Bridging the chasm between patients' needs and current rehabilitation care: perceptions of adults presenting for primary care in the Eastern Cape

BACKGROUND

The need for rehabilitation in low-to-middle income countries (LMICs) is rapidly increasing as more people are living longer with chronic diseases. Primary health care (PHC) is ideally placed to provide the spectrum of care required to meet most of the complex and evolving population's health needs locally. This study aimed to describe the patient journeys of adults attending primary care in the Eastern Cape province of South Africa to understand the factors that affected their access to primary care rehabilitation services (or the lack thereof) and obtain suggestions on how rehabilitation may be enhanced at primary care.

METHODS

A maximum variation sampling approach was used to purposefully select persons with varied chronic health conditions and demographic characteristics to gain diverse perspectives regarding their rehabilitation needs and ways in which the current rehabilitation services at primary care may be enhanced. Data were collected via face-to-face semi-structured interviews between March and June 2022 which were electronically recorded. Inductive thematic analysis of transcribed data was done and coded in Atlas.ti.22®.

RESULTS

Twenty-five adult patients participated in the study. The patients had different experiences at their local PHC facilities that affected their access to rehabilitation at primary care. The study found that most patients were not able to access rehabilitation at primary care. There were several personal and contextual factors that resulted in the patients having a low perceived need to receive rehabilitation that potentially lowered patients' demand for and utilization of rehabilitation at primary care. Patients suggested increasing rehabilitation workforce at primary care, improving availability of assistive devices, increasing their knowledge regarding rehabilitation, and facilitating socio-economic integration into their communities.

CONCLUSIONS

Patients attending primary care are not guaranteed access to rehabilitation by virtue of having entered the PHC system. It is important to consider the patient perspectives regarding their health needs and suggestions for enhancing care.

Nurses' and patient' descriptions about forms of power in pro re nata medication participation in forensic psychiatric care: A qualitative secondary analysis

Despite there being an emphasis on patient participation in their own care, it has been a challenge in pro re nata (PRN, as the circumstance arises) medication in forensic psychiatric care. The power imbalance in treatment relationships can be a barrier to patient participation and should therefore be further explored. This qualitative descriptive study aimed to explore the aspect of power in the descriptions of patients and nurses interviewed in a Finnish forensic psychiatric hospital about patient participation in PRN. A qualitative secondary analysis was conducted through the semi-structured interviews of the patients (n = 34) and nurses (n = 19). The data were analysed with deductive content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to ensure comprehensive reporting. The findings revealed that patients and health professionals may have conflicting goals in PRN and that they both use power to try to achieve them. Power in PRN was described in different forms, including authority, force, manipulation and persuasion. Based on our results, the power that health professionals have in PRN medication is particularly based on their legitimate authority and the hierarchical structures of the hospital environment. Patients also hold power in the dynamics of PRN medication care, but their position as a power holder can vary individually and situationally. Recognizing different forms of power and supporting patients with a decreased capacity for decision-making is essential for promoting high-quality and patient-centred forensic psychiatric nursing.

Two variants of 'constrained participation' in the care of vulnerable adults: A proof-of-concept study

There has been a radical turn towards ideals of patient autonomy and person-centred care, and away from historically entrenched forms of medical paternalism, in the last 50 years of nursing practice. However, along the way, some shades of grey between the areas of ideal patient participation and of outright patient non-participation have been missed. The current article constitutes an exploratory proof-of-concept study of the real-world traction of a distinction-straddling concept of 'constrained participation' and its two sub-concepts of 'fought-for participation' and 'forced-to participation'. In order to concretise these additions to the conceptual terrain of person-centred participation and its anti-theses, we apply them to themes in the care of vulnerable older adults. In the final section, we close by eliciting some characterological, educational and clinical implications of adding these new tools also to the conceptual repertoire of nursing practice and education.

Rehabilitees' conceptions of participation after a six-month rehabilitation period: a phenomeno-graphic study

PURPOSE

A prerequisite for successful rehabilitation is that the rehabilitees are in central role of the rehabilitation process. However, the rehabilitees and rehabilitation professionals may both lack knowledge and understanding of how to implement rehabilitee-centered participation in practice. This study aimed to explore the qualitatively different ways of understanding rehabilitee participation as conceptualized by the rehabilitees.

METHODS

We generated data from individual interviews with 20 rehabilitees after a six-month rehabilitation process. These interviews were analyzed based on phenomenographic methodology.

RESULTS

We identified three understandings of rehabilitee participation as conceptualized by the participants: 1) Dependent participation; 2) Progressive participation; and 3) Committed participation. These categories varied according to four themes: 1) Rehabilitation process; 2) Rehabilitation in everyday life; 3) Interaction in rehabilitation; and 4) Rehabilitation support network. We also identified critical aspects highlighting differences between the qualitatively distinct categories.

CONCLUSION

This study generated new insights into understanding the phenomenon of rehabilitee participation, as conceptualized by rehabilitees themselves. The findings in terms of three descriptive categories and critical aspects between the categories, reflect the ascending and shifting complexity from dependent to progressive and committed participation. These findings as such can be utilized in the design, development, and implementation of rehabilitee participation and rehabilitee-centered practice.

Protecting Personhood: A Classic Grounded Theory

The importance of perceiving and considering patients as healthcare partners has been increasingly promoted. Healthcare systems around the world are now highly interested in patient engagement, participation, collaboration, and partnership. Healthcare professionals are advised that patients, as autonomous beings, should be active in and responsible for a portion of their own care. The study presented here focused on patients' perceptions of interprofessional collaboration. It was conducted using the classic grounded theory methodology. The theory of protecting personhood emerged as the core concept of hospitalized patients, cared for by interprofessional healthcare teams. This theory encapsulates the process hospitalized patients go through to find balance in their sense of self, oscillating between personhood and patienthood in the unfamiliar hospital environment. The process consists of four stages: the stage of introspection, during which hospitalized patients become aware of their self as a person and as a patient; the stage of preservation, when patients find a balance between the sense of personhood and patienthood; the stage of rupture, wherein patients experience an imbalance between their sense of personhood and patienthood; and the stage of reconciliation, in which personhood is restored. The theory of protecting personhood offers insights into a better understanding of hospitalized patients' experiences and strategies, revealing the importance of relationships, and the driving force of empowerment. This study is about patients' perspectives of interprofessional healthcare teams. A grounded theory process allowed the emergence of patients' concerns and expectations, leading to a substantive theory grounded in the patients' data.

Patient participation in end-stage kidney disease care: variation over time and effects of staff-directed interventions - a quasi-experimental study

BACKGROUND

Among those elements establishing decent quality of care from a patient perspective, opportunities to participate in accord with one's individual needs and preferences are central. To date, little is known the extent of preference-based patient participation in kidney care, and what facilitates optimal conditions. This study investigated i) preference-based patient participation in kidney care over time, and ii) the effects of interventions designed to enhance person-centred patient participation.

METHODS

A quasi-experimental study was conducted across nine kidney care sites in southeast Sweden. A cohort of 358 patients with stage IV chronic kidney disease (eGRF 15-19 ml/min) or V (eGRF < 15 mL/min) entered the study. Of these, 245 patients (with kidney replacement therapy or intermittent outpatient visits only) completed a survey on patient participation at four time points: every six months from August 2019 to May 2021, patients reported their preferences for and experiences of participation using the validated Patient Preferences for Patient Participation tool, the 4Ps. Between the first and second data collection points, interventions were provided for designated staff to facilitate person-centred participation, using two strategies for two subgroups at three sites each: the managers receiving a bundle of information via e-mail on patient participation in a standard dissemination procedure (three sites), or an additional half-year support program for implementation offered to 1-2 staff per site (three sites), with no intervention for a control group (three sites). The differences in 4Ps data between groups were analysed using multilevel ordinal regression.

RESULTS

Over time and across all sites, most patients' experiences of participation fully or almost fully matched their engagement preferences (57%-90%). Still, up to 12% of patient reports indicated that their preferences and experiences were insufficiently matched: in these cases, the patients had preferred to be more involved than they had experienced, for example, in making healthcare plans and setting health-related goals. The interventions did not affect the levels of preference-based participation, but patients in the control group sites had slightly more consistent matches.

