Changing Healthcare Context Research Articles

Barriers and facilitators to use of digital health tools by healthcare practitioners and their patients, before and during the COVID-19 pandemic: a multimethods study

ObjectivesTo explore how healthcare practitioners (HCPs) made decisions about the implementation of digital health technologies (DHTs) in their clinical practice before and during the COVID-19 pandemic.DesignA multimethods study, comprising semistructured...

Adapting Connect for Health pediatric weight management program for telehealth in response to the COVID-19 pandemic

BackgroundTo address the evolving needs and context changes due to the COVID-19 pandemic, we adapted Connect for Health, an evidence-based, primary care, pediatric weight management intervention. The objective of this study is to describe the planned adaptation process to ensure continued and equitable program uptake during the pandemic.MethodsGuided by adaptation frameworks, we identified the core functions and forms of Connect for Health and then adapted the intervention in response to a changing healthcare context. We engaged stakeholders and surveyed parents of children with a BMI ≥ 85th percentile and pediatric clinicians and examined their experiences using telehealth for pediatric weight management and needs and preferences. Using multivariable logistic regression, we examined the preferences of parents with limited English proficiency regarding key aspects of pediatric weight management.ResultsWe surveyed 200 parents and 43% had a primary language of Spanish. Parents wanted care to be a combination of in-person and virtual visits (80%). We found that parents with limited English proficiency had a higher odds ratio of affirming in-person visits are better than virtual visits for ensuring their child’s health concern can be taken care of (OR: 2.91; 95% CI: 1.36, 6.21), feeling comfortable when discussing personal information (OR: 3.91; 95% CI: 1.82, 8.43), talking about healthy behaviors and setting goals (OR: 3.09; 95% CI: 1.39, 6.90), and talking about mental health and overall well-being (OR: 4.02; 95% CI: 1.83, 8.87) than parents without limited English proficiency. We surveyed 75 clinicians and 60% felt telehealth was a useful tool to provide care for pediatric weight management. Clinicians felt virtual visits did not pose barriers to all aspects of care. Informed by the surveys and stakeholder input, we made clinician- and family-level adaptations while retaining the program’s function.ConclusionsBy engaging stakeholders and adapting the program for telehealth, we optimized the reach and fit of Connect for Health to ensure its continued uptake. We have provided a real-world example of how clinical innovations can evolve and how to systematically plan adaptations in response to changing healthcare contexts.Trial registrationClinicaltrials.gov (NCT04042493), Registered on August 2, 2019.

Examining subacute nurses' roles in a changing healthcare context.

To explore and describe nurses' role in the rehabilitation and care of patients in one subacute care facility in Melbourne, Australia. The role of nurses in subacute care and within the rehabilitation team is evolving and remains unclear. Mixed methods. Fourteen nurses from seven rehabilitation and geriatric evaluation and management wards in one subacute facility in Melbourne, Australia, were observed in practice for two hours and then interviewed. Activities were recorded electronically. Interviews were audio-recorded and transcribed. Data were analysed using content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ). Three main themes are as follows: (a) Nurses as rehabilitators; (b) Teamwork in rehabilitation; and (c) The changing context of subacute care. Nurses prioritised patient personal and clinical care above other responsibilities. They were largely excluded from team decision-making because clinical responsibilities precluded them from attending team meetings. Unsuitable buildings, increased patient acuity and time constraints were further challenges. Nurses have a multifaceted role in patient rehabilitation that is poorly understood. An evaluation of the nursing role within the interdisciplinary team, skills and processes of care may increase understanding, and improve communication and relationships between disciplines potentially benefiting patients. Role clarity and differentiation in nursing skills are required within the nursing workforce. Nurses have a unique role in both clinical care and rehabilitation of patients, and as part of the interdisciplinary team. Respectful professional relationships need fostering within the interdisciplinary team to achieve optimal patient outcomes. The way that team meetings and decision-making occur in the subacute wards requires adjustment to ensure that the valuable contribution of nurses, both to the interdisciplinary team and to the rehabilitation of patients, is used and acknowledged to improve patient care.

Coaching to improve self-directed learning.

