Expanding the primary care workforce to alleviate general practitioner (GP) workload, improve access and improve quality of care is a current UK strategy. Evidence suggests dietitians can improve patient outcomes and make cost savings. The present study aimed to evaluate a dietitian working as an expert generalist and first contact practitioner (FCP) in a general practice multi-disciplinary team (MDT) to provide appropriate care to patients and reduce GP workload.
A dietitian was employed for 6 months at 0.6 full-time equivalents in a group of general practices in Devon, UK. Data were collected on the referral source, patient satisfaction, health outcomes and changes in prescribing data for all patients seen by the dietitian. Focus groups and interviews provided data to understand the experience of introducing a dietitian into the team.
This model of service delivery showed the dietitian acting as an expert generalist, a FCP and able to educate the MDT. A range of professionals within the MDT referred patients with a wide range of diagnoses (both paediatric and adults) and the dietitian acted as a FCP for 29% of patients. Saving were made for the optimisation of medicine management.
The dietitian can improve patient-centred care for several patient groups; enhance learning for staff around nutrition and dietary issues; and contribute to more efficient working and cost savings around prescription of nutritional products. This was an evaluation of one service and further research is needed to understand the value dietitians can contribute and the factors supporting effective and efficient working in this context.

BACKGROUND: Workplace violence against medical staff in China is a widespread problem that has negative impacts on medical service delivery. The study aimed to contribute to the prevention of workplace violence against medical staff in China by identifying patterns of workplace violence, key risk factors, and the interplay of risk factors that result in workplace violence.
METHODS: Ninety-seven publicly reported Chinese healthcare violent incidents from late 2013 to 2017 were retrospectively collected from the internet and analysed using content analysis. A modified socio-ecological model guided analysis of the violent incidents focusing on risk.
RESULTS: Physical violence, yinao, or a combination of physical and verbal violence were the typical forms of violence reported. The findings identified risk at all levels. Individual level risk factors included service users\' unreasonable expectations, limited health literacy, mistrust towards medical staff, and inadequacy of medical staff\'s communication during the medical encounter. Organisational level risk factors under the purview of hospital management included problems with job design and service provision system, inadequacies with environmental design, security measures, and violence response mechanisms within hospitals. Societal level risk factors included lack of established medical dispute-handling mechanisms, problems in legislation, lack of trust and basic health literacy among service users. Situational level risks were contingent on risk factors on the other levels: individual, organisational, and societal.
CONCLUSIONS: Interventions at individual, situational, organisational, and societal levels are needed to systematically address workplace violence against medical staff in China. Specifically, improving health literacy can empower patients, increase trust in medical staff and lead to more positive user experiences. Organizational-level interventions include improving human resource management and service delivery systems, as well as providing training on de-escalation and violence response for medical staff. Addressing risks at the societal level through legislative changes and health reforms is also necessary to ensure medical staff safety and improve medical care in China.

Despite its historic role in Chinese society and its popularity with an elderly Chinese population, limited research has explored the discursive practices of Traditional Chinese Medicine (TCM). Our analysis of practitioner-patient interactions illustrated the reasons why TCM is widely welcomed by a specific patient group. This paper adopted the concept of Community of Practice (CoP) as a theoretical framework to document how patients interact with TCM practitioners to construct meaning through a process of participation and reification. This study aimed to explore how patients in a medical consultation context developed an understanding of their conditions and how they strategically used medical terminology to enact meaningful exchanges to realise their CoP. An inductive qualitative discourse analysis was conducted to for nine elderly patients (i.e., age > 65) in Hong Kong to demonstrate the role that a CoP played in a joint process of knowledge construction to promote a patient-centred practice and foster the active participation of the patients. TCM practitioners can develop specific communication skills to promote their patients\' CoP, which will improve patient-centred care, empower patients to actively engage in their treatments and result in higher levels of patient satisfaction.

Health systems are expanding efforts to address health and social risks, although the heterogeneity of early evidence indicates need for more nuanced exploration of how such programs work and how to holistically assess program success. This qualitative study aims to identify characteristics of success in a large-scale, health and social needs case management program from the perspective of interdisciplinary case managers.
Case management program for high-risk, complex patients run by an integrated, county-based public health system.
30 out of 70 case managers, purposively sampled to represent their interdisciplinary health and social work backgrounds. Interviews took place in March-November 2019.
The analysis intended to identify characteristics of success working with patients.
Case managers described three characteristics of success working with patients: (1) establishing trust; (2) observing change in patients\' mindset or initiative and (3) promoting stability and independence. Cross-cutting these characteristics, case managers emphasised the importance of patients defining their own success, often demonstrated through individualised, incremental progress. Thus, moments of success commonly contrasted with external perceptions and operational or productivity metrics.
Themes emphasise the importance of compassion for complexity in patients\' lives, and success as a step-by-step process that is built over longitudinal relationships.

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In this study, we tested the feasibility of using a narrative inquiry - three-dimensional space inquiry to elicit the experiences of an adult family member who shared her journey of care and advocacy for her husband situated in a dementia care unit.
The voices of family members are rarely heard in relation to their experiences about being included in or making decisions about their loved one\'s care. Shared decision-making has been an important patient-centred approach to nursing care since the 1990s; however, it is often not a reality in aged care facilities.
An interview was conducted with one adult family member using the three-dimension space that is inspired by narrative theorists to analyse the narrative.
Three themes were identified in the responses: communication between staff and family, staffing in the dementia care unit, and loss of voice and shared decision making.
Results of this study indicate that narrative inquiry supports the telling of personal experiences around a problem and then using that information to raise awareness of those issues that are not always heard but which are essential for change in health care policy and practice.