CONCLUSIONS

Living with kidney failure necessitates patient engagement, but opportunities to participate in accordance with one's preferences are not fully provided for all patients. Additional efforts to support a common understanding and to ensure person-centred patient participation is still needed.

A tension between surrendering and being involved: An interview study on person-centeredness in clinical reasoning in the acute stroke setting

OBJECTIVE

To explore how stroke survivors experience and prefer to participate in clinical reasoning processes in the acute phase of stroke care.

METHODS

An explorative qualitative design was used. Individual interviews were conducted with 11 stroke survivors in the acute phase of care and analyzed using reflexive thematic analysis.

RESULTS

The analysis identified five themes: What's going on with me?; Being a recipient of care and treatment; The need to be supported to participate; To be seen and strengthened; and Collaboration and joint understanding.

CONCLUSION

Stroke survivors experience many attributes of person-centeredness in the acute phase of care but, according to their stories, their participation in clinical reasoning can be further supported. The tension between surrendering and the desire to be more actively involved in the care needs to be considered to facilitate participation in clinical reasoning.

PRACTICE IMPLICATIONS

Stroke survivors' participation in clinical reasoning in the acute phase can be facilitated by health professionals noticing signs prompting a shift towards increased willingness to participate. Furthermore, health professionals need to take an active role, sharing their expertise and inviting the stroke survivors to share their perspective. The findings can contribute to further develop person-centered care in acute settings.

Patient Participation in Forensic Psychiatric Care: The Initial Development and Content Validity of a New Instrument

ABSTRACT

Patient participation is central in modern health care. However, it is a complex phenomenon that lacks a clear definition, and what constitutes participation varies depending on the context and theoretical perspective. It is known that patient participation in forensic psychiatric care is often rated as low by both patients and professionals, and it can be assumed that interventions to increase it are beneficial. In this process, management and staff could benefit from assessing perceived patient participation, and reliable and valid measurement instruments are essential. The aim of this study was to develop an instrument that could be used to measure experiences of participation in forensic psychiatric care from a patient perspective and test it for content validity. A definition of patient participation in forensic psychiatric care was formulated and operationalized in an instrument that an expert group, consisting of patients with ongoing care, evaluated for content validity. In total, 50 items were sorted into five different dimensions: to have good communication, to be involved, to have mutual trust, to trust the care, and to take responsibility. After psychometric testing, the instrument has the potential to become a tool to use in research, clinical work, and development work in the field of forensic psychiatric care. In addition to being used as a measure, the Patient Participation in Forensic Psychiatric Care can also be used to encourage a dialogue about their care and to make both patients and staff more aware of patient participation.

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

Patient engagement, involvement, or participation - entrapping concepts in nurse-patient interactions: A critical discussion

The importance of patients taking an active role in their healthcare is recognized internationally, to improve safety and effectiveness in practice. There is still, however, some ambiguity about the conceptualization of that patient role; it is referred to interchangeably in the literature as engagement, involvement, and participation. The aim of this discussion paper is to examine and conceptualize the concepts of patient engagement, involvement, and participation within healthcare, particularly nursing. The concepts were found to have semantic differences and similarities, although, from a nursing perspective, they can be summoned to illustrate the establishment of a mutual partnership between a patient and a nurse. The individualization of such processes requires the joint effort of engagement, involvement, or participation, represented by interactive actions of both the patient (asking questions, telling/speaking up, knowledge acquisition, learning, and decision-making) and the nurse (recognizing, responding, information sharing, teaching, and collaborating). Suggesting that the concepts can be used interchangeably comes with some caution, requiring that nurses embrace patients playing a role in their health and healthcare. Further research and practice development should focus on how patients and nurses receive and respond to each other to establish patient engagement, involvement, and participation.

Development and psychometric testing of the patient participation in bedside handover survey

Introduction

When handover is conducted at the patient's bedside, active patient participation can be encouraged, which may improve the safety and quality of care. There is a need for valid and reliable tools to measure patient perceptions of participation in bedside handover, to ensure the rising number of implementation and improvement efforts are consistently and effectively evaluated. The aim of this study is to systematically develop and evaluate the psychometric properties of a self‐report survey to measure patients' perceptions of participation in bedside handover.

Methods

In Phase 1, our team developed a conceptual framework and item pool (n = 130). In Phase 2, content validity was assessed with four health consumers, four nurses and four researchers. Next, 10 current hospital inpatients tested the survey for end‐user satisfaction. In Phase 3, 326 inpatients completed the survey, allowing exploratory factor analysis, reliability analyses and convergent/divergent validity analyses to occur.

Results

Phase 1 and 2 resulted in a 42‐item survey. In Phase 3, 321 surveys were available for analysis. Exploratory factor analysis revealed a three‐factor solution, with 24 items, which matched our conceptual framework. The three factors were: ‘Conditions for patient participation in bedside handover’, ‘Level of patient participation in bedside handover’ and ‘Evaluation of patient participation in bedside handover’. There was strong evidence for factor reliability and validity. Additionally, the correlation between factors was strong.

Conclusion

This study furthers our conceptual understanding by showing that nurse facilitating behaviours are a strong precursor for patient participation and perceived handover outcomes, justifying the need for nursing training. A robust survey has been developed to measure patient perceptions of participation in bedside handover, which can effectively evaluate this approach to care. Engaging consumers and nurses as research team members was invaluable in ensuring that the survey is acceptable for end‐users.

Patient or Public Contribution

A health consumer and nurse partnered as members of the research team from study inception to dissemination.

Feasibility of PURPOSE T in clinical practice and patient participation-A mixed-method study

This study aimed to evaluate the feasibility of implementing an electronic version of PURPOSE T, a risk assessment instrument for pressure ulcers, in a Swedish hospital ward. A mixed-method was used. Nursing staff received training in PURPOSE T and a record review was performed (n = 30). PURPOSE T replaced the Modified Norton Scale, and after one month another record review was performed (n = 30). Individual interviews with patients (n = 15) and focus group interviews with nursing staff (n = 23) were performed after the implementation. The results of the record review and the focus group interviews showed good clinical feasibility of PURPOSE T. The record review showed that more patients were at risk of developing pressure ulcers and more nursing interventions were prescribed with PURPOSE T compared to the Modified Norton Scale. The focus group interviews showed that all nursing staff were satisfied with PURPOSE T. The instrument contributed to increased reflection and analysis as well as the opportunity for nursing staff to draw their own conclusions regarding patients´ risk status. The documentation encouraged the prescription of more preventive actions, and the nurses were more involved at bedside. However, almost all the patients expressed not receiving any information about pressure ulcers.

Patient coaching: What do patients want? A mixed methods study in waiting rooms of outpatient clinics

Introduction

Effective communication in specialist consultations is difficult for some patients. These patients could benefit from support from a coach who accompanies them to and during medical specialist consultations to improve communication in the consultation room. This study aims to investigate patients’ perspective on interest in support from a patient coach, what kind of support they would like to receive and what characterizes an ideal patient coach.

Methods

We applied a mixed method design to obtain a realistic understanding of patients’ perspectives on a patient coach. Patients in the waiting rooms of outpatient clinics were asked to fill out a short questionnaire which included questions about demographic characteristics, perceived efficacy in patient-provider interaction and patients’ interest in support from a patient coach. Subsequently, patients interested in a patient coach were asked to participate in a semi-structured interview. The quantitative data were examined using univariate analysis and the qualitative interview data were analysed using content analysis.

Results

The survey was completed by 154 patients and eight of them were interviewed. Perceived efficacy in patient-physician interactions was the only variable that showed a significant difference between patients with and without an interest in support from a patient coach. The interviews revealed that a bad communication experience was the main reason for having an interest in support from a patient coach. Before the consultation, a patient coach should take the time to get to know the patient, build trust, and help the patient create an agenda, so take the patient seriously and recognize the patient as a whole person. During the consultation, a patient coach should support the patient by intervening and mediating when necessary to elicit the patient’s agenda. After the consultation, a patient coach should be able to explain and discuss medical information and treatment consequences. An ideal patient coach should have medical knowledge, a strong personality and good communication skills.

