Patient participation in decision making about care

The role of time in involving patients with cancer in treatment decision making: A scoping review

BACKGROUND

Time is often perceived as a barrier to shared decision making in cancer care. It remains unclear how time functions as a barrier and how it could be most effectively utilized.

OBJECTIVE

This scoping review aimed to describe the role of time in patient involvement, and identify strategies to overcome time-related barriers.

METHODS

Seven databases were searched for any publications on patient involvement in cancer treatment decisions, focusing on how time is used to involve patients, the association between time and patient involvement, and/or strategies to overcome time-related barriers. Reviewers worked independently and in duplicate to select publications and extract data. One coder thematically analyzed data, a second coder checked these analyses.

RESULTS

The analysis of 26 eligible publications revealed four themes. Time was a resource 1) to process the diagnosis, 2) to obtain/process/consider information, 3) for patients and clinicians to spend together, and 4) for patient involvement in making decisions.

DISCUSSION

Time is a resource throughout the treatment decision-making process, and generic strategies have been proposed to overcome time constraints.

PRACTICE VALUE

Clinicians could co-create decision-making timelines with patients, spread decisions across several consultations, share written information with patients, and support healthcare redesigns that allocate the necessary time.

"I am not just a place for implementation. I should be a partner": a qualitative study of patient-centered care from the perspective of diabetic patients in Saudi Arabia

INTRODUCTION

Patient involvement in care is a major component of high quality of care and is becoming recognized worldwide with many beneficial for improving patient outcomes. However, a little is known about patient involvement in the Middle East region and Saudi Arabia in particular.

OBJECTIVES

To evaluate patients' perceptions of their involvement during their interactions with healthcare providers in Saudi Arabia.

METHODS

A qualitative exploratory study using semi structured interview was conducted from February 2022 to March 2022. Responses were transcribed and analyzed using a thematic analysis approach.

RESULTS

We conducted seven interviews with patients with diabetes ranging in age from 19 to 69 years old. We identified the following themes:1) patients' perceptions of their involvement in care, 2) barriers to patient involvement, 3) effective communication, 4) empathy, and 5) culture. We found that patients had minimal knowledge of patient involvement in care.

CONCLUSION

There is a clear need to improve education and awareness of patient involvement in Saudi Arabia. By educating patients about the possibilities of patient involvement and explaining their role it will make it easier for patients to understand appropriate levels of involvement. In addition, there is a need to understand the patient-centred care culture in Saudi Arabia through establishing frameworks with the focus on culture and patient-centred healthcare delivery.

Best-Worst Scaling Survey of Inpatients' Preferences in Medical Decision-Making Participation in China

This study assesses inpatients' preferences for participating in medical decision-making and determines the factors' rankings in order of importance and whether they vary for respondents with different characteristics. Case 1 best-worst scaling (BWS) was used for the study design. Thirteen attributes influencing inpatient medical decision-making participation were identified based on a literature review and interview results. A balanced incomplete block design was used to form choice sets for the BWS questionnaire for a cross-sectional study examining inpatients' preferences for participating in medical decision-making. Based on results from 814 inpatient participants, the three most important factors influencing inpatients' medical decision-making participation were inpatients' trust in physicians, physicians' professional expertise, and physicians' attitudes. The mixed logit model results reflect the significant heterogeneity in respondents' preferences for shared decision-making. To facilitate resource allocation, improve the physician-patient relationship, and encourage patient decision-making participation more actively and effectively, decision-makers should emphasize patients' trust, enhance physicians' ability to diagnose and treat diseases, and improve their attitudes toward providing care and communication from the perspectives of patients, physicians, and the social environment. Further research is needed on the heterogeneity of patients' preferences for participating in medical decision-making and how to improve patient participation.

Comparing Transactional eHealth Literacy of Individuals With Cancer and Surrogate Information Seekers: Mixed Methods Study

Background

The number of adults entering higher-risk age groups for receiving a cancer diagnosis is rising, with predicted numbers of cancer cases expected to increase by nearly 50% by 2050. Living with cancer puts exceptional burdens on individuals and families during treatment and survivorship, including how they navigate their relationships with one another. One role that a member of a support network may enact is that of a surrogate seeker, who seeks information in an informal capacity on behalf of others. Individuals with cancer and surrogate seekers often use the internet to learn about cancer, but differences in their skills and strategies have received little empirical attention.

Objective

This study aimed to examine the eHealth literacy of individuals with cancer and surrogate information seekers, including an investigation of how each group evaluates the credibility of web-based cancer information. As a secondary aim, we sought to explore the differences that exist between individuals with cancer and surrogate seekers pertaining to eHealth literacies and sociodemographic contexts.

Methods

Between October 2019 and January 2020, we conducted a web-based survey of 282 individuals with cancer (n=185) and surrogate seekers (n=97). We used hierarchical linear regression analyses to explore differences in functional, communicative, critical, and translational eHealth literacy between individuals with cancer and surrogate seekers using the Transactional eHealth Literacy Instrument. Using a convergent, parallel mixed methods design, we also conducted a thematic content analysis of an open-ended survey response to qualitatively examine how each group evaluates web-based cancer information.

Results

eHealth literacy scores did not differ between individuals with cancer and surrogate seekers, even after adjusting for sociodemographic variables. Individuals with cancer and surrogate seekers consider the credibility of web-based cancer information based on its channel (eg, National Institutes of Health). However, in evaluating web-based information, surrogate seekers were more likely than individuals with cancer to consider the presence and quality of scientific references supporting the information. Individuals with cancer were more likely than surrogate seekers to cross-reference other websites and web-based sources to establish consensus.

Conclusions

Web-based cancer information accessibility and evaluation procedures differ among individuals with cancer and surrogate seekers and should be considered in future efforts to design web-based cancer education interventions. Future studies may also benefit from more stratified recruitment approaches and account for additional contextual factors to better understand the unique circumstances experienced within this population.

