How to practice person-centred care: A conceptual framework

Approved or disregarded? Exploring arenas for narrative relations in geriatric care

PURPOSE

The use of narration in healthcare has been accentuated as a response to the requested shift towards person-centred care. The notion of narrative relations refers to a process of involving several people in mutual and ongoing narrative exchange. This study aimed to explore how and where narrative relations may be adopted and enacted in everyday healthcare practice.

METHODS

The study has a qualitative, explorative design. Seven interprofessional focus group discussions with healthcare staff were prompted by vignettes. A multidisciplinary team of healthcare staff (n = 31) were recruited on a geriatric ward. Data were analysed using a constant comparative method.

RESULTS

A core theme shows how narrative relations are adopted and enacted both as part of an approved practice-the work procedures commonly approved as part of healthcare, and as a disregarded practice where covert but important narrative relations take place to support fundamental qualities of healthcare. Moreover, the findings consider arenas of healthcare practice where approved or disregarded practices are enacted in the clinic frontstage and the clinic backstage.

CONCLUSIONS

Narrative relations may take place in different arenas of healthcare practice yet simultaneously become a cohesive force interconnecting those arenas and uphold continuity. Impeded narrative relations in one arena may have unintended consequences in another.

A narrative orientation for the longitudinal integrated clerkship

BACKGROUND

This paper follows through with findings from a longitudinal integrated curriculum (LIC) programme evaluation, which revealed that (1) experiential perspectives and (2) the integration of learning featured weakly in the programme's structure. On examination, these two areas were seen to be linked because, by granting authority to experience, we are called to follow its lead wherever it may take us.

METHODS

Data was collected from students, clinicians and programme administrators using participatory mapping and discussions and analysed through four lenses, one of which was to identify what seemed to be missing or quiet.

FINDINGS

Two features of the LIC model were not explicitly structurally supported in the programme: integration of learning and experiential perspectives.

DISCUSSION

The authors draw on narrative medicine and visual thinking to propose a novel response to the problem, which locates the clinical educator as embodying a narrative orientation to teaching. A narrative orientation affirms the power of human experience, told through stories, to enable integrative, whole-person, big picture thinking in the medical education curriculum. Teaching ideas are scaffolded through metaphors of form, space and integration.

CONCLUSION

In pursuit of an authentic integrator of learning in the LIC, we already have within our reach the power to grant human experience the authority to teach us wherever we find it and follow wherever it leads. However, its potential is yet to be realised, and this discussion throws up new questions for practical enquiry: how best to support educators to adopt a narrative orientation.

Impact of a health literacy sensitive model of care in outpatient nephrology dietetic clinics

BACKGROUND

Inadequate health literacy in people with chronic kidney disease is associated with poorer disease management and greater complications. Adherence to the renal diet is known to be suboptimal and patient feedback about the renal diet suggests that patients leave nephrology clinics feeling confused. The present study aimed to evaluate the impact of a health literacy sensitive model of care (MOC) in outpatient nephrology dietetic clinics.

METHODS

This quasi-experimental non-randomised pre-post study recruited adults attending three renal dietitian clinics. The revised MOC consisted of a renal diet question prompt sheet, teachback, and plain language materials and instructions. Outcomes assessed included clinical, dietary, patient-reported satisfaction and quality of life. Differences between and within groups were analysed using paired t-tests, independent sample t-tests (or non-parametric equivalent), chi-squared and McNemar's tests. Linear mixed models evaluated change in total diet quality score, fruit, vegetable, protein and dairy intake with time as a fixed effect and a random subject specific effect.

RESULTS

Fail to attend rates at the initial appointments were lower in the revised MOC (21.5% vs. 9.1%). The revised MOC was associated with significantly improved fruit (p = 0.03) and vegetable (p = 0.003) intake and an improved proportion with adequate diet quality (p = 0.03). These impacts were of moderate effect size (d = 0.5, 95% confidence interval = 0.0-1.0). The revised MOC was also associated with greater satisfaction at baseline (p = 0.04) and higher acceptability scores for all questions at the review appointments. Quality of life improved clinically but not significantly in the revised MOC (p = 0.92).

CONCLUSIONS

This low-cost health literacy sensitive intervention is a promising strategy to improve fruit and vegetable intake in adults attending renal dietitian clinics. Further research to determine fidelity of teachback use and cost utility analysis would be beneficial. Larger scale trials powered to detect changes in quality of life would also be informative.

Transforming self-experienced vulnerability into professional strength: a dialogical narrative analysis of medical students' reflective writing

Medical students' efforts to learn person-centered thinking and behavior can fall short due to the dissonance between person-centered clinical ideals and the prevailing epistemological stereotypes of medicine, where physicians' life events, relations, and emotions seem irrelevant to their professional competence. This paper explores how reflecting on personal life experiences and considering the relevance for one's future professional practice can inform first-year medical students' initial explorations of professional identities. In this narrative inquiry, we undertook a dialogical narrative analysis of 68 essays in which first-year medical students reflected on how personal experiences from before medical school may influence them as future doctors. Students wrote the texts at the end of a 6-month course involving 20 patient encounters, introduction to person-centered theory, peer group discussions, and reflective writing. The analysis targeted medical students' processes of interweaving and delineating personal and professional identities. The analysis yielded four categories. (1) How medical students told their stories of illness, suffering, and relational struggles in an interplay with context that provided them with new perspectives on their own experiences. Students formed identities with a person-centered orientation to medical work by: (2) recognizing and identifying with patients' vulnerability, (3) experiencing the healing function of sharing stories, and (4) transforming personal experiences into professional strength. Innovative approaches to medical education that encourage and support medical students to revisit, reflect on, and reinterpret their emotionally charged life experiences have the potential to shape professional identities in ways that support person-centered orientations to medical work.

"Sorry for Holding You Up": Surgeons' Apologies for Lateness in Clinic Settings

Doctors running late may convey a lack of respect which can impair the therapeutic relationship. This study examines how surgeons address lateness in consultations with patients. We analyzed 52 consultation recordings from a range of surgical specialties in an Australian metropolitan setting. Conversation analysis was used to analyze interactional sequences where lateness was addressed. Six sequences were identified within four recordings. The two consultations with two apologies include a surgeon and registrar apologizing in a neurosurgical consultation and a surgeon apologizing twice within a colorectal consultation. Apologies were either accepted or responded to with an account for not accepting the apology. When these accounts were made, consultations could only progress when patients accepted an explanation for lateness or the degree of complainability about lateness was reduced. The infrequent occurrence of apologies for lateness, and the way in which these sequences unfolded when they did occur, suggest that there is greater acceptability of lateness for surgeons than in ordinary social situations.

An exploration of person-centredness among emergency department physiotherapists: a mixed methods study

PURPOSE

There is a growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED) who are expected to deliver person-centred practices. Perceptions of physiotherapists working in these high-pressure environments on person-centredness are currently unknown. A mixed methods exploration of person-centredness among ED physiotherapists targeted this knowledge gap to inform future clinical practice.

METHODS

Online survey and semi-structured interviews followed a convergent mixed methods design with sequential explanatory features. Data sets were analysed separately using descriptive statistics and thematic analysis, respectively, before merged analysis using joint display.

RESULTS

Twenty-six surveys and 11 in-depth interviews were completed. The three overarching themes of ED patients, ED physiotherapists, and ED environment were generated. Themes were integrated and analysed alongside quantitative survey findings. This produced three novel contributions that further our understanding of person-centred practices among ED physiotherapists.

CONCLUSION

ED physiotherapists were mindful of an apparent, yet unspoken struggle between the competing philosophies of biomedicine and person-centredness. The results here support entering a patient's world as a person-centred approach to help navigate the line between what an ED attender wants and the clinical need of their visit.

Lessons learned from implementing a digital rehabilitation care planning platform to improve care access for patients with work disability: qualitative process evaluation of the RehaPro-SERVE study

BACKGROUND

Inpatient rehabilitation therapies can be applied for in Germany by patients of working age to support their return to work. However, there are some problems that impede an easy and uncomplicated application process. An interdisciplinary case management approach for rehabilitation care planning was developed to facilitate the access to rehabilitation. Case conferences (CCs) were held with relevant stakeholders and took place on a digital communication platform. We conducted a qualitative process evaluation to understand the implementation of the intervention and to identify contextual factors as well as mechanisms for a successful implementation in the context of primary care.

METHODS

The process evaluation included interviews with primary care physicians (PCPs), patients and stakeholders involved in the intervention process. Reflexive thematic analysis was used to analyse the data. Emerging themes were structured according to the Donabedian framework of structure, process and outcomes.

RESULTS

A total of 18 interviews were conducted. Important results included the desire for more patient involvement and case management. Patients especially valued the opportunity to receive support from a social worker. Limitations of the platform related to usability and limited opportunities for stakeholder communication. Despite training for PCPs, several problems arose regarding the clarity of the intervention process. Patients were satisfied with their application process and the treatments offered, while PCPs reported an increase in workload.

