Reluctant collaborators: do patients want to be involved in decisions concerning care?

Turkish Adaptation and Validation of Patient Participation Questionnaire (PPQ)

Background/Objectives: The concept of patient participation is increasingly recognized as an important component in many areas, such as redesigning healthcare processes, improving patient safety, increasing satisfaction, and managing chronic diseases. In this context, measuring the level of patient participation in healthcare services is an important factor. The "Patient Participation Questionnaire" is a tool used to assess patients' evaluations of their participation in their in-hospital care. The absence of a scale in the Turkish literature that measures this concept reveals the importance of this research. Methods: In this study conducted in a tertiary public hospital in Turkey, the final scale translated into Turkish was applied to 355 people using the convenience sampling method. In addition to the "Patient Participation Scale", the "Patient Satisfaction Scale" was used for context validity in the study. Data were analyzed with SPSS 27 and AMOS programs. Results: As a result of the confirmatory factor analysis, the scale, which originally consisted of 16 questions and four dimensions, was adapted to Turkish as 14 questions and four dimensions. As a result of confirmatory factor analysis, the goodness of fit values of the scale were found to be x2/sd = 2.53, GFI = 0.93, AGFI = 0.90, CFI = 0.93, RMSEA = 0.066, RMR = 0.041, and NFI = 0.90. These values are within the acceptable and good fit level ranges. As a result of the correlation analysis performed for context validity, it was determined that there was a positive significant relationship between the adapted patient participation scale and the patient satisfaction scale (r = 0.692, p < 0.001). In addition, the internal consistency coefficient of the scale was examined to determine the reliability of the scale, and it was revealed that the scale was reliable at a good level (α = 0.86). Conclusions: Based on the findings, it was revealed that the "Patient Participation Scale" developed in English is a valid and reliable measurement tool in Turkish culture.

Facilitating active participation in anticoagulant decisions in advanced kidney disease: co-production of a question prompt list

BACKGROUND

People with chronic kidney disease are at increased risk of thrombotic and bleeding episodes making anticoagulant treatment decisions challenging. Currently, there are no support tools for people with chronic kidney disease regarding anticoagulant therapy decisions. This work aimed to co-produce materials to support shared-decision making when considering anticoagulant use in advanced chronic kidney disease.

METHODS

Focus groups were undertaken to explore the views of people with kidney disease towards anticoagulant prescribing. Data was thematically analysed based on Makoul and Clayman's model of shared-decision making. Co-production methods were used to develop a question prompt list based on themes from the focus groups in conjunction with people with kidney disease over three meetings.

RESULTS

A question prompt list, to be used by patients when initiated on anticoagulant therapy, was co-produced. These questions were based upon participants' experiences of the various stages of shared-decision making within the context of anticoagulant use in advanced chronic kidney disease. Of particular importance to participants was the individualised discussion around treatment risks and follow up arrangements.

CONCLUSION

Shared-decision making is important when initiating medication to ensure the best outcomes for patients, yet it can be difficult to engage in shared-decision making without prompts or guidance. This co-produced question prompt list could be included as part of national guideline to support shared-decision making for anticoagulant initiation in patients with advanced chronic kidney disease.

Building trust in long-term care settings using assistive technology: a systematic review

Background

This review investigates the dynamics of trust between caregivers and care receivers in long-term care settings, where the implementation of assistive technology also becomes chronically crucial. Trust is essential in the care receiver-caregiver relationship as it impacts the effectiveness of care and the care receiver's participation in treatment. Moreover, integrating assistive technology significantly affects the quality of care by increasing care receivers' autonomy and reducing caregivers' workload. Despite its significance, the mechanisms of trust involving assistive technology in long-term care have not been clarified.

Methods

To address this gap, this review systematically analyzed 32 articles published in English since 2,000, sourced from Web of Science, PubMed, Scopus, and Science Direct databases.

Results

The review identified the dynamics of trust in long-term care settings involving assistive technology. Based on this trust dynamics, three critical factors were analyzed: care receiver-related, caregiver-related, and assistive technology-related.

Discussion

The findings provide a detailed understanding of the factors affecting trust in long-term care settings involving assistive technology. These insights contribute to long-term care facility operators making informed decisions regarding technology adoption in care practice and care service strategies, ultimately enhancing trust and the quality of care in long-term care settings.

Getting specific: participation preference in urooncological decision-making

BACKGROUND

Shared decision-making is the gold standard for good clinical practice, and thus, psychometric instruments have been established to assess patients' generic preference for participation (e.g., the Autonomy Preference Index, API). However, patients' preferences may vary depending on the specific disease and with respect to the specific decision context. With a modified preference index (API-Uro), we assessed patients' specific participation preference in preference-sensitive decisions pertaining to urological cancer treatments and compared this with their generic participation preference.

METHODS

In Study 1, we recruited (N = 469) urological outpatients (43.1% urooncological) at a large university hospital. Participation preference was assessed with generic measures (API and API case vignettes) and with the disease-specific API-Uro (urooncological case vignettes describing medical decisions of variable difficulty). A polychoric exploratory factor analysis was used to establish factorial validity and reduce items. In Study 2, we collected data from N = 204 bladder cancer patients in a multicenter study to validate the factorial structure with confirmatory factor analysis. Differences between the participation preference for different decision contexts were analyzed.

