The moral nature of patient-centeredness: is it "just the right thing to do"?

Oral Health-Related Quality of Life in a Paediatric Population in the Dominican Republic

Introduction: During the summer of 2019 and within the framework of a social dentistry program carried out in the low-income town of San Francisco de Macorís (Dominican Republic), a descriptive study was carried out on oral health-related quality of life (OHRQoL), aiming to find out the oral health status of a population of children in the aforementioned Dominican city. Objective: The aim of this study was to describe the oral health status of a child population and its relationship with the quality of life perceived by these children in the aforementioned population of San Francisco de Macorís in order to develop an specific oral health program taking into account not only the existing oral health status but also the perceptions and feelings of the child population in this regard. Method: A descriptive cross-sectional study was carried out on a representative sample of children who were examined on their oral health status, following WHO guidelines, by professionals from the University of Seville (Spain) together with professionals from private practice (USA) and students from the Universidad Católica Nordestana (UCNE, Dominican Republic). Likewise, the children's parents voluntarily completed the Oral Quality of Life questionnaire COHIP-19 in its culturally adapted Spanish version. Results: For this purpose, 94 children with a mean age of 10.34 (SD 3.38) were observed in our study following WHO recommendations for oral health studies and evaluating OHQoL using the specific questionnaire validated in Spanish COHIP-19 in its short format (SF). The results show a state of oral health with a significant prevalence of caries (80.9%) and a DMFT of 1.70 (SD 1.90). The OHQoL perceived by these children shows that pain, bad breath or feeling sad because of the condition of their teeth were the factors with the worst evaluation score. Conclusions: The conclusion that mainly emerges from this study is that caries continues to be the main problem to be solved (more than other variables studied, such as malocclusion or fluorosis), and this ailment also causes pain, dysfunction, and bad breath and is therefore perceived as a problem to be solved in the children of this Dominican city.

Getting to Know Your Patient: Content Analysis of Patients' Answers to a Questionnaire for Promoting Person-Centered Care

BACKGROUND

Person-centered care (PCC) encourages patients to actively participate in health care, thus facilitating care that fits the life of the patient. Therefore, health care professionals (HCPs) need to know the patient. As part of a broad policy for improving PCC, a digital questionnaire ("We would like to know you") consisting of 5 questions has previously been developed to help HCPs to get to know the patient with the help of patient and staff involvement.

OBJECTIVE

The purpose of this study was to provide insight into the content and aims of the questionnaire to understand its potential and usability.

METHODS

We conducted a qualitative, retrospective content analysis of patients' answers using NVivo Pro (QSR International). The questionnaire was used in the outpatient neuro-oncology department of a Dutch academic hospital.

RESULTS

Of 374 invited patients, 78 (20.9%) completed the questionnaire. We selected a sample of 42 (54%) of the 78 patients. Patients used a median of 16 (IQR 7-27) words per question, and most answers were easily interpretable. When asked about important activities, social activities, sports, or maintaining a normal life were most frequently mentioned. Patients wrote about fear of the disease, its possible influence on life, or fear of the future in general. Patients wanted HCPs to know about their care and communication preferences or shared personal information. They formulated expectations about effective treatment, communication, and the care process.

CONCLUSIONS

The questionnaire seems usable because patients provide interpretable answers that take little time to read, which HCPs can use to personalize care. Our study shows the potential of the questionnaire to help deliver PCC.

Midwifery students' experiences: Violations of dignity during childbirth

BACKGROUND

The principle of human dignity is woven into the ethical principles of the midwifery profession, noted as both an obligation and a human right.

RESEARCH OBJECTIVES

The aim of this study is to explore the experiences of midwifery students regarding threats to women's dignity during childbirth.

RESEARCH DESIGN

This is a qualitative study with explorative design. Participants and Research Context: The research was carried out in 2022 at Kermanshah University of Medical Sciences, involving 32 midwifery students in individual interviews that lasted between 30 and 90 minutes. These participants aged 21 to 28 years, with an average age of 23.5 years, provided their perspectives on the matter.

RESULTS

Four key themes described the threats to women's dignity during childbirth: 1) professional incompetence, 2) abuse of power imbalance, 3) caring only for physical and not mental health, and 4) structural issues within the healthcare system. Professional incompetence was characterized by outdated practices and lack of adherence to evidence-based medicine. Abuse of power imbalance was demonstrated in instances where the authoritative position of healthcare providers was misused, thereby disrupting the respectful care that women are entitled to receive. The disproportionate emphasis on physical health over mental health was evidenced by the disregard for mothers' psychological well-being during childbirth. Lastly, systemic structural issues emerged as significant impediments, revealing the need for system-wide changes. Ethical considerations: This study was approved by the Ethics Committee of the Research Deputy at Kermanshah University. Participation was voluntary and the confidentiality were maintained.

CONCLUSION

The findings underscore the role that unprofessional behavior, ethical lapses in medical practices, and systemic challenges play in undermining maternal dignity during childbirth. These threats necessitate urgent attention and must be adequately addressed in policy development and program implementation to safeguard the dignity of mothers during childbirth.

Is it fun or is it hard? Studying physician-related attributes of shared decision-making by ranking case vignettes

Objective

This study investigated provider-related attributes of shared decision-making (SDM). It studied how physicians rank SDM cases compared to other cases, taking 'job satisfaction' and 'complexity' as ranking criteria.

Methods

Ten vignettes representing three cases of SDM, three cases dealing with patients' emotions and four with technical problems were designed to conduct a modified ordinal preference elicitation study. Gynaecologists and trainees ranked the vignettes for 'job satisfaction' or 'complexity'. Results were analysed by comparing the top three and down three ranked cases for each type of case using exact p-values obtained with custom-made randomisation tests.

Results

Participants experienced more satisfaction significantly from performing technical cases than cases dealing with emotions or SDM. Moreover, technical cases were perceived as less complex than those dealing with emotions. However, results were inconclusive about whether gynaecologists find SDM complex.

Conclusion

Findings suggest gynaecologists experience lower satisfaction with SDM tasks, possibly due to them falling outside their comfort zone. Integrating SDM into daily routines and promoting culture change favouring dealing with non-technical problems might help mitigate issues in SDM implementation.

Innovation

Our novel study assesses SDM in the context of task appraisal, illuminating the psychology of health professionals and providing valuable insights for implementation science.

VHA Whole Health Services and Complementary and Integrative Health Therapies: a Gateway to Evidence-Based Mental Health Treatment

BACKGROUND

Engagement in evidence-based psychotherapy (EBP) among veterans with behavioral health conditions is often low. The Veterans Health Administration (VHA) is implementing a "Whole Health (WH)" system of care, to identify veteran personal health goals, align care with those goals, and offer services designed to engage and empower veterans to achieve well-being.

OBJECTIVE

To examine the relationship between veteran WH utilization and subsequent engagement in EBP.

DESIGN

Retrospective analysis of VHA administrative records from 18 facilities implementing WH.

SUBJECTS

Veterans (n = 265,364) with a diagnosis of depression, post-traumatic stress disorder (PTSD), and/or anxiety who had a mental healthcare encounter but no EBP use in fiscal year (FY) 2018. Among this cohort, 33,146 (12.5%) began using WH in FY2019.

