- Email: [email protected]
The impact of an intervention to improve patient participation in a surgical care unit: A quasi-experimental study
International Journal of Nursing Studies 49 (2012) 528–538
Contents lists available at SciVerse ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
The impact of an intervention to improve patient participation in a surgical care unit: A quasi-experimental study Eva Jangland a,*, Maria Carlsson b, Ewa Lundgren a, Lena Gunningberg b,c a
Department of Surgical Sciences, Uppsala University, Entrance 70, SE-751 85 Uppsala, Sweden Department of Public Health and Caring Sciences, Uppsala University, Sweden c School of Nursing, University of California, San Francisco, USA b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 April 2011 Received in revised form 14 September 2011 Accepted 26 October 2011
Background: Organizational changes in surgical care are requiring patients to become more responsible for their own care, both before and after surgery, and also during recovery. Involving patients in their care is vital to improving quality of care and patient safety. Objective: The aim of this study was to investigate the impact of the ‘Tell-us’ card on patients’ perceptions of quality of care, with a specific focus on patient participation. Another aim was to evaluate the use of the Tell-us card from the patients’ perspective. Design: A quasi-experimental design with an intervention group and control groups was used. The patient’s self-written Tell-us card was introduced as the intervention. Setting: The study was conducted in two surgical care units at a Swedish university hospital. Participants: A consecutive sample of patients admitted from the waiting list and from the emergency department was included (n = 310). The inclusion criteria were surgical patients with a hospital stay of at least one day. Patients who were younger than 18 years, not able to speak or write in Swedish, or unable or unwilling to give informed consent to participate were excluded. Methods: Quality of care was assessed using the questionnaire ‘Quality from the Patient’s Perspective’. The patients included in the intervention group were asked to write what was most important for them during the day or just before discharge on patient-written Tell-us cards. Results: The use of the Tell-us card resulted in significant improvements (5 out of 17 items) in patients’ abilities to participate in decisions about their nursing and medical care. The patients found the Tell-us card more useful in their interaction with registered nurses and assistant nurses than with physicians. Conclusions: The use of the Tell-us card improved patients’ participation in some areas of nursing and medical care in the surgical care units. The Tell-us card is an uncomplicated and inexpensive tool that could be an important step towards improved patient participation in the surgical care unit. More research is needed to evaluate the use of the Tell-us card in different hospital units and over a longer period of time. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Intervention study Patient-centred care Patient participation Surgical care unit Quality of care
* Corresponding author. Tel.: +46 0 18 6113722; fax: +46 0 18 559410. E-mail address: [email protected] (E. Jangland). 0020-7489/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2011.10.024
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
What is already known about the topic? Involving and recognizing the patient as a partner in the healthcare team is one of the mainstays of patientcentred care. Involvement of the patient in decision-making improves quality of care from the patients’ perspective and is associated with positive patient health outcomes. Organizational changes in the surgical care unit demand that patients are more responsible for their own care before and after surgery and also during recovery. What this paper adds The use of the Tell-us card improved patients’ participation in some areas of nursing and medical care in a surgical care unit. The Tell-us card, an inexpensive, uncomplicated tool could be used in clinical practice to improve patient participation in their own care. 1. Introduction In recent years studies have reported the need to recognize the patient as a resourceful partner in the health care team (Edwards, 2002; Taylor and Rutherford, 2010). Patient involvement has been found to improve quality of care, is associated with positive health outcomes for the patient (Griffin et al., 2004; Say et al., 2006), and is also an important factor in patient safety (Joint Commission, 2010). Government guidelines describe patient participation as a prerequisite to patient-centred care and require health professionals to involve patients in their care (IHI, 2009; Joint Commission, 2010). However, several studies show that for a variety of reasons patients may be displaced, forgotten, or hindered from being equal partners in the health care team (Sahlsten et al., 2005; Simi and Patoia, 2010). Although patient participation is a widely used concept, it is a complex phenomenon (Say et al., 2006; Eldh, 2006). Critical attributes for patient participation include an established relationship, respect for the individual, recognition of the individual’s knowledge and circumstances, and shared information (Eldh, 2006; Sahlsten et al., 2008). Patients’ preferences for involvement are influenced by many different factors (Doherty and Doherty, 2005; Say et al., 2006). Several studies show that women prefer a more active role in decision making than men (Say et al., 2006; Florin, 2006; Beaver et al., 2009). Experiences of illness and medical care, kind of decision, and earlier interactions and relationships with health professionals are also reported to influence patients’ preferences for participation (Say et al., 2006). Although several reports address improving patient involvement in consultations, fewer seem to consider the hospital setting. Clinical interventions including patienttargeted checklists and patient-held records, and providertargeted interventions such as education and training in communication skills, have been introduced to enhance patient participation in consultations (Lewin et al., 2009; Kinnersley et al., 2007). Bedside reporting (Timonen and
529
Sihvonen, 2000) and routinely asking patients to establish daily goals have been suggested as strategies to improve patient participation during hospital stay (Scott-Smith and Greenhouse, 2007; Sehgal et al., 2010). In a patient safety programme in the United States, patients took part in the care plan by writing down their goals each day to make clear to all members of the health care team what was most important to them. The patients’ self-written card was called the ‘Tell-us’ card (Sehgal et al., 2008, 2010). According to the communication framework outlined by Feldman-Stewart et al. (2005), it is important in the patient–health-professional interaction to address the patient’s goal. This goal may be seen as an expression of one or more of the patient’s needs that provides an opening for dialogue during the day and one more step towards patient involvement in care. The context of the present study is a surgical care unit in Sweden. Patient participation is highlighted as an important issue in Swedish health care (SOSFS, 2005, 2010), and descriptive studies report on the need to improve patient participation (Sahlsten et al., 2005; Fro¨jd et al., 2011). The patients cared for in such surgical units are operated on with more advanced surgery than only 20 years ago. Patients come to the unit earlier in the postoperative phase and they need more advanced nursing and monitoring. At the same time, length of hospital stay is becoming shorter, patients are older, and more planning of future care is required before discharge. Because of these contextual changes, patients today are more responsible for their own care before and after surgery and during recovery. Therefore, it is important that patients have the necessary knowledge and opportunity to be involved in their hospital care, and it is crucial to work out interventions in this setting that involve the patients in their own care. Within this study the definition of patient participation is inspired by the work of Eldh (2006), who recommends that the patient have knowledge of, and when possible, control of, the disease and treatment, to enable the patient to experience trust during the hospital stay and at discharge. A prerequisite for patient participation is a patient–healthprofessional interaction that includes dialogue characterized by respect, empathy, and recognition of the patient as an individual as well as a partner in the health care team. Patient participation is often used as an important outcome measure in questionnaires about quality of care (Donabedian, 1988; Wilde et al., 1994; Wilde Larsson and Larsson, 2002). Our hypothesis was that if patients were invited in a structured way to participate with their health care team during the hospital stay, the quality of care, and specifically patient participation, would be improved. The aims of the study were to investigate the impact of the Tell-us card on patient perception of quality of care, with a specific focus on patient participation, and to evaluate the use of the Tell-us card from the patients’ perspective. 2. Methods 2.1. Design The study had a quasi-experiemental design with ABA phases. Phase A was a period without intervention and
530
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
phase B a period with intervention. Phase A could also be called baseline (A1) or return-to-baseline (A2). The ABA design makes it possible to control the intervention and to evaluate the outcome after withdrawal of the intervention (Kazdin, 2003). 2.2. Setting The study was performed from October 2009 to May 2010 in two surgical care units in a large university hospital in Sweden. The hospital has 1100 patient beds and 8000 employees. The surgical units in this study admit mainly adult patients undergoing colorectal, endocrine, or breast surgery and acute patients with abdominal pain or trauma. During data collection the two units treated a large number of patients every month (mean 162 in unit 1 and 185 in unit 2), with hospital stays ranging less than one day to 99 days. The mean hospital stays in the units were 4.6 and 3.6 days, respectively. A number of patients with other medical diagnoses were temporarily in the surgical units because the hospital was short of beds. These patients were not included in the study. In the units a registered nurse and an assistant nurse work in a team responsible for 6–17 patients depending on the time of the day. A resident performs the ward rounds twice a day on weekdays and a surgeon on call once a day on weekends. Both report to a senior consultant. During hospital stay patients meet the surgeon responsible for the operation, the resident, or both. In each unit there is a nurse manager responsible for nursing care and a senior consultant for medical care. About 50 health professionals in various positions work in each unit.
