Article

Discrepancies between patient and professionals recall and perception of an outpatient consultation

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Abstract

To explore the degree of agreement between patient and health care professional's perceptions of consultations. Immediately after 141 dietitian/nurse specialist consultations, patients and professional's completed the Health Care Climate questionnaire (HCC), Medical Interview Satisfaction Scale (MISS) and the Treatment Self-Regulation Questionnaire (TSRQ) In addition, both parties were asked about any key points or issues discussed in the consultation; any decisions that were made about their diabetes treatment today; any goals that were set as a result of today's consultation. Patient and professional's scores on the HCC and MISS were not correlated (r=0.3 and 0.16). Patient and professionals disagreed on the issues discussed 19.6% of the time, on the decisions made 20.7% of the time and goals set 44.3% of the time. More autonomy support in the consultation was associated with greater autonomous motivation for self-care (r=0.31; P<0.001) more controlled motivation was associated with less agreement on issues discussed and goals set (r=-0.20; r= -0.24; P<0.05). There is significant disagreement between patients and professionals perceptions and recollection of the content of consultations. Professional's communications skills need to be developed to ensure these discrepancies are minimized. Skills to provide greater autonomy support in the consultation would help to enhance this process and improve outcomes.

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... Discrepancies between patients' and physicians' perceptions of clinical phenomena have also been documented elsewhere [34][35][36]. It has been shown that health professionals value the quality of their own information more positively than patients and that health professionals to a higher degree than patients experience that specific information was delivered to patients [35] Additionally, a study on patients' and health professionals' ability to recall information provided in consultations revealed that patients were unable to call to mind even half of the topics discussed and could recall even fewer decisions that were made about their treatment than did health professionals [36]. ...
... Discrepancies between patients' and physicians' perceptions of clinical phenomena have also been documented elsewhere [34][35][36]. It has been shown that health professionals value the quality of their own information more positively than patients and that health professionals to a higher degree than patients experience that specific information was delivered to patients [35] Additionally, a study on patients' and health professionals' ability to recall information provided in consultations revealed that patients were unable to call to mind even half of the topics discussed and could recall even fewer decisions that were made about their treatment than did health professionals [36]. According to the authors, this lack of agreement could be related to health professionals bringing their own agendas into the consultation. ...
... This includes the development of health professionals' communication skills e.g. skills to include patients in clinical decision making and encourage patient autonomy [36]. It has been shown that patient autonomy is associated with increased motivation, better self-care and metabolic control in patients [38]. ...
Article
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The number of new technologies for risk assessment available in health care is increasing. These technologies are intended to contribute to both improved care practices and improved patient outcomes. To do so however, there is a need to study how new technologies are understood and interpreted by users in clinical practice. The objective of this study was to explore patient and physician perspectives on the usefulness of a new technology to detect Cardiovascular Autonomic Neuropathy (CAN) in a specialist diabetes clinic. The technology is a handheld device that measures resting heart rate and conducts three cardiac autonomic reflex tests to evaluate heart rate variability. The study relied on three sources of data: observations of medical consultations where results of the CAN test were reported (n = 8); interviews with patients who had received the CAN test (n = 19); and interviews with physicians who reported results of the CAN test (n = 9). Data were collected at the specialist diabetes clinic between November 2013 and January 2014. Data were analysed using the concept of technological frames which is used to assess how physicians and patients understand and interpret the new technology. Physicians generally found it difficult to communicate test results to patients in terms that patients could understand and to translate results into meaningful implications for the treatment of patients. Results of the study indicate that patients did not recall having done the CAN test nor recall receiving the results. Furthermore, patients were generally unsure about the purpose of the CAN test and the implications of the results. Involving patients and physicians is essential when a new technology is introduced in clinical practice. This particularly includes the interpretation and communication processes related to its use. The integration of a new risk assessment technology into clinical practice can be accompanied by several challenges. It is suggested that more information about the CAN test be provided to patients and that a dialogue-based approach be used when communicating test results to patients in order to best support the use of the technology in clinical practice.
... Baseline data and video consultations consisted of the results of a previously published study. 13 This was con-ducted two years prior to the second set of data collection. Immediately after the consultations conducted by six diabetes nurse specialists and two diabetes specialist dietitians (professionals), patients and professionals were given a questionnaire to complete. ...
... Agreement was coded using three categories: Complete Agreement where the topics and specific content were the same; Some Agreement where either the topics were the same but the specifics differed, or where there was overlap between the topics given by the patient and professional; and Complete Disagreement where there was no overlap on the topics given by the patient and professional. 13 Two of the authors coded the responses independently, and then met to discuss any discrepancies between coded responses, until agreement on coding category was reached. ...
... The intervention consisted of two days' training for the six diabetes nurse specialists and the two diabetes dietitians who took part in the original study. 13 Pre-training results from the baseline study were fed back to the professionals before training began. This was done in order to provide an objective marker of each professional's practice in terms of their own and the patients' perception of the consultation, and the levels of agreement achieved. ...
Article
This study aimed to examine whether professional-centred training improves consultation outcomes.Using a pre- and post-data collection design, immediately after consultations, professionals and patients completed a consultation review sheet which was coded for the level of agreement on issues discussed and decisions made. Patients also completed the Health Care Climate Questionnaire (HCCQ). Pre-training results were fed back to the professionals to provide an objective measure of current practice. Training day one comprised 10 minutes' observation of videoed consultations of each professional in order to identify strengths and training needs. Each professional identified key areas of their consultation that they felt needed further development. Training day two centred on goal setting and negotiating agendas as these were identified as priority areas requiring more skills.Data from 110 baseline and 73 follow-up consultations were collected. The HCCQ showed no significant difference between baseline and follow up. Non-parametric tests indicated that the level of agreement on decisions had improved (Mann-Whitney U = 951; p = 0.002; χ2 = 3.67; df = 2; p = 0.026). The number of consultations where complete disagreement occurred between the patient and professional, on decisions made, reduced from 17% at baseline to 11% at follow up.It was concluded that professional-centred training can be effective in improving patients' perceptions of the consultation, and in increasing patient/professional agreement on recall of decisions made. Copyright © 2006 John Wiley & Sons, Ltd.
... The consultation is the main method used by healthcare professionals to provide, update and reinforce diabetes education, review clinical and other progress, make decisions about treatments and treatment changes; and, support motivation to undertake diabetes management tasks. However, as studies of consultations involving adult patients have shown, there may be significant disagreement between participants and health professionals about what they consider the main outcomes of diabetes consultations to be and participants may leave their consultations with questions unanswered [5,6], with detrimental implications for their diabetes (self-) management practices [5,6]. While most research to date has focused on adult diabetes consultations [5][6][7][8][9], only a minority of studies have explored paediatric consultations and, more specifically, the perspectives of parents and/or their child's health care providers [10][11][12][13][14]. ...
... The consultation is the main method used by healthcare professionals to provide, update and reinforce diabetes education, review clinical and other progress, make decisions about treatments and treatment changes; and, support motivation to undertake diabetes management tasks. However, as studies of consultations involving adult patients have shown, there may be significant disagreement between participants and health professionals about what they consider the main outcomes of diabetes consultations to be and participants may leave their consultations with questions unanswered [5,6], with detrimental implications for their diabetes (self-) management practices [5,6]. While most research to date has focused on adult diabetes consultations [5][6][7][8][9], only a minority of studies have explored paediatric consultations and, more specifically, the perspectives of parents and/or their child's health care providers [10][11][12][13][14]. ...
... However, as studies of consultations involving adult patients have shown, there may be significant disagreement between participants and health professionals about what they consider the main outcomes of diabetes consultations to be and participants may leave their consultations with questions unanswered [5,6], with detrimental implications for their diabetes (self-) management practices [5,6]. While most research to date has focused on adult diabetes consultations [5][6][7][8][9], only a minority of studies have explored paediatric consultations and, more specifically, the perspectives of parents and/or their child's health care providers [10][11][12][13][14]. In keeping with the broader literature on adult consultations, studies of paediatric diabetes consultations have tended to focus on health professionals' consultation skills and communication styles and how these could be capitalized upon and/or improved to promote parental knowledge, confidence and experience [10,13,14]; optimize health care delivery [12,14]; and, improve the child's clinical outcomes [12,14]. ...
Article
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Background Parents of non-adolescent children with type 1 diabetes are responsible for most of their child’s diabetes management tasks. Consultations are used to provide diabetes education, review clinical progress and promote diabetes management tasks. This study explored parents’ experiences of, and views about, their child’s diabetes consultations. The objective was to identify ways in which consultations could be improved to aid communication, understanding and knowledge retention. Methods In-depth interviews with 54 parents of children (aged ≤12 years) with type 1 diabetes. Data were analysed using an inductive thematic approach. Results Parents’ accounts revealed structural and contextual factors which could hinder effective communication and knowledge acquisition during consultations. Most reported feeling anxious going into consultations and worrying about being reprimanded by health professionals if their child’s glycaemic control had not improved. As a consequence, many parents highlighted problems concentrating and assimilating information during consultations. In extreme cases, worries about being reprimanded led parents to omit or fabricate information when discussing their child’s treatment or even to their cancelling appointments. Many parents described wanting opportunities to speak to health professionals alone because young children could be distracting and/or they did not want to raise distressing issues in front of their child. Parents described the benefits of receiving clinical advice from health professionals familiar with their family circumstances and disliking attending busy clinics and seeing different health professionals on each occasion. Parents also highlighted the benefits of receiving treatment recommendations in a written form after the consultation. Discussion and conclusions This study has highlighted unrecognised and undocumented aspects of the consultation which may result in parents leaving uncertain about the main issues discussed and with questions unanswered and support needs unaddressed. Structural and contextual changes to consultations are recommended to improve concentration, knowledge acquisition and retention. These include: sending letters/written summaries after consultations highlighting key decisions, providing opportunities for parents to consult health professionals without their child being present, encouraging parents to ask more questions during consultations, having procedures in place to promote continuity of care and providing parents with consistent and non-contradictory advice.
... Clinicians often give conflicting advice, both within the team and among individuals from one consultation to the next [20]. Goals are often not followed up, leaving the person with diabetes feeling frustrated [20]. ...
... Clinicians often give conflicting advice, both within the team and among individuals from one consultation to the next [20]. Goals are often not followed up, leaving the person with diabetes feeling frustrated [20]. Typically, physicians interrupt their patients 18 seconds after their patient starts to describe their problems; approximately half of patients' concerns are not discussed, and in 50% of consultations, patients and physicians disagree on the central problem presented [19]. ...
... Typically, physicians interrupt their patients 18 seconds after their patient starts to describe their problems; approximately half of patients' concerns are not discussed, and in 50% of consultations, patients and physicians disagree on the central problem presented [19]. Disagreement about treatment goals, inconsistency among healthcare teams and confusion about treatment priorities are associated with poorer outcomes [20]. By contrast, supporting the person with diabetes in making choices based on the best evidence available, and ...
Article
National Audit Data highlight persistent sub-optimum control among increasing numbers of people living with diabetes, with severe consequences for the individual and the NHS. The aim of the present review was to introduce a new cohesive, holistic model of care, tailored to individual needs to support optimum diabetes outcomes. This model of diabetes is necessary in order to understand the driving forces behind behaviour and their impact on diabetes management. Feelings (an emotional state or reaction) and beliefs (an acceptance that something is true or real) are fundamental behavioural drivers and influence diabetes self-management choices. Individually, these explain some of the complexities of behaviour and, collectively, they impact on personal motivation (rationale/desire to act) to achieve a specific outcome. Inevitably, they independently affect diabetes self-management and the environment in which individuals live. A model of care that proposes the encompassing of environment, intrinsic thought and therapy regimens to provide tailored, personalized healthcare should support enhanced diabetes self-management and outcomes from diagnosis. The Kaleidoscope model of care could be deliverable in routine care, incorporating each of the influences on diabetes self-management, and should benefit both individuals with diabetes and healthcare professionals. This article is protected by copyright. All rights reserved.
... The level of agreement between the participant and professionals was coded into three categories: complete agreement, some agreement and complete disagreement, as per a previous study. 29 Patients' and professionals' responses were entered into a spreadsheet, where the group allocation was removed and the order randomised. This spreadsheet was then coded by researchers TP and SC, who were blind to group allocation and trained to code the level of agreement using data from Parkin and Skinner's study results 29 to ensure reliability of coding. ...
... 29 Patients' and professionals' responses were entered into a spreadsheet, where the group allocation was removed and the order randomised. This spreadsheet was then coded by researchers TP and SC, who were blind to group allocation and trained to code the level of agreement using data from Parkin and Skinner's study results 29 to ensure reliability of coding. ...
