How to improve communication between doctors and patients. Learning more about the decision making context is important

Patient-Identified Solutions to Primary Care Access Barriers in Canada: The Viewpoints of Nepalese Immigrant Community Members

BACKGROUND

Accessing healthcare for immigrants in Canada is complicated by many difficulties. With the continued and upward trend of immigration to Canada, it is crucial to identify the solutions to the barriers from the perspectives of different immigrant communities as they encounter them including the relatively smaller and less studied population groups of immigrants. As such, Nepalese immigrants in Canada are a South Asian ethnic group who have their own distinct language, culture, and socio-economic backgrounds, however, their experience with accessing healthcare in Canada is scarce in the literature.

METHODS

We conducted 12 focus group discussions with first-generation Nepalese immigrants who had experiences with primary care use in Canada. Informed consent and demographic information were obtained before each focus group discussion. The verbatim transcription of the focus groups was analyzed using thematic analysis.

RESULTS

The participants expressed a range of potential solutions to overcome the barriers, which we presented using the socio-ecological framework into 4 different levels. This includes individual-, community-, service provider-, and government/policy-levels. Individual-level actions included improving self-awareness and knowledge of health in general and navigating the healthcare system and proactively improving the language skills and assimilating into the Canadian culture. Examples of community-level actions included community events to share health information with immigrants, health literacy programs, and driving/carpooling to clinics or hospitals. Actions at the service provider level were mainly focused on enhancing communications, cultural competency training for providers, and ensuring to hire primary care workforce representing various ethnocultural backgrounds. Overall, focus group participants believed that the provincial and federal government, as appropriate, should increase support for dental and vision care support and take actions to increase the healthcare capacity, particularly by employing internationally graduated health professionals.

CONCLUSIONS

Access to primary care is essential for the health of immigrant populations in Canada. Individuals, community organizations, health service providers, and governments need to work both individually and collaboratively to improve immigrants' primary care access.

Disclosing Adverse Events in Clinical Practice: The Delicate Act of Being Open

Practicing a "safe" disclosure of adverse events remains challenging for healthcare professionals. In addition, knowledge on how to deliver a disclosure is still limited. This review focuses on how disclosure communication may be practiced based on the perspectives of patients and healthcare professionals. Empirical studies conducted between September 2008 and October 2019 were included from the databases PubMed, Web of Science and Psychinfo. After full text analysis and quality appraisal this scoping review included a total of 23 studies out of 2537 studies. As a first step, the needs of patients and the challenges of healthcare professionals with the practice of providing an effective disclosure were extracted from the empirical literature. Based on these findings, the review demonstrates that specific disclosure communication strategies on the level of interpersonal skills, organization, and supportive factors may facilitate healthcare professionals to provide optimal disclosure of adverse events. These may be relevant to provide patients with a tailored approach that accompanies their preferences for information and recognition. In conclusion, healthcare professionals may need training in interpersonal (verbal and nonverbal) communication skills. Furthermore, it is important to develop an open (organizational) culture that supports the communication of adverse events and disclosure as a standard practice.

Overcoming the Challenges Faced by Immigrant Populations While Accessing Primary Care: Potential Solution-oriented Actions Advocated by the Bangladeshi-Canadian Community

Introduction:

Immigrants continue to face significant challenges in accessing primary healthcare (PHC) that often negatively impact their health. The present research aims to capture the perspectives of immigrants to identify potential approaches to enhance PHC access for this group.

Methods:

Focus group discussions (FGDs) were conducted among a sample of first-generation Bangladeshi immigrants who had experience with PHC in Canada. A total of 13 FGDs (7 among women, 6 among men) were conducted with 80 participants (women = 42, men = 38) in their preferred language, Bangla. We collected demographic information prior to each focus group and used descriptive statistics to identify the socio-demographic characteristics of participants. We applied thematic analysis to examine qualitative data to generate a list of themes of possible approaches to improve PHC access.

Results:

The focus group findings identified different levels of approaches to improve PHC access: individual-, community-, service provider-, and policy-level. Individual-level approaches included increased self-awareness of health and wellness and personal knowledge of cultural differences in healthcare services and improved communication skills. At the community level, supports for community members to access care included health education workshops, information sessions, and different support programs (eg, carpool services for senior members). Suggested service-level approaches included providers taking necessary steps to ensure an effective doctor-patient relationship with immigrants (eg, strategies to promote cultural competencies, hiring multicultural staff). FGD participants also raised the importance of government- or policy-level solutions to ensure high quality of care (eg, increased after-hour clinics and lab/diagnostic services).

Conclusions:

Although barriers to immigrants accessing healthcare are well documented in the literature, solutions to address them are under-researched. To improve healthcare access, physicians, community health centers, local health agencies, and public health units should collaborate with members of immigrant communities to identify appropriate interventions.