the United States in the Triad for Optimal Patient Safety project as a way to assess patients’ goals for the day. Permission to use the American version of the Tell-us card as a model was obtained from the original researcher. The card was translated into Swedish by the authors and slightly modified for the surgical care context. The Tell-us card was designed as a tent card with two sides, where the patients could write down their specific questions and concerns for the day or before discharge. One side of the card was printed with brief instructions and information about patient participation as follows: ‘Tell us what is important for you today or before discharge. It is important that you have the knowledge you need and that you are involved in your care. Please use the space on the opposite side of this card and write down your questions and concerns’. On the oppsite side of the card, with space for responses, was printed (a) This is important for me today______, and (b) This is important for me before discharge_______. The patients in the intervention group were asked to use the cards each day, and every morning the registered nurse responsible for their care provided new cards. The card was placed in a fully visible spot on the table in the patients’ room. At the start of the intervention both verbal and written information was given to all health professionals in the two units. The information was repeated during the study, directing health professionals to regard what the patient wrote on the Tell-us card as a tool in their dialogue with the patients, e.g. during ward rounds and discharge information sessions. 2.5. Standard procedure
2.3. Participants The study included a consecutive sample of patients admitted from the surgical waiting list or from the emergency department. The inclusion criteria were surgical patients with an expected hospital stay of at least one day. Patients were excluded if they were younger than 18 years, not able to speak or write in Swedish, or not willing or able to give informed consent. A power calculation was carried out, based on mean score and standard deviation from surveys using the questionnaire ‘Quality from the Patient’s Perspective’ (Wilde Larsson et al., 2005; Muntlin et al., 2006;), to decide the number of patients needed in the different study phases. It was estimated that to detect a mean difference of 0.35 in the primary endpoint ‘participation’ a sample size of 65 (A1), 130 (B), and 65 (A2) patients would be needed to find a significant difference between groups. With an estimated withdrawal of 25% and the lower power of a nonparametric analysis set at 10%, the number of patients included in the three phases was set to 95 (A1), 190 (B), and 95 (A2) (alpha < 0.05 and power 0.80, with an estimated standard deviation of 1.0 in each item). 2.4. Intervention Patient-written Tell-us cards were introduced as the intervention. The Tell-us card had previously been used in
The control group received the units’ standard level of information and communication during hospital stay and at discharge. Both units had routine preoperative information, ward rounds, and discharge information. However, the standard could vary depending upon the attending physician’s or nurse’s knowledge and capacity to perceive the patient’s need for conversation, information, and support. In certain cases, but not all, patients received written information at discharge. 2.6. Data collection The data collection was performed using the questionnaire ‘Quality from the Patient’s Perspective’. The questionnaire is based on a patient-centred theoretical model of quality of care developed through a grounded theory approach. The theoretical model describes four dimensions of care: an identity-orientation approach, medical technical competence, physical–technical conditions, and socio-culture atmosphere, and the questionnaire consists of questions designed to measure those four dimensions (Wilde, 1994; Wilde et al., 1994). A short version of the questionnaire was used, but with items from the long version added in the dimension of an identityorientation approach (Wilde Larsson and Larsson, 2002). The questionnaire has been developed in different groups of patients and settings, and the questionnaire for medical
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
and surgical units was used. The questionnaire has been tested for validity and reliability. Cronbach alpha coefficients range from 0.81 to 0.9 in the dimension of an identity-orientation approach (Wilde et al., 1994; Wilde Larsson and Larsson, 2002; Wilde Larsson et al., 2005). The analysis was made at the level of individual items. The questionnaire consisted of 54 items for patients in the control group (periods A1 and A2) and 62 for the intervention group (period B), measured the patient’s perception of the quality of care (‘This is what I experienced’) and the subjective importance of each item (‘This is how important it was to me’), and took about 15– 20 min to complete. Items related to perceived quality of care were rated on a scale of 1 (‘do not agree at all’) to 4 (‘completely agree’), the subjective importance of the various items was also rated from 1 (‘little or no importance’) to 4 (‘of the very highest importance’), and each item had a ‘not applicable’ response alternative. The questionnaire also contained questions about the patient’s background and state of health. The patients in the intervention group were also asked study-specific questions concerning the Tell-us card: (a) whether the patient used the card, (b) reason (if applicable) for not using the card, (c) whether the card was useful in the dialogue with the health care professionals during hospital stay and/or before discharge, and finally (d) whether the card allowed them to raise anything for discussion that they would not have mentioned had they not had the opportunity of writing it down on the card. 2.7. Procedure At the start of the first phase (A1), information provided to the health professionals was limited in order to avoid affecting the result. This information was given by the nurse managers. Before start of the intervention both verbal and written information was given to all health professionals in the two units by the first author. Information about the study and how to use the Tell-us card was also repeated during the intervention several times during daily practice. Patients in all periods were approached to take part in the study by the first author or one of four registered nurses who acted as co-ordinators for the study during data collection. Patients meeting the inclusion criteria were invited to participate at admission or, at the latest, within their first day of hospital stay. The patients were given verbal and written information about the study and informed consent was collected. Within a week after discharge all patients were sent the questionnaire by post and were asked to send it back in a prepaid envelope. The questionnaires were coded, and up to two reminders were sent. All administration of the questionnaires was handled by the first author.
531
versus control group) Chi-square test was used for dichotomous variables (e.g. gender, nationality, family situation, surgery or not, type of admission) and Mann– Whitney U-test was used for ordinal variables (e.g. hospital stay, education, and the items about perceived quality of care). Student’s t-test was used for the continous variable age. Statistical significance was set at p < 0.05. Responses of ‘not applicable’ were regarded as missing data in the analysis. 2.9. Ethical considerations The study was appoved by the Regional Ethical Review Board (No. 2009/170) and the head of the department of surgery. All patients received written and oral information about participation. The patients had the right to refuse participation without giving any reason and to withdraw from the study at any time (Codex, 2010). 3. Results A total of 451 patients meeting the inclusion criteria were approached, 387 agreed to participate, 310 completed the questionnaire in the different phases, and 77 patients did not complete the questionnaire. The response rate in the groups varied from 78% to 81%. The flow of the patients’ through each stage of the study is presented in Fig. 1. There was no significant difference between phases A1 and A2 with respect to perceived quality of care, and in the results the two groups are combined and presented as a single control group. There were no significant differences between the intervention group and the control group with respect to age, gender, nationality, family situation, occupation, educational level, or patients’ self-reported health status. The mean age was 58 years (range 21–86; SD = 16) in the intervention group and 58.5 years (range 22–92; SD = 14.5) in controls. However, the patients in the intervention group were admitted significantly more often from the waiting list (x2 = 7.49, df 1, p = 0.006), were more likely to have had a surgical procedure (x2 = 23.74, df 1, p < 0.001), and had a longer hospital stay (p = 0.01) than those in the control group (Table 1). No significant difference in gender was detected between the patients who declined and those who completed the questionnaire. However, the patients who declined to participate were significantly older (mean 65 years, t = 2.6, p = 0.01) and more often admitted from the emergency department (x2 = 25.48, df 1, p < 0.001) than the patients who participated. The patients’ ratings of the subjective importance of quality of care items (‘this is how important it was to me’) showed a significant difference between the groups in only 2 of 31 items. The patients’ perceived quality of care (‘this is what I experienced’) is reported below.
2.8. Data analysis 3.1. Quality of care from the patient perspective The data were registered in the KUPPIT computer programme (2007) and imported to SPSS version19.0 for analysis. Means, standard deviations, ranges, and percentages were used to describe the data. For comparisons between groups (i.e. A1 versus A2, and intervention group
Significant differences in perceived quality of care between the intervention group and the control group were detected in 5 out of 17 items in the dimension of identity-orientation approach (Table 2). The patients’
532
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
A1
B
A2
October 2009
November 2009/January 2010
April 2010
Surgical patients with a hospital stay > 1 day assessed for eligibility
Surgical patients with a hospital stay > 1 day assessed for eligibility
Surgical patients with a hospital stay > 1 day assessed for eligibility
N= 149
N = 297
N = 145
Excluded according to criteria
Excluded according to criteria
Excluded according to criteria
n= 38
n = 59
n = 43
Patients approached according to criteria
Patients approached according to criteria
Patients approached according to criteria
N = 111
N = 238
N = 102
Declined participation
Declined participation
Declined participation
n = 14
n = 45
n=5
Included patients
Included patients
Included patients
N = 97
N = 193
N = 97
Internal dropouts
Internal dropouts
Internal dropouts
n = 20
n = 36
n = 21
Analysed questionnaires
Analysed questionnaires
Analysed questionnaires
N = 77
N = 157
N = 76
Response rate 79%
Response rate 81%
Response rate 78 %
Fig. 1. The flow of the participants through each stage of the study.
opportunity to participate in decisions about their nursing care revealed a significant difference (p = 0.020) between the groups: a mean score of 3.2 (SD = 1.0) was reported in the intervention group compared to 2.9 (SD = 1.0) in the control group. Also a significant difference (p = 0.004) in the patients’ opportunity to participate in the decisions about their medical care was seen between the groups. The patients in the intervention group had a mean score of 3.5 (SD = 1.0) on the item, while the control group scored a mean of 2.7 (SD = 1.1). The patients in the intervention group reported significantly higher quality of care regarding registered nurses’ and assistant nurses’ commitment (p = 0.008), empathy (p = 0.004), and respectful treatment of patients (p = 0.011) compared to the patients in the control group. However, there was no significant difference in the patients’ perception of physicians’ commitment, empathy, or respectful treatment between the groups.
There were no significant differences in any of the six items related to information. The item regarding useful information about self-care had the lowest mean score throughout the study phases with a mean of 2.5 (SD = 1.1) in the intervention group and 2.4 (SD = 1.1) in the control group. To summarize, 141 patients (51%) reported that they did not receive useful information about self-care (scores 1 and 2), 120 patients (40%) reported that they did not receive information about which physician was responsible for their medical care, and 109 patients (36%) did not receive information about which registered nurse was responsible for their nursing care. No significant differences between the intervention and control groups were found in perceived quality of care in the three other dimensions (i.e. medical technical competence, physical–technical conditions, and socio-cultural atmosphere). However, patients in both groups had low mean scores on the quality of the food (2.8 and 2.7) and on
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
533
Table 1 Background information of the participants. Control group n = 153 %
n Gender Men Women Nationality Swedish Other Family situation Married/living together Single/living alone Occupation Working Student Other Education Elementary school Upper secondary school University Admissiona Waiting list Acute Surgeryb Yes No Days of admissionc 0–1 day 2–3 days 4–6 days 2–9 days 10 or more days
Intervention group n = 157 n
%
65 88
42 58
58 99
37 63
137 16
90 10
140 17
90 10
107 46
70 30
122 34
78 22
77 6 70
50 4 46
82 8 67
52 5 43
44 55 53
29 36 35
30 67 58
19 43 37
80 73
52 48
106 51
68 32
88 65
58 42
130 27
83 17
21 74 34 13 11
14 48 22 8 7
16 60 42 14 25
10 38 27 9 16
Where numbers in a category do not add up to n or 100%, there was internal dropout. a Differences between groups: p = 0.006 (Chi-square test). b Differences between groups: p < 0.001 (Chi-square test). c Differences between groups: p = 0.01 (Mann–Whitney U-test).
the opportunity to talk to physicians privately when they wanted to (2.9 and 2.8) (Table 3). 3.2. Subgroup analyses Subgroup analysis showed that patients in the intervention group who had a surgical procedure reported significantly more often (p = 0.035) that the information they received about examination and treatment was useful compared to the same subgroup of controls. Furthermore, the patients in the intervention group with a hospital stay under one week reported significantly more often that they had had the opportunity to participate in decisions that applied to their medical care (p = 0.003) and nursing care (p = 0.02) than the same subgroup of control patients. Finally, the subgroup analysis showed that patients in the intervention group who had been admitted from the waiting list significantly more often reported that they had had the opportunity to participate in decisions that applied to their medical care (p = 0.048) than the same subgroup of control patients. 3.3. Evaluation of the Tell-us card from a patients’ perspective In the intervention group, 126 out of 157 patients (80%) used the card every day or at least once during the hospital stay. Twenty-four patients (15%) did not use the card at all. The reasons for not using the card were ‘did not feel well’,
‘no one paid attention to the card’, ‘received information without using the card’, ‘too short hospital stay’, and ‘did not receive a card’. Seven patients (5%) did not answer this part of the questionnaire. Forty-two patients (34%) answered that they wrote questions or concerns on the Tell-us card which they would not have raised without the opportunity of writing them down on the card. There were significant differences in how useful the Tell-us card was in the dialogue with registered nurses and assistant nurses compared with physicians. Sixty-seven patients (56%) found the card useful in the dialogue with the registered nurses and assistant nurses during the hospital stay, while 30 patients (25%) thought the card was useful in the dialogue with the physician (x2 = 27.53, df 1, p < 0.001). Corresponding figures for usefulness at discharge show that 43 patients (36%) found the card useful with the registered nurses and assistant nurses, and only 28 patients (24%) found it useful with the physicians (x2 = 34.06, df 1, p < 0.001). Patients most often wrote short comments on the cards, but some long descriptions were also seen. A brief summary of what the patients wrote on the Tell-us card is shown in Table 4. 4. Discussion The aim of this study was to investigate the impact of the Tell-us card on patients’ perceptions of quality of care,
534
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
Table 2 Patients’ perception of the quality of care in the dimension of ‘identity-oriented approach’ in surgical care units. Dimension/factor
Identity-oriented approach Participation Perception of health problems was taken into consideration Had opportunity to participate in the decisions that applied to medical care Had opportunity to participate in the decisions that applied to nursing care Receiving information about How the examinations and treatments would take place The results of examinations and treatments Self-care: ‘How I should take care of myself’ Medication Which physician was responsible for my medical care Which registered nurse was responsible for my nursing care Showing commitment The physicians The registered nurses and the assistant nurses Empathic and personal The physicians Seemed to understand how I experienced my situation Showed empathy when I felt bad, e.g. worry or pain The registered nurses and the assistant nurses Seemed to understand how I experienced my situation Showed empathy when I felt bad, e.g. worry or pain Being respectful towards the patient The physicians The registered nurses and assistant nurses
Control group (n = 153)
Intervention group (n = 157)
Mann–Whitney U-test
n
Mean
SD
n
Mean
SD
p-value
134 116
3.3 2.7
0.8 1.1
137 155
3.3 3.5
0.9 0.9
0.790 0.004
116
2.9
1.0
117
3.2
1.0
0.020
152 150 132 120 147 150
3.4 3.2 2.4 3.0 2.8 2.8
0.9 1.0 1.1 1.0 1.2 1.1
157 150 143 135 154 152
3.3 3.2 2.5 3.0 2.9 2.9
0.94 0.9 1.1 1.0 1.1 1.1
0.508 0.886 0.360 0.492 0.438 0.436
148 151
3.2 3.5
0.9 0.7
150 154
3.3 3.7
0.9 0.6
0.455 0.008
150 114
3.2 3.1
0.9 0.9
154 119
3.2 3.1
0.9 1.0
0.852 0.542
150 123
3.4 3.5
0.8 0.7
153 126
3.6 3.7
0.6 0.6
0.004 0.112
149 153
3.5 3.6
0.7 0.6
154 156
3.5 3.8
0.8 0.5
0.692 0.011
Where item numbers (n) are less than group numbers (N), there was internal dropout or patients who answered ‘not applicable’. Item scores ranged from 1 (do not agree at all) to 4 (completely agree).