CONCLUSIONS

A digitalisation of the application procedure for rehabilitation and further treatment options is acceptable to patients and personal support of a social worker is particularly valued. However, patients should be included in the CC in terms of a shared decision-making process. The digital platform requires sufficient training and adjustments have to be made to enhance usability and to improve the efficiency of the process for PCPs. Overall, the exchange between the various stakeholders in the CC is considered particularly useful in more complex cases.

TRIAL REGISTRATION

DRKS German Clinical Trials Register, DRKS0 00242 07. Registered on 22 March 2021.

The impact and value of the Parkinson's nurse specialist to people with Parkinson's and their care partners: a grounded theory qualitative study

BACKGROUND

Where available, Parkinson's Nurse Specialists (PNS) provide a range of care, support, guidance, and advocacy for people with Parkinson's (PwP), and, where appropriate, their care partners (CP). Parkinson's is a complex and progressive condition. Consequently, evaluating health outcomes is not a reliable method to understand the value and impact of PNS. Previous research has identified PNS can improve the subjective well-being of PwP in the community, also that barriers to care include heavy caseloads and a lack of time. Yet little is known about the value of the role of the PNS, particularly about the impact of pharmacological management and review. This research aims to close this research gap by providing explanatory theories of the impact and value of PNS to PwP, their CP, and other professionals.

METHODS

A social constructivist grounded theory approach was used. Semi-structured interviews were conducted with three groups, PNS, PwP, and CP. Interviews were analysed using NVivo for coding and categorising and Word for memo-writing. Data was analysed inductively and iteratively to identify contexts, social processes, actions, and behaviours, before final emergent theories were identified.

RESULTS

46 semi-structured interviews (PNS 18, PwP 19, CP 9) led to four data categories and 13 sub-categories that delineated PNS value. (1) Expert Counsel; provision of emotional support, education, and lifestyle guidance; CP inclusion; provision from diagnosis; and across all stages of Parkinson's. (2) Conduit of Care; signposting, referral, and connection to PwP, CP, others; PNS barriers and facilitators; (3) Team/Partnership; continuity and partnership, 'working together'; (4) Pharmacological Support, PNS prescribing; concordance; speed of treatment. Where PNS were accessible they could offer personalised support and partnership, so providing person-centred care that improves health and well-being.

CONCLUSION

Where a PNS is accessible due to service availability and manageable caseloads, to provide person-centred care, they deliver several benefits to PwP and CP which improve health and perceived well-being. Where PNS are not available, PwP and CP often struggle to manage their Parkinson's with negative impacts on health and well-being.

Stakeholders' perceptions towards patients' participation in promoting hand hygiene among health care workers in Wakiso district, Uganda

INTRODUCTION

Hand hygiene compliance is one of the key performance indicators for infection prevention and control programmes, patient safety and quality of health services. WHO guidelines and the patient centred approach stress the need to increase patient involvement in hand hygiene promotion in healthcare settings. Patients' and health care workers' perspectives are critical for developing interventions to foster patient involvement in promoting hand hygiene. This study explored perceptions of health care workers and patients towards patients' involvement in hand hygiene promotion.

METHODS

An exploratory qualitative study was conducted in four health facilities: three public, and one private non-profit in central Uganda. We conducted key informant interviews (KIIs) with health care workers and focus group discussions (FGDs) with patients. Respondents were asked their views about a patient reminding a health care worker to practice hand hygiene and how best this can be done. Interviews were audio-recorded, and transcribed. Thematic content analysis was used.

RESULTS

We led seven FGDs grouped by sex (6 participants each), with patients from different units of the study health care facilities and 23 KIIs with the in-charges of the health care facilities, wards, and infection control committee members. The majority of the KIIs were in the age category 30 to 45 years (10/23), females (14/23), and 7/23 were nurses by cadre. For the FGD participants, the majority were aged 30 to 45 years (23/42), 24/42 were females, 21/42 had attained secondary education as their highest level of education and 21/42 were Catholics. The health care workers' and patients' views towards patients' participation in promoting hand hygiene among health care workers are presented according to the four themes that emerged: i) Patients reminding health care workers to practice hand hygiene was offensive; ii) Patients fear of negative response from health care workers, including being denied or receiving poor quality services; iii) Role of management in influencing hand hygiene (patient reminding a health care workers to wash hands could be acceptable in private health facilities compared to the public ones); iv) Suggestions on how patients' reminders to health care workers can be done, included empowering patients to do the reminders in a friendly and polite approach to the HCW.

CONCLUSION

Patients are reluctant to remind health workers to practice hand hygiene, because they feel it is confrontational and embarrassing, while health care workers find it offensive. Patient involvement seems to threaten patient-provider relationships. However patient empowerment was reported to be critical in promoting it and this is in-line with the hand hygiene guidelines.

Evaluation of chiropractic students' knowledge and attitudes following pain interventions: A randomized educational trial at 2 institutions

OBJECTIVE

To examine chiropractic students' attitudes regarding knowledge of pain neuroscience, chronic pain, and patient-centered care before and after educational interventions. Secondarily, this study aimed to compare measures of these skills between cohorts at different timepoints throughout training programs.

METHODS

Using stratified randomization, 281 Year 3 chiropractic students at 2 institutions were allocated into 1 of 3 educational interventions and served as active-control comparison groups: pain neuroscience education, chronic pain education, or patient-centered care. Participants completed validated surveys regarding their experience with the education interventions immediately pre- and post-lecture and 12 weeks after completion. For further comparison, surveys were also completed by 160 Year 1 students and 118 Year 2 students at 1 of the institutions. Independent sample t tests and 1-way analysis of variance were used for data analysis.

RESULTS

All Year 3 lecture groups showed immediate improvements (pain neuroscience education: 3.99 + 3.09/100, p = .18 [95% CI: 10.10 to -1.77]; chronic pain education: 0.42 + 0.74/7, p = .02 [95% CI: 0.72 to 0.07]; patient-centered care: 0.25 + 0.12/6, p = .05 [95% CI: 0.12-0.51]), but these were not sustained at the 12-week follow-up (pain neuroscience education: -6.25 + 4.36/100, p = .15 [95% CI: 14.93 to -2.42]; chronic pain education: 0.33 + 0.16/7, p = .19 [95% CI, 0.66 to 0.01]; patient-centered care: 0.13 + 0.13/6, p = .30 [95% CI: 0.41 to -0.13]). Compared to active controls, only the patient-centered care group showed an immediate statistically significant difference.

CONCLUSIONS

While this study found that immediate improvement in targeted competencies is possible with focused interventions, they were not sustained long term.

Relationally competent attitudes and actions: a systematic review of general practice literature

OBJECTIVE

To explore core elements from Teachers' Relational Competence in general practice literature regarding building relationships in consultations, specifying actions doctors take to create and maintain relationship quality with patients. This systematic literature review aims to map and propose a similar framework for the doctor-patient relationship.

BACKGROUND

The doctor-patient relationship, a well-researched yet complex field, often lacks clear descriptions. In recent definitions of patient-centred medicine, the responsibility of this relationship falls on the doctor, though how both relationship and responsibility is enacted needs clarification. Pedagogical literature on the student-teacher relationship provides a framework for relational competence, incorporating the needs and interactions between teacher and student and their alignment with institutional goals.

METHODS

A systematic review of two databases yielded 1256 hits. After screening, 15 studies were included and assessed. A qualitative synthesis was conducted through iterative and thematic deductive analysis.

RESULTS

Four relationally competent attitudes identified were: Attention to emotion, Devotion, Mentalization, and Time-oriented presence. Four relationally competent actions identitfied were: Being open, Attunement, Offering Support, and Using humor. Additionally, Trust and Continued connectedness were found as components of both attitudes and actions.

CONCLUSION

An explanatory framework for professional relational competence for GPs includes concrete actions and specific attitudes before and during consultations. These consist of four key attitudes and four categories of actions with several subgroups of actions. Two additional components to the framework was found.

Empowered or challenged? The dual impact of condition-specific electronic Patient-Reported Outcome Measures in the person-centred care of women with breast cancer: A qualitative study

PURPOSE

This study aimed to investigate patients' experiences with electronic Patient-Reported Outcome Measures (ePROMs) during follow-up consultations with registered nurses and surgeons in breast cancer care.

METHODS

A qualitative approach was employed, using focused ethnography with participant observations during patient consultations at a Plastic and Breast Surgery outpatient clinic, followed by individual interviews with the patients. Data were analysed using reflexive thematic analysis by Braun and Clarke. The discussion was informed by theory on person-centred practice.

RESULTS

A total of 38 participants were included. ePROMs strengthened person-centred practice by nudging patients to reflect on their health, voice their concerns and engage in active dialogue during consultations, particularly regarding body image issues. The relevance and impact of ePROMs were highly dependent on the timing of the patient's treatment trajectory. Patients found that ePROMs were more meaningful and contextually appropriate when completed during late follow-up. This could be because patients faced challenges with ePROMs, including not understanding their purpose, the need for assistance from relatives and instances when ePROMs were not integrated into consultations.

