Approach to acute agitation in the pediatric emergency department

PURPOSE OF REVIEW

The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED.

RECENT FINDINGS

Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time.

SUMMARY

Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.

Linking patient-centered communication with cancer information avoidance: The mediating roles of patient trust and literacy

OBJECTIVES

This study, drawing on the pathway mediation model developed by Street and his colleagues (2009) that links communication to health outcomes, explores how patient-centered communication affects cancer information avoidance.

METHODS

Data was gathered through online access panel surveys, utilizing stratified sampling across Germany, Switzerland, the Netherlands, and Austria. The final sample included 4910 non-cancer and 414 cancer patients, all receiving healthcare from clinicians within the past year.

RESULTS

The results demonstrated that patient-centered communication is directly associated with reduced cancer information avoidance, especially among cancer patients. Additionally, this association is indirectly mediated through patient trust and healthcare literacy.

CONCLUSION

The findings provide empirical evidence that reveals the underlying mechanism linking clinician-patient communication to patient health information behavior.

PRACTICE IMPLICATIONS

The potential of clinician-patient communication in addressing health information avoidance is highlighted by these findings. Future interventions in healthcare settings should consider adopting patient-centered communication strategies. Additionally, improving patient trust and literacy levels could be effective in reducing cancer information avoidance.

The Delivery of Person-Centered Care for People Living With Dementia in Residential Aged Care: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Person-centered care is the gold standard of care for people living with dementia, yet few systematic reviews have detailed how it is delivered in practice. This mixed-methods review aimed to examine the delivery of person-centered care, and its effectiveness, for people living with dementia in residential aged care.

RESEARCH DESIGN AND METHODS

A systematic review and meta-analysis. Eligible studies were identified across 4 databases. Quantitative and qualitative studies containing data on person-centered care delivered to people with dementia living in residential aged care were included. Meta-analysis using a random-effects model was conducted where more than 3 studies measured the same outcome. A narrative meta-synthesis approach was undertaken to categorize verbatim participant quotes into representative themes. Risk of bias was undertaken using quality appraisal tools from the Joanna Briggs Institute.

RESULTS

41 studies were identified for inclusion. There were 34 person-centered care initiatives delivered, targeting 14 person-centered care outcomes. 3 outcomes could be pooled. Meta-analyses demonstrated no reduction in agitation (standardized mean difference -0.27, 95% confidence interval [CI], -0.58, 0.03), improvement in quality of life (standardized mean difference -0.63, 95% CI: -1.95, 0.70), or reduced neuropsychiatric symptoms (mean difference -1.06, 95% CI: -2.16, 0.05). Narrative meta-synthesis revealed barriers (e.g., time constraints) and enablers (e.g., staff collaboration) to providing person-centered care from a staff perspective.

DISCUSSION AND IMPLICATIONS

The effectiveness of person-centered care initiatives delivered to people with dementia in residential aged care is conflicting. Further high-quality research over an extended time is required to identify how person-centered care can be best implemented to improve resident outcomes.

Educational programmes for paediatric healthcare professionals in patient- and family-centred care. A scoping review

To identify and describe educational programmes in patient- and family-centred care for paediatric healthcare professionals. This scoping review was conducted and reported according to the JBI Manual for Evidence Synthesis and the PRISMA guideline. The databases searched included MEDLINE (PubMed), PsycINFO, CINAHL, Scopus, Cochrane, and Embase. Inclusion criteria were experimental, observational and qualitative studies about educational programmes on patient- and family-centred care for paediatric healthcare professionals. Exclusion criteria were reviews and non-peer-reviewed literature. Two reviewers independently screened and extracted the data using Covidence. Of the 13922 records identified, 49 articles met the inclusion criteria. There was a large variety of educational programmes, half of which were interdisciplinary, that mainly targeted nurses and doctors. The median number of participants was 51 (range 7 to 1411). The predominant target population was children with chronic disabilities and neonatal intensive care units, and only one programme specifically targeted adolescents. The median duration was one day (range 5 min to 3.5 years). Development of competencies was the most common objective. We identified 12 different educational content areas. Content mainly focused on communication and relational competencies, including partnership, which involved shared decision-making, mutual agenda setting, and negotiation of a plan. Many kinds of educational strategies were found but experiential learning through simulation and roleplay was used most.   Conclusion: A large variety of educational programmes in paediatric patient- and family-centred care exist. Educational content mainly focused on communication and relational competencies. Experiential learning including roleplay and simulation was the most used educational strategy. What is Known: • Delivery of patient- and family-centred care improves parental satisfaction of care but requires clinicians have a certain attitude towards involving the child and parents in a healthcare partnership as well as advanced triadic communication skills. Little is known about how this attitude, and more broadly, patient- and family-centred care, can be facilitated through education and training. What is New: • This scoping review found a wide array of programmes.. Workshops with simulation or roleplay was the most frequent educational strategy. The programmes, which typically targeted nurses and doctors, chiefly focused on basic and advanced communication and relational competencies, including partnership, which involved shared decision-making and negotiation of plans.

Dimensions of patient-centred care from the perspective of patients and healthcare workers in hospital settings in sub-Saharan Africa: A qualitative evidence synthesis

INTRODUCTION

The United States Institute of Medicine defines patient centred care (PCC), a core element of healthcare quality, as care that is holistic and responsive to individual needs. PCC is associated with better patient satisfaction and improved clinical outcomes. Current conceptualizations of PCC are mainly from Europe and North America. This systematic review summarises the perceived dimensions of PCC among patients and healthcare workers within hospitals in sub-Saharan Africa (SSA).

METHODS

Without date restrictions, searches were done on databases of the Web of Science, Cochrane Library, PubMed, Embase, Global Health, and grey literature, from their inception up to 11th August 2022. Only qualitative studies exploring dimensions or perceptions of PCC among patients, doctors and/or nurses in hospitals in (SSA) were included. Review articles and editorials were excluded. Two independent reviewers screened titles and abstracts, and conducted full-text reviews with conflicts resolved by a third reviewer. The CASP (critical appraisal skills program) checklist was utilised to assess the quality of included studies. The framework synthesis method was employed for data synthesis.

RESULTS

5507 articles were retrieved. Thirty-eight studies met the inclusion criteria, of which 17 were in the specialty of obstetrics, while the rest were spread across different fields. The perceived dimensions reported in the studies included privacy and confidentiality, communication, shared decision making, dignity and respect, continuity of care, access to care, adequate infrastructure and empowerment. Separate analysis of patients' and providers' perspective revealed a difference in the practical understanding of shared-decision making. These dimensions were summarised into a framework consisting of patient-as-person, access to care, and integrated care.

CONCLUSION

The conceptualization of PCC within SSA was largely similar to findings from other parts of the world, although with a stronger emphasis on access to care. In SSA, both relational and structural aspects of care were significant elements of PCC. Healthcare providers mostly perceived structural aspects such as infrastructure as key dimensions of PCC.

TRIAL REGISTRATION

PROSPERO Registration number CRD42021238411.

The discourse of delivering person-centred nursing care before, and during, the COVID-19 pandemic: Care as collateral damage

The global COVID-19 pandemic challenged the world-how it functions, how people move in the social worlds and how government/government services and people interact. Health services, operating under the principles of new public management, have undertaken rapid changes to service delivery and models of care. What has become apparent is the mechanisms within which contemporary health services operate and how services are not prioritising the person at the centre of care. Person-centred care (PCC) is the philosophical premise upon which models of health care are developed and implemented. Given the strain that COVID-19 has placed on the health services and the people who deliver the care, it is essential to explore the tensions that exist in this space. This article suggests that before the pandemic, PCC was largely rhetoric, and rendered invisible during the pandemic. The paper presents an investigation into the role of PCC in these challenging times, adopting a Foucauldian lens, specifically governmentality and biopolitics, to examine the policies, priorities and practical implications as health services pivoted and adapted to changing and acute demands. Specifically, this paper draws on the Australian experience, including shifting nursing workforce priorities and additional challenges resulting from public health directives such as lockdowns and limitations. The findings from this exploration open a space for discussion around the rhetoric of PCC, the status of nurses and that which has been lost to the pandemic.

