Power Relations and Health Care Communication in Older Adulthood: Educating Recipients and Providers

How do the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home? A qualitative interview study with multiple stakeholders

Introduction

Often, homecare services are task-focused rather than person-based and fragmented instead of integrated. Consequently, several stakeholders have requested a transformation of the service ecosystem for senior citizens living at home. This transformation may be facilitated by an idealized design approach. However, few studies have applied such an approach. Moreover, previous research did not assess the ways in which the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home. Therefore, the purpose of this study is to gain an understanding of how the existing homecare services correspond with the preferred service ecosystem for senior citizens living at home, according to different stakeholders.

Methods

Four stakeholder groups (n = 57) from a Norwegian municipality participated in an interview study (2019-2020): senior citizens, carers, healthcare professionals and managers. A directed qualitative content analysis was applied, guided by a four-category framework for the preferred service ecosystem.

Results

All stakeholder groups highlighted several limitations that hindered continuity of the services. There was also agreement on deficiencies in professionals' competence, yet professionals themselves did not focus on this as a significant aspect. Managers emphasised the importance of professionals' reablement competence, which was also considered to be deficient in the current homecare services. Contrary to the other stakeholder groups, most senior citizens seemed satisfied with the practical and social support they received. Together with carers, they also explained why they thought some professionals lack compassion. Their dependency on professionals may limit them in sharing honestly their opinions and preferences during care provision. Involvement of senior citizens in improvement of the current services was limited. Insufficient time and resources, as well as a complex organisation impacted the existing homecare services, and therefore served as barriers to the preferred service ecosystem.

Discussion

In this study there were different degrees of correspondence between the existing homecare services and the preferred service ecosystem according to four stakeholder groups. To develop the preferred service ecosystem, aspects such as predictability, adaptivity, and relationships are key, as well as continuous involvement of senior citizens and other stakeholders. The four-category framework applied in this study served as a tool to assess the existing homecare services.

Patient-Reported Outcomes in a Nationally Representative Sample of Older Internet Users: Cross-sectional Survey

BACKGROUND

The rapid diffusion of the internet has decreased consumer reliance on health care providers for health information and facilitated the patients' ability to be an agent in control of their own health. However, empirical evidence is limited regarding the effects of health-related internet use among older adults, which is complicated by the proliferation of online health and medical sources of questionable scientific accuracy.

OBJECTIVE

We explore the effects of health-related internet use, education, and eHealth literacy on medical encounters and patient-reported outcomes. Patient-reported outcomes are categorized into two dimensions: (1) self-reported health problem and (2) affective distress (feeling worried and anxious) due to information obtained. We were particularly interested in whether education and eHealth literacy moderate the association between perceived strain in medical encounters and patient-reported outcomes.

METHODS

Our study sample consisted of online panel members who have used the internet as a resource for health information, randomly drawn from one of the largest probability-based online research panels. This paper specifically reports results obtained from older panel members (age≥60 years: n=194). First, we examined descriptive statistics and bivariate associations (Pearson correlations and independent samples t tests). We used hierarchical ordinary least squares regression analyses by running separate regressions for each patient-reported outcome. In model 1, we entered the main effects. In model 2, technology and medical encounter variables were included. Model 3 added the statistical interaction terms.

RESULTS

Age (β=-.17; P=.02), gender (β=-.22; P=.01), and medical satisfaction (β=-.28; P=.01) were significant predictors of self-reported health problems. Affective distress was positively predicted by gender (β=.13; P=.05) and satisfaction with medical encounters (β=.34; P<.001) but negatively predicted by education (β=-.18; P=.03) and eHealth literacy (β=-.32; P=.01). The association between experiencing a health problem in relation to health-related internet use and perception of strained medical encounters was greater among respondents with lower levels of education (β=-.55; P=.04). There was also a significant interaction between education and eHealth literacy in predicting the level of affective distress (β=-.60; P=.05), which indicated that higher levels of education predicted lower averages of feeling anxiety and worry despite lower eHealth literacy. Older women reported higher averages of affective distress (β=.13; P=.05), while older men reported higher averages of experiencing a self-reported health problem (β=-.22; P=.01).

CONCLUSIONS

This study provides evidence for the effect of health-related internet use on patient-reported outcomes with implications for medical encounters. The results could be used to guide educational and eHealth literacy interventions for older individuals.

Family carers' involvement strategies in response to sub-optimal health services to older adults living with dementia - a qualitative study

BACKGROUND

While dementia policy strategies emphasize the importance of partnerships between families and formal carers to provide tailored care and effectively allocate community resources, family carers often feel left out or excluded. Poor communication has been identified as one reason for the lack of good partnerships. Few studies have investigated how family carers seek to involve themselves when they experience sub-optimal services, and how their strategies may depend on different considerations and personal abilities.