Table 3 Patients’ perceptions of the quality of care in the dimensions of ‘medical-technical competence’, ‘Physical-technical conditions’, and ‘Socio-cultural atmosphere’ in the surgical care units. Dimension/factor
Medical-technical competence Received medical care The best possible medical care according to the patient Effective pain relief Effective relief for nausea Treatment waiting time Received treatments within acceptable waiting time Physical conditions Received the best possible physical care; e.g. help to take care of personal hygiene Physical-technical conditions Nutrition Received food and drink that I liked Socio-cultural atmosphere General atmosphere There was a pleasant atmosphere on the ward Could talk to the registered nurse in private when desired Could talk to the physicians in private when desired Family and friends Easy for my family to call and receive an answer My family was treated well Routines Could shower when I liked and use the toilet when I needed Could wake on my own schedule Could retire to bed on my own schedule
Control group (n = 153)
Intervention group (n = 157)
Mann–Whitney U-test
n
Mean
(SD)
n
Mean
SD
p-Value
148 136 84
3.5 3.7 3.5
0.7 0.7 0.9
155 146 103
3.5 3.5 3.3
0.9 0.9 0.9
0.574 0.606 0.059
150
3.2
1.0
148
3.3
0.9
0.594
119
3.2
1.0
134
3.2
0.9
0.797
141
2.7
1.1
149
2.8
1.0
0.651
148 77 88
3.3 3.0 2.8
0.8 1.1 1.2
157 78 86
3.3 3.1 2.9
0.9 1.0 1.1
0.779 0.810 0.579
103 106
3.7 3.7
0.7 0.6
107 118
3.8 3.7
0.6 0.6
0.155 0.913
128 131 133
3.6 3.3 3.7
0.7 0.9 0.6
134 143 141
3.6 3.1 3.7
0.7 1.0 0.6
0.762 0.139 0.905
Where item numbers (n) are less than group numbers (N), there was internal dropout or patients who answered ‘not applicable’. Item scores ranges from 1 (do not agree at all) to 4 (completely agree).
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
with a specific focus on patient participation. The present findings show that an uncomplicated intervention that let patients express their daily questions and concerns in writing improved the patients’ perceptions of their own participation in their care in a surgical care unit. The patients felt that the Tell-us card was more useful in the interaction with the registered nurses and assistant nurses than with the physicians. However, the findings also show that many patients did not feel they received useful information about self-care or about the identity of the physician or registered nurse in charge. In the present study, the patients in the control group had lower scores on items regarding participation than did surgical patients in a study conducted in private hospitals in different countries (Wilde Larsson et al., 2005). Similarly, our control group’s scores were lower on both participation and information about self-care than those of patients from both surgical and medical units in another survey carried out in the same hospital as our study (Fro¨jd et al., 2011). The lower scores could be related to the fact that our study included patients with a shorter hospital stay than those in the study by Fro¨jd et al. (2011), and thus a shorter time for the provision of information. Our study took place in a more complex context than the study by Wilde Larsson et al. (2005), with our patients admitted both from the waiting-list and from the emergency department. However, the introduction of the Tell-us card in the present study resulted in patients reporting higher scores on participation in their care than patients in the studies above. Although the patients in our study reported improved participation in decision making, some patients found it difficult to handle the card or simply did not use the card. Similar findings were reported by Sehgal et al. (2010), when patients in a hospital setting also used self-written cards during hospital stay. Being asked to take a more active role in their care was perhaps a new idea to most patients, and the researcher might need to underscore the need to present the card several times to the patient. Earlier studies report similar findings when trying to enhance patient participation in consultations (Kinnersley et al., 2007). The patients’ preferences for involvement in their care are complex (Say et al., 2006), and in a surgical care unit health professionals have to remember that the individual patients’ preferences towards involvement are often related to health status and could change the next day. Our findings show that the Tell-us card was more useful in the interaction with registered nurses and assistant nurses than with physicians. Although information about the study was given to all health professionals before the start of the intervention, many health professionals seemed at first to regard the introduction of the card as the main purpose, and inviting the patient to write down questions or concerns as their main role in the intervention. The next step, addressing the written questions and concerns and using these in the interaction with the patient, was sometimes neglected. Probably the timeframe for the intervention was too short. We know that the implementation of any change to routine in a clinical setting is a complicated process that takes time (Rycroft-Malone et al.,
535
2004; Kitson et al., 2008). Furthermore, for quality improvement work to succeed, the engagement and involvement of staff is vital (Batalden and Davidoff, 2007). To further improve the use of the Tell-us card it is important to identify facilitators in the unit, including all health professionals. It is crucial that all health professionals consider patient participation as fundamental and collaborate to improve it. After withdrawal of the intervention a continuing improvement might be expected, with health professionals more aware of the importance of patient participation. However, no such continued improvement was observed during the last phase of the study. As often noted (Rycroft-Malone et al., 2004; Kitson et al., 2008), implementation of a new routine is an ongoing process that needs to be stressed and supported. Some patients in this study reported that they used the card, but that no one in the health care team paid attention to their concerns. This raises questions about how health professionals understand the concept of ‘patient participation’. A patient-centred approach is stressed at the government level (SOSFS, 2005; IHI, 2009; Joint Commission, 2010), and the patient should be considered a full member of the health-care team (Edwards, 2002; Eldh, 2006). However, it has been reported that both staff and patients understand patient participation as a matter of merely giving or receiving information (Ho¨glund et al., 2010). There is a need for health professionals to shift from a task-centred to a patient-centred approach (Bolster and Manias, 2010; Taylor and Rutherford, 2010; Jangland et al., 2010). A number of patients in the present study reported that they wrote questions or concerns on the Tell-us card that they would not have raised had they not had the opportunity to write them down. According to the framework outlined by Feldman-Stewart et al. (2005) it is important in the patient-health professional interaction to address the patient’s goal. We believe that the Tell-us card – an inexpensive and uncomplicated tool – could be one valuable approach to elicit and address patients’ questions, and thereby to improve patient involvement in the surgical care unit. However, it requires that health professionals take the time to read the card and listen to the patient. Many patients in this study did not receive useful information about self-care. Moreover, they did not have access to information about who was the physician or registered nurse in charge during their hospital stay. The patients reported that this information was important for them. Swedish health legislation requires that patients should be informed and involved in their care (SOSFS, 2010). However, studies report that patients experience inadequate access to information (Jangland et al., 2009; Fro¨jd et al., 2011). There is always a risk that patients’ questions after ‘routine surgery’ may be considered by health professionals to be of minor importance. However, when these concerns are addressed, patients’ health during the recovery phase has been shown to be better and they seek health services less often after discharge (Henderson and Zernike, 2001). Our study supports the recommendation that patient needs for information should be prioritized in quality improvement work in surgical care units. It should be easy to improve information about the physician and registered nurse in charge by simply adding
536
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
Table 4 A summary of areas in which the patients addressed their questions and concerns on the Tell-us card. This is important for me during hospital stay. . . Information (e.g. about the operation, diagnosis, treatment, examinations, complications, and medicine) Emotional support (e.g. feeling cared for before and after the operation, before having anaesthesia, and when worried and anxious) Support and help with specific nursing needs (e.g. mobilization, taking a shower, learning about stoma care or how to stimulate bowel movement) Improved atmosphere and environment in the unit (e.g. noise abatement during the night, fewer annoying telephone calls, improved cleaning) Coordination with different health professionals (e.g. dietician, acute pain team service, social worker) This is important for me before discharge. . . Information about self-care (e.g. how long to wait before carrying or lifting after surgery, when and how to exercise, when to take a shower or bath, how to follow diet prescriptions) Information about the operation (e.g. reminder of information perhaps forgotten during stress) Information about follow-up (e.g. time for follow-up, time to remove surgical clips) Coordination (e.g. transport to other hospital, time to meet the stoma nurse) Practical support (e.g. transport, prescription)
their names to the Tell-us card or to the written discharge information already used in some cases. Our findings indicate that the Tell-us card was most valuable for patients admitted from the waiting-list for a surgical procedure, who had a hospital stay under one week. In future research this should be investigated further. Future research should also include an intervention using both the Tell-us card and education sessions. 4.1. Methodological considerations The major strength of this study is that it includes the patient in the intervention. If we want to improve patient participation, interventions also need to be targeted at both the patient and the health professional. A quasiexperimental design is admittedly a weaker design than a randomized controlled trial, but it was not possible to randomize the patients to different groups; because most of the patients in the units are cared for in rooms with several beds, it would be difficult to treat them in different ways. Furthermore, the health professionals would likely be more aware of patient participation when the Tell-us card was in use, and part of the intervention effect could be carried over to the control group. The ABA-design was choosen because it is important to evaluate the effect on the outcome after the withdrawal of an intervention. However, no continuing improvement was observed in the last phase of the study (A2). Because there were no significant differences between phase A1 and A2 with respect to perceived quality of care, the two groups were combined as one control group. While the high number of statistical tests performed increase the risk of false positive results, the primary endpoint of participation was subject to only three statistical tests; the findings would still be regarded as significant if a more strict significance threshold of 0.02 (Bonferroni) were used for this category. It is important to consider how meaningful an increase of 0.35 is for the patient. This level was based on earlier descriptive and comparative studies (Wilde Larsson et al., 2005; Muntlin et al., 2006). No earlier intervention studies using the questionnaire ‘Quality from the Patient’s Perspective’ have been reported. In future research the implementation of the Tell-us card should include different patient groups and hospital units, and the questionnaire should be used to confirm the findings. Also, a limitation of this study was
that only two surgical units were included, but because the study evaluates the implementation of a new tool this relatively small setting was considered an appropriate first step. Another limitation is the fact that the questionnaire was in Swedish, which excluded a number of non-Swedish speakers. The intervention also seemed to exclude patients who found it difficult either to write on the Tell-us card or to answer the postal questionnaire because of a vision impairment, dyslexia, or tremor related to medical diagnosis. In future research these patient groups need to be included. Patients with acute illness and an expected short hospital stay also seemed more likely to decline participation in the intervention group. It is possible that the procedure of enrolling patients sometime during the first day by only a limited number of registered nurses, rather than at admission by the registered nurse on charge, resulted in more exclusions among acute patients. However, we considered it important to limit the number of persons responsible for the inclusion process in order to limit drop-out related to shortage of time in the clinical practice. The questionnaire is a validated instrument that has been tested for reliability and it seems to be easy for patients to use, however, internal drop-out rates of 19–22% were seen. The major reason for not answering the questionnaire is unknown, but some reasons for dropout were unknown address, hospital stay longer than two months, and death of the patient. It may be argued that if Tell-us cards are put in a visible place in the patients’ room, there is a risk that other patients or visitors could read them, and thus patients may be reluctant to write down sensitive questions. However, it is not possible to read the content of the Tell-us card from a distance, and writing down a sensitive question might be easier and more private than saying it out loud in a care room with several patients present who could overhear. 5. Conclusion The use of the Tell-us card improved patients’ participation in some areas of nursing and medical care in the surgical care units. The implementation of the Tellus card is an uncomplicated and inexpensive tool and could be an important step towards improved patient participation in the surgical care unit. More research is
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
needed to evaluate the use of the Tell-us card. This should include patient groups in different hospital units, over a longer term, to confirm these findings and further improve the use of the Tell-us card. Funding The study was financially supported by the Department of Surgery at Uppsala University Hospital. Grants were received from Uppsala County Council and Uppsala University Hospital.
