Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care?

Factors influencing health-seeking behaviours and self-care practices among black-African Caribbean people living with type 2 diabetes: a community-focused qualitative study from Southwestern England

BACKGROUND/OBJECTIVE

To examine factors influencing health-seeking behaviours and self-care practices of diabetes, including the uptake and use of diabetic services among community-dwelling black African-Caribbean people living in the UK.

DESIGN

Cross-sectional/qualitative.

SETTING

Community (Southwestern England).

PARTICIPANTS

Nineteen individuals of African-Caribbean heritage, over the age of 50 years, diagnosed with type 2 diabetes.

METHODS

Three focus group discussions (FGDs), each of which lasted for approximately 90 min, were held. These interviews were facilitated by a community-based health champion and a researcher of African-Caribbean heritage. Audio recordings were transcribed verbatim, coded in NVivo software, and analysed using an inductive thematic approach.

PRIMARY OUTCOME MEASURES

FGD data.

RESULTS

A total of nine culturally specific and non-specific (generic) themes were identified. Culturally specific themes included the normalisation of diabetes at the community level, which was more pronounced among men than women. Participants were found to be inclined to either substitute or complement diabetes medications with cultural herbal remedies. There was a lack of trust in medical centric advice received from healthcare practitioners. Participants also expressed that healthcare practitioners do not always listen to or understand their needs and reported that there was a lack of culturally appropriate diabetes education and training programmes for their community members. Generic themes included difficulties and frustrations in getting doctor's appointments, self-indiscipline and poor motivation for engaging in physical exercise and healthy eating.

CONCLUSION

Several cultural/community-related factors influence health-seeking behaviours and self-care practices of diabetes in African-Caribbean people living in the UK, often affecting men and women differently, alongside more general individual and healthcare system-related barriers. Addressing these factors is imperative in designing a culturally and demographically tailored diabetes education programme for these people.

Understanding patient and staff perspectives on dignified rehabilitation care experiences

PURPOSE

Dignity in healthcare significantly impacts patient satisfaction and care personalisation. This study explores dignity from the perspectives of patients and staff in an inpatient rehabilitation unit, addressing the challenges of undignified care.

MATERIALS AND METHODS

Using a Generative Co-design Framework for Healthcare Innovation, specifically reporting on the pre-design phase, semi-structured interviews were conducted with 18 patients and 20 staff members over approximately 5 months. Patient interviews occurred during hospitalisation and post-discharge.

RESULTS

Dignity was experienced through interactions influenced by people, infrastructure, and policies. Participants defined dignity as being acknowledged and respected as people, or the acknowledgement of personhood. Positive dignified experiences were reported, but some patients reported undignified, but necessary care activities. Staff and patients highlighted the need for flexible, person-centred policies. Practices enhancing dignity included validating patient choices, respecting privacy, and ensuring informed decision-making. Despite some systemic challenges, staff showed a strong commitment to dignified care.

CONCLUSIONS

Dignity is challenging to define. Rehabilitation units and health systems more broadly should cultivate more responsive care interfaces, through flexible, person-centred policies, prioritising and hiring staff with disability aware attitudes, and embedding dignity into the organisational culture.

Efficacy of Educational Presentations in the Pediatric Orthopaedics Clinic

BACKGROUND

The patient education process is an important part of healthcare, and tools including handouts, videos, and webpage suggestions have been used to aid this process. Although educational slide presentations are commonly used for teaching in academic settings and have been used in certain specialty clinics, their use for educating families and improving the shared decision-making process has, to our knowledge, not been described in the orthopaedic surgery clinic.

QUESTIONS/PURPOSES

(1) How effective were educational PowerPoint presentations in the pediatric orthopaedics clinic as assessed by scores on a validated shared decision-making scale? (2) What were the families' preferred ways of learning about healthcare conditions?

METHODS

This prospective case series was conducted at an outpatient pediatric orthopaedic surgery clinic. Between May 2024 to January 2025, all new patients whose clinic visit was the initial visit for a single problem received an educational PowerPoint presentation specific to their diagnosis, delivered by the senior author (EDS) from a laptop. These presentations were developed for the top 10 most common diagnoses seen in the pediatric orthopaedic clinic. The presentation took on average 4 minutes to complete and outlined details of the diagnosis, natural history of the condition, treatment plan, and answers to frequently asked questions. Fifty-six patients with mean ± age of 11 ± 5 years were included in this study. The most common condition was scoliosis (52% [29 of 56]). After the clinic visit, the parents or guardians were given the Shared Medical Decision Making Satisfaction Scale, a validated tool that assessed their understanding of the diagnosis, ability to participate in shared decision-making, and perception of the visit. This survey included nine questions scored 1 to 5 or "not applicable" for a maximum score of 45. Higher scores indicated better understanding of the diagnosis and treatment options. Parents or guardians also ranked their preferred ways of learning from a list of four options, with options including educational presentation, verbal explanation, handout, or webpage suggestion. They were asked to draw from past experiences with the different modalities to compare to their experience with the provided educational PowerPoint. Fifty-six families completed the Shared Medical Decision Making Satisfaction Survey; 71% (40) of those families completed the ranking of preferred ways of learning, while the others left it blank for unknown reasons. A chi-square goodness-of-fit test was performed to determine which method of learning was preferred among parents or guardians.

RESULTS

Parents or guardians of the children treated generally gave the educational tool (the brief PowerPoint presentation about the child's condition) very high scores on the Shared Medical Decision Making Satisfaction Scale (mean ± SD 43 ± 4 of a possible 45 points, with higher scores representing the perception of a more engaging and satisfying process). Mean scores on all of the subscales of that tool exceeded 4.5 of a possible 5 points. When asked to compare their experience with the educational PowerPoint presentation to earlier experiences with verbal explanations, printed handouts, or web-based resources, the presentation was the preferred mode of receiving information; 60% (24 of 40) ranked this as the preferred approach, compared with verbal explanation (23% [9 of 40]), webpage suggestion (10% [4 of 40]), and printed materials (8% [3 of 40]) (p < 0.001).

CONCLUSION

Educational PowerPoint presentations seemed useful in delivering information to patients and families and in the facilitating of the shared decision-making process. Creating presentations for every diagnosis encountered in clinic is not feasible; however, presentations for the most common diagnoses may help to create a more effective practice. Further studies are warranted to investigate which slides are most effective, which healthcare information is best conveyed over PowerPoint for each diagnosis, and how reading level affects the ability of patients to understand the presentations.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Family physician service quality and sustainability: a roadmap for Pakistan's healthcare sector

Introduction

The number of family medicine consultants has increased during and after the COVID-19 pandemic. However, research on family medicine services specific to Pakistan remains limited. Therefore, this study aimed to explore family physician services in Pakistan.

Methods

To meet the study goals, we collected data using snowball and purposive sampling. A questionnaire was used exclusively to collect data from family physician consultations. The data were examined using the SmartPLS structural equation model to test the study model's reliability and validity.

Results

The study findings showed that using resource utilization and allocation, utilization of technology, professionalism improvement, medical attention, cooperation, and caring were positively significant to employee welfare and assistance in family medicine services. These dimensions were also positively significant to community involvement and advocacy for the sustainable development of family medical services in Pakistan.

Conclusion

The study concluded that effective resource utilization, professionalism, medical care, cooperation, and the evaluation of quality and outcomes are key factors in promoting the growth of family medicine services. These indicators may enhance staff satisfaction, community involvement, and family physician service sustainability.

The doctor will polygraph you now

Artificial intelligence (AI) methods have been proposed for the prediction of social behaviors that could be reasonably understood from patient-reported information. This raises novel ethical concerns about respect, privacy, and control over patient data. Ethical concerns surrounding clinical AI systems for social behavior verification can be divided into two main categories: (1) the potential for inaccuracies/biases within such systems, and (2) the impact on trust in patient-provider relationships with the introduction of automated AI systems for "fact-checking", particularly in cases where the data/models may contradict the patient. Additionally, this report simulated the misuse of a verification system using patient voice samples and identified a potential LLM bias against patient-reported information in favor of multi-dimensional data and the outputs of other AI methods (i.e., "AI self-trust"). Finally, recommendations were presented for mitigating the risk that AI verification methods will cause harm to patients or undermine the purpose of the healthcare system.

