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Development of an instrument to measure seniors’ patient safety health beliefs: The Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey
Abstract
To develop a survey to measure seniors' embracement of ambulatory patient safety self-advocacy behaviors, the Senior Empowerment and Advocacy in Patient Safety (SEAPS) survey.
Content was developed by review of published recommendations combined with interviews and focus groups with community members; items were generated for subscales based on the health belief model (HBM). Psychometric characteristics were assessed by cluster and correlation analyses on a pilot test of 143 community dwelling seniors; the ability of the subscales and demographic variables to predict reported behavior was investigated by multiple regression.
The four subscales of the SEAPS were outcome efficacy (OE), attitudes (ATT), self-efficacy (SE) and behaviors (BEH). Cronbach alphas were 0.74 for ATT, 0.79 for BEH, and 0.91 for OE and SE. Analysis of variance showed that there were no differences in any subscale score by race, education level or frequency of doctor visits, but women were noted to have significantly higher scores (p<.01) on the ATT and SE subscales and for the total of all the scales. Multiple regressions showed that SE significantly predicted self-reported behavior (p<.001). OE was a significant predictor for whites (p<.001) but not for African-Americans (p=.24).
We have developed a short, 21-item self-administered survey to assess seniors' views about their participation in safety tasks.
We believe the SEAPS shows promise to be a tool for evaluating interventions and training programs aimed at improving seniors' self-advocacy skills. Effective interventions may improve the involvement of patients in their own safety in the clinical setting.
... Among the included questionnaires, the contents most commonly used to describe PPPS were 'attitudes and perceptions', 'experience', 'information and feedback' and 'willingness'. Seven questionnaires investigated patients' attitudes and perceptions towards involvement in safety behaviours Bishop et al., 2015;Davis et al., 2015;Davis, Anderson, et al., 2012;Davis, Pinto, et al., 2012;Elder et al., 2007;Zhang et al., 2012). ...
... Moreover, we found that measurement error was particularly poorly reported, except for the SEAPS (Elder et al., 2007). It was concerning that other studies failed to assess the measurement error of the questionnaires, as accuracy and reproducible measurements are critically important for a scale. ...
... Three studies examined the test-retest reliability of the questionnaires: PMOS(McEachan et al., 2014), PREOS-PC (Ricci-Cabello et al., 2016) andIIMSS(Wang et al., 2019), and all of them showed positive psychometric results. Apart from internal consistency and test-retest reliability, only one study assessed the measurement error of the tool, but the psychometric results were rated as indeterminate(Elder et al., 2007). ...
Aim:
The purpose of this review was to evaluate the content, validity and reliability of patient-reported questionnaires on patient participation in patient safety.
Background:
Patient participation in patient safety is one of the key strategies that are increasingly regarded as a critical intervention to improve the quality of safety care.
Evaluation:
A systematic review was conducted according to PRISMA guidelines. The content, reliability and validity of patient-reported questionnaires on patient participation in patient safety were assessed.
Key issues:
Twenty-seven studies were included for data extraction and synthesis. The questionnaire contents most commonly used to describe patient participation in patient safety were 'attitudes and perceptions', 'experience', 'information and feedback' and 'willingness'. Internal consistency was evaluated for seventeen questionnaires, and test-retest reliability was tested for four questionnaires. Content validity was assessed among all included questionnaires, and structural validity was evaluated for twelve questionnaires.
Conclusions:
Future research targeting the different safety issues is still indispensable for developing patient-reported questionnaires with great psychometric quality in validity, reliability, feasibility and usability in patient participation in patient safety.
Implications for nursing management:
Clinical nurses should consider the internal consistency, test-retest reliability, content validity and structural validity of the questionnaires that have been positively appraised for methodological quality before use.
... Although there is high interest in patient involvement in the enhancement of patient safety, few previous studies have attempted to explain how to increase patient involvement and what factors influence the safety behaviors of patients [4][5][6][7]. Moreover, only limited studies have tried to explain patient involvement in the field of patient safety using health-related theories [8][9][10][11][12]. According to previous studies, the lack of confidence of patients is the main barrier to their taking action to prevent medical errors; if patients feel they are unable to contribute to their own safety, they will not participate in securing their own safety during hospitalization [5,7]. ...
... To measure self-efficacy and safety behaviors, the Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey was used after permission was obtained from the author [9]. The SEAPS survey was developed using a multistep process with rigorous psychometric analysis. ...
... Originally, the SEAPS survey was developed with 40 items; these were reduced to 21 items after a pretest and pilot testing, which confirmed that 21 items were in good agreement with the initial 40 items. With good validity, the Cronbach's alphas of the subscales, namely, outcome efficacy, attitudes, self-efficacy, and behaviors were 0.91, 0.74, 0.91, and 0.79, respectively, in the study conducted by Elder et al. [9]. The SEAPS survey was adopted in this work for several reasons. ...
Objectives:
This study aimed to determine whether self-educational intervention on patient safety via a smartphone application could improve the level of self-efficacy and safety behaviors of patients. In addition the effect of change in self-efficacy on the improvement of safety behaviors after self-educational intervention was investigated.
Methods:
A one-group pre- and post-test design and convenience sampling were implemented. Self-educational intervention via smartphone application was provided to 94 participants in a tertiary university hospital in South Korea. The smartphone application included learning contents on why the participation of patients is critical in preventing hospital-acquired infections and surgery-related adverse events during hospitalization. Paired t-tests and hierarchical regression analysis were conducted to assess the effect of selfeducational intervention and self-efficacy on the improvement of safety behaviors of patients.
Results:
After the intervention, the level of self-efficacy and safety behaviors significantly increased from 2.53 to 2.95 and from 2.00 to 2.62, respectively. In the hierarchical regression analysis, the change in self-efficacy accounted for 35.4% of the variance in the improvement of safety behaviors.
Conclusions:
The results of this study demonstrated that self-education on patient safety via a smartphone application was an effective strategy to enhance patients' self-efficacy and safety behaviors. This process could ultimately enhance patient safety by promoting patient involvement during hospitalization and preventing the occurrence of medical errors.
... '환자안전'이라는 용 어는 환자의 관점에서 사건을 바라보는 것으로, 환자의 입장에 서 '위해'를 받거나 '안전'에 위협을 받지 않는 상태를 의미한다 [15]. 따라서 [1,17,24,27], 의료진에게 치료에 관해 협 조적으로 말할 수 있는 '개방적 의사소통' [1,8,14,15,23,[25][26][27], 안전관리를 실천하려는 '자기효능' [13,17,18,26,27], 안전사고 예방과 적절한 조치를 하는 '행동' [5,[13][14][15]17,25], 위험한 상황 을 예방하는 '병원의 구조적 환경' [24,26,27] ...
... '환자안전'이라는 용 어는 환자의 관점에서 사건을 바라보는 것으로, 환자의 입장에 서 '위해'를 받거나 '안전'에 위협을 받지 않는 상태를 의미한다 [15]. 따라서 [1,17,24,27], 의료진에게 치료에 관해 협 조적으로 말할 수 있는 '개방적 의사소통' [1,8,14,15,23,[25][26][27], 안전관리를 실천하려는 '자기효능' [13,17,18,26,27], 안전사고 예방과 적절한 조치를 하는 '행동' [5,[13][14][15]17,25], 위험한 상황 을 예방하는 '병원의 구조적 환경' [24,26,27] ...
