Promoting Meaning and Recovery for Psychosis: Comparison of Metacognitively-Oriented Psychotherapists and Clinicians in Psychiatric Rehabilitation

Introduction

Recovery from psychosis is an expected and desired outcome in psychiatric rehabilitation that may involve subjective outcomes related to personal recovery. While a considerable amount of qualitative research has examined patients' experience of recovery oriented approaches, there are less studies examining clinicians' perspectives. Examining the clinician point of view is important for both supporting clinicians within recovery-oriented practice, as well as for understanding underlying therapeutic processes. The aims of this study were to explore clinician experience of offering different psychiatric rehabilitation treatments for individuals with psychosis, and to understand similarities and differences of clinicians whose work differed in its recovery emphasis.

Methods

Open-ended interviews were conducted with 10 psychotherapists providing Metacognitive Reflection and Insight Therapy (MERIT), a recovery oriented form of integrative psychotherapy focused on subjective aspects of recovery, and 10 clinicians providing standard psychiatric rehabilitation services.

Results

Thematic analysis revealed important similarities and differences between these two groups of providers. There were seven themes found for MERIT therapists: Comfort with uncertainty, Emphasis on collaboration, Being part of therapeutic change, Connecting with clients, Emphasis on patient autonomy, Experiencing growth, and Therapist use of self-awareness. There were four themes found for psychiatric rehabilitation clinicians: Value of a structured approach, Focus on a strengths-based approach, Witnessing behavioral change, and Building rapport to support the work.

Discussion

As expected, both similarities and differences arose between clinician groups. Results indicated that both groups focused on the therapeutic relationship and monitoring progress and outcomes. Unexpectedly, MERIT therapists reported growth as well as comfort with uncertainty. These findings suggest that MERIT is a a psychotherapy that offers unique opportunities for creative and flexible exploration of meaning and agency that is both challenging and rewarding for clinicians. Implications for supporting healthy clinician practice and the development of services are discussed.

The Influence of the Clinicians' Experience on the Outcome of Dental Implants: A Clinical Audit

The purpose of this outcome audit is to evaluate the influence of the clinicians' experience on the outcome of dental implants. In addition, it is to identify the associated risk factors that might influence the success and survival of these implants.

METHODOLOGY

The records of patients treated with SLA/SLActive Straumann implants were screened. This enabled us to have a minimum of 12 months of follow-up. Eligible patients, according to the inclusion criteria, were contacted and invited to undergo a follow-up assessment. Success was accounted for and defined in a comprehensive manner by considering four different categories: implant perspective, peri-implant soft tissue perspective, prosthetic perspective, and patient satisfaction. The patient investigations included a clinical examination of the implant mobility, suppuration, width of keratinized mucosa, probing depth, plaque accumulation, prosthetic complications, and patient satisfaction. In addition, a periapical radiograph was taken to evaluate bone loss and peri-implant radiolucency. The data were analysed using SPSS version 26.

RESULTS

Thirty-eight patients with 84 SLA/SLActive Straumann implants were available for the assessment. The mean age of the patients at implant surgery was 49.05 ± 13.19 years. Over the mean follow-up period of 26 months, no implant fractures were noted. Overall, eight implants were considered failures (9.5%). Two out of six patients with a history of periodontitis (HoP) and two out of five smokers exhibited failed implants. The patients' satisfaction responses showed that all the responses were statistically higher than the test median value of three. The median value of general satisfaction using a visual analogue scale was 9 out of 10.

CONCLUSIONS

The implants placed on partially and fully edentulous patients revealed high survival and success rates (100% and 90.5%, respectively) at a mean follow-up time of 26 months. It can be concluded that the implant practise among trainees in the programme is satisfactory. A history of periodontitis and a lack of patient compliance with supportive periodontal therapy in some cases have been shown to be risk factors associated with increased implant failure, mainly peri-implantitis.

The Role of Virtual Triage in Improving Clinician Experience and Satisfaction: A Narrative Review

Objective

This review examines the literature on improving clinician satisfaction with a focus on what has been most effective in improving experience from the perspective of clinicians, and the potential role that virtual triage (VT) technology can play in delivering positive clinician experiences that improve clinical care, and bring value to health care delivery organizations (HDOs).

