Patients' attitudes towards, and information needs in relation to, nurse prescribing in rheumatology

Aims and objectives: To assess the level of confidence that rheumatology patients would have in nurse prescribing, the effects on likely adherence and particular concerns that these patients have. In addition, given that information provision has been cited as a potential benefit of nurse prescribing, the present study assessed the extent to which these patients would want an explanation for the selected medicine, as well as which types of information should be included in such an explanation. Background: Nurse prescribing has been successfully implemented in the UK in several healthcare settings. Existing research has not addressed the effects on patients' confidence and likely adherence, nor have patients' information needs been established. However, we know that inadequate medicines information provision by health professionals is one of the largest causes of patient dissatisfaction. Methods: Fifty-four patients taking disease-modifying drugs for inflammatory joint disease attending a specialist rheumatology clinic self-completed a written questionnaire. Results: Patients indicated a relatively high level of confidence in nurse prescribing and stated that they would be very likely to take the selected medication. The level of concern was relatively low and the majority of concerns raised did not relate to the nurse's status. Strong support was expressed for the nurse providing an explanation for medicine choice. Conclusion: This research provides support for the prescription of medicines by nurses working in the area of rheumatology, the importance of nurses providing a full explanation about the selected medicines they prescribe for these patients and some indication as to which categories of information should be included. Relevance to clinical practice: Rheumatology patients who have not yet experienced nurse prescribing are, in general, positive about nurses adopting this role. It is important that nurses provide appropriate information about the prescribed medicines, in a form that can be understood.

Health informatics: improving patient-centred healthcare pathway

Nowadays the use of information and communication technology is becoming prevalent in many aspects of healthcare services from patient registration, to consultation, treatment and pathology tests request. Manual interface techniques have dominated data-capture activities in primary care and secondary care settings for decades. Despites the improvements made in IT, usability issues still remain over the use of I/O devices like the computer keyboard, touch-sensitive screens, light pen and barcodes. Furthermore, clinicians have to use several computer applications when providing healthcare services to patients. One of the problems faced by medical professionals is the lack of data integrity between the different software applications which in turn can hinder the provision of healthcare services tailored to the needs of the patients. The use of digital pen and paper technology integrated with legacy medical systems hold the promise of improving healthcare quality. This paper discusses the issue of data integrity in e-health systems and proposes the modelling of "Smart Forms" via semiotics to potentially improve integrity between legacy systems, making the work of medical professionals easier and improve the quality of care in primary care practices and hospitals.

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis

Background: Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. Methods: In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to general practices, patients, pharmacists, researchers, and statisticians. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-eff ectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299. Findings: 72 general practices with a combined list size of 480 942 patients were randomised. At 6 months’ follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0∙58, 95% CI 0∙38–0∙89); a β blocker if they had asthma (0∙73, 0∙58–0∙91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0∙51, 0∙34–0∙78). PINCER has a 95% probability of being cost eff ective if the decision-maker’s ceiling willingness to pay reaches £75 per error avoided at 6 months. Interpretation: The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. Funding: Patient Safety Research Portfolio, Department of Health, England.

Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Iatrogenic errors and patient safety in clinical processes are an increasing concern. The quality of process information in hardcopy or electronic form can heavily influence clinical behaviour and decision making errors. Little work has been undertaken to assess the safety impact of clinical process planning documents guiding the clinical actions and decisions. This paper investigates the clinical process documents used in elective surgery and their impact on latent and active clinical errors. Eight clinicians from a large health trust underwent extensive semi- structured interviews to understand their use of clinical documents, and their perceived impact on errors and patient safety. Samples of the key types of document used were analysed. Theories of latent organisational and active errors from the literature were combined with the EDA semiotics model of behaviour and decision making to propose the EDA Error Model. This model enabled us to identify perceptual, evaluation, knowledge and action error types and approaches to reducing their causes. The EDA error model was then used to analyse sample documents and identify error sources and controls. Types of knowledge artefact structures used in the documents were identified and assessed in terms of safety impact. This approach was combined with analysis of the questionnaire findings using existing error knowledge from the literature. The results identified a number of document and knowledge artefact issues that give rise to latent and active errors and also issues concerning medical culture and teamwork together with recommendations for further work.

An organisational semiotics inspired information architecture: pervasive healthcare as a case study

Information architecture (IA) is defined as high level information requirements of an organisation. It is applied in areas such as information systems development, enterprise architecture, business processes management and organisational change management. Still, the lack of methods and theories prevents information architecture becoming a distinct discipline. Healthcare organisation is always seen as information intensive organisation, moreover in a pervasive healthcare environment. Pervasive healthcare aims to provide healthcare services to anyone, anywhere and anytime by incorporating mobile devices and wireless network. Information architecture hence plays an important role in information provisioning within the context of pervasive healthcare in order to support decision making and communication between clinician and patients. Organisational semiotics is one of the social technical approaches that contemplate information through the norms or activities performed within an organisation prior to pervasive healthcare implementation. This paper proposes a conceptual design of information architecture for pervasive healthcare. It is illustrated with a scenario of mental health patient monitoring.