MAIN MEASURES

We examined use of an EBP for depression, anxiety, and/or PTSD within 1 year of the index date of WH use compared to use of an EBP anytime during FY2019 for veterans not identified as using WH. We used multiple logistic regression to examine the association between veteran WH use and EBP engagement.

KEY RESULTS

Approximately 3.0% (n = 7,860) of the veterans in our overall cohort engaged in an EBP in the year following their index date. Controlling for key demographic, health, and utilization variables, WH users had 2.4 (95% CI: 2.2-2.5) times higher odds of engaging in an EBP the following year than those with no WH utilization. Associations between utilization of specific WH services (vs. no utilization of that service) and engagement in an EBP in the subsequent year ranged from 1.6 (95% CI: 1.0-2.6) to 3.5 (95% CI: 3.2-3.9) across the different types of WH services used.

CONCLUSIONS

WH use was associated with increased engagement in EBPs among veterans with depression, anxiety, and/or PTSD. Future interventions intended to promote veteran engagement in EBPs may benefit from leveraging WH services and therapies.

Shared decision making: a personal view from two kidney doctors and a patient

Shared decision making (SDM) combines the clinician's expertise in the treatment of disease with the patient's expertise in their lived experience and what is important to them. All decisions made in the care of patients with kidney disease can potentially be explored through SDM. Adoption of SDM in routine kidney care faces numerous institutional and practical barriers. Patients with chronic disease who have become accustomed to paternalistic care may need support to engage in SDM-even though most patients actively want more involvement in decisions about their care. Nephrologists often underestimate the risks and overestimate the benefits of investigations and treatments and often default to recommending burdensome treatments rather than discussing prognosis openly. Guideline bodies continue to issue recommendations written for healthcare professionals without providing patient decision aids. To mitigate health inequalities, care needs to be taken to provide SDM to all patients, not just the highly health-literate patients least likely to need additional support in decision making. Kidney doctors spend much of their time in the consulting room, and it is unjustifiable that so little attention is paid to the teaching, audit and maintenance of consultation skills. Writing letters to the patient to summarise the consultation rather than sending them a copy of a letter between health professionals sets the tone for a consultation in which the patient is an active partner. Adoption of SDM will require nephrologists to relinquish long-established paternalistic models of care and restructure care around the values and preferences of patients.

Interprofessional Identity in Health and Social Care: Analysis and Synthesis of the Assumptions and Conceptions in the Literature

Interprofessional identity (IPI) development is considered essential in reducing incongruency and improving interprofessional collaboration. However, noticeable differences in conceptualizations are being put forward in the literature, hindering interpretation of research findings and translation into practice. Therefore, a Concept Analysis and Critical Interpretative Synthesis of empirical research articles were conducted to explore the assumptions and conceptions of IPI. Independent literature screening by two researchers led to the inclusion and extraction of 39 out of 1334 articles. Through critical analysis, higher order themes were constructed and translated to a synthesizing argument and a conceptual framework depicting what constitutes IPI (attributes), the boundary conditions (antecedents) and the outcomes (consequences) of its development. The attributes refer to both IPI's structural properties and the core beliefs indicative of an interprofessional orientation. The antecedents inform us on the importance of IPI-fitting constructivist learning environments and intergroup leadership in enabling its development. This development may lead to several consequences with regard to professional wellbeing, team effectiveness and the quintuple aim. Given the educational orientation of this study, ways for facilitating and assessing the development of IPI among learners across the professional continuum have been proposed, although empirical research is needed to further validate links and mediating and moderating variables.

Interpreting patient-rated outcome measures in adolescent patients following concussion

OBJECTIVE

To estimate scale scores for patient-reported outcome (PRO) measures that classify patients as improved or unimproved at days 3 and 10 post-concussion.

METHODS

Data from 187 adolescent patients who sustained a concussion (150 males, 32 females, 5 not reported) were analyzed. Patients completed the Pediatric Quality of Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), Headache Impact Test (HIT-6), and Global Rating of Change (GROC) on days 3 and 10 post-concussion. Dependent variables: PedsQL total score, 3 MFS subscale scores [general (MFS-GF), sleep (MFS-SLF), cognitive (MFS-CF) fatigue], and HIT-6 total score. Higher scores on PedsQL and MFS indicate better health; lower scores on HIT-6 indicate less impact on headache-related health. GROC ascertained patient-perceived magnitude of change in health status since concussion. Receiver Operating Characteristic Curve analyses estimated PRO cut-point scores that classified patients as improved or unimproved.

RESULTS

Day 3 PRO cut-points: PedsQL total = 90; MFS-GF = 73; MSF-CF = 85; MFS-SLF = 81; and HIT-6 total = 54. Day 10 PRO cut-points: PedsQL total = 91; MFS-GF = 85; MFS-CF = 85; MFS-SLF = 90; and HIT-6 total = 51.

CONCLUSIONS

Our results define PedsQL, MFS, and HIT-6 scores as they relate to perceived improvement following concussive injuries. Cut-point scale scores help clinicians interpret concussion PROs and make informed decisions during the management of patients with concussion.

Sexual history taking by doctors in primary care in North West province, South Africa: Patients at risk of sexual dysfunction overlooked

Background

Sexual history taking seldom occurs during a chronic care consultation and this research focussed on consultation interaction factors contributing to failure of screening for sexual dysfunction.

Aim

This study aimed to quantify the most important barriers a patient and doctor experienced in discussing sexual challenges during the consultation and to assess the nature of communication and holistic practice of doctors in these consultations.

Setting

The study was done in 10 primary care clinics in North West province which is a mix of rural and urban areas.

Methods

One-hundred and fifty-five consultation recordings were qualitatively analysed in this grounded theory research. Doctors and patients completed self-administered questionnaires. A structured workplace-based assessment tool was used to assess the communication skills and holistic practice doctors. Template analysis and descriptive statistics were used for analysis. The quantitative component of the study was to strengthen the study by triangulating the data.

Results

Twenty-one doctors participated in video-recorded routine consultations with 151 adult patients living with hypertension and diabetes, who were at risk of sexual dysfunction. No history taking for sexual dysfunction occurred. Consultations were characterised by poor communication skills and the lack of holistic practice. Patients identified rude doctors, shyness and lack of privacy as barriers to sexual history taking, whilst doctors thought that they had more important things to do with their limited consultation time.

Conclusion

Consultations were doctor-centred and sexual dysfunction in patients was entirely overlooked, which could have a negative effect on biopsychosocial well-being and potentially led to poor patient care.

Who is at the centre of what? A scoping review of the conceptualisation of 'centredness' in healthcare

OBJECTIVES

We aimed to identify the core elements of centredness in healthcare literature. Our overall research question is: How has centredness been represented within the health literature published between 1990 and 2019?

METHODS

A scoping review across five databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus; August 2019) to identify all peer-reviewed literature published since 1990 that focused on the concept of centredness in any healthcare discipline or setting. Screening occurred in duplicate by a multidisciplinary, multinational team. The team met regularly to iteratively develop and refine a coding template that was used in analysis and discuss the interpretations of centredness reported in the literature.

