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Background: Patient-reported outcome measures (PROMs) are standardized instruments used for assessing patients' perspectives on their health status at a point in time, including their health-related quality of life, symptoms, functionality, and physical, mental, and social wellbeing. For people with kidney failure receiving hemodialysis, addressing high symptom burden and complexity relies on care team members integrating their expertise to achieve common management goals. In the context of a program-wide initiative integrating PROMs into routine hemodialysis care, we aimed to explore patients' and clinicians' perspectives on the role of PROMs in supporting interdisciplinary symptom management. Methods: We employed a qualitative descriptive approach using semi-structured interviews and observations. Eligible participants included adult patients receiving intermittent, outpatient hemodialysis for > 3 months, their informal caregivers, and hemodialysis clinicians (i.e., nurses, nephrologists, and allied health professionals) in Southern Alberta, Canada. Guided by thematic analysis, team members coded transcripts in duplicate and developed themes iteratively through review, refinement, and discussion. Results: Thirty-three clinicians (22 nurses, 6 nephrologists, 5 allied health professionals), 20 patients, and one caregiver participated in this study. Clinicians described using PROMs to coordinate care across provider types using the resources available in their units, whereas patients tended to focus on the perceived impact of this concerted care on symptom trajectory and care experience. We identified 3 overarching themes with subthemes related to the role of PROMs in interdisciplinary symptom management in this setting: (1) Integrating care for interrelated symptoms ("You need a team", conducive setting, role clarity and collaboration); (2) Streamlining information sharing and access (symptom data repository, common language for coordinated care); (3) Reshaping expectations (expectations for follow-up, managing symptom persistence). Conclusions: We found that use of PROMs in routine hemodialysis care highlighted symptom interrelatedness and complexity and helped to streamline involvement of the interdisciplinary care team. Issues such as role flexibility and resource constraints may influence sustainability of routine PROM use in the outpatient hemodialysis setting. Plain English summary: People with kidney failure receiving hemodialysis are faced with complex symptoms that impact their day-to-day functioning and quality of life. Patient-reported outcome measures (PROMs) are tools used by patients to directly communicate symptoms to their care team and guide symptom-focused care. Little is known about how PROMs could be integrated into the team-based care models of outpatient hemodialysis centres. In this study, we conducted interviews with people receiving hemodialysis and their clinicians about their perspectives on how PROMs could support interdisciplinary symptom management (i.e., integration of expertise to achieve common management goals). Participants described how the interrelatedness of symptoms was well suited to an integrated care approach and how PROMs enhanced communication and access to information across team members. In cases where symptoms persisted despite appropriate treatment, patients and clinicians explained how PROMs served as a tool to set realistic goals and reshape illness perception. Findings from this study suggest that access to resources, role flexibility, and established relationships within hemodialysis centres are important for sustaining PROM use in this setting. [ABSTRACT FROM AUTHOR]

Hospital discharge of older people in need of both medical and social care following their hospital stay requires extensive coordination. This study aims to examine and compare the views of nurses in three Nordic cities on the influence of sociodemographic factors and having close relatives, for the hospital discharge and post hospital care of older people with complex health and social care needs. Thirty-five semi-structured interviews (Copenhagen n = 11, Tampere n = 8, Stockholm n = 16) with nurses were conducted. The nurses were identified through the researchers' networks, invitation and snowball sampling, and recruited from hospitals, primary care practices, home care units, home nursing units, and geriatric departments. The interviews were transcribed and analysed using thematic analysis. Interpretations were discussed and agreed within the team. Four main themes and 13 sub-themes were identified. Across the cities, informants reported that the patient's health status, rather than their gender or ethnicity, steered the discharge date and further care. Care costs, commonly reported in Tampere but also in Copenhagen and Stockholm including costs for medications and home help, were considered barriers for disadvantaged older people. Home situation, local arrangements and differences in collaboration between healthcare professionals at different sites also influenced the hospital discharge. Generally, the patient's health status steered the hospital discharge and post-hospital care. Close relatives were regarded important and a potential advantage. Some informants tried to compensate for the absence of close relatives, highlighting the importance of care systems that can compensate for this to minimise avoidable inequity. [ABSTRACT FROM AUTHOR]