... '환자안전'이라는 용 어는 환자의 관점에서 사건을 바라보는 것으로, 환자의 입장에 서 '위해'를 받거나 '안전'에 위협을 받지 않는 상태를 의미한다 [15]. 따라서 [1,17,24,27], 의료진에게 치료에 관해 협 조적으로 말할 수 있는 '개방적 의사소통' [1,8,14,15,23,[25][26][27], 안전관리를 실천하려는 '자기효능' [13,17,18,26,27], 안전사고 예방과 적절한 조치를 하는 '행동' [5,[13][14][15]17,25], 위험한 상황 을 예방하는 '병원의 구조적 환경' [24,26,27] ...
Purpose: The purpose of this study was to develop a instrument to evaluate patient safety perception in hospitalized patient and to examine its validity and reliability. Methods: For the development of the initial items, the literature was reviewed along with the existing measuring tools. The items were evaluated by experts for content validity. This study was conducted from September 2017 to January 2018. A total of 294 hospitalized patients participated in the study to verify the validity and reliability of the instrument. Data were analyzed by item analysis, exploratory factor analysis, confirmatory factor analysis, criterion-related validity, and internal consistency. Results: The final instrument were derived containing 24 items and 3 factors. There were 10 items on "activities to ensure", 10 items on "patient's safety practices", and 4 items on "trust of the medical system." The criterion-related validity was established using the Patient Measure of Safety (r=.72, p < .001). The Cronbach's α for this instrument was .93. Conclusion: The findings of this study indicate that this instrument has satisfactory validity and reliability. It can quantitatively measure the degree of patient safety awareness of hospitalized patients.
... Dabei müssen bei der Erfassung dieser Ereignisse im ambulanten Sektor methodische Schwierigkeiten überwunden werden: Patient*innen verlassen nach der ambulanten Behandlung sofort die Praxis, sodass nur ein sehr kurzes Zeitfenster zur Erfassung verbleibt, und Krankenakten sowie Routinedaten enthalten im Allgemeinen zu wenige Informationen zum Vorkommen von sicherheitsrelevanten Ereignissen. Auch die freiwillige Berichterstattung ambulant tätiger Ärzte*innen wird in Studien als eine unzuverlässige Informationsbasis diskutiert, da die Anzahl der berichteten Ereignisse untererfasst werde [4] und somit mit einer hohen Dunkelziffer an Fehlern und Schäden zu rechnen sei [5,6]. Aus diesen Gründen ist es naheliegend, Patient*innen trotz ihrer subjektiven Einschätzungen selbst als Berichterstatter zur Erfassung patientensicherheitsrelevanter Ereignisse im ambulanten Sektor einzubeziehen. ...
... Eine abschließende ärztliche Objektivierung der berichteten PSP und Aussagen zu deren Vermeidbarkeit sind bei der gewählten Methode nicht möglich, da die Befragung anonym erfolgte und eine Validierung mittels der Patientenakten nicht möglich ist. Dennoch folgt die vorliegende Studie der internationalen Forderung, Patient*innen sowohl im stationären als auch im ambulanten Sektor als wertvolle Quelle zu beachten und für die systematische Erfassung von PSP aktiv zu involvieren [4][5][6][7][8]. So zeigten Weingart et al. in ihrer Studie, dass nur etwa die Hälfte der von stationären Patient*innen gemeldeten und von Ärzt*innen validierten UE in den Krankenakten dokumentiert waren [9]. ...
•Hintergrund•
Die Epidemiologie patientensicherheitsrelevanter Probleme (PSP) im ambulanten Sektor Deutschlands ist weitgehend unbekannt. Bislang fehlen entsprechende Erfassungsinstrumente.
•Fragestellung•
Entwicklung und Anwendung eines Fragebogens (PSP-AMB), der in Form computergestützter Telefoninterviews (CATI) an einer Bevölkerungsstichprobe ≥40-Jähriger die Epidemiologie von PSP im ambulanten Sektor aus der Patientenperspektive erfasst.
•Methoden•
Die Fragebogenitems wurden mittels Literaturrecherche und Leitfadeninterviews mit ambulanten Ärzt*innen (N=10) und Patient*innen (N=20) entwickelt. Die Umsetzung in CATI und dessen Anwendung im Feld erfolgten durch ein Befragungsinstitut. Vor dem Feldeinsatz fanden qualitative (N=20) und quantitative (N=110) Pretests statt. Die Stichprobe wurde über zufällig generierte Festnetz- und Mobilfunknummern gezogen.
•Ergebnisse•
PSP-AMB erhebt 32 PSP in sieben Bereichen der ärztlichen Behandlung, von der Anamnese bis zur Praxisorganisation, und erfragt PSP der letzten 12 Monate (PSP-Ein-Jahres-Inzidenz), PSP mit Schaden seit dem 40. Lebensjahr (PSP-40+-Prävalenz) sowie PSP mit der Folge Tod oder Schwerstpflegebedürftigkeit per Proxy-Befragung der Teilnehmer*innen zu ihren Eltern und Kindern. Detailfragen erfassen Folgen und Umgang der Betroffenen mit PSP sowie die Soziodemografie. Zwischen Mai und Oktober 2018 konnten insgesamt 10.037 Bürger (Teilnahmequote: 12,4%) befragt werden. Die Abbruchquote lag bei 8,3%. Die Stichprobe repräsentiert die deutsche Bevölkerung ≥40 Jahre.
•Diskussion•
PSP-AMB eignet sich dazu, aus Patientenperspektive PSP in der ambulanten Versorgung systematisch zu erfassen. Damit erfüllt PSP-AMB die internationale Forderung, Patienten als wertvolle Informationsquelle zur Verbesserung der Patientensicherheit aktiv einzubeziehen.
... From many patients' perspectives, medical care belongs exclusively with medical providers who know best. Patients trust that their caretakers have their best interest at heart and defer all decisions passively to them (Beisecker & Beisecker, 1993;Elder et al., 2007;Flynn & Smith, 2007). ...
... Particularly vulnerable were the elderly who came from an era when the doctor was not only authoritarian but was also paternalistic and hopefully beneficent (Beisecker & Beisecker, 1993;Elder et al., 2007;Nettles, 2005). Minorities and the less educated, who were perplexed by the technical circumstances in which they found themselves, were especially less able to cope with the new problems of a depersonalized medical system. ...
... Various tests of descriptive statistics and inferential statistics would be used to fnd the answers to research questions and to testify the hypotheses. Te researcher used measurement scales of self-efcacy (SE) of Elder et al. [43], patient safety engagement of Grafgna et al. [44], and patient safety of Ricci-Cabello et al. [45]. ...
Patient safety and involvement of the patients in their safety engagement activities are considered the most important elements in the healthcare professions due to their impact on various individual and organizational outcomes. The study used responses of 456 patients. The simple random sampling (SRS) technique was used to collect data from the respondents. The researcher used individuals as the unit of analysis in this study. The results revealed that patient safety engagement had a positive significant effect on patient safety. When the mediating variable of self-efficacy was analyzed, it showed a significant mediated effect on patient safety. Therefore, it was concluded that self-efficacy mediated the relationship between patient safety engagement and patient safety. The findings of the current study convey that engagement of the patient in the practices for patient safety is predicted through the level of self-efficacy of the patient. The study discussed various implications for theory and practice. The study also discussed potential avenues for future research.
