Patients' engagement in primary care: powerlessness and compounding jeopardy. A qualitative study

Exploring the experience of cognitive changes among community-dwelling stroke survivors: a qualitative study

PURPOSE

Cognitive deficits are common among stroke survivors and impact their functional independence. Despite the prevalence of cognitive deficits after stroke, cognitive function is largely overlooked in post-stroke care. The aim of this qualitative study was to explore the experiences of individuals living with post-stroke cognitive changes to understand the impact of these changes on their daily lives.

MATERIALS AND METHODS

Semi-structured interviews were conducted with a purposeful sample of thirteen community-dwelling adults 50 years and older with chronic stroke who self-identified cognitive changes post-stroke. Interviews were transcribed and an inductive thematic analysis was completed.

RESULTS

Four key themes were identified: 1) inability to maintain everyday activities; 2) experiencing emotional responses to living with post-stroke cognitive changes; 3) a shrinking social world and; 4) seeking care for cognitive health post-stroke.

CONCLUSIONS

Post-stroke cognitive changes were described by participants as a driving force behind negative shifts in their daily lives, emotional health, and social connections after stroke. Despite seeking care for their post-stroke cognitive changes, many participants were unable to find support in mainstream healthcare. There is a demonstrated need to further elucidate the gaps in care for post-stroke cognitive deficits and implement community interventions targeting cognitive health post-stroke.

A qualitative exploration of the barriers and facilitators to self-managing multiple long-term conditions amongst people experiencing socioeconomic deprivation

BACKGROUND

Globally, it is estimated that one in three adults live with two or more long-term conditions (multiple long-term conditions, MLTCs), that require self-management. People who experience socioeconomic deprivation face significant health inequalities due to a range of interrelated characteristics that lead to a lack of resources and opportunities. Previous research with underserved populations indicate low levels of trust towards primary care providers and potential barriers for developing patient-healthcare professional relationships. The purpose of this paper is to explore the barriers and facilitators to self-managing MLTCs, amongst people who experience socioeconomic deprivation.

METHODS

Semistructured one-to-one interviews with adults (n = 28) living in London and Sheffield, United Kingdom with MLTCs who are experiencing socioeconomic deprivation. Participants were recruited through general practices, community channels and social media. Data were analysed in NVivo using reflexive thematic analysis methods.

FINDINGS

Four analytical themes were developed: (1) challenges in accessing healthcare services, financial assistance, and cultural awareness; (2) empowerment and disempowerment through technology, including digital exclusion, and use of technology; (3) impact and causes of exclusion on self-management, including social isolation, area-based and economic exclusion, and health-related stigma and (4) adapting self-management strategies, including cost-effective, and culturally/lifestyle appropriate strategies.

CONCLUSIONS

Future health interventions and services need to be developed with consideration of the combined complexities of managing MLTCs while experiencing socioeconomic deprivation. Increased awareness in practitioners and commissioners of the complexities surrounding the lives of people experiencing socioeconomic deprivation, and the need for targeted strategies to promote self-management of MLTCs are of great importa.

PATIENT OR PUBLIC CONTRIBUTION

A patient advisory group contributed to all stages of the study, including providing important feedback on study documents (topic guides and recruitment materials), as well as providing critical insights surrounding the interpretation of interview data.

Exploring Foreign Domestic Workers' Perceived Contextual Factors That Influence Their Participation in Medical Consultations: An Ecological Lens

Foreign domestic workers have reported various health problems after moving to Hong Kong, which suggests the need for them to seek medical attention. Yet, much uncertainty exists about their perception of healthcare experiences as patients, particularly how they perceive their communication with ethnic-discordant healthcare providers. Drawing on foreign domestic workers' perspectives, we extracted non-interpersonal factors from Street's ecological model and its extension proposed by Head and Bute (2018) and examined how foreign domestic workers perceived these contextual factors affected their communication with healthcare providers. Thematic analysis was conducted on thirty Filipina and Indonesian domestic workers' narratives. Our findings confirmed that the context of digital media (characterized by Internet use and the adoption of a telemedicine approach) and the context of social ties (characterized by employers' involvement and everyday communication with friends and peers) were both potential contextual factors that domestic workers reported accounted for their participation in medical encounters. Theoretical and practical implications are discussed. Future research building on these findings is proposed.

Older Men, The Patient-Physician Relationship, and Patient Involvement

Despite the fact that older adults interact frequently with physicians, there is little research examining their preferences, and perceptions of the patient-physician relationship. Research on this topic is particularly sparse when it comes to older men. This study investigates older men's experiences with physicians, their perceptions of the patient-physician relationship, and the extent to which they wished to be involved in their health care. In-depth, face-to-face interviews were conducted with 23 men 55-96 years of age. Findings reveal that older men want to participate in the medical encounter and be involved in their care, contradicting earlier work suggesting that older adults prefer to be passive patients. Preferred involvement, however, varied along a continuum ranging from "quasi-involvement" to "taking charge", with most participants being in the middle, preferring a "partnership" patient-physician relationship. Factors influencing patient involvement and potential to negotiate the patient-physician relationship are discussed.

Health and illness beliefs regarding pain and pain management of New Zealand resident Sāmoan community leaders: A qualitative interpretive study based on Pasifika paradigms

ISSUE ADDRESSED

Ethnic disparities in chronic pain exist in Aotearoa New Zealand, including a greater impact of pain, less access to chronic pain services and less benefit from treatment for Pasifika people. This study investigated Sāmoan health perceptions and beliefs in relation to pain and how it is managed.

METHODS

An interpretive descriptive study was undertaken involving interviews with nine Sāmoan key informants from Aotearoa New Zealand. Interviews explored their beliefs in relation to interpretations of pain and experiences of and preferences for pain management. Interviews were recorded and transcribed. Data were analysed using thematic analysis.

RESULTS

Four main themes were constructed from the data. Pain is interpreted holistically described the attribution of pain to many causes, without limitation to physiological explanations. Stoicism is a character virtue described the predominant belief that pain should be endured without display or complaint. Strength in connectivity described the inherent pain coping strategies that are present within Sāmoan communities. To improve healthcare is to nurture vā described the disconnect Sāmoan people feel from healthcare services and the need to foster relationships to improve health delivery.

CONCLUSIONS

Sāmoan people have beliefs and perceptions about pain and its management that extend beyond traditional Western interpretations. While pain is often endured using traditional strengths within the 'āīga (family) and community, the Sāmoan community faces challenges in receiving healthcare from mainstream pain services. SO WHAT?: Clinicians need to foster stronger relationships with Sāmoan individuals and their 'āīga and appreciate the wider psychosocial context of pain, including spirituality.

Integrating shared decision-making, expressing preferences and active participation of older adults in primary care nursing: a systematic review of qualitative studies and qualitative meta-synthesis

OBJECTIVES

To systematically synthesise the results of primary qualitative studies on how community-dwelling older adults experience shared decision-making processes, express preferences and actively participate in care.

DESIGN

Systematic review of qualitative studies and qualitative meta-synthesis.

METHODS

We focused on studies about community-dwelling participants aged ≥65 undergoing a health-disease process circumscribed to a primary healthcare setting, and the central theme should focus on either shared decision-making, expressing preferences or patient participation. We searched the following databases: MEDLINE, CINAHL, Web of Science, Scopus and PsycINFO (time publication frame 2012-2022). We excluded studies in those cases where the qualitative results were not analysed or unrelated to the phenomenon addressed, phenomena were not clear enough to be included or the setting did not occur in the community.