The continuously changing health care context necesitates that medical trainees develop self-directed learning skills. This study examined the effect of coaching on the self-directed learning process in pre-clerkship medical students. We conducted a longitudinal educational intervention using standardised patient assessments to determine the effect of self-assessment, feedback, and coaching on the development and implementation of learning goals (LGs). Students were sorted into control and intervention groups. Following each assessment, students received feedback on performance and created LGs. Students in the intervention group worked with a faculty member coach on their LGs. Students in the control group developed their LGs without a coach. Prior to the final assessment, students reported whether they had implemented their LGs. Of 171 students enrolled, 167 completed all four assessments and were included. All 167 developed an LG after each assessment. Overall, 79.0% of students reported implementing an LG. Of students receiving coaching, 91.8% implemented anLG, whereas only 65.9% of students in the control group implemented an LG (odds ratio, OR 5.7; 95% confidence interval,CI2.4-14.2). Students whoreceived coaching were morelikely to incorporate performancefeedback into their LGs (90.2 versus 38.1%; p<0.05). For students, faculty member coaching facilitated better LG development and more frequent implementation compared with students who did not receive coaching.

Developing the experts we need: Fostering adaptive expertise through education.

In this era of increasing complexity, there is a growing gap between what we need our medical experts to do and the training we provide them. While medical education has a long history of being guided by theories of expertise to inform curriculum design and implementation, the theories that currently underpin our educational programs do not account for the expertise necessary for excellence in the changing health care context. The more comprehensive view of expertise gained by research on both clinical reasoning and adaptive expertise provides a useful framing for re-shaping physician education, placing emphasis on the training of clinicians who will be adaptive experts. That is, have both the ability to apply their extensive knowledge base as well as create new knowledge as dictated by patient needs and context. Three key educational approaches have been shown to foster the development of adaptive expertise: learning that emphasizes understanding, providing students with opportunities to embrace struggle and discovery in their learning, and maximizing variation in the teaching of clinical concepts. There is solid evidence that a commitment to these educational approaches can help medical educators to set trainees on the path towards adaptive expertise.

‘Bolam’ to ‘Montgomery’ is result of evolutionary change of medical practice towards ‘patient-centred care’

The Supreme Court judgement in ‘Montgomery v Lanarkshire Health Board’ has caused a change in the law concerning the duty of doctors on disclosure of information to patients regarding risks....

Implementing lean management/Six Sigma in hospitals: beyond empowerment or work intensification?

This article analyses a process improvement project based on Lean Six Sigma (LSS) techniques in the emergency department (ED) of a large Australian hospital. We consider perspectives of the clinical and managerial staff involved in the project implementation, its implications for empowerment and work intensification. We find that the project appeared to improve patient flow from the ED to the wards and to have positive implications for some staff. However, these achievements tended to be the result of senior staff using the project to leverage resources and create desirable outcomes, rather than the result of the use of LSS, in particular. We found some evidence of work intensification, but this was attributable to wider systemic issues and budget constraints, rather than being a direct consequence of the use of LSS. We argue that translating LSS from a manufacturing context into the politicised and professionalised context of healthcare changes the usual questions about empowerment or work intensification to questions about the influences of powerful stakeholders.

The role of the sign-off mentor in the community setting.

In an move to identify nursing as an all-graduate profession, the Nursi Midwifery Council standards identified that future nurses need to be equipped with the skills and knowledge to lead and deliver high-quality care. Inorder to have these skills within the changing context of health care, students need to experience care delivery across a range of community, hospital and other settings. Students have to undertake a final clinical placement of 12 weeks at the end of their programme, commonly called a consolidation placement, and are allocated a sign-off mentor to confirm they meet the requirements for entry to the register. Placement capacity within primary care settings continues to be a challenge alongside the need for providing a sign-off mentor. This article discusses some of the challenges and opportunities of the role of the sign-off mentor and the potential impact for encouraging newly qualified recruitment in this area.

A single competency-based education and training and competency-based career framework for the Australian health workforce: discussing the potential value add

This brief discusses the policy implications of a research study commissioned by Health Workforce Australia (HWA) within its health workforce innovation and reform work program. The project explored conceptually complex and operationally problematic concepts related to developing a whole-of-workforce competency-based education and training and competency-based career framework for the Australian health workforce and culminated with the production of three reports published by HWA. The project raised important queries as to whether such a concept is desirable, feasible or implementable - in short what is the potential value add and is it achievable? In setting the scene for discussion, the foundation of the project's genesis and focus of the study are highlighted. A summary of key definitions related to competency-based education and training frameworks and competency-based career frameworks are provided to further readers' commonality of understanding. The nature of the problem to be solved is explored and the potential value-add for the Australian health workforce and its key constituents proposed. The paper concludes by discussing relevance and feasibility issues within Australia's current and changing healthcare context along with the essential steps and implementation realities that would need to be considered and actioned if whole-of-workforce frameworks were to be developed and implemented.

