Nurses' experiences of communicating respect to patients: Influences and challenges.

BACKGROUND: Respectful care is central to ethical codes of practice and optimal patient care, but little is known about the influences on and challenges in communicating respect. RESEARCH QUESTION: What are the intra- and inter-personal influences on nurses' communication of respect? RESEARCH DESIGN AND PARTICIPANTS: Semi-structured interviews with 12 hospital-based UK registered nurses were analysed using interpretative phenomenological analysis to explore their experiences of communicating respect to patients and associated influences. ETHICAL CONSIDERATIONS: The study was approved by the Institutional ethics board and National Health Service Trust. FINDINGS: Three interconnected superordinate themes were identified: 'private self: personal attitudes', 'outward self: showing respect' and 'reputational self: being perceived as respectful'. Respectful communication involved a complex set of influences, including attitudes of respect towards patients, needs and goals, beliefs around the nature of respectful communication, skills and influencing sociocultural factors. A tension between the outward self as intended and perceived presented challenges for nurses' reputational self as respectful, with negative implications for patient care. DISCUSSION: The study offers an in-depth understanding of intra- and inter-personal influences on communicating respect, and sheds light on challenges involved, helping provide practical insights to support respectful care. CONCLUSION: Findings stress the need for improved conceptualisations of respect in healthcare settings to formally recognise the complex attitudinal and socially constructed nature of respect and for appropriate professional training to improve its communication.

Cancer patients' respect experiences in relation to perceived communication behaviours from hospital staff: analysis of the 2012-2013 National Cancer Patient Experience Survey.

PURPOSE: Respect experiences are poorly understood despite respect being central to professionalism in health care and patient well-being, and needed for optimal patient care. This study explores which patient-perceived communication behaviours from hospital staff contribute most to cancer patients' respect experiences and account for variation in their experience by socio-demographic and clinical characteristics. METHODS: We present a secondary analysis of data from the 2012-2013 National Cancer Patient Experience Survey of 45,191 patients with a primary cancer diagnosis treated in English National Health Service trusts providing adult acute cancer services who provided data on experienced respect and dignity. RESULTS: Both autonomy-supportive and caring/emotionally sensitive behaviours were associated with reported respect, although the latter showed stronger associations and accounted for most differences in reports of respect between patient groups. Differences in respect were found by gender, race/ethnicity, age, the presence of long-standing conditions, treatment response, time since first treated for cancer (p < .001), employment and type of cancer (p < .05). CONCLUSIONS: The study questions the tendency to conceptualise respect primarily in terms of autonomy-supportive behaviours and shows the relative contribution of autonomy-supportive and caring/emotionally sensitive behaviours in explaining disparities in respect experiences. More attention should be paid to affective communication behaviours from hospital staff to reduce disparities in respect experiences.

Differential effects of single and double parental death on child emotional functioning and daily life in South Africa.

There is a high level of orphaning in Africa due to war, violence, and more recently HIV and AIDS. This study examines parental death in South African children and examines the differential impact on child functioning of double, single and non-orphanhoods. Bereavement, depression, behavior problems, and violence were examined in a consecutive sample of 381 children/adolescents (51.2% girls) between 8 and 19 years of age (M = 12.8). Parental death experience was high; 70 (17.5%) reported the death of one parent, and a further 24 (6%) reported the death of both. Group comparisons showed double orphans had elevated depression, worse psychosocial functioning, were more likely to be kept home from school for household chores, and were more likely to be slapped. Single orphans were more similar to the non-orphans than the double orphans on most scores. Our study reveals that parental loss should be studied with more fine-grained definitions and that emotional sequelae should be addressed.

Behavioral surveillance study: sexual risk taking behaviour in UK HIV outpatient attendees.

This study aimed to determine demographic, behavioural and self-report disease/treatment variables among HIV-infected individuals (n = 666) that predict unprotected intercourse with a partner of unknown/discordant status. Sexual risk behaviour was reported by 12.8%. In multivariable analysis, risk was more likely to be reported by gay men compared to women or heterosexual men, and for those with higher psychological symptom burden. Psychological symptoms should be assessed and managed in the HIV outpatient setting to ensure integrated care that enhances prevention.

