Using the Walker Avant model of concept analysis, the concept of patient partnership will be explored, in hopes of using information gained within this analysis to address a problem that exists in patient compliance and involvement on a pediatric long term acute unit at a hospital in New Britain, CT (Walker & Avant, 2010). The analysis will include a discussion of the aim of the concept analysis, a literature review, current uses and historical perspectives, a discussion of definition attributes and related terms which will help to construct a conceptual definition of patient partnership.
Furthermore, a model case, contrary case, antecedents and consequences will be discussed. Lastly, a concept map will be provided to illustrate the linking throughout this process. Through this analysis, a firm understanding of the concept of patient partnership will be reached, and the importance of its application as a solution to pediatric compliance and involvement will be shown.
The concept of partnership will be explored in relationship to pediatric patients.
A problem has been identified at a long term acute pediatric unit where a working medical relationship exists between healthcare providers and parents, excluding children, particularly those behavioral disorders from active participation in education, decision-making, and communication related to their medical care. This leads to a situation where medical care is something happening to patients instead of with patients, which decreases compliance and promotes an external locus of control.
The purpose of this analysis is to define and explore the concept of partnership including its definition, functional and theoretical components, current and historical uses and its historical context, as well as the antecedents and consequences of partnership.
Furthermore, this analysis will provide a model case and a contrary case to illustrate the concept in practice. The hope of this concept analysis is that an in-depth understanding of partnership will aid in the identification of methods to assess partnership and actionable interventions with measurable outcomes to improve patient partnership in the pediatric population.
Currently, at a long-term acute pediatric floor at a hospital in New Britain, CT, an issue is frequently encountered when treating patients who are old enough to understand their treatment, but still too young to legally refuse or consent to care, that providers and parents work together to come up with a treatment plan pertaining to the patient, without involving the patient in decision making or education related to the whole picture of the child’s health. When this occurs, pediatric patients typically exhibit noncompliant behavior with medication administration, therapy goals, and other nursing interventions. Often this results in more discussion about the patient’s plan without the patient’s involvement in creating behavior plans, additional medication protocols, or other interventions to “treat” the noncompliance. The end result is a cyclical pattern of frustration for providers, parents, all healthcare workers associated with the case, and most of all the patient, as well concessions in healthcare provided based not on best practice, but on what the parent and provider think they can reasonably coax out of the patient in terms of compliance. Patient partnership with these pediatric patients is explored in this analysis as a possible solution to improve compliance and satisfaction of pediatric patients and to reduce frustration related to healthcare for all involved in the case.
Current Uses and Historical Perspectives
According to the Merriam-Webster dictionary, synonyms for partnership include affiliation, alliance, association, collaboration, confederation, connection, cooperation, hook-up, liaison, linkup, relation, relationship, tie-up, and union. Antonyms listed are disaffiliation and dissociation(“Definition of PARTNERSHIP,” n.d.). Across definitions, the concept of partnership is comprised by a consensual relationship between parties or entities, often to accomplish a goal or end. Merriam-Webster defines partnership as, “a relationship resembling a legal partnership and usually involving close cooperation between parties having specified and joint rights and responsibilities”(“Definition of PARTNERSHIP,” n.d.). Similarly, the Oxford Dictionary defines partnership as “The state of being a partner or partners” and “An association of two or more people as partners,” with partner defined as, “Either of a pair of people engaged together in the same activity,” “A person or group that takes part with another or others in doing something,” and “Any of a number of individuals with interests and investments in a business or enterprise, among whom expenses, profits, and losses are shared”(“Partner | Definition of Partner by Lexico,” n.d.).
The etymology of the word partner stems from Anglo-Norman French word “parcener” which has a similar meaning to definitions today but also includes the definition of a “joint heir.” The word Parcener, in turn, stems from the Latin word, partitionem, meaning, “a sharing, partition, or division”(“Partner | Search Online Etymology Dictionary,” n.d.) Truly, there is a common trend across definitions that a partnership is a relationship between parties to accomplish an end, and importantly, as several of the definitions indicate, both the parties stand to gain or lose from the success or failure of the relationship. They become, as the Anglo-Norman French root “parcener” points to, “join heirs” in the fruit of their work.
Current literature supports the use of patient partnership to increase compliance and better outcomes of patients (Clark et al., 1995). However, concept of partnership within the concept of current literature encompasses many operational definitions across the current literature. Literature spanning the past three decades is discussed to ensure adequate exploration of the concept as it has developed over recent years.
In the book, Healthcare Partnerships for Pediatric Adherence: Promoting Collaborative Management for Pediatric Chronic Illness Care, the authors explore the concept of pediatric partnership as a means of increasing pediatric patient’s adherence, though more peripherally than the title would suggest. Within this work, partnership is achieved through education of the client, and including the patient in decision making processes, working to align treatment goals of the patient with personal goals to increase motivation. The emphasis on partnership in this model is inclusion in decision making, trouble shooting, and goal setting as a means to promote patient partnership and thereby improve adherence and compliance with care plans. Inclusion of technology-based monitoring and communication as a means to improve communication and partnership are also explored (Schwartz & Axelrad, 2015).