RESULTS

Study 1: Scores on the specific urooncological case vignettes (API-Uro) correlated with the generic measure (r = .44) but also provided incremental information. Among the disease-specific vignettes of the API-Uro, there were two factors with good internal consistency (α ≥ .8): treatment versus diagnostic decisions. Patients desired more participation for treatment decisions (77.8%) than for diagnostic decisions (22%), χ²(1) = 245.1, p ≤ .001. Study 2: Replicated the correlation of the API-Uro with the API (r = .39) and its factorial structure (SRMR = .08; CFI = .974). Bladder cancer patients also desired more participation for treatment decisions (57.4%) than for diagnostic decisions (13.3%), χ²(1) =84, p ≤ .001.

CONCLUSIONS

The desire to participate varies between treatment versus diagnostic decisions among urological patients. This underscores the importance of assessing participation preference for specific contexts. Overall, the new API-Uro has good psychometric properties and is well suited to assess patients' preferences. In routine care, measures of participation preference for specific decision contexts may provide incremental, allowing clinicians to better address their patients' individual needs.

An answer recommendation framework for an online cancer community forum

Health community forums are a kind of online platform to discuss various matters related to management of illness. People are increasingly searching for answers online, particularly when they are diagnosed with cancer like life-threatening diseases. People seek suggestions or advice through these platforms to make decisions during their treatments. However, locating the correct information or similar people is often a great challenge for them. In this scenario, this paper proposes an answer recommendation system in an online breast cancer community forum that provide guidance and valuable references to users while making decisions. The answer is the summary of already discussed topic in the forum, so that they do not need to go through all the answer posts which spans over multiple pages or initiate a thread once again. There are three phases for the answer recommendation system, including query similarity model to retrieve the past similar query, query-answer pair generation and answer recommendation. Query similarity model is employed by a Siamese network with Bi-LSTM architecture which could achieve an F1-score of 85.5%. Also, the paper shows the efficacy of transfer learning technique to generalize the model well in our breast cancer query-query pair data set. The query-answer pairs are generated by an extractive summarization technique that is based on an optimization algorithm. The effectiveness of the generated summary is evaluated based on a manually generated summary, and the result shows a ROUGE-1 score of 49%.

Identifying Influences in Patient Decision-making Processes in Online Health Communities: Data Science Approach

Background

In recent years, an increasing number of users have joined online health communities (OHCs) to obtain information and seek support. Patients often look for information and suggestions to support their health care decision-making. It is important to understand patient decision-making processes and identify the influences that patients receive from OHCs.

Objective

We aimed to identify the posts in discussion threads that have influence on users who seek help in their decision-making.

Methods

We proposed a definition of influence relationship of posts in discussion threads. We then developed a framework and a deep learning model for identifying influence relationships. We leveraged the state-of-the-art text relevance measurement methods to generate sparse feature vectors to present text relevance. We modeled the probability of question and action presence in a post as dense features. We then used deep learning techniques to combine the sparse and dense features to learn the influence relationships.

Results

We evaluated the proposed techniques on discussion threads from a popular cancer survivor OHC. The empirical evaluation demonstrated the effectiveness of our approach.

Conclusions

It is feasible to identify influence relationships in OHCs. Using the proposed techniques, a significant number of discussions on an OHC were identified to have had influence. Such discussions are more likely to affect user decision-making processes and engage users’ participation in OHCs. Studies on those discussions can help improve information quality, user engagement, and user experience.

Striving for Balance: Palliative Care Patients’ Experiences of Making Everyday Choices

A fundamental principle of palliative care is the provision of patient-centred care, an approach explicitly based on the patient's perspective. Although much attention has been given to determining patients’ preferences for involvement in medical decisions, choices related to personal and nursing care routines have been largely ignored in the literature. Data from participant observations of nurse-patient interactions involving 16 palliative care patients and their nurses as well as 10 in-depth open-ended interviews with patients were analyzed using grounded theory methods. Although the choices made by patients appeared uncomplicated on the surface, the context of unfamiliarity, uncertainty, and unpredictability in palliative care increased the underlying complexity of decision making. Through a process of deliberation and trade-offs, patients attempted to regain or maintain some balance in their lives. This process of striving for balance consisted of three overlapping phases: weighing things up, communicating choice, and living with one's choices.

Sufficiency and relevance of information for inpatients in general ward settings: A qualitative exploration of information exchange between patients and nurses

BACKGROUND

Information exchange as part of shared decision-making is widely discussed in research and policy literature as a means of improving patient involvement in treatment and care. To date information exchange between patients and nurses has not been explored in ward contexts.

OBJECTIVE

To explore the sufficiency of, and intentions behind, information exchanged by patients and nurses in surgical and medical ward settings using a recognised model of shared decision-making.

DESIGN

A multiple-case study design was used. Data were collected from 19 cases. Each case comprised one patient, the nurses interacting with that patient, the interactions between them, and their perceptions about the interactions.

SETTINGS

The study was undertaken across six surgical, six medical and one rehabilitation ward in a large teaching hospital in the United Kingdom.

PARTICIPANTS

Purposive sampling was used to first recruit nurses and then patients. Inclusion criteria included nurses registered with the Nursing and Midwifery Council, and patients who had been in hospital for more than 24h and who could consent to participating. Twenty-two nurses and 19 patients participated.

