Nurse-patient consultations in primary care: do patients disclose their concerns?

Archetypes of incomplete stories in chronic illness medical encounters

OBJECTIVE

During encounters, patients and practitioners engage in conversations to address health concerns. Because these interactions are time-pressured events, it may be inevitable that any story exchanged during these encounters will be incomplete in some way, potentially jeopardizing how quality and safety of care is delivered. In this study, we explored how and why incomplete stories might arise in health interactions.

METHODS

Constructivist grounded theory methodology was used to explore how patients and practitioners approach their interactions during encounters. In this two-phase study, we interviewed patients (n = 21) then practitioners (n = 12).

RESULTS

We identified three distinct archetypes of incomplete storytelling - the hidden story, the interpreted story, and the tailored story. Measured information sharing, triadic encounters and pre-planned agendas influenced these storylines, respectively.

CONCLUSION

Both patient and practitioner participants focused on what each considered important, appropriate, and useful for productive encounters. While incomplete stories may be a reality, educating practitioners about how incomplete stories come about from both sides of the conversation creates new opportunities to optimize interactions at medical encounters for in-depth patient practitioner storytelling.

Evidence for person-centred care in chronic wound care: A systematic review and recommendations for practice

BACKGROUND

Chronic wounds affect an estimated 2.21 per 1000 population. They are a significant source of morbidity and affect individuals physically, psychologically, socially and financially. Person-centered care is one approach to improve patient outcomes in wound care as it values patients' perspectives, beliefs and autonomy and considers the person as a whole within the cultural context in which care is provided.

AIM

We aimed to review the evidence on the use of person-centered care (PCC) in chronic wound care management and provide recommendations for practice and future research.

METHOD

Using a systematic review methodology, we searched six databases for full-text papers from 2009-2019 published in peer-reviewed journals with no limits on language.

RESULTS

Eighteen articles on studies involving 3149 patients from nine countries were identified. Studies were conducted under three broad intervention categories: healthcare professional education (n=1); patient education (n=14) and telemedicine (n=3). Studies were equally focused on prevention and treatment of chronic wounds. Significant improvements were reported in patient knowledge, pain and self-care behaviours. Only two studies evaluated the impact on wound healing and one study estimated the cost of implementing person-centered care.

CONCLUSIONS

The evidence base to support PCC in wound management is developing and based on our review has shown improved outcomes in areas of pressure ulcer prevention, patient satisfaction, patient knowledge and quality of life, but clinical outcomes such as wound healing were less well explored. Further research with more objective outcome measures are required.

Non-disclosure of symptoms in primary care: an observational study

BACKGROUND

Symptoms form a major component of patient agendas, with the need for an explanation of symptoms being a prominent reason for consultation.

OBJECTIVES

To estimate the prevalence of different symptoms pre-consultation, to investigate whether intention to mention a symptom in the consultation varied between patients and across symptoms, and to determine how patients' intended agendas for mentioning symptoms compared with what was discussed.

METHOD

We videorecorded consultations of an unselected sample of people aged 45 and over consulting their GP in seven different practices in UK primary care. A pre-consultation questionnaire recorded the patient's agenda for the consultation, current symptoms and symptoms the patient intended to discuss with their GP. The videorecorded consultation was viewed and all patient agendas and 'symptoms with intention to discuss' were compared with the actual topics of discussion.

RESULTS

Totally, 190 patients participated. Eighty-one (42.6%) were female and the mean age was 68 (range 46-93). Joint pain was the most commonly reported symptom. One hundred thirty-nine (81.8% of those reporting symptoms) patients reported intention to discuss a symptom. In 43 (22.6%) consultations, 67 symptoms (27.2%), where an intention to discuss had been expressed, remained undisclosed. Tiredness and sleeping difficulty were more likely to be withheld than other symptoms after an intention to discuss had been expressed. Of the more physically located symptoms, joint pain was the most likely to remain undisclosed.

CONCLUSION

This study suggests that the extent of symptom non-disclosure varies between patients, physicians and symptoms. Further work needs to explore the consequences of non-disclosure.

