[Health care safety: The discrepancies between experience and degree of satisfaction of hospitalized patients observed in interviews performed by user representatives]. / La sécurité liée aux soins : écarts entre l'expérience et la satisfaction de patients hospitalisés à partir d'entretiens menés par des représentants d'usagers.

INTRODUCTION: The purpose of this article is to present the results of a qualitative survey conducted by user representatives (URs) focusing on the health care safety experience of hospitalized patients. The authors wished to identify factors associated with safety of care and, more specifically, with the possibly ominous medical events reported by patients. METHODS: After being trained with these objectives in mind, eight URs conducted semi-directive interviews with fourteen patients hospitalized in eleven separate hospital units in nine different hospitals. RESULTS: Eight types of factors consisting in 30 contributing factors liable to be reported by patients were identified: 1) factors related to patients' basic needs; 2) personalization of care; 3) professional factors; 4) organizational factors; 5) communication factors; 6) caregiver responsiveness; 7) infectious risks; 8) continuity of care. Patients' overall feelings about their hospitalization remained excellent notwithstanding more tempered, even negative experiences. CONCLUSION: This paradoxical result shows that the patients' actual experience is far more instructive than their degree of satisfaction. In light of this study, the acceptability of this type of research (i.e. research conducted by URs) is excellent and it also appears highly feasible, whatever the limitations imposed by organizational considerations.

What do we mean by multimorbidity? An analysis of the literature on multimorbidity measures, associated factors, and impact on health services organization.

BACKGROUND: Multimorbidity is a consequence of both epidemiological and demographic transition. Unlike comorbidity, it currently has no consensus definition, making it difficult to assess its epidemiological and socioeconomic burden, to organize healthcare services rationally, and to determine the skills needed for patient self-reliance. The aim of this study is to define the spectrum of multimorbidity and to discuss current implications for the organization of care. METHODS: Two independent readers analyzed the literature indexed in PubMed, Embase, CINAHL, and Scopus. RESULTS: The bibliographic search conducted on July 16, 2013, retrieved 2287 articles (670 in PubMed, 666 in Embase, 582 in Scopus, and 369 in CINAHL). Of these, 108 articles were retained. Multimorbidity is designated by a variety of terms, none of them being MeSH terms. There is no single measure of multimorbidity, as this entity is usually studied for its functional or economic impact, rather than its causes. The prevalence varies considerably, depending on the measure used and the population studied. Factors associated with multimorbidity are age, gender, and socioeconomic characteristics of the populations studied. Studies evaluating the organization-of-care are inconclusive or insufficient. CONCLUSIONS: Multimorbidity serves as an avatar for the fundamental, recurrent problems of modern medicine and the organization-of-care. It may be defined by its causes or its consequences and reflects our concept of both individual health and its collective management. Tools that would allow a more appropriate measurement of this entity are available; we should use them to match medical reality to the needs of patients.

Patient resources in the therapeutic education of haemophiliacs in France: their skills and roles as defined by consensus of a working group.

The activities of 'expert patients' or 'patient tutors', who help educate their peers, are gaining recognition in the health care system. This study investigates the role played by such patients in therapeutic education programmes organized by caregivers to validate the role of patients in implementing the therapeutic education of haemophilic patients and to define the skills required for such activities. This study employs the consensus methodology recommended by France's National Authority for Health. The working group includes seven caregivers from Hemophiliac Treatment Centers (HTCs) and three patients from the French Association of Hemophiliacs (FAH). The role of patients in haemophilia education is recognized. Patients participating in the education of their peers are referred to as 'patient resources'. A patient resource should be an adult, a volunteer and live in the same region as his peers. Candidates are chosen by the FAH and the HTCs to serve based on their motivation to facilitate the education of other patients as well as on their psychological and pedagogical aptitudes. A patient resource participates in the conception and administration of therapeutic education programmes. He also mediates between the caregivers and the patients. He ensures that the patients understand the material and are able to apply their knowledge in daily life. His activities are governed by professional ethics. Seven categories of skills were defined, permitting the group to determine precisely which skills are required to function as a patient resource. Supervision of the patients is planned to reinforce reflexive practices in the patients. Evolution of the health care system has led patients to become involved in therapeutic education. This phenomenon calls for a framework to be developed and an evaluation of its eventual effects.

