Using Visual Methods to Capture Patient Perspectives in Interprofessional Team-Based Care for Chronic Disease Management

Background: Understanding how patients perceive their role in the healthcare team can improve overall satisfaction of care and health outcomes. However, it has been challenging to capture the diversity of patient experiences using traditional research approaches. The goal of this study was to explore the perspectives of patients involved in an interprofessional team-based chronic disease management program for chronic obstructive pulmonary disease using visual research techniques. Methods: Our visual approach began with patients autonomously drawing (or mapping) experiences with their healthcare team. The maps were explored with the patients through focus group discussions. Maps were inductively coded to identify similarities and differences between participants’ perceptions. Focus group transcripts were first analyzed independently, then compared to and integrated into the map analysis. Findings: Overall, participants (n = 13) were satisfied as patients of team-based care. Participants drew multiple healthcare providers, sources of information, and themselves to represent their teams. Relationships and significance were represented using arrows, the size of each team member, facial expressions, and symbols. Four key elements of effective team-based models of care emerged: 1) effective information sharing, 2) diversity of providers’ roles, 3) empowerment through self-management, and 4) enhanced access to care. Conclusion: This study used visualization methodology to obtain patient feedback on the program’s performance, elicit patients’ experiences, and attempt to mitigate some of the limitations of isolated survey and focus group methodology, subsequently obtaining rich data on team-based care. Our research also informs ongoing quality improvement of the team nbased model for chronic disease management

Managing exacerbations of chronic obstructive pulmonary disease - An investigation of treatment decisions from a primary care perspective

