Article Critique
zaqingt
Jerofkeetal.2013.docxT. Jerofke et al.
T. Jerofke et al.
T. Jerofke et al.
ORIGINAL
RESEARCH
Patient perceptions of patient-empowering nurse behaviours, patient activation and functional health status in postsurgical patients with life-threatening long-term illnesses
Teresa Jerofke, Marianne Weiss & Olga Yakusheva
JAN: ORIGINAL RESEARCH Patient perceptions of patient-empowering nurse behaviours
T. Jerofke et al.
1310 © 2013 John Wiley & Sons Ltd
1312 © 2013 John Wiley & Sons Ltd
© 2013 John Wiley & Sons Ltd 1313
Accepted for publication 29 September 2013
Correspondence to T. Jerofke: e-mail: [email protected]
Teresa Jerofke PhD RN APNP-BC
Assistant Professor
College of Nursing, Marquette University,
Milwaukee, Wisconsin, USA
Marianne Weiss DNSc RN
Associate Professor
College of Nursing, Marquette University,
Milwaukee, Wisconsin, USA
Olga Yakusheva PhD
Associate Professor
Department of Economics, Marquette
University College of Business and Graduate
School of Management, Marquette
University, Milwaukee, Wisconsin, USA
JE ROFKE T . , WEISS M . & YAKUSHEVA O . ( 2014) Patient perceptions of patientempowering nurse behaviours, patient activation and functional health status in postsurgical patients with life-threatening long-term illnesses. Journal of Advanced Nursing 70(6), 1310–1322. doi: 10.1111/jan.12286
Abstract
Aim. 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).
|
|
|
|
Introduction 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 |
Background 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).
Theoretical framework
The design for this study was guided by an integrated model using two explanatory theories: Meleis’s Transitions Theory (Meleis et al. 2000) and The Individual and Family Self-Management Theory [IFSMT] (Ryan & Sawin 2009) to address the relationship between patient-empowering nurse behaviours and patients’ engagement in long-term ill- ness self-management. Transitions Theory provides a conceptualization of the trajectory experienced by patients with life-threatening long-term illnesses as they progress from surgical intervention to long-term illness management. In this trajectory, patients shift to self-management of their illness. Using the conceptual-theoretical-empirical structure format (Fawcett 1999), concepts of the two theories were represented as concepts relevant to study aims and operationalized as study variables (Table 1). The two theo- ries use different concept labels to denote the contextual patient and illness factors that influence the patient’s trajectory and both theories evaluate outcomes, referred to as patterns of response (Transitions Theory) and proximal outcomessign (IFSMT). Transitions Theory includes the concept of nursing therapeutics in promoting positive outcomes, while the IFSMT identifies the patient process components (knowledge and beliefs, self-regulation skills and abilities, social facilitation) towards which patient-empowering nursing behaviours can be targeted. The study concepts representing nursing therapeutics and self-management processes are operationalized in a measure of patient perceptions of patient-empowering nurse behaviours, with subscales addressing the self-management process compo- nents.
The study
Aim
The aim of this study was to explore the trajectory of associations between the nursing care process of patient empowerment during postsurgical hospitalization and postdischarge patient self-management outcomes, specifi- cally patient activation and functional health status. The following hypotheses were tested:
|
Table 1 Relationships of Meleis’ Transitions Theory* and the Individual and Family Self-Management Theory† to Study Variables and Measures.
Meleis’
transitions
theory
concepts
Nature of
the transition
Transition conditions
Nursing therapeutics
Patterns
of response
Risk &
Protective
Context
Factors
Process of Self - Management
|
*Meleis et al. 2000, Schumacher and Meleis (1994).
†Ryan and Sawin (2009).
‡Hibbard et al. (2005). § Ware (n.d.).
· Patient characteristics and illness factors will have significant associations with patient perceptions of patient-empowering nurse behaviours; • Patient characteristics, illness factors and patient perceptions of patient-empowering nurse behaviours will have significant associations with 6-week postdis- charge patient activation; and
· Patient characteristics, illness factors, patient perceptions of patient-empowering nurse behaviours and 6-week postdischarge patient activation will have significant associations with functional health status (physical and mental) 6 weeks postdischarge.