Educational content and challenges encountered when training service user representatives as peer researchers in a mixed study on patient experience of hospital safety.

BACKGROUND AND OBJECTIVES: In France, following the passing of a 2002 law, service user representatives (SURs) are part of hospital committees in charge of care quality and safety issues. Ten service user representatives (SURs) were recruited and trained as "peer researchers" to participate in all phases of a study aimed at outlining how patients experience hospital safety. This article aims to describe the study protocol and how peer researchers training was designed and implemented to prepare them to drive a qualitative and quantitative research. It also examines the challenges related to collaborative research and how these were resolved. METHODS: The way our training was conceived belongs to the field of "design-based research", known for its pragmatic and collaborative scope, in which viewpoints of all participants are included. Our training was therefore based on peer researchers and research sponsors expectations, as well as on recommendations of the literature. RESULTS: A 45-h training was held. While the program was meant to train peer researchers to respect scientific norms, it also aimed to improve their sense of self-legitimacy as they navigated their new role. Peer researchers were particularly eager to understand meaning behind the instructions, especially in the field of ethical and scientific norms. Various challenges occurred related to project organization, recruitment and peer researchers involvement. Some issues were overcome by learning how to share control over the research process. CONCLUSION: This experiment highlights the importance of a training program's duration and quality to prepare SURs for their roles as peer investigators and to create a group dynamic around a research project, even with SURs familiar with patient involvement and our research theme (safety issues). Trainers overcame hurdles by being adaptive and by using educational approaches. They also learned to include trainees' input, even when it forced them to reconsider their own assumptions.

"Patient participation" and related concepts: A scoping review on their dimensional composition.

OBJECTIVES: Several concepts on collaboration between patients and healthcare systems have emerged in the literature but there is little consensus on their meanings and differences. In this study, "patient participation" and related concepts were studied by focusing on the dimensions that compose them. This review follows two objectives: (1) to produce a detailed and comprehensive overview of the "patient participation" dimensions; (2) to identify differences and similarities between the related concepts. METHODS: A scoping review was performed to synthesize knowledge into a conceptual framework. An electronic protocol driven search was conducted in two bibliographic databases and a thematic analysis was used to analyse the data. RESULTS: The search process returned 39 articles after exclusion for full data extraction and analysis. Through the thematic analysis, the dimensions, influencing factors and expected outcomes of "patient participation" were determined. Finally, differences between the included concepts were identified. CONCLUSION: This global vision of "patient participation" allows us to go beyond the distinctions between the existing concepts and reveals their common goal to include the patient in the healthcare system. PRACTICE IMPLICATIONS: This scoping review provides useful information to propose a conceptual model of "patient participation", which could impact clinical practice and medical training programs.

[Surgery training of gynecologic residents: master and student in the operating room]. / Formation chirurgicale au bloc opératoire: enquête d'opinion auprès des praticiens et des internes en gynécologie-obstétrique.

OBJECTIVES: Describe the surgical training of gynecologic residents in the operating room, by collecting the opinion of French gynecologists. MATERIALS AND METHODS: A questionnaire investigating this subject was put on a web site. Every French gynecologist could answer the questionnaire from a duration of six months. The data of the inquiry were studied by comparing five groups: residents (group 1), fellows (group 2), seniors of public hospital (group 3), and seniors of private hospitals (group 4), or, groups 2, 3 and 4 together, as Group A. RESULTS: Six hundred and fifty-seven gynecologists answered the inquiry. For the residents, lack of time and senior's weak educational motivation are the explanations most frequently retained in order to explain that residents do not operate. For group A, it is rather the residents' skills which is the most important fact to have residents operate. Residents more often practice surgery in general public hospital that in faculty hospital. For 31% of all the referees, heads of departments do not incite their teams to have residents operate. Nearly 25% of all the investigated believe that a man operates more than a woman in resident curriculum. Besides, by analyzing the answers of groups 1 and 2, we were able to correlate resident seniority at their first practice of 13 surgical operations. For 26% of the group A, residents operate less than they do during their own studies. Finally, all the investigated confirm the lack of surgical assessment in the resident curriculum. DISCUSSION AND CONCLUSION: Decision to let the resident operate remains too dependent on senior personal appreciation and does not seem to join a strategy of training. Opinions of surgical training in the operating room is different between residents and seniors. Operating time increases when residents operate but there is no effect on quality of care. These results show again the necessity of a formal teaching and assessment, in a resident program with objectives, collecting every resident's surgery volume. These educational improvements will contribute certainly to the professionalization of residents.