Article
The objective of this study was to assess whether using a computerised touch screen assessment tool prior to outpatient consultation makes patients more active in the consultation. In a non-randomised control group design, immediately after consultations, which were recorded, patients and professionals completed a consultation review sheet and the Health Care Climate Questionnaire (HCCQ). Views about the assessment were then elicited. Intervention participants completed the Accu-Chek Interview (a computerised psychosocial assessment) prior to the consultation. After completing the Accu-Chek Interview, participants were more active in the consultation asking twice as many questions (t = 3.167; df = 67.07; p = 0.002), without lengthening the consultations. There was no significant difference in the duration of consultations (t = -1.20; df = 129; p = 0.234). Patients valued completing the interview: ‘it does prompt you to ask questions that you may not think of at the time.’ The demographics were similar for both groups and there was no effect on the HCCQs. It was concluded that the Accu-Chek Interview seems to activate patients into asking more questions (a marker for better bio-medical outcomes in a recent meta-analysis) and is valued by patients to help improve diabetes care. The Accu-Chek Interview could be routinely offered to outpatients attending diabetes centres as a tool to improve communication, increase autonomy and potentially improve outcomes. Copyright
... Furthermore studies have found that patients recall less than 50% of what they are told in consultations [27][28][29] and that patients and doctors often have conflicting views surrounding the key messages from a consultation. [30][31][32] Rosenfeld et al. highlighted the importance of oral exchange in the management of chronic illness, in particular speaking skills and listening skills. 33 In addition, effective communication can be achieved through the use of a variety of techniques; using plain language during physician patient consultations, using the teach back or talk back method, using images, diagrams and other visual aids to explain health matters. ...
... Furthermore studies have found that patients recall less than 50% of what they are told induring consultations [27][28][29] and that patients and doctors often have conflicting views surrounding the key messages from a consultation. [30][31][32] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 ...
... The benefits of the good use of CSBC are evident and patients' preferences are clear, but what happens if these skills are not demonstrated to a high standard? Parkin and Skinner (28) found significant disagreement between patient and professional (diabetes specialist nurses and dietitians) perceptions and recollection of the content of consultations. Patients reported fewer topics being discussed by the professionals and fewer decisions about treatment. ...
... The patient may appear non-compliant but their response may be due to a joint lack of communication skills. In cases where the patient was given more autonomy in the consultation they were able to develop more autonomous motivation to diabetes self-care which is an important outcome (28) . Lack of confidence in using CSBC has been shown to stop healthcare professionals in a diabetes team (including dietitians) addressing psychosocial issues that were of key importance to the patients (29) . ...
Article
The need to support people to change diet-related behaviour is widely advocated and how to do this effectively in practice is an expanding area of research. Important factors to consider are how healthcare practitioners communicate with their patients and how that communication may affect diet-related behaviour change and subsequent outcomes. The aim of the present paper is to discuss communication skills for behaviour change (CSBC), focusing predominantly on registered dietitians who are required to communicate effectively and have an important role in supporting patients to change diet-related behaviour. The views of dietitians in relation to CSBC have been investigated and respondents have consistently reported that they perceive these skills to be of vital importance in practice. Patient views have reiterated the importance of good CSBC in one-to-one consultations. However, pre-qualification training of dietitians is thought to deliver practitioners who are competent at a minimum level. The need for ongoing continuous professional development (CPD) in relation to CSBC has been recognised but currently most CPD focuses on updating knowledge rather than improving these essential skills. Measuring CSBC in a consistent and objective manner is difficult and an assessment tool, DIET-COMMS, has been developed and validated for this purpose. DIET-COMMS can be used to support CSBC development, but concerns about logistical challenges and acceptability of implementing this in practice have been raised. Although a suitable assessment tool now exists there is a need to develop ways to facilitate assessment of CSBC in practice.
... In conclusion, our study shows that at least part of acute complications could be avoided through better use of existing therapeutic options, better education to individuals with diabetes and their families, and greater attention to psychosocial problems of children and their families. These principles are in line with the more modern approach to education, based on therapeutic intervention of a multidisciplinary team to create a care centered on the needs and ability of the patient [25] and the achievement of an agreement on the objectives of the treatment between the patient, their parents and the health care professionals [26,27]. ...
Article
Background and aims Evaluation of incidence and correlates of severe hypoglycemia (SH) and diabetes ketoacidosis (DKA) in children and adolescents with T1DM. Methods and Results Retrospective study conducted in 29 diabetes centers from November 2011 to April 2012. The incidence of SH and DKA episodes and their correlates were assessed through a questionnaire administered to parents of patients aged 0-18 years. Incidence rates and incident rate ratios (IRRs) were estimated through multivariate Poisson regression analysis and multilevel analysis. Overall, 2025 patients were included (age 12.4±3.8 years; 53% males; diabetes duration 5.6±3.5 years; HbA1c 7.9±1.1%). The incidence of SH and DKA were of 7.7 and 2.4 events/100 py, respectively. The risk of SH was higher in females (IRR=1.44; 95%CI 1.04-1.99), in patients using rapid acting analogues as compared to regular insulin (IRR=1.48; 95%CI 0.97-2.26) and lower for patients using long acting analogues as compared to NPH insulin (IRR=0.40; 95%CI 0.19-0.85). No correlations were found between SH and HbA1c levels. The risk of DKA was higher in patients using rapid acting analogues (IRR=4.25; 95%CI 1.01-17.86) and increased with insulin units needed (IRR=7.66; 95%CI 2.83-20.74) and HbA1c levels (IRR=1.63; 95%CI 1.36-1.95). Mother’s age was inversely associated with the risk of both SH (IRR=0.95; 95%CI 0.92-0.98) and DKA (IRR=0.94; 95%CI 0.88-0.99). When accounting for center effect, the risk of SH associated with the use of rapid acting insulin analogues was attenuated (IRR=1.48; 95%CI 0.97-2.26); 33% and 16% of the residual variance in SH and DKA risk was explained by center effect. Conclusion The risk of SH and DKA is mainly associated with treatment modalities and strongly depends on the practice of specialist centers.
... The book, Simple Tips to Developing a Productive Clinician-Patient Relationship gives simple tips to achieve some level of tranquility for 16 different scenarios of patient attitudes/behaviors [1][2][3][4][5][6][7]. Book is available at www.ptdrsimpletips.com. ...
... French data from DAWn2™ study questionnaires incorporated items from the original DAWN study; new questions developed by a multi-disciplinary, multinational team; as well as standardized instruments including World Health Organization Quality of Life-BREF (WHO QOL-BREF), 8 EuroQoL-5D, 9 World Health Organization 5-item Well-Being Index (WHO-5), 10 the Problem Areas in Diabetes 5 Short Form (PAID-5-SF), 11,12 the Problem Areas in Diabetes Distress of Family Members (PAID-5-DFM), the Health Care Climate Questionnaire (HCC), 13 and the Summary of Diabetes Self-Care Activities Measure (SDSCA). 14 In addition, questions integrated in the questionnaires were developed with inspiration from or were adapted or modified from existing validated instruments including the Diabetes Empowerment Scale-Short Form (DES-SF), 15 Helpfulness Active Patient Involvement-DAWN Short Form (HAPI-DSF), 16 Patient Assessment of Chronic Illness Care (PACIC), 17,18 Diabetes Family Behavior Checklist, 19 and DAWN Impact of Diabetes Profile (DIDP). ...
Article
Full-text available
The second Diabetes, Attitudes, Wishes and Needs (DAWN2™) multinational cross-sectional study was aimed at generating insights to facilitate innovative efforts by people with diabetes (PWD), family members (FMs), and health care professionals (HCPs) to improve self-management and psychosocial support in diabetes. Here, the French data from the DAWN2™ study are described. In France, 500 PWD (80 with type 1 diabetes [T1] and 420 with type 2 diabetes [T2]), 120 FMs, and 288 HCPs were recruited. The questionnaires assessed the impact of diabetes on quality of life and mood, self-management, attitudes/beliefs, and care/support. Diabetes negatively impacted the emotional well-being of 59% of people with T1 versus 45% of people with T2 (P<0.05) and about half of FMs. A high level of distress was felt by about half of PWD and FMs. About half of HCPs reported assessing depression in their patients. Sixty-two percent of FMs considered managing diabetes to be a burden. Hypoglycemia was a source of concern for 64% of people with T1 and 73% of FMs of insulin users. About two-thirds of non-insulin-medicated people with T2 agreed to start insulin if prescribed, while half of HCPs preferred to delay insulin initiation. A discrepancy between HCPs' perceptions of their interactions with their patients and PWD's recollection of these interactions with regard to patients' personal needs and distress was also observed. While distress remains under-assessed by HCPs, the negative impact of diabetes on the lives of PWD and FMs clearly induces distress on both groups. These findings provide new understanding of barriers precluding optimal management of diabetes. Developing strategies to overcome these barriers is now warranted.
... This was not only to receive more encouragement and affirmation as others have recommended [14], but also to bring in their own expertise and experiences and to discuss these with health professionals cognizant in, and sympathetic to, the difficulties of caring for a child with Type 1 diabetes and keeping blood glucose levels within target ranges. It should be acknowledged that people's recall and understanding of diabetes consultations may differ from those of health professionals [26], which may result in both parties coming out with incongruent treatment goals [27]. However, parents' accounts suggest a need for improvements in how consultations are currently delivered, to aid treatment decision-making in ways that take account of a child's everyday life and needs. ...
Article
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To explore the difficulties parents encounter in trying to achieve clinically recommended blood glucose levels and how they could be better supported to optimize their child's glycaemic control. In-depth interviews were conducted with 54 parents of children with Type 1 diabetes (≤12 years). Data were analysed thematically. Parents described being reluctant and finding it difficult to keep their child's blood glucose levels consistently within clinically recommended ranges. As well as worrying about their child's ability to detect/report hypoglycaemia, parents highlighted a multitude of factors that had an impact on their child's blood glucose levels and over which they could exercise little control. These included: leaving their child with other caregivers who could not be trusted to detect hypoglycaemia; difficulties remotely monitoring and regulating their child's food consumption and activity; and physical and social changes accompanying childhood development. Most parents used two sets of blood glucose targets, with clinically recommended targets employed when their child was in their immediate care and higher targets when in the care of others. Parents described health professionals as lacking in understanding of the difficulties of keeping blood glucose within target ranges and needing more empathetic, tailored and realistic advice. It is not parents' fear of hypoglycaemia in isolation that leads to decisions to raise their child's blood glucose but, rather, parental fear in conjunction with other factors and considerations. Hence, to improve diabetes management in children, these factors may need to be addressed; for instance, by training others in diabetes management and using new technologies. Changes to consultations are also recommended. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
... Dietitians perceive their ability to deliver CSBC to be high (9,32) , however perceived skill can vary considerably from true proficiency (33)(34)(35)(36)(37) and may contribute to variations seen in patient outcomes (38) . Validated tools to assess CSBC are therefore required to identify skill level, support skill development and application in practice (7,39) . ...
Article
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Background In 2007, a survey of UK dietitians identified that dietitians were positive about the use of Communication Skills for Behaviour Change (CSBC) in practice but barriers to implementation of skills were acknowledged. This follow up survey aimed to explore current perceptions of CSBC and compare with the previous survey. Methodology A cross‐sectional on‐line survey of British Dietetic Association (BDA) members views of CSBC was undertaken. Results for full members are presented. Quantitative data was analysed descriptively. Qualitative data was subject to either content, or inductive thematic analysis. Results A 9.4% response rate (n=729) was achieved. Respondents were predominately female (n=684, 95.1%) and worked in the NHS (n=634, 87.4%). They were positive about the importance of CSBC in practice (n=714, 99.5%). Pre‐registration training had been completed by 346 respondents (48.7%). Post‐registration training had been undertaken by 520 (74.7%) respondents and 514 of these (99.6%) had implemented training into practice, with few barriers identified. Perception of ability to use skills had increased with 513 (83.6%) respondents rating their skills as excellent/very good, compared to 62% previously. The majority (n=594, 93.7%) reported that post‐registration training was necessary, skills should be regularly reviewed (n=456, 74.5%) and 235 (51.9%) respondents suggested this be mandatory. In contrast, some suggested skill review was not a priority, would be difficult to administer and stressful. Conclusions Perception of importance of CSBC remains high. Although perceived ability to apply CSBC has increased, perceived need for post‐registration training is high, with respondents’ favouring mandatory training.