Acknowledgements The authors thank all the patients who participated in the study. We are grateful to Inger Carlsson, Marit Bakos, Ulrika Kindlund, and Elisabeth Nyga˚rdhs, registered nurses, for their valuable help in the data collection. We would also like to thank Mary Blegen, Professor at the University of California San Francisco School of Nursing, for generously sharing the experience of the Tell-us card. Ethical approval: The study was approved by the Regional Ethical Review Board in Uppsala, Sweden (No. 2009/170). Conflict of interest: None. References Batalden, P.B., Davidoff, F., 2007. What is ‘‘quality improvement’’ and how can it transform health care? Quality and Safety in Health Care 16 (1), 2–3. Beaver, K., Campbell, M., Craven, O., Jones, D., Luker, K., Susnerwala, S., 2009. Colorectal cancer patient’ attitudes towards involvement in decision making. Health Expectations 12, 27–37. Bolster, D., Manias, E., 2010. Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observations and interview study. International Journal of Nursing Studies 47 (2), 154–165. Codex. Regler och riktlinjer fo¨r forskning [Rules and guidelines for research]. Available at: http://www.codex.uu.se (accessed on 10.06.10) [in Swedish]. Doherty, C., Doherty, W., 2005. Patients’ preferences for involvement in clinical decision-making within secondary care and the factors that influence their preferences. Journal of Nursing Management 13, 119–127. Donabedian, A., 1988. The quality of care. How can it be assessed? Journal of the American Medical Association 260 (12), 1743–1748. Edwards, C., 2002. A proposal that patients be considered honorary members of the healthcare team. Journal of Clinical Nursing 11, 340–348. Eldh, A., 2006. Patient participation—what it is and what it is not. Doctoral ¨ rebro Studies in Caring Sciences, O ¨ rebro University, DepartThesis. O ¨ rebro, Sweden. ment of Health Sciences, O Feldman-Stewart, D., Brundage, M.D., Tishelman, C., 2005. A conceptual framework for patient–professional communication: an application to the cancer context. Psycho-oncology 14 (10), 801–809. Florin, J., 2006. Patient participation in clinical decision making in nursing—collaborative effort between patients and nurses. Doctoral The¨ rebro Studies in Caring Sciences, O ¨ rebro University, Department sis. O ¨ rebro, Sweden. of Health Sciences, O Fro¨jd, C., Leo Swenne, C., Rubertsson, C., Gunningberg, L., Wadensten, B., 2011. Patient information and participation still in need of improvement. Evaluation of patients’ perception of quality of care. Journal of Nursing Management 19 (2), 226–236. Griffin, S.J., Kinmonth, A.-L., Veltman, M.W.M., Gillard, S., Grant, J., Stewart, M., 2004. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Annals of Family Medicine 2 (6), 595–608.
537
Henderson, A., Zernike, W., 2001. A study of the impact of discharge information for surgical patients. Journal of Advanced Nursing 35 (3), 435–441. Ho¨glund, A., Winblad, U., Arnetz, A., Arnets, J., 2010. Patient participation during hospitalization for myocardial infarction: perceptions among patients and personal. Scandinavian Journal of Caring Sciences 24 (3), 482–489. Institute for Healthcare Improvement (IHI), 2009. Patient-centered Care. IHI, Cambridge, MA Available at: http://www.ihi.org/IHI/Topics/ PatientCenteredCare/ (accessed on 16.11.10). Jangland, E., Gunningberg, L., Carlsson, M., 2009. Patients’ and relatives’ complaints about encounters and communication in health care: evidence for quality improvement. Patient Education and Counseling 75 (2), 199–204. Jangland, E., Larsson, J., Gunningberg, L., 2010. Surgical nurses’ different understandings of their interactions with patients: a phenomenographic study. Scandinavian Journal of Caring Sciences, doi:10.1111/ j.1471-6712.2010.00860.x (online publication). Joint Commission, 2010. National Patient Safety Goals (NPSGs). Available at: http://www.jointcommission.org/PatientSafety/NationalPatient SafetyGoals/ (accessed on 17.11.10). Kazdin, A.E., 2003. Research Design in Clinical Psychology, 4th edition. Allyn & Bacon, Boston. Kinnersley, P., Edwards, A., Hood, K., Cadbury, N., Owen, D., Butow, P., Butler, C., 2007. Interventions before consultations for helping patients address their information needs. Cochrane Database Systematic Reviews 3 . Kitson, A., Rycroft-Malone, J., Harvey, G., McCormack, B., Seers, K., Titchen, A., 2008. Evaluating the successful implementation of evidence into practice using the PARISH framework: theoretical and practical challenges. Implementation Science 7 (31), 1. KUPPIT, Version 2007. Administration and support by ImproveIT, Halmstad, Sweden. Available at: http://www.improveit.se (in Swedish). Lewin, S., Skea, Z., Entwistle, V.A., Zwarensteine, M., Dick, J., 2009. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews 4 , doi:10.1002/14651858.CD003267 2001, Art. No.: CD003267 (edited [no change to conclusions], published in Issue 1, 2009). Muntlin, A˚., Gunningberg, L., Carlsson, M., 2006. Patients’ perception of quality of care at an emergency department and identification of areas for quality improvement. Journal of Clinical Nursing 15 (8), 1045–1056. Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., McCormack, B., 2004. What counts as evidence in evidence-based practice? Journal of Advanced Nursing 47 (1), 81–90. Sahlsten, M., Larsson, I., Plos, K., Lindecrona, C., 2005. Hindrance for patient participation in nursing care. Scandinavian Journal of Caring Sciences 19, 223–229. Sahlsten, M., Larsson, I., Sjo¨stro¨m, B., Plos, K., 2008. An analysis of the concept of patient participation. Nursing Forum 43 (1), 2–11. Say, R., Murtagh, M., Thomson, R., 2006. Patients’ preferences for involvement in medical decision making: a narrative review. Patient Education and Counseling 60, 102–114. Scott-Smith, J.L., Greenhouse, P.K., 2007. Transforming care at the bedside: patient-controlled liberalized diet. Journal of Interprofessional Care 21 (2), 179–188. Sehgal, N., Fox, M., Vidyarthi, A., Sharpe, B., Gearhart, S., Bookwalter, T., Barker, J., Alldredge, B., Blegen, M., Wachter, R.A., 2008. Multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience. Journal of General Internal Medicine 23 (12), 2053–2057. Sehgal, N., Green, A., Vidyarthi, A., Blegan, M., Wachter, R., 2010. Patients’ whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. Journal of Hospital Medicine 5 (4), 234–239. Simi, S., Patoia, L., 2010. The importance of being patient. Journal of Ambulatory Care Management 33 (3), 257–264. SOSFS, 2005. God Va˚rd. Om ledningssystem fo¨r kvalitet och patient sa¨ker va˚rd i ha¨lso- och sjukva˚rden (Good Care. System for Quality and Patient Safety in Health Care), National Board of Health and Welfare, Stockholm (in Swedish). SOSFS, 2010. Din skyldighet att informera och go¨ra patienten delaktig handbok fo¨r va˚rdgivare, verksamhetschefer och personal [Your Obligation to Inform and Involve the Patient—Handbook for Caregivers, Heads of Departments and Staff]. National Board of Health and Welfare, Stockholm (in Swedish). Taylor, J., Rutherford, P., 2010. The pursuit of genuine partnerships with patients and family members: the challenge and opportunity for
538
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
executive leaders. Frontiers of Health Services Management 26 (4), 3–14. Timonen, L., Sihvonen, M., 2000. Patient participation in bedside reporting on surgical wards. Journal of Clinical Nursing 9, 542–548. Wilde B., 1994. Quality of Care: Models, Instruments and Empirical Results among the Elderly. Doctoral Thesis. University of Gothenburg, Gothenburg, Sweden. Wilde, B., Larsson, G., Larsson, M., Starrin, B., 1994. Quality of care. Development of a patient-centred questionnaire based on a
grounded theory model. Scandinavian Journal of Caring Sciences 8, 39–48. Wilde Larsson, B., Larsson, G., 2002. Development of a short form of the Quality from the Patient’s Perspective (QPP) questionnaire. Journal of Clinical Nursing 11, 681–687. Wilde Larsson, B., Larsson, G., Wickman Chantereau, M., Stael von Holstein, K., 2005. International comparison of patients’ views on quality of care. International Journal of Health Care Quality Assurance 18 (1), 62–73.
