What matters to you? An observational field study of patient and care provider expectations for health care relationships.

Therapeutic connections (TC) between patients and providers are foundational to patient-centered care, which is co-produced between patients and care providers. This necessitates that we understand what patients expect from TCs, the extent to which providers know what patients expect, and what providers expect. The purpose of this study was to examine nine TC dimensions and determine which are most important to patients, which dimensions providers believe are most important to patients, and which are most important to providers. An online survey of patients (n = 388) and care providers (n = 433) was conducted in the USA in March 2021. Respondents rated the extent to which the nine TC dimensions were important to them, followed by open-ended questions to expand upon what matters. The quantitative responses were rank-ordered and rankings were compared across groups. All groups ranked "having the patient's best interest in mind no matter what" as the top expectation. Patients also ranked "caring commitment" and being "on the same page" as highly important. Providers were relatively accurate in ranking what they believed was most important to patients. Respondents affirmed the TC dimensions in the qualitative results, adding nuance and context, such as patients feeling "heard" and noting providers that go "above and beyond." Providers ranked dimensions differently for themselves, prioritizing "full presence" and "emotional support" of patients. This study is among the first to examine expectations for TC. TC could play an explanatory role in understanding variation in patient experience ratings and other outcomes.

Good therapeutic connections and patient psychological safety: A qualitative survey study.

BACKGROUND: Therapeutic connections (TCs) between patients and care providers are important for achieving desired patient outcomes. For patients, TC is associated with greater health self-efficacy, better health status, mental health status, and higher satisfaction with providers. PURPOSE: The aim of the study was to examine patients' descriptions of what signals to them they have a TC with their care provider. METHODOLOGY: We conducted an online survey of patients with a recent health care visit ( n = 1,766). This study analyzed the results of an open-ended question that asked how patients know they have a good TC with their care provider. Data were analyzed using framework analysis to determine the extent to which patient responses indicated TC dimensions. A thematic content analysis identified emergent themes. RESULTS: Of the TC dimensions, words associated with Shared Deliberation were mentioned by 60% of respondents. Other dimension mentions ranged between 14% (Shared Mind) and 2% (Bond). Thematic content analysis revealed that patient psychological safety seems to be required for many patients to feel connected. CONCLUSION: A majority of patients indicated that good TCs happen when they feel seen and heard by providers. However, it appears that prior to feeling a strong TC, patients need to feel safe to be fully welcome into the encounter. PRACTICE IMPLICATIONS: Health care organizations need to give care providers the uninterrupted time and space they need to fully connect with patients. Training about how to create a psychologically safe environment for patients should be tailored for practicing providers, leaders, and students in health care fields.

System justification theory as a foundation for understanding relations among toxic health care workplaces, bullying, and psychological safety.

BACKGROUND: Toxic work environments and bullying are rampant in health care organizations. The Joint Commission asserted that bullying is a threat to patient safety, and furthermore, it implied that bullying affects clinician psychological safety. However, after decades of trying to reduce bullying, it persists. PURPOSE: The purpose of this study was to determine if system justification (SJ) theory can help explain the persistence of bullying in health care organizations. SJ theory posits that people are motivated to justify the systems with which they are embedded, even if those systems are dysfunctional or unfair. METHOD: A cross-sectional survey of health care workers ( n = 302) was used to test a moderated mediation model to examine relations between instrumental work climate perceptions and psychological safety, as mediated by SJ and moderated by experiences of workplace bullying. RESULTS: Analysis revealed that SJ fully mediated negative relations between instrumental climate and psychological safety; because of SJ the instrumental climate no longer had a direct negative association with psychological safety. Furthermore, bullying was found to play a moderating role in the instrumental climate-SJ relationship. CONCLUSION: This study found some support for the role of SJ in perpetuating instrumental workplaces and workplace bullying in health care. PRACTICE IMPLICATIONS: Some scholars have proposed that a focus on disrupting workplace contexts that trigger SJ in workers could help break patterns of behavior that enable toxic work environments and bullying to persist.

Better outcomes through patient - Provider therapeutic connections? An exploratory study of proposed mediating variables.

