Learning from patients about patient-centredness: A realist review: BEME Guide No. 60

Abstract

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes. Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness. Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory. Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusterscomparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisationto show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness. Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.

Fostering patient-centredness by following patients outside the clinical setting: an interview study

“…When students built meaningful relationships with their patients, engagement occurred, which in turn provided opportunities for the development of patientcentredness -engagement being a learning mechanism [16]. On the other hand, our students struggled with their non-clinical role and how to balance professional and personal proximity in the patient panel.…”

“…Furthermore, following patients for a prolonged time provided the possibility of continuity in the relationship with the patient. In the context of a meaningful relationship and of continuity learning mechanisms related to patient-centredness were triggered, such as contextualizing disease with life stories and exploring new territories [16].…”

“…Besides, the literature suggests that following patients in a non-clinical setting enhances patient-centredness [13,14,[17][18][19]. A feasibility study, done by Mol et al at the end of year one of the patient panel pilot, contains a more detailed program description [16].…”

“…Health institutions aim to enhance patient-centredness by extending the duration of contact between patients and medical students. New models of longitudinal integrated clerkships (LICs) are increasing rapidly throughout the world [11][12][13][14][15][16]. A review discussing 58 studies has shown short-term successes of LICs.…”

“…These provide insight into how an intervention influences the context so that it triggers learning mechanisms which, in turn, lead to the outcome [15]. A realist review by de Groot et al (in press, [16]) looked at educational interventions where patients play an active role. The authors identified learning mechanisms related to the development of caregivers' patient-centredness.…”