RESULTS

A total of 23 006 title and abstracts, and 499 full-text articles were screened. A total of 159 articles were included in the review. Most articles were from the USA, and nursing was the disciplinary perspective most represented. We identified nine elements of centredness: Sharing power; Sharing responsibility; Therapeutic relationship/bond/alliance; Patient as a person; Biopsychosocial; Provider as a person; Co-ordinated care; Access; Continuity of care. There was little variation in the concept of centredness no matter the preceding word (eg, patient-/person-/client-), healthcare setting or disciplinary lens. Improving health outcomes was the most common justification for pursuing centredness as a concept, and respect was the predominant driving value of the research efforts. The patient perspective was rarely included in the papers (15% of papers).

CONCLUSIONS

Centredness is consistently conceptualised, regardless of the preceding word, disciplinary lens or nation of origin. Further research should focus on centring the patient perspective and prioritise research that considers more diverse cultural perspectives.

Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients

An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient’s values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient’s perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient’s relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD.

Expanding the conversation: A Person-centred Communication Enhancement Model

The intricacy and impact of human communication has long captured the attention of philosophers, scholars and practitioners. Within the realm of care and service provision, efforts to maximize outcomes through optimal person-provider communication have drawn research and clinical focus to this area for several decades. With the dawning of the person-centred care movement within healthcare, and in particular long-term care home and dementia care settings, improvement in care providers’ use of person-centred communication strategies and enhancement of relationships between residents, their families and care providers are desired outcomes. Thus, several person-centred care and communication theoretical perspectives have been employed to ground study in this field. However, a comprehensive theoretical position to underpin person-centred communication in dementia and older adult research does not exist to our knowledge. To offer expansion to the theoretical work in this emerging field, a Person-Centred Communication Enhancement Model for long-term care and dementia care is proposed, as well as rationale for its development. This discussion will also provide an overview and critique of the extant philosophies, theories, frameworks and models that have been utilized in the study of person-centred communication within the context of long-term care and dementia care.

Clinical reasoning as midwifery: A Socratic model for shared decision making in person-centred care

Shared decision making has become the standard of care, yet there remains no consensus about how it should be conducted. Most accounts are concerned with threats to patient autonomy, and they address the dangers of a power imbalance by foregrounding the patient as a person whose complex preferences it is the practitioner's task to support. Other corrective models fear that this level of mutuality risks abdicating the practitioner's responsibilities as an expert, and they address that concern by recovering a nuanced but genuinely directive clinical role. Cribb and Entwistle helpfully categorize models of shared decision making as 'narrower' and 'broader' and praise the latter's 'open-ended and fully dialogical ways of relating'. However, they stop short of providing a philosophical account of how that dialogue works. In this paper, a nurse-midwife and a philosopher collaborate to argue that the Socratic model of dialogue offers a solution to the practitioner-patient dilemma. In the Theaetetus, Socrates compares dialogical reasoning to 'midwifery with all its standard features'. By means of a three-way analogy, elements of midwifery practice are used to illuminate features of Socrates' claim that his dialogue is like midwifery; those features are then translated into an approach to shared decision making as the 'midwifery of good thinking' which both midwives and physicians would do well to adopt. A key concept that emerges is the need for practitioners to make a risk-confidence assessment of the particular content of any decision to appropriately modulate their role in the practice of shared decision making.

Stakeholder Research Priorities to Promote Implementation of Shared Decision-Making for Lung Cancer Screening: An American Thoracic Society and Veterans Affairs Health Services Research and Development Statement

Rationale: Shared decision-making (SDM) for lung cancer screening (LCS) is recommended in guidelines and required by Medicare, yet it is seldom achieved in practice. The best approach for implementing SDM for LCS remains unknown, and the 2021 U.S. Preventive Services Task Force calls for implementation research to increase uptake of SDM for LCS. Objectives: To develop a stakeholder-prioritized research agenda and recommended outcomes to advance implementation of SDM for LCS. Methods: The American Thoracic Society and VA Health Services Research and Development Service convened a multistakeholder committee with expertise in SDM, LCS, patient-centered care, and implementation science. During a virtual State of the Art conference, we reviewed evidence and identified research questions to address barriers to implementing SDM for LCS, as well as outcome constructs, which were refined by writing group members. Our committee (n = 34) then ranked research questions and SDM effectiveness outcomes by perceived importance in an online survey. Results: We present our committee's consensus on three topics important to implementing SDM for LCS: 1) foundational principles for the best practice of SDM for LCS; 2) stakeholder rankings of 22 implementation research questions; and 3) recommended outcomes, including Proctor's implementation outcomes and stakeholder rankings of SDM effectiveness outcomes for hybrid implementation-effectiveness studies. Our committee ranked questions that apply innovative implementation approaches to relieve primary care providers of the sole responsibility of SDM for LCS as highest priority. We rated effectiveness constructs that capture the patient experience of SDM as most important. Conclusions: This statement offers a stakeholder-prioritized research agenda and outcomes to advance implementation of SDM for LCS.

Patient Reported Experience Measure in Endoscopic Ultrasonography: The PREUS Study Protocol

The evaluation of the patient’s experience is becoming increasingly important as a better patient experience can improve the quality of the health service delivered. Patient-reported experience measures (PREMs) are self-report assessment tools provided to patients about their experience during any health event. There are few PREM instruments in the field of gastrointestinal endoscopy, and none is specific for endoscopic ultrasound (EUS). This study aims to develop a questionnaire to evaluate the experience of patients undergoing EUS, identifying and prioritizing the factors related to the patient’s experience. The study will consist of several phases: (A) tool creation; (B) face and content validity; (C) ranking: to evaluate the relevance of the identified questions in the previous phase; (D) questionnaire creation and validity testing. The final output will be the production of a specific tool that can be used to measure patients’ experience during EUS. This questionnaire may become a relevant part of actions taken to measure the quality of care provided to patients undergoing EUS. Furthermore, correlation between health care providers’ and patients’ views of the relevance of the included items will allow optimization of empathetic and psychological aspects.

Working towards integrated client-oriented care and services: A qualitative study of the perceptions of Finnish health and social care professionals

Introduction

Client orientation is an essential principle that underlines the delivery of high-quality health and social care. Despite this, little is known about how the health and social care professionals perceive this principle. The aim of this qualitative study was to describe the integrated perceptions of health and social care professionals of client orientation and the requirements for competencies and care and service systems.

Methods

The 29 participants were Finnish health and social care professionals and the data were collected with asynchronous online discussions in a closed Internet-based group from November 2017 to January 2018 and analysed with inductive content analysis.

Results

Client orientation was a core value in health and social care and services due to the humane approach required and the client's rights and responsibilities. It also required the professionals to have specific competencies and collaborate. The system elements that supported client orientation were an integrating and responsive service system, service availability and accessibility, guidance, leadership, resources and the effective use of technology.

Discussion

Professionals need additional training and structural support from their organizations if they were to deliver efficient, flexible, high-quality client-oriented health and social care and services.

