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Patient participation in health care has been a worry since the social movements of the 1960s and 1970s, which opposed former social hierarchies in support of individual independence (Meleis, 2001) and it has therefore become a frequent term in the field of caring (Tauber, 1994). In 1984 the World Health Organization (WHO) assured that there is a "need to reinforce the values of solidarity, equity and human rights, while recognizing the rights of individuals to freedom of choice, participation and dignity". (WHO 1994).
These primary rights lead to the significance of the right of each individual, healthy or unhealthy, to partake in care on his or her own terms (WHO, 2005). WHO also stated that patients should be given information and that patient participation should be encouraged.
Degner (1992) stated that the principal viewpoint of patient 'participation' is that it corresponds to taking part in decision making. This point of view is in line with dictionary explanation of 'participation' which is "the specific involvement of members of a community or organization in decisions that affect their lives and work to participate is to share or communicate, whereas participation is the action of partaking, taking part, associating or sharing with others in some action or matter, indicating a broader meaning for the concept of participation than solely decision making". (Oxford English dictionary, 2008).
However, patient's views on participation can differ, and participation may be understood as being involved in decision making or expressing one's observation on different treatments (Sainio and Lauri, 2001). Sainio and Lauri (2001) noted that even though participation can be defined in terms of raising questions and/or obtaining information, previous studies have revealed that patient participation can be used to communicate feelings and symptoms to health care professionals.
Saddler (2009) gave an example of Homerton University Hospital NHS Foundation Trust, in London, where patients take frequent electronic surveys on wards and in clinics and are able to comment on features of their care, such as privacy and staff attitude, by using easy-to-use hand-held devices. The survey results and improvement action plans are then placed on view in the wards so that patients and visitors can see that comments are being taken seriously and appreciated. Visitors can also see how the trust is improving and what actions are being taken. Saddler noted that this helped staff re-establish confidence in patients where an issue has been raised, as the staff can then show that the issue has been acknowledged and is being addressed.
Efforts have been made to elucidate the significance of patient participation from the point of view of nurses as well as patients. These researchers place participation as an active communication process that transforms over time in the context of the nurse-patient relationship (Henderson, 2003).
Doctors are failing to fully understand patients and their needs. Steward et al (1979) found that communication problems in the medical practice are both important and common. For example, physicians do not listen to 54% of patient complaints and 45% of patient concerns are not taken into account. Schulberg & Burns (1988) noted that psychosocial and psychiatric problems are common in the medical practice, but these diagnoses are missed in up to 50% of cases. Starfield (1979) found that in 50% of visits the patient and the doctor do not agree on the nature of the main reoccurring problem.
Beckman and Frankel (1984) found in their study that patients were interrupted by physicians so soon after they began telling their problems. On average this was within 18 seconds. This meant that the patients failed to disclose other significant concerns which in extreme cases could have helped spot illnesses and diseases at an earlier stage. Richards (1990) found for the most part criticisms by the public about physicians deal not with medical experience problems, but with communication problems. In another study by Shapiro et al (1989) the majority of unprofessional conduct accusations arise from communication inaccuracies. Patient's nowadays are health consumers and would like to be active participants in medical decision making. Kaplan et al (1996) showed that patients tended to leave doctors who failed to involve them in decisions. Waitzkin (1984) found that only low quantities of visits with doctors consist of any patient education.
Simpson (1980) noted the language doctors use is often unclear. The language included a high usage of jargon and there were issues with patients in regards to a lack of shared meanings of reasonably familiar terms. This study is supported by Lev (1988) who found that high amount of patients do not understand or retain information regarding what their physicians tell them about their diagnosis and treatment. Kleinman, Eisenberg, & Good (1987) found that cultural differences and language barriers also delay the work with patients.
Davidoff (1997) concluded that doctors who had guidance in interviewing skills attained higher scores than those with no such guidance. It was noted by Davidoff that under pressure to restrain costs, doctors react by increasing their practice capacity, with an equivalent decline in time spent per patient.
Problems with a lack of trust in doctors, language barriers, unfamiliar medical terminology and restricted time allowance with visiting the doctor all play a role in an inactive patient's participation. It can be concluded that patients appreciate tailored programme and would like doctors to appreciate active participations. The implication from studies on patient participations suggest that doctors need training on communicating with patients, specifically on common social and psychological issues surrounding patients such as depression and anxiety. As proved by the study conducted by Davidoff, when doctors are guided they perform better when dealing with patients. Laine et al (1996) suggested improvements in the area of training doctors regarding patient participation. The researchers recommended that medical educators should use understanding of patients' perceptions of care to focus teaching on areas that will help trainee doctors to meet patient's expectations.
High-quality doctor-patient communication offers patients substantial benefits. Researchers' are interested in looking at the link between an active communications with the doctor on to the outcome of the patient's health. Ong et al (1995) found noteworthy positive links between doctor's communication skills and patient's satisfaction. Maguire &Pitceathly, (2002) found that Doctors with good communication skills recognize patients' problems more precisely. Their patients grow healthier psychologically and are further fulfilled with their care. Maguire & Pitceathly also found in their study that the doctors with high-quality communication skills have better job contentment and a reduced amount of occupation stress. It was recommended in their study that effectual methods of communication skills tutoring are obtainable. Along with more training on communication skills, the chance to practise key skills and obtain constructive criticism of performance is necessary.
Evidence by Kaplan et al (1989) suggests that when patients participate more in the encounter, there is more agreement and control over the effect of treatment such as control of diabetes and hypertension, where it is important to adhere to the treatment plan. Freedman and Deci (1998) noted that patients' devoted participation in their own care is known to increase motivation, improve their own condition, give better healing results and create greater satisfaction with received care.