What factors are associated with patient self-reported health status among HIV outpatients? A multi-centre UK study of biomedical and psychosocial factors.

Patient self-reported outcomes are increasingly important in measuring disease, treatment and care outcomes. It is unclear what constitutes well-being using a combined biomedical and psychosocial approach for patients with antiretroviral therapy (ART) access. This study aimed to determine the variance within the visual analogue scale (VAS) measure of health status using the existing five dimensions of the EuroQOL-5D, to identify which domains have the greatest effect on self-reported health status and to identify associations with the VAS using both biomedical and psychosocial factors among HIV outpatients. Consecutive patients in five UK clinics were recruited to a cross-sectional survey, n=778 (86% response rate). Patients self-completed validated measures, with treatment variables extracted from file. On the EuroQOL-5D, nearly one-third (28.1%) had mobility problems, one-fifth (18.7%) self-care problems, one-third (37.4%) difficulty in performing usual tasks and one-half (44.4%) reported pain/discomfort. In the regression model to determine associations with self-reported health status (VAS score), neither CD4 count nor ART status was associated with the outcome. However, in addition to four dimensions of the EuroQOL-5D, poorer health status was associated with worse physical symptom burden, treatment optimism and psychological symptoms. There is a relatively high prevalence of psychological morbidity and poor physical function, and these burdens of disease are associated with worse self-reported health status. As HIV management focuses on treatment for extended survival and a chronic model of disease, clinical attention to physical and psychological dimensions of patient care are essential to achieve optimal well-being.

Respect for a young male with and without a hearing aid: a reversal of the "hearing-aid effect" in medical and non-medical students?

OBJECTIVE: To investigate, in line with the "hearing-aid effect", whether medical students would have less respect for a young male with a hearing aid than without when he was described as either respectworthy (i.e. as deserving respect) or non-respectworthy, and whether their attitudes differed from non-medical students. The interaction between the presence/absence of a hearing aid and respectworthiness on respect level was also explored. DESIGN: Participants were shown a photograph and a written description of a young male. They were pseudo-randomly assigned to one of four core conditions reflecting the presence or absence of a hearing aid and the young man's respectworthiness, and completed questions regarding their behaviours, beliefs, and feelings of respect towards him. STUDY SAMPLE: One hundred and eighty-one medical students and a control group of 92 non-medical students. RESULTS: Results showed more respect for the young male with a hearing aid than without from female participants, and for the young male described as respectworthy compared to non-respectworthy in medical and in non-medical students. However, medical students had more respect for the young male with and without a hearing aid than non-medical students. CONCLUSIONS: Findings were contrary to the "hearing-aid effect". Possible explanations are given and implications are discussed.

Gender and mental health aspects of living with HIV disease and its longer-term outcomes for UK heterosexual patients.

Gender is important in the experience of illness generally and HIV specifically. In this study the authors compare 183 HIV positive women with 76 HIV positive heterosexual men attending United Kingdom HIV clinics on clinical, treatment, and mental health factors. Participants completed a questionnaire on mental health and HIV-related factors. Laboratory measures of HIV viral load and CD4 cell count were obtained at baseline and 6-18 months later. After adjusting for age, employment, and treatment status, men were significantly less likely than women to suffer from high psychological [adjusted odds ratio (OR) = 0.38, 95% confidence interval (CI): 0.17, 0.86] and global symptom distress (adjusted OR = 0.42, 95% CI: 0.19, 0.92). However, men were more likely than women to report having suicidal thoughts (adjusted OR = 1.85, 95% CI: 0.95, 3.58). Relational, sexual behavior, and quality of life factors were similar for men and women. Adherence levels did not differ by gender but were sub-optimal in 56% of patients. Men had significantly lower CD4 counts than women at baseline, but not at follow-up. No differences were observed in the proportions with viral suppression. The groups had generally similar HIV experiences with high psychological distress. Adherence monitoring and gender appropriate psychological support are needed for these groups.

Influence of patients' self-respect on their experience of feeling respected in doctor-patient interactions.

