Engaging Clinicians in Cocreating Health
This thesis contributes to the wider debate on Prudent Healthcare and Relational Practise. The study aimed to determine how to engage clinicians in cocreating health by developing a framework for cocreating health to support the patient-clinician interaction and to identify the factors in its successful implementation in health services. The interaction between patients and clinicians is at the heart of health care. They are the first point of contact and a familiar interaction with the health service for most patients. Within UK health services there are three hundred million consultations held every year. Consultations happen in a variety of contexts, locations and with many different clinical professions. The overwhelming majority of these interactions follow a set pattern, the rules of engagement, which governs how patients are examined, histories established, symptoms described, test results discussed, progress monitored, treatment options given and decisions made. However, the traditional medical model of consultation can reinforce a power imbalance between clinician and patient, and create paternalistic relationships that reduce patients’ control, leading to their ‘systematic disempowerment’. Cocreating health is about enablement, viewing patients as assets not burdens and seeks to support them to recognise, engage with and develop their own sense of resourcefulness building on their own unique range of capabilities. Cocreation means that health care services support people’s individual abilities, preferences, lifestyles and goals. In a cocreating health model of interaction, patients work with a supporting clinician. Such interactions consider the patient’s life goals, how they plan to work towards them and what support they need to help her get there. Working in cocreation, a clinician would support patients to think about goals that are meaningful and adaptive. A number of elements of cocreating health such as self-supported management and decision support have previously been developed. However, these have generally been implemented within the context of the traditional ‘medical model’ of consultation. In the development of the cocreating health framework, a mixed qualitative and quantitative approach was taken to explore different aspects of cocreating health and to triangulate knowledge obtained from the different methodologies. Principles of grounded theory were used in the qualitative research. Data and insights were obtained in two phases. In the first phase, over thirty workshops were held with over five hundred participants from Welsh Government, local authorities, voluntary sector and across the NHS in Wales including policy makers, leaders of health services and clinicians. Insights from these participants combined with knowledge gained from the literature review were used to develop a cocreating health framework for testing. The initial data suggested that for clinicians, working collaboratively with patients in agenda setting was the most unfamiliar and potentially transformative element of cocreating health. Accordingly, training was arranged for one hundred and sixty four clinicians whose attitudes towards cocreating health were explored using questionnaires. In the second phase, semi structured interviews were held with thirty one participants from professional backgrounds of doctor, nurse and therapist and at levels of policy maker, leader and clinician to determine their insights on the test cocreating health framework. These insights were used to refine the framework and develop a number of methods to convey the framework to different audiences. The cocreating health framework contains seven elements namely ; preparation; agenda setting; information gathering; discussing options; agreeing the way forward; implementation; review and further actions, with each of these elements supported by reflective learning and service improvement. Insights were obtained from these same thirty one interviewees on factors relating to implementation of the framework. These insights led to development of a grounded theory model for implementation of cocreating health. This model has its roots in the theory of planned behaviour and describes elements of clinician attitude, clinician norms and controls impacting on the intention to cocreate health with action factors of patient self-efficacy, the cocreating health framework and leadership support leading to actual cocreating health behaviours. The most significant issues perceived in cocreating health were found to be ; conflict between the cocreating health framework and the current ‘medical model’; power relationships; the context of the interaction; patient self-efficacy; clinician understanding of cocreating health; the conflicting expectance of patients about the clinician’s role; time constraints and ; clinician training. Implementation of the cocreating health framework was examined through the lens of normalisation process theory. Results of this suggested that neither patients, clinicians nor health systems and currently sufficiently ‘activated’ for successful widespread implementation of the cocreating health framework. It was concluded that implementation of cocreating health requires willing advocates to embed cocreating health approaches within their multidisciplinary team work, collecting evidence and case studies to generate ‘permission’ and buy in from influential leaders. Rather than attempting to ‘persuade’ highly experienced clinicians with many years of working to the medical model, this research suggests that cocreating health would be more successfully implemented in the initial training of clinicians in the curricula of medical schools, schools of nursing and training of other clinical groups. The research explores the properties of an ‘activated’ health system, that would provide clinician training in the elements identified in the framework, patient education programmes, appropriate employer expectations set through policy, information technology such as an electronic patient record and sources of information about clinical conditions that are openly available to both patient and clinician to read from and write to, and adequate time and flexibility for appointments. Finally, the sociological characteristics of cocreating health interactions between patients and clinicians were described within a symbolic interactionist paradigm.
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