Living with chronic illness: A phenomenological study of the health effects of the patient–provider relationship

Sex gaps in perception of tobacco conversations between adult patients who now smoke cigarettes and oral health care providers: National Health and Nutrition Examination Survey 2017-March 2020 prepandemic

BACKGROUND

Smoking cessation is difficult. A potential gap based on sex exists in the tobacco cessation aid that dental care professionals provide to patients. The purpose of this research was to examine whether there is a sex difference in dental patients' reports of having a direct conversation about the benefits of giving up cigarettes or other types of tobacco products with their oral health care provider.

METHODS

National Health and Nutrition Examination Survey 2017-March 2020 prepandemic data were used in this cross-sectional study for participants 18 years and older who reported that they "now smoke cigarettes," had a dental visit within the previous year, self-reported their sex, and responded whether their oral health care provider had a direct conversation about the benefits of giving up cigarettes or other types of tobacco products to improve dental health at their last visit (n = 582). Multivariable logistic regression analysis was conducted to compare data according to sex.

RESULTS

Overall, 50.7% of patients (59.2% of men, 42.9% of women; P = .0037) reported having a conversation about tobacco cessation at their dental visit. The odds of women reporting having no such discussion were twice those of men (odds ratio, 2.17; 95% CI, 1.10 to 4.28; P = .0270).

CONCLUSIONS

One-half of the participants reported having no tobacco cessation conversation about the benefits of giving up cigarettes or other types of tobacco with their dental care provider. Women were twice as likely to report no such discussion.

PRACTICAL IMPLICATIONS

Oral health care providers need to ensure that primary and secondary prevention information and intervention programs about the benefits of giving up cigarettes or other types of tobacco products are provided equitably to all patients.

'Is there something wrong with your voice?' A qualitative study of the voice concerns of people with laryngotracheal stenosis

BACKGROUND

Acquired laryngotracheal stenosis (LTS) is a rare condition that causes breathlessness and dyspnoea. Patients have reconstructive airway surgery to improve their breathing difficulties, but both LTS and the surgery can cause voice difficulties. The existing evidence base for management of voice difficulties for adults with LTS focuses on symptoms. There is limited information to provide clinical guidance for speech and language therapists (SLTs) and a limited understanding of the impact of voice changes on adults with LTS.

AIM

To investigate the lived experience of adults with laryngotracheal stenosis (LTS), who have had reconstructive surgery; here focussing on voice concerns with the aim of guiding clinical care for SLTs.

METHODS AND PROCEDURES

A phenomenological, qualitative study design was used. Focus groups and semi-structured interviews were completed with adults living with LTS who had had reconstructive surgery. Audio recordings were transcribed and inductive thematic analysis was used by the research team to identify themes and sub-themes.

OUTCOMES AND RESULTS

A total of 24 participants (five focus groups and two interviews) took part in the study before thematic saturation was identified in analysis. Three main themes were identified specific to the experience of living with LTS: the Medical, Physical and Emotional journey. All participants referenced voice difficulties as they related to each of these overall themes. Sub-themes directly related to voice included experience of surgery, information provision, staff expertise/complacency, symptoms, symptom management, identity, support networks, impact on life and living with a chronic condition.

CONCLUSIONS AND IMPLICATIONS

In this qualitative study participants have described the integral part voice difficulties play in their lived experience of LTS and reconstructive surgery. This is considered in the context of their clinical care and the need for individualised management and information provision throughout the course of their condition. The broader research literature relating to voice difficulties is explored with links made to people with LTS and recommendations made for future research into people living with LTS and dysphonia.

WHAT THIS PAPER ADDS

What is already known on this subject Adults with laryngotracheal stenosis (LTS) experience voice changes as a result of their condition, and the surgeries necessary as a treatment. These changes can lead to altered pitch, vocal fatigue, loss of pitch range and loss of volume control. Although there are known psychosocial implications both to living with a chronic condition and voice difficulties there has been no research exploring this in adults with LTS, and there is minimal clinical guidance for speech and language therapists (SLTs) working with these patients. What this paper adds to existing knowledge This research is the first study to explore the lived experience of adults with LTS who undergo reconstructive surgery, focusing on their voice concerns. This study demonstrates the multifactorial impacts of voice changes on all aspects of the lives of adults with LTS and the need for individualised information provision and clinical care to help support them. What are the potential or actual clinical implications of this work? Adults with LTS want expert SLTs to facilitate their care and support them throughout their LTS journey alongside other support networks. They want to be carefully prepared for reconstructive surgery and given clear information about symptoms and management of their voice difficulties. This has led to the reorganisation of the care pathway at our centre, and the introduction of a patient-led pretreatment session.

