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PubMed2002

The generalist's patient and the subspecialist.

OBJECTIVE: To examine if required referring procedures from generalists to subspecialists for managed care patients affect communication between the physicians. BACKGROUND: Collaboration between generalists and subspecialists is essential for successful referrals and a satisfactory relationship between the physicians. However, breakdowns in information transfers in outpatient referrals continue to be described. Moreover, the referral process within managed care systems may be adding new elements that interfere with communication between physicians, promoting fragmentation of care. OBSERVATIONS: Current referral forms or electronic approval mechanisms encourage responses for billing approval, but neglect methods to require questions from generalists and replies from the subspecialist. Other barriers to communication between physicians are discussed. Responsibilities for agencies, patients, and doctors are reviewed. CONCLUSIONS: Insuring agencies need to provide uniform rules and educational mechanisms describing patients' timely responsibilities in the consultation process. In addition, methods need to be created to convey reasons and data for referral from generalists to subspecialists, and recommendations from subspecialists back to the generalists.

Communication↗
PubMed2004

Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators.

BACKGROUND: Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline. METHODS: This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals. RESULTS: Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use. CONCLUSIONS: When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

Communication Barriers↗
PubMed2004

Retrospective study into the delivery of telephone cardiopulmonary resuscitation to "999" callers.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is an essential part of the chain of survival, with early administration directly affecting the patient's chance of survival. Pre-arrival telephone CPR instructions provide callers who have no CPR training on how to undertake this intervention. With the emergency medical dispatcher unable to see the caller or the patient, it is possible that problems will arise, presenting barriers, that stop the caller undertaking effective CPR. OBJECTIVE: To examine how commonly barriers to telephone CPR occur and whether this affects the time it takes to perform the intervention. METHOD: A retrospective quantitative analysis was undertaken using a convenience sample of 100 emergency calls. Calls were identified in the emergency control room as cardiac arrests and confirmed by the responding paramedics as cardiac arrests. The calls were listened to, established if CPR instructions were given, if the instructions were followed, if anything hindered the instructions undertaken, and the time taken to reach key points. FINDINGS: 18 cases had bystander CPR administered. An additional 56 of cases had CPR instructions provided but "barriers" in 49% (n = 27) hindered the effectiveness of these. The median time to recognition of cardiac arrest was 40 seconds, with time to first ventilation being 4 min 10 s and time to first compression 5 min 30 s. These times were notably higher in those cases where a barrier to effective telephone CPR existed. CONCLUSIONS: Barriers to undertaking telephone CPR occurred with a high degree of frequency. These barriers affect the ability of the caller to perform rapid and effective telephone CPR.

Cardiopulmonary Resuscitation↗
PubMed2006

The challenges of transferring evidence-based dentistry into practice.

The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment. Though clinicians embrace this concept, its implementation in clinical practice has been slow. In this paper, barriers against the implementation of evidence-based care are examined and possible solutions are offered.

Attitude of Health Personnel↗
PubMed1994

Physician reluctance to discuss advance directives. An empiric investigation of potential barriers.

BACKGROUND: To determine the relative impact of five proposed barriers to physician usage of advance directives with the aim of increasing the number of advance directives generated. METHODS: Questionnaires were sent to 460 internal medicine resident and attending physicians at a large New York, NY, hospital. Of these, 277 (60%) responded. We used multiple regression to measure the impact of five barriers to physician-initiated discussions of advance directives (time constraints, compensation concerns, discomfort with the subject, beliefs about appropriateness, and lack of understanding) on respondents' estimates of the number of advance directives held by respondents' patients, the number of recent advance directive discussions, and the number of discussions initiated by physicians. RESULTS: Physician lack of understanding and erroneous beliefs about appropriateness had particularly strong effects, serving as barriers to recent advance directive discussions (P < .0001 and P < .0001, respectively) and total number of advance directives held (P < .0001 and P < .02). Physicians' lack of knowledge also served as a barrier to the percentage of discussions that were physician initiated (P < .003 and P < .04). Time constraints and lack of comfort affected only discussions that were physician initiated (P < .001). Compensation concerns did not appear to serve as a barrier. Respondents were supportive of the concept of advance directives but reported minimal use of them in appropriate situations. CONCLUSIONS: Attention can now be focused on methods to overcome the five barriers studied and thereby enhance the execution of advance directives.

Adult↗
PubMed1996

Cultural barriers to health care for refugees and immigrants. Providers' perceptions.

What are the barriers to good health care for immigrants who have come to the Minneapolis-St. Paul metropolitan area since the early 1980s? Why do immigrants often delay or avoid seeking mainstream health care services? The research described here examines these questions from the perspective of nonimmigrant health care providers in the Twin Cities. The 24 metropolitan health care providers interviewed in our study confirmed the existence of significant barriers to health care-barriers that probably differ from those experienced by nonimmigrant patients. Refugees and immigrants from other cultures had varying culturally based reactions to Western-style, allopathic medicine-some positive and many negative. Providers and administrators must consider these barriers when serving a growing population of immigrant patients.

