Stakeholder inclusion in patient care: a grounded theory study

Nursing

Plan and implement and evaluate the proposed change to a process of patient care

IC/PROBLEM: The purpose of this study was to demonstrate ways to include more 'stakeholders' in the care of patients in-patient environments.

Grounded theory (Forchuk, Mound and Yama*****a, 2005) was the method of choice. Interviews with nurses, nurse-managers, DONs, patients and families will be conducted in several regional hospitals sharing essentially the same population base, that is, with similar ethnic and racial constituencies. The literature will also be searched for information that can help in designing a program.

Moving care from a top-down process to one that involved all stakeholders from physician to patient, is helpful in building interest in, commitment to and behavioral changes regarding patient self-care in post-surgical periods, at least regarding the interplay between maxillofacial surgery and orthodontics in order to produce the best patient result.

CONCLUSIONS: Making the transfer of care information more interactive than informative and gaining patient 'buy in' is essential to moving the patient toward the best possible outcome.

Search terms: patient commitment, compliance, behavioral change

Introduction

In former times, patients regarded doctors, and to some extent, nurses as infallible providers of care that would result in cure or at least improvement. However, this belief has been eroded because of the vagaries of managed care (in which an administrator somewhere is the unseen arbiter of whether a patient receives excellent, mediocre, execrable, or no care at all). It has been eroded because of stunning lawsuits, that have, at the same time, driven up medical costs in order to both pay for the mounting need for insurance and for the extensive testing that is believed to protect medical personnel from lawsuits.

However, it stands to reason that any patient care in which the patient the patient's family are intimately involved would both provide greater protection from eventual lawsuits, and assist the patient in achieving the best possible result from whatever treatment is prescribed or suggested from a list of alternatives and discussed.

In fact, Young and Klingle investigated this possibility in relation to increasing patient commitment to medical decisions and increasing patient satisfaction. Their work "supported the claim patient participation is higher for Mainland American patients than Asian-American patients. The justification for cultural differences, however, was not supported" (1996, p. 29). With that information to begin, it is logical to conclude that if the Asian population, with a completely different culture than the mainstream American/Canadian lifestyle paradigm, responded substantially similarly to the mainstream culture patients, then it is likely that patients form some, most or even all other cultures will also be able to be influenced to participate in their own care in similar ways, thus providing better outcomes and potentially reducing the possibility of lawsuits due to patient care issues.

Steps for implementing change

While it is not possible to transfer all physician information to nursing staff, it is likely that some behavioral changes will be accepted best through the sort of 'confrontational' drama described earlier. Therefore, in order to test the hypothesis, a single aspect of patient care will be chosen (for example, 24/7 wear of orthodontic maxillary headgear post- mandibular surgery).

Using this as an example, the first aim of the transfer of knowledge is to ensure that the patient is aware of the need for wearing the appliance post-surgically. The patient is likely to be uncomfortable with the surgery and with any wiring of the jaws. Adding to this the application of the maxillary headgear might be rejected.

Ordinarily, the oral-maxillofacial surgeon will explain the importance to the patient of returning to the orthodontist post-surgery for replacement of the maxillary headgear. While this may be issued as a stringent warning that the work on the upper jaw and dentition must proceed as the healing of the lower jaw progresses, patients may be disinclined to follow these instructions due to pain and discomfort and appearance. Moreover, the patient has only a short time in the medical facility post-surgery, so that the staff has little time to transfer knowledge to the patient.

In the new regime, while it is the province of the orthodontist to monitor the patient's headgear use, and of the surgeon/staff to monitor healing of the osteotomy, the headgear wear will be included as a part of the post-surgical follow-up of the surgeon/nursing staff.

A baseline of compliance will be constructed by accessing the records of orthodontists referring for surgery concerning their patients' compliance with headgear use.

Assuming that there will have been significant non-compliance, a target for increased compliance via the new method of transferring information and gaining behavioral change will be constructed.

The change in nursing staff procedures will be:

When the surgeon speaks with the patient post-surgery, the nurse will adopt one of three postures.

He or she will simply echo the physician's warnings.

