Interpersonal Processes Of Care Research Articles

Client Perceptions of Cultural Competence of Community-Based Nurses

Cultural competence is best understood by assessing provider and client perspectives. In this descriptive quantitative study, clients assessed dimensions of nurses' cultural competence including communication, decision-making, and interpersonal style. Nurses in 7 county health departments in North Carolina assessed their own cultural competence. Sixty-nine clients completed the Interpersonal Processes of Care and 71 nurses completed the Cultural Competence Assessment. Clients perceived their nursing care to contain key components of cultural competence. Nurses rated themselves as moderate to high cultural competence. Consistencies were noted between the clients' and nurse perceptions of cultural competence. These findings contribute to the enhancement of cultural competence among community nurses.

Health literacy and the quality of physician‐patient communication during hospitalization

Overall, poor physician-patient communication is related to post-discharge adverse events and readmission. We analyzed patients' ratings of the quality of physician-patient communication during hospitalization and how this varies by health literacy. Medical patients were interviewed during their hospitalization to assess personal characteristics and health literacy. After discharge, patients completed by telephone the 27-item Interpersonal Processes of Care in Diverse Populations Questionnaire (IPC). Using the IPC, patients rated the clarity and quality of physicians' communication during the hospitalization along the following 8 domains: General clarity, Responsiveness to patient concerns, Explanation of patients' problems, Explanation of processes of care, Explanation of self-care after discharge, Empowerment, Decision making, and Consideration of patients' desire and ability to comply with recommendations. A total of 84 patients completed both the in-hospital and telephone interviews. Subjects had a mean age of 55, and 44% had inadequate health literacy. Overall, patients gave the poorest ratings to communication that related to Consideration of patients' desire and ability to comply with recommendations. Patients with inadequate health literacy gave significantly worse ratings on the domains of General clarity, Responsiveness to patient concerns, and Explanation of processes of care (P < 0.05 for each). In multivariable analyses, the relationship with General clarity did not persist. Physicians received relatively poor ratings on their Consideration of patients' desire and ability to comply with recommendations. Patients with inadequate health literacy experienced lower quality and clarity of hospital communication along multiple domains. More attention to effective health communication is warranted in the hospital setting.

Interpersonal Processes of Care and Patient Satisfaction: Do Associations Differ by Race, Ethnicity, and Language?

Describe association of patient satisfaction with interpersonal processes of care (IPC) by race/ethnicity. Interview with 1,664 patients (African Americans, English- and Spanish-speaking Latinos, and non-Latino Whites). Cross-sectional study of seven IPC measures (communication, patient-centered decision making, and interpersonal style) and three satisfaction measures (satisfaction with physicians, satisfaction with health care, and willingness to recommend physicians). Regression models explored associations, controlling for patient characteristics. In all groups: patient-centered decision making was positively associated with satisfaction with physicians (B=0.10, p<.0001) and health care (B=0.07, p<.001), and "recommend physicians" (OR=1.23, 95 percent CI 1.06, 1.43); discrimination was negatively associated with satisfaction with physicians (B=0.09, p<.05) and health care (B=0.17, p<.001). Unclear communication was associated with less satisfaction with physicians among Spanish-speaking Latinos. Explaining results was positively associated with all satisfaction outcomes for all groups with one exception (no association with satisfaction with physicians for Latino Spanish-speakers). Compassion/respect was positively associated with all outcomes for all groups with two exceptions (no association with satisfaction with health care among English-speaking Latinos and Whites). All IPC measures were associated with at least one satisfaction outcome for all groups except for unclear communication.

