How to measure person-centred practice - An analysis of reviews of the literature.

BACKGROUND: Facilitation and collaboration differentiates person-centred practice (PcP) from biomedical practice. In PcP, a person-centred consultation requires clinicians to juggle three processes: facilitation, clinical reasoning and collaboration. How best to measure PcP in these processes remains a challenge. AIM: To assess the measurement of facilitation and collaboration in selected reviews of PcP instruments. METHODS: Ovid Medline and Google Scholar were searched for review articles evaluating measurement instruments of patient-centredness or person-centredness in the medical consultation. RESULTS: Six of the nine review articles were selected for analysis. Those articles considered the psychometric properties and rigour of evaluation of reviewed instruments. Mostly, the articles did not find instruments with good evidence of reliability and validity. Evaluations in South Africa rendered poor psychometric properties. Tools were often not transferable to other socio-cultural-linguistic contexts, both with and without adaptation. CONCLUSION: The multiplicity of measurement tools is a product of many dimensions of person-centredness, which can be approached from many perspectives and in many service scenarios inside and outside the medical consultation. Extensive research into the myriad instruments found no single valid and reliable measurement tool that can be recommended for general use. The best hope for developing one is to focus on a specific scenario, conduct a systematic literature review, combine the best items from existing tools, involve multiple disciplines and test the tool in real-life situations.

Learning person-centred consultation skills in clinical medicine: A randomised controlled case study.

BACKGROUND: Training institutions need to ensure that healthcare students learn the skills to conduct person-centred consultations. We studied changes in person-centred practice over time following a quality improvement (QI) intervention among Bachelor of Clinical Medical Practice undergraduate students. METHODS: Students were randomised to intervention and control groups. The intervention group received training and did a QI cycle on their own consultation skills. Consultations with simulated patients were recorded during structured clinical examinations in June (baseline) and November (post-intervention) 2015. RESULTS: Matched consultations for 64 students were analysed. The total SEGUE (Set the stage, Elicit information, Give information, Understand the patient's perspective and End the encounter scores) were significantly higher in the final assessment compared to baseline for both the whole group and the intervention group (p = 0.005 and 0.015, respectively). The improvement did not differ significantly between intervention and control groups (p = 0.778). Third-year students improved significantly more than second years (p = 0.007). CONCLUSION: The person-centred practice (including collaboration) of clinical associate students did improve over the period studied. The results show that students' learning of person-centred practice also happened in ways other than through the QI intervention. There is a need to develop students' collaborative skills during the medical consultation.

Trends in practice intentions and preferences of clinical associate students: Implications for training and health services in South Africa.

BACKGROUND: The University of Pretoria (UP) had its first intake of Bachelor of Clinical Medical Practice (BCMP) students in 2009. The objectives of this study were to examine the trends in geographical practice intentions and preferences of the first nine cohorts of BCMP students. We also assessed sector and level of care preferences of six BCMP cohorts. METHODS: Cross-sectional studies were conducted 2011, 2014 and 2017. First-, second- and third-year UP BCMP students were invited to complete a electronic questionnaire. Our analyses consisted of calculating proportions for the practice intentions and preferences for each surveys, and performing multiple logistic regression on the aggregated date to determine their associations with sociodemographic and training characteristics. RESULTS: The proportion of participants intending to practise as a clinical associate in a rural area in South Africa directly after graduating was 62.5% in the 2014 survey and 69.7% in the 2017 survey, compared to 59.6% in the 2011 survey. The majority in all three surveys (53.4% in 2011, 56.6% in 2014 and 59.8% in 2017) indicated a preference for rural practice. Both rural practice intention and rural practice preference were found to be significantly associated with respondent's self-description of having lived most of her/his life in a rural area, and rural district hospital exposure during training. In 2014 and 2017, approximately two-thirds of the participants selected a public sector option as their most preferred work setting. District hospitals were the most preferred setting of 30.3% participants in 2014 and 32.0% in 2017. CONCLUSION: Most participants across the three surveys intended to work in rural settings. Considering that this could provide a sustainable solution to the shortage of health care workforce in rural areas, policy makers in both higher education and health need to promote and ensure the viability of the training of this category of health care providers.

Patient- or person-centred practice in medicine? - A review of concepts.

BACKGROUND: Person-centred practice in medicine may provide solutions to several pressing problems in health care, including the cost of services, poor outcomes in chronic care and the rise in litigation. It is also an ethical imperative in itself. However, patient- or person-centred care is not well researched partly because of a lack of conceptual and definitional clarity. AIM: The aim of this review was to analyse essential elements, ethical principles, logic and the practical application of person-centred practice described in clinician- and researcher-defined conceptual frameworks, terms and practices. METHODS: A search of review articles on patient- and person-centred care or medicine was conducted using Medline and Google Scholar. Secondary searches were conducted using references and citations from selected articles. RESULTS: Five conceptual frameworks were identified in terms of their practical application of the ethical principles of beneficence, autonomy and justice. They converge around a few central ideas such as having a holistic perspective of patients and their illness experience, a therapeutic alliance between the patient and clinician as well as respectful, enabling collaboration with the patient. CONCLUSIONS: Terminological differences appear to owe more to disciplinary origins than to substantive meaning. Beneficence needs to be balanced by and practised through respect for patient autonomy. Core ideas in existing conceptual frameworks of patient or person centredness can guide teaching and research. Considering the value and ethical imperative of person-centred practice, training institutions should train health care students and practitioners in its precepts.

Cost effectiveness of clinical associates: A case study for the Mpumalanga province in South Africa.

BACKGROUND: The National Department of Health of South Africa decided to start a programme to train mid-level healthcare workers, called clinical associates, as one of the measures to increase healthcare workers at district level in rural areas. Unfortunately, very little is known about the cost effectiveness of clinical associates. AIMS: To determine, on a provincial level, the cost effectiveness of training and employing clinical associates and medical practitioners compared to the standard strategy of training and employing only more medical practitioners. METHODS: A literature study was performed to answer several sub questions regarding the costs and effectiveness of clinical associates. The results were used to present a case study. RESULTS: The total cost for a province to pay for the full training of a clinical associate is R 300 850. The average employment cost per year is R196 329 and for medical practitioners these costs are R 730 985 and R 559 397, respectively.Effectiveness: Clinical associates are likely to free up the time of a medical practitioner by 50-76%. They can provide the same quality of care as higher level workers, provided that they receive adequate training, support and supervision. Furthermore, they seem more willing to work in rural areas compared to medical practitioners. CONCLUSIONS: The case study showed that training and employing clinical associates is potentially a cost-effective strategy for a province to meet the increasing demand for rural healthcare workers. This strategy will only succeed when clinical associates receive adequate training, support and supervision and if the province keeps investing in them.