METHODS

Interactions from 19 cases were observed and audio-recorded. Individual interviews with patients and nurses followed, and were related to, the observed interactions.

RESULTS

Patients and nurses perceived they had exchanged sufficient information for their own needs including patient involvement, due to: information being shared previously and on an ongoing basis; having asked all their questions; therapeutic patient/nurse relationships; and, nurses speaking in lay terms. In contrast, the observational data suggested that insufficient information was exchanged between patients and nurses due to: lost opportunities for sharing information; paternalistic practice; and withholding information.

CONCLUSION

The elements of information exchange within a recognised model of shared decision-making do not adequately fit with patient/nurse interactions in ward settings. Participants generally perceived they had given and received enough information for their own needs. Therefore, the ways in which patients and nurses currently interact, could remain as they are. Policymakers should be aware of the varying contexts where healthcare staff work, and should promote information exchange and shared decision-making more strategically. Due to the complexities of patient/nurse interactions, consideration should be given to situation and context when applying these findings to practice.

The Importance of Independence in Toileting: the Views of Stroke Survivors and their Occupational Therapists

The profession of occupational therapy claims to be patient centred; however, research shows that the views of patients and health care professionals often differ. Toileting is a fundamental daily activity, yet to date there have been few studies investigating the perceived importance of independence in toileting.

A qualitative study was conducted to determine the views of stroke survivors and their occupational therapists regarding the importance of independence in toileting. A symbolic interactionistic framework was used, allowing the views of these two disparate groups to be compared. Thirteen stroke survivors and seven occupational therapists were interviewed.

Five categories were identified in the data collected: the occupational form normally used in toileting; incontinence and continence; independence and dependence in toileting; issues relating to toileting and hospital discharge; and the role of occupational therapy. Both participant groups agreed that independence in toileting was important in avoiding the need for assistance and in avoiding feelings of decreased self-esteem. However, the patient participants' views extended further in that they stated that the method of toileting was important, not merely that it was conducted independently.

In conclusion, it is essential that occupational therapists consider how they can facilitate a return to the method usually undertaken for toileting by patients. If a return to the previous methodology for toileting will not be possible, then the occupational therapists must give consideration as to how to facilitate adjustment by the patients.

How Much Information is Too Much Information for Patients?

An effective pre-operative information-giving strategy is important in day surgery units, where a low pain score is essential for early discharge home. Good post-operative recovery at home is of utmost importance, as it has to be remembered that one-day surgery does not mean one-day recovery. Integrated care pathways (ICPs) have recognised and well documented benefits, and an ICP which includes a patient information strategy was thought likely to benefit staff and patients in the day surgery setting, where it is essential that patients receive timely, appropriate and evidenced-based care and information.

The benefits of giving patients pre-operative information are well documented, and a large majority of patients in this study ( n=100) received written pre-operative information prior to their admission to an orthopaedic day surgery ward. However, it was found that 49% ( n = 42) of patients would have preferred more information. The post-operative pain scores of these patients were demonstrably higher than those of patients who were satisfied with the information they received.

Who Wants to be involved? Decision-Making Preferences among Residents of Long-Term Care Facilities

While the benefits of participating in care or medical decision making are widely reported, research on decision-making participation preferences usually reveals some portion of individuals who do not want to be involved. Data collected through structured, in-person interviews with 100 residents of six long-term care (LTC) facilities in Victoria, British Columbia, were used to examine participation preferences with respect to four types of care decisions (bedtimes, medication choice, room transfer, and advance directives), as well as predictors of these preferences. Residents with higher levels of formal education, a greater number of chronic conditions, and greater confidence about the worth of their input tend to prefer more active involvement in decision making. This research also suggests that predictors of preference for independent control over decision making (active involvement) differ from predictors of preference for joint or shared decision making. Implications for the empowerment of LTC facility residents and the meaning of decision-making involvement in these environments are discussed.

Informed Consent Prior to Nursing Care Procedures

It is largely undisputed that nurses should obtain consent prior to nursing care procedures. This article reports on a qualitative study examining the way in which nurses obtain such informed consent. Data were collected through focus group discussion and by using a critical incident technique in order to explore the way in which nurses approach consent prior to nursing care procedures. Qualified nurses in two teaching hospitals in England participated in the study. An analysis of the data provides evidence that consent was often not obtained by those who participated in the study and that refusals of care were often ignored. In addition, participants were often uncertain how to proceed with care when the patient was unable to consent. Consent prior to nursing care procedures is an essential but undeveloped concept, for which a new ethos is required.

Patient-sensitive treatment decision- making? Preferences and perceptions in a sample of renal patients

Patient participation in various aspects of healthcare is rapidly expanding. However, patients' preferences with regard to participation in treatment decision-making remain relatively under-explored, as does the congruence between such preferences and patients' perceptions of their actual role in decision-making. The aims of this study were to identify and to compare treatment decision-making role preferences and perceptions of the actual decisional role in a sample of renal patients.

A cross-sectional survey was conducted at a single regional renal unit in the North of England. A convenience sample of 405 patients was obtained (pre-dialysis N=155; dialysis N=103; transplant N=147). Preferred and perceived role were identified using a card sort technique (choice of five options, active to passive). Rationales for role preference were recorded verbatim.