RESULTS

A total of 12 studies were included in this meta-synthesis. We appraised the quality of the selected studies through Critical Appraisal Skills Programme (CASP) Checklist. The metasummary comprised the frequency and intensity of qualitative patterns across the included studies. The meta-synthesis revealed four influential elements in their interaction: recognising personal qualities, facing professional characteristics, experiences of discrimination and a double-edged context.

CONCLUSIONS

The phenomena studied were influenced by how older people approached their role in their binomial relationship with healthcare professionals. Those with a reinforced self-concept were better aware of health-disease-related situations regarding shared decision-making and the importance of being communicatively assertive. Professional characteristics were also crucial in how older people modulated their acting ability through their personality, communication skills and the approach healthcare professionals used towards older adults. Situations of discrimination generated through an imbalance of power inhibited the expression of preferences and hindered the active participation of older people. The context surrounding the participants influenced all these situations, key in tipping the balance between a therapeutic and a harmful side.

PROSPERO REGISTRATION NUMBER

CRD42022363515.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Connective and Tactfully Tactical: Connective Tactics and Professional Authority in Doctor-Patient Relationships

Medical authority is often thought to be threatened by lay access to information, but how does professional authority work when citizens have more knowledge and choices? We seek to understand how professional authority works in doctor-patient relationships and what each side does to navigate medical encounters. Our abductive study is relational as it builds on qualitative interviews with both doctors and patients. While doctors and patients each try to steer the encounter towards their desired outcomes, they also employ a series of 'connective tactics' to maintain a good, professional relationship. These connective tactics are often draped in a 'tactful' and informal manner so as not to threaten the continuous authority relationship between professionals and citizens. Both sides have a repertoire of how to act on authority relations, often supported by courteous attempts to not insist on formal superiority or patient rights. Each side shifts between what may seem like traditional and connective ways to perform medical authority. Doctors can continue to act as knowledge authorities if they also at least appear to be equals with patients; and patients can use internet findings to get involved in medical decisions as long as they pretend to still respect medical authority.

"It's like asking for a necktie when you don't have underwear": Discourses on patient rights in southern Karnataka, India

BACKGROUND

Ensuring patient rights is an extension of applying human rights principles to health care. A critical examination of how the notion of patient rights is perceived and enacted by various actors through critical discourse analysis (CDA) can help understand the impediments to its realization in practice.

METHODS

We studied the discourses and discursive practices on patient rights in subnational policies and in ten health facilities in southern Karnataka, India. We conducted interviews (78), focus group discussions (3) with care-seeking individuals, care-providers, health care administrators and public health officials. We also conducted participant observation in selected health facilities and examined subnational policy documents of Karnataka pertaining to patient rights. We analyzed the qualitative data for major and minor themes.

RESULTS

Patient rights discourses were not based upon human rights notions. In the context of neoliberalism, they were predominantly embedded within the logic of quality of care, economic, and consumerist perspectives. Relatively powerful actors such as care-providers and health facility administrators used a panoply of discursive strategies such as emphasizing alternate discourses and controlling discursive resources to suppress the promotion of patient rights among care-seeking individuals in health facilities. As a result, the capacity of care-seeking individuals to know and claim patient rights was restricted. With neoliberal health policies promoting austerity measures on public health care system and weak implementation of health care regulations, patient rights discourses remained subdued in health facilities in Karnataka, India.

CONCLUSIONS

The empirical findings on the local expression of patient rights in the discourses allowed for theoretical insights on the translation of conceptual understandings of patient rights to practice in the everyday lives of health system actors and care-seeking individuals. The CDA approach was helpful to identify the problematic aspects of discourses and discursive practices on patient rights where health facility administrators and care-providers wielded power to oppress care-seeking individuals. From the practical point of view, the study demonstrated the limitations of care-seeking individuals in the discursive realms to assert their agency as practitioners of (patient) rights in health facilities.

Supporting care engagement in primary care; the development of a maturity matrix

BACKGROUND

Care engagement or active patient involvement in healthcare contributes to the quality of primary care, but organisational preconditions in routine practice need to be aligned. A Maturity Matrix for Care Engagement to assess and discuss these preconditions in the general practice team was developed and tested on feasibility and acceptability in general practice.

METHODS AND FINDINGS

A systematic user-centred approach was applied, starting with a scoping literature search to describe the domains on the horizontal axis of the maturity matrix. The domains and growing steps (vertical axis) were refined by patients (n = 16) and general practice staff (n = 11) in three focus group discussions and reviewed by six experts (local facilitators and scientists). Seven domains could be distinguished: Personalised Care, Shared Decision Making, Self-Management, Patient as Partner, Supportive Means, Patient Environment, and Teamwork among Healthcare Professionals. The growing steps described three to six activities per domain (n = 32 in total) that contribute to care engagement. Local facilitators implemented the tool in two general practice teams according to a user guide, starting with a two-hour kick-off meeting on care engagement. In the next step, practitioners, nurses and assistants in each practice indicated their score on the domains individually. The scores were discussed in the facilitated practice meeting which was aimed at SMART improvement plans. Feasibility and acceptability were assessed in interviews showing that the tool was well received by the pilot practices, although the practice assistants had difficulties scoring some of the activities as they did not always relate to their daily work. An assessment after three months showed changes in practice organisation towards increased care engagement.

CONCLUSIONS

The maturity matrix on care engagement is a tool to identify the organisational practice maturity for care engagement. Suggested adaptations must be implemented before large-scale testing.

Ineffective health management in people with hypertension: Accuracy study

PURPOSE

To analyze the accuracy of the clinical indicators of the nursing diagnosis Ineffective Health Management in people with hypertension.

METHODS

This is a cross-sectional diagnostic accuracy study. The ineffective health management was investigated in 120 people with hypertension in a referral public outpatient clinic in Brazil between August and November 2020. The accuracy measures were analyzed using Rasch analysis, considering the difficulty of clinical indicator and person's ability.

RESULTS

Ineffective health management is probably present in 37.5% of people with hypertension. 'Failure to include treatment regimen in daily living' was the clinical indicator with the highest sensitivity value, and 'failure to take action to reduce risk factor' had the highest specificity value.

CONCLUSIONS

Rasch analysis demonstrated that all clinical indicators contribute significantly to estimating the presence of ineffective health management in people with hypertension in the outpatient scenario.

IMPLICATIONS FOR NURSING PRACTICE

This research contributes by providing accurate clinical indicators of ineffective health management, helping nurses prescribe and deliver the appropriate nursing interventions for people with hypertension by telenursing.

Do people perceive benefits in the use of social prescribing to address loneliness and/or social isolation? A qualitative meta-synthesis of the literature

Social prescribing is a means by which clinical services can link individuals who have psychological, social and/or practical needs with non-clinical services within their local community. There is a lack of empirical evidence investigating whether social prescribing helps such individuals and which interventions are the most effective and accepted by them to address their loneliness. This meta-synthesis aimed to synthesise findings from qualitative studies exploring experiences of people (of any age) who participated in any social prescribing intervention aimed at loneliness and/or social isolation to ascertain whether they felt it helped address loneliness/isolation and the potential mechanisms by which this might occur. We conducted a systematic search of 5 electronic databases and 4 other databases that would yield grey literature in April 2021 to identify qualitative articles on this topic written in English or French. We assessed the quality of the included studies using recognised tools, and synthesised findings using the approach of thematic analysis. We identified 19 records analysed (e.g. journal articles) from 18 studies meeting inclusion criteria. Our analysis identified three themes: (1) increased sense of wellbeing (with six subthemes), (2) factors that engendered an ongoing desire to connect with others, and (3) perceived drawbacks of social prescribing. These themes illustrate the benefits and difficulties people perceive in social prescribing programmes addressing loneliness and social isolation, with an overall balance of more benefits than drawbacks in social prescribing participation. However, given the unhelpful aspects of social prescribing identified by some participants, greater thought should be given to potential harms. Moreover, further qualitative and quantitative research is needed to better understand mechanisms and effectiveness, and how different components of social prescribing might be best matched to individual participants.