CONCLUSION

ePROMs can empower patients by facilitating meaningful discussions about body image and other concerns during postoperative follow-up consultations. However, their effectiveness relies on clear communication and proper integration into clinical practice. The results add to existing litterature by highlighting the dual impact of ePROMs, as they can enhance patient-centred care but also present challenges when their purpose is unclear. The implications for future practice include the need to develop strategies that engage diverse patient groups in the ePROM process, supporting equal access to follow-up care and addressing health disparities.

Health and healthcare use of homeless population: Evaluation study of joint social work and healthcare provision

BACKGROUND

Homelessness as an extreme form of poverty perpetuates and exacerbates health inequalities. People experiencing homelessness face a mortality rate 10 times higher than that of the general population, with an average age of death at 45. There is a significant disconnect between the mainstream healthcare system and the specific health needs of people experiencing homelessness, leading to substantial human and economic costs.

OBJECTIVE

The objective of this evaluation study is to assess the impact of an intervention in nurse-led healthcare outreach services to people experiencing homelessness on their utilization of healthcare services.

DESIGN

This study is a part of research program aimed at assuring health equity of most vulnerable members of a society. Detailed understanding of barriers to care is a necessary precondition for improvements in healthcare use.

DATA

The study analyzes data on hospitalization and emergency department visits by people experiencing homelessness across three cities in Czechia from 2014 to 2021.

METHODS

A quantitative difference-in-differences approach is complemented by insights from field studies in these three cities.

RESULTS

The intervention in people experiencing homelessness outreach led to a reduction in both hospital admissions and the emergency visits by people experiencing homelessness, alleviating pressure on health service capacity and reducing associated healthcare costs. Enhanced primary nurse-led healthcare outreach, along with cross-sectoral integration and activation, has lowered the barriers to accessing essential healthcare services.

CONCLUSION

A pivotal policy outcome of this study is the establishment of an insurance provision that allows medical doctors to claim additional costs incurred in treating people experiencing homelessness from a public insurance system.

Marketing mental health services: a mixed-methods analysis of racially and ethnically diverse college students' engagement with and perspectives on U.S. university mental health clinics' websites

BACKGROUND

The United States (U.S.) faces a significant mental health crisis, with around 52.9 million adults experiencing mental health disorders, with young adults (18-25 years old), such as college students, having the highest prevalence and lowest service utilization rates. While efforts to expand mental health services through "push" strategies are in place (e.g., training therapists in evidence-based therapies), limited initial engagement suggests a need for "pull strategies" and targeted marketing that make services attractive to college students and increase demand. This mixed-methods study identifies U.S. university mental health clinic websites and website characteristics that are attractive and engaging to college students interested in seeking mental health services (i.e., students were considering or actively looking for mental health support).

METHODS

Eleven U.S. university websites were chosen (10 randomly and one from the university where students were attending) from a pool of 44 Psychological Clinical Science Accreditation System training clinics websites. Fifty-seven college students (Mage = 20.95, SD = 2.97; 81% female; 68% racial/ethnic minority) were videorecorded engaging with two U.S. university mental health clinic websites, completed self-report engagement measures, and gave detailed feedback about websites through semi-structured interviews.

RESULTS

Likert scale scores revealed moderate engagement with all websites (e.g., they were interesting and helpful). Qualitative results indicated that websites that provided important and easily understood information about key features of services (e.g., types, evidence-base, and cost), therapist backgrounds, psychoeducation, used lay language, and had an appealing website layout (e.g., color, font, images, organization, and interactive components) generated greater consumer interest and trust in their mental health services.

CONCLUSIONS

This study emphasizes the importance of using marketing strategies to enhance college students' engagement through mental health service websites. Salient features, psychoeducation, and effective promotional strategies (e.g., how information is presented) were identified as crucial for website engagement and subsequent mental health service uptake. Using marketing strategies, such as tailoring language to consumer literacy levels, describing the evidence-base of services, and improving website design may address college students' needs and enhance initial mental health service engagement.

Perceived Impact of Healthcare Relationships and Interactions on Parental Experiences of Prenatal Diagnosis and Termination of Pregnancy for Foetal Anomaly on the Island of Ireland

OBJECTIVE

The aim of this study was to explore parents' experiences of their relationships and interactions with healthcare professionals (HCPs) during care related to prenatal diagnosis and termination of pregnancy for foetal anomaly (TOPFA).

METHODS

A qualitative approach was used. Participants included 33 parents (23 women and 10 men) from Northern Ireland (n = 11) and Ireland (n = 22) who had a TOPFA. Data collection methods included semi-structured interviews and written narrative accounts. Data were analysed using thematic analysis.

RESULTS

Findings confirmed that TOPFA was a traumatic, life-altering experience for parents, impacting their health and well-being. The actions, behaviours and words of HCPs impacted how parents perceived and interpreted their healthcare experiences and their access to services and supports. In relation to this, five themes are presented: (1) the importance of compassionate and non-judgemental care, (2) the value of effective information and communication, (3) the desire for compassionate care for baby and facilitation of memory making, (4) the need for continuity of care and (5) parents' experiences of healthcare relationships during times of legislative change.

CONCLUSION

This research reveals the important role HCPs play in helping parents cope with prenatal testing and TOPFA. Parents who had a positive relationship with an HCP, in which information was communicated effectively and compassionate and non-judgmental care was provided, felt more supported and more able to accept and adapt to their loss.

PATIENT AND PUBLIC CONTRIBUTION

An advisory group composed of parents who had experienced TOPFA and HCPs with experience in caring for such families were involved in the study from the outset, contributing to the design and development of data collection materials, interpretation of the findings and design of dissemination materials.

Attitudes of nurses and physicians working in hard-to-heal wound management towards person-centred care

OBJECTIVE

Person-centred care (PCC) is an important approach as it positively affects disease management. Guiding studies are needed on the use and development of PCC in hard-to-heal (chronic) wound management. This study aimed to determine attitudes and approaches of nurses and physicians working in hard-to-heal wound management towards PCC, and obtain their views and suggestions for its scope and improvement.

METHOD

Participants of this descriptive survey study consisted of nurses and physicians responsible for hard-to-heal wound care and treatment in healthcare institutions at all levels in Turkey. Data were collected through a structured online survey shared with members of professional associations via social media platforms between March-November 2020. Descriptive statistics and qualitative inductive content analysis were used to analyse data.

RESULTS

Participants (n=418) included physicians (84.2%) and nurses (15.8%). Mean participant-graded their person-centred behaviour level was 8.18±1.80 (out of 10 points). The majority of participants reported that they informed patients about care, treatment processes and options (87.3%) as well as including them in the decision-making process (74.6%). Responses of the participants regarding the scope of PCC were classified into five main categories, the most prominent being: 'individual', 'care', 'professional development' and healthcare system'. Suggestions for the improvement of PCC were classified into seven main categories, with 'personalised care', 'disease-specific care', 'continued training of healthcare professionals should be ensured' and 'home care system should be developed for the continuity of care' among the prominent subcategories.

CONCLUSION

The findings of this study suggests that education on PCC is an important approach. Institutional protocols and guidelines can support person-centred hard-to-heal wound management. In this study, the level of person-centred behaviour of the participants was determined to be good. Although the results of the study cannot be generalised to all health professionals-the majority of the participants were physicians-it is recommended to develop and disseminate the PCC model in hard-to-heal wound management using the findings.

Application of the Person-Centered Care to Manage Responsive Behaviors in Clients with Major Neurocognitive Disorders: A Qualitative Single Case Study

OBJECTIVES

Our study aimed to describe "how" and "why" the person-centered care (PCC) approach was applied within a long-term care (LTC) community to manage responsive behaviors (RBs) in individuals with major neurocognitive disorders.

METHODS

A descriptive holistic single case study design was employed in the context of an LTC community in Quebec, using semi-structured interviews and non-participatory observations of experienced care providers working with clients with RBs, photographing the physical environment, and accessing documents available on the LTC community's public website. A thematic content analysis was used for data analysis.

RESULTS

The findings generated insight into the importance of considering multiple components of the LTC community to apply the PCC approach for managing RBs, including a) creating a homelike environment, b) developing a therapeutic relationship with clients, c) engaging clients in meaningful activities, and d) empowering care providers by offering essential resources.

CONCLUSIONS

Applying and implementing the PCC approach within an LTC community to manage clients' RBs is a long-term multi-dimensional process that requires a solid foundation.

CLINICAL IMPLICATIONS

These findings highlight the importance of considering multiple factors relevant to persons, environments, and meaningful activities to apply the PCC approach within LTC communities to manage RBs.