Most patients were found to prefer passive (N=186, 45.9%; 95% Cl 41.2- 50.9) or collaborative (N=147; 36.3%; 95% Cl 31.3-40.7) decisional roles; perceived role was typically passive (N=319; 78.8%; 95% Cl 74.8-82.8). Trust in health professionals, perceived lack of knowledge and severity of condition were the most frequently cited determinants of role preference. Patients' decisional role preferences were often at variance with their perceived roles. Taking a highly active role in treatment decision-making was undesirable to most patients. Trust in healthcare professionals was an important contributor to desire to defer or retain control over treatment decisions.

Actual Interaction and Client Centeredness in Home Care

The purpose of this study is to explore client-nurse interaction from a client perspective with respect to client-centered care. A grounded theory study was conducted with Dutch clients who were chronically ill and receiving home care. Data were collected by focus interviews with 8 client informants, participatory observations with 45 clients, and semistructured interviews with 6 clients. The core category actual interaction was identified. Six patterns of actual interaction were distinguished. Changes in actual interaction could be related to changes in desired participation by the client and in allowed client participation by the professional. From the client's perspective, client-centeredness means congruence between desired and allowed participation. Congruence was experienced with consent, dialogue, and consuming. Congruence is not necessarily synonymous with promoting patient participation or with doing as the client wants. Ongoing attentiveness, responsiveness, promotion of client autonomy, and being a critical caregiver are recommended.

Nurse-patient collaboration: a grounded theory study of patients with chronic obstructive pulmonary disease on non-invasive ventilation

OBJECTIVES

This paper provides a theoretical account of nurses' collaboration with patients with chronic obstructive pulmonary disease during non-invasive ventilation treatment in hospital.

BACKGROUND

Despite strong evidence for the effect of non-invasive ventilation treatment, success remains a huge challenge. Nurse-patient collaboration may be vital for treatment tolerance and success. A better understanding of how nurses and patients collaborate during non-invasive ventilation may therefore contribute to improvement in treatment success.

DESIGN

A constant comparative classical grounded theory.

METHOD

The data comprised sessions of qualitative participant observation during the treatment of 21 patients with non-invasive ventilation that included informal conversations with the nurses and semi-structured interviews with 11 patients after treatment completion. Data were collected at three intensive care units and one general respiratory ward in Denmark.

RESULTS

Succeeding emerged as the nurses' main concern in the nurse-patient collaboration during non-invasive ventilation treatment. Four collaborative typologies emerged as processing their main concern: (1) twofold oriented collaboration; (2) well-being oriented collaboration; (3) outcome oriented collaboration; and (4) absent collaboration.

CONCLUSIONS

This study offers a theoretical account of nurses' main concern and how they activate different ways of collaboration to achieve successful treatment. We offer a theoretical basis for developing complex interventions.

How do persons with dementia participate in decision making related to health and daily care? a multi-case study

BACKGROUND

Many countries have passed laws giving patients the right to participate in decisions about health care. People with dementia cannot be assumed to be incapable of making decisions on their diagnosis alone as they may have retained cognitive abilities.The purpose of this study was to gain a better understanding of how persons with dementia participated in making decisions about health care and how their family carers and professional caregivers influenced decision making.

METHODS

This Norwegian study had a qualitative multi-case design. The triad in each of the ten cases consisted of the person with dementia, the family carer and the professional caregiver, in all 30 participants. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2, moderate dementia; (3) able to communicate verbally. The family carers and professional caregivers were then asked to participate.A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day centre. How the professional caregivers facilitated decision making was the focus of the observations that varied in length from 30 to 90 minutes. The data were analyzed using framework analysis combined with a hermeneutical interpretive approach.

RESULTS

Professional caregivers based their assessment of mental competence on experience and not on standardized tests. Persons with dementia demonstrated variability in how they participated in decision making. Pseudo-autonomous decision making and delegating decision making were new categories that emerged. Autonomous decision making did occur but shared decision making was the most typical pattern. Reduced mental capacity, lack of available choices or not being given the opportunity to participate led to non-involvement. Not all decisions were based on logic; personal values and relationships were also considered.

CONCLUSIONS

Persons with moderate dementia demonstrated variability in how they participated in decision making. Optimal involvement was facilitated by positioning them as capable of influencing decisions, assessing decision-specific competence, clarifying values and understanding the significance of relationships and context.

Perspective: To what end communication? Developing a conceptual framework for communication in medical education

A growing discourse about broadening the educational experience of physicians in medical education focuses on professional formation and the wider social context within which health care is delivered. This shift suggests a complex reconfiguration of medical education. Where does one begin this task? First, medical education reform must be grounded in a clarification of the conceptual terrain where proposed changes in pedagogy and practice are occurring. More specifically, some clarity is needed regarding the basic or key competencies that students are expected to acquire through educational processes. Accordingly, the author argues that having a clear and comprehensive conceptual understanding of the educational aims defining this reform is a necessary starting point. Although descriptions of competencies (such as those required by CanMeds and the Accreditation Council for Graduate Medical Education) focus on lists of skills, greater detail is needed regarding our understanding of the values and rationale underlying such skills if they are to be applied in educationally effective ways. The author shows the extent to which and ways in which our understanding of these basic concepts will influence the direction of reforms. He examines various conceptions of the role of communication in medicine and indicates various educational benefits and shortcomings in these approaches. He concludes by identifying one concept of communication, termed "communication as a medical-epistemic competency, " that can include and incorporate many facets of communication in the medical context while also responding to broader societal changes being addressed through post-Flexner developments in educational reform.