An integrative review of negative emotions of older adults in later life

BACKGROUND

Older adults are one of the most vulnerable populations requiring scientific, psychological, and clinical attention. Although several studies have explored psychoemotional needs in later life, one critical gap in the literature is a shortage of studies comprehensively reviewing negative emotional experiences and their antecedents associated with later life.

AIM

This integrative review aims to identify negative emotional experiences during older adult years.

METHODS

This review of articles from Medline, CINAHL, Science Direct, Web of Science, ProQuest, and Taylor and Francis synthesized negative emotional experiences during older adult years. Across these six electronic databases, we searched and identified 17 relevant articles from 2005 to 2020 containing quantitative, qualitative, and mixed-method studies.

RESULTS

Based on the review, we identified five negative emotions (sadness, anxiety, frustration, anger, and loneliness). These negative emotions were rooted in marital problems, separation from families, medical problems, physical functioning and disability, and financial limitations. Additionally, we identified common antecedents of negative emotions.

CONCLUSION

At the center of numerous interventions, older adults are reinvigorated to understand the antecedents of negative emotions. The complex array of emotions, specifically regrets and frustration in later life, is depicted by more negativity than positivity. Such array of emotions could help develop strategies to prevent the causes of regret and frustration that nurses see when working with older adults in a clinical practice setting.

Scope and activities of Māori health provider nurses: an audit of nurse–client encounters

Introduction The activities and consultations undertaken by Māori health provider nurses are likely broad and operate within a Māori nursing model of care. However, there is little quantitative evidence to document and describe these encounters with clients. The Omaha coding system provides a mechanism in which to quantify nursing encounters through classifying client problems by domain, interventions and specific targets relating to interventions. Aim The aim of this study was to document the types of encounters and interventions undertaken by Māori health provider nurses. Methods An audit was undertaken of patient encounters occurring within a Māori health provider between 1 January 2020 and 31 December 2020. Encounters were randomly selected and problems, activities and interventions coded utilising the Omaha coding system. Simple descriptive statistics were used. Results A total of 5897 nurse-client encounters occurred over the study period. Overall, 61% of the audited nurse-client encounters related to the physiological domain and only 6% of encounters were related to the psychosocial domain. And 29% of nursing interventions involved teaching/guiding/counselling and a further 29% of interventions were case management. Discussion The wide variety of conditions seen and the number of interventions carried out indicate the broad scope of Māori health provider nurses. However, there were likely undocumented problems, which could reflect the medicalisation of the electronic health record. Redesigning electronic health records to apply more of a nursing and Māori health provider lens may facilitate more inclusive ways of documentation.

Co-creating the Patient Partner Guide by a Multiple Chronic Conditions Team of Patients, Clinicians, and Researchers: Observational Report

BACKGROUND

Engaging patients as partners can influence research, with rewards and deterrents. The authors are researchers and patient co-investigators who collaborated on a comparative effectiveness, randomized controlled study of a structured quality improvement (QI) process to improve behavioral health and primary care integration for people managing multiple chronic conditions (MCC). Patient co-investigators responded to a gap in available resources to support study clinics in partnering with their own patients in QI and co-created the Patient Partner Guide (PPG).

OBJECTIVE

Describe the development of the PPG, its use by clinics undertaking the QI project, and research team partnerships.

DESIGN

Observational report of study intervention component.

PARTICIPANTS

Diverse patients and family members managing MCC and members of their primary care clinics.

INTERVENTION

The PPG component of the study intervention is a five-step workbook providing practical tools and resources to sustain partnerships across clinic QI team members, including patient partners. The process of developing the PPG relied on relationship-building tools that were iteratively assessed, practiced, improved, and incorporated into the PPG under the leadership of patient co-investigators.

MAIN MEASURES

Observations related to PPG use and patient partner inclusion in clinic QI; impact on the research team.

KEY RESULTS

Of 20 clinics, 6 engaged patients as full partners on QI teams. Clinics found resistance in partnering and challenges in using the PPG but valued the material and their partners' contributions. Similarly, engagement of patient co-investigators in research brought a shift in perspective to team members. The PPG is available and was adapted for use by research teams.

CONCLUSIONS

Engagement of patients and other stakeholders in research can be transformative and productive. Building relationships through meaningful work benefits others, and in turn, the research process. This approach can enhance clinical care QI and may result in substantial contributions to the conduct of research.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT02868983.

Critical physician behaviors in the formation of a good physician-patient relationship: Concept mapping the perspective of patients with chronic conditions

OBJECTIVE

A robust physician-patient relationship has been linked to better health outcomes for a range of chronic conditions. Our study aimed to identify physician behaviors patients consider contribute to good physician-patient relationships.

METHOD

Fifty patients with a chronic condition and a self-reported good physician-patient relationship were interviewed using the Critical Incidents technique and asked to describe observable behaviors that contributed to their good physician-patient relationship. A sub-sample of 30 participants rated the importance of each behavior and sorted them into self-labelled, mutually exclusive, and conceptually homogenous categories. Multivariate concept mapping with hierarchal cluster analysis was performed.

RESULTS

Patients reported 65 behaviors, which were grouped into six overarching domains: valuing the whole person, investigation and future planning, collaboration and empowerment, validation and emotional support, politeness and courtesy, and professionalism.

CONCLUSION

Results indicate patients with chronic conditions have a broader conceptualization and identified additional behaviors that reflect components of the physician-patient relationship than has been identified in researcher and practitioner based models.

PRACTICE IMPLICATIONS

Practitioners could utilize these concrete behaviors when forming relationships with their patients. These behaviors could also be incorporated into a tool designed to teach and assess the physician-patient relationship.

Ineffective health management: A systematic review and meta-analysis of related factors

PURPOSE

A standardized language system can support the elaboration of clinical guidelines by matching information from similar patterns of response to people. To identify the factors that are related to a higher likelihood of an ineffective health management nursing diagnosis.

METHODS

We conduct a systematic review and meta-analysis. An electronic search was conducted in MEDLINE databases via PubMed, Web of Science, SciELO, CINAHL, SCOPUS, and Embase between October and November 2020. Descriptive data were extracted from each article. The odds ratios for each etiological factor related to ineffective health management were directly extracted from the articles or calculated from the data described in the articles. The analysis of the measurements of exposure and the magnitude of the effect was performed using the statistical software R, and a forest plot was constructed for each etiological factor.

FINDINGS

Ten studies were included, and 15 related factors were recovered from the primary studies. The factors that significantly increased the likelihood of an ineffective health management nursing diagnosis were insufficient knowledge of the therapeutic regimen, perceived barriers, powerlessness, economic disadvantage, and difficulty managing complex treatment regimens. No effect was verified with the following factors: decision conflict, family pattern of healthcare, and inadequate number of cues to action.

