Treating patients as persons: a capabilities approach to support delivery of person-centered care

Exploring the meaning of a good life for older widows with extensive need of care: a qualitative in-home interview study

INTRODUCTION

Studies of older women's life transitions is rare but gains relevance as the aging population, with older women as the majority, expands.

PURPOSE

To explore the meaning of a good life for older widows with extensive home care needs.

MATERIALS AND METHODS

Semi-structured interviews were carried out with eleven women, aged 80 and over (82-95 years, mean 90) residing at home with extensive care needs (≥4 daily sessions, averaging 2.5-6 hours, mean 3). Data were analysed by reflexive thematic analysis.

RESULTS

The theme "This Day in My Home, the frame of my life" reflects the women's experience of a good life. A good day imbued them with hope, trust and security, carrying them forward with the assurance that night would usher in a new day. However, there were moments when life was merely about navigating daily challenges. During such days, the women felt trapped in time, unsafe and lonely.

CONCLUSION

A day at home may seem static, yet it mirrors life's dynamism, evolving with shifting circumstances. Older widows navigate challenges while maintaining their sense of self, independence, and connection to home. These findings have implications for aged care, recognizing the multifaceted aspects of life and the centrality of home.

A more equitable approach to economic evaluation: Directly developing conceptual capability wellbeing attributes for Tanzania and Malawi

Capability wellbeing can potentially provide a holistic outcome for health economic evaluation and the capability approach seems promising for African countries. As yet there is no work that has explored the evaluative space needed for health and care decision making at the whole population level and procedures that merely translate existing measures developed in the global north to contexts in the global south risk embedding structural inequalities. This work seeks to elicit the concepts within the capability wellbeing evaluative space for general adult populations in Tanzania and Malawi. Semi-structured interviews with 68 participants across Tanzania and Malawi were conducted between October 2021 and July 2022. Analysis used thematic coding frames and the writing of analytic accounts. Interview schedules were common across the two country settings, however data collection and analysis were conducted independently by two separate teams and only brought together once it was clear that the data from the two countries was sufficiently aligned for a single analysis. Eight common attributes of capability wellbeing were found across the two countries: financial security; basic needs; achievement and personal development; attachment, love and friendship; participation in community activities; faith and spirituality; health; making decisions without unwanted interference. These attributes can be used to generate outcome measures for use in economic evaluations comparing alternative health interventions. By centring the voices of Tanzanians and Malawians in the construction of attributes that describe a good life, the research can facilitate greater equity within economic evaluations across different global settings.

Social participation in the promoting activity, independence and stability in early dementia (PrAISED), a home-based therapy intervention for people living with dementia: a realist evaluation

BACKGROUND

Interventions promoting social activity may reduce behavioural psychological symptoms and improve quality of life in people living with dementia. This study aimed to identify social benefits for participants living with dementia in the context of Promoting Activity, Independence and Stability in Early Dementia (PrAISED), an exercise intervention programme promoting physical activity and independence in participants living with dementia in England.

METHODS

This was a multi-method realist evaluation undertaking secondary analysis of data collected during the PrAISED process evaluation, including qualitative interviews with participants with dementia, caregivers and therapists, personal notes of researchers, and video recordings of therapy sessions. The study consisted of four phases: (1) Setting operational definition of social outcomes in PrAISED; (2) Developing Context, Mechanisms, Outcome (CMO) configurations; (3) Testing and refining CMOs; and (4) Synthesising definitive CMOs into a middle range theory.

RESULTS

Two CMOs were identified. (1) When therapists were able to make therapy sessions engaging and had the caregivers' support, the participants experienced therapy sessions as an opportunity to achieve goals in areas they were interested in. They also found the sessions enjoyable. This all led to the participants being highly engaged in their social interactions with the therapists. (2) When the participants realised that they were gaining benefits and progress through the PrAISED intervention, such as increased balance, this boosted their confidence in physical ability. It might also reduce caregivers' risk-aversion/gatekeeping attitude, which in turn would lead to participants' increased participation in social activities.

CONCLUSION

The PrAISED intervention supported social participation in participants living with dementia. Under certain circumstances, home-based therapy interventions can be beneficial for social health (regardless of physical health gains). Given the limitations of currently available outcome measures to assess social participation, qualitative methods should be used to explore social health outcomes.

Caesarean section on maternal request: a qualitative study of conflicts related to shared decision-making and person-centred care in Sweden

BACKGROUND

Today, person-centred care is seen as a cornerstone of health policy and practice, but accommodating individual patient preferences can be challenging, for example involving caesarean section on maternal request (CSMR). The aim of this study was to explore Swedish health professionals' perspectives on CSMR and analyse them with regard to potential conflicts that may arise from person-centred care, specifically in relation to shared decision-making.

METHODS

A qualitative study using both inductive and deductive content analysis was conducted based on semi-structured interviews. It was based on a purposeful sampling of 12 health professionals: seven obstetricians, three midwives and two neonatologists working at different hospitals in southern and central Sweden. The interviews were recorded either in a telephone call or in a video conference call, and audio files were deleted after transcription.

RESULTS

In the interviews, twelve types of expressions (sub-categories) of five types of conflicts (categories) between shared decision-making and CSMR emerged. Most health professionals agreed in principle that women have the right to decide over their own body, but did not believe this included the right to choose surgery without medical indications (patient autonomy). The health professionals also expressed that they had to consider not only the woman's current preferences and health but also her future health, which could be negatively impacted by a CSMR (treatment quality and patient safety). Furthermore, the health professionals did not consider costs in the individual decision, but thought CSMR might lead to crowding-out effects (avoiding treatments that harm others). Although the health professionals emphasised that every CSMR request was addressed individually, they referred to different strategies for avoiding arbitrariness (equality and non-discrimination). Lastly, they described that CSMR entailed a multifaceted decision being individual yet collective, and the use of birth contracts in order to increase a woman's sense of security (an uncomplicated decision-making process).

CONCLUSIONS

The complex landscape for handling CSMR in Sweden, arising from a restrictive approach centred on collective and standardised solutions alongside a simultaneous shift towards person-centred care and individual decision-making, was evident in the health professionals' reasoning. Although most health professionals emphasised that the mode of delivery is ultimately a professional decision, they still strived towards shared decision-making through information and support. Given the different views on CSMR, it is of utmost importance for healthcare professionals and women to reach a consensus on how to address this issue and to discuss what patient autonomy and shared decision-making mean in this specific context.

Are the content and usability of a new direct observation tool adequate for assessing competency in delivering person-centred care: a think-aloud study with patients and healthcare professionals in Sweden

OBJECTIVE

To evaluate the content and usability of a new direct observation tool for assessing competency in delivering person-centred care based on the Gothenburg Centre for Person-Centred Care (gPCC) framework.

DESIGN

This is a qualitative study using think-aloud techniques and retrospective probing interviews and analyzed using deductive content analysis.

SETTING

Sessions were conducted remotely via Zoom with participants in their homes or offices.

PARTICIPANTS

11 participants with lengthy experience of receiving, delivering and/or implementing gPCC were recruited using purposeful sampling and selected to represent a broad variety of stakeholders and potential end-users.

RESULTS

Participants generally considered the content of the four main domains of the tool, that is, person-centred care activities, clinician manner, clinician skills and person-centred care goals, to be comprehensive and relevant for assessing person-centred care in general and gPCC in particular. Some participants pointed to the need to expand person-centred care activities to better reflect the emphasis on eliciting patient resources/capabilities and psychosocial needs in the gPCC framework. Think-aloud analyses revealed some usability issues primarily regarding difficulties or uncertainties in understanding several words and in using the rating scale. Probing interviews indicated that these problems could be mitigated by improving written instructions regarding response options and by replacing some words. Participants generally were satisfied with the layout and structure of the tool, but some suggested enlarging font size and text spacing to improve readability.

CONCLUSION

The tool appears to satisfactorily cover major person-centred care activities outlined in the gPCC framework. The inclusion of content concerning clinician manner and skills was seen as a relevant embellishment of the framework and as contributing to a more comprehensive assessment of clinician performance in the delivery of person-centred care. A revised version addressing observed content and usability issues will be tested for inter-rater and intra-rater reliability and for feasibility of use in healthcare education and quality improvement efforts.

Perceptions of Hearing Health Care: A Qualitative Analysis of Satisfied and Dissatisfied Online Reviews

PURPOSE

The aim of this study was to examine the hearing health care experience of satisfied and dissatisfied consumers as reported on Google reviews.

METHOD

Using qualitative thematic analysis, open-text responses from Google regarding hearing health care clinics across 40 U.S. cities were examined. During the original search, 13,168 reviews were identified. Purposive sampling led to a total of 8,420 five-star reviews and 321 one-star reviews. The sample consisted of 500 five-star (satisfied) and 234 one-star (dissatisfied) reviews, describing experiences with audiology clinics, excluding reviews related to ear, nose, and throat services; other medical specialties; and those not relevant to hearing health care.