Design
A non-experimental, prospective, correlational design was used in this study. Patient characteristics, illness factors and patient perceptions of patient-empowering nurse behaviours were measured during the postsurgical hospitalization. Patient activation and functional health status were measured 6 weeks following hospital discharge through a telephone interview. Six weeks postdischarge marks a transitional period from postoperative recovery to living with and managing a life-threatening long-term illness (Tay- lor et al. 2010), making it an appropriate time to measure patient activation and functional health status.
Sample
The target sample was postsurgical patients with life-threaten- ing long-term illnesses. The study was conducted on two surgi- cal units at a Magnet-designated academic medical centre in the Midwestern USA: one unit cares for cardiac surgical patients, including those having surgery for coronary, congeni- tal or valvular heart disease and one unit cares for surgical oncology patients, including those having surgery for gastroin- testinal and lung cancers. While cancer and cardiac patients experience different treatments and disease courses, they share the experience of transition from surgical intervention to long- term illness self-management, the focus of this study.
An a priori power analysis using G*Power 3 (Faul et al.
2010) estimated the required sample size of 114 partici-
pants for a multiple linear regression model (hypothesis 3) with a fixed effect for diagnosis, power of 0-8, a medium effect size (f2 = 0-15), an alpha of 0-05 and eight predic- tors. Oversampling due to an estimated attrition rate of 30% gave a target enrolled sample size of 163.
A convenience sample was selected using the following inclusion criteria: (1) at least 18 years of age; (2) able to speak and read English; (3) had surgery during the present hospitalization for a cancer or cardiac diagnosis; (4) stayed at least 2 nights in the hospital; and (5) had telephone availabil- ity for postdischarge data collection. Patients who were enrolled in palliative or hospice care, had a documented cog- nitive deficit or developmental delay or were discharged to a rehabilitation facility were excluded from this study. All eligi- ble patients present in the units during selected days for data collection were approached for participation.
A total of 250 patients were screened, 179 patients were eligible and 164 consented. Of the 164 patients, 144 com- pleted all the pre-discharge measures and 127 completed the 6-week discharge interview. The 17 patients lost to fol- lowup did not differ from the rest of the sample on patient characteristics and illness factors. Consistent with PAM-13 scoring recommendations, fourteen patients who answered ‘strongly agree’ for every item were excluded from the final sample. The excluded patients also did not significantly differ from the remaining sample on patient characteristics and illness factors. The final sample had 113 patients.
Measures
Patient characteristics and illness factors
Patient characteristics (age, socioeconomic status [SES], race, pre-discharge patient activation) were collected from patients at the time of enrolment, usually the day before discharge. SES was calculated using Hollingshead 4-Factor Index of Social Status (Hollingshead 1975). Pre-discharge patient activation was measured with the PAM-13 (described below). Illness factors were collected directly from the patient (time since initial diagnosis) and from medi- cal records (length of stay and diagnosis). Additional patient characteristics (gender, education level, marital status, living alone and prior hospitalizations for the same diagnosis) and illness factors (stage of cancer or heart failure, surgical procedure) were collected for sample description.
Patient perceptions of patient-empowering nurse behaviours Patient perceptions of patient-empowering nurse behaviours were measured with the Patient Perceptions of PatientEmpowering Nurse Behaviors Scale (PPPNBS). The
PPPNBS was developed based on a concept analysis of empowerment (Jerofke 2013) and patient empowerment model of Laschinger et al. (2010), supporting its content validity. After review by five experts, the final 45-item scale consisted of seven subscales: (1) Initiation (five items); (2) Access to Information (seven items); (3) Access to Support (10 items); (4) Access to Resources (six items); (5) Access to Opportunities to Learn and Grow (five items); (6) Infor- mal Power (5 items); and (7) Formal Power (seven items). Items were rated by patients on an 11-point Likert scale, with 0 meaning ‘not at all’–10 meaning ‘a great deal’, higher scores indicating more positive perceptions of patient-empowering nurse behaviours.