Depressive Symptoms and Perceived Doctor-Patient Communication in the Heart and Soul Study

BACKGROUNDDoctor-patient communication is an important marker of health-care quality. Little is known about the extent to which medical comorbidities, disease severity and depressive symptoms influence perceptions of doctor-patient communication in patients with chronic disease.METHODSIn a cross-sectional study of 703 outpatients with chronic coronary disease, we evaluated the extent to which patient reports of doctor-patient communication were influenced by medical comorbidities, disease severity and depressive symptoms. We assessed patient reports of doctor-patient communication using the Explanations of Condition and Responsiveness to Patient Preferences subscales from the “Interpersonal Processes of Care” instrument. Poor doctor-patient communication was defined as a score of <4 (range 1 to 5) on either subscale. All patients completed the nine-item Patient Health Questionnaire (PHQ) for measurement of depressive symptoms and underwent an extensive evaluation of medical comorbidities and cardiac function.RESULTSIn univariate analyses, the following patient characteristics were associated with poor reported doctor-patient communication on one or both subscales: female sex, white or Asian race and depressive symptoms. After adjusting for demographic factors, medical comorbidities and disease severity, each standard deviation (5.4-point) increase in depressive symptom score was associated with a 50% greater odds of poor reported explanations of condition (OR 1.5, 95% CI, 1.2–1.8; p < 0.001) and a 30% greater odds of poor reported responsiveness to patient preferences (OR 1.3, 95% CI, 1.1–1.5; p = 0.01). In contrast, objective measures of disease severity (left ventricular ejection fraction, exercise capacity, inducible ischemia) and medical comorbidities (hypertension, diabetes, myocardial infarction) were not associated with reports of doctor-patient communication.CONCLUSIONSIn outpatients with chronic coronary heart disease, depressive symptoms are associated with perceived deficits in doctor-patient communication, while medical comorbidities and disease severity are not. These findings suggest that patient reports of doctor-patient communication may partly reflect the psychological state of the patient.

Effects of Self-Management Support on Structure, Process, and Outcomes Among Vulnerable Patients With Diabetes

Despite the importance of self-management support (SMS), few studies have compared SMS interventions, involved diverse populations, or entailed implementation in safety net settings. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model. A total of 339 outpatients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial. Participants, more than half of whom spoke limited English, were uninsured, and/or had less than a high school education, were randomly assigned to usual care, interactive weekly automated telephone self-management support with nurse follow-up (ATSM), or monthly group medical visits with physician and health educator facilitation (GMV). We measured 1-year changes in structure (Patient Assessment of Chronic Illness Care [PACIC]), communication processes (Interpersonal Processes of Care [IPC]), and outcomes (behavioral, functional, and metabolic). Compared with the usual care group, the ATSM and GMV groups showed improvements in PACIC, with effect sizes of 0.48 and 0.50, respectively (P < 0.01). Only the ATSM group showed improvements in IPC (effect sizes 0.40 vs. usual care and 0.25 vs. GMV, P < 0.05). Both SMS arms showed improvements in self-management behavior versus the usual care arm (P < 0.05), with gains being greater for the ATSM group than for the GMV group (effect size 0.27, P = 0.02). The ATSM group had fewer bed days per month than the usual care group (-1.7 days, P = 0.05) and the GMV group (-2.3 days, P < 0.01) and less interference with daily activities than the usual care group (odds ratio 0.37, P = 0.02). We observed no differences in A1C change. Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life.

Mexican American Parent’s Perceptions of Culturally Congruent Interpersonal Processes of Care During Childhood Immunization Episodes: A Pilot Study

One of the goals of Health People 2010 is to eliminate health disparities among minority populations by 2010, including improved childhood immunization rates among Mexican-American children. Prior research has identified the importance of interpersonal process-related factors as significant components of care sought by Mexican-Americans, but more knowledge is needed about what Mexican-American parents view as a beneficial relationship with the nurse during the immunization encounter. The purpose of this qualitative, descriptive pilot study was to explore and describe the perceptions of Mexican-American parents‟ regarding their relationships with clinic nurses in a rural, primarily agricultural community. Thematic analysis of data describes a beneficial relationship between Mexican American women, their children, and nurses during immunization encounters as consisting of 1) trust in the nurse, 2) building confidence in the mother and child, and 3) language concordance.