Disclosure of conventional and complementary medicine use to medical doctors and complementary medicine practitioners: A survey of rates and reasons amongst those with chronic conditions

Chronic conditions are prolonged and complex, leading patients to seek multiple forms of care alongside conventional treatment, including complementary medicine (CM). These multiple forms of care are often used concomitantly, requiring patient-provider communication about treatments used in order to manage potential risks. In response, this study describes rates and reasons for disclosure/non-disclosure of conventional medicine use to CM practitioners, and CM use to medical doctors, by individuals with chronic conditions. A survey was conducted online in July and August 2017 amongst the Australian adult population. Participants with chronic conditions were asked about their disclosure-related communication with CM practitioners (massage therapist, chiropractor, acupuncturist, naturopath) and medical doctors. Patients consulting different professions reported varying disclosure rates and reasons. Full disclosure (disclosed ALL) to medical doctors was higher (62.7%-79.5%) than full disclosure to CM practitioners (41.2%-56.9%). The most strongly reported reason for disclosing to both MDs and CM practitioners was I wanted them to fully understand my health status, while for non-disclosure it was They did not ask me about my CM/medicine use. Reasons regarding concerns or expectations around the consultation or patient-provider relationship were also influential. The findings suggest that patient disclosure of treatment use in clinical consultation for chronic conditions may be improved through patient education about its importance, direct provider inquiry, and supportive patient-provider partnerships. Provision of optimal patient care for those with chronic conditions requires greater attention to patient-provider communication surrounding patients’ wider care and treatment use.

A mixed methods systematic review of the effects of patient online self-diagnosing in the 'smart-phone society' on the healthcare professional-patient relationship and medical authority

BACKGROUND

As technology continues to advance, the internet is becoming increasingly popular. Self-diagnosis and health information seeking online is growing more common and it will be important to understand the influence this may have on the patient-healthcare professional relationship.

METHODS

A mixed-method systematic review of quantitative, qualitative and mixed method studies concerning the public and healthcare professionals' perceptions of online self-diagnosis and health information seeking and how this can impact the patient-healthcare professional relationship. We searched MEDLINE, EMBASE, CINAHL, ACM & SCOPUS between 2007 and 2018. Relevant data were extracted, and a thematic analysis was conducted and conceptualised using the Normalisation Process Theory framework.

RESULTS

Of 6107 records identified, 25 articles met the review eligibility criteria which included 16 qualitative, 8 quantitative and 1 mixed method study. The findings indicated that patients found the internet as a complementary information source alongside healthcare professionals. Health care professionals were perceived to be the most reliable and valued information source. People feel responsible for their own health and find the internet to be a source that provides information rapidly with accessibility at their convenience. Most healthcare professionals agreed on the importance of collaboration with patients and the need to develop a partnership and shared decision-making process but struggled to find time in the consultation to do so efficiently. Some healthcare professionals felt that the internet was advantageous for patients looking after their own health, while others felt it was due to a lack of trust in their expertise. Patients tended to present information to the healthcare professional to support the therapeutic relationship rather than to challenge it and to become more involved in the decision-making process of their healthcare.

CONCLUSION

The results of this review suggests that patients value healthcare professionals as a source of medical advice more than the internet. While health professionals' views were mixed our findings indicate that online health information seeking can potentially improve the patient-healthcare professional relationship as patients reported they usually conducted an online search to form a partnership with the healthcare professional as opposed to trying to prove them wrong.

Perspectives on decision making amongst older people with end-stage renal disease and caregivers in Singapore: A qualitative study

BACKGROUND

End-stage renal disease (ESRD) is increasing both globally and in Asia. Singapore has the fifth highest incidence of ESRD worldwide, a trend that is predicted to rise. Older patients with ESRD are faced with a choice of haemodialysis, peritoneal dialysis or conservative management, all of which have their risks and benefits.

