Elderly patients' decision-making embedded in the social context: a mixed-method analysis of subjective norms and social support.

BACKGROUND: Older patients are increasingly encouraged to be actively involved but how they perceive their role in the decision-making process varies according to their health care providers and their health situation. Their role could be influenced by their social context but more specifically by subjective norms (i.e. patients' view of the role that significant others expect them to play in the decision-making process) and perceived social support. We explore how social context (i.e. subjective norms and social support) relates to how the patient perceives their role in the decision-making process. Also, we explore the level of alignment on subjective norms between patients and their informal caregivers and nurses. METHODS: Mixed-method study among older patients, informal caregivers and nurses. For the quantitative questionnaire, a home care organisation randomly selected patients. The patients were asked to identify their informal caregiver and the home care organisation was asked to identify the nurse who was most involved in their care. In total 133 patients, 64 informal caregivers and 72 nurses were questioned. Participants for the qualitative interviews were selected using convenience sampling, resulting in the inclusion of ten patients, five informal caregivers and six nurses. Subjective norms were based on a previous study. Social support was measured with the 'social support for health scale' of the Health Literacy Questionnaire. The Control Preference Scale was used as outcome variable. The interviews focused on subjective norms, social support and how the patient perceived their role. Quantitative analysis included the calculation of subjective norm difference scores between respondent groups, one-way analysis of variance and multinomial logistic regression analysis. Directed content analysis was applied to the interviews using Atlas TI. RESULTS: Lower difference scores were found for patient-informal caregiver dyads (mean = 0.95), implying more alignment than in patient-nurse dyads (mean = 2.12). Patients perceiving themselves to have a shared or passive role tend to believe that they are expected to leave decision-making to the health care provider. Higher social support scores related more to a shared role. Alignment relates to: familiarity with the patient's preferences, overprotectiveness or valuing the care provider's opinion and the severity of the patient's medical history. CONCLUSION: Patients and informal caregivers align on whether the patient should make decisions. The more patients believe that they are expected to leave decision-making to the health care provider, the more they perceive themselves as having a passive role. The more patients who feel they have support, the more they perceive themselves as having a shared role. Patients and caregivers could be facilitated to make role expectations explicit. Examining support resources in the social network is desirable.

Interventions to improve team effectiveness within health care: a systematic review of the past decade.

BACKGROUND: A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design. OBJECTIVES: To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research. METHODS: Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence. RESULTS: Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements. CONCLUSION: Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Trust in older persons: A quantitative analysis of alignment in triads of older persons, informal carers and home care nurses.

Self-management by older persons could be influenced by the level of trust found in triads of informal carers, formal care providers and care recipient, the older person. Little research has been done on care providers' trust in older persons. This study aims to explore the level of trust that informal carers and home care nurses have in older persons, the extent of alignment in triads and the relationship between trust in older persons and self-management. We conducted a cross-sectional survey study in the Netherlands, sampling 133 older persons, 64 informal carers and 72 nurses, which resulted in 39 triads. Alignment level was analysed through Intraclass Correlation Coefficient 1 scores and absolute and mean difference scores. Correlation analysis and one-way analysis of variance measured the relationship between trust and self-management. The results show that triads contain both alignment and misalignment. Misalignment occurs mostly when informal carers and nurses have little trust in the older person while this person views their own behaviour towards their caregivers positively. Care providers' trust levels relate significantly to their perception of the person's ability to self-manage, but not to the person's self-rated ability. This could be explained by care providers not communicating their intrinsic trust in the older person to them. Trust building could be enhanced by organising discussions of mutual expectations of trust and both formal and informal care providers could benefit from compassionate assessment training, to learn how to openly express their trust in the older person.

The Impact of the Patient-Centered Medical Home on Health Care Disparities: Exploring Stakeholder Perspectives on Current Standards and Future Directions.