The study aimed to investigate the effect of patients' self-respect on their experience of feeling respected in doctor-patient interactions. It also explored influences of different behaviours of doctors on patients' experience of feeling respected. Forty-five participants were invited to identify with either a respect worthy or non-respect worthy self-description in random order and subsequently, to watch a series of ten video clips of doctor-patient interactions, while imagining they were the patients depicted. The video clips were designed to illustrate five behaviours of doctors that varied in terms of respectfulness. After watching each one, participants indicated how respected they felt on a visual analogue scale. Results showed a significant main effect of self-description on participants' feelings of being respected. Differences between the effects of doctors' behaviours on participants' feelings of being respected were also observed. The study thus showed that patients' self-respect is likely to have an impact on how respected they feel when interacting with their doctor. Implications of this for the quality of the doctor-patient relationship and patient health outcomes are raised. Implications of the respect shown by doctors are also discussed.

HIV and depression--a systematic review of interventions.

HIV-positive individuals are more likely to be diagnosed with major depressive disorder than HIV-negative individuals. Depression can precede diagnosis and be associated with risk factors for infection. The experience of illness can also exacerbate depressive episodes and depression can be a side effect to treatment. A systematic understanding of which interventions have been tested in and are effective with HIV-seropositive individuals is needed. This review aims to provide a comprehensive understanding of evaluated interventions related to HIV and depression and provide some insight on questions of prevalence and measurement. Standard systematic research methods were used to gather quality published papers on HIV and depression. From the search, 1015 articles were generated and hand searched resulting in 90 studies meeting adequacy inclusion criteria for analysis. Of these, 67 (74.4%) were implemented in North America (the US and Canada) and 14 (15.5%) in Europe, with little representation from Africa, Asia and South America. Sixty-five (65.5%) studies recruited only men or mostly men, of which 31 (35%) recruited gay or bisexual men. Prevalence rates of depression ranged from 0 to 80%; measures were diverse and rarely adopted the same cut-off points. Twenty-one standardized instruments were used to measure depression. Ninety-nine interventions were investigated. The interventions were diverse and could broadly be categorized into psychological, psychotropic, psychosocial, physical, HIV-specific health psychology interventions and HIV treatment-related interventions. Psychological interventions were particularly effective and in particular interventions that incorporated a cognitive-behavioural component. Psychotropic and HIV-specific health psychology interventions were generally effective. Evidence is not clear-cut regarding the effectiveness of physical therapies and psychosocial interventions were generally ineffective. Interventions that investigated the effects of treatments for HIV and HIV-associated conditions on depression generally found that these treatments did not increase but often decreased depression. Interventions are both effective and available, although further research into enhancing efficacy would be valuable. Depression needs to be routinely logged in those with HIV infection during the course of their disease. Specific data on women, young people, heterosexual men, drug users and those indiverse geographic areas are needed. Measurement of depression needs to be harmonized and management into care protocols incorporated.

A systematic review of interventions for anxiety in people with HIV.

People with human immunodeficiency virus (HIV) show elevated anxiety levels compared to the general population. Anxiety can predate HIV infection or be triggered by HIV diagnosis and the many stresses that emerge during the course of HIV disease. Many psychological and pharmacological therapies have been shown to treat anxiety in the general population but a systematic understanding of which interventions have been tested in and are effective with HIV-seropositive individuals is needed. This review examines all published intervention studies on anxiety and HIV from 1980 to 2009 covered by the databases MedLine (1980-2009) and PsycINFO (1980-2009) for a definitive account of effectiveness of interventions and an indication of prevalence of HIV-related anxiety and measurement within studies. Standard systematic research methods were used to gather quality published papers on HIV and anxiety, searching published data bases according to quality inclusion criteria. From the search, 492 papers were generated and hand searched resulting in 39 studies meeting adequacy inclusion criteria for analysis. Of these, 30 (76.9%) were implemented in North America (the USA and Canada), with little representation from developing countries. Thirty-three (84.6%) studies recruited only men or mostly men. A total of 50 interventions were investigated by the 39 studies; 13 targeted HIV, symptoms or associated outcomes/conditions, 20 directly targeted anxiety and another 17 indirectly targeted anxiety. Twenty-four (48%) interventions were effective in reducing anxiety (including 11 indirect interventions), 16 (32%) were ineffective and 10 (20%) had an unknown effect on anxiety. Sixty-five percent of interventions directly targeting anxiety were effective. Psychological interventions (especially cognitive behavioural stress management interventions and cognitive behavioural therapy) were generally more effective than pharmacological interventions. Only three studies provided prevalence rates - these ranged from 13% to 80%. Anxiety was measured using 16 different instruments. Our detailed data suggest that interventions are both effective and available, although further research into enhancing efficacy would be valuable. Also, the vast majority of studies were Western-based, no studies looked at children or adolescents and few looked specifically at women. An international effort to harmonise measurement of anxiety is also missing. There is a need to routinely log anxiety in those with HIV infection during the course of their disease, to provide specific data on women, young people and those in diverse geographic areas and incorporate management into care protocols.