The doctor will polygraph you now: ethical concerns with AI for fact-checking patients

Artificial intelligence (AI) methods have been proposed for the prediction of social behaviors which could be reasonably understood from patient-reported information. This raises novel ethical concerns about respect, privacy, and control over patient data. Ethical concerns surrounding clinical AI systems for social behavior verification can be divided into two main categories: (1) the potential for inaccuracies/biases within such systems, and (2) the impact on trust in patient-provider relationships with the introduction of automated AI systems for "fact-checking", particularly in cases where the data/models may contradict the patient. Additionally, this report simulated the misuse of a verification system using patient voice samples and identified a potential LLM bias against patient-reported information in favor of multi-dimensional data and the outputs of other AI methods (i.e., "AI self-trust"). Finally, recommendations were presented for mitigating the risk that AI verification methods will cause harm to patients or undermine the purpose of the healthcare system.

It Is Time to Take Complaints Seriously? An Exploratory Analysis of Communications Sent by Users to a Public Healthcare Agency before, during and after the COVID-19 Pandemic

Taking due account of users' perspectives is crucial for improving the quality of healthcare services. This study aimed to analyse the representations and evaluation criteria that users of a public health agency express towards care and treatment services and to explore whether and how the content and meaning of their communications varied according to pre-pandemic, pandemic or post-pandemic periods. A total of 501 communications sent to the public relations office of an Italian health agency were collected. An automatic content analysis procedure was applied to the textual corpus. Four main thematic cores were identified concerning the request for care and respect, the value of the doctor-patient relationship and the difficulties in contacting services and accessing care. Two main latent dimensions of meaning were identified, which capture the dialectic between the demand for relationships and the demand for access to care, and between attention to the relational competence of health workers and attention to the needs and rights of users. Communications collected during the pre-pandemic and post-pandemic periods mainly concern the difficulty of access to care; those collected during the pandemic period mainly concern the doctor-patient relationship. Interpersonal aspects and timely access to care appear to be crucial in users' assessment of the quality of care.

"I Felt Like I Mattered": Caring is a key ingredient of collaborative care for chronic illness

OBJECTIVES

To identify perceptions and experiences related to caring science and collaborative care in intervention participants of the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) study, a randomized, multi-site clinical trial for patients with chronic heart failure and reduced health status.

METHODS

Forty-five participants completed semi-structured, telephone interviews with a focus on intervention components, impact of the intervention on participants' lives, and recommendations for intervention change. Data were analyzed using an inductive content analysis approach focusing on the presence and frequency of text to identify patterns, categories, and themes across participants without an a priori code book. The validity of the identified categories was enhanced through triangulation.

RESULTS

Three themes were identified: (1) intervention providers' caring/helping attitude and caring/helping communication; (2) care team availability to respond to concerns or questions; and (3) help with understanding and navigating the healthcare system.

DISCUSSION

Patients highly value caring attitudes and communication, availability, and empowerment to understand and navigate healthcare systems. These attitudes and behaviors may be important mediators of the success of collaborative care programs. These are consistent with the theory of caring science, a framework that is relevant more broadly to patient-centered and team-based care models.

Design and validation of an instrument to evaluate Person-Centered care in health services

BACKGROUND

The concept of quality in health care has evolved, placing greater importance on the patient's needs, culture, and social context, as well as their participation in clinical decision-making, as highlighted by Mead and Bower's Person-Centered Care Model. The aim of the present study was to design and validate an instrument to assess the extent to which healthcare services provided by PEMEX (Petróleos Mexicanos) offer person-centered care according to user perceptions.

METHODS

The first phase comprised the development of 57 items based on the analysis of responses from an open-ended questionnaire administered to 30 users of Pemex healthcare services. This questionnaire was designed considering the four factors of the person-centered care model, however, the high correlation between the 4 factors (i.e., r ≥ .80) indicated an overfactoring effect and consequently an increase in the risk of overfitting. Therefore, an exhaustive analysis of the instrument was performed, starting with the review of the individual behavior of each item, and carrying out exploratory and confirmatory factor analysis. Using a sample of 330 individuals, an exploratory factor analysis was perfomed. Afterward, a confirmatory factorial analysis was carried out with 335 participants. Finally, a new confirmatory factorial analysis included 130 participants due to the refinements made in the previous phase. Internal consistency was assessed using Cronbach's α and McDonald's ω at every phase.

RESULTS

The exploratory factor analysis retained 35 items in a single factor that accounted for 49% of the variance with an internal consistency of Cronbach's α and McDonald's ω = 0.97. Because the factorial structure by confirmatory factorial analysis was unsatisfactory, the initial model was refined, leading to the retention of 11 items and a final model with adjustment index of χ2 = 127.53, χ2/gl = 2.89, RMSEA = 0.07, IC RMSEA 0.06 to 0.09, TLI = 0.95 and CFI = 0.96, with an internal consistency of Cronbach's α and McDonald's ω = 0.93. Due to the refinements, a new confirmatory factorial analysis was conducted with suitable goodness-of-fit criteria in most items (χ2 = 151.44, χ2/gl = 3.43, RMSEA = 0.13, IC RMSEA 0.11 to 0.16, TLI = 0.93 and CFI = 0.94), resulting in a Cronbach's α and McDonald's ω = 0.98.

CONCLUSIONS

The instrument exhibits suitable psychometric properties to be employed to measure the degree to which medical care is patient centered. This instrument represents a strategy for promoting an innovative healthcare model.

Which clinician responses to emotion are associated with more positive patient experiences of communication?

OBJECTIVES

To identify communication strategies that may improve clinician-patient interactions, we assessed the association between clinician response to emotion and patient ratings of communication.

METHODS

From a cohort of 1817 clinician-patient encounters, we designed a retrospective case-control study by identifying 69 patients who rated their interpersonal care as low-quality and 69 patients who rated their care as high-quality. We used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to identify patient emotional expressions and clinician responses. Using mixed-effects logistic regression, we evaluated the association between clinician responses to patients' emotions and patient ratings of their interpersonal care.

RESULTS

In adjusted analyses, explicit responses that reduced space for further emotional communication were associated with high ratings of care (OR 1.94, 95% CI 1.25, 2.99); non-explicit responses providing additional space were associated with low ratings (OR 0.54, 95% CI 0.36-0.82). In terms of specific response types, neutral/passive responses were associated with low ratings (OR 0.59, 95% CI 0.39-0.90), whereas giving information/advice was associated with high ratings (OR, 95% 1.91 CI 1.17-3.1).

CONCLUSIONS

Patients may prefer responses to their expressed emotions that demonstrate clinician engagement, with or without expressions of empathy.

PRACTICE IMPLICATIONS

These findings may inform educational interventions to improve clinician-patient communication.

Dignity in Medicine: Definition, Assessment and Therapy

PURPOSE OF REVIEW

Over the last 20 years, dignity and dignity-conserving care have become the center of investigation, in many areas of medicine, including palliative care, oncology, neurology, geriatrics, and psychiatry. We summarized peer-reviewed literature and examined the definition, conceptualization of dignity, potential problems, and suggested interventions.

