Canadians are worried about the future of the health care system, and provincial governments are questioning the ability of the existing system to support Canadians health care needs in the 21st Century(Industry Canada, 2011). Health care providers and system administrators are both driving and experiencing a paradigm shift; moving away from paternalism and toward an egalitarian approach. In order to practice patient centredness, health care providers must prioritize patient needs; provide information regarding treatments while taking patient preferences into account (Romanow, 2002). While there is a growing body of literature regarding patient centredness, there is scant information from the patient perspective. If the most effective and acceptable health services are those that realize the expectations of the users, this is an important area of study. Using phenomenological research methods and the theory of planned behaviour as a theoretical framework, the purpose of the study was to explore the influence of beliefs, attitudes and experiences on behaviour from the perspective of patients in primary health care or stroke rehabilitation. A second purpose was to explore the degree to which beliefs, attitudes and behaviour were similar between clinical contexts. The theory of planned behaviour was unsuitable for understanding peoples’ beliefs, attitudes and behaviour about being a patient. Being a patient was not a single, observable behaviour, but rather a set of contextually dependent strategies patients’ directed at a particular goal. The goal for each participant group was different; rehabilitation patients focused on the specific goal of recovery and discharge, while PHC patients focused on a broader goal of accessing and receiving best health care possible. These goals were reflected in their respective approaches to accessing health care services, an experience they described as socially oriented, governed and reinforced. Although patients described themselves as actively engaged, they did not approach each interaction with health care with a set of behavioural beliefs about being a patient. During the course of their participation, patients identified, developed and adopted strategies to assist in achieving the target; and evaluated those strategies more positively.

Canadians are worried about the future of the health care system, and provincial governments are questioning the ability of the existing system to support Canadians health care needs in the 21st Century(Industry Canada, 2011). Health care providers and system administrators are both driving and experiencing a paradigm shift; moving away from paternalism and toward an egalitarian approach. In order to practice patient centredness, health care providers must prioritize patient needs; provide information regarding treatments while taking patient preferences into account (Romanow, 2002). While there is a growing body of literature regarding patient centredness, there is scant information from the patient perspective. If the most effective and acceptable health services are those that realize the expectations of the users, this is an important area of study. Using phenomenological research methods and the theory of planned behaviour as a theoretical framework, the purpose of the study was to explore the influence of beliefs, attitudes and experiences on behaviour from the perspective of patients in primary health care or stroke rehabilitation. A second purpose was to explore the degree to which beliefs, attitudes and behaviour were similar between clinical contexts. The theory of planned behaviour was unsuitable for understanding peoples’ beliefs, attitudes and behaviour about being a patient. Being a patient was not a single, observable behaviour, but rather a set of contextually dependent strategies patients’ directed at a particular goal. The goal for each participant group was different; rehabilitation patients focused on the specific goal of recovery and discharge, while PHC patients focused on a broader goal of accessing and receiving best health care possible. These goals were reflected in their respective approaches to accessing health care services, an experience they described as socially oriented, governed and reinforced. Although patients described themselves as actively engaged, they did not approach each interaction with health care with a set of behavioural beliefs about being a patient. During the course of their participation, patients identified, developed and adopted strategies to assist in achieving the target; and evaluated those strategies more positively.

Cultural competency is theorized as the sensitivity of practitioners from the dominant culture towards the diverse cultural backgrounds of their patients. Less attention is placed on how communication between providers and patients can enable patients to share their health care beliefs. An evidence review of the literature around the conceptualization of cultural competency in health care was performed, and interviews were conducted aiming to understand what immigrant patients perceive as culturally competent care and its effect on the relationship between them and their providers. Definitions of cultural competence varied, and no conclusive studies linking cultural competence to improved health outcomes were found. Findings from the participant interviews helped to address gaps in the literature by confirming a preference for a patient-centred approach to culturally competent care, in addition to identifying pre-existing expectations for the health care encounter and patient-dependent factors as additional elements influencing the physician-patient relationship.

Cultural competency is theorized as the sensitivity of practitioners from the dominant culture towards the diverse cultural backgrounds of their patients. Less attention is placed on how communication between providers and patients can enable patients to share their health care beliefs. An evidence review of the literature around the conceptualization of cultural competency in health care was performed, and interviews were conducted aiming to understand what immigrant patients perceive as culturally competent care and its effect on the relationship between them and their providers. Definitions of cultural competence varied, and no conclusive studies linking cultural competence to improved health outcomes were found. Findings from the participant interviews helped to address gaps in the literature by confirming a preference for a patient-centred approach to culturally competent care, in addition to identifying pre-existing expectations for the health care encounter and patient-dependent factors as additional elements influencing the physician-patient relationship.