The Influence of Depressive Symptoms on Clinician–Patient Communication Among Patients With Type 2 Diabetes

Depression is associated with poor chronic illness outcomes, but it is unknown whether depression influences the quality of communication during the clinical encounter. We investigated whether diabetes patients with depressive symptoms, compared with those without depressive symptoms, report worse clinician-patient communication, and which domains of communication are most affected. We surveyed 231 ethnically diverse, English-speaking patients with diabetes to ascertain their experiences of communication with their primary care clinician. We selected measures from the interpersonal processes of care (IPC) instrument to assess communication and dichotomized the 7 subscales into "optimal" or "suboptimal" communication. We used the Clinical Epidemiologic Services for Depression (CES-D 10) to categorize patients as having no (CES-D 10 score <10), mild (CES-D 10 score 10-14), or severe (CES-D 10 score >14) depressive symptoms. We used multivariable logistic regression to evaluate the relationship between depressive symptoms and communication subscales. Thirty-five percent of subjects reported severe depressive symptoms. Compared with those with no depressive symptoms, the presence of severe depressive symptoms was independently associated with suboptimal communication in 4 of 7 subscales: elicitation of patient problems, concerns, and expectations (adjusted odds ratio [AOR], 2.94; 95% confidence interval [CI], 1.14-7.61); explanations of condition (AOR, 3.79; 95% CI, 1.41-10.21); empowerment (AOR, 2.98; 95% CI, 1.35-6.58); and decision-making (AOR, 2.56; 95% CI, 1.14-5.78). Diabetes patients with severe depressive symptoms are more likely than those without depressive symptoms to report suboptimal clinician-patient communication across multiple domains of communication, especially those that involve more interactive and "patient-centered" communication. Further investigation of this relationship may uncover explanatory mechanisms and help guide interventions for improving care for both conditions.

Using Cognitive Interviews to Develop Surveys in Diverse Populations

Conceptual equivalence of measures is essential in research that compares health across diverse racial/ethnic groups. Cognitive interviews are pretest methods to explore the conceptual equivalence of survey items. Systematic approaches for using these methods are emerging. We describe an interaction analysis (IA) approach using qualitative data analysis software to analyze transcripts of cognitive interviews in a study to develop a survey instrument of the quality of interpersonal processes of care of diverse patients. Cognitive interviews included standard administration of the survey followed by retrospective probes for selected items. Interviews were completed with 48 Latino, black, and non-Latino white respondents 18 years of age or older with at least one doctor's visit in the past 12 months. Participants averaged 45.8 years in age (standard deviation [SD] = 18.4), 58% were women, and mean education was 14.7 years (SD = 4.0). Problems were identified in 126 of 159 items (79%). Behavior coding identified 32 problematic items (20%). IA of the transcript of the survey and retrospective probes identified 94 additional problematic items (59%). IA often revealed the nature of the problems, enabling decisions to modify or drop items based on respondents' comments. Behavior coding and IA identified ethnic and language similarities and differences in the use of response sets and the interpretation of items. IA and behavior coding of cognitive interview transcripts can identify efficiently problems with items and their source to increase the likelihood of the revised items being conceptually equivalent across ethnic groups.

Interpersonal Processes of Care Survey: Patient‐Reported Measures for Diverse Groups

To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ethnic groups that allows reliable, valid, and unbiased comparisons across these groups. DATA SOURCE/DATA COLLECTION: Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) (N=1,664). In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups. The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability. The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities.