RECENT FINDINGS

We performed a review utilizing several databases, including the most relevant studies in full journal articles, investigating the problems of dignity in medicine. It emerged that dignity is a multifactorial construct and that dignity-preserving care should be at the center of the health organization. Dignity should be also regularly assessed through the tools currently available in clinical practice. Among dignity intervention, besides dignity models of care, dignity intervention, such as dignity therapy (DT), life review and reminiscence therapy, have a role in maintaining both the extrinsic (preserved when health care professionals treat the patient with respect, meeting physical and emotional needs, honors the patient's wishes, and makes attempts to maintain privacy and confidentiality) and intrinsic dignity (preserved when the patient has appropriate self-esteem, is able to exercise autonomy and has a sense of hope and meaning). Unified trends across diverse medical contexts highlight the need for a holistic, patient-centered approach in healthcare settings. Challenges compromising dignity are pervasive, underscoring the importance of interventions and systematic efforts to address these issues. Future research and interventions should prioritize the multifaceted nature of dignity, striving to create healthcare environments that foster compassion, respect, and dignity across all medical settings.

Bridge the gap caused by public health crises: medical humanization and communication skills build a psychological bond that satisfies patients

BACKGROUND

Patient satisfaction is an important outcome domain of patient-centered care. Medical humanization follows the patient-centered principle and provides a more holistic view to treat patients. The COVID-19 pandemic posed significant barriers to maintaining medical humanization. However, empirical study on the relationship between medical humanization and patient satisfaction is clearly absent.

OBJECTIVES

We examined the mediation effects of communication on the relationship between medical humanization and patient satisfaction when faced with a huge public health crisis like the COVID-19 pandemic, and the moderation effect of medical institutional trust on the mediation models.

METHODS

A cross-sectional survey study was performed. A final sample size of 1445 patients was surveyed on medical humanization, communication, patient satisfaction and medical institutional trust.

RESULTS

All correlations were significantly positive across the main variables (r = 0.35-0.67, p < 0.001 for all) except for medical institutional trust, which was negatively correlated with the medical humanization (r=-0.14, p < 0.001). Moderated mediation analysis showed that the indirect effect of medical humanization on patient satisfaction through communication was significant (b = 0.22, 95% CI: 0.18 ~ 0.25). Medical institutional trust significantly moderated the effect of medical humanization on patient satisfaction (b=-0.09, p < 0.001) and the effect of medical humanization on communication (b= -0.14, p < 0.001).

CONCLUSION

Medical humanization positively influence patient satisfaction, communication mediated the association between medical humanization and patient satisfaction, and medical institutional trust negatively moderated the effects of medical humanization on patient satisfaction and communication. These findings suggest that humanistic communication contributes to patient satisfaction in the face of a huge public health crisis, and patients' evaluation of satisfaction is also regulated by rational cognition.

Validating computer-generated measures of linguistic style matching and accommodation in patient-clinician communication

OBJECTIVE

To explore the validity of computer-analyzed linguistic style matching (LSM) in patient-clinician communication.

METHODS

Using 330 transcribed HIV patient encounters, we quantified word use with Linguistic Inquiry and Word Count (LIWC), a dictionary-based text analysis software. We measured LSM by calculating the degree to which clinicians matched patients in the use of LIWC "function words" (e.g., articles, pronouns). We tested associations of different LSM metrics with patients' perceptions that their clinicians spoke similiarly to them.

RESULTS

We developed 3 measures of LSM: 1) at the whole-visit level; (2) at the turn-by-turn level; and (3) using a "rolling-window" approach, measuring matching between clusters of 8 turns per conversant. None of these measures was associated with patient-rated speech similarity. However, we found that increasing trajectories of LSM, from beginning to end of the visit, were associated with higher patient-rated speech similarity (β 0.35, CI 0.06, 0.64), compared to unchanging trajectories.

CONCLUSIONS

Our findings point to the potential value of clinicians' adapting their communication style to match their patients, over the course of the visit.

PRACTICE IMPLICATIONS

With further validation, computer-based linguistic analyses may prove an efficient tool for generating data on communication patterns and providing feedback to clinicians in real time.

The Unbefriended Patient, Their Professional Guardians, and Clinical Liaison Psychiatry: The Challenging Ethics of Changing Goals of Care

AbstractUnbefriended patients are those with decisional impairments who lack family or friends to serve as healthcare surrogates. When such patients cannot make decisions, the court typically appoints a professional guardian to make choices aligned with the patient's values and preferences. However, this case report illustrates ethical challenges that can arise when professional guardians disregard the patient's authentic wishes. In this case study, the 38-year-old unbefriended African American male patient expressed fears about traumatic resuscitation efforts and ultimately desired de-escalation of care, which the guardian was hesitant to honor despite confirmed decision-making capacity. The guardian quickly reversed a new do-not-resuscitate order when the patient later changed his mind. Decisions about aggressive interventions like a colostomy were significantly delayed while awaiting final judgments involving the guardian's supervisors and the judicial system. The case highlights pitfalls with guardians defaulting to treatment escalation without sufficiently engaging with ethical standards or eliciting the patient's narrative identity, leading to inconsistent surrogate decisions. We propose that more robust reforms are needed, including enhanced training of guardians in ethical decision-making, and we present other means to facilitate best practices in proxy decision-making.

The ethical imperative to honor autistic clients' autonomy in mental health treatment

Autistic adolescents and adults commonly experience mental health concerns; however, mental health clinicians may hold implicit stigmatizing views of autism that contribute to case conceptualization and treatment goal setting that align more with caregivers' than clients' goals. This impingement on client autonomy is concerning, problematic, and potentially harmful for autistic clients who are of an age to set their own treatment agenda regardless of co-occurring intellectual disability and/or language delays. An application of the shared decision-making framework, an evidence-based tool for promoting client autonomy, can help to avoid these challenges in treatment. In this perspective, we use a case vignette as an anchor for discussing the imperative of honoring autistic clients' autonomy in mental health treatment and guiding shared decision-making to reduce stigma, promote autonomy, and increase collaborative care for autistic clients in mental health treatment.

What is 'successful rehabilitation'? A multi-stakeholder nominal group technique study to inform rehabilitation outcome measurement

OBJECTIVE

To explore how stakeholders in rehabilitation conceptualise 'successful rehabilitation', to inform the development of a minimum dataset and core outcomes for sub-acute rehabilitation.

DESIGN

Qualitative consensus study using the nominal group technique.

SETTING

Online focus groups.

PARTICIPANTS

Consumer representatives (n = 7), clinicians (n = 15), and health service managers (n = 9) from Australia.

INTERVENTION

Participants responded to the question, 'What does successful rehabilitation look like?'. Following item generation, they prioritised their top five responses, allocating 100 points across items to denote relative importance.

MAIN MEASURES

Prioritised responses were analysed across stakeholder groups using qualitative content analysis.

RESULTS

Ten themes were identified. 'Successful rehabilitation' is: (1) person and family centred; (2) effective; (3) inter-professional; (4) accessible; (5) goal oriented with meaningful outcomes; (6) connected to the continuum of care; (7) evidence-based and supportive of innovation and research; (8) appropriately funded and skilled; (9) satisfying and engaging; and (10) safe.

CONCLUSIONS

Stakeholder-defined 'successful rehabilitation' aligned with principles of value-based care and evidence-based rehabilitation. Provision and receipt of person and family centred care was the most important indicator of successful rehabilitation. Measures of success should include indicators of structure, process, outcome, and experience, and be conducted at multiple time-points.

Physicians' professionalism from the patients' perspective: a qualitative study at a single-family practice in Saudi Arabia

INTRODUCTION

Professionalism is a crucial component of medical practice. It is a culturally sensitive notion that generally consists of behaviors, values, communication, and relationships. This study is a qualitative study exploring physician professionalism from the patients' perspective.

METHODS

Focus group discussions with patients attending a family medicine center attached to a tertiary care hospital were carried out using the four gates model of Arabian medical professionalism that is appropriate to Arab culture. Discussions with patients were recorded and transcribed. Data were thematically analyzed using NVivo software.