Iranian Cancer Patients Perceptions of Barriers to Participation in Decision-Making: Potential Impact on Patient-Centered Care

Objective:

The purpose of this study was to explore perceptions about barriers to decision-making in Iranian patients with cancer about their care.

Methods:

Utilizing a qualitative approach, semi-structured interviews were conducted with 15 cancer patients.

Results:

Data analysis revealed four central categories reflecting patient perceptions about barriers that included medical dominance (uninformed decision-making, perceived inability to disagree secondary to despair, and patient objectification), healthcare system mistrust (physician, nurse, and medical center facility and equipment), healthcare system characteristics (services and facilities’ limitations, poor communication, healthcare setting compulsion), and cultural barriers (feeling unfamiliar, insecurity in an unfamiliar environment, language barriers, limited attention to religious beliefs).

Conclusions:

Barriers may impact the perceived ability of Iranian patients’ with cancer ability to participate in decision-making regarding their care. Such barriers contain the potential to disrupt patient-centered care. Perceptions about barriers articulated by patients are modifiable. While some Iranian healthcare systems may have problematic challenges, targeted allocation of resources and education of healthcare providers convey strong possibilities to enhance patient-centered care.

Patients with Cancer: their approaches to participation in treatment plan decisions

The aim of this study was to explore experiences of participation in treatment planning decisions from the perspective of patients recently treated for colorectal cancer. Ten patients were purposively selected and interviewed. Constant comparative analysis, the core concept of grounded theory, was used. The dimensions were developed and organized into the main theme of ‘compliant participation in serious decisions’, which was composed of the two variations: complying with participation; and complying without participation. Complying with participation was characterized by feelings of self-confidence and self-competence and by open dialogue between the participants, significant others and the physician. Complying without participation was characterized by participants’ feelings of uncertainty and distress, and of being rushed into submitting to decisions without having time to reflect on the information provided or the opportunity to influence the treatment and care process. To participate (or choosing not to participate) builds on open and affirming dialogue, information and knowledge about the illness. Patient participation in treatment and care decision making is interpreted as a health promoting way of coping with illness.

Patients’ perceptions and preferences of participation in nursing care

The aim of this study was to investigate patients’ perceptions and preferences of their participation in nursing care during hospitalisation in Greece. The sample consisted of medical and surgical patients ( n = 300). A questionnaire was developed to measure patients’ perception of participation, including an open question and the control preference scale. Descriptive and inferential statistics were used for quantitative data analysis and content analysis for qualitative data. Participation was described as ‘information receiving and responsibility’ and ‘ability to influence’. One-third of the respondents preferred a collaborative role with the nurses, while 77.2% rationalised patient participation with the themes ‘strengthening patient’s role’, ‘improve hospitalisation’ and ‘collaborative relationship’. The meaning of participation seems to support shared information, patient responsibility and motivation during nursing care. Patients were aware of the positive effects of their involvement in care and were willing to assume, at least to some extent, an active role in their own care. Changes in nursing care organisation, nurses’ communication skills and additional educational strategies need to be developed and implemented in clinical practice to optimise patient participation.

Adverse events in nursing: A retrospective study of reports of patient and relative experiences

BACKGROUND

Patient safety is an important global issue. While it is well known that patients can suffer from adverse events in nursing care, there is a lack of knowledge as to how they experience them.

AIM

To examine adverse events in nursing care as they are experienced by patients and relatives.

METHODS

This was a retrospective study taking both a qualitative and a quantitative approach. It was based on data regarding 242 adverse events in nursing care, as reported by patients and relatives to Sweden's Medical Responsibility Board, content analysis was used to analyse the reports.

RESULTS

Patients' and relatives' experiences were analysed into four categories of adverse events, as concerning participation, clinical judgement, nursing intervention and the essentials of care.

LIMITATIONS

The reports were classified by the Medical Responsibility Board, without a standardized system. The adverse events reported were few in number and were reported by patients and relatives only.

CONCLUSION

Lack of participation has negative consequences and contributes to adverse events. Adverse events occur through missed care as well as through carer errors.

IMPLICATIONS ON NURSING AND HEALTH PRACTICE

Nurses need to improve their skills that support patient participation. Patient participation needs to be incorporated into nurses' duties.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Resources for patients to participate in their own care needs to be a priority underpinning policy-making in health systems. Nursing education systems need to teach students about the value and benefits of involving patients in their care.

Patient participation in patients with heart failure receiving structured home care--a prospective longitudinal study

BACKGROUND

Patient participation is important for improving outcomes, respect for self-determination and legal aspects in care. However, how patients with heart failure view participation and which factors may be associated with participation is not known. The aim of this study was therefore to describe the influence of structured home care on patient participation over time in patients diagnosed with heart failure, and to explore factors associated with participation in care.

METHODS

The study had a prospective pre-post longitudinal design evaluating the influence of structured home care on participation in patients at four different home care units. Patient participation was measured using 3 scales and 1 single item. Self-care behavior, knowledge, symptoms of depression, socio- demographic and clinical characteristics were measured to explore factors associated with patient participation. Repeated measure ANOVA was used to describe change over time, and stepwise regression analyses were used to explore factors associated with patient participation.

RESULTS

One hundred patients receiving structured heart failure home care were included. Mean age was 82 years, 38 were women and 80 were in New York Heart Association functional class III. One aspect of participation, received information, showed a significant change over time and had increased at both six and twelve months. Better self-care behavior was associated with all four scales measuring different aspects of participation. Experiencing lower degree of symptoms of depression, having better knowledge, being of male sex, being of lower age, cohabiting and having home help services were associated with one or two of the four scales measuring different aspects of participation.

CONCLUSION

Patients experienced a fairly high level of satisfaction with participation in care at baseline, and there was a significant improvement over time for participation with regard to received information after being admitted to structured home care. Higher level of patient participation was consistently associated with better self-care behavior. This study shows that patient participation may need to be further focused upon, and that the association with self-care may be interesting to target in future interventions.