Converting policy into care: women’s satisfaction with the early labour telephone component of the All Wales Clinical Pathway for Normal Labour

This article is a report of a study of women's experiences of, and satisfaction with, telephone communications within the All Wales Clinical Pathway for Normal Labour ('the Pathway'). The Pathway was introduced throughout Wales over 2003-2004. Its philosophy emphasizes the desirability of a woman remaining at home until labour is established with assessment by telephone, in contrast to the more common scenario where the phone call is a precursor to admission and face-to-face assessment. In 2005-2006, telephone interviews were carried out with 46 low-risk first-time mothers in Wales. This was a mixed-methods study with iterative quantitative and qualitative analysis, focusing on differences in the accounts of women with different levels of satisfaction. Women were not well prepared for the Pathway; however, satisfaction was more strongly related to interpersonal interactions with midwives. Dissatisfied women reported unclear advice, unmet needs, unaddressed anxieties and negative midwife manner. 'Very satisfied' women were distinguished by feeling welcome to attend the maternity unit and by the perceived adequacy of the advice given. This study provides new knowledge about telephone interactions between first-time mothers and midwives around labour onset. This is important in a changing healthcare context in which face-to-face interactions are likely to become less routine. Being made to feel welcome to attend the maternity unit might appear counter to the Pathway philosophy, but appeared to reduce women's anxieties about 'being allowed in' or getting to hospital in time, and gave them confidence to remain at home longer.

Commentary on Chung BPM, Wong TKS, Suen ESB &amp; Chung JWY (2005) SARS: caring for patients in Hong Kong. Journal of Clinical Nursing 14, 510–517

The emergence of Severe Acute Respiratory Syndrome (SARS) posed a major challenge to the health care sectors of many countries of the world. China and Hong Kong were most severely affected by this new infectious disease. Being at the vanguard of the health care team, nurses were at the centre of the effort to fight this battle. As SARS was a completely unknown, highly contagious and potentially lethal disease, nursing patients with SARS was inevitably challenging and stressful. In fact, a number of nurses in Hong Kong had contracted SARS and the first health care worker who died as a result of SARS was a nurse. Being an unknown disease, SARS is heavily researched. Much of the work, however, has been reported from the perspectives of biomedicine. This paper by Chung et al. adds knowledge to this field by describing the lived experiences of nurses caring for SARS patients and raises a number of perceptive issues with regard to nurses’ roles and their contribution in health care delivery. It also provided us with an opportune invitation to reflect on what nursing is about in this changing health care context. Ever since the era of Florence Nightingale, public health and infection control have been important agendas in nursing. SARS served as a reminder of the indispensable role we play in dealing with a real threat to the health of the public. The experiences of caring for SARS patients as articulated in Chung et al.’s paper, however, have particularly reminded us of the ‘taken for granted’ features of nursing: being sensitive and present, ‘doing’ the little things that ‘go above and beyond just the routine’ such as getting patients a hot drink and buying a newspaper. Nurses in this study regarded these ‘little things’ as making a difference to the patients’ perceptions of being cared for. They also exercised their professionalism by demonstrating accountability not only to their patients but also their families. Families highly value the ‘physical and emotional presence’ of nurses, especially at times of crisis. These ‘humanistic’ aspects of nurses’ role, which have apparently been under-valued in the highly technological world of today, were brought out again in this crisis. Indeed, SARS has not only highlighted the major clinical, educational and public health implications for nursing (Thompson et al. 2004), it has also provided an opportunity for us to reflect on our roles in the health care system. As a result of inadequate manpower planning and the implementation of various cost-saving initiatives, nurses in Hong Kong, for example, have ‘delegated’ most of our basic care to health care assistants. Gottlieb (2004) commented that nursing and other health-care personnel were the first to suffer and made redundant when governments exercise fiscal restraints on the health-care system. It is a worry that while nurses are ‘giving away’ what the public has perceived as their responsibilities, they have not adequately demonstrated their other health care duties, which have a positive impact on patient outcomes. In fact, just before SARS, our graduates were faced with the possibilities of unemployment. The ‘arrival’ of SARS served as a wake-up call and ignited a great demand for nurses. It was evident that nurses were highly respected by the public for their professionalism and expertize in the SARS battle. They were seen as heroes and guardians of people's health. The question for us now is how we can best seize this ‘opportunity’, continue with this momentum to raise our profile and contribute our knowledge and skills to the planning and organizing of health care.

