The role of physician-patient communication in promoting patient-participatory decision making

Patient Activeness During Online Medical Consultation in China: Multilevel Analysis

Background

Online medical consultation is an important complementary approach to offline health care services. It not only increases patients’ accessibility to medical care, but also encourages patients to actively participate in consultation, which can result in higher shared decision making, patient satisfaction, and treatment adherence.

Objective

This study aims to explore multilevel factors that influence patient activeness in online medical consultations.

Methods

A data set comprising 40,505 patients from 300 physicians in 10 specialties was included for multilevel analysis. Patient activeness score (PAS) was calculated based on the frequency and the proportion of patient discourses to the total frequency of doctor-patient interactions. Intraclass correlation coefficients were calculated to identify between-group variations, and the final multilevel regression model included patient- and physician-level factors.

Results

Patients were not equally active in online medical consultations, with PASs varying from 0 to 125.73. Patient characteristics, consultation behavioral attributes, and physician professional characteristics constitute 3 dimensions that are associated with patient activeness. Specifically, young and female patients participated more actively. Patients’ waiting times online (β=–.17; P<.001) for physician responses were negatively correlated with activeness, whereas patients’ initiation of conversation (β=.83; P<.001) and patient consultation cost (β=.52; P<.001) in online medical consultation were positively correlated. Physicians’ online consultation volumes (β=–.10; P=.01) were negatively associated with patient activeness, whereas physician online consultation fee (β=.03; P=.01) was positively associated. The interaction effects between patient- and physician-level factors were also identified.

Conclusions

Patient activeness in online medical consultation requires more scholarly attention. Patient activeness is likely to be enhanced by reducing patients’ waiting times and encouraging patients’ initiation of conversation in online medical consultation. The findings have practical implications for patient-centered care and the improvement of online medical consultation services.

Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind

BACKGROUND

Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown").

DISCUSSION

Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement.

CONCLUSION

For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.

Experiences of inpatient rehabilitation from the perspective of persons with acquired brain injury

BACKGROUND

Perspectives of individuals with acquired brain injury (ABI) regarding inpatient rehabilitation experiences can inform patient-centered care; however, these voices are under-represented in the literature.

PURPOSE

To explore the experiences, needs, and preferences of patients from an ABI inpatient rehabilitation program in Ontario.

METHODS

Using an interpretive description approach, we interviewed 12 participants and analyzed the transcripts inductively to generate themes.

FINDINGS

We identified three major themes: (1) Life Rerouted - participants felt their lives diverted due to ABI, with rehabilitation seen as a way to return to pre-injury life, (2) Autonomy within Rehab highlighted the perceived importance of personal autonomy in decision-making within rehabilitation, and (3) Life (and Recovery) Go On reflected an ongoing recovery process after discharge - leading to mixed emotions. An overall message, "re-establishing personal identity is important to the recovery process," reflected theories of biographical disruption and relational autonomy.

IMPLICATIONS

Our findings provide a patient perspective for clinicians and administrators to consider. We found that ABI was significantly disruptive to personal identity - resulting in tensions in autonomy while attempting to reclaim a sense of identity. We suggest counseling services and strategies supporting post-injury adjustment, along with ways for rehabilitation professionals to enhance patient autonomy where possible.Implications for rehabilitationSustaining an ABI can significantly disrupt personal identity and sense of autonomy - especially as persons occupy the role of "patient" while in inpatient rehabilitation.Psychological support is recommended to address the impacts of ABI on patients' sense of identity, as well as on family members.Strategies of support might include, providing formal psychotherapy, as well as creating opportunities for patients and family members to discuss the changes they are experiencing, and to establish their personal narratives (e.g., through writing or art) or peer mentorship programs between discharged and current patients.Clinicians can enhance patient autonomy by increasing opportunities for communication with patients about choice; educating patients and family members on the rehabilitation team's decision-making process, and other methods that increase communication and provide consistent up-to-date information to patients and their family members.