Communication Matters: The Role of Patient-Centered Communication in Improving Old Adults' Health Competence and Health Outcomes

Research has demonstrated links between patient-centered communication (PCC) and patients' health outcomes. However, little is known about the underlying processes that may mediate the relationship. This study is one of the first to examine the influence of PCC on older adults' health outcomes, as well as the mediation role of health competence, from a longitudinal perspective. With a general basis of Street et al.'s pathway model, we proposed and tested mediation pathways linking patient-centered communication to the older population's general and mental health, mediated by health competence. Data from 2011, 2017 and 2020 iterations of the Health Information National Trends Survey (HINTS) were used for this study. This study focused on older adults aged 60 and above. Results indicated that after controlling participants' age, gender, education, income and race, PCC is related to the older people's health outcomes either directly or indirectly, irrespective of time series. Specifically, health competence was found to significantly mediate the associations between PCC and the older adults' general health or mental health over the three iterations. Noteworthily, findings from this study also revealed that different dimensions of PCC might exert different influences on older patients' health competence and health outcomes.

Body work and body meanings in patient-centered care: Health care professionals and patients with disabilities in Italian hospitals

BACKGROUND

This study integrates patient-centered care (PCC) research and body work studies to understand how a focus on physical and sensorial aspects in the relationship between health care professionals (HPs) and patients contribute to the implementation of PCC.

PURPOSE

To understand how HPs' body work practices contribute to the implementation of PCC, we investigate the meanings HPs ascribe to their and to patients' bodies. The goal is to grasp how these practices and meanings, rooted in unexplored sensorial perceptions, account for the emergence of a relationship of mutual acknowledgment between HPs and patients.

METHODOLOGY

Thirty-nine in-depth interviews were carried out with HPs, who interact with patients with disabilities in Italian hospitals.

RESULTS

HPs engage in different body work practices: adopting a diagnostic gaze and an empathetic gaze, touching, and playing. The diagnostic gaze concurs to create a feeling of promptness between HPs and patients, but also a stronger distance with respect to other practices. The empathetic gaze, touching, and playing are associated with feelings of shared vulnerability and resilience. These shared perceptions and emotions build a common ground and shape a relationship focused on patients' involvement.

PRACTICE IMPLICATIONS

Voicing and feedback sessions can be arranged to listen to how HPs interpret their own and patients' bodies. An organizational culture acknowledging emotions should be promoted to sponsor among HPs the consideration of the sensorial aspects of their connection with patients. The value of bricolage should be observed, where the HPs feel free to readjust tools, spaces, and routines. Sensitivity training exercises should be arranged to understand the interactions with patients with disabilities.

Nurses' experiences of integrating the salutogenic perspective with person-centered care for older people in Swedish nursing home care: an interview-based qualitative study

BACKGROUND

Even though there has been a cultural change within residential aged care to a more person-centered care, there remain improvements to be made for a more consistent way of working. Using a salutogenic approach along with person-centered care is a potential way to promote it. This study aimed to describe nurses' experiences of combining person-centered care with a salutogenic approach at a nursing home for older people.

METHODS

Nine nurses, specially trained in salutogenesis and Sense of coherence, were individually interviewed using a semi-structured interview approach. Data was analysed through qualitative content analysis.

RESULTS

The nurses experienced that the residential aged care was improved by using salutogenesis and Sense of coherence as a complement to person-centered care. Core aspects of person-centered care were thereby promoted, as the resources of the older persons were emphasized, and aged care became more holistic. In addition to improved residential aged care, the results indicate that this manner of working also contributed to enhanced work satisfaction of the care personnel themselves.

CONCLUSIONS

The results suggest that a salutogenic approach facilitates the implementation of person-centered care by focusing on the older persons' resources and maintaining health. The organization needs to prioritize training staff in salutogenesis and person-centered care, as it supports working toward a common goal and benefits both the older persons and the staff.

Leveraging Patients' Creative Ideas for Innovation in Health Care

Policy Points Patients' creative ideas may inform learning and innovation that improve patient-centered care. Routinely collected patient experience surveys provide an opportunity to invite patients to share their creative ideas for improvement. We develop and assess a methodological strategy that validates question wording designed to elicit creative ideas from patients. Health care organizations should consider how to report and use these data in health care delivery and quality improvement, and policymakers should consider promoting the use of narrative feedback to better understand and respond to patients' experiences.

CONTEXT

Learning health systems (LHSs) have been promoted for a decade to achieve high-quality, patient-centered health care. Innovation driven by knowledge generated through day-to-day health care delivery, including patient insights, is critical to LHSs. However, the pace of translating patient insights into innovation is slow and effectiveness inadequate. This study aims to evaluate a method for systematically eliciting patients' creative ideas, examine the value of such ideas as a source of insight, and examine patients' creative ideas regarding how their experiences could be improved within the context of their own health systems.

METHODS

The first stage of the study developed a survey and tested strategies for elicitation of patients' creative ideas with 600 patients from New York State. The second stage deployed the survey with the most generative open-ended question sequence within a health care system and involved analysis of 1,892 patients' responses, including 2,948 creative ideas.

FINDINGS

Actionable, creative feedback was fostered by incorporating a request for transformative feedback into a sequence of narrative elicitation questions. Patients generate more actionable and creative ideas when explicitly invited to share such ideas, especially patients with negative health care experiences, those from minority racial/ethnic backgrounds, and those with chronic illness. The most frequently elicited creative ideas focused on solving challenges, proposing interventions, amplifying exceptional practices, and conveying hopes for the future.

CONCLUSIONS

A valid and reliable method for eliciting creative ideas from patients can be deployed as part of routine patient experience surveys that include closed-ended survey items and open-ended narrative items in which patients share their experiences in their own words. The elicited creative ideas are promising for patient engagement and innovation efforts. This study highlights the benefits of engaging patients for quality improvement, offers a rigorously tested method for cultivating innovation using patient-generated knowledge, and outlines how creative ideas can enable organizational learning and innovation.

Mapping interventional components and behavior change techniques used to promote self-management in people with multimorbidity: a scoping review

Ageing populations and improved survival, have contributed to a rise in the number of people living with multimorbidity, raising issues related to polypharmacy, treatment burden, competing priorities and poor coordination of care. Self-management programs are increasingly included as an essential component of interventions to improve outcomes in this population. However, an overview of how interventions supporting self-management in patients with multimorbidity is missing. This scoping review focused on mapping the literature on patient-centered interventions for people living with multimorbidity. We searched several databases, clinical registries, and grey literature for RCTs published between 1990-2019 describing interventions that supported self-management in people with multimorbidity. We included 72 studies that were found to be very heterogeneous when it comes to the population, delivery modes and modalities, intervention elements and facilitators. The results pointed to an extensive use of cognitive behavioral therapy as a basis for interventions, as well as behavior change theories and disease management frameworks. The most coded behavior change techniques stemmed from the categories Social Support, Feedback and monitoring and Goals and Planning. To allow for implementation of effective interventions in clinical practice, improved reporting of intervention mechanisms in RCTs is warranted.

Receiving person-centred care in a hospital-A qualitative study of socially marginalised patients' experiences of social nursing

BACKGROUND

Socially marginalised people are at a substantially increased risk of diseases and typically have several contacts with the healthcare system. Health professionals at hospitals often lack the knowledge, skills, confidence, and time to provide relevant care for socially marginalised patients. Danish hospitals have implemented a social nursing initiative consisting of social nurses with specialised knowledge about marginalisation to support socially marginalised patients. Limited research into patients' perceptions of social nursing has been undertaken.

OBJECTIVE

To explore patients' experiences with the in-hospital social nursing initiative.

DESIGN

A qualitative study was conducted using a phenomenological hermeneutical approach.

SETTING

Odense University Hospital, Denmark.

PARTICIPANTS

Patients aged 18 years and older who had been in contact with a social nurse during hospital admission were purposely sampled. Data saturation was reached when 15 participants were recruited.

METHODS

In-depth patient interviews were conducted from November 2021 to April 2022 using a semi-structured interview guide. The interviews were transcribed verbatim and analysed using systematic text condensation. NVivo 12 software was employed for the analysis. Patient representatives were involved to validate the analysis and interpretations.