... 또한, 의료현장에서는 의료인을 대상으로 환자안전관리 교육 및 예방 활동을 수행하고 있다 [6,7] [18][19][20], 간호대학생의 환자안전 역량 강화를 위한 측정도구가 있었다 [21]. 최근에는 의료소비자인 입원환자를 대상으로 환자안전인식•을 측정하는 연구도 진행되고 있다 [13,17,22]. 그리고 의료기관에서 환 자안전사고 경험이 있는 일반인을 대상으로 환자안전사건 소통하기 경험과 증상을 조사한 연구가 수행되었다 [23]. ...
Purpose:
This study was aimed to investigate experiences, perceptions, and educational needs related to patient safety and the factors affecting these perceptions.
Methods:
Study design was a descriptive survey conducted in November 2019. A sample of 1,187 Koreans aged 20-80 years participated in the online survey. Based on previous research, the questionnaire used patient safety-related and educational requirement items, and the Patient Safety Perception Scale. Descriptive statistics and a decision tree analysis were performed using SPSS 25.0.
Results:
The average patient safety perception was 71.71 (± 9.21). Approximately 95.9% of the participants reported a need for patient safety education, and 88.0% answered that they would participate in such education. The most influential factors in the group with low patient safety perceptions were the recognition of patient safety activities, age, preference of certified hospitals, experience of patient safety problems, and willingness to participate in patient safety education.
Conclusion:
It was confirmed that the vulnerable group for patient safety perception is not aware of patient safety activities and did not prefer an accredited hospital. To prevent patient safety accidents and establish a culture of patient safety, appropriate educational strategies must be provided to the general public.
... A survey pilot test of elderly individuals found that African Americans were significantly less likely than whites to report participation in patient safety behaviors. 60 Another quantitative study with 2,765 respondents found that both Hispanics and African Americans were more likely than whites to prefer leaving decisions about medical care to the doctor. 61 Moreover, cognitive testing of the Spanish version of AHRQ's Five Steps to Safer Care revealed that many Spanish-speaking consumers were uncomfortable asking any questions of their physicians and did not know they could ask providers for test results. ...
Patient portals (ie, electronic personal health records tethered to institutional electronic health records) are recognized as a promising mechanism to support greater patient engagement, yet questions remain about how health care leaders, policy makers, and designers can encourage adoption of patient portals and what factors might contribute to sustained utilization.
The purposes of this state of the science review are to (1) present the definition, background, and how current literature addresses the encouragement and support of patient engagement through the patient portal, and (2) provide a summary of future directions for patient portal research and development to meaningfully impact patient engagement.
We reviewed literature from 2006 through 2014 in PubMed, Ovid Medline, and PsycInfo using the search terms "patient portal" OR "personal health record" OR "electronic personal health record". Final inclusion criterion dictated that studies report on the patient experience and/or ways that patients may be supported to make competent health care decisions and act on those decisions using patient portal functionality.
We found 120 studies that met the inclusion criteria. Based on the research questions, explicit and implicit aims of the studies, and related measures addressed, the studies were grouped into five major topics (patient adoption, provider endorsement, health literacy, usability, and utility). We discuss the findings and conclusions of studies that address the five topical areas.
Current research has demonstrated that patients' interest and ability to use patient portals is strongly influenced by personal factors such age, ethnicity, education level, health literacy, health status, and role as a caregiver. Health care delivery factors, mainly provider endorsement and patient portal usability also contribute to patient's ability to engage through and with the patient portal. Future directions of research should focus on identifying specific populations and contextual considerations that would benefit most from a greater degree of patient engagement through a patient portal. Ultimately, adoption by patients and endorsement by providers will come when existing patient portal features align with patients' and providers' information needs and functionality.
Empowerment is seen as an important thinking and working framework for social work. Ideally, it is possible to measure the empowering effects of social work. However, various factors complicate measuring empowerment, making it a difficult exercise. In past decades many instruments for measuring empowerment have been developed and there are many variations in the way these instruments have been developed. The aim of this review is to provide a comprehensive overview of the available instruments, scales or questionnaires that intent to measure the empowerment of users of social work in different contexts of social work, by means of a scoping review. A total of 2,711 studies were screened, resulting in 49 unique instruments for measuring empowerment in contexts related to social work. The results show that the found instruments are almost exclusively Patient-Reported Outcome Scales. Whilst many instruments measure individual empowerment, only a few measure community empowerment. The results also show that there are many variations in which instruments operationalise empowerment. This overview provides social work organisations and its researchers an overview of measuring tools necessary to measure the effects of their efforts, allowing them to build on what is available.
Background
To improve harm prevention, patient engagement in safety at the direct care level is advocated. For patient safety to most effectively include patients, it is critical to reflect on existing evidence, to better position future research with implications for education and practice.
Methods
As part of a multi‐phase study, which included a qualitative descriptive study (Duhn & Medves, 2018), a scoping review about patient engagement in safety was conducted. The objective was to review papers about patients’ attitudes and behaviours concerning their involvement in ensuring their safe care. The databases searched included MEDLINE, CINAHL and EMBASE (year ending 2019).
Results
This review included 35 papers about “Patient Attitudes” and 125 papers about “Patient Behaviours”—indicative of growing global interest in this field. Several patterns emerged from the review, including that most investigators have focused on a particular dimension of harm prevention, such as asking about provider handwashing, and there is less known about patients’ opinions about their role in safety generally and how to actualize it in a way that is right for them. While patients may indicate favourable attitudes toward safety involvement generally, intention to act or actual behaviours may be quite different.
Conclusion
This review, given its multi‐focus across the continuum of care, is the first of its kind based on existing literature. It provides an important international “mapping” of the initiatives that are underway to engage patients in different elements of safety and their viewpoints, and identifies the gaps that remain.
Older adults' self-advocacy in patient safety: a cross-sectional study.
Abstract
BACKGROUND:
patient advocacy is a major nursing role, which is linked to supporting, encouraging and reinforcing self-advocacy in patients. Patient safety is an important nursing outcome, especially in older adults.
AIMS:
older adults' self-advocacy regarding patient safety behaviour and its relationship with some demographic characteristics were assessed.
METHODS:
a valid older adult patients' self-advocacy questionnaire, which included subscales of behaviour, self-efficacy, attitude and outcome efficacy (range of scores=0-63), was used. In this cross-sectional study, 230 patients aged over 60 years were selected using a stratified sampling method.
FINDINGS:
an association was found between total self-advocacy score (mean=40.16; SD=9.6) and rural living (β=-0.168; P=0.016) using multiple linear regression analysis. Similar findings were found between questionnaire subscales and sex, rural living, occupation and age.
CONCLUSION:
older adults, especially women, those of advanced age and those in rural areas, may benefit from nursing interventions to improve their self-advocacy in patient safety.