RESULTS

Satisfied and dissatisfied consumer reviews yielded nuanced dimensions of the hearing health care consumer experience, which were grouped into distinct domains, themes, and subthemes. Six and seven domains were identified from the satisfied and dissatisfied reviews, encompassing 23 and 26 themes, respectively. The overall experience domain revealed emotions ranging from contentment and gratitude to dissatisfaction and waning loyalty. The clinical outcomes domain highlights the pivotal contribution of well-being and hearing outcomes to the consumer experience, while the standard of care domain underscores shared expectations for punctuality, person-centered care, and efficient communication. Facility quality, professional competence, and inclusive care were also highlighted across positive and negative reviews.

CONCLUSIONS

Findings indicate dimensions of satisfied and dissatisfied hearing health care consumer experiences, identifying areas for potential service refinement. These consumer experiences inform person-centric service delivery in hearing health care.

Towards new perspectives: A scoping review and meta-synthesis to redefine brain health for multiple sclerosis

BACKGROUND AND PURPOSE

Research promoting the health of the brain has increased exponentially over the last decade. The importance of 'brain health' for multiple sclerosis (MS), as one example, is a high priority. However, as research into the concept increases, so does varied use of the term.

METHODS

A scoping review, guided by the methodological framework of the Joanna Briggs Institute, was conducted to collate the evidence relating to brain health for MS. A comprehensive literature search incorporated six search strategies to retrieve both scientific and grey literature sources. All evidence sources were qualitatively charted and synthesized (meta-synthesis) according to their definition of brain health used, outcome measures and brain-healthy lifestyle elements.

RESULTS

Seventy evidence sources (34 peer reviewed, 36 grey literature) were eligible for inclusion. Of these, just over half (n = 40, 57%) provided a definition of brain health. The most common definition alluded to the biomedical model of neurological reserve (n = 22, 55%), a self-remodelling theory described to retain optimal brain function. Twenty-nine outcome measures of brain health were identified, the most frequent being magnetic resonance imaging metrics (n = 25, 83%). Physical activity was the most prevalent brain-healthy lifestyle element (n = 44), followed by avoidance of smoking (n = 26) and diet (n = 24).

CONCLUSIONS

Brain health should be considered a primary target for optimal disease and lifestyle management across the MS disease course. A working definition reflecting a shift from a medical lens towards broader biopsychosocial contexts that may influence brain health for people living with MS is proposed.

"They seemed to be like cogs working in different directions": a longitudinal qualitative study on Long COVID healthcare services in the United Kingdom from a person-centred lens

BACKGROUND

The COVID-19 pandemic has presented significant challenges to the already over-stretched healthcare system in the United Kingdom (UK). These challenges are particularly pronounced for people living with the novel condition of Long COVID (LC) as they often face persistent and fluctuating symptoms, encountering prolonged uncertainty when seeking medical support. Despite a growing understanding of the healthcare challenges associated with LC, existing qualitative studies have predominantly focused on individual experiences rather than examining the structural aspects of healthcare.

METHODS

A longitudinal qualitative study with 80 participants and 12 healthcare practitioners was conducted in the UK to explore the healthcare experiences of those with LC. In total, 178 interviews (with attrition) were collected across two rounds, from November 2021 to March 2022, and from June to October 2022.

RESULTS

Embracing a person-centred framework that recognises and nurtures interconnected individual, relational, and existential needs, we investigated healthcare experiences related to LC across primary, secondary, and specialist integrated care. Using this perspective, we identified three overarching themes. Theme 1 addresses the persistent hurdle of accessing primary care as the initial point of contact for LC healthcare; Theme 2 underscores the complexity of navigating secondary care; and Theme 3 encapsulates the distinctive challenges of developing LC integrated care. These themes are interlinked, as people with LC often had to navigate or struggle between the various systems, with practitioners seeking to collaborate across the breadth of their professional responsibilities.

CONCLUSION

From a person-centred approach, we were able to identify the needs of those affected by lasting LC symptoms and comprehend how health services intricately influence these needs. The focus on healthcare systems also captures the nuanced impact that continuing healthcare struggles can have on people's identity. As such, our findings provide evidence to inform a more effective and sustainable delivery of person-centred care for people with LC across various healthcare settings and over time.

At the Heart of Resilience: Empowering Women's Agency in Navigating Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death among women globally, emphasizing the need for a healthcare approach that empowers women through agency. This review focuses on the critical role of women's agency in navigating CVD, integrating insights from various fields, including medicine, education, psychology, and sociology. The review highlights the shift toward patient-centred care, a framework in which women are recognized as key decision-makers, a crucial change given the historical underemphasis on women's health issues in medical practice. The diagnosis of CVD in women often involves emotional and psychological challenges. Unexpected diagnoses significantly disrupt perceived well-being, and prolonged diagnostic processes lead to professional skepticism and neglect of symptoms, resulting in delayed or inaccurate diagnoses and strained healthcare relationships. Effective management of CVD necessitates continuous self-management and a holistic approach to care, particularly for those with trauma who are at increased risk of cardiac incidents. Empowerment for women with CVD involves promoting self-confidence, autonomy, and active patient participation in healthcare. Implementing comprehensive care models is crucial for improving chronic CVD management, highlighting the need for healthcare systems that prioritize patient agency and empowerment. From the perspective of a woman with lived experience, this article examines the impact of CVD on women's agency throughout the diagnostic journey. By highlighting women's agency rather than particular behavioural changes, this review offers a comprehensive analysis that can shape policy, stimulate new research, and foster a more equitable, efficient, and empathetic healthcare system for women with CVD.

Self-efficacy and healthcare costs in patients with chronic heart failure or chronic obstructive pulmonary disease

AIMS

This study aims to explore possible associations between self-efficacy and healthcare and drug expenditures (i.e. direct costs) in patients with chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) in a study investigating the effects of person-centred care delivered by telephone.

METHODS AND RESULTS

This exploratory analysis uses data from an open randomized controlled trial conducted between January 2015 and November 2016, providing remote person-centred care by phone to patients with CHF, COPD, or both. Patients hospitalized due to worsening of CHF or COPD were eligible for the study. Randomization was based on a computer-generated list, stratified for age ≥ 75 and diagnosis. At a 6 month follow-up, 118 persons remained in a control group and 103 in an intervention group. The intervention group received person-centred care by phone as an addition to usual care. Trial data were linked to register data on healthcare and drug use. Group-based trajectory modelling was applied to identify trajectories for general self-efficacy and direct costs. Next, associations between self-efficacy trajectories and costs were assessed using regression analysis. Five trajectories were identified for general self-efficacy, of which three indicated different levels of increasing or stable self-efficacy, while two showed a decrease over time in self-efficacy. Three trajectories were identified for costs, indicating a gradient from lower to higher accumulated costs. Increasing or stable self-efficacy was associated with lower direct costs (P = 0.0013).

CONCLUSIONS

The findings show that an increased or sustained self-efficacy is associated with lower direct costs in patients with CHF or COPD. Person-centred phone contacts used as an add-on to usual care could result in lower direct costs for those with stable or increasing self-efficacy.

Balancing between being the most valuable player (MVP) and passing the ball: a qualitative study of support when living with chronic pain in Sweden

OBJECTIVE

This study aimed to elucidate the meaning of lived experiences of support from social networks and the healthcare sector in persons with chronic pain.

DESIGN

A qualitative, phenomenological hermeneutic method was used to analyse interview data.

SETTING

Participants were recruited from patient organisations in Sweden.

PARTICIPANTS

Ten (seven women, two men and one non-binary) individuals with chronic musculoskeletal pain were included.

FINDINGS

The meaning of lived experiences of support in persons with chronic pain involves balancing between being the most valuable player (MVP) and passing the ball, meaning balancing between being a capable person and accepting support to be that capable person.

CONCLUSION

For participants who lived with chronic pain, support means balancing between being capable (the MVP) and willing to accept support (passing the ball), which aligns with the concept of person-centred care. Our findings may be useful for policy-makers, managers and clinical professionals when planning and performing care for persons with chronic pain. Future research should focus on how the healthcare sector can create support to enable persons with chronic pain to be the MVP while being able to pass the ball to their social networks and the healthcare sector.

Psychometric properties of the client-centred rehabilitation questionnaire-is derived from a large and varied group of rehabilitation users

PURPOSE

The purpose of this study was to inspect and establish the factor structure of the Icelandic Client-Centred Rehabilitation Questionnaire [CCRQ-is] and investigate the service experiences of a large and varied sample of rehabilitation users.

