Patient-Centered Care - Part 1

In 2001, the Institute of Medicine defined Patient-centered care (PCC) as one that “establishes a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and solicit patients’ input on the education and support they need to make decisions and participate in their own care.” The NAEPP Expert Panel 3: Guidelines for the Diagnosis and Management of Asthma1 repeatedly emphasize the need for teamwork and partnership that involves the patient and the family. It emphasizes that goal setting should be done with suggestions and input from the patient, and should take into consideration the patient’s needs, knowledge and beliefs, health literacy, culture and ethnicity. According to Culturally Competent Nursing Care: A Cornerstone of Caring,2 PCC “involves being aware of the role of cultural health beliefs and practices in a person’s health-seeking behaviour and being able to collaborate with patients and negotiate treatment options appropriately and in a culturally sensitive way.” PCC is also called patient-focused care (PFC).

Control of asthma requires that the patient not only self-monitor the disease but also requires that the individual avoid all triggers, anticipate environmental problems, reduce exposure to triggers and take immediate action when symptoms occur so that the severity and intensity of exacerbations can be reduced. It is a lot to ask of patients and educators have always been aware that education is not merely the sum of the variety of explanations required but that for education to be successful, it must be defined based on the needs of the patient and be shown in the patient’s changed behaviour.

PCC involves four areas of intervention: communication, partnering, health promotion and physical care.3

Communication

Communication is the key but it is a two-way process that requires the asthma educator to understand the needs and concerns of the patient, to assay and guide so that those needs are fulfilled. Miscommunication can occur in dealing with patients of the same culture. It is much more difficult to communicate with patients of different cultures when there may be a variety of barriers that include

  • verbal language (different language or even same language but different use/meaning of words – for instance, pavement in England is the sidewalk whereas pavement in the USA is the road on which cars drive – same word, different meanings)
  • non-verbal communication (including gestures, postures, etc.)
  • literacy
  • practices of formal interaction
  • cultural and even religious factors
  • a variety of health-seeking behaviours

PCC requires that healthcare professionals (HCP) not only be aware of such barriers but that they take steps to overcome, avoid or reduce them so that education can take place. This is not easy for 85% of all communication is non-verbal.2 Body language and para language can be confusing. Variations in voice volume, tone and intonation can be distinctly different from one culture to the next and interpreted differently.

Other areas of non-verbal communication that can give rise to difficulty is cultural interpretation that includes eye contact, facial expression, manners, body language, and gestures. For instance, in the western world, the nodding of the head indicates agreement and the side to side movement is indicative of disagreement. Yet this is reversed in other parts of the world where a nod indicates a negative and a side-to-side shake indicates concurrence.

Communication is vital. Moffat et al4 showed that paucity of good communication skills in HCP resulted in poor asthma management particularly for patients with difficult to control asthma or who had ‘difficult lifestyles’. Hence awareness of the importance of communication and the development of good communication skills makes for a more patient-centered approach. Awareness of cultural differences is the first step. Then comes the challenge of communicating and working with cultural differences in order to offer PCC.

Partnering

Patients rely on physicians and HCP for information pertaining to their disease and treatment. Laine et al5 found that this need produced the greatest discrepancy between what was considered important by physicians and patients. Physicians ranked it sixth while patients ranked it second.

Physicians, when dealing with patients of different race/ethnicity may6

  • be unknowingly biased
  • underestimate the patient's symptoms, culture and education
  • have low expectations
  • be non-compliant with the EPR3 Guidelines1

Further, it has been shown that in dealing with black rather than white patients, physicians exhibit more verbal dominance and less patient-centered communication.7 Cooper-Patrick8 theorized that physicians and patients who belong to the same racial/ethnic group have shared beliefs, values and culture that allows for a greater degree of communication and comfort than in non-similar racial parings. Her study showed that patients who had primary care physicians who belonged to their racial/ethnic group had more participatory decision making visits than those who did not. Race concordance was related to patient satisfaction. She8 found that decision making was more participatory when patients saw physicians of their own race. Cross-cultural communication between physicians and patients was essential for more patient involvement, satisfaction and improved health outcomes.

This does not mean that patients must be treated by someone from their own culture. It does require that the physician and HCP be aware of and open to understanding cultural differences. Partnering requires input from the patient and treating the patient (and family) as members of the team. It also requires understanding and negotiation so that dominance by one party or other is absent and most importantly, patients feel that their decisions are accepted. Patients do not want to be judged and labeled as ‘uncooperative’ when cultural impediments and family matters hinder what healthcare professionals deem as acceptable.

    . . . to be continued

References:

  1. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NHLBI 2007. NIH publication #07-4051
  2. Culturally Competent Nursing Care: A Cornerstone of Caring www.thinkculturalhealth.org
  3. Irwin RS. Patient-focused care: using the right tools. Chest 2006; 130:73S - 82S
  4. Moffat M, Cleland J, van der Molen T, Price D. Poor communication may impair optimal asthma care: a qualitative study. Family Practice 2007; 24: 65-70
  5. Laine C, Davidoff F, Lewis CE et al. Important elements of outpatient care: a comparison of patients’ and physicians’ opinions. Ann Intern Med 1996; 125: 640-45
  6. Bryant-Stephens T. Asthma disparities in urban environments. J Allergy Clin Immunol. 2009; 123(6): 1199-1205
  7. Johnson RL, Roter D, et al. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2004; 94:2084-90
  8. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-9.