KEYWORDS:
Cross-sectional descriptive study; Older adults; Patient safety; Self-advocacy
PMID: 31518535 DOI: 10.12968/bjon.2019.28.16.1076
Older adults with complex comorbidities are at risk for challenges that compromise their post-discharge safety at home. A growing body of evidence suggests that post-hospitalization outcomes for vulnerable elders can be improved by interventions that encourage patient empowerment. The purpose of this pilot project was to determine if an individualized transition intervention would improve patient empowerment 30 days after home discharge following an acute illness. Through individualized interaction with an advanced practice nurse, a sample of 25 elder patients was encouraged to acquire the knowledge and confidence to advocate for their needs after discharge from a subacute facility. Pre and post-intervention patient empowerment was measured through the Senior Empowerment and Advocacy in Patient Safety survey. Quantitative data from this study provided evidence to support the benefit of transition care in enhancing patient empowerment. The data generated by this project will add to the existing body of evidence on transitional care.
Background:
Patient safety in primary care is a developing field with an embryonic but evolving evidence base. This narrative review aims to identify tools that can be used by family practitioners as part of a patient safety toolkit to improve the safety of the care and services provided by their practices.
Methods:
Searches were performed in 6 healthcare databases in 2011 using 3 search stems; location (primary care), patient safety synonyms and outcome measure synonyms. Two reviewers analysed the results using a numerical and thematic analyses. Extensive grey literature exploration was also conducted.
Results:
Overall, 114 Tools were identified with 26 accrued from grey literature. Most published literature originated from the USA (41%) and the UK (23%) within the last 10 years. Most of the literature addresses the themes of medication error (55%) followed by safety climate (8%) and adverse event reporting (8%). Minor themes included; informatics (4.5%) patient role (3%) and general measures to correct error (5%). The primary/secondary care interface is well described (5%) but few specific tools for primary care exist. Diagnostic error and results handling appear infrequently (<1% of total literature) despite their relative importance. The remainder of literature (11%) related to referrals, Out-Of-Hours (OOH) care, telephone care, organisational issues, mortality and clerical error.
Conclusions:
This review identified tools and indicators that are available for use in family practice to measure patient safety, which is crucial to improve safety and design a patient safety toolkit. However, many of the tools have yet to be used in quality improvement strategies and cycles such as plan-do-study-act (PDSA) so there is a dearth of evidence of their utility in improving as opposed to measuring and highlighting safety issues. The lack of focus on diagnostics, systems safety and results handling provide direction and priorities for future research.
Background:
Despite the enormous potential for adverse events in primary care, the knowledge base about patient safety in this context is still sparse. The lack of appropriate measurement methods is a key factor limiting the development of research in this field.
Objective:
To identify and characterize available patient reported instruments to measure patient safety in primary care.
Methods:
We conducted a systematic literature review. We searched in bibliographic sources for empirical studies describing the development, evaluation or use of patient reported instruments assessing patient safety in primary care. Study selection and data extraction were independently conducted by two researchers.
Results:
We identified 28 studies reporting on 23 different instruments. Fifteen instruments were designed for paper-based self-administration, six for phone interview and two consisted in electronic reporting systems. Most instruments focused on specific aspects of patient safety, most commonly on experiences of adverse drug reactions. Face validity was assessed for 10 instruments (43%), three reported construct validity (13%) and three described reliability (13%). Responsiveness was not ascertained.
Conclusions:
Although there is evidence of good psychometric properties for a reduced number of patient reported instruments, currently available instruments do not offer a comprehensive set of resources to measure the effects of interventions to improve patient safety in primary care from a patient perspective. Future research in the field should prioritize (i) the evaluation of the performance of already available instruments and (ii) the development of new instruments that enable an comprehensive assessment of patient safety at general practices.
Das Konzept „Empowerment” wird trotz seiner Verbreitung oft als unbestimmt kritisiert. Daher wurde ein Konzeptueller Review über Empowerment in Prävention und Gesundheitsförderung durchgeführt. Einbezogen waren 62 deutsche und internationale Überblicksarbeiten, Reviews und Einzelstudien aus Prävention, Krankenversorgung, Rehabilitation, Versorgungsforschung sowie Pflege und Arbeitsbelastungen. Die Auswertung zeigte acht Hauptdimensionen von „Empowerment”: (1) Beteiligung an Entscheidungen, (2) Selbstwirksamkeitserwartung, (3) soziale Unterstützung und soziales Kapital, (4) Kompetenzen, (5) Inanspruchnahmeverhalten, (6) Fähigkeit zur Zielsetzung und -verfolgung, (7) Reflexionsvermögen und (8) Innovation. Deren Erhebung kann auf der Mikro-, Meso- und Makroebene erfolgen. Die Studien sind drei Grundverständnissen mit jeweils eigenen Fragestellungen und Operationalisierungen zuzuordnen: dem klinischen, dem organisational-professionellen und dem politischen. Diese Teilkonzepte sollten deshalb separat weiterentwickelt werden; empirische Arbeiten sollten möglichst alle acht Dimensionen erfassen.
OBJECTIVES:: Most advice to patients regarding advocating for their safety relates to hospital care and is not grounded in the patient experience. We developed a patient-centered intervention to train elderly patients to be self-advocates for safer care in ambulatory settings. METHODS:: We pilot-tested a 2-part intervention that 1) educated the elderly regarding their role in identifying and preventing common errors in primary care and 2) provided them with skills to improve communication with health care providers. Participants completed a validated 21-question Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey before and 2 to 3 months after participation. Paired sample t tests were used to measure the impact of the intervention at 2 periods. In addition, field notes of participant comments regarding the intervention were analyzed qualitatively using immersion and crystallization. RESULTS:: The mean total SEAPS score of the 61 participants (mean age, 74.5 years) improved from 44.6 to 48.3 (range, 0-63; P < 0.001). All demographic groups (sex, race, education, and frequency of doctors' visits) showed significant improvement except those with more than a high school education. All participants acknowledged learning new skills and ideas, as well as new ways of organizing their own health care information. Participants noted needed improvements in the intervention related to the roles that others are asked to play. CONCLUSIONS:: Although intensive in effort, this pilot intervention demonstrated that elderly patients can improve their beliefs and self-reported safety behaviors in the ambulatory setting. Further work is needed to confirm the most useful aspects of the training and assess its impact on error reduction.
Virtual Communities (VCs) emerged in the beginning of the 1990’s due to the proliferation of the World
Wide Web. Researchers explored the potentials of virtual communities in health and created different
types of Health VCs. There is growing evidence that health virtual communities can empower patients
with knowledge, facilitate health information dissemination, and provide social and psychological support.
Although Health VCs present several advantages, many challenges are still ahead and opportunities
as well. This chapter will provide an overview of non-mobile and mobile VCs; it will then provide
an overview of Health VCs research and applications as well as their advantages and challenges. The
chapter ends with an outline of the main future opportunities and perspectives in Health VCs.
Several factors affect observed racial/ethnic health disparities in the United States. Among them are features of provider-patient communication. In Study 1, the literature in patient communication skills training is reviewed to determine the extent to which researchers have reported comparative effects of interventions designed to enhance patients'communication skills and participation in medical interviews. Of the 27 studies reported, only 1 conducted a comparative analysis. In Study 2, a post hoc analysis of available communication skills training data sets is conducted to explore comparative intervention effectiveness. Similar to the results of the single report found in Study 1, the communication intervention was more effective with White than with non-White patients. These results are discussed with respect to implications for addressing racial/ethnic health disparities.