OBJECTIVE

This study seeks to explore perspectives on decision making amongst older (≥70) Singaporean ESRD patients and their caregivers to undergo (or not to undergo) dialysis.

DESIGN

Qualitative study design using semi-structured interviews.

SETTING AND PARTICIPANTS

Twenty-three participants were recruited from the largest tertiary hospital in Singapore: seven peritoneal dialysis patients, five haemodialysis patients, four patients on conservative management and seven caregivers.

RESULTS

While some patients believed that they had made an independent treatment decision, others reported feeling like they had no choice in the matter or that they were strongly persuaded by their doctors and/or family members to undergo dialysis. Patients reported decision-making factors including loss of autonomy in daily life, financial burden (on themselves or on their families), caregiving burden, alternative medicine, symptoms and disease progression. Caregivers also reported concerns about financial and caregiving burden.

DISCUSSION AND CONCLUSION

This study has identified several factors that should be considered in the design and implementation of decision aids to help older ESRD patients in Singapore make informed treatment decisions, including patients' and caregivers' decision-making factors as well as the relational dynamics between patients, caregivers and doctors.

Struggling to be seen and understood as a person - Chronic back pain patients' experiences of encounters in health care: An interview study

AIM

The aim of this study was to describe how patients with chronic back pain experience encounters with health care. Persons with chronic back pain are a stigmatized group often treated based on stereotypes, which may lead to misunderstandings and create frustrated patients and healthcare personnel. Few studies have examined the generic aspects of quality of care in this context.

DESIGN

A descriptive design with a qualitative approach was used.

METHODS

Nine individual interviews were conducted with chronic back pain patients after admission to an orthopaedic hospital ward. Data were analysed using content analysis.

RESULTS

The patients' experiences of healthcare encounters can be described by the theme "Struggling to be seen and understood as a person," comprising the categories "Lack of access and trust to care," "A desire to be taken care of and listened to" and "Own strength to handle healthcare situations."

Barriers in addressing body image and eating issues in primary care: an overview of women's narratives

Disordered eating and body image concerns continue to be rising problems for young women that come with significant mental and physical health risks. Primary care may be a potential avenue for early identification and intervention of eating and body image issues. However, few studies have explored this area in depth. Preliminary studies show that few women discuss these issues with their primary care providers (PCPs), and the barriers to these conversations remain unknown. This study used an open-ended survey to explore women's narratives concerning their experiences and barriers to discussing eating and body image issues with their PCPs. A total sample of 102 female college students (aged 18-35 years) in the Boston area completed self-report questionnaires online (February 2015 through January 2016). Themes in both communication and relationship domain emerged. Communication themes for participants included: health information, prompting by the PCP, and other barriers. Relationship themes included: patient and provider characteristics, negative and positive emotions, and trust. According to these participants, many women experience negative interactions with their providers when discussing these sensitive topics. Strategies for improving these outcomes in primary care are discussed.

Infertility patient-provider communication and (dis)continuity of care: An exploration of illness identity transitions

OBJECTIVE

To identify how and why infertility patients' communication with health care providers relates to their continuity of care within infertility treatment.

METHOD

A grounded theory analysis was conducted for 25 in-depth interviews across three coding phases, where we remained open to all themes present in the data, narrowed to most prominent themes, and found the connections between the themes.

RESULTS

Based on our identified themes, we created a conceptual model that explains why infertility patients (dis)continued care with one or more clinician. Through this model, we describe two infertility identity transitions for patients: Transition 1: "Infertility as Temporary" to "Infertility as Enduring"; and Transition 2: "Infertility as Enduring" to "Infertility as Integrated."

CONCLUSION

The study explains how and why patients' view of their infertility affects their communication, and thus their continuity of care, with clinicians.

PRACTICE IMPLICATIONS

To provide patient-centered care within infertility treatment, providers can recognize how patients' view of their infertility, and thus their needs, goals, and expectations, shift throughout their infertility experience.

[Chronically Ill Patients' Perception of Hospital Nurses]

PURPOSE

The purpose of this qualitative research was to investigate chronically ill patients' perception of hospital nurses.