Implementing Shared Decision-Making for Lung Cancer Screening across a Veterans Health Administration Hospital Network

Shared-decision making (SDM) for lung cancer screening (LCS) is recommended by multiple organizations, reflecting a larger movement towards patient-centered care. Yet SDM for LCS does not routinely occur due to barriers at multiple levels. Moreover, how best to implement SDM into routine clinical practice remains unknown. There is a need for a novel approach to overcome multi-level barriers and ensure high-quality SDM for LCS is integrated into routine practice. We present the protocol for our US Department of Veteran Affairs (VA) funded study. Our protocol is designed to implement and evaluate a multi-level, tailored approach to SDM for LCS in routine clinical practice within the VA New England Health Care Network, comprising eight medical centers. In this prospective, pragmatic hybrid implementation-effectiveness study, we will first conduct a formative evaluation of barriers to SDM for LCS at each level of the socioecological model, which will inform our tailored implementation plan. We will then sequentially introduce components of our tailored, multi-level approach to implementing SDM for LCS across VA New England. Finally, using mixed methods, we will evaluate the implementation and its impact on Effectiveness (primary outcome, defined as patient-centeredness of SDM), as well as implementation outcomes informed by the RE-AIM implementation science framework (i.e., Reach to patients, Adoption by providers, Implementation fidelity). Tailored implementation will address identified challenges to achieving policy recommendations for SDM for LCS in VA New England, inform nationwide implementation of SDM for LCS, and address stakeholder interests in promoting more patient-centered interactions across the VA.

Mothers' experiences of client-centred flexible planning in home-based postpartum care: A promising tool to meet their diverse and dynamic needs

OBJECTIVE

To explore mothers' perspectives and experiences when facilitating greater flexibility in the planning range of home-based postpartum care, as an innovative tool to more client-centred care.

DESIGN

A qualitative study design with semi-structured in-depth interviews.

SETTING

The study was executed in collaboration with a postpartum care organisation in the Netherlands. It was part of a larger research project that studied the health effects of a new way of planning home-based postpartum care. This so-called 'flexible planning' made spreading and pausing of care possible up to the 14^th day postpartum instead of the standard care planning up to the 8^th day postpartum.

PARTICIPANTS

Mothers eligible to be interviewed for this study were participants of the larger research project who were allowed to plan their care according to the flexible planning. Twenty-one mothers were recruited through purposive sampling, of which ten were first-time mothers.

FINDINGS

Mothers valued the flexible planning as the timing of care could be tailored to their personal preferences and contexts. Yet, two main challenges were found: 1. mothers experienced difficulties in communicating and translating their dynamic needs into a care planning and 2. they felt discomfort in assigning tasks to care workers. Besides, our findings showed that care workers' practical as well as their emotional support (i.e. 'doing' vs. 'being') are greatly important in responding to mothers' needs.

KEY CONCLUSIONS

A flexible planning is a promising tool to facilitate more client-centred care in the postpartum care period. Yet, the hectic and overwhelming nature of the first few postpartum days can complicate the forward planning of care. In addition, not knowing what to expect from the postpartum care period and having a main focus on care workers 'doing' can lead to unclear and undesired working relations.

IMPLICATIONS FOR PRACTICE

When planning care in practice, a dialogue should be held between care workers and parents in which both their fields of expertise are respected. Above all, our study elucidated that novel care innovations like ours need to be co-created directly from the start with all involved parties to truly be successful.

Personal values as early predictors of emotional and cognitive empathy among medical students

The present study contributes to the literature by examining the association between personal values (PVs), assessed with the Schwartz’s Portrait Values Questionnaire, and empathy, assessed with the Davis’ Interpersonal Reactivity Index, in a sample of first-year medical students. We also examined medical students’ PVs profile and gender differences in terms of PVs. All participants (N = 398) were Italian, young (average age = 19.62 years, SD = 1.22), and unmarried; none had children. Zero-order correlations and hierarchical multiple regression models were performed to verify the association between PVs and empathy; in contrast, t-tests were run to explore gender differences in scoring on PVs. Benevolence and Universalism correlated positively with both the emotional and cognitive dimensions of empathy, whereas Power, Achievement, Hedonism, and Security were negatively associated with empathy. The three most important PVs in the whole sample were Benevolence, Self-Direction, and Universalism. Male medical students outscored their female counterparts on Power, Achievement, and Hedonism, whereas female students outscored the males on Benevolence, Universalism, Conformity, and Tradition. Our findings highlight the importance of fostering self-transcending PVs and discouraging self-enhancing PVs in medical students during the early years of medical school, as a means of supporting other-oriented responses such as empathy in future doctors.

Shared Decision-Making and Medicolegal Aspects: Delivering High-Quality Cancer Care in India

It is often difficult for people with cancer to make decisions for their care. The aim of this review is to understand the importance of shared decisionmaking (SDM) in Indian clinical scenario and identify the gaps when compared to practices in the Western world. A systematic search (2000-2019) was executed in Medline and Google Scholar using predefined keywords. Of the approximate 400 articles retrieved, 43 articles (Indian: 5; Western: 38) were selected for literature review. Literature review revealed the paucity of information on SDM in India compared to the Western world data. This may contribute to patientreported physical or psychological harms, life disruptions, or unnecessary financial costs. Western world data demonstrate the involvement and sharing of information by both patient and physician, collective efforts of the two to build consensus for preferred treatment. In India, involvement of patients in the planning for treatment is largely limited to tertiary care centers, academic institutes, or only when the cost of therapy is high. In addition, cultural beliefs and prejudices impact the extent of participation and engagement of a patient in disease management. Communication failures have been found to strongly correlate with the medicolegal malpractice litigations. Research is needed to explore ways to how to incorporate SDM into routine oncology practice. India has a high unmet need towards SDM in diagnosis and treatment of cancer. Physicians need to involve patients or their immediate family members in decision making, to make it a patient-centric approach as well. SDM enforces to avoid uninformed decisionmaking or a lack of trust in the treating physician's knowledge and skills. Physician and patient education, development of tools and guiding policies, widespread implementation, and periodic assessments may advance the practice of SDM.

Loss of patient centeredness in interpreter-mediated primary care visits

OBJECTIVES

To explore consequences of interpreter mediation of visit communication on patient centered dialogue and patient satisfaction with interpreter listening.

METHODS

Fifty-five professionally interpreted primary care visits were coded using the Roter Interaction Analysis System (RIAS). Two corresponding quantitative measures of patient-centered dialogue were calculated as ratios of psycho-emotional to biomedical statements based on (1) patient and clinician expressed codes and (2) interpreter conveyed codes. Multilevel models examined consequences of interpreter mediation on patient-centered dialogue and patient ratings of interpreter listening.

RESULTS

Study participants included 27 Cantonese, 17 Mandarin and 11 Spanish-speaking primary care patients and 31 of their clinicians. Overall, clinicians expressed 2.26 times more statements and patients expressed 1.74 times more statements than interpreters conveyed. Interpreters conveyed significantly less patient-centered dialogue than expressed by patients and clinicians. All differences were evident within each study language. Interpreter conveyed patient centered dialogue positively predicted patient ratings of interpreter listening (B = 0.817; p < .007).

CONCLUSIONS

The level of interpreter-conveyed patient-centered dialogue was both substantially lower than that expressed by patients and clinicians and a positive predictor of patient satisfaction with interpreter listening.

PRACTICE IMPLICATIONS

Fuller interpretation of patient-centered dialogue may enhance patient experience with interpreters and thereby increase care quality.

Qualitative exploration of factors associated with shared decision-making in diabetes management: a health care provider's perspective

OBJECTIVE

Internationally, patient-doctor interaction has shifted from the paternalist model to the shared decision-making (SDM) model, which is an essential part of effective management of chronic illnesses, especially diabetes. It is a relatively new concept in Pakistan, and data about healthcare providers' perspectives are lacking. The aim was to explore significant facilitators and barriers to effective SDM as perceived by endocrinologists.