Conclusion

Especially patients who had a bad communication experience in a specialist consultation would like support from a patient coach. The kind of support they valued most was intervening and mediating during the consultation. To build the necessary trust, patient coaches should take time to get to know the patient and take the patient seriously. Medical knowledge, good communication skills and a strong personality were considered prerequisites for patient coaches to be capable to intervene in specialist consultations.

Every Story Is Different: Experiences With Body Changes Related to Cancer

One of the important aspects of stakeholder engagement in cancer care and system planning is hearing from individuals who have been diagnosed with cancer about the impact of the diagnosis and treatment on their lives. Hearing stories from the perspectives of cancer survivors offers opportunity to gain new insight and understanding about experiences of being diagnosed and treated for cancer. This article presents ten short narratives about survivors' perspectives on body image and cancer. Each story is unique but, taken together, the picture they create is one of facing challenges, discovering personal resilience, and moving forward to engage in living. The stories emphasize the importance of communication and support from healthcare providers and understanding needs for a person-centered cancer care system.

The Effectiveness of a Mobile Health Care App and Human Coaching Program in Primary Care Clinics: Pilot Multicenter Real-World Study

Background

As the global burden of chronic conditions increases, their effective management is a concern. Although the need for chronic disease management using mobile self-management health care apps is increasing, there are still many barriers to their practical application in the primary care field.

Objective

This study evaluated the effectiveness of primary care services combining a mobile self-management health care app with human coaching for patients with chronic diseases in the current primary care system.

Methods

A total of 110 patients (mean age 53.2, SD 9.2 years; 64 of 110, 58.2% female) with hypertension, diabetes, dyslipidemia, or metabolic syndrome who visited one of 17 participating primary care clinics from September to November 2020 were included in this study. All participants recorded data regarding changes in body weight, sleep conditions, quality of life, depression, anxiety, stress, BMI, waist circumference, blood sugar levels, blood pressure, and blood lipids levels. The app user group (n=65) used a mobile self-management health care app with human coaching for 12 weeks, and the control group (n=45) underwent conventional self-managed health care.

Results

Patients in the app user group reported significantly more weight loss than those in the control group—the body weight of the app user group decreased by 1.43 kg (95% CI –2.07 to –0.79) and that of the control group decreased by 0.13 kg (95% CI –0.67 to 0.41; P=.002). The weight loss was markedly greater after using the app for 9 weeks than that when used for 4 weeks or 5-8 weeks (P=.002). Patients in the app user group reported better sleep quality (P=.04) and duration (P=.004) than those in the control group.

Conclusions

The combination of primary care clinics and a mobile self-management health care app with human coaching results in better management of chronic conditions. This study shows that the primary care services combining a mobile self-management health care app with human coaching are effective in the current primary care system. An implication of this study is the possibility that a mobile self-management health care app with human coaching is a treatment option in the current primary care system.

The interactive work of narrative elicitation in person-centred care: Analysis of phone conversations between health care professionals and patients with common mental disorders

INTRODUCTION

Narratives play a central part in person-centred care (PCC) as a communicative means of attending to patients' experiences. The present study sets out to explore what activities are performed and what challenges participants face in the interactive process of narrative elicitation, carried through in patient-professional communication in a remote intervention based on PCC.

METHODS

Data were gathered from a randomized controlled trial (RCT) in a Swedish city where health care professionals (HCPs) conducted remote PCC for patients on sick leave due to common mental disorders. A sample of eleven audio-recorded phone conversations between HCPs and patients enroled in the RCT were collected and subjected to conversation analysis.

RESULTS

Three interactive patterns in narrative elicitation were identified: Completed narrative sequences driven by the patient, question-driven narrative sequences guided by the HCP, and narrative sequences driven as a collaborative project between the patient and the HCP. In the question-driven narrative sequences, communication was problematic for both participants and they did not accomplish a narrative. In the other two patterns, narratives were accomplished but through various collaborative processes.

CONCLUSION

This study provides insight into what challenges narrative elicitation may bring in the context of a remote PCC intervention and what interactive work patients and HCP need to engage in. Importantly, it also highlights tensions in the ethics of PCC and its operationalization, if the pursuit of a narrative is not properly balanced against the respect for patients' integrity and personal preferences. Our findings also show that narrative elicitation may represent an interactive process in PCC in which illness narratives are jointly produced, negotiated and transformed.

PATIENT OR PUBLIC CONTRIBUTION

Stakeholders, including patient representatives, were involved in the design of the main study (the RCT). They have been involved in discussions on research questions and dissemination throughout the study period. They have not been involved in conducting the present study.

Patient-Reported Experience in the Pediatric Emergency Department: What Matters Most?

INTRODUCTION

Although the Child Hospital Consumer Assessment of Healthcare Providers and Systems is a validated tool for the inpatient experience, it may not address features unique to the pediatric emergency department (PED). There is currently no publicly available validated patient-reported experience survey for the PED, and what matters most in this setting remains unknown.

METHODS

Twelve semistructured interviews were conducted with a convenience sample of parents of children younger than 14 years at a Canadian PED. Data analysis was performed using inductive thematic analysis to identify aspects of patient-reported experiences that matter most to parents in the PED.

RESULTS

Five themes were identified: (1) making waiting a positive experience, (2) taking the time to provide care, (3) forging a positive partnership, (4) speak up for safe care, and (5) making the environment feel safer. Parents highlighted that while waiting for care is not desirable, it is made more acceptable through the communication of wait time estimates and the presence of child activities in the waiting room. Furthermore, although interactions with providers are brief, parents emphasized the importance of creating an environment of partnership with open communication, taking the time to examine their child, and actively demonstrating the provision of safe, quality care.

CONCLUSIONS

Results from this study suggest that a patient-reported experience survey in the PED may need to embed elements not currently captured in Child Hospital Consumer Assessment of Healthcare Providers and Systems, such as waiting room experience, comprehensiveness of health assessments, and observations of safety measures. Future studies can use these findings to develop a patient-reported experience survey for use in the PED.

Older People With Type 2 Diabetes-Individualising Management With a Specialised Community Team (OPTIMISE): Perspectives of Participants on Care

Despite the high prevalence of diabetes in older people, there is limited information on optimal methods to support their diabetes management, including how to incorporate technology. This article reports on the results of semi-structured interviews with 41 adult participants with type 2 diabetes (mean age 74 ± 7 years) on their perspectives of a new model of care (the Older People With Type 2 Diabetes-Individualising Management With a Specialised Community Team [OPTIMISE] program) for older people with type 2 diabetes. The OPTIMISE program involved telemedicine consultations, home visits by a credentialed diabetes educator, and intermittent flash glucose monitoring. Human connection and relationships were key to the positive perspectives expressed by participants in this program that used technology to enhance the care of older people in their homes.

Stroke survivors' perceptions of participating in a high repetition arm training trial early after stroke

PURPOSE

The study explored the acceptability of high repetition arm training as part of a randomised controlled trial, early after stroke, when fatigue levels and emotional strain are often high.

MATERIALS AND METHODS

36 sub-acute stroke survivors (61 years+/-15) attended for assessment sessions at 3, 6, and 12 weeks after stroke. Individuals were randomised to receive 6 high repetition arm training sessions between 3 and 6 weeks (intervention) or the control group. Semi-structured interviews were conducted at trial completion. Interview transcripts were analysed through framework analysis conducted independently by 2 researchers.

RESULTS

Stroke survivors participated despite high levels of fatigue because they hoped for personal benefit or to potentially benefit future patients. Benefits reported from participation included physical improvements, psychological benefit, improved understanding of their condition as well as a feeling of hope and distraction. The arm training at three weeks after stroke, aiming for 420 movement repetitions was not considered to be too intensive or too early, and most individuals felt lucky to have been, or would have preferred to be in the early training group.