Patient activation
Pre-discharge and 6-week postdischarge patient activation was measured with the 13-item Patient Activation Measure (PAM-13). Originally consisting of 22 items, the PAM-13 measures patients’ self-reported knowledge, skill and confi- dence for self-management of their health or long-term ill- ness (Hibbard et al. 2004). Scores on the PAM-13 account for 92% of the variance in the 22-item instrument (Hibbard et al. 2005). The PAM-13 can be used with a wide array of patients. Items are scored on a 4-point scale (1 = strongly disagree, 4 = strongly agree). Patients are assigned a total raw score ranging from 13–52, which is recalibrated to an activation score of 0–100, with higher scores indicating higher activation. The calibrated activation score can also be categorized into four levels of patient activation: (1) level 1: does not yet believe active participation in self-man- agement is important; (2) level 2: lacks confidence and knowledge necessary to be an active participant; (3) level 3: begins to take action, but may lack confidence or skills nec- essary to support active participation; (4) level 4: has adopted new behaviours, but has difficulty maintaining behaviours during times of stress (Hibbard et al. 2007).
Functional health status
The SF-36 was used to measure functional health status. The SF-36 consists of 36 items, eight subscales and two summary measures. The items of the SF-36 ask individuals to recall their experiences over the prior 4 weeks. The men- tal component summary measure (MCS) includes vitality, social functioning, role-emotional and mental health sub- scales; the physical component summary measure (PCS) includes physical functioning, role-physical, bodily pain and general health subscales (Ware & Sherbourne 1992). MCS and PCS raw scores are transformed to a standardized scale (mean 50, SD 10). The MCS and PCS measures were used in analyses as a measure of mental and physical functional health status. The SF-36 has demonstrated its ability to detect group differences in both physical and mental health status (Ware et al. 1994).
Validity/reliability
In this study, Cronbach’s alpha reliability estimate for pre-discharge PAM-13 was 0-85 and for 6-week
postdischarge PAM-13 was 0-87; Cronbach’s alpha reliabil- ity estimates for the subscales comprising the MCS measure were between 0-77–0-89 and for the PCS measure were between 0-79–0-91.
Data collection
Data were collected between August 2012–February 2013. Informed consent was obtained prior to the day of discharge, at which time the contact information form, enrolment form and pre-discharge PAM-13 were completed. The PPPNBS was placed in patients’ charts and was given to patients by either their nurse or the research staff within 4 hours before discharge. The PPPNBS was returned in a sealed envelope. If patients were discharged without com- pleting the PPPNBS, they were contacted by the research staff within 2 days of their discharge and the PPPNBS was completed over the telephone. Six patients’ (5-3%) data were obtained by this mechanism. Six weeks following dis- charge, patients were contacted for a telephone interview, at which time the postdischarge PAM-13 and SF-36 (MCS and PCS) were completed.
Ethical considerations
Institutional Review Board (corr) approval was obtained from university and hospital institutional review boards.
Data analysis
Analyses were conducted using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA) and Stata version 11.0 (StataCorp 2009a). Variables used in analyses were checked for nor- mality using graphs and extreme outliers were winsorized (Tabachnick & Fidell 2007) to the next highest or lowest number. Missing data on the PPPNBS and PAM-13 were mean substituted if more than 70% of item responses were completed. Descriptive statistics were calculated for sample description and for patient characteristics, illness factors, PPPNBS, PAM-13, MCS and PCS.
Predictors of PPPNBS, postdischarge PAM-13 and SF-36 (MCS and PCS) were analysed by two separate systems of three simultaneous multiple linear regression equations. This estimation model allowed for testing of direct and indirect relationships among variables that appear in more than one equation, while adjusting the estimates for corre- lated standard errors among the equations (Davidson & MacKinnon 1993). To reflect the sequential nature of the relationships, outcome variables in one equation became predictor variables in the subsequent equation, while accounting for the presence of all other variables. This approach allowed the researcher to evaluate the indepen- dent contribution of each predictor to the outcome (Stata- Corp 2009b). A significance level of P < 0-05 was used for all analyses. All equations were calculated with robust stan- dard errors and fixed effect for diagnosis (which also con- trolled for nursing unit). Because of the broad range of time since diagnosis, a fixed effect for new diagnosis (diagnosed less than 1 year prior) was included.