CONCLUSION

Factors related to a higher likelihood of ineffective health management may be the focus of early and targeted nursing interventions, contributing to an improved quality of care.

CLINICAL RELEVANCE

Understanding exposure to these factors can improve diagnostic reasoning at different population levels.

Health (il)literacy: Structural vulnerability in the nurse navigator service

Health literacy is a contemporary term used in health services, often used to describe individuals requiring additional support to access, understand and implement health service information. It is used as a measure of self-efficacy in chronic disease models of care such as the nurse navigator service. The aim of the research was to investigate the concept of health literacy in the nurse navigator service, particularly in relation to the defined role objective of person-centred care. Fairclough's critical discourse analysis was used to analyse the experiential, relational and expressive elements of texts, investigating the hidden truths which are represented in discourse. Texts from a variety of health service micro-, meso- and macro-hierarchical sources were selected for analysis using the nurse navigator evaluation data set and other associated texts. Health literacy in the nurse navigator service is a technology of government used to increase participation of individuals in their own health and well-being. The discourse suggests that health literacy responsibilises both individuals and nurses and is discursively formed within a matrix of rational choice. In this context, health literacy contributes to structural vulnerability.

What is the lived experience of anxiety for people with Parkinson's? A phenomenological study

PURPOSE

Anxiety is a common non-motor symptom of Parkinson's and there is no specific pharmacological intervention for people with Parkinson's who experience anxiety. Yet there is little specific research documenting how individuals with this condition experience anxiety. It is important to explore the experiences of people with Parkinson's to identify potential issues in developing future non-pharmacological interventions. This study explored the lived experience of anxiety for people with Parkinson's.

MATERIALS AND METHODS

Six participants were recruited into a descriptive phenomenological study, through the charity Parkinson's UK, using a maximum variation sampling strategy. Face to face interviews were conducted. Data analysis employed thematic analysis.

RESULTS

Three key themes encapsulated the data: Finding ways to cope to "Try not to let it rule your life", Amplifies symptoms "It's emotionally draining it it's also physically draining" and "Anxiety is a funny thing" experienced in myriad ways. A model of the experience of PWP experience of anxiety is proposed.

CONCLUSIONS

Anxiety is a complex experience constructed of interlinked parts affecting people with Parkinson's in myriad ways. Researchers and healthcare professionals should take these findings into account when designing future studies and interventions.

Understanding the impact and causes of 'failure to attend' on continuity of care for patients with chronic conditions

Aim

To understand the impact and causes of ‘Failure to Attend’ (FTA) labelling, of patients with chronic conditions.

Background

Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended.

Method

The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation.

Results

Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient’s capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap.

Conclusion

The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase ‘Failure to Attend’ has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase “appointment did not proceed” to replace FTA.

Implications for Nursing management

This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term ‘appointment did not proceed.’

Nurse navigators and person-centred care; delivered but not valued?

Positioning the individual at the centre of care (person-centred care [PCC]) is essential to improving outcomes for people living with multiple chronic conditions. However, research also suggests that this is structurally challenging because health systems continue to adopt long-standing, episodic care encounters. One strategy to provide a more cohesive, individualised approach to care is the implementation of the nurse navigator role. Current research shows that although PCC is a focus of navigation, such care may be hindered by the rigid, systematised health services providing siloed specialist care. In this paper, we utilised a case study method to investigate the experiences of a nurse navigator and patient. The nurse navigator and the patient participated in individual interviews, the transcripts of which were analysed using critical discourse analysis. Findings from a larger research project suggest that traditional measures (hospital avoidance, emergency department usage) which work as the service objectives of the nurse navigator service have the potential to stifle the delivery of PCC. The analysis from this case study supports the broader findings and further highlights the need for improved alignment between service objectives and the health and well-being of the individuals utilising the services.

Examining the hurdles in defining the practice of Nurse Navigators

BACKGROUND

Nurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care.

PURPOSE

A critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident.

DISCUSSION

Nurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance.

CONCLUSION

Nurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.

Person-centred rhetoric in chronic care: a review of health policies

PURPOSE

The purpose of the paper is to explore how the national, state and organisational health policies in Australia support the implementation of person-centred care in managing chronic care conditions.

DESIGN/METHODOLOGY/APPROACH

A qualitative content analysis was performed regarding the national, state and organisational Queensland Health policies using Elo and Kyngas' (2008) framework.

FINDINGS

Although the person-centred care as an approach is well articulated in health policies, there is still no definitive measure or approach to embedding it into operational services. Complex funding structures and competing priorities of the governments and the health organisations carry the risk that person-centred care as an approach gets lost in translation. Three themes emerged: the patient versus the government; health care delivery versus the political agenda; and health care organisational processes versus the patient.

RESEARCH LIMITATIONS/IMPLICATIONS

Given that person-centred care is the recommended approach for responding to chronic health conditions, further empirical research is required to evaluate how programs designed to deliver person-centred care achieve that objective in practice.

PRACTICAL IMPLICATIONS

This research highlights the complex environment in which the person-centred approach is implemented. Short-term programmes created specifically to focus on person-centred care require the right organisational infrastructure, support and direction. This review demonstrates the need for alignment of policies related to chronic disease management at the broader organisational level.

ORIGINALITY/VALUE

Given the introduction of the nurse navigator program to take up a person-centred care approach, the review of the recent policies was undertaken to understand how they support this initiative.

Cognitive Processing of Miscommunication in Interactive Listening: An Evaluation of Listener Indecision and Cognitive Effort

Purpose The purpose of the current study was to evaluate the social and cognitive underpinnings of miscommunication during an interactive listening task. Method An eye and computer mouse-tracking visual-world paradigm was used to investigate how a listener's cognitive effort (local and global) and decision-making processes were affected by a speaker's use of ambiguity that led to a miscommunication. Results Experiments 1 and 2 found that an environmental cue that made a miscommunication more or less salient impacted listener language processing effort (eye-tracking). Experiment 2 also indicated that listeners may develop different processing heuristics dependent upon the speaker's use of ambiguity that led to a miscommunication, exerting a significant impact on cognition and decision making. We also found that perspective-taking effort and decision-making complexity metrics (computer mouse tracking) predict language processing effort, indicating that instances of miscommunication produced cognitive consequences of indecision, thinking, and cognitive pull. Conclusion Together, these results indicate that listeners behave both reciprocally and adaptively when miscommunications occur, but the way they respond is largely dependent upon the type of ambiguity and how often it is produced by the speaker.

What information do patients want about their medicines? An exploration of the perspectives of general medicine inpatients

BACKGROUND

Medicines are one of the most common healthcare interventions, yet evidence shows patients often do not receive the information they want about their medicines. This affects their adherence and healthcare engagement. There is limited research exploring what information patients want about their medicines, from whom and in what format. The aim of this study was to determine the medicines information needs of patients admitted to the general medical service of a large New Zealand (NZ) hospital, and identify the barriers and enablers to meeting these needs.

METHODS

A descriptive exploratory approach using semi-structured interviews was used to understand the needs and preferences of patients for information about their regular medicines and the barriers and facilitators to obtaining this information. Patients admitted to a general medical ward at a large NZ hospital, aged 18 years and over, prescribed one or more regular medicines, and self-managing their own medicines prior to hospitalisation were included. Semi-structured interviews were conducted with each participant (n = 30) and transcribed, then analysed using a general inductive thematic analysis approach.