... Although guidelines are in place, it is unclear to what extent these are adhered to, or to what extent individuals with diabetes fully understand the progressive nature of their condition and the possibility of requiring injectable therapy. Communication research has shown that dissonance between what healthcare professionals think they have covered with patients, compared with patients' perceptions of a consultation is not uncommon (Parkin and Skinner, 2003). Communication needs to be improved to minimise these discrepancies. ...
Article
The transition from oral to injectable agents is often delayed in type 2 diabetes by both people with diabetes and their healthcare providers. This study aimed to assess the experiences of people with type 2 diabetes in order to identify improvements that could be made in the transition to injectable therapy. Both positive and negative experiences were identified and a number of practice recommendations have been made, which may improve the experience of transition for all individuals. This will continue to be an important issue for the health service due to the increasing number of people being diagnosed with type 2 diabetes and the emphasis on “treating to target”.
... Research indicates that both parties' recall of consultations is poor. Moreover, the assumption that professional recall of consultations is more accurate, is insufficiently substantiated (Parkin & Skinner, 2003;Skinner, Barnard, Cradock, & Parkin, 2007). This only increases the importance of well-maintained patient records. ...
Book
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Exploring the current roles of practice nurses in Belgian general practice, investigating the impact of a practice nurse-general practitioner collaboration on patient outcomes, and finding out how current barriers to the integration of practice nurses in Belgian general practice can possibly be overcome.
... diabetes language at diagnosis has a lasting impact on the person with diabetes [4,5]. diabetes language is confusing, unrealistic, inaccurate, frustrating, intimidating, and harmful [6][7][8][9]. diabetes language affects continuity of care. This includes attendance and experiences at diabetes clinics and services, including feeling criticised, judged, belittled and patronised, or feeling understood, supported and confident [10][11][12]. ...
Article
The words used about diabetes affect the physical and emotional health of people living with diabetes. They also affect how individuals and society view people living with, or at risk of, diabetes. People with diabetes, their families, and people at risk of diabetes, need and deserve communications that are clear and accurate, respectful and inclusive, and free from judgement and bias. The aim of this position statement is to help bring about positive change in the language used about diabetes. It is based on 30+ years of research into the experiences of people with diabetes. Changing the language of diabetes can make a powerful and positive difference to the emotional well-being, self-care and health outcomes of people affected by diabetes. It also affects community and government support for funding diabetes care, prevention and research. Diabetes Australia encourages everyone communicating about diabetes, or about people affected by diabetes, to choose and use their words carefully to support all people affected by diabetes. This is intended as a guide for people working in healthcare, the media, government and policy, academia, industry, as well as employers and the community. It may also be helpful for the family and friends of people with diabetes.
... Este hallazgo es reforzado por una valoración positiva de los pacientes en cuanto a la profesionalidad enfermera, aunque esto coexiste con la percepción de los pacientes de mala comunicación en la consulta (19). Existen importantes diferencias entre la información que el paciente recibe y lo que el profesional cree que ha transmitido durante la consulta (20). Teniendo en cuenta el objetivo de motivar a los pacientes para modificar hábitos y estilos de vida, a menudo el mensaje genera disonancias en el receptor. ...
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Objetivos: Se expone una revisión sistemática de las evidencias disponibles sobre las competencias de la especialidad de Enfermería Familiar y Comunitaria (Orden SAS 1729/2010, de 17 de junio). Método:Las bases de datos de consulta son MEDLINE, SciELO, IBECS, Cochrane, INAHTA. La búsqueda se realiza en castellano, inglés y portugués, limitando por fecha a los artículos publicados entre los años 2000 y 2013. Se incluyen artículos disponibles en el momento de la búsqueda. Se analiza la calidad de los estudios con las listas de comprobación de CASPe y se clasifican por niveles de evidencia según la estructura FAME de Joanna Briggs Institute. Resultados: Se encuentran 51649 artículos, de los cuales se seleccionan 62. Los resultados se exponen en una tabla organizados por las competencias a las que se asocian. Conclusión: Destaca que existan gran cantidad de publicaciones relacionadas con determinadas competencias, encontrando numerosos estudios sobre calidad y satisfacción; en cambio, no se han encontrado estudios sobre competencias en prevención primaria en adulto sano. Tampoco se encuentran artículos que engloben todas las competencias de la especialidad en su conjunto. Esta revisión señala y propone la necesidad de enriquecer este tema de reciente implantación en el ámbito de las especialidades de la enfermería
... In addition issues discussed may be more pertinent to individuals [64,65], which may result in greater engagement [66], and lead to increased agreement about decisions as seen in this study. Data on agreement about decisions from other studies focusing on nurses/physicians obtained similar agreement levels to those obtained in this study [51,67], suggesting that findings from this study relating to agreement can be generalised. ...
... In addition, patient and physician recall of a consul-tation frequently differ. Research indicates that both parties' recall of consultations is poor and that the assumption that professional recall of consultations is more accurate, is insufficiently substantiated [27,28]. This only increases the importance of well-maintained patient records. ...
Article
Aim The aim of this research is to explore the current early-stage diabetes mellitus type 2 care in Belgian general practices. This, to find out if the care is provided according to the proposed evidence-based national diabetes care guideline. Additionally, this research aims to detect which person and practice characteristics can be associated with a more evidence-based care provision. Methods People were included in the study if they were recently diagnosed with type 2 diabetes by the participating practice. Practice and person characteristics, and clinical parameter monitoring and lifestyle monitoring data were collected by using a questionnaire and a topic list. Results A total of 27 general practices participated and a total of 249 people were included through their patient records. People monitored in a practice according to a self-developed protocol were 5.5 times more likely to have a better clinical parameter follow-up. Larger practices (>2000 patients), follow-up by general practitioners and practice nurses together and according to self-developed protocols were associated with a significantly better lifestyle follow-up. Conclusion Practices providing multidisciplinary diabetes care, in collaboration with practice nurses, and with diabetes care based on self-developed protocols achieved a more comprehensive follow-up.
... One study, by FALVO et al. [57], has shown that after their consultation, patients remember very little (less than 50%) of what they were told. Another study has shown that patients and doctors often have different views regarding the key messages that should be taken away from a consultation [58]. This situation can be improved in several ways: by giving the patient an information leaflet with details of their individual medication, for instance [59]. ...
... Additionally, patients with limited health literacy can experience feelings of embarrassment and shame when interacting with health care providers and may try to hide or compensate for a lack of understanding (Baker et al., 1996). Many patients with chronic illness leave health care encounters with a different perception and recollection from health care professionals regarding issues that were discussed, decisions that were made, and the goals that were set (Parkin & Skinner, 2003). The problem of limited health literacy, particularly in disadvantaged socioeconomic groups with chronic diseases, begs for disruptive innovation to improve health care outcomes. ...
Article
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Eight years ago my father was being released home from the large academic hospital where I worked, and I was able to be present for his discharge instructions. I was not wearing my white coat or hospital badge and, therefore, was treated as a layperson in this specialized unit because I didn't visit it routinely in my clinical practice. Table 1 is an approximation of the discharge summary my father received. It should be noted that my father was actually taking 25 mcg of fentanyl (not the 125-mcg dose he was erroneously going to be discharged on) to dull the pain and burning he felt in his mouth and throat from the chemotherapy and radiation he was receiving as part of his treatment regimen for stage III head and neck cancer. The combination of pain and loss of appetite led to the placement of a gastrostomy tube so that he could receive adequate nutrition, hydration, and prescription medications. There were several duplications of medications in different formulations, frequencies, and routes of administration, such as ciprofloxacin, prochlorperazine, and a prescription mouthwash. Also, the medical abbreviation “PO” and the more patient-friendly term “orally” were used interchangeably. When my father received these instructions he was asked if he had any questions, and as anyone who has been present when discharge instructions are given to a friend or family member can probably attest, he quickly answered, “No.”
... Clínica y metodología avanzada 15 publ. [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] Refuerza el uso de la EBE en la práctica diaria, el registro en la historia clínica y la necesidad de que los profesionales tengan formación específica en comunicación -; 3b; C La atención en la infancia 1 publ. 27 Dirigir los mensajes de educación sanitaria a la familia. ...
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PARANINFO DIGITAL es una publicación periódica que difunde materiales que han sido presentados con anterioridad en reuniones y congresos con el objeto de contribuir a su rápida difusión entre la comunidad científica, mientras adoptan una forma de publicación permanente. Este trabajo es reproducido tal y como lo aportaron los autores al tiempo de presentarlo como COMUNICACIÓN DIGITAL en "CUIDADOS Y TECNOLOGÍA: UNA RELACIÓN NECESARIA" I Congreso Virtual, IX Reunión Internacional de Enfermería Basada en la Evidencia, reunión celebrada del 21 al 22 de noviembre de 2013 en Granada, España. En su versión definitiva, es posible que este trabajo pueda aparecer publicado en ésta u otra revista científica. Título Dime qué estudias y te diré cómo eres. Competencias de Enfermería Familiar y Comunitaria. Una revisión sistemática Autores Lucía Pérez- RESUMEN Competencia es un término polisémico que sirve para describir diferentes cuestiones. Se define como "la aptitud del profesional sanitario para integrar y aplicar los conocimientos, habilidades y actitudes asociados a las buenas prácticas de su profesión para resolver las situaciones que se le plantean". Actualmente, en España se están desarrollando las siguientes especialidades las cuales tienen definidas las competencias a adquirir para la obtención del título de especialista: Enfermería Familiar y Comunitaria, Enfermería Obstétrico-Ginecológica, Salud Mental, Enfermería Geriátrica, Enfermería Pediátrica y Enfermería del Trabajo [...]
... Este hallazgo es reforzado por una valoración positiva de los pacientes en cuanto a la profesionalidad enfermera, aunque esto coexiste con la percepción de los pacientes de mala comunicación en la consulta (19). Existen importantes diferencias entre la información que el paciente recibe y lo que el profesional cree que ha transmitido durante la consulta (20). Teniendo en cuenta el objetivo de motivar a los pacientes para modificar hábitos y estilos de vida, a menudo el mensaje genera disonancias en el receptor. ...
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Resumen Objetivos: Se expone una revisión sistemática de las evidencias disponibles sobre las competencias de la especialidad de Enfermería Familiar y Comunitaria (Orden SAS 1729/2010, de 17 de junio). Método:Las bases de datos de consulta son MEDLINE, SciELO, IBECS, Cochrane, INAHTA. La búsqueda se realiza en castellano, inglés y portugués, limitando por fecha a los artículos publicados entre los años 2000 y 2013. Se incluyen artículos disponibles en el momento de la búsqueda. Se analiza la calidad de los estudios con las listas de comprobación de CASPe y se clasifican por niveles de evidencia según la estructura FAME de Joanna Briggs Institute. Resultados: Se encuentran 51649 artículos, de los cuales se seleccionan 62. Los resultados se exponen en una tabla organizados por las competencias a las que se asocian. Conclusión: Destaca que existan gran cantidad de publicaciones relacionadas con determinadas competencias, encontrando numerosos estudios sobre calidad y satisfacción; en cambio, no se han encontrado estudios sobre competencias en prevención primaria en adulto sano. Tampoco se encuentran artículos que engloben todas las competencias de la especialidad en su conjunto. Esta revisión señala y propone la necesidad de enriquecer este tema de reciente implantación en el ámbito de las especialidades de la enfermería. Pérez-vico-Díaz et cols. Competencias enfermeras de la especialidad de Enfermería Familiar y Comunitaria: una revisión sistemática. ENE. Revista de Enfermería. Ago. 2013; 7(3) Recibido: 18/jun/2013 Aceptado: 11/ago/2013 2 Descriptores: C o m p e t e n c i a Profesional; Enfermería en Salud Comunitaria; Revisión Sistemática. Abstract Aim: It presents a systematic review of the available evidence on specialty competencies Family and Community Nursing (SAS Order 1729/2010, of 17 June). Method: The query databases are MEDLINE, SciELO, IBECS, Cochrane, INAHTA. The search is performed in Castilian, English and Portuguese, limiting by date to articles published between 2000 and 2013. They include items available at the time of the search. We analyze the quality of the studies with CASPe checklists and categorized by level of evidence according to the structure FAME Joanna Briggs Institute. Results: 51649 articles are, of which 62 are selected. The results are listed in a table arranged by the powers to which they associate. Conclusion: Stresses that there are large number of publications related to certain skills, finding numerous studies on quality and satisfaction, whereas no studies found skills in primary prevention in healthy adult. Nor are items that encompass all the skills of the specialty as a whole. This review discusses and proposes the need to enhance this topic recently introduced in the field of nursing specialties.