Background and objectives: Approaches to translating medical error information into effective interventions have not been well described. The Applied Strategies for Improving Patient Safety (ASIPS) Collaborative developed a mixed-methods approach to analyze medical errors to (1) develop an initial conceptual framework for depicting specific clinical processes at risk for error, (2) validate the framework through critical inquiry with clinicians and staff from participating practices and through concurrent analysis of malpractice insurance data, and (3) implement practice-specific quality improvement interventions to reduce medical errors. Methods: We identified two areas for possible practice-level intervention: laboratory errors and prescription errors. Expert panels of local stakeholders provided grounded input into the refinement of the frameworks and causal flows, resulting in the development of realistic “principles for process improvement” (PPIs) for developing flexible and locally relevant interventions. Results: The intervention for laboratory tests involved the use of a portable bar coding utility to support an electronic laboratory test tracking system. The prescription/medication interventions were based upon an electronic mechanism designed to ensure timely and accurate transmittal of prescription data from practices to pharmacies; incorporate important data elements such as the purpose/indication on each prescription; and develop timely, accurate, and accessible medication lists for the medical record. Conclusion: Using multiple data sources, locally developed and relevant quality improvement interventions to improve patient safety can be successfully implemented in primary care. However, a clear understanding of the processes that require change is essential to successfully address implementation challenges and put interventions into routine use.
An intervention was developed to increase patient involvement in care. Using a treatment algorithm as a guide, patients were helped to read their medical record and coached to ask questions and negotiate medical decisions with their physicians during a 20-minute session before their regularly scheduled visit. In a randomized controlled trial we compared this intervention with a standard educational session of equal length in a clinic for patients with ulcer disease. Six to eight weeks after the trial, patients in the experimental group reported fewer limitations in physical and role-related activities (p less than 0.05), preferred a more active role in medical decision-making, and were as satisfied with their care as the control group. Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians (p less than 0.05). Results of the intervention included increased involvement in the interaction with the physician, fewer limitations imposed by the disease on patients' functional ability, and increased preference for active involvement in medical decision-making.
This article has no abstract; the first 100 words appear below.
Since its publication in the Journal in 1961, “The Ecology of Medical Care,” by White et al.,¹ has provided a framework for thinking about the organization of health care, medical education, and research (Figure 1). This conceptualization, inspired in part by careful reporting on the part of British general practitioners,² suggested that in a population of 1000 adults, in an average month, 750 reported an illness, 250 consulted a physician, 9 were hospitalized, 5 were referred to another physician, and 1 was referred to a university medical center. These data have been used repeatedly by investigators, authors of textbooks, task . . .
Larry A. Green, M.D.
George E. Fryer, Jr., Ph.D.
Robert Graham Center, Washington, DC 20036
Barbara P. Yawn, M.D.
Olmsted Medical Center, Rochester, MN 55904
David Lanier, M.D.
Agency for Healthcare Research and Quality, Rockville, MD 20852
Susan M. Dovey, M.P.H.
Robert Graham Center, Washington, DC 20036
Supported by the Robert Graham Center, the Olmsted Medical Center, and the Agency for Healthcare Research and Quality.
Source Information
Address reprint requests to Dr. Green at the Robert Graham Center, Policy Studies in Family Practice and Primary Care, 2023 Massachusetts Ave., NW, Washington, DC 20036.
To describe and classify process errors and preventable adverse events that occur from medical care in outpatient primary care settings.
Systematic review and synthesis of the medical literature.
We searched MEDLINE and the Cochrane Library from 1965 through March 2001 with the MESH term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care and limited the search to English-language publications. Published bibliographies and Web sites from patient safety and primary care organizations were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed and from seminal papers in the field.
Process errors and preventable adverse events.
Four original research studies directly studied and described medical errors and adverse events in primary care, and 3 other studies peripherally addressed primary care medical errors. A variety of quantitative and qualitative methods were used in the studies. Extraction of results from the studies led to a classification of 3 main categories of preventable adverse events: diagnosis, treatment, and preventive services. Process errors were classified into 4 categories: clinician, communication, administration, and blunt end.
Original research on medical errors in the primary care setting consists of a limited number of small studies that offer a rich description of medical errors and preventable adverse events primarily from the physician's viewpoint. We describe a classification derived from these studies that is based on the actual practice of primary care and provides a starting point for future epidemiologic and interventional research. Missing are studies that have patient, consumer, or other health care provider input.
To develop a preliminary taxonomy of primary care medical errors.
Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods.
The National Network for Family Practice and Primary Care Research.
Family physicians.
Medical error category, context, and consequence.
Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died.
This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.
We wanted to explore how patients' experiences with preventable problems in primary care have changed their behavioral interactions with the health care system.
We conducted semistructured interviews with 24 primary care patients, asking them to describe their experiences with self-perceived preventable problems. We analyzed these interviews using the editing method and classified emotional and behavioral responses to experiencing preventable problems.
Anger was the most common emotional response, followed by mistrust and resignation. We classified participants' behavioral responses into 4 categories: avoidance (eg, stop going to the doctor), accommodation (eg, learn to deal with delays), anticipation (eg, attend to details, attend to own emotions, acquire knowledge, actively communicate), and advocacy (eg, get a second opinion).
Understanding how patients react to their experiences with preventable problems can assist health care at both the physician-patient and system levels. We propose an association of mistrust with the behaviors of avoidance and advocacy, and suggest that further research explore the potential impact these patient behaviors have on the provision of health care.
To examine multiple risk factors for medical injury using administrative data.
This cross-sectional study used logistic regression models to examine associations among patient characteristics such as age, sex, and insurance payer status and hospital characteristics such as ownership, teaching status and trauma level, and comorbidities and presence of a medical injury diagnosis. Data were from the Bureau of Health Information: Wisconsin hospital in-patient discharge records and hospital characteristics for the year 2001.
All Wisconsin non-federal, acute-care hospitals.
A total of 556 899 patients discharged from 132 Wisconsin hospitals, excluding newborns, participated.
None. Main outcome measure. Medical injury, defined as untoward harm to a patient as a result of a medical intervention, was determined using discharge diagnosis criteria.
Medical injuries were found in 13.3% of 556 899 hospital discharge records. Covariates associated with increased risk of a recorded medical injury code included age 45-84 years, female sex, comorbidities, non-profit religious order ownership, proportion of cardiac intensive care in-patient days to total in-patient days, percent of board-certified medical staff, and community trauma center or regional trauma resource.
This article describes an innovative analysis of risk factors for medical injury that controlled for numerous potential confounding factors, including hospital coding characteristics. The associations we found, such as increased risk of medical injury in women, can be used to generate hypotheses for further testing through other methods and suggest intervention points for patient safety efforts.
Background: Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers. Objectives: The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patient's personal characteristics (age, gender, education, ethnicity); 2) the physician's communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty). Research Design and Subjects: The authors conducted a post hoc cross-sectional analysis of 279 physician–patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas. Main Outcome Measures: The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations. Results: The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients. Conclusions: Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physician's communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care.
OBJECTIVE: To assess the association between HMO practice, time pressure, and physician job satisfaction.
DESIGN: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one’s career and one’s specialty. Linear regression-modeled satisfaction (on 1–5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. “HMO physicians” (9% of total) were those in group or staff model HMOs with >50% of patients capitated or in managed care.
RESULTS: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P<.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P<.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P<.05) and from job, career, and specialty satisfaction (P<.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P<.05 after Bonferroni’s correction).
CONCLUSIONS: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians’ satisfaction with staff, community, resources, and the duration of new patients visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined.
