Investigating the Meaning of Patient Ownership: An Exploratory Study of a Commonly Used Phrase within an Internal Medicine Department

Learning to assume responsibility or "ownership" for patient care is an important aspect of learning what it means to be a physician. To date, most of the research on patient ownership has focused on residents' understanding of what it means to own patients. This exploratory study explored third- and fourth-year students', residents, and attending physicians' understanding of the phrase "taking ownership of a patient." Data included participant observations and interviews that expanded over a five month period. Interviews were transcribed and analyzed using psychological ownership as an analytical lens and latent content analysis as a method. Third-year students primarily understood the phrase to mean communicating with patients and their immediate team. Fourth-year students indicated it was an expectation to contribute to the management of patient care. Residents and faculty thought patient ownership included an emotional investment in patients. The phrase taking ownership of patients is understood differently depending on where participants are in their development, even though it is assumed there is a shared understanding across team members. Given the variability in understanding, educators should have explicit discussions with learners about commonly used concepts to help them develop sophisticated understandings and monitor their own development.

Linking Patient Care Ownership and Professional Identity Formation through Simulation

The link between ownership of patient care and professional identity formation (PIF) has not been formally established, yet PIF researchers frequently cite clinical experiences as powerful contributions to PIF. Hypothesis: Using clinical simulation, this study aimed to explore the relationship between patient care ownership and the cognitive processes involved in the creation of a professional identity. Methods: In 2018-2019, 189 third-year students participated in a simulation in which they were placed in the role of a physician treating a patient in respiratory distress. Data were collected from 12 focus groups (n = 84; 44% of the third-year class), each lasting 15-25 minute. Students were asked four questions designed to identify moments when they felt like a physician and experienced feelings of ownership. Each focus group was transcribed and analyzed for the presence of known elements that contribute to feelings of psychological ownership, and then inductively for how students related their feelings of ownership to their professional identity. Results: When students were asked to take ownership of their patient's care, they underwent a three-step process: (1) experiencing disorientation, (2) reconceptualizing roles and responsibilities, and (3) reorientation to professional goals. Patient care ownership was disorienting because it marked a departure from the clinical roles the students had previously experienced. While disoriented, students engaged in a process of reflection during which they asked themselves who they were, who they were becoming, and who they needed to become to effectively serve in the role of a physician. This process prompted students to realize the limitations of their clinical reasoning abilities and that the role of a physician requires new ways of thinking. Conclusions: This study advances a conceptual model of PIF that identifies patient care ownership as a catalyst in developing a professional identity. Assuming responsibility for patients places students into an unfamiliar role, which opens a channel for students to access new perspectives in their development as physicians.

GPs' decisions about prescribing end-of-life anticipatory medications: a qualitative study

BACKGROUND

GPs have a central role in decisions about prescribing anticipatory medications to help control symptoms at the end of life. Little is known about GPs' decision-making processes in prescribing anticipatory medications, how they discuss this with patients and families, or the subsequent use of prescribed drugs.

AIM

To explore GPs' decision-making processes in the prescribing and use of anticipatory medications for patients at the end of life.

DESIGN AND SETTING

A qualitative interview study with GPs working in one English county.

METHOD

Semi-structured interviews were conducted with a purposive sample of 13 GPs. Interview transcripts were analysed inductively using thematic analysis.

RESULTS

Three themes were constructed from the data: something we can do, getting the timing right, and delegating care while retaining responsibility. Anticipatory medications were a tangible intervention GPs felt they could offer patients approaching death (something we can do). The prescribing of anticipatory medications was recognised as a harbinger of death for patients and their families. Nevertheless, GPs preferred to discuss and prescribe anticipatory medications weeks before death was expected whenever possible (getting the timing right). After prescribing medications, GPs relied on nurses to assess when to administer drugs and keep them updated about their use (delegating care while retaining responsibility).

CONCLUSION

GPs view anticipatory medications as key to symptom management for patients at the end of life. The drugs are often presented as a clinical recommendation to ensure patients and families accept the prescription. GPs need regular access to nurses and rely on their skills to administer drugs appropriately. Patients' and families' experiences of anticipatory medications, and their preferences for involvement in decision making, warrant urgent investigation.

A qualitative study of community nurses' decision-making around the anticipatory prescribing of end-of-life medications

AIMS

The aim of this study was to explore community nurses' decision-making processes around the prescribing of anticipatory medications for people who are dying.

BACKGROUND

Community nurses frequently initiate the prescribing of anticipatory medications to help control symptoms in those who are dying. However, little is known about their decision-making processes in relation to when they instigate anticipatory prescribing and their discussions with families and General Practitioners.

DESIGN

A qualitative interpretive descriptive enquiry.

METHODS

A purposive sample of 11 Community Palliative Nurses and District Nurses working in one geographical area participated. Data were collected between March and June 2016 via audio recorded semi-structured interviews and analysed inductively using Braun and Clarke's thematic analysis.

RESULTS

Three themes were identified: (1) Drugs as a safety net. Anticipatory medications give nurses a sense of control in last days of life symptom management; (2) Reading the situation. The nurse judges when to introduce conversations around anticipatory medications, balancing the need for discussion with the dying person and their family's likely response; (3) Playing the game. The nurse owns the decision to initiate anticipatory medication prescribing and carefully negotiates with the General Practitioner.

CONCLUSION

Nurses view pain control through prescribed medication as key to symptom management for dying people. Consequently, they own the role of ascertaining when to initiate discussions with families about anticipatory medicines. Nurses believe they advocate for dying person and their families' needs and lead negotiations with General Practitioners for medications to go into the home. This nurse led care alters the traditional boundaries of the General Practitioners-nurse professional relationship.

Nursing futility, managing medicine: Nurses’ perspectives on the transition from life-prolonging to palliative care

The shift from life-prolonging and palliative care can be fraught with interpersonal complexities as patients face dilemmas around mortality and the dying process. Nurses can play a central role in managing these moments, often with a focus on promoting and enhancing communication around: the meaning of palliative care, the nature of futility and the dying process more broadly. These sites of nurse–patient communication can be highly charged and pose unique challenges to nurses including how to balance nursing perspectives versus those of other stakeholders including doctors. Here, drawing on interviews with nurses, we explore their accounts of communication about futility and the process of transitioning to palliative care. The interviews reveal nurses’ perspectives on the following: the art of conversing around futility and managing patient resistance, the influence of guilt and individual biographies in shaping communication, the importance of non-verbal and the informal in communication, the impact of conflicting organisational expectations on nurses and the process of learning to effectively communicate. We argue that these transitional moments articulate important, and at times problematic, aspects of contemporary nursing and nurse–medical relations.

The Long Way Toward Cooperation: Nurses and Family Physicians in Northern Germany

To better understand why cooperation between health care professionals is still often problematic, we carried out 25 semistructured face-to-face expert interviews with physicians and nurses in different rural and urban areas in northern Germany. Using Mayring's qualitative content analysis method to analyze the data collected, we found that doctors and nurses interpreted interprofessional conflicts differently. Nursing seems to be caught in a paradoxical situation: An increasing emphasis is placed on achieving interprofessional cooperation but the core areas of nursing practice are subject to increasing rationalization in the current climate of health care marketization. The subsequent and systematic devaluation of nursing work makes it difficult for physicians to acknowledge nurses' expertise. We suggest that to ameliorate interprofessional cooperation, nursing must insist on its own logic of action thereby promoting its professionalization; interprofessional cooperation cannot take place until nursing work is valued by all members of the health care system.