Hospital Diversity, Equity, and Inclusion Efforts: Perspectives of Patient and Family Advisors

BACKGROUND AND OBJECTIVES

Patient and family advisory councils are common within children's hospitals. However, lack of diversity among patient and family advisors (PFAs) may result in exclusion of crucial perspectives and perpetuate inequities. We sought to understand PFA perspectives on how children's hospitals should approach: (1) recruitment and support of PFAs from groups at greater risk of health inequities; and (2) development of meaningful partnerships with PFAs or patient and family advisory councils on institutional diversity, equity, and inclusion (DEI) efforts.

METHODS

We conducted a qualitative study of PFAs of children's hospitals from communities at greater risk for health inequities based on self-identified race, ethnicity, gender, socioeconomic status, disability, language, or other factors. Focus groups were virtual and group discussions were recorded, transcribed, and analyzed using inductive qualitative analysis.

RESULTS

In total, 17 PFAs participated across 5 focus groups (4 in English, 1 in Spanish). We identified 6 themes: (1) PFA diversity is necessary to understand existing health inequities; (2) diversity needs to be considered broadly; (3) recruiting for diverse PFAs requires intentionality, visibility of PFACs within and outside of the hospital, and deliberate connections with families and communities; (4) efforts to increase PFAC diversity must be accompanied by work to develop inclusive environments; (5) diversity efforts require meaningful engagement and equity; and (6) diverse PFACs can enrich DEI efforts but require organizational commitment and follow-through.

CONCLUSIONS

Insights from our qualitative study of PFAs can be used by healthcare systems to foster diversity and inclusion in PFACs and advance hospital DEI efforts.

A comparison of preoperative soft tissue contour versus bone accuracy as a predictor of quality of life outcomes in osseous free flap jaw reconstruction using occlusal-based virtual surgical planning

OBJECTIVES

Occlusal-based virtual surgical planning (VSP) prioritises the placement of endosseous dental implants, over replicating native bone contour. This may compromise facial aesthetics. This study aimed to compare function and health-related quality of life (HRQOL) following maxillomandibular reconstruction according to the ability to replicate preoperative soft-tissue contour and virtual plan.

MATERIALS AND METHODS

Patients who underwent occlusal based VSP osseous free flap reconstruction of the maxilla or mandible with high-resolution pre- and post-operative facial computerised tomography imaging and completed the FACE-Q questionnaire were retrospectively identified. Accuracy of reconstruction compared to preoperative soft tissue contour and virtual plan, was measured using 3DSlicer® and CloudCompare® in three dimensions. Random effects modelling determined the associations between bony and soft tissue accuracy and HRQOL/functional domains.

RESULTS

Twenty-two patients met the inclusion criteria. For mandibular and maxillary reconstructions, better soft tissue accuracy was associated with improved appearance (p = 0.048) and appearance distress (p = 0.034). For mandibular reconstructions, better soft tissue accuracy was associated with improved smile (p = 0.039) and smile distress (p = 0.031). For maxillary reconstructions, better bony accuracy was associated with improved appearance (p = 0.023) and drooling distress (p = 0.001). Unexpectedly, better bony accuracy was associated with worse eating and drinking (p = 0.015), oral competence (p = 0.005) and eating distress (p = 0.013) in mandibular reconstructions.

CONCLUSION

Whilst soft tissue accuracy was associated with better functional and HRQOL outcomes, bone accuracy was associated with worse oral function or distress in mandibular reconstruction. These results require validation but should be considered when performing occlusal-based VSP, which prioritises dental rehabilitation over replicating facial bony contour.

The Encounter of Two Worlds: Divided Narratives of Decision-Making on Cancer Treatment Between Physicians and Patients

INTRODUCTION

Divided narratives pose long-standing difficulties in physician and patient communication. In decision-making on cancer treatment, divided narratives between physicians and patients hinder mutual understanding and agreement over the illness and its treatment. For effective decision-making on treatments, it is necessary to investigate the similarities and differences in these divided narratives.

METHODS

This study adopted a qualitative research design of narrative inquiry to examine the data, which included interviews with 32 cancer patients and 16 paired physicians in two hospitals in China. Data analysis was conducted using grounded theory to generate findings.

RESULTS

Both physicians and patients were concerned about goals and obstacles to their decision-making on cancer treatment. Four common aspects of goal setting were identified from the divided narratives: decision pools, treatment goals, identity practice and preferred identity. Four common obstacles were identified: pains and trust, communication gap, financial issues and complex family. However, the meanings attached to these eight aspects differed between physicians and patients.

CONCLUSION

Cancer treatment decision-making is an encounter of the scientific world and lifeworld. A divided narrative approach can identify the similarities and differences in the decision-making on cancer treatment between physicians and patients. Physicians generally adopt a rational decision-making approach, whereas patients generally adopt a relational decision-making approach. Despite the common concerns in their goals and obstacles, physicians and patients differed in their contextualized interpretations, which demonstrates the physicians' and the patients' pursuit of preferred identities in decision-making. The results of this study provide a new perspective to treatment decision-making, emphasizing the importance of narrative integration in reaching mutual agreement.

PATIENT AND PUBLIC CONTRIBUTION

The findings were shared with 15 cancer patients and caregivers for feedback and advice in June 2024. This study was also presented at the international conferences of COMET (International and Interdisciplinary Conference on Communication, Medicine, and Ethics) and ICCH (International Conference on Communication in Healthcare) 2023 for continuous feedback and comments.

Electronic Patient Reported Outcomes Measures (e-PROMs) in Pediatric Palliative Oncology Care: A Scoping Review

Objective: Research findings regarding child-centered care and electronic patient reported outcome measures (e-PROMs) within pediatric palliative oncology care reveal an intricate field of study. This study aimed to map innovations in e-PROMs for the pediatric cancer population in palliative care and their impact on symptom management, and communication with healthcare professionals. Methods: A scoping review was designed following the Arksey and O'Malley framework. Literature searches were conducted in CINAHL, Embase, MEDLINE, PsycINFO, SCOPUS, and Web of Science. Inclusion criteria targeted children aged 0-18 years with cancer, receiving palliative and/or end-of-life care, and using e-PROMs. Results: Twelve articles were included: 10 quantitative studies, one qualitative study, and one mixed-method study. A narrative synthesis approach was used to summarize the findings, categorized into three sections: (a) technological innovation of e-PROMs in pediatric palliative oncology care; (b) the impact of e-PROMs on symptom monitoring, management, and children's care; (c) the effects of e-PROMs on communication between children and healthcare professionals in pediatric palliative oncology care. Conclusion: e-PROMs have proven effective in empowering children to express their perspectives and actively engage in their end-of-life care. Due to flexible software and devices designed for various age groups, these tools fit seamlessly into children's daily routines and preferences, including the use of play-oriented applications. They facilitate a deeper understanding, and management of physical and emotional symptoms while ensuring care remains child-centered. This emphasizes the importance of preserving the essence of childhood and addressing the unique needs and experiences of young patients in pediatric palliative oncology care.

Physicians' training and patient education initiative to improve quality of care decision communication at the emergency department

BACKGROUND

Discussions about care decisions, including code status documentation and advance care planning, are crucial components of patient-centred care. However, due to numerous barriers, these discussions are often avoided by both physicians and patients. As a result, these discussions often take place at the emergency department (ED). We aimed to improve the quality of care decision conversations in the internal medicine ED.

METHODS

This pre-post intervention study was conducted at the internal medicine ED of a tertiary hospital in the Netherlands. Two interventions were implemented simultaneously: physician training and patient education. Physician training included an e-learning module and simulated patient sessions. Patients received a leaflet providing information about care decisions. Primary outcome was patient satisfaction with the care decision discussions, assessed using the Quality of Communication questionnaire. Secondary outcomes included the percentage of patients recalling a care decision discussion, initiator of the discussion, leaflet recall, leaflet evaluation, prior care decision discussions and perceived appropriate timing for discussions.

RESULTS

333 patients participated, 149 before and 184 after the interventions. Postintervention, there were significant improvements in patient-reported quality of care decision communication (p<0.001) and more patients recalled having care decision discussions (63.7% vs 45.9%, p=0.001). However, only 12% of patients recalled receiving the leaflet.

CONCLUSIONS

Implementation of physician training and patient education significantly improved the quality of care decision conversations in our internal medicine ED. Despite low leaflet recall, the interventions demonstrated a notable impact on patient satisfaction with care decision discussions. Future research could explore alternative patient education methods and involve other healthcare professionals in initiating discussions. These findings underscore the importance of ongoing efforts to enhance communication in healthcare settings, particularly in emergency care.

Fostering nurse-patient relationships in palliative care: An integrative review with narrative synthesis

BACKGROUND

Nurse-patient relationships are an integral component of person-centred palliative care. Greater understanding of how nurse-patient relationships are fostered and perceived by patients and nurses can be used to inform nursing practice.

AIM

To systematically identify and synthesise how nurse-patient relationships are fostered in specialist inpatient palliative care settings, and how nurse-patient relationships were perceived by patients and nurses.

DESIGN

Integrative review with narrative synthesis. The review protocol was registered with PROSPERO (CRD42022336148, updated April, 2023).