DESIGN

A qualitative research using in-depth interviews based on grounded theory was done. It was written in line with the Consolidated Criteria for Reporting Qualitative Research checklist.

SETTING

The interviews were conducted at the workplace of the endocrinologist between April and July 2019.

PARTICIPANTS

Prominent endocrinologists of Pakistan residing in Lahore were approached for in-depth interviews. The transcripts were analyzed simultaneously, and theme saturation was achieved in 11 interviews.

MAIN OUTCOME MEASURES

Thematic analysis of data done using grounded theory.

RESULTS

Four major and two minor themes were identified. The most cited barriers to effective SDM from the doctors' side were the shortage of time during consultations and the absence of formal training of clinicians in communication skills. However, the patients' hesitation in questioning the doctor, perceiving him as a paternalist 'messiah' in society and lack of education limits their ability to understand and comprehend treatment options.

CONCLUSION

There are many barriers perceived by providers as well as clients/patients by effectively using SDM. Local cultural context is influencing a lot.

The Integration of Resource Patients in Collaborative Research: A Mixed Method Assessment of the Nesting Dolls Design

OBJECTIVES

This is a quality assessment of a research design developed for a collaborative study on adolescents and young adults who survived a brain tumor.

METHODS

A descriptive and critical mixed methods approach was used to assess the design itself, the quality and information power of the database and the integration of collaborators. Project documentation, field notes and transcripts from focus groups interviews(n = 19) were used for the evaluation, which was based on the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

The design proved to be pertinent to resolve methodological stakes in a "fragile field". The mobilisation of collaborators as members of a "Sherpa team" in all phases of the project helped the team create a progressive focus approach well-adapted for data gathering and analysis as well as produce a high-quality database.

CONCLUSION

The Nesting Dolls Design including the didactic approach developed along the deployment of the project helped researchers, clinicians and resource patients/parents understand the research procedures and the roles of all collaborators. This fostered a meaningful engagement in the project.

PRACTICE IMPLICATIONS

Resources and time for training, communication and supervision are necessary to reach the objectives of collaborative research involving novices and are worth the time and efforts.

Effect of medical students' values on their clinical decision-making

INTRODUCTION Personal and professional values of health-care practitioners influence their clinical decisions. AIM To investigate how medical students' values influence their clinical decisions. METHODS Values of 117 medical students were measured using an instrument we developed, the Healthcare Practitioner Values Scale. Factors that students consider in clinical decision-making were identified in four clinical scenarios using qualitative coding. Differences in values between students who considered given factors in decision-making and students who did not consider the same factors were analysed. Random effects models were used to investigate which differences were explained by variation in the clinical scenarios and factors considered in decision-making. RESULTS Six factors that students consider in clinical decision-making were identified and grouped into three categories: patient-centred (patient perspective, family and social circumstances); clinical (patient safety, symptoms and treatment efficacy); and situational factors (health-care practitioner self-awareness and service cost). Students who prioritised spirituality placed more emphasis on patient-centred factors, and less emphasis on clinical factors in different scenarios; students who prioritised critical thinking placed less emphasis on patient-centred factors; and students who prioritised capability, professionalism and safety values placed more emphasis on situational factors. Total proportion of variance in value differences explained by factors and clinical scenarios was 25.2% for spirituality and 56.2% for critical thinking. DISCUSSION Students who prioritise different values consider different factors in their clinical decisions. Spirituality and critical thinking values are more likely to influence students' decision-making approaches than other values. Improving students' awareness of how their own values influence their decisions can help them improve their clinical decision-making.

Moral competence, moral teamwork and moral action - the European Moral Case Deliberation Outcomes (Euro-MCD) Instrument 2.0 and its revision process

Background

Clinical Ethics Support (CES) services are offered to support healthcare professionals in dealing with ethically difficult situations. Evaluation of CES is important to understand if it is indeed a supportive service in order to inform and improve future implementation of CES. Yet, methods to measure outcomes of CES are scarce. In 2014, the European Moral Case Deliberation Outcomes Instrument (Euro-MCD) was developed to measure outcomes of Moral Case Deliberation (MCD). To further validate the instrument, we tested it in field studies and revised it. This paper presents the Euro-MCD 2.0 and describes the revision process.

Methods

The revision process comprised an iterative dialogue among the authors as Euro-MCD-project team, including empirical findings from six Euro-MCD field-studies and input from European experts in CES and theory. Empirical findings contained perceptions and experiences of MCD outcomes among healthcare professionals who participated in MCDs in various settings in Norway, Sweden and the Netherlands. Theoretical viewpoints on CES, literature on goals of CES and MCD and ethics theory guided the interpretation of the empirical findings and final selection of MCD outcomes.

Results

The Euro-MCD 2.0 Instrument includes three domains: Moral Competence, Moral Teamwork and Moral Action. Moral Competence consists of items about moral sensitivity, analytical skills and virtuous attitude. Moral Teamwork includes open dialogue and supportive relationships and Moral Action refers to moral decision-making and responsible care. During the revision process, we made decisions about adding and reformulating items as well as decreasing the number from 26 to 15 items. We also altered the sentence structure of items to assess the current status of outcomes (e.g. ‘now’) instead of an assumed improvement over time (e.g. ‘better’) and we omitted the question about perceived importance.

Conclusions

The Euro-MCD 2.0 is shorter, less complex and more strongly substantiated by an integration of empirical findings, theoretical reflections and dialogues with participants and experts. Use of the Euro-MCD 2.0 will facilitate evaluation of MCD and can thereby monitor and foster implementation and quality of MCD. The Euro-MCD 2.0 will strengthen future research on evaluation of outcomes of MCD.

An evaluation of the facilitator training to implement 'Taking charge of my life and health', a peer-led group program to promote self-care and patient empowerment in Veteran participants

OBJECTIVE

We developed a peer-led group program for Veterans called Taking Charge of My Life and Health (TCMLH) that emphasizes patient education, goal setting, shared decision making, and whole person care. Our aim was to conduct an evaluation of a facilitator training course to deliver TCMLH in VA sites.

METHODS

Repeated measures ANOVA models were used to examine change over three timepoints (pre-test, post-test, and two-month follow-up) in outcomes of attitudes, knowledge, skills, and self-efficacy related to patient empowerment, skills acquisition, self-care strategies, and curriculum facilitation. Qualitative data analysis of participant feedback was used to identify potential training adaptations and barriers to TCMLH delivery.

RESULTS

Our sample comprised 70 trainees who completed all three assessments. Participants reported high levels of training satisfaction, quality, and utility, and sustained improvements in knowledge of Whole Health, self-efficacy for group facilitation, and self-efficacy for using Whole Health concepts and tools. Implementation barriers included challenges related to group management and site logistics.

CONCLUSION

The facilitator training course improved knowledge and self-efficacy associated with successful peer-led program delivery and identified opportunities to improve the training course and TCMLH dissemination.

PRACTICE IMPLICATIONS

Findings provide insights on the design and implementation of training models to support peer-led programs.

Scoping review of the person-centered literature in adult physical rehabilitation

PURPOSE

To describe the amount, range, and key characteristics (e.g., publication years, methods, topics) of the person-centered rehabilitation literature in adults with physical impairments.