RESULTS

Five overarching themes captured the medicines information needs of patients: (1) autonomy; (2) fostering relationships; (3) access; (4) communication; and (5) minimal information needs. Patients desired information to facilitate their decision-making and self-management of their health. Support people, written information, and having good relationships with health providers enabled this. Having access to information at the right time, communicated in a clear and consistent way with opportunities for follow-up, was important. A significant portion of participants were satisfied with receiving minimal information and had no expectations of needing more medicines information.

CONCLUSIONS

Although patients' medicines information needs varied between individuals, the importance of receiving information in an accessible, timely manner, and having good relationships with health providers, were common to most. Considering these needs is important to optimise information delivery in general medical patients.

Support for living well with long-term conditions: How people manage

AIMS AND OBJECTIVES

To explore how people self-manage their long-term conditions and the support enabling them to do so.

BACKGROUND

People with long-term conditions are required to engage in daily self-management with the support of health practitioners, family and friends.

DESIGN

A qualitative interview study.

METHODS

Thirty-two New Zealand European and Pacific people with long-term conditions were interviewed about how they manage their condition/s at home with support from family, neighbours, agencies and general practice doctors and nurses. Interviews were recorded, transcribed, checked and analysed for thematic content. The COREQ checklist was used.

RESULTS

Three themes emerging from the data were as follows: 'acceptance' of conditions, limitations, support and advice; 'making it work' regarding life with long-term conditions; and the need for health practitioners to 'work alongside me'.

CONCLUSIONS

People with long-term conditions struggle with acceptance of a diagnosis and symptoms, and acceptance of help which conflicts with their need to maintain independence and personal control. They self-manage every day, learning to plan, choose what and what not to do and negotiate with others to get tasks done and maintain quality of life. They manage better with support from understanding health practitioners, especially advanced nurses, with whom they have established a positive, sustained relationship.

RELEVANCE TO CLINICAL PRACTICE

Active support for people to self-manage has been shown to assist people to achieve their goals and improve overall health and well-being. Nurses are well positioned to provide self-management support for people with long-term conditions but require allocated time and system changes to enable this. Practitioners need to acknowledge that it is difficult for people to accept diagnoses and symptoms and provide individualised support for this process. The desire to remain independent may limit acceptance of help, making it harder for people to maintain life quality. A change in length and content of consultations is required in order for practitioners to really get to know people and provide the self-management support they need to meet their goals.

What is the answer to the challenge of multimorbidity in New Zealand?

The increasing prevalence of multimorbidity, a growing ageing population and lack of success in addressing the negative effect of socioeconomic and cultural determinants of health are major challenges for New Zealand's primary care sector. Self-management support strategies, personalised care planning, integrated care and shared health records have all been proposed as mechanisms to address these challenges. The organisation of the health system, however, remains largely unchanged, with limited accommodation and few funding concessions made for the requirements of these different approaches and tools. As a result, the primary care system is no longer a good match for the population it serves. With one in four New Zealanders reporting multimorbidity, and people aged >65 years predicted to double in number by 2050, this article argues that over the next decade, New Zealand requires a health system focused on incorporating self-management support, personalised and integrated care and shared health records. This will require further educating of not only health professionals, but also patients in the purpose behind these approaches. In addition, it will mean transitioning to a primary care system more suited to the needs of people with long-term conditions. The key gain from a radical redesign will be a more equitable health system focused on a broader range of health needs.

Nurse-patient interaction and self-transcendence: assets for a meaningful life in nursing home residents?

Background

Due to the shift to an older population worldwide and an increased need for 24-h care, finding new and alternative approaches to increase wellbeing among nursing home (NH) residents is highly warranted. To guide clinical practice in boosting wellbeing among NH residents, knowledge about nurse-patient interaction (NPI), inter- (ST1) and intra-personal (ST2) self-transcendence and meaning-in-life (PIL) seems vital. This study tests six hypotheses of the relationships between NPI, ST1, ST2 and PIL among cognitively intact NH residents.

Methods

In a cross-sectional design, 188 (92% response rate) out of 204 long-term NH residents representing 27 NHs responded to NPI, ST, and the PIL scales. Inclusion criteria were: (1) municipality authority’s decision of long-term NH care; (2) residential time 3 months or longer; (3) informed consent competency recognized by responsible doctor and nurse; and (4) capable of being interviewed. The hypothesized relations between the latent constructs were tested through structural equation modeling (SEM) using Stata 15.1.

Results

The SEM-model yielded a good fit (χ2 = 146.824, p = 0.021, df = 114, χ2/df = 1.29 RMSEA = 0.040, p-close 0.811, CFI = 0.97, TLI = 0.96, and SRMR = 0.063), supporting five of the six hypothesized relationships between the constructs of NPI, ST1, ST2 and PIL.

Conclusion

NPI significantly relates to both ST1, ST2 and PIL in NH residents. ST revealed a fundamental influence on perceived PIL, while NPI demonstrated a significant indirect influence on PIL, mediated by ST.

Joy-of-life in cognitively intact nursing home residents: the impact of the nurse-patient interaction

BACKGROUND

The nursing-home population is at a high risk of declined well-being and quality of life. Finding approaches to increase well-being among older adults in nursing-homes is highly warranted. Responding to this need, the approach framed 'Joy-of-Life-Nursing-Homes' (JoLNH) was developed in Norway.

AIM

To investigate the association between nurse-patient interaction and joy-of-life in the nursing-home population.

METHODS

Cross-sectional data were collected in 2017 and 2018 using the Nurse-Patient Interaction Scale and the Joy-of-Life Scale. A total of 204 cognitively intact nursing-home residents met the inclusion criteria and 188 (92%) participated. A structural equation model (SEM) of the relationship between nurse-patient interaction and joy-of-life was tested by means of STATA/MP 15.1. Ethical approval was given and each participant provided voluntarily written informed consent.

RESULTS

The SEM-model yielded a good fit with the data (χ²  = 162.418, p = 0.004, df = 118, χ² /df = 1.38, RMSEA = 0.046, p-close 0.652, CFI = 0.97, TLI = 0.96, and SRMR = 0.054). As hypothesised, nurse-patient interaction related significantly with joy-of-life (γ1,1 = 0.61, t = 7.07**).

LIMITATIONS

The cross-sectional design does not allow for conclusions on causality. The fact that the researchers visited the participants to help fill in the questionnaire might have introduced some bias into the respondents' reporting.

CONCLUSION

Relational qualities of the nurse-patient interaction should be essential integral aspects of nursing-home care. Consequently, such qualities should be emphasised in clinical practice, and research and education should pay more attention to nurse-patient interaction as an important, integral part of the caring process promoting joy-of-life and thereby well-being.

Whose centre is it anyway? Defining person-centred care in nursing: An integrative review

AIM

The aims of this literature review were to better understand the current literature about person-centred care (PCC) and identify a clear definition of the term PCC relevant to nursing practice.

METHOD/DATA SOURCES

An integrative literature review was undertaken using The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scopus and Pubmed databases. The limitations were English language, full text articles published between 1998 and 2018 within Australian, New Zealand, Canada, USA, Europe, Ireland and UK were included. The international context off PCC is then specifically related to the Australian context.

REVIEW METHODS

The review adopted a thematic analysis to categorise and summarise themes with reference to the concept of PCC. The review process also adhered to the Preferred Reporting System for Meta-Analysis (PRISMA) and applied the Critical Appraisal Skills Programme (CASP) tools to ensure the quality of the papers included for deeper analysis.