HIV infection and mental health: suicidal behaviour--systematic review.

Suicide has long been associated with serious illness generally and HIV specifically. New treatments have affected prognosis in HIV positively, but it is unclear how they impact on suicidal burden (thoughts, self-harm and completions). This review examines all published suicide and HIV data for a definitive account of (1) prevalence of HIV-related suicidality, (2) measurement within studies and (3) effectiveness of interventions. Standard systematic research methods were used to gather quality published papers on HIV and suicide, searching published databases according to quality inclusion criteria. From the search, 332 papers were generated and hand searched resulting in 66 studies for analysis. Of these, 75% were American/European, but there was representation from developing countries. The breakdown of papers provided 12, which measured completed suicides (death records), five reporting suicide as a cause of attrition. Deliberate self-harm was measured in 21, using 22 instruments; 16 studies measured suicidal ideation using 14 instruments, suicidal thoughts were measured in 17, using 15 instruments. Navigating the diverse range of studies clearly points to a high-suicidal burden among people with HIV. The overview shows that autopsy studies reveal 9.4% of deceased HIV+ individuals had committed suicide; 2.4% HIV+ study participants commit suicide; approximately 20% of HIV+ people studied had deliberately harmed themselves; 26.9% reported suicidal ideation, 28.5% during the past week and 6.5% reported ideation as a side effect to medication; 22.2% had a suicide plan; 19.7% were generally "suicidal" (11.7% of people with AIDS, 15.3% at other stages of HIV); 23.1% reported thoughts of ending their own life; and 14.4% expressed a desire for death. Only three studies recruited over 70% female participants (39 studies recruited over 70% men), and six focussed on injecting drug users. Only three studies looked at interventions - predominantly indirect. Our detailed data suggest that all aspects of suicide are elevated and urgently require routine monitoring and tracking as a standard component of clinical care. There is scant evidence of direct interventions to reduce any aspect of suicidality, which needs urgent redress.

HIV infection associated post-traumatic stress disorder and post-traumatic growth--a systematic review.

The phenomenon of post-traumatic stress has been well documented in the literature as a lasting mental health condition associated with exposure to traumatic life events. The diagnosis and experience of human immunodeficiency virus (HIV) disease may be such a trauma. On the other hand, the phenomenon of post-traumatic growth (PTG) has been described, whereby people show positive mental health growth in the face of such trauma. This systematic review was set out to explore post-traumatic stress disorder (PTSD) and PTG in people with HIV to monitor prevalence, measurement and efficacy of interventions to reduce stress and/or promote growth. Standardised review techniques were used to track reports on both PTSD and PTG. A total of 206 papers were retrieved from the PTSD and HIV searches, and 13 from the PTG and HIV searches. After reviewing the papers for inclusion according to adequacy and relevance criteria and to remove duplicates, 33 PTSD papers and three PTG were available for full coding. Prevalence of PTSD in HIV ranged from 5% to 74%, which were much greater than the 7-10% in the general population. Seven studies showed a relation between trauma and PTSD, while six showed a link between PTSD diagnosis and reduced antiretroviral treatment adherence. Women were more likely to be diagnosed with PTSD. Only three intervention reports were identified that fitted our inclusion criteria. All of these reported on psychological interventions for HIV+ individuals with trauma. The interventions utilised HIV education, training in coping techniques and support groups. Only coping interventions were shown to be effective. PTG was under researched but showed a promising avenue of study. There needs to be harmonised measurement and the evidence base would need strengthening in order to build on the understanding of the impact of PTSD and PTG over the course of HIV disease. There is good evidence to associate HIV diagnosis and experiences during the course of illness as traumatic. PTSD has been shown to be prevalent and there seems to be good evidence to incorporate standardised measures to track the course of the disorder. There is extremely limited evidence that interventions may affect the course of symptom experience. The evidence and insight into PTG show promise but is currently inadequate.