[Surgical training of trainees, specialists in obstetrics and gynecology: results from a national electronic survey]. / Formation chirurgicale des internes, spécialistes en gynécologie-obstétrique : résultats d'une enquête électronique nationale.

OBJECTIVES: The goal of this dissertation is to assess the current situation of surgical training provided to French trainees in obstetrics and gynecology. MATERIALS AND METHODS: An online survey was made available to all French gynecologists. Within six months, 657 answer forms had been submitted and respondents were sorted out into five subgroups: residents (group 1 [G1]), fellows (group 2 [G2]), public sector surgeons (group 3 [G3]), private sector surgeons (group 4 [G4]) and all surgeons and fellows (group A [GA]). RESULTS: Only 30% of interns (G1) and 78% of surgeons (GA) were satisfied with their training. Most respondents agreed that two general surgery courses as currently offered in the curriculum do not provide enough good basic surgical knowledge. Courses that allow residents to train in other hospitals are generally preferred to those that focus on a particular hospital. Ninety-two percent of respondents consider camaraderie and bonding within a medical unit to be key to a successful course. Theoretical training, including lectures and access to listed references, is thought to be weak. Resources and tools for practical training outside the operating room, including pelvic trainer and anatomical dissection, are scarce. Course evaluation is expected by 83% of all respondents, although it is now virtually nonexistent. CONCLUSION: Surgical training of residents in obstetrics and gynecology can be improved in many ways, such as using synthetic materials and operating on animals or cadavers. Rigorous course evaluation is key to improving surgical training of French residents in obstetrics and gynecology.

[A guide for education programs in atopic dermatitis]. / Dermatite atopique: un référentiel d'éducation du malade.

BACKGROUND: Education about therapy applies to many chronic diseases. The aim is to improve patient management through the development of certain skills by patients themselves. Atopic dermatitis is an area amenable to the development of therapeutic education. The purpose of this study was to define the skills required for management of atopic dermatitis suitable for therapeutic education and to bring together these skills in a handbook suitable for use. MATERIALS AND METHODS: Thirty caregivers were involved in the drafting of the handbook (dermatologists, a doctor specialising in therapeutic education, a psychologist and nurses), each of whom has experience of therapeutic education in atopic dermatitis. RESULTS: Four age groups were selected (under 5 years, 6 to 10 years, pre-teens/adults, parents of children aged under 5 years). For each age group, different levels of skill were identified for patients or parents of children and suitable learning methods were selected. Skills were classed according to 3 levels: (i) knowledge about the disease, treatments, triggering factors, (ii) knowledge about provision of care by patients or their parents, (iii) knowledge in terms of explaining the disease and treatment methods to family, and knowing who to contact and when. Finally, a 10-question evaluation guide was drawn up. DISCUSSION: In this paper we report the method of production and content of the handbook of skills for atopic dermatitis patients. The aim is not to impose all skills listed in this work on patients but rather to provide caregivers with a complete handbook covering therapeutic education. The book is intended for patients with moderate to severe forms of atopic dermatitis currently in therapeutic failure. It may be used by anyone treating such patients, whether doctors, nurses or psychologists, depending on the items chosen. It is intended for use as a support for the elaboration, diffusion and evaluation of a therapeutic education programme for atopic dermatitis.

[A concept mapping study of nutritional knowledge in diabetic children and their parents]. / Etude par cartes conceptuelles des connaissances sur l'alimentation des enfants diabétiques et de leurs parents.

This study describes, using concept mapping, the nature, organization of knowledge on nutrition and its evolution following therapeutic patient education program in 5 diabetic children (8 to 9 years old) and their mothers. Before the education session, mothers and children are highly knowledgeable about food. The organization of knowledge in children is conceptual and differs from that found in mothers which is based on problems solving. After education, new knowledge and new links between old and recent knowledge testify of learning. A comparison between the maps of children and their mother reveals similarities but also differences in their preoccupations. This research shows that using the preexisting knowledge networks of parents and children could contribute to improve their education on nutrition.