RESULTS

Three themes were identified: (1) an equal and trusting relationship, (2) receiving person-centred care, and (3) coherence in the patient trajectory. The results show that when patients have established a relationship with a social nurse, they are willing to let her into their lives and share personal information. Patients also experience person-centred care and coherence in their trajectory when a social nurse participated in their treatment and care.

CONCLUSION

The findings indicate that the social nursing initiative bridges the gap between socially marginalised patients and healthcare services.

Role of digital health communication, sociodemographic factors, and medical conditions on perceived quality of patient-centered communication

OBJECTIVE

To simultaneously explore associations between digital health, sociodemographic factors, and medical conditions on patient-centered communication (PCC). These are under-explored, yet important knowledge gaps to fill because perceived quality PCC may influence health information seeking behaviors and health outcomes.

METHODS

Data from the 2019 Health Information National Trends Survey were analyzed. The primary outcome was PCC, which was the summed score of 7 PCC-related questions. Factors of interest included whether participants used electronic methods to communicate with health professionals, age, gender, race/ethnicity, education, feelings about household income, and history of medical conditions. Descriptive statistics and linear regressions were conducted.

RESULTS

In the multivariate linear regression model, people aged 65-74 years compared with 18-34 year-olds, those with some college compared with college graduates, and those who felt they were living comfortably on their household income compared with all others reported higher PCC scores. People with a history of hypertension compared with those without reported higher PCC scores.

CONCLUSION

Similar to past studies, sociodemographic factors were associated with PCC. A novel finding was that a history hypertension was associated with perceived quality of PCC.

PRACTICE IMPLICATIONS

This research may inform methods to enhance communication between patients and clinicians.

Exploration of the factors that influence perceived quality of patient centered care among cancer survivors: A systematic review

PURPOSE

The purpose of this study was the estimation of the quality of patient centered care among cancer survivors.

METHODS

Following the PRISMA guidelines, MEDLINE and Google Scholar were systematically searched using the keywords "quality of patient centered care" and "cancer" from 2012 to 2022.

RESULTS

In this systematic review 7 articles were included, from which 5557 patients were derived, 3050 of them being females. The majority of them (2553 patients) suffered from haematological malignancies, while a considerable amount of them suffered from breast cancer. Three studies were conducted in Australia and four studies in Mexico. Factors, such as respect to patients' values and preferences, emotional support, management of psychological needs and integrated and coordinated care received a lower score. The characteristics that were statistically significantly related to the dimensions of person-centered care were numerous and were grouped into two major categories: a) socio-demographic such as gender, age, marital status, professional status, level of education, place of residence, type of insurance and b) clinical factors such as type of malignancy, psychiatric comorbidities, time interval of diagnosis, follow-up center, type of treatment.

CONCLUSIONS

The literature showed that there is a lack of comparative data regarding the perceived quality of patient centered care among cancer survivors. More psychometric tools of quality of patient centered care, or validation of the existed ones among all types of cancer survivors are needed, in order to identify and further improve the aspects of care that are not delivered successfully.

The Relational Care Framework: Promoting Continuity or Maintenance of Selfhood in Person-Centered Care

We argue that contemporary conceptualizations of "persons" have failed to achieve the moral goals of "person-centred care" (PCC, a model of dementia care developed by Tom Kitwood) and that they are detrimental to those receiving care, their families, and practitioners of care. We draw a distinction between personhood and selfhood, pointing out that continuity or maintenance of the latter is what is really at stake in dementia care. We then demonstrate how our conceptualization, which is one that privileges the lived experiences of people with dementia, and understands selfhood as formed relationally in connection with carers and the care environment, best captures Kitwood's original idea. This conceptualization is also flexible enough to be applicable to the practice of caring for people at different stages of their dementia. Application of this conceptualization into PCC will best promote the well-being of people with dementia, while also encouraging respect and dignity in the care environment.

Can Implementing Person-Centered Care Tools Reduce Complaints? Evidence from the Implementation of PELI in Ohio Nursing Homes

Nursing homes receive complaints when actual care provided to residents misaligns with desired care, suggesting that person-centered care (PCC) and honoring resident preferences in care delivery may help prevent complaints from arising. We explore whether nursing home implementation of a PCC tool, the Preferences for Everyday Living Inventory (PELI), is related to measures of complaints. Publicly available data on Ohio nursing homes was used to examine 1,339 nursing home-year observations. Regression techniques were used to evaluate the relationship between the extent of PELI implementation and four complaint outcomes: any complaint, number of complaints, any substantiated complaint, and number of substantiated complaints. Nursing homes with complete PELI implementation were less likely to have any complaints by 4.7% points (P < .05) and any substantiated complaints by 11.5% points (P < .001) as compared to partial PELI implementers. When complete PELI implementers did have complaints, they were fewer than partial PELI implementers. Complete PELI implementers were not immune from receiving complaints; however, the complaints they did receive were fewer in number and less likely to be substantiated as compared to communities who only partially implemented a PCC tool.

Using Collaborative Documentation to Support Person-Centered Care in Substance Use Settings

The delivery of person-centered care (PCC) is critical to promoting service engagement among individuals who use substances. Collaborative documentation (CD) is an emerging person-centered practice used in community mental health, but has not been evaluated in substance use settings. This qualitative study conducted focus groups with substance use treatment providers (n=22) in an outpatient clinic to examine the impact of CD on PCC and clinical quality. Rapid qualitative analysis methods were used to identify key themes. Participants reported that using CD reduced documentation time and helped build trust and better understand their clients. Using CD presented unique challenges and opportunities when used with mandated populations or those with complex symptoms. The importance of honoring clients' preference not to collaborate in care was a salient theme. Findings indicate that CD can promote PCC in substance use treatment. Targeted strategies to optimize CD for mandated and clinically complex populations are needed.

Nothing About Patients Without Patients: More Than Just a Catchphrase!

Health care is sometimes called a "team sport," yet patients were traditionally not considered to be "on the team" in medicine. In 2001, the Institute of Medicine (now National Academy of Medicine) published its seminal book Crossing the Quality Chasm, in which patient-centered care was identified as 1 of 6 quality aims. Many organizations have since included patient-centered care as an important aspect of quality, including The Joint Commission, Centers for Medicare and Medicaid, and many large employers. In the past 10 years, the focus on patient-centered care has expanded in the Kaiser Permanente, Southern California region to include innovative ways for patients to collaborate with health care teams to codesign improvement efforts that are truly patient-centered. We will describe 3 important approaches that have greatly increased the patient-centeredness of our organization: individual patient approaches; adding patients onto health care teams; and effectively utilizing patient and family advisory councils. We will provide examples of how all health care organizations can better partner with their patients to improve their ability to provide higher quality, safer, more equitable, and affordable health care. The slogan "Nothing About Patients Without Patients" was an early rallying cry of the patient engagement movement. It conveyed the idea that as with everything else in our society, patients now expect to have a say in the design and implementation of their care. We show that this is not only possible, but also highly effective and even necessary to improving care.

Fostering Patient-Centered Equitable Care in Radiology: AJR Expert Panel Narrative Review

Patient-centered care (PCC) and equity are two of the six core domains of quality health care, according to the Institute of Medicine. Exceptional imaging care requires radiology practices to provide patient-centered (i.e., respectful and responsive to individual patient preferences, needs, and values) and equitable (i.e., does not vary in quality on the basis of gender, ethnicity, geographic location, or socioeconomic status) care. Specific barriers that prevent the delivery of patient-centered equitable care include information gaps, breaches of trust, organizational medical culture, and financial incentives. Information gaps limit practitioners in understanding the lived experience of patients. Breaches of trust prevent patients from seeking needed medical care. Organizational medical cultures may not be centered around patient experiences. Financial incentives can impede practitioners' ability to spend the time and resources required to meet patient goals and needs. Intentional approaches that integrate core principles in both PCC and health equity are required to deliver high-quality patient-centered imaging care for diverse patient populations. The purpose of this AJR Expert Panel Narrative Review is to review the origins of the PCC movement in radiology, characterize connections between the PCC and health equity movements, and describe concrete examples of ways to foster patient-centered equitable care in radiology.