Adult↗
PubMed1998

Cultural and linguistic barriers to mental health service access: the deaf consumer's perspective.

OBJECTIVE: The authors investigated knowledge, attitudes, and beliefs about mental illness and providers held by a group of deaf adults. METHOD: The American Sign Language interviews of 54 deaf adults were analyzed. RESULTS: Recurrent themes included mistrust of providers, communication difficulty as a primary cause of mental health problems, profound concern with communication in therapy, and widespread ignorance about how to obtain services. CONCLUSIONS: Deaf consumers' views need due consideration in service delivery planning. Outreach regarding existing programs is essential.

Adult↗
PubMed2005

[Access to health care: perceptions of patients with multiple chronic conditions].

OBJECTIVE: To explore access to health care for patients presenting with multiple chronic conditions and to identify barriers and factors conducive to access. DESIGN: Qualitative study with focus groups. SETTING: Family practice unit in Chicoutimi (Saguenay), Que. PARTICIPANTS: Twenty-five male and female adult patients with at least four chronic conditions but no cognitive disorders or decompensating conditions. METHODS: For this pilot study, only three focus group discussions were held. MAIN FINDINGS: The main barriers to accessing follow-up appointments included long waits on the telephone, automated telephone-answering systems, and needing to attend at specific times to obtain appointments. The main barriers to specialized care were long waiting times and the need to get prescriptions and referrals from family physicians. Factors reported conducive to access included systematic callbacks and the personal involvement of family physicians. Good communication between family physicians and specialists was also perceived to be an important factor in access. CONCLUSION: Systematic callbacks, family physicians' personal efforts to obtain follow-up visits, and better physician-specialist communication were all suggested as ways to improve access to care for patients with multiple chronic conditions.

Appointments and Schedules↗
PubMed2004

Barriers to the implementation of patient safety initiatives.

Since release of the Institute of Medicine Report "To Err is Human:Building a Safer Health System" in 1999, a huge effort has been expended on error-related clinically applied research and on the implementation of new standards and practices related to quality improvement and patient safety. Nonetheless, measurable improvements in the quality of delivered care and reductions in medical errors have been variable and modest in most cases. Multiple barriers to the implementation of patient safety and error reduction initiatives have been identified in the literature. The greater part of this article is devoted to three fundamental barriers: physicians' intolerance for uncertainty, health professionals' fears, and an organizational structure and culture that are incongruent with increasing patient safety.

Communication Barriers↗
PubMed2001

Perceived needs and service use of Spanish speaking monolingual patients followed at a Hispanic clinic.

This study compared Spanish speaking monolingual patients at a Hispanic Clinic, with Hispanics and non-Hispanics at a conventional mental health center. A questionnaire in English and Spanish surveyed sociodemographic characteristics and subjectively reported health needs. The monolingual Hispanic Clinic patients perceived a significantly greater need for help with health and benefits, and better access to physical health care providers. Hispanics seen at the Hispanic Clinic report more difficulties managing medications than the other groups suggesting that this problem is not adequately addressed by receiving services in a culturally sensitive clinic, possibly due to the persistent effect of language barriers and low level of education. Additional interventions may be needed to address this problem.

Adult↗
PubMed2001

Barriers to getting needed services for Ryan White CARE clients.

To determine why HIV-infected persons do not access needed services, we interviewed clients of Ryan White CARE-funded agencies in San Francisco, San Mateo and Marin Counties. From July to September 1996, we interviewed 519 clients receiving services at 65 CARE-funded sites. Just over half the clients (54.5%) had at least one unmet service need in the previous four months; persons in an unstable living situation and those with lower perceived health status were significantly more likely to have an unmet need. For persons with unmet needs, agency barriers were most common (54.0%), followed by emotional issues (44.8%), lack of information (44.0%) and financial/practical barriers (19.4%). None of the client characteristics (sex, race/ethnicity, age, living situation, perceived health status and risk group) were consistently or significantly (p < 0.05) associated with specific barriers. We believe that the similarity between clients with and without unmet needs reflects the success of CARE in eliminating many barriers. However, the persistence of certain barriers and lack of sub-group-specific barriers suggests the need for individualized interventions to improve service delivery, publicize service availability and address the emotional barriers to accessing HIV-related care.

Adult↗
PubMed2003

Barriers and successful strategies to antiretroviral adherence among HIV-infected monolingual Spanish-speaking patients.