A descriptive study of advising practices during travel health consultations in France.

BACKGROUND: Recommendations for improving traveler adherence address both the content of the advice given and the structure of the consultation. The objective of this article is to describe how travel health consultations are structured in France. METHODS: A questionnaire based on both theoretical foundations and recommendations in the literature was sent to health professionals who practice in travel clinics, all of them members of France's Société de Médecine des Voyages. RESULTS: The response rate was 78.5% (176/224). One hundred thirty nine respondents (78.9%) reported that treatment (vaccinations, in particular) and advising were done at separate times in the consultation. The majority of respondents questioned the traveler on his wishes, difficulties, expectations, experiences, and previous knowledge. A third explored the traveler's perceptions regarding the seriousness of diseases, the effectiveness of prevention measures and the latter's adverse effects with a difference when health professionals were practicing >5 years and/or had received specific training ( P < 0.05). At the end of the consultation, 92% of the respondents asked the traveler whether he understood the advice given. One hundred thirty seven respondents (77.8%) gave travelers a booklet with additional advice, and 66.5% gave them a website where they could find health advice on their destination. Travelers were almost never offered group consultations or the opportunity to work on real-life situations. When there were language barriers, the respondents were more likely to seek help from a French-speaking member of the traveler's entourage (48.9%) than from an interpreter (22.7%). CONCLUSIONS: While the majority of practitioners follow most of the recommendations regarding the structure of travel health consultations, some of the factors that enhance traveler learning are underutilized, reducing the likelihood that travelers will apply the advice given. The study illustrates the need to develop more educational intervention methods and to evaluate their impact on travelers.

Educating diabetic patients about insulin use: changes over time in certainty and correctness of knowledge.

AIM: Diabetic patients should understand their disease correctly and be sure of what they know, but certainty is rarely considered by educators. Furthermore little is known about how certainty changes with time after an educational intervention. To clarify this, in 38 patients with type 1 diabetes (0.3-36 years duration) we analysed the effect of a course on insulin use by administering a questionnaire before the course, after the course and 1 and 3 years later. METHODS: Answers, accompanied by a subjective estimate of the degree of certainty, were assigned to mastered knowledge (certainty>or=90%, correctness>or=90%), hazardous knowledge (certainty>or=90%, correctnessor=90%) and residual knowledge (total-[mastered+hazardous+uncertain]). Answers were then counted and changes in distribution among areas were analysed by the chi2 test. We also followed the fate of wrong answers. RESULTS: The course increased mastered knowledge, while other types of knowledge decreased. With time mastered knowledge decreased, patients losing both correctness and certainty. The loss affected declarative knowledge, based purely on theory, more than procedural knowledge, which concerns the way things are done. Wrong answers, mostly given with high degree of certainty, were heterogeneous since some became correct after the course, some remained wrong, some became wrong after the course, some became mistaken after having been corrected earlier. CONCLUSIONS: The analysis of certainty helps in evaluating patient's knowledge; programmes tending to improve procedural knowledge are more likely to have long lasting effects; wrong answers need to be considered on a individual basis.

[Written asthma action plans: a useful tool for self-management]. / Le plan d'action écrit : un outil pour l'autogestion de l'asthme.

Written action plans for asthma have been recommended for many years. However, despite the fact that their effectiveness has been demonstrated, they are not used enough. The plans that we propose are serviceable and the method that we suggest makes them easy to use in the treatment of asthmatic children. These plans are made for patients who do not use a peak-flow meter (plans based on symptoms) and those who control this tool (plans based on peak expiratory flow).

[The use of telephone for counseling diabetic patients: a descriptive and pedagogic approach]. / Conseiller des patients diabétiques au téléphone: approche descriptive et pédagogique.