Contents lists available at SciVerse ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
The impact of an intervention to improve patient participation in a surgical care unit: A quasi-experimental study Eva Jangland a,*, Maria Carlsson b, Ewa Lundgren a, Lena Gunningberg b,c a
Department of Surgical Sciences, Uppsala University, Entrance 70, SE-751 85 Uppsala, Sweden Department of Public Health and Caring Sciences, Uppsala University, Sweden c School of Nursing, University of California, San Francisco, USA b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 April 2011 Received in revised form 14 September 2011 Accepted 26 October 2011
Background: Organizational changes in surgical care are requiring patients to become more responsible for their own care, both before and after surgery, and also during recovery. Involving patients in their care is vital to improving quality of care and patient safety. Objective: The aim of this study was to investigate the impact of the ‘Tell-us’ card on patients’ perceptions of quality of care, with a specific focus on patient participation. Another aim was to evaluate the use of the Tell-us card from the patients’ perspective. Design: A quasi-experimental design with an intervention group and control groups was used. The patient’s self-written Tell-us card was introduced as the intervention. Setting: The study was conducted in two surgical care units at a Swedish university hospital. Participants: A consecutive sample of patients admitted from the waiting list and from the emergency department was included (n = 310). The inclusion criteria were surgical patients with a hospital stay of at least one day. Patients who were younger than 18 years, not able to speak or write in Swedish, or unable or unwilling to give informed consent to participate were excluded. Methods: Quality of care was assessed using the questionnaire ‘Quality from the Patient’s Perspective’. The patients included in the intervention group were asked to write what was most important for them during the day or just before discharge on patient-written Tell-us cards. Results: The use of the Tell-us card resulted in significant improvements (5 out of 17 items) in patients’ abilities to participate in decisions about their nursing and medical care. The patients found the Tell-us card more useful in their interaction with registered nurses and assistant nurses than with physicians. Conclusions: The use of the Tell-us card improved patients’ participation in some areas of nursing and medical care in the surgical care units. The Tell-us card is an uncomplicated and inexpensive tool that could be an important step towards improved patient participation in the surgical care unit. More research is needed to evaluate the use of the Tell-us card in different hospital units and over a longer period of time. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Intervention study Patient-centred care Patient participation Surgical care unit Quality of care
* Corresponding author. Tel.: +46 0 18 6113722; fax: +46 0 18 559410. E-mail address: [email protected] (E. Jangland). 0020-7489/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2011.10.024
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
What is already known about the topic? Involving and recognizing the patient as a partner in the healthcare team is one of the mainstays of patientcentred care. Involvement of the patient in decision-making improves quality of care from the patients’ perspective and is associated with positive patient health outcomes. Organizational changes in the surgical care unit demand that patients are more responsible for their own care before and after surgery and also during recovery. What this paper adds The use of the Tell-us card improved patients’ participation in some areas of nursing and medical care in a surgical care unit. The Tell-us card, an inexpensive, uncomplicated tool could be used in clinical practice to improve patient participation in their own care. 1. Introduction In recent years studies have reported the need to recognize the patient as a resourceful partner in the health care team (Edwards, 2002; Taylor and Rutherford, 2010). Patient involvement has been found to improve quality of care, is associated with positive health outcomes for the patient (Griffin et al., 2004; Say et al., 2006), and is also an important factor in patient safety (Joint Commission, 2010). Government guidelines describe patient participation as a prerequisite to patient-centred care and require health professionals to involve patients in their care (IHI, 2009; Joint Commission, 2010). However, several studies show that for a variety of reasons patients may be displaced, forgotten, or hindered from being equal partners in the health care team (Sahlsten et al., 2005; Simi and Patoia, 2010). Although patient participation is a widely used concept, it is a complex phenomenon (Say et al., 2006; Eldh, 2006). Critical attributes for patient participation include an established relationship, respect for the individual, recognition of the individual’s knowledge and circumstances, and shared information (Eldh, 2006; Sahlsten et al., 2008). Patients’ preferences for involvement are influenced by many different factors (Doherty and Doherty, 2005; Say et al., 2006). Several studies show that women prefer a more active role in decision making than men (Say et al., 2006; Florin, 2006; Beaver et al., 2009). Experiences of illness and medical care, kind of decision, and earlier interactions and relationships with health professionals are also reported to influence patients’ preferences for participation (Say et al., 2006). Although several reports address improving patient involvement in consultations, fewer seem to consider the hospital setting. Clinical interventions including patienttargeted checklists and patient-held records, and providertargeted interventions such as education and training in communication skills, have been introduced to enhance patient participation in consultations (Lewin et al., 2009; Kinnersley et al., 2007). Bedside reporting (Timonen and
529
Sihvonen, 2000) and routinely asking patients to establish daily goals have been suggested as strategies to improve patient participation during hospital stay (Scott-Smith and Greenhouse, 2007; Sehgal et al., 2010). In a patient safety programme in the United States, patients took part in the care plan by writing down their goals each day to make clear to all members of the health care team what was most important to them. The patients’ self-written card was called the ‘Tell-us’ card (Sehgal et al., 2008, 2010). According to the communication framework outlined by Feldman-Stewart et al. (2005), it is important in the patient–health-professional interaction to address the patient’s goal. This goal may be seen as an expression of one or more of the patient’s needs that provides an opening for dialogue during the day and one more step towards patient involvement in care. The context of the present study is a surgical care unit in Sweden. Patient participation is highlighted as an important issue in Swedish health care (SOSFS, 2005, 2010), and descriptive studies report on the need to improve patient participation (Sahlsten et al., 2005; Fro¨jd et al., 2011). The patients cared for in such surgical units are operated on with more advanced surgery than only 20 years ago. Patients come to the unit earlier in the postoperative phase and they need more advanced nursing and monitoring. At the same time, length of hospital stay is becoming shorter, patients are older, and more planning of future care is required before discharge. Because of these contextual changes, patients today are more responsible for their own care before and after surgery and during recovery. Therefore, it is important that patients have the necessary knowledge and opportunity to be involved in their hospital care, and it is crucial to work out interventions in this setting that involve the patients in their own care. Within this study the definition of patient participation is inspired by the work of Eldh (2006), who recommends that the patient have knowledge of, and when possible, control of, the disease and treatment, to enable the patient to experience trust during the hospital stay and at discharge. A prerequisite for patient participation is a patient–healthprofessional interaction that includes dialogue characterized by respect, empathy, and recognition of the patient as an individual as well as a partner in the health care team. Patient participation is often used as an important outcome measure in questionnaires about quality of care (Donabedian, 1988; Wilde et al., 1994; Wilde Larsson and Larsson, 2002). Our hypothesis was that if patients were invited in a structured way to participate with their health care team during the hospital stay, the quality of care, and specifically patient participation, would be improved. The aims of the study were to investigate the impact of the Tell-us card on patient perception of quality of care, with a specific focus on patient participation, and to evaluate the use of the Tell-us card from the patients’ perspective. 2. Methods 2.1. Design The study had a quasi-experiemental design with ABA phases. Phase A was a period without intervention and
530
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
phase B a period with intervention. Phase A could also be called baseline (A1) or return-to-baseline (A2). The ABA design makes it possible to control the intervention and to evaluate the outcome after withdrawal of the intervention (Kazdin, 2003). 2.2. Setting The study was performed from October 2009 to May 2010 in two surgical care units in a large university hospital in Sweden. The hospital has 1100 patient beds and 8000 employees. The surgical units in this study admit mainly adult patients undergoing colorectal, endocrine, or breast surgery and acute patients with abdominal pain or trauma. During data collection the two units treated a large number of patients every month (mean 162 in unit 1 and 185 in unit 2), with hospital stays ranging less than one day to 99 days. The mean hospital stays in the units were 4.6 and 3.6 days, respectively. A number of patients with other medical diagnoses were temporarily in the surgical units because the hospital was short of beds. These patients were not included in the study. In the units a registered nurse and an assistant nurse work in a team responsible for 6–17 patients depending on the time of the day. A resident performs the ward rounds twice a day on weekdays and a surgeon on call once a day on weekends. Both report to a senior consultant. During hospital stay patients meet the surgeon responsible for the operation, the resident, or both. In each unit there is a nurse manager responsible for nursing care and a senior consultant for medical care. About 50 health professionals in various positions work in each unit.
the United States in the Triad for Optimal Patient Safety project as a way to assess patients’ goals for the day. Permission to use the American version of the Tell-us card as a model was obtained from the original researcher. The card was translated into Swedish by the authors and slightly modified for the surgical care context. The Tell-us card was designed as a tent card with two sides, where the patients could write down their specific questions and concerns for the day or before discharge. One side of the card was printed with brief instructions and information about patient participation as follows: ‘Tell us what is important for you today or before discharge. It is important that you have the knowledge you need and that you are involved in your care. Please use the space on the opposite side of this card and write down your questions and concerns’. On the oppsite side of the card, with space for responses, was printed (a) This is important for me today______, and (b) This is important for me before discharge_______. The patients in the intervention group were asked to use the cards each day, and every morning the registered nurse responsible for their care provided new cards. The card was placed in a fully visible spot on the table in the patients’ room. At the start of the intervention both verbal and written information was given to all health professionals in the two units. The information was repeated during the study, directing health professionals to regard what the patient wrote on the Tell-us card as a tool in their dialogue with the patients, e.g. during ward rounds and discharge information sessions. 2.5. Standard procedure
2.3. Participants The study included a consecutive sample of patients admitted from the surgical waiting list or from the emergency department. The inclusion criteria were surgical patients with an expected hospital stay of at least one day. Patients were excluded if they were younger than 18 years, not able to speak or write in Swedish, or not willing or able to give informed consent. A power calculation was carried out, based on mean score and standard deviation from surveys using the questionnaire ‘Quality from the Patient’s Perspective’ (Wilde Larsson et al., 2005; Muntlin et al., 2006;), to decide the number of patients needed in the different study phases. It was estimated that to detect a mean difference of 0.35 in the primary endpoint ‘participation’ a sample size of 65 (A1), 130 (B), and 65 (A2) patients would be needed to find a significant difference between groups. With an estimated withdrawal of 25% and the lower power of a nonparametric analysis set at 10%, the number of patients included in the three phases was set to 95 (A1), 190 (B), and 95 (A2) (alpha < 0.05 and power 0.80, with an estimated standard deviation of 1.0 in each item). 2.4. Intervention Patient-written Tell-us cards were introduced as the intervention. The Tell-us card had previously been used in
The control group received the units’ standard level of information and communication during hospital stay and at discharge. Both units had routine preoperative information, ward rounds, and discharge information. However, the standard could vary depending upon the attending physician’s or nurse’s knowledge and capacity to perceive the patient’s need for conversation, information, and support. In certain cases, but not all, patients received written information at discharge. 2.6. Data collection The data collection was performed using the questionnaire ‘Quality from the Patient’s Perspective’. The questionnaire is based on a patient-centred theoretical model of quality of care developed through a grounded theory approach. The theoretical model describes four dimensions of care: an identity-orientation approach, medical technical competence, physical–technical conditions, and socio-culture atmosphere, and the questionnaire consists of questions designed to measure those four dimensions (Wilde, 1994; Wilde et al., 1994). A short version of the questionnaire was used, but with items from the long version added in the dimension of an identityorientation approach (Wilde Larsson and Larsson, 2002). The questionnaire has been developed in different groups of patients and settings, and the questionnaire for medical
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
and surgical units was used. The questionnaire has been tested for validity and reliability. Cronbach alpha coefficients range from 0.81 to 0.9 in the dimension of an identity-orientation approach (Wilde et al., 1994; Wilde Larsson and Larsson, 2002; Wilde Larsson et al., 2005). The analysis was made at the level of individual items. The questionnaire consisted of 54 items for patients in the control group (periods A1 and A2) and 62 for the intervention group (period B), measured the patient’s perception of the quality of care (‘This is what I experienced’) and the subjective importance of each item (‘This is how important it was to me’), and took about 15– 20 min to complete. Items related to perceived quality of care were rated on a scale of 1 (‘do not agree at all’) to 4 (‘completely agree’), the subjective importance of the various items was also rated from 1 (‘little or no importance’) to 4 (‘of the very highest importance’), and each item had a ‘not applicable’ response alternative. The questionnaire also contained questions about the patient’s background and state of health. The patients in the intervention group were also asked study-specific questions concerning the Tell-us card: (a) whether the patient used the card, (b) reason (if applicable) for not using the card, (c) whether the card was useful in the dialogue with the health care professionals during hospital stay and/or before discharge, and finally (d) whether the card allowed them to raise anything for discussion that they would not have mentioned had they not had the opportunity of writing it down on the card. 2.7. Procedure At the start of the first phase (A1), information provided to the health professionals was limited in order to avoid affecting the result. This information was given by the nurse managers. Before start of the intervention both verbal and written information was given to all health professionals in the two units by the first author. Information about the study and how to use the Tell-us card was also repeated during the intervention several times during daily practice. Patients in all periods were approached to take part in the study by the first author or one of four registered nurses who acted as co-ordinators for the study during data collection. Patients meeting the inclusion criteria were invited to participate at admission or, at the latest, within their first day of hospital stay. The patients were given verbal and written information about the study and informed consent was collected. Within a week after discharge all patients were sent the questionnaire by post and were asked to send it back in a prepaid envelope. The questionnaires were coded, and up to two reminders were sent. All administration of the questionnaires was handled by the first author.