METHODS

Individual in-depth interviews and qualitative content analysis were used for data collection and analysis respectively. Participants were 13 chronically ill hospitalized patients or outpatients in three universities hospitals. All interviews were recorded and transcribed verbatim. Data were analyzed using the qualitative content analysis suggested by Graneheim and Lundman (2004).

RESULTS

Three themes emerged from the 10 sub-themes, which were categorized from the 21 condensed meaning units by interpreting the underlying meanings. The three themes were "person giving comfort and support by caring", "person facilitating the process of healing", and "person taking the initiative in power relations". Two themes involved positive experiences of patients and the other included negative ones.

CONCLUSION

The results showed that the participants perceived the hospital nurses as devoted to caring for patients and facilitating treatments, but authoritative in performing their duty. Based on these results, it is recommended that hospital nurses improve their nursing knowledge, skills and humanistic attitude.

Type 2 Diabetes Education and Support in a Virtual Environment: A Secondary Analysis of Synchronously Exchanged Social Interaction and Support

Background

Virtual environments (VEs) facilitate interaction and support among individuals with chronic illness, yet the characteristics of these VE interactions remain unknown.

Objective

The objective of this study was to describe social interaction and support among individuals with type 2 diabetes (T2D) who interacted in a VE.

Methods

Data included VE-mediated synchronous conversations and text-chat and asynchronous emails and discussion board posts from a study that facilitated interaction among individuals with T2D and diabetes educators (N=24) in 2 types of sessions: education and support.

Results

VE interactions consisted of communication techniques (how individuals interact in the VE), expressions of self-management (T2D-related topics), depth (personalization of topics), and breadth (number of topics discussed). Individuals exchanged support more often in the education (723/1170, 61.79%) than in the support (406/1170, 34.70%) sessions or outside session time (41/1170, 3.50%). Of all support exchanges, 535/1170 (45.73%) were informational, 377/1170 (32.22%) were emotional, 217/1170 (18.55%) were appraisal, and 41/1170 (3.50%) were instrumental. When comparing session types, education sessions predominately provided informational support (357/723, 49.4%), and the support sessions predominately provided emotional (159/406, 39.2%) and informational (159/406, 39.2%) support.

Conclusions

VE-mediated interactions resemble those in face-to-face environments, as individuals in VEs engage in bidirectional exchanges with others to obtain self-management education and support. Similar to face-to-face environments, individuals in the VE revealed personal information, sought information, and exchanged support during the moderated education sessions and unstructured support sessions. With this versatility, VEs are able to contribute substantially to support for those with diabetes and, very likely, other chronic diseases.

A Connectedness Primer for Healthcare Providers: Adolescents/Young Adult Cancer Survivors' Perspectives on Behaviors That Foster Connectedness During Cancer Treatment and the Resulting Positive Outcomes

PURPOSE

Many healthcare providers (HCPs) struggle to communicate and connect with adolescents and young adults (AYA) with cancer that hinders their ability to adequately assess and address the psychosocial needs of AYA. The purpose of this article is to describe the key behaviors of HCPs AYA perceive as essential to fostering connectedness with them and the outcomes AYA experience from such connectedness.

METHODS

The sample for this empirical phenomenological study was nine AYA cancer survivors (aged 20-23 years) who were diagnosed in adolescence. In-person individual interviews were conducted using a broad, data-generating question and analyzed using an adapted Colaizzi's method.

RESULTS

The key behaviors of HCPs AYA perceive as essential to fostering connectedness include (1) exhibiting characteristics of knowing how to connect; (2) being watchful and attentive to AYA needs; (3) displaying a willingness to foster the relationship; (4) using humor; and (5) conveying respect, support, and caring. Outcomes of connectedness for AYA include a sense of being cared about, understood, and respected as unique individuals. In addition, AYA experience a sense of confidence/comfort in expressing themselves to HCPs, anticipation of interacting with HCPs in the future, a sense of gratitude for HCPs, and enhanced well-being.

CONCLUSION

Findings highlight the specific behaviors HCPs can use to foster connectedness with AYA and the outcomes AYA experience from connectedness. Improving HCPs' ability to connect with AYA and maintain connectedness is essential to identifying and addressing the psychosocial needs of AYA. AYA-HCP connectedness may help reduce the psychosocial distress AYA experience during and after treatment.