Effects of family-centered care on bonding: A systematic review

Most critically ill neonates require constant monitoring, continuous care, and supervision. However, distance created by admission and prolonged stay in a neonatal intensive care unit (NICU) may contribute to a delay in parent-infant bonding. This review aimed to determine how family-centered care (FCC) in the NICU affects parental bonding with critically ill infants. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to perform a systematic search of the literature within the following four electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Cochrane Library, and Web of Science. The search was conducted through July/August 2020. Research quality was evaluated using the Johns Hopkins Nursing Evidence-Based Practice Grading Scale. Out of 816 articles identified through literature search, 16 of the studies met our inclusion criteria. The majority of the studies (n = 14) found FCC interventions resulted in a significant increase in parental bonding. Results showed evidence practicing FCC in the NICU setting supports early parent-infant bonding. Nurses should consider implementing evidence-based FCC strategies into practice, such as allowing parents unrestricted access to their infants. More rigorous research with larger samples is recommended. More studies are also needed focusing on father-infant dyads and mother-father-infant triads.

Developing a person-centred care environment aiming to enhance the autonomy of nursing home residents with physical impairments, a descriptive study

BACKGROUND

Enhancing autonomy is important within the context of the care environment in nursing homes. A nursing home is a place for older adults with physical impairments, who need assistance, to live and where staff work who help them to exercise autonomy. Previous research shows that older adults and staff are influenced by the care environment to apply autonomy-enhancing activities. Therefore, organisational policies regarding the care environment seem promising for enhancing autonomy. The aim is to gain a deeper insight into the development and implementation of organisational policies aimed to enhance the autonomy of older adults with physical impairments.

METHODS

A qualitative descriptive design was chosen, using two methods. A document study was conducted on the policies, plans and proceedings in two care organisations. Moreover, interviews were conducted with 17 stakeholders involved in the policies, such as managers and members of the client council. The fragments of the 137 documents and 17 verbatim transcripts were coded and deductively categorised into the seven aspects (i.e., power-sharing, supportive organisational systems, appropriate skill mix, potential for innovation and risk-taking, the physical environment, effective staff relationships and shared decision-making systems) of the key domain care environment, as defined in the person-centred practice (PCP) framework developed by McCormack and McCance.

RESULTS

The aspect of power-sharing was used the most in the policies of the two participating organisations. The organisations expected much from the implementation of indirect interventions, such as access to the electronic care plan for residents and the development of staff towards self-managing teams. Less attention was paid to interventions in the physical environment, such as the interior of the building and privacy, and the collaboration processes between staff.

CONCLUSIONS

The PCP framework poses that all aspects of the key domain care environment are important to develop a person-centred practice. This is not yet the case in practice and the authors therefore recommend using all seven aspects of the care environment in a balanced combination with the other key domains of the PCP framework to achieve person-centred practice and as a result the enhancement of the autonomy of nursing home residents with physical impairments.

People-centred primary health care: a scoping review

BACKGROUND

Integrated people-centred health services (IPCHS) are vital for ensuring comprehensive care towards achieving universal health coverage (UHC). The World Health Organisation (WHO) envisions IPCHS in delivery and access to health services. This scoping review aimed to synthesize available evidence on people-centred primary health care (PHC) and primary care.

METHODS

We conducted a scoping review of published literature on people-centred PHC. We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar) using search terms related to people-centred and integrated PHC/primary care services. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to select studies. We analyzed data and generated themes using Gale's framework thematic analysis method. Themes were explained under five components of the WHO IPCHS framework.

RESULTS

A total of fifty-two studies were included in the review; most were from high-income countries (HICs), primarily focusing on patient-centred primary care. Themes under each component of the framework included: engaging and empowering people and communities (engagement of community, empowerment and empathy); strengthening governance and accountability (organizational leadership, and mutual accountability); reorienting the model of care (residential care, care for multimorbidity, participatory care); coordinating services within and across sectors (partnership with stakeholders and sectors, and coordination of care); creating an enabling environment and funding support (flexible management for change; and enabling environment).

CONCLUSIONS

Several people-centred PHC and primary care approaches are implemented in HICs but have little priority in low-income countries. Potential strategies for people-centred PHC could be engaging end users in delivering integrated care, ensuring accountability, and implementing a residential model of care in coordination with communities. Flexible management options could create an enabling environment for strengthening health systems to deliver people-centred PHC services.

Balancing evidence-based care with patient-centered individualized care

Weak evidence, when manifested in clinical guidelines, can translate into biased vascular care. In vascular surgery, we have few randomized controlled trials with appropriate representation of females and persons of color, so generalizability of trial results can be problematic. Physicians are required to balance evidenced-based care (which is only as good as the underlying evidence) with personalized treatment recommendations that are often based on demographics, social circumstances, and/or existing therapeutic relationships. Biases, whether implicit or explicit, have an oversized effect on treatment decisions, and patient outcomes. In this commentary, we propose three principles to strengthen the vascular surgery evidence foundation and patient-centered decision-making going forward: (1) generating evidence designed for individualized care, (2) constructing clinical guidelines that are context specific and complexity aware, and (3) strengthening the training and support for surgeons to deliver patient-centered individualized care.

Partnering with consumers to co-design a person-centred coding framework for qualitative patient experience data

BACKGROUND

Patient Reported Experience Measures (PREMs) provide health organisations insight into how 'person-centric' care is. Qualitative data in PREMs surveys provide essential context about experience but are challenging to analyse at an organisational level.

OBJECTIVE

To co-design a person-centred coding framework to assist in the analysis of qualitative PREMs data.

PATIENT INVOLVEMENT

Consumer representatives were involved in problem identification, co-design, coding of raw data (testing), evaluation and manuscript authorship.

METHODOLOGY

Co-design principles guided production of a deductive coding framework with Picker Principles of Person-Centred Care as a conceptual framework. The framework was co-designed over 4 stages, with cross-professional stakeholders (including two consumer representatives): 1) assessment of current state and understanding priorities; 2) adapting Picker Principles of Person-Centred Care as a coding framework; 3) testing and evaluation of a coding template over two quality improvement (QI) cycles against measures of inter-coder reliability and perceived usefulness; 4) endorsement and planning for implementation.

RESULTS

The Picker Principles were a suitable coding framework for inpatient PREMs data, and a coding template in an electronic spreadsheet met end-user needs. Results of the first QI cycle indicated a need for 'less academic' domain names and definitions, which were reviewed and updated to a first-person perspective in partnership with a consumer representative. Inter-coder reliability measures and qualitative feedback improved after cycle two testing and evaluation.

DISCUSSION

This single site study produced a feasible solution to apply person-centred principles to analyse PREMs data and requires testing in different settings. Cross-disciplinary partnerships enabled the development of a reliable and acceptable deductive coding framework that was usable for people without prior experience in qualitative data analysis.

PRACTICAL VALUE

Our solution offers an example for health services to harness the value of qualitative PREMs data and partner with consumers to take person-centric action to improve the safety, equity, and experience of healthcare.

Fast-track and person-centred care in geriatric traumatology in a German-speaking Swiss hospital - A practice development project

INTRODUCTION

Elderly persons have an increased risk for negative health-related outcomes, including higher mortality rates. A centre for geriatric traumatology was established in a German-speaking Swiss hospital to provide more specialised, person-centred care and to lower negative health outcomes. Adaptations and changes in the patient pathway were made by implementing fast-track and person-centred care to better address individual needs.

METHODS

The current patient pathway was analysed by an interprofessional and interdisciplinary geriatric traumatology expert team. The practice development methodology and the Person-Centred Practice Framework (PCP-Framework) were used throughout this engagement process. In consensus within the expert team, the sample was defined as elderly persons aged 65 years or older with suspected hip joint closed fractures. The focus was on three elements of "practice environment" from the PCP-Framework. These were: (1) supportive organisational systems; (2) the physical environment; (3) appropriate skill mix.

RESULTS

Several adaptations and changes were made addressing the three elements of "practice environment". These were for example: (1) use of specific assessments, shared decision-making; (2) proper and effective use of aids; (3) integration of Advanced Practice Nurses. The adaptations in the patient pathway were integrated into the standard operating procedures.

CONCLUSIONS

Through active engagement with the practice development methodology and the focus on person-centredness, the process of care for elderly persons was adapted. Thus, by addressing individual needs, fast-track and person-centred care in geriatric traumatology is provided. Further research is needed to evaluate and to verify implications in clinical practice.

