Type 2 diabetes is a common condition that is associated with high rates of morbidity, mortality and healthcare costs. Multifactorial management has been shown to be effective in preventing complications and inducing remission or cure of the disease. Despite this, the rate of new cases and the overall burden of the disease remains high. There is a need, therefore, to refocus efforts on strategies to prevent complications in type 2 diabetes. Most of the disease in the UK is now managed in primary care consultations and there is increasing emphasis in health policy on 'making every consultation count'. Accordingly, the overall aim of my thesis is to contribute new knowledge and understanding on the role of the primary care consultation as a strategy in managing and preventing complications of diabetes, with a particular focus on the contribution of patient experiences. Data from the ADDITION-Cambridge and ADDITION-Plus population-based cohorts were used to quantify associations between experiences of primary care consultations measured with the Consultation and Relational Empathy Measure (CARE), and i) cardiovascular (CVD) risk factors, ii) CVD events, iii) all-cause mortality and iv) remission of type 2 diabetes. This was followed by further observational analyses to examine the role of patient health behaviours as a mediator of these associations. Qualitative analysis of semi-structured interviews with practitioners and patients were carried out to further elucidate theory that might explain how primary care consultations relate to the management of diabetes, and to understand the practicalities and barriers in delivering optimal experiences. Social practice theory was then used as a frame of reference to collate findings and contextualise the primary care consultation in managing and preventing complications of diabetes from a wider social perspective. The results of the observational analyses suggest that the primary care consultation may have a small impact on CVD risk factors early in the course of illness (higher levels of high-density lipoprotein cholesterol, lower systolic blood pressure and lower diastolic blood pressure). However, these associations are unlikely to be mediated through patient health behaviours. Over the longer term, consultation experience was significantly associated with the incidence of all-cause mortality; a 40% lower risk of mortality was found in patients with type 2 diabetes who reported better primary care consultation experiences compared to those with poor experiences. Similar trends were observed with CVD events but these were not statistically significant. Consultation experiences were additionally associated with remission of diabetes in adjusted models; 2-3% lower odds of remission with better patient-reported experiences of the consultation according to the CARE measure. The qualitative chapters identified issues around consultation length, relational continuity, face-to-face contact and type of practitioner as important contributors to primary care consultation experience. Moreover, my findings highlighted the difficult balance that needs to be achieved within the consultation between patient experience and disease management, and also between patient-centred and doctor-centred consultations. Further interviews with practitioners emphasised how the wider problems of pressures on the service and increased workloads in primary care are impacting consultation experience. This highlighted competing priorities which could distract from effectively utilising the consultation in diabetes. The final analysis chapter used social practice theory to collate the findings across chapters and suggested that a whole system and societal approach is needed to develop and inform the delivery of effective diabetes strategies. Overall, my thesis suggests that the primary care consultation experience has the potential to be an important strategy in managing and preventing diabetes complications. There are opportunities to more effectively use the consultation in primary care in a way that considers the individual, healthcare system and wider society together. More research is required to establish the causal pathways to explain how these experiences relate to outcomes and to understand what form a future whole system societal intervention might take.