A multitrait-multimethod design was employed to assess the construct validity of the Health Belief Model. The data were obtained from a non-representative sample of 85 graduate students at The University of Michigan's School of Public Health. The traits consisted of the respondents' perceptions of: health interest, locus of control, susceptibility to influenza, severity of influenza, benefits provided by a flu shot, and the barriers or costs associated with getting a flu shot. Each trait was measured by three methods: a seven-point Likert scale, a fixed-alternative multiple choice scale, and a vignette. The results indicate that the Health Belief Model variables can be measured with a substantial amount of convergent validity using Likert or multiple choice questionnaire items. With regard to discriminant validity, evidence suggests that subjects' perceptions of barriers and benefits are quite different from their perceptions of susceptibility and severity. Perceptions of susceptibility and severity are substantially but not entirely independent. Perceived benefits and barriers demonstrate a strong negative relationship which suggests the possibility that these two variables represent opposite ends of a single continuum and not separate health beliefs.
These preliminary results provide the basis for developing brief health belief scales that may be administered to samples of consumers and providers to assess educational needs. Such needs assessment, in turn, could then be used to tailor messages and programs to meet the particular needs of a client group.
A major concern among occupational health nurses is the efficacy of their health education and health promotion programs. The success of programs may be improved when they are built on a sound and appropriate theoretical foundation. Four models that present a logical and reasonable approach to behavioral change include the Health Belief Model, the Theory of Self Efficacy, the Theory of Reasoned Action, and the Multiattribute Utility Model. Behavioral models provide a framework for the development of interventions and strategies which will facilitate behavioral change.
Growing interest in the doctor-patient relationship focuses attention on the specific elements of that relationship that affect patients' health outcomes. Data are presented for four clinical trials conducted in varied practice settings among chronically ill patients differing markedly in sociodemographic characteristics. These trials demonstrated that "better health" measured physiologically (blood pressure or blood sugar), behaviorally (functional status), or more subjectively (evaluations of overall health status) was consistently related to specific aspects of physician-patient communication. We conclude that the physician-patient relationship may be an important influence on patients' health outcomes and must be taken into account in light of current changes in the health care delivery system that may place this relationship at risk.
The Health Belief Model, social learning theory (recently relabelled social cognitive theory), self-efficacy, and locus of control have all been applied with varying success to problems of explaining, predicting, and influencing behavior. Yet, there is conceptual confusion among researchers and practitioners about the interrelationships of these theories and variables. This article attempts to show how these explanatory factors may be related, and in so doing, posits a revised explanatory model which incorporates self-efficacy into the Health Belief Model. Specifically, self-efficacy is proposed as a separate independent variable along with the traditional health belief variables of perceived susceptibility, severity, benefits, and barriers. Incentive to behave (health motivation) is also a component of the model. Locus of control is not included explicitly because it is believed to be incorporated within other elements of the model. It is predicted that the new formulation will more fully account for health-related behavior than did earlier formulations, and will suggest more effective behavioral interventions than have hitherto been available to health educators.
Research was conducted to develop valid and reliable scales to test the Health Belief Model (HBM). The dependent variable chosen for scale development was frequency of breast self-examination. Independent variables were constructs related to the HBM: susceptibility, seriousness, benefits, barriers, and health motivation. Analyses for construct validity and theory testing included factor analysis and multiple regression. Chronbach Alpha and Pearson r were used to compute reliabilities. Scales that were judged valid and reliable were susceptibility, seriousness, benefits, barriers, and health motivation.
This investigation tested the ability of the Health Belief Model (HBM), dimensions of self-efficacy, various behavioral variables (i.e., number of sex partners in the past 12 months, frequency of drunkenness during sexual intercourse, and number of diagnosed sexually transmitted diseases), and demographic measures to distinguish between three condom user groups (i.e., nonusers, sporadic users, and consistent users). The usable sample consisted of 366 college students, ages 18 to 24. The study operationalized the following HBM components: perceived susceptibility, perceived benefits, and perceived barriers. The multidimensional Condom Use Self-Efficacy Scale (CUSES) was also used in this investigation. Results from a discriminant analysis indicated that sporadic users were best distinguished from both consistent and nonusers by number of sex partners in the past year, frequency of drunkenness during sexual intercourse, perceived susceptibility to HIV/AIDS and other STDs, and a self-efficacy factor labeled Assertive. The sporadic users had significantly more sex partners, were drunk more often when engaging in sexual intercourse, perceived themselves as more susceptible to HIV/AIDS and other STDs, and were less confident in their ability to discuss and insist on condom use with a partner. It was also discovered that each condom user group was best defined by different subsets of discriminating variables. Implications of these findings for campus-based prevention programs and future research are discussed.
Models of doctor-patient relations vary between "paternalistic" and "informative." The paternalistic model emphasizes doctors' authority; alternative models allow patients to exercise their rights to autonomy. Published surveys indicate that most patients want to be informed about their diseases, that a proportion of patients want to participate in planning management of their illnesses, and that some patients would rather be completely passive and would avoid any information. The severity of the patients' conditions, and their being older, less well educated, and male are predictors of a preference for the passive role in the doctor-patient relationship, but demographic and situational characteristics explain only 20% or less of the variability in preferences. The only way a physician can gain insight into an individual patient's desire to participate in decision making is through direct enquiry. The ability to communicate health-related information and to determine the patients' desire to participate in medical decisions should be viewed as a basic clinical skill.
To examine the relationship between communication skills training for patients and their compliance with recommended treatment.
A randomized control design was used, with patients nested within physicians. Each physician was audiotaped with 6 patients, 2 patients in each of the 3 intervention conditions: (1) a trained group (n = 50) received a training booklet in the mail 2 to 3 days prior to the scheduled appointment, (2) an informed group (n = 49) received a brief written summary of the major points contained in the training booklet while in the waiting room prior to the scheduled appointment, and (3) an untrained group (n = 51) did not receive any form of communication skills intervention.
Participants included physicians and patients from 9 different primary care, family practice locations. Two locations were clinics associated with a large, university-based medical school and hospital, while 7 were private practice offices in the community.
The sample included 25 family physicians (averaging 11 years postresidency) and 150 patients. Patients were randomly selected from appointment records and randomly assigned to 1 of 3 intervention conditions.
A training booklet designed to instruct patients in information seeking, provision, and verification.
Patients' compliance with medications, behavioral treatment (e.g., diet, exercise, smoking cessation), and/or follow-up appointments and referrals.
Trained patients were more compliant overall than untrained or informed patients. Training positively influenced compliance with behavioral treatments and follow-up appointments and referrals.
Training patients in communication skills may be a cost-effective way of increasing compliance and improving the overall health of patients.
Although time can be measured, it is fundamentally a subjective experience. Patients judge the time spent with their physicians not only according to elapsed time but also by the physician's interest, presence, attention, and responsiveness. Physicians whose posture indicates interest and who address all of the patient's concerns, including psychosocial issues, are perceived to have spent more time and have more satisfied patients. The relationship between perceived time and elapsed time is complex from the perspective of the physician and the trainee as well. For example, physicians tend to overestimate the time spent when they address more of the patient's concerns.1 While the quality of time is important, so is the quantity. Visits averaging 15 minutes or less tend to skimp on psychological data gathering and prevention and are positively associated with inappropriate prescribing and malpractice litigation, and are negatively associated with patient satisfaction.2
Patient education has evolved from its medically-dominated and narrow origin in patient teaching to support of patient empowerment in interpersonal, organizational, and policy domains relevant to health. This essay reflects on both the historical and contemporary context of patient education in the US and explores implications of the empowerment movement on new initiatives and directions in patient education. By using diabetes education as an exemplar, innovations in patient activation and empowerment are explored and future directions and challenges to the field are considered.