METHODS

Qualitative in-depth interviews were conducted with 23 family carers to explore their experiences with, perspectives on, contributions to, and interactions with healthcare services provided to older adults living with dementia. To capture nuances and variations, a semi-structured interview guide was used. Interviews were audio-recorded and transcribed verbatim. A four-step analysis of the transcripts was conducted, informed by hermeneutic and phenomenological methodology.

RESULTS

Two main involvement strategies were identified: 1) being "the hub in the wheel" and 2) getting the wheel rolling. The first strategy was used to support and complement health services, while the second was used to add momentum and leverage to arguments or processes. The two main strategies were used differently among participants, in part due to differences in personal resources and the ability to utilize these, but also in light of family carers' weighing conflicting concerns and perceived costs and benefits.

CONCLUSIONS

Awareness and acknowledgment of family carers' strategies, personal resources, and considerations may help policymakers and healthcare personnel when they build or maintain good partnerships together with family carers. A better understanding of family carers' own perspectives on carer involvement is a necessary precursor to developing good care partnerships.

Families' perceptions of relational practice in the emergency department: A qualitative study

PURPOSE

The purpose of this study was to describe families' perceptions of relational practice when interacting with health care professionals in emergency departments in the South African context.

BACKGROUND

Relational practice is seen as an approach that amplifies the voices of families through creating meaningful connections with health care professionals. However, the voices of families maybe obliterated by factors in the clinical environment including the pressure to perform and timely patient flow.

DESIGN

The study adopted a qualitative design.

METHODS

Qualitative data were collected from six family members by means of semi-structured interviews and were analysed using qualitative content analysis.

RESULTS

Four major categories emerged from family members' perceptions regarding relational practice when interacting with health care professionals in the emergency department, Disrupted worlds; Care is what you see and hear; Powerlessness; Feeling disconnected.

CONCLUSIONS

Findings highlighted the need for improved relational practice between families and health care professionals in the emergency department. Pathways need to be created to involve families in decision-making and genuinely engage with them. There is a need to move away from the hierarchical "expert" emergency department culture towards one that seeks to include the voices of families in driving emergency department care.

Meanings of Care Convoys: The Structure, Function, and Adequacy of Care Networks Among Frail, Community-Dwelling Older Adults

Researchers propose that the convoy of care model should be used to study care networks of frail, older individuals. Care convoys are defined as the evolving collection of individuals who may or may not have close personal connections to the recipient or to one another, but who provide care, including help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), socio-emotional care, skilled health care, monitoring, and advocacy. This study reports on community-dwelling older adults' experiences of their care convoy, how care convoys change over time, and perceived (positive) outcomes. A qualitative analysis among 65 semi-structured interviews with frail, community-dwelling older adults demonstrates a great variety in the composition of care convoys. Participants were often actively involved in their care convoy and valued the social/relational aspect of care. Care and support covered a wide range of activities, with some activities being provided by specific types of caregivers. Participants expressed the adequacy of their care convoy in terms of satisfaction and sufficiency. Noteworthy, participants who were satisfied with their care convoy did not necessarily receive sufficient help. Policies and practice should recognize the relational aspect of care, the complex interplay between all actors, and the dynamic character of care convoys.

A Prospective Examination of Racial Microaggressions in the Medical Encounter

Disparities in healthcare and health outcomes between whites and non-whites continue to plague the US healthcare system. A large literature suggests that people of color face obstacles at various points in the healthcare system. This article examines one such obstacle: whether patients of color experience microaggressions from physicians during primary care medical visits. A majority of microaggression studies are qualitative and retrospective in nature. In the current study, we use a prospective approach to broaden how microaggressions are measured, as well as understand differential treatment of racial minorities within healthcare. Using data derived from audio recordings of medical visits (n = 224), we utilize a quantitative measure to examine microaggressions in the medical encounter. We find that when race status differences are present between patient and physician, patients of color are more likely to experience microaggressions from their physician. The results suggest that medical encounters differ depending on characteristics of the parties involved. These differences may not only perpetuate the differential treatment of people of color but also contribute to health disparities for people of color.

Searching for Health: Doctor Google and the Shifting Dynamics of the Middle-Aged and Older Adult Patient-Physician Relationship and Interaction

Objectives: While online health information (OHI) has become ubiquitous, little is known about its use by middle-aged and older adults. This contribution examines the role of OHI and its influence on the patient-physician relationship. Method: This qualitative study reports the thematic analysis of 40 semistructured, in-depth interviews with Flemish middle-aged and older adults between the ages of 50 and 80 years. Results: Middle-aged and older adults obtain OHI pre- and post-consultation, albeit with different motivations and in search of different types of information. Patients strategically and carefully introduce OHI in the clinical encounter. "Doctor Google" expands the traditional patient-physician dyad into an information triangle. Discussion: The findings have implications for policy guidance and clinical practice. Public campaigns against "Googling" for health information might have to be amended to be successful. Importantly, physicians are increasingly expected to refer to and appraise OHI and put it into the individual patient context.