In the first equation of the first system, PPPNBS total score was the explanatory variable and patient character- istics (age, SES, race, pre-discharge PAM-13) and illness factors (days since initial diagnosis, type of illness and length of stay) were the predictors (equation 1, hypothe- sis 1). In equation 2 (hypothesis 2), 6-week postdischarge PAM-13 was the explanatory variable and PPPNBS total score was added to the predictors from equation 1. In equation 3 (hypothesis 3), MCS was the explanatory vari- able and patient characteristics, illness factors, PPPNBS total score and postdischarge PAM-13 were the predictor variables. In the second system of equations, PCS replaced MCS (equation 4; hypothesis 3) as the explana- tory variable and the predictor variables remained the same.
Results
Description of the sample
Characteristics of the sample are presented in Table 2. The 113 patients used in analyses included 50 females (44%) and 63 males (56%). The sample included a range of ages
|
Age Socioeconomic Status* Race White African American Asian Hispanic Other Total pre-discharge PAM-13 Illness Factors Time Since Initial Diagnosis 0–60 days 61–180 days 181–365 days >365 days Length of Stay (days) Type of Illness Cancer Cardiac Disease Additional Sample Descriptors Level of pre-discharge PAM-13 One Two Three Four Stage of Cardiac Disease† I II III IV Stage of Cancer‡ |
95 10 1 3 4 27 38 13 35 86 27 6 13 30 64 6 16 4 1 |
84-1 8-8 0-9 2-7 3-5 23-9 33-6 11-5 31-0 76-1 23-9 5-3 11-5 26-5 56-6 22-2 39-3 14-8 3- 7 |
57-6 44-6 68-0 6-5 |
12-7 13-7 12-5 3-3 |
|
I |
12 |
14-0 |
|
|
|
II |
21 |
24-4 |
|
|
|
III |
16 |
18-6 |
|
|
|
IV |
37 |
43-0 |
|
|
|
Number of comorbidities Gender |
|
|
2-1 |
1-7 |
|
Male |
63 |
55-8 |
|
|
|
Female |
50 |
44-2 |
|
|
|
Highest Completed Level of Education |
|
|
|
|
|
<High school 3 |
2-7 |
|
|
|
|
High school 25 |
22-1 |
|
|
Table 2 Sample Characteristics (N = 113).
Patient
demographics
N
%
Mean
SD
Table 2 (Continued).
Patient demographics N % Mean SD
Prior hospitalization for same diagnosis
No 72 63-7
Yes 41 36-3
*Hollingshead (1975) 4-Factor Index of Social Status. †NYHA Heart Failure Classification System (American Heart Association 2013).
‡AJCC 7th edition (Edge et al. 2010).
from 24–87, with a mean age of 57-6 (SD 12-7). Seventy- one per cent of patients were married and 12% lived alone. The Hollingshead 4-Factor Index of Social Status mean score (SES) was greater than the scale’s median value of 37, with 45% of the sample reporting that they were college graduates. The sample was primarily Caucasian (84%) with 9% being African American. Eighty-three per cent of the sample reported a pre-discharge patient activation level cat- egorized as level 3 or level 4. There were 27 cardiac (24%) and 86 (76%) people with cancer in the study, each hospi- talized on their respective units.
Time since initial diagnosis (in years) was significantly higher for cardiac patients than for people with cancer (t (26-72) = 3-03, P = 0-005); however, time since initial diagnosis was not a significant predictor in any of the equa- tions. Cardiac and people with cancer did not differ signifi- cantly by age, SES, race, pre-discharge PAM-13, LOS and illness type.