DATA SOURCES

Five electronic databases (PubMed, CINAHL Complete, Medline, Web of Science and PsycINFO) were searched for articles published from their inception to December 2023. Studies were included if they (i) examined nurse and/or patient perspectives and experiences of nurse-patient relationships in specialist inpatient palliative care, (ii) were published in English in a (iii) peer-reviewed journal. The Mixed Methods Appraisal Tool was used to evaluate study quality. Data were synthesised using narrative synthesis.

RESULTS

Thirty-four papers from 31 studies were included in this review. Studies were mostly qualitative and were of high methodological quality. Four themes were identified: (a) creating connections; (b) fostering meaningful patient engagement; (c) negotiating choices and (d) building trust.

CONCLUSIONS

Nurses and patients are invested in the nurse-patient relationship, benefitting when it is positive, therapeutic and both parties are valued partners in the care. Key elements of fostering the nurse-patient relationship in palliative care were revealed, however, the dominance of the nurses' perspectives signifies that the nature and impact of these relationships may not be well understood.

The experience sampling methodology as a digital clinical tool for more person-centered mental health care: an implementation research agenda

This position paper by the international IMMERSE consortium reviews the evidence of a digital mental health solution based on Experience Sampling Methodology (ESM) for advancing person-centered mental health care and outlines a research agenda for implementing innovative digital mental health tools into routine clinical practice. ESM is a structured diary technique recording real-time self-report data about the current mental state using a mobile application. We will review how ESM may contribute to (1) service user engagement and empowerment, (2) self-management and recovery, (3) goal direction in clinical assessment and management of care, and (4) shared decision-making. However, despite the evidence demonstrating the value of ESM-based approaches in enhancing person-centered mental health care, it is hardly integrated into clinical practice. Therefore, we propose a global research agenda for implementing ESM in routine mental health care addressing six key challenges: (1) the motivation and ability of service users to adhere to the ESM monitoring, reporting and feedback, (2) the motivation and competence of clinicians in routine healthcare delivery settings to integrate ESM in the workflow, (3) the technical requirements and (4) governance requirements for integrating these data in the clinical workflow, (5) the financial and competence related resources related to IT-infrastructure and clinician time, and (6) implementation studies that build the evidence-base. While focused on ESM, the research agenda holds broader implications for implementing digital innovations in mental health. This paper calls for a shift in focus from developing new digital interventions to overcoming implementation barriers, essential for achieving a true transformation toward person-centered care in mental health.

Transgender and Nonbinary Individuals' Perceptions Regarding Gender-Affirming Hormone Therapy and Cardiovascular Health: A Qualitative Study

BACKGROUND

Transgender and nonbinary individuals face substantial cardiovascular health uncertainties. The use of gender-affirming hormone therapy can be used to achieve one's gender-affirming goals. As self-rated health is an important predictor of health outcomes, an understanding of how this association is perceived by transgender and nonbinary individuals using gender-affirming hormone therapy is required. The objective of this research was to explore transgender and nonbinary individuals' perceptions of cardiovascular health in the context of using gender-affirming hormone therapy.

METHODS

In this qualitative study, English-speaking transgender and nonbinary adults using gender-affirming hormone therapy for 3 months or more were recruited from across Canada using purposive and snowball sampling methods. Semistructured interviews were conducted through videoconference to explore transgender and nonbinary individuals' perceptions of the association between gender-affirming hormone therapy and cardiovascular health between May and August 2023. Data were transcribed verbatim, and transcripts were analyzed independently by 3 reviewers using thematic analysis.

RESULTS

Twenty-one participants were interviewed (8 transgender women, 9 transgender men, and 3 nonbinary individuals; median [range] age, 27 [20-69] years; 80% White participants). Three main themes were identified: cardiovascular health was not a primary concern in the decision-making process with regard to gender-affirming hormone therapy, the improved well-being associated with gender-affirming hormone therapy was felt to contribute to improved cardiovascular health, and health care provider knowledge and attitude facilitate the transition process.

CONCLUSIONS

Gender-affirming hormone therapy in transgender and nonbinary individuals is perceived to improve cardiovascular health. Given the positive associations between care aligned with patient priorities, self-rated health, and health outcomes, these findings should be considered as part of shared decision-making and person-centered care.

Relationship between missed nursing care and patients' trust in nurses and satisfaction with care: A cross-sectional study

Missed nursing care is a global health problem that can have negative consequences for patients, nurses, and healthcare institutions. The purpose of the research is to determine the relationship of missed nursing care with patients' trust in nurses and satisfaction with care. A descriptive and cross-sectional study was conducted with 350 patients treated at the cardiology clinic of a university hospital. Data were collected using the MISSCARE Survey-Patient, the Trust in Nurses Scale (TNS), and the Newcastle Satisfaction with Nursing Scale (NSNS). There was a strong positive relationship between trust in nursing and satisfaction with care. Additionally, missed care in communication and basic care had a negative relationship with trust in nursing and satisfaction with care (p < 0.001). The multiple linear regression analysis revealed that the communication subscale score was the best negative predictor of trust in nurses and satisfaction with care. The results of this research indicate a deficiency in adequately addressing all nursing care activities. The failure to meet nurse-patient communication needs is the most important missed care factor that negatively affects satisfaction with care and trust in nurses.

End-of-life conversations for the older person: A concept analysis

AIM

The aim of this concept analysis is to seek clarity as to what end-of-life conversations involve by developing a clear working definition and using model cases to conceptualise the defining attributes of an end-of-life conversations with the older person.

DESIGN

Walker and Avant's eight step approach to Concept Analysis.

DATA SOURCES

Four databases were searched, including PubMed, CINAHL, PsycINFO, and Scopus. A total of 339 publications were identified with 30 papers meeting the inclusion criteria and put forward for the final conceptual analysis.

RESULTS

The defining attributes associated with end-of life conversations included (1) an ongoing process of older person empowerment, (2) discussion's concerning values and preferences concerning end-of-life issues, and (3) maintaining an open dialogue between all concerned individuals. Antecedents were associated with the older person is their readiness to talk openly about death and dying. Consequences were identified as having a better understanding of what death and dying may mean to the older person in a more specific manner.

CONCLUSIONS

End-of-life conversations are vital in understanding an individual's values and preferences at the end of life, and yet, the concept of the end-of-life conversation has not been well defined in the literature. End-of-life conversations with the older person encompass ongoing discussions and maintaining open dialogue around end-of-life care while developing strategies to promote individual empowerment in making informed choices. Using a conceptual model, aides in addressing aspects of end-of-life conversations and an acknowledgment of the dynamic process of end-of-life conversations.

Working with adults with intellectual challenges to enhance their employability skills

The employability of the intellectually challenged has received little attention in the past. In order to fill this research gap, the present study was undertaken. The study is centered on the experiences of six intellectually challenged individuals who received employability training at a non-governmental organization. A focus group discussion along with a case study was conducted. The researchers employed the Rigorous and Accelerated Data Reduction (RADaR) technique to analyze the data from the focus group discussion. Results from both the focus group discussion and the case study revealed that the training program has had a significant impact on the lives of the participants and has aided them in becoming economically empowered and independent.

Empathy in Nutrition and Dietetics: A Scoping Review

BACKGROUND

Empathy is fundamental to the provision of efficacious patient-centered health care. Currently, there is no comprehensive synthesis of peer-reviewed empirical research related to empathy in the nutrition and dietetics profession. Understanding empathy in the context of nutrition and dietetics care may lead to improved teaching practices that support nutrition and dietetics students and practitioners to provide high-quality, empathic, patient-centered care.

OBJECTIVE

This scoping review aimed to understand the approaches through which empathy is conceptualized, measured, and taught in the field of nutrition and dietetics.

METHODS

Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses-Scoping Reviews Statement and Checklist, a scoping review process was undertaken. Five databases were searched in February 2023: Cumulative Index to Nursing and Allied Health, Embase, Medline, PsycInfo, and Scopus, with no date limits. Eligible studies were English language-based, peer-reviewed, empirical research exploring or measuring empathy as an outcome in primary data stratified to nutrition and dietetics. Extracted qualitative data were synthesized and analyzed thematically with an inductive, interpretivist approach applied to conceptualize the interrelationship between empathy and dietetic practice. Quantitative data were extracted and summarized in a table.

RESULTS

Twenty-six studies were included in the scoping review. Analysis identified 2 overarching themes underpinning the current literature on empathy in nutrition and dietetics that described empathy as a key skill in the application of patient-centered care, which was supported by approaches to lifelong cultivation of empathy in the nutrition and dietetics profession. A range of tools has measured empathy in nutrition and dietetics students and practitioners with no clear consensus in findings across studies.

CONCLUSIONS

This review identified the extent and nature of empathy within nutrition and dietetics, from both practitioner and patient perspectives, and the vast array of approaches used to teach and quantify empathy in students and practitioners. Insights from this review inform the need for future studies. The results of this review suggest that future research include exploring implications of empathic dietetics care on patient outcomes and identification of best practice, evidence-based curricula and strategies to support sustainable cultivation and maintenance of empathic care across the career span of nutrition and dietetics practitioners.