Patient involvement in health care decision making: a review

BACKGROUND

Patient participation means involvement of the patient in decision making or expressing opinions about different treatment methods, which includes sharing information, feelings and signs and accepting health team instructions.

OBJECTIVES

Given the importance of patient participation in healthcare decision making which empowers patients and improves services and health outcomes, this study was performed to review previous studies on patient participation in healthcare decision making.

MATERIALS AND METHODS

To prepare this narrative review article, researchers used general and specific search engines, as well as textbooks addressing this subject for an in-depth study of patient involvement in healthcare decision-making. As a result, 35 (out of 100 relevant) articles and also two books were selected for writing this review article.

RESULTS

BASED ON THE REVIEW OF ARTICLES AND BOOKS, TOPICS WERE DIVIDED INTO SIX GENERAL CATEGORIES: definition of participation, importance of patient participation, factors influencing participation of patients in healthcare decisions, method of patient participation, tools for evaluating participation, and benefits and consequences of patient participation in health care decision-making.

CONCLUSIONS

IN MOST STUDIES, FACTORS INFLUENCING PATIENT PARTICIPATION CONSISTED OF: factors associated with health care professionals such as doctor-patient relationship, recognition of patient's knowledge, allocation of sufficient time for participation, and also factors related to patients such as having knowledge, physical and cognitive ability, and emotional connections, beliefs, values and their experiences in relation to health services.

Heart failure patients' descriptions of participation in structured home care

BACKGROUND

To strengthen the patient's position in health care, patient participation has been decreed in policy documents and legalizations. For patients suffering from heart failure, self-care is an important part of disease management and participation is crucial to succeed with this.

OBJECTIVE

To examine how heart failure patients receiving structured home care described participation in the care.

DESIGN

Qualitative study.

SETTING AND PARTICIPANTS

Thirteen men and six women, aged between 63 and 90 years, were interviewed. The informants received structured home care at four home care units in Sweden. The interviews were analysed using qualitative content analysis.

RESULTS

Five categories with associated subcategories describing participation in care were identified: communication between patients and health-care professionals (HCPs) including time and space for dialogue and exchange of care-related information, accessibility to care through awareness of the plan for home visits or feasibility to initiate home visits, active involvement in care by engaging in self-care and collaboration with HCPs, trustful relation with HCPs, with confidence in competence and individually adapted care, options for decision making, by making decisions or entrusting decisions.

CONCLUSIONS

Patient participation could be strengthened through structured home care. Participation was facilitated when there was a balance between the patient's own preferences to influence care and the health-care professional's actions and values and the organization of care. Barriers to participation could depend on the health-care organization, lack of continuity and confidence in HCPs.

Concept Analysis of Empowerment From Survivor and Nurse Perspectives Within the Context of Cancer Survivorship

The liberal usage of the concept of empowerment has led to the development of a broad and ambiguous term. In health care, empowerment is a core principle of patient-centered care that promotes patient engagement in health management. This is an analysis of the concept of empowerment within the context of cancer survivorship using both Rodgers’ evolutionary concept analysis and Caron and Bower’s dimensional analysis. The dimensional analysis followed the evolutionary concept analysis as the perspectives of patients and nurse providers emerged in the analysis. Data sources included a sample of 249 papers from multiple disciplines covering the period 2000–2013. Empowerment is defined as power-with that is actualized through a beneficial relationship of mutual trust and respect for autonomy that develops within a dynamic and patient-centered process. The attributes, along with the antecedents and consequences, provide a foundation for future theory development of empowerment in the context of cancer survivorship. This analysis demonstrated that although nurses and survivors may have a similar definition of the concept of empowerment, the uses and assumptions of that definition may differ. Future studies should be conducted measuring the effectiveness of an intervention that uses the components of the process of empowerment from survivors’ perspectives.

A qualitative identification of categories of patient participation in decision-making by health care professionals and patients during surgical treatment

The aim of this article is to identify how health care professionals and patients experience patient participation in decision-making processes in hospitals. Eighteen semi-structured interviews with experts from different disciplines such as medicine and nursing in surgical departments as well as patients who have undergone surgical treatment constitute the data. By content analysis four categories of patient participation were identified: information dissemination, formulation of options, integration of information, and control. To meet the increasing demands of patient participation, this categorization with four identified critical areas for participation in decision-making has important implications in guiding information support for patients prior to surgery and during hospitalization.

Rationale, design, and implementation protocol of the Dutch clinical practice guideline pain in patients with cancer: a cluster randomised controlled trial with Short Message Service (SMS) and Interactive Voice Response (IVR)

Background

One-half of patients with cancer have pain. In nearly one out of two cancer patients with pain, this was undertreated. Inadequate pain control still remains an important problem in this group of patients. Therefore, in 2008 a national, evidence-based multidisciplinary clinical practice guideline 'pain in patients with cancer' has been developed. Yet, publishing a guideline is not enough. Implementation is needed to improve pain management. An innovative implementation strategy, Short Message Service with Interactive Voice Response (SVS-IVR), has been developed and pilot tested. This study aims to evaluate on effectiveness of this strategy to improve pain reporting, pain measurement and adequate pain therapy. In addition, whether the active role of the patient and involvement of caregivers in pain management may change.

Methods/design

A cluster randomised controlled trial with two arms will be performed in six oncology outpatient clinics of hospitals in the Southeastern region of the Netherlands, with three hospitals in the intervention and three in the control condition. Follow-up measurements will be conducted in all hospitals to study the long-term effect of the intervention. The intervention includes training of professionals (medical oncologists, nurses, and general practitioners) and SMS-IVR to report pain in patients with cancer to improve pain reporting by patients, pain management by medical oncologists, nurses, and general practitioners, and decrease pain intensity.