Integration of Person-Centered Narratives Into the Electronic Health Record

BACKGROUND

Care delivery that is not person-centered has been called discordant care . There has been a shift to incorporate more of a person's narrative into their individual healthcare treatment plan to reduce discordant care. Aligning with this shift in healthcare delivery, we developed a person-centered narrative intervention (PCNI) to address existing gaps in delivery of person-centered care.

OBJECTIVES

This study aimed to evaluate the feasibility of conducting a randomized study and describe the outcomes of PCNI to usual care on the following person (patient)-reported outcomes: perceptions of the quality of communication with their nurses and their psychosocial and existential well-being.

METHODS

This study's design was an Obesity-Related Behavioral Intervention Trials model Phase II proof-of-concept randomized study. The participants were people admitted to an acute care hospital diagnosed with heart failure and/or end-stage renal disease.

RESULTS

Despite COVID-19 challenges, the PCNI was feasible in an acute care setting; it showed a moderate positive difference between conditions in the person's perception of their quality of communication and a small positive difference in their perception of feeling heard and understood. For our secondary outcomes of anxiety, depression, and psychosocial illness effect, there were small or no effects in the acute care setting.

DISCUSSION

Using a person-centered narrative, such as the PCNI, can help inform delivery of care that incorporates a person's (patient's) beliefs, values, and preferences into their healthcare. This study used a pragmatic approach to evaluate the PCNI in real time in an acute care setting to assess patient-reported outcomes. These positive results in a small sample indicate the need for continued testing of the PCNI. These promising effects require further testing in a Phase III efficacy study within a larger randomized controlled clinical trial.

The moderating effects of nurses' background characteristics on the relationship between family-centred care perception and practice for hospitalized children and their families in Malawi

PURPOSE

Globally, limited information is available on the relationship between the perception and practice of family-centered care (FCC), and the moderating effects of nurses' background characteristics on this relationship. This study investigated the relationship between FCC perception and FCC practice and the moderating effects of the nurses' background characteristics on this relationship.

DESIGN AND METHODS

A cross-sectional study was conducted using a two-stage stratified sampling method. Data were collected from 444 nurses using the Family Centered Care Questionnaire-Revised and analyzed using IBM SPSS Version 25. The Hayes PROCESS macro model, version 3, was integrated into SPSS to examine the moderating effects at a significance level of 0.05.

RESULTS

The response rate was 98%, and a statistically significant positive association was found between FCC perception and FCC practice (r = 0.353, p < .001). Gender of a nurse (ΔR2 = 0.0206, p < .002), having children (ΔR2 = 0.0231, p < .001), experience (ΔR2 = 0.0107, p = .028), and working in a medical-surgical ward (ΔR2 = 0.0208, p = .008) had a statistically significant moderating effect on the relationship between FCC perception and FCC practice.

CONCLUSION

These findings provide minimal evidence of the existence of non-modifiable moderators of FCC. Future studies with modifiable moderators are therefore needed.

PRACTICE IMPLICATIONS

Understanding the moderating effects of nurses' background characteristics on the relationship between FCC perception and FCC practice may facilitate the development of FCC interventions that favor these background characteristics and facilitate the integration of FCC into routine policies and practices.

Using technology to encourage ward-culture change and provide individualised bladder care

When discussing continence care in an acute hospital setting, it can be viewed as a negative subject that is a thinly veiled jab at overstretched nurses. This article takes a fresh and holistic look at continence care, identifying factors that could be causing poor care and how technology could support a change in care. This article includes suggestions on how the data collected could be used to deliver the person-centred care outcomes that may be lacking in some environments, something that one of the authors (DP) has experienced first hand. This article describes the results of a recent trial at Ysbyty Cwm Cynon (Canon Valley Hospital), NHS Wales, which looked at how continence care technology could support positive care outcomes.

Life Story Book to enhance communication in persons with dementia: A systematic review of reviews

The Life Story Book has been commonly used in promoting person-centred care in older adults, especially for persons with dementia. This involves collecting the life stories and memories of the person living with dementia and compiling them into a book or folder, which is used by staff or family to assist the person recall these memories. Evidence on the use, benefits and influences of the Life Story Book in dementia care is limited. This systematic literature review aimed to collect past reviews and provide a thorough overview of the use, benefits, and impact of the Life Story Book for the person with dementia, the relatives, family, and caregivers. The electronic databases PubMed, Scopus, Science Direct and Web of Science as well as grey literature through Google Scholar were searched to select the relevant studies. Seven studies that meet the inclusion criteria were selected and data synthesised. Findings revealed that the use of the Life Story Book has no specific guidelines and has been described with numerous characteristics and varied implementation methods. The Life Story Book intervention is found to provide positive outcomes for the person with dementia and the carers involved. Six out of the seven studies reported that Life Story Book enhanced communication between persons with dementia, relatives, care staff, and residents. The review extends the current evidence on the usage of the Life Story Book in dementia care and confirms that the use of life stories leads to better care in various settings. However, more research is needed to reveal the potential of the Life Story Book in enhancing communication. Guidelines and training are also required to make the best use of the Life Story Book.

Reconsidering patient-centred care: Authority, expertise and abandonment

Patient-centred care is commonly framed as a means to guard against the problem of medical paternalism, exemplified in historical attitudes of 'doctor knows best'. In this sense, patient-centred care (PCC) is often regarded as a moral imperative. Reviews of its adoption in healthcare settings do not find any consistent improvement in health outcomes; however, these results are generally interpreted as pointing to the need for more or 'better' training for staff, rather than raising more fundamental questions. Patient autonomy is generally foregrounded in conceptualizations of PCC, to be actualized through the exercising of choice and control. But examining healthcare interaction in practice shows that when professionals attempt to enact these underpinnings, it often results in the sidelining of medical expertise that patients want or need. The outcome is that patients can feel abandoned to make decisions they feel unqualified to make, or even that care standards may not be met. This helps to explain why PCC has not produced the hoped-for improvement in health outcomes. It also suggests that, rather than focusing on scoring individual consultations, we need to consider how medical expertise can be rehabilitated for a 21st century public, and how patient expertise can be better incorporated into co-design and co-production of services and resources rather than being seen as something to be expressed through a binary notion of control. PATIENT AND PUBLIC CONTRIBUTION: This viewpoint draws on research conducted by the author across a range of settings in health and social care, all of which incorporated patient and public involvement when it was conducted.

Conceptualization of patient-centered care in Latin America: A scoping review

INTRODUCTION

Patient-centered care (PCC) has been declared as a desirable goal for health care in Latin American countries, but a coherent definition of what exactly PCC entails for clinical practice is missing. This article's aim was to identify how PCC is conceptualized in Latin American countries.

METHODS

Scientific databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Scielo, Scopus, Web of Science) and webpages of the ministries of health were searched, and experts were contacted for suggestions of literature. References were included if they contained one of a range of a priori defined keywords related to PCC in the title, were published between 2006 and 2021, and were carried out in or concerned Latin America. Definitions of PCC were extracted from the included articles and analyzed using deductive and inductive coding. Deductive coding was based on the integrative model of patient-centeredness, which unites the definitions of PCC in the international literature (mainly North America and Europe) and proposes 16 dimensions describing PCC.

RESULTS

Thirty-two articles were included in the analysis and about half of them were from Brazil. Numerous similarities were found between the integrative model of patient-centeredness and the definitions of PCC given in the selected literature. The dimensions of the integrative model of patient-centeredness that were least and most prominent in the literature were physical support and patient information, respectively. A differentiation between PCC and family-centered care (FCC) was observed. Definitions of PCC and FCC as well as their cited references were diverse.

CONCLUSION

A considerable overlap between the conceptualization of PCC in Latin America and the integrative model of patient-centeredness has been identified. However, there are substantial differences between countries in Latin America regarding the emphasis of research on PCC versus FCC and diverse conceptualizations of PCC and FCC exist.

PATIENT CONTRIBUTION

This scoping review takes the patient's perspective based on the integrative model of patient-centeredness. Due to the study being a review, no patients, neither caregivers, nor members of the public, were involved.

