More than a feeling? What does compassion in healthcare 'look like' to patients?

OBJECTIVE: Compassion is important to patients and their families, predicts positive patient and practitioner outcomes, and is a professional requirement of physicians around the globe. Yet, despite the value placed on compassion, the empirical study of compassion remains in its infancy and little is known regarding what compassion 'looks like' to patients. The current study addresses limitations in prior work by asking patients what physicians do that helps them feel cared for. METHODS: Topic modelling analysis was employed to identify empirical commonalities in the text responses of 767 patients describing physician behaviours that led to their feeling cared for. RESULTS: Descriptively, seven meaningful groupings of physician actions experienced as compassion emerged: listening and paying attention (71% of responses), following-up and running tests (11%), continuity and holistic care (8%), respecting preferences (4%), genuine understanding (2%), body language and empathy (2%) and counselling and advocacy (1%). CONCLUSION: These findings supplement prior work by identifying concrete actions that are experienced as caring by patients. These early data may provide clinicians with useful information to enhance their ability to customize care, strengthen patient-physician relationships and, ultimately, practice medicine in a way that is experienced as compassionate by patients. PUBLIC CONTRIBUTION: This study involves the analysis of data provided by a diverse sample of patients from the general community population of New Zealand.

The Role of Beliefs and Psychological Factors in Caring of Patients With Cancer: The Lived Experiences of Informal Caregivers.

Cancer affects not only the patient but also family members as informal caregivers. In order for family caregivers to achieve balance and improve their caregiving roles, it is essential to identify the beliefs and psychological aspects affecting them. The present study was carried out qualitatively with a descriptive phenomenological design in 2020. The main participants in this study were selected from one of the major referral centers for cancer patients in West Azerbaijan Province, located in northwestern, Iran. Twenty-two family caregivers were selected through a purposive sampling method. Data analysis showed that the 3 main themes of "emotional and religious preconceptions," "feeling committed to caring for beloveds," and "resilience" played a prominent role in family caregivers. These factors led to caregivers' commitment to and responsibility for care. Holistic care necessitates consideration of all aspects of human life. The results of this study led to an understanding of the complex tendencies and feelings of family caregivers. Based on the results, it was found that care is influenced by beliefs, religious preconceptions, sociocultural, and psychological factors. Identifying these variables helps medical staff share planning, interventions, and counseling with family caregivers and address issues that affect them.

Holistic vision of the patient with chronic kidney disease in a universalistic healthcare system.

Chronic kidney disease (CKD) is an increasing public health problem. Aging is one of the leading causes, particularly in Western countries, but several comorbidities, such as hypertension and diabetes are involved in its pathogenesis. Thus, the treatment of CKD patient is very complex and requires an integrated strategy. In this context, the holistic approach to the CKD patient and not to the disease itself should be the answer. General practitioners, specialists, voluntary associations, and nonprofit organizations, in addition to the family of the patient, all contribute to the patient care. Moreover, due to the low sensitivity of creatinine values in the early stages of renal failure, its diagnosis often occurs in the advanced phases of the disease. Therefore, the health costs for CKD patients are hardly sustainable by health systems. The reorganization of economic and epidemiological data through new models is necessary to allow the sustainability of the system and to ensure medical care for all patients. In this review, we aim to deal with all the issues about patient care, standards of care, and the impact of chronicity from a global perspective in light of the current state of the Italian healthcare system.

Access and Delivery of Adult Congenital Heart Disease Care in the United States: Quality-Driven Team-Based Care.

The landscape of congenital heart disease has changed rapidly over the past few decades. The shift from pediatric to adult congenital heart disease care has stretched resources and the ability to provide high-quality access and delivery of care for the more than 1.5 million adults with congenital heart disease in the United States. Meeting the demand for delivering high-quality care requires a team-based approach, with each member highly specialized. This review describes the deficits and deficiencies in providing care for adults with congenital heart disease in the United States and a team-based approach to improving access and delivery of care.

Perceptions of isolation during facility births in Haiti - a qualitative study.