A fearful stranger to the healthcare sector when she became a frequent user 2 years ago, Goeltz clearly is now a sophisticated and creative partner. She is fully engaged in decision-making and holds the decisions made as her own. Physicians often worry that their patients don't fully consent to the treatment given them because they don't fully understand the risks. This is often a factor in malpractice litigation. Goeltz's healers don't have that worry. When it comes to the complicated process of treatment, Goeltz doesn't take for granted that the system will operate optimally and holds herself accountable for doing what she can to deliver good outcomes for herself and her loved ones. She knows her active participation keeps the system safer. She challenges those she meets who want to discount her role and refuses to be treated by those who can't meet and adapt to those challenges. She has a lot to teach us all. The circumstances of my brother's death are what taught me the crucial importance of active participation in my own health care. The best tribute I can pay to him is to continue trying to show consumers and those in health care how they can partner with each other to truly improve safety. To those health care workers who are willing to work with me and put up with my challenging them from time to time, please accept my deepest gratitude. I would not be as healthy as I am today without you, and maybe I wouldn't even be alive. I know your jobs aren't easy, and you have earned my greatest respect.
This study used a focus group methodology to examine how Medicare beneficiaries reacted to messages on specific kinds of preventive action, including those adopted by public and private section health organizations. Beneficiaries were asked to rank the messages on their own, and then to discuss their rankings in focus groups. The best-received messages advocated a collaborative patient-provider relationship. They also specified which actions to take, and how to implement them. The authors conclude that public health campaigns to reduce errors need not undermine trust in providers.
Wrong-site orthopaedic surgery is an uncommon, devastating, and preventable complication. The sole responsibility for avoiding this inadvertent event has historically been placed on physicians, nurses, and ancillary health-care personnel. Very little attention has been focused on the role of the patient. The successful outcome of any surgical or medical intervention requires an interactive doctor-patient relationship. The hypothesis of this study was that a substantial number of patients who undergo elective orthopaedic surgery do not comply with instructions designed specifically to prevent wrong-site surgery.
We prospectively evaluated the frequency with which 100 consecutive patients in a private foot-and-ankle practice followed the explicit preoperative instruction, before they underwent elective orthopaedic surgery, to mark "NO" on the extremity that was not to be operated on. Full compliance was defined as a mark on the correct extremity consistent with the instructions. Partial compliance was defined as a mark that was different from that requested by the specific preoperative instructions, and noncompliance was defined as the absence of any mark. Specific demographic and surgical factors were recorded from medical charts and compared between compliant and noncompliant patients.
Fifty-nine of the 100 patients marked the extremity correctly, thirty-seven made no mark, and four were considered partially compliant. Of the ten patients with a Workers' Compensation claim, seven were noncompliant compared with thirty (33%) of the ninety patients who had not made a Workers' Compensation claim (p = 0.023). Patients who had had a previous related surgical procedure also had a significantly higher rate of noncompliance (51%; nineteen of thirty-seven) compared with those with no previous surgery (29%; eighteen of sixty-three; p = 0.023).
A surprisingly high number of patients do not comply with explicit preoperative instructions created specifically to prevent wrong-site surgery. This behavior suggests that patients expect the system to "take care of everything," despite solicitation of their active participation to avoid such adverse events. Although physicians and related health-care personnel certainly have the greatest responsibility to provide the highest possible quality of care, patients undergoing surgery must be encouraged to take a more active role in their health care in order to optimize outcome and minimize risk.
Despite recent attention given to medical errors, little is known about the kinds and importance of medical errors in primary care. The principal aims of this study were to develop patient-focused typologies of medical errors and harms in primary care settings and to discern which medical errors and harms seem to be the most important.
Thirty-eight in-depth anonymous interviews of adults from rural, suburban, and urban locales in Virginia and Ohio were conducted to solicit stories of preventable problems with primary health care that led to physical or psychological harm. Transcriptions were analyzed to identify, name, and organize the stories of errors and harms.
The 38 narratives described 221 problematic incidents that predominantly involved breakdowns in the clinician-patient relationship (n = 82, 37%) and access to clinicians (n = 63, 29%). There were several reports of perceived racism. The incidents were linked to 170 reported harms, 70% of which were psychological, including anger, frustration, belittlement, and loss of relationship and trust in one's clinician. Physical harms accounted for 23% of the total and included pain, bruising, worsening medical condition, and adverse drug reactions.
The errors reported by interviewed patients suggest that breakdowns in access to and relationships with clinicians may be more prominent medical errors than are technical errors in diagnosis and treatment. Patients were more likely to report being harmed psychologically and emotionally, suggesting that the current preoccupation of the patient safety movement with adverse drug events and surgical mishaps could overlook other patient priorities.
Now that active involvement by patients in their health care is widely endorsed, valid and reliable methods for determining preferences for involvement in treatment decision making are essential. Relatively little methodological work has been conducted to compare and contrast their reliability and validity. Available single-item measures exist to determine preferences, ranging from 'menu-based' questions to simpler Likert-type scales.
Within a larger community survey of 514 men aged 50-70 years in Sydney, Australia, we compared two measures to assess their preferences for involvement in medical decision making. Using the 'menu-based' Control Preference Scale (CPS), men were classified as preferring to be either 'passive' or 'active' during decision making or to share ('shared') with their doctors on an equal basis. Men also were classified as preferring to be either 'passive' or 'active' according to a Likert-scale measure.
Agreement between the two measures was 'poor' (kappa=0.19). While 24.9% of participants were classified as preferring a 'passive' role in treatment decision making according to the CPS, almost half (47.9%) were so classified according to Arora and McHorney's measure. In the absence of a 'shared' response option on the Arora and McHorney measure, 45.3% of men classified as preferring a 'shared role' on the CPS were instead categorized as 'passive' using Arora and McHorney's measure. Predictors of preferring a 'passive' role also differed, depending on the measure employed. Only occupational skill level predicted men's preferences for a 'passive' role when measured by the CPS [odds ratio (OR)=1.67; 95% CI 1.09-2.55] (P=0.02). For the Arora and McHorney's measure of preferences for involvement, men were significantly more likely to prefer a 'passive' role if they were older [adjusted odds ratio (AOR)=1.06, 95% CI 1.02-1.09] (P=0.001), currently smoking (AOR=1.86, 95% CI 1.09-3.17) (P=0.02) and had higher chance health locus of control scores (AOR=1.26; 95% CI 1.01-1.56) (P=0.04). Having been employed or previously employed in an occupation of a lower skill level was also significantly and independently predictive of a passive role (AOR=2.35, 95% CI 1.57-3.50) (P<0.001).
Single-item measures of decisional preferences have poor convergent validity. Characteristics associated with preference classifications also differ, depending upon the measures used. These results suggest that research efforts should be directed towards developing psychometrically robust measures to determine decisional preferences.
The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation.
1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making.
A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences.
Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined.