Safety and efficacy of physician-supervised self-managed C1 inhibitor replacement therapy

BACKGROUND

C1 inhibitor (C1INH) has recently been approved in the USA for the treatment of acute attacks in hereditary angioedema (HAE) patients. The literature suggests that treatment with C1INH is most effective when administered early in an attack. Home infusion of C1INH allows for the earliest possible intervention since patients can initiate therapy at the first sign of symptoms.

METHODS

We performed an observational, prospective study on 39 subjects with HAE utilizing two groups of patients: one receiving on-demand C1INH replacement therapy in a medical facility and the other self-managing on-demand C1INH replacement therapy in the home setting under the supervision of a treating physician. All subjects completed online questionnaires weekly for 8 weeks.

RESULTS

There were statistically significant decreases in attack duration (p < 0.0001), pain medication use (p < 0.0001) and graded attack severity (p < 0.005) in the subjects who received C1INH in the home setting versus the clinic-based group. Attack frequency was similar between the groups. The home group experienced more frequent injection-related side effects; however, the clinic group noted more severe adverse events from C1INH.

CONCLUSION

Physician-supervised self-managed C1INH replacement therapy is a safe and effective treatment for patients with HAE with potential benefits in diminishing attack duration and attack severity.

A critical analysis of health promotion and 'empowerment' in the context of palliative family care-giving

Traditionally viewed as in opposition to palliative care, newer ideas about 'health-promoting palliative care' increasingly infuse the practices and philosophies of healthcare professionals, often invoking ideals of empowerment and participation in care and decision-making. The general tendency is to assume that empowerment, participation, and self-care are universally beneficial for and welcomed by all individuals. But does this assumption hold for everyone, and do we fully understand the implications of health-promoting palliative care for family caregivers in particular? In this study, we draw on existing literature to highlight potential challenges arising from the application of 'family empowerment' strategies in palliative home-care nursing practice. In particular, there is a risk that empowerment may be operationalized as transferring technical and medical-care tasks to family caregivers at home. Yet, for some family caregivers, a sense of security and support, as well as trust in professionals, may be equally if not more important than empowerment. Relational and role concerns may also at times take precedence over a desire for empowerment. The potential implications of 'family empowerment' are explored in this regard. 'Family empowerment' approaches need to be accompanied by a strong understanding of how to best support individual palliative family caregivers.

Patient reported outcomes: looking beyond the label claim

The use of patient reported outcome scales in clinical trials conducted by the pharmaceutical industry has become more widespread in recent years. The use of such outcomes is particularly common for products developed to treat chronic, disabling conditions where the intention is not to cure but to ameliorate symptoms, facilitate functioning or, ultimately, to improve quality of life. In such cases, patient reported evidence is increasingly viewed as an essential complement to traditional clinical evidence for establishing a product's competitive advantage in the marketplace. In a commercial setting, the value of patient reported outcomes is viewed largely in terms of their potential for securing a labelling claim in the USA or inclusion in the summary of product characteristics in Europe. Although, the publication of the recent US Food and Drug Administration guidance makes it difficult for companies to make claims in the USA beyond symptom improvements, the value of these outcomes goes beyond satisfying requirements for a label claim. The European regulatory authorities, payers both in the US and Europe, clinicians and patients all play a part in determining both the availability and the pricing of medicinal products and all have an interest in patient-reported data that go beyond just symptoms. The purpose of the current paper is to highlight the potential added value of patient reported outcome data currently collected and held by the industry for these groups.

"I like to be an informed person but..." negotiating responsibility for treatment decisions in cancer care

Social expectations surrounding sickness have undergone a transformation in Western welfare states. Emerging discourses about patients' roles and responsibilities do not however always map neatly onto patients' actions, experiences or desires. This paper emerges from a study in Ontario, Canada. Drawing on in-depth interviews with 5 women diagnosed with breast cancer we explore the activity and effort prompted for patients by the routine professional practice of outlining treatment options and encouraging patients to choose between them. We highlight research participants' complex responses to their responsibility for treatment decisions: their accepting, deflecting and reframing and their active negotiation of responsibility with professionals. The literature on treatment decision making typically characterizes people who resist taking an active role as overwhelmed, misinformed about the nature of treatment decisions, or more generally lacking capacity to participate. In this paper we suggest that patients' expressions of ambivalence about making treatment choices can be understood otherwise: as efforts to recast the identities and positions they and their physicians are assigned in the organization of cancer care. We also begin to map key features of this organization, particularly discourses of patient empowerment, and evidence-based medicine.

Palliative family caregivers' accounts of health care experiences: The importance of “security”

Objective:

When providing care for a loved one with a terminal illness, family members often look to health care providers for guidance and expertise. The objective of this study is to explore family caregiver accounts of their experiences within the health care system and with individual providers.

Methods:

A thematic analysis of secondary qualitative data was performed. Data are from a subsample of bereaved and current family caregivers (N = 31) in a prior study of coping in end-of-life cancer situations. Data from these participants referring to experiences with health care providers was thematically coded and the concept of “security” was used as an analytic lens to facilitate conceptual development and exploration.