Methods

Review and synthesis of evidence on clinician satisfaction indicating a potential for VT to favorably impact clinician experience, sense of effectiveness, efficiency, and reduction of administrative task burden. Analysis considers how to conceptualize and the value of improving clinician experience, leading clinician dissatisfiers, and the potential role of VT in improving clinician experience/satisfaction.

Results

Contributors to poor clinician experience/satisfaction where VT could have a beneficial impact include better managing resource limitations, administrative workload, lack of care coordination, information overload, and payer interactions. VT can improve clinician experience through the technology's ability to leverage real-time actionable data clinicians can use, streamlining patient-clinician communications, personalizing care delivery, optimizing care coordination, and better aligning digital/virtual services with clinical practice. From an organizational perspective, improvements in clinician experience and satisfaction derive from establishing an effective digital back door, increasing the clinical impact of and satisfaction derived from telemedicine and virtual care, and enhancing clinician centricity.

Conclusions

By embracing digital transformation and implementing solutions such as VT that focus on improving patient and clinician experience, HDOs can address barriers to delivery of high-quality, efficient, and cost-effective care. VT is a digital health tool that can create a more streamlined and satisfying experience for clinicians and the patients they care for. VT is a technology solution that can help clinicians make faster more informed decisions, reduces avoidable care, improves communication with patients and within care teams, and lowers their administrative burden so they have more quality time to care for patients.

Clinician End-of-Life Experiences With Pediatric Muslim Patients at a US Quaternary Care Center

CONTEXT

A small, growing body of data exist discussing the experiences of Muslim patients with the palliative care system, both in the United States and abroad, as well as providers' experiences with Muslim patients. However, no studies evaluate clinician experiences with Muslim patients in the United States, and none address the unique dynamics of pediatric clinician experiences with Muslim patients and their families in the EOL setting.

OBJECTIVES

The purpose of this study is to perform a thematic analysis of clinician experiences with pediatric Muslim patients and families at the end of life.

METHODS

This was a qualitative study of pediatric clinicians at Duke University Medical Center in the Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit from August 2018 to February 2019. We conducted semistructured interviews with nurses, attending physicians, and social workers to assess participants' experiences caring for Muslim patients and families. We analyzed interview transcripts using descriptive content analysis with NVivo10.

RESULTS

We interviewed 16 clinicians at Duke University Medical Center Pediatric Intensive Care Unit, Pediatric Cardiac Intensive Care Unit, and Pediatric Bone Marrow Unit. Five physicians, five social workers, and six nurses were interviewed. The majority of providers were female, Caucasian, and Christian in an institution where Muslim patients are a significant minority. Several themes emerged highlighting language barriers, difficulty engaging with Muslim families, variations in approach to care and communication, discomfort with gender roles, moral distress with unrelatable decision-making, and external pressures on patient decision-making.

CONCLUSION

A thematic analysis of pediatric clinicians at a quaternary care center in the Southern United States yielded several prominent themes. Many clinicians recognize they likely provide disparate care to minority patients for a variety of reasons encompassing the above barriers. As we work to care for an increasingly diverse patient population, more research into barriers to care and effective educational methods is needed.

Promise and peril-defining ethical telehealth practice from the clinician and patient perspective: A qualitative study

Objectives

We undertook a qualitative study to examine and compare the experience of ethical principles by telehealth practitioners and patients in relation to service delivery theory. The study was conducted prior to and during the recent global increase in the use of telehealth services due to the COVID-19 pandemic,

Methods

We conducted semi-structured interviews with 20 telehealth practitioners and patients using constructionist grounded theory methods to collect and analyse data. Twenty-five axial coded data categories were then unified and aligned through selective coding with the Beauchamp and Childress (2013) framework of biomedical ethics. The groups were then compared.

Results

Thirteen categories aligned to the ethical framework were identified for practitioners and 12 for patients. Variance existed between the groups. Practitioner results were non-maleficence 4/13 or (31%), beneficence 4/13 (31%), professional–patient relationships 3/12 (22%), autonomy 1/13 (8%) and justice 1/13 (8%). Patient data results were non-maleficence 4/12 (33%), professional–patient relationships 3/12 (33%), autonomy 2/12 (18%), beneficence 1/12 (8%) and justice 1/12 (8%).