BACKGROUND: Haiti's maternal mortality, stillbirth, and neonatal mortality rates are the highest in Latin America and the Caribbean. Despite inherent risks, the majority of women still deliver at home without supervision from a skilled birth attendant. The purpose of this study was to elucidate factors driving this decision. METHODS: We conducted six focus group discussions with women living in urban (N = 14) or rural (N = 17) areas and asked them questions pertaining to their reasons for delivering at a facility or at home, perceptions of staff at the health facility, experiences with or knowledge of facility or home deliveries, and prior pregnancy experiences (if relevant). We also included currently pregnant women to learn about their plans for delivery, if any. RESULTS: All of the women interviewed acknowledged similar perceived benefits of a facility birth, which were a reduced risk of complications during pregnancy and access to emergency care. However, many women also reported unfavorable birthing experiences at facilities. We identified four key thematic concerns that underpinned women's negative assessments of a facility birth: being left alone, feeling ignored, being subject to physical immobility, and lack of compassionate touch/care. Taken together, these concerns articulated an overarching sense of what we term "isolation," which encompasses feelings of being isolated in the hospital during delivery. CONCLUSION: Although Haitian women recognized that a facility was a safer place for birthing than the home, an overarching stigma of patient neglect and isolation in facilities was a major determining factor in choosing to deliver at home. The Haitian maternal mortality rate is high and will not be lowered if women continue to feel that they will not receive comfort and compassionate touch/care at a facility compared to their experience of delivering with traditional birth attendants at home. Based on these results, we recommend that all secondary and tertiary facilities offering labor and delivery services develop patient support programs, where women are better supported from admission through the labor and delivery process, including but not limited to improvements in communication, privacy, companionship (if deemed safe), respectful care, attention to pain during vaginal exams, and choice of birth position.

Establishing a Comprehensive Aromatherapy Program in Patient Care Settings.

Since the profession began, nurses have sought to comfort through their healing presence and interventions. Clinical aromatherapy is an ancient practice finding new attention in modern-day health care to contribute to relief of symptoms of pain, anxiety and nausea. The use of complementary and integrative therapies is on the rise as clinicians and consumers seek to reduce the use of medications and the evidence-base for integrative therapies continues to expand. This article describes the development and introduction of a clinical aromatherapy program into a hospital system using a train-the-trainer model. Lessons learned from the process and future considerations are also discussed.

Evaluating Breast Cancer Care Coordination at a Rural National Cancer Institute Comprehensive Cancer Center Using Network Analysis and Geospatial Methods.

BACKGROUND: Variation in cancer care coordination may affect care quality and patient outcomes. We sought to characterize the impact of geographic access to and dispersion of cancer care providers on variation in care coordination. METHODS: Using electronic health record data from 2,507 women diagnosed with breast cancer at a National Cancer Institute Comprehensive Cancer Center from April 2011 to September 2015, a breast cancer patient-sharing physician network was constructed. Patient "care networks" represent the subnetworks of physicians with whom the focal patient had a clinical encounter. Patient care networks were analyzed to generate two measures of care coordination, care density (ratio of observed vs. potential connections between physicians), and clustering (extent to which physicians form connected triangles). RESULTS: The breast cancer physician network included 667 physicians. On average, the physicians shared patients with 12 other physicians. Patients saw an average of 8 physicians during active treatment. In multivariable models adjusting for patient sociodemographic and clinical characteristics, we observed that greater travel burden (>2 hours) and lower geographic dispersion were associated with higher care density (P < 0.05 and P < 0.001, respectively) but lower care network clustering (P < 0.05). CONCLUSIONS: Variation in network-based measures of care coordination is partially explained by patient travel burden and geographic dispersion of care. IMPACT: Improved understanding of factors driving variation in patient care networks may identify patients at risk of receiving poorly coordinated cancer care.

Blowing the whistle: Perceptions of surgical staff and medical students in a public South African hospital.

Whistleblowing is defined as raising a concern about wrong doing and has gained prominence in the UK National Health Service (NHS) following the publication of the Francis Report (the report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry) in 2013. The report revealed that lack of diligence and a reluctance to speak out about poor practice amongst staff had contributed to increased patient morbidity and mortality. In the wake of this report, a new framework was introduced by the NHS to help workers raise concerns regarding other staff and poor working practices in general. Nevertheless, it has been suggested that this new framework has not helped to increase whistleblowing or prevented staff who do raise concerns from being penalised. Furthermore, it has been claimed that such implementations will encourage defensive medicine and reduce the willingness of staff to report concerns, despite the important role of whistleblowing in helping to prevent catastrophic events and improve care. Further research is required to understand why healthcare professionals are reticent regarding whistleblowing. Moreover, while some research in the nursing and allied health community exists, this study is important as it adds to the limited evidence amongst medical students and staff in general.

Regionalization and Its Alternatives.