RESULTS

While definitions of PCC do exist, there is no universally used definition within the nursing profession. This review has found three core themes which contribute to how PCC is understood and practiced, these are People, Practice and Power. This review uncovered a malalignment between the concept of PCC and the operationalisation of the term; this misalignment was discovered at both the practice level, and at the micro, meso and micro levels of the healthcare service.

CONCLUSION

The concept of PCC is well known to nurses, yet ill-defined and operationalised into practice. PCC is potentially hindered by its apparent rhetorical nature, and further investigation of how PCC is valued and operationalised through its measurement and reported outcomes is needed. Investigation of the literature found many definitions of PCC, but no one universally accepted and used definition. Subsequently, PCC remains conceptional in nature, leading to disparity between how it is interpreted and operationalised within the healthcare system and within nursing services.

The use of telephone communication between nurse navigators and their patients

Background

Hospitals and other health care providers frequently experience difficulties contacting patients and their carers who live remotely from the town where the health service is located. In 2016 Nurse Navigator positions were introduced into the health services by Queensland Health, to support and navigate the care of people with chronic and complex conditions. One hospital in Far North Queensland initiated an additional free telephone service to provide another means of communication for patients and carers with the NNs and for off-campus health professionals to obtain details about a patient utilising the service. Calls made between 7am and 10pm, seven days per week are answered by a nurse navigator.

Aim

To report utilisation of the service by navigated clients and remotely located clinicians compared to use of navigators’ individual work numbers and direct health service numbers. We report the reason for calls to the free number and examine features of these calls.

Methods

Statistical analysis examined the call reason, duration of calls, setting from where calls originated and stream of calls. Interactions between the reasons for calls and the features of calls, such as contact method, were examined.

Results

The major reason for calls was clinical issues and the source of calls was primarily patients and carers. Clinical calls were longer in duration. Shorter calls were mainly non-clinical, made by a health professional. Setting for calls was not related to the reason. The most frequent number used was the individual mobile number of the NN, followed by the hospital landline. Although the free number was utilised by patients and carers, it was not the preferred option.

Conclusion

As patients and carers preferred to access their NN directly than via the 1800 number, further research should explore options best suited to this group of patients outside normal business hours.

Satisfaction with Primary Care Providers and Health Care Services Among Patients with Chronic Pain: a Mixed-Methods Study

BACKGROUND

Chronic pain is a prevalent health concern in the United States (US) and a frequent reason for patients to seek primary care. The challenges associated with developing effective pain management strategies can be perceived as a burden on the patient-provider relationship.

OBJECTIVE

This study explored the relationship between patients' overall satisfaction with their primary care providers (PCPs) and their satisfaction with their chronic pain treatment, as well as the provider behaviors that contributed to chronic pain patients' satisfaction with their PCPs.

DESIGN

Concurrent nested mixed-methods design PARTICIPANTS: 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study.

APPROACH

We analyzed phone interview and survey data (n = 97). Interviews assessed provider behaviors that led to patient satisfaction. Interview transcripts were analyzed based on a content analysis approach. Survey responses assessed patient satisfaction with primary care and pain services. We calculated a Pearson's correlation coefficient using five response categories.

KEY RESULTS

Interviews revealed that high satisfaction with primary care was driven by five concrete PCP behaviors: (1) listening, (2) maintaining communication with patients, (3) acting as an access point to comprehensive pain care, (4) providing an honest assessment of the possibilities of pain care, and (5) taking time during consultations with patients. In surveys, participants reported higher satisfaction with their primary care services than with the pain services they received; these variables were only moderately correlated (r = 0.586).

CONCLUSIONS

Results suggest that patients with chronic pain can view the relationship with their PCPs as positive, even in the face of low satisfaction with their pain treatment. The expectations that these patients held of PCPs could be met regardless of providers' ability to successfully relieve chronic pain.

Reported Māori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis

BACKGROUND

Persistent inequities in health experiences and outcomes are observed for Māori compared to non-Māori in Aotearoa New Zealand. We conceptualised factors associated with Māori consumer experiences of health programs and services and characterise how the recommendations arising from qualitative research inform strategies to address inequities.

METHODS

In this systematic review, electronic literature searching was conducted in February 2018. Qualitative studies reporting Māori consumer experiences of health services and programs in Aotearoa New Zealand were eligible. Māori consumer experiences of health services were mapped to the WHO Commission of Social Determinants of Health (CSDH) conceptual framework on health inequities as related to: (i) the socioeconomic and political context; (ii) socioeconomic positioning; or (iii) intermediary factors that increase exposure to health-compromising conditions. Recommendations to improve consumer experiences were mapped to the CSDH framework for tackling social determinants of health inequities as policy directions on: (i) unequal consequences of illness (individual interaction); (ii) risks of exposure to health-damaging factors (community); (iii) exposures to health-damaging factors (public policies); and (iv) mitigating effects of socioeconomic and political stratification (environment).

RESULTS

Fifty-four studies were included. Māori consumer experiences mapped to social determinants of health inequities were most frequently related to direct interactions with health services and programs, particularly patient-clinician interactions (communication, relationships) and cultural competencies of clinicians and the system. Key recommendations by researchers mapped to potential strategies to address inequity were identified at all levels of the political, social and health system from individual interactions, community change, and broader public and system-level strategies. Recommendations were predominantly focused on actions to reduce risks of exposure to health-damaging factors including health literacy interventions, increased resources in cultural competencies and Māori capacity in health service development and workforce.

CONCLUSIONS

Māori consumer experiences of health services and programs are an important informer of variables that impact health inequity. Strategies to tackle health inequities informed by Māori consumer experiences can be drawn from existing empirical research. Future qualitative exploration of how socioeconomic, political and public policies influence Māori consumer experiences of health services and programs could inform a broader range of structural policies to address health inequities.

Understandings of disease among Pacific peoples with diabetes and end-stage renal disease in New Zealand

BACKGROUND

Compared with New Zealand Europeans, Pacific peoples in New Zealand develop type 2 diabetes at a higher rate and a younger age, and have 3.8 times higher incidence of end-stage renal disease (ESRD).

OBJECTIVE

To investigate contextual factors that shape understandings of disease for Pacific peoples with diabetes and ESRD.

METHODS

Focussed ethnography. In-depth interviews were conducted with 16 Pacific people on haemodialysis for diabetic ESRD, in Auckland, New Zealand. Study participants aged between 30 and 69 years old were of Samoan, Cook Islander, Tongan, Niuean or Tokelauan ethnicity. Thematic analysis was used to code and identify themes.

RESULTS

Participants were embedded in a multigenerational legacy of diabetes. The limited diabetes-related education of earlier generations influenced how future generations behaved and understood diabetes. Perceptions were compounded by additional factors including the invisibility of early-stage diabetes; misunderstandings of health risks during communication with health providers; and misunderstandings of multiple conditions' symptoms and management. Participants had limited engagement with health services until their diagnosis of ESRD acted as a trigger to change this behaviour. However, this trigger was not effective in itself-rather, it was in combination with relevant education delivered in a way that made sense to participants, given their current understandings.

CONCLUSIONS

Illness representations drive choices and behaviours with respect to self-management of diabetes and engagement with health services. Diabetes is often present in multiple generations of Pacific people; therefore, illness representations are developed and shared within a family. Changing illness representations requires engagement with the individual within a family context.