Conclusions

Ethical principles are experienced differently between telehealth practitioners and patients. These differences can impact the quality and safety of care. Practitioners feel telehealth provides better care overall than patients do. Patients felt telehealth may force a greater share of costs and burdens onto them and reduce equity. Both patients and practitioners felt telehealth can be more harmful than face-to-face service delivery when it creates new or increased risk of harms. Building sufficient trust and mutual understanding are equally important to patients as privacy and confidentiality.

Clinician Experiences With Reach Out and Read: An Exploratory Qualitative Analysis

BACKGROUND

Enhanced literacy and increased vocabulary related to Reach Out and Read (ROR) are well described. Less is known about clinicians' experience with the program.

OBJECTIVE

Understand clinician experiences of implementing ROR.

DESIGN/METHODS

This study was a collaboration between ROR and the Academic Pediatric Association's Continuity Research Network. Participants completed an anonymous online survey to evaluate Literacy Promotion activities and training, and were asked "What has been the most meaningful experience you have encountered with using ROR?" and "Is there anything else you would like to add?" Responses were evaluated by researchers and 4 themes were generated through discussion. All responses were divided and coded by researchers working in pairs and subsequently by all researchers until consensus was reached. Data were organized into themes.

FINDINGS

Responses were provided by 592 (35%) participants. Qualitative analysis revealed benefits to participation in ROR within 4 themes: 1) Child/Family Impact (60%): "Seeing a child read for the first time" 2) Physician Impact (16%): "I... use the books... to connect with patients." 3) Impact on clinic practice (25%): "I... enjoy modeling for parents and use the books to assess... development" 4) Social Determinants of Health (2%): "The books... are an invaluable resource to our under-served population."

CONCLUSION

Clinicians who implement ROR report positive impact on patients, families, and their own satisfaction and methods in practice. Clinicians value that the program addresses social determinants of health and facilitates developmental surveillance. Further study is needed to understand how clinician's perspectives affect and are affected by their experiences.

"What matters to me": A multi-method qualitative study exploring service users', carers' and clinicians' needs and experiences of therapeutic engagement on acute mental health wards

Nurse-patient therapeutic engagement on acute mental health wards is beneficial to service users' outcomes and nurses' job satisfaction. However, engagement is not always fulfilled in practice and interventions to improve engagement are sparse and ineffective. We explored the experiences of service users, carers, and clinicians drawing from 80 hours of non-participant observations in an acute mental health ward and semi-structured interviews with 14 service users, two carers, and 12 clinicians. Analysis of these data resulted in 28 touchpoints (emotionally significant moments) and eight overarching themes. Service users, carers, and clinicians identified a lack of high-quality, person-centred, collaborative engagement and recognized and supported efforts to improve engagement in practice. Potential solutions to inform future intervention development were identified. Our findings align with previous research highlighting negative experiences and support the need to develop multicomponent interventions through participatory methods.

Implementing Automated Triggers to Identify Hospitalized Patients with Possible Unmet Palliative Needs: Assessing the Impact of This Systems Approach on Clinicians

Background: Understanding patients' goals and values is important to ensure goal-concordant care; however, such discussions can be challenging. Little is known about the impact of having these discussions on hospitalists. Objective: To assess the impact on hospitalists of a system that reminds them to have serious illness conversations with their patients identified with potential unmet palliative needs. Design: Two group cohort trial. Setting/Subjects: Single academic center. Internal medicine hospitalist physicians, nurse practitioners, and physician's assistants. Measurements: Before the trial, all participants received serious illness conversation training. During the trial, hospitalists on intervention units received verbal notification when their recently admitted patients were identified using a computer algorithm as having possible unmet palliative needs. Hospitalists on the control unit received no notifications. At baseline and three months, hospitalists completed questionnaires regarding communication skill acquisition, perception of the importance of these conversations, and sense of the meaning gained from having them. Results: Both groups had similar improvements in their self-reported communication skills and experienced a small decline in how important they felt the conversations were. Neither group perceived having the discussions as being affectively harmful to patients. The intervention hospitalists, over time, reported a slight reduction in the sense of meaning they achieved from the conversations. Conclusion: Routinely informing hospitalists when their patients were identified as being at increased risk for unmet palliative needs did not increase the sense of meaning these providers achieved. It is likely the pretrial training accounted for many of the positive outcomes in communication skills observed in both arms of the trial.