BACKGROUND: Patient-provider therapeutic connections (TCs) have been theorized to enhance patient outcomes as well as care provider job satisfaction and to reduce burnout. High-quality TCs may result in better matching of health care to patient needs, and thus, better care quality and patient outcomes. For care providers, work environments that enable high-quality TCs may make the work more motivating and facilitate resilience. METHOD: We surveyed patients (n = 346) and care providers (n = 341) about their experiences of TCs, and how TCs related to outcomes. We tested parallel mediation models to examine relations. RESULTS: TCs predicted better patient health status, mental health status, and satisfaction, and predicted greater care provider job satisfaction and lower burnout. TCs were theorized to operate through two sets of mechanisms (health self-efficacy and activation for patients; meaningfulness of work and psychological safety for providers). Results revealed significant indirect associations between TCs and outcomes for both groups. CONCLUSIONS: TCs are associated with patient and provider outcomes; however, these relations appear to be explained by several mediating variables. It appears that TCs are associated with better outcomes for patients through health self-efficacy and activation, and TCs are associated with better outcomes for care providers through meaningfulness of work and psychological safety.

Patient-provider therapeutic connections to improve health care: Conceptual development and systematic review of patient measures.

BACKGROUND: The Triple Aim (improved population health, improved patient experiences, and lower costs) has influenced U.S. health care since it was introduced in 2008. With it, value-based purchasing has brought unprecedented focus on patient experience measurement. Despite having devoted extensive resources toward improving patient experiences, inconsistent improvements suggest there are some dimensions not yet being widely measured or addressed. Furthermore, a renewed focus on health disparities calls for stronger patient-provider connections in order to reduce health care inequities. PURPOSE: The aim of this study was to articulate the concept of therapeutic connections (TCs) in health care and examine existing survey measures, from the patient perspective, to learn whether they capture the TC construct. METHOD: We interviewed subject matter experts ( n = 24) and patients ( n = 22) about measuring TCs and then conducted a systematic review of quantitative measures from three databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria. RESULTS: Of 31 unique measures, none captured all of the theorized TC dimensions. Most were measures of collaboration and shared decision-making or caring. DISCUSSION: Focusing on the nature of patient-provider connections is vital because they are the backbone of most delivery models seeking to achieve the Triple Aim . Further development of the TC concept and measures is warranted to facilitate organizational and financing policies that meaningfully support widespread improvement. PRACTICE IMPLICATIONS: A focus on barriers and facilitators of TCs is needed. Without advancing our understanding of the role TCs play in care, policymakers and practitioners will be limited in their ability to make impactful changes.

Caring work environments and clinician emotional exhaustion: Empirical test of an exploratory model.

BACKGROUND: Burnout has been a chronic problem in the workplace, especially in health care. Although the literature has examined many antecedents to burnout, specific workplace practices to reduce burnout remain elusive. Nascent research has begun to examine how health care work places can become more caring for workers. Although psychological safety has been proposed as an important predictor of burnout, relations have not yet been comprehensively examined. PURPOSE: Underpinned by conservation of resources theory, we argue that a caring work environment, in which compassion and interpersonal support are key priorities, provides resources for workers, which should increase psychological safety and in turn help reduce emotional exhaustion. METHOD: To explore our proposed model, we conducted a paper-and-pencil survey of clinical health care providers working in medical units of a large acute care hospital. Response rate was 44% (n = 631). RESULTS: Analysis found support for a moderated-mediation model in which psychological safety partially mediated relations between caring climate and emotional exhaustion, and this effect was stronger for those who were less empowered in their jobs. CONCLUSION: Our findings suggest that a caring work environment holds psychological resources that may help buffer against resource losses through increased psychological safety. PRACTICAL IMPLICATIONS: Although health care work environments will continue to experience constraints on key resources, worker emotional exhaustion may be mitigated through a focus on systematically increasing caring and compassion in the work environment, as opposed to relying on individual workers to support one another in an uncaring workplace.

Associations Between Patient-Provider Secure Message Content and Patients' Health Care Visits.