Training pharmacists to deliver a complex information technology intervention (PINCER) using the principles of educational outreach and root cause analysis

Objective: To describe the training undertaken by pharmacists employed in a pharmacist-led information technology-based intervention study to reduce medication errors in primary care (PINCER Trial), evaluate pharmacists’ assessment of the training, and the time implications of undertaking the training. Methods: Six pharmacists received training, which included training on root cause analysis and educational outreach, to enable them to deliver the PINCER Trial intervention. This was evaluated using self-report questionnaires at the end of each training session. The time taken to complete each session was recorded. Data from the evaluation forms were entered onto a Microsoft Excel spreadsheet, independently checked and the summary of results further verified. Frequencies were calculated for responses to the three-point Likert scale questions. Free-text comments from the evaluation forms and pharmacists’ diaries were analysed thematically. Key findings: All six pharmacists received 22 hours of training over five sessions. In four out of the five sessions, the pharmacists who completed an evaluation form (27 out of 30 were completed) stated they were satisfied or very satisfied with the various elements of the training package. Analysis of free-text comments and the pharmacists’ diaries showed that the principles of root cause analysis and educational outreach were viewed as useful tools to help pharmacists conduct pharmaceutical interventions in both the study and other pharmacy roles that they undertook. The opportunity to undertake role play was a valuable part of the training received. Conclusions: Findings presented in this paper suggest that providing the PINCER pharmacists with training in root cause analysis and educational outreach contributed to the successful delivery of PINCER interventions and could potentially be utilised by other pharmacists based in general practice to deliver pharmaceutical interventions to improve patient safety.

Pragmatic oriented data interoperability for smart healthcare information systems

Smart healthcare is a complex domain for systems integration due to human and technical factors and heterogeneous data sources involved. As a part of smart city, it is such a complex area where clinical functions require smartness of multi-systems collaborations for effective communications among departments, and radiology is one of the areas highly relies on intelligent information integration and communication. Therefore, it faces many challenges regarding integration and its interoperability such as information collision, heterogeneous data sources, policy obstacles, and procedure mismanagement. The purpose of this study is to conduct an analysis of data, semantic, and pragmatic interoperability of systems integration in radiology department, and to develop a pragmatic interoperability framework for guiding the integration. We select an on-going project at a local hospital for undertaking our case study. The project is to achieve data sharing and interoperability among Radiology Information Systems (RIS), Electronic Patient Record (EPR), and Picture Archiving and Communication Systems (PACS). Qualitative data collection and analysis methods are used. The data sources consisted of documentation including publications and internal working papers, one year of non-participant observations and 37 interviews with radiologists, clinicians, directors of IT services, referring clinicians, radiographers, receptionists and secretary. We identified four primary phases of data analysis process for the case study: requirements and barriers identification, integration approach, interoperability measurements, and knowledge foundations. Each phase is discussed and supported by qualitative data. Through the analysis we also develop a pragmatic interoperability framework that summaries the empirical findings and proposes recommendations for guiding the integration in the radiology context.

Information analytics for healthcare service discovery

The concept of being ‘patient-centric’ is a challenge to many existing healthcare service provision practices. This paper focuses on the issue of referrals, where multiple stakeholders, i.e. general practitioners and patients, are encouraged to make a consensual decision based on patient needs. In this paper, we present an ontology-enabled healthcare service provision, which facilitates both patients and GPs in jointly deciding upon the referral decision. In the healthcare service provision model, we define three types of profile, which represents different stakeholders’ requirements. This model also comprises of a set of healthcare service discovery processes: articulating a service need, matching the need with the healthcare service offerings, and deciding on a best-fit service for acceptance. As a result, the healthcare service provision can carry out coherent analysis using personalised information and iterative processes that deal with requirements change over time.

Letters in cognitive analytic therapy: The patient's experience

Patient perspectives on how therapeutic letters contributed to their experience of cognitive analytic therapy (CAT) were investigated. Eight patients took part in semistructured interviews. A grounded, thematic analysis of their accounts suggested four general processes. First, letters offered a tangible, lasting framework for the assimilation of a new perspective about themselves and their relationships and facilitated coping with a complex range of emotions and risks this awareness required. Second, they demonstrated therapists’ commitment to patients’ growth. Third, they helped to teach participants about the therapy process as an example of an interpersonal exchange. Fourth, they helped participants consider how they wished to share personal information. These data offer a more complex understanding of this standard CAT intervention. Although some findings are consistent with CAT theory, the range of emotional dilemmas associated with letters has not received specific attention. Clinical implications are discussed.