MATERIALS AND METHODS

Altogether 499 rehabilitation users completed the questionnaire. Confirmatory and exploratory factor analysis was conducted for analysis of items. Mann-Whitney's U and Kruskal-Wallis test was used to compare subscale responses based on participants' characteristics.

RESULTS

Four factors explained 53,2% of the variance: Respect and attentiveness, Interaction with significant others, Responsiveness to needs and preferences and Education and enablement. Subscales showed internal consistency from 0.72-0.91 and 0.92 for the whole instrument. The subscale Respect and attentiveness represented user centred rehabilitation the most and Interaction with significant others the least. Significant differences in relation to health conditions and age were obtained on all four subscales and differences by gender on one subscale.

CONCLUSIONS

Our results suggest the CCRQ-is is a reliable tool that can be used with rehabilitation users with a broad range of characteristics within the Icelandic context. The extent to which the intersection of age, gender and health issues influence users' perception of services needs to be further scrutinized.

Identifying personal health-related resources of women with breast cancer for nursing: An integrative review

Personal health-related resources are essential for women with breast cancer, as these help them to maintain their own health and well-being during different phases of their illness. The purpose of this integrative review was to identify, describe and synthetise what personal health-related resources have already been identified for this patient group. We carried out an integrative review to find papers that focused on personal health-related resources for women with breast cancer aged 18-64 years. The search covered 1 January 2005 to 31 May 2021 and was carried out using the CINAHL, PubMed, PsycINFO, Web of Science and Cochrane Library databases. It was limited to peer-reviewed scientific papers with abstracts published in English and 23 papers met the inclusion criteria. The data were analysed using content analysis. Personal health-related resources for women with breast cancer consisted of three different, but inherently interconnected, categories of personal strengths, person-centred cancer care and social support from and involvement in their cultural community. Personal health-related resources for women with breast cancer were multifaceted. Women need nursing support to identify and use these resources and future studies are needed to strengthen how they are measured.

Patients' experiences of patient-centred care in hospital setting: A systematic review of qualitative studies

BACKGROUND

Patient-centred care (PCC) has been proposed as an appropriate approach for addressing current shifts in healthcare needs. Although the importance of PCC is generally recognised, PCC is poorly understood by patients in the hospital settings.

OBJECTIVES

To identify patients' experiences of PCC in hospital settings.

METHODOLOGICAL DESIGN

This systematic review followed the Joanna Briggs Institute's (JBI) guidance for systematic reviews of qualitative evidence and the PRISMA checklist for reporting systematic reviews. The search strategy included peer-reviewed qualitative studies published after 2010 in English or Finnish. The databases searched were SCOPUS, MEDLINE, CINAHL and Medic. Unpublished studies and grey literature were searched in MedNar. Ten qualitative studies were included, and their quality was assessed by two independent reviewers using JBI quality assessment criteria. The data were analysed using thematic analysis.

SETTING AND PARTICIPANTS

Studies were included if they had explored adult patient experiences of PCC in hospital settings.

RESULTS

A thematic analysis produced 14 subthemes which were grouped into five analytical themes: the presence of the professional, patient involvement in care, receiving information, the patient-professional relationship and being seen as a person.

CONCLUSIONS AND IMPLICATIONS

This review suggests that the implementation and provision of PCC in hospitals is incomplete and patients' involvement in their own care should be in the focus of PCC. The majority of patients experienced receiving PCC, but others did not. The need for improvement of patient involvement was strongly emphasised. Patients highlighted the importance of professionals being present and spending time with patients. Patients felt well-informed about their care but expressed the need for better communication. Meaningful patient-professional relationships were brokered by professionals demonstrating genuine care and respecting the patient as an individual. To improve the implementation of PCC, patient experiences should be considered in the development of relevant hospital care strategies. In addition, more training in PCC and patient-professional communication should be provided to health care professionals.

A lowered threshold to partnerships: a mixed methods process evaluation of participants' experiences of a person-centred eHealth intervention

BACKGROUND

In order to understand pathways of complex interventions, the Medical Research Council has suggested that process evaluations should be conducted alongside randomised controlled trials (RCTs). This paper presents a mixed methods process evaluation of a complex, person-centred eHealth intervention for persons on sick leave with common mental disorders.

AIM

The aim of the study was to explore participants' experiences of a person-centred eHealth intervention and illuminate meaningful activities and processes.

METHODS

Participants were recruited from the intervention arm of an RCT (n = 102). Questionnaires on perceived meaningfulness of the overall intervention and intervention activities were sent to participants on two occasions, after 3 and 6 months, and semi-structured interviews were conducted with a purposeful sample of 15 participants in the intervention group. Questionnaire data were analysed using descriptive statistics, and interview data were analysed using qualitative content analysis. The quantitative and qualitative data strands were integrated at interpretation.

RESULTS

At both follow-ups, a majority of participants reported that the intervention was fully or partly meaningful and that the most meaningful activity was the phone calls with health care professionals working in the intervention. In the qualitative analysis, three categories describing participants' experiences of the intervention were formed: Acknowledgment in a disconcerting situation, Finding ways forward and Unmet expectations. A synthesis of quantitative and qualitative findings resulted in the overarching theme of meaningfulness as constituted by a lowered threshold to partnerships: support within reach, when needed.

CONCLUSION

Experiences of meaningfulness of the intervention were constituted by a lowered threshold to forming care partnerships, in which support was within reach, when needed. If the content of the intervention was not in accordance with individuals' needs or expectations, access alone did not suffice to constitute meaningfulness.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03404583; 19/01/2018.

Patient Experiences of Communication with Healthcare Professionals on Their Healthcare Management around Chronic Respiratory Diseases

BACKGROUND

Communication is an important clinical tool for the prevention and control of diseases, to advise and inform patients and the public, providing them with essential knowledge regarding healthcare and disease management. This study explored the experience of communication between healthcare professionals (HCPs) and people with long-term lung conditions, from the patient perspective.

METHODS

This qualitative study analyzed the experience of people with chronic lung disease, recruited via Asthma & Lung UK (A&LUK) and COPD research databases. A&LUK invited people who had expressed a desire to be involved in research associated with their condition via their Expert Patient Panel and associated patients' groups. Two focus group interviews (12 participants) and one individual interview (1 participant) were conducted. Thematic analysis was used for data analysis.

RESULTS

Two main themes were identified and we named them 'involving communication' and 'communication needs to be improved. 'They included seven subthemes: community-led support increased the patients' social interaction with peers; allied-HCP-led support increased patients' satisfaction; disliking being repeatedly asked the same basic information; feeling communication was unengaging, lacking personal specifics and the use of medical terminology and jargon.

CONCLUSIONS

The study has identified what most matters in the process of communication with HCPs in people with long-term respiratory diseases of their healthcare management. The findings of the study can be used to improve the patient-healthcare professional relationship and facilitate a better communication flow in long-term healthcare management.

Person-Centered Mindfulness: A Culturally and Spiritually Sensitive Approach to Clinical Practice

Mindfulness meditation is rapidly being integrated into many different forms of counseling and psychotherapy, and there is a growing evidence base for its effectiveness. It is important to understand the spiritual roots of mindfulness, and to apply it in a patient-centered manner, sensitive to the patient's own faith tradition rather than taking a one-size-fits-all approach, assuming that mindfulness-based practice is a purely secular approach. The philosophical underpinning of mindfulness lies squarely in the Buddhist faith tradition. Indeed, mindfulness is the 7th step on the Eightfold Path, which is the heart of Buddhist teachings. Many practitioners, however, may not realize that there are Western meditative techniques that are very similar to mindfulness and that have deep roots within Christian, Jewish, and Muslim faith traditions. Patient-centered mindfulness involves the use of mindfulness and other meditation methods that are based on the patient's own faith tradition, rather than applying Eastern forms of mindfulness claiming these are a secular approach appropriate for everyone regardless of religious beliefs, even if those beliefs are not consistent with the Buddhist religious or philosophical approach. In this article, I briefly examine the evidence for the clinical effectiveness of mindfulness meditation, and then go into greater depth on Hindu, Buddhist, Christian, Jewish, and Muslim forms of mindfulness or similar meditative practices, providing resources that will better equip clinicians and researchers to provide patient-centered culturally-sensitive care.

Integrating health promotion with and for older people - eHealth (IHOPe) - evaluating remote integrated person-centred care : Protocol of a randomised controlled trial with effectiveness, health economic, and process evaluation

BACKGROUND

Healthcare and welfare systems worldwide are unprepared to accommodate the growing population of older people. Simultaneously, the cost of reactive care for older people is increasing. However, healthcare systems in many countries are reforming towards integrated and person-centred care with a focus on health promotion and proactive actions. The Integrating Health Promotion with and for Older People - eHealth (IHOPe) project aims to describe and evaluate a person-centred e-support intervention that promotes a sustainable partnership between community-dwelling frail older people and health and social care professionals.