Discussion

This innovative implementation strategy with technical tools and the involvement of patients, may enhance the use of the guideline 'pain in patients with cancer' for pain management. Short Message Service alerts may serve as a tool to support self-management of patients. Therefore, the SMS-IVR intervention may increase the feeling of having control over one's life.

Trail registration

Netherlands Trial Register (NTR): NTR2739

Researching involvement in health care practices: interrupting or reproducing medicalization?

In this paper we reflect upon and problematize the ways in which 'patient involvement' is interpreted in a substantial proportion of the research literature on involvement and shared decision making. Drawing upon an analysis of this literature we raise concerns about the 'medicalization of involvement' embedded in, and reproduced by, some dominant research lenses, suggesting that this medicalization has powerful discursive and material effects. For example, we suggest that it tends to normalize and arguably trivialize intrinsically problematic and contentious concepts such as 'patient preferences' and, at the same time, to obscure the full range of possibilities for reciprocity in the exchanges between the medical world of the professional and the experiential and narrative world of the patient. We argue that richer conceptualizations of collaboration in clinical work are both possible and very much needed, and we indicate some examples of scholarly resources and perspectives that point towards richer and more defensible accounts of involvement. Overall we call for more attention to the idea of 'epistemic involvement' and much greater cross-fertilization between different epistemological paradigms in this area of research.

Same description, different values. How service users and providers define patient and public involvement in health care

BACKGROUND

Patient and public involvement in health care is important, but the existing definitions of the concept do not integrate the stakeholders' own perceptions.

OBJECTIVE

To investigate and compare service users' and service providers' own definitions of patient and public involvement and their implications.

DESIGN, SETTING AND PARTICIPANTS

Qualitative study with mainly individual in-depth semi-structured interviews conducted between June 2007 and June 2009. Data were analysed using a grounded theory approach.

RESULTS

A total of 20 patients, 13 public representatives and 44 health service providers/managers in both somatic and mental health care were interviewed. A common definition of patient and public involvement emerged: It is founded on mutual respect, carried out through dialogue aiming at achieving shared decision making. Nevertheless, users and providers assigned different values to the core aspects: Respect was imperative for service users and implied for providers, dialogue was a way to gain respect for service users and to achieve good outcome for providers, and both worried that the other party wanted to make sole decisions.

CONCLUSIONS

Users and providers need to consider that although they have a common definition of involvement in health care, they assign different values to its aspects. Increasing and improving patient and public involvement therefore requires knowledge on and dialogue between the parties about these differences.

Patient decision-making about complementary and alternative medicine in cancer management: context and process

Objective

In this paper, we set out to describe the personal and social contexts of treatment decisions made by cancer patients concerning complementary and alternative medicine (cam) and also the process through which cancer patients reach cam decisions throughout the cancer trajectory.

Methods

We selected and reviewed a variety of cam decision-making models published in the past 10 years within the Canadian health literature.

Results

The cam decision-making process is influenced by a variety of sociodemographic, disease-related, psychological, and social factors. We reviewed four main phases of the cam decision-making process:

Immediately following diagnosis, cancer patients become interested in taking stock of the full spectrum of conventional and cam treatment options that may enhance the effectiveness of their treatment and mediate potential side effects. Information about cam is then gathered from numerous information sources that vary in terms of credibility and scientific legitimacy, and is evaluated. When making a decision regarding cam options, patients attempt to make sense of the diverse information obtained, while acknowledging their beliefs and values. The cam decision is often revisited at key milestones, such as the end of conventional treatment and when additional information about disease, prognosis, and treatment is obtained.

Conclusions

The cam decision-making process is a dynamic and iterative process that is influenced by a complex array of personal and social factors. Oncology health professionals need to be prepared to offer decision support related to cam throughout the cancer trajectory.

Patient decision making among older individuals with cancer

Patient decision making is an area of increasing inquiry. For older individuals experiencing cancer, variations in health and functional status, physiologic aspects of aging, and tension between quality and quantity of life present unique challenges to treatment-related decision making. We used the pragmatic utility method to analyze the concept of patient decision making in the context of older individuals with cancer. We first evaluated its maturity in existing literature and then posed analytical questions to clarify aspects found to be only partially mature. In this context, we found patient decision making to be an ongoing process, changing with time, reflecting individual and relational components, as well as analytical and emotional ones. Assumptions frequently associated with patient decision making were not consistent with the empirical literature. Careful attention to the multifaceted components of patient decision making among older individuals with cancer provides guidance for research, supportive interventions, and targeted follow-up care.

Prevention of delay in the patient discharge process: an emphasis on nurses' role

Planning for a patient's postdischarge needs care does not begin on the day when decision is made to release the patient from the hospital. It is generally accepted that discharge planning should start before admission (for a planned admission) or at the time of admission (for an unplanned admission). A combination of individual factors, most notably age, medical factors such as presence of multiple pathology, and organizational factors such as lack of alternative forms of care facilities put patients at risk of delayed discharge. Moreover, lack of nurses' participation also contributes toward the delaying of discharge. In this article, the author provides strategies to improve nurses' participation in discharge planning and discusses the importance of involving patients and their caretakers in decision making.

Patient information and participation still in need of improvement: evaluation of patients' perceptions of quality of care

AIMS

To identify areas in need of quality improvement by investigating inpatients' perceptions of quality of care, and to identify differences in perceptions of care related to patient gender, age and type of admission.

BACKGROUND

Nursing managers play an important role in the development of high-quality care.

METHODS

Quality of care was assessed using the Quality from the Patients' Perspective (QPP). In all, 2734 inpatients at a Swedish university hospital completed the QPP.

RESULTS

Inadequate quality was identified for 15 out of 24 items, e.g. information given on treatment and examination results, opportunities to participate in decisions related to care and information on self-care. Patients with emergency admissions reported lower scores for quality of information and doctors' care than did patients with planned admissions.