CONCLUSION

High repetition arm training early after stroke was acceptable to participants. Study participation was generally viewed as a positive experience, suggesting that early intervention may not only be physically beneficial but also psychologically.Implications for rehabilitationStroke survivors report that high repetition arm training early after stroke is acceptable.Participation in rehabilitation research early after stroke provides stroke survivors with hope and meaning despite the high prevalence of fatigue.Complex information needs to be repeated and provided in a number of formats early after stroke.

Acceptability and perceived utility of different diagnostic tests and sample types for trachoma surveillance in the Bijagos Islands, Guinea Bissau

BACKGROUND

Trachoma is the leading infectious cause of blindness worldwide and is nearing elimination as a public health problem in Guinea Bissau. It is imperative that elimination is followed by a successful postvalidation surveillance programme. The aim of this study was to determine the acceptability and perceived utility of different diagnostic tests and sample types that could be used for postvalidation trachoma surveillance in the Bijagos Islands, Guinea Bissau.

METHODS

Semistructured interviews with community members and stakeholders involved in trachoma elimination were followed by focus group discussions with community members, covering experiences with trachoma and views on trachoma diagnostic methods and sample types.

RESULTS

In this setting, all diagnostic tests and sample types used for trachoma surveillance were generally considered acceptable by communities. A preference for laboratory-based testing and finger-prick blood samples was expressed as these results were considered more accurate and applicable to a range of diseases beyond trachoma.

CONCLUSIONS

Appropriate community and stakeholder engagement and communication regarding the purpose and processes around diagnostic practice prior to trachoma programme implementation are crucial for long-term successful disease-elimination efforts.

Patient participation during primary health-care encounters among adult patients with multimorbidity: A cross-sectional study

Background

Patient participation is essential for achieving high‐quality care and positive outcomes, especially among patients with multimorbidity, which is a major challenge for health care due to high prevalence, care complexity and impact on patients' lives.

Objective

To explore the patient participation related to their own care among patients with multimorbidity in primary health‐care settings.

Methods

A cross‐sectional survey was conducted among adult multimorbid patients who visited primary health‐care facilities. The key instrument used was the Participation in Rehabilitation Questionnaire. Data representing 125 patients were analysed using various statistical methods.

Results

The respondents generally felt patient participation to be important, yet provided highly varying accounts regarding the extent to which it was realized by professionals. Information and knowledge and Respect and encouragement were considered the most important and best implemented subcategories of participation. Several patient‐related factors had a statistically significant effect on patient perceptions of participation for all subcategories and as explanatory factors for perceptions of total participation in univariate models. Most patients reported active participation in health‐care communication, positively associated with patient activation and adherence. Gender, perceived health, patient activation and active participation were explanatory factors for total importance of participation in multivariate models, while patient activation was retained for realization of participation.

Conclusions

Multimorbid patients require individualized care that promotes participation and active communication; this approach may further improve patient activation and adherence. Poor perceived health and functional ability seemed to be related to worse perceptions of participation.

Patient and public involvement

The study topic importance was based on the patients' experiences in author's previous research and the need to develop patient‐centred care.

Interactional practices in person-centred care: Conversation analysis of nurse-patient disagreement during self-management support

Background

Person‐centred care implies a change in interaction between care professionals and patients where patients are not passive recipients but co‐producers of care. The interactional practices of person‐centred care remain largely unexplored.

Objective

This study focuses on the analysis of disagreements, which are described as an important part in the co‐production of knowledge in interaction.

Design

A qualitative exploratory study using conversation analysis.

Setting and participants

Data were collected from a nurse‐led person‐centred intervention in a hospital outpatient setting. Interactions between adult patients with irritable bowel syndrome (n = 17) and a registered nurse were audio‐recorded. COREQ guidelines were applied.

Results

Disagreements were found after demonstration of the nurse's or patients’ respective professional or personal knowledge. Disagreements were also evident when deciding on strategies for self‐management. Although negotiations between opposing views of the nurse and patient were seen as important, the patient generally claimed final authority both in knowing how IBS is perceived and in the right to choose self‐management strategies. The nurse generally oriented towards patient authority, but instances of demonstration of nurse authority despite patient resistance were also found.

Discussion and conclusions

This study provides information on how co‐production of knowledge and decisions occur in the context of a person‐centred care intervention. Negotiations between nurse and patient views require a flexible approach to communication, adapting interaction to each context while bearing in mind the patients having the final authority. To facilitate co‐production, the patient's role and responsibilities in interaction should be explicitly stated.

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

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

Nephrologists' experiences with patient participation when long-term dialysis is required

Background

For individuals in need of dialysis, patient participation is important when determining care goals and in decision making regarding dialysis modality. Nephrologists hold a key role in delivering evidence-based healthcare that integrates patient preferences and values throughout the trajectory, and their experiences with patient participation are important for improving health care. The aim of this study was to explore nephrologists’ experiences with patient participation in different phases of the end-stage renal disease trajectory for working-age individuals who require dialysis.

Methods

This explorative study comprised interviews with ten nephrologists from four different dialysis units in Central Norway. We analysed the interviews by applying an interpretive phenomenological approach.

Results

Nephrologists had varied experiences with patient participation throughout the different phases of the treatment trajectory. During decision making on the dialysis modality, nephrologists emphasised patients’ choices in two approaches. In the first approach, they expected patients to choose the modality based on the provided information, which could be actively steered. In the second approach, they recognised the patients’ values and lifestyle preferences through shared decision-making. Within hospital haemodialysis, nephrologists considered patients’ self-care activities equivalent to patient participation, seeing self-care as a source of patient empowerment. They identified divergent patient–professional values and organisational structures as barriers to patient participation.

Conclusion

Our study shows that nephrologists have different approaches to patient participation in different phases of the end-stage renal disease trajectory. Individual understanding as well as organisational structures are important factors to address to increase patient participation in end-stage renal disease care. Shared decision making, in which patient values are balanced against biomedical treatment targets, allows for mutual agreement between patients and healthcare professionals concerning medical plans and minimises the potential for patient–professional tensions.

Epistemic injustices in clinical communication: the example of narrative elicitation in person-centred care

The increasing popularity of the term 'person-centred' in the healthcare literature and a wide range of ideals and practices it implies point to the need for a more inclusive and holistic healthcare provision. A framework developed in a Swedish context suggested narrative elicitation as a key practice in transition to person-centred care. Initiating clinical communication by inviting people to tell their stories makes persistent yet often subtle problems in clinical communication visible. By drawing upon an observational study on narrative elicitation and vignette-based focus group interviews with nurses, our aim is to trace 'credibility deficits' (Fricker 2007. Epistemic Injustice. Power and the Ethics of Knowing. Oxford: Oxford University Press) and 'credibility excesses' (Medina 2011, Social Epistemology, 25, 1, 15-35, 2013, The Epistemology of Resistance: Gender and Racial Oppression, Epistemic Injustice, and the Social Imagination. Oxford: Oxford University Press) in narrative elicitation. We argue that narrative elicitation may be one way to tackle epistemic injustices by giving voice to previously silenced groups, yet it is not enough to erase the effects of 'credibility deficits' in clinical communication. Rather than judging individual professionals' success or failure in eliciting narratives, we underline some extrinsic problems of narrative elicitation, namely structural and positional inequalities reflecting on narrative elicitation and the credibility of patients. 'Credibility excesses' can be useful and indicative to better understand where they are missing.

Meaningful Text: Total Hip Replacement Patients’ Lived Experience of a Nursing Care Plan Written in Lay Language

Background:

Person-centred care involves respecting patients’ experiences, preferences, and needs, as well as sharing information with them and involving them in care planning. Scant research has been conducted on how it influences patients to have direct access to their care planning when it has been established through the use of standardised care plans or pathways. In the orthopaedic ward in which this study was conducted, a standardised nursing care plan for total hip replacement patients (THR), which was originally written in professional language, was rewritten in lay language and used as peri-operative teaching material for this patient group.