Background:Between-visit communications can play a vital role in improving intermediate patient outcomes such as access to care and satisfaction. Secure messaging is a growing modality for these communications, but research is limited about the influence of message content on those intermediate outcomes. We examined associations between secure message content and patients' number of health care visits.Methods:Our study included 2,111 adult patients with hypertension and/or diabetes and 18,309 patient- and staff-generated messages. We estimated incident rate ratios (IRRs) for associations between taxonomic codes assigned to message content, and the number of office, emergency department, and inpatient visits.Results:Patients who initiated message threads in 2017 had higher numbers of outpatient visits (p < 0.001) compared with patients who did not initiate threads. Among patients who initiated threads, we identified an inverse relationship between outpatient visits and preventive care scheduling requests (IRR = 0.92; 95% confidence interval [CI]: 0.86-0.98) and requests for appointments for new conditions (IRR = 0.95; 95% CI: 0.92-0.99). Patients with higher proportions of request denials or more follow-up appointment requests had more emergency department visits compared with patients who received or sent other content (IRR = 1.18; 95% CI: 1.03-1.34 and IRR = 1.14; 95% CI: 1.07-1.23, respectively). We identified a positive association between outpatient visits and the proportion of threads that lacked a clinic response (IRR = 1.02; 95% CI: 1.00-1.03).Discussion:We report on the first analyses to examine associations between message content and health care visits.Conclusions:Our findings are relevant to understanding how to better use secure messaging to support patients and their care.

Are Online Patient Reviews Associated With Health Care Outcomes? A Systematic Review of the Literature.

Although online patient reviews (OPRs) are ubiquitous, there has been debate about whether OPRs are associated with measures of health care outcomes. The majority of patients search for online information about a hospital or provider before scheduling an encounter, therefore, the extent to which OPRs are valid information is important. We conducted a systematic review of the literature to examine the extent to which OPRs are associated with measures of patient experience, clinical quality, and other outcomes. We searched Medline, CINAHL, Web of Science, and PsycInfo, which yielded 32 studies. There were consistent positive correlations between OPRs and patient experience at both the organization and individual provider levels of analysis. However, associations between OPRs and quality measures were mixed. Organizational level OPRs may be more reliable than individual provider OPRs. In addition, the strength of association could be affected by the type of encounter setting, specialty, and specific measures.

Patient and Clinician Characteristics Associated With Secure Message Content: Retrospective Cohort Study.

BACKGROUND: Good communication has been shown to affect patient outcomes; however, the effect varies according to patient and clinician characteristics. To date, no research has explored the differences in the content of secure messages based on these characteristics. OBJECTIVE: This study aims to explore characteristics of patients and clinic staff associated with the content exchanged in secure messages. METHODS: We coded 18,309 messages that were part of threads initiated by 1031 patients with hypertension, diabetes, or both conditions, in communication with 711 staff members. We conducted four sets of analyses to identify associations between patient characteristics and the types of messages they sent, staff characteristics and the types of messages they sent, staff characteristics and the types of messages patients sent to them, and patient characteristics and the types of messages they received from staff. Logistic regression was used to estimate the strength of the associations. RESULTS: We found that younger patients had reduced odds of sharing clinical updates (odds ratio [OR] 0.77, 95% CI 0.65-0.91) and requesting prescription refills (OR 0.77, 95% CI 0.65-0.90). Women had reduced odds of self-reporting biometrics (OR 0.78, 95% CI 0.62-0.98) but greater odds of responding to a clinician (OR 1.20, 95% CI 1.02-1.42) and seeking medical guidance (OR 1.19, 95% CI 1.01-1.40). Compared with White patients, Black patients had greater odds of requesting preventive care (OR 2.68, 95% CI 1.30-5.51) but reduced odds of requesting a new or changed prescription (OR 0.72, 95% CI 0.53-0.98) or laboratory or other diagnostic procedures (OR 0.66, 95% CI 0.46-0.95). Staff had lower odds of sharing medical guidance with younger patients (OR 0.83, 95% CI 0.69-1.00) and uninsured patients (OR 0.21, 95% CI 0.06-0.73) but had greater odds of sharing medical guidance with patients with public payers (OR 2.03, 95% CI 1.26-3.25) compared with patients with private payers. Staff had reduced odds of confirming to women that their requests were fulfilled (OR 0.82, 95% CI 0.69-0.98). Compared with physicians, nurse practitioners had greater odds of sharing medical guidance with patients (OR 2.74, 95% CI 1.12-6.68) and receiving prescription refill requests (OR 3.39, 95% CI 1.49-7.71). Registered nurses had greater odds of deferred information sharing (OR 1.61, 95% CI 1.04-2.49) and receiving responses to messages (OR 3.93, 95% CI 2.18-7.11) than physicians. CONCLUSIONS: The differences we found in content use based on patient characteristics could lead to the exacerbation of health disparities when content is associated with health outcomes. Disparities in the content of secure messages could exacerbate disparities in patient outcomes, such as satisfaction, trust in the system, self-care, and health outcomes. Staff and administrators should evaluate how secure messaging is used to ensure that disparities in care are not perpetuated via this communication modality.