Symptoms are highly prevalent among HIV outpatients and associated with poor adherence and unprotected sexual intercourse.

OBJECTIVES: There is a paucity of data reporting the prevalence and burden of pain and symptoms among HIV patients in the era of antiretroviral therapy (ART). This study aimed to measure symptom prevalence and determine associations with key variables: demographics, treatment status, adherence and risk behaviours. DESIGN: Cross-sectional self-completion questionnaire in five HIV outpatient clinics in London and the south east UK. METHODS: Consecutive patients were invited to participate, responding to clinical and behavioural variables including the memorial symptom assessment schedule (short form). Four multivariable models examined the relationship between dependent variables of psychological, physical, global symptom burden scores, the number of symptoms and key independent variables. 778 patients participated; response rate 77% of all patients approached. RESULTS: Both physical and psychological symptoms were highly prevalent: in the previous 7 days, 70.8% experienced lack of energy, 69.9% worry, 53.6% diarrhoea, 53.5% sexual dysfunction and 53.2% pain. In multivariable analysis, both unprotected sexual intercourse with a partner of unknown status, and poorer ART treatment adherence were significantly and independently associated with psychological symptom burden. Lower educational achievement was significantly associated with increasing physical, psychological and global symptom burden and with higher number of symptoms. Being on ART was not associated with any symptom distress measure. CONCLUSIONS: In the era of treatment, patients continue to experience high prevalence and burden of psychological and physical symptoms, which are not associated with treatment status. Attention to these distressing problems is essential and may enhance quality of life and adherence and minimise risk behaviour. Symptoms are highly prevalent among HIV outpatients and associated with poor adherence and unprotected sexual intercourse.

Understanding Self-Respect and Its Relationship to Self-Esteem.

The concept of self-respect has received little attention in the psychological literature and is not clearly distinguished from self-esteem. The present research sought to empirically investigate the bases of self-respect by manipulating adherence to morals together with interpersonal appraisals (IAs), or task-related competence, in hypothetical scenarios (Studies 1a and 1b) and a situation participants relived (Studies 2 and 3). Participants' levels of state self-respect and self-esteem were measured. Studies 1 to 3 found main effects of adherence to morals on self-respect, with self-respect mediating the effect of adherence to morals on self-esteem, but little support for competence and IAs directly influencing self-respect. Self-respect uniquely contributed to anticipated/felt self-esteem alongside competence or IAs. The pattern of results supports the conceptualization of self-respect as a component of self-esteem associated with morally principled conduct, distinct from performance and social self-esteem. The findings have implications for our understanding of self-esteem and moral behavior.

How Can Respectfulness in Medical Professionals Be Increased? A Complex But Important Question.

Respectfulness is demanded of doctors and predicts more positive patient health-related outcomes, but research is scarce on ways to promote it. This study explores two ways to conceptualize unconditional respect from medical students, defined as respect paid to people on the basis of their humanity, in order to inform strategies to increase it. Unconditional respect conceptualized as an attitude suggests that unconditional respect and conditional respect are additive, whereas unconditional respect conceptualized as a personality trait suggests that people who are high on unconditional respect afford equal respect to all humans regardless of their merits. One hundred and eighty-one medical students completed an unconditional respect measure then read a description of a respect-worthy or a non-respect-worthy man and indicated their respect towards him. The study found a main effect for unconditional respect and a main effect for target respect-worthiness but no interaction between the two when respect paid to the target was assessed, supporting the attitude-based conceptualization. This suggests that unconditional respect can be increased through relevant interventions aimed at increasing the relative salience to doctors of the human worth of individuals. Interventions to increase unconditional respect are discussed.

The long-term effectiveness of the International Child Development Programme (ICDP) implemented as a community-wide parenting programme.

