Mwamba Chanda, Mukamba Njekwa, Sharma Anjali, Lumbo Kasapo, Foloko Marksman, Nyirenda Herbert, Simbeza Sandra, Sikombe Kombatende, Holmes Charles B, Sikazwe Izukanji, Moore Carolyn Bolton, Mody Aaloke, Geng Elvin, Beres Laura K
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Front Health Serv. 2022 Sep 14;2:918874. doi: 10.3389/frhs.2022.918874. eCollection 2022.
Traditional patient-provider relationships privilege the providers, as they possess the formal authority and clinical knowledge applied to address illness, but providers also have discretion over how they exercise their power to influence patients' services, benefits, and sanctions. In this study, we assessed providers' exercise of discretionary power in implementing patient-centered care (PCC) practices in Lusaka, Zambia.
HIV clinical encounters between patients on antiretroviral therapy (ART) and providers across 24 public health facilities in Lusaka Province were audio recorded and transcribed verbatim. Using qualitative content analysis, we identified practices of discretionary power (DP) employed in the implementation of PCC and instances of withholding DP. A codebook of DP practices was inductively and iteratively developed. We compared outcomes across provider cadres and within sites over time.
We captured 194 patient-provider interactions at 24 study sites involving 11 Medical Officers, 58 Clinical Officers and 10 Nurses between August 2019 to May 2021. Median interaction length was 7.5 min. In a hierarchy where providers dominate patients and interactions are rapid, some providers invited patients to ask questions and responded at length with information that could increase patient understanding and agency. Others used inclusive language, welcomed patients, conducted introductions, and apologized for delayed services, narrowing the hierarchical distance between patient and provider, and facilitating recognition of the patient as a partner in care. Although less common, providers shared their decision-making powers, allowing patients to choose appointment dates and influence regimens. They also facilitated resource access, including access to services and providers outside of scheduled appointment times. Application of DP was not universal and missed opportunities were identified.
Supporting providers to recognize their power and intentionally share it is both inherent to the practice of PCC (e.g., making a patient a partner), and a way to implement improved patient support. More research is needed to understand the application of DP practices in improving the patient-centeredness of care in non-ART settings.
传统的医患关系赋予了医疗服务提供者特权，因为他们拥有用于诊治疾病的正式权威和临床知识，但医疗服务提供者在如何行使权力以影响患者的服务、福利和处罚方面也有自由裁量权。在本研究中，我们评估了赞比亚卢萨卡的医疗服务提供者在实施以患者为中心的护理（PCC）实践中自由裁量权的行使情况。
对卢萨卡省24家公共卫生机构中接受抗逆转录病毒治疗（ART）的患者与医疗服务提供者之间的HIV临床诊疗过程进行录音，并逐字转录。通过定性内容分析，我们确定了在实施PCC过程中使用的自由裁量权（DP）实践以及未行使DP的情况。通过归纳和迭代开发了一个DP实践编码手册。我们比较了不同医疗服务提供者类别以及不同时间点各地点之间的结果。
在2019年8月至2021年5月期间，我们在24个研究地点记录了194次医患互动，涉及11名医生、58名临床医生和10名护士。互动的中位数时长为7.5分钟。在医疗服务提供者主导患者且互动迅速的层级关系中，一些医疗服务提供者邀请患者提问，并详细回答以增加患者的理解和自主性。另一些人使用包容性语言，欢迎患者，进行自我介绍，并为服务延迟道歉，缩小了医患之间的层级距离，促进了将患者视为护理伙伴的认可。虽然不太常见，但医疗服务提供者分享了他们的决策权，允许患者选择预约日期并影响治疗方案。他们还协助患者获取资源，包括在预约时间之外获取服务和医疗服务提供者。DP的应用并不普遍，并且发现了一些错失的机会。
支持医疗服务提供者认识到自己的权力并有意分享权力，这既是PCC实践的内在要求（例如，使患者成为伙伴），也是改善患者支持的一种方式。需要更多研究来了解DP实践在提高非ART环境下以患者为中心的护理方面的应用。