Social Work Gerontological Assessment Revisited

Summary Research has learned much in the last forty years about the factors critical in a gerontological social work assessment. However, assessment must be constantly readdressed, because the context of health care changes and the research technology that enables the study of factors critical to the assessment process becomes more sophisticated. This paper presents the evolution of assessment research and identifies critical assessment factors as related to the changing social work practice in the context of the country's changing health care environment.

Measuring the socialization of graduate and diplomate nurses using the Corwin Role Orientation Scale.

The nature of United Kingdom (UK) nursing education has changed significantly as the responsibility has been transferred from hospitals to the University sector. More information is needed on the outcome of the Project 2000 diploma and degree courses given the rapidly changing health care context. This paper focuses on the role socialization of graduate and diploma nurses. As part of a larger study, this research investigated the role orientations of 52 nursing graduates and 28 diplomates from two different universities at three time points; on graduation and at 6 and 12 months postgraduation. The Corwin Role Orientation Scale was selected and modified for the study. It comprised of three separate scales measuring professional, bureaucratic and service orientation. The data from the two groups of nurses were examined to identify nurses' ideal role orientations and role discrepancies over the transitionary period from graduate to qualified nurse. Although the results showed observed differences between the groups over time, none of these differences were statistically significant. The findings raise a number of questions about the value of the instrument as a measure in the contemporary nursing context. Furthermore, each of the Corwin subscales had a low internal reliability. A possible explanation may be that the instrument, which was developed in the United States of America (USA) in the 1960s, and modified, for this study, has little relevance for contemporary UK nursing. The study findings are also limited by the small size of the sample. In spite of these limitations, the study suggests there are few differences between the role orientations and socialization experiences of UK nursing graduates and diplomates. Indeed, both programmes commonly take place in university settings and students receive the same amount of clinical experience. Further instrument development and exploratory research is recommended to identify the role socialization and orientations of UK nurses through larger national studies.

Seeds of Change: The Development of a Spiritual Assessment Model

The changing health care context is one of the most important issues facing chaplains today. Assuming that chaplains are best served by developing models out of the context in which they minister, this article gives a narrative account of the pastoral care department's methods to work creatively with the on-going course of change at High Point Regional Health System of North Carolina. A significant part of the process was the development of a psycho-social/spiritual screen which was eventually incorporated into the admission screening of all in-patients, providing for automatic referral of patients needing pastoral care assessment and intervention. Efforts to learn about the process of change as well as to make changes in our approach to pastoral care effectively created new opportunities for the integration of pastoral care into the health care system.

Whither the almshouse? Overutilization and the role of the emergency department.

The problem of emergency department (ED) overutilization or "inappropriate" utilization is commonly conceptualized in terms of inadequate access to appropriate primary medical care. Although medical care access is a critical issue, a focus on increased access to medical care as the sole solution to "inappropriate" ED utilization may obscure other, perhaps equally relevant, issues from consideration. This article reports findings from an ethnographic study focusing on heavy users (HUs) of EDs in two inner-city hospitals. Drawing on fieldwork and on interviews with HU patients and ED clinicians, I argue that the emergence of heavy ED utilization as both a clinical and policy problem is a function not merely of unmet medical care needs for individuals, but of "almshouse" needs in a changing health care context. The emergence of ED overutilization as a problem occurs in the context of market forces that are contributing to shifts in the role of EDs and in the moral boundaries of accepted ED practice. If the problem of heavy ED use is more broadly conceptualized in terms of this role shift, not solely in terms of medical care access, a different set of issues and priorities for research, policy, and clinical practice emerges.

Why psychologists should treat alcohol and drug problems.

Because of the prevalence of substance abuse in general clinical populations, it is important for psychologists to have knowledge and skill in this area. Psychologists also have special expertise to offer in the assessment and treatment of alcohol/drug problems. Current evidence indicates that (a) alcohol/drug problems generally obey ordinary behavioral principles and processes, (b) substance abuse frequently occurs within a broader cluster of psychological problems, (c) the treatment approaches most strongly supported by outcome research are fundamentally psychological in nature, (d) cognitive-behavioral principles are of demonstrable value in motivating change in alcohol/drug use, and (e) clinical skills and styles (e.g., empathy) commonly included in the training of psychologists are important determinants of favorable treatment outcomes with substance use disorders. These factors in the context of changing health care indicate that psychologists should play an increasing role in assessing and treating addictive behaviors.