METHODS

The IHOPe project is designed as a randomised controlled trial comparing a control group receiving standard care with an intervention group receiving standard care and add-on person-centred care through telephone support and a digital platform. The primary outcome measure is a composite score of changes in general self-efficacy and the need for unscheduled hospital care. The project is conducted in Gothenburg, Sweden. At least 220 participants aged ≥ 75 years will be included after being screened using a frailty instrument. The study design, intervention components, digital platform, and questionnaires were developed in close collaboration with an advisory group of inter-professional researchers, stakeholders, clinicians, and older representatives. Data will mainly be collected through questionnaires at baseline and 3, 6, and 12 months after inclusion in the study. Recruitment is ongoing and should be completed during 2023. Data will be analysed using quantitative and qualitative methods. The evaluation will include effectiveness, process, and health economics. The study was approved by the Regional Ethical Review Board in Gothenburg, Sweden (Dnr 2019-05364, Dnr 2020-03550, Dnr 2021-03255).

DISCUSSION

The findings will expand our knowledge of remotely integrated person-centred care for frail older people. Thereby, the IHOPe project is expected to fill highlighted knowledge gaps on intervention evaluations including the triad of person-centred, digital, and integrated care elements, as well as economic evaluations of remote health services for frail older people. The study is ongoing, and the results are not completed but if they turn out to be positive, implementation is not limited to time or location.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT04416815. Registered 07/06/2021.

Shared Decision Making in Psychiatry: Dissolving the Responsibility Problem

Person centered care (PCC) invites ideas of shared responsibility as a direct result of its shared decision making (SDM) process. The intersection of PCC and psychiatric contexts brings about what I refer to as the responsibility problem, which seemingly arises when SDM is applied in psychiatric settings due to (1) patients’ potentially diminished capacities for responsibility, (2) tension prompted by professional reasons for and against sharing responsibility with patients, as well as (3) the responsibility/blame dilemma. This paper aims to do away with the responsibility problem through arguing for a functional approach to mental illness, a blameless responsibility ascription to the person with mental illness, as well as a nuanced understanding of SDM as part of an emancipation-oriented PCC model.

Unifying and universalizing Personalised Care? An analysis of a national curriculum with implications for policy and education relating to person-centred care

OBJECTIVE

To examine the Curriculum of England's Personalised Care Institute as a national initiative to promote person-centred practice.

METHOD

Analysis of Curriculum content and discourse RESULTS: The Curriculum describes an educational framework which aspires to unify approaches and universalize provision of Personalised Care. It presents 8 "models and approaches" and 6 "components" within the "whole" of Personalised Care. It locates their unity in an underlying common core repertoire of professional capabilities and values and an anchoring belief in people's strengths, resourcefulness and ability to develop their own solutions with appropriate support. The Curriculum indicates some complexity in the provision of Personalised Care but leaves unanswered questions about the theoretical coherence of the concept. It also neglects some important aspects of person-centredness (especially values beyond empowerment and choice); the implications of entrenched social inequalities and systemic prejudices; and other practical-ethical implementation challenges that can be difficult for health professionals.

CONCLUSION

The Curriculum signals a national commitment to person-centred practice, but its practical potential is limited by its neglect of the value tensions and diverse situational challenges involved.

PRACTICE IMPLICATIONS

The Curriculum and similar policy-education initiatives could be strengthened by more explicit attention to the normative complexities of person-centred practice.

"I was afraid they will be judging me and even deny me the service": Experiences of denial and dissuasion during abortion care in Ethiopia

INTRODUCTION

Disrespect and abuse are components of poor quality abortion care. This analysis aimed to understand negative experiences of care from perspectives of abortion clients in public and private facilities in Ethiopia.

STUDY DESIGN

We conducted 23 in-depth interviews with people who obtained abortion care in Addis Ababa, Ethiopia as well as Aksum and Mekele in Tigray State, Ethiopia. The interviews were coded using a priori and emergent codes and we conducted thematic analysis to understand negative interactions with providers from participant's perspectives.

RESULTS

Participants experienced denial of abortion services along their pathway to care and attempts by providers to dissuade them prior to providing an abortion. Underlying both the denial and the dissuasion were reports of disrespect and condemnation from providers. Participants described how providers doubted or forced them to justify their reasons for having an abortion, stigmatized them for seeking multiple abortions or later abortions, and ascribed misinformation about abortion safety. Despite reports of denial, dissuasion, and disrespect, abortion clients generally felt that providers had their best interest at heart and were grateful for having access to an abortion.

CONCLUSIONS

Participants in Ethiopia experienced providers as gatekeepers to legal abortion services, facing disrespect and judgment at facilities where they sought care. Interventions aimed at increasing awareness of abortion laws such that clients understand their rights and values clarification interventions for providers could help reduce barriers to accessing care and improve the quality of abortion services.

Caregiver perspectives on patient capacities and institutional pathways to person centered forensic psychiatric care

The ethical discourse surrounding patients’ agential capacities, vis-à-vis their active participation in shared decision-making (SDM) in forensic psychiatric (FP) contexts, is an unexplored area of inquiry. The aim of this paper is to explore caregivers’ perceptions of patient agential capacities and institutional pathways and barriers to person centered care (PCC) in the context of FP. Following an exploratory qualitative design, we conducted eight semi-structured interviews with hands-on caregivers at an in-patient FP facility in Sweden. A deductive framework method of analysis was employed, and four themes emerged: “Fundamental Variability in Patient Capacity”, “Patient Participation: Narration or Compliance?”, “Antagonism Rooted in Power Struggles”, and “System Structure Thwarts Patient Release”. While the results generally paint a bleak picture for the possibility of a person-centered FP care, we describe a constrained version of PCC with high-level SDM dynamics which promotes a certain degree of patient empowerment while allowing care strategies, within set restrictions, to promote patient adherence and treatment progress.

Revisiting respect for persons: conceptual analysis and implications for clinical practice

In everyday conversations, professional codes, policy debates, and academic literature, the concept of respect is referred to frequently. Bioethical arguments in recent decades equate the idea of respect for persons with individuals who are capable of autonomous decision-making, with the focus being explicitly on 'autonomy,' 'capacity,' or 'capability.' In much of bioethics literature, respect for persons is replaced by respect for autonomy. Though the unconditional respect for persons and their autonomy (irrespective of actual decision-making capacity) is established in Kantian bioethics, current argument and debates often revolve around a thin concept of autonomy, focusing on capacity and capability: persons are owed respect because they are 'rational beings' or with a focus on 'agency' and 'decision-making abilities.' However, these aspects alone are insufficient while engaging the concept of respect for persons, particularly in healthcare settings. This paper sets out to explore if the concept of respect for persons-as opposed to a thin concept of autonomy-could help us engage better in healthcare practices. We shall probe the practical value of the experiential aspect of respect-understood as the recognition of persons as respect-worthy through certain dispositions and deliberative acts-by reflecting on instances in clinical practice that tend to be dismissed as negligible or even unavoidable in a stressful environment such as a busy hospital. We shall argue that these instances are far from trivial but carry moral significance and express an unacceptable-disrespectful-attitude that can compromise the moral habitus in hospital settings. In our conclusion, we call for practicing recognition respect in the health professional-patient encounter by focussing on manners, attitudes, and behaviors. Furthermore, we call for continuous medical ethics education programs to address the moral significance of disrespectful behaviors and their manifestations in particular socio-cultural contexts.

Developing a global practice-based framework of person-centred care from primary data: a cross-national qualitative study with patients, caregivers and healthcare professionals

INTRODUCTION

Person-centred care (PCC) is internationally recognised as a critical component of high-quality healthcare. However, PCC evolved in a few high-income countries and there are limited data exploring this concept across the vast majority of countries which are low- and middle-income. This study aimed to appraise and adapt a PCC model across three serious physical conditions in three middle-income countries and generate an evidence-based framework and recommendations for globally relevant PCC.

METHODS

Cross-national, cross-sectional qualitative study. In depth, semistructured interviews conducted with: advanced cancer patients in Jordan (n=50), their caregivers (n=20) and healthcare professionals (HCPs) (n=20); chronic obstructive pulmonary disease patients in South Africa (n=22), their caregivers (n=19) and HCPs (n=22); heart failure patients in Thailand (n=14), their caregivers (n=10) and HCPs (n=12). Data were analysed using framework analysis. Santana et al's PCC model (2018) and Giusti et al's systematic review (2020) were used to construct an a priori coding frame for deductive analysis, with additional inductive coding for coding that did not fit the frame.