METHOD

Following the published scoping review protocol, papers were identified through: three major databases, snowball searches and expert consultation. Two independent reviewers have identified English-language papers on adult person-centered rehabilitation according to six pre-defined inclusion categories - theoretical, quantitative and qualitive research papers are included; and then have extracted their key characteristics (e.g., aims, methods, participants). Descriptive statistics, regression and content analyses were used to synthesize the results.

RESULTS

Of 5912 deduplicated records initially screened, 170 papers were included: 136 empirical, including 13 systematic reviews. Empirical papers had data from 15264 clients and 4098 providers, in total. Yearly publications grew significantly from 2009 to 2018 (r² = 0.71; b = 1.98: p < 0.01). Publications were unevenly distributed by countries (e.g., United States' publications per population was 44 times lower than New Zealand's). Most papers focused in more than one profession, setting-type or health conditions. Finally, many empirical papers (n = 67) studied implementation of person-centered rehabilitation approaches, including its effect.

CONCLUSION

This scoping review synthesizes key characteristics and publication trends in the person-centered rehabilitation literature on adults with physical impairments, a growing but unchartered territory thus far. This large and diverse body of literature can ground further person-centered rehabilitation practices and research, including toward building a transdisciplinary, trans-service model of person-centered rehabilitation.Implications for rehabilitationThe person-centered rehabilitation literature on adults with physical impairments, especially the empirical one, has been growing significantly over time, despite inequitably distributed per countries.Rehabilitation stakeholders, including practitioners, have a growing amount of literature in which they can rely for the operationalization and implementation of person-centered rehabilitation approaches into routine practice.Based on our work, person-centered rehabilitation emerges as a practice requirement that cuts across professional and other rehabilitation silos.

Development of the concept of patient-centredness - A systematic review

OBJECTIVE

Patient-centredness is often linked to high-quality patient care, but the concept is not well-defined. This study aims to provide an overview of how patient-centredness has been defined in the literature since Mead and Bower's review in 2000, and to provide an updated definition of the concept.

METHOD & DESIGN

We performed a systematic literature search in PubMed to identify original articles with a sufficient definition of patient-centredness. We analysed extracted data defining patient-centredness.

RESULTS

Eighty articles were included. The dimensions "biopsychosocial", "patient-as-person", "sharing power and responsibility" and "therapeutic alliance" corresponded to four of five dimensions described by Mead and Bower. "Coordinated care" was a new dimension.

CONCLUSION

The identified dimensions are encompassed by three elements: the patient, the doctor-patient relationship and the framework of care i.e. the health care system. The additional focus on coordinated care could reflect increasing complexity of the health care system.

PRACTICE IMPLICATIONS

Narrowing down the understanding of patient-centredness to these three focus areas, viz. 1) understanding of the patients' experience of the illness in their life situation, 2) the professional's relationship with the patient, and 3) coordination of care in the system, could make the operationalisation and implementation of a patient-centred approach more manageable.

Giving birth after caesarean: Identifying shared preferences among pregnant women using Q methodology

BACKGROUND

Caesarean rates are rising worldwide, the main contributor being the elective repeat caesarean. During the past decades, rates of vaginal birth after caesarean dropped considerably. This requires insight in women's preferences regarding giving birth following a previous caesarean.

AIM

To gain a better understanding of women's values and preferences regarding the upcoming birth following a previous caesarean. Using Q methodology, this study systematically explores and categorises their preferences.

METHODS

Q methodology is an innovative research approach to explore and compare a variety of viewpoints on a certain subject. Thirty-one statements on birth after caesarean were developed based on the health belief model. Thirty-six purposively sampled pregnant women with a history of caesarean ranked these statements from least to most important. By-person factor analysis was used to identify patterns which, supplemented with interview data, were interpreted as preferences.

FINDINGS

Three distinct preferences for giving birth after a caesarean were found; (a) "Minimise the risks for me and my child", giving priority to professional advice and risk of adverse events, (b) "Seek the benefits of normal birth", desiring to give birth as normal as possible for both emotional and practical reasons, (c) "Opt for repeat caesarean", expressing the belief that a planned caesarean brings comfort.

CONCLUSIONS

Preferences for birth after caesarean vary considerably among pregnant women. The findings help to understand the different types of information valued by women who need to decide on their mode of birth after a first caesarean.

Ethical and moral considerations of (patient) centredness in nursing and healthcare: Navigating uncharted waters

This discussion paper aims to explore potential ethical and moral implications of (patient) centredness in nursing and healthcare. Healthcare is experiencing a philosophical shift from a perspective where the health professional is positioned as the expert to one that re-centres care and service provision central to the needs and desires of the persons served. This centred approach to healthcare delivery has gained a moral authority as the right thing to do. However, little attention has been given to its moral and ethical theoretical grounding and potential implications for nurses, persons served and the healthcare system. Based upon a review of academic and grey literature, centredness is proposed as a value-laden concept in nursing inquiry. Potential moral and ethical implications of centredness on nurses/healthcare providers, persons served and the healthcare system are discussed. These challenges are then considered within the context of normative and relational ethical theories. These perspectives may offer guidance relative to how one should act in those circumstances as well as an understanding as to how interdependency and engagement with the other person(s) can help navigate the challenges of a centred care approach. Viewing centredness through an ethical theoretical lens provides a valuable discourse to nursing in efforts to expand the knowledge base and integrate centred approaches into practice and policy.

Case Study Application of an Ethical Decision-Making Process for a Fragility Hip Fracture Patient

In Canada, up to 32,000 older adults experience a fragility hip fracture. In Ontario, the Ministry of Health and Long Term Care has implemented strategies to reduce surgical wait times and improve outcomes in target areas. These best practice standards advocate for immediate surgical repair, within 48 hours of admission, in order to achieve optimal recovery outcomes. The majority of patients are good candidates for surgical repair; however, for some patients, given the risks of anesthetic and trauma of the operative procedure, surgery may not be the best choice. Patients and families face a difficult and hurried decision, often with no time to voice their concerns, or with little-to-no information on which to guide their choice. Similarly, health-care providers may experience moral distress or hesitancy to articulate other options, such as palliative care. Is every fragility fracture a candidate for surgery, no matter what the outcome? When is it right to discuss other options with the patient? This article examines a case study via an application of a framework for ethical decision-making.

Measuring the patient experience in community mental health services for older people: A study of the Net Promoter Score using the Friends and Family Test in England

OBJECTIVES

The research aimed to explore the value of the Net Promoter Score as a service improvement tool and an outcome measure. The study objectives were to (1) explore associations between the Net Promoter Score with patient and service-receipt characteristics; (2) evaluate the strength of association between the Net Promoter Score and a satisfaction score; and (3) evaluate its test-retest reliability.

METHODS

A postal survey was sent to service users on caseloads of community mental health teams for older people in four localities of England. The survey collected the Net Promoter Score, a single satisfaction question, and data on socio-demographics, clinical profile, and service receipt. Analysis used non-parametric tests of association and exploratory least squares regression. A second survey was administered for test-retest reliability analysis. Fieldwork concluded in April 2016.

RESULTS

For 352 respondents, the Net Promoter Score was negatively related to age and was lowest for those still within 6 months of their initial referral. Receiving support from a psychiatrist and/or support worker was linked to higher scores. A strong but imperfect correlation coefficient with the satisfaction score indicates they evaluate related but distinct constructs. It had a reasonable test-retest reliability, with a weighted kappa of 0.706.