The importance of relationships in treatment for chronic leg ulceration

Leg ulcers are a hard-to-heal wound that can have a profound impact on the lives of those that they affect. While a significant body of evidence has explored the efficacy of various treatments for leg ulcers, little research has addressed the patient experience of such treatment. A total of 21 participants were recruited for this qualitative interview study, exploring patient’s experiences of non-surgical treatment for leg ulcers. Thematic analysis identified two major themes, ‘Failure’ and ‘Powerlessness’, as well as the overarching theme of ‘Relationships’. These findings are discussed in relation to concepts of acceptance and in the broader context of patient-centred care.

Healthcare provider relational quality is associated with better self-management and less treatment burden in people with multiple chronic conditions

PURPOSE

Having multiple chronic conditions (MCCs) can lead to appreciable treatment and self-management burden. Healthcare provider relational quality (HPRQ) - the communicative and interpersonal skill of the provider - may mitigate treatment burden and promote self-management. The objectives of this study were to 1) identify the associations between HPRQ, treatment burden, and psychosocial outcomes in adults with MCCs, and 2) determine if certain indicators of HPRQ are more strongly associated than others with these outcomes.

PATIENTS AND METHODS

This is a cross-sectional survey study of 332 people with MCCs. Patients completed a 7-item measure of HPRQ and measures of treatment and self-management burden, chronic condition distress, self-efficacy, provider satisfaction, medication adherence, and physical and mental health. Associations between HPRQ, treatment burden, and psychosocial outcomes were determined using correlational analyses and independent samples t-tests, which were repeated in item-level analyses to explore which indicators of HPRQ were most strongly associated with the outcomes.

RESULTS

Most respondents (69%) were diagnosed with ≥3 chronic conditions. Better HPRQ was found to be associated with less treatment and self-management burden and better psychosocial outcomes (P<0.001), even after controlling for physical and mental health. Those reporting 100% adherence to prescribed medications had higher HPRQ scores than those reporting less than perfect adherence (P<0.001). HPRQ items showing the strongest associations with outcomes were "my healthcare provider spends enough time with me", "my healthcare provider listens carefully to me", and "I have trust in my healthcare provider".

CONCLUSION

Good communication and interpersonal skills of healthcare providers may lessen feelings of treatment burden and empower patients to feel confident in their self-management. Patient trust in the provider is an important element of HPRQ. Educating healthcare providers about the importance of interpersonal and relational skills could lead to more patient-centered care.

Patients' Experiences With Vehicle Collision to Inform the Development of Clinical Practice Guidelines: A Narrative Inquiry

OBJECTIVE

The purpose of this narrative inquiry was to explore the experiences of persons who were injured in traffic collisions and seek their recommendations for the development of clinical practice guideline (CPG) for the management of minor traffic injuries.

METHODS

Patients receiving care for traffic injuries were recruited from 4 clinics in Ontario, Canada resulting in 11 adult participants (5 men, 6 women). Eight were injured while driving cars, 1 was injured on a motorcycle, 2 were pedestrians, and none caused the collision. Using narrative inquiry methodology, initial interviews were audiotaped, and follow-up interviews were held within 2 weeks to extend the story of experience created from the first interview. Narrative plotlines across the 11 stories were identified, and a composite story inclusive of all recommendations was developed by the authors. The research findings and composite narrative were used to inform the CPG Expert Panel in the development of new CPGs.

RESULTS

Four recommended directions were identified from the narrative inquiry process and applied. First, terminology that caused stigma was a concern. This resulted in modified language ("injured persons") being adopted by the Expert Panel, and a new nomenclature categorizing layers of injury was identified. Second, participants valued being engaged as partners with health care practitioners. This resulted in inclusion of shared decision-making as a foundational recommendation connecting CPGs and care planning. Third, emotional distress was recognized as a factor in recovery. Therefore, the importance of early detection and the ongoing evaluation of risk factors for delayed recovery were included in all CPGs. Fourth, participants shared that they were unfamiliar with the health care system and insurance industry before their accident. Thus, repeatedly orienting injured persons to the system was advised.