The Role of Engagement in Teleneurorehabilitation: A Systematic Review

The growing understanding of the importance of involving patients with neurological diseases in their healthcare routine either for at-home management of their chronic conditions or after the hospitalization period has opened the research for new rehabilitation strategies to enhance patient engagement in neurorehabilitation. In addition, the use of new digital technologies in the neurorehabilitation field enables the implementation of telerehabilitation systems such as virtual reality interventions, video games, web-based interventions, mobile applications, web-based or telephonic telecoach programs, in order to facilitate the relationship between clinicians and patients, and to motivate and activate patients to continue with the rehabilitation process at home. Here we present a systematic review that aims at reviewing the effectiveness of different engagement strategies and the different engagement assessments while using telerehabilitation systems in patients with neurological disorders. We used PICO's format to define the question of the review, and the systematic review protocol was designed following the Preferred Reported Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Bibliographical data was collected by using the following bibliographic databases: PubMed, EMBASE, Scopus, and Web of Science. Eighteen studies were included in this systematic review for full-text analyses. Overall, the reviewed studies using engagement strategies through telerehabilitation systems in patients with neurological disorders were mainly focused on patient self-management and self-awareness, patient motivation, and patient adherence subcomponents of engagement, that are involved in by the behavioral, cognitive, and emotional dimensions of engagement. Conclusion: The studies commented throughout this systematic review pave the way for the design of new telerehabilitation protocols, not only focusing on measuring quantitative or qualitative measures but measuring both of them through a mixed model intervention design (1). The future clinical studies with a mixed model design will provide more abundant data regarding the role of engagement in telerehabilitation, leading to a possibly greater understanding of its underlying components.

The Management of Chronic Back Pain in Primary Care Settings: Exploring Perceived Facilitators and Barriers to the Development of Patient-Professional Partnerships

Supporting patients in forming partnerships with health professionals is the key of effective self-management. This study aimed to explore the nature of patient-professional partnerships and its related factors that create facilitators and barriers to patients' self-management ability. A constructivist grounded theory approach was undertaken. Three main themes emerged: interaction and communication, integrated care, and service and system. A theoretical model was generated that posits effective communication, individualized integrated care, and high-quality service as key influences on the successful development of patient-professional partnerships and patients' ability to self-manage. Giving attention to these factors helps understand the development, implementation, mechanisms, and evaluation of building a patient-professional partnership and maximizes the opportunities for patient self-management of chronic pain. Future research and practice are needed to move beyond a simplistic focus on health outcomes to address the complex links between partnerships and treatment delivery processes, and interventions, effects, and patients' context.

Counseling in urogynecology: A difficult task, or simply good surgeon-patient communication?

Surgical treatments for pelvic organ prolapse (POP) and urinary incontinence (UI) have greatly changed in recent years. Prompted by increases in reports of adverse outcomes in relation to such treatments, several scientific societies and researchers have emphasized providing patients with thorough counseling before treating them. Patient-centered communication has become the gold standard for excellence in clinical care. This challenges clinicians to be cognizant of their patients' perspectives, motivations, expectations, fears, concerns, and social contexts to enable them to reach a shared understanding with patients. Considering this, urogynecology counseling represents a crucial process through which women can gain a clear understanding of their clinical condition and the risks and benefits of potential treatment options. However, many urogynecologists believe that proposing a treatment and providing only enough detail to secure informed consent constitutes counseling. This article is intended to describe good counseling for women undergoing urogynecological surgery and to suggest optimal methodologies for implementation.

Nutritional treatment of advanced CKD: twenty consensus statements

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Influential factors on treatment decision making among patients with colorectal cancer: A scoping review

PURPOSE

In recent years, a greater emphasis has been placed on shared decision-making (SDM) techniques between providers and patients with the goal of helping patients make informed decisions about their care and subsequently to improve patient health outcomes. Previous research has shown variability in treatment decision-making among patients with colorectal cancer (CRC), and there is little comprehensive information available to help explain this variability. Thus, the purpose of this study was to evaluate the current state of the literature on factors that are influential in treatment decision-making among patients with CRC.

METHOD

A priori search terms using Boolean connectors were used to examine PubMed, PsycINFO, Web of Science, CINAHL, and MEDLINE for relevant studies. Eligibility criteria for inclusion in the study included patients with CRC and examination of influences on CRC treatment decision-making. All relevant data were extracted including, author, title and year, study methodology, and study results.

RESULTS

Findings (n = 13) yielded influences in four areas: informational, patient treatment goals, patient role preferences, and relationship with provider. Quality of life and trust in physician were rated a high priority among patients when making decisions between different therapeutic options. Several studies found that patients wanted to be informed and involved but did not necessarily want to make autonomous treatment choices, with many preferring a more passive role.

CONCLUSIONS

Providers who initiate a dialog to better understand their patients' treatment goals can establish rapport, increase patient understanding of treatment options, and help patients assume their desired role in their decision-making. Overall, there were a small number of studies that met all inclusion criteria with most used a cross-sectional design.

Key stakeholders' perceptions of the acceptability and usefulness of a tablet-based tool to improve communication and shared decision making in ICUs

PURPOSE

Although barriers to shared decision making in intensive care units are well documented, there are currently no easily scaled interventions to overcome these problems. We sought to assess stakeholders' perceptions of the acceptability, usefulness, and design suggestions for a tablet-based tool to support communication and shared decision making in ICUs.

METHODS

We conducted in-depth semi-structured interviews with 58 key stakeholders (30 surrogates and 28 ICU care providers). Interviews explored stakeholders' perceptions about the acceptability of a tablet-based tool to support communication and shared decision making, including the usefulness of modules focused on orienting families to the ICU, educating them about the surrogate's role, completing a question prompt list, eliciting patient values, educating about treatment options, eliciting perceptions about prognosis, and providing psychosocial support resources. The interviewer also elicited stakeholders' design suggestions for such a tool. We used constant comparative methods to identify key themes that arose during the interviews.