This article begins by introducing the historical background surrounding the volume-outcomes relationship literature, particularly in complex cancer surgery. The state of evidence surrounding mortality, as well as other outcomes, in relation to both hospital and surgeon procedure volume is synthesized. Where it is understood, the level of adoption of regionalization of various complex surgeries in the United States is also presented. Various controversies are weighed and discussed. Finally, various models of regionalization and proposed alternatives to regionalization from the peer-reviewed literature are presented.

Evaluating Integrative Cancer Clinics With the Claim Assessment Profile: An Example With the InspireHealth Clinic.

BACKGROUND: The evaluation of freestanding integrative cancer clinical programs is challenging and is rarely done. We have developed an approach called the Claim Assessment Profile (CAP) to identify whether evaluation of a practice is justified, feasible, and likely to provide useful information. OBJECTIVES: A CAP was performed in order to (1) clarify the healing claims at InspireHealth, an integrative oncology treatment program, by defining the most important impacts on its clients; (2) gather information about current research capacity at the clinic; and (3) create a program theory and path model for use in prospective research. STUDY DESIGN/METHODS: This case study design incorporates methods from a variety of rapid assessment approaches. Procedures included site visits to observe the program, structured qualitative interviews with 26 providers and staff, surveys to capture descriptive data about the program, and observational data on program implementation. RESULTS: The InspireHealth program is a well-established, multi-site, thriving integrative oncology clinical practice that focuses on patient support, motivation, and health behavior engagement. It delivers patient-centered care via a standardized treatment protocol. There arehigh levels of research interest from staff and resources by which to conduct research. CONCLUSIONS: This analysis provides the primary descriptive and claims clarification of an integrative oncology treatment program, an evaluation readiness report, a detailed logic model explicating program theory, and a clinical outcomes path model for conducting prospective research. Prospective evaluation of this program would be feasible and valuable, adding to our knowledge base of integrative cancer therapies.

Creation of a certification requirement for pharmacists in direct patient care roles.

PURPOSE: Steps taken by a large health system to require certification for all pharmacists in direct patient care roles are detailed. SUMMARY: Major supply chain changes and rising payer expectations are reshaping pharmacy practice, resulting in expanded responsibilities for pharmacists and a heightened need for certification in specialized practice areas. In response, the pharmacy leadership team at UW Health, the integrated health system of the University of Wisconsin-Madison, used an iterative process and a "rolling" FAQ format to develop and implement a certification requirement. Key decisions during the process included decisions to accept only rigorous certifications (mainly those offered by the Board of Pharmacy Specialties), to provide institutional support for continuing education-based recertification, and to use an accepted definition of direct patient care in determining which pharmacists need to be certified. The team obtained the support of the UW Health human relations department by drafting a policy and rewriting all pharmacist position descriptions to incorporate the certification requirement. An all-pharmacist forum was held to build staff commitment. As a result of the requirement, 73 pharmacists were required to obtain certification by 2018 at a total cost to UW Health of $44,000; ongoing support of certification maintenance will cost an estimated $40,000 per year. CONCLUSION: Health systems can be successful in establishing uniform certification expectations for pharmacists in direct patient care roles, even across diverse practice settings, by aligning expectations with organizational goals.

Aspectos metodológicos de los procesos asistenciales integrados (PAI) / Methodological aspects of integrated care pathways

Un proceso asistencial integrado (PAI) es una herramienta cuyo propósito es aumentar la efectividad de las actuaciones clínicas a través de una mayor coordinación y garantía de continuidad asistencial. Los PAI sitúan al paciente como el eje central de la organización asistencial. Se definen como el conjunto de actividades que realizan los proveedores de la atención sanitaria con la finalidad de incrementar el nivel de salud y el grado de satisfacción de la población que recibe los servicios. La elaboración de un PAI precisa analizar el flujo de actividades, la interrelación entre profesionales y dispositivos asistenciales y las expectativas del paciente. En este artículo se presenta y se discute la metodología para la elaboración de un PAI, así como los factores de éxito para su definición y su efectiva implantación. Se explica también, a modo de ejemplo, el reciente PAI para hipoglucemias en personas con diabetes mellitus tipo 2 elaborado por un equipo multidisciplinar y avalado por varias sociedades científicas (AU)

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies (AU)

When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out": justification of disrespectful and abusive care during childbirth among midwifery students in Ghana.

Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation. Key Messages •Midwifery students in Ghana's public midwifery schools report witnessing and participating in many forms of disrespect and abuse during deliveries as part of their education. While they are clear as to why respectful care is important and necessary, they are able to justify and explain reasons for disrespectful and abusive care. This poor treatment of labouring women was explicitly and tacitly supported by these students' teachers and preceptors. •All study materials and methods were reviewed and approved by the Ghana Health Service Ethical Review Committee, the Kwame Nkrumah University of Science and Technology Committee on Publication and Human Ethics, and the University of Michigan Institutional Review Board. •This research was made possible through a grant from the African Studies Center, University of Michigan. For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana's regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data. While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse. Although midwifery students in Ghana's public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.

[The Need of a New Integral Approach to the Care of Patient with Severe Mental Disorder Thirty Years after the Psychiatric Reform]. / Necesidad de un nuevo enfoque en la atención integral a los pacientes con trastorno mental grave treinta años después de la reforma psiquiátrica.

More than thirty years have passed since the beginning of the psychiatric reform, a period of intense and relevant social, scientific and cultural changes which have directly impacted on mental disorders and their management. Improvement in psychopharmacological treatment, a new model of physician-patient relationship, patient´s empowerment as a key issue and the fight against social stigma related to mental health disorders, changes in clinical governance and health policy, the assistential burden derived from the treatment of less severe pathology in mental health community centers, improvements in teamwork and coordination with other resources involved… are some of the relevant changes which determine the scene of community-based mental health assistance. We think this is a right time to check the state of the community-based care programmes for severe mental disorders, and the role of mental health center. We propose to have a reflexion about two relevant topics: where we are and where we are heading.

Han pasado más de 30 años desde el inicio de los procesos de reforma psiquiátrica, periodo además de importantes e intensos cambios sociales, científicos y culturales que afectan de manera directa a la enfermedad mental grave y a su manejo. Las mejoras del tratamiento farmacológico, un nuevo modelo de relación médico-paciente, el empoderamiento del paciente como elemento clave y la lucha contra el estigma social de la enfermedad, los cambios en la gestión de los recursos, el incremento de la carga que suponen los pacientes con patología menor en los centros de salud mental, las mejoras en el trabajo en equipo y en la coordinación de los recursos implicados… son algunas de las modificaciones importantes que condicionan el escenario de la atención en salud mental comunitaria. Se nos antoja, por tanto, como un buen momento para revisar el estado de los programas de gestión del trastorno mental grave en el adulto y de los centros de salud mental, y plantear dos cuestiones sencillas a la par que relevantes: dónde estamos y hacia dónde nos dirigimos.

Comprehensive care of pain: Developing systems and tools to improve patient care and resident education.

Chronic non-cancer pain is a common condition associated with tremendous risk for morbidity and mortality. In many settings, the management of chronic non-cancer pain by primary care providers, although customary, can be difficult due to inadequate training and conflicts between patient expectations and best practices. Resident physicians, faculty, and staff of this family medicine residency program developed a comprehensive chronic pain management program to address these issues while improving patient outcomes. The program was aligned with evidence-based chronic non-cancer pain management strategies yet tailored to the needs of the providers and patients and the strengths of the clinic. In the end, the societal demand for improved chronic non-cancer pain management resulted in a massive curricular and clinical practice overhaul for this residency program.

Exposure to disrespectful patient care during training: Data from midwifery students at 15 midwifery schools in Ghana.

OBJECTIVE: to determine what midwifery students throughout Ghana were witnessing, perceiving, and learning with regard to respectful care during labour and childbirth. DESIGN: cross-sectional survey. SETTING: public midwifery schools in all 10 regions of Ghana. PARTICIPANTS: all graduating midwifery students in Ghana. MEASUREMENTS: 929 final-year students at 15 public midwifery schools in Ghana were asked to complete a self-administered computerised survey addressing a range of topics, including experiences during training. All data were collected anonymously and analyzed using Stata 13.0. FINDINGS: 853 students completed the questionnaire (91.8% response rate): 72.0% said maltreatment was a problem in Ghana and 77.4% said women are treated more respectfully in private than public facilities. Students described providers: telling women to stop making noise (78.5%), shouting at women (68.8%), scolding women if they didn't bring birth supplies (54.5%), treating educated/wealthy women better than less educated / poor women (41.5%/38.9%), detaining women who couldn't pay (37.9%), and speaking disrespectfully to women (34%). Only 4% of students reported not witnessing any disrespectful treatment. Students reported providers being overworked (76.5%), stressed (74.2%), and working without adequate resources (64.1%). Where students performed their clinical training (teaching hospital, district hospital, public health clinic, private facility) had no effect on perception of maltreatment as a problem. However, students who trained in district hospitals witnessed more types of disrespectful care than those who did not train in district hospitals (p=0.01). CONCLUSIONS AND IMPLICATIONS: a majority of midwifery students throughout Ghana witness disrespectful care during their training. Implications include the need for provider curricula that address psychosocial elements of care, as well as the need to improve monitoring, accountability, and consequences for maltreatment within facilities without creating a culture of blame.