CONCLUSIONS

Despite doubts over its validity in community mental health services, the Net Promoter Score may produce results of value to researchers, clinicians, service commissioners, and managers, if part of wider data collection. However, multi-item measures would provide greater breadth and improved reliability.

The moral discourse of HIV providers within their organizational context: An ethnographic case study

OBJECTIVE

Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts.

METHODS

Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes.

RESULTS

We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges.

CONCLUSIONS AND PRACTICE IMPLICATIONS

When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.

Reconciling the theory and reality of shared decision-making: A "matching" approach to practitioner leadership

Shared decision making (SDM) evolved to resolve tension between patients’ entitlement to make health‐care decisions and practitioners’ responsibility to protect patients’ interests. Implicitly assuming that patients are willing and able to make “good” decisions, SDM proponents suggest that patients and practitioners negotiate decisions. In practice, patients often do not wish to participate in decisions, or cannot make good decisions. Consequently, practitioners sometimes lead decision making, but doing so risks the paternalism that SDM is intended to avoid. We argue that practitioners should take leadership when patients cannot make good decisions, but practitioners will need to know: (a) when good decisions are not being made; and (b) how to intervene appropriately and proportionately when patients cannot make good decisions. Regarding (a), patients rarely make decisions using formal decision logic, but rely on informal propositions about risks and benefits. As propositions are idiographic and their meanings context‐dependent, normative standards of decision quality cannot be imposed. Practitioners must assess decision quality by making subjective and contextualized judgements as to the “reasonableness” of the underlying propositions. Regarding (b), matched to judgements of reasonableness, we describe levels of leadership distinguished according to how directively practitioners act; ranging from prompting patients to question unreasonable propositions or consider new propositions, to directive leadership whereby practitioners recommend options or deny requested procedures. In the context of ideas of relational autonomy, the objective of practitioner leadership is to protect patients’ autonomy by supporting good decision making, taking leadership in patients’ interests only when patients are unwilling or unable to make good decisions.

Conscientious objection and person-centered care

Person-centered care offers a promising way to manage clinicians' conscientious objection to providing services they consider morally wrong. Health care centered on persons, rather than patients, recognizes clinicians and patients on the same stratum. The moral interests of clinicians, as persons, thus warrant as much consideration as those of other persons, including patients. Interconnected moral interests of clinicians, patients, and society construct the clinician as a socially embedded and integrated self, transcending the simplistic duality of private conscience versus public role expectations. In this milieu of blurred boundaries, person-centered care offers a constructive way to accommodate conscientious objection by clinicians. The constitutionally social nature of clinicians commits and enables them, through care mechanisms such as self-care, to optimize the quality of health care and protect the welfare of patients. To advance these conditions, it is recommended that the medical profession develop a person-centered culture of care, along with clinician virtues and skills for person-centered communication.

Caregiver burden and the medical ethos

Are physicians sometimes morally required to ease caregiver burden? In our paper we defend an affirmative answer to this question. First, we examine the well-established principle that medical care should be centered on the patient. We argue that although this principle seems to give physicians some leeway to lessen caregivers' suffering, it is very restrictive when spelled out precisely. Based on a critical analysis of existing cases for transcending patient-centeredness we then go on to argue that the medical ethos should indeed contain a rule requiring physicians to alleviate caregiver burden under certain circumstances. Finally, we apply our findings to deep brain stimulation (DBS) for Parkinson's disease. We present empirical data from a recent study of DBS indicating that spousal caregivers of Parkinson patients treated with DBS are sometimes deeply troubled by the effects of the therapy and discuss what moral obligations the treating physicians may have in such cases.

Analyzing Knowledge Construction in Online Health Group Discussion

The ongoing transition to the patient-centred healthcare paradigm suggests that patients adopt an active role in managing their health conditions. As a result, the Internet is becoming an important source of health-related information. Internet-based health support groups allow patients to access diverse information relevant to their particular situation by participating in online discussions. The quality of such information may have effects on the patients’ health outcomes. The purpose of the present study was to investigate the effects of knowledge construction in health support group online discussions on perceived information quality, information quality from the perspective of information consumers, and on information integrity, that is, validity from the point of view of the current state of scientific knowledge. It was hypothesised that knowledge construction results in better perceived information quality and in higher information integrity. A health support group online discussion site devoted to weight management was used as a source of data. Quantitative content analysis was used with a discussion thread as a unit of analysis. Based on the findings, the study suggested that moderators of health support group online discussions should promote explicitation or lower level knowledge construction by encouraging clarifications and refinements of health-related recommendations. Moreover, participation of qualified health practitioners is desirable to promote health-related behaviours based on evidence-based knowledge and to expose recommendations that have uncertain or even dangerous effects.

Nephrologists' Perspectives on Defining and Applying Patient-Centered Outcomes in Hemodialysis

BACKGROUND AND OBJECTIVES

Patient centeredness is widely advocated as a cornerstone of health care, but it is yet to be fully realized, including in nephrology. Our study aims to describe nephrologists' perspectives on defining and implementing patient-centered outcomes in hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Face-to-face, semistructured interviews were conducted with 58 nephrologists from 27 dialysis units across nine countries, including the United States, the United Kingdom, Australia, Austria, Belgium, Canada, Germany, Singapore, and New Zealand. Transcripts were thematically analyzed.

RESULTS

We identified five themes on defining and implementing patient-centered outcomes in hemodialysis: explicitly prioritized by patients (articulated preferences and goals, ascertaining treatment burden, defining hemodialysis success, distinguishing a physician-patient dichotomy, and supporting shared decision making), optimizing wellbeing (respecting patient choice, focusing on symptomology, perceptible and tangible, and judging relevance and consequence), comprehending extensive heterogeneity of clinical and quality of life outcomes (distilling diverse priorities, highly individualized, attempting to specify outcomes, and broadening context), clinically hamstrung (professional deficiency, uncertainty and complexity in measurement, beyond medical purview, specificity of care, mechanistic mindset [focused on biochemical targets and comorbidities], avoiding alarm, and paradoxical dilemma), and undermined by system pressures (adhering to overarching policies, misalignment with mandates, and resource constraints).

CONCLUSIONS

Improving patient-centered outcomes is regarded by nephrologists to encompass strategies that address patient goals and improve wellbeing and treatment burden in patients on hemodialysis. However, efforts are hampered by ambiguities about how to prioritize, measure, and manage the plethora of critical comorbidities and broader quality of life outcomes in a care setting that is technically demanding and driven by biochemical targets. Identifying critical patient-important outcomes and mechanisms for integrating them into practice may help to deliver patient-centered care in hemodialysis and other chronic disease settings.

Differences that matter: developing critical insights into discourses of patient-centeredness

Patient-centeredness can be considered a popular, and at the same time "fuzzy", concept. Scientists have proposed different definitions and models. The present article studies scientific publications that discuss the meaning of patient-centeredness to identify different "discourses" of patient-centeredness. Three discourses are presented; the first is labelled as "caring for patients", the second as "empowering patients" and the third as "being responsive". Each of these discourses has different things to say about (a) the why of patient-centeredness; (b) the patient's identity; (c) the role of the healthcare professional; (d) responsibilities for medical decision-making, and (e) the role of health information. This article compares and contrasts the discourses in ways that allow us to see differences that matter for practitioners in healthcare. On the basis of a relational constructionist philosophy, it is argued that discursive diversity is both an inevitable and a potentially valuable aspect of conversations in healthcare. We are therefore invited to center the challenge of dealing with diversity in productive ways. This article ends with a discussion of the practical implications of the discourse analysis for projects that aim to make healthcare more patient-centered. Debates on patient-centered "Health Information Exchange" are used to explain the need for a recognition of different discourses of patient-centeredness and a reflexive stance towards them.