This descriptive study of telephone interviews, conducted between the staff of a diabetes unit and patients, is intended to clarify a professional manner in which the telephone should be used as part of patient care. Having examined simulated calls from diabetic patients, analysis of the interviews conducted by the doctors, nurses and members of the office staff in a hospital unit demonstrates wide differences in the content, the quality of the content, and the interview strategy. An interpretation of the results signals the importance of the manner in which the staff member answers, a knowledge of patients' genuine needs, and an ability to adequately acknowledge the emotional state of the patient. Structuring telephone conversations, allowing sufficient time for patient responses, avoids over-long interviews. The decisions taken by the staff member answering the call, in terms of advice and suggestions of actions to take, must be systematically backed-up by ensuring that the patient has properly understood what has been said. The study poses a number of questions, notably concerning the specific requirements demanded by these new remote-care services in the organization of care within a hospital unit, and the professional approach to the use of the telephone as part of the relationship with patients. Recommendations are given concerning the general principles governing a telephone interview and the definition of training objectives for healthcare professionals.

The use of concept mapping to enlighten the knowledge networks of diabetic children: a pilot study.

OBJECTIVE: The value of concept mapping in enlightening nature and organization of knowledge was shown with adult diabetic or obese patients. Our objectives were to ascertain the relevance and feasability of concept mapping in diabetic children during an educational program. METHOD: This qualitative research was performed in 5 children from 8 to 13 years. Concept maps were drawn at the beginning (Phase 1) and at the end (Phase 2) of an educational program. During the interview each child was invited to express himself starting from the central concept: "diabetes", and to express his/her knowledge, representations, and life experience. RESULTS: The ten maps analysis shows: an increase of knowledge between phase 1 and phase 2 (+34%), towards a deepening of initial knowledge and an addition of new knowledge (43% and 41% of the added knowledge); a decrease of inaccurate knowledge in phase 2; an enrichment of the knowledge networks (+16 cross links); an increase of knowledge related to the ways to behave knowledge (+42%). CONCLUSION: This preliminary report demonstrated that concept maps were feasible, useful and relevant in therapeutic education of children. This method allowed us to show how every child connected his knowledge and how it was modified by an educational intervention. Concept maps therefore contributed to individual educational diagnosis and assessment of new knowledge integration.

Learning difficulties of diabetic patients: a survey of educators.

This study was designed to shed light on the learning difficulties of diabetic patients. An open-ended questionnaire was sent to 85 health care professionals working in the field of diabetes and nutrition who had been trained in patient education techniques. They were asked to describe the skills that were the easiest to teach patients and those that patients mastered the best, as well as the skills they found hardest to teach patients, those that patients mastered the least and those that gave rise to errors persisting after the patients education was completed. On the whole, the results showed that the educators found it easy to teach techniques: patients mastered procedures well and made few mistakes. In contrast, diabetic patients seem to have problems learning skills, such as insulin dose adjustment, that require complex problem-solving (involving multiple variables). Based on these findings, the authors discuss the notions of learning complexity and the time needed for successful patient education.

Difficulties of diabetic patients in learning about their illness.

The aim of this report is to shed light on the difficulties experienced by diabetic patients in learning about their illness. One hundred and thirty-eight diabetic people (97 IDD and 41 NIDD) were questioned at two survey locations, one national (63) and one regional (75), by means of a closed answer questionnaire. One hundred and four (75%) had attended a formal programme of diabetes education. They were asked which points in their diabetes education they had best understood and which they had least understood. The main results show that, globally, they easily acquire the manual skills. Conversely, numerous learning difficulties are associated with the skills required to solve problems and make decisions, such as adaptation of doses of insulin. These results are comparable to those obtained in a previous study in which professional carers were asked about their difficulties in educating their patients.

An analysis of the teaching techniques used in diabetic specialist consultations.

We attempted to explore the teaching practices of 11 senior diabetic specialists consulting in a out-patient hospital setting and known to have a strong commitment to patient education. The survey consisted of a questionnaire dealing with the duration and distribution of speaking time, the classification of questions, the type of oral questions asked of patients, written materials, teaching aids, demonstrations, if any, care techniques used, and whether or not information was summarized. Our study of 44 consultations showed an average consultation time of 26 +/- 10 min and a balanced sharing of speaking time. The percentage of consultations during which no questions were asked depended on the type and classification of test questions, i.e. oral questions to check knowledge (13.6%), open-ended problem-solving questions (27.3%) or problems involving written materials (54.5%). One to two problems involving open-ended questions were set during 36.4% of the consultations and one to two problems involving written materials were set in 20.5% of the cases; visual aids prepared in advance took a back seat to sketches made during the consultation itself. Information was summed up by the caregiver 75% of the time, and 50% with the patient's help. Our results indicate a patient education orientation during consultations and help to design a standard model formation combined teaching/treatment consultations.