RESULTS

The findings both reveal specific practical actions that contribute towards delivering PCC and highlight new cross-national domains of person-centredness: interdependency and collectivism; bringing care into the home and community; equity and non-discrimination; addressing health and illness within the context of limited resources; and workforce well-being.

CONCLUSION

The data suggest that PCC requires particular structural features of the healthcare system to be in place, such as professional education in PCC values and partnerships with community-based workers. These structures may better enable PCC processes, including tailored information sharing and providing genuine opportunities for patients to do the things that matter to them, such as making informed care decisions and sustaining social relationships. PCC must also accommodate a collectivist perspective and support the well-being of the workforce.

Toward a paradigm shift in healthcare: using the International Classification of Functioning, Disability and Health (ICF) and the capability approach (CA) jointly in theory and practice

PURPOSE

Over the past two decades, healthcare systems have shifted to adopt a more holistic, patient-centered care system. However, operationalization in practice remains challenging. Two frameworks have contributed substantially to the transformation toward more holistic and patient-centered care: the International Classification of Functioning, Disability and Health (ICF) and the capability approach (CA). Using these frameworks jointly can contribute to improved patient-centered care in clinical practice.

METHODS

This article explores the strengths and weaknesses of the use of the two frameworks in care and investigates whether using them jointly might contribute to more appropriate and patient-centered care. We will present a practical example of this integration in the form of a novel e-health application.

RESULTS

The exploration indicated that if the frameworks are used jointly, the individual weaknesses can be overcome. The application, used to exemplify the joint use of the frameworks, contains all categories of the ICF. It offers a unique tool that allows a person to self-assess, record, and evaluate their functioning and capabilities and formulate related goals.

CONCLUSIONS

Using the ICF jointly with the CA can foster holistic, patient-centered care. The e-health application provides a concrete example of how the frameworks can be used jointly. Implications for rehabilitationUsing the International Classification of Functioning, Disability and Health jointly with the capability approach can foster holistic, patient-centered care.The joint use of the frameworks is demonstrated by an e-health application which enables users to evaluate their functioning in relation to their own goals, provides them with the opportunity to increase control over their health and have a more active role in their care.Tools to record both functioning and goals from a patient's perspective can support professionals in offering patient-centered care in daily practice.Individual recording, monitoring and evaluation of functioning, capabilities and goals regarding functioning can provide a basis for research and quality improvement.

Person-centred care to prevent hospitalisations - a focus group study addressing the views of healthcare providers

Background

The primary healthcare sector comprises various health services, including disease prevention at local level. Research shows that targeted primary healthcare services can prevent the development of acute complications and ultimately reduce the risk of hospitalisations. While interdisciplinary collaboration has been suggested as a means to improve the quality and responsiveness of personal care needs in preventive services, effective implementation remains a challenge. To improve the quality and responsiveness of primary healthcare and to develop initiatives to support the interdisciplinary collaboration in preventive services, there is a need to investigate the views of primary healthcare providers. The aim of this study was to investigate perceptions of preventive care among primary healthcare providers by examining their views on what constitutes a need for hospitalisation, and which strategies are found useful to prevent hospitalisation. Further, to explain how interdisciplinary collaboration can be supported with a view to providing person-centred care.

Methods

Five focus group interviews were conducted with 27 healthcare providers, including general practitioners, social and healthcare assistants, occupational therapists, physiotherapists, home care nurses, specialist nurses and acute care nurses. Interviews were transcribed, and analysed with qualitative content analysis.

Results

Three categories emerged from the analysis: 1) Mental and social conditions influence physical functioning and hospitalisation need, 2) Well-established primary healthcare services are important to provide person-centred care through interdisciplinary collaboration and 3) Interdisciplinary collaboration in primary healthcare services is predominantly focussed on handling acute physical conditions. These describe that the healthcare providers are attentive towards the influence of mental, social and physical conditions on the risk of hospitalisation, entailing a focus on person-centred care. Nevertheless, in the preventive services, interdisciplinary collaboration focusses primarily on handling acute physical conditions, which constitutes a barrier for interdisciplinary collaboration.

Conclusions

By focusing on the whole person, it could be possible to provide more person-centred care through interdisciplinary collaboration and ultimately to prevent some hospitalisations. Stakeholders at all levels should be informed about the relevance of considering mental, social and physical conditions to improve the quality and responsiveness of primary healthcare services and to develop initiatives to support interdisciplinary collaboration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08198-6.

Vagueness and variety in person-centred care

Person-centred care is a cornerstone of contemporary health policy, research and practice. However, many researchers and practitioners worry that it lacks a ‘clear definition and method of measurement,’ and that this creates problems for the implementation of person-centred care and limits understanding of its benefits. In this paper we urge caution about this concern and resist calls for a clear, settled definition and measurement approach. We develop a philosophical and conceptual analysis which is grounded in the body of literature concerning the theory and practice of person-centred care. We consider a range of influential definitional frameworks of person-centred care, highlighting their differences and showing that they do not correspond to a clearly circumscribed and consistent underlying concept. We argue that a degree of indeterminacy and vagueness should not be seen as a problem with the concept of person-centred care; these are features of a rich and contested concept which exists prior to and outside of practical and technical operational definitions and applications. We defend the value of operating with multiple accounts of person-centred care, arguing that what counts as being person-centred can vary across different care contexts, in relation to different patient groups, and as a reflection of different, defensible ethical perspectives. Although the idea of a single, agreed definition is attractive and may seem to be a practical or even necessary step towards meaningful and coordinated action, we argue that this is only the case in a qualified sense. Comprehensive attempts to narrow down the concept in this way should be resisted, as they risk undermining what it is that makes person-centredness a valuable concept in healthcare.

Phantosmia and psychogenic non-epileptic seizures in a patient with burning mouth syndrome suffering from severe depression

Burning mouth syndrome (BMS) is a rare but serious medical condition with important psychiatric comorbidity and specific psychological correlates. Psychopathology related with BMS represents a real challenge for clinical decision-making. In this case, depression is the leading psychiatric diagnosis associated with patient's BMS somatic pain and is driven by anxiety and a dissociative functioning. Facing a complex psychosomatic symptomatology, we offer new clinical perspectives for the screening of psychological traits of BMS. Moreover, we highlight the need to foster interdisciplinarity to improve differential diagnosis and defining an optimal care path. This case report stimulates a reflection on management challenges for the consultation-liaison psychiatry and shows the importance of a person-centred approach when communicating the diagnosis.

Integrating Self-Management Education and Support in Routine Care of People With Type 2 Diabetes Mellitus: A Conceptional Model Based on Critical Interpretive Synthesis and A Consensus-Building Participatory Consultation

The integration of self-management education and support into the routine diabetes care is essential in preventing complications. Currently, however, there is no consensus on how to conceptualise integration in relation to self-management education and support. Therefore, this synthesis presents a framework conceptualising integration and self-management.

Methods

Seven electronic databases (Medline, HMIC, PsycINFO, CINAHL, ERIC, Scopus and Web of Science) were searched. Twenty-one articles met the inclusion criteria. Data were synthesised using principles of critical interpretive synthesis to build the conceptual framework. The framework was presented to 49 diabetes specialist nurses working at different levels of care during a multilingual workshop.

Results

A conceptual framework is proposed in which integration is influenced by five interacting components: the programme ethos of the diabetes self-management education and support intervention (content and delivery), care system organisation (the framework in which such interventions are delivered), adapting to context (the aspects of the people receiving and delivering the interventions), interpersonal relationship (the interactions between the deliverer and receiver of the intervention), and shared learning (what deliverer and receiver gain from the interactions). The critical inputs from the workshop participants related to the different priorities given to the components according to their sociolinguistic and educational experiences, Overall, they agreed with the conceptualisation of the components and their content specific to diabetes self-management education and support.

Discussion

Integration was conceptualised in terms of the relational, ethical, learning, contextual adapting, and systemic organisational aspects of the intervention. It remains uncertain which prioritised interactions of components and to what extent these may moderate the integration of self-management education and support into routine care; in turn, the level of integration observed in each of the components may moderate the impact of these interventions, which may also apply to the impact of the professional training.

Conclusion

This synthesis provides a theoretical framework that conceptualises integration in the context of diabetes self-management education and support in routine care. More research is required to evaluate how the components identified in the framework can be addressed in clinical practice to assess whether improvements in self-management education and support can be effectively realised in this population.

An exploration of person-centred approach in end-of-life care policies in England and Japan

Background

Increasing evidence has suggested that a person-centred approach (PCA) is beneficial not only for improving care outcomes but also for mitigating the pressure on public health systems. However, policy implementation gaps have prevented the translation of this complex framework into useful practical, ethical and moral stances for end-of-life care (EOLC). This article aims to explore the meaning and implications of person-centredness in EOLC policy discourses.