A Retrospective Evaluation of TeleMental Healthcare Services for Remote Military Populations

The objective of this study was to compare specific treatment and outcome variables between mental health care via videoconferencing to care provided in person. The study was a retrospective record review of service members and their adult civilian family members seen at two remotely located military bases. One group was seen via video conferencing (telemental health care [TMHC]) while a second group was seen face-to-face care (FTFC) and served as a control group. Chi-square tests were used to test for significance associations between therapy format and secondary variables. The Global Assessment of Functioning was unexpectedly and significantly more improved for the TMHC group than the FTFC care group. Mean change in Global Assessment of Functioning for FTFC (8.4) was significantly less than mean change for TMHC (15.3). There were no significant differences between the groups in the number of laboratories or studies ordered, self-help recommendations made, selected mental status elements, or number of patients prescribed two or more psychotropic medications. The rate of full compliance with the medication plan and follow-up appointments was significantly better for TMHC. Providers using TMHC told more patients to return for follow-up appointments in 30 days or less. Improved compliance, the unique interpersonal processes of care via TMH, and slightly shorter times to next follow-up appointment were the chief contributors. Alterations in the process of communication may have implications in the business, political, and military sectors.

Health care discrimination, processes of care, and diabetes patients’ health status

Objective We examined whether diabetes patients report discrimination when seeking health care, whether problems with interpersonal processes of care (IPC) were associated with discrimination reports, and the linkage between discrimination and patients’ health. Methods 810 diabetes patients were surveyed. Surveys were linked to hemoglobin A1c (A1C) and total cholesterol test results. Results 14% of participants reported experiencing discrimination in health care during the prior year, including discrimination due to their race (8%), education or income (9%), age (7%), and gender (10% of women). Patients with poorer than average ratings of their IPC had 2–8 times greater risk of reporting health care discrimination. Patients reporting health care discrimination had A1C levels that were higher than other patients ( P = 0.002), more symptoms ( P < 0.01), and poorer physical functioning ( P = 0.007). Conclusions Diabetes patients’ reports of health care discrimination are strongly linked to the quality of their interactions with providers as well as multiple health outcomes. Practice implications Physicians exert control over the clinical encounter and should endeavor to reduce patients’ perceptions of discrimination during outpatient visits. Such efforts may result in more satisfied patients as well as improved health outcomes.

Consumer assessment of the quality of interpersonal processes of prenatal care among ethnically diverse low-income women: Development of a new measure

Purpose Consumer assessments of interpersonal processes of care during prenatal care provide important information about how well clinicians satisfy the perceived needs of the women they serve, but few measures are available that tap the various components of these processes. The purpose of this study is to develop a multidimensional measure of prenatal interpersonal processes of care (PIPC) that demonstrates reliability and validity in ethnically diverse women in Medicaid managed care plans. Methods A telephone survey of African American, Latino (U.S. and foreign born) and Caucasian pregnant women in four Medicaid managed care plans in California was conducted in English and Spanish in 2001. Factor analytic methods were used to test the PIPC measures. A psychometric evaluation, including reliability, variability, and construct validity, was conducted with the final scales for the total sample and for each racial/ethnic group. Results Three dimensions, Communication, Patient-Centered Decision Making, and Interpersonal Style, with seven scales were supported with 30 items. The scales for each dimension exhibit acceptable reliability for the total sample (Internal Consistency Reliability ranged from 0.66 to 0.85) and for all racial/ethnic groups. All scales had significant associations with satisfaction with prenatal care and explained considerable variation in satisfaction (19–43%). The scale qualities and validity associations held for all scales and ethnic groups except some scales for U.S.-born Latinas. Conclusions The multidimensional PIPC measure for assessing what actually happens between providers and low-income pregnant women of diverse ethnic groups demonstrates acceptable reliability and construct validity.

Physician language ability and cultural competence. An exploratory study of communication with Spanish-speaking patients.