Design and implementation of a training programme for general practitioners in emergency surgery and obstetrics in precarious situations in Ethiopia.

Médecins Sans Frontières (MSF) has been implementing medical assistance programs in Ethiopia since 1994, including the rehabilitation of health structures and the supply of drugs and medical equipment. In 1995, the serious shortage of surgeons in Ethiopia prompted MSF to add a programme to train general practitioners to perform surgery in the Woldya region. The results of the relevant feasibility study were encouraging. The programme's design is based on recent educational data and MSF's experience with introducing transcultural training in countries where unstable conditions prevail. The training programme is currently being studied by the Ethiopian Health Ministry for use as a model for training general practitioners in surgery throughout the country.

[Training missions in Cambodia: impact on the anesthesiologists and intensive care workers who carried out these missions]. / Missions de formation au Cambodge: impact sur les médecins anesthésistes-réanimateurs ayant assuré ces missions.

OBJECTIVES: 1) To analyse the incentives and the significance of the participation of anaesthesiologists in training missions for male nurse anaesthetists in Cambodia; 2) to assess the professional and private impact of these missions on them; 3) to evaluate the level of contribution of hospital administration. STUDY DESIGN: Retrospective survey. PERSONS AND METHOD: Twelve anaesthesiologists, mainly males, mean age 44 +/- 6 years, with some expertise in missions in developing countries complete anonymously a written questionnaire including standardized answers and open questions. RESULTS: The mean reason for participating was the wish to transmit knowledge and expertise. For most of them the mission was an extension of their clinical activity. The reverse effects were a change of their mind on medical practice, on teaching and training, assistance projects for developing countries. For the latter, all considered that the health care institutions in association with Faculties of medicine should be involved in these missions. DISCUSSION: Initially, these missions expressed a need of self-sacrifice and appraisal of professional expertise. However the educational goal of the mission, the difference of cultural environment, determined a change in links with other persons. As a result, they wished to share expertise with other colleagues, in modifying the procedures for education and their participation in future assistance projects for development. However these intentions remained without professional impact as these educational actions were not included in a real institutional project. CONCLUSION: Every international assistance project for development build by hospital doctors should be examined not only by staff members of the department, but also by the hospital administration.

[Evaluation of professional development of Cambodian male nurses specializing in anesthesia and intensive care, trained through humanitarian care programs]. / Evaluation du devenir professionnel d'infirmiers cambodgiens spécialisés en anesthésie-réanimation, formés dans le cadre de l'action humanitaire.

OBJECTIVES: To assess the working conditions of Cambodian male nurses specialised in anaesthesia and intensive care (NSAIs), degree of satisfaction, whether training was suited to the Cambodian needs and practical application of training. STUDY DESIGN: Prospective survey. PERSONS: Two training years including 30 NSAIs. METHOD: External assessors evaluated working conditions, practice of anaesthesia, analysed logbooks and theatre reports, organised semi-directive interviews and examinations using clinical cases. RESULTS: Out of the 30 NSAIs, 28 had an appointment, mainly in anaesthesia (80% of their activity) and three-quarters of them felt that their skills were appreciated by their superiors. Seventeen had some form of responsibility in the management of a department. For the administration of an anaesthetic, 13 NSAIs of the second year had achieved an acceptable level of performance and resolved effectively 85% of the submitted cases. Twenty-two NSAIs reported difficulty in applying techniques learned during their training to real working conditions. The causes were poor equipment, poor organisation and poor relations with the hierarchy. The latter cause decreased the capacity to take appropriate decisions, which was the most common error made by the second year NSAIs. Finally, as their wages remained unchanged, 19 out of the 28 NSAIs were obliged to look for an additional source of income. CONCLUSION: This survey shows the medium-term effectiveness of an NSAI training programme basing on teaching and public health principles and organised in the humanitarian aid sector.