Elena Vegni

Assumptions and blind spots in patient-centredness: action research between American and Italian health care professionals

Objective  To examine how patient‐centredness is understood and enacted in an American (US) and an Italian group of health care professionals.

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare.

Background: The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians’ preparedness to engage in difficult conversations. Aim: To describe the implementation of PERCS in an Italian hospital and assess the programs efficacy. Methods: The Italian PERCS program featured 4-h experiential workshops enrolling 10–15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. Results: 146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patients perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. Conclusion: PERCS proved culturally adaptable to the Italian context and effective in improving participants’ sense of preparation, communication skills, and confidence.

‘Engage me in taking care of my heart’: a grounded theory study on patient–cardiologist relationship in the hospital management of heart failure

Objective In approaching the study and practice of heart failure (HF) management, authors recognise that the patient–doctor relationship has a central role in engaging patients in their care. This study aims at identifying the features and the levers of HF patient engagement and suggestions for orienting clinical encounters. Design Using a grounded theory approach, we conducted 22 in-depth interviews (13 patients with HF, 5 physicians and 4 caregivers). Data were collected and analysed using open, axial and selective coding procedures according to the grounded theory principles. Settings All interviews were conducted in an office in a university hospital located in a metropolitan area of Milan, Italy. Participants The data comprised a total of 22 patient, hospital cardiologist and caregiver interviews. Patients aged ≥18 years with New York Heart Association (NYHA) Functional Class of II or III were eligible to take part. Patients were recruited primarily through their referral cardiologist. Results The HF patient engagement process develops in four main phases that are characterised by different patients’ emotional, cognitive and behavioural dynamics that contribute to shape the process of a patients meaning making towards health and illness regarding their care. The emerging model illustrates that HF patient engagement entails a meaning-making process enacted by the patient after the critical event. This implies patients’ ability to give sense to their care experience and to their disease, symptomatology and treatments, and their changes along their illness course. Doctors are recognised as crucial in fostering patients’ engagement along all the phases of the process as they contribute to providing patients with self-continuity and give new meaning to their illness experience. Conclusions This study identifies the core experiential domains and the main levers involved in driving patients with HF to effectively engage in their disease management. The model emerging from this study may help clinicians think in a fresh way about encounters with patients and their role in fostering their patients’ health engagement.

An exploratory study on the Italian patients’ preferences regarding how they would like to be told about their cancer

GoalMajor cross-cultural differences in truth-telling attitudes and practices have been demonstrated. Until recently, in Italy the doctor could conceal both diagnosis and prognosis to seriously ill patients out of beneficence. Signs of change have been reported, but the extent and way patients would be informed is still unknown. The aim of the study was to assess Italian patients’ preferences regarding how they would like to be told about their cancer and its treatment. We examined the factor structure of the Measure of Patients’ Preferences—Italian version (MPP-It) and whether demographical and medical variables were associated with the dimensions of patients’ preferences.Materials and methodsPatients were invited to participate during a visit to the oncology department of the Lecco hospital (Italy) for chemotherapy or follow-up. An Italian version of the MPP-It was administered. Data were analyzed through a factor analysis.Main resultsA total of 210 cancer patients agreed to participate. Three main factors were identified: (1) Information (Talking About the Disease). Items in this factor were concerned with the dialogue about the disease and treatment options; (2) Support (The Emotional World of the Patient). These items referred to the supportive and relational aspects of the physician–patient encounter; (3) Care (The Ideal Doctor). These items related to the patients’ desires about the doctor’s personal attributes.ConclusionsThe first two factors, information and support, were comparable to those of similar American and Asian studies. The study suggests a cross-cultural uniformity among cancer patients who appreciate the informative and clearness of the communication aspects as being primarily important, while also giving high points to relationship aspects. The third factor appears unique to the Italian context.

Role of psychological factors in burning mouth syndrome: A systematic review and meta-analysis:

Background Burning mouth syndrome (BMS) is a chronic medical condition characterised by hot, painful sensations in the lips, oral mucosa, and/or tongue mucosa. On examination, these appear healthy, and organic causes for the pain cannot be found. Several studies have yielded scant evidence of the involvement of psychological and/or psychopathological factors, and several have outlined a model for the classification of BMS. Aim This review aims to provide a systematic review of research examining the psychological, psychiatric, and/or personality factors linked to BMS. Findings Fourteen controlled studies conducted between 2000 and the present were selected based on stringent inclusion/exclusion criteria. All studies but one reported at least some evidence for the involvement of psychological factors in BMS. Anxiety and depression were the most common and the most frequently studied psychopathological disorders among BMS patients. Discussion and conclusion Anxiety and depression play critical roles in this condition. Evidence on the role of personality characteristics of BMS patients has also been produced by a few studies. Further studies on the role of specific psychological factors in BMS are warranted, but the importance of a multidisciplinary approach (medical and psychological) to BMS is no matter of discussion.

Stories from doctors of patients with pain. A qualitative research on the physicians’ perspective

Goal of work.The aim of this study was to explore the physicians’ internal representation of the doctor–patient relationship in the dramatic field of the patient with pain.MethodsUsing an open narrative format, 151 physicians were asked to “Tell us about an episode during your professional experience in which you found yourself in difficulty whilst confronting a patient who was in pain”. The narrations were examined in accordance with a clinical-interpretive method.Main resultsThree “perspectives of observation” were identified, namely: the biological perspective, the professional perspective, and the personal perspective. The biological perspective is about the biological model and the “depersonalization” of pain. In the professional perspective, the narrative concerns the patient as a “person” and the reattribution of the pain to the suffering person. The personal perspective is about the emotional-relational explosion within the meeting between the doctor as human being and the patient as human being. Most of the narrations did not strictly connect to one or another of the perspectives, but each story seemed a journey without peace back and forth among the perspectives.ConclusionsThe professional perspective seemed to be the only place in which physicians could “stop”, a space not extreme in which they seemed to express the need for education about the management of the professional relationship with the other person.