He or she will illustrate the importance of compliance with a dramatic story of how non-compliance negatively affected Patient A.

He or she will literally take issue with the physician and issue and even sterner and more emotional warning concerning why compliance is essential.

Before the patient is released, the nurse will once again speak with the patient and ask, on a scale of ten, how important do they think it is to wear the appliance post-surgically. The nurse will also ask how likely the patient himself or herself thinks it is that compliance will be virtually 100%. The nurse will ascertain that the patient is competent to apply the device, removing it only for cleaning the teeth and the appliance, and that there are no other factors in the patient's home/work environment that would preclude compliance.

The nurse will then personally assess the likelihood she ascribes to the patient's 100% compliance.

When the patient is seen by the surgeon for his or her first follow-up visit, the same questions will be asked/answered. This will be true at each follow-up visit, no matter how many there are, and also at the end of the healing/follow-up period.

In addition, at the end of this period, the nurse will access information from the orthodontist regarding:

What the patient told the orthodontist regarding the patient's compliance.

What the orthodontist has concluded medically that the patient did about compliance (i.e., if there was non-compliance to a great extent, it should be revealed in the less acceptable outcome of the surgery.)

In notating the outcomes, National Quality Measures Clearinghouse Convention 3 will be used. That convention looks like this:

An additional area of study will be that of adverse effects. These will be tabulated separately, and matched against a control group that has not gotten the nursing patient care originally, nor the follow-up.

Patients in the study will be asked about negative outcomes and will also be asked to determine whether they thought the outcome was due to their own non-compliance, or other reasons. If non-compliance is ascribed to 'other reasons,' the patient's orthodontist will be queried to see if this is an accurate assessment by the patient. If it is, the patient will be eliminated from the study. If the orthodontist believes that the noncompliance caused a problem, the patient's information will be tabulated.

It is not possible to ascertain whether compliance made a difference to the outcome of the surgery/orthodontic treatment per se; it is only possible to ascertain whether shifting the burden of information regarding patient self-care and patient follow up in that self-care improved under the new process. Therefore, a control group will be needed that is not provided with the physician/nurse 'drama' to reinforce the need for compliance. This group will be asked the same questions at before discharge, and again when he or she is released from the surgeon's care.

For both groups, the orthodontist in the case will be asked to apply a numerical value to his assessment of the patient's compliance with the post-surgical need for wearing of the orthodontic headgear.

The results from the control group and from the three subgroups in the Change of Process study will be compared.

Resources required

Very few resources will be required for this change in the process of patient care in this instance. The results, however, will be suggestive across a broad range of patient care events and issues, and this project will add valuable insights into the need for and value of shifting the burden of obtaining patient commitment to compliance from physician to nurse, and for using relatively dramatic, not simply informative, means for gaining a commitment to compliance and possible compliance per se.

Conclusion

Kreps (1988) found that patients want information, trust and a close personal relationship with their physician. In the current managed care setting, a close, personal relationship with a physician is the exception, arguably, rather then the rule. In the case of oral and maxillofacial surgery, especially as an adjunct to orthodontia, it is unlikely that the patient will bring any relationship to the surgical event, nor will he or she be under care long enough to develop such a relationship. Because of that, it is necessary to find other ways to enhance the process of patient care in order to produce the best outcome. Shifting the burden to a nurse who works with the surgeon and who can (theoretically) spend time with the patient building such a relationship would seem to be logical and workable. In addition, by involving both the nurse and the physician, it is possible to provide the sort of dramatic transfer of information several earlier researchers deemed essential to gaining a commitment by the patient to act on that information.

Moreover, it is likely that this process will also contribute to the patient's asking questions, in short, actively participating, which will help them fulfill their own expectations concerning the experience, or at the very least, understand logically why some of their expectations may not be met: either purely medical reasons, or for reasons of their own non-compliance.

Finally, Street and Weimann (1987) showed that patients prefer more egalitarian relationships in their heath care, relationships in which both sides contribute equally. Removing the process from that of a physician speaking to the patient 'from on high' to one in which physician, nurse and patient form a team dedicated to bringing the patient the best possible outcome, would seem to be an avenue of the patient care process well worth exploring.