CONCLUSION

Results from the present survey identified areas in need of quality improvement and differences in perceived care quality between patients. Quality of care must be developed in close collaboration with other healthcare professionals; in this respect, nursing managers could play an important role.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers could play a more active part in measuring quality of care, and in using results from such measurements to develop and improve quality of care.

Nurses as patient navigators in cancer diagnosis: review, consultation and model design

The diagnostic phase of cancer care is an anxious time for patients. Patient navigation is a way of assisting and supporting individuals during this time. The aim of this review is to explore patient navigation and its role in the diagnostic phase of cancer care. We reviewed the literature for definitions and models of navigation, preparation for the role and impact on patient outcomes, specifically addressing the role of the nurse in patient navigation. Interviews and focus groups with healthcare providers and managers provided further insight from these stakeholder groups. Common to most definitions of navigation is the navigator's multifaceted role in facilitating processes of care, assisting patients to overcome barriers and providing information and support. Navigation may be provided by laypersons, clerical staff and/or healthcare professionals. In the diagnostic phase it has the potential to affect efficiency of diagnostic testing, patients' experience during this time and preparation for decision-making around treatment options. Patient care during the diagnostic phase requires various levels of navigation, according to individual informational, physical and psychosocial needs. Identifying those individuals who require more support--whether physical or psychosocial--during the diagnostic phase is of critical importance.

Using decision trees to enhance interdisciplinary team work: the case of oncofertility

PURPOSE

Oncofertility, an emerging discipline at the intersection of cancer and fertility, strives to give cancer patients options when they are confronting potential infertility as a consequence of cancer treatment. Fertility preservation decisions must be made before treatment begins, adding stress to the decision-making process.

METHODS

Healthcare providers need to be aware of the intricacies involved in oncofertility decision making, and the often tight time line that patients face when making these decisions. Cancer patient's perspectives may also change, as the dual burden of a cancer diagnosis and potential infertility can cause great flux in emotions.

RESULTS

A provider-facing decision tree was created to enhance patient decision-making capacities and outline the multiple potential intervention points.

CONCLUSIONS

Decision trees, which highlight the important decision points during which providers can approach patients, can be a useful tool to help providers in counseling patients on fertility preservation.

A model of treatment decision making when patients have advanced cancer: how do cancer treatment doctors and nurses contribute to the process?

This qualitative study describes how doctors and nurses report their contribution to treatment decision-making processes when patients have advanced cancer. Thirteen nurses and eight doctors involved in cancer treatment and palliation in one geographical location in New Zealand participated in the study. Data were collected using qualitative in-depth, face-to-face interviews. Content analysis revealed a complex context of decision making influenced by doctors and nurses as well as the patient and other factors. A model of clinician and patient decision making emerged with a distinct and cyclical process as advanced cancer remits and progresses. When patients have advanced cancer, nurses and doctors describe a predictable model of decision making in which they both contribute and that cycles through short- and long-term remissions; often nowadays to the point of the patient dying. In conclusion, the findings suggest doctors and nurses have different but complementary roles in what, when and how treatment choices are negotiated with patients, nevertheless within a distinct model of decision making.

Patients' perceptions of their participation in discharge planning after acute stroke

AIMS AND OBJECTIVES

To describe stroke patients' perceptions of their participation in the discharge planning process and identify correlates of perceived participation.

BACKGROUND

Patients have the right to participate in discharge planning, but earlier research has shown that they are often dissatisfied with the information they receive and their involvement in goal-setting during discharge planning.

DESIGN

Cross-sectional study.

METHODS

The sample consisted of 188 persons (mean age 74 years, SD 11.2) with acute stroke who were admitted to a stroke unit at a hospital in southern Sweden during 2003-2005. Data was collected by face-to-face interviews 2-3 weeks after discharge using the 'Patients' Questionnaire on Participation in Discharge Planning'. This instrument measures perceived participation in discharge planning in three subscales: P-Information, P-Medical Treatment, P-Goals and Needs.

RESULTS

The percentage of patients who perceived that they had participated in discharge planning was as follows: 72-90% according to P-Information, 29-38% according to P-Medical Treatment and 15-47% according to P-Goals and

NEEDS

Age, education and performance of activities of daily living were significantly related to perceived participation as measured by different subscales.

CONCLUSIONS

Most of the patients perceived that they received information, but fewer perceived participation in the planning of medical treatment and needs of care/service/rehabilitation and goal-setting. Professionals need to pay more attention to patients in different subgroups to facilitate their participation in discharge planning. Relevance to clinical practice. To facilitate and increase patients' participation in discharge planning, methods should be implemented for goal-setting and identifying patients' needs. Methods that foster patient participation may improve goal-orientated care, services and rehabilitation after discharge.

[The experience of the "oncologic patient": (re)conceptualizing the informative act]

The adaptation of the patient to the conditions of chronic illness makes the information given to the patient one of the most powerful strategies, capable of contributing to a change in the social representation of the patient, from that of a mere clinical case to that of a holistic being. The objective of this study was to investigate the scientific work published in periodicals indexed by the Medline and Lilacs databases between 1990 and 2006 as to the informative act and the different forms in which information is provided to oncology patients. This analysis of the literature led to the conclusion that there has been an increase in the volume of publications, underlining the role of the oncology patient as a catalyst for new strategies for psychosocial adjustment and revealing her key role through her status as a 'professional patient'.

Where have all the copy letters gone? A review of current practice in professional-patient correspondence

OBJECTIVE

This article reviews the literature in relation to patients receiving copies of health professional correspondence. It examines progress in adopting the practice 3 years on from its introduction as policy in the UK, and considers potential benefits and obstacles to implementation.

METHODS

A review of the literature on copy correspondence, accessed via Medline, PubMed, CINAHL and also online resources, using the search terms "patient letter", "copy letter", "copy correspondence" and "doctor letter".

RESULTS

Studies describe a range of benefits from copying letters, but implementation remains inconsistent, ranging from 8 to 87% of patients reporting receiving copy correspondence. A number of concerns are identified which may be delaying whole scale adoption of the policy by health professionals.