Results:

Considered together, the findings can be viewed as manifestations of a need and desire for security in palliative family caregiving. Specifically, family caregivers' accounts illustrate the importance of feeling secure that health care services will be provided by competent professionals; feeling secure in their timely access to needed care, services, and information; and feeling secure in their own identity and self-worth as a caregiver and individual. In addition, the findings suggest a conceptualization of security that extends beyond trust in individuals to include a generalized sense of institutional trust in the health care system.

Significance of results:

The concept of security moves beyond description of individual satisfaction or dissatisfaction with health care to identify a common, foundational need underlying such evaluations. Further empirical research is needed that explicitly focuses on caregivers' experiences of security and insecurity in the domains identified in this article. This will contribute to theory building as well as assist in identifying the causes and consequences of security.

Building empowering partnerships for interprofessional care

While partnership approaches have the potential to achieve cost-effective quality health care, several attributes of the current context make partnerships difficult to achieve. This paper provides an analysis of the socio-cultural, structural and human challenges to building partnerships at both personal and organizational levels, together with an empowering interdisciplinary approach for overcoming these barriers. Premised on empirical evidence, 'flexible client-driven care', currently being tested in the home care sector in Canada, encompasses structures and processes that promote relationship-building and conscientious critical application of individual and collective potential for achieving health care. Strategies for implementing empowering partnership-building at both personal and organizational levels are elaborated, together with the challenges encountered. The practical issues addressed afford insights and ideas for others who may be attempting to achieve similar partnership aims.

Clinical decision-making: predictors of patient participation in nursing care

AIM

To investigate predictors of patients' preferences for participation in clinical decision-making in inpatient nursing care.

BACKGROUND

Patient participation in decision-making in nursing care is regarded as a prerequisite for good clinical practice regarding the person's autonomy and integrity.

DESIGN

A cross-sectional survey of 428 persons, newly discharged from inpatient care.

METHODS

The survey was conducted using the Control Preference Scale. Multiple logistic regression analysis was used for testing the association of patient characteristics with preferences for participation.

RESULTS

Patients, in general, preferred adopting a passive role. However, predictors for adopting an active participatory role were the patient's gender (odds ratio = 1.8), education (odds ratio = 2.2), living condition (odds ratio = 1.8) and occupational status (odds ratio = 2.0). A probability of 53% was estimated, which female senior citizens with at least a high school degree and who lived alone would prefer an active role in clinical decision-making. At the same time, a working cohabiting male with less than a high school degree had a probability of 8% for active participation in clinical decision making in nursing care.

CONCLUSIONS

Patient preferences for participation differed considerably and are best elicited by assessment of the individual patient. Relevance to clinical practice. The nurses have a professional responsibility to act in such a way that patients can participate and make decisions according to their own values from an informed position. Access to knowledge of patients'basic assumptions and preferences for participation is of great value for nurses in the care process. There is a need for nurses to use structured methods and tools for eliciting individual patient preferences regarding participation in clinical decision-making.

Involvement of older people in care, service and policy planning

In line with other helping professions nursing has moved from traditional views of technical expertise as the prime shaper of health care, to a more equal relationship with service users and patients which respects their expertise, knowledge, goals and choices. This philosophy has underpinned the movement to involve older people in care, policy and planning activities. The literature review presented in this paper highlights the growing literature on this subject with respect to older people and maps the key issues and debates for nursing.

Development of the client-centred care questionnaire

AIM

This paper reports the development and testing of the Client-Centred Care Questionnaire, aimed at evaluating the client-centredness of professional home nursing care from a client perspective.

BACKGROUND

Client-centred care has become an important theme in health care. To evaluate the client-centredness of care and services from a client's perspective, there is a need for measurement instruments.

METHOD

The questionnaire was developed on the basis of a qualitative study into client perspectives on home nursing care. Items were formulated that closely followed the aspects clients mentioned as central to client-centred home care. A pilot study was conducted with a sample of 107 clients in three home care organizations in 2003 and 2004. These clients had chronic diseases and were expected to receive care for at least another 6 months. The questionnaire comprises 15 items.

FINDINGS

Principal components analysis and internal consistency analysis show strong internal consistency of the items. All items had strong factor loadings on one dimension, and Cronbach's alpha was 0.94. Clients tended to be most critical about their say in the practical arrangements and organization of care: which person came, how often and when? Clients of the three organizations differed in their perceptions of client-centredness, which may indicate that the questionnaire is capable of differentiating between respondents.

CONCLUSION

The results of this pilot study are promising. The validity of the questionnaire needs further testing.

Attitude toward direct-to-consumer advertising and drug inquiry intention: the moderating role of perceived knowledge

This study examined how consumers' general attitude toward direct-to-consumer advertising (DTCA) influenced their drug inquiry intent, and whether the relationship between attitude toward DTCA and drug inquiry intent was moderated by their perceived knowledge of health and medicine. Results showed that those with favorable views of DTCA were more likely to inquire and request an advertised drug they saw. The effect was greater in magnitude for consumers with high perceived knowledge in health and medicine, however, than for those with low perceived knowledge.

Patient participation in nursing care from a patient perspective: a Grounded Theory study

the study's rationale: Patients' active participation in their own care is expected to contribute to increased motivation to improve their own condition, better treatment results and greater satisfaction with received care. Knowledge of patients' understanding of participation is of great importance for nurses in their efforts to meet patient expectations and for quality of nursing care.