Moral nexus of unmet needs and care in person-centred care for patients with advanced dementia in a multicultural society

RATIONALE

Patients with advanced dementia experience multifaceted vulnerabilities because of their diminished capacities for decision making. The dominant versions of person-centred care (PCC) emphasise patient preferences and autonomy, which often undermines a recognition of their distinct unfulfilled needs. Determining whether an individual autonomy conception of personhood applies to patients with advanced dementia is morally problematic from various theoretical perspectives and leads to the one-approach-fits-all problem when caring for this patient population.

AIMS AND OBJECTIVES

The availability of patients' advanced directives varies depending on their cultural backgrounds. The goal of the study is to argue that PCC, with a focus on relational autonomy, should be the first step for caring for patients with advanced dementia.

METHOD

The study engages in a critical exploration of inclusivity and diversity in ethical thinking within a framework of PCC and uses philosophical argumentation to assess the viability of a relational autonomy conception of PCC.

RESULTS AND CONCLUSION

By taking relationality seriously, especially in caring for patients with advanced dementia in a multicultural society, and by considering the moral nexus of unmet needs through the perspective of PCC, we can resolve the problem of one-approach-fits-all in dementia care.

Social Determinants of Health Disparities Increase 5-Year Revision Rates but Not Postoperative Complications After Primary Hip Arthroscopy

PURPOSE

To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and 5-year secondary surgery rates after primary hip arthroscopy using a large national database.

METHODS

A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Queries were performed to identify patients who experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH disparities within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. The odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of 5-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis.

RESULTS

A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who did not experience SDOH disparities (age of 41.0 years and 79.6% female sex in both cohorts). The odds of adverse events after arthroscopy were low and did not differ between the SDOH cohort (1.51%) and no-SDOH cohort (1.57%, P = .09). Additionally, there was no difference in the odds of 30-day ED visits between the SDOH cohort (5.65%) and no-SDOH cohort (4.79%, P = .10). The rate of 5-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs 4.1%, P = .02); however, there was no difference in the rate of any secondary surgery between cohorts (11.8% vs 10.4%, P = .10).

CONCLUSIONS

Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of 5-year revision hip arthroscopy compared with a matched-control cohort of patients not experiencing SDOH disparities.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Chronic health conditions and disability are prevalent among community users of a digital mental health service: a scoping survey

Objectives: Digital interventions can offer accessible and scalable treatment for chronic conditions, though often focus separately on physical or mental health. People accessing digital health services may live with multiple conditions or experience overlapping symptoms. This study aimed to describe the breadth and characteristics of chronic health conditions and self-reported disability among routine users of a digital mental health service, and to examine related motivations to engage with digital mental health interventions.

Methods: A cross-sectional survey of adults registered with a digital mental health service in the Australian community (THIS WAY UP) was conducted. Participant demography, chronic health conditions, self-reported disability and motivations for accessing digital treatment were collected and analyzed descriptively.

Results: 366 participants responded (77% female, mean age 50 ± 15 years). 71.6% of participants (242/338) reported ≥1 chronic health condition and one-third reported multimorbidity (112/338, 33.1%). Chronic pain, musculoskeletal and connective tissue disorders were most common. 26.9% of respondents (90/334) reported a disability, most commonly physical disabilities. 95% of those with chronic conditions reported negative mental health effects and 46% reported heightened interest in digital mental health treatments because of their condition. Primary motivations for digital service use were receiving a recommendation from a health professional and service accessibility.

Discussion: People who access digital mental health services in routine care report high rates of heterogenous chronic illness and related disability. There is interest in accessible digital treatments to support mental health at scale among people who live with varied chronic conditions and disabilities.

Perceived challenges in treatment decision-making for endometriosis: healthcare professional perspectives

Background

Endometriosis, a systemic chronic inflammatory condition which has no cure, has a high symptom burden that can negatively impact every facet of life. Given the absence of a gold-standard treatment, the best symptom management regimen in endometriosis is heavily reliant on a patient's values and preferences, making shared decision-making (SDM) vital. However, a comprehensive patient decision aid (PtDA) intervention that could facilitate patient decision-making and promote SDM is lacking in endometriosis, and there is little research on the decisional support needs of individuals with this condition. This qualitative study aimed to explore healthcare professional (HP) perspectives of their clients' decisional support needs when choosing treatments to manage endometriosis symptoms, with a view to evaluating the need for a PtDA.

Methods

Australian HPs identified as specialising in endometriosis care (N = 13) were invited to participate in a short interview over the Internet by phone. Questions focussed on perceived facilitators and challenges of decision-making when choosing treatments for endometriosis. Transcribed qualitative data were thematically analysed and verified by multiple coders, using the template approach.

Results

Four themes were identified: (1) Identifying and setting priorities; (2) HPs' lack of time and perceived lack of knowledge; (3) Patient-centred care and SDM, including patient capacity; and (4) Decision-making blinded by hope. This is the first known study to explore HPs' perspectives on patient decision-making challenges in endometriosis.

Discussion

Findings draw attention to the difficulties people with endometriosis experience when assessing and choosing treatments, highlighting the need for a comprehensive PtDA intervention to support this decision-making.

The Use of Person-Centered Outcome Measures to Support Integrated Palliative Care for Older People: A Systematic Review

OBJECTIVES

The aim was to synthesize evidence on the use of person-centered outcome measures to facilitate integrated palliative care for older people and build a logic model depicting the mechanisms through which person-centered outcome measures support integrated care.

DESIGN

Mixed methods systematic review using a data-based convergent synthesis design.

SETTING AND PARTICIPANTS

Older people aged ≥60 years who are approaching the end of their lives in multiple settings.

METHODS

The study was underpinned by a conceptual framework of integrated palliative care, which informed the search strategy, data extraction, analysis, and synthesis. A hybrid search strategy was implemented, with database searches (PsycINFO, MEDLINE, CINAHL, and ASSIA) complemented by snowball searches. Qualitative and quantitative data were analyzed by narrative synthesis to summarize and explain the findings. The findings informed a logic model depicting the mechanisms of using person-centered outcome measures to support integrated palliative care.

RESULTS

Twenty-six studies were included. Three mixed methods studies, 2 qualitative studies, and 21 quantitative studies were included. There was evidence that person-centered outcome measures could support integrated palliative care through informing palliative care policy development (n = 4), facilitating joint working across settings (n = 5), enabling close collaboration of multidisciplinary teams (n = 14), promoting joint education (n = 1), facilitating timing and specialist referral (n = 6), and enhancing patient-centered care (n = 3).

CONCLUSIONS AND IMPLICATIONS

This review makes an important, novel, and theoretically informed contribution to the delivery of scalable and sustainable integrated palliative care into the care of older people using person-centered outcome measures. The constructed logic model provides a conceptual framework and practical approach to how person-centered outcome measures support multilevel integration. A future area of research is the development of person-centered outcome measure interventions informed by the logic model to meet clinical needs.

Comorbid Dementia and Cancer Therapy Decision-Making: A Scoping Review

Comorbid dementia complicates cancer therapy decision-making in older adults. We aimed to synthesize the recent literature (<5 years) on the challenges associated with cancer therapy decision-making among older people living with dementia (PLWD) and their caregivers. Of the 20,763 references, 8767 had their title and abstract screened, and eight met the inclusion criteria. Six studies were qualitative, one study employed mixed methods, and one study was quasi-experimental. Most studies were conducted in the UK (89%) and reported homogeneity in race and geography. Breast (56%) and prostate (45%) were the most frequent reported cancers. Five studies (56%) reported multiple types of dementia, with two (22%) indicating stages. The studies indicated that communication between patients, caregivers, and clinical teams might alleviate stress caused by worsening health prospects and potential ethical concerns. Information from this review can lead to better-informed, patient-centered treatment decision processes among older PLWD and cancer, their caregivers, and clinicians.

Recommendations for patient-centered emergency care

INTRODUCTION

Patient-centred care is more than just an aspiration, it represents a fundamental shift in the way healthcare must be delivered. Patient-centred emergency care is important for improving the patient and clinician experience and is essential for optimizing health outcomes. Creating a patient-centred emergency department emphasizes the importance of the patient's experience, preferences, and values.

METHODS

To formulate recommendations for patient-centred care, we synthesized a literature review, stakeholder interviews, consensus from an expert panel of diverse healthcare professionals and a patient advocate, and reviewed our recommendations for feedback with a presentation at the Canadian Association of Emergency Physicians (CAEP) 2023 Annual Conference Academic Symposium.

RESULTS

This paper gives practical recommendations for areas and strategies to improve patient-centredness in Emergency Medicine. It delves into the various dimensions of this approach, including the role of the physical environment, communications and interpersonal interactions, systems of care, and measurement, all of which are essential in providing optimal care to match the patients' needs.