Omvårdnad vid Amyotrofisk lateral skleros : erfarenheter ur ett patient och anhörigperspektiv : En systematisk litteraturstudie

Amyotrofisk lateral skleros (ALS) är en fortskridande neurologiska sjukdom som ger den drabbade och de anhöriga mycket sorg och smärta. Syftet med föreliggande systematiska litteraturstudie var att utifrån aktuell vetenskaplig litteratur beskriva upplevelsen och behovet av omvårdnad som den sjuke i ALS och deras anhöriga behövde. Syftet var också att beskriva vilken typ av information och stöd som behövdes. De vetenskapliga artiklarna som ligger till grund för denna litteraturstudie har sökt på databaserna Elin@Dalarna och Blackwell Synergy. Artiklarna skulle vara publicerade mellan åren 2000-2007 och vara skrivna på engelska. Även manuella sökningar har gjorts. Resultatet visade att sjukvården hade ett stort ansvar att stötta, hjälpa och informera vid denna fortskridande neurologiska sjukdom. Det fanns behov av multiinriktad omvårdnad där många olika professioner ingick för att kunna ge patienterna den helhetsvård de behövde. Det framkom att anhöriga var de som hade den givna omvårdnadsrollen och att de hade ett behov av avlastning och information om sjukdomen, behandlingen och symtomen. Anhöriga upplevde sjukdomen som en stor börda och påverkade deras egna hälsa.

Att vara anhörigvårdare till en patient inom palliativ hemsjukvård

Syftet var att beskriva anhörigvårdarens erfarenheter av palliativ vård av sin närstående i hemmet. Studien genomfördes som en litteraturstudie. I studien ingick 10 vetenskapliga artiklar från åren 2002-2008. Samtliga var av kvalitativ ansats. Resultatet i studien delades upp i fyra teman: erfarenheter av kommunikation, hantera den nya situationen, känsla av otillräcklighet och meningsfullhet trots allt. Resultatet belyste bland annat att information om patientens hälsotillstånd var viktigt för att anhörigvårdarna skulle känna sig bättre mentalt förberedda. Anhörigvårdare som upplevde brist på information och kommunikation tappade förtroende till sjukvården. Erfarenheter av existentiella frågor och samtal visade sig vara viktiga för att känna hopp och meningsfullhet. De som upplevde att de fick vara en del av det palliativa teamet kände sig delaktiga i vården i motsats till de som kände sig som en utomstående vilka kände sig förolämpade. Anhörigvårdarnas deltagande i vården gav dem möjlighet att leva ett mer naturligt familjeliv Det var viktigt att kunna behålla en vardag. För att klara av att vara anhörigvårdare behövde de få avlastning. När situationen blev ohanterbar kände de dåligt samvete och skuld över att inte levt upp till kraven. De upplevde frustration och en känsla av otillräcklighet. De erfarenheter som anhörigvårdarna hade av palliativ vård i hemmet var att stödet de fick från vårdpersonalen var avgörande för hur de skulle hantera situationen. En tillfredställande kommunikation innebar att vårdpersonalen var lyhörd för den enskilde anhörigvårdarens behov och att de såg patienten och anhörigvårdaren som en enhet.

Patient participation : what it is and what it is not

In general, patient participation is regarded as being informed and partaking in decision making regarding one’s care and treatment. This interpretation is common in legislation throughout the Western world and corresponding documents guiding health care professionals, as well as in scientific studies. Even though this understanding of the word participation can be traced to a growing emphasis on individuals’ autonomy in society and to certain dictionary defi nitions, there are other ways of understanding participation from a semantic point of view, and no trace of patients’ descriptions of what it is to participate can be found in these definitions. Hence, the aim of this dissertation was to understand patients’ experience of the phenomenon of patient participation. An additional aim was to understand patients’ experience of non-participation and to describe the conditions for patient participation and non-participation, in order to understand the prerequisites for patient participation. The dissertation comprises four papers. The philosophical ideas of Ricoeur provided a basis for the studies: how communication can present ways to understand and explain experiences of phenomena through phenomenological hermeneutics. The first and second studies involved a group of patients living with chronic heart failure. For the fi rst study, 10 patients were interviewed, with a narrative approach, about their experience of participation and non-participation, as defi ned by the participants. For the second study, 11 visits by three patients at a nurse-led outpatient clinic were observed, and consecutive interviews were performed with the patients and the nurses, investigating what they experience as patient participation and non-participation. A triangulation of data was performed to analyse the occurrence of the phenomena in the observed visits. For paper 3 and 4, a questionnaire was developed and distributed among a diverse group of people who had recent experience of being patients. The questionnaire comprised respondent’s description of what patient participation is, using items based on findings in Study 1, along with open-ended questions for additional aspects and general issues regarding situations in which the respondent had experienced patient participation and/or non-participation. The findings show additional aspects to patient participation: patient participation is being provided with information and knowledge in order for one to comprehend one’s body, disease, and treatment and to be able to take self-care actions based on the context and one’s values. Participation was also found to include providing the information and knowledge one has about the experience of illness and symptoms and of one’s situation. Participation occurs when being listened to and being recognised as an individual and a partner in the health care team. Non-participation, on the other hand, occurs when one is regarded as a symptom, a problem to be solved. To avoid non-participation, the information provided needs to be based on the individual’s need and with recognition of the patient’s knowledge and context. In conclusion, patient participation needs to be reconsidered in health care regulations and in clinical settings: patients’ defi nitions of participation, found to be close to the dictionaries’ description of sharing, should be recognised and opportunities provided for sharing knowledge and experience in two-way-communication.