... Studies by Falvo and Tippy (1988) and Schillinger et al (2003) have shown that patients recall very little (less than 50%) of what they are told about during their consultations and another study has shown that patients and doctors often have confl icting views regarding the key messages that should be taken away from a consultation (Parkin 2003). Even when information is given patients commonly complain that physicians do not provide understandable explanations (Ziegler et al 2001). ...
Article
If patients are to participate fully in their care and in the management of a long term condition such as chronic obstructive pulmonary disease, good communication is essential. However, not all patients are able to use the written word and we need to be aware of the size of this problem and its implications for the way in which we give information and conduct medical consultations. The impact of health literacy on outcomes can be considerable and improvements can be made by being aware of the problem, offering information in several different forms, and by reinforcing the spoken word with pictorial images.
... Dentist-patient agreement over consultation content supported previous work. [12][13][14] Patients' and dentists' recollections of discussions were discordant in terms of the dental health advice given and future actions that were agreed upon. These results support an Australian study on smoking cessation that found dentists believing they had advised smoking cessation, but patients not recalling such advice ever having been given. ...
Article
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There is a lack of information about the extent to which patients recall key facts of dental consultations. Forgetting health advice undermines adherence with such instructions and is a potential problem. This study assessed the quantity and type of information recalled in a dental consultation, dentist-patient agreement over the contents of the consultation, and the relationship of such recall with patient satisfaction. Using a cross-sectional design, questionnaire data were obtained from patients recruited through a letter and presenting for a routine dental consultation. General issues discussed, specific information about oral health given, dentist-performed procedures, and agreed future actions were reported independently in writing, by patients and also by the treating dentist immediately postconsultation. Additionally, patients completed a dental visit satisfaction questionnaire. Responses (n = 26, 55% response rate) were content-analyzed, and data on the number and type of information that was recalled were obtained. Interrater reliability was established. Inferential testing showed differences in dentist-patient recall, dentist-patient agreement, and the association between patient recall and satisfaction. Dentists recalled more information than patients (P = 0.001). Dentists further reported giving more dental health education (P = 0.006) and discussing more future actions (P = 0.002) than patients actually remembered. Technical (eg, crowns/bridges) rather than psychosocial (eg, pain/embarrassment) issues were reported more often (P = 0.001) by both dentists and patients. Dentist-patient agreement over issues discussed and procedures performed was higher (kappa = 0.210-0.310) than dental health education agreement and agreed future actions (kappa = 0.060-0.110). There was no relationship between patient recall and patient satisfaction with the consultation (P = 0.240). Patients do not recall as much advice and agreed actions about future dental care as dentists believe they have discussed. These results have implications for patient adherence with oral health instructions.
... 5 Furthermore, studies have found that patients recall less than 50% of what they are told during consultations [27][28][29] and that patients and doctors often have conflicting views surrounding the key messages from a consultation. [30][31][32] Rosenfeld et al 33 highlighted the importance of communication skills (speaking and listening) in the management of chronic illness. Effective communication can be achieved through the use of a variety of techniques: using plain language during physician-patient consultations, using the teachback or talkback method and using images, diagrams and other visual aids to explain health matters. ...
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To establish, in the context of the revised European Pharmacovigilance Directive and based on physicians' perspectives, how Summaries of Product Characteristics (SmPCs) could be more user friendly and better support physicians' interactions with patients, thereby improving patients' own understanding of their medicines. Qualitative focus group discussions (step 1), development of an alternative SmPC (step 2) and an online quantitative survey (step 3) comparing the alternative SmPC to the currently approved version. Office-based physicians (n=218) from all federal states of Germany. 218 German physicians participated, with an equal representation of office-based general practitioners and specialists. For step 1 (n=18), physicians were recruited who frequently consulted SmPCs. Planned and performed: Mayring's qualitative content analysis of focus group discussions (step 1), rating on a five-point Likert scale of preference of current versus alternative SmPCs (step 3). Physicians confirmed the importance of SmPCs as a comprehensive source of medicinal product information, but were moderately satisfied with the current SmPCs, utilised it infrequently and were more likely to engage additional sources of information. The alternative SmPC was consistently preferred. It differed in the way information for particular patient groups was presented, included additional sections (synopsis, checklist for patient information) and used a tabular format. Physicians indicated that SmPCs should be available with search and hyperlink functions, as well as be automatically updated and integrated in available practice software or similar solutions. This research contributes to the development of an official, reliable medicinal product information system meeting the needs of a modern information society while providing the reliability of an officially authorised source. In the context of health literacy, SmPCs should be established as the primary information source for healthcare professionals to ensure compliant and safe utilisation of medicinal products.
... the Diabetes Empowerment Scale-DAWN Short Form (DES-DSF) [22], validated to assess self-efficacy [23]; and the Health Care Climate (HCC) DAWN Short Form 3 [24], validated to assess patient experience of being in the healthcare system [25]. ...
Article
Aims: To compare clinical, psychological, education and social variables in emerging adults (aged 18-30 years) with Type 1 diabetes with their adult counterparts aged >30 years. Methods: A single assessment multinational sample was surveyed as part of the larger second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Participants completed a series of surveys incorporating demographic as well as clinical questions (comorbidities, hypoglycaemia) and validated self-report scales concerning psychosocial (health impact, quality of life, beliefs and attitudes, self-management behaviours, healthcare experience and family support) and diabetes education factors. Results: Emerging adults differed from adults aged >30 years with regard to a number of psychosocial variables. Emerging adults reported better overall quality of life, social support and support from their healthcare team compared with adults aged >30 years of age; however, emerging adults experienced greater diabetes-specific distress and were less engaged in self-management. Diabetes education was related to a number of indicators, while experience of discrimination was harmful, but these impacts did not differ between emerging adults and adults aged >30 years. An analysis of geographical regions suggested that emerging adults in North America and Europe had better well-being than older adults, while the opposite was observed in Asia. Conclusions: Emerging adults, particularly those in the later phase (ages 25-30 years) are especially at risk in terms of diabetes-specific distress. There is a need for novel interventions to meet the needs of these vulnerable emerging adults more effectively. This article is protected by copyright. All rights reserved.
... Misunderstandings during patient-doctor interactions are common, as indicated by a significant discrepancy between patients' and professionals' perceptions and recollections of the content of consultations. 28 Furthermore, ''recommendations'' are not identical to ''collaborative goal setting,'' which has been recognized as improving clinical outcomes 29 and includes an ongoing patient involvement in defining diabetes treatment goals and strategies. ...
Article
Background: "Psychological insulin resistance" (PIR) is an obstacle to insulin treatment in type 2 diabetes, and patients' expectations regarding alternative ways of insulin delivery are poorly understood. Subjects and methods: PIR and beliefs regarding treatment alternatives were analyzed in patients with type 2 diabetes (n=532; mean glycated hemoglobin, 68±12 mmol/mol [8.34±1.5%]) comparing oral antidiabetes treatment, subcutaneous insulin injections, or inhaled insulin. Questionnaires were used to assess barriers to insulin treatment (BIT), generic and diabetes-specific quality of life (Short Form 36 and Problem Areas in Diabetes, German version), diabetes knowledge, locus of control (Questionnaire for the Assessment of Diabetes-Specific Locus of Control, in German), coping styles (Freiburg Questionnaire of Illness Coping, 15-Items Short Form), self-esteem (Rosenberg Self-Esteem Scale, German version), and mental disorders (Patient Health Questionnaire, German version). Patients discussed treatment optimization options with a physician and were asked to make a choice about future diabetes therapy options in a two-step treatment choice scenario. Step 1 included oral antidiabetes drugs or subcutaneous insulin injection (SCI). Step 2 included an additional treatment alternative of inhaled insulin (INH). Subgroups were analyzed according to their treatment choice. Results: Most patients perceived their own diabetes-related behavior as active, problem-focused, internally controlled, and oriented toward their doctors' recommendations, although their diabetes knowledge was limited. In Step 1, rejection of the recommended insulin was 82%, and in Step 2, it was 57%. Fear of hypoglycemia was the most important barrier to insulin treatment. Patients choosing INH (versus SCI) scored higher regarding fear of injection, expected hardship from insulin therapy, and BIT-Sumscore. Conclusions: The acceptance of insulin is very low in type 2 diabetes patients. The option to inhale insulin increases the acceptability for some but not the majority of patients.
Article
Since its launch as a smoking cessation aid, varenicline use has been linked to a number of serious adverse events, notably the exacerbation of pre-existing psychiatric illness, depressed mood and suicidal ideation. Regulators’ fears have been somewhat allayed by varenicline's status as a prescription only medication. The purpose of this study was to examine the care provided by physicians – or general practitioners – and pharmacists to varenicline users under real-world conditions. Participants were 141 patients who had filled a prescription for varenicline at a participating pharmacy within the previous six-months. Identified patients were mailed a survey to complete that included items on interactions with their physician and pharmacy staff, and knowledge of treatment side-effects. Most participants reported that their physician encouraged them to set a quit date (82.5%) and provided additional cessation materials (57.2%). While most (79.0%) physicians discussed whether varenicline was appropriate for the patient, fewer asked about psychiatric illness (40.1%), or asked to be informed about mood or behaviour change during treatment (48.1%). Participants (78.4%) reported that their physician had discussed a follow-up consultation, but only 59.4% of patients who had finished treatment at the time of the survey reported having one. Most reported discussing potential drug side-effects with their physician (71.0%) and or pharmacist (52.9%); when probed, knowledge was variable. These results suggest that many patients do not receive the level of support that physicians and pharmacists are assumed to provide.
Article
Self-determination theory (0160 and 0170) suggests that autonomy-supportive environments, where one's perspective is considered, feelings are recognized, meaningful informations are given, and opportunities for choice are provided, promote optimal functioning. Many studies show that autonomy support leads to positive affective, cognitive, and behavioral consequences. However, this body of research is little known because studies are scattered throughout various research fields and no review of the overall positive impact of autonomy support in various life domains is available. This literature review presents studies on this interpersonal style in five life domains.
The international evidence on socioeconomic inequalities in health is compelling: in all European countries, people who live in disadvantaged circumstances have poorer health, more disability and shorter lives than those who are more affluent. Also, the health of migrants is often poorer compared to the health status of the host population, particularly among some ethnic groups and for some conditions. Poorer access to health services and lower quality of services provided to disadvantaged populations may potentially contribute to the explanation of inequalities in health. Knowledge of these shortcomings can be used by policy makers as potential entry points for improvements in population health and for reductions of socioeconomic and ethnic inequalities in health. The research underlying this thesis aims to contribute to the discussion on the role that the health care system plays in socioeconomic and ethnic inequalities in health. Specifically, we aim to measure the magnitude of socioeconomic and ethnic inequalities related to the functioning of the health care system. We do so by estimating the levels of inequalities in avoidable mortality, utilization and quality of health services. The following specific research questions are addressed: 1) What is the magnitude of socioeconomic and ethnic inequalities in mortality in different European countries? 2) What is the magnitude of socioeconomic and ethnic inequalities in mortality from causes that are related to the functioning of health care in Europe? 3) What is the magnitude of socioeconomic and ethnic inequalities in the utilization and quality of specific health care services?
Article
Abstract Good communication will impact clinical practice by assisting patients in understanding health information as well as medical recommendations. Health literacy is important for communication between healthcare professionals and patients with Chronic Obstructive Lung Disease (COPD). In this article we review the concepts, definitions and measurement tools used to evaluate health literacy and recommend ways in which this information may be integrated into clinical practice. Increased awareness of health literacy will assist clinicians to improve patients' knowledge of their disease and adherence to healthcare recommendations.
Article
Background: The purpose of this study is to explore the professional and personal experiences of multidisciplinary healthcare professionals during and following diabetes counselling and empowerment education. Methods: Everyone who had participated in a diabetes counselling and empowerment course between 2008-2016 was invited to respond to an online survey and follow-up telephone interview if willing. Interviews were recorded and transcribed verbatim. The research team used interpretative phenomenology to identify core themes from both the survey and telephone interviews and which captured the impact of empowerment education. Results: 22 doctors, nurses, dieticians, and psychologists completed an online questionnaire. 10 subsequently took part in telephone interviews. Empowerment education changed them from fixers to facilitators. Their transformation included a sense of becoming authentic, ‘being the way I want to be’ in clinical practice and becoming more self-reflective. This affected them personally as well as reinvigorating them professionally. Conclusions: The participants described a personal and professional journey of transformation that included discovering their person-centred philosophy. They adopted a consultation structure that empowered people with diabetes to care for themselves. It can be speculated that participants’ experience of transformation may also guard against professional burnout.