The Impact of Dementia on Cancer Treatment Decision-Making, Cancer Treatment, and Mortality: A Mixed Studies Review

Dementia and cancer occur commonly in older adults. Yet, little is known about the effect of dementia on cancer treatment and outcomes in patients diagnosed with cancer, and no guidelines exist. We performed a mixed studies review to assess the current knowledge and gaps on the impact of dementia on cancer treatment decision-making, cancer treatment, and mortality. A search in PubMed, Medline, and PsycINFO identified 55 studies on older adults with a dementia diagnosis before a cancer diagnosis and/or comorbid cancer and dementia published in English from January 2004 to February 2020. We described variability using range in quantitative estimates, ie, odds ratios (ORs), hazard ratios (HRs), and risk ratios (RR) when appropriate and performed narrative review of qualitative data. Patients with dementia were more likely to receive no curative treatment (including hospice or palliative care) (OR, HR, and RR range = 0.40-4.4, n = 8), while less likely to receive chemotherapy (OR and HR range = 0.11-0.68, n = 8), radiation (OR range = 0.24-0.56, n = 2), and surgery (OR range = 0.30-1.3, n = 4). Older adults with cancer and dementia had higher mortality than those with cancer alone (HR and OR range = 0.92-5.8, n = 33). Summarized findings from qualitative studies consistently revealed that clinicians, caregivers, and patients tended to prefer less aggressive care and gave higher priority to quality of life over life expectancy for those with dementia. Current practices in treatment-decision making for patients with both cancer and dementia are inconsistent. There is an urgent need for treatment guidelines for this growing patient population that considers patient and caregiver perspectives.

Interpersonal influences on self-management in the eHealth era: Predicting the uses of eHealth tools for self-care in America

Drawing on the social cognitive theory and the comprehensive model of information seeking, this study proposes a theoretical framework that systematically examines the role of interpersonal factors in individuals' self-management in the eHealth context. The framework was tested with a sample of 965 eHealth users drawn from the National Cancer Institute's 2018 Health Information National Trends Survey. Structural equation modelling was performed to model the relationships among patient-centred communication, social support, self-efficacy, perceptions of eHealth tools and eHealth behaviours. The results established social support and patient-centred communication as two important sources of self-efficacy. Self-efficacy together with characteristics of eHealth tools were associated with higher utility of eHealth tools, which further predicted higher levels of eHealth behaviours. The results show that incorporating interpersonal factors in health interventions may enhance the targets' self-efficacy in self-management and indirectly motivates eHealth behaviours.

What Influences the Implementation of Shared Decision Making: An Umbrella Review

OBJECTIVE

To provide a cogent summation of the evidence base of the key barriers and facilitators to implementing shared decision making (SDM).

METHODS

An umbrella review of existing reviews on SDM was adopted. Databases were searched from 1997 to December 2018. Studies were included if they performed a review of barriers and facilitators to SDM.

RESULTS

7 eligible reviews were identified. The five themes identified were: patient factors, professional factors, environmental factors, relationship factors, and factors related to information provision. Lack of time was the main factor hindering the implementation of SDM. Encouragement and motivation of providers to use SDM was a significant enabler of SDM implementation.

CONCLUSIONS

The provision of time and resources are insufficient if not accompanied by efforts to support and motivate providers to use SDM.

PRACTICE IMPLICATIONS

Healthcare providers need to be educated on the importance of building a relationship with their patients. To enhance this relationship, physicians may need to improve their interaction skills. They need to be curious and explore their patients' preferences, listen to them and respect their opinions, explain options and outcomes, and encourage them to participate in the decision making.

Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review

BACKGROUND

Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool.

RESULTS

Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias.

CONCLUSIONS

DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.

Attitudes to Cardiac Xenotransplantation by Pediatric Heart Surgeons and Physicians

Background:

Cardiac transplantation in early childhood is limited by scarcity of organ donors. Advances in cardiac xenotransplantation (XTx) research suggest that xenografts may one day represent an alternative to allografts. We sought to determine the attitudes among surgeons and cardiologists in the field of pediatric cardiac transplantation toward the potential use of XTx if this clinical option were to become a reality.