Psychological factors associated with failure of detoxification treatment in chronic headache associated with medication overuse

Aim The aim of this study was to evaluate the psychological factors associated with a negative outcome following detoxification in a 2-month follow-up in medication-overuse headache. Methods All consecutive patients entering the detoxification program were analysed in a prospective, non-randomised fashion. Psychiatric conditions and personality characteristics were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID-I) and the Minnesota Multiphasic Personality Inventory (MMPI)-2. χ2 tests, one-way analyses of variance, and odds ratios (ORs) were used. Results A total of 248 patients completed the follow-up: 156 stopped overuse and their headaches reverted to an episodic pattern (Group A); 23 kept overusing without any benefit on headache frequency (Group B); and 51 stopped overuse without any benefit on headache frequency (Group C). The prognostic factors for the outcome of Group B were higher scores on the correction (OR 1.128; p = 0.036), depression (OR 1.071; p = 0.05), hysteria (OR 1.106; p = 0.023), and overcontrolled hostility (OR 1.182; p = 0.04) MMPI-2 scales, whereas those for Group C were psychiatric comorbidities (OR 1.502; p = 0.021) and higher scores on the hysteria scale (OR 1.125; p = 0.004). Conclusions The outcome of detoxification is influenced by psychological factors that should be considered when considering treatment strategies.

Do occupational therapists’ communication behaviours change with experience?

Abstract Background: An increasing amount of literature has studied changes in communication skills in medical and nursing undergraduate students. Aim: To evaluate whether occupational therapists’ communication behaviours change with experience. Material and methods: A total of 45 participants (second-year OT students, final-year OT students, professional OTs) were enrolled and met three simulated clients. The role plays were video-recorded and analysed through OT-RIAS (Occupational Therapy-Roter Interaction Analysis System). Chi-square tests were used to analyse the statistical differences between groups for the OT-RIAS categories. Results: Process represented 30.74% of communication for second-year students, 33.69% for final year students, and 35.58% for professional OTs; Occupational therapy ranged from 30.41% in the second-year students to 32.54% in the undergraduates and 37.04% in the professional OTs; Medical increased from 18.66% to 34.33% of the final-year students and 47.01% of the professional therapists. Personal and Psychosocial slightly decreased through experience. Emotional decreased gradually: 39.8% in the second-year students, 29.54% in final-year students, and 30.66% in professional OTs. Conclusion: During training in occupational therapy the communication skills changed, assuming a more technical shape, increasing control and content-related OT communication. Nevertheless, the therapists’ communication behaviours showed the endurance of attention to the client’s point of view.

To be or not to be: The patient's view of thrombophilia testing

INTRODUCTION The literature on the psychological effects of thrombophilia testing is unclear. Little is known about the complex world of significance subjects construct around the test. OBJECTIVE The study explored the peculiar network of implicit meanings that may be linked to the experience of being tested. MATERIALS AND METHODS The research was designed according to Interpretative Phenomenological Analysis (IPA). 19 patients were interviewed. Integral verbatim reports of the interviews were analyzed through an inductive process aimed at gaining a holistic understanding of the narratives. RESULTS Two main issues were identified, each with sub-issues: (1) the clinical problem: (1.1) unhealthy blood and (1.2) the family issue; (2) the test: (2.1) knowing for the sake of knowing; (2.2) knowing for the sake of doing; (2.3) not knowing. CONCLUSIONS The thrombophilia test is part of a larger network of meanings, where information about the test and its results seem to be lost. PRACTICE IMPLICATION The study suggests the importance of paying greater attention to the process of doctor-patient communication at the time of the test. The theme of being informed is important for patients, yet often they are not able to understand or retain the information they receive, increasing the risk of misunderstandings.

Fertilizing a patient engagement ecosystem to innovate healthcare: Toward the first Italian Consensus conference on patient engagement

Currently we observe a gap between theory and practices of patient engagement. If both scholars and health practitioners do agree on the urgency to realize patient engagement, no shared guidelines exist so far to orient clinical practice. Despite a supportive policy context, progress to achieve greater patient engagement is patchy and slow and often concentrated at the level of policy regulation without dialoguing with practitioners from the clinical field as well as patients and families. Though individual clinicians, care teams and health organizations may be interested and deeply committed to engage patients and family members in the medical course, they may lack clarity about how to achieve this goal. This contributes to a wide “system” inertia—really difficult to be overcome—and put at risk any form of innovation in this filed. As a result, patient engagement risk today to be a buzz words, rather than a real guidance for practice. To make the field clearer, we promoted an Italian Consensus Conference on Patient Engagement (ICCPE) in order to set the ground for drafting recommendations for the provision of effective patient engagement interventions. The ICCPE will conclude in June 2017. This document reports on the preliminary phases of this process. In the paper, we advise the importance of “fertilizing a patient engagement ecosystem”: an oversimplifying approach to patient engagement promotion appears the result of a common illusion. Patient “disengagement” is a symptom that needs a more holistic and complex approach to solve its underlined causes. Preliminary principles to promote a patient engagement ecosystem are provided in the paper.