531
versus control group) Chi-square test was used for dichotomous variables (e.g. gender, nationality, family situation, surgery or not, type of admission) and Mann– Whitney U-test was used for ordinal variables (e.g. hospital stay, education, and the items about perceived quality of care). Student’s t-test was used for the continous variable age. Statistical significance was set at p < 0.05. Responses of ‘not applicable’ were regarded as missing data in the analysis. 2.9. Ethical considerations The study was appoved by the Regional Ethical Review Board (No. 2009/170) and the head of the department of surgery. All patients received written and oral information about participation. The patients had the right to refuse participation without giving any reason and to withdraw from the study at any time (Codex, 2010). 3. Results A total of 451 patients meeting the inclusion criteria were approached, 387 agreed to participate, 310 completed the questionnaire in the different phases, and 77 patients did not complete the questionnaire. The response rate in the groups varied from 78% to 81%. The flow of the patients’ through each stage of the study is presented in Fig. 1. There was no significant difference between phases A1 and A2 with respect to perceived quality of care, and in the results the two groups are combined and presented as a single control group. There were no significant differences between the intervention group and the control group with respect to age, gender, nationality, family situation, occupation, educational level, or patients’ self-reported health status. The mean age was 58 years (range 21–86; SD = 16) in the intervention group and 58.5 years (range 22–92; SD = 14.5) in controls. However, the patients in the intervention group were admitted significantly more often from the waiting list (x2 = 7.49, df 1, p = 0.006), were more likely to have had a surgical procedure (x2 = 23.74, df 1, p < 0.001), and had a longer hospital stay (p = 0.01) than those in the control group (Table 1). No significant difference in gender was detected between the patients who declined and those who completed the questionnaire. However, the patients who declined to participate were significantly older (mean 65 years, t = 2.6, p = 0.01) and more often admitted from the emergency department (x2 = 25.48, df 1, p < 0.001) than the patients who participated. The patients’ ratings of the subjective importance of quality of care items (‘this is how important it was to me’) showed a significant difference between the groups in only 2 of 31 items. The patients’ perceived quality of care (‘this is what I experienced’) is reported below.
2.8. Data analysis 3.1. Quality of care from the patient perspective The data were registered in the KUPPIT computer programme (2007) and imported to SPSS version19.0 for analysis. Means, standard deviations, ranges, and percentages were used to describe the data. For comparisons between groups (i.e. A1 versus A2, and intervention group
Significant differences in perceived quality of care between the intervention group and the control group were detected in 5 out of 17 items in the dimension of identity-orientation approach (Table 2). The patients’
532
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
A1
B
A2
October 2009
November 2009/January 2010
April 2010
Surgical patients with a hospital stay > 1 day assessed for eligibility
Surgical patients with a hospital stay > 1 day assessed for eligibility
Surgical patients with a hospital stay > 1 day assessed for eligibility
N= 149
N = 297
N = 145
Excluded according to criteria
Excluded according to criteria
Excluded according to criteria
n= 38
n = 59
n = 43
Patients approached according to criteria
Patients approached according to criteria
Patients approached according to criteria
N = 111
N = 238
N = 102
Declined participation
Declined participation
Declined participation
n = 14
n = 45
n=5
Included patients
Included patients
Included patients
N = 97
N = 193
N = 97
Internal dropouts
Internal dropouts
Internal dropouts
n = 20
n = 36
n = 21
Analysed questionnaires
Analysed questionnaires
Analysed questionnaires
N = 77
N = 157
N = 76
Response rate 79%
Response rate 81%
Response rate 78 %
Fig. 1. The flow of the participants through each stage of the study.
opportunity to participate in decisions about their nursing care revealed a significant difference (p = 0.020) between the groups: a mean score of 3.2 (SD = 1.0) was reported in the intervention group compared to 2.9 (SD = 1.0) in the control group. Also a significant difference (p = 0.004) in the patients’ opportunity to participate in the decisions about their medical care was seen between the groups. The patients in the intervention group had a mean score of 3.5 (SD = 1.0) on the item, while the control group scored a mean of 2.7 (SD = 1.1). The patients in the intervention group reported significantly higher quality of care regarding registered nurses’ and assistant nurses’ commitment (p = 0.008), empathy (p = 0.004), and respectful treatment of patients (p = 0.011) compared to the patients in the control group. However, there was no significant difference in the patients’ perception of physicians’ commitment, empathy, or respectful treatment between the groups.
There were no significant differences in any of the six items related to information. The item regarding useful information about self-care had the lowest mean score throughout the study phases with a mean of 2.5 (SD = 1.1) in the intervention group and 2.4 (SD = 1.1) in the control group. To summarize, 141 patients (51%) reported that they did not receive useful information about self-care (scores 1 and 2), 120 patients (40%) reported that they did not receive information about which physician was responsible for their medical care, and 109 patients (36%) did not receive information about which registered nurse was responsible for their nursing care. No significant differences between the intervention and control groups were found in perceived quality of care in the three other dimensions (i.e. medical technical competence, physical–technical conditions, and socio-cultural atmosphere). However, patients in both groups had low mean scores on the quality of the food (2.8 and 2.7) and on
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
533
Table 1 Background information of the participants. Control group n = 153 %
n Gender Men Women Nationality Swedish Other Family situation Married/living together Single/living alone Occupation Working Student Other Education Elementary school Upper secondary school University Admissiona Waiting list Acute Surgeryb Yes No Days of admissionc 0–1 day 2–3 days 4–6 days 2–9 days 10 or more days
Intervention group n = 157 n
%
65 88
42 58
58 99
37 63
137 16
90 10
140 17
90 10
107 46
70 30
122 34
78 22
77 6 70
50 4 46
82 8 67
52 5 43
44 55 53
29 36 35
30 67 58
19 43 37
80 73
52 48
106 51
68 32
88 65
58 42
130 27
83 17
21 74 34 13 11
14 48 22 8 7
16 60 42 14 25
10 38 27 9 16
Where numbers in a category do not add up to n or 100%, there was internal dropout. a Differences between groups: p = 0.006 (Chi-square test). b Differences between groups: p < 0.001 (Chi-square test). c Differences between groups: p = 0.01 (Mann–Whitney U-test).
the opportunity to talk to physicians privately when they wanted to (2.9 and 2.8) (Table 3). 3.2. Subgroup analyses Subgroup analysis showed that patients in the intervention group who had a surgical procedure reported significantly more often (p = 0.035) that the information they received about examination and treatment was useful compared to the same subgroup of controls. Furthermore, the patients in the intervention group with a hospital stay under one week reported significantly more often that they had had the opportunity to participate in decisions that applied to their medical care (p = 0.003) and nursing care (p = 0.02) than the same subgroup of control patients. Finally, the subgroup analysis showed that patients in the intervention group who had been admitted from the waiting list significantly more often reported that they had had the opportunity to participate in decisions that applied to their medical care (p = 0.048) than the same subgroup of control patients. 3.3. Evaluation of the Tell-us card from a patients’ perspective In the intervention group, 126 out of 157 patients (80%) used the card every day or at least once during the hospital stay. Twenty-four patients (15%) did not use the card at all. The reasons for not using the card were ‘did not feel well’,
‘no one paid attention to the card’, ‘received information without using the card’, ‘too short hospital stay’, and ‘did not receive a card’. Seven patients (5%) did not answer this part of the questionnaire. Forty-two patients (34%) answered that they wrote questions or concerns on the Tell-us card which they would not have raised without the opportunity of writing them down on the card. There were significant differences in how useful the Tell-us card was in the dialogue with registered nurses and assistant nurses compared with physicians. Sixty-seven patients (56%) found the card useful in the dialogue with the registered nurses and assistant nurses during the hospital stay, while 30 patients (25%) thought the card was useful in the dialogue with the physician (x2 = 27.53, df 1, p < 0.001). Corresponding figures for usefulness at discharge show that 43 patients (36%) found the card useful with the registered nurses and assistant nurses, and only 28 patients (24%) found it useful with the physicians (x2 = 34.06, df 1, p < 0.001). Patients most often wrote short comments on the cards, but some long descriptions were also seen. A brief summary of what the patients wrote on the Tell-us card is shown in Table 4. 4. Discussion The aim of this study was to investigate the impact of the Tell-us card on patients’ perceptions of quality of care,
534
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
Table 2 Patients’ perception of the quality of care in the dimension of ‘identity-oriented approach’ in surgical care units. Dimension/factor
Identity-oriented approach Participation Perception of health problems was taken into consideration Had opportunity to participate in the decisions that applied to medical care Had opportunity to participate in the decisions that applied to nursing care Receiving information about How the examinations and treatments would take place The results of examinations and treatments Self-care: ‘How I should take care of myself’ Medication Which physician was responsible for my medical care Which registered nurse was responsible for my nursing care Showing commitment The physicians The registered nurses and the assistant nurses Empathic and personal The physicians Seemed to understand how I experienced my situation Showed empathy when I felt bad, e.g. worry or pain The registered nurses and the assistant nurses Seemed to understand how I experienced my situation Showed empathy when I felt bad, e.g. worry or pain Being respectful towards the patient The physicians The registered nurses and assistant nurses
Control group (n = 153)
Intervention group (n = 157)
Mann–Whitney U-test
n
Mean
SD
n
Mean
SD
p-value
134 116
3.3 2.7
0.8 1.1
137 155
3.3 3.5
0.9 0.9
0.790 0.004
116
2.9
1.0
117
3.2
1.0
0.020
152 150 132 120 147 150
3.4 3.2 2.4 3.0 2.8 2.8
0.9 1.0 1.1 1.0 1.2 1.1
157 150 143 135 154 152
3.3 3.2 2.5 3.0 2.9 2.9
0.94 0.9 1.1 1.0 1.1 1.1
0.508 0.886 0.360 0.492 0.438 0.436
148 151
3.2 3.5
0.9 0.7
150 154
3.3 3.7
0.9 0.6
0.455 0.008
150 114
3.2 3.1
0.9 0.9
154 119
3.2 3.1
0.9 1.0
0.852 0.542
150 123
3.4 3.5
0.8 0.7
153 126
3.6 3.7
0.6 0.6
0.004 0.112
149 153
3.5 3.6
0.7 0.6
154 156
3.5 3.8
0.8 0.5
0.692 0.011
Where item numbers (n) are less than group numbers (N), there was internal dropout or patients who answered ‘not applicable’. Item scores ranged from 1 (do not agree at all) to 4 (completely agree).