Self-management action and motivation of Pacific adults in New Zealand with end-stage renal disease

AIMS

To explore actions and motivations for self-management practices of Pacific adults following diagnosis of end stage renal disease (ESRD).

METHODS

Focused ethnography using in-depth interviews with 16 Pacific people on haemodialysis for diabetic ESRD, in Auckland, New Zealand. Study participants were of Samoan, Cook Islander, Tongan, Niuean, or Tokelauan ethnicity and aged between 30 to 69 years old. Thematic analysis was used to code and identify emergent themes.

RESULTS

All participants assumed active responsibility for their self-management following their diagnosis of ESRD. They reported positive differences in their current self-management behaviours, compared to pre-ESRD diagnosis. In the face of their terminal diagnosis, participant's motivations to self-manage their health were fuelled by hope; the hope to live long enough to change their family legacy of diabetes and ESRD. To achieve this, there was a dependency upon family members as a resource for self-management support. Yet at the same time, family members also had health concerns (including diabetes), and several participants themselves were carers for sick or elderly family members.

CONCLUSION

The growing number of members (within family units) progressing from moderate to late-stage diabetes raises concerns about the sustainability of future family support in Pacific families in New Zealand with histories of diabetes, ESRD, and other chronic diseases. While the burden upon informal carers (family) has been well documented throughout the past few decades, the dynamics of bi-directional carer support between (two or more) sick family members and their families have had less exposure. This has potentially significant implications for Pacific peoples in New Zealand, considering the increases in diabetes prevalence within their families.

Community care for severely frail older people: Developing explanations of how, why and for whom it works

BACKGROUND

A Community Wellness Team was implemented in North East England in 2014, in line with national policy directives to support frail older people in the community. The service provides a comprehensive and integrated care package, which aims to reduce avoidable admissions, inappropriate service use and enable patients to stay at home.

DESIGN

A realist design combining a review of the literature and primary data collection from service providers and patients was used to develop programme theories explaining the links between the Team interventions and expected outcomes.

RESULTS

Five programme theories were developed, detailing: trust development and relationship building; risk minimisation in the home environment; advice on self-management; referral to preventative services; and coordination of services.

DISCUSSION

The programme theories explain the role and impact of the Community Wellness Team. These programme theories are interrelated and impact one another; a hypothesised progression of programme theories indicating how the Community Wellness Team "works" is discussed. Of particular importance was the comprehensive initial assessment, which leads to the alteration of the social and physical environment within which older people live.

CONCLUSION

Severely frail older people present cases that are complex socially, medically, financially and environmentally. In order to meet these needs, the Team coordinators are adopting a complex and flexible person-centred approach.

IMPLICATIONS FOR PRACTICE

This study paves the way for further research into the care networks surrounding severely frail older people living in the community, and how they can most effectively be implemented.

A systematic review of pharmacist-led medicines review services in New Zealand - is there equity for Māori older adults?

BACKGROUND

Pharmacist involvement in medicines reviews for older adults can improve prescribing and reduce adverse drug reactions. Māori experience poorer health outcomes than non-Māori resulting, in part, from inequitable access to and quality of medicine-related care. Despite international data showing benefit, it is unclear whether pharmacist-led medicines review services can improve outcomes for Māori older adults.

OBJECTIVE

This systematic review aims to describe pharmacist-led medicines review services for community-dwelling adults in New Zealand, assess effectiveness of these interventions and identify their effect on health equity for Māori and older adults.

METHODS

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Equity (PRISMA-E 2012). Observational studies were included. The intervention in included studies had to involve a pharmacist, occur in the outpatient setting in New Zealand, and involve review of all medicines for an individual patient. At least one patient-related outcome had to be reported.

RESULTS

The search identified seven observational studies with 542 total participants. Study interventions included adherence-based reviews in community pharmacies and multi-step comprehensive clinical reviews in outpatient haemodialysis units. Medicines reviews identified up to a median of 3 drug-related problems per review. The effect of interventions on medicines adherence and knowledge was not clear. Māori may have been less likely than non-Māori to benefit from improved medicines knowledge as a result of interventions. None of the studies incorporated aspects in study design or delivery to address inequities for Māori.

CONCLUSION

Further investigation is needed to understand whether the development of culturally safe pharmacist-led medicines review services, responsive to community identified needs, can help to achieve equity in health outcomes for Māori older adults.

Hearing the voices of older adult patients: processes and findings to inform health services research

PLAIN ENGLISH SUMMARY

Whilst Patient and Public Involvement and Engagement (PPIE) are widely regarded as critical to developing clinical research, there is a perception that older adults may not be able to contribute and there is less emphasis on gaining a wide range of opinions before developing research questions or projects; for example an organisational change. This PPIE initiative used three PPIE processes including existing panels and wider networking to access older adults in the community who had used the hospital services and been discharged. Older adults expressed a range of views about their experience of discharge planning and this provided an important perspective on patients' research priorities associated with their personal independence. Efforts were taken to ensure representative views across a cross section of the population. As a result of this initial PPIE, a permanent, co-ordinated 'elders' panel has been established to ensure a representation of older adult views for research, service development and evaluation. This panel has permanent, fully supported members who provide reflection and feedback on any projects and programmes relating to older people's services in the City.

ABSTRACT

Background Clinical academic research and service improvement is planned using Patient and Public Involvement and Engagement (PPIE) but older PPIE participants are consulted less often due to the perception that they are vulnerable or hard to engage. Objectives To consult frail older adults about a recently adopted service, discharge to assess (D2A), and to prioritise services improvements and research topics associated with the design and delivery of discharge from hospital. To use successive PPIE processes to enable a permanent PPIE panel to be established. Participants Following guidance from an established hospital PPI panel 27 older adult participants were recruited. Participants from Black, Asian and Minority Ethnic (BAME) communities, affluent and non-affluent areas and varied social circumstances were included. Methods Focus groups and individual interviews were conducted in participants own homes or nearby social venues. Results Priorities for discharge included remaining independent despite often feeling lonely at home; to remain in hospital if needed; and for services to ensure effective communication with families. The main research priority identified was facilitating independence, whilst establishing a permanent PPIE panel involving older adults was viewed favourably. Conclusions Taking a structured approach to PPIE enabled varied older peoples' voices to express their priorities and concerns into early discharge from hospital, as well as enabling the development of health services research into hospital discharge planning and management. Older people as participants identified research priorities after reflecting on their experiences. Listening and reflection enabled researchers to develop a new "Community PPIE Elders Panel" to create an enduring PPIE infrastructure for frail older housebound people to engage in research design, development and dissemination.

Patients’ perceptions of participation: Pilot validation study of the FI-PPRQ questionnaire in Finnish primary healthcare settings

Patient participation is is a highly valued goal within healthcare. The aim of this study was to assess the validity of a Finnish version of the Participation in Rehabilitation Questionnaire (FI-PPRQ) developed to measure patients’ perceptions of the importance and their experience of participation in care. The original PPRQ was translated from Swedish into Finnish, then subjected to psychometric pilot testing using data acquired in a cross-sectional survey with a sample of adult patients in eight primary healthcare units (n = 88). The importance and experience ratings were evaluated separately, by calculating distributions of item and scale scores, Cronbach’s alpha coefficients, and correlations between items and scales. In addition, experience ratings were subjected to exploratory factor and multi-trait scaling analyses. The results of this study support the validity and reliability of the instrument for use in clinical settings to provide information about patient participation. However, further studies are needed with more varied settings.