Nickel et al describe patient and family partnership is emphasized as means to increase adherence, reduce costs, and increase patient satisfaction. Within their definition of partnership, there is an emphasis on respect and dignity, ensuring patient’s feel their voice is heard, and their opinion is valuable within the context of their care. Furthermore, they explore the importance of shared decision-making in patient partnership and the promotion of patient education to support good decision making. Lastly, this article suggests that patients should be involved not only as a partner within their case, but as a partner in the bettering of the health care system overall, through participation in quality improvement projects, training programs, and curriculum designs. They suggest that patient input should be solicited for improvement within the healthcare system to both better it and increase the culture of partnership (Nickel, Weinberger, & Guze, 2018).
Velji also emphasizes the importance of patient partnership in increasing medical adherence and improving both satisfaction and outcomes. Within her exploration of the concept of partnership, she emphasizes the importance of relationship and shared burden of outcome between the provider and patient. She explains that partnership in healthcare changes medical care from something done “to” the patient to something done “with” the patient, a fundamental culture shift that makes a great difference in outcome and satisfaction (Velji, 2017).
In the Walker and Avant approach, the object of defining attributes is to cluster attributes that are frequently associated with said concept and to allow for an expanding of comprehension of the concept (Walker & Avant, 2010). Within both the definition and uses within literature, there is an emphasis on relationship, education, shared-decision making, and shared burden of outcome. The idea in partnership across these fields is that instead of an actor and a recipient, patient partnership in healthcare involves relationship and joint responsibility, shifting healthcare from something that happens to an individual, to something that happens, “with” an individual.
Related terms according to the Webster dictionary reference include connection, cooperation, affiliation, and alliance (“Definition of PARTNERSHIP,” n.d.). In the literature, other related terms used are “collaboration and “coalition” (Schwartz & Axelrad, 2015). These terms are used interchangeably with partnership at times throughout the literature. Other related terms consistently used that contribute to the concept of partnership are relationship and communication (Nickel et al., 2018).
All these definitions and features lead to a conceptual definition of patient partnership that involves the sharing of information, decision making, goal setting, and burden of outcome between the provider and the patient. This process yields increased compliance and satisfaction with healthcare as the patient is viewed as a participant in rather than an object of their own healthcare.
A pediatric patient who enters a long-term acute facility participates in a consultation with the provider during their intake for rehabilitation related knee surgery. During this process, communication preferences are noted and the patient is made aware that the patient’s willingness to participate in partnership is integral to the success of their case. The provider consults with the patient, determining their personal goals, and aligning those goals with the health care goals. The patient is then educated about their disease process and the important factors in his recovery. For example the patient prioritizes attaining rapid independence in mobility and long-term ability to participate in sports. The provider then educates the patient on the necessary steps required to get the patient to that level of functioning, and established interventions are linked to these goals, which the patient evaluates and assists in making. Open lines of communication are established between the patient, parent, and the provider and the patient goes on to work hard to achieve goals and troubleshoot problems with the provider, utilizing established methods of communication. Feedback is requested from the patient at all stages. The patient meets healthcare goals and is satisfied with his healthcare.
A pediatric patient enters a long-term acute facility after a gun-shot wound to the spine. The patient experiences grief related to permanent loss of function, which leaves the patient feeling hopeless and unmotivated. The provider identifies this behavior as obstinance and speaks only to the parent about the patient in decision making and goal setting. The patient then refuses to participate in care and refuses medications on a frequent basis. The parent-child relationship is strained because the parent is left arguing with the child about his refusal. The child’s relationship with healthcare providers and staff are strained because while they have consent to treat, they are unable to treat outside of force. The patient shows no compliance and treatment goals are not reached.
Antecedents to patient partnership include the presence of a healthcare need and a patient-provider relationship. Furthermore, communication is required for partnership to occur, as it is through communication that partnership is achieved. Education is required so that decision-making and goal setting can be shared while supporting and managing the disease process or healthcare need. Time for the collaboration and partnership to take place is a necessary antecedent for partnership. Lastly, mutual respect is required for effective partnership to take place, as share in healthcare decision-making, goal setting, and problem-solving when both parties respect one another.
The consequences of partnership are increased compliance and adherence to medical care plan. Furthermore, increased communication and a feeling of “being heard” can lead to more accurate diagnostics of problems that arise as more pertinent information will be shared with the provider. When the patient participates in partnership through decision-making, goal-setting, and problem-solving, healthcare can become more patient-centered, meeting healthcare needs more fully and specifically. Lastly, a possible consequence of patient partnership is patient empowerment and self-advocacy in future healthcare interchanges.
According to the Walker and Avant model, empirical referents, or measurable or observable phenomenon that indicate the concept has taken place, in the case of patient partnership would rely largely on patient and provider reports of perceived partnership (Walker & Avant, 2010). Other empirical referents might include the patient’s beliefs regarding how much their provider values his or her input, how involved the patient felt in goal setting, decision-making, and problem-solving across their case, and how likely they are to communicate future issues. Provider evaluations of perceived patient involvement would also be empirical referents of partnership.
In conclusion, patient partnership requires the antecedents of a healthcare need, a relationship between a patient and a provider communication, education, time, and mutual respect. With these in place, patient partnership can exists and is defined by collaboration, shared burden of outcome, shared decision making, shared goal setting, and shared problem solving. Patient partnership then leads to increased compliance, which leads to better outcomes. It also leads to increased communication, which leads to better diagnostics. Lastly, patient partnership leads to patient empowerment, which in turn increases patient satisfaction with their healthcare and can lead to increased health advocacy by the patient in the future. Truly patient partnership can be seen as a solution to compliance issues on a pediatric long-term acute unit, with empirical referents of self-reported experiences of both the provider and the patient as the scales used to determine if changes in future studies lead to increased patient partnership.
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