AIM

The aim was to explore the meaning of patient participation in nursing care from a patient point of view.

METHODOLOGICAL DESIGN AND JUSTIFICATION

Six tape-recorded focus group interviews with 26 Swedish informants described opinions on and experiences of patient participation. The informants consisted of patients in somatic inpatient care as well as discharged patients from such a setting. The Grounded Theory method was used and the data were analysed using constant comparative analysis.

ETHICAL ISSUES AND APPROVAL

The ethics of scientific work was followed. Each study participant gave informed consent after verbal and written information. The Ethics Committee of Göteborg University approved the study.

FINDINGS

The patients emphasised the importance of collaboration to improve participation. The core category, Insight through consideration, was generated from four inter-related categories: (i) Obliging atmosphere; (ii) Emotional response; (iii) Concordance; and (iv) Rights and their 15 subcategories.

CONCLUSIONS

The meaning structures of patient participation in nursing care revealed from a patient point of view, seemed to mainly consist of not only external factors presented by the institutions -- by the professionals -- but also internal patient factors. The patients' view of participation should be considered to a greater degree in nursing practice and education, as should also further development of nursing care policy programmes, evaluation and quality assurance criteria. For further development, studies are needed in similar and other settings.

'With woman' philosophy: examining the evidence, answering the questions

'With woman', 'woman centred' and 'in partnership with women' are new terms associated with midwifery care in Australia, and the underlying philosophy has emerged both as an antidote to the medicalisation of pregnancy and in a bid to reacquaint women with their natural capacity to give birth successfully and without intervention. A reorientation of midwifery services in the 1990s, a shift towards midwifery-led care (MLC) and the subsequent introduction of direct entry midwifery programs all contributed to this new direction. Central concepts are a focus on the childbearing woman and a valuing of women's experiences. While this philosophical re-alignment has been applauded by many midwives in terms of maternal empowerment and improved autonomy for midwives, there are nonetheless some concerns that, with its emphasis on normality, midwifery-led care is in danger of becoming an exclusionary model. Particular concerns include meeting the needs of a growing cohort of women, those with 'high risk' pregnancies, and the educational adequacy of direct entry midwifery programs. To date, there has been no thorough evaluation of this emerging midwifery philosophy in Australia. In order to open the debate, this paper aims to initiate a discussion of 'with woman' midwifery care as it applies to Australian practice.

Challenging the philosophy of partnership with parents: A grounded theory study

BACKGROUND

Parent participation is viewed as a pivotal concept to the provision of high quality nursing care for children and their families. Since the 1990's, the term 'partnership with parents' has increasingly been reported in the literature and adopted as a philosophy of care in most paediatric units in the United Kingdom.

OBJECTIVES

To explore children's, parents', and nurses' views on participation in care in the healthcare setting.

DESIGN

Using grounded theory, data were collected through in-depth interviews, and participant observation. Sample consisted of eleven children, ten parents and twelve nurses from four paediatric wards in two hospitals in England.

RESULTS

Most nurses assumed that parents would participate in care and viewed their role as facilitators rather than 'doers'. Nurses reported that the ideology of partnership with parents did not accurately reflect or describe their relationships with parents. Parents could never be partners in care as control of the boundaries of care rested with the nurses. Parents felt compelled to be there and to be responsible for their children's welfare in hospital.

CONCLUSIONS

The pendulum of parent participation has swung from excluding parents in the past to making parents feel total responsibility for their child in hospital. It is argued that the current models or theories on parent participation/partnership are inappropriate or inadequate because they do not address important elements of children's, parents' and nurses' experiences in hospital.

Patient autonomy in nurse-led shared care: a review of theoretical and empirical literature

AIM

This paper presents a review of the theoretical and empirical literature addressing patient autonomy and how nurses can support patient autonomy.

BACKGROUND

Nurse-led, shared care settings provide needs-based care to patients who are encouraged to participate actively in their care. Patient autonomy is a complex ethical concept with many different meanings. As a result, nurses must solve various problems to foster patient autonomy successfully.

METHOD

Two methods were used to identify literature for the review: (a) a search of the MEDLINE, Embase, CINAHL and Online Contents databases and the keywords 'patient autonomy' in combination with 'nursing', and the Dutch Central Catalogue for material published from 1966 to 2005; (b) ethical and nursing literature was selected on the basis of its identification of positive and negative freedom. We reviewed qualitative empirical research to explore the patients' views of autonomy.

FINDINGS

Negative freedom emphasizes freedom of action and freedom from interference by others. Positive freedom stresses the idea that people should direct their lives according to their personal convictions and individual reasons and goals. The most prominent theories fitting negative freedom are those defining autonomy as self-governance and self-care. Theories fitting positive freedom are those focusing on autonomy in caring, autonomy as identification, autonomy as communication and autonomy as goal achievement. In the empirical literature, two studies centred on patient autonomy in home care, one in nursing home care and three in hospital settings. To achieve autonomy, patients prefer a mixed approach that combines features of negative and positive freedom.

CONCLUSION

Nurses cannot rely exclusively on one model of autonomy to foster patient autonomy. Rather, it requires in-depth knowledge of, and interaction with, patients in the context of each particular nursing encounter because people express their autonomy through particular courses of action.