Patients reported high perceptions of patient-empowering nurse behaviours, with a mean PPPNBS total score of 381-5 (SD 59-6, range 134–450) and item mean of 8-5 (SD 2-0) out of 10. Patients’ 6-week postdischarge PAM-13 scores were skewed towards higher activation (mean = 68-8, SD 12-5, Range 41-7–91-6), with the majority of patients reporting level 4 activation (56%). Three per cent of patients were in level 1, 12% in level 2 and 29% in level 3. Both MCS
(mean = 49-8, SD 9-6, Range 20-2–66-0) and PCS
(mean = 41-7, SD 8-8, Range 20-6–62-8) measures were
Some College (at least 1 year) 34 30-1 /Specialized Training
|
College Graduate |
28 |
24-8 |
|
Graduate Degree Marital Status |
23 |
20-4 |
|
Married |
80 |
70-8 |
|
Single |
17 |
15-0 |
|
Divorced |
8 |
7-1 |
|
Other Live alone |
8 |
7-1 |
|
No |
100 |
88-5 |
|
Yes |
13 |
11-5 |
below the general population norm (mean = 50-0) (Ware
n.d.). There was not a significant change (t(112) = -0-60, P = 0-55) between pre-discharge PAM-13 (mean = 68-0, SD 12-5) and 6-week postdischarge PAM-13 (mean = 68-8, SD 12-5) for the total sample, but there was a significant increase between pre-discharge PAM-13 (mean = 55-9, SD 7-1) and 6-week postdischarge PAM-13 (mean = 63-5, SD
12-2) in those patients in levels 1–3 at baseline (t(48) = 4-63, P < 0-001). Seventy per cent of patients who were in level 4 of patient activation pre-discharge remained in level 4, 6 weeks postdischarge.
B SE Lower Upper P > z B SE Lower Upper P > z
95
%
CI
95
%
CI
|
6- Week Postdischarge PAM-13 PPPNBS |
|
|
|
|
|
0-04 |
0-02 |
0-01 |
0-08 |
0-02 |
|
Race |
14-88 |
14-99 |
-14-50 |
44-27 |
0-32 |
6-82 |
3-05 |
0-83 |
12-80 |
0-03 |
|
Pre-discharge PAM-13 |
0-88 |
0-47 |
-0-04 |
1-80 |
0-06 |
0-42 |
0-09 |
0-24 |
0-59 |
<0-01 |
|
LOS |
0-08 |
1-54 |
-2-94 |
3-11 |
0-96 |
-0-24 |
0-24 |
-0-71 |
0-23 |
0-31 |
|
R2 |
0-10 |
|
|
|
|
0-31 |
|
|
|
|
|
|
Equation 3 MCS |
|
|
|
Equation 4 PCS |
|
|
|
95% CI 95% CI
|
Predictors of PPPNBS, PAM-13 and SF-36 The results of the simultaneous equation models (equations [1–4]) are presented in Table 3. Patient characteristics and illness factors were not significant predictors of PPPNBS (equation 1; hypothesis 1). Patient characteristics, illness fac- tors and PPPNBS explained 30-6% of 6-week postdischarge PAM-13 variance (equation 2; hypothesis 2). Race, pre-dis- charge PAM-13 and PPPNBS were significantly associated with 6-week postdischarge PAM-13. A one point increase on the PPPNBS (scale range of 450 points) was associated with a 0-04 (P = 0-02) point increase on the 6-week postdis- charge PAM-13 and Caucasian patients scored, on average, 6-8 points higher (P = 0-03) on the 6-week postdischarge PAM-13 than non-Caucasian patients. Patients’ pre-dis- charge PAM-13 was significantly associated with their 6- week postdischarge PAM-13 (B = 0-42, P < 0-001). Patient characteristics, illness factors, PPPNBS and 6week postdischarge PAM-13 explained 27% of the variance in MCS (equation 3; hypothesis 3). A one point increase on the 6-week postdischarge PAM-13 (scale range
Table 3 Results for Simultaneous Equation Estimation (n = 113).
|
of 100 points) was directly associated with a 0-27 point (P < 0-001) increase on the MCS measure. Patient charac- teristics, PPPNBS and 6-week postdischarge PAM-13 were not significant predictors of PCS (equation 4; hypothesis 3). Only length of stay was a significant predictor of PCS. Each 1 day increase in length of stay was associated with a 0-54 point (P = 0-02) decrease in the PCS measure.