Patient discourse on chronic kidney disease monitoring: a qualitative study at a Veterans Affairs Renal Clinic

Background

Knowing how chronic kidney disease (CKD) patients talk about their encounters with providers (i.e., their discourse) can inform the important clinical goal of engaging patients in their chronic disease self-management. The aim of this study was to analyze patient discourse on ongoing CKD monitoring encounters for health communication strategies that motivate patient engagement.

Methods

Passages regarding CKD monitoring from 6 focus group transcripts on self-management with a total of 30 participants age ≥ 70 years from the Atlanta Veterans Affairs Renal Clinic across three different CKD trajectories (stable, linear decline, and non-linear) were extracted. These passages were examined using three-stage critical discourse analysis (description, interpretation, explanation) for recurring patterns across groups.

Results

Focus group participants were an average age of 75.1, 96.7% male, and 60% Black. Passages relating to CKD monitoring (n = 55) yielded predominantly negative communication themes. Perceived negative communication was characterized through a patient discourse of unequal exchange, whereby engaged patients would provide bodily fluids and time for appointments and continued to wait for meaningful, contextualized monitoring information from providers and/or disengaged providers who withheld that information. However, some encounters were depicted as helpful. Perceived positive communication was characterized by a patient discourse of kidney protection, whereby patients and providers collaborate in the mutual goal of preserving kidney function.

Conclusions

Patient perceived an unequal exchange in CKD monitoring encounters. This perception appears rooted in a lack of easily understandable information. By accessing the positive discourse of protecting the kidneys (e.g., through eGFR level) vs. the discourse of damage (e.g., serum creatinine level), healthcare professionals can clarify the purpose of monitoring and in ways that motivate patient engagement in self-management. Patients being monitored for CKD progression may best be supported through messaging that conceptualizes monitoring as kidney protection and provides concrete contextualized information at each monitoring encounter.

A qualitative examination of patients experiences of dietitians ' consultation engagement styles within nephrology

BACKGROUND

Dietitians provide individuals with tailored, practical nutritional advice. For this reason, skills in effective interpersonal communication are essential. In the case of chronic kidney disease, the specifics of dietary advice may change according to renal function. The conveyance of accurate dietary advice and compliance is critical and requires full engagement with the service. The effect of communication styles on patients ' engagement experiences with renal dietetics is unknown. Accordingly, the present study aimed to explore patients ' engagement experiences with renal dietitians.

METHODS

A qualitative phenomenology study using semi-structured in-depth interviews was undertaken with 20 adult renal service users who had engaged with renal dietitians to receive dietary advice. Interpretive phenomenological analysis was used to analyse data.

RESULTS

Two main themes emerged from consultation experiences: helpful and unhelpful engagement styles. Individuals reporting helpful engagement styles experienced dietitians ' communication as empathetic, demonstrating positive regard for their lifestyles. However, individuals who reported experiences of unhelpful engagement styles found dietetic care indifferent and communication styles paternalistic. These individuals continued to engage reluctantly despite unhelpful engagement experiences, but felt disempowered. These diverse experiences of engagement can be interpreted by means of 'ego states' within the theoretical model of transactional analysis (TA). Adult ego states may underpin a helpful engagement style whilst a dietitians ' parental ego state was more likely to precipitate an unhelpful engagement style.

CONCLUSIONS

Ego states, in the context of TA theory, can help to explain the way in which patients engage with renal dietitians. Attention should be given to the employment of a humanistic approach within dietetic consultations. Dietitans need to ensure that they can demonstrate expertise and confidence in the specific communication skills required for patient-centred care.

Active and non-active agents: residents’ agency in assisted living

Culturally, institutional care has been seen to strip older people of their status as full adult members of society and turn them into ‘have-nots’ in terms of agency. The substantial emphasis in gerontology of measuring the activity and functional ability of the elderly has unintentionally fostered these stereotypes, as have traditional definitions of agency that emphasise individuals’ choices and capacities. The aim of this paper is to discover what kind of opportunities to feel agentic exist for people who have reduced functional abilities and therefore reside in assisted living. In this paper, agency is approached empirically from the viewpoint of Finnish sheltered housing residents. The data were gathered using participant observation and thematic interviews. This study suggests that even people with substantial declines in their functional abilities may feel more or less agentic depending on their functional and material surroundings and the support they receive from the staff, relatives and other residents. The perception that residents’ agency in assisted living cannot be reduced to measurable activity has methodological implications for gerontological research on agency. Care providers can utilise our findings in reasserting their residents’ quality of life.