RESULTS

Three main themes emerged from the data. (1) In dealing with patients, participants expected respect but understood delays in seeing physicians due to their busy schedules. In communication, participants expected to be informed about their health conditions and to have their questions answered. (2) In dealing with tasks, participants expected proper examination and transparency of diagnosis, but some expected the physician to know everything and did not appreciate them seeking outside opinions. They expected to see the same physician at every visit. (3) In physician characteristics preferences, participants preferred friendly smiling physicians. Some cared about the outer appearance of the physician whereas others did not.

DISCUSSION/CONCLUSIONS

The findings of the study explained only two themes of the four gates model namely dealing with patients and dealing with tasks. Cultural competence and how to benefit from patients' perceptions to be an ideal physician should be incorporated into the process of physicians' training.

Racial and ethnic disparities in the perception of respect from physicians among skin cancer patients in the United States

Background

Racial and ethnic minority groups are at increased risk of poor skin cancer outcomes. Successful patient-physician communication is linked to better health outcomes, but it is unknown whether disparities in perceived care exist among skin cancer patients.

Objective

To investigate whether there are racial and ethnic disparities in the perception of physicians showing respect, listening, and explaining during clinical encounters.

Methods

A cross-sectional study was conducted using data from participants with a self-reported skin cancer history from the 2008 to 2017 and 2019 Medical Expenditure Panel Survey. Race and ethnicity were self-identified.

Results

Of 5570 participants, 5263 were non-Hispanic White and 307 were racial and ethnic minority individuals. Racial and ethnic minority participants were less likely to report that their doctors show them respect, listen to, and explain to them than non-Hispanic White participants, even when adjusting for age, sex, insurance type, health status, and survey year. Among racial and ethnic minority participants, perceptions of physicians listening and explaining were strongly associated with perceived respect.

Limitations

Lack of disaggregated racial and ethnic subgroup analysis.

Conclusions

Our findings suggest racial and ethnic disparities in perceived care among skin cancer patients. Future research is warranted to determine whether such perceptions contribute to disparities in skin cancer care and/or outcomes.

Linking Nonverbal Rapport to Health Outcome: Testing an Organizational Pathway Model

A growing body of research on medical communication indicates that nonverbal rapport (e.g., smiling, eye contact, closer proximity) is central to productive health care delivery. However, mechanisms integral to the process by which nonverbal rapport influences health improvement remain under-researched. This study breaks new grounds in proposing and testing mediation pathways that take into account organizational factors. We conducted a cross-sectional survey in a private hospital in Singapore among 417 patients to examine their communication with physicians and nurses. Results indicated that nonverbal rapport did not have a significant direct relationship with perceived health outcome in both the patient-physician dyad and the patient-nurse dyad. Instead, communication satisfaction and organizational identity completely mediated this relationship. In addition, respect positively moderated the relationship between nonverbal rapport and communication satisfaction in both dyads, while health literacy was not a significant moderator. The findings suggest that the organizational context should be considered in pathways research.

Racial and Ethnic Differences in Communication Quality During Family-Centered Rounds

OBJECTIVES

To evaluate racial and ethnic differences in communication quality during family centered rounds.

METHODS

We conducted an observational study of family-centered rounds on hospital day 1. All enrolled caregivers completed a survey following rounds and a subset consented to audio record their encounter with the medical team. We applied a priori defined codes to transcriptions of the audio-recorded encounters to assess objective communication quality, including medical team behaviors, caregiver participatory behaviors, and global communication scores. The surveys were designed to measure subjective communication quality. Incident Rate Ratios (IRR) were calculated with regression models to compare the relative mean number of behaviors per encounter time minute by race and ethnicity.

RESULTS

Overall, 202 of 341 eligible caregivers completed the survey, and 59 had accompanying audio- recorded rounds. We found racial and ethnic differences in participatory behaviors: English-speaking Latinx (IRR 0.5; 95% confidence interval [CI] 0.3-0.8) Black (IRR 0.6; 95% CI 0.4-0.8), and Spanish-speaking Latinx caregivers (IRR 0.3; 95% CI 0.2-0.5) participated less than white caregivers. Coder-rated global ratings of medical team respect and partnership were lower for Black and Spanish-speaking Latinx caregivers than white caregivers (respect 3.1 and 2.9 vs 3.6, P values .03 and .04, respectively: partnership 2.4 and 2.3 vs 3.1, P values .03 and .04 respectively). In surveys, Spanish-speaking caregivers reported lower subjective communication quality in several domains.

CONCLUSIONS

In this study, Black and Latinx caregivers were treated with less partnership and respect than white caregivers.

What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient's past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.

Dignity encounters: the experiences of people with long-term illnesses and their close relatives within a primary healthcare setting

Aim:

To describe the experiences of dignity encounters from the perspective of people with long-term illness and their close relatives within a primary healthcare setting.

Background:

The importance of dignity as a concept in nursing care is well known, and in every healthcare encounter, the patient’s dignity has to be protected.

Methods:

A purposive sample of 10 people (5 couples) participated in this qualitative descripted study. One person in each of the couples had a long-term illness. Conjoint interviews were conducted and analyzed with an inductive qualitative content analysis.

Results:

The analysis resulted in three themes: i) Being supported by an encouraging contact; ii) Being listen to and understood; and iii) Being met with respect. Couples described being encountered with dignity as having accessibility to care in terms of being welcomed with their needs and receiving help. Accessibility promoted beneficial contact with healthcare personnel, who empowered the couples with guidance and support. Couples described a dignity encounter when healthcare personnel confirmed them as valuable and important persons. A dignity encounter was promoted their sense of feeling satisfied with the care they received and promoted safe care. Treated with dignity had a positive impact on the couples’ health and well-being and enhanced their sense of a good impression of the healthcare personnel within the primary health care.

Conclusions:

Healthcare personnel must regard and consider people with long-term illnesses and their close relatives’ experiences of dignity encounters to gain an understanding that enables them to support their needs and to know that the care is directed toward them.

Perceptions of Respect From Clinicians by Patients in Racial and Ethnic Minority Groups With Eye Disease

Importance

The perception of being treated with respect by clinicians may be a driver of disparities in individuals in racial and ethnic minoritie groups with eye diseases. Understanding these drivers may help identify potential interventions to reduce eye health disparities to prevent vision loss and blindness.

Objective

To evaluate the association between racial and ethnic minority status and the perception of being treated with respect by clinicians.

Design, Setting, and Participants

This cross-sectional analysis of a nationally representative cohort study using data from the National Health Interview Survey (NHIS) included participants in the 2017 survey with complete data on outcomes, associated factors, and covariates. Data analysis took place from January 2021 to February 2021. Using a population-based survey conducted in the US in 2017 by the US census bureau on behalf of the National Center for Health Statistics, NHIS study participants (age ≥18 years) who self-reported having an eye disease (macular degeneration, diabetic retinopathy [DR], glaucoma, cataracts) were included, and patients who self-reported as Black, Asian, other/multiple races, or Hispanic ethnicity were considered to be in racial and ethnic minority groups.

Main Outcomes and Measures

Multivariable logistic regression models were used to evaluate the association of minority status with self-reported "always" being treated with respect by clinicians and self-reported "always" being asked about opinions/beliefs about medical care.

Results

Participants in racial and ethnic minority groups had 23% lower odds of reporting being treated with respect compared with non-Hispanic White patients (adjusted odds ratio [AOR], 0.77; 95% CI, 0.61-0.97; P = .03). A minority of participants had 66% higher odds of reporting being asked about their beliefs (AOR, 1.66; 95% CI, 1.39-1.98; P < .001). For all patients, being asked about opinions/beliefs by their clinician was associated with a 5.8 times higher odds of reporting being treated with respect (AOR, 5.80; 95% CI, 4.35-7.74; P < .001).

Conclusions and Relevance

In this nationally representative US population of patients with eye diseases, being a patient in a racial or ethnic minority group was associated with feeling less respected by health care professionals compared with non-Hispanic White patients. Asking about opinions and beliefs, regardless of race or ethnicity, is associated with patients feeling that they are treated with respect.