Introduction: Patient-centred communication is vital to ensure a good patient experience in the emergency department. Visits to the emergency department leave patients disillusioned regarding the communication experienced and this increases patient dissatisfaction. There is a need to put the "patient" back in communication in order to make it more patient-centred and provide the patient the opportunity to voice their individual needs pertaining to patient-centred communication. The aim of the study was to co-design patient-centred communication in an emergency department. In order to reach the aim of the study the following objectives were set: To explore current communication in an emergency department as experienced by patients and healthcare professionals. To collaboratively co-design strategies to enhance patient-centred communication in an emergency department. Research design and methods: An Experience-based Co-design has been used. Unstructured observation was done to observe existing communication in the emergency department. Patients have told their stories through narrative-based film interviews and healthcare professionals have been interviewed to share their experiences regarding communication in the emergency department. The observation notes and interviews have been shared during a Co-design event. Patients and healthcare professionals have collaboratively analysed the data to identify key touch points and co-design strategies to enhance patient-centred communication in the emergency department. Results: Three (3) key touch points were identified namely; professionalism, communication and daily focus. The patients and healthcare professionals were equal partners to change the communication culture in the emergency department to be more patient-centred. This may lead to positive patients' experiences with an increase in patient satisfaction. Conclusion: The ultimate goal of this study was to raise awareness relating existing communication in the emergency department and collaboratively plan strategies to work towards patient-centred communication. / Dissertation (MCur)--University of Pretoria, 2017. / Nursing Science / MCur / Unrestricted

Cultural competency is theorized as the sensitivity of practitioners from the dominant culture towards the diverse cultural backgrounds of their patients. Less attention is placed on how communication between providers and patients can enable patients to share their health care beliefs. An evidence review of the literature around the conceptualization of cultural competency in health care was performed, and interviews were conducted aiming to understand what immigrant patients perceive as culturally competent care and its effect on the relationship between them and their providers. Definitions of cultural competence varied, and no conclusive studies linking cultural competence to improved health outcomes were found. Findings from the participant interviews helped to address gaps in the literature by confirming a preference for a patient-centred approach to culturally competent care, in addition to identifying pre-existing expectations for the health care encounter and patient-dependent factors as additional elements influencing the physician-patient relationship.

The general practitioner has a central position in the health care system, but demands have increased and there are signs of exhaustion in the corps. Patient-centredness is beneficial for the patients and probably for the outcome of health care. In Balint groups general practitioners study and gain further understanding of the physician-patient relationship by means of the participants’ own experiences. This thesis aims at studying experienced effects of Balint groups on the working life of general practitioners. General practitioners with and without Balint group experience are compared by means of a questionnaire, using statistical methods. General practitioners with Balint group experience are interviewed. Both these studies show positive experiences of Balint group participation in the physicians’ working life in terms of feeling of control and satisfaction, and on relations to patients, particularly patients with complex problems. A new instrument for measuring physicians’ degree of patient-centredness is presented. It can be used in groups of physicians to evaluate training programmes or by the individual physician to detect decline in patient-centredness as an early sign of burnout. Balint groups are viewed critically in interviews with Balint group leaders, focussed on difficulties and dropouts from the groups. Balint groups are found to fit into modern theories of small groups as complex systems, submitted to group dynamics that are sometimes malicious. Professionally conducted Balint groups seem to be a gentle, efficient method to train physicians, but with limits. Participation of a member demands a stable psychological condition and an open mind, and obligatory Balint groups are questioned. The thesis concludes that Balint groups are generally beneficial for general practitioners’ working life as a means to enable the physicians endure, even thrive in their job. The method facilitates development of new understanding of the physician-patient relationship with possible positive effects for the patient as well.

