Association of Patient Centered Communication and Patient Enablement

Abstract

There is increasing attention in assessing patient centered communication (PCC) as a measure of health quality and patient’s outcome. Difference in perception between patient and health provider on communication during medical consultation may lead to poor health outcome and compliance. Limited studies in assessing health provider communication in Malaysian primary care setting make it difficult to determine whether this country evolving towards patient centered communication. This study was aimed at identifying the association between PCC and patient’s enablement (PE). A cross sectional investigation involving a total of 69 outpatients was conducted in an outpatient clinic at the Pulau Pinang Hospital. Respondents were recruited using convenience sampling in February 2016 and the data was collected using a self-administered questionnaire. PCC was measured by three domains; exchanging information (EI), socioemotional behavior (SB) and communication skill (COS). Patients scored highest on SB domain with mean (SD) was 4.06(0.51), followed by EI, 3.84(0.45) and COS, 2.75(0.70). Only SB showed a statistically significant association with patient enablement, p<0.05. The findings of this study provide useful information towards improving health provider communication skill to enhance patient’s understanding and self-care management. Further studies need to be conducted to explore other factors that contribute to the patient enablement during medical consultation.

Keywords: Patient centred communicationPatient enablement

Introduction

Effective patient-healthcare provider (HCP) communication is a vital element in establishing patient centered care. Patient centeredness focus on a psychosocial approach, identifying patients as experts in themselves and their experience, and involving them appropriately in consultations (Steward et al. 2012). Its core component, known as Patient Centered Communication (PCC) is increasingly promoted in many health facilities around the world. PCC elicit the patient’s need, shared mutual understanding and encourage patient involvement in the decision making process. Hence, adoption of PCC holds great potential in creating good interpersonal relationship, and facilitating good communication between doctors and patients (Nor Azmaniza & Khadijah, 2015). It has been suggested that quality in healthcare can be assessed additionally by measuring consultation length, continuity of care, and patient enablement, reflecting the core values of primary care. The construct of Patient Enablement (PE) is based on the assumption that patient outcome is greatly influenced by how patients feel after the consultation: whether consultation has increased their understanding, and/or their ability to cope with their illness (Howie et al. 1999). It is considered an aspect of consultation quality based on core values of holism and patient-centeredness. Most patients want their HCPs to explain more factual information relevant to their illness (Ong et al. 1995) in particular for those with poor health status. This will increase their enablement to cope with their illness and life thus, empowers self-management and treatment adherence (Howie et al. 1999: Hudon et al. 2011).

Problem Statement

There is increasing attention in evaluating patient-HCP communication as measures of healthcare quality and patient’s outcome (Nor Azmaniza & Khadijah, 2013: Branson et al. 2003). Previous studies have reported that many patients were unhappy eventhough the majority of HCPs claimed that they communicated satisfactorily with their patients. HCPs, on other hand, tend to overestimate their communication skill and always perceive themselves to communicate similarly to all patients. Difference in self-perception in medical consultation has widened the gap between doctor-patient interactions. Appropriate communication integrates both patient-HCP centered approaches. However, as time progresses, communication skill among HCPs has been reported to have deteriorated. In addition, patients’ holistic of care is no longer a priority of HCP (Fong & Longnecker, 2010). If the components of PCC urges effective communication and relationship between patients and HCPs, then PCC should be actively promoted in the healthcare system. However, little to no information has been reported concerning the attitudes of Malaysian patients and HCP towards PCC. Although Communication Skill Training (CST) has been formalized in the medical curriculum, very few organizations have provided Continuous Medical Education (CME) programs to medical undergraduates. In addition, very limited publications on evaluating CST methods employed by medical schools and their effectiveness, make it difficult to determine whether medical education in this country is evolving towards producing HCPs that are patient centered in their practice (Lukman et al. 2009). Lack of research on patient-HCP communication measurement in Malaysia justifies the need of the thorough analysis of patient-HCP communication. To our knowledge, only one recent study was conducted, investigating barriers in patient-doctor communication (Khan et al. 2011).

Research Methods

A cross sectional pilot study was conducted in an Outpatient Department (OPD) in the Pulau Pinang Hospital in February 2016. An outpatient setting was selected based on recent encounter and consultation. The participants consisted of 69 outpatients who were recruited using convenience sampling method. This sampling technique was widely used in previous studies (Noor Hazilah & Phang, 2009: Ismail et al. 2008). Inclusion criteria were as follows: ages of 18 years and above, completed medical consultation at the time of the data collection and willing to participate. PCC was measured using a 36 item survey, defined by three dimensions; Exchanging Information (EI), Socio Emotional Behavior (SB) and Communication Orientation Skill (COS). EI domain consists of 12 items measuring information sharing about patient’s illness. SB consists of 6 items measuring HCP interpersonal attitudes such as politeness, courtesy, empathy when communicating with patients. EI and SB dimensions were measured by a modified version of the “Healthcare Provider-Patient Communication” instrument, developed by Nor Azmaniza & Khadijah, (2013) and COS was measured by using the Patient-Practitioner Orientation Skill (PPOS) instrument. PPOS consists of 18 items that measure patient beliefs regarding patient-centeredness. Summing up the responses provides a range, in which higher scores indicate a belief that the provider is patient-centered, while lower scores indicate a belief that the provider is doctor- or disease-centered (Trap, 2013). Patient enablement was measured by the Patient Enablement Instrument (PEI). This instrument consists of six items asking whether as a result of information sharing, patients were able to understand and cope with their illnesses better. (Howie et al. 1999). The original three-point scale – “same or less” or “not applicable” (0), “better/more” (1), and “much better/much more” was modified to a five point Likert scale ranging from “strongly agree to strongly disagree”. The questionnaires was translated into the Malay language for the use of Malay patients and distributed to the participants immediately after consultation with the HCP. The data were analyzed using Statistical Package for Social Science (SPSS). Pearson correlation was used to examine association between PCC and PE.