Some researchers argue that it is not enough to simply communicate with patients and that key skills and personality traits are required for the most effective participation. Kalb (2008) believes that compassion, empathy and understanding are key traits needed by doctors for patient satisfaction. She noted that patients enjoyed being able to communicate with their doctors on the same level as they would with their close friends.
Cancer Care for the Whole Patient is a report which found that health-care providers often fail to distinguish the emotional and social problems their patient's are subjected to, for example depression or a general lack of unawareness about the nature of their condition. This can undermine the patient's confidence and obstruct their treatment. It is important that patients have confidence in their doctors as otherwise the patient may refuse to act on the doctor's prescription and refuse to participate in the treatment plan.
Roter (1977) noted that most of the required diagnostic information is extracted from the first interview with the patient. Rotter found that the physician's interpersonal proficiency on the whole, largely establishes the patient's satisfaction, adherence and positively effects health outcomes. This study is supported by a later study by Orth et al (1987) who established that reduction in blood pressure was drastically superior in patients who, during appointments with the doctor, had been allowed to convey their health worry without intrusion. When a doctor allows the patient to communicate without being stopped the patient feels more positive and more willing to take note of the doctor's opinions. This in return leads to a healthy mind of the patient which as seen in the above studies links to following the treatment plan provided by the doctor.
Hawken (2005) found that effective communication involved assisting thorough data gathering, supporting patients to develop good understanding about their condition, and to participate in shared decision making. Hawken proposed that these actions lead to better health outcomes in the patients. MacLeod (1991) found that explaining and appreciating patient concerns, even when they cannot be worked out, results in a considerable decrease in anxiety.
A few studies have found differences in the gender differences on influencing patient satisfaction and health outcomes. Rotter (2002) initiated that male doctors are more likely to direct consultations, to use medical jargon and to focus more discussion on medical situation compared with female doctors. McKinstry (2008) claimed that although female doctors offer a more compassionate communication style and spend longer with patients, they also create more referrals to hospitals in comparison with male doctors, and are less cost-effective overall. However Dacre (2008) disagreed and stated that the longer consultations and patient-centred consulting styles of female doctors lead to better patient outcomes, and hence cost savings. Therefore it is evident that patients benefit from in-depth consultations from doctor who act in an empathic manner.
Patient Insight presents guiding principles to help organisations take full advantage of the value of information from, about and to patients. A review by Patient Insight (2008) noted that there are a number of reasons why medical practices should ensure that procedures are in place for patients to have the information they require to make choices about their health and care. The review noted that information from and about patients directs improvement. Paying attention to patients and their needs identifies areas of strength and weak points for organisations, leading to an improved satisfaction for both patients and staff. The review observes that informed patients have better clinical results. Greater patient participation leads to improved health outcomes by improving treatment adherence and self management for patients. The review concluded that it was important to improve patient participation as informed patients are more satisfied. Patients' insight of both the quality of care and their quality of life are related with clinicians' ability to communicate key information to patients.
Suggestions by the above studies on improving greater participation by the patient in the medical encounter propose that doctors need to allow the patient to communicate everything they wish to say without being stopped. When the patients have fully communicated everything to the doctor, they feel satisfied and willing to listen to the doctor, in the same way the doctor listened to the patient. In order for the doctor to show they are understood the patient, they need to be compassionate and allow for extra time depending on the patient. Implications from the studies regarding gender differences influencing doctor-patient communication are that a compassionate communication style and longer time spent with each patient may not be cost effective but does link to better patient outcomes and satisfaction.
To conclude, patient participation is linked to being involved in decision making (Degner, 1992). A more thorough meaning of the term 'patient participation' can be that it also involves the patient expressing their concerns, regarding the doctor's opinions and/or a particular treatment plans (Sainio and Lauri, 2001). Due to various reasons, doctors appear to 'rush' consultations with patients and therefore the patient is unable to fully communicate all their concerns and anxieties. When the patient is allowed to fully communicate everything they wish to say, studies have shown that the patient is more likely to communicate further with their doctor and adhere to the treatment plan. Patients are for that reason more likely to take medicines and seek treatment when they are explained and talked to by the doctor. If the doctor and patient do not communicate well or at all then the patient will not feel motivated.
However, on a global level, greater participation does not necessarily guarantee a positive health outcome. For example if a patient has an incurable terminal disease, this cannot be cured by conversing regularly with your doctor. On the other hand your satisfaction will be increased and you will therefore take the doctors recommendations which can link to a less painful experience with the illness. The positive outcomes influenced by a greater participation in the medical encounter are a healthier emotional health, pain control, and physiological issues such as blood pressure and blood sugar concentration (Stewart, 1995). The difficulties doctors have in acquiring new communication skills can be overcome fairly easily according to researchers. There is a lot of evidence which suggests that changing doctors' behaviour and communication skills can be accomplished quite without difficulty with proper teaching and that it will last (Ong et al 1995). Doctors hold a moral and social responsibility and not just a medical one; therefore they must strive to continuously conserve their patients' trust. Teaching communication skills should be incorporated at all stages of medical education and, should be a compulsory aspect of the medical school programme of study. Communication is an interactive process and patients will need to acquire skills, be supported to become involved in decision making and raise questions about quality. Doctors can put confidence in patient by treating them individually and going through unique tailored treatment plans. Scope for improvement in this area can include more longitudinal studies to investigate whether greater patient participation does cure health outcomes and illnesses.