Methods:

A Likert-scale anonymous survey addressing the use of XTx in pediatric patients was sent to members of the Congenital Heart Surgeons (CHS) Society and the Pediatric Heart Transplant Society. Results were described and compared between the two surgeon/physician groups.

Results:

Ninety-two CHS and 42 pediatric transplant cardiologists (PTC) responded (N = 134). The potential acceptance of XTx was high in both groups, assuming risks and results were similar to those of cardiac allotransplantation (88% CHS vs 81% PTC; P = .07). When asked if they would recommend a xenograft, if the results were anticipated to be inferior to those of cardiac allotransplantation, as a bridge to a human heart, potential acceptance fell dramatically but remained higher among CHS than PTC (41% vs 17%, p 0.02). Approximately only one-third of CHS and half of PTC preferred primary cardiac XTx for hypoplastic left heart syndrome if there was no waitlist time and had similar outcomes to allotransplantation.

Conclusions:

Our findings suggest that potential acceptance of XTx by CHS and PTC would not be a major barrier if XTx demonstrated similar outcomes to allotransplantation. Acceptance by other congenital heart stakeholders remains to be investigated.

Knowledge Is Power, but Is Ignorance Bliss? Optimising Conversations About Disease Progression in Multiple Sclerosis

Communication about multiple sclerosis (MS) disease progression between healthcare professionals (HCPs) and people with MS (PwMS) has historically been considered difficult, and attention to improving it has been neglected. However, a growing number of studies have shown that this is a key area to get right, since negative experiences can affect patient satisfaction, treatment adherence, and clinical outcomes. This article reports on a symposium at the European Charcot Foundation, 2018, led by a panel of leading clinicians and patient experts from MS in the 21st Century, who debated the benefits, drawbacks, and challenges of communicating about disease progression, for both HCPs and PwMS, and potential ways to optimise these discussions. PwMS' preferences and priorities regarding conversations about disease progression vary widely. While the majority want to have these conversations, some will be reluctant and/or emotionally unready. Communication therefore needs to be personalised, and HCPs should always be prepared to have such conversations in an appropriate and sensitive manner. Clinical information can be opaque for PwMS, so HCPs also need to use language that is clear, easily understandable, and patient-friendly. MS in the 21st Century is in the process of developing several resources and programmes to help improve disease progression communication between HCPs and PwMS. FUNDING: Merck KGaA, Darmstadt, Germany. Plain language summary available for this article.

Meaningful shared decision-making: complex process demanding cognitive and emotional skills

BACKGROUND

Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences.

METHODS

The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM.

RESULTS

We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills.

CONCLUSIONS

We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

Humanistic communication in the evaluation of shared decision making: A systematic review

OBJECTIVE

To assess the extent to which evaluations of shared decision making (SDM) assess the extent and quality of humanistic communication (i.e., respect, compassion, empathy).

METHODS

We systematically searched Web of Science and Scopus for prospective studies published between 2012 and February 2018 that evaluated SDM in actual clinical decisions using validated SDM measures. Two reviewers working independently and in duplicate extracted all statements from eligible studies and all items from SDM measurement instruments that referred to humanistic patient-clinician communication.

RESULTS

Of the 154 eligible studies, 14 (9%) included ≥1 statements regarding humanistic communication, either in framing the study (N = 2), measuring impact (e.g., empathy, respect, interpersonal skills; N = 9), as patients'/clinicians' accounts of SDM (N = 2), in interpreting study results (N = 3), and in discussing implications of study findings (N = 3). Of the 192 items within the 11 SDM measurement instruments deployed in the included studies, 7 (3.6%) items assessed humanistic communication.

CONCLUSION

Assessments of the quality of SDM focus narrowly on SDM technique and rarely assess humanistic aspects of patient-clinician communication.

PRACTICE IMPLICATIONS

Considering SDM as merely a technique may reduce SDM's patient-centeredness and undermine its' contribution to patient care.

Shared decision-making in older patients with colorectal or pancreatic cancer: Determinants of patients' and observers' perceptions

OBJECTIVE

To identify determinants of older patients' perceptions of involvement in decision-making on colorectal (CRC) or pancreatic cancer (PC) treatment, and to compare these with determinants of observers' perceptions.