The paper II of this thesis is not available in Munin. Paper II: Laue, J., Melbye, H., Risør, M. B.: “Self-treatment of acute exacerbations of chronic obstructive pulmonary disease requires more than symptom recognition – A qualitative study of COPD patients’ perspectives on self-treatment”. Published version available in BMC Fam Pract. 2017; 18: 8. Exacerbations of chronic obstructive pulmonary disease (COPD) compose a considerable burden for both patients and health care systems. Optimal management in primary care, including self-treatment of COPD exacerbations with antibiotics and oral corticosteroids, is considered to be one key for providing good care for patients at reasonable costs. This thesis aimed to explore treatment of COPD exacerbations with antibiotics and/or oral corticosteroids and hospitalization from different primary care perspectives, e.g. guidelines, general practitioners and patients. A systematic review of treatment criteria for antibiotics and oral corticosteroids in national and international COPD guidelines, and an assessment of the underlying evidence for these recommendations composed the first part of the project. The results showed that the recommended treatment criteria were mostly based on respiratory symptoms, and that the studies the recommendations are based on are often conducted with patients that are not representative for a primary care setting. The second study explored COPD patients’ perspective on self-treatment with antibiotics and oral corticosteroids through a thematic analysis of 12 semi-structured in-depths interviews. We found that concerns with the medications’ adverse effects play a key role in CODD patients’ decisions to initiate self-treatment with antibiotics and/or oral corticosteroids. The nature of the patient-physician relationship including the patients’ understanding of legitimacy to seek help is important to their help seeking behaviour when feeling insecure about the need for treatment or in case of treatment failure. The third study investigated GPs’ accounts of their decision-making regarding treatment with antibiotics and oral corticosteroids and hospitalization through a thematic analysis of seven focus group discussions. The results show that one main driver of GPs’ decision-making are worries about having overlooked a severe underlying illness. GPs consider at holistic understanding of illness and the patients’ own experiential knowledge important to make reasonable decisions for the individual patient under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the healthcare systems’ organization and sociocultural ‘code of conduct’. Overall, the findings of this thesis support an integrative and collaborative approach to management of COPD exacerbations. The heterogeneous, versatile and often individualized nature of COPD exacerbations requires a flexible framework to decision-making that integrates both medical knowledge and other types of knowledge that are grounded in human experience and relationships. Such an integrative understanding of knowledge may guide future clinical research and guideline development in considering primary care evidence and expertise from primary care stakeholders and patients to a larger extent, and may also facilitate collaborative management of COPD exacerbations that allows for sharing expertise and responsibility between patients and the involved carers.Forverringer av kronisk obstruktiv lungesykdom (KOLS) er en betydelig byrde for pasienter og helsesystemer. Optimal behandling av KOLS forverringer i primærhelsetjenesten, inkludert egenbehandling med antibiotika og orale kortikosteroider, ansees som meget viktig for å sikre god behandling og samtidig redusere den økonomiske byrden. Denne avhandlingen ønsker å øke kunnskapen om behandling av KOLS pasienter med eksaserbasjoner i primærhelsetjenesten ved å utforske tre forskjellige perspektiver (retningslinjer, pasienter og allmennleger) på dette fenomenet. Denne avhandlingen er basert på tre studier. Første studie er en systematisk review av behandlingskriterier for antibiotika og orale kortikosteroider i nasjonale og internasjonale KOLS retningslinjer og en kritisk evaluering av evidensen som anbefalingene er basert på. Resultatene viser at behandlingskritene er hovedsakelig basert på respiratoriske symptomer og at evidensen er i lite grad overførbar til en primærhelsetjenestekontekst. I den andre studien ble KOLS pasienters erfaringer med egenbehandling utforsket ved tematisk analyse av 12 semi-strukturerte dybde-intervjuer. Hovedfunnene viser at bekymringer for medisinenes bivirkninger spiller en viktig rolle i pasientens beslutninger angående behandlingsstart, og at lege-pasient forholdet inkludert pasientens forståelse av eget ansvar for behandlingen kan påvirke i stor grad om og når pasienter søker hjelp ved usikkerhet eller når behandlingen ikke virker. Målet for den tredje studien var å utforske allmennlegers beslutninger på behandling av KOLS eksaserbasjoner med antibiotika og orale kortikosteroider, og innleggelser, ved tematisk analyse av 7 fokusgruppeintervjuer fra forskjellige europeiske land og Hongkong. Hovedfunnene viser at usikkerhet og redsel for å ha oversett alvorlig sykdom er sterke pådrivere i allmennlegers beslutninger. Allmennlegene syntes at en holistisk forståelse av sykdommen og å involvere pasienters erfaringsbasert kunnskap i beslutningene er viktig for adekvat behandling av den enkelte pasienten. Samlet støtter resultatene av de tre studiene integrativ og samhandlingsbasert behandling av KOLS pasienter med eksaserbasjoner. De heterogene, komplekse og ofte individualiserte KOLS eksaserbasjoner krever en fleksibel ramme for beslutninger som integrerer både biomedisinsk kunnskap og andre typer kunnskap som er basert på menneskers erfaring og relasjoner. En slik integrativ forståelse av kunnskap vil kunne guide fremtidig klinisk forskning og utvikling av retningslinjer i å ta større hensyn til medisinsk kunnskap og ekspertise fra primærhelsetjenesten og pasienter, og vil også kunne fremme samhandling basert på deling av kunnskap og ansvar mellom pasienter og helsepersonell, og helsepersonell imellom

Educating Staff Nurses for Successful Patient Discharge

The definition of a successful discharge is a discharge that results in patients successfully managing a chronic disease for at least 30 days without requiring an acute inpatient hospitalization. Many chronic disease readmissions are preventable. Successful discharge planning takes a multidisciplinary team that includes nurses who assess the discharge plan and provide additional education where needed. The purpose of this project was to determine staff nurses\u27 understanding of their role in discharge education. Dorothea Orem\u27s self-care deficit theory guided the project and root cause analysis was used in the development of the problem statements. Staff nurses (n=12) from evening and day shift of a rural hospital were interviewed using questions developed from the content from the literature review. Individual interviews were conducted with the volunteer participants and data from the interviews were examined using content analysis. Results included barriers to discharge education were related to inadequate nursing education, poor patient compliance, and inadequate discharge planning. Recommendations from the nurses\u27 interviewed included the need for staff nurse education regarding their role in the educational needs of the patient and their family prior to discharge. The findings from this project may benefit nurses\u27 practice by providing them with an understanding of the need for effective discharge education for patients. When patients are appropriately educated prior to discharge, their ability to self-manage their disease may improve, which can result in a decrease in health care costs and preventable readmissions. Educating nurses about their role in discharge planning promotes positive social change by improving the quality of the discharge education and patient outcomes