Clinician perspectives on patient-centered conversations about weight management with patients with early breast cancer

BACKGROUND

The aim of this study is to gather detailed insights from breast cancer (BC) clinicians on how to have patient-centered conversations about weight and weight management with women diagnosed with early BC. A high body mass index (BMI) is a risk factor for female BC, and many women diagnosed with BC experience unhealthy weight gain after their primary treatment. The oncology team has the opportunity to discuss the importance of healthy weight for BC prognosis and survival.

METHODS

The sample of community-based BC clinicians included the following: three Black clinicians, three White clinicians, and two clinicians who were neither Black nor White; six females and two males; and six MDs and two physician assistants or nurse practitioners. Semistructured telephone interviews were conducted with these clinicians regarding their experience with and insights into having healthy weight conversations during routine clinic visits.

RESULTS

Clinicians noted that weight-related conversations should focus less on BMI and weight loss and more on "healthy behavior." Clinicians looked for cues from their patients as to when they were ready for "healthy weight" counseling, receptive to diet/nutrition counseling and referrals, and ready to attempt behavioral change. Clinicians noted that encouraging physical activity could be especially challenging with patients accustomed to a sedentary lifestyle.

CONCLUSIONS

Clinic-based conversations about healthy weight are likely to be most productive for both patients and their treating oncologists during the post-primary treatment phase when patients are most receptive to behavioral change that enhances their prognosis and survival.

Patient-Centered Communication Tools for the Patch Test Clinic

Patient-centered communication positively impacts the clinical encounter. Multiple strategies exist to improve communication between providers and their patients; the application and impact of these strategies have been studied in multiple specialties, though little exists regarding communication best practices in the patch test clinic. Because the procedural components of patch testing often span the course of an entire week, effective communication with patients during the patch testing visit is important for not only technical success, but also patient understanding and experience. In this study, we highlight the value of beginning the patch testing visit with clear introductions and agenda setting, improving patient understanding and engagement through methods such as teach backs and cycles of questions and answers that create patient-provider dialogue, and using communication techniques to make expressions of empathy. We provide detailed examples regarding the application of these techniques to the patch testing process, aimed at enhancing the patch testing experience and improving clinical outcomes. Our review exemplifies how dermatologists can leverage communication tools to improve patient satisfaction and outcomes during patch testing.

Development of an interprofessional person-centred care concept for persons with care needs living in their own homes (interprof HOME): study protocol for a mixed-methods study

INTRODUCTION

People receiving home care usually have complex healthcare needs requiring the involvement of informal caregivers and various health professionals. In this context, successful collaboration is an important element of person-centred care, which is often insufficiently implemented. Consequences might be found in avoidable hospitalisations. The aim of the study is to develop a care concept to improve person-centred interprofessional collaboration for people receiving home care considering the perspectives of all person groups involved.

METHODS AND ANALYSIS

This study uses a mixed-methods design consisting of a literature review, several qualitative inquiries, a cross-sectional quantitative study and a final structured workshop. After a literature review (work package (WP) 1), we will explore the perspectives of people receiving home care (n=20), their relatives (n=20) and representatives of statutory health insurances (n=5) in semistructured interviews (WP2). Moreover, 100 individuals of each group (people receiving home care, relatives, registered nurses, general practitioners and therapists) involved in home care will answer a survey on collaboration that will be analysed descriptively (WP3). Additionally, monoprofessional focus groups (n=9) of registered nurses, general practitioners and therapists, respectively, will discuss current practices. Data will be analysed by qualitative content analysis. Best practice cases (n=8) will be analysed by a case-based qualitative content analysis based on data of observations of home visits and interviews (WP4). The findings of WP2 will be discussed in mixed focus groups (n=4) with 10 participants each (WP5). Considering the results of joint displays of WP3, WP4 and WP5, the interprofessional care concept and its implementation will be elaborated in an expert workshop (WP6).

ETHICS AND DISSEMINATION

Ethical approval was obtained from all ethics committees of the project partners. Study results will be disseminated through publications, conference presentations, student education and advanced training of health professionals.

TRIAL REGISTRATION NUMBER

NCT05149937.

Enacting person-centred care: a multi-perspective study of practices in clinical encounters for people living with chronic kidney disease

BACKGROUND

There is growing emphasis on the need for ensuring person-centred care for patients living with chronic kidney disease as this will benefit patients, providers, and healthcare systems alike. Nevertheless, less emphasis is given to how this complex concept is practiced in clinical encounters and how it is experienced by patients. This qualitative multi-perspective study investigates how person-centred care for people living with chronic kidney disease is practiced and experienced by patients in clinical encounters at a nephrological ward at a hospital in the capital region of Denmark.

METHODS

The study builds upon qualitative methodologies, including field notes from observations of clinical encounters between clinicians and patients in an out-patient clinic (n = ~ 80) and in-person interviews with patients in peritoneal dialysis (n = 4). Key themes from field notes and interview transcripts were identified through thematic analysis. Analyses were informed by practice theory.

RESULTS

Findings illustrate that person-centred care is practiced in a relational and situational encounter between patients and clinicians as dialogues about choice of treatment modality, which is shaped by the individual's life circumstances, preferences, and values. The practice of person-centred care appeared to be complex and interlinked with a range of factors, individual to each patient. We identified three themes of relevance for practices and experiences related to person-centred care: (1) Patients' perceptions of living with chronic kidney disease. Perceptions differed according to medical history, life situation and prior experiences with treatment in the healthcare system. These patient-related factors were perceived to be important for person-centred care to unfold; (2) Relations between patients and healthcare professionals were important for patients' experiences of trust and appeared fundamental for the practice and experiences of person-centred care; and (3) Decision-making on treatment modality that is the best fit for each patient's everyday life, appear to be shaped by the patient's need for knowledge about treatment modalities and level of self-determination in the decision-making.

CONCLUSIONS

The context of clinical encounters influences the practices and experiences of person-centred care, where health policies and lack of embodiment are identified as barriers for providing and experiencing person-centred care.

A paradigm for fostering patient-centered research in liver disease: The liver transplant patient-engagement program

BACKGROUND

Many federal funding and regulatory agencies require patient engagement to conduct patient-centered research and drug development. We developed a liver transplantation patient-engagement program, which can serve as a model for bringing the patient perspective to digestive diseases research.

METHODS

Six liver transplantation patient-engagement program advisors completed training in patient engagement; participated in several virtual sessions; and completed postsession surveys.

RESULTS

Qualitative and quantitative results elucidated patient-centered liver transplantation study outcomes and barriers/facilitators to conducting clinical research. Group satisfaction was very high.

CONCLUSIONS

The liver transplantation patient-engagement program model provides a paradigm for how to engage patients in the formative steps of patient-centered clinical research.

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study

To reduce the burden of chronic diseases on society and individuals, European countries implemented chronic Disease Management Programs (DMPs) that focus on the management of a single chronic disease. However, due to the fact that the scientific evidence that DMPs reduce the burden of chronic diseases is not convincing, patients with multimorbidity may receive overlapping or conflicting treatment advice, and a single disease approach may be conflicting with the core competencies of primary care. In addition, in the Netherlands, care is shifting from DMPs to person-centred integrated care (PC-IC) approaches. This paper describes a mixed-method development of a PC-IC approach for the management of patients with one or more chronic diseases in Dutch primary care, executed from March 2019 to July 2020. In Phase 1, we conducted a scoping review and document analysis to identify key elements to construct a conceptual model for delivering PC-IC care. In Phase 2, national experts on Diabetes Mellitus type 2, cardiovascular diseases, and chronic obstructive pulmonary disease and local healthcare providers (HCP) commented on the conceptual model using online qualitative surveys. In Phase 3, patients with chronic conditions commented on the conceptual model in individual interviews, and in Phase 4 the conceptual model was presented to the local primary care cooperatives and finalized after processing their comments. Based on the scientific literature, current practice guidelines, and input from a variety of stakeholders, we developed a holistic, person-centred, integrated approach for the management of patients with (multiple) chronic diseases in primary care. Future evaluation of the PC-IC approach will show if this approach leads to more favourable outcomes and should replace the current single-disease approach in the management of chronic conditions and multimorbidity in Dutch primary care.