Many nature conservation projects fail primarily not because of a lack of knowledge about upcoming threats or viable conservation concepts but rather because of the inability to transfer knowledge into the creation of effective measures. Therefore, an increase in information exchange and collaboration between theory- and practice-oriented conservation actors, as well as between conservation actors, land user groups, and authorities may enhance the effectiveness of conservation goals. By considering the interactions between conservation stakeholders as social networks, social network analysis (SNA) can help identify structural optimization potential in these networks. The present study combines SNA and stakeholder analysis (SA) to assess the interactions between 34 conservation stakeholders in the major city and district of Osnabrück in northwestern Germany and offers insights into cost/benefit optimizations of these stakeholder interactions. Data were acquired using a pile sort technique and guideline-based expert interviews. The SA, based on knowledge mapping and SWOT (strength, weaknesses, opportunities, and threats) analysis, identified individual stakeholder's complementary properties, indicating which among them would most benefit from mutual information exchange and collaboration. The SNA revealed discrepancies in information exchange and collaboration between theory- and practice-focused stakeholders. Conflicts were found predominantly between conservation associations, authorities and land user groups. Ecological research, funding, land-use conflicts, and distribution of conservation knowledge were identified as fields with high potential for increased information exchange and collaboration. Interviews also showed that the stakeholders themselves see many opportunities for increased networking in the region. The results are discussed in relation to the existing literature on nature conservation networks and used to recommend optimization measures for the studied network. Finally, the conclusion reflects upon the developed approach's implications and possibilities for conservation stakeholders and planners in general. Highlights: A combination of social network analysis and stakeholder analysis using knowledge mapping and SWOT analysis as a basis for cost/benefit optimization of regional conservation stakeholder interactions. A discrepancy in information exchange between theory- and practice-focused conservation actors. A high concentration of conflicts between conservation associations, authorities, and land users. Intensified networking in the fields of ecological research, land-use conflicts, and conservation knowledge might be prioritized. Transfer of the developed method to other regions seems feasible. [ABSTRACT FROM AUTHOR]

Background: Patient-reported outcomes (PROs) are increasingly collected in clinical trials as they provide unique information on the physical, functional and psychological impact of a treatment from the patient's perspective. Recent research suggests that PRO trial data have the potential to inform shared decision-making, support pharmaceutical labelling claims and influence healthcare policy and practice. However, there remains limited evidence regarding the actual impact associated with PRO trial data and how to maximise PRO impact to benefit patients and society. Thus, our objective was to qualitatively explore international stakeholders' perspectives surrounding: a) the impact of PRO trial data, b) impact measurement metrics, and c) barriers and facilitators to effectively maximise the impact of PRO trial data upon patients and society. Methods: Semi-structured interviews with 24 international stakeholders were conducted between May and October 2018. Data were coded and analysed using reflexive thematic analysis. Results: International stakeholders emphasised the impact of PRO trial data to benefit patients and society. Influence on policy-impact, including changes to clinical healthcare practice and guidelines, drug approval and promotional labelling claims were common types of PRO impact reported by interviewees. Interviewees suggested impact measurement metrics including: number of pharmaceutical labelling claims and interviews with healthcare practitioners to determine whether PRO data were incorporated in clinical decision-making. Key facilitators to PRO impact highlighted by stakeholders included: standardisation of PRO tools; consideration of health utilities when selecting PRO measures; adequate funding to support PRO research; improved reporting and dissemination of PRO trial data by key opinion leaders and patients; and development of legal enforcement of the collection of PRO data. Conclusions: Determining the impact of PRO trial data is essential to better allocate funds, minimise research waste and to help maximise the impact of these data for patients and society. However, measuring the impact of PRO trial data through metrics is a challenging task, as current measures do not capture the total impact of PRO research. Broader international multi-stakeholder engagement and collaboration is needed to standardise PRO assessment and maximise the impact of PRO trial data to benefit patients and society. [ABSTRACT FROM AUTHOR]