Background: Considerable attention has been paid to evaluating the roles and relationships of professionals participating in team-based or collaborative practice; however, less attention has been paid to exploring the patients’ views and impact of such practice despite claims of it being patient-centred. Objectives: To examine the relationship between patient and provider characteristics and patients’ ratings of measures of quality of care and integration, and to explore the patient views of care delivered in a patient-centred collaborative study involving chiropractors and physicians. Design: Cross-sectional survey. Method: A mixed methods sequential approach with a quantitative priority was used in data analysis. Quantitative data were collected from 2597 patients participating in a collaborative study involving chiropractors and physicians and 530 patients attending chiropractors not involved in collaborative care. All participants presented with musculoskeletal pain. The Primary Care Assessment Survey (PCAS) was modified and scores from six of its scales were used to assess attributes of quality patient-centred care between the two study groups. Qualitative transcript-based data from six purposefully selected focus groups was analyzed using an interpretivist approach. Results: The revised PCAS demonstrated acceptable psychometric properties. Patients in both study groups received quality, patient-centred care. Patients’ reporting being completely satisfied and feeling improved by their care was positively associated with rating chiropractors as high performers on all scales. Survey findings were confirmed in focus groups of study patients. Patients appreciated positive interpersonal interactions, sharing in the treatment decision-making process, having a choice in provider and treatment, and the provision of holistic care. Patients perceived that collaboration between chiropractors and physicians varied, favouring those who were co-located. Patients with chronic or co-morbid conditions desired greater involvement in their care. Patients felt sharing of clinical information was more important than co-location as facilitating coordination and integration of collaborative care. Conclusion: The study suggests that patients suffering from musculoskeletal pain benefit from interprofessional collaborative care that includes improved access to and choice of providers and treatment options, as well as enhanced interprofessional communication and coordination of care.

Background: Considerable attention has been paid to evaluating the roles and relationships of professionals participating in team-based or collaborative practice; however, less attention has been paid to exploring the patients’ views and impact of such practice despite claims of it being patient-centred. Objectives: To examine the relationship between patient and provider characteristics and patients’ ratings of measures of quality of care and integration, and to explore the patient views of care delivered in a patient-centred collaborative study involving chiropractors and physicians. Design: Cross-sectional survey. Method: A mixed methods sequential approach with a quantitative priority was used in data analysis. Quantitative data were collected from 2597 patients participating in a collaborative study involving chiropractors and physicians and 530 patients attending chiropractors not involved in collaborative care. All participants presented with musculoskeletal pain. The Primary Care Assessment Survey (PCAS) was modified and scores from six of its scales were used to assess attributes of quality patient-centred care between the two study groups. Qualitative transcript-based data from six purposefully selected focus groups was analyzed using an interpretivist approach. Results: The revised PCAS demonstrated acceptable psychometric properties. Patients in both study groups received quality, patient-centred care. Patients’ reporting being completely satisfied and feeling improved by their care was positively associated with rating chiropractors as high performers on all scales. Survey findings were confirmed in focus groups of study patients. Patients appreciated positive interpersonal interactions, sharing in the treatment decision-making process, having a choice in provider and treatment, and the provision of holistic care. Patients perceived that collaboration between chiropractors and physicians varied, favouring those who were co-located. Patients with chronic or co-morbid conditions desired greater involvement in their care. Patients felt sharing of clinical information was more important than co-location as facilitating coordination and integration of collaborative care. Conclusion: The study suggests that patients suffering from musculoskeletal pain benefit from interprofessional collaborative care that includes improved access to and choice of providers and treatment options, as well as enhanced interprofessional communication and coordination of care.