CONCLUSION

A narrative inquiry of 11 patients' experiences with traffic collision and their recommendations for clinical guidelines informed the Ontario Protocol for Traffic Injury Management Collaboration in the development of new Minor Injury Guidelines. The values and findings of the qualitative inquiry were interwoven into each clinical pathway and embedded within the final guideline report submitted to government.

Building sustainable organizational capacity to deliver HIV programs in resource-constrained settings: stakeholder perspectives

Background

In 2008, the US government mandated that HIV/AIDS care and treatment programs funded by the US President's Emergency Plan for AIDS Relief (PEPFAR) should shift from US-based international partners (IPs) to registered locally owned organizations (local partners, or LPs). The US Health Resources and Services Administration (HRSA) developed the Clinical Assessment for Systems Strengthening (ClASS) framework for technical assistance in resource-constrained settings. The ClASS framework involves all stakeholders in the identification of LPs’ strengths and needs for technical assistance.

Objective

This article examines the role of ClASS in building capacity of LPs that can endure and adapt to changing financial and policy environments.

Design

All stakeholders (n=68) in Kenya, Zambia, and Nigeria who had participated in the ClASS from LPs and IPs, the US Centers for Disease Control and Prevention (CDC), and, in Nigeria, HIV/AIDS treatment facilities (TFs) were interviewed individually or in groups (n=42) using an open-ended interview guide. Thematic analysis revealed stakeholder perspectives on ClASS-initiated changes and their sustainability.

Results

Local organizations were motivated to make changes in internal operations with the ClASS approach, PEPFAR's competitive funding climate, organizational goals, and desired patient health outcomes. Local organizations drew on internal resources and, if needed, technical assistance from IPs. Reportedly, ClASS-initiated changes and remedial action plans made LPs more competitive for PEPFAR funding. LPs also attributed their successful funding applications to their preexisting systems and reputation. Bureaucracy, complex and competing tasks, and staff attrition impeded progress toward the desired changes. Although CDC continues to provide technical assistance through IPs, declining PEPFAR funds threaten the consolidation of gains, smooth program transition, and continuity of treatment services.

Conclusions

The well-timed adaptation and implementation of ClASS successfully engaged stakeholders who committed their own resources toward strengthening organizational capacity. The sustainability of built capacity depends on continued investment in leadership, staff retention, and quality improvement.

Obese women's perceptions and experiences of healthcare and primary care providers: a phenomenological study

BACKGROUND

Nearly two thirds of the adult population in the United States is overweight or obese. Adults who are overweight or obese require the same high-quality healthcare from their providers as any other adult. Unfortunately, stigma is a reality experienced by individuals who are overweight or obese, and healthcare professionals' views have sometimes been reported to be biased against individuals who are overweight or obese. However, there are gaps and inconsistencies in the literature regarding the types of experiences and perceptions of obese women receiving healthcare and whether stigma is present.

OBJECTIVE

The aim of this study was to describe the experiences and perceptions of obese women with regard to stigma in healthcare and from their healthcare provider.

METHODS

A phenomenological research approach using the Colaizzi method was utilized to examine and describe the lived experience of overweight and obese women with healthcare. Semistructured interviews were conducted with a diverse, purposive sample of 26 English-speaking women with a body mass index of over 30 kg/m. Participants were asked to describe their perceptions and experiences with regard to healthcare and their relationship with their healthcare providers.

RESULTS

Four themes emerged from the analysis of the data: (a) perceptions of health and healthcare, (b) respect me as a person, (c) establishing a healthcare connection, and (d) assertiveness is necessary. Although stigma was not named by women in this study, all acknowledged some negative treatment by healthcare providers.

DISCUSSION

Discussion relating to the current professional literature is presented. Implications for nursing education and research are discussed.

The seriously mentally ill older adult: perceptions of the patient-provider relationship

PURPOSE

The purpose of this study was to give voice to the lived experiences of older adults with serious mental illness and their perceptions of the healthcare provider relationship.

DESIGN AND METHODS

A qualitative phenomenological research design was used. In-depth interviews were conducted with eight members of a mental health clubhouse.

FINDINGS

Study themes revealed not only elements of goodwill toward providers but also elements of concern about the reliability and quality of healthcare provider relationships. Findings provided theoretical support for using Peplauian approaches in clinical practice.