RESULTS

Overall, 95% (55/58) of participants perceived the proposed tool to be acceptable, with 98% (57/58) of interviewees finding six or more of the seven content domains acceptable. Stakeholders identified several potential benefits of the tool including that it would help families prepare for the surrogate role and for family meetings as well as give surrogates time and a framework to think about the patient's values and treatment options. Key design suggestions included: conceptualize the tool as a supplement to rather than a substitute for surrogate-clinician communication; make the tool flexible with respect to how, where, and when surrogates can access the tool; incorporate interactive exercises; use video and narration to minimize the cognitive load of the intervention; and build an extremely simple user interface to maximize usefulness for individuals with low computer literacy.

CONCLUSION

There is broad support among stakeholders for the use of a tablet-based tool to improve communication and shared decision making in ICUs. Eliciting the perspectives of key stakeholders early in the design process yielded important insights to create a tool tailored to the needs of surrogates and care providers in ICUs.

Patient educational technologies and their use by patients diagnosed with localized prostate cancer

BACKGROUND

Two urology practices in Calgary, Canada use patient educational technology (PET) as a core component of their clinical practice. The purpose of this study was to determine how patients interact with PET designed to inform them about their treatment options for clinically localized prostate cancer.

METHODS

A PET library was developed with 15 unique prostate-related educational modules relating to diagnosis, treatment options, and potential side effects. The PET collected data regarding its use, and those data were used to conduct a retrospective analysis. Descriptive analyses were conducted and comparisons made between patients' utilization of the PET library during first and subsequent access; Pearson's Chi-Square was used to test for statistical significance, where appropriate.

RESULTS

Every patient (n = 394) diagnosed with localized prostate cancer was given access to the PET library using a unique identifier. Of those, 123 logged into the library and viewed at least one module and 94 patients logged into the library more than once. The average patient initially viewed modules pertaining to their diagnosis. Viewing behavior significantly changed in subsequent logins, moving towards modules pertaining to treatment options, decision making, and post-surgical information.

DISCUSSION

As observed through the longitudinal utilization of the PET library, information technology offers clinicians an opportunity to provide an interactive platform to meet patients' dynamic educational needs. Understanding these needs will help inform the development of more useful PETs.

CONCLUSION

The informational needs of patients diagnosed with clinically localized prostate cancer changed throughout the course of their diagnosis and treatment.

A Preliminary Investigation of Barriers to Achieving Patient-Centered Communication with Patients Who Have Stroke-Related Communication Disorders

This article reports on research investigating barriers to achieving patient-centered communication (PCC) with patients who have stroke-related communication disorders. A focus group, including people who had strokes and their family members, identified PCC issues they encounter when communicating with health care providers. The two key themes that emerged from this research were the desire to be treated with respect and the importance of allowing adequate time for a person with a speech disorder to communicate. Suggestions are given for improving PCC with people who have stroke-related communication disorders.

INvolvement of breast CAncer patients during oncological consultations: a multicentre randomised controlled trial--the INCA study protocol

INTRODUCTION

Studies on patient involvement show that physicians make few attempts to involve their patients who ask few questions if not facilitated. On the other hand, the patients who participate in the decision-making process show greater treatment adherence and have better health outcomes. Different methods to encourage the active participation during oncological consultation have been described; however, similar studies in Italy are lacking. The aims of the present study are to (1) assess the effects of a preconsultation intervention to increase the involvement of breast cancer patients during the consultation, and (2) explore the role of the attending companions in the information exchange during consultation.

METHODS AND ANALYSIS

All female patients with breast cancer who attend the Oncology Out-patient Services for the first time will provide an informed consent to participate in the study. They are randomly assigned to the intervention or to the control group. The intervention consists of the presentation of a list of relevant illness-related questions, called a question prompt sheet. The primary outcome measure of the efficacy of the intervention is the number of questions asked by patients during the consultation. Secondary outcomes are the involvement of the patient by the oncologist; the patient's perceived achievement of her information needs; the patient's satisfaction and ability to cope; the quality of the doctor-patient relationship in terms of patient-centeredness; and the number of questions asked by the patient's companions and their involvement during the consultation. All outcome measures are supposed to significantly increase in the intervention group.

ETHICS AND DISSEMINATION

The study was approved by the local Ethics Committee of the Hospital Trust of Verona. Study findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01510964.

Measuring patient participation in surgical treatment decision-making from healthcare professionals' perspective

AIMS AND OBJECTIVES

To develop, empirical test, and validate an instrument measuring patient participation in surgical treatment decision-making from healthcare professionals' perspective.

BACKGROUND

Since the advent of New Public Management in many Western countries, patient participation in healthcare decision-making has been considered to be a best practice. A common notion is that well-educated and well-informed public want to choose their own treatments and providers and want to ask questions about the quality of their health services.

DESIGN

Survey.

METHODS

A self-report-measuring instrument was designed and administered to 620 healthcare professionals. Items were developed, validated and tested by 451 nurses and physicians working in six surgical wards in a University Hospital in Norway.

RESULTS

A 16-item scale with the following four dimensions was developed: information dissemination, formulation of options, integration of information and control. Factor analysis procedures and reliability testing were performed. A one-way, between-groups analysis of variance was conducted to compare doctors' and nurses' opinions on four dimensions of patient participation in surgical treatment decision-making.