Understanding the Hawthorne effect in wound research-A scoping review

The Hawthorne Effect (HE) is considered a methodological artefact in research, although its definition and influence on research outcomes lack consensus. This review explored how this term has been mentioned and discussed in the area of wound research. A scoping review was conducted on ProQuest Central, Scopus, EbscoHost, and online databases of indexed wound journals using the methodological framework by Arksey and Malley. A review protocol was applied to detail key terms, truncation and Boolean operators, and inclusion and exclusion criteria. Search findings were reported using PRISMA guidelines. A total of 38 articles reporting primary evidence were identified. Three themes emerged from the review: wound researchers' awareness of HE, the acknowledgement of the existence or otherwise of HE, and the mentioning of HE in passing. These results reflect a lack of attention to and understanding and awareness of the HE in the area of wound research. It is suggested that the HE receives more attention as a methodological concern, and its potential influence is considered and mitigated when planning future studies. Recommendations are provided to minimise the impact of the HE on the rigour of the research and confidence afforded to research findings.

Nursing staff's responses to thematic content of patients' expressed worries: observing communication in home care visits

Background

The aim of the study was to explore the thematic content of older persons’ expressed worries in home care visits, and how nursing staff respond to different thematic contents.

Methods

The study had a descriptive, observational design, including 195 audio-recorded Norwegian home care visits with 33 nursing staff and 48 older persons. In all, 638 patient cues/concerns (worries) and subsequent nursing staff’s responses were identified using Verona Coding Definitions of Emotional Sequences. A novel thematic coding scheme was used to label the thematic content of the cues/concerns. The nursing staff’s responses were grouped based on communicative function as emotion-focused, content-focused or ignoring/blocking the cue/concern. Group difference was analysed using Pearson’s chi-squared test, Fisher’s exact test, and adjusted residuals.

Results

The theme of worries was associated with elicitation of the cue/concern, either elicited by the nursing staff or spontaneously expressed by the patient (Chi-square, p< 0.001). “Ageing and bodily impairment” was the most common theme (66%) and was equally elicited by patients and nursing staff. Worries about “Relationships with others” (9%), “Health care-related issues” (15%) and “Life narratives and value issues” (9%) were mainly elicited by nursing staff. The nursing staff response was associated with the theme of worries (p˂0.001). For the sub-themes of “Ageing and bodily impairment”, Coping with existential challenges received more frequently emotion-focused responses (adjusted residuals: 3.2) and Expression of pain felt in the moment were more frequently ignored/blocked (adjusted residuals: 4.0, Fisher’s exact test, p< 0.001). For the sub-themes of “Relationships with others”, Being a burden more frequently received a content-focused response (adjusted residuals: 2.8), while Losing social ties more frequently received an emotion-focused response (adjusted residuals: 3.1, Fisher’s exact test, p = 0.009).

Conclusion

“Ageing and bodily impairment” was the most common theme and more frequently elicited by the older persons than other themes. Emotionally focused nursing staff responses were most common when addressing existential challenges and fear of losing social ties. Whereas nursing staff showed a tendency to ignore patients’ spontaneous expressions of pain. Further research should explore the influence of nursing staff’s responses on quality of care and patient satisfaction.

Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care Part 2: Development and evaluation of the consultation template

Part 2 in this article series summarises the final two phases of a study which explored the experiences of patients with leg ulcers and the impact of this condition on their quality of life. Early phases of the study revealed a mismatch between issues that affected a patient's quality of life and what they discussed during subsequent health care consultations. In light of this, a nominal group technique was employed to facilitate the development of a new leg ulcer consultation template with patient partners. The aim of this was to include many of the issues raised in phases 1. The new template was evaluated in terms of its utility, significance and clinical potential. The application of this template during routine consultations appears to encourage the patient to disclose issues that are important to them and may have otherwise been overlooked.

Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care. Part 1: exploring the consultation

This article, the first of two, summarises a study that explored the lived experiences of patients with leg ulcers and the impact of this condition on their quality of life. The study had four study phases; phases 1 and 2 employed qualitative methods and are reported here. Initially, unstructured interviews were held; these revealed significant issues for the patients including the dominance of pain, issues relating to exudate and odour, social isolation and psychological effects. A checklist based on these issues was completed by the researcher during observations of routine care for these same patients; this revealed the extent and depth to which these matters were addressed. On many occasions, significant issues were not disclosed or explored during consultations. These findings confirmed that participants with chronic venous leg ulcers have concerns far beyond wound care.

Nurse Practitioner Mental Health Care in the Primary Context: A Californian Case Study

In America, mental health needs surpass the availability of specialized providers. This vulnerable population also has other obstacles for comprehensive care including gaps in medical coverage, stigma, economic barriers, and a geographical mal-distribution of qualified mental health professionals. A wide availability of primary care providers, including primary care and family nurse practitioners, are well-positioned to deliver integrated mental and physical health care. A case study from a Southern California Coachella Valley primary care clinic with integrated services is used to demonstrate the much-needed approach of care to address health disparities that face low-income immigrants, migrant workers, and others without access to specialized care centers and providers. It is argued that mental health care should be part of all holistic treatment provided by primary care and family nurse practitioners. This has implications for curricula and practice development.

A new quality of life consultation template for patients with venous leg ulceration

OBJECTIVE

Chronic venous leg ulcers (CVLUs) are common and recurrent, however, care for patients predominantly has a focus which overlooks the impact of the condition on quality of life. The aim of this study was to develop a simple, evidence-based consultation template, with patients and practitioners, which focuses consultations on quality of life themes.

METHOD

A nominal group was undertaken to develop a new consultation template for patients with CVLUs based on the findings of earlier qualitative study phases.

RESULTS

A user-friendly two-sided A4 template was designed to focus nurse-patient consultations on the quality of life challenges posed by CVLUs.

CONCLUSION

CVLUs impact negatively on the quality of life of the patient but this receives inadequate attention during current consultations. This new template will help to ensure that key concerns are effectively raised, explored and addressed during each consultation.

DECLARATION OF INTEREST

The NHS West Midlands Strategic Health Authority funded this study. The authors have no conflicts of interest to declare.

Enhancing person-centred care through the development of a therapeutic relationship

More than ever, district nurses require highly developed communication and interpersonal skills to enable and nurture a therapeutic relationship. The 'shift left'-whereby patients are being assessed and cared for in the community at a much earlier stage of their illness or recovery-has significant implications. The complexity of patient care and the need for collaborative working and shared decision making necessitates a focus on fostering person-centred care and improving the patient experience in practice. District nurses are adept communicators with a specialist body of knowledge and skills. In Northern Ireland, the single assessment tool (NISAT) is used by health professionals and follows a person-centred framework. This case study reflects on the assessment process used by a district nursing student in clinical practice and demonstrates how a therapeutic relationship is developed, thereby supporting person centredness.

The challenge of multimorbidity in nurse education: an international perspective

The rise in prevalence of chronic diseases has become a global healthcare priority and a system wide approach has been called for to manage this growing epidemic. Whilst healthcare reform to tackle the scale of chronic disease and other long term conditions is still in its infancy, there is an emerging recognition that in an ageing society, people often suffer from more than one chronic disease at the same time. Multimorbidity poses new and distinct challenges and was the focus of a global conference held by the Organization of Economic Cooperation and Development (OECD) in 2011. Health education was raised as requiring radical redesign to equip graduates with the appropriate skills to face the challenges ahead. We wanted to explore how different aspects of multimorbidity were addressed within pre-registration nurse education and held an international (United Kingdom-Sweden) nurse workshop in Linköping, Sweden in April 2013, which included nurse academics and clinicians. We also sent questionnaire surveys to final year student nurses from both countries. This paper explores the issues of multimorbidity from a patient, healthcare and nurse education perspective and presents the preliminary discussions from the workshop and students' survey.