Article
Aim: The second Diabetes, Attitudes, Wishes and Needs (DAWN2™) multinational cross-sectional study was aimed at generating insights to facilitate innovative efforts by people with diabetes (PWD), family members (FMs), and health care professionals (HCPs) to improve self-management and psychosocial support in diabetes. Here, the French data from the DAWN2™ study are described. Methods: In France, 500 PWD (80 with type 1 diabetes [T1] and 420 with type 2 diabetes [T2]), 120 FMs, and 288 HCPs were recruited. The questionnaires assessed the impact of diabetes on quality of life and mood, self-management, attitudes/beliefs, and care/support. Results: Diabetes negatively impacted the emotional well-being of 59% of people with T1 versus 45% of people with T2 (P0.05) and about half of FMs. A high level of distress was felt by about half of PWD and FMs. About half of HCPs reported assessing depression in their patients. Sixty-two percent of FMs considered managing diabetes to be a burden. Hypoglycemia was a source of concern for 64% of people with T1 and 73% of FMs of insulin users. About two-thirds of non-insulin-medicated people with T2 agreed to start insulin if prescribed, while half of HCPs preferred to delay insulin initiation. A discrepancy between HCPs’ perceptions of their interactions with their patients and PWD’s recollection of these interactions with regard to patients’ personal needs and distress was also observed. Conclusion: While distress remains under-assessed by HCPs, the negative impact of diabetes on the lives of PWD and FMs clearly induces distress on both groups. These findings provide new understanding of barriers precluding optimal management of diabetes. Developing strategies to overcome these barriers is now warranted. Keywords: health care provision, household study, psychosocial, quality of life
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This chapter examines changing approaches to health care over the last 20 years and the development of a patient-centred approach. This has resulted in a recognition of the importance of those communication skills which are fundamental to person-centred counselling. The chapter explains what is involved in using a counselling approach in dietetic practice. It also introduces the communication skills and approaches to psychotherapy and counselling which are used in the book. It concludes with an overview of the current research evidence concerning the use of communication skills by dietitians.
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Objective In a sample of adults with type 2 diabetes mellitus (T2DM), the aim of this study was to examine whether self-reported physical activity level is associated with recall of specific physical activity-related interactions used by general practitioners (GP). Research design and methods Adults with T2DM completed an online survey reporting physical activity behaviors and recall of 14 GP–patient interactions about physical activity, mapped onto discrete behavior change techniques (BCT). Stepped logistical regression examined associations between recommended physical activity (≥600 MET-min/week) and GP–patient interactions, controlling for body mass index, diabetes-related comorbidities, depressive symptoms and self-efficacy. Results In total, 381 respondents (55% men, mean±SD age: 62±10 years and T2DM duration 8±8 years) provided complete data. Most (73%) reported receiving ‘general advice’, while interactions related to goal setting, monitoring, and relapse prevention were least commonly reported (all <20%). Self-reported achievement of the recommended physical activity level was significantly associated with recall of GP interactions involving praise for ‘efforts to be active’ (OR 2.1; 95% CI 1.24 to 3.53), ‘lost weight’ (OR 1.81; 95% CI 1.05 to 3.12) or lowering ‘glucose levels as a result of being active’ (OR 1.75; 95% CI 1.03 to 2.96). Conclusions Findings suggest GPs can be somewhat effective in promoting physical activity with simple, positive, reinforcing messages/interactions. Future research to develop and evaluate very brief primary care BCT-based physical activity interventions is needed.
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Limitations in health literacy have been projected to cost the United States economy between $106 billion and $238 billion annually (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007), in addition to being associated with worse health care outcomes (Berkman, Sheridan, Donahue, Halpern & Crotty, 2011). Health literacy scores are independently associated with household income, and with lower scores associated with decreased income (Rikard, Thompson, McKinney, & Beauchamp, 2016). Unfortunately, people in the bottom 5th percentile of a country's income distribution have a life expectancy that is 25% shorter than those in the top 5th percentile (Cutler, Deaton, & Lleras-Muney, 2006). Therefore, it is critical for health care providers to understand the health effects of social and economic policies that affect not only individual people, but the communities in which they live (Marmot, 2005).
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Starting to Use An Insulin PumpAdditional Pump FunctionsLearning How to Manage Pump TherapyDeveloping A Training PlanConclusion References
Article
Many people living with Chronic Obstructive Pulmonary Disease (COPD) have low general health literacy; however, there is little information available on these patients’ eHealth literacy, or their ability to seek, find, understand, and appraise online health information and apply this knowledge to address or solve disease-related health concerns. A nationally representative sample of patients registered in the COPD Foundation’s National Research Registry (N = 1,270) was invited to complete a web-based survey to assess socio-demographic (age, gender, marital status, education), health status (generic and lung-specific health-related quality of life), and socio-cognitive (social support, self-efficacy, COPD knowledge) predictors of eHealth literacy, measured using the 8-item eHealth literacy scale (eHEALS). Over 50% of the respondents (n = 176) were female (n = 89), with a mean age of 66.19 (SD = 9.47). Overall, participants reported moderate levels of eHealth literacy, with more than 70% feeling confident in their ability to find helpful health resources on the Internet. However, respondents were much less confident in their ability to distinguish between high- and low-quality sources of web-based health information. Very severe versus less severe COPD (β = 4.15), lower lung-specific health-related quality of life (β = −0.19), and greater COPD knowledge (β = 0.62) were significantly associated with higher eHealth literacy. Higher COPD knowledge was also significantly associated with greater knowledge (ρ = 0.24, p = .001) and use (ρ = 0.24, p = .001) of web-based health resources. Findings emphasize the importance of integrating skill-building activities into comprehensive patient education programs that enable patients with severe cases of COPD to identify high-quality sources of web-based health information. Additional research is needed to understand how new social technologies can be used to help medically underserved COPD patients benefit from web-based self-management support resources.
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Key pointsRationaleIntroductionLearning stylesEducation theoriesCommunication – the central element of effective teaching and learningTeaching: an art and a processHealth literacySurvival skillsSample diabetes education record chartEmpowermentSpecial issuesThe nurses' role in diabetes educationInsulin administrationGuidelines for instructing patients about insulin delivery systemsDocumenting diabetes educationExamples Instruction SheetsExample Instruction Sheet 3: How to draw up insulin – one bottle onlyExample Instruction Sheet 4: How to draw up insulin – two bottlesExample Instruction Sheet 5: How to give an insulin injection using syringes or insulin pensExample Instruction Sheet 6a: Managing your diabetes when you are ill: patients with Type 1 diabetesExample Instruction Sheet 6b: Managing your diabetes when you are ill: patients with Type 2 diabetesReferences
Article
The dictionary definition of a consultation is ?a meeting for deliberation, discussion, or decision?. In medicine, the consultation is of huge importance. It is the framework within which the doctor and patient interact, and thus forms the platform upon which everything else we do for our patients is built ? it is the cornerstone of general practice.
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Diabetes is a chronic condition that requires lifelong lifestyle and pharmacological treatment. The aims of diabetes care to improve quality of life are fourfold. Life-threatening diabetes emergencies should be effectively managed, including their prevention. The acute manifestations of hyperglycemia need to be addressed. The majority of care is directed towards minimizing the long-term complications through screening and supporting optimal glycemic control and cardiovascular risk factor management. Complications of diabetes should be managed effectively if and when they present to reduce the morbidity associated with them. Finally, iatrogenic side effects, such as hypoglycemia, should be prevented. People with diabetes should be recognized as individuals with a condition that has medical, personal, and social consequences; they are not passive recipients of healthcare and should not be defined by their disease state. Optimal diabetes care occurs when the multidisciplinary diabetes care team actively works with the person with diabetes as equal partners in diabetes management.
Article
Purpose The purpose of the paper is to explore the notion of a diabetes language restricted code or “dialect” and its effect on people with diabetes. Language is a complex phenomenon comprising verbal and nonverbal components used to communicate in human interactions. Methods Information was collected from a literature review, during clinical consultations, and from an email survey. Results Language and the way clinicians use language affect motivation, behaviors, and outcomes of people with diabetes. Language is influenced by culture, experience, and familiarity with words and their use and is idiosyncratic. “Diabetes” is a particular restricted code or dialect that people with diabetes gradually learn to speak, usually after they are diagnosed with diabetes. The diabetes dialect contains many metric and target words and very few positive, encouraging words, and it is often discriminatory, negative, judgmental, labelling, distressing, and stigmatizing: for example, victim, sufferer, and lifestyle disease. Conclusion Language codes/dialects can compound the already high levels of emotional distress and self-care burden associated with living with diabetes and can affect outcomes. The information presented in this article will be useful for clinicians caring for people with diabetes and will be helpful for professionals who develop information for people with diabetes and those who create policies and guidelines.
Article
Objectives: DAWN2 assessed the psychosocial impact of diabetes on persons with diabetes (PWDs), family members and healthcare professionals (HCPs) across 17 countries. This article reports on the Canadian cohort of PWDs. Methods: PWDs completed online, validated self-report scales assessing quality of life (QOL), self-management, beliefs, social support and priorities for improving diabetes care. Analyses used unweighted data. Results: Of 500 participants (80 type 1, 420 type 2) positive self-reported QOL was common (64.6%) and likely depression less common (12.8%). Diabetes distress, however, was identified by almost half of PWDs with type 1 diabetes, and one-quarter of PWDs with type 2 (47.5% vs. 25.7% type 2; p<0.001). Numerous life areas were negatively impacted, particularly finances, work and emotional well-being for those with type 1 diabetes (p<0.001 vs. type 2). Most PWDs reported support from family, friends and HCPs, but few reported being asked by HCPs how diabetes affected their lives. Most PWDs participated in (type 1, 90.0%; type 2, 85.7%) and valued (type 1, 84.7%; type 2, 78.1%) diabetes education. Few PWDs relied on community supports (type 1, 17.5%; type 2, 26.9%), and discrimination was not uncommon for those with type 1 (33.8% vs. 12.4% for type 2; p<0.001). Conclusions: PWDs experience psychological challenges that should be addressed within diabetes management services.
Article
Clinical data-mining (CDM) involves the conceptualization, extraction, analysis, and interpretation of available clinical data for practice knowledge-building, clinical decision-making, and practitioner reflection. Depending upon the type of data mined, CDM can be qualitative or quantitative; it is generally retrospective, but may be meaningfully combined with original data collection. Any research method that relies on the contents of case records or information systems data inevitably has limitations, but with proper safeguards these can be minimized. Among CDM's strengths however, are that it is unobtrusive, inexpensive, presents little risk to research subjects, and is ethically compatible with practitioner value commitments. When conducted by practitioners, CDM yields conceptual as well as data-driven insight into their own practice- and program-generated questions. This book covers all the basics of conducting practitioner-initiated CDM studies or CDM doctoral dissertations, drawing extensively on published CDM studies and completed CDM dissertations from multiple social work settings in the United States, Australia, Israel, Hong Kong, and the United Kingdom. In addition, it describes consulting principles to help with forging collaborative university-agency CDM partnerships.
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Insulin pump therapy is now a well-established option for treating diabetes. This method of insulin delivery offers the opportunity for people with diabetes to manage their diabetes confidently and competently to achieve good glycaemic control and a better quality of life. Using Insulin Pumps in Diabetes covers all aspects of insulin pump therapy in a clear and informative style, and is an essential guide for all health professionals involved in caring for people with diabetes using insulin pumps. Using Insulin Pumps in Diabetes explores issues such as the advantages and disadvantages of insulin pump therapy; the experiences of insulin pump users, how to set up an insulin pump service, how to set and adjust insulin doses and optimising glycaemic control. It also includes chapters on insulin pumps in pregnancy, and in babies, toddlers and young children.
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People with diabetes hold major responsibility for the day-to-day management of their chronic condition. The management that, amongst others, includes blood glucose monitoring, medication taking, diet and physical activity, aims at normalizing blood glucose levels. In many individuals, the level of glycaemia, however, frequently exceeds the recommendations. This observation, together with patients' and practitioners' reports, suggests that active self-management is suboptimal. Various reasons, both individual and environment related, contribute to the suboptimal concordance with treatment regimen. The aim of this review is to discuss some of the barriers to optimal diabetes self-management. © 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.