CONCLUSION

This review suggests that researchers should move from examining the benefits and concerns around copying letters to patients, and instead focus on exploring the quality of correspondence and the optimum process of implementing the practice. As patients can "opt out" of receiving copy correspondence, audit of service delivery may be better assessed by whether patients have been offered a letter, rather than the current measure of whether one has been received.

PRACTICE IMPLICATIONS

Copying letters to patients may have a number of important benefits and should be routine practice where patients wish to receive correspondence. Further discussion regarding the style and content of letters would be beneficial, together with attention paid to the mechanisms for recording patient preference. There is also a need for studies in non-medical professions.

Cancer survivors' experience of time: time disruption and time appropriation

AIM

This paper reports a study to explore how cancer survivors talk about, experience and manage time in everyday life.

BACKGROUND

There is an increasing interest in specific physical and psychosocial aspects of life after cancer diagnosis and treatment, but hardly any research follows cancer survivors over time to explore how perceptions and experiences change.

METHODS

An exploratory study was carried out in 2002-2004 with a purposive sample of adults who had experienced various forms of cancer. Data collection included 9 weeks of participant observation at a Cancer Rehabilitation Centre and ethnographic interviews with 23 informants. Ten men and 13 women were interviewed twice: 2 weeks after their stay and 18 months later.

FINDINGS

Data were analysed from a culture-analytical perspective. Three main themes regarding the survivors' handling and perception of time were found: (1) cancer disrupts time and life; (2) awareness of time increases, time is verbalized and reflected; and (3) the informants appropriate time. A diagnosis of cancer, even for a survivor, means a confrontation with death. It means a disruption of continuous clock and calendar time. Survivors appropriate time, and prioritize how and with whom they want to spend their time.

CONCLUSION

With an increasing number of people being cured following a cancer diagnosis, nurses and oncology nurse specialists who work with cancer survivors must be aware of the fact that time is a central theme in understanding cancer survivors' lives, and they must know how to guide these survivors in their new lives and take care of their well-being.

Personality and health care decision-making style

Using the Wisconsin Longitudinal Study Graduate Survey (N = 5,830), a population-based cohort of older adults (most aged 63-66 years), we explored relationships between five factors of personality and four preference types that account for multiple components of the health care decision-making process (information exchange, deliberation, and selection of treatment choice). After adjustment for personal, health, social, and economic factors, we found that increased conscientiousness and openness to experience and decreased agreeableness and neuroticism corresponded to preferring the most active decision-making style compared with the least active. A better understanding of how personality traits relate to patient decision-making styles may help clinicians tailor treatment discussions to the needs and preferences of individual patients.

Information to the relatives of people with ostomies: is it satisfactory and adequate?

PURPOSE

The aim of this study was to evaluate how relatives of patients with an ostomy rated the various aspects of care, how they perceived the quality of the care provided, and how they ranked their involvement in the care. Patients' satisfaction was also sought, particularly their perception of relatives' involvement.

DESIGN

Descriptive cross-sectional.

SETTINGS AND SUBJECTS

The study comprised a colostomy group (32 pairs) and an ileostomy group (28 pairs). All patients attended a stoma outpatient clinic.

METHODS

Quality of care was assessed using the identity-oriented dimension of the validated questionnaire Qualityof Care from the Patient's Perspective. Questionnaires were mailed to patients and their relatives.

RESULTS

Relatives and patients in both study groups considered most topics covered by the questionnaire to be important. Half of the patients with an ileostomy and their relatives and approximately 30% of those in the colostomy group were dissatisfied with the information they received, however. Moreover, a greater proportion (41-89%) of the patients were unhappy with the opportunities they were offered to participate in the decision-making process. Patients with an ileostomy and their relatives tended to be more dissatisfied with the quality of care than the colostomy group, but the difference was not statistically significant.

CONCLUSION

The topics covered by the questionnaire were considered important to both patients and their relatives. Information and counseling offered by the ET nurses and the colorectal surgeons were judged to be unsatisfactory, indicating the need for frequently assessing and improving general standards of quality of care.

Understanding treatment decision making: contexts, commonalities, complexities, and challenges

BACKGROUND

The diagnosis of cancer sets off a cascade of complex decisions at a time when patients feel vulnerable and distressed. Although clinical decisions used to follow one standard, many guidelines now outline several options and include explicit recognition of the need to incorporate patients' preferences to determine the most appropriate treatment.

PURPOSE

The purpose of this article is to provide a brief overview of empirical studies about cancer patients' treatment-related decision making, to highlight the areas of congruence and divergence in that empirical literature, and then to generate a framework that points to future interventions and research.

METHODS

Through a group discussion with a range of experts in the field, we generated a framework for the critical treatment decisions and key issues within those decisions. Then, we reviewed the literature describing the experiences of cancer patients and evaluating interventions designed to improve the quality of treatment decisions.

RESULTS

We identified four major differences that influence decision making across cancers and across individuals with the same diagnosis. We also identified four common themes across situations and people. There is considerable evidence that decision aids can improve the quality of decisions across a range of diseases, although the data for cancer treatment decision making are limited. Other interventions such as navigation-skill training are promising but have little evidence of benefit for cancer decisions.

CONCLUSIONS

There are many opportunities for behavioral research to extend and contribute to the understanding and improvement of cancer treatment decision making. Some key areas in need of research include developing taxonomies of disease and patient characteristics and increasing understanding of the lived experiences of cancer survivors, of the influence of time and timing, of the relationship of information and preferences, and of participation in randomized clinical trials.

The process of developing audiovisual patient information: challenges and opportunities

AIM

The aim of this project was to produce audiovisual patient information, which was user friendly and fit for purpose. The purpose of the audiovisual patient information is to inform patients about randomized controlled trials, as a supplement to their trial-specific written information sheet.