PRACTICE IMPLICATIONS

Partnering with patients, utilizing peer support networks, and placing a broader emphasis on the recovery model should be explored.

An integrated model of care for inflammatory bowel disease sufferers in Australia: development and the effects of its implementation

BACKGROUND

Psychological comorbidities are associated with poor outcome and increased healthcare utilization in patients with inflammatory bowel disease (IBD). However, a model of care addressing the biopsychosocial dimension of disease is not routinely applied in IBD. This review describes the development of such a model and the effects of its implementation in a hospital-based cohort of patients with IBD.

METHODS

Three different approaches were used: 1) collecting baseline epidemiological data on mental health comorbidities; 2) raising awareness of and targeting mental health problems; 3) examining the effects of the model implementation.

RESULTS

High rates of anxiety and depressive symptoms (36% and 13%, respectively) that are maintained over time were identified in IBD patients presenting at a metropolitan teaching hospital. Patients with documented psychological comorbidities were more likely to be hospitalized than those without (odds ratio [OR] = 4.13, 95% confidence interval [CI]: 1.25, 13.61). Improvements in disease activity, anxiety, depression, quality of life, and coping have been noted when cognitive-behavioral therapy (CBT) was provided to patients. A drop in the use of opiates (P = 0.037) and hospitalization rates (from 48% to 30%) in IBD patients has been noted as a result of introduction of the changed model of care. In addition, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 [US$15,236.79] vs. US$ 30,467.78 [US$ 53,760.20], P = 0.005).

CONCLUSION

Our data to date suggest that an integrated model of care for patients with IBD may yield superior long-term outcomes in terms of medication use and hospitalization rates and reduce healthcare costs.

Experiences of abdominal massage for constipation

AIM

This study aims to illuminate participants' experiences of receiving abdominal massage for constipation.

BACKGROUND

Abdominal massage has been found to decrease the severity of constipation and abdominal pain, but little is known about how patients experience receiving abdominal massage.

DESIGN

The present study is a qualitative descriptive study, based on individual interviews.

METHOD

Nine adults receiving abdominal massage for constipation were invited to participate. Semi-structured interviews were conducted in Sweden between 2005-2007. The interviews were transcribed and subjected to qualitative content analysis.

RESULTS

Four themes were formulated: 'being on one's guard', 'becoming embraced by safe hands', 'being touched physically and emotionally' and 'feeling vulnerable'. The participants reported that they were on guard, i.e. they were sceptical about whether or not abdominal massage was effective and suitable. However, as the massage sessions continued, they found the massage pleasant and began to feel embraced and in safe hands. They described how the abdominal massage made them feel as 'being touched physically and emotionally' and their bowel habits were improved. Along with the improvements, their agony was gone and they felt relieved. However, they considered their new condition fragile and they felt vulnerable to relapse.

CONCLUSIONS

Abdominal massage was experienced as pleasurable, and after treatment, the participants felt more comfortable with their bowel function. Participants described abdominal massage as affecting the whole person.

RELEVANCE TO CLINICAL PRACTICE

Abdominal massage has been shown to be an effective intervention for constipation. A crucial aspect is that nurses need to be sensitive and respect the intimacy associated with the abdomen.

Storied experiences of nurse practitioners managing prehypertension in primary care

PURPOSE

The purpose of this study was to explore the nurse practitioner (NP) experience with caring for prehypertensive patients. Lifestyle modifications are the primary recommendation for management of prehypertension. Given the historical foundation of health promotion and disease prevention as a fundamental component of NP professional identity, gaining insight into the experience of caring for prehypertensive patients in the current healthcare environment is valuable to the profession, patients, and communities. Therefore, the NP role in health promotion and disease prevention related to prehypertension was explored as well.

DATA SOURCES

Narrative inquiry was the chosen methodology to gather narrative accounts of eight NPs caring for prehypertensive patients in primary care. The three-dimensional narrative inquiry space was used to guide the researcher during data analysis.

CONCLUSIONS

Three themes emerged from the NPs' narratives: realities of practice, ambiguous role identity, and bridging models. Time constraints, financial considerations, and bridging the nursing and medical models while adapting to practice environments were barriers identified as components of the NP experience caring for patients with prehypertension.