CONCLUSION

We seek to inspire a renewed commitment of placing the patient at the heart of emergency care, recognizing that patient-centredness is not merely an option but a fundamental aspect of delivering high quality, compassionate and effective healthcare in the emergency setting. In an era marked by technological advancements and evolving healthcare paradigms, the essence of medicine as a deeply human endeavour is becoming in some ways more possible, if we seize the opportunities.

Understanding Indigenous peoples experiences to inform recommendations for improving cultural safety and care in radiation therapy centres in Alberta, Canada

BACKGROUND

Worldwide there has been a shift in the ideology within healthcare systems that focuses on 'people' rather than the 'patients'. A patient should not only be perceived by their condition but rather viewed holistically as a person. Within a South African (SA) context, the constitution has been amended to state that all South African citizens have the right to healthcare that is caring, free from harm, and effective. Hence, it can be rationalized that patient-centered care (PCC) is a necessary and vital approach in South African healthcare as well. A study conducted by Hyde and Hardy in the United Kingdom (UK) explored measures of PCC from radiography patients, radiographers, radiography managers, radiography educators, and radiography students' perspectives. This study was duplicated to define informed measures of PCC from a South African perspective. Therefore, this study aimed to gain perspectives on PCC measures in diagnostic radiography within a sample of the South African community. This paper focuses on the perspectives of the clinical radiographer and patient respondents.

METHOD

This study was conducted using a quantitative approach with the use of an online survey. The Qualtrics software was utilized to design the survey. The survey consisted of three PCC themes; use of technology, comfort and emotional support, and control over the environment. Recruitment of the subgroups was via advertisement in social media, email networks, and word of mouth.

RESULTS

There were 28 radiographer responses and 14 patient responses. The data were analyzed using SPSS software version 28. Patient care while explaining the use of technology in radiography, received positive responses from both respondent groups. Patient care measures that explored comfort and emotional support received varied responses from patients and radiographers. Important PCC concepts, such as asking the patient about their care needs and health problems, were lacking. Patients indicated that radiographers do not include their family members in the discussion of the care needs even though family involvement is a PCC element.

CONCLUSION

The perceptions of PCC measures differed between the two groups which indicated that there are still some gaps in clinical practice. Patient involvement in their care and individualized care should be prioritized. There is a need for family involvement during radiography procedures to be better highlighted within clinical practice. It is also recommended that more importance be placed on PCC during undergraduate training. While service delivery is important, radiographers must not disregard their PCC responsibilities towards the patient.

The experiences of patients attending the emergency department who were managed by physiotherapists: a person-centred perspective

PURPOSE

The expectation for all clinicians to deliver person-centred practices extends to the growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED). Research on ED patients' experience of this physiotherapy role has yet to consider this through the lens of person-centredness. A qualitative exploration of person-centredness among ED physiotherapists through the experiences of attending patients targeted this knowledge gap to inform future clinical practice.

METHODS

Semi-structured interviews with thematic analysis.

RESULTS

13 interviews were completed with four overarching themes generated: (1) patient experience of the ED; (2) the importance of connection, competence, and time; (3) recognising the benefits of being seen by a physiotherapist in ED; and (4) patient experience of the ED physical environment.

CONCLUSION

Novel contributions from the patient perspective, here, reflected a cognisance of certain environment limitations to PCP, as well as institutional challenges to their personhood, with a suggestion that ED patients anticipated a validation of their visit and valued the educational aspects that the physiotherapists provided. Considering this new knowledge can help ED physiotherapists to be more person-centred.

Patient-centered care in diabetes care-concepts, relationships and practice

We still do not have comprehensive knowledge of which framework of patient-centered care (PCC) is appropriate for diabetes care, which elements of PCC are evidence-based, and the mechanism by which PCC elements are associated with outcomes through mediators. In this review, we elaborate on these issues. We found that for diabetes care, PCC elements such as autonomy support (patient individuality), cooperation and collaboration (system-level approach), com-munication and education (behavior change techniques), emotional support (biopsychosocial approach), and family/other involvement and support are critically important. All of these factors are directly associated with different patient outcomes and indirectly associated with outcomes through patient activation. We present the practical implications of these PCC elements.

Medication administration in aged care facilities: A mixed-methods systematic review

AIM(S)

To synthesize aged care provider, resident and residents' family members' perspectives and experiences of medication administration in aged care facilities; to determine the incidence of medication administration errors, and the impact of medication administration on quality of care and resident-centredness in aged care facilities.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42023426990.

DATA SOURCES

The AMED, CINAHL, MEDLINE, EMBASE, EMCARE, PsycINFO, Scopus and Web of Science core collection databases were searched in June 2023.

REVIEW METHODS

Included studies were independently screened, selected and appraised by two researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed, with the Mixed Methods Appraisal Tool was used for critical appraisal. Convergent synthesis of data, thematic synthesis and meta-analysis were performed.

RESULTS

One hundred and twenty-eight studies were included (33 qualitative, 85 quantitative and 10 mixed-methods). Five themes were formulated, including 1) Staffing concerns, 2) The uncertain role of residents, 3) Medication-related decision-making, 4) Use of electronic medication administration records and 5) Medication administration errors. Educational interventions for aged care workers significantly reduced medication administration errors, examined across five studies (OR = 0.37, 95%CI 0.28-0.50, p < .001).

CONCLUSIONS

Medication administration in aged care facilities is challenging and complex on clinical and interpersonal levels. Clinical processes, medication errors and safety remain focal points for practice. However, more active consideration of residents' autonomy and input by aged care workers and providers is needed to address medication administration's interpersonal and psychosocial aspects. New directions for future research should examine the decision-making behind dose form modification, aged care workers' definitions of medication omission and practical methods to support residents' and their family members' engagement during medication administration.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

It is important that medication administration in aged care facilities be more clearly acknowledged as both a clinical and interpersonal task. More attention is warranted regarding aged care workers clinical decision-making, particularly concerning dose form modification, covert administration and medication omissions. Resident-centred care approaches that support resident and family engagement around medication administration may improve adherence, satisfaction and quality of care.

IMPACT

What Problem Did the Study Address? Medication administration in aged care facilities is a complex clinical and interpersonal activity. Still, to date, no attempts have been made to synthesize qualitative and quantitative evidence around this practice. There is a need to establish what evidence exists around the perspectives and experiences of aged care workers, residents and resident's family members to understand the challenges, interpersonal opportunities and risks during medication administration. What Were the Main Findings? There is a lack of empirical evidence around resident-centred care approaches to medication administration, and how residents and their families could be enabled to have more input. Dose form modification occurred overtly and covertly as part of medication administration, not just as a method for older adults with swallowing difficulties, but to enforce adherence with prescribed medications. Medication administration errors typically included medication omission as a category of error, despite some omissions stemming from a clear rationale for medication omission and resident input. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The findings of this systematic review contribute to aged care policy and practice regarding medication administration and engagement with older adults. This review presents findings that provide a starting point for aged care workers in regards to professional development and reflection on practice, particularly around clinical decision-making on dose form modification, medication administration errors and the tension on enabling resident input into medication administration. For researchers, this review highlights the need to develop resident-centred care approaches and interventions, and to assess whether these can positively impact medication administration, resident engagement, adherence with prescribed medications and quality of care.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Views of patients with progressive illness and carers about the role of digital advance care planning systems to record and share information: A qualitative study

BACKGROUND

Digital approaches are being explored internationally to support the elicitation, documentation and sharing of advance care planning information. However, the views and experiences of patients and carers are little understood, impeding the development and impact of digital approaches to strengthen palliative and end-of-life care.

AIM

To explore perspectives of patients with progressive illness and their carers on digital approaches to advance care planning, anticipated impact from their use and expectations for their future development.

DESIGN

A qualitative study employing thematic framework analysis of data collected from focus groups and semi-structured interviews.

SETTING/PARTICIPANTS

Purposive sample of 29 patients and 15 current or bereaved carers in London and West Yorkshire from hospice settings, non-governmental support and advocacy groups, and care home residents.

RESULTS

Four generated themes included: 1. 'Why haven't you read what's wrong with me?'; uncertainty around professionals' documenting, sharing and use of information; 2. The art of decision-making relies on the art of conversation; 3. The perceived value in having 'a say in matters': control and responsibility; 4. Enabling patient and carer control of their records: 'custodianship is key'.

CONCLUSIONS

Lived experiences of information sharing influenced trust and confidence in digital advance care planning systems. Despite scepticism about the extent that care can be delivered in line with their preferences, patients and carers acknowledge digital systems could facilitate care through contemporaneous and accurately documented wishes and preferences. There remains a need to determine how independent patient and public-facing advance care planning resources might be integrated with existing digital health record systems.

Physiotherapists' decision-making about transition to independent walking in hospital after stroke: a qualitative study

PURPOSE

Physiotherapists working in hospitals have a key role in decisions about when a person with stroke is safe to walk independently. The aim of this study was to explore the factors influencing decision-making of physiotherapists in this situation.