Assessment of Nursing Staff Learning Needs Around Person-Centered Risk Management in Nursing Homes

The purpose of the current study was to describe nursing home (NH) staff's perceived learning and practice competency needs to facilitate effective delivery of person-centered care (PCC) when older adult residents' care preferences involve perceived risks. This needs assessment included a survey of NH staff and leaders (N = 87) and two focus groups (FGs) (N = 14). Results indicated staff were most confident handling preferences related to medication refusal (mean item rating = 4.1) and least confident in preferences related to smoking (mean item rating = 2.4). Staff were challenged in denying residents' preferences (mean item rating = 3.6) and worried about risk outcomes for residents or themselves (71.6%), reporting lack of policy and procedures to support them (48.1%). Survey results were enriched by FG themes: Establishing Person-Centered Values, Navigating Risk, and Operational Characteristics. Together, this information informed the development of a practice protocol to improve nursing competence in situations involving negotiation of resident and/or NH risks in care delivery. [Journal of Gerontological Nursing, 49(2), 7-12.].

Examining the knowledge work of person-centred care: Towards epistemic reciprocity

OBJECTIVE

It is increasingly recognised that when healthcare staff fails to give adequate credence to patients' illness-related knowledge work, this epistemic injustice undermines person-centred care. Therefore, we set out to examine the experiences of people with long-term conditions with knowledge work in healthcare settings to identify changes needed to strengthen person-centred primary care.

METHODS

We designed a qualitative study and recruited people with long-term conditions in the UK. We conducted individual interviews (analysed using interpretive phenomenological analysis) and focus groups (analysed using thematic analysis), then integrated findings from both methods through an approach focused on their complementarity.

RESULTS

Participants described how successful person-centred consultations were characterised by a negotiation between patient and doctor and moments of broad exploration, reflexive listening, and reciprocal enquiry, which allowed for epistemic reciprocity.

CONCLUSIONS

Epistemic reciprocity is a core component of person-centred clinical consultations, fostering the co-creation of new knowledge of patient experience and need through the interactive knowledge work of patient and doctor.

PRACTICE IMPLICATIONS

Medical education could benefit from initiatives that develop knowledge use and integration skills across primary care professionals. Accommodating for patient's and doctor's knowledge work during clinical practice requires redesigning the consultation process, including timing, headspace, pre-consultation, and post-consultation work.

Improving patient-centered communication in breast cancer: a study protocol for a multilevel intervention of a shared treatment deliberation system (SharES) within the NCI community oncology research program (NCORP) (Alliance A231901CD)

BACKGROUND

Advances in precision medicine have given oncologists new evaluative tools to better individualize treatments for patients with curable breast cancer. These innovations have revealed a need to improve patient understanding of novel, often complex information related to breast cancer treatment decisions. Ensuring patients have the emotional support to face consequential treatment decisions, as well as the opportunity to engage and discuss with their clinicians, is key to improving patient-centered communication and patient understanding.

METHODS/DESIGN

This study will implement a multilevel intervention with patient and clinician components as a NCORP Cancer Care Delivery Research (CCDR) trial within the Alliance for Clinical Trials in Oncology Research Base (Alliance). The two interventions in this study, the Shared Decision Engagement System (SharES), include (1) two versions of an evidence-based patient-facing breast cancer treatment decision tool (iCanDecide +/- an emotional support module) and (2) a clinician-facing dashboard (Clinician Dashboard) that is reviewed by surgeons/clinicians and summarizes ongoing patient needs. The design is a near minimax, hybrid stepped wedge trial of SharES where both interventions are being evaluated in a crossed design over six 12-week time periods. The primary outcome (knowledge) and key secondary outcomes (i.e., self-efficacy and cancer worry) are assessed via patient report at 5 weeks after surgery. Secondary outcomes are also assessed at 5 weeks after surgery, as well as in a second survey 9 months after registration. We anticipate recruiting a total of 700 breast cancer patients (600 evaluable after attrition) from 25 surgical practices affiliated with Alliance.

DISCUSSION

Upon study completion, we will have better understanding of the impact of a multilevel intervention on patient-centered communication in breast cancer with a specific focus on whether the intervention components improve knowledge and self-efficacy and reduce cancer worry.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04549571 . Registered on 16 September 2020.

Person-centred care in the Dutch primary care setting: Refinement of middle-range theory by patients and professionals

In a previous rapid realist review (RRR) of international literature insight was provided into how, why, and under what circumstances person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, by establishing a middle-range programme theory (PT), which describes the relationship between context items, mechanisms, and outcomes. Since the application of PCC in primary care in the Dutch setting is expected to differ from other countries, the objective of this study is to validate the items (face validity) resulting from the RRR for the Dutch setting by assessing consensus on the relevance of items. Four focus group discussions with patient representatives and patients with limited health literacy skills (n = 14), and primary care professionals (n = 11) were held partly combined with a Delphi-study. Items were added to refine the middle-range PT for the Dutch primary care setting. These items indicated that in order to optimally align care to the patient tailored supporting material that is developed together with the target group is important, next to providing tailored communication. Healthcare providers (HCPs) and patients need to have a shared vision and set up goals and action plans together. HCPs should stimulate patient's self-efficacy, need to be aware of the patient's (social) circumstances and work in a culturally sensitive way. Better integration between information and communications technology systems, flexible payment models, and patients access to documents, and recorded consultations should be in place. This may result in better alignment of care to the needs of patients, improved accessibility to care, improved patient's self-efficacy, and improved health-related quality of life. On the long-term higher cost-effectiveness and a higher quality of healthcare can be realised. In conclusion, this study shows that for PCC to be effective in Dutch primary care, the PT based on international literature was refined by leaving out items and adding new items for which insufficient or sufficient consensus, respectively, was found.

How does patient-centered communication in ovarian cancer care enhance patient well-being? A mixed methods study

OBJECTIVE

Greater perceived patient-centered communication (PCC) is associated with better health-related quality of life (HRQoL) in patients with ovarian cancer. Quantitative measures of PCC and HRQoL do little to explain this association. We interviewed patients with high and low ratings of PCC to understand how it is associated with HRQoL.

METHODS

Explanatory sequential mixed methods study. Participants were English-speaking U.S. adults with ovarian cancer. We assessed PCC with the Patient-Centered Communication - Cancer (PCC-Ca)-36 (possible score range 1-5; higher scores represent greater patient-centeredness), and purposively sampled 14 participants with total scores in the top and bottom quartiles. Participants completed individual, semi-structured interviews about their communication experiences. Guided by the National Cancer Institute Framework for PCC in Cancer Care, we analyzed interview transcripts using directed content analysis. We integrated survey and interview findings in a joint display.

RESULTS

Among 176 survey respondents, PCC-Ca-36 total scores ranged from 1.7 to 5.0. Participants with scores in the top quartile (4.8-5.0) perceived clinicians as proactive and attentive to psychosocial concerns. Those with scores in the bottom quartile (1.7-3.5) described not feeling known as an individual and receiving limited support for self-management.

CONCLUSIONS

The association between PCC and QoL may be partially explained by differences in perceived support for psychosocial concerns and self-management. PCC may facilitate receipt of proactive, personalized care.

Relationships and power: An exploration of person-centredness in an intellectual disability service in Ireland

Institutionalised cultures and imbalances of power have been identified within the literature as risk factors for the abuse of adults with intellectual disability living in residential services. Governments in the Republic of Ireland and internationally continue to support person-centredness as a framework of care that can promote cultural change within disability services as a safeguard against abuse. However, there is limited research which seeks to explore if person-centredness as a framework of care has had much impact on changing cultures within disability services as a protective factor against abuse. This study aims to explore how adults with intellectual disability living in residential services and staff experience the professional caring relationship and the framework of person-centredness. The study was based on a phenomenological approach using thematic analysis which enabled six adults with intellectual disability and six staff to participate through one-to-one interviews. The thematic analysis resulted in three main themes: (1) Conflict within the relational dynamic between service users and staff. (2) Challenges to delivering person-centred care. (3) Shared needs. Participants reported that there was conflict within the relationship between service users and staff influenced by relational and cultural issues. Participants also experienced challenges in delivering person-centred care within the service. This study revealed that as a result of wider organisational and cultural influences, person-centred cultures, which are vital to underpin changes in power imbalances, were often undermined. This research highlights that it is not enough to have a system of quality of care guided by the principles of person-centredness alone to ensure a shift in culture and safeguard against abuse of adults with intellectual disability. Rather, consideration of the relational and cultural factors that impact their lives also needs to be built into the values and practices of services offered to adults with intellectual disability.