Study Aim:

To explore the meaning THR patients ascribe to the lived experience of reading and retaining their standardised nursing care plan in lay language during their hospital stay.

Methods:

The data collection and analysis followed a method adapted by the Vancouver School of Doing Phenomenology. Data were collected through 12 in-depth interviews with six THR patients.

Results:

The main finding was that the participants acquired knowledge from the text of the care plan that was understandable and meaningful, as evidenced by the empowering impact it had on them. This impact included improved psychological wellbeing, more open communication, and the provision of a tool to keep track of care. Some revisions of the care plan were recommended.

Conclusion:

The study suggests that a patient version of standardised care plans can act as an important educational tool for THR patients that can empower them to manage their health situations.

The benefits of consumer involvement in nursing handover on acute inpatient unit: Post-implementation views

The involvement of consumers in handover with nurses has been identified as reducing miscommunication between transitions in care and associated with reduction in adverse events in generalist nursing settings. The notion of having consumers present in nursing handover on acute mental health inpatient unit remains a relatively new concept. Central to recovery-focused mental health care is the consumer's active participation in the delivery of their care. The aim of this study was to explore the views of consumers with a mental illness about their experiences of being involved in nursing handover on acute mental health inpatient unit post-implementation of a new nursing handover involving consumers. Using an exploratory descriptive qualitative design, participants (N = 10) were recruited using purposive convenience sampling. Semi-structured interviews were undertaken, and the data were thematically analysed. Participants' principal diagnoses were schizophrenia (n = 2), schizoaffective disorder (n = 3), bipolar affective disorder (n = 2), borderline personality disorder (n = 1), and depression (n = 2). Three themes were generated from the interviews: (i) Knowing who, (ii) Shared decision-making, with subthemes: my voice was heard and not just a meet and greet, and (iii) Having time and space. The delivery of mental health care needs to put the consumer at the centre of such care regardless of the setting. In line with recovery-focused principles, the consumer's active involvement in the crucial activity of nursing handover on acute mental health inpatient unit is very important. The study has implications for ensuring consumer voices are heard in all aspects of their care delivery.

An app for supporting older people receiving home care - usage, aspects of health and health literacy: a quasi-experimental study

Background

During the last decade, there has been an increase in studies describing use of mHealth, using smartphones with apps, in the healthcare system by a variety of populations. Despite this, few interventions including apps are targeting older people receiving home care. Developing mobile technology to its full potential of being interactive in real time remains a challenge. The current study is part of a larger project for identifying and managing health concerns via an app by using real-time data. The aim of the study was to describe older people’s usage of an app and to evaluate the impact of usage on aspects of health and health literacy over time.

Methods

A quasi-experimental design was employed. Seventeen older people self-reported health concerns via Interaktor twice a week for 3-months and answered questionnaires at baseline, the end of the intervention and at a 6–month follow-up. Logged data on app usage and data on Sense of Coherence, Health Index, Nutrition Form for the Elderly, Geriatric Depression Scale-20, Swedish Communicative and Critical Health Literacy and Swedish Functional Health Literacy were collected and analysed using descriptive and non-parametric inferential statistics.

Results

The median usage of the app as intended was 96%. Pain was one of the most reported health concerns and was also the health concern that triggered an alert (n = 33). The older people’s communicative and critical health literacy improved significantly over time. Regarding the scores of Sense of Coherence, Health Index, Nutritional Form for the Elderly, Geriatric Depression Scale-20 and Swedish Functional Health Literacy scale, there were no significant differences over time.

Conclusions

The high app usage showed that an app may be a suitable tool for some older people living alone and receiving home care. The results indicate that the usage of Interaktor can support older people by significantly improving their communicative and critical health literacy. Aspects of health were not shown to be affected by the usage of the app. Further research with larger sample is needed for evaluation the effect on health literacy, and which aspects of health of importance to support by an app.

Patients' perspectives on interprofessional collaboration between health care professionals during hospitalization: a qualitative systematic review

OBJECTIVE

The objective of this review was to gain a better understanding of the interprofessional collaboration between health care professionals from the patients' point of view during hospitalisation; the influence of interprofessional collaboration on patient care, safety, and well-being; and patients' perspectives of their role in the interprofessional collaboration process.

INTRODUCTION

Interprofessional collaboration is a key factor in improving patient health care outcomes and safety through better communication between health care professionals, better teamwork, and better care coordination. However, implementing interprofessional collaboration in the clinical setting can prove complex. Patients are increasingly interested in becoming partners within the health care system. They have the potential to contribute to their own safety and to observe professionals during the care process, thus gaining a better understanding of the interprofessional collaboration process and facilitating changes in the behavior of health care professionals.

INCLUSION CRITERIA

This review considered qualitative research and mixed-method studies. Participants were hospitalized patients. Studies were included when they explored i) patients' perceptions of interprofessional collaboration, ii) the influence of interprofessional collaboration on patients' care, safety, or well-being, or iii) patients' perceptions of their own role in interprofessional collaboration. Qualitative studies focusing only on the care process or families' points of view were excluded.

METHODS

Searches of six databases including MEDLINE, CINAHL, Embase, Web of Science, PsycINFO, and Sociological Abstract, limited to English, French, and German were conducted from March 2017 to June 2018. Assessment of methodological quality of studies was performed using the JBI Qualitative Assessment and Review Instrument. Data were extracted using the standardized data extraction tool from JBI. Data synthesis following the JBI approach of meta-aggregation was performed. The level of confidence for each synthesized finding was established based on ConQual.

RESULTS

A total of 22 studies were included, which resulted in 89 findings and 24 categories. Eight synthesized findings were generated: patients' perceptions of interprofessional collaboration based on personal experiences and observations; patients' experiences with effective or ineffective interprofessional communication; patients' experience with power imbalance and paternalistic attitudes; patients' perceptions of key factors for a confident relationship with the interprofessional health care team; patients' need for comprehension of discussions between health care professionals; patients' perceptions of their role in an interprofessional health care team; patients' perceptions of opportunities for empowerment in interprofessional health care teams; and patients' need for humanizing care from interprofessional health care teams. The level of confidence of synthesized findings varied from low to moderate according to ConQual.

CONCLUSIONS

This systematic review synthesized the perspectives of hospitalized patients regarding interprofessional collaboration and their perceived role in collaborative practices. Hospitalized patients observe interprofessional collaboration, either directly or indirectly, and the way interprofessional collaboration is performed may impact both their care and their well-being. However, little evidence has been found regarding the impact of interprofessional collaboration on patient safety. Patients' perspectives on their perceived role is not unanimous; some patients want to play an active role in the collaborative process, whereas others prefer to trust the health care professionals' expertise. Health care professionals should consider patients' preferences and act accordingly regarding both the collaborative process and the inclusion of the patients in collaborative practices.

Engagement in an Interactive App for Symptom Self-Management during Treatment in Patients With Breast or Prostate Cancer: Mixed Methods Study

Background

Using mobile technology for symptom management and self-care can improve patient-clinician communication and clinical outcomes in patients with cancer. The interactive app Interaktor has been shown to reduce symptom burden during cancer treatment. It includes symptom assessment, an alert system for contact with health care professionals, access to self-care advice, and visualization of symptom history. It is essential to understand how digital interventions operate; one approach is to examine engagement by assessing usage and exploring user experiences. Actual usage in relation to the intended use—adherence—is an essential factor of engagement.

Objective

This study aimed to describe engagement with the Interaktor app among patients with breast or prostate cancer during treatment.

Methods

Patients from the intervention groups of two separate randomized controlled trials were included: patients with breast cancer receiving neoadjuvant chemotherapy (n=74) and patients with locally advanced prostate cancer receiving treatment with radiotherapy (n=75). The patients reported their symptoms daily. Sociodemographic and clinical data were obtained from baseline questionnaires and medical records. Logged data usage was retrieved from the server and analyzed descriptively and with multiple regression analysis. Telephone interviews were conducted with patients about their perceptions of using the app and analyzed using content analysis.