Table 3 Patients’ perceptions of the quality of care in the dimensions of ‘medical-technical competence’, ‘Physical-technical conditions’, and ‘Socio-cultural atmosphere’ in the surgical care units. Dimension/factor
Medical-technical competence Received medical care The best possible medical care according to the patient Effective pain relief Effective relief for nausea Treatment waiting time Received treatments within acceptable waiting time Physical conditions Received the best possible physical care; e.g. help to take care of personal hygiene Physical-technical conditions Nutrition Received food and drink that I liked Socio-cultural atmosphere General atmosphere There was a pleasant atmosphere on the ward Could talk to the registered nurse in private when desired Could talk to the physicians in private when desired Family and friends Easy for my family to call and receive an answer My family was treated well Routines Could shower when I liked and use the toilet when I needed Could wake on my own schedule Could retire to bed on my own schedule
Control group (n = 153)
Intervention group (n = 157)
Mann–Whitney U-test
n
Mean
(SD)
n
Mean
SD
p-Value
148 136 84
3.5 3.7 3.5
0.7 0.7 0.9
155 146 103
3.5 3.5 3.3
0.9 0.9 0.9
0.574 0.606 0.059
150
3.2
1.0
148
3.3
0.9
0.594
119
3.2
1.0
134
3.2
0.9
0.797
141
2.7
1.1
149
2.8
1.0
0.651
148 77 88
3.3 3.0 2.8
0.8 1.1 1.2
157 78 86
3.3 3.1 2.9
0.9 1.0 1.1
0.779 0.810 0.579
103 106
3.7 3.7
0.7 0.6
107 118
3.8 3.7
0.6 0.6
0.155 0.913
128 131 133
3.6 3.3 3.7
0.7 0.9 0.6
134 143 141
3.6 3.1 3.7
0.7 1.0 0.6
0.762 0.139 0.905
Where item numbers (n) are less than group numbers (N), there was internal dropout or patients who answered ‘not applicable’. Item scores ranges from 1 (do not agree at all) to 4 (completely agree).
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
with a specific focus on patient participation. The present findings show that an uncomplicated intervention that let patients express their daily questions and concerns in writing improved the patients’ perceptions of their own participation in their care in a surgical care unit. The patients felt that the Tell-us card was more useful in the interaction with the registered nurses and assistant nurses than with the physicians. However, the findings also show that many patients did not feel they received useful information about self-care or about the identity of the physician or registered nurse in charge. In the present study, the patients in the control group had lower scores on items regarding participation than did surgical patients in a study conducted in private hospitals in different countries (Wilde Larsson et al., 2005). Similarly, our control group’s scores were lower on both participation and information about self-care than those of patients from both surgical and medical units in another survey carried out in the same hospital as our study (Fro¨jd et al., 2011). The lower scores could be related to the fact that our study included patients with a shorter hospital stay than those in the study by Fro¨jd et al. (2011), and thus a shorter time for the provision of information. Our study took place in a more complex context than the study by Wilde Larsson et al. (2005), with our patients admitted both from the waiting-list and from the emergency department. However, the introduction of the Tell-us card in the present study resulted in patients reporting higher scores on participation in their care than patients in the studies above. Although the patients in our study reported improved participation in decision making, some patients found it difficult to handle the card or simply did not use the card. Similar findings were reported by Sehgal et al. (2010), when patients in a hospital setting also used self-written cards during hospital stay. Being asked to take a more active role in their care was perhaps a new idea to most patients, and the researcher might need to underscore the need to present the card several times to the patient. Earlier studies report similar findings when trying to enhance patient participation in consultations (Kinnersley et al., 2007). The patients’ preferences for involvement in their care are complex (Say et al., 2006), and in a surgical care unit health professionals have to remember that the individual patients’ preferences towards involvement are often related to health status and could change the next day. Our findings show that the Tell-us card was more useful in the interaction with registered nurses and assistant nurses than with physicians. Although information about the study was given to all health professionals before the start of the intervention, many health professionals seemed at first to regard the introduction of the card as the main purpose, and inviting the patient to write down questions or concerns as their main role in the intervention. The next step, addressing the written questions and concerns and using these in the interaction with the patient, was sometimes neglected. Probably the timeframe for the intervention was too short. We know that the implementation of any change to routine in a clinical setting is a complicated process that takes time (Rycroft-Malone et al.,
535
2004; Kitson et al., 2008). Furthermore, for quality improvement work to succeed, the engagement and involvement of staff is vital (Batalden and Davidoff, 2007). To further improve the use of the Tell-us card it is important to identify facilitators in the unit, including all health professionals. It is crucial that all health professionals consider patient participation as fundamental and collaborate to improve it. After withdrawal of the intervention a continuing improvement might be expected, with health professionals more aware of the importance of patient participation. However, no such continued improvement was observed during the last phase of the study. As often noted (Rycroft-Malone et al., 2004; Kitson et al., 2008), implementation of a new routine is an ongoing process that needs to be stressed and supported. Some patients in this study reported that they used the card, but that no one in the health care team paid attention to their concerns. This raises questions about how health professionals understand the concept of ‘patient participation’. A patient-centred approach is stressed at the government level (SOSFS, 2005; IHI, 2009; Joint Commission, 2010), and the patient should be considered a full member of the health-care team (Edwards, 2002; Eldh, 2006). However, it has been reported that both staff and patients understand patient participation as a matter of merely giving or receiving information (Ho¨glund et al., 2010). There is a need for health professionals to shift from a task-centred to a patient-centred approach (Bolster and Manias, 2010; Taylor and Rutherford, 2010; Jangland et al., 2010). A number of patients in the present study reported that they wrote questions or concerns on the Tell-us card that they would not have raised had they not had the opportunity to write them down. According to the framework outlined by Feldman-Stewart et al. (2005) it is important in the patient-health professional interaction to address the patient’s goal. We believe that the Tell-us card – an inexpensive and uncomplicated tool – could be one valuable approach to elicit and address patients’ questions, and thereby to improve patient involvement in the surgical care unit. However, it requires that health professionals take the time to read the card and listen to the patient. Many patients in this study did not receive useful information about self-care. Moreover, they did not have access to information about who was the physician or registered nurse in charge during their hospital stay. The patients reported that this information was important for them. Swedish health legislation requires that patients should be informed and involved in their care (SOSFS, 2010). However, studies report that patients experience inadequate access to information (Jangland et al., 2009; Fro¨jd et al., 2011). There is always a risk that patients’ questions after ‘routine surgery’ may be considered by health professionals to be of minor importance. However, when these concerns are addressed, patients’ health during the recovery phase has been shown to be better and they seek health services less often after discharge (Henderson and Zernike, 2001). Our study supports the recommendation that patient needs for information should be prioritized in quality improvement work in surgical care units. It should be easy to improve information about the physician and registered nurse in charge by simply adding
536
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
Table 4 A summary of areas in which the patients addressed their questions and concerns on the Tell-us card. This is important for me during hospital stay. . . Information (e.g. about the operation, diagnosis, treatment, examinations, complications, and medicine) Emotional support (e.g. feeling cared for before and after the operation, before having anaesthesia, and when worried and anxious) Support and help with specific nursing needs (e.g. mobilization, taking a shower, learning about stoma care or how to stimulate bowel movement) Improved atmosphere and environment in the unit (e.g. noise abatement during the night, fewer annoying telephone calls, improved cleaning) Coordination with different health professionals (e.g. dietician, acute pain team service, social worker) This is important for me before discharge. . . Information about self-care (e.g. how long to wait before carrying or lifting after surgery, when and how to exercise, when to take a shower or bath, how to follow diet prescriptions) Information about the operation (e.g. reminder of information perhaps forgotten during stress) Information about follow-up (e.g. time for follow-up, time to remove surgical clips) Coordination (e.g. transport to other hospital, time to meet the stoma nurse) Practical support (e.g. transport, prescription)
their names to the Tell-us card or to the written discharge information already used in some cases. Our findings indicate that the Tell-us card was most valuable for patients admitted from the waiting-list for a surgical procedure, who had a hospital stay under one week. In future research this should be investigated further. Future research should also include an intervention using both the Tell-us card and education sessions. 4.1. Methodological considerations The major strength of this study is that it includes the patient in the intervention. If we want to improve patient participation, interventions also need to be targeted at both the patient and the health professional. A quasiexperimental design is admittedly a weaker design than a randomized controlled trial, but it was not possible to randomize the patients to different groups; because most of the patients in the units are cared for in rooms with several beds, it would be difficult to treat them in different ways. Furthermore, the health professionals would likely be more aware of patient participation when the Tell-us card was in use, and part of the intervention effect could be carried over to the control group. The ABA-design was choosen because it is important to evaluate the effect on the outcome after the withdrawal of an intervention. However, no continuing improvement was observed in the last phase of the study (A2). Because there were no significant differences between phase A1 and A2 with respect to perceived quality of care, the two groups were combined as one control group. While the high number of statistical tests performed increase the risk of false positive results, the primary endpoint of participation was subject to only three statistical tests; the findings would still be regarded as significant if a more strict significance threshold of 0.02 (Bonferroni) were used for this category. It is important to consider how meaningful an increase of 0.35 is for the patient. This level was based on earlier descriptive and comparative studies (Wilde Larsson et al., 2005; Muntlin et al., 2006). No earlier intervention studies using the questionnaire ‘Quality from the Patient’s Perspective’ have been reported. In future research the implementation of the Tell-us card should include different patient groups and hospital units, and the questionnaire should be used to confirm the findings. Also, a limitation of this study was
that only two surgical units were included, but because the study evaluates the implementation of a new tool this relatively small setting was considered an appropriate first step. Another limitation is the fact that the questionnaire was in Swedish, which excluded a number of non-Swedish speakers. The intervention also seemed to exclude patients who found it difficult either to write on the Tell-us card or to answer the postal questionnaire because of a vision impairment, dyslexia, or tremor related to medical diagnosis. In future research these patient groups need to be included. Patients with acute illness and an expected short hospital stay also seemed more likely to decline participation in the intervention group. It is possible that the procedure of enrolling patients sometime during the first day by only a limited number of registered nurses, rather than at admission by the registered nurse on charge, resulted in more exclusions among acute patients. However, we considered it important to limit the number of persons responsible for the inclusion process in order to limit drop-out related to shortage of time in the clinical practice. The questionnaire is a validated instrument that has been tested for reliability and it seems to be easy for patients to use, however, internal drop-out rates of 19–22% were seen. The major reason for not answering the questionnaire is unknown, but some reasons for dropout were unknown address, hospital stay longer than two months, and death of the patient. It may be argued that if Tell-us cards are put in a visible place in the patients’ room, there is a risk that other patients or visitors could read them, and thus patients may be reluctant to write down sensitive questions. However, it is not possible to read the content of the Tell-us card from a distance, and writing down a sensitive question might be easier and more private than saying it out loud in a care room with several patients present who could overhear. 5. Conclusion The use of the Tell-us card improved patients’ participation in some areas of nursing and medical care in the surgical care units. The implementation of the Tellus card is an uncomplicated and inexpensive tool and could be an important step towards improved patient participation in the surgical care unit. More research is
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
needed to evaluate the use of the Tell-us card. This should include patient groups in different hospital units, over a longer term, to confirm these findings and further improve the use of the Tell-us card. Funding The study was financially supported by the Department of Surgery at Uppsala University Hospital. Grants were received from Uppsala County Council and Uppsala University Hospital.