Working at the intersection of medical sociology and the psychology of health, language and communication, in this PhD I use thematic analysis (TA) and conversation analysis (CA) to provide an insight into various aspects of doctor-patient communication that may be considered, or are constructed as, challenging and/or delicate for either the patient, doctor or both at a Gender Identity Clinic (GIC) in the UK. This project involves the secondary analysis of two existing data-sets: (i) 21 recorded telephone interviews between my PhD supervisor and transsexual patients who attended the GIC; (ii) 156 transcribed audio-recordings and 38 video-recordings (total = 194) of psychiatrist-patient consultations in the GIC. The first original research paper uses TA to investigate the views and experiences of transsexual patients regarding their communication with psychiatrists at the GIC. An important finding was that patients actually appreciated being challenged in this setting, subsequently the implications of this are considered with regards to the achievability and desirability of patient centred communication. The second research paper uses CA to consider how patients overtly challenge psychiatrists in the GIC in ways that have not been shown in conversation analytic research on medical interactions to date. Analysis of the data corpus revealed that there were three common ways in which patients challenged psychiatrists at the GIC, which are (1) by problematising their questions; (2) by disagreeing with statements that are made regarding their treatment; (3) and by initiating complaints. The findings of this study are considered in relation to the implications that they have for clinicians and for the persistence and desirability of asymmetry in clinical interaction in light of the current debates surrounding the concept of patient-centeredness. The final research paper also uses CA, in this instance to study how the topic of weight, which is often constructed and orientated towards as delicate in talk-in-interaction, is occasioned and discussed by psychiatrists and patients at the GIC. Whereas previous CA research on this topic has focused on how this is constructed by speakers as a moral issue, this paper is concerned with focusing on how psychiatrists (1) establish with patients that their weight is an issue, (2) encourage patients to lose weight by informing them that this is their responsibility and (3) offer advice on the behavior changes associated with weight loss. The results of this paper are discussed with regards to the implications that they have for clinicians who discuss the potentially delicate topic of weight with patients in a number of different settings. This project contributes towards the growing debates regarding the achievability and desirability of patient centred communication and the persistence of asymmetry in clinical interaction. It also contributes to medical conversation analytic literature to date on asymmetry and talk about weight in clinical interactions.

The thesis presented consists of two parts: a theory and the empirical part. The theory is introduced with a brief survey of the history of the patient centred care followed with current trends in nursing. It is followed with the three key areas determining nursing care. The first one consists of the objective factors - the health care system. The second area is formed by the factors associated with the practical implementation of nursing. The third area is devoted to the role of the patient and his surroundings. Objective of the thesis: The mapping of the factors influencing patient-oriented care by the nursing staff and management in various health care institutions. Research group The research group consisted of 11 female respondents state-registered nurses, aged from 24 to 58 years of age. The respondents varied in their position, level of education, and specialization, and they worked in various health-care institutions. Among them, there were 6 registered nurses, 4 ward nurses, and 1 head nurse. The willingness to cooperate and the saturation of responses were principal in forming the research team in question. The way adopted for achieving of the objective A qualitative research method has been chosen to achieve the goal. The phenomenological focus of the work has led to the selection of the method. The data were collected using semi-structured interviews. The findings were further categorized and confronted with the source material to answer the research questions. Results The research confirms the nursing care is a complex phenomenon. The recently-adopted health care legislation shows a shift from the paternalistic concept of care on behalf of the right of the patient to self-determination. On the other hand, however, the principle of solidarity the basis of the health care system in the Czech Republic retains some paternalismus, and that can negatively affects the relationship of the patient to the nursing staff in some cases. The respondents are in agreement as to the notion of PCC but a single one respondent knows its concept. The possibility of putting the PCC in practice is hampered by a wide range of factors. According to the respondents, the major obstacle is the undernumerousness of the nursing staff, resulting in the omnipresent time stress. The excessive red-tape demands have been seen as the almost equally important factor, together with the lack of continuity of care, but also the fast-and-loose approach of some nurses. The evaluation of the cooperation between staff nurses at the bed and the nurses in senior positions differed. Staff nurses see the problem in cooperation with their superiors, lacking appreciation of their work. Management, i.e. head nurses and ward nurses are often seen as systemic obstacles. The research investigation also shows insufficient cooperation with the patient's family. Permanent changes in the nursing education concept are seen as a hindrance to the problem solution. Regretfully, the actual approach of a nurse often slides down from a vocation to a mere employment. Conclusion The problems identified in the healthcare system indicate a wide range of factors influencing the relations between the nursing staff and patients. Multidimensional patient care concepts and examples from our healthcare system illustrate how clinical, structural, and interpersonal factors can interact in the relations between nursing staff and patient. The PCC concept should enable any health-care provider to set ways to improvement the care rendered and to motivate the caring staff to adopting it.