Examining chronic care patient preferences for involvement in health-care decision making: the case of Parkinson's disease patients in a patient-centred clinic

Background

Patient‐centred care is a recommended model of care for Parkinson's disease (PD). It aims to provide care that is respectful and responsive to patient preferences, values and perspectives. Provision of patient‐centred care should entail considering how patients want to be involved in their care.

Objective

To understand the participation preferences of patients with PD from a patient‐centred care clinic in health‐care decision‐making processes.

Design, setting and participants:

Mixed‐methods study with early‐stage Parkinson's disease patients from a patient‐centred care clinic. Study involved a modified Autonomy Preference Index survey (N=65) and qualitative, semi‐structured in‐depth interviews, analysed using thematic qualitative content analysis (N=20, purposefully selected from survey participants). Interviews examined (i) the patient preferences for involvement in health‐care decision making; (ii) patient perspectives on the patient–physician relationship; and (iii) patient preferences for communication of information relevant to decision making.

Results

Preferences for participation in decision making varied between individuals and also within individuals depending on decision type, relational and contextual factors. Patients had high preferences for communication of information, but with acknowledged limits. The importance of communication in the patient–physician relationship was emphasized.

Discussion

Patient preferences for involvement in decision making are dynamic and support shared decision making. Relational autonomy corresponds to how patients envision their participation in decision making. Clinicians may need to assess patient preferences on an on‐going basis.

Conclusion

Our results highlight the complexities of decision‐making processes. Improved understanding of individual preferences could enhance respect for persons and make for patient‐centred care that is truly respectful of individual patients’ wants, needs and values.

Medical Staff’s Opinions Regarding Factors which Influence the Case Management of Children with Insulin-dependent Diabetes Mellitus

Insulin-dependent diabetes mellitus (IDDM) is a chronic disease with high incidence, especially in children, and for a better outcome the individual case management is required. The patient and his family can experience different levels of anxiety, with negative effects on disease evolution and prognosis.

Objectives: identify relevant factors which influence the case management of children with IDDM. The implementation of the results of this study will help to elaborate an efficient method of intervention for improving the treatment adherence and obtaining a better outcome of IDDM in children.

Methods: A semi-structured interview was done individually to 10 experts in diabetes for collecting their opinion concerning relevant factors that may influence treatment adherence and what are the characteristics of an efficient method of intervention.

Results: Majority of experts considered that the main factor which influences the outcome is doctor-patient relationship. The need of child, to feel that it is understood and protected, was considered that can directly motivate a better self-management and a good outcome. The increase of importance of individual resources of children with IDDM and accent on the quality of life of those children could be considered a starting point for creating a psychological clinic intervention in this field. The results were compared with scientific literature data.

Conclusions: understanding of the causes which have interfered negatively with therapeutic plan is a starting point for develop a clinical - psychological protocol for children with IDDM.

Psychometric evaluation of the Client-Centered Rehabilitation Questionnaire (CCRQ) in a large sample of German rehabilitation patients

Objective:

Structural analysis of the German translation of the “Client-Centered Rehabilitation Questionnaire” (CCRQ).

Design:

Cross-sectional multicenter study.

Setting:

Ten inpatient rehabilitation centers in Germany.

Subjects:

The CCRQ was completed by patients in the ten rehabilitation centers.

Main measures:

The psychometric analysis of the CCRQ was conducted using exploratory and confirmatory factor analysis.

Results:

The CCRQ was completed by 496 patients (average age: 59 years; 59.7% women). The CCRQ’s 7-factor structure could not be confirmed. Factor analysis showed that the three latent constructs “decision-making/communication”, “self-management/empowerment”, and “psychosocial well-being” (60.73% variance explained) adequately represent patient-centeredness in medical rehabilitation assessed by the CCRQ. The scales possess good reliability (Cronbach’s α = .83 to .87) and convergent criterion validity (r = 0.48 to 0.68). The three-factorial model exhibited good local and global data fit (RMSEA: 0.063, CFI 0.962, TLI 0.954) and proved to have a better data fit than concurring models (e.g. a model assuming an underlying factor).

Conclusions:

A validated short form of the Client-Centered Rehabilitation Questionnaire, CCRQ-15, could be identified. Three scales based on 15 items allow assessing the key aspects of patient-centeredness in German medical rehabilitation.

Person-centred rehabilitation: what exactly does it mean? Protocol for a scoping review with thematic analysis towards framing the concept and practice of person-centred rehabilitation

INTRODUCTION

Person-centredness is a philosophy for organising and delivering healthcare based on patients' needs, preferences and experiences. Although widely endorsed, the concept suffers from a lack of detail and clarification, in turn accounting for ambiguous implementation and outcomes. While a conceptual framework based on a systematic review defines person/patient-centred care components (Scholl et al, 2014), it applies across healthcare contexts and may not be sensitive to the nuances of the rehabilitation of adults with physical impairments. Accordingly, this study aims to build a conceptual framework, based on existing literature, of what person-centredness means in the rehabilitation of adults with physical impairments in the clinical encounter and broader health service delivery.

METHODS AND ANALYSIS

We will use a scoping review methodology. Searches on relevant databases will be conducted first, combining keywords for 'rehabilitation', 'person-centered' and associated terms (including patient preferences/experiences). Next, snowball searches (citation tracking, references lists) will be performed. Papers will be included if they fall within predefined selection categories (seen as most likely informative on elements pertaining to person-centred rehabilitation) and are written in English, regardless of design (conceptual, qualitative, quantitative). Two reviewers will independently screen titles and abstracts, followed by screening of the full text to determine inclusion. Experts will then be consulted to identify relevant missing papers. This can include elements other than the peer-reviewed literature (eg, book chapters, policy/legal papers). Finally, information that helps to build the concept and practice of person-centred rehabilitation will be abstracted independently by two reviewers and analysed by inductive thematic analysis to build the conceptual framework.

DISSEMINATION

The resulting framework will aid clarification regarding person-centred rehabilitation, which in turn is expected to conceptually ground and inform its operationalisation (eg, measurement, implementation, improvement). Findings will be disseminated through local, national and international stakeholders, both at the clinical and service organisation levels.

Systematic review of patients' views on the quality of primary health care in sub-Saharan Africa

This is the first systematic review of patient views on the quality of primary health care services in sub-Saharan Africa using studies identified from MEDLINE, CINAHL Plus, EMBASE and PsycINFO. In total, 20 studies (3 qualitative, 3 mixed method and 14 quantitative) were included. Meta-analysis was done using quantitative findings from facility- and community-based studies of patient evaluation of primary health care. There was low use of validated measures, and the most common scales assessed were humanness (70%) and access (70%). While 66% (standard deviation = 21%) of respondents gave favourable feedback, there were discrepancies between surveys in community and facility contexts. Findings suggest that patient views could vary with subject recruitment site. We recommend improvement in the methods used to examine patient views on quality of primary health care.