BACKGROUND

Audiovisual patient information is known to be an effective way of informing patients about treatment. User involvement is also recognized as being important in the development of service provision. The aim of this paper is (i) to describe and discuss the process of developing the audiovisual patient information and (ii) to highlight the challenges and opportunities, thereby identifying implications for practice. A future study will test the effectiveness of the audiovisual patient information in the cancer clinical trial setting.

METHODS

An advisory group was set up to oversee the project and provide guidance in relation to information content, level and delivery. An expert panel of two patients provided additional guidance and a dedicated operational team dealt with the logistics of the project including: ethics; finance; scriptwriting; filming; editing and intellectual property rights.

RESULTS

Challenges included the limitations of filming in a busy clinical environment, restricted technical and financial resources, ethical needs and issues around copyright. There were, however, substantial opportunities that included utilizing creative skills, meaningfully involving patients, teamworking and mutual appreciation of clinical, multidisciplinary and technical expertise.

CONCLUSION

Developing audiovisual patient information is an important area for nurses to be involved with. However, this must be performed within the context of the multiprofessional team. Teamworking, including patient involvement, is crucial as a wide variety of expertise is required.

RELEVANCE TO CLINICAL PRACTICE

Many aspects of the process are transferable and will provide information and guidance for nurses, regardless of specialty, considering developing this format of patient information.

Significance of fellow patients for patients with myocardial infarction

The purpose of the study was to present both positive and negative experiences with respect to the significance of fellow patients for patients with myocardial infarction (MI), both inside and outside the hospital. Five focus group sessions were carried out, each having between four and six participants. A total of 25 patients with MI at an age of 40-71 participated. The analysis was carried out by the moderator and co-moderator of the focus groups. The results, which are elucidated by theories of social support, show a great amount of positive support in the interactions of patients, such as support from others in the same situation, a lot of humour, encountering true understanding and consideration, getting practical assistance, and benefiting from other patients' knowledge and experience as well as experiencing an increase in motivation. The participants also discussed negative experiences such as dramatic situations when fellow patients got worse and sometimes even died. Many patients were bothered by various kinds of noise and other disturbances. Insight into the significance of fellow patients will make health personnel able to encourage a patient environment that will strengthen positive and reduce negative effects of fellow patients on the health of each individual patient. One relevant measure would be involving former patients or starting up physical activity in groups. The findings show that the informal patient community among fellow patients is an important part of their social support system and thereby also may contribute to health and well-being.

The decision-making experience among women diagnosed with stage I and II breast cancer

A cancer diagnosis signals entry for many patients into the complex and often bewildering world of cancer care. Understanding the role women prefer and their level of satisfaction with the decision-making process at time of diagnosis will help to inform healthcare professionals how to better support breast cancer patients as they navigate the cancer journey. Logistic regression was used to identify significant factors influencing outcomes in role preferences and satisfaction. A complementary method, principal components analysis was used to explore patterns of co-association between outcomes and their influencing factors. Results showed women tended to adopt cancer decision-making roles similar to those used for general health decision-making. Overall, women preferred a collaborative/active role (40/38%) over a passive role (16%). Satisfaction rates were high with 88.1% of women being satisfied/very satisfied with their cancer treatment choice; 89.7% of women satisfied with their decision-making role and; 83.6% satisfied with the information provided to support their decision. Further research involving cohorts of women diagnosed with more advanced disease and for whom decisional regret may be greater, is needed to further explore the link between preferred decision-making role and satisfaction.

Treatment decision-making in a group of patients with colo-rectal cancer before surgery and a one-year follow-up

Encouraging patient participation in medical and nursing care is an active expression of respect for a person's autonomous choice. The aim of the present study was to compare preferences about the degree of participation in treatment decision-making in a group of patients with colo-rectal cancer before and one-year after surgery, and further to compare these preferences to the patients' actual participating role before surgery and their sense of coherence. Fifty-five persons diagnosed as having rectal or colon cancer were studied. The following instruments were used: The Control Preferences Scale (CPS) and the Sense of Coherence Scale (SOC). Results show that 71% and 75%, respectively, chose a collaborative participation role, before surgery and at follow-up. A majority, 64%, maintained their preferred role from before surgery to the one-year follow-up. Agreement between the preferred and the actual participating role was achieved by 31%. There were no statistically significant differences between the preferred role and with respect to the participants' sense of coherence either before surgery or at follow-up. The sense of coherence seemed not to be related to the preferences before surgery or at follow-up preferences. Further research is needed to elaborate the understanding about patients' preferences for participating in treatment and care decisions.

Perceptions of supportive communication in Chinese patients with cancer: experiences and expectations

AIM

This paper reports the findings of a study exploring the experiences and expectations of patients with cancer of supportive communication in the context of Chinese culture.

BACKGROUND

Patients with cancer experience psychological distress, particularly in the initial period after diagnosis. Supportive communication can positively affect their psychological adjustment. Previous studies have reported the functions, contents, types and sources of informational support for patients with cancer in Western studies, but patients from different cultural backgrounds who have cancer might have different preferences in seeking support.

METHODS

Semi-structured interviews were carried out with a convenience sample of 20 Chinese patients with cancer during 2002. Content analysis was used to identify themes within the data.

FINDINGS

Chinese patients with cancer have a substantial need to receive informational and emotional support during the period of their hospitalization. Their support networks include doctors, nurses, family members, relatives and fellow patients. The expectations of support from different sources varied according to the nature of the relationship between patients with cancer and providers of support. Patients were active in seeking information and they perceived communication with doctors, nurses and fellow patients as beneficial. Most would only express emotional needs to their close family members and did not expect healthcare professionals to provide emotional support. However, interviewees perceived the caring behaviours of nurses and the emotional support of fellow patients as two important sources of support.

CONCLUSION

For Chinese patients, coping with illness and misfortune is largely a private and family affair, and most of them did not expect nurses to meet their emotional needs. Nurses should be aware of the type, timing and source of supportive communication that Chinese patients find valuable. This will help them to provide the appropriate support to meet patients' needs.