How do middle-aged and older adults with chronic hip pain view their health problem and its care? A protocol for a systematic review and qualitative evidence synthesis

INTRODUCTION

Chronic hip pain in middle-aged and older adults is common and disabling. Patient-centred care of chronic hip pain requires a comprehensive understanding of how people with chronic hip pain view their health problem and its care. This paper outlines a protocol to synthesise qualitative evidence of middle-aged and older adults' views, beliefs, expectations and preferences about their chronic hip pain and its care.

METHODS AND ANALYSIS

We will perform a qualitative evidence synthesis using a framework approach. We will conduct this study in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and the Enhancing Transparency in Reporting the synthesis of Qualitative research checklist. We will search MEDLINE, CINAHL, The Cochrane Central Register of Controlled Trials, EMBASE and PsycINFO using a comprehensive search strategy. A priori selection criteria include qualitative studies involving samples with a mean age over 45 and where 80% or more have chronic hip pain. Two or more reviewers will independently screen studies for eligibility, assess methodological strengths and limitations using the Critical Appraisal Skills Programme qualitative studies checklist, perform data extraction and synthesis and determine ratings of confidence in each review finding using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach. Data extraction and synthesis will be guided by the Common-Sense Model of Self-Regulation. All authors will contribute to interpreting, refining and finalising review findings. This protocol is registered on PROSPERO and reported according to the PRISMA Statement for Protocols (PRISMA-P) checklist.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review as primary data will not be collected. The findings of the review will be disseminated through publication in an academic journal and scientific conferences.

PROSPERO REGISTRATION NUMBER

PROSPERO registration number: CRD42021246305.

Investigating the Added Value of the EQ-5D-5L With Two Bolt-On Items in Patients With Hemophilia

Objective: This study examined the impact of adding two condition-specific bolt-on items to the EQ-5D-5L and assessed their psychometric properties in patients with hemophilia.

Methods: The data were obtained from a nationwide cross-sectional online survey of patients with hemophilia in China. Self-reported and proxy-reported data were analyzed separately. Ceiling effect, informativity, and discriminatory power of the EQ-5D-5L with two bolt-on items, dignity (DG), and bleeding (BL), were examined. Spearman's rank correlation (rho) was used to assess the associations of the EQ-5D-5L and two bolt-on items with the Hemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) and SF-12. Multiple regression analysis was performed to evaluate the explained variance of the EQ-5D-5L and bolt-on items in predicting EQ-VAS scores.

Results: A total of 895 patients and 222 caregivers completed the questionnaire. The ceiling effect decreased from 1.9 to 0.6% and 5.9 to 0.9% when using the EQ-5D-5L and the EQ-5D-5L with two bolt-on items among participants with both self- and proxy-completed questionnaires. Both DG and BL were strongly correlated with Haem-A-QoL sum score [rho: DG = 0.64 (patient) vs. 0.66(proxy); BL = 0.49 (patient) vs. 0.31 (proxy)], SF-12 mental component [rho: DG = −0.36 (patient) vs. −0.41 (proxy); BL = −0.53 (patient) vs. −0.57(proxy)], and SF-12 physical component [rho: DG = −0.61 (patient) vs. −0.61 (proxy); BL = −0.35 (patient) vs. −0.39 (proxy)]. Known-group comparisons confirmed that the two bolt-on items had satisfactory discriminatory power. Multiple regression analysis indicated that adding two bolt-on items significantly increased the ability to predict EQ-VAS scores. The adjusted R² increased by 8.2 and 8.8% for reports completed by the patients or patients' proxy respondents, respectively.

Conclusion: Adding the DG and BL bolt-on items can increase performance on the EQ-5D-5L in patients with hemophilia. A future valuation study will be carried out.

Racial differences in patient perception of interactions with providers are associated with health outcomes in type II diabetes

OBJECTIVES

Examine the association of patient perceptions of care with hemoglobin A1c (HbA1c), medication adherence, and missed appointments in non-Hispanic Black (NHB) and White (NHW) patients with type 2 diabetes (T2DM).

METHODS

We used linear and logistic regression models to analyze the association of the Interpersonal Processes of Care survey (IPC) with HbA1c, medication adherence, and missed appointments. We then examined how these associations differed by race.

RESULTS

There was no overall association between IPC subdomains and HbA1c in our sample (N = 221). NHB patients perceiving their provider always explained results and medications had a HbA1c on average 0.59 (-1.13, -0.04; p = 0.04) points lower than those perceiving their provider sometimes explained results and medications. No effect was observed in NHWs. Never perceiving disrespect from office staff was associated with an average 0.67 (-1.1, -0.24; p = 0.002) point improvement in medication adherence for all patients. Never perceiving discrimination from providers was associated with a 0.44 (-0.63, -0.25; p < 0.0001) decrease in the probability of missing an appointment for NHB patients.

CONCLUSIONS

These results demonstrate that particular aspects of communication in the patient-provider interaction may contribute to racial disparities in T2DM.

PRACTICE IMPLICATIONS

Communication training for both providers and staff may reduce disparities in T2DM.

Patients' and Care Partners' Perspectives on Dignity and Respect During Acute Care Hospitalization

BACKGROUND

Delivering patient-centered care (PCC) is essential to our healthcare system. Patient dignity and respect are foundational elements of PCC. Understanding patients' and their care partner's perspectives on the meaning of dignity and respect within a clinical care environment is critical to achieving our goal of PCC.

OBJECTIVE

The aim of the study was to understand how patients and their care partners define, describe, and experience dignity and respect during hospitalization.

METHODS

We conducted a qualitative study with 22 patients and care partners hospitalized in high-acuity patient care areas in 1 academic medical center. Data collected from semistructured interviews were analyzed using grounded theory open coding in Atlas Ti software.

RESULTS

Our data provide a definition of dignity and respect during hospitalization from the patient and care partner perspective and a conceptual model of the factors needed to enhance patients' and care partners' experience of dignity and respect in the hospital setting. Dignity was felt to be intrinsic to personhood including the recognition of that person's value by others. Respect was characterized as the behavioral or social norms that acknowledge dignity. Determinants of dignity and respect were categorized at the organizational (macro) level and within the microsystem between clinicians, patients, and their care partners.

CONCLUSIONS

The definition of dignity and respect and the conceptual model presented here represent an important supplement to our understanding of dignity and respect during hospitalization. Healthcare organizations should focus on the key factors found in this study to create a culture that treats patients with dignity and respect.

Patient hospital experience and satisfaction on social media

Purpose

The purpose of this paper is to show the value of open-ended narrative patient reviews on social media for elucidating aspects of hospital patient satisfaction.

Design/methodology/approach

Mixed methods analyses using qualitative (manual content analyses using grounded theory and algorithmic analyses using the Natural Language Toolkit) followed by quantitative analyses (negative binomial regression).

Findings

Health-care team communication, health-care team action orientation and patient hospital room environment are positively related to patient hospital satisfaction. Patients form their hospital satisfaction perceptions based on the three facets of their hospital stay experience.

Research limitations/implications

In the spirit of continuous quality improvement, periodically analyzing patient social media comments could help health-care teams understand the patient satisfaction inhibitors that they need to avoid to offer patient-centric care.

Practical implications

By periodically analyzing patient social media comments hospital leaders can quickly identify the gaps in their health service delivery and plug them, which could ultimately give the hospital a competitive advantage.

Originality/value

To the best of the authors’ knowledge, this is one of the first studies to apply mixed methods to patient hospital review comments given freely on social media to critically understand what drives patient hospital satisfaction ratings.

Patient perspectives on how to demonstrate respect: Implications for clinicians and healthcare organizations

OBJECTIVE

Clinicians and healthcare organizations are ethically obligated to treat patients with respect, yet it is not clear what actions best demonstrate respect to patients. This exploratory qualitative study aimed to understand what actions on both an individual and organizational level effectively demonstrate respect for primary care patients.