METHODS

Patients' perceptions of involvement were constructed by the 9-item SDM questionnaire (SDM-Q-9) and a Visual Analogue Scale for Involvement (VAS-I). Observers' perceptions were constructed by the OPTION5, OPTION12, and MAPPIN'SDM. Convergent validities were calculated between the patient-sided and observer instruments using Spearman's correlation coefficient. Linear regression was used to identify determinants per criterion.

RESULTS

58 CRC and 22 PC patients were included (mean age: 71.8 ± 5.2 years, 45.0% female). No significant correlations were found between the patient-sided and observer instruments. Patients' impression of involvement was influenced by patient characteristics such as quality of life and satisfaction, while observers' perceptions mainly referred to encounter characteristics such as the mean duration of consultations and general communication skills.

CONCLUSION

Due to evident differences in determinants, older CRC/PC patients' and observers' perceptions of involvement should both be collected in evaluating the quality of medical decision-making.

PRACTICE IMPLICATIONS

General communication skills should be integrated in SDM training interventions. New SDM measurement tools for patients are needed to sufficiently discriminate between the constructs of involvement and satisfaction.

The Patient Experience With Shared Decision Making: A Qualitative Descriptive Study

Shared decision making is a process characterized by a partnership between a nurse and a patient. The existence of a relationship does not ensure shared decision making. Little is known about what nurses need to know and do for this experience to take place. A qualitative descriptive study was implemented using Coalizzi's method. Semistructured interviews were held with patients, and 3 themes were uncovered. The findings suggest that a nurse's conduct aimed at drawing patients in and inviting them to participate in a conversation leads toward shared decisions. Infusion nurses may find this information useful as they engage their patients in shared decisions.

Does sharing the electronic health record in the consultation enhance patient involvement? A mixed-methods study using multichannel video recording and in-depth interviews in primary care

BACKGROUND

Sharing the electronic health-care record (EHR) during consultations has the potential to facilitate patient involvement in their health care, but research about this practice is limited.

METHODS

We used multichannel video recordings to identify examples and examine the practice of screen-sharing within 114 primary care consultations. A subset of 16 consultations was viewed by the general practitioner and/or patient in 26 reflexive interviews. Screen-sharing emerged as a significant theme and was explored further in seven additional patient interviews. Final analysis involved refining themes from interviews and observation of videos to understand how screen-sharing occurred, and its significance to patients and professionals.

RESULTS

Eighteen (16%) of 114 videoed consultations involved instances of screen-sharing. Screen-sharing occurred in six of the subset of 16 consultations with interviews and was a significant theme in 19 of 26 interviews. The screen was shared in three ways: 'convincing' the patient of a diagnosis or treatment; 'translating' between medical and lay understandings of disease/medication; and by patients 'verifying' the accuracy of the EHR. However, patients and most GPs perceived the screen as the doctor's domain, not to be routinely viewed by the patient.

CONCLUSIONS

Screen-sharing can facilitate patient involvement in the consultation, depending on the way in which sharing comes about, but the perception that the record belongs to the doctor is a barrier. To exploit the potential of sharing the screen to promote patient involvement, there is a need to reconceptualise and redesign the EHR.

A Latin American, Portuguese and Spanish consensus on a core communication curriculum for undergraduate medical education

BACKGROUND

To present learning outcomes in clinical communication for a Core Curriculum for medical undergraduate students in Latin America, Portugal and Spain (LAPS-CCC) and to establish an expert network to support a transnational implementation.

METHODS

Through an iterative process, an international group of 15 experts developed an initial set of learning outcomes following a review and discussion of relevant international and local literature. A two-round Delphi survey involving 46 experts from 8 countries was performed. Quantative and qualitative analisis permited the definition of the final consensus.

RESULTS

The initial proposal included 157 learning outcomes. The Delphi process generated 734 comments and involved the modification, deletion and addition of some outcomes. At the end of the process, a consensus was reached on 136 learning outcomes grouped under 6 competency domains with a high overall acceptance (95.1 %).