Methods

By perceiving policy documents as a medium embodied with socio-political and cultural norms, we analysed how PCA in EOLC is constructed within specific socio-cultural contexts and the implications of these contexts on resultant care. Focusing on England and Japan, we conducted a critical policy analysis to examine and compare key policy and legal documents released between 2000 and 2019 in these two post-industrial and socio-culturally distinctive countries.

Results

Our analysis found that the PCA is mobilised in policy discourses primarily through three interconnected dimensions: individual, relational and existential. While acknowledging that both countries have developed varied policy and legal mechanisms to emphasise holistic and integrated care with respect to these three dimensions, we also identified significant gaps in the pol icies both within and between England and Japan. They include ambiguity in defining patients’ best interests, fragmented support for social and family care and the neglect of existential needs.

Conclusions

This cross-cultural analysis has revealed the complex nature of discourses around PCA in English and Japanese EOLC policies, which often concentrate on the multifaceted aspects of experiences as one approaches the end of life. Despite this, we argue that a more holistic construction of PCA is needed in EOLC policies not only in England and Japan but also more broadly, to encapsulate the richness of end-of-life experiences.

Who is at the centre of what? A scoping review of the conceptualisation of 'centredness' in healthcare

OBJECTIVES

We aimed to identify the core elements of centredness in healthcare literature. Our overall research question is: How has centredness been represented within the health literature published between 1990 and 2019?

METHODS

A scoping review across five databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus; August 2019) to identify all peer-reviewed literature published since 1990 that focused on the concept of centredness in any healthcare discipline or setting. Screening occurred in duplicate by a multidisciplinary, multinational team. The team met regularly to iteratively develop and refine a coding template that was used in analysis and discuss the interpretations of centredness reported in the literature.

RESULTS

A total of 23 006 title and abstracts, and 499 full-text articles were screened. A total of 159 articles were included in the review. Most articles were from the USA, and nursing was the disciplinary perspective most represented. We identified nine elements of centredness: Sharing power; Sharing responsibility; Therapeutic relationship/bond/alliance; Patient as a person; Biopsychosocial; Provider as a person; Co-ordinated care; Access; Continuity of care. There was little variation in the concept of centredness no matter the preceding word (eg, patient-/person-/client-), healthcare setting or disciplinary lens. Improving health outcomes was the most common justification for pursuing centredness as a concept, and respect was the predominant driving value of the research efforts. The patient perspective was rarely included in the papers (15% of papers).

CONCLUSIONS

Centredness is consistently conceptualised, regardless of the preceding word, disciplinary lens or nation of origin. Further research should focus on centring the patient perspective and prioritise research that considers more diverse cultural perspectives.

Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients

An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient’s values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient’s perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient’s relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD.

'Are they really allowed to treat me like that?' - A qualitative study to explore the nature of formal patient complaints about mental healthcare services in Sweden

The improvement of mental healthcare services requires patients' experiences to identify problems and possible deficits in care. In this study, we explored the nature and meaning of formal patient complaints about mental healthcare services in one region of Sweden using a descriptive design with a qualitative approach. A systematic random sample of 106 formal patient complaints about mental healthcare services in 1 Swedish county was selected and analysed thematically, based on descriptive phenomenology. Themes identified were: lack of access to mental healthcare services and specialist treatment, problems related to unmet needs and difficulties with healthcare staff, insufficient care and treatment and lack of continuity in care, and experiences of not been taken seriously or feeling abused by staff. The vulnerability of patients already in the system is a greater issue than realized. The human right to health and the healthcare of patients with mental ill health can be strengthened by increased access to care, listening to patients properly, and delivering continuity in care.

Measuring with quality: the example of person-centred care

Qualitative data analysis should be embedded in routine health service measurement, management and organizational practices. The rigorous use of such analyses should become an institutional norm, comparable to the routine use of quantitative data. Our case is intended to have general relevance, but we develop it by reference to person-centred care and patient-centred outcome measures (PCOMs). The increased use of qualitative data analysis of individualized PCOMs is a crucial complementary counterweight to steps towards the standardization of PCOMs. More broadly, our argument is that health care organizations cannot make confident judgements about whether they are offering appropriate care without collecting qualitative data on what matters to individual patients. Introducing properly supported and conducted qualitative data analyses is important in its own right, and also helps underpin the validity and usefulness of quantitative measurement.

Effects of a Person-Centered eHealth Intervention for Patients on Sick Leave Due to Common Mental Disorders (PROMISE Study): Open Randomized Controlled Trial

BACKGROUND

Sick leave due to common mental disorders (CMDs) is a public health problem in several countries, including Sweden. Given that symptom relief does not necessarily correspond to return to work, health care interventions focusing on factors that have proven important to influence the return to work process, such as self-efficacy, are warranted. Self-efficacy is also a central concept in person-centered care.

OBJECTIVE

The aim of this study is to evaluate the effects of a person-centered eHealth intervention for patients on sick leave due to CMDs.

METHODS

A randomized controlled trial of 209 patients allocated to either a control group (107/209, 51.2%) or an intervention group (102/209, 48.8%) was conducted. The control group received usual care, whereas the intervention group received usual care with the addition of a person-centered eHealth intervention. The intervention was built on person-centered care principles and consisted of telephone support and a web-based platform. The primary outcome was a composite score of changes in general self-efficacy (GSE) and level of sick leave at the 6-month follow-up. An intention-to-treat analysis included all participants, and a per-protocol analysis consisted of those using both the telephone support and the web-based platform.

RESULTS

At the 3-month follow-up, in the intention-to-treat analysis, more patients in the intervention group improved on the composite score than those in the control group (20/102, 19.6%, vs 10/107, 9.3%; odds ratio [OR] 2.37, 95% CI 1.05-5.34; P=.04). At the 6-month follow-up, the difference was no longer significant between the groups (31/100, 31%, vs 25/107, 23.4%; OR 1.47, 95% CI 0.80-2.73; P=.22). In the per-protocol analysis, a significant difference was observed between the intervention and control groups at the 3-month follow-up (18/85, 21.2%, vs 10/107, 9.3%; OR 2.6, 95% CI 1.13-6.00; P=.02) but not at 6 months (30/84, 35.7%, vs 25/107, 23.4%; OR 1.8, 95% CI 0.97-3.43; P=.06). Changes in GSE drove the effects in the composite score, but the intervention did not affect the level of sick leave.

CONCLUSIONS

A person-centered eHealth intervention for patients on sick leave due to CMDs improved GSE but did not affect the level of sick leave.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03404583; https://clinicaltrials.gov/ct2/show/NCT03404583.

Response-Forty-Seven Years Later: Further Studies in Disappointment?

This paper provides a commentary on "Vascular amputees: A study in disappointment" (Little et al. 1974) and its significance in the development of the disability rights movement, as well as the movements for values-based medicine and person-centred health and social care.

An Archeology of Corruption in Medicine

Corruption is a word used loosely to describe many kinds of action that people find distasteful. We prefer to reserve it for the intentional misuse of the good offices of an established social entity for private benefit, posing as fair trading. The currency of corruption is not always material or financial. Moral corruption is all too familiar within churches and other ostensibly beneficent institutions, and it happens within medicine and the pharmaceutical industries. Corrupt behavior reduces trust, costs money, causes injustice, and arouses anger. Yet it persists, despite all efforts since the beginnings of societies. People who act corruptly may lack conscience and empathy in the same way as those with some personality disorders. Finding ways to prevent corruption from contaminating beneficent organizations is therefore likely to be frustratingly difficult. Transparency and accountability may go some way, but the determined corruptor is unlikely to feel constrained by moral and reporting requirements of this kind. Punishment and redress are complicated issues, unlikely to satisfy victims and society at large. Both perhaps should deal in the same currency-material or social-in which the corrupt dealing took place.

Practising the ethics of person-centred care balancing ethical conviction and moral obligations

Person‐centred care is founded on ethics as a basis for organizing care. In spite of healthcare systems claiming that they have implemented person‐centred care, patients report less satisfaction with care. These contrasting results require clarification of how to practice person‐centred ethics using Paul Ricoeur's ‘Little ethics’, summarized as: ‘aiming for the good life, with and for others in just institutions’. In this ethic Kantian morality is at once subordinate and complementary to Aristotelian ethics because the ethical goal needs to be critically assessed and passed through the examination of the norm in each care situation. This paper presents examples that describes a person‐centred care practice that balance a critical review of care activities based on a conviction of aiming for patients' wellbeing. In contrast to patients' experiences of person‐centred care in real life, research projects have shown that if the clinical performers comprehend and apply the practice of person‐centred ethics, patients report positive outcomes. The implementation of person‐centred care therefore demands that stakeholders and managers enables and requires that healthcare staff study ethics in the same way as studying for example pharmacology is required when handling patients' medicines.