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To maximize disease control, patients must participate effectively in their medical care. The authors developed an intervention designed to increase the involvement of patients in medical decision making. In a 20-minute session just before the regular visit to a physician, a clinic assistant reviewed the medical record of each experimental patient with him/her, guided by a diabetes algorithm. Using systematic prompts, the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor. A randomized trial was conducted in two university hospital clinics to compare this intervention with standard educational materials in sessions of equal length. The mean pre-intervention glycosylated hemoglobin (HbA1) values were 10.6 +/- 2.1% for 33 experimental patients and 10.3 +/- 2.0% for 26 controls. After the intervention the mean levels were 9.1 +/- 1.9% in the experimental group (p less than 0.01) and 10.6 +/- 2.22% for controls. Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician. Experimental patients reported significantly fewer function limitations. The authors conclude that the intervention is feasible and that it changes patient behavior, improves blood sugar control, and decreases functional limitations.
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Background Improved blood-glucose control decreases the progression of diabetic microvascular disease, but the effect on macrovascular complications is unknown. There is concern that sulphonylureas may increase cardiovascular mortality in patients with type 2 diabetes and that high insulin concentrations may enhance atheroma formation. We compared the effects of intensive blood-glucose control with either sulphonylurea or insulin and conventional treatment on the risk of microvascular and macrovascular complications in patients with type 2 diabetes in a randomised controlled trial. Methods 3867 newly diagnosed patients with type 2 diabetes, median age 54 years (IQR 48-60 years), who after 3 months' diet treatment had a mean of two fasting plasma glucose (FPG) concentrations of 6.1-15.0 mmol/L were randomly assigned intensive policy with a sulphonylurea (chlorpropamide, glibenclamide, or. glipizide) or with insulin, or conventional policy with diet. The aim in the intensive group was FPG less than 6 mmol/L. in the conventional group, the aim was the best achievable FPG with diet atone; drugs were added only if there were hyperglycaemic symptoms or FPG greater than 15 mmol/L. Three aggregate endpoints were used to assess differences between conventional and intensive treatment: any diabetes-related endpoint (sudden death, death from hyperglycaemia or hypoglycaemia, fatal or non-fatal myocardial infarction, angina, heart failure, stroke, renal failure, amputation [of at least one digit], vitreous haemorrhage, retinopathy requiring photocoagulation, blindness in one eye,or cataract extraction); diabetes-related death (death from myocardial infarction, stroke, peripheral vascular disease, renal disease, hyperglycaemia or hypoglycaemia, and sudden death); all-cause mortality. Single clinical endpoints and surrogate subclinical endpoints were also assessed. All analyses were by intention to treat and frequency of hypoglycaemia was also analysed by actual therapy. Findings Over 10 years, haemoglobin A(1c) (HbA(1c)) was 7.0% (6.2-8.2) in the intensive group compared with 7.9% (6.9-8.8) in the conventional group-an 11% reduction. There was no difference in HbA(1c) among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p=0.029) for any diabetes-related endpoint; 10% lower (-11 to 27, p=0.34) for any diabetes-related death; and 6% lower (-10 to 20, p=0.44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p=0.0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints the three intensive agents (chlorpropamide, glibenclamide, or insulin). Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p<0.0001). The rates of major hypoglycaemic episodes per year were 0.7% with conventional treatment, 1.0% with chlorpropamide, 1.4% with glibenclamide, and 1.8% with insulin. Weight gain was significantly higher in the intensive group (mean 2.9 kg) than in the conventional group (p<0.001), and patients assigned insulin had a greater gain in weight (4.0 kg) than those assigned chlorpropamide (2.6 kg) or glibenclamide (1.7 kg). Interpretation Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.
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To maximize disease control, patients must participate effectively in their medical care. The authors developed an intervention designed to increase the involvement of patients in medical decision making. In a 20-minute session just before the regular visit to a physician, a clinic assistant reviewed the medical record of each experimental patient with him/her, guided by a diabetes algorithm. Using systematic prompts, the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor. A randomized trial was conducted in two university hospital clinics to compare this intervention with standard educational materials in sessions of equal length. The mean pre-intervention glycosylated hemoglobin (HbA1) values were 10.6±2.1% for 33 experimental patients and 10.3±2.0% for 26 controls. After the intervention the mean levels were 9.1±1.9% in the experimental group (p<0.01) and 10.6±2.22% for controls. Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician. Experimental patients reported significantly fewer function limitations. The authors conclude that the intervention is feasible and that it changes patient behavior, improves blood sugar control, and decreases functional limitations.
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Patient satisfaction is a variable of increasing interest to researchers, clinicians, and medical educators. Of several studies reviewed, only a few have shown evidence of careful methodology. Most surveys have focused on general evaluations of doctors and/or health care services or of a particular facility. The present article reports the development of a scale to measure patient satisfaction with an encounter with a physician or other primary care provider. Methods of item generation and pretesting are detailed. The overall reliability of the scale (Cronbach's coefficient alpha) is 0.93. The distribution of satisfaction scores is broader than that reported for other scales and approaches the normal in shape. Clinical and research applications of the scale are suggested.
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Full-text available
To maximize disease control, patients must participate effectively in their medical care. The authors developed an intervention designed to increase the involvement of patients in medical decision making. In a 20-minute session just before the regular visit to a physician, a clinic assistant reviewed the medical record of each experimental patient with him/her, guided by a diabetes algorithm. Using systematic prompts, the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor. A randomized trial was conducted in two university hospital clinics to compare this intervention with standard educational materials in sessions of equal length. The mean pre-intervention glycosylated hemoglobin (HbA1) values were 10.6 +/- 2.1% for 33 experimental patients and 10.3 +/- 2.0% for 26 controls. After the intervention the mean levels were 9.1 +/- 1.9% in the experimental group (p less than 0.01) and 10.6 +/- 2.22% for controls. Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician. Experimental patients reported significantly fewer function limitations. The authors conclude that the intervention is feasible and that it changes patient behavior, improves blood sugar control, and decreases functional limitations.
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The purpose of this study was to determine if participation in a patient empowerment program would result in improved psychosocial self-efficacy and attitudes toward diabetes, as well as a reduction in blood glucose levels. This study was conducted as a randomized, wait-listed control group trial. The intervention group received a six-session (one session per week) patient empowerment education program; the control group was assigned to a wait-list. At the end of 6 weeks, the control group completed the six-session empowerment program. Six weeks after the program, both groups provided follow-up data. The intervention group showed gains over the control group on four of the eight self-efficacy subscales and two of the five diabetes attitude subscales. Also, the intervention group showed a significant reduction in glycated hemoglobin levels. Within groups, analysis of data from all program participants showed sustained improvements in all of the self-efficacy areas and two of the five diabetes attitude subscales and a modest improvement in blood glucose levels. This study indicated that patient empowerment is an effective approach to developing educational interventions for addressing the psychosocial aspects of living with diabetes. Furthermore, patient empowerment is conducive to improving blood glucose control. In an ideal setting, patient education would address equally blood glucose management and the psychosocial challenges of living with diabetes.
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This study set out to identify the present and future training needs of practice nurses in South West Thames Regional Health Authority and to examine these needs within the nurses' current and changing workloads and social, educational and occupational profiles. A questionnaire was sent to 899 practice staff identified by family health services authority records whose salaries were in part reimbursed and in whose job title the word nurse appeared. The questionnaire enquired about personal and practice demography, tasks and activities currently undertaken, perceived role development and training requirements, and preferred organization of training. A total of 620 completed questionnaires were returned (69%). Nurses' work involved treatments, immunizations investigations, administration, first contact with patients, support to the general practitioner and health promotion. The areas of role development selected most commonly by nurses were counselling skills (60%) and health promotion (54%); in terms of training the most popular areas were communication skills (62%) and the theory and practice of health promotion (48%). Fewer than one third of the nurses who were engaged in health checks for elderly people or the provision of diabetes care, asthma care or advice about the human immunodeficiency virus (HIV) and the acquired immune deficiency syndrome (AIDS) held an appropriate qualification. Practice nurses in the region were engaged in a wide range of activities for which many have had little formal training; the majority wished to develop their role and undertake further training. If practice nurses are to play a key part in the development of primary care services they must be adequately prepared for their clinical and health promotion role.
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To determine whether nurses' and NIDDM patients' communication styles during consultations are related to subsequent metabolic control and to examine factors influencing patterns of communication in these consultations. A total of 47 NIDDM patients participated in the study and completed the following procedures: 1) assessment of baseline HbA1, 2) attended 3.5 days of diabetes education, 3) returned in 1 mo for a follow-up consultation with a nurse, and (4) returned in 9-12 wk for a follow-up HbA1 assessment. The communication variables coded from the consultations were the frequency with which nurses produced controlling, informative, and patient-centered utterances and the frequency with which patients sought information, engaged in decision making, and expressed negative affect. The results were as follows: 1) patients experienced poorer metabolic control after interacting with nurses who were more controlling and directive in their communication with patients (r = 0.39, P < 0.01); 2) the nurses' use of patient-centered responses was directly related to the degree to which patients expressed feelings (r = 0.34, P < 0.01) and exhibited decision-making behavior (r = 0.62, P < 0.01); and 3) several of the nurses' and patients' communicative behaviors were related to patient characteristics such as age, sex, education, and baseline HbA1 levels. The results suggest that providers' attempts to exert considerable control during consultations with NIDDM patients may be counterproductive and contribute to poorer outcomes. The findings also indicate that patient-centered behaviors (e.g., encouraging the patient's involvement, respecting the patient's opinion, and offering support) facilitate the patient's ability to be an active participant in the consultation.
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We applied the self-determination theory of human motivation to examine whether patient perceptions of autonomy supportiveness (i.e., patient centeredness) from their diabetes care providers related to improved glucose control over a 12-month period. We conducted a prospective cohort study of patients with diabetes from a diabetes treatment center at a university-affiliated community hospital. Participants were 128 patients between 18 and 80 years of age who took medication for diabetes, had no other major medical illnesses, and were responsible for monitoring their glucose and taking their medications. The main outcome measure was a change in HbA1c values over the 12 months of the study Patient perception of autonomy support from a health care provider related to a change in HbA1c values at 12 months (P < 0.05). Further analyses showed that perceived autonomy support from the staff related to significant increases in patient autonomous motivation at 12 months (P < 0.05); that increases in autonomous motivation related to significant increases in perceived competence (P < 0.05); and that increases in a patient's perceived competence related to significant reductions in their HbA1c values over 12 months (P < 0.001). The findings support the prediction of the self-determination theory that patients with diabetes whose health care providers are autonomy supportive will become more motivated to regulate their glucose levels, feel more able to regulate their glucose, and show improvements in their HbA1c values.
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To review reliability, validity, and normative data from 7 different studies, involving a total of 1,988 people with diabetes, and provide a revised version of the Summary of Diabetes Self-Care Activities (SDSCA) measure. The SDSCA measure is a brief self-report questionnaire of diabetes self-management that includes items assessing the following aspects of the diabetes regimen: general diet, specific diet, exercise, blood-glucose testing, foot care, and smoking. Normative data (means and SD), inter-item and test-retest reliability, correlations between the SDSCA subscales and a range of criterion measures, and sensitivity to change scores are presented for the 7 different studies (5 randomized interventions and 2 observational studies). Participants were typically older patients, having type 2 diabetes for a number of years, with a slight preponderance of women. The average inter-item correlations within scales were high (mean = 0.47), with the exception of specific diet; test-retest correlations were moderate (mean = 0.40). Correlations with other measures of diet and exercise generally supported the validity of the SDSCA subscales (mean = 0.23). There are numerous benefits from standardization of measures across studies. The SDSCA questionnaire is a brief yet reliable and valid self-report measure of diabetes self-management that is useful both for research and practice. The revised version and its scoring are presented, and the inclusion of this measure in studies of diabetes self-management is recommended when appropriate.
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To evaluate the efficacy of self-management education on GHb in adults with type 2 diabetes. We searched for English language trials in Medline (1980-1999), Cinahl (1982-1999), and the Educational Resources Information Center database (ERIC) (1980-1999), and we manually searched review articles, journals with highest topic relevance, and reference lists of included articles. Studies were included if they were randomized controlled trials that were published in the English language, tested the effect of self-management education on adults with type 2 diabetes, and reported extractable data on the effect of treatment on GHb. A total of 31 studies of 463 initially identified articles met selection criteria. We computed net change in GHb, stratified by follow-up interval, tested for trial heterogeneity, and calculated pooled effects sizes using random effects models. We examined the effect of baseline GHb, follow-up interval, and intervention characteristics on GHb. On average, the intervention decreased GHb by 0.76% (95% CI 0.34-1.18) more than the control group at immediate follow-up; by 0.26% (0.21% increase - 0.73% decrease) at 1-3 months of follow-up; and by 0.26% (0.05-0.48) at > or = 4 months of follow-up. GHb decreased more with additional contact time between participant and educator; a decrease of 1% was noted for every additional 23.6 h (13.3-105.4) of contact. Self-management education improves GHb levels at immediate follow-up, and increased contact time increases the effect. The benefit declines 1-3 months after the intervention ceases, however, suggesting that learned behaviors change over time. Further research is needed to develop interventions effective in maintaining long-term glycemic control.