Person-Centered Practice in Hospitalized Older Adults with Chronic Illness: Clinical Study Protocol

The aging trend in the population, the high rate of hospitalization, the affliction by multiple chronic illnesses, and the increased vulnerability of older people when hospitalized undoubtedly require a person-centered approach to healthcare-an approach that values a person's participation in the healthcare relationship, supports shared decision making and mutual understanding, and respects a person's values, preferences, and beliefs. However, despite widespread recognition that the adoption of such a clinical practice paradigm is paramount, its implementation and development are still challenging for various health systems and professionals worldwide. The implementation strategy for such a healthcare paradigm must be based on each country's health system organization and practice contexts, as well as the professionals involved. The present work aims to provide guidelines for the understanding of the state of development of person-centered practice in the daily care of hospitalized older adults with chronic illnesses within the internal medicine department of a secondary hospital in an urban area of Portugal. We focus on the characterization of (i) the perceptions of a multidisciplinary team working at an inpatient hospital department of person-centered practice, (ii) the perceptions of hospitalized older adults with chronic illnesses about person-centered practice, (iii) the work culture of an inpatient hospital department with a high prevalence of older adults with chronic illnesses, (iv) the Person-Centred Practice Framework at the organizational and structural levels of the healthcare system, and (v) the elements that influence the implementation of person-centered practice at the individual, organizational, and structural levels in this specific hospital context. To this end, a mixed-methods analysis with a convergent design was planned to use questionnaire instruments to collect data in parallel and independently from distinct samples of health professionals and older inpatient adults within this department. Furthermore, health policies and strategic plans will be analyzed to identify and evaluate references and guidelines for the practice of person-centered care. Studying the dimensions of clinical practice in this specific healthcare context following the Person-Centred Practice Framework can allow us to understand the extent of its development in terms of prerequisites, care environment, care processes, and the macro-context of the healthcare system. Therefore, it is possible to identify and characterize the dimensions achieved and those that need to be improved and, thus, establish a starting point for the definition of new strategies to advance practice towards person-centeredness and monitor changes in healthcare practice.

Program, cultural and neighbourhood factors related to attrition from a community-based enriched medical home program in the United States

Attrition from clinical interventions targeting underserved populations is a substantive challenge to achieving optimal health outcomes. Our nationally recognised enriched medical home intervention (EMHI) utilised community health worker home visitation to improve health outcomes of children by engaging the entire family and removing barriers to care-seeking. Families were enrolled into the program between 2013 and 2016, and, as part of the evaluation of the program's success, we identified predictors of program completion by conducting a secondary analysis of 304 families participating in the EMHI evaluation research. Program completers finished participation in the EMHI with mutual agreement that the family can independently follow recommended care. Program non-completers were either lost to follow-up or dropped out before reaching this milestone. Data were collected using electronic medical records and validated self-report surveys to assess constructs such as social support, mental health difficulties and neighbourhood characteristics. The EMHI participants were primarily families with infants <24 months old, Medicaid-insured and Latino. In the multivariable logistic regression model, EMHI program factors as well as community factors independently predicted program continuation and retention. Specifically, families learning about newborn care or with preferred spoken language Spanish were more likely to complete the program. Participants reporting neighbourhood distrust had a greater likelihood of non-completion than others. Results underscore the importance of cultural competency and community involvement in program design and dissemination. Our findings are applicable to other home-based interventions with the goal of supporting underserved families in following recommended clinical care.

Exploring expectations and assumptions in the public and patient engagement literature: A meta-narrative review

OBJECTIVES

Public and patient engagement (PPE) is increasingly recognized in policy statements as essential to achieving transformation towards patient-centred, value-based, integrated care. Despite extensive research over two decades, important gaps and questions remain around how the efforts invested in engagement drive the changes needed to meet these objectives.

METHODS

We conducted a meta-narrative review of systematic and scoping reviews to understand persistent difficulties and uncertainties in this research domain. Thirty-eight reviews looking at studies of PPE in care, healthcare organizations and systems were appraised. We synthesized the expectations of PPE that prompted each review, the guiding ideas about how PPE comes about, main findings and the questions and gaps they raise.

RESULTS

Four storylines are found in reviews: 1. Terminology is inconsistent and concepts are weak; 2. Outcomes of care can be improved 3. Influence on healthcare delivery and design is uncertain; 4. Characteristics of engagement efforts are consequential.

DISCUSSION AND PRACTICE IMPLICATIONS

Three assumptions underlie these storylines and appear as barriers to practice and research; alternative approaches based on collaborative governance and theories of change are proposed to understand and support engagement with transformative potential.

[Patient- and Family-Centered Physical and Psychological Distress Care Model for Adult Patients With Cancer]

Patient- and family-centered care (PFCC) has become more important due to advances in medical treatment and the impact of the COVID-19 pandemic. The evidence in the literature has proven the ability of PFCC to accomplish win-win results for the three principal parties (patients, family, and healthcare providers). In Taiwan, pancreatic cancer has risen to the 7th largest cause of cancer mortality, with increasing numbers of pancreatic-cancer-related deaths over the past ten years. Pancreatic cancer is difficult to diagnose early, and diagnoses are nearly always made during the late stage, resulting in high levels of physical and psychological distress for patients. This article was developed to introduce the core concept of PFCC and its evidence in the context of adult patients with cancer. Furthermore, the rehabilitation care model, based on PFCC, includes the 6 aspects of Family involvement, Optimistic attitude, Coping effectiveness, Uncertainty reduction, Symptom management, and Physical enhancement (FOCUS+P). A PFCC-based example of pancreatic cancer care is proposed that may be expanded to the care of patients with other types of cancer to improve the quality of life of patients and their families.

Acute pain pathways: protocol for a prospective cohort study

INTRODUCTION

Opioid analgesics are often used to treat moderate-to-severe acute non-cancer pain; however, there is little high-quality evidence to guide clinician prescribing. An essential element to developing evidence-based guidelines is a better understanding of pain management and pain control among individuals experiencing acute pain for various common diagnoses.

METHODS AND ANALYSIS

This multicentre prospective observational study will recruit 1550 opioid-naïve participants with acute pain seen in diverse clinical settings including primary/urgent care, emergency departments and dental clinics. Participants will be followed for 6 months with the aid of a patient-centred health data aggregating platform that consolidates data from study questionnaires, electronic health record data on healthcare services received, prescription fill data from pharmacies, and activity and sleep data from a Fitbit activity tracker. Participants will be enrolled to represent diverse races and ethnicities and pain conditions, as well as geographical diversity. Data analysis will focus on assessing patients' patterns of pain and opioid analgesic use, along with other pain treatments; associations between patient and condition characteristics and patient-centred outcomes including resolution of pain, satisfaction with care and long-term use of opioid analgesics; and descriptive analyses of patient management of leftover opioids.

ETHICS AND DISSEMINATION

This study has received approval from IRBs at each site. Results will be made available to participants, funders, the research community and the public.

TRIAL REGISTRATION NUMBER

NCT04509115.

Experiences of Patient-Centered Care Among Older Community-Dwelling Australians

Background

Older adults represent the largest consumers of health care. It is, therefore, important that they receive adequate patient-centered care to empower them to be proactive in managing their health.

Aims

This study examined the proportion of older community-dwelling individuals who report receiving patient-centered care during healthcare consultations.

Methods

A cross-sectional study was conducted with 117 clients of an Australian aged care provider. Clients completed a survey examining their perceptions of whether they received patient-centered care (11-items) from healthcare professionals.

Results

The mean number of patient-centered care items reported was 8.7 (±3.1). Speaking to the patient with respect was the item most often reported to be patient-centered (94%). Asking patients about treatment goals or expectations (62%) and how involved they would like to be in treatment (67%) were the items least reported to be patient-centered.

Conclusion

Older adults perceived some important aspects of care were not provided with a patient-centered approach. There is a need to improve healthcare providers' elicitation of older patients' care preferences, enabling patients to determine their level of involvement in their health management.