METHODS

We conducted semi-structured telephone interviews with primary care patients in an integrated healthcare delivery system in Oregon and an integrated safety net health system in Colorado who were participating in a genomics implementation research study of a hereditary cancer screening program. We systematically coded interview transcripts using a coding framework developed based on iterative review of the interview guide and transcripts. We further analyzed the data coded with sub-codes relating to patients' experiences with respect in healthcare using a descriptive content analysis approach.

RESULTS

We interviewed 40 English-speaking (n = 30, 75%) and Spanish-speaking (n = 10, 25%) patients. Most interviewees identified as female (n = 35, 88%) and either Hispanic/Latino(a) (n = 17, 43%) or White or European American (n = 15, 38%). Interviewees identified two categories of efforts by individual clinicians that demonstrate respect: engaging with patients and being transparent. They identified five efforts by healthcare organizations: promoting safety and inclusivity, protecting patient privacy, communicating about scheduling, navigating financial barriers to care, and ensuring continuity of care.

CONCLUSIONS

Our findings suggest that patients' experiences of respect depend on efforts by individual clinicians as well as healthcare organizations. Our findings offer insight into how clinicians can build stronger partnerships with patients and how organizations can seek to promote access to care and patient safety and comfort. They also illustrate areas for future research and quality improvement to more effectively respect patients.

Patient's Dignity: Viewpoints of Patients and Nurses in Hospitals

Much of the available research on perceptions of patient dignity either is qualitative in type or explores them in specific patient groups, such as elderly patients, cancer patients, terminally-ill patients, and adolescent patients. The present study addresses nurses' and adult patients' views on patient dignity. A total of 400 individuals (200 nurses and 200 patients) from 39 internal and surgical units from four hospitals affiliated to Shiraz University of Medical Sciences participated in the study. The collected data were analyzed using descriptive, t-test, one-way ANOVA, and Pearson's correlation coefficient using SPSS v. 23.0. A significant difference between nurses' and patients' points of view was identified in relation to four domains: the importance of privacy (p < 0.001); attention to patient autonomy (p < 0.001); respect for patients (p < 0.001); and communication between nurses and patients (p < 0.001). In order to maintain patients' dignity in practice, nurses must become better acquainted with patients' expectations. The questionnaire assessing respect for patient's dignity developed in the present study is a reliable and valid instrument for this purpose.

Moving cupping therapy for plaque psoriasis: A PRISMA-compliant study of 16 randomized controlled trials

BACKGROUND

Clinical treatment of plaque psoriasis typically involves a comprehensive therapy, which is expensive and unsatisfactory, and some medications have serious side effects. Moving cupping therapy has shown good clinical efficacy in the treatment of plaque psoriasis; it can significantly relieve skin inflammation and excessive thickening of plaque psoriasis and has fewer side effects. However, a comprehensive evaluation of the current clinical evidence regarding its use is lacking.

METHODS

Several databases were systematically searched from inception to March 2, 2020, including PubMed, Embase, Cochrane Central Register of Controlled Trials, China Network Knowledge Infrastructure, and Wan Fang. This review included randomized controlled trials on plaque psoriasis treatment with the use of moving cupping and in combination with Chinese herbs or conventional Western medicine therapy. These trial findings were compared with the treatment results using placebo, pharmaceutical medications, or Chinese herbs. Moving cupping treatment frequency was also compared.

RESULTS

Sixteen trials with 1164 participants met the inclusion criteria. Meta-analysis showed that the intervention group (moving cupping therapy) had a significant effect compared with the no-moving cupping therapy group (weighted mean difference = -1.22, 95% confidence interval [CI] [-1.58, -0.85], P < .00001 random model; I = 85%). Furthermore, moving cupping (weighted mean difference = -1.19, 95% CI [-1.98, -0.39], P = .003 random model; I = 85%) or combined with pharmaceutical medications (weighted mean difference = -1.55, 95% CI [-1.89, -1.20], P < .00001 random model; I = 0%) were better than pharmaceutical medications alone in treating plaque psoriasis. Cupping therapy significantly improved psoriasis recurrence rate (risk ratio = 0.33, 95% CI [0.16, 0.68], P = .003 fixed model; I = 28%). However, for the visual analogue score, moving cupping showed no obvious advantages (weighted mean difference = -0.27, 95% CI [-0.71, 0.17], P = .22 random model; I = 64%). Moreover, studies reported that moving cupping reduced serum tumor necrosis factor-α and vascular endothelial growth factor levels more significantly than pharmaceutical medications. Moving cupping was associated with few transient adverse reactions, such as redness, itching, and local skin burning.

CONCLUSION

Moving cupping therapy could be an effective treatment either alone or as a combination therapy for plaque psoriasis. However, further large-scale, rigorously designed trials are needed to confirm these findings.

Improving Our Ability to Predict Resident Applicant Performance: Validity Evidence for a Situational Judgment Test

Construct: We investigated whether a situational judgment test (SJT) designed to measure professionalism in physicians predicts residents' performance on (a) Accreditation Council for Graduate Medical Education (ACGME) competencies and (b) a multisource professionalism assessment (MPA). Background: There is a consensus regarding the importance of assessing professionalism and interpersonal and communication skills in medical students, residents, and practicing physicians. Nonetheless, these noncognitive competencies are not well measured during medical education selection processes. One promising method for measuring these noncognitive competencies is the SJT. In a typical SJT, respondents are presented with written or video-based scenarios and asked to make choices from a set of alternative courses of action. Interpersonally oriented SJTs are commonly used for selection to medical schools in the United Kingdom and Belgium and for postgraduate selection of trainees to medical practice in Belgium, Singapore, Canada, and Australia. However, despite international evidence suggesting that SJTs are useful predictors of in-training performance, end-of-training performance, supervisory ratings of performance, and clinical skills licensing objective structured clinical examinations, the use of interpersonally oriented SJTs in residency settings in the United States has been infrequently investigated. The purpose of this study was to investigate whether residents' performance on an SJT designed to measure professionalism-related competencies-conscientiousness, integrity, accountability, aspiring to excellence, teamwork, stress tolerance, and patient-centered care-predicts both their current and future performance as residents on two important but conceptually distinct criteria: ACGME competencies and the MPA. Approach: We developed an SJT to measure seven dimensions of professionalism. During calendar year 2017, 21 residency programs from 2 institutions administered the SJT. We conducted analyses to determine the validity of SJT and USMLE scores in predicting milestone performance in ACGME core competency domains and the MPA in June 2017 and 3 months later in September 2017 for the MPA and 1 year later, in June 2018, for ACGME domains. Results: At both periods, the SJT score predicted overall ACGME milestone performance (r = .13 and .17, respectively; p < .05) and MPA performance (r = .19 and .21, respectively; p < .05). In addition, the SJT predicted ACGME patient care, systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism competencies (r = .16, .15, .15, .17, and .16, respectively; p < .05) 1 year later. The SJT score contributed incremental validity over USMLE scores in predicting overall ACGME milestone performance (ΔR = .07) 1 year later and MPA performance (ΔR = .05) 3 months later. Conclusions: SJTs show promise as a method for assessing noncognitive attributes in residency program applicants. The SJT's incremental validity to the USMLE series in this study underscores the importance of moving beyond these standardized tests to a more holistic review of candidates that includes both cognitive and noncognitive measures.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

The effect of health-related information seeking and financial strain on medication nonadherence among patients with diabetes and/or hypertension in central Texas

Objective

To assess self-reported financial strain and persistence in asking treatment- and medication-related questions in relation to medication nonadherence.

Method

Data were analysed from a cross-sectional study of adults with diabetes, hypertension or both in central Texas in 2013. Measures of medication nonadherence in the past 12 months, financial strain and patients' persistence in asking treatment- and medication-related questions were identified. Medication nonadherence resulting from cost, transportation or work was compared with medication nonadherence resulting from other reasons. Binary and multinomial regression models were fitted to identify factors associated with medication nonadherence among the respondents.