Patient and clinician experience of a serious illness conversation guide in oncology: A descriptive analysis

BACKGROUND/OBJECTIVE

Oncology guidelines recommend earlier communication with patients about prognosis and goals-of-care in serious illness. However, current evidence leaves gaps in our understanding of the experience of these conversations. This analysis evaluates the patient and clinician experience of a conversation using a Serious Illness Conversation Guide (SICG).

DESIGN/SETTING

Secondary analysis from a cluster-randomized clinical trial in a northeastern cancer center.

PARTICIPANTS

Physicians, advanced practice clinicians, and patients with advanced cancer who received the intervention.

INTERVENTION

SICG, clinician training, systems-changes.

MAIN OUTCOMES AND MEASURES

The patient questionnaire assessed perceptions of the conversation and impact on anxiety, hopefulness, peacefulness, sense of control over medical decisions, closeness with their clinician, and behaviors. The clinician questionnaire assessed feasibility, acceptability, and impact on satisfaction in their role.

RESULTS

We enrolled 54 clinicians and 163 patients; 41 clinicians and 118 patients had a SICG discussion. Most patients described the conversation as worthwhile (79%) and reported no change or improvement in their sense of peacefulness, hopefulness, and anxiety (on average 79%); 56% reported feeling closer with their clinician. Qualitative patient data described positive behavior changes, including enhanced planning for future care and increased focus on personal priorities. Nearly 90% of clinicians agreed that the SICG facilitated timely, effective conversations, and 70% reported increased satisfaction in their role.

CONCLUSION

Conversations using a SICG were feasible, acceptable, and were associated with positive experiences for both patients and clinicians in oncology in ways that align with national recommendations for serious illness communication. This trial is registered at ClinicalTrials.gov: NCT01786811 https://clinicaltrials.gov/ct2/show/NCT01786811.

Role of clinician's experience and implant design on implant stability. An ex vivo study in artificial soft bones

OBJECTIVES

Clinical experience in implant placement is important in order to prevent implant failures. However, the implant design affects the primary implant stability (PS) especially in poor quality bones. Therefore, the aim of this study was to compare the effect of clinician surgical experience on PS, when placing different type of implant designs.

METHODS

A total of 180 implants (90 parallel walled-P and 90 tapered-T) were placed in freshly slaughtered cow ribs. Bone quality was evaluated by two examiners during surgery and considered as 'type IV' bone. Implants (ø 5 mm, length: 15 mm, Osseotite, BIOMET 3i, Palm Beach Gardens, FL, USA) were placed by three different clinicians (master/I, good/II, non-experienced/III, under direct supervision of a manufacturer representative; 30 implants/group). An independent observer assessed the accuracy of placement by resonance frequency analysis (RFA) with implant stability quotient (ISQ) values. Two-way analysis of variance (ANOVA) and Tukey's post hoc test were used to detect the surgical experience of the clinicians and their interaction and effects of implant design on the PS.

RESULTS

All implants were mechanically stable. The mean ISQ values were: 49.57(± 18.49) for the P-implants and 67.07(± 8.79) for the T-implants. The two-way ANOVA showed significant effects of implant design (p < .0001), clinician (p < .0001), and their interaction (p < .0001). The Tukey's multiple comparison test showed significant differences in RFA for the clinician group I/II (p = .015) and highly significant (p < .0001) between I/III and II/III. The P-implants presented (for I, II, and III) mean ISQ values 31.25/49.18/68.17 and the T-implants showed higher ISQ values, 70.15/62.08/68.98, respectively. Clinicians I and II did not show extreme differences for T-implants (p = .016). In contrast, clinician III achieved high ISQ values using P- and T-implants following the exact surgical protocol based on the manufacturer guidelines. T-implants provided high stability for experienced clinicians compared with P-implants.

CONCLUSION

T-implants achieved greater PS than the P-implants. All clinicians consistently achieved PS; however, experienced clinicians achieved higher ISQ values with T-implants in poor quality bone.