The 'Earlybird' gets the breastmilk: findings from an evaluation of combined professional and peer support groups to improve breastfeeding duration in the first eight weeks after birth

Australia has high initiation rates of breastfeeding, but the challenges of establishing and maintaining breastfeeding in the first few months of infant life result in many women changing to artificial formula feeding. This paper reports on the impact of a new strategy to improve breastfeeding duration rates in the first 8 weeks post-partum. The Earlybird Program (EBP) combines the professional expertise of child and family health (C&FH) nurses with the expertise of the participating mothers to support each other in establishing breastfeeding in the first 8 weeks. This retrospective study compared the breastfeeding patterns of first-time mothers who attended the EBP, with the breastfeeding patterns of mothers who accessed individual appointments with the nurses in a 12-month period, and examined the predictors of continued breastfeeding at 8 weeks. The total sample comprised 193 infant records. Women who selected the EBP were more likely to be employed and less likely to be categorized as non-English speaking background. These women also had more visits to the C&FH service. Logistic regression was used to determine the factors associated with breastfeeding cessation at 8 weeks post-natal. After adjusting for variables, only exclusive breastfeeding at first visit and attending the EBP were significant predictors of continuing to breastfeed at 8 weeks. Facilitation skills that recognize the expertise of participating women were considered an important aspect of the programme.

Nurses? perceptions, understanding and experiences of health promotion

AIM

This paper presents an account of nurses' perceptions and understanding of health promotion in an acute setting.

BACKGROUND

Health promotion is considered the remit of every nurse. To engage in health-promoting practice, however, nurses need to understand the term 'health promotion' clearly.

METHOD

A single qualitative embedded case study was used. Purposive sampling of eight nurses was employed. Initially, theses nurses were observed in practice and, following this, a semi-structured one-to-one interview was conducted with each observed nurse. Qualitative data analysis guided by work of Miles and Huberman was employed.

RESULTS

The data revealed one main theme: health-promoting nursing practice and this consisted of six categories and five subcategories. The findings indicated that nurses struggled to describe their understanding of health promotion, their understanding was limited and the strategies described to conduct health promotion were narrow and focused on the individual. Their perceptions and descriptions of health promotion were more in keeping with the traditional health education approach. Overall health promotion was reported to occur infrequently, being added on if the nurse had time. Factors relating to education, organizational and management issues were identified as key barriers prohibiting health-promoting nursing practice.

CONCLUSIONS

Nurses must recognize that health promotion is a broad concept that does not exclusively focus on the individual or lifestyle factors. Nurses must be educated to recognize health-promoting opportunities in the acute setting, as well as how to plan for and conduct health promotion so that it becomes integral to practice. A review of the methods of organizing and delivering nursing care is also advocated.

RELEVANCE TO CLINICAL PRACTICE

Ward managers have an important role in supporting nurses, creating a culture for health promotion and sharing power in decision-making processes, so that nurses feel valued and empowered.

Patient empowerment: does it still occur in the ICU?

The theoretical underpinnings of patient empowerment were developed through the work of educators and community psychologists, working primarily with the socially disadvantaged. Empowerment is seen as a philosophy based upon the belief of the inherent worth and creative potential of each individual. Therefore, the aim of this paper is to explore whether this creative potential associated with patient choice that encapsulates empowerment is applicable to the Intensive Care Unit.

Health beliefs and expectations implicit in decision-making in a Hong Kong Chinese surgical population

AIMS AND OBJECTIVES

This study was undertaken to explore health beliefs and expectations implicit in decision-making preferences of Chinese patients admitted for a surgical procedure in a regional hospital in Hong Kong.

BACKGROUND

Patient participation in decision-making about healthcare options is presently being advocated; however, its nature is complex and inadequately explored and understood.

METHOD

Twenty surgical patients, 10 who desired active participation and 10 who desired passive participation, were interviewed about their reasons for their decision-making preference.

RESULTS

From thematic analysis of the interviews, 'trust' and 'certainty' emerged as important concepts. Of particular interest is how 'certainty' was construed differently by participants: participants who desired to be passive and have minimal participation in decision-making did not focus on 'certainty' as meaning the predictability of the treatment outcome, but rather 'certainty' related to trust and belief in the ability of the doctor to choose the best option for them. Alternatively, participants who desired greater participation in decision-making spoke much more about the 'certainty' of the treatment outcome.

CONCLUSIONS

These findings suggest that patients' desire for participation in decision-making about surgery may be related to beliefs, expectations and understanding about certainty.

RELEVANCE TO CLINICAL PRACTICE

It could potentially benefit patients if this concept was explored further prior to patients undertaking decisions about undergoing surgery.

Competent patients' refusal of nursing care

Competent patients' refusals of nursing care do not yet have the legal or ethical standing of refusals of life-sustaining medical therapies such as mechanical ventilation or blood products. The case of a woman who refused turning and incontinence management owing to pain prompted us to examine these situations. We noted several special features: lack of paradigm cases, social taboo around unmanaged incontinence, the distinction between ordinary versus extraordinary care, and the moral distress experienced by nurses. We examined this case on the merits and limitations of five well-known ethical positions: pure autonomy, conscientious objection, paternalism, communitarianism, and feminism. We found each lacking and argue for a 'negotiated reliance' response where nurses and others tread as lightly as possible on the patient's autonomy while negotiating a compromise, but are obligated to match the patient's sacrifice by extending themselves beyond their usual professional practice.