METHODS

A qualitative design with semi-structured interviews and reflexive thematic analysis was used. Fifteen physiotherapists with recent experience working in inpatient stroke rehabilitation participated.

RESULTS

Multiple factors influence decision-making about walking independence after stroke in hospitals. Four themes were identified: (1) Assessment of walking safety involves observation of walking function and consideration of complex individual factors; (2) Perspectives on risk vary, and influence whether a person is considered safe to walk; (3) Institutional culture involves background pressures that may influence decision-making; and (4) Physiotherapists adopt a structured, individualised mobility progression to manage risk. Physiotherapists consistently use observation of walking and understanding of attention and perception in this decision-making. There can sometimes be a conflict between goals of independence and of risk avoidance, and decisions are made by personal judgements.

CONCLUSIONS

Decision-making about independent walking for people in a hospital after a stroke is complex. Improved guidance about clinical assessment of capacity and determining acceptable risk may enable physiotherapists to engage more in shared decision-making.IMPLICATIONS FOR REHABILITATIONRegaining independence in walking after a stroke comes with the potential risk of falls.Assessment of walking safety should be specific to the complexity of the situation and consider perception and cognition.Benefits of activity and autonomy, and the risk of falls need to be considered in decisions about walking independence.Patients with the capacity to understand consequences and accept risk can be active participants in determining what is sufficiently safe.

Person-centred care and online pedagogy in nursing education: a discussion paper

AIM

To discuss person-centred care in nursing education and the role of online pedagogy to facilitate meaninful learning.

BACKGROUND

The core principles and values of person-centred care are at the centre of national and international healthcare education. Person-centred care recognises partnerships and relationships between nurses, healthcare practitioners and individual patients, carers and their families and part of the training of healthcare professionals. However, the literature on how person-centred care is taught to facilitate meaningful learning in nursing education particularly in the context of online pedagogy is limited.

DESIGN

A critical discussion paper.

METHODS

A critical discussion of person-centred care and online pedagogy that can facilitate teaching practices are presented, drawing on authors' positionality and case exemplars.

RESULTS

Teaching person-centred care using online pedagogy appears to have a promising impact on undergraduate and postgraduate nursing students' experiences. Engaging students in critical examination and reflection on the complexities of person-centred care in practice creates meaningful experiential learning for both students and educators.

CONCLUSION

Evidence suggests that the use of online pedagogy is a beneficial and effective way to incorporate the teaching of person-centred care into nursing education, yet more evidence is needed to evaluate its impact on nursing practice.

Exploring facilitators and barriers for delivering person-centered care in a socio-economically diverse context: Perspectives of speech-language pathologists and audiologists

OBJECTIVE

The study aimed to explore facilitators and barriers in delivering person-centered care from the perspective of speech-language pathologists and audiologists in a socio- economically diverse workplace across micro, meso, and macro levels.

METHOD

A national cross-sectional e-survey was conducted among pooled speech-language pathologists and/or audiologists from South Africa. The e-survey included quantitative components to describe participant demographics which was analysed using descriptive and inferential statistics. The qualitative data was analyzed using metaphor and thematic analysis approaches to describe respondents' perspectives of barriers and facilitators in delivering person-centered care.

RESULTS

The e-survey was completed by 63 clinicians (36.5% Audiologists; 36.5% Speech-Language Therapists; 27.0% dually qualified Speech-Language Therapists and Audiologists) mostly between the ages of 26 to 35 years old (33.3%). Respondents were working in various settings including the public sector (41.3%), private sector (44.4%) and in academia (14.3%). Facilitators and barriers were identified within all three systems (macro, meso and micro). The metaphor analysis resulted in six categories: uncertainty of Person centered care; its essential nature; associated challenges; relational aspect; analogies referring to animals; and food-related analogies. Thematic analysis of open-ended questions revealed five barriers, with three relating to micro systems; i) clinician factors, ii) client factors, iii) clinician and client interaction, and two related to factors within the meso system; iv) resources, and v) workplace. Only two themes were identified as facilitators towards PCC, clinician factors (mirco) and workplace factors (meso).'

CONCLUSIONS

Insights gained from exploring Speech-Language Pathologists' and Audiologists' perceptions of implementing PCC in a socio-economically diverse setting highlight the need to address contextual (meso and macro systems) and personal (micro system) factors to promote and deliver PCC effectively. Notably, for the public sector, resources emerged as a major concern and barrier on the macro system level. Despite these challenges, the investigation revealed two noteworthy facilitators: clinician factors, at the micro level, and workplace factors, at the meso level. This nuanced understanding emphasizes the necessity of tailored interventions targeting both individual and systemic aspects to enhance the successful implementation of person-centered care.

PRACTICAL IMPLICATIONS

Strategies should focus on enhancing clinicians' communication skills, collaboration, and teamwork, as well as addressing resource limitations through the adaptation of tools and implementation of PCC ISO standards.

Performance measurement and user-centeredness in the healthcare sector: Opening the black box adapting the framework of Donabedian

The framework of Donabedian is widely applied to performance assessment at the healthcare system level. Donabedian categorised the care quality measurement around three dimensions, namely structure, process, and outcomes. The first dimension concerns the inputs; the second one, the combinations of factors and inputs; the last one, the effectiveness in terms of patients' health status. Donabedian early included in the last dimension the patient satisfaction. Nevertheless, nowadays, outcomes are generally measured through hard endpoints, such as re-admissions and mortality indicators. Recently, the Patient-Reported Outcome Measures (PROMs) have been included among the outcome measures within the Donabedian framework. How to move the concept of patient-centeredness to a macro level, including the patient point of view in care quality measurement, evaluation, and improvement? This paper integrates the Donabedian structure-process-outcome framework, by incorporating in the proper dimension the patient-indicators, namely the abovementioned PROMs and Patient-Reported Experience Measures (PREMs). While PROMs are clearly measures of outcome, PREMs can be collocated in the process dimension, since they can be useful for mapping processes and care pathways, in a lean perspective, as well as in the outcome dimension, because inherently linked to outcome, and enablers of patient-centeredness.

Developing integrated person-centered care quality indicators for home health agencies in Shanghai, China: A modified Delphi-analytic hierarchy process study

OBJECTIVES

To develop person-centered integrated care quality indicators for home health agencies in Shanghai, China.

DESIGN

The study combined the Delphi method and the analytic hierarchy process (AHP).

MATERIAL AND METHODS

The Delphi consultation questionnaire was distributed to experts in home healthcare in Shanghai, China. A panel of experts with experience in home healthcare in Shanghai, China, was selected. Purposive sampling was used to choose experts. In this study, ten experts were selected from within sub-fields of home healthcare, including nursing, health policy, quality improvement, person-centered care (PCC), and integrated care.

RESULTS

The authority coefficient (Cr) in this study was 0.835. The coordination degree of experts' opinions, which is expressed by Kendall coordination coefficient W (a higher value, better coordination of the item), ranged from 0.352 to 0.386 (p < 0.001). The consistency ratio (CR) values for each level were less than 0.1. The quality indicator system included three first-level indicators, 15 second-level indicators, and 56 third-level indicators.

CONCLUSIONS

A person-centered integrated care quality indicator system was developed for home health agencies. The findings from this study enable nurses, managers, and policymakers in home and community-based settings to evaluate person-centered integrated care quality using a robust framework. In addition, these indicators can also be used as a standardized tool to guide the development of long-term care services and supports (LTSS) for home-bound elderly.

Characterizing the Physical and Psychological Experiences of Newly Diagnosed Pancreatic Cancer Patients

BACKGROUND

Pancreatic cancer is a devastating disease with a poor prognosis, causing significant physical and psychological distress that detrimentally impacts patients' quality of life.

AIM

This study aimed to comprehensively assess the physical and psychological status of newly diagnosed pancreatic cancer patients.

METHODS

A cohort of 138 newly diagnosed patients completed standardized assessments, including the Edmonton Symptom Assessment System (ESAS), Patient Health Questionnaire-9 (PHQ-9), Mini-Mental State Examination (MMSE), and Distress Thermometer (DT). Data were analysed using descriptive statistics.

RESULTS

The ESAS scores revealed high symptom burden, with mean scores of 6.8 for pain, 7.2 for fatigue, and 4.9 for depression. Measures of well-being indicated low scores, with means of 2.3 for physical well-being, 1.5 for social/family well-being, and 1.7 for emotional well-being. Distress levels were also high, with a mean score of 7.6 on the DT.

CONCLUSION

Newly diagnosed pancreatic cancer patients experience substantial physical and psychological challenges, including severe symptom burden, distress, depressive symptoms, and cognitive impairment. Holistic care approaches that prioritize symptom management and address psychological distress are essential to improve patient outcomes and enhance overall well-being.

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study

BACKGROUND

Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

METHODS

This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals (N = 8) and patients (N = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach.

RESULTS

Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: 'structure', 'culture', 'education', 'emotional', and 'physical and technology'. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients.

CONCLUSIONS

Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, 'politics'. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations' structure, culture and practices.