trajectory of associations
To explore the trajectory of associations between the nursing care process of patient empowerment during postsurgical hospitalization and postdischarge patient self-management outcomes, specifically patient activation and functional health status.
Background. Patient-centred care models advocate for patient empowerment in long-term illness care. Postsurgical patients with life-threatening long-term illnesses frequently feel powerless, have unmet needs, decreased functional health status and high readmission rates; however, previous studies of patient empowerment have conceptualized empowerment as an outcome primarily in outpatient settings, with little attention paid to provider processes used to empower patients during hospitalizations.
Design. A non-experimental, prospective, correlational study.
Methods. This sample consisted of 113 postsurgical cancer and cardiac patients enrolled between August 2012–February 2013. Patient perceptions of patient-empowering nurse behaviours and baseline patient activation were measured prior to discharge. Patient activation and functional health status were measured 6 weeks following discharge. Data were analysed with multiple linear regression using a simultaneous equation approach. Results. Patients reported high perceptions of patient-empowering nurse behaviours and patient activation levels. Functional health status scores were below population norms. Patient perceptions of empowering nurse behaviours were positively associated with postdischarge patient activation, which was positively associated with mental functional health status. Length of stay was the only significant predictor of physical functional health status.
Conclusion. This study provides further quantitative evidence supporting the relationship between quality nursing care and postdischarge patient outcomes. Intentional use of patientempowering nurse behaviours could lead to improved patient activation and functional health status in postsurgical patients with life-threatening long-term illnesses.
Keywords: long-term illness, nurse–patient relationships, nurses, patient participation, postoperative care, self-efficacy, therapeutic relationships
healthcare improvement (National Health Service n.d., Australian Commission on Safety & Quality in Healthcare
2010, Bupa 2011, Patient-Centered Outcomes Research Institute (PCORI) 2012). The process of patient empowerment occurs within collaborative provider–patient relationships with the intention of increasing patients’ capacities to take control of their illnesses (World Health Organization 2012). In their many encounters with patients across the continuum of long-term illness care, nurses can empower patients by: (1) helping patients to realize that they can participate in their care and treatment planning; (2) providing patients with access to information, support, resources and opportunities to learn and grow; (3) helping to facilitate collaboration with providers, family and friends; and (4) allowing patients autonomy in decision-making (Laschinger et al. 2010, Munn 2010). Engaging patients through empowering behaviours is an important component in patient care, as interventions using empowering behaviours have been shown to reduce healthcare costs (Melnyk & Feinstein 2009, Hibbard & Greene 2013).
Patient-empowering nurse behaviours can help facilitate the engagement of patients in self-management behaviours through the development of patient activation. Activated patients have the knowledge, skills and confidence necessary to manage their long-term illnesses effectively (Hibbard et al. 2004). Highly activated patients have dem- onstrated lower costs of care and predicted future costs (Remmers et al. 2009, Hibbard et al. 2013) and higher functional health status through successful engagement in self-management behaviours (Hibbard et al. 2007, Skolasky et al. 2011a).
The majority of research on patient empowerment has studied empowerment as an outcome in outpatient settings (Chen & Li 2009, Herbert et al. 2009). Little attention has been paid to provider processes used to empower patients during a hospitalization. Postoperative patients with life- threatening long-term illnesses, such as cancer and cardiac disease, face multiple illness-related transitions associated with the recovery from their surgery and taking on the role of managing their life-threatening long-term illness on hospital discharge (Schumacher & Meleis 1994, Kralik et al. 2004).
As the burden of long-term illness rises due to increasing prevalence and cost of care, the engagement of patients in managing their long-term illness through the process of patient empowerment has been advocated as a critical component of emerging patient-centred models for
Several published studies have examined the relationship between empowering behaviours and self-management of long-term illness in outpatient and long-term care settings. Interventions using an empowering approach in the outpatient setting have been associated with increased confi-
dence in self-management and problem-solving ability in individuals with long-term illnesses, such as cancer, diabetes, heart failure, obesity and hypertension (Chen & Li 2009, Munn 2010, Suter et al. 2011). Empowering behaviours have also been associated with improved quality of life in people with cancer (Bakitas et al. 2009) and nursing home patients in Taiwan (Tu et al. 2006).
Patient activation can be viewed as a precursor to the engagement in self-management behaviours, as the components of patient activation (knowledge, skills and confidence) are factors that influence the process of self- management behaviour (Ryan & Sawin 2009). Higher patient activation has been linked to higher functional sta- tus, adherence to self-management behaviours and lower costs of care (Mosen et al. 2007, Hibbard et al. 2013). Functional health status, used as a measure of quality of life, is a useful outcome measure to evaluate an individual’s physical and psychological adjustment to long-term illness (Stanton et al. 2007) and has been identified as a nurse- sensitive outcome (Doran 2011).
Various patient characteristics or illness factors may influence patients’ perceptions of patient-empowering nurse behaviours. Younger patients may prefer a more active role in their care (Deber et al. 2007) or place a higher value on empowering behaviours than older patients. Patients from a lower socioeconomic status (SES) and non-Caucasian patients may have lower perceptions of patient-empowering nurse behaviours because of feelings of powerlessness and lower levels of education (Ross & Mirowsky 2002, Lubet- kin et al. 2010) and trust (Halbert et al. 2006). The amount of time since diagnosis of a long-term illness may have an impact on a patient’s ability to perceive or be receptive to empowering behaviours, as some patients may experience disarray closer to time of diagnosis, but over time may successfully incorporate their long-term illness into their lives (Kralik 2002, Aujoulat et al. 2007). Lastly, a longer length of stay may affect patient perceptions of patient-empowering nurse behaviours through greater opportunity for interaction with the nursing staff.
Patients with life-threatening long-term illnesses, such as cancer and cardiac disease, frequently experience height- ened feelings of powerlessness following surgery (Taylor et al. 2010, Barnason et al. 2012). During the discharge transition, they are suddenly expected to take responsibil- ity for the management of a long-term illness while still experiencing the physical and psychological effects of surgery (Lapum et al. 2011) and a loss of control over their bodies and identities (McCorkle et al. 2011,
Okamoto et al. 2011). The transition from postsurgical hospitalization to self-management postdischarge is threa- tened by unmet discharge needs (McMurray et al. 2007) and decreased functional health status (Hodgson & Given 2004, Elliott et al. 2006). Postsurgical cancer and cardiac patients have high readmission rates secondary to inade- quate self-management ability (Slamowicz et al. 2008, Martin et al. 2011).