Hope for “Continued Vitality”: Qualitative Study of Adults With Traumatic Brain Injury and Low Mood on Their Rehabilitation

Objective

Depression is highly comorbid with traumatic brain injury (TBI) with often complex and interacting symptomology that contributes to the experience of disability. Comorbid depression results in poorer TBI rehabilitation and downstream participation outcomes yet perspectives of this group regarding person-centered care is unknown.

Purpose

This study aimed to explicate the perspectives of persons with TBI and depression on their values, preferences, and desired outcomes for optimal rehabilitation.

Methods

A qualitative descriptive approach was taken. Thirteen adults [mean age: 40.5 (standard deviation 9.8)] diagnosed with TBI and with self-reported low mood were recruited through convenience sampling. Participants were predominantly female (n = 12) with concussion/mild TBI and at least 6 months post-injury. One-on-one, semi-structured interviews were conducted by phone with Canadian participants (March-May 2020). Interviews were transcribed; data were analyzed thematically by two researchers and the thematic map refined by the research team.

Results

Three themes were identified on values, preferences, and desired outcomes in person-centered care. Participants valued “validation” from healthcare providers and the health system to feel seen and believed about their conditions and concerns. They preferred for healthcare providers to “share the burden of managing care” through improved interactions and better access to concussion care. Participants expressed that “meaningful outcomes” were to be symptom free, to resume valued life activities, and to be able to adapt/be resilient. The latter indicated hope for “continued vitality” for life participation despite past and ongoing challenges.

Conclusions

Many adults with TBI and self-identified low mood expressed rehabilitation experiences that were invalidating. Their identified values, preferences, and desired outcomes provide directions for better person-centered care by healthcare providers and health systems to support participation.

The interactive work of narrative elicitation in person-centred care: Analysis of phone conversations between health care professionals and patients with common mental disorders

INTRODUCTION

Narratives play a central part in person-centred care (PCC) as a communicative means of attending to patients' experiences. The present study sets out to explore what activities are performed and what challenges participants face in the interactive process of narrative elicitation, carried through in patient-professional communication in a remote intervention based on PCC.

METHODS

Data were gathered from a randomized controlled trial (RCT) in a Swedish city where health care professionals (HCPs) conducted remote PCC for patients on sick leave due to common mental disorders. A sample of eleven audio-recorded phone conversations between HCPs and patients enroled in the RCT were collected and subjected to conversation analysis.

RESULTS

Three interactive patterns in narrative elicitation were identified: Completed narrative sequences driven by the patient, question-driven narrative sequences guided by the HCP, and narrative sequences driven as a collaborative project between the patient and the HCP. In the question-driven narrative sequences, communication was problematic for both participants and they did not accomplish a narrative. In the other two patterns, narratives were accomplished but through various collaborative processes.

CONCLUSION

This study provides insight into what challenges narrative elicitation may bring in the context of a remote PCC intervention and what interactive work patients and HCP need to engage in. Importantly, it also highlights tensions in the ethics of PCC and its operationalization, if the pursuit of a narrative is not properly balanced against the respect for patients' integrity and personal preferences. Our findings also show that narrative elicitation may represent an interactive process in PCC in which illness narratives are jointly produced, negotiated and transformed.

PATIENT OR PUBLIC CONTRIBUTION

Stakeholders, including patient representatives, were involved in the design of the main study (the RCT). They have been involved in discussions on research questions and dissemination throughout the study period. They have not been involved in conducting the present study.

Disrupting Essentialism in Medical Genetics Education

Many traditional practices in medical genetics education need review to counteract messages of essentialism, or the belief in an underlying natural structure differentiating social categories. While genomics research increasingly disproves a genetic foundation for race, research from educational scholars demonstrates that current medical genetics instruction may actually reinforce racial bias in learners. In this monograph, we outline seven recommendations for medical educators to actively counteract essentialism, racial, and otherwise, in the genetics classroom. In particular, we emphasize the importance of engaging learners in nuanced discussions around stereotyping and its negative consequences for both accurate diagnoses and promoting health equity.

From a Place of Love: The Experiences of Birthing in a Black-Owned Culturally-Centered Community Birth Center

Introduction

Racial and ethnic disparities in perinatal health outcomes are among the greatest threats to population health in the United States. Black birthing communities are most impacted by these inequities due to structural racism throughout society and within health care settings. Although multiple studies have shown that structural racism and the disrespect associated with this system of inequity are the root causes of observed perinatal inequities, little scholarship has centered the needs of Black birthing communities to create alternative care models. Leaning on reproductive justice and critical race theoretical frameworks, this study explores good birth experiences as described by Black birthing people.

Methods

Thematic analysis of two focus groups and three one-on-one interviews conducted with clients at a Black-owned free-standing culturally-centered birth center (n=10).

Results

We found that Black birthing persons' concerns centered on three main themes: agency, historically- and culturally-safe birthing experiences, and relationship-centered care. Many participants pointed directly to past experiences of medical mistreatment and obstetric racism when defining their ideal birth experience.

Conclusion

Black birthing people seeking care from culturally-informed providers often do so because they have been mistreated, disregarded, and neglected within traditional care settings. The needs articulated by our study participants provide a powerful framework for understanding alternative patient-centered models of care that can be developed to improve the care experiences of Black birthing people in the pursuit of birth equity.

Aligning Patient's Ideas of a Good Life with Medically Indicated Therapies in Geriatric Rehabilitation Using Smart Sensors

New technologies such as smart sensors improve rehabilitation processes and thereby increase older adults’ capabilities to participate in social life, leading to direct physical and mental health benefits. Wearable smart sensors for home use have the additional advantage of monitoring day-to-day activities and thereby identifying rehabilitation progress and needs. However, identifying and selecting rehabilitation priorities is ethically challenging because physicians, therapists, and caregivers may impose their own personal values leading to paternalism. Therefore, we develop a discussion template consisting of a series of adaptable questions for the patient–physician encounter based on the capability approach. The goal is to improve geriatric rehabilitation and thereby increase participation in social life and well-being. To achieve this goal, we first analyzed what is considered important for participation on basis of the capability approach, human rights, and ethics of care. Second, we conducted an ethical analysis of each of the four identified dimensions of participation: political, economic, socio-cultural, and care. To improve compliance with rehabilitation measures, health professionals must align rehabilitation measures in an open dialogue with the patient’s aspiration for participation in each dimension. A discussion template based on the capability approach allows for a proactive approach in patient information and stimulates a critical assessment of treatment alternatives while reducing the risk of imposing personal values.

Are We Transitioning Toward Person-centered Practice on Self-management Support? An Explorative Case Study Among Rheumatology Outpatient Clinic Nurses in Norway

Introduction

There are only a few studies investigating nurses’ views on self-management in the care of patients with rheumatic diseases.

Objective

The aim of this study is to explore how Norwegian rheumatology outpatient nurses describe their ways of supporting patients’ self-management focusing on the core dimensions of person-centered self-management support.

Methods

Ten individual semistructured interviews with rheumatology outpatient nurses were conducted in Norway from March to September 2017. The interviews were audiorecorded and transcribed verbatim. NVIVO was used to support a systematic analysis of themes and patterns.

Results

Nurses’ views on self-management support fell into three approaches; (1) narrowly biomedically orientated, (2) biomedically and holistic, and (3) person-centered. The nurse's views of self-management support varied and did not fully align with the core dimensions of person-centered practice.

Conclusion

The findings indicate that the biomedical paradigm continues to influence Norwegian rheumatology outpatient clinic nurses’ approach to self-management support. If person-centered principles of self-management support are to be translated into standard nursing practice, including identifying and supporting patient-defined self-management goals and processes, there is a need to challenge established structures in health care systems.

Experiences of Wearable Technology by Persons with Knee Osteoarthritis Participating in a Physical Activity Counseling Intervention: Qualitative Study Using a Relational Ethics Lens

Background

Current evidence indicates physical activity wearables could support persons with knee osteoarthritis (OA) to be more physically active. However, recent evidence also identifies some persons with arthritis experience guilt or worry while using a wearable if they are not as active as they feel they should be. Questions remain around how persons with knee OA experience benefits or downsides using a wearable in their everyday lives. Better understanding is needed if wearables are to be incorporated in arthritis self-management in ethically aware ways.

Objective

Using an ethics lens, we aimed to describe a range of experiences from persons with knee OA who used a wearable during a physical activity counseling intervention study.