Key findings

In the bivariate model, medication nonadherence from any cause was significantly associated with financial strain, not asking questions about treatments or medications, and all demographic characteristics. However, in the multinomial model, medication nonadherence resulting from cost, work or transportation was only associated with not asking medication-related question about financial strain, lack of health insurance, age and gender. This was true for nonadherence resulting from other reasons except that ethnicity was significant while gender was not.

Conclusions

While removing financial strain could aid medication adherence, clinicians should also encourage patients to be persistent in asking questions about their medications until they understand the purpose for taking them. Our findings have implications for empowering patients to be more proactive in enhancing their adherence to medications.

A framework and toolkit of interventions to enhance reflective learning among health-care professionals: the PEARL mixed-methods study

Background

Although most health care is high quality, many patients and members of staff can recall episodes of a lack of empathy, respect or effective communication from health-care staff. In extreme form, this contributes to high-profile organisational failures. Reflective learning is a universally promoted technique for stimulating insight, constructive self-appraisal and empathy; however, its efficacy tends to be assumed rather than proven. The Patient Experience And Reflective Learning (PEARL) project has used patient and staff experience to co-design a novel reflective learning framework that is based on theories of behaviour and learning.

Objective

To create a toolkit to help health-care staff obtain meaningful feedback to stimulate effective reflective learning that will promote optimal patient-, family- and colleague-focused behaviours.

Design

A 3-year developmental mixed-methods study with four interlinked workstreams and 12 facilitated co-design meetings. The Capability, Opportunity, Motivation – Behaviour framework was used to describe factors influencing the behaviour of reflection.

Setting

This took place at five acute medical units and three intensive care units in three urban acute hospital trusts in England.

Participants

Patients and relatives, medical and nursing staff, managers and researchers took part.

Data sources

Two anonymous surveys, one for patients and one for staff, were developed from existing UK-validated instruments, administered locally and analysed centrally. Ethnographers undertook interviews and observed clinical care and reflective learning activities in the workplace, as well as in the co-design meetings, and fed back their observations in plenary workshops.

Main outcome measures

Preliminary instruments were rated by participants for effectiveness and feasibility to derive a final set of tools. These are presented in an attractively designed toolbox with multiple sections, including the theoretical background of reflection, mini guides for obtaining meaningful feedback and for reflecting effectively, guides for reflecting ‘in-action’ during daily activities, and a set of resources.

Results

Local project teams (physicians, nurses, patients, relatives and managers) chaired by a non-executive director found the quarterly reports of feedback from the patient and staff surveys insightful and impactful. Patient satisfaction with care was higher for intensive care units than for acute medical units, which reflects contextual differences, but in both settings quality of communication was the main driver of satisfaction. Ethnographers identified many additional forms of experiential feedback. Those that generated an emotional response were particularly effective as a stimulus for reflection. These sources of data were used to supplement individual participant experiences in the nine local co-design meetings and four workshops to identify barriers to and facilitators of effective reflection, focusing on capability, opportunity and motivation. A logic model was developed combining the Capability, Opportunity, Motivation – Behaviour framework for reflection and theories of learning to link patient and staff experience to changes in downstream behaviours. Participants proposed practical tools and activities to enhance reflection ‘in-action’ and ‘on-action’. These tools were developed iteratively by the local and central project teams.

Limitations

Paper-based surveys were burdensome to administer and analyse.

Conclusions

Patients and health-care staff collaborated to produce a novel reflective learning toolkit.

Future work

The toolkit requires evaluating in a cluster randomised controlled trial.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 32. See the NIHR Journals Library website for further project information.

The true penalty of the waiting room: the role of wait time in patient satisfaction in a busy spine practice

OBJECTIVE

Most clinics collect routine data on performance metrics on physicians for outpatient visits. However, the relationship of these metrics with patient experience is unclear. The goal of this study was to investigate the relationships between the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS), the standard patient experience survey, and clinic performance metrics to understand the determinants of patient satisfaction and identify targets for improving patient experience.

METHODS

The authors performed a retrospective single-institution cohort review of spine surgeon metrics over 15 months including demographics, waiting-room times, in-room times, lead times, timely note closure, timely MyChart responses, and monthly patient volume. Kruskal-Wallis tests and mixed-model regression were used to determine the predictors of 3 domains of patient satisfaction-Global, Access, and Communication.

RESULTS

Over 15 months, 22 surgeons conducted 27,090 visits. The average clinic visit total time was 85.17 ± 25.75 minutes. Increased wait times were associated with poor Global (p = 0.008), Access (p < 0.001), and Communication scores (p = 0.003) in univariate analysis. Every 10-minute increase in waiting time was associated with a 3%, 9.8%, and 2.4% decrease in Global, Access, and Communication scores, respectively. Increased in-room time was also an independent predictor of poor Access scores (p < 0.001). In multivariate analysis, increased wait times were negative predictors of Global (p = 0.005), Access (p < 0.001), and Communication (p = 0.002) scores.

CONCLUSIONS

Excessive waiting-room time significantly impacts unexpected dimensions of the patient experience and impacts communication with patients. Understanding the complex relationship between the factors that inform the patient experience will help target effective interventions to improve clinic efficiency and patient satisfaction.

Communication Skills and Professional Practice: Does It Increase Self-Efficacy in Nurses?

The relationship between nurses and their patients is changing significantly, resulting in a patient-focused model. This work aims to contribute new knowledge about the effect of communication skills on perceived self-efficacy of nursing professionals. A cross-sectional descriptive study was conducted with a final sample consisting of 242 nurses. Different instruments that measured communication skills and the general and specific self-efficacy of nursing professionals were utilized. A positive and statistically significant correlation (p < 0.01) between the communication skills and the perceived general and specific self-efficacy was obtained. Nursing professionals who have adequate communication skills feel more confident and more competent, fostering good interpersonal relationships with their patients, and therefore, their perceived general and specific self-efficacy improved as well. Teaching communication skills is important to help nurses cope with a broad range of stressors in their daily interactions with patients, increasing their perceived self-efficacy.

Effects of Patient-Centered Communication on Influenza Vaccination and Self-Reported General Health Status among Asian Americans: A Comparison Model for Young/Middle-Aged and Older Adults

Objectives: Asian American subgroups’ influenza vaccination is still below the US standards. This study examined the effects of patient-centered communication (PCC) on influenza vaccination and the general health (GH) of Chinese, Vietnamese, and Korean Americans. A group difference between younger and older adults was investigated. Methods: The 2014–2016 California Health Interview Surveys were merged (Chinese [ N = 1,680], Korean [ N = 514], and Vietnamese [ N = 644]; age 18+; younger = 1,629 and older = 1,209). Two path models (PCC [measured by physicians’ careful listening], vaccination, and GH; PCC [measured by physicians’ clear explanation], vaccination, and GH) were evaluated. Regression maximum likelihood was applied for missing values. Results: Both the first and second models showed good model fit scores (comparative fit index [CFI] = .95, root mean square error of approximation [RMSEA] = .04, and standardized root mean residual [SRMR] = .03; CFI = .93, RMSEA = .04, and SRMR = .03). There were direct effects of PCC on vaccination among younger adults. PCC directly influenced GH for both age-groups. Discussion: A PCC manual for physicians in local or community health centers could enhance both younger and older adults’ influenza vaccination.

The communication skills and quality perceived in an emergency department: The patient's perspective

AIM

To examine the influence of health care provider's communication skills on the quality of care perceived by Emergency Department patients.

BACKGROUND

Communication between patients and health care providers in the context of Emergency Department is challenging and can potentially have a negative impact on the quality of care perceived by patients.

DESIGN

Cross-sectional descriptive study conducted in the Emergency Department at the University Clinical Hospital Virgen de la Arrixaca of Murcia, Spain.

METHOD

Data were collected from 6 to 9 June 2016. Different instruments were used to evaluate the perception of patients on the communication skills and quality of care at the Emergency Department.