CONCLUSIONS

This article shows that patient participation in surgical treatment decision-making can be measured by a 16-item scale and four distinct dimensions. The analysis demonstrated a reasonable level of construct validity and reliability. Nurses and physicians have a positive attitude towards patient participation overall, but the two groups differ in the extent to which they accept the idea of patient participation in treatment decision-making.

RELEVANCE TO CLINICAL PRACTICE

The instrument can be a tool for managers and healthcare professionals in the implementation of patient participation in clinical practice. Data from the instrument can be useful to identify health services being provided and what areas that could strengthen patient participation.

Person centred care and shared decision making: implications for ethics, public health and research

This paper presents a systematic account of ethical issues actualised in different areas, as well as at different levels and stages of health care, by introducing organisational and other procedures that embody a shift towards person centred care and shared decision-making (PCC/SDM). The analysis builds on general ethical theory and earlier work on aspects of PCC/SDM relevant from an ethics perspective. This account leads up to a number of theoretical as well as empirical and practice oriented issues that, in view of broad advancements towards PCC/SDM, need to be considered by health care ethics researchers. Given a PCC/SDM-based reorientation of health care practice, such ethics research is essential from a quality assurance perspective.

Patient participation in surgical treatment decision making from the patients' perspective: validation of an instrument

The aim of this paper is to describe the development of a new, brief, easy-to-administer self-reported instrument designed to assess patient participation in decision making in surgical treatment. We describe item generation, psychometric testing, and validity of the instrument. The final scale consisted of four factors: information dissemination (5 items), formulation of options (4 items), integration of information (4 items), and control (3 items). The analysis demonstrated a reasonable level of construct validity and reliability. The instrument applies to patients in surgical wards and can be used to identify the health services that are being provided and the areas that could strengthen patient participation.

New dimensions in patient-physician interaction: values, autonomy, and medical information in the patient-centered clinical encounter

Patient-physician interactions are increasingly influenced by the extraordinary diversification of populations and rapid expansion of medical knowledge that characterize our modern era. By contrast, the patient-physician interaction models currently used to teach medical trainees have little capacity to address these twin challenges. We developed a new model of patient-physician interaction to explicitly address these problems. Historically, models of patient-physician interaction viewed patient autonomy and the manifestation of clearly defined health care-related values as tightly linked, and it was assumed that patients' medical knowledge was low. Unfortunately, this does not adequately represent patients such as 1) the highly educated non-medical specialist who possesses little familiarity with health-related values but is highly autonomous, and 2) the patient from a non-Western background who may have well-established health care-related values but a low sense of personal independence. In addition, it is evident to us that the assumption that all patients possess little medical knowledge can create alienation between patient and physician, e.g. the well-informed patient with a rare disease. We propose a paradigm that models autonomy, health care-related values formation, and medical knowledge as varying from patient to patient. Four examples of patient types are described within the context of the model based on clinical experience. We believe that adopting this model will have implications for optimizing patient-physician interactions and teaching about patient-centered care. Further research is needed to identify relevant patient types within this framework and to assess the impact on health care outcomes.

Qualitative research in evidence-based medicine: improving decision-making and participation in randomized controlled trials of cancer treatments

BACKGROUND

Since the 1990s there has been increasing emphasis on 'evidence-based medicine'. The randomized controlled trial is widely regarded as the 'gold-standard' study design for evaluating interventions. However, placing too strong an emphasis on a phase III trial, to the neglect of earlier development and piloting work, may result in weaker interventions that are more difficult to evaluate and less likely to be implemented.

AIM

To illustrate the benefits and outcomes of qualitative research at the early stages of the research continuum.

SETTING/PARTICIPANTS

Two cancer studies are evaluated in which the best treatment option is uncertain: ASPECTS (A Study of Patients ExperienCes of TreatmentS) and ProtecT (Prostate Testing for Cancer and Treatment).

DESIGN

To examine decision-making in relation to palliative chemotherapy for advanced cancer, ASPECTS was a qualitative study involving non-participant observation and recording of oncology consultations. During the ProtecT feasibility study, recruitment interviews were routinely audiotaped and in-depth interviews conducted with men to explore their understanding of treatment options and randomization to trial arms.

RESULTS

ASPECTS identified that insufficient information was given to patients about the survival benefits of palliative chemotherapy with implications for informed consent. ProtecT illustrated the effective use of qualitative research methods to resolve recruitment and randomization problems for a randomized controlled trial.

CONCLUSIONS

These studies illustrate the value of qualitative research, particularly during the earlier phases of the research continuum. Such research may generate hypotheses, strengthen the development and implementation of interventions and enhance their evaluation: all of which are essential to evidence-based medicine.

'I didn't want her to panic': unvoiced patient agendas in primary care consultations when consulting about antidepressants

BACKGROUND

Patient participation in primary care treatment decisions has been much debated. There has been little attention to patients' contributions to primary care consultations over a period of time, when consulting about depression and its treatment with antidepressants.

AIM

To explore: (1) what issues remain unsaid during a primary care consultation for depression but are later raised by the patient as important during a research interview; (2) patients' reasons for non-disclosure; (3) whether unvoiced agendas are later voiced; and (4) the nature of the GP-patient relationship in which unvoiced agendas occur.

