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Understanding Patient Engagement in Patient Safety Using a Qualitative Approach: Creation of a 5-Facet Framework
What was the opportunity, issue or challenge you were trying to address and in what setting?
In recognition of the value the World Health Organization and other organizations have placed on the role of the client and family in promoting healthcare safety, and given the limited (evidence-informed) depth of our current understanding of what this means from a patient- and family-centred approach and how it should most realistically be operationalized, the team undertook a multi-phased study to examine this issue. This case study presentation would address Phase II – a qualitative approach to understanding patient perspectives about being engaged in patient safety at the clinical level.
What process did you use to develop a solution?
Initially, a literature review was conducted to determine existing evidence related to this topic.
Overall, there were gaps and inconsistencies in the literature, which included how safety is perceived by patients depending on the settings and across populations, the actual (versus anticipated) actions patients feel most comfortable in performing and the effect of these actions. If there is encouragement that patients have a role at the bedside in ensuring their safety, more substantial evidence was needed to determine the most appropriate and beneficial strategies for their involvement that is based on patient and family insights, not provider-driven. As such, a research study was planned. The work was conducted as ethics-approved research. The team used a descriptive, exploratory qualitative approach.
The primary question was: How do patients and families describe healthcare safety and what are their attitudes and beliefs about their role in promoting it while receiving care in a Canadian community hospital?
The secondary questions were:
- What behaviours do patients and families report in promoting their safety while receiving care in a Canadian community hospital?
- What do patients and families report enables and hinders their involvement in promoting their safety while receiving care in a Canadian community hospital?
- What information needs do patients report about promoting their own safety while receiving care in a Canadian community hospital?
- What activities do patients and families report are comfortable to do to promote their safety while receiving healthcare in a Canadian community hospital?
What outcomes were you looking to achieve?
The aim of this research was to address the above noted research questions, and ultimately, to advance our understanding of how patients and families feel about having a partnered role in safety at the clinical level. While we have many patient engagement advisories/tips for involvement [e.g. asking providers about hand-washing], and policy-makers advocate for their involvement, we have limited credible evidence as to how patients feel about being engagement in safety and what they believe their role can and should be. This research was a foundational step to understand patient perspectives, before future patient-partnered intervention studies can be designed/implemented.
What specific steps did you take to address the problem?
The work was conducted as ethics-approved research in a community hospital in Canada. Specifically, the following methods were used.
The setting was a community hospital (52 beds) in Ontario, Canada. At the time of the study, this hospital had 24 medical/surgical beds, 4 special care beds (level 2 ICU), 22 complex continuing care beds, 2 palliative care beds and outpatient ambulatory clinics.
The participants were adult inpatients or outpatients receiving care at the study site. To be eligible, participants had to be 1)able to speak and read English; 2) 18 years of age or older; 3) able to provide consent; and 4) medically stable as determined by the healthcare providers.
Further, for the inpatient group, those who participated must have spent at least one night in hospital prior to being interviewed and were soon to be discharged. The family members were included in the interview as desired by the participant, and their comments were incorporated into the transcripts and analyses.
The open-ended questions developed and used to garner information from participants were based on professional knowledge and common sense. The topics for some questions were informed by existing patient safety strategies2,35 and the study site’s patient information booklet, as well as common clinical processes (e.g. administration of medications; diagnostic testing; & staff hand washing). The questions were written at a Flesch-Kincaid grade level 5 to reduce the need for clarification and as part of best practice to facilitate patient understanding.36 The demographic questions included: a) age in years; b) gender; c) reason for admission; d) length of hospitalization; e) health status; f) previous hospitalizations; and g) previous personal experience with adverse events in healthcare. All the patient information was collected from the participants only.
The associated university research ethics board and the study site granted ethics approval. In the inpatient units, the nurses helped identify any eligible patients. Once patients were identified, staff approached them with a recruitment brochure to inquire if they would be interested in meeting the researcher [LD]. The interviews were audio-recorded.
Data Management and Analysis
All the data were treated as confidential, and the master participant list was kept separate from the raw data. The audio-recordings of each interview were transcribed verbatim. Code words were created for all proper nouns and kept in a separate code sheet.
Inductive content analysis was employed for analyzing the patients’ narratives to identify prominent themes and patterns.37 This process involved a first and second cycle coding process, wherein transcripts were coded in the first phase, and the codes were categorized into larger groupings/themes in the second phase. The family members who joined the interviews were also given a ‘family’ code name linked to the related participant, and their statements were analysed based on the content and coded accordingly. This permitted analyses of all content as appropriate, as well as tracking of whether data was provided by a participant or family member.
What resources, if any, did you engage – either internally or externally – to address the problem?
This descriptive, exploratory qualitative study included the voluntary participation of 30 patients, who were interviewed face-to-face before their discharge from hospital. The interviews were audio-recorded, and conducted & transcribed by the PI [L.D.].
What measures did you establish to determine the success of this effort?
In this qualitative research, an interview guide with semi-structured questions, based on the literature and published safety tips, was used. Patients were most forthcoming in their willingness to participate, which was testament to the success of recruitment and interest in the topic. Further, the elements of trustworthiness was attended to ensure the study’s rigor.
What was the ultimate outcome of your effort?
The results of this research, now published in Health Expectations [Duhn & Medves, 2018], enabled the creation of a 5-factor framework for patient engagement in patient safety (see below). It has provided a novel approach in how to consider patient engagement in safety, and an evidence-informed building block for future research & advancement in clinical practice.
5-Facet Framework to Describe Patient Engagement in Patient Safety
What lessons did you learn you would share with others as they consider addressing a similar issue?
In conducting this research, it was very evident that patients’ and family members wanted to share their experiences. It also became clear that, as policy-makers and practitioners, what we believe patients should engage in may not be what patients wish to and can engage in. It is imperative that we develop pragmatic ways in clinical practice to engage patients in safety in ways that are right for them, at the right time. This study provides a foundation for enabling that discussion and approach.
About Queen’s University
This work for this case study was part of a multi-phase research study conducted at the School of Nursing, Queen’s University, in Ontario, Canada. Queen’s University is a mid-sized, research-intensive, academic institution.
The research work that will be presented in this study was conducted in a community hospital in Ontario, Canada.
View Research Report
Case Study Authored by: Dr. Lenora Duhn, PhD, School of Nursing, Queen’s University