RESULTS

The sample was composed of 200 patients, with an average age of 44.1 (SD = 18.3), of which 106 (53%) were men. The multiple linear regression analysis showed the association between communication skills (respect, problem solving, and nonverbal communication) and age with the quality of care perceived by the patients.

CONCLUSIONS

We found that the communication skills of the health care providers were explanatory variables of the quality of care perceived in an Emergency Department.

Lived experience and attitudes of people with plantar heel pain: a qualitative exploration

Background

Plantar heel pain is a common source of pain and disability. Evidence-based treatment decisions for people with plantar heel pain should be guided by the best available evidence, expert clinical reasoning, and consider the needs of the patient. Education is a key component of care for any patient and needs to be tailored to the patient and their condition. However, no previous work has identified, far less evaluated, the approaches and content required for optimal education for people with plantar heel pain. The aim of this study was to gather the patients’ perspective regarding their lived experience, attitudes and educational needs in order to inform the content and provision of meaningful education delivery approaches.

Methods

Using a qualitative descriptive design, semi-structured interviews were conducted with participants with a clinical diagnosis of plantar heel pain. A topic guide was utilised that focused on the experience of living with plantar heel pain and attitudes regarding treatment and educational needs. Interviews were audio recorded, transcribed verbatim and analysed using the Framework approach. Each transcription, and the initial findings, were reported back to participants to invite respondent validation.

Results

Eighteen people with plantar heel pain were interviewed. Descriptive analysis revealed eight themes including perceptions of plantar heel pain, impact on self, dealing with plantar heel pain, source of information, patient needs, patient unmet needs, advice to others and interest in online education. Participants revealed doubt about the cause, treatment and prognosis of plantar heel pain. They also expressed a desire to have their pain eliminated and education individually tailored to their condition and needs. Respondent validation revealed that the transcripts were accurate, and participants were able to recognise their own experiences in the synthesised themes.

Conclusion

Plantar heel pain has a negative impact on health-related quality of life. Participants wanted their pain eliminated and reported that their expectations and needs were frequently unmet. Health professionals have an important role to be responsive to the needs of the patient to improve their knowledge and influence pain and behaviour. Our study informs the content needed to help educate people with plantar heel pain.

The Rhetoric of the 'Passive Patient' in Indian Medical Negligence Cases

In this paper, I examine the rhetoric employed by court judgements, with a particular emphasis on the narrative construct of the 'passive patient'. This construction advances and reinforces paternalistic values, which have scant regard for the patients' preferences, values, or choices within the legal context. Further, I critique the rhetoric employed and argue that the use of this rhetoric is the basis for a precedent that limits the understanding and respect of patients. Through this paper, I present the contemporary use of the 'passive patient' construct in the context of the Indian legal system and describe how such constructions have become a source of normative justification for legal reasoning that jeopardizes the patient's agency. I argue for the primacy of 'respect for persons' within Indian law and the need to treat each patient as a person who has agency, preferences, and values during clinical interactions. I conclude by suggesting that laws that adopt narratives that acknowledging the significance of patient engagement and the relevance of effective communication during clinical encounters would help cultivate a culture of patient-centred care, by moving beyond the rhetoric of 'passive patient' and the 'health/choice' dichotomy.

Humanization of Care: Key Elements Identified by Patients, Caregivers, and Healthcare Providers. A Systematic Review

BACKGROUND

Given the automatization of care and rationing of time and staff due to economic imperatives, often resulting in dehumanized care, the concept of 'humanization of care' has been increasingly discussed in the scientific literature. However, it is still an indistinct concept, lacking well-defined dimensions and to date no literature review has tried to capture it.

OBJECTIVES

The objectives of this systematic review were to identify the key elements of humanization of care by investigating stakeholders' (patients, patients' caregivers, healthcare providers) perspectives and to assess barriers and strategies for its implementation.

METHODS

We carried out a systematic search of five electronic databases up to December 2017 as well as examining additional sources (e.g., gray literature). Search terms included "humanization/humanisation of care" and "dehumanization/dehumanisation of care". We conducted a thematic synthesis of the extracted study findings to identify descriptive themes and produce key elements.

RESULTS

Of 1327 records retrieved, 14 full-text articles were included in the review. Three main areas (relational, organizational, structural) and 30 key elements (e.g., relationship bonding, holistic approach, adequate working conditions) emerged. Several barriers to implementation of humanization of care exist in all areas.

CONCLUSION

Our systematic review and synthesis contributes to a deeper understanding of the concept of humanization of care. The proposed key elements are expected to serve as preliminary guidance for healthcare institutions aiming to overcome challenges in various forms and achieve humanized and efficient care. Future studies need to fully examine specific practices of humanized care and test quantitatively their effectiveness by examining psychosocial and health outcomes.

The Practice of Respect in the ICU

Although "respect" and "dignity" are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating "failures of respect" as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

Patient experience and reflective learning (PEARL): a mixed methods protocol for staff insight development in acute and intensive care medicine in the UK

INTRODUCTION

Patient and staff experiences are strongly influenced by attitudes and behaviours, and provide important insights into care quality. Patient and staff feedback could be used more effectively to enhance behaviours and improve care through systematic integration with techniques for reflective learning. We aim to develop a reflective learning framework and toolkit for healthcare staff to improve patient, family and staff experience.

METHODS & ANALYSIS

Local project teams including staff and patients from the acute medical units (AMUs) and intensive care units (ICUs) of three National Health Service trusts will implement two experience surveys derived from existing instruments: a continuous patient and relative survey and an annual staff survey. Survey data will be supplemented by ethnographic interviews and observations in the workplace to evaluate barriers to and facilitators of reflective learning. Using facilitated iterative co-design, local project teams will supplement survey data with their experiences of healthcare to identify events, actions, activities and interventions which promote personal insight and empathy through reflective learning. Outputs will be collated by the central project team to develop a reflective learning framework and toolkit which will be fed back to the local groups for review, refinement and piloting. The development process will be mapped to a conceptual theory of reflective learning which combines psychological and pedagogical theories of learning, alongside theories of behaviour change based on capability, opportunity and motivation influencing behaviour. The output will be a locally-adaptable workplace-based toolkit providing guidance on using reflective learning to incorporate patient and staff experience in routine clinical activities.

ETHICS & DISSEMINATION

The PEARL project has received ethics approval from the London Brent Research Ethics Committee (REC Ref 16/LO/224). We propose a national cluster randomised step-wedge trial of the toolkit developed for large-scale evaluation of impact on patient outcomes.

Nurses' experiences of communicating respect to patients: Influences and challenges

BACKGROUND

Respectful care is central to ethical codes of practice and optimal patient care, but little is known about the influences on and challenges in communicating respect.

RESEARCH QUESTION

What are the intra- and inter-personal influences on nurses' communication of respect?

RESEARCH DESIGN AND PARTICIPANTS

Semi-structured interviews with 12 hospital-based UK registered nurses were analysed using interpretative phenomenological analysis to explore their experiences of communicating respect to patients and associated influences.

ETHICAL CONSIDERATIONS

The study was approved by the Institutional ethics board and National Health Service Trust.

FINDINGS

Three interconnected superordinate themes were identified: 'private self: personal attitudes', 'outward self: showing respect' and 'reputational self: being perceived as respectful'. Respectful communication involved a complex set of influences, including attitudes of respect towards patients, needs and goals, beliefs around the nature of respectful communication, skills and influencing sociocultural factors. A tension between the outward self as intended and perceived presented challenges for nurses' reputational self as respectful, with negative implications for patient care.

DISCUSSION

The study offers an in-depth understanding of intra- and inter-personal influences on communicating respect, and sheds light on challenges involved, helping provide practical insights to support respectful care.

CONCLUSION

Findings stress the need for improved conceptualisations of respect in healthcare settings to formally recognise the complex attitudinal and socially constructed nature of respect and for appropriate professional training to improve its communication.