DESIGN OF STUDY

Qualitative interview study.

SETTING

Primary health care.

METHOD

Patients were recruited through six general practices in the south west of England. Qualitative interviews were carried out with 10 'pairs' of GPs and patients who presented with a new or first episode of moderate to severe depression and were prescribed antidepressants. Follow-up patient interviews were conducted at 3 and 6 months. Throughout the 6-month period, patients were invited to record subsequent consultations (with GPs' consent), using a patient-held tape recorder.

RESULTS

Twenty-three unvoiced agendas were revealed, often within decision-making relationships that were viewed in positive terms by patients. Unvoiced agendas included: a preference for immediate treatment, a preference to increase dosage, and the return or worsening of suicidal thoughts. In some cases, patients were concerned that they were 'letting the GP down' by not being able to report feeling better.

CONCLUSION

Unvoiced agendas are not necessarily an indication that 'shared decision making' is absent but may in some cases represent patients' attempts to 'protect' their GPs.

Training physicians in shared decision-making-who can be reached and what is achieved?

OBJECTIVE

To report on experiences with a general shared decision-making (SDM) physician training program offered to physicians throughout Germany.

METHODS

This study enrolled 150 physicians in an 8-h SDM training program. Physicians were assessed with standardized instruments before and after training. Main variables of interest were physician professional attributes, personality characteristics, attitudes, measures of training success (quality rating, knowledge, competency ratings), and variables associated with training success.

RESULTS

The SDM training obtained positive quality ratings, led to an amelioration in an objective SDM knowledge test (p<.001), and highly improved physicians' confidence in their SDM competencies (p<0.001). It attracted experienced, middle-aged (45 years), male and female (46%) physicians, mostly office-based (2/3) general practitioners and internists (2/3). Most physicians (94%) reported positive attitudes towards SDM. They were securely attached (63%) with predominant social career choice motives (46%). Physicians with personality characteristics clashing with the SDM concept benefited mostly from the training.

CONCLUSION

A voluntary SDM training program is attractive to practicing physicians and effective in increasing SDM-related confidence and knowledge.

PRACTICE IMPLICATIONS

Even physicians who are highly motivated to use SDM can improve their skills and benefit from SDM training. The dissemination of SDM training programs should be encouraged.

"Open your heart first of all": perspectives of holistic providers in Costa Rica about communication in the provision of health care

Research documents how the care the holistic providers offer represents the quality communication that patients often do not receive from their biomedical providers. However, research investigating the perspectives of holistic providers concerning the role they see themselves playing in the provision of health is limited. This research explores the perceptions of holistic providers in Costa Rica about their communication with their patients. The results reveal two practices of communication-authenticating and integrating as central to providers' communication with patients in the provision of holistic health care. Providers describe their communication as an exploration of an anatomy of pain/suffering, including investigating the location, timing, length, intensity, and overall rhythm of the patient's condition and sense making that leads them to seek the care of a holistic provider. Most holistic providers see their role as being careful or full of care and suggest that they have an obligation to open their heart first of all.

The Blue Card: a hand-held health record card for mental health consumers with comorbid physical health risk

OBJECTIVE

We aimed to determine the effectiveness of a hand-held record (the 'Blue Card') for seriously mentally ill consumers by investigating effects on consumer knowledge of physical health risk factors, consumer involvement in care and communication with healthcare professionals.

METHOD

Consumers were given and educated in the use of the Blue Card, which contained information regarding their physical health. Consumers completed a pre- and post-knowledge questionnaire and commented on the effectiveness of the Blue Card with respect to their knowledge of physical health risks.

RESULTS

Statistically significant improvements in consumer knowledge were shown at the 3-month follow-up, with high retention of the Blue Card being demonstrated. Consumers that used the card described their use of the card positively.

CONCLUSIONS

The results are very encouraging. Further studies of this low-cost intervention are warranted to establish its effectiveness and utility.

What oncologists tell patients about survival benefits of palliative chemotherapy and implications for informed consent: qualitative study

OBJECTIVE

To examine how much oncologists tell patients about the survival benefit of palliative chemotherapy during consultations at which decisions about treatment are made.

DESIGN

Qualitative study in which consultations were observed and digitally recorded.

SETTING

Teaching hospital and district general hospital in south west England.

PARTICIPANTS

37 patients with advanced non-small cell lung cancer (n=12), pancreatic cancer (n=13), and colorectal cancer (n=12); and nine oncologists, including four consultants and five registrars.

MAIN OUTCOME MEASURES

All recordings were transcribed completely, anonymised, and electronically coded with ATLAS.ti. Constant comparison was used to identify themes and patterns. The framework method of data management, in which data were charted, was used to aid transparency of interpretation.

RESULTS

During the consultations, information given to patients about survival benefit included numerical data ("about four weeks"), an idea of timescales ("a few months extra"), vague references ("buy you some time"), or no mention at all. In most consultations (26/37) discussion of survival benefit was vague or non-existent.

CONCLUSIONS

Most patients were not given clear information about the survival gain of palliative chemotherapy. To aid decision making and informed consent, we recommend that oncologists sensitively describe the benefits and limitations of this treatment, including survival gain.

Development and implementation of a clinician reporting system for advanced stage cancer: initial lessons learned

OBJECTIVE

Innovative approaches can strengthen patient-caregiver-clinician information exchange and more effectively address the physical and psychosocial challenges of advanced disease. This study reports initial findings from implementation of the Clinician Report (CR)-a patient and caregiver status report tool accessible by the oncology clinic team.