CONCLUSIONS

The learning outcomes of this proposal provide a guide to introduce, support and develop communication curriculae for undergraduate medical studies in the countries involved or in other Spanish- or Portuguese-speaking countries.

Attitudes of healthcare professionals providing pulmonary rehabilitation toward partnership in care

OBJECTIVES

This multicenter study sought to explore attitudes of pulmonary rehabilitation (PR) professionals toward self-management and which patients' competencies are considered important.

BACKGROUND

Self-management in patients with chronic obstructive pulmonary disease (COPD) requires a patients' active role. Whether patient-clinician partnership in care is supported by PR professionals remains unknown.

METHODS

Attitudes of 75 PR professionals were assessed using an online version of the Clinician Support - Patient Activation Measure (CS-PAM) 13™.

RESULTS

Mean CS-PAM 13™ activation score was 66.5 (11.9) points - professionals support patient's participation in the care process. However, competencies related to patient as member of a care team and patient as an independent information seeker were only extremely important for 30.7-38.7% and 9.3-17.3% of the professionals, respectively.

CONCLUSION

PR professionals embrace the idea of a patients' active role in the process of COPD self-management. Nonetheless, endorsement of the patient's involvement as an independent information seeker is needed.

[Theory of action on patient relationships. A different way of representing and understanding the behaviour of the family doctor in the clinic]

Objetivo

Identificar la «teoría en la acción» según el concepto de Argyris y Schon de un grupo de médicos de familia y comprobar si esta «teoría» aparece como una representación válida de su comportamiento y congruente con otros estudios.

Diseño

Descriptivo transversal.

Emplazamiento

Atención Primaria.

Participantes

Diez médicos de familia con una experiencia mínima de 10 años de otros tantos centros de salud de una ciudad y su comarca.

Método

Selección por muestreo intencional en función de la antigüedad, sexo, características del centro de referencia y estilo de práctica. Grabación y trascripción de audiograbaciones y observación de consultas. Formulación y agrupación inductiva de las proposiciones a partir de la identificación de las conductas en la consulta y su contexto siguiendo las propuestas de Argyris y Schon. Comparación de las proposiciones de los participante entre sí y con la literatura.

Resultados y discusión

Las 84 proposiciones de los entrevistados se agrupan en 9 categorías temáticas que en orden del peso de su presencia son: confianza/interés, medicalización, dimensión subjetiva, dirección, negociación, distancia e información, calidad clínica, comunicación clínica. Las proposiciones de los dos primeros temas son básicamente coincidentes mientras que en el resto aparecen diferencias en la teoría en la acción de distintos médicos. Las proposiciones pueden ser integradas con los resultados de otros estudios.

Conclusión

Es factible formular la teoría en la acción de los MF que aparece como una representación global y coherente de su comportamiento en la consulta.

The German version of the Four Habits Coding Scheme - association between physicians' communication and shared decision making skills in the medical encounter

OBJECTIVE

To translate a measure of physicians' communication skills, the Four Habits Coding Scheme (4HCS), into German, to examine its psychometric properties, and to analyze its association with the OPTION Scale, which assesses physicians' shared decision making (SDM) behavior.

METHODS

We performed a secondary data analysis of 67 audio-recorded medical consultations. Reliability, internal consistency, and factorial validity of the translated 4HCS were analyzed. The association with the OPTION Scale was examined using correlation and linear regression.

RESULTS

Testing of reliability revealed intraclass correlation coefficients above .70. Results regarding internal consistency and factorial validity were inconclusive. The correlations between the OPTION score and the four dimensions of the 4HCS were .04 (p=.782), -.14 (p=.303), -.15 (p=.279) and .55 (p<.001), respectively. In multiple regression the four dimensions of the 4HCS explained substantial amount of variation in the OPTION scores (R(2)=.42, P<.001).

CONCLUSION

The measure showed good observer reliability, however further testing is necessary. Due to the strong interrelation of both measures, SDM should be seen in the context of broader communication skills.