Philosophiae Doctor - PhD / Background: Satisfaction with the care mothers receive during child-birth is known to have a very strong influence on their future use of facility-based care during child-birth. Women and children continue to die from complications associated with pregnancy and child-birth and the majority of the causes that lead to mortality are related to labour and delivery. For this reason it is imperative for mothers to access facility-based child-birth care to receive skilled birth care. Mothers report dissatisfaction with facility-based child-birth care as one of the reasons for home births without skilled attendants. The presence of the skilled birth attendants is known to reduce maternal and neonatal mortality rates because of their ability to diagnose any early complications, and to intervene appropriately. Aim: The aim of the current study was to develop an in-service training programme for midwives to provide patient-centred child-birth care that would increase client satisfaction with child-birth care. Method and findings: The intervention research model by Rothman and Thomas (1994) – Design and development (D & D) – was used as the research framework. Only the first four of the six phases of the D & D model were applied in this study. In the first phase, a situational analysis was done using a qualitative study. The expectations, experiences, and satisfaction with child-birth care of antenatal and postnatal mothers, were explored. The research was conducted in four health institutions within the Kumasi Metropolis. Between 12 and 15 participants were purposively sampled in each hospital. Data were collected by means of individual in-depth interviews using an interview guide and data were analysed using content analysis. The study found that mothers expected to receive respectful care and safe care. Mothers had encouraging experiences and discouraging experiences during their child-birth care. The discouraging experiences did not align with their expectations of care, leading to dissatisfaction with child-birth care. In the second phase of the study an integrative literature review was conducted to identify evidence-based best practices to deal with client dissatisfaction with health care. The integrative literature review indicated that in-service training was commonly used as best-practice to improve health professionals' knowledge, skills and attitudes towards work and consequently to improve health outcomes for patients, including client satisfaction. In the third phase of the study, the in-service training programme to enhance patient-centred care was developed using Chinn and Kramer (2005) guidelines for programme development and steps to programme development by Management Sciences for Health (2012). The fourth phase entailed an assessment of feasibility and usability of the in-service training programme using 6 midwives in a district Hospital. The procedure was guided by the I-Tech Technical Implementation guide (2010). The outcomes of the assessment was used to refine and revise the developed in-service training programme. Conclusion: This study sought to develop an intervention to increase client satisfaction with child-birth care service by engaging the following processes in phases: • Assessing the expectations and experiences of mothers about child-birth care services. • An integrative literature review for evidence-based best practice to tackle client dissatisfaction with health care. • Designing a patient-centred care in-service training programme together with experts in the field of maternal and child health. • As assessment of feasibility and usability of the in-service training programme by means of a pilot test to refine the programme. Recommendations: It was recommended among others that, the study is carried out on a national scale to cover all administrative regions of Ghana. It is further recommended that the study findings and the programme developed form part of the continuous professional assessment course requirement for nurses and midwives.

Aim and objectives. Although many international sources in literature describe the treatment regimes for the management of adult female rape survivors, very few actually evaluate if the care that is implemented, are beneficial and supportive towards an optimal level of health. The researcher initiated this study to specifically determine what the experiences of adult female rape survivors were with regards to the management they received from health care workers in the emergency care environment. This information that was gathered was then incorporated into the writing of recommendations for health care services towards the improvement of patient-centred care. Method. A qualitative phenomenological methodology guided the research process in which ten semi-structured voluntary interviews was held with adult female rape survivors. This study was conducted in a private hospital in Gauteng, South Africa, which is at the top of the international statistics list for the incidence of rape. Findings. Patient management with regards to accessibility to health care services, the forensic examination and the use of medications proved to be a major concern. Participants in this study emphasized the value and importance of the physical presence of family members or significant others. A positive attitude from these support-givers improved the patient’s psychological state, memory and co-operation. Prolonged waiting times in all areas of management contributed to an increased level of anxiety, where as the prompt and competent interventions by empathetic multi-disciplinary team members had improved patient satisfaction. Various patient responses after the rape incident warranted that minimal, but yet effective and professional health care workers be involved in rape survivor management. Confidentiality and honest, effective communication that is based on patient preference, should guide all interventions. Conclusion. The medical management of adult female rape survivors in this hospital compared favorably to international standards, however, the need to improve the level of specific patient-centred care exists in order to ultimately facilitate a better quality of service provision. Copyright / Dissertation (MCur)--University of Pretoria, 2009. / Nursing Science / unrestricted