BACKGROUND: Patient-centred care (PCC) is one of the pillars of Malawi\'s quality of care policy initiatives. The role of PCC in facilitating quality service delivery is well documented, and its importance may heighten in chronic disease management. Yet, PCC conceptualisation is known to be context specific.
OBJECTIVE: The study aimed to understand the conceptualisation of PCC amongst patients, healthcare providers (HCP) and policy makers in Diabetes Mellitus (DM) management.
METHODS: This study was conducted in DM clinics in Southern Malawi.
METHODS: Our qualitative exploratory research study design used in-depth and focus group interviews. We interviewed patients with DM, HCPs and policy makers. The study used framework analysis guided by Mead and Bower\'s work.
RESULTS: Patient-centred care conceptualisations from groups of participants showed convergence. However, they differed in emphasis in some elements. The prominent themes emerging from the participants\' conceptualisation of PCC included the following: meeting individual needs, goals and expectations, accessing medication, supporting relationship building, patient involvement, information sharing, holistic care, timeliness and being realistic.
CONCLUSIONS: Patient-centred care conceptualisation in Malawi goes beyond the patient-HCP relational framework to include the technical aspects of care. Contrary to the global view, accessing medication and timeliness are major elements in PCC conceptualisation in Malawi. Whilst PCC conceptualisation is contextual, meeting expectations and needs of patients is fundamental.

BACKGROUND: Previous studies have found that patients with lung cancer report worse patient experience compared to other tumour groups. Reasons that may negatively impact patient experience include delays in diagnosis as well as inadequate symptom management. The purpose of this study was to compare the diagnostic timelines and symptom reports of patients with lung and gastrointestinal (GI) cancers.
METHODS: This study included patients diagnosed with lung or GI cancers who attended a radiation oncology (RO) consultation and/or received radiation treatment between May and August 2019 at the Tom Baker Cancer Centre, Calgary, Alberta, Canada. Data collected included demographics, dates of diagnostic time points, and self-reported symptom scores across 3 time points. A descriptive analysis was completed, and the median number of days between time points was compared between tumour groups.
RESULTS: Patients with lung cancer had longer diagnostic timelines compared to GI patients. The median number of days between the first investigative test and biopsy was 21 days longer for patients with lung cancer (p < 0.05). From RO consultation to the first treatment review appointment, 25% and 4% of lung and GI patients, respectively, reported worsening of symptoms. A greater proportion of lung patients reported worse symptom scores during treatment compared to GI patients. This varied by specific symptom.
CONCLUSIONS: Patients with lung cancer experienced delays in receiving a diagnosis and worse symptom burden during radiation therapy in this study. We identified potential targets to improve patient experience.

OBJECTIVE: The challenges of improving the integration of care for older people with complex care needs are well recognised. Evidence suggests that solutions should be co-designed with older people to ensure they are contextually relevant and person-centred.
METHODS: As a first step in a co-design project to improve integrated care for older people, seven interviews and three workshops were held with older people and service providers. Data collected via recordings, notes and journey maps were inductively analysed.
RESULTS: Five themes were identified: relationships and roles, patient capacity and safety, information and systems, multiway communication, and transitions and flow. This created a more holistic and person-centred picture of integrated care than typically derived from published literature.
CONCLUSIONS: Older people perceive integrated care from relational, organisational, informational and individual viewpoints. This reinforces the central importance of adopting a person-centred, as opposed to health system-focused, approach to designing and implementing integrated care solutions.

BACKGROUND: Following a knowledge management analysis, Médecins Sans Frontières (MSF) - a medical humanitarian non-governmental organisation (NGO) - identified significant loss of medical knowledge from the field, owing primarily to the absence of a platform on which to share clinical lessons learned in humanitarian and resource-limited settings (HRLS). Wishing to address these missed opportunities to retain important scientific and pragmatic knowledge, the NGO has begun to actively encourage its clinicians to publish case reports/series that bring new and/or practical insights of benefit to patients and population groups. In parallel, we wished to obtain a clearer understanding of how case reports (CRs)/series can best play their role as \'first-line evidence\' from HRLS, especially in areas suffering from a significant lack of data.
METHODS: We developed a survey with closed and open questions on \'The value of CRs from HRLS\' to explore primarily (1) the reasons why this form of evidence from HRLS is often lacking, (2) what makes a case report/series worth sharing with the wider global health community, and (3) how we can ensure that published case reports/series reach their target audience.
RESULTS: Over a 6-month period, 1115 health professionals responded to the survey. Participants included clinicians and public health specialists from all over the world, with a majority based in Africa. The main reason cited for the dearth of CRs from HRLS was that practitioners are simply not writing and/or submitting reports (as versus having their papers rejected) due mainly to (1) a lack of skills and (2) time constraints. A large majority of respondents felt the CRs are a valuable tool for HRLS given their ability to discuss how cases are managed with rudimentary means as well as to draw attention to emerging or underestimated public health problems and neglected populations.
CONCLUSIONS: We conclude that the clinical knowledge gained in resource-challenged settings is being underutilised in the interest of patients and global health. Consequently, clinicians in HRLS need greater access to basic training in scientific investigation and writing in addition to awareness as to the potential value of sharing their clinical experience with a view to broadening evidence production from high-income to low-income settings.