DESIGN

The CR tracks and communicates essential information from cancer patients and caregivers to the oncology team. The CR conveys patient symptoms, emotional strain, and key concerns.

MEASUREMENTS

Authors used a model developed to explain acceptance, implementation, and sustainability of Interactive Health Communication Systems (IHCS) to evaluate implementation of the new CR system. The study carried out qualitative analyses of interviews with clinicians regarding their experience utilizing the Clinician Report.

RESULTS

Primary CR benefits included enhancement of patients' clinic visit experiences, greater caregiver involvement, and facilitation of earlier interventions. Challenges included CR functional issues, users' desire for greater depth of information, user privacy concerns, and limited patient use. These findings are discussed using parameters of the implementation model. Limitations of this study include its small clinician sample size, which represented only a portion of existing organizational settings in which CR systems might be implemented.

CONCLUSION

Though in its early implementation stages, the CR demonstrates the potential to positively impact care delivery in the cancer clinic setting, particularly by facilitating earlier interventions and improving patient-caregiver-clinician communication both during and between clinic visits.

Perspectives of patients with type 2 diabetes following a critical cardiac event - an interpretative approach

AIM

This study aimed to gain in-depth understanding of the actual hospital and home experience of patients with diabetes and a critical cardiac event to assist in developing a pertinent diabetes self-management programme.

BACKGROUND

Type 2 diabetes can lead to cardiac complications requiring critical nursing care. Patients with diabetes and a history of cardiac disease are at greater risk of a further cardiac event. Greater self-efficacy or confidence in regulating diabetes and reducing the risk of a further cardiac event can be achieved through self-management programmes. However, the start of such a programme within the critical care environment presents challenges to critical care staff. It is important to understand patients' experiences and needs to improve quality of care.

DESIGN

An interpretive approach comprising open-ended interviews was used to collect data from patients with type 2 diabetes experiencing a cardiac event who had a coronary care unit admission in 2002-2003.

FINDINGS

The findings revealed that patients with diabetes who had a critical cardiac event experienced considerable feelings of hopelessness and fatigue. Patients also had concerns in the areas of self-confidence and confidence in health professionals. Patients indicated that greater self-confidence and confidence in health professionals would help their ability to manage their daily lives.

CONCLUSION

This paper provides in-depth understanding of the perspectives of patients with type 2 diabetes who have also been hospitalized for a critical cardiac event. This study concluded that further research is needed to fully explore whether enhancing self-confidence for these patients will lead to improved diabetes management, reduced negative feelings and more positive health outcomes.

RELEVANCE TO CLINICAL PRACTICE

The themes identified in this study provide direction and strategies for nursing staff to improve patients' confidence levels and reduce their feelings of hopelessness and fatigue.

Care as a mutual endeavour: experiences of a multiple sclerosis patient and her healthcare professionals

In Dutch healthcare policy patients are seen as informed, autonomous experts and active decision makers with control over their illness and care. Healthcare professionals are expected to operate as providers of information. The purpose of this article is to argue that the consumerist approach of the patient-professional relationship is not a productive way to envision the patient-professional relationship. We argue that an interpretive/deliberative model is a more productive way to envision this relationship, especially in the care for people with a chronic illness. This is illustrated with a case study. It concerns a study of the experiences of a Multiple Sclerosis (MS) patient and healthcare professionals involved in her care. The presented stories show that the participants did not act in line with the roles and responsibilities embodied in the consumerism rhetoric in Dutch healthcare policy. Expectation of patients and healthcare professionals are better met when care is redefined as mutual endeavour in which the caring abilities of healthcare professionals and the vulnerability of chronically ill patients are taken into account.

Empowering patients with essential information and communication support in the context of diabetes

OBJECTIVES

Patients with diabetes need to be aware of essential information to be involved in decision-making, manage diabetes properly, and communicate with doctors and other healthcare providers effectively. We have developed Violet Technology (VT) to provide features beyond previous health information tailoring systems by dynamically prioritizing diabetes learning topics and providing integrated direct support for patient-provider communication through formulation of individualized agendas to take to healthcare encounters.

METHODS

A particular feature of the VT approach is a Diabetes Information Profile (DIP) that models psychosocial and educational exposure features, as well as clinical characteristics, and considers expressed patient information preferences and recent information browsing history. The agenda facility recommends questions that the patients may have based on their profile, as well as helping to initialize a patient empowerment protocol. The technology uses a modular and extensible approach for key components, including consumer health information, prioritization rules, and methods of instantiating the DIP. VT has been implemented into a web portal for patient use. Two phases of evaluation studies have been conducted to collect patient and healthcare provider feedback.

RESULTS AND CONCLUSIONS

Results indicate that VT prioritizes relevant and important information for individual patients. Moreover, both patients and providers indicate that formulating an agenda of questions is important for patients. More extensive system use is needed to establish if the technology can deliver an improved patient-provider partnership and, ultimately, improved health outcomes.

Information-giving sequences in general practice consultations

RATIONALE, AIMS AND OBJECTIVE

Most patients want to be involved in the decision-making process regarding their health and doctors need to improve their ability to meet these needs. Before implementing educational interventions, a better understanding of how information is provided in routine clinical practice is necessary. Aim of this study was to analyse the information-giving sequence of general practice consultations.