Focus groups were conducted with HIV-infected, monolingual Spanish-speaking patients (N = 81) taking antiretrovirals in order to: (1) determine what barriers impede medication adherence; (2) determine what strategies facilitate adherence; and (3) investigate the health care provider-patient relationship and whether it impacts adherence. Both quantitative and qualitative information was gathered. Participants were prescribed an average of 11 pills per day (M = 11.4, SD = 7.0, range = 1-30). Only 32% of participants were consistently adherent when self-report of medication taking (yesterday, the day before yesterday, and last Saturday) was compared to prescribed regimen. The most frequently reported strategies were: learning more about the medications (77%), accepting the need to take them (75%) and refilling prescriptions early or on time (70%). Barriers most often reported were: feeling depressed or overwhelmed (21%), simply forgetting (19%) and sleeping through a dose (17%). From the qualitative data, four main issues emerged: patient characteristics, the health care professional-patient relationship, language and cultural barriers within the health care system, and the medication regimen. Among this Latino sample, having someone to live for was extremely important in terms of patient adherence. Language barriers were reported, and the use of translators was not always seen as a sufficient remedy. Differences between monolingual Spanish-speaking patients' and English-speaking patients' strategies and barriers are discussed.

Adult↗
PubMed1995

Culturally sensitive perinatal care for southeast Asians.

This article presents strategies for providing perinatal care to Southeast Asians living in the United States and Canada. The population is described, and attention is paid to how their past and continued lifestyle contribute to health problems. Traditional healing beliefs and practices, especially those pertaining to childbearing, are discussed. A demonstration project in Long Beach, California, is described as a model for delivering culturally sensitive care.

Asia, Southeastern↗
PubMed1991

Assuring quality of care: nursing home resident councils.

Increasing concern over the quality of care in nursing homes has prompted the National Institute of Medicine to recommend that residents have regular input into nursing home administration, primarily through the development of resident councils. Yet little is known of the effectiveness of resident councils. The literature is divided in its assessment of the potential of the institutionalized to represent themselves. Rather than suggesting either that resident councils are impotent or that they are a cure-all, these data, which examine the activities and effectiveness of existing resident councils, suggest that resident councils are successful in accomplishing some but not all of their objectives, that their success is maximized when professional organizers are available to help residents overcome the many barriers they face, and that there are many institutional factors that resident councils are seldom in any position to control.

Aged↗
PubMed2001

Korean women: breast cancer knowledge, attitudes and behaviors.

INTRODUCTION: Clustered within the nomenclature of Asian American are numerous subgroups, each with their own ethnic heritage, cultural, and linguistic characteristics. An understanding of the prevailing health knowledge, attitudes, and screening behaviors of these subgroups is essential for creating population-specific health promotion programs. METHODS: Korean American women (123) completed baseline surveys of breast cancer knowledge, attitudes, and screening behaviors as part of an Asian grocery store-based breast cancer education program evaluation. Follow-up telephone surveys, initiated two weeks later, were completed by 93 women. RESULTS: Low adherence to the American Cancer Society's breast cancer screening guidelines and insufficient breast cancer knowledge were reported. Participants' receptiveness to the grocery store-based breast cancer education program underscores the importance of finding ways to reach Korean women with breast cancer early detection information and repeated cues for screening. The data also suggest that the Asian grocery store-based cancer education program being tested may have been effective in motivating a proportion of the women to schedule a breast cancer screening between the baseline and follow-up surveys. CONCLUSION: The program offers a viable strategy to reach Korean women that addresses the language, cultural, transportation, and time barriers they face in accessing breast cancer early detection information.

Asian↗
PubMed1999

On establishing trust.

Mutual understanding and trust are most easily attained between persons who share a common cultural background. Persons of color often see physicians as members of an alien culture who are not to be trusted. Physicians can and should transcend cultural barriers and secure the trust of patients of color. To do this, a common culture is not required; effort, kindness and sympathy are.

Communication Barriers↗
PubMedDate not supplied

Patient treatment adherence. Facility design and counseling skills.

OBJECTIVE: To describe the essential facility characteristics for a model patient counseling area: (1) activities that should be accommodated by the facility; (2) special environmental and interior design features, with a discussion of their impact on the healthcare provider-patient interaction; (3) storage and equipment requirements; and (4) determination of space requirements for the counseling area. A second objective is to suggest a strategy to follow when justifying an adherence clinic. DATA SOURCE: Primary and secondary sources of literature were reviewed in the areas of pharmacy, psychology, and architecture to identify design specifications for the patient counseling area. CONCLUSIONS: The design of a counseling area can indirectly affect the quality of the interaction between the patient and healthcare provider, primarily in terms of its effect on communication. The key features that should be included in the design of the area are different levels of privacy (visual and auditory), "soft" interior decoration, and accommodation of people with disabilities. There are several design-related barriers to communication that should be avoided in the facility. The space required for a counseling area is dependent upon the scope of services provided--approximately 100-130 square feet may be necessary.

Ambulatory Care Facilities↗
PubMed2001

Toxic epidermal necrolysis induced by nevirapine therapy: description of two cases and review of the literature.

We describe two cases of toxic epidermal necrolysis developed during an antiretroviral therapy regimen containing nevirapine. It seems likely that the poor adherence to the dose escalation regimen of nevirapine has caused this life-threatening disease. A complete and written information on the scheduled antiretroviral therapy is mandatory, above all for individuals coming from developing countries where language barriers have not yet been successfully overcome.

Adult↗