Short-term effectiveness of the International Child Development Programme (ICDP) for parents in the general population has been studied. The aim of this paper was to investigate the longer term impact of the ICDP programme on parents looking for sustained changes 6-12 months after the programme. For this, a non-clinical caregiver group attending the ICDP programme (N = 79) and a non-attending comparison group (N = 62) completed questionnaires on parenting, psychosocial functioning, and child difficulties before, on completion and 6-12 months after the ICDP programme. Analyses compare changes in scores over time. The results revealed that the ICDP group showed significantly improved scores on parenting measures, less loneliness, and trends towards improved self-efficacy compared to the comparison group 6-12 months after programme completion. The ICDP group also reported that their children spent significantly less time on television and computer games and a trend towards fewer child difficulties. Key positive effects sustained over time but at a somewhat lower level, supporting community-wide implementation of ICDP as a general parenting programme. It is concluded that more intensive training with follow-up sessions should be considered to sustain and boost initial gains.

Student nurses' views on respect towards service users - an interpretative phenomenological study.

AIM: To explore student nurses' understanding and behaviours of respect towards patients in order to inform educational strategies to optimise respectful care. BACKGROUND: There is a causal relationship between the perception of being treated with respect and patient satisfaction. Concerns over standards of care prompted a commissioned report into the quality of nurse education in the United Kingdom. DESIGN: A hermeneutic phenomenological interview study was used to identify and interpret student nurses' behaviours and understanding of respect towards patients. SETTING: University health and social care faculty in the north-west of England, United Kingdom. PARTICIPANTS: Eight third-year student nurses (adult branch), on different university sites, with practice placements across different healthcare trusts. METHODS: Interviews about their understanding of respect and their behavioural intentions of respect towards patients were recorded and transcribed, then analysed using interpretative phenomenological analysis (IPA) to produce themes from the data. FINDINGS: Three themes of relevance to nurse education were identified. Respect is a complex concept that is difficult to apply in practice. Students are not always aware of incongruence between their feelings of respect towards patients and their behaviours towards them. Role-modelling of respectful care is variable, and essential care is often learned from healthcare assistants. DISCUSSION: Awareness of emotional responses and their relationship to patient perceptions of respect should be facilitated in theory and practice. Rehearsal of the application of respect involving emotional labour, and reflection in and on the practice of respectful care, are needed to address student learning needs. The theory-practice gap in relation to respect, variation in professional practice and the under-recognised importance of healthcare assistants in student nurse education, are barriers to the learning of respect to patients. CONCLUSIONS: Interactive education experiences are important to develop self-awareness and insight into respectful care. Mentorship in practice should encourage reflection in and on the practice of respect towards patients.

Respect in final-year student nurse-patient encounters - an interpretative phenomenological analysis.

Very little is known regarding health-care professionals' understanding and experiences of respect towards patients. The study aimed to explore student nurses' understanding and experiences of respect in their encounters with patients. Semi-structured interviews were conducted with eight final-year student nurses with practice placements across different health-care trusts in the UK. Transcripts were analysed using interpretative phenomenological analysis (IPA). Three super-ordinate themes were identified: understanding of what it means to show respect, negotiating role expectations and personal attitudes in practice, and barriers related to the performance of the nursing role. The factors identified should be investigated further and addressed as they are likely to influence patients' experiences of feeling respected in nurse-patient interactions and subsequently their well-being and health-related behaviours.

Evaluation of the International Child Development Programme (ICDP) as a community-wide parenting programme.

BACKGROUND: Many parenting programmes lack proper evaluation, especially under community-wide implementation. OBJECTIVE: Examining the effectiveness of the eight-week International Child Development Programme (ICDP), implemented as a general programme. METHODOLOGY: Non-clinical caregivers attending ICDP (N = 141) and a non-attending community comparison group (N = 79) completed questionnaires on parenting, psychosocial functioning, and child difficulties before and after ICDP course. Analyses compare changes in scores for both groups over time. RESULTS: The ICDP group showed more positive attitudes towards child management and reported better child management, improved parental strategies and less impact of child difficulties. Caregivers with low initial scores benefited most. The comparison group showed little change with a significant decrease in scores on the caregiver-child activity scale. DISCUSSION: The results suggest that caregivers in the community who do not show clinical signs or have children with behaviour or other disorders, may benefit from participating in parent training based on ICDP.