PRACTICE IMPLICATIONS

The 4HCS can be used in research and medical education. Further studies are necessary that investigate SDM within the context of communication skills.

Interactional difficulties as a resource for patient participation in prenatal screening consultations in Hong Kong

OBJECTIVE

In this paper, we examine the interactional means by which non-native English speaking patients in Hong Kong participate in prenatal screening sessions.

METHODS

Using interactional sociolinguistics as the theoretical framework, we apply the concept of contextualization cues to illustrate that patients indicate their participation in the consultation through verbal and non-verbal modes.

RESULTS

We find that non-native English speaking patients participate: (1) by displaying the interactional difficulties they are encountering and (2) by coordinating their displays of interactional difficulties with the activities of the healthcare provider.

CONCLUSIONS

We conclude that the notion of patient participation must be expanded to take into account non-native speaking contexts; in particular, that collaborative displays of knowledge (or lack thereof) must be included as part of the definition of patient participation. While verbal contributions represent an important mode of participation in consultations, patients also participate by contextualizing their lack of understanding, which then can serve as a resource to healthcare providers in pursuing meaningful consultations.

PRACTICE IMPLICATIONS

Our analysis illustrates how health care professionals' awareness of the modes of patient participation and what these modes may signal in non-native consultations can help to establish what the patient knows in the consultation.

Whole mind and shared mind in clinical decision-making

OBJECTIVE

To review the theory, research evidence and ethical implications regarding "whole mind" and "shared mind" in clinical practice in the context of chronic and serious illnesses.

METHODS

Selective critical review of the intersection of classical and naturalistic decision-making theories, cognitive neuroscience, communication research and ethics as they apply to decision-making and autonomy.

RESULTS

Decision-making involves analytic thinking as well as affect and intuition ("whole mind") and sharing cognitive and affective schemas of two or more individuals ("shared mind"). Social relationships can help processing of complex information that otherwise would overwhelm individuals' cognitive capacities.

CONCLUSIONS

Medical decision-making research, teaching and practice should consider both analytic and non-analytic cognitive processes. Further, research should consider that decisions emerge not only from the individual perspectives of patients, their families and clinicians, but also the perspectives that emerge from the interactions among them. Social interactions have the potential to enhance individual autonomy, as well as to promote relational autonomy based on shared frames of reference.

PRACTICE IMPLICATIONS

Shared mind has the potential to result in wiser decisions, greater autonomy and self-determination; yet, clinicians and patients should be vigilant for the potential of hierarchical relationships to foster coercion or silencing of the patient's voice.

[Opinions of family doctors on the involvement of patients in the taking of decisions: a study with focus groups]

OBJECTIVE

To determine what family doctors think about various aspects of patient involvement in clinical decision making in Primary Care.

DESIGN

Qualitative study using focus groups.

LOCATION

Primary Care.

PARTICIPANTS

Family physicians with and without expertise in clinical communication.

METHODS

Three focus groups were developed, involving 6-8 professionals per group, and took part in two meetings. The conversations were recorded and transcribed verbatim. The discussion was analysed using literature-based categories and other emerging from the text, encoding the information and making an inductive interpretation.

RESULTS

Family physicians refer mainly to involving the patient in decisions by proposing a plan tailored to the knowledge of patient problems and then verifying their approval or rejection. However, some professionals ponder whether this could be classified as patient involvement, questioning the real role that both players would take at the time of deciding.

CONCLUSIONS

The explanation of how family physicians would involve the patient in decisions clashes with the most widespread theories on the subject and, also opposes the view of patients who would like to be involved more actively. Taking into account discordant reflections on the relevance of considering this process as real patient involvement, it is necessary to describe a realistic theoretical model that allows further development of strategies to improve the attitude and training of professionals to patient involvement in clinical decisions.

Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitative study

Stroke is a leading cause of disability. Early treatment of acute ischaemic stroke with rtPA reduces the risk of longer term dependency but carries an increased risk of causing immediate bleeding complications. To understand the challenges of knowledge translation and decision making about treatment with rtPA in hyperacute stroke and hence to inform development of appropriate decision support we interviewed patients, their family and health professionals. The emergency setting and the symptomatic effects of hyper-acute stroke shaped the form, content and manner of knowledge translation to support decision making. Decision making about rtPA in hyperacute stroke presented three conundrums for patients, family and clinicians. 1) How to allow time for reflection in a severely time-limited setting. 2) How to facilitate knowledge translation regarding important treatment risks and benefits when patient and family capacity is blunted by the effects and shock of stroke. 3) How to ensure patient and family views are taken into account when the situation produces reliance on the expertise of clinicians. Strategies adopted to meet these conundrums were fourfold: face to face communication; shaping decisions; incremental provision of information; and communication tailored to the individual patient. Relational forms of interaction were understood to engender trust and allay anxiety. Shaping decisions with patients was understood as an expression of confidence by clinicians that helped alleviate anxiety and offered hope and reassurance to patients and their family experiencing the shock of the stroke event. Neutral presentations of information and treatment options promoted uncertainty and contributed to anxiety. ‘Drip feeding’ information created moments for reflection: clinicians literally made time. Tailoring information to the particular patient and family situation allowed clinicians to account for social and emotional contexts. The principal responses to the challenges of decision making about rtPA in hyperacute stroke were relational decision support and situationally-sensitive knowledge translation.

Patient participation in the discussions of options in Spanish primary care consultations

OBJECTIVES

To determine patients' participation in the discussion of options in primary care consultations. Identify the patients' wish to participate and their perceptions of their participation and explore the potential factors that may influence these.

DESIGN

Cross-sectional study. Setting. Ninety-seven general practices. Participants. six hundred and fifty-eight patients who went to their doctors for unselected reasons. Measurements. All the encounters were videoed, patient participation in decision making (DM) was assessed with two tools. After the consultation, GPs completed a questionnaire about biomedical and relational information. Patients' preferences and perception of participation was explored with different type of questions.

RESULTS

Encounters successfully videoed: 638. Of these, only 90 interviews clearly showed patient participation. In 161 other interviews, patient participation was considered possible. Questionnaires collected: 645. In 60% of the situations (390 encounters), patients wished they could have stated their views about the proposed option(s), but they perceived this did not happen. The degree of participation at the consultation did not relate significantly with the physician's ideas about the type of problem, evolution and treatment. Neither did any of the considered variables influence either the patients' wish to participate in the discussion of the suggested option or their perception of this.

CONCLUSIONS

GPs ask patients for their opinion and promote discussion about the suggested plan in few encounters. Patients perceive this, including many patients that previously had declared not to be interested in being involved in decisions. These results revealed an important mismatch between what patients wish and what they perceive.

'It's coming at things from a very different standpoint': evaluating the 'Supporting Self-Care in General Practice Programme' in NHS East of England

AIM

To undertake a service evaluation of the NHS East of England Supporting Self-Care in General Practice programme.

BACKGROUND

The number of people purported to live with long-term conditions continues to rise generating increasing policy emphasis on the importance of self-care. Previous work has highlighted barriers to implementing self-care interventions in general practice, including a lack of organisational approaches to providing self-care and limited engagement and training of healthcare professionals. In response to these barriers and policy drivers, NHS East of England Strategic Health Authority developed and commenced the Supporting Self-care in General Practice (SSCiGP) programme, which seeks to transform the relationships between people with long-term conditions and primary care practitioners.

METHODS

This was a mixed methods study, carried out over two phases, which included interviews, survey work and practice-based case studies.

RESULTS

This paper focuses on findings related to clinician and practice level change. Clinicians reported changes in their perceptions and in consultation practices following attendance on the SSCiGP programme. These changes were linked to empathy and patient-centredness that mirrored what patients valued in interactions with clinicians. There were qualitative and descriptive differences, but no statistically significant differences between clinicians who had and had not attended the SSCiGP programme. Time was recognised as a significant barrier to implementing, and sustaining skills learnt from the SSCiGP programme. Greater impact at practice level could be achieved when there was whole practice commitment to values that underpinned the SSCiGP programme. There was evidence that such approaches are being incorporated to change practice systems and structures to better facilitate self-care, particularly in practices who were early programme adopters.

