The rapidly growing population of older people may pose a challenge to healthcare systems due to the increased diversity of treatment and care.1,2
The challenge may be rooted in the gap between treatment provided and what is of importance to older patients, who may prefer a dialogue with HCPs concerning personal values, options, benefits and harms in order to decide what is best for them in their health and well-being.3-6
A dialogue between a HCP and an older patient encompasses seeing, hearing, understanding and experiencing the patient's present situation in hospital. It also requires being available and attentive to the patient in order to participate and be involved. Additionally, it requires involvement in the patient's emotions and their understanding of illness and suffering as a human being, rather than the patient being reduced to just a disease or a diagnosis. In dialogues, patients are respected and support is given to help them regain their spirits and wellbeing.7
The World Health Organization (1989) defines health and wellbeing as physical, mental and social wellbeing, while the German philosopher Martin Heidegger (1889–1976) advocates that human beings are whole beings, which means that wellbeing must be studied as a complex human experience.8
Older patients may accept treatment and care, believing HCPs to be able to accurately understand their values and preferences. Moreover, older patients experience communication issues such as hearing loss, speech impairments, slow cognitive processing and low activation.4
Despite these challenges, a review shows that older patients prefer HCPs who adopt a relationship-centered approach who openly share information with an individual.9 However, some older patients experience some HCPs as being uncaring and overly autocratic.3 They claim to experience continuous pressure from some HCPs to eat, drink and get out of bed.10 Older patients seem to follow HCPs’ recommendations without voicing their concerns if disagreements arise.4 Therefore, HCPs may have the impression that the older patients wish to defer decision-making to their providers.11 This perception, however, conflicts with findings in studies that show that the preference for participation in healthcare decisions is variable across all ages.4,12
Older patients may be overwhelmed by illness, which can cause them to be bedridden, and have low energy levels, bodily discomfort and pain, and even to verbalize their suffering and expectations from HCPs represents a challenge.3,13 As a consequence, it may be necessary for HCPs to initiate dialogues.14,15 In general, a patient's gender, education, age, marital status and experience of illness and the type of decisions that need to be made appear to have an influence on the dialogue with the HCPs.13-15 Evidence suggests that patients underestimate their own personal knowledge for fear of being labelled “difficult”, and having a desire to be a good patient which is characterized by passivity and compliance, and to avoid encounters that lead to conflict.16,17 However, every condition requires the patient's participation in a dialogue as patients live with the consequences for their own health and well-being in their day-to-day lives.18
Patients’ views, concerns and values need two-way communication.16,19 However, in their relationship with the HCPs, patients experience several barriers to participating in a dialogue, such as difficulties in understanding medical jargon or being intimidated by there being too many people participating in, for instance, ward rounds.16,20 Other barriers include overloaded, unstructured information presented in a chaotic manner, HCPs’ paternalistic and bureaucratic attitudes or HCPs who do not listen.19 Additionally, lack of time, privacy, trust and acknowledgment, and a noisy environment, are also influencers.17 Furthermore, patients may experience a dialogue with HCPs as being absent and sliding into insignificance, feeling uncared for or disregarded. On the other hand, facilitators for dialogues from the patients perspective are good information, support, explanations and advice from HCPs, which add to their positive feelings, dispel fears and create a sense of familiarity.21
Dialogue is an important part of nursing care and medical treatment and, in western countries, it is a legal right for patients to receive such considerations,22 and therefore HCPs have a responsibility to involve patients in decisions concerning care and treatment.23 For decades, patients have been encouraged to become actively involved in their own healthcare decisions as incorporating patients’ preferences into decisions may lead to improved wellbeing through better adherence to treatment, fewer concerns about illness, and higher satisfaction with outcomes.18,24,25
Ward rounds, with HCPs being at the patients’ bedside, are an opportunity for HCPs to start up these dialogues, enabling the patients to communicate their’ views, concerns and which can have an influence the decisions made.26 Since 1982, shared decision-making has become another essential part of care and medical treatment,27,28 that is, involving patients in dialogues with HCPs regarding their own present health and wellbeing.29 Although the underlying principles are clearly laid out, the implementation seems to have been less successful.18 A one-year follow-up research study investigated if shared decision-making can improve the interaction between patients and, HCPs, and the individual health outcome. The results provide evidence of a significantly improved relationships and dialogues between HCPs and patients, where HCPs listen and act attentively and empathetically, which makes the patients content and more able to cope with their symptoms, despite there being no direct influence on somatic outcomes.30 Other facilitators for patient participation are adequate time, a positive environment and HCPs as mediators to both explain information and facilitate trust.17
To date, research has provided evidence that older patients face several challenges in dialogues with HCPs when undergoing treatment and care in hospitals, such as hearing loss, speech impairments, low activation, acceptance of authority and HCPs believing older patients to be not interested in a dialogue. However, older patients prefer conversations with HCPs regarding their thoughts and personal values, focusing on their health and wellbeing. Insights are sparse in relation to understanding older patients’ experiences of dialogues with HCPs and the facilitators and barriers to this experience. Therefore the findings of this review may provide evidence of use to HCPs in hospitals who participate in dialogues with older patients and to future research. Synthesizing older patients’ experiences of dialogues with HCPs can enhance and develop the awareness and understanding of what is important in treating and caring for older patients in hospitals.
A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, CINAHL, PubMed, PROSPERO or Google Scholar did not locate any systematic reviews on this topic. Therefore, we aim to present new evidence on the topic of older hospitalized patients’ experiences of dialogue with HCPs concerning their health and wellbeing.
Types of participants
This review will consider studies that include older patients, aged 65 and over who have been hospitalized in any setting. Excluded will be studies with psychiatric patients and patients with dementia.
Phenomena of interest
This review will consider studies that investigate older patients’ experiences of the barriers and facilitators for initiating and participating in dialogues with HCPs concerning any aspect of their health and wellbeing.
This review will consider research in any setting in hospitals. The review will only consider results from research dealing with older (>65) patients’ experiences of the barriers and facilitators to having dialogues with HCPs concerning their health and wellbeing.
Types of studies
The review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
In the absence of research studies, other text such as opinion papers and reports will be considered. The textual component of the review will consider expert opinion, discussion papers, position papers and other text.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Danish, Norwegian, Swedish and German will be considered for inclusion in this review. Studies published from January 2000 to the present will be considered for inclusion in this review. In this period, patient participation has become a common term in hospitals18,31 involving dialogues between older patients and HCPs.
The databases to be searched include: PubMed, CINAHL, PsycINFO, Embase.
The search for gray literature will include: ProQuest Dissertations and Theses Global and MedNar.
Initial keywords to be used will be: older (+65) hospitalized patients: experiences; dialogue; conversation; relationship; patient's role; patient's present health and well-being; health care providers; qualitative studies.
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI).32 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instrument from the JBI SUMARI.32 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-SUMARI.32 The data extracted will include specific details about the populations, study methods and phenomena of significance to the review question and specific objectives.
Textual data will be extracted from papers included in the review using the standardized data extraction tool from JBI-SUMARI.32 The data extracted will include specific details about the populations, study methods and phenomena of significance to the review question and specific objectives. In case of missing information, authors will be contacted.
Qualitative research findings and textual data will, where possible, be pooled using JBI-SUMARI.32 This will involve the aggregation or synthesis of findings/conclusions to generate a set of statements that represent that aggregation, through assembling the findings/conclusions rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings/conclusions will be presented in narrative form.
The authors thank Research Librarian Niels Juul Nielsen, Aalborg University Hospital, for assisting in the literature search plan.
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