Using concept mapping to identify policy options and interventions towards people-centred health care services: a multi stakeholders perspective

BACKGROUND

People-centred health care (PCC) services are identified by the WHO as important building blocks towards universal health coverage. In 2016 the WHO formulated a comprehensive framework on integrated PCC services based on an international expert consultation. Yet, expert opinions may fail to recognize the needs of all health system stakeholders. Therefore, a consultation method that includes the health workforce and laypersons, can be instrumental to elaborate this framework more in-depth. This research sought to identify participants' perspectives on policy options and interventions to achieve people-centred health care services from a multi stakeholder perspective.

METHODS

Study participants, both laypersons and health professionals, were recruited in Belgium. A total of 53 participants engaged in one of the seven concept mapping workshops. In this workshop the concept mapping methodology developed by Trochim, a highly structured qualitative group method for brainstorming and idea sharing, was used to generate and structure participants´ perspectives on what is needed to achieve PCC services. The method was validated using the WHO framework.

RESULTS

The seven workshops together resulted in 452 different statements that were structured in a framework forming 35 clusters and four overarching domains. The four domains with their most prominent clusters were: (1) governance & policy with intersectoral health policies and affordable health for all; (2) health workforce with excellent communication skills, appreciation of health literacy challenges and respectful attitude based on cultural self-awareness; (3) integrated health services with a greater emphasis on prevention, health promotion and the availability of health education and (4) patient, person and community empowerment and participation with support for informal care, promotion of a healthy lifestyle and contextualised health education. Additionally, this study generated ideas that fitted into every single approach described in the WHO framework.

DISCUSSION AND CONCLUSION

This study shows that in order to achieve PCC a participative approach involving all stakeholders at all levels is needed. The concept mapping process is one of these approaches that brings together diverse stakeholders and foments their egalitarian and respectful participation. The framework that resulted from this study can inform future debate regarding planning, implementation and monitoring of PCC.

Patient empowerment: A critique of individualism and systematic review of patient perspectives

OBJECTIVE

The purpose of this review is two-fold: 1) to broaden conceptualization of patient empowerment by synthesizing qualitative research on patient perspectives, and 2) to examine how researcher's method and background may have affected their framing of patient empowerment, thereby shaping the results.

METHODS

A systematic search for qualitative research on patient definitions of power, powerlessness, and empowerment was completed. Articles were analyzed at three levels (theory, method, and data) as suggested by the meta-study method for qualitative synthesis.

RESULTS

The search yielded 13 articles from 11 investigator teams across 9 countries (the United Kingdom, Norway, Australia, Taiwan, New Zealand, China, Iran, Belgium and Italy). Emergent themes from patient perspectives included control, psychological coping, legitimacy, support, knowledge, and participation.

CONCLUSIONS

Despite variation in diagnosis, age, ethnicity, income and country of origin, patients share many perspectives on empowerment. Furthermore, there are indications that interview questions may have influenced findings such that structural barriers to empowerment were not deeply explored.

PRACTICE IMPLICATIONS

This review provides knowledge that can be of direct use to medical professionals who aim to increase patient empowerment (via findings on patient perspectives) and to researchers who can use the critical appraisal of past work to improve future research on this topic.

Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: a scoping review

BACKGROUND

As the population is aging, the number of persons living with multiple chronic conditions (MCC) is expected to increase. This review seeks to answer two research questions from the perspectives of older adults with MCC, their caregivers and their health care providers (HCPs): 1) What are the health and social care needs of community-dwelling older adults with MCC and their caregivers? and 2) How do social and structural determinants of health impact these health and social care needs?

METHODS

We conducted a scoping review guided by a refinement of the Arksey & O'Malley framework. Articles were included if participants were 55 years or older and have at least two chronic conditions. We searched 7 electronic databases. The data were summarized using thematic analysis.

RESULTS

Thirty-six studies were included in this review: 28 studies included participants with MCC; 12 studies included HCPs; 5 studies included caregivers. The quality of the studies ranged from moderate to good. Five main areas of needs were identified: need for information; coordination of services and supports; preventive, maintenance and restorative strategies; training for older adults, caregivers and HCPs to help manage the older adults' complex conditions; and the need for person-centred approaches. Structural and social determinants of health such as socioeconomic status, education and access influenced the needs of older adults with MCC.

CONCLUSION

The review highlights that most of the needs of older adults with MCC focus on lack of access to information and coordination of care. The main structural and social determinants that influenced older adults' needs were their level of education/health literacy and their socioeconomic status.

Discursive practice - lean thinking, nurses' responsibilities and the cost to care

PURPOSE

The purpose of this paper is to explore the literature regarding work intensification that is being experienced by nurses, to examine the effects this is having on their capacity to complete care. The authors contend that nurses' inability to provide all the care patients require, has negative implications on their professional responsibility.

DESIGN/METHODOLOGY/APPROACH

The authors used institutional ethnography to review the discourse in the literature. This approach supports inquiry through the review of text in order to uncover activities that remain institutionally accepted but unquestioned and hidden.

FINDINGS

What the authors found was that the quality and risk management forms an important part of lean thinking, with the organisational culture influencing outcomes; however, the professional cost to nurses has not been fully explored.

RESEARCH LIMITATIONS/IMPLICATIONS

The text uncovered inconsistency between what organisations accepted as successful cost savings, and what nurses were experiencing in their attempts to achieve the care in the face of reduced time and human resources. Nurses' attempts at completing care were done at the risk of their own professional accountability.

PRACTICAL IMPLICATIONS

Nurses are working in lean and stressful environments and are struggling to complete care within reduced resource allocations. This leads to care rationing, which negatively impacts on nurses' professional practice, and quality of care provision.

ORIGINALITY/VALUE

This approach is a departure from the standard qualitative review because the focus is on the textual relationships between what is being advocated by organisations directing cost reduction and what is actioned by the nurses working at the coalface. The discordant standpoints between these two juxtapositions are identified.

How does it feel to be a problem? Patients' experiences of self-management support in New Zealand and Canada

BACKGROUND

The impact of long-term conditions is the "healthcare equivalent to climate change." People with long-term conditions often feel they are a problem, a burden to themselves, their family and friends. Providers struggle to support patients to self-manage. The Practical Reviews in Self-Management Support (PRISMS) taxonomy lists what provider actions might support patient self-management.

OBJECTIVE

To offer providers advice on how to support patient self-management.

DESIGN

Semi-structured interviews with 40 patient-participants.

SETTING AND PARTICIPANTS

Three case studies of primary health-care organizations in New Zealand and Canada serving diverse populations. Participants were older adults with long-term conditions who needed support to live in the community.

MAIN OUTCOME MEASURES

Qualitative description to classify patient narratives of self-management support according to the PRISMS taxonomy with thematic analysis to explore how support was acceptable and effective.

RESULTS

Patients identified a relationship-in-action as the mechanism, the how by which providers supported them to self-manage. When providers acted upon knowledge of patient lives and priorities, these patients were often willing to try activities or medications they had resisted in the past. Effective self-management support saw PRISMS components delivered in patient-specific combinations by individual providers or teams.

DISCUSSION AND CONCLUSIONS

Providers who establish relationships with patients can support them to self-manage and improve health outcomes. Delivery of taxonomy components, in the absence of a relationship, is unlikely to be either acceptable or effective. Providers need to be aware that social determinants of health can constrain patients' options to self-manage.