This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.
We applied constructs from the transtheoretical model (TTM) of behavior change to identify modifiable determinants of patient participation in medical decision-making.
We surveyed a convenience sample of 621 primary care patients at one Boston hospital (response rate 60.6%). With a random half of the sample, we examined the factor structure of a new Patient Attitudes and Beliefs Scale (PABS) that focused on issues about participation in medical decision-making, and with the other half we confirmed the factor structure and examined the association of patients' stage of readiness to participate in decision-making with subscales of the PABS (pros, cons, and decisional balance), self-efficacy, and trust in physician.
Patients were classified into 4 stages: precontemplation (don't participate and don't intend to, 17.2%), contemplation (don't participate but contemplating participating, 6.9%), preparation (participate to some degree, 36.1%), and action (participate fully, 39.8%). Factor analysis of the PABS items indicated 2 factors representing pros and cons of participation. Scores on the pros increased and cons decreased significantly from precontemplation to action (P < 0.001). Significant nonlinear associations of stage of readiness with self-efficacy (P < 0.01) and trust in physician (P < 0.01) were evident; self-efficacy scores were highest for those in action whereas trust scores were highest for those in precontemplation.
To move people from precontemplation towards action in participating in medical decision-making, interventions focusing on increasing the pros and decreasing the cons of participation may be needed. The challenge is to balance advocacy for an active patient role with individual patients' preference for participation.
Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers.
The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patient's personal characteristics (age, gender, education, ethnicity); 2) the physician's communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty).
The authors conducted a post hoc cross-sectional analysis of 279 physician-patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas.
The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations.
The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients.
Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physician's communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care.
Patients have the potential to play an important role in preventing medical errors. Yet little is known about how to effectively engage patients in this role as a "vigilant partner" in care. Respondents were asked to assess the perceived effectiveness of fourteen recommended actions for preventing medical errors. The findings indicate that most of the actions are viewed as effective. However, respondents also indicate that they are unlikely to engage in many of the recommended actions. Having a greater sense of self-efficacy in being able to prevent medical errors is significantly linked with a greater reported likelihood of engaging in preventive action.
The relations of diet adherence (DA) and self-monitoring of blood glucose (SMBG) to metabolic control, as measured with glycosylated hemoglobin A(tc) (GHbA(tc), and correlates of self-care were examines among a type I diabetic sample (n = 423). The Health Belief Model (HBM), supplemented by other factors (locus of control, self-efficacy, health value, and social support), was used as a theoretical model. In multiple regression analyses both DA (p<.01) and SMBG (p<.001). SMBG showed strong associations with self-efficacy in SMBG (p,.001) and net benefits of SMBG (p<.001). The revised models explained 14% and 21% of the variation in DA and SMBG, respectively. The results suggest that although perceived net benefits are important determinants of both SMBG and DA, DA is also related to diabetes support, whereas SMBG is more strongly related to perceived self-efficacy. Thus self-care regimen should be planned individually for diabetic patients.
Many health care providers now disseminate advisories telling patients what they can do to avoid errors and harms in their care.
The content of five leading safety advisories for patients was analyzed and a critique of their development, content, and impact was developed, drawing on published literature and 40 interviews with a diverse sample of 50 key informants.
Very little is known about the effects of the distribution of safety advisories to patients, but several grounds for concern were identified. There was a lack of attention to patients' perspectives during the development of advisory messages, and the advisories say little about what health care providers should do to ensure patient safety. Patients are given little practical support to carry out the recommended actions, and health professionals' responses may render their attempts to act to secure their own safety ineffective. Some messages suggest an inappropriate shifting of responsibility onto patients. Advice that involves checking on or challenging health professionals' actions appears to be particularly problematic for patients. Such behaviors conflict with the expectations many people have--and think health professionals have--of patients' roles.
A serious commitment to optimizing patients' contributions to safe care requires a research-based understanding of patients' perspectives and more practical facilitation of patient involvement.
This review aimed to clarify present knowledge about the factors which influence patients' preference for involvement in medical decision making.
A thorough search of the literature was carried out to identify quantitative and qualitative studies investigating the factors which influence patients' preference for involvement in decision making. All studies were rigorously critically appraised.
Patients' preferences are influenced by: demographic variables (with younger, better educated patients and women being quite consistently found to prefer a more active role in decision making), their experience of illness and medical care, their diagnosis and health status, the type of decision they need to make, the amount of knowledge they have acquired about their condition, their attitude towards involvement, and the interactions and relationships they experience with health professionals. Their preferences are likely to develop over time as they gain experience and may change at different stages of their illness.
While patients' preferences for involvement in decision making are variable and the process of developing them likely to be highly complex, this review has identified a number of influences on patients' preference for involvement in medical decision making, some of which are consistent across studies.
By identifying the factors which might influence patients' preference for involvement, health professionals may be more sensitive to individual patients' preferences and provide better patient-centred care.
Although many patient safety organizations and hospital leaders wish to involve patients in error prevention, it is unknown whether patients will take the recommended actions or whether error prevention involvement affects hospitalization satisfaction.
Telephone interviews with 2,078 patients discharged from 11 Midwest hospitals.
Ninety-one percent agreed that patients could help prevent errors. Patients were very comfortable asking a medication's purpose (91%), general medical questions (89%), and confirming their identity (84%), but were uncomfortable asking medical providers whether they had washed their hands (46% very comfortable). While hospitalized, many asked questions about their care (85%) and a medication's purpose (75%), but fewer confirmed they were the correct patient (38%), helped mark their incision site (17%), or asked about handwashing (5%). Multivariate logistic regression revealed that patients who felt very comfortable with error prevention were significantly more likely to take 6 of the 7 error-prevention actions compared with uncomfortable patients.
While patients were generally comfortable with error prevention, their participation varied by specific action. Since patients who were very comfortable were most likely to take action, educational interventions to increase comfort with error prevention may be necessary to help patients become more engaged.
Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medication decision making.
To explore the views of older adults regarding participation in medication decision making.
Qualitative study.
Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices.
One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis.
The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making.
While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.
Patients as partners How to involve patients and families in their own care
- M Mcgreevey
- Editor
McGreevey M, editor. Patients as partners. How to involve patients and families in their own care. Chicago: Joint Commission on Accreditation of Healthcare Organizations; 2006.
Patientreportsofpreventableproblemsandharmsinprimary health care
- Aj Kuzel
- Sh Woolf
- Vj Gilchrist
- Jd Engel
- Ta Laveist
- Vincent
Kuzel AJ, Woolf SH, Gilchrist VJ, Engel JD, LaVeist TA, Vincent C, FrankelRM.Patientreportsofpreventableproblemsandharmsinprimary health care. Ann Fam Med 2004;2:333–40.
Trialanderrorin myquesttobea partnerin myhealth care: a patient’s story
- Goeltzr
GoeltzR,HatlieM.Trialanderrorin myquesttobea partnerin myhealth care: a patient’s story. Crit Care Nurs Clin N Am 2002;14:391–9. N.C. Elder et al./Patient Education and Counseling 69 (2007) 100–107107
On addressing racial and ethnic health disparities. The potential role of patient communication skills interventions
- Cegala
Cegala DJ, Post DM. On addressing racial and ethnic health disparities. The potential role of patient communication skills interventions. Am Behav Scientist 2006;46:853–67.