Findings

Table 1 shows the demographic profile of the respondents. A total of 69 patients included in this study provide the demographic information: 49 (71.0%) of the respondents were females while 20 were males (29.0). More than half of the respondents, 37 (53.6%) were aged 18-30 while 32 (46.4%) were aged above 30 years. The major ethnic group that sought treatments at the OPD were Malays, 41 (59.4%) while 28 (40.6%) were non-Malay. A total of 25 patients (36.2%) were from a low educational background while 44 patients (63.8%) were from a high educational background. 50 (72.5%) patients with high income dominated those who sought services at the clinic, compared to 19 (27.5%) lower income patients. All the patients, 69 (100%) rated their health status as good.

Table 2 shows mean scores according to domain. Patients scored highest on the socioemotional behaviour domain with mean (SD) was 4.06 (0.51), followed by exchanging information, 3.84 (0.45) and communication skill, 2.75 (0.70).

Table 3 shows the association between PCC and PE. There was a significant moderate relationship between socio-emotional behavior and PE, p<0.05. However, no significant relationship was reported between exchanging information and communication orientation skill with PE, p>0.05.

*Pearson Correlation, significant at p<0.05

4. Discussion

A large of body research has reported positive effects of technical skill such as information sharing on patient’s outcome (Birhanu et al. 2010: Qian, 2010: Iconomou et al. 2001). As with Butow et al. (1999), we found no significant association between technical skill and patient’s enablement. We believe that people derive physiological benefits from enhanced perceptions over their health. When they are healthy, they are confident that they can control their health, but when they are sick, this sense of control is threatened, leading them to consult HCPs to better understand their condition and illness (Makuol, 2003). Previous evidence has reported that patients with chronic illness or poor health usually need more information from HCPs to understand and cope with their illness, thus lead to the higher enablement. Hence, the ability of HCPs to facilitate and help these patients express their feelings and opinions contributed to them having higher enablement (Udondowa & Ogbonna, 2012). Looking at the demographic profile of the respondents, all our respondents rated their health status as good. This might justify the difference in findings from previous studies.

HCPs are increasingly expected to demonstrate good interpersonal skills in terms of empathic, patient-centred care in practice (Campbell et al. 2000: Mercer et al. 2004). HCP interpersonal aspects such as showing empathy and interest in their patients’ health-related concerns have been shown to have positive associations with patient enablement in a wide range of settings. Although other factors influence patient enablement, the patients' perceptions of the doctors' empathy is of key importance in patient enablement in general practice consultation (Steward et al. 2012). HCPs who showed more empathic response as perceived by patients were reported to have an impact on patient’s understanding about their illness (Street et al. 2005). Our finding showed that was a significant relationship between socio-emotional behaviour and patient enablement. This concurs with several studies (Pawlikowska et al. 2010: Mercer et al. 2008: Howie et al. 1999). Previous evidence reported that the degree of patient enablement was facilitated by the emotional behaviour related to the patient’s need (Nor Azmaniza & Khadijah, 2013). This concurs with our findings, which showed that the score for technical skill and socio-emotional behaviour was almost equivalent. Communication orientation skill is an important component of patient-centred care. One way to deliver patient-centred care is to communicate with the patient in a patient-centred way (Castro et al., 2007). We found no significant relationship between communication orientation skill and patient enablement. HCPs might have different perspectives of their communication skill, while patients perceived them differently (Verlinde et al. 2012: Khalid & Farid, 2010).

Conclusion

The findings showed highest mean score was reported for the domain of EI, followed by SB and COS. However, only the SB domain showed a significant association with patient enablement. There are several calls for future studies to explore other dimensions of PCC and how it affects patient enablement. This is important for developing appropriate strategies to improve patients’ understanding about their illness.

Implications and Recommendations

The findings in this study provide baseline information to policy makers in developing appropriate strategies to help both patients and healthcare providers to communicate effectively. The patient activation program is one of the strategies that can be used to encourage good communication style, provide practical and emotional support for patients engaging in medical treatment decision making. Patient activation training program can increase patient self-management, confidence and participation in decision making regarding their treatment. Also, this program can teach, educate and provide instruction on how to explain their problem clearly, ask relevant questions, seek clarification and make sure they understand what had been conveyed. The most important aspect about this strategy is that it fits easily into busy clinic schedules like outpatient clinics in Malaysian public hospitals.

In addition, PCC should be actively promoted in many health care settings in Malaysia. PCC enables facilitated communication between patient and health providers. The fact is that patients who visit clinics/hospitals might come from different social demographic backgrounds. Hence, it is important for health providers to help their patients understand their illness by clearly writing educational materials and providing illustrated aids that match their patients’ literacy level. This approach could promote interactive communication and encourage a more active role in information exchange particularly for those who are from lower socio-economic class and educational background.

Acknowledgements

This study was supported by the Ministry of Higher Education (MOHE), Malaysia and Universiti Teknologi MARA under “Research Acculturation Grant Scheme (RAGS)” (Project Code: 43/2015). The authors also would like to express their appreciation to the Assistant Director and Head of Outpatient Department of the Pulau Pinang Hospital for granting permission for this study to be conducted as well as the patients who participated in this study.

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