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Self-determination theory was applied to explore the motivational basis of adherence to long-term medication prescriptions. Adult outpatients with various diagnoses who had been on a medication for at least 1 month and expected to continue (a) completed questionnaires that assessed their autonomous regulation, other motivation variables, and perceptions of their physicians' support of their autonomy by hearing their concerns and offering choice; (b) provided subjective ratings of their adherence and a 2-day retrospective pill count during an interview with a clinical psychologist; and (c) provided a 14-day prospective pill count during a subsequent, brief telephone survey. LISREL analyses supported the self-determination model for adherence by confirming that patients' autonomous motivation for adherence did mediate the relation between patients' perceptions of their physicians' autonomy support and their own medication adherence.
Article
Objective - To analyse agreement between patients' and general practitioners' perception of content of consultations. Design - Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs). Setting - General practices in the County of Funen, Denmark. Subjects - All 291 GPs in the County were invited to join the investigation, and 137 accepted. All patients who consulted the participating GPs in a 3 day period were included in the investigation. The GPs registered 6021 patients, of whom 3578 (59%) returned the completed questionnaire. Main outcome measures - GPs and patients were asked about the urgency of the consultation, number of problems presented, duration of consultation, and quality of communication. The GPs' and patients' answers were matched, and variables of agreement were made. Patients were furthermore asked about their satisfaction with the consultation. Results and conclusion - Agreement for the four matched answers varied from 69% to 83%. Disagree...
Article
BACKGROUND Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications. METHODS A total of 1441 patients with IDDM -- 726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly. RESULTS In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of ≥ 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of ≥ 300 mg per 24 hours) by 54 percent (95 percent confidence interval, 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia. CONCLUSIONS Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.
Article
Intensive insulin treatment effectively delays the onset and slows the progression of microvascular complications in insulin-dependent diabetes mellitus (IDDM). Variable adherence to insulin treatment is thought to contribute to poor glycaemic control, diabetic ketoacidosis, and brittle diabetes in adolescents and young adults with IDDM. We assessed the association between the prescribed insulin dose and the amount dispensed from all community pharmacies with the Diabetes Audit and Research in Tayside Scotland (DARTS) database.
Article
This study used a combination of quantitative and qualitative analytic approaches to examine the nature of patient participation in medical consultations. The hospital clinic interviews of 101 rheumatology outpatients were analysed using the Verbal Response Mode coding scheme. Patient participation was, in general, low throughout the consultation. In addition, high patient participation was significantly correlated with low satisfaction-with-treatment scores. Qualitative analysis of transcripts from high and low participation patients showed that increased patient participation often reflected distress, dissatisfaction with prior care, and was more common with diagnostic uncertainty on the part of the doctor. Low participation reflected low emotion content and more diagnostic certainty. The results are discussed in terms of the inconsistent and methodological difficulties in examining patient participation in the medical interview.
Article
Following the evidence from earlier research that one-to-one interventions can increase the patient's contribution to the consultation, this paper reports the results from a randomised control trial which assessed the effects of a leaflet designed to enhance patient participation in consultations. A random sample of patients (aged 16 to 74) waiting to see a general practitioner were given either an intervention leaflet, which encouraged the patient to take an active role in the consultation, or a control leaflet which gave dietary advice. The effects of the intervention were assessed by measuring length of consultation, number of questions asked by the patient, patient satisfaction score, doctor's feelings about the consultation, the change in patients' health in the 4 weeks following the consultation (measured by the SF-36 Health Survey) and the number of patient visits to a GP in the following year. The results showed that patients in the intervention group had significantly longer consultations than those in the control group and tended to ask more questions but there was no significant effect on patient satisfaction. The doctor tended to feel that he had a better understanding of patients in the intervention group. Overall there was no significant effect on SF-36 scores but, for patients under the age of 40, and for those in higher social classes the scores of patients in the intervention group improved to a significantly greater degree than did those for the control group. The intervention did not have any effect on the number of GP visits made by patients in the subsequent year. The study results show that a relatively simple leaflet can have an impact on patients' behaviour during the consultation, even though there were no effects on patient satisfaction with the consultation or in the number of GP visits in the following year.
Article
Physicians very often do not perceive themselves as being efficient in affecting patients' life style. The aim of this article is to elucidate theoretical constructs and models in health education and their practical implications for individual health counselling in daily work as a guidance for physicians. The current most commonly used strategies are giving information and exhorting people, which have a limited ability to change peoples' behaviour. Derived from current behavioural constructs and models in health education - such as the health belief model, social learning theory, health beliefs, self-efficacy, self-determination theory - principles for successful strategies are described: to use patient-centredness instead of directing, to encourage patients to reflect and decide on their behavior, to find out the patient's readiness to change, to present knowledge as neutral facts instead of valuations, to focus on the actual behaviour instead of information-giving, to highlight patients' health beliefs and to discuss the advantages and disadvantages which the patients experience with their life style. The article concludes with a comprehensive model for individual health counselling in consecutive steps.
Article
Self-determination theory was applied to explore the motivational basis of adherence to long-term medication prescriptions. Adult outpatients with various diagnoses who had been on a medication for at least 1 month and expected to continue (a) completed questionnaires that assessed their autonomous regulation, other motivation variables, and perceptions of their physicians' support of their autonomy by hearing their concerns and offering choice; (b) provided subjective ratings of their adherence and a 2-day retrospective pill count during an interview with a clinical psychologist; and (c) provided a 14-day prospective pill count during a subsequent, brief telephone survey. LISREL analyses supported the self-determination model for adherence by confirming that patients' autonomous motivation for adherence did mediate the relation between patients' perceptions of their physicians' autonomy support and their own medication adherence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objectives: To evaluate whether a course teaching flexible intensive insulin adjustment can improve both glycaemic control and quality of life in type 1 diabetes. Design: randomized design with participants either attending training immediately (immediate DAFNE) or acting as waiting list controls and attending "delayed DAFNE" training 6 months later. Setting: Secondary care diabetes clinics in three English health districts. Participants: 169 adults with type 1 diabetes and moderate or poor glycaemic control. Main outcome measures: Glycated haemoglobin (HbA 1c), severe hypoglycaemia, impact of diabetes on quality of life (ADDQoL). Results: At 6 months, HbA 1c was significantly better in immediate DAFNE patients (mean 8.4%) than in delayed DAFNE patients (9.4%) (t=6.1, P<0.0001). The impact of diabetes on dietry freedom was significantly improved in immediate DAFNE patients compared with delayed DAFNE patients (t= -5.4, P<0.0001), as was the impact of diabetes on overall quality of life (t = 2.9, P<0.01). General wellbeing and treatment satisfaction were also significantly improved, but severe hypoglycaemia, weight, and lipids remained unchanged. Improvements in "present quality of life" did not reach significance at 6 months but were significant by 1 year. Conclusion: Skills training promoting dietary freedom improved quality of life and glycaemic control in people with type 1 diabetes without worsening severe hypoglycaemia or cardiovascular risk. This approach has the potential to enable more people to adopt intensive insulin treatment and is worthy of further investigation.
Article
This paper reports a follow-up of previous meta-analysis research conducted by the author on the effects of diabetes patient education on patient outcomes. An expanded sample of studies and psychological outcome variables were added to the previously studied variables of patient knowledge, self-care behaviors (compliance and skill performance) and metabolic control. The purpose was to determine: (1) the effects of patient education on specific outcome variables; and (2) the relationships between effects of education and characteristics of the studies and/or subjects. Following an extensive literature search, a total of 82 studies were found which met the inclusion criteria for this analysis; 68% were published and 32% were unpublished. Homogeneity analyses of specific patient outcome variables yielded the following results: knowledge effects ranged from 0.49 to 1.05; self-care behavior effects from 0.17 to 0.57, with insulin injection and weight loss associated with the smallest effect sizes; metabolic control from 0.16 to 0.41; and psychological outcomes 0.27. Mean age of the subjects was negatively correlated with knowledge and cholesterol, indicating that the older the mean age of the subjects, the lower the effects of patient education on these variables. Findings of this meta-analysis on the expanded data set were consistent with the previous meta-analysis and lend support to the effectiveness of diabetes patient education in improving patient outcomes.
Article
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.
Article
A meta-analysis of the literature of controlled studies of educational and psychosocial interventions in the treatment of diabetes mellitus yielded 93 studies of 7451 patients testing the effects of eight intervention types: (1) didactic education, (2) enhanced education, (3) diet instruction, (4) exercise instruction, (5) self-monitoring instruction, (6) social learning/behavior modification, (7) counseling, and (8) relaxation training. An overall mean effect size (ES) of +0.51 +/- 0.11 was found moderate but significant (P less than 0.05) improvements for all intervention subjects. Physical outcome and knowledge gain were most affected, followed by psychological status and compliance. Diet instruction and social learning interventions showed the strongest (ES = +0.68 +/- 0.58 and ES = +0.57 +/- 0.42, respectively) and relaxation training the weakest (ES = +0.30 +/- 0.74) effects. Associations between study and sample characteristics and mean ES values were explored with type of setting and methodological weaknesses such as single group design and non-random assignment achieving statistical significance. Neither intervention type, number of visits, sex, age, nor type of diabetes were significantly correlated with mean ES values. Implications of these findings for clinical treatment and future research are discussed.
Article
The literature on nurse-patient communication is selectively reviewed. Previous research has been critical of the quality and quantity of nurse-patient communication, describing it as brief and superficial. Nurses are depicted as controlling and restricting the course and topics of conversations with patients. Communication skills training for nurses has been advocated as a solution for this apparent deficit. In this paper it is argued that research has over-emphasized nurses' roles in nurse-patient communication, particularly their communication skills. The patients' contribution to the content and organization skills. The patients' contribution to the content and organization of nurse-patient communication has been largely ignored. Assumptions have been made about nurses' and patients' intentions and motives during nurse-patient conversations, but the participants, particularly patients, are rarely asked for their views. There has been a tendency to view nurse-patient communication in terms of isolated excerpts of conversation. When environmental and organizational factors are included, it is their effect on nurses' communication capability, not the patients', that are the interest. It is suggested that future research consider both patients' and nurses' contributions to nurse-patient communication.
Article
Depth interviews were carried out with 46 people with non-insulin dependent diabetes. In the course of narrative accounts, respondents displayed their thinking about the nature of diabetes and their understandings of how one ought to respond to it. Two variations in patients′ interpretations of diabetes are discussed here: the extent to which patients primarily orientated themselves toward symptom control or toward prevention of complications, and their perceptions of the seriousness of the condition. Most patients believed diabetes to be a serious condition, which could cause complications. However, many were able to reconcile such beliefs with a less than whole-hearted adherence to medical advice about lifestyle. The analysis suggests a range of specific areas of diabetes care where patients could be more fully informed. Most importantly it describes a range of ways in which patients present their nonadherence to medical advice about lifestyle as entirely rational, given their perceptions of diabetes and its personal implications for each of them. Better understanding of such perceptions by health professionals may improve therapeutic alliances.
Article
To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes. The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed. Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable. The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes. Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.
Article
This study investigated patient and physician perceptions of their relationship and examined how their perceptions related to patient satisfaction. Data are based on 134 patient-physician interactions. Study participants included 12 physicians (five women and seven men) and 134 male patients with a diagnosis of diabetes mellitus being seen on an outpatient basis. Information on patient and physician demographics, patient's metabolic control and functional status and time spent in the interaction were also collected. Results revealed that patients with lower levels of education were most satisfied and that physicians who viewed the relationship as a patient-physician partnership had more satisfied patients than those who viewed the relationship as physician controlled. Findings also indicated that physicians' gender and number of years in practice were not related to patient satisfaction. Practical implications include: (1) increasing attention to physician's perceptions of his or her relationship with individual patients and (2) exposing newly trained physicians to partnership types of relationships, if future research confirms these findings in chronic disease management.