Acknowledgements The authors thank all the patients who participated in the study. We are grateful to Inger Carlsson, Marit Bakos, Ulrika Kindlund, and Elisabeth Nyga˚rdhs, registered nurses, for their valuable help in the data collection. We would also like to thank Mary Blegen, Professor at the University of California San Francisco School of Nursing, for generously sharing the experience of the Tell-us card. Ethical approval: The study was approved by the Regional Ethical Review Board in Uppsala, Sweden (No. 2009/170). Conflict of interest: None. References Batalden, P.B., Davidoff, F., 2007. What is ‘‘quality improvement’’ and how can it transform health care? Quality and Safety in Health Care 16 (1), 2–3. Beaver, K., Campbell, M., Craven, O., Jones, D., Luker, K., Susnerwala, S., 2009. Colorectal cancer patient’ attitudes towards involvement in decision making. Health Expectations 12, 27–37. Bolster, D., Manias, E., 2010. Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observations and interview study. International Journal of Nursing Studies 47 (2), 154–165. Codex. Regler och riktlinjer fo¨r forskning [Rules and guidelines for research]. Available at: http://www.codex.uu.se (accessed on 10.06.10) [in Swedish]. Doherty, C., Doherty, W., 2005. Patients’ preferences for involvement in clinical decision-making within secondary care and the factors that influence their preferences. Journal of Nursing Management 13, 119–127. Donabedian, A., 1988. The quality of care. How can it be assessed? Journal of the American Medical Association 260 (12), 1743–1748. Edwards, C., 2002. A proposal that patients be considered honorary members of the healthcare team. Journal of Clinical Nursing 11, 340–348. Eldh, A., 2006. Patient participation—what it is and what it is not. Doctoral ¨ rebro Studies in Caring Sciences, O ¨ rebro University, DepartThesis. O ¨ rebro, Sweden. ment of Health Sciences, O Feldman-Stewart, D., Brundage, M.D., Tishelman, C., 2005. A conceptual framework for patient–professional communication: an application to the cancer context. Psycho-oncology 14 (10), 801–809. Florin, J., 2006. Patient participation in clinical decision making in nursing—collaborative effort between patients and nurses. Doctoral The¨ rebro Studies in Caring Sciences, O ¨ rebro University, Department sis. O ¨ rebro, Sweden. of Health Sciences, O Fro¨jd, C., Leo Swenne, C., Rubertsson, C., Gunningberg, L., Wadensten, B., 2011. Patient information and participation still in need of improvement. Evaluation of patients’ perception of quality of care. Journal of Nursing Management 19 (2), 226–236. Griffin, S.J., Kinmonth, A.-L., Veltman, M.W.M., Gillard, S., Grant, J., Stewart, M., 2004. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Annals of Family Medicine 2 (6), 595–608.
537
Henderson, A., Zernike, W., 2001. A study of the impact of discharge information for surgical patients. Journal of Advanced Nursing 35 (3), 435–441. Ho¨glund, A., Winblad, U., Arnetz, A., Arnets, J., 2010. Patient participation during hospitalization for myocardial infarction: perceptions among patients and personal. Scandinavian Journal of Caring Sciences 24 (3), 482–489. Institute for Healthcare Improvement (IHI), 2009. Patient-centered Care. IHI, Cambridge, MA Available at: http://www.ihi.org/IHI/Topics/ PatientCenteredCare/ (accessed on 16.11.10). Jangland, E., Gunningberg, L., Carlsson, M., 2009. Patients’ and relatives’ complaints about encounters and communication in health care: evidence for quality improvement. Patient Education and Counseling 75 (2), 199–204. Jangland, E., Larsson, J., Gunningberg, L., 2010. Surgical nurses’ different understandings of their interactions with patients: a phenomenographic study. Scandinavian Journal of Caring Sciences, doi:10.1111/ j.1471-6712.2010.00860.x (online publication). Joint Commission, 2010. National Patient Safety Goals (NPSGs). Available at: http://www.jointcommission.org/PatientSafety/NationalPatient SafetyGoals/ (accessed on 17.11.10). Kazdin, A.E., 2003. Research Design in Clinical Psychology, 4th edition. Allyn & Bacon, Boston. Kinnersley, P., Edwards, A., Hood, K., Cadbury, N., Owen, D., Butow, P., Butler, C., 2007. Interventions before consultations for helping patients address their information needs. Cochrane Database Systematic Reviews 3 . Kitson, A., Rycroft-Malone, J., Harvey, G., McCormack, B., Seers, K., Titchen, A., 2008. Evaluating the successful implementation of evidence into practice using the PARISH framework: theoretical and practical challenges. Implementation Science 7 (31), 1. KUPPIT, Version 2007. Administration and support by ImproveIT, Halmstad, Sweden. Available at: http://www.improveit.se (in Swedish). Lewin, S., Skea, Z., Entwistle, V.A., Zwarensteine, M., Dick, J., 2009. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews 4 , doi:10.1002/14651858.CD003267 2001, Art. No.: CD003267 (edited [no change to conclusions], published in Issue 1, 2009). Muntlin, A˚., Gunningberg, L., Carlsson, M., 2006. Patients’ perception of quality of care at an emergency department and identification of areas for quality improvement. Journal of Clinical Nursing 15 (8), 1045–1056. Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., McCormack, B., 2004. What counts as evidence in evidence-based practice? Journal of Advanced Nursing 47 (1), 81–90. Sahlsten, M., Larsson, I., Plos, K., Lindecrona, C., 2005. Hindrance for patient participation in nursing care. Scandinavian Journal of Caring Sciences 19, 223–229. Sahlsten, M., Larsson, I., Sjo¨stro¨m, B., Plos, K., 2008. An analysis of the concept of patient participation. Nursing Forum 43 (1), 2–11. Say, R., Murtagh, M., Thomson, R., 2006. Patients’ preferences for involvement in medical decision making: a narrative review. Patient Education and Counseling 60, 102–114. Scott-Smith, J.L., Greenhouse, P.K., 2007. Transforming care at the bedside: patient-controlled liberalized diet. Journal of Interprofessional Care 21 (2), 179–188. Sehgal, N., Fox, M., Vidyarthi, A., Sharpe, B., Gearhart, S., Bookwalter, T., Barker, J., Alldredge, B., Blegen, M., Wachter, R.A., 2008. Multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience. Journal of General Internal Medicine 23 (12), 2053–2057. Sehgal, N., Green, A., Vidyarthi, A., Blegan, M., Wachter, R., 2010. Patients’ whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. Journal of Hospital Medicine 5 (4), 234–239. Simi, S., Patoia, L., 2010. The importance of being patient. Journal of Ambulatory Care Management 33 (3), 257–264. SOSFS, 2005. God Va˚rd. Om ledningssystem fo¨r kvalitet och patient sa¨ker va˚rd i ha¨lso- och sjukva˚rden (Good Care. System for Quality and Patient Safety in Health Care), National Board of Health and Welfare, Stockholm (in Swedish). SOSFS, 2010. Din skyldighet att informera och go¨ra patienten delaktig handbok fo¨r va˚rdgivare, verksamhetschefer och personal [Your Obligation to Inform and Involve the Patient—Handbook for Caregivers, Heads of Departments and Staff]. National Board of Health and Welfare, Stockholm (in Swedish). Taylor, J., Rutherford, P., 2010. The pursuit of genuine partnerships with patients and family members: the challenge and opportunity for
538
E. Jangland et al. / International Journal of Nursing Studies 49 (2012) 528–538
executive leaders. Frontiers of Health Services Management 26 (4), 3–14. Timonen, L., Sihvonen, M., 2000. Patient participation in bedside reporting on surgical wards. Journal of Clinical Nursing 9, 542–548. Wilde B., 1994. Quality of Care: Models, Instruments and Empirical Results among the Elderly. Doctoral Thesis. University of Gothenburg, Gothenburg, Sweden. Wilde, B., Larsson, G., Larsson, M., Starrin, B., 1994. Quality of care. Development of a patient-centred questionnaire based on a
grounded theory model. Scandinavian Journal of Caring Sciences 8, 39–48. Wilde Larsson, B., Larsson, G., 2002. Development of a short form of the Quality from the Patient’s Perspective (QPP) questionnaire. Journal of Clinical Nursing 11, 681–687. Wilde Larsson, B., Larsson, G., Wickman Chantereau, M., Stael von Holstein, K., 2005. International comparison of patients’ views on quality of care. International Journal of Health Care Quality Assurance 18 (1), 62–73.