METHODS

This is an observational study that involved six general practitioners (GPs) in single-handed practices and patients (aged between 16 and 74) who consulted over a 2-month period for a new illness episode. Transcripts of 252 consultations were coded using the Verona Medical Interview Classification System that provides three categories for information giving (information on illness management; instructions on illness management and information and instructions on psychosocial aspects). Lag1 and lag2 sequential analyses were performed.

RESULTS

Information represented about one-third of the average consultation length. Medical and psychosocial information were preceded most often by patients' replies to previous questions (36% and 41%, respectively) and by listening and agreement (21% and 23%, respectively), less frequently by expression of opinions (10% and 6%, respectively). Listening and agreement were the most likely patient response after information (36%). GPs rarely tried to find out patients' view before and after the delivery of information or an instruction (<1%).

CONCLUSION

The low frequency of expressions of opinions and questions immediately before and after GPs' information and instructions, and the lack of facilitating questions indicate a limited degree of patient involvement in the information-giving sequence.

Why do providers contribute to disparities and what can be done about it?

This paper applies social cognition research to understanding and ameliorating the provider contribution to racial/ethnic disparities in health care. We discuss how fundamental cognitive mechanisms such as automatic, unconscious processes (e.g., stereotyping) can help explain provider bias. Even well-intentioned providers who are motivated to be nonprejudiced may stereotype racial/ethnic minority members, particularly under conditions of that diminish cognitive capacity. These conditions-time pressure, fatigue, and information overload-are frequently found in health care settings. We conclude with implications of the social-cognitive perspective for developing interventions to reduce provider bias.

‘It takes three to tango’:

Since the late 1990s, the term 'partnership' has increasingly been inserted into the literature and rhetoric of the UK health-care system. In this paper, the assumptions and implications surrounding the usage of the term in relation to doctor-patient interaction are examined in the context of paediatric services. The paper considers recent ideas about partnership in medical encounters, especially those of Charles et al., and the extent to which they are applicable to children. The paper then goes on to develop a framework for understanding patient-partnership issues. It is argued that any investigation of partnership will need to take account of the organisational and legal setting, as well as the beliefs and agendas that all parties bring to the medical encounter. In the context of paediatrics, the perspectives of three actors--the child, parent and health service professional--need to be explored. Our framework allows for different sorts of 'coalition' to develop between these actors as they try to reconcile their perspectives in the clinic and offers a situationally contextualised view of partnership. We also argue that these matters require study outside as well as inside the clinic, through the use of a range of methods, including those that help children at home review their involvement in decision making in the clinic.

Exploring doctor and patient views about risk communication and shared decision-making in the consultation

BACKGROUND

There have been significant conceptual developments regarding shared decision-making (SDM) and assessments of people's hypothetical preferences for involvement in treatment or care decisions. There are few data on the perceptions of patients and professionals about SDM in actual practice.

OBJECTIVE

To explore, from paired doctor-patient interviews, participants' perceptions of SDM in the consultation and the level of consensus between the participants in the consultation process.

DESIGN

Qualitative analysis of semi-structured interview data.

SETTING AND PARTICIPANTS

Twenty general practitioners received training packages in 'risk communication' (RC) and 'SDM' to use as tools within the consultation. Forty patients with one of four conditions, for which a range of treatment options is available, were selected. Patient/doctor pairs were interviewed separately following consultations at four stages -'baseline' [general practitioner's (GP) usual consultation style], SDM training, RC alone, and both RC and SDM training. Interviews were transcribed and analysed using NVivo software.

RESULTS

Risk communication interventions by doctors appeared to result in a greater perception of decisions being made in the consultation. High levels of satisfaction with consultations were evident before application of the interventions and did not change after the interventions. Doctors' and patients' perceptions of the consultations were highly congruent at all phases of the study.

CONCLUSION

Shared decision-making and RC approaches were helpful in selected consultations and showed no detrimental effects to patients. However, the use of RC and SDM made only small differences to decision-making in consultations within the population studied. Increasing patient participation may be seen as more ethically justifiable than the traditional paternalistic approach but this needs to be set against the additional training costs incurred.

General practitioners' views on shared decision making: a qualitative analysis

Despite rhetoric about increasing partnership in the consultation, shared decision making (SDM) is not necessarily happening in practice. As patient involvement in decision making cannot be achieved without general practitioners' (GPs) co-operation, attention to their concerns is essential. Previous research has used simulated patients to explore this area. Here, data from consultations and interviews with patients and GPs were used in focus group discussions enabling GPs to ground their views of the practical application of SDM in their own and other participants' real life practice. The following ideas were discussed; what constitutes SDM in practice, negotiation about treatment, perceptions of patients' viewpoints and perceived barriers to SDM. Agreement with SDM in theory may not translate into practice. The process outlined is being developed in order to establish whether the techniques could provide a supportive environment in which GPs can make changes to their practice to increase patient participation.