Results

The median adherence percentage to daily symptom reporting was 83%. Most patients used the self-care advice and free text message component. Among the patients treated for breast cancer, higher age predicted a lower total number of free text messages sent (P=.04). Among the patients treated for prostate cancer, higher age (P=.01) and higher education level (P=.04), predicted an increase in total views on self-care advice, while higher comorbidity (P=.004) predicted a decrease in total views on self-care advice. Being married or living with a partner predicted a higher adherence to daily symptom reporting (P=.02). Daily symptom reporting created feelings of having continuous contact with health care professionals, being acknowledged, and safe. Being contacted by a nurse after a symptom alert was considered convenient and highly valued. Treatment and time-related aspects influenced engagement. Daily symptom reporting was perceived as particularly meaningful at the beginning of treatment. Requests were made for advice on diet and psychological symptoms, as well as for more comprehensive and detailed information as the patient progressed through treatment.

Conclusions

Patient engagement in the interactive app Interaktor was high. The app promoted patient participation in their care through continuous and convenient contact with health care professionals. The predictive ability of demographic variables differed between patient groups, but higher age and a higher educational level predicted usage of specific app functions for both patient groups. Patients’ experience of relevance and interactivity influenced their engagement positively.

Assessing and reporting patient participation by means of patient preferences and experiences

BACKGROUND

Although patient participation is strongly associated with high quality of healthcare, valid means to measure and report a comprehensive notion of patient participation are scarce. The Patient Preferences for Patient Participation (4Ps) is a new healthcare practice and research tool, comprising patients' preferences as well as experiences. The 4Ps employs 12 items for the patient to conceptualise patient participation. The aim of this paper is to describe how the two perspectives of patient participation, namely preferences and experiences, can be combined to visualise and report preference-based patient participation.

METHODS

With four response alternatives in each section, the 4Ps offers sixteen possible combinations of degree of match per item. Theoretical and clinical principles fostered a tentative order of six ranks and three levels of preference-based patient participation. To test the standard, statistical analyses for ordinal data were performed, using data from a randomised controlled trial evaluating an intervention aiming to improve patient participation. Further, structures for visualising the preference-based patient participation of individuals and groups were suggested.

RESULTS

Data from the 4Ps demonstrated the individuals' preference-based patient participation, indicating either a match or a mismatch for each item. Mismatches represented either the experience of participation surpassing the patient's preferences, or the patient's preferences for patient participation not being established. At group level, the suggested approach for visualising and reporting the 4Ps demonstrated that the intervention group had a significantly higher proportion of sufficient preference-based patient participation for certain items than the control group. These results had not been identified earlier, when using the preferences and experiences of patient participation as separate measures.

CONCLUSIONS

Ways to easily acquaint stakeholders with patients' preferences for patient participation are needed, in order for healthcare staff to better use resources to match the basic requirements of individuals and groups. While the 4Ps can guide professionals to patient participation as framed in legislations, concept analyses and by patients, a visualisation of the results is needed to capture preference-based patient participation. The proposed route to representing degree of match in preferences and experiences may also be relevant to other dimensions of quality of healthcare.

Defining Patient Engagement in Research: Results of a Systematic Review and Analysis: Report of the ISPOR Patient-Centered Special Interest Group

OBJECTIVES

Lack of clarity on the definition of "patient engagement" has been highlighted as a barrier to fully implementing patient engagement in research. This study identified themes within existing definitions related to patient engagement and proposes a consensus definition of "patient engagement in research."

METHODS

A systematic review was conducted to identify definitions of patient engagement and related terms in published literature (2006-2018). Definitions were extracted and qualitatively analyzed to identify themes and characteristics. A multistakeholder approach, including academia, industry, and patient representation, was taken at all stages. A proposed definition is offered based on a synthesis of the findings.

RESULTS

Of 1821 abstracts identified and screened for eligibility, 317 were selected for full-text review. Of these, 169 articles met inclusion criteria, from which 244 distinct definitions were extracted for analysis. The most frequently defined terms were: "patient-centered" (30.5%), "patient engagement" (15.5%), and "patient participation" (13.4%). The majority of definitions were specific to the healthcare delivery setting (70.5%); 11.9% were specific to research. Among the definitions of "patient engagement," the most common themes were "active process," "patient involvement," and "patient as participant." In the research setting, the top themes were "patient as partner," "patient involvement," and "active process"; these did not appear in the top 3 themes of nonresearch definitions.

CONCLUSION

Distinct themes are associated with the term "patient engagement" and with engagement in the "research" setting. Based on an analysis of existing literature and review by patient, industry, and academic stakeholders, we propose a scalable consensus definition of "patient engagement in research."

The conditions of possibilities for recovery: A critical discourse analysis in a Danish psychiatric context

AIMS AND OBJECTIVES

This paper explores the conditions for the possibilities of recovery in a Danish mental healthcare practice, expressed from the perspective of nurses. The results and discussion of the study help to make visible and explore the muddle of conceptualisations of recovery in mental healthcare practice.

BACKGROUND

Few studies examine the possibilities of recovery for inpatients and outpatients in mental health centres from a nursing perspective.

DESIGN

A qualitative design using a critical social constructionist frame of understanding, in which the real world is considered as a series of social constructions.

METHOD

A Fairclough-inspired critical discourse analysis was chosen as the analytical strategy. The analysis is comprised of ten interviews in mental health care and notes, written by nurses, in medical records of ten patients with a mental illness admitted to a mental healthcare centre in 2016-2017. The Consolidated Criteria for Reporting Qualitative Research checklist was used as a guideline to secure accurate and complete reporting of the study (See Appendix S1).

RESULTS

From the findings of the textual analysis and the analysis of the discourse practice, it seems clear that the social relations and structures relating to recovery in Danish psychiatry are steered and controlled by discourses that reflect, in general terms, the essence of the core of neoliberal ideology.

CONCLUSION

Recovery is generally articulated from an overall discourse of neoliberalism with its embedded discourses of paternalism, biomedicine, self-care and holism. All these discourses coexist in nursing practice, but the paternalistic discourse becomes the framework for the conditions for the possibility of how recovery is expressed in practice.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to be supported to seek clarity in the understanding and operationalisation of a recovery-oriented approach, if the agenda is to be truly adopted and strengthened.

Patient pathways as social drama: a qualitative study of cancer trajectories from the patient's perspective

Purpose: The number of persons living with and beyond cancer is increasing. Such persons often have complex needs that last, and change, over time. The aim of this study is to get insights of lived experience of person diagnosed with colorectal cancer and to create an understanding of cancer trajectories as a dynamic process. This study thus explores Victor Turner’s model of social drama in a cancer care context. Method: Turner suggests that crisis is a dynamic process structured by four phases: 1) breach of norm 2) crisis 3) redressive actions 4) reintegration or schism. The research team employed content analysis to explore material gathered through a series of qualitative interviews with nine Norwegian cancer patients over a period of one year. Results: To the authors’ knowledge, Turner’s model has not earlier been applied to such materials. The results show that Turner’s model of social drama is useful in achieving new and possibly important knowledge on illness trajectories from a lived experience perspective. Conclusions: The model of social drama may contribute to a deeper understanding of the processes patients are going through in long-term illness trajectories, demonstrating that illness is not a static matter.

The inter-relationship of diversity principles for the enhanced participation of older people in their care: a qualitative study

Background

The health and aged care workforce must understand and support the diverse needs of older people to enhance their care experience. We previously identified five principles of diversity training for this workforce: awareness of unconscious bias and prejudice; promotion of inclusion; access and equity; appropriate engagement; and intersectionality. This study aims to explore how these principles are considered from the perspectives of older Australians.

Methods

Older people (≥65 years) receiving home care and nursing services based in Victoria, Australia were invited to participate in a home-based semi-structured interview about their experience of, or with, diversity. Interviews were thematically analysed using a priori categories based on our previous work on principles of diversity training, and themes were interpreted and expanded upon based on the participants’ experiences and understanding of diversity concepts and their care needs.

