment-based psychosocial intervention in type 2 diabetic patients was shown to favourably affect their quality of life and to improve their metabolic control, the latter in a modest degree. Better educated patients believing in internal health control and efficacy of diabetes treatment seemed to benefit the most. Further research is needed in order to highlight individual preferences for different educational approaches, as well as social and cultural factors affecting them.

Developing patient-centred information for back pain sufferers

OBJECTIVE

To identify information needs among a group of back pain sufferers as well as the barriers that may prevent them from accessing this information.

DESIGN

Data were collected through the use of open, in-depth interviews, through contributions to the Norwegian Back Pain Association's online discussion list, and through a search of the literature.

PARTICIPANTS

Norwegian back pain sufferers and their carers.

MAIN VARIABLES STUDIED

Information needs and barriers.

RESULTS

The informants described information needs that covered a wide range of topics, clinical, financial, emotional and social. Informants wanted to understand the cause of their pain and wanted information about existing diagnoses and diagnostic procedures. Informants asked for information about treatment alternatives, both within and outside the established health-care system, the effects of these treatment alternatives, their procedures, side-effects and costs. In addition, informants wanted information about the social and emotional effects of long-term pain; coping with everyday life; other people's experiences; and about welfare benefits and patient rights. Barriers to this information included the use of medical, legal and other jargon, doctors' lack of time, lack of communication skills, lack of knowledge about back pain and attitudes to back pain patients.

CONCLUSIONS

To successfully address the questions and concerns of users, there should be an attempt to present information on as many of these topics as possible. Information should be presented in the user's own language, at several levels of understanding, and should include both evidence- and experienced-based knowledge.

The role of patients' meta-preferences in the design and evaluation of decision support systems

The arrival of new analysis-based decision technologies will necessitate a profound rethinking both of the nature of the patient-doctor relationship and of the way aids and support systems designed to improve decision-making within that relationship are designed and evaluated. One-dimensional typologies of the traditional 'paternalist/shared/informed' sort do not provide the complexity called for by the heterogeneity of patient's 'meta-preferences' regarding their relationship with a doctor on the one hand and regarding the analytical level of judgement and decision-making on the other. A multidimensional matrix embodying this distinction is proposed as a framework of the minimal complexity required for the design and evaluation of the full range of decision aids and decision modes. Essentially aids should be conceived of and evaluated cell-specifically and the search for universally satisfactory decision support systems abandoned. 'shared' and'informed' are best interpreted as attributes which may or not be in line with a patient's meta-preferences. Future research should focus on the higher level goal of better decision-making, a goal that will need to respect and reflect these meta-preferences.

Evolution not revolution? The struggle for the recognition and development of patient education in the UK

In this paper, a review of patient education in the United Kingdom (UK) is presented. Some of the reasons for the development of patient education are identified and its relationship to other educational activities in health care settings is discussed. The gap between the theory and practice of UK patient education is then examined and emerging new practices are considered. The concluding section of the paper identifies a number of important questions to ask when considering the future development of patient education. These are relevant questions for patients, practitioners, researchers and politicians.

Communicator styles of hospital patients during nurse-patient counseling

This article describes nurse-patient communication during counseling sessions. It focuses on the patient as a participant in a discussion and aims at a description of patients' communicator styles, which were observed on videotape based on 38 counseling sessions transcribed word by the word. Interviews of the participating nurses and patients were used for partial support of the interpretations. The analytic method chosen was typology, and it has been used for achieving a multifaceted qualitative description of patient communication. The research material yielded seven types of communicator styles: Quietly Assenting, Emotionally Expressive, Storyteller, Stoic Observer, Inquisitive of Detail, Dominant, and Critical Self-observer. The communicator styles were indicative of the multitude of ways in which patients participate in counseling discussions and they make it possible to describe the varying expressions of patient communication. This article presents new background information on patient communication and the outcome may prove to be useful for developing health counseling.

Patient information systems that tailor to the individual

The potential of computers in patient education has been well described by Skinner et al. One of their recommendations was for more personalized systems. In this article we discuss how computer-based patient information systems can provide material that is tailored to the individual, giving a number of examples of systems developed in Scotland. We review some of the techniques used in developing tailored systems, and consider the evidence to date as to their efficacy.