Background: Type 2 diabetes is a serious disease that is increasing globally. The focus of diabetes care has been to prevent diabetes related complications and thereby reduce mortality. An older population, the disease progression and decreased ability to perform self-management activities increases the risk for complications. Group education and patient-centred care are recommended to improve self-management through increased patient empowerment. Despite these recommendations, professionals have been reluctant to adopt these methods referring to lack of knowledge, time and tools to deliver patient-centred care in diabetes. Focusing on the patient’s illness integration process has in the literature been suggested to improve self-management and metabolic balance. Aim: The overall aim of the thesis was to describe the experiences of illness integration, self-management and support in type 2 diabetes and to evaluate the metabolic effects of a nurse-led patient-centred model for self-management support. Methods: The study setting was primary health care in Västerbotten County, Sweden. In total, 21 diabetes nurses (Study I) and 257 patients (Studies II-IV) participated in the four studies (Study II, n=44; Study III, n= 18; Study IV, n= 195). Data consisted of focus group interviews (Study I), individual semi-structured interviews (Studies II-III) and laboratory measurements (Study IV). Methods for analyses were qualitative content analysis (Studies I-III) and statistics (Study IV). Results: Study I revealed that diabetes nurses found the ideal diabetes care complex to achieve. Conflicting paradigms, power relations and departmentalisation of work were described. Study II describes a process whereby illness integration and self-management in type 2 diabetes develop simultaneously. When a turning-point occurs, people view self-management as both necessary and feasible. In study III, turning points in self-management are illuminated. Turning-point transitions include existential and emotional aspects that increase inner motivation and power for lifestyle change. Study IV evaluates the effects of a nurse-led intervention in which haemoglobin A1c (HbA1c) was significantly decreased at 12 months’ follow-up. Group intervention and individual intervention were both effective compared to traditional diabetes care. Conclusions: There is a potential for improvement of type 2 diabetes care. Increased patient-centredness is important to support patients towards illness integration and self-management. Focusing on the patients’ illness experiences, including the existential and emotional aspects of having and managing type 2 diabetes, in counselling can lead to improved self-management and glycaemic control. Patients’ experiences of illness are central to their inner motives for change, and patient-centred self-management support and patient education preferably emanate from this perspective. / Bakgrund: Typ 2 diabetes är en allvarlig sjukdom som ökar globalt. Fokus i diabetesvården har varit att förebygga diabetesrelaterade komplikationer och därmed minska dödligheten. En åldrande befolkning, progression av sjukdomen samt en begränsad förmåga att utföra egenvårdsaktiviteter ökar risken för komplikationer. Grupputbildning och patientcentrerad vård rekommenderas för att förbättra egenvården genom ökad empowerment. Trots dessa rekommendationer har läkare och sjuksköterskor rapporterats vara tveksamma till dessa metoder och hänvisat till bristande kunskap, tidsbrist och avsaknad av verktyg. Att fokusera på patienters sjukdomsintegrationsprocess har i litteraturen föreslagits förbättra såväl egenvård som metabol balans. Syfte: Avhandlingens övergripande syfte var att beskriva erfarenheter av sjukdomsintegration, sjukdomshantering och support vid typ 2 diabetes samt att utvärdera effekter av en sjuksköterskeledd patientcentrerad modell för egenvårdssupport. Metod: Studierna genomfördes inom primärvården i Västerbottens läns landsting. Totalt deltog 21 diabetessjuksköterskor (Studie I) och 257 patienter (Studie II-IV), i de fyra studierna (Studie II, n=44; Studie III, n= 18; Studie IV, n= 195). Data bestod av fokusgruppsintervjuer (Studie I), individuella halvstrukturerade intervjuer (Studie II-III) och laboratoriemätningar (Studie IV). Analysmetoderna var kvalitativ innehållsanalys (Studie I-III) och statistik (Studie IV). Resultat: Studie I visade att en ideal diabetesvård är svår att uppnå enligt diabetessjuksköterskorna. Paradigmkrockar, maktrelationer och splittrade arbetsuppgifter beskrevs. Studie II beskriver en modell där sjukdomsintegration och sjukdomshantering utvecklas samtidigt. När en ”turning point” nåddes såg patienterna sjukdomshanteringen som både nödvändig och möjlig att genomföra. I studie III belystes ”turning points” och som omfattar både existentiella och emotionella aspekter som kan öka inre motivation och egenkraft att utföra livsstilsförändringar. Studie IV utvärderade 12-månaderseffekterna av en sjuksköterskeledd intervention och HbA1c sänktes signifikant. Gruppintervention och individuell intervention visades vara effektiva metoder i jämförelse med traditionell diabetesvård. Slutsatser: Det finns en förbättringspotential inom diabetesvården och ökad patientcentrering är viktig för att stödja patienter att integrera sjukdom och egenvård i livet. Att i diabetesvården fokusera på patienters sjukdomsupplevelser inklusive de existentiella och emotionella aspekterna av att leva med och hantera en sjukdom kan innebära förbättrad sjukdomshantering och metabol balans. Patienters sjukdomsupplevelser är centrala för deras inre motiv till förändring och patientcentrerad egenvårdssupport och patientutbildning bör utgå från detta perspektiv.

Background - Patients as active partners in their personal healthcare are key drivers to reducing costs, securing an effective usage of resources, and ensuring patient-provider satisfaction. Even though these benefits are acknowledged, a theoretical framework for the plethora of concepts used in this context, such as patient engagement, patient empowerment, or patient involvement is missing. Furthermore, the heterogeneous or synonymous usage of these terms leads to miscommunication, missing standard conceptual measures, and a deficiency in theory building and testing. Our objective is to show what the relationships and distinctions between concepts focussing on patients as active partners in their personal healthcare are. - Methods - systematic literature review was conducted to consolidate terms related to patients’ having an active role in their healthcare. From 442 articles screened in PubMed, a final set of 17 papers was included. Any articles conceptualising or presenting relationships between the concepts were included. Information was synthesised, and contradictions were unravelled systematically. The concepts and their relationships are structured and represented by employing a concept map. - Results - Patient-centredness is a concept dominantly influenced by health care providers and can enhance patients’ competencies, attitudes, and behaviours towards their personal healthcare. Enabling patients to become more empowered can ultimately lead to their greater involvement and engagement. Fostering an active role of patients can also increase their adherence to the care pathway. In general, patient engagement seems to be the most conclusive and furthest developed concept in terms of turning patients into active partners in their personal healthcare. - Conclusions We plead for a stricter demarcation and therefore a terminological standardisation of the terms in the future to avoid further ambiguity and miscommunication. The concept map presents a basis for a uniform understanding and application of the concepts. Through a comprehensive understanding of the terms and their dimensions, relationships between the concepts can be utilised, measures can be derived, and theory building and testing can be enhanced, leading to better acceptance and utilisation of concepts in healthcare services. Furthermore, patient engagement is presented to be the most conclusive and furthest developed concept in the subject area.

Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.