The importance of taking a religious and spiritual history.

OBJECTIVE: The objective of this study was to explain the reasons for taking a religious and spiritual history, which is often neglected by psychiatrists, and to introduce some religious and spiritual assessment tools to assist those psychiatrists who feel inexperienced in this area. CONCLUSION: Religious and spiritual assessment enhances quality of patient care. Training programs for psychiatry registrars need to include modules on religious and spiritual assessment of patients.

Barriers Influencing Linkage to Hypertension Care in Kenya: Qualitative Analysis from the LARK Hypertension Study.

BACKGROUND: Hypertension, the leading global risk factor for mortality, is characterized by low treatment and control rates in low- and middle-income countries. Poor linkage to hypertension care contributes to poor outcomes for patients. However, specific factors influencing linkage to hypertension care are not well known. OBJECTIVE: To evaluate factors influencing linkage to hypertension care in rural western Kenya. DESIGN: Qualitative research study using a modified Health Belief Model that incorporates the impact of emotional and environmental factors on behavior. PARTICIPANTS: Mabaraza (traditional community assembly) participants (n = 242) responded to an open invitation to residents in their respective communities. Focus groups, formed by purposive sampling, consisted of hypertensive individuals, at-large community members, and community health workers (n = 169). APPROACH: We performed content analysis of the transcripts with NVivo 10 software, using both deductive and inductive codes. We used a two-round Delphi method to rank the barriers identified in the content analysis. We selected factors using triangulation of frequency of codes and themes from the transcripts, in addition to the results of the Delphi exercise. Sociodemographic characteristics of participants were summarized using descriptive statistics. KEY RESULTS: We identified 27 barriers to linkage to hypertension care, grouped into individual (cognitive and emotional) and environmental factors. Cognitive factors included the asymptomatic nature of hypertension and limited information. Emotional factors included fear of being a burden to the family and fear of being screened for stigmatized diseases such as HIV. Environmental factors were divided into physical (e.g. distance), socioeconomic (e.g. poverty), and health system factors (e.g. popularity of alternative therapies). The Delphi results were generally consistent with the findings from the content analysis. CONCLUSIONS: Individual and environmental factors are barriers to linkage to hypertension care in rural western Kenya. Our analysis provides new insights and methodological approaches that may be relevant to other low-resource settings worldwide.

A clinical clerkship collaborative program in Taiwan: Acquiring core clinical competencies through patient care responsibility.

BACKGROUND/PURPOSE: Traditionally, clinical clerkship training in Taiwan does not provide medical students with sufficient patient care responsibilities and often results in inadequate clinical skills. METHODS: We implemented a pilot clerkship program at a comprehensive cancer center that emphasizes core clinical competency through direct patient care and dedicated faculty and mentors. Students were an integral part of the patient care team held accountable for providing coordinated and holistic care. Students' self-assessment of clinical competencies, faculty evaluation, and objective structured clinical examination were compared against their peers trained by traditional clerkship at a main teaching hospital. RESULTS: Fifty medical students completed the clerkship program in the first 3 years. At the end of the clerkship, participants rated themselves significantly higher than their peers in almost all patient care and clinical skill domains. The most significant areas included physical examination, clinical reasoning, developing management plan, holistic approach, handling ethical issues, and time management skills. The students rated their clerkship teachers significantly higher in time spent with students, skills and enthusiasm in teaching, as well as giving students appropriate patient care responsibilities. There was no significant difference in the end-of-clerkship objective structured clinical examination performance, but participants of the program achieved better grades in their subsequent internship. CONCLUSION: This pilot collaborative program presented a successful model for clinical education in the teaching of core clinical competencies through direct patient care responsibilities at the clerkship stage. It is hoped that the project will become a catalyst for medical education reform in Taiwan and regions with similar traditions.