Hindrance for patient participation in nursing care

THE STUDY'S RATIONALE: Patients' influence in health care through participation, freedom of choice and information, is laid down in laws, national and local directives. In nursing care situations, the degree to which a patient participates depends on the nursing staff. Accordingly, hindrances for patient's participation during nursing care is an important question for the nursing profession.

AIMS AND OBJECTIVES

The aim was to focus on Swedish Registered Nurses opinion of hindrances for patient participation in nursing care and to uncover the informants' perspectives in depth.

METHODOLOGICAL DESIGN AND JUSTIFICATION

The study was limited to inpatient somatic care and has a qualitative approach. Data were collected through seven focus group interviews with 31 Registered Nurses from five hospitals. An analysis of the tape-recorded interview material was made, combining elements of content analysis with aspects of the Grounded Theory approach.

ETHICAL ISSUES AND APPROVAL

The ethics of scientific work was followed. The participants gave informed consent. Verbal and written information was given as a guarantee that all information would be treated confidentially outside the focus group. Formal approval by ethical committee was not required according to national and local directives.

RESULTS

Hindrance for patient participation in nursing care comprised three themes: Competence, Influence of significant others and Organization and work environment, and their seven underlying subthemes.

CONCLUSIONS

The study clarified factors, which individually or combined may be hindrance for patient participation in nursing practice. Professional nurses must be able to find a balance for their patients' participation in nursing care activities through identification and coping with the hindrances. The three themes and seven subthemes here identified, can be used in patient care and its' evaluation, like also quality assurance of care and work organization and in nursing education. For further development replication studies are needed, like additional studies of patients and significant others.

Teaching elderly adults to use the Internet to access health care information: before-after study

BACKGROUND

Much has been written about the Internet's potential to revolutionize health care delivery. As younger populations increasingly utilize Internet-based health care information, it will be essential to ensure that the elderly become adept at using this medium for health care purposes, especially those from minority, low income, and limited educational backgrounds.

OBJECTIVE

This paper presents the results of a program designed to teach elderly adults to use the Internet to access health care information. The objective was to examine whether the training led to changes in participant's perceptions of their health, perceptions of their interactions with health care providers, health information-seeking behaviors, and self-care activities.

METHODS

Participants attended a 5-week training course held in public libraries and senior community centers within the greater Pittsburgh and Allegheny County region. Classes within each seminar lasted 2 hours and consisted of lecture and hands-on training. Baseline surveys were administered prior to the course, 5-week follow-up surveys were administered immediately after the course, and final surveys were mailed 1 year later. Instruments included the Multidimensional Health Locus of Control (MHLC) Scale, which measures three domains of locus of control (internal, external, and chance); the Krantz Health Opinion Survey (HOS); and the Lau, Hartman, and Ware Health Value Survey. Two additional questionnaires included multiple choice and qualitative questions designed to measure participants' Internet utilization and levels of health care participation. The Health Participation Survey was administered with the baseline survey. The Internet Use Survey was administered at the 1-year mark and contained several items from the Health Participation Survey, which allowed comparison between baseline and 1-year responses.

RESULTS

Of the60 elderly adults who began the training course, 42 (mean age 72) completed the entire 5-week training program and the 5-week follow-up questionnaire administered immediately after the program, and 27 completed the 1-year follow-up survey. Statistically significant differences were found between baseline and 5-week follow-up results for MHLC chance subscores in males (P = .02) and females (P = .05), as well as total HOS information seeking scores (P = .05). However, these statistically significant findings disappeared when all 60 original participants were included using a "last observation carried forward" imputation. No statistically significant changes were found between baseline and 5-week follow-up surveys for MHLC external (P = .44) and internal (P = .97) locus of control scores in both genders, or for the HOS behavioral involvement subscale (P = .65).

CONCLUSIONS

We failed to show robust before-after effects for most of the outcomes measured. Elderly adults may be willing to use the Internet as a source for general health information; however, when making decisions about their health care, our participants seemed to adhere to a physician-centered model of care. Demographic and situational variables may play a large role in determining which seniors will use the Internet for making behavioral decisions about their health care and in which scenarios they will do so.

Patient participation in discussing palliative radiotherapy

Cancer patients' participation in doctor-patient interactions has been shown to be an important factor in the emotional processing of their condition, particularly when only palliative treatments can be offered. In this study, we assessed incurable cancer patients' participation in initial consultations with their radiation oncologists (ROs). RO stimulation of patient participation and discussions about treatment decisions were also measured. The entire consultation was videotaped and analyzed using the Roter Interaction Analysis System (RIAS). Patients' participation proved to be low on medical information, but high on discussing their experiences and life circumstances. The ROs stimulated patient participation mainly by providing medical information and giving patients opportunities to tell their stories. Decisions about radiation treatment had previously taken place and were rarely discussed in the consultations studied. The results suggest that patient participation in palliative treatment consultations might be improved for facilitating patients' emotional processing of the incurable nature of their cancer.

Cancer patient and caregiver experiences: communication and pain management issues

This study examined facilitators and barriers to effective patient and caregiver communication with providers with emphasis on communication related to cancer pain management. Focus groups and personal interviews were conducted with cancer patients and family caregivers of patients. Communication experiences of subjects as well as suggestions for ways to improve the communication process were elicited. Twenty-two cancer patients and 16 family caregivers participated in the study. Seven themes emerged suggesting improvements that are needed in the communication process. These include: 1) improving the process of information exchange, 2) increasing active participation of patient and caregiver in the care process, 3) improving provider relationship-building skills, 4) overcoming time barriers, 5) addressing fears regarding use of pain management medications, 6) fostering appropriate involvement of family and caregivers in the communication process, and 7) improving coordination of care among providers. Specific suggestions and their practice implications for health care providers are highlighted.