Micro-Meso-Macro Practice Tensions in Using Patient-Reported Outcome and Experience Measures in Hospital Palliative Care

Abstract

This article applies a micro-meso-macro analytical framework to understand clinicians' experiences and perspectives of using patient-reported outcome and experience measures (PROMs and PREMs) in routine hospital-based palliative care. We structure our discussion through qualitative analysis of a design and implementation project for using an electronic tablet-based tool among hospital-based palliative clinicians to assess patients' and their family caregivers' quality of life concerns and experiences of care. Our analysis identified three categories of practice tensions shaping clinicians' use of PROMs and PREMs in routine care: tensions surrounding implementation, tensions in standardization and quantification, and tensions that arose from scope of practice concerns. Our findings highlight that clinicians necessarily work within the confluence of multiple system priorities, that navigating these priorities can result in irreducible practice tensions, and that awareness of these tensions is a critical consideration when integrating PROMs and PREMs into routine practice.

Patient Work and Their Contexts: Scoping Review

“…The contextual factors were grouped into how they fit within the patient work system (either in the macroergonomic triad of physical, social, and organizational factors or within the microergonomic triad of person-task-tools) [ 2 , 14 , 32 ]. As the patient work system has 3 layers, with households and communities comprising the mesoergonomic layer between the macro and microergonomic contexts, we also grouped contextual factors based on the level (macro, meso, or micro) at which they affected patient work tasks [ 33 , 34 ]. Although Holden et al [ 100 ] have identified mesoergonomics as the study of the relationship between variables in different layers of an ergonomics system, the meso contextual factors we identified here correspond to factors that sit between the micro- and macroergonomics levels.…”

“…Work tasks were identified from the included articles, were clustered based on common themes that emerged, and were consulted against Dack et al’s model [ 31 ]. Contextual factors were grouped according to where they fit within the dimensions outlined in the patient work framework (patient, tasks, tools, physical, social, and organizational) [ 2 , 14 , 32 ] and the level at which they exert influence (micro, meso, or macro) [ 33 , 34 ]. We identified microlevel contextual factors as aspects that only affected the patient’s body or were psychological factors.…”

“…We identified macrolevel contextual factors as aspects that arose from the society, culture, or geopolitical entity in which the patient lived. The micro-meso-macro framework has been used extensively in health care, ranging from describing the quality of life assessments at different levels of decision making [ 36 ], patient-reported outcome measures in hospital palliative care [ 34 ], enablers and barriers affecting nursing practices [ 37 ], policy implementation of health leadership [ 38 ], to health care priority setting across different countries [ 39 ].…”

Enabling patients with advanced chronic obstructive pulmonary disease to identify and express their support needs to health care professionals: A qualitative study to develop a tool

“…Indirect indicators of need assume that patients consider there is legitimacy in discussing their support needs with health care professionals, that they understand the holistic nature of supportive care and have the opportunity and confidence to contribute to discussions on what they require to manage life with their illness. Evidence suggests this is not always the case 42,43 and therefore there is a need for designed-for-purpose tools, such as the SNAP tool. The SNAP tool has therefore been specifically developed to facilitate delivery of a holistic, person-centred approach for the identification of patient support needs: the Support Needs Approach for Patients (SNAP).…”

A cluster randomized controlled trial for the Evaluation of routinely Measured PATient reported outcomes in HemodialYsis care (EMPATHY): a study protocol

“…Other factors identified include the use of technology, having the appropriate infrastructure in place, embedding PROMs into routine workflow, improving the interpretability of PROMs data, and engaging clinicians in the planning phase of the intervention [35]. Finally, a key element identified by clinicians is the linkage of PROMs with tools to support the clinical management of symptoms or problems identified by assessments [37]. For example, if a patient identifies problems with anxiety or depression, clinicians should have readily available treatment protocols to follow to alleviate those symptoms [35,36].…”