Background: Successful community-engaged research depends on the quality of the collaborative partnerships between community -members and academic researchers and may take several forms depending on the purpose which dictates the degree to which power dynamics are handled within the collaborative arrangement. Methods: To understand the power dynamics and related concepts within community-engaged research arrangements, a secondary analysis of an existing qualitative data set was undertaken. Two models of community-engaged research, a review of literature, and the applied experiences of researchers familiar with community engagement practices confirmed the power dynamics concepts used to carry out the analysis of the qualitative data set according to the principles of directed content analysis. This analysis yielded quotes on power dynamics and related issues. Tools to address the power dynamics exposed by the quotes were selected using the literature and lived experience of the researchers. Finally, to ensure trustworthiness, the selected quotes on power dynamics and the recommended tools were subjected to naturalistic treatment using peer debriefings and triangulation. Results: Analysis of existing qualitative data made clear that community-engaged research between health practitioners and communities may take several forms depending on the purpose and dictate how power dynamics, including inequities, biases, discrimination, racism, rank and privilege, are handled within the collaborative arrangement. Three tools including implicit bias training, positionality, and structural competency may be used to address power dynamics and related concepts. Conclusion: Analysis of the qualitative data set highlighted the power dynamics within different community-engaged research models and the tools that may be used to address inequitable power dynamics including implicit bias training, positionality, and structural competency. [ABSTRACT FROM AUTHOR]

Background: This study investigates clinicians' views of clinician-patient and clinician-clinician communication, including key factors that prevent clinicians from achieving successful communication in a large, high-pressured trilingual Emergency Department (ED) in Hong Kong. Methods: Researchers interviewed 28 doctors and nurses in the ED. The research employed a qualitative ethnographic approach. The interviews were audio-recorded, transcribed, translated into English and coded using the Nvivo software. The researchers examined issues in both clinician-patient and clinician-clinician communication. Through thematic analyses, they identified the factors that impede communication most significantly, as well as the relationship between these factors. This research highlights the significant communication issues and patterns in Hong Kong EDs. Results: The clinician interviews revealed that communication in EDs is complex, nuanced and fragile. The data revealed three types of communication issues: (1) the experiential parameter (i.e. processes and procedures), (2) the interpersonal parameter (i.e. clinicians' engagements with patients and other clinicians) and (3) contextual factors (i.e. time pressures, etc.). Within each of these areas, the specific problems were the following: compromises in knowledge transfer at key points of transition (e.g. triage, handover), inconsistencies in medical record keeping, serious pressures on clinicians (e.g. poor clinician-patient ratio and long working hours for clinicians) and a lack of focus on interpersonal skills. Conclusions: These communication problems (experiential, interpersonal and contextual) are intertwined, creating a complex yet weak communication structure that compromises patient safety, as well as patient and clinician satisfaction. The researchers argue that hospitals should develop and implement best-practice policies and educational programmes for clinicians that focus on the following: (1) understanding the primary causes of communication problems in EDs, (2) accepting the tenets and practices of patient-centred care, (3) establishing clear and consistent knowledge transfer procedures and (4) lowering the patient-to-clinician ratio in order to create the conditions that foster successful communication. The research provides a model for future research on the relationship between communication and the quality and safety of the patient safety. [ABSTRACT FROM AUTHOR]

This article analyzes interviews with pediatric physicians ( N = 30) and chaplains ( N = 22) who work at the same large academic medical centers ( N = 13). We ask how pediatric physicians understand and work with chaplains and how chaplains describe their own work. We find that physicians see chaplains as part of interdisciplinary medical teams where they perform rituals and support patients and families, especially around death. Chaplains agree but frame their contributions in terms of the perspectives related to wholeness, presence, and healing they bring. Chaplains have a broader sense of what they contribute to patient care than do physicians. [ABSTRACT FROM AUTHOR]

Background: International medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited.Objective: To characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US.Design: Qualitative study based on in-depth in-person interviews.Participants: Purposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut.Approach: A standardized interview guide was used to explore professional experiences of IMGs.Key Results: Four recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of "the deal"; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace.Conclusions: Our data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs' experiences may also improve the experiences of an increasingly diverse healthcare workforce. [ABSTRACT FROM AUTHOR]

Background: Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes.Methods: We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient's PCP was associated with the 30-day composite outcome.Results: A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 - 1.34), the presence of a discharge summary (0.84, 95% CI 0.57-1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73-1.59).Conclusion: Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample. [ABSTRACT FROM AUTHOR]

Objectives: To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care.Design: Cross-sectional qualitative interview study of primary care physicians.Setting: Physicians' offices.Participants: Forty primary care physicians in Northern California.Measurements: Open-ended interviews lasted 30-60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process.Results: Recurring themes (i.e., those present in > or = 25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, "reactive" as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches.Conclusion: Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short. [ABSTRACT FROM AUTHOR]