We studied physician-patient dyads to determine how physician self-rated Spanish-language ability and cultural competence affect Spanish-speaking patients' reports of interpersonal processes of care. Questionnaire study of 116 Spanish-speaking patients with diabetes and 48 primary care physicians (PCPs) at a public hospital with interpreter services. Primary care physicians rated their Spanish ability on a 5-point scale and cultural competence by rating: 1) their understanding of the health-related cultural beliefs of their Spanish-speaking patients; and 2) their effectiveness with Latino patients, each on a 4-point scale. We assessed patients' experiences using the interpersonal processes of care (IPC) in diverse populations instrument. Primary care physician responses were dichotomized, as were IPC scale scores (optimal vs nonoptimal). We analyzed the relationship between language and two cultural competence items and IPC, and a summary scale and IPC, using multivariate models to adjust for known confounders of communication. Greater language fluency was strongly associated with optimal IPC scores in the domain of elicitation of and responsiveness to patients, problems and concerns [Adjusted Odds Ratio [AOR], 5.25; 95% confidence interval [CI], 1.59 to 17.27]. Higher score on a language-culture summary scale was associated with three IPC domains - elicitation/responsiveness (AOR, 6.34; 95% CI, 2.1 to 19.3), explanation of condition (AOR, 2.7; 95% CI, 1.0 to 7.34), and patient empowerment (AOR, 3.13; 95% CI, 1.2 to 8.19)-and not associated with two more-technical communication domains. Physician self-rated language ability and cultural competence are independently associated with patients' reports of interpersonal process of care in patient-centered domains. Our study provides empiric support for the importance of language and cultural competence in the primary care of Spanish-speaking patients.

Functional health literacy and the quality of physician–patient communication among diabetes patients

While patients with poor functional health literacy (FHL) have difficulties reading and comprehending written medical instructions, it is not known whether these patients also experience problems with other modes of communication, such as face-to-face encounters with primary care physicians. We enrolled 408 English- and Spanish-speaking diabetes patients to examine whether patients with inadequate FHL report worse communication than patients with adequate FHL. We assessed patients’ experiences of communication using sub-scales from the Interpersonal Processes of Care in Diverse Populations instrument. In multivariate models, patients with inadequate FHL, compared to patients with adequate FHL, were more likely to report worse communication in the domains of general clarity (adjusted odds ratio [AOR] 6.29, P<0.01), explanation of condition (AOR 4.85, P=0.03), and explanation of processes of care (AOR 2.70, P=0.03). Poor FHL appears to be a marker for oral communication problems, particularly in the technical, explanatory domains of clinician–patient dialogue. Research is needed to identify strategies to improve communication for this group of patients.

Enhancing creativity to improve palliative care: the role of an experiental self-care workshop.

Creativity plays an important part in all aspects of life. Although the nature of creativity is hypothesized in a variety of ways, there is no common agreement as to how or why it manifests. In the USA and UK, creative ability is often restricted by education, and nursing education programmes appear to be no exception. This article discusses the development of a weekend workshop programme for health professionals working with older people and in palliative care, using Alligood's (1991) hypotheses, that there are positive correlations between creativity, self-actualization and empathy. Actualization and creativity are closely related to self-care and there is evidence that 'selfishness' is an essential ingredient in the actualizing process. There is also evidence that an empathic relationship between health workers and their patients has a significant positive impact on interpersonal care processes. If the creative potential of nurses and carers can be enhanced through self-care, their ability to empathize may be increased. The focus of the workshops is on creative methods of self-care, using experiential exercises in relaxation, music, touch, massage and silence. Evaluation of the workshops revealed that the potential of using this method to develop care practices is worthy of investigation and development.

Interpersonal processes of care in diverse populations.

Persons of lower socioeconomic status and members of racial and ethnic minority groups experience poorer health and increased health risk factors. A framework of interpersonal processes of care specifies distinct components and incorporates the perspective of diverse racial and ethnic or socioeconomic groups. Its dimensions, each with several domains, are communication (general clarity, elicitation of and responsiveness to patient concerns, explanations, empowerment), decision making (responsiveness to patient preferences, consideration of ability and desire to comply), and interpersonal style (friendliness, respectfulness, discrimination, cultural sensitivity, support). All the domains, except cultural sensitivity, were validated through a survey of 603 ethnically diverse, low-income adults. Confirmation of the framework's usefulness should enable researchers to explore how interpersonal processes might account for observed ethnic and social class differences in health care and health.