Results

Fifteen older people (seven female, eight male), mean age 76 years (range 71–85 years), were interviewed. Five themes were drawn from the data. It was found that human connection through building (1) trust and rapport was highly valued as an approach by older people, crucial as a first step to understanding what is important to the older person. Identifying with (2) intersectionality, that is, the different intersecting aspects of who they are and their experiences was understood by the participants as an important framework to meet their needs. The participants were aware of (3) unconscious bias and prejudice by health professionals and its impact on their care. Participants also noted that (4) promotion of inclusion through language was important to for a positive relationship with the healthcare worker. The participants understood that to facilitate human connection, these four principles of human interaction were critical, underpinned by (5) access and equity of the system. A model articulating these relationships was developed.

Conclusion

Health and aged care training should incorporate the five diversity principles to support older people to participate in their own care.

"Patient participation" and related concepts: A scoping review on their dimensional composition

OBJECTIVES

Several concepts on collaboration between patients and healthcare systems have emerged in the literature but there is little consensus on their meanings and differences. In this study, "patient participation" and related concepts were studied by focusing on the dimensions that compose them. This review follows two objectives: (1) to produce a detailed and comprehensive overview of the "patient participation" dimensions; (2) to identify differences and similarities between the related concepts.

METHODS

A scoping review was performed to synthesize knowledge into a conceptual framework. An electronic protocol driven search was conducted in two bibliographic databases and a thematic analysis was used to analyse the data.

RESULTS

The search process returned 39 articles after exclusion for full data extraction and analysis. Through the thematic analysis, the dimensions, influencing factors and expected outcomes of "patient participation" were determined. Finally, differences between the included concepts were identified.

CONCLUSION

This global vision of "patient participation" allows us to go beyond the distinctions between the existing concepts and reveals their common goal to include the patient in the healthcare system.

PRACTICE IMPLICATIONS

This scoping review provides useful information to propose a conceptual model of "patient participation", which could impact clinical practice and medical training programs.

Nurses' articulations of the patients' role when the vision is partnership: A qualitative study

Although principles such as 'patient participation' and 'patient involvement' have become ideals in health-care, they have proven to be difficult to apply in practice. In 2014, one Danish region issued an official document that included the vision of 'the patient as partner'. However, little is known about how such a vision affects clinical practice. The purpose of this study was to investigate nurses' views on how partnerships between them and patients are established considering this vision. We conducted semi-structured interviews with eight nurses working in Danish hospitals. Then, we analysed the interviews in a Norman Fairclough-inspired critical discourse analysis. During this three-dimensional analysis, we identified three discourses. We found that a liberalistic discourse wins hegemony based on the nurses' expectations of the patient's role. Nurses construct a picture of the patient's role, expecting the patient to be responsible and to participate. For the partnership to arise as envisioned, the patient is perceived as being dependent on the nurse's professional knowledge. Surprisingly, the nurses' articulations of the patient's role were identical to the vision's elements. Therefore, we suggest that the vision reflects prevailing societal norms for individuals, thereby reflecting society's attitude towards people's responsibility for their own lives.

Patient participation in dialysis care-A qualitative study of patients' and health professionals' perspectives

BACKGROUND AND OBJECTIVE

End-stage renal disease (ESRD) affects a multitude of aspects in the patient's daily life, often entailing their own involvement in various aspects of the treatment. Although patient participation is a core health-care value, what the concept signifies is not yet fully known. The purpose of this paper is to conceptualize patient participation in dialysis care, depicting patients' and health-care professionals' perspectives.

DESIGN

This explorative study employed qualitative interviews and content analysis.

SETTING AND PARTICIPANTS

Seven focus group discussions engaging 42 key informants were performed, including patients, staff and managers with experience of dialysis care.

RESULTS

In dialysis care, patient participation connotes a sharing of information and knowledge, the learning of and planning of care, including partaking in shared decisions with regards to treatment and management, and being involved in the management of one's own health-care treatment and/or self-care activities. Although these attributes were illustrated by all stakeholders, their significance varied: patients suggested that their preferences regarding primary aspects of participation vary, while staff considered patients' performance of dialysis to be the ultimate form of participation. Further, while patients considered multiple ways to execute participation, staff suggested that aspects such as sharing information were a route to, rather than actual, involvement.

CONCLUSIONS

Without a common understanding to denote the idea of patient participation, staff and patients are exposed to a potential deficit in terms of facilitating patient participation in everyday encounters of dialysis treatment. Further studies and means to serve a mutual understanding are needed.

Health professionals' understanding of person-centred communication for risk prevention conversations: an exploratory study

Background: Health Professionals are required to balance care practices against patient risk to optimise safety. Communicating clinical risk with the patient requires confidence.Objective: The objective was to explore health professionals understanding and confidence of patient-centred communication during conversations of risk prevention.Design: An exploratory study was conducted.Methods: Nurses, physiotherapists and social workers in a metropolitan hospital in Sydney (New South Wales, Australia) completed face to face interviews (n = 16) regarding person-centred communication and clinical risk.Results: The sample was predominately female and had been a health profession for 11.5 years (mean). Six key themes were generated including: Perceptions of person-centred communication; Preparing for person-centred communication and Understanding and prioritising conversations about preventable clinical risk.Conclusions: Person-centred communication was embedded in clinical practice; the 'patient voice' was considered central. Clinical risk was a priority. Education to improve communication was highlighted as a way to enhance person-centred communication.

Goal-setting in physiotherapy: exploring a person-centered perspective

Objective: To analyze definitions and related requirements, processes, and operationalization of person-centered goal-setting in the physiotherapy research literature; to discuss those findings in relation to underlying principles of person-centeredness; and to provide an initial framework for how person-centered goal-setting could be conceptualized and operationalized in physiotherapy. Methods: A literature search was conducted in the databases: CINAHL, PubMed, PEDro, PsycINFO, REHABdata and Scopus. A content analysis was performed on how person-centered goal-setting was described.Results: A total of 21 articles were included in the content analysis. Five categories were identified: 1) Understanding goals that are meaningful to the patients; 2) Setting goals in collaboration; 3) Facing challenges with person-centered goal-setting; 4) Developing skills by experiences and education; and 5) Changing interaction and reflective practice. These categories were abstracted into two higher-ordered interlaced themes: 1) To seek mutual understanding of what is meaningful to the patient; and 2) To refine physiotherapy interaction skills, which we suggest would be useful for further conceptualization.Conclusion: In this analysis, we interpreted person-centered goal-setting in physiotherapy as a process of interaction toward a mutual understanding of what is meaningful to the patient. Future research may explore how to integrate mindful listening, embodied interaction and continuous ethical reflection with different assessments and treatment methods.

Patient coaching in specialist consultations. Which patients are interested in a coach and what communication barriers do they perceive?

OBJECTIVE

To characterize patients interested in support by a patient coach to guide them in medical specialist consultations.

METHODS

We compared 76 patients interested in a patient coach with 381 patients without such an interest, using a representative panel of patients with a chronic disease in the Netherlands. Independent variables were demographic factors, socio-economic status, perceived efficacy in patient-provider interaction, communication barriers, health literacy, (duration and type of) disease(s) and activation level.

RESULTS

In univariate analyses, patients who are interested in a coach were significantly older, had lower health literacy skills and less self-efficacy and, overall, experienced more communication barriers (>4), than patients without such interest (1-2 barriers). Multivariate analyses indicated three communications barriers as determinants of patient interest in a coach: feeling tense, uncertainty about own understanding, and believing that a certain topic is not part of a healthcare providers' task.

CONCLUSION

Patients interested in a coach perceive specific barriers in communicating with their medical specialist. In addition, patients who are > = 65 years, have lower health literacy and low self-efficacy may have interest in a coach.

PRACTICE IMPLICATIONS

Characterizing patients interested in a patient coach facilitates identification of those who could benefit from such a coach in clinical practice.

Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice

Background

Primary health professionals are well positioned to support the delivery of patient self-management in an evidence-based, structured capacity. A need exists to better understand the active components required for effective self-management support, how these might be delivered within primary care, and the training and system changes that would subsequently be needed.