Bakgrund: Brister i kommunikation och informationsöverföring är en av de största orsakerna till vårdskador. För att arbeta mot en säkrare vård måste patienterna bli delaktiga. Delaktiga patienter är nyckeln till personcentrerad och säker vård. Ett sätt att involvera patienterna är genom att de får delta i bedsiderapportering. Syfte: Att beskriva patienters upplevelser när sjuksköterskor använder bedsiderapportering vid skiftbyten.  Metod: En litteraturöversikt med induktiv ansats, baserad på sju artiklar med kvalitativ design och tre artiklar med mixad design. Artiklarna är hämtade från CINAHL och Medline. Resultat: Analysen resulterade i två teman, inkluderande vårdrelation och samtal på lika villkor. Patienterna upplevde att bedsiderapportering kunde främja delaktighet i vården, patienterna fick vara en del av informationsutbytet och bidra med meningsfull information. Patienternas känsla av trygghet ökade och sjukhusupplevelsen förbättrades vid säkerställandet av informationsutbytet. Däremot framkom även önskan från patienterna om ökat deltagande, bibehållen konfidentialitet och bli inbjuden i bedsiderapporteringen av sjuksköterskorna. Slutsats: Resultatet framhäver både positiva och negativa upplevelser. Bedsiderapportering kan vara ett steg mot mer personcentrerad vård men ytterligare riktlinjer behövs som berör hur konfidentialiteten bör hanteras. Framtida forskning behövs för att studera om metoden är lämplig för alla patientgrupper. / Background: Healthcare related injuries are often caused by insufficient communication and poor transferring of information. To make healthcare better the patients need to be included in the process. Keeping the patients involved is the key to patient-centred and safer health care. One way to involve the patient is through implementing “bedside handover”. Aim: To describe patient’s experiences when nurses implement bedside handover during shift change. Method: The study is a literature review with an inductive approach, based on seven articles with a qualitative method and three articles with mixed methods. The articles were taken from the databases CINAHL and Medline. Results: The results generated in in two themes: healthcare relationship and conversations on equal terms. The patients experienced that bedside handover could promote participation in care, patients could be a part of the information exchange and contribute with meaningful information. Patients' sense of security increased, and the hospital experience improved when they could secure the information. However, some patients wished for increased participation, maintained confidentiality and to be more invited to participate in the nursing bedside handover. Conclusion: The result highlights both positive and negative experiences. Bedside reporting can be a step toward more person-centered care, but additional guidelines are needed that address how confidentiality should be handled. Future research is needed to study whether the method is appropriate for all patient groups.

My thesis examines patients’ and caregivers’ perspectives on educating healthcare providers(HCPs). Specifically, it examined two research questions: 1) What do patients think about their involvement in the education of HCPs? and 2) What roles do patients want to have in the education of HCPs? It is important for educational leaders and HCPs to understand answers to these questions, from patients’ own perspectives, to make effective changes in current and future health professions education and ultimately, the delivery of patient-centred care. I conducted semi-structured interviews with 27 patients and caregivers for this study. Through conventional content analysis, I identified five themes for what patients think about their involvement in the education of HCPs. Namely, patient involvement in the education of HCPs: (1) is challenging because of power-differentials between themselves and HCPs; (2) requires patient training; (3) needs to start early in HCPs’ education process; (4) can improve patient-HCP partnerships; and (5) requires compensation for patients. I also identified three roles that patients want to have in the education of HCPs. Specifically, they want to: (1) teach HCPs about patients’ expectations, experiences, and perspectives through case studies, storytelling, and research; (2) provide direct feedback to HCPs; and (3) advise on curricula development and admission boards for HCPs. My research adds to the limited research on patients’ and caregivers’ perspectives on their involvement in the education of HCPs, identifies barriers to patient involvement, and provides a foundation that HCPs and educational leaders can use to improve patients’ active involvement in the education of HCPs. Further, it highlights that patients’ voices are important to the education of HCPs. It also illuminates my own perspectives on patient involvement in the education of HCPs, which I share as part of my positionality as a researcher who conducted this study.