Over the past decade, the Patient-Centered Medical Home (PCMH) has become a preeminent model for primary care delivery. Simultaneously, health care disparities have gained increasing attention. There has been limited research on whether and how the PCMH can or should affect health care disparities. The authors conducted qualitative interviews with key stakeholders and experts on the PCMH model and health care disparities, including grant and policy makers, accreditors, researchers, patient advocates, primary care practices, practice transformation organizations, and payers, to assess perspectives on the role of the PCMH in addressing health care disparities. The application of grounded theory and thematic analysis elucidated best practice recommendations for the PCMH model's role in addressing health care disparities. Although the majority of stakeholders support greater integration of efforts to reduce health care disparities into the PCMH model, most stakeholders view the current PCMH model as having minimal or indirect influence on health care disparities. The majority supported greater integration of efforts to reduce health care disparities into the PCMH model. As the PCMH model continues to be refined, and as the health care system strives toward improving population health, there must be reflection on the policies and delivery systems that impact health care disparities.

The different perspectives of patients, informal caregivers and professionals on patient involvement in primary care teams. A qualitative study.

BACKGROUND: Patient involvement in the decision-making process, especially for chronically ill elderly patients, has become an important element of patient-centred primary care in many countries, including the Netherlands. This study openly explores different perspectives of patients, informal caregivers and primary care professionals on patient involvement in primary care team interactions. METHODS: Sixty-four qualitative semi-structured interviews with chronically ill elderly patients, informal caregivers and primary care professionals from various disciplines. Underpinned by a phenomenology approach, this study used conventional content analysis for data analysis. RESULTS: Participants have different views of the roles of patients and informal caregivers in the primary care team and thus different expectations of the extent and level of patient involvement. Three challenges impact patient involvement in the team: (a) patients feel misunderstood and less involved that they would like when professionals take control, (b) patients have to balance the conflicting opinions of different professionals and (c) informal caregivers act undesirably as team leaders due to their own view of the level of patient involvement. DISCUSSION AND CONCLUSION: Patient involvement is formed in complex interactions between patients, informal caregivers and multiple professionals whose perspectives and expectations can be misaligned. Recognizing the value of patients and informal caregivers on the team could help professionals to understand them better and thus limit the likelihood of challenges arising in team interactions.

Who is on the primary care team? Professionals' perceptions of the conceptualization of teams and the underlying factors: a mixed-methods study.

BACKGROUND: Due to the growing prevalence of elderly patients with multi-morbidity living at home, there is an increasing need for primary care professionals from different disciplinary backgrounds to collaborate as primary care teams. However, it is unclear how primary care professionals conceptualize teams and what underlying factors influence their perception of being part of a team. Our research question is: What are primary care professionals' perceptions of teams and team membership among primary care disciplines and what factors influence their perceptions? METHODS: We conducted a mixed-methods study in the Dutch primary care setting. First, a survey study of 152 professionals representing 12 primary care disciplines was conducted, focusing on their perceptions of which disciplines are part of the team and the degree of relational coordination between professionals from different disciplinary backgrounds. Subsequently, we conducted semi-structured interviews with 32 professionals representing 5 primary care disciplines to gain a deeper understanding of the underlying factors influencing their perceptions and the (mis)alignment between these perceptions. RESULTS: Misalignments were found between perceptions regarding which disciplines are members of the team and the relational coordination between disciplines. For example, general practitioners were viewed as part of the team by helping assistants, (district) nurses, occupational therapists and geriatric specialized practice nurses, whereas the general practitioners themselves only considered geriatric specialized practice nurses to be part of their team. Professionals perceive multidisciplinary primary care teams as having multiple inner and outer layers. Three factors influence their perception of being part of a team and acting accordingly: a) knowing the people you work with, b) the necessity for knowledge exchange and c) sharing a holistic view of caregiving. CONCLUSION: Research and practice should take into account the misalignment between primary care professionals' perceptions of primary care teams, as our study notes variations in the conceptualization of primary care teams. To enhance teamwork between professionals from different disciplinary backgrounds, professionals acknowledge the importance of three underlying conditions: team familiarity, regular and structured knowledge exchange between all professionals involved in the care process and realizing and believing in the added value for patients of working as a team.