Methods

This is a secondary analysis of qualitative interviews nested within a randomized controlled trial. Guided by phenomenography, we explored the experiences of persons with knee OA following participation in a physical activity counseling intervention that involved using a Fitbit Flex and biweekly phone calls with a study physiotherapist (PT) in an 8-week period. Benefits or downsides experienced in participants’ relationships with themselves or the study PT when using the wearable were identified using a relational ethics lens.

Results

Interviews with 21 participants (12 females and 9 males) aged 40 to 82 years were analyzed. Education levels ranged from high school graduates (4/21, 19%) to bachelor’s degrees or above (11/21, 52%). We identified 3 categories of description: (1) participants experienced their wearable as a motivating or nagging influence to be more active, depending on how freely they were able to make autonomous choices about physical activity in their everyday lives; (2) some participants felt a sense of accomplishment from seeing progress in their wearable data, which fueled their motivation; (3) for some participants, sharing wearable data helped to build mutual trust in their relationship with the study PT. However, they also expressed there was potential for sharing wearable data to undermine this trust, particularly if this data was inaccurate.

Conclusions

Findings provide an early glimpse into positive and negative emotional impacts of using a wearable that can be experienced by participants with knee OA when participating in a randomized controlled trial to support physical activity. To our knowledge, this is the first qualitative study that uses a relational ethics lens to explore how persons with arthritis experienced changes in their relationship with a health professional when using a wearable during research participation.

How staff characteristics influence residential care facility staff's attitude toward person-centered care and informal care

BACKGROUND

Staff members, and their attitudes, are crucial for providing person-centered care in residential care facilities for people with dementia. However, the literature on the attitudes of nursing staff regarding person-centered care is limited. The objective of this study is to explore the association between staff characteristics (age, education level, years of work experience and function, i.e., care or welfare) and staff attitudes toward perceived person-centered care provision and including informal caregivers in the caregiving process in residential care facilities.

METHODS

A convenience sample of 68 care staff - nurses and nurse assistants - welfare staff members - activity counselors, hostesses, and living room caretakers - of two residential care facilities filled out a questionnaire. Staff attitudes regarding perceived person-centered care were measured with the Person-centered Care Assessment Tool (P-CAT). Staff attitudes regarding informal care provision were measured with the Attitudes Toward Families Checklist (AFC). Multiple linear regression analysis explored the association between variables age, work experience, education, and function (care or welfare).

RESULTS

A higher age of staff was associated with a more negative attitude toward perceived person-centered care and informal care provision. Welfare staff had a more negative attitude toward the inclusion of informal caregivers than care staff. The perceived person-centered care provision of the care and welfare staff was both positive. Work experience and education were not associated with perceived person-centered care provision or informal care provision.

CONCLUSION

This study is one of the first to provide insight into the association between staff characteristics and their attitude toward their perceived person-centered care provision and informal care provision. A higher age of both the care and welfare staff was associated with a more negative attitude toward their perceived person-centered care and informal care provision. Welfare staff had a less positive attitude toward informal care provision. Additionally, future studies, also observational studies and interview studies, are necessary to collect evidence on the reasons for negative attitudes of older staff members towards PCC and informal care giving, to be able to adequately target these reasons by implementing interventions that eliminate or reduce these negative attitudes.

Themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making in healthcare systems: a scoping review

OBJECTIVE

To identify the key themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making across the organisation and system domains of healthcare systems.

METHODS

We conducted a scoping review. Seven databases of journal articles were searched from their inception to June 2019. Eligible articles were literature reviews published in English and provided useful information for determining aspects of engaging patients and family caregivers in decision-making to evaluate. We extracted text under three predetermined categories: structure, process and outcomes that were adapted from the Donabedian conceptual framework. These excerpts were then independently open-coded among four researchers. The subsequent themes and their corresponding excerpts were summarised to provide a rich description of each theme.

RESULTS

Of 7747 unique articles identified, 366 were potentially relevant, from which we selected the 42 literature reviews. 18 unique themes were identified across the three predetermined categories. There were six structure themes: engagement plan, level of engagement, time and timing of engagement, format and composition, commitment to support and environment. There were four process themes: objectives, engagement approach, communication and engagement activities. There were eight outcome themes: decision-making process, stakeholder relationship, capacity development, stakeholder experience, shape policy/service/programme, health status, healthcare quality, and cost-effectiveness.

CONCLUSIONS

The 18 themes and their descriptions provide a foundation for identifying constructs and selecting measures to evaluate the quality of initiatives for engaging patients and family caregivers in healthcare system decision-making within the organisation and system domains. The themes can be used to investigate the mechanisms through which relevant initiatives are effective and investigate their effectiveness.

Older people's experiences of dignity and support with eating during hospital stays: analytical framework, policies and outcomes

There is growing recognition of the importance of dignity and support with eating as markers of high-quality and older-person-centred hospital services. We use data on these markers from the national Adult Inpatient Survey for England to build up statistical evidence on older people's experiences. We find that poor and inconsistent experiences of being treated with dignity and respect, and of receiving support with eating, affect a substantial proportion of inpatients across the vast majority of acute hospital trusts. There has been remarkably little change over time, although small improvements provide some grounds for optimism relating to policy developments in the period following the Francis Inquiry. Amongst people over 65, the prevalence of inconsistent and poor experiences of dignity and support with eating was higher amongst the ‘oldest of the old’ (inpatients aged over 80), individuals who experience a long-standing limiting illness or disability, and women. The highest rates of prevalence were observed amongst disabled women over 80. Perceptions of inadequate nursing quantity and quality, and lack of choice of food, stand out from logistic regression analysis as having consistent, large associations with lack of support with eating. These factors provide potential policy levers since they are within the control of hospitals to a certain extent. In drawing lessons from our analysis for inspection, regulation and monitoring, we highlight the importance of inequalities analysis – including systematic disaggregation and separate identification of at risk sub-groups (e.g. older disabled women) – rather than relying on a ‘population average approach’.

It is time for us all to embrace person-centred language for people in prison and people who were formerly in prison

The use of person-centred language is well accepted regarding substance use and infectious disease healthcare and research, and appropriate acronyms have become commonplace, e.g., "people who inject drugs (PWID)" has mostly replaced phrases like "injecting drugs users". However, the use of the term's 'prisoner' or 'prisoners' remains common. Although less common, terms such as 'offenders' and 'inmates' are also still used on occasion. This persists despite calls from people with lived experience of incarceration, and fellow academics, to stop using these terms. Given the considerable overlap between substance use, infectious diseases, and incarceration, in this commentary we discuss how they interact, including the stigma that is common to each. We propose that using person-centred language (i.e., people in prison or people formerly in prison) needs to become the default language used when presenting research related to people in prison or people formerly in prison. This is a much-needed step in efforts to overcome the continued stigma that people in prison face while incarcerated from prison officers and other employees, including healthcare providers. Likewise, overcoming stigma, including legalised discrimination, that follows people who were formerly in prison upon gaining their freedom is critical, as this impacts their health and related social determinants, including employment and housing.

Creating person-al space for unspoken voices during diagnostic medical imaging examinations: a qualitative study

Background

There is emerging interest in person-centred care within a short-lived yet complex medical imaging encounter. This study explored this event from the viewpoint of patients referred for an imaging examination, with a focus on the person and their person-al space.

Methods

We used convenience sampling to conduct semi-structured interviews with 21 patients in a private medical imaging practice in Australia. The first phase of data analysis was conducted deductively, using the six elements of the person-centred, patient-journey framework of the Australian Commission on Safety and Quality in Healthcare: transition in; engagement; decisions; well-being; experience; and transition out. This was followed by inductive content analysis to identify overarching themes that span a patient’s journey into, through and out of an imaging encounter.

Results

The transition-in phase began with an appointment and the first point of contact with the imaging department at reception. Engagement focused on patient-radiographer interactions and explanations to the patient on what was going to happen. Decisions related primarily to radiographers’ decisions on how to conduct a particular examination and how to get patient cooperation. Participants’ well-being related to their appreciation of gentle treatment; they also referred to past negative experiences that had made a lasting impression. Transitioning out of the imaging encounter included the sending of the results to the referring medical practitioner. Person-al vulnerabilities emerged as a cross-cutting theme. Patients’ vulnerability, for which they needed reassurance, pertained to uncertainties about the investigation and the possible results. Healthcare professionals were vulnerable because of patient expectations of a certain demeanour and of pressure to perform optimal quality investigations. Lastly, patients’ personal lives, concerns and pressures – their person-al ‘baggage’ – shaped their experience of the imaging encounter.

Conclusion

To add value to the quality of the service they deliver, radiography practitioners should endeavour to create a person-al space for clients. Creating these spaces is complex as patients are not in a position to judge the procedures required by technical imaging protocols and the quality control of equipment. A reflective tool is proposed for radiographers to use in discussions with their team and its leaders on improving person-centred care and the quality of services in their practice.