Background: Parkinson's disease [PD] is increasing more than any other neurological disease worldwide. PD is a multifactorial neurodegenerative disease with progressive impairment of motor control. Those affected by PD need an individual assessment regarding the care, rehabilitation and aids. Relatives are seen as a resource and carers can spend up to 110 hours a week caring for their relatives with PD. Aim: The aim was to investigate how elderly people with Parkinson's disease experience their care at home and how carers are affected. Method: The study is a literature review where previous knowledge is compiled into an overview. The literature review includes both qualitative and quantitative articles that where searched and selected from the databases Pubmed and Cinahl.  Results: Two major themes emerged: Aging with PS in the ordinary home and the impact of support in everyday life. The participants expressed the value of support, communication and care from health organisations, relatives and other PD-effected people.  Conclusion: The results showed that access to good healthcare and support was a decisive factor to be able to continue to live as normal as possible in the ordinary housing. Most family carers needed support from formal caregivers to cope. Information and education about Parkinson's pathophysiology and emotional support had a major impact to be able to plan the future and to be able to cope with the disease. / Att åldras medför förändringar och nya anpassningar i vardagen både för den äldre och de anhöriga. Att samtidigt drabbas av Parkinsons sjukdom (PS) medför ytterligare utmaningar och många som drabbas av sjukdomen upplever en livskris. Många av de som drabbas av sjukdomen och deras anhöriga har en önskan om att den drabbade ska kunna fortsätta bo kvar i det ordinära boendet och för att detta skall vara möjligt krävs rätt stöd och hjälpmedel för att vardagen skall kunna fungera på ett liknande sätt som tidigare. Denna litteraturöversikt undersöker hur personer som är äldre och har drabbats av PS upplevervården i det ordinära boendet samt hur anhörigvårdarna påverkas. I resultatet framkom vikten av stöd i hemmet för att skapa en fungerande vardag, både socialt och praktiskt. Sjuksköterskan har en avgörande roll för de som vårdas i det ordinära boendet även om de har en anhörigvårdare. Emotionellt stöd, kunskap om sjukdomens patofysiologi, de formella vårdgivarnas kunskaper och anhörigvårdarnas möjlighet till avlastning är viktiga delar som studien kom fram till. PS är en multifaktoriell neurodegenerativ sjukdom med progressiv försämring av motorisk kontroll. Att vara anhörig till en som drabbats av PS kan upplevas frustrerande eftersom den framtida prognosen inte är självklar och framtiden upplevs som oviss. Sjuksköterskan blir därför en bra resurs och informationskälla för medicinska- och patofysiologiska kunskaper hos båda parter. I diskussionen framkom det att vardagen förändrades markant för de som blir involverade i sjukdomen när någon drabbas. Sjukdomen uttrycker sig på olika sätt hos de drabbade och många av de vardagliga aktiviteterna behöver anpassas efter den PS-drabbades enskilda förmåga. Stöd i vardagen och utbildning om sjukdomens patofysiologi var viktiga grundstenar för att få en fungerande vardag. Studiens metod var litteraturöversikt där både kvalitativa- och kvantitativa artiklar har använts. Resultatet består av tio artiklar som analyserats och kodats enligt Friberg (2017). De valda artiklarna till resultatet kom ifrån sju olika länder vilket ökar överförbarheten då det kan leda till internationell kunskap.