Recognising the psychosocial issues involved in hand hygiene

Non-adherence to hand hygiene among those involved in the provision of health care is the principal route by which infection is spread. However, despite an extensive research base, regular education and the application of prescriptive rules there has been a consistent failure to achieve long-term adherence in appropriate hand hygiene practice. Where improved adherence has been achieved there has been little evidence to show that it was for anything other than a limited period with individuals ultimately reverting back to their original practice. This paper therefore proposes that the principal cause of non-adherence to safe hand hygiene practice among those involved in the provision of health care is psychosocial in its nature. Further, until strategies are developed that will reflect this, the well-being of individuals seeking health care intervention will continue to be compromised.

[Perspective of patients on type-2 diabetes and their relationship with primary care health professionals: a qualitative study]

AIM

The objective of this study is to investigate the perception that people with type 2 diabetes have about the disease and about their relationship with the primary healthcare professionals.

DESIGN

Qualitative research, carried out between September-November 2000.

SETTING

Primary healthcare center Barrio del Pilar from Madrid.

PARTICIPANTS

15 persons with type 2 diabetes. Variables considered to design the profiles of the interviewed were: age, gender, educational level, and time since diagnosis.

METHOD

Structural sampling and open interviews.

RESULTS

Patients express having scarce information regarding the consequences of diabetes. As diabetes is symptom free represents a difficulty for being perceived as a severe disease. The most valued aspects of the relationship with health professionals are that they provide with clear and tailored information, build a trust context, support changes and take account their perspectives and living circumstances.

CONCLUSIONS

It is essential to recognize how patients understand and shape the disease. Information provided by professionals have to be tailored to patients necessities, and take place in a trusting environment. Decisions related with diabetes management have to be aligned with patients perspectives. Effective communication could be considered as a useful tool to encourage adherence and improve healthcare quality.

Defining patient-based minimal clinically important effect sizes: a study in palliative radiotherapy for painful unresectable pelvic recurrences from rectal cancer

PURPOSE

To measure patient-based minimal clinically important effect sizes (minimal incremental benefit that an individual would require to accept one treatment option over another) for pain relief between two contrasting palliative radiotherapy regimens for painful pelvic recurrences from rectal cancer.

METHODS AND MATERIALS

Forty-three patients with a history of cancer pain without prior pelvic radiotherapy participated in decision aid-facilitated trade-off exercises. The clinical scenario and treatment options of a 5-day vs. a 20-day course of radiotherapy were described. The duration of pain relief for the 20-day regimen was increased until the respondents' preferences switched to the 20-day regimen. The exercises were repeated for different probabilities of benefit and pain intensity at the time of decision making.

RESULTS

When the probability of pain relief was unchanged, the median switch point for the duration of pain relief was 6.7 and 7.2 months for severe and mild pain, respectively. The cumulative percentage frequency curve for the switch points approximated a sigmoid distribution.

CONCLUSION

Determining the minimal clinically important effect sizes for symptom relief for palliative therapies is feasible. This type of information can be used to incorporate patient values into clinical trial designs. Modification of this method can be used to improve our understanding of shared (physician and patient) decision making.

Making and sharing decisions about management with patients: the views and experiences of pre-registration house officers in general practice and hospital

OBJECTIVES

To explore the views and experiences of pre-registration house officers (PRHOs) in general practice and hospital settings regarding the concept of patient partnership and their experience of involving patients in management decisions.

DESIGN

The 12 PRHOs who had graduated from British universities and who were working within the Yorkshire Deanery were interviewed towards the end of their four-month general practice attachments. The interviews were semi-structured and analysed qualitatively.

RESULTS

Three major themes emerged. The PRHOs perceived differences in approach between consultations carried out in hospital and primary care settings, with general practitioners being more likely to share information and decisions with patients. As medical students, the PRHOs had little opportunity to practise sharing information and management decisions with patients, and variable experience of this after graduation. On the whole they were favourable to the concept of patient partnership.

CONCLUSIONS

Medical students and PRHOs lack training and opportunities to decide on management and discuss this with patients and yet, particularly in general practice settings, they have to practise these skills. The PRHOs had begun to develop strategies to decide how much information to give to patients and to what extent to involve patients in management decisions. This is an area that needs further consideration when planning both undergraduate and postgraduate medical education.

Adverse drug reactions as a cause for admissions to a department of internal medicine

PURPOSE

To assess the occurrence and pattern of adverse drug reactions as a cause for acute hospital admission.

METHODS

In 681 randomly selected patients, acutely admitted to a clinic of internal medicine at a Swedish university hospital, information was collected from their medical records about current symptoms and use of drugs, previous diseases and the results of medical investigations and tests. In addition, a standardized interview according to a questionnaire was carried out. A group of experts in clinical pharmacology assessed the data obtained from the patients' case records and the results of the interviews, and then, according to WHO criteria, judged the probability that an adverse drug reaction could have caused or contributed to the actual admission to hospital.

RESULTS

Out of the 681 cases included, 94 (13.8%) had symptoms and signs that were judged as drug-related and that had caused or contributed to the admission. Eighty-two patients (12.0%) had altogether 99 symptoms that were classified as adverse drug reactions. Of these, 91% were type A reactions. The relationship between the medication and the reaction was judged certain in eight, probable in 17, and possible in 74 cases. The most common adverse drug reactions were cardiovascular (36.3%). Twelve patients (1.8%) had symptoms indicating intoxications.

CONCLUSIONS

The prevalence of drug-related problems causing or contributing to admission to a clinic of internal medicine is high and is dominated by type A reactions, i.e. reactions in principle predictable and preventable. This implies a possibility to increase drug safety by preventive measures.