Article
To examine health promotion in a primary-care context, we studied perceived and actual communication in 271 consultations between general practitioners and patients in Oxford (England). Although health promotion is a term usually reserved for public-health or wellness programs, a health promotion perspective enriches the examination of communication in physician-patient interactions by emphasizing issues of empowerment, competence and control. Accordingly, we are interested in how communication during medical encounters can improve patients' abilities to exercise appropriate control over their health. A major factor in enabling patients to increase control over their health involves developing their competencies for making decisions and enacting behaviors that can lead to desired, and attainable, health outcomes. This report focuses on communication and decision making about prescription medications, since whether and how to use medications are among the most common and important decisions in which patients can participate. Five instruments were employed to collect data about physicians, patients and their consultations: a Video Analysis, which allowed assessment of actual communication behavior; a Patient Questionnaire designed to gauge perceptions of the encounter and collect demographic information; a Medical-Record Review, which provided information on utilization, diagnosis and treatment; a Telephone Interview, conducted 14 days after the consultation to obtain follow-up information (e.g. experience with the prescribed medication); and a Doctor Questionnaire that focused on attitudes toward consultations and patients. With respect to communication about prescription medications, physicians most frequently mentioned product name (78.2% of consultations) and instructions for use (86.7% of consultations). Patients were extremely passive, rarely offering their opinion or initiating discussion about any aspect of the treatment. We suggest that improving patients' decision-making competencies may require more discussion of benefits and risks, as well as discussion of patients' opinions about the prescribed medications and their abilities to follow through with the treatment plans. The research design proved useful in highlighting discrepancies between perceived and actual communication. Physicians tended to overestimate the extent to which they discussed patients' ability to follow the treatment plan, elicited patients' opinion about the prescribed medication and discussed risks of the medication. And, 24.3% of the patients left the consultation with an 'illusion of competence', a belief that important topics had been discussed when, in fact, they had not been mentioned at all. The pattern of results illustrates the complexity of health promotion in primary care, and underscores the importance of attending to both perceived and actual communication in medical encounters.
Article
For patients, treatment of diabetes involves complex changes in basic behaviors and adherence to complicated regimens. Understanding the factors that enable patients to adhere to diabetes treatment is the first step to designing effective interventions. Researchers of diabetes care have postulated that increasing diabetic patients' participation in medical decision making during the doctor visit is likely to improve their adherence to self-care. However, a critical review of the impact of patient participation on diabetic patients adherence to self-care is absent from the literature. We review the subject of patient participation in medical decision making and its effect on adherence to self-care for patients with diabetes. We introduce a model of the determinants of adherence to diabetes self-care that incorporates the effects of patient participation in medical decision making. In this model, we suggest three ways that patient participation can affect adherence to self-care: 1) it may have a direct effect; 2) it may affect adherence to self-care indirectly by affecting patients' understanding of their treatment regimen or the fit of their regimen with their lifestyle; and 3) perceived omissions of participation can affect adherence to self-care indirectly through an effect on patient satisfaction. Research is needed to identify more clearly which components of patient participation affect adherence to self-care and in what ways. Distinguishing patient and physician behaviors that contribute to the process of patient participation would provide a means to develop specific behavioral interventions.
Article
The structure and content of medical consultations concerning diabetes were examined in two, successive quarterly medical consultations between two physicians and their diabetes patients (N = 44). The consultations were audio-taped and coded for structure (e.g. question asking, information giving) using a modified version of the Roter Interactional Analysis System (inter-coder correlations typically exceeded 0.90 for the composite variables derived from the coding system). The tapes were also coded for content by monitoring the topics discussed (e.g. diet, medication, exercise). The majority of the interactions consisted primarily of information giving and positive talk on the part of both patients and providers. Nutrition-related issued, blood glucose monitoring, medication and exercise were addressed in the majority of interactions, but other regimen areas such as foot care, smoking habits, and alcohol were seldom discussed. There was little stability across the two consultations in terms of either structure (median test-retest correlation = 0.24) or content (majority of test-retest correlations were below 0.30). The importance of studying more than one patient-physician encounter when studying interaction style and content is discussed, as is the need for investigation of interactions between non-physician health care providers and patients with chronic disease.
Article
As the treatment of non-insulin-dependent diabetes mellitus (NIDDM) largely depends on self-management, patient compliance and satisfaction, diabetes-specific beliefs and fears need special consideration during medical consultations by means of effective communication. Communication patterns are likely to change through time. For that reason, the first three consultations between 18 newly referred patients with poorly controlled NIDDM and their medical specialist were videotaped. Subsequently, changes in doctor's and patients' verbal and nonverbal communication behaviours during these 54 consultations were analysed. Furthermore, an investigation was carried out to distinguish those communication behaviours most strongly related to patient satisfaction. Findings suggest that the first consultation is most important for building an effective doctor-patient relationship, the second for discussing treatment matters, and the third for addressing psychosocial issues. Further research incorporating clinical outcome measures is recommended to determine which were the behaviours with the greatest influence on patient health outcome.
Article
Intensive insulin treatment effectively delays the onset and slows the progression of microvascular complications in insulin-dependent diabetes mellitus (IDDM). Variable adherence to insulin treatment is thought to contribute to poor glycaemic control, diabetic ketoacidosis, and brittle diabetes in adolescents and young adults with IDDM. We assessed the association between the prescribed insulin dose and the amount dispensed from all community pharmacies with the Diabetes Audit and Research in Tayside Scotland (DARTS) database. We studied 89 patients, mean age 16 (SD 7) years, diabetes duration 8 (4) years, and glycosylated haemoglobin (HbA1c) 8.4 (1.9)%, who attended a teaching hospital paediatric or young-adult diabetes clinic in 1993 and 1994. The medically recommended insulin dose and cumulative volume of insulin prescriptions supplied were used to calculate the days of maximum possible insulin coverage per annum, expressed as the adherence index. Associations between glycaemic control (HbA1c), episodes of diabetic ketoacidosis, and all hospital admissions for acute complications and the adherence index were modelled. Insulin was prescribed at 48 (19) IU/day and mean insulin collected from pharmacies was 58 (25) IU/day, 25 (28%) of the 89 patients obtained less insulin than their prescribed dose (mean deficit 115 (68; range 9-246] insulin days/annum). There was a significant inverse association between HbA1c and the adherence index (R2 = 0.39; p < 0.001). In the top quartile (HbA1c > 10%), 14 (64%) of individuals had an adherence index suggestive of a missed dose of insulin (mean deficit 55 insulin days/annum). There were 36 admissions for complications related to diabetes. The adherence index was inversely related to hospital admissions for diabetic ketoacidosis (p < 0.001) and all hospital admissions related to acute diabetes complications (p = 0.008). The deterioration in glycaemic control observed in patients aged 10-20 years was associated with a significant reduction (p = 0.01) in the adherence index. We found direct evidence of poor compliance with insulin therapy in young patients with IDDM. We suggest that poor adherence to insulin treatment is the major factor that contributes to long-term poor glycaemic control and diabetic ketoacidosis in this age group.
Article
Can nurses learn to let go? Issues arising from an intervention designed to improve patients’ involvement in their own care The aim of the paper was to explore the reasons behind a perplexing observation that an intervention designed to alter professional behaviour in general practice consultations in South Wales was poorly sustained despite initial enthusiasm among the nurses. Nurses’ baseline and continuing responses to the new approach with patients with non-insulin dependent diabetes are described, drawing on observations and interviews with the 18 practice nurses in the 15 experimental practices. The nurses fell into two groups: those showing greater understanding of the principles underlying the approach and a more reflective attitude to their work; and those who adapted the simple technology provided to their usual consultation style. This variation was related to their perception of their role and their attitudes to diabetic care, especially the challenge posed by the ‘difficult patient’. They were noticeably less willing to allow the patient freedom to decide what to do once diabetic control was deteriorating according to biochemical measures. It is concluded that the failure of the nurses to sustain behaviour change over time stems from a basic dilemma, namely, what is the extent of my responsibility and how ought I to discharge it? There is scope for more research into professional perspectives on chronic care, the strategies they use to manage patients and to cope with their own feelings, and the implications of these strategies for patients.
Article
To analyse agreement between patients' and general practitioners' perception of content of consultations. Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs). General practices in the County of Funen, Denmark. All 291 GPs in the County were invited to join the investigation, and 137 accepted. All patients who consulted the participating GPs in a 3 day period were included in the investigation. The GPs registered 6021 patients, of whom 3578 (59%) returned the completed questionnaire. GPs and patients were asked about the urgency of the consultation, number of problems presented, duration of consultation, and quality of communication. The GPs' and patients' answers were matched, and variables of agreement were made. Patients were furthermore asked about their satisfaction with the consultation. Agreement for the four matched answers varied from 69% to 83%. Disagreement was observed more often in consultations where the patient's self-evaluated health was poor, the patient was female, had a chronic disease, expected a prescription or felt that the GP had little knowledge of his/her life circumstances. Agreement concerning urgency, number of problems and quality of communication was associated with a higher degree of patient satisfaction.
Article
The aim of this study was to assess the reliability and validity of three different observation-based measures of patient-centredness. The three face-valid instruments were each applied to the same sample of 55 videotaped GP consultations. Associations were explored with consultation 'input' variables (e.g. patient and doctor demographic characteristics, patient health status) and 'process' variables (e.g. consultation length). The three measures demonstrated varying levels of inter-rater reliability. Reliability was proportional to training requirements. Differences in construct validity of the three measures were evident and their concurrent validity was relatively low. Researchers must exercise caution in their choice of measurement method because of differences in how the concept of 'patient-centredness' is operationalized. Greater conceptual specificity and simplification are required for meaningful, reliable measurement. The implications for research, and for assessing the quality of individual doctors' 'interpersonal' care are discussed.
Article
One year after diagnosis, 250 patients with type 2 diabetes identified concerns related to having diabetes, in response to an open question and checklist. Their practice nurses independently reported what they believed were the patients' concerns. Nurses identified patients' main concerns in only 20% of cases. Patients' most frequent main concerns were 'fear of getting worse', 'following dietary advice' and 'damage caused by diabetes'. Nurses most frequently cited 'following dietary advice', 'illness or pain unrelated to diabetes' and 'overweight'. BMI over 25 was related to patient concerns about 'overweight' but not 'following dietary advice' nor 'taking exercise', mentioned also by people of lower weight. Only 19/106 patients with raised HbA1c levels reported concerns about high blood glucose levels. Nurse education in patient-centred care should build on the findings that patients focus more on current and future burden of symptoms and treatment than on blood glucose levels.
Article
The primary goals in treating patients with diabetes are maintaining blood glucose levels as close to normal as possible and making a relatively normal quality of life achievable. Both of these goals are influenced by a multitude of somatic and psychological factors that should be seen as building a complex network. We examined whether a mathematical model can be construed that can depict the relative significance of each factor for achieving these treatment goals. A total of 625 patients from 32 different treatment facilities were examined (224 type 1 and 401 type 2 diabetic patients) using HbA(1c) values (high-performance liquid chromatography), number of secondary illnesses, and standardized questionnaires with respect to health-related quality of life (World Health Organization Quality of Life questionnaire), coping behavior (Freiburger Illness-Coping Strategies questionnaire), diabetes-specific knowledge (Test of Diabetes-Specific Knowledge), doctor-patient relationship (Medical Interview Satisfaction Scale), and personality characteristics (Giessen Test and Assessment of Beliefs in Self-Efficacy and Optimism). The analyses were carried out by means of a structural equation model. The model proved to be valid (chi(2) = 88.5, df = 76, P = 0.16), showing a sound fit (adjusted goodness of fit [AGFI] = 0.94). It explained 62% of the variance of the quality of life and 5% of the HbA(1c) values. Subjects characterized by strong beliefs in their self-efficacy and an optimistic outlook on life were more likely to be satisfied with their doctor-patient relationships. They demonstrated more active coping behavior and proved to have a higher quality of life. Active coping behavior was the only psychological variable significant for the HbA(1c) values. It was possible to illustrate the various factors involved and their mutual dependency and significance for the treatment goals. Belief in self-efficacy and active coping behavior appear to have the greatest relevance for achieving the primary treatment goals.
Article
To evaluate the patterns and predictors of adherence in all patients with Type 2 diabetes in the community receiving treatment with a single oral hypoglycaemic drug. In particular, to test the hypothesis that one tablet per day is associated with better adherence than more than one. The study design was a retrospective cohort study set in the Tayside region of Scotland (population approx. 400 000). Participants were residents of Tayside from 1 January 1993 until 31 December 1995 with at least 12 months of prescriptions of oral hypoglycaemic drugs (OHDs). The main outcome measures were adherence indices for sulphonylureas and metformin separately, adjusting for prescribing while hospitalized. Of the total 2920 subjects identified, adequate adherence (> or = 90%) was found in 31% of those prescribed sulphonylureas alone (n = 1329, median adherence = 300 days per year), and in 34% of those prescribed metformin alone (n = 528, median = 302 days per year). There