Objectives

(1) To examine self-management support interventions in primary care on health outcomes for a wide range of diseases compared to usual standard of care; and (2) To identify the effective strategies that facilitate positive clinical and humanistic outcomes in this setting.

Method

A systematic review of randomized controlled trials evaluating self-management support interventions was conducted following the Cochrane handbook & PRISMA guidelines. Published literature was systematically searched from inception to June 2019 in PubMed, Scopus and Web of Science. Eligible studies assessed the effectiveness of individualized interventions with follow-up, delivered face-to-face to adult patients with any condition in primary care, compared with usual standard of care. Matrices were developed that mapped the evidence and components for each intervention. The methodological quality of included studies were appraised.

Results

6,510 records were retrieved. 58 studies were included in the final qualitative synthesis. Findings reveal a structured patient-provider exchange is required in primary care (including a one-on-one patient-provider consultation, ongoing follow up and provision of self-help materials). Interventions should be tailored to patient needs and may include combinations of strategies to improve a patient’s disease or treatment knowledge; independent monitoring of symptoms, encouraging self-treatment through a personalized action plan in response worsening symptoms or exacerbations, psychological coping and stress management strategies, and enhancing responsibility in medication adherence and lifestyle choices. Follow-up may include tailored feedback, monitoring of progress with respect to patient set healthcare goals, or honing problem-solving and decision-making skills. Theoretical models provided a strong base for effective SMS interventions. Positive outcomes for effective SMS included improvements in clinical indicators, health-related quality of life, self-efficacy (confidence to self-manage), disease knowledge or control. An SMS model has been developed which sets the foundation for the design and evaluation of practical strategies for the construct of self-management support interventions in primary healthcare practice.

Conclusions

These findings provide primary care professionals with evidence-based strategies and structure to deliver SMS in practice. For this collaborative partnership approach to be more widely applied, future research should build on these findings for optimal SMS service design and upskilling healthcare providers to effectively support patients in this collaborative process.

Information and Communication Technology Can Increase Patient Participation in Pressure Injury Prevention: A Qualitative Study in Older Orthopedic Patients

PURPOSE

The aim of this study was to assess the participatory capabilities of hospitalized older adults in response to the Continuous Bedside Pressure Mapping system placed on the beds to prevent pressure injuries.

DESIGN

Descriptive study.

SUBJECTS AND SETTING

A convenience sample of 31 orthopedic patients were recruited from an orthopedic rehabilitation unit at a university hospital in Uppsala, Sweden, that served patients aged 65 years and older.

METHODS

Semistructured interviews were conducted between November 2016 and February 2017, audio-recorded, and transcribed verbatim. Data were analyzed using qualitative content analysis.

RESULT

The overall theme from 21 interviews was "A new way of understanding helped patients to recognize vulnerable pressure points and to take action in their own care" from which 2 categories, "awareness" and "action," emerged. The study showed that verbally adapted information combined with using information and communication technology increased most participants' knowledge and as they became aware of increased pressure, they started to take preventative action by changing position.

CONCLUSIONS

It is possible for older participants in a rehabilitation unit who had recent orthopedic surgery to understand and use new information and communication technology and should be invited to participate in pressure injury prevention.

Reprint of: Patient participation in nursing bedside handover: A systematic mixed-methods review

BACKGROUND

Numerous reviews of nursing handover have been undertaken, but none have focused on the patient's role.

OBJECTIVES

To explore how patient participation in nursing shift-to-shift bedside handover can be enacted.

DESIGN

Systematic mixed- methods review.

DATA SOURCES

Three search strategies were undertaken in July-August 2016: database searching, backwards citation searching and forward citation searching. To be included, papers had to either be research or quality improvement (QI) projects focusing on the patient role. Fifty-four articles were retrieved, including 21 studies and 25 QI projects.

REVIEW METHODS

Screening, data extraction and quality appraisal was undertaken systematically by two reviewers. Research studies and QI projects were synthesised separately using thematic synthesis, then the results of this synthesis were combined using a mixed-method synthesis table.

RESULTS

Segregated synthesis of research of patients' perceptions revealed two contrasting categories; patient-centred handover and nurse-centred handover. Segregated synthesis of research of nurses' perceptions included three categories: viewing the patient as an information resource; dealing with confidential and sensitive information; and enabling patient participation. The segregated synthesis of QI projects included two categories: nurse barriers to enacting patient participation in bedside handover; and involving patients in beside handover. Once segregated findings were configured, we discovered that the patient's role in bedside handover involves contributing clinical information related to their care or progress, which may influence patient safety. Barriers related to nurses' discomfort encouraging patient participation and worries for sharing confidential and sensitive information. The way nurses approach patients, and how patient-centred they are, constitute further potential barriers. Strategies to improve patient participation in handover include training nurses, making handovers predictable for patients and increasing the interpersonal approach during handover.

CONCLUSIONS

Using research and QI projects allowed diverse findings to expand each other and identify gaps between research and heuristic knowledge. Our review showed the tension between standardising handovers and making them predictable for patient participation, while promoting tailored and flexible handovers. Further investigation of this issue is required, to understand how to train nurses to achieve this and prepare patients to do this. Many barriers and strategies identified were from QI projects and the nurse perspective, thus caution interpreting results is required. We recommend steps be taken in the future to ensure high quality QI projects.

Encountering staff-directed aggression within mental health and substance abuse services: exploring conceptions of practice following education

Background

Staff-directed aggression represents a considerable concern in mental health and substance abuse services, and presents a substantial challenge to the quality and continuity of service provision for people with mental health and substance abuse problems. The practitioners themselves frequently request increased competence as a way to mediate the negative effects of staff-directed violence and aggression. The aim of this study is to explore how practitioners in municipal mental health and substance abuse services conceptualize practice in prevention and management of staff-directed violence. Furthermore, we seek to explore how these conceptions change following participation in two complementary and specially developed courses advancing respectively, qualified risk assessment and situational awareness and disempowerment-sensitive and de-escalation principles for practice.

Method

The study was conducted by using a qualitative phenomenographic research approach. The data-material comprised two-step semi-structured interviews with ten participants from various parts of community mental health and substance abuse services in the Municipality of Oslo, Norway.

Results

The analysis resulted in the development of five qualitatively different, hierarchically ordered, yet logically interrelated conceptual categories of practice concerning prevention and management of staff-directed aggression in community mental health and substance abuse services. These are: (1) Observation, reporting and expectation of organizational intervention, (2) Application of personalized de-escalating skills and behaviour, (3) Delivery of team-based and standardized services, (4) Provision of perceptive and responsive services, and (5) Facilitation of sensitive, involving and reflexive care. The categories vary according to the participants' attentional focus on either the responsibility of the organization, staff members' personally developed skills and techniques, team-based solutions, knowledgeable information processing in making professional judgements and reflexive, interpersonal service provision, as well as according to what meaning participants assign to practice. The authors have identified varying degrees of conceptual change following education in half of the participants.

Conclusion

The results of this study both show that practitioners conceptualize practice in aggressive encounters quite differently. The study also indicate that it is important to consider participant awareness of the phenomenon of interest when devising educational activities for personnel in mental health and substance abuse services.

Facilitation of a Person-Centered Approach in Health Assessment of patients with chronic pain: An Ethnographic Study

A phenomenologically derived assessment tool, Hermes, was developed in a rehabilitation setting for adopting the central ideals of person-centered care and patient participation into health-assessment practices in nursing. This focused ethnographic study aimed at exploring the feasibility of using Hermes for enabling the application of these ideals into assessment of patients with chronic pain upon admission to a rehabilitation center. Participants were patients with chronic pain, enrolled in rehabilitation, and their nurses. Data were collected by participant observation and interviews, and analyzed by thematic analysis. By the use of Hermes, the impact of illness was explored through supportive connection and dialogue with open, reflective, and interpretative features; understanding of the illness situation was enhanced; and possibilities provided in adjusting to health issues of concern. In sum, Hermes facilitated person-centered participation of patients with chronic pain in their health assessment and made a phenomenological philosophy usable in nursing-assessment practices.