IMPLICATIONS FOR PRACTICE

This study revealed that caring for prehypertensive patients is a complex and multilayered experience.

A longitudinal qualitative study examining the factors impacting on the ability of persons with T1DM to assimilate the Dose Adjustment for Normal Eating (DAFNE) principles into daily living and how these factors change over time

BACKGROUND

The literature reveals that structured education programmes, such as DAFNE, result in many positive outcomes for people with Type 1 diabetes including a decrease in HbA1c levels and reductions in hypoglycaemia. While there is evidence that some of these outcomes are maintained we do not know at present what factors are most important over time. The study aim was to identify the key factors impacting on persons with Type 1 diabetes ability to assimilate the Dose Adjustment For Normal Eating (DAFNE) DAFNE principles into their daily lives and how these factors change over time.

METHODS

This is a longitudinal descriptive qualitative study. Interviews were undertaken with 40 participants who had attended DAFNE in one of 5 study sites across the Island of Ireland, at 6 weeks, 6 and 12 months after completion of the programme. The interviews lasted from 30 to 60 minutes and were transcribed verbatim. Data were analysed in three ways, a within time analysis, a cross sectional analysis for each participant and a thematic analysis which focused on examining changes over time

RESULTS

Four themes that influenced participants' ability to assimilate DAFNE into their daily lives over time were identified. These were: embedded knowledge, continued responsive support, enduring motivation and being empowered. Support at the 6 month period was found to be crucial to continued motivation.

CONCLUSIONS

Understanding the factors that influence people's ability to assimilate DAFNE principles over time into their daily lives can help health professionals give focused responsive support that helps people with diabetes become more empowered. Understanding that continued support matters, particularly around 6 months, is important as health professionals can influence good management by providing appropriate support and enhancing motivation.

TRIAL REGISTRATION

ISRCTN79759174.

Emancipatory actions displayed by multi-ethnic women: "Regaining control of my health care"

PURPOSE

Despite the recognized importance of patient involvement in primary care interactions, little information describing women's needs and expectations for these interactions is available. This participatory action study was based in Critical Action Theory and designed to describe any emancipatory interests that surfaced when eight ethnically diverse women examined their interactions with primary care nurse practitioners (PCNPs) over the course of five successive focus group meetings.

DATA SOURCES

Focus group meeting transcripts, field notes, interaction notations, seating maps, and first impression summaries.

CONCLUSIONS

Participants wanted to learn how to "stand up" for themselves in primary care interactions. They believed this could be accomplished by developing a positive sense of self-esteem. Ultimately, they identified the right way to "talk back" to clinicians and created a method for regaining control of their own health care and maintaining equality in interactions with primary care clinicians.

IMPLICATIONS FOR PRACTICE

Nurse practitioners working in the primary setting are especially well situated to support self-management and foster patient participation by women as they live with chronic disease, engage in health promotion activities, and deal with common symptomatic problems for themselves and their families.

Being in the patient position: experiences of health care among people with irritable bowel syndrome

The purpose of this study was to gain in-depth understanding of what it is like for a person with irritable bowel syndrome to be in the patient position in encounters with health care providers. We conducted qualitative interviews with nine individuals. Our analysis, guided by interpretive description, revealed experiences of unsupportive and supportive encounters. Unsupportive encounters were shaped by humiliation, insignificance, and abandonment. Not feeling believed and acknowledged as persons made the participants lose trust in their own experience, which enhanced their unfamiliar mood of being in the world. Supportive encounters were less prominent. These were characterized by openness and acknowledgment of the patient's lifeworld. Feeling significant and being listened to promoted feelings of being in a partnered, cocreating relationship. It is reasonable to assume that care originating in the patient's lifeworld would support the patients to use their strength to manage illness and regain familiarity in everyday life.

Forging partnerships between rural women with chronic conditions and their health care providers

Successful adaptation to chronic illness is enhanced by active client-health care provider partnerships. The purposes of this article are to (a) examine the health care partnership needs of western rural women with chronic illness who participated in a computer-based support and education project, (b) describe how the role of the women in the partnership can be maximized by the use of a personal health record and improving health literacy, and (c) discuss ways health care providers can enhance their role in the partnership by careful listening and creating environments conducive to forging productive client-provider partnerships.