CONCLUSION

This evaluation demonstrates that training around clinician change can be effective in shifting service delivery when sat within a cultural framework that genuinely situates patients at the centre of consultations and practice activity.

The illusion and the paradox of being autonomous, experiences from persons with spinal cord injury in their transition period from hospital to home

PURPOSE

To open a discourse on the concept of autonomy as a precursor for participation in individuals with Spinal Cord Injury (SCI) by exploring the experiences about their perceived autonomy in their transition period from hospital to home.

METHOD

Based on the 'grounded theory' approach; in-depth, semi structured interviews were conducted with 11 SCI-patients. A theoretical sampling strategy was used and the data was analysed according to the constant comparative method.

RESULTS

To capture this complexity of autonomy, the results have been structured in themes with regard to the self of the patient and his independency. The analysis showed four different typologies of how autonomy is perceived; (1) the active agent, (2) the active follower, (3) the passive follower and (4) the passive victim.

CONCLUSION

Rehabilitation professionals can help individuals in disconnecting their internalised ideal of independency to avoid the illusion of being autonomous and can gain insight in the patients' typology and empower patients to avoid the paradox of being autonomous. If the ultimate goal of rehabilitation is participation; empowering the patient to achieve a 'sense of agency' instead of autonomy is the central goal for rehabilitation professionals. Empowerment and agency are key topics for the patient to gain mastery over his own life.

[Preferences, satisfaction level of patient participation in making decisions in health centre nursing clinics]

AIMS

To assess patient preferences their satisfaction level and their participation in decision making with nurses.

METHODS

Cross-sectional and mixed quantitative-qualitative study carried out in people attending the nursing services of 9 Health Centres in Andalusia. Patients were interviewed immediately after receiving nursing treatment using two different questionnaires for assessing their opinions, satisfaction and perception of involvement in the decisional process. A descriptive analysis using the χ(2) test (P<.05) was performed to assess the differences among close-ended and open-ended questions. Qualitative analysis: Open-ended questions were grouped into categories by a process involving three researchers independently.

RESULTS

A total of 235 patients took part, of whom 59% (138) preferred a collaborative role with the nurse when making decisions. In the closed questions, 96.2% (228) of the surveyed patients declared to be satisfied or very satisfied with the decision making process; nevertheless 17.4% (41) made specific suggestions for improving this process. For them the main improvement areas were related to: general communication skills or a more specific one such as: strategies for helping them make decisions, reaching common ground or giving advice.

CONCLUSIONS

Nurses should be aware that most patients wish to be involved in decision making and in clinical practice this participation can be improved by obtaining specific communicational skills. Surveys that include open-ended questions are more useful to assess the quality of care.

[Patient opinion and perception of their participation in family medicine consultation decision making]

OBJECTIVES

To find out the views of the patient on their participation in decision making (DM) when visiting their family physician.

DESIGN

A cross-sectional, qualitative and quantitative study.

SETTING AND PARTICIPANTS

Patients attending their family doctors in diverse geographical Health Centres.

MEASUREMENTS

Personal interviewing using different kinds of questions (close-ended, close-ended with options and open-ended questions).

RESULTS

Patients participation: 658 (52 ± 17.4 years, 62% females, consulting with 97 doctors (from urban centres: 36 (458); rural centres: 22 (200). Most patients (94%; 620) declared to be satisfied with DM and up to 41% (266) thought that DM should be taken only by the doctor. Nevertheless, after the consultation 60% of patients (360) confirmed that they would have liked the physician to have asked them for their opinion, but the doctor did not encourage them to do this. Furthermore, patients considered information, discussion about options, ways to make decisions, medical advice, active listening and empathy as key aspects to encourage them to participate.

CONCLUSIONS

After a medical consultation, most patients wanted to give their opinion about the proposals of treatment. Nevertheless, they felt that their doctors offered them these opportunities on very few occasions. Some types of questions are better than others in detecting of these kinds of needs, and are more useful to design strategies for involving patients in the DM process.