Discussion The results of this study provide preliminary evidence of a path of association from patient perceptions of patient- empowering nurse behaviours during acute care hospitaliza- tion to patient activation at 6 weeks postdischarge to the mental component of functional health status. These find- ings are consistent with previous studies, which have dem- onstrated a significant association between the method in which nursing care is delivered during hospitalization and patient outcomes after discharge (Suhonen et al. 2007, Weiss et al. 2007). |
|
Equation 1 PPPNBS |
Equation 2 6-week Postdischarge PAM-13 |
P>z P>z
B
SE
Lower
Upper
B
SE
Lower
Upper
|
6-Week Postdischarge PAM-13 PPPNBS Race Pre-discharge PAM-13 LOS R2 |
0-27 0-00 0-27 0-10 0-03 0-27 |
0-08 0-02 2-45 0-08 0-27 |
0-11 -0-03 -4-52 -0-05 -0-49 |
0-43 0-03 5-07 0-25 0-56 |
<0-01 0-96 0-91 0-19 0-90 |
0-11 -0-01 1-84 0-06 -0-54 0-15 |
0-08 0-02 2-25 0-08 0-24 |
-0-04 -0-04 -2-56 -0-10 -1-00 |
0-27 0-02 6-25 0-23 -0-07 |
0-16 0-42 0-41 0-46 0-02 |
The model was estimated using the simultaneous equations method with robust standard errors. Estimates are from linear regressions. Only significant predictors are displayed. All equations also included controls for age, socioeconomic status, type of illness [cancer, cardiac], time since initial diagnosis [in days] and new diagnosis [yes/no].
PPPNBS, Patient Perceptions of Patient-Empowering Nurse Behaviors Scale; PAM-13, 13-item Patient Activation Measure; MCS, Mental Component Summary Measure; PCS, Physical Component Summary Measure. Bolded values represent significant predictors in the model.
Controlling for level of patient activation prior to dis- charge, patient-empowering nurse behaviours were signifi- cantly associated with postdischarge patient activation levels. Although the coefficient was small, we believe that these findings provide support for the contribution of patient-empowering nurse behaviours to patient participa- tion in self-management behaviours during a stressful transition period following a surgical procedure for a lifethreatening long-term illness. While the PAM-13 was not used to measure self-management directly in this study, it was used as a precursor to engagement in self-manage- ment behaviours, as knowledge, skill and confidence are necessary components in the process of patient self-manage- ment. The findings in this study are consistent with previous studies, which have shown improved knowledge, confidence, ability to self-manage, autonomy, self-capacity building and purposeful participation in patients exposed to interventions incorporating an empowering approach (Munn 2010). Future studies should focus on tailoring patient-empowering nurse behaviours to baseline patient activation levels, as previous studies have demonstrated that tailored interventions improve patient activation levels and engagement in self-management behaviours in patients with long-term illness (Ryan & Lauver 2002, Hibbard et al. 2009, Shively et al. 2013).
There have been numerous studies that have found significant positive associations between confidence levels in self-management and functional health status in individuals with a long-term illness (Weng et al. 2010, Yoo et al. 2011) and between patient activation levels, mental func- tional health status (Green et al. 2010) and depressive symptoms (Hibbard et al. 2007, Skolasky et al. 2008). While there was a significant positive association between 6week postdischarge patient activation level and mental functional health status in this study, both outcome mea- sures were collected at the same time. Future studies should measure functional health status and postdischarge patient activation at different time points to validate the sequential nature of the influence of patient activation on functional health status or vice versa.
Interestingly, patient perceptions of patient-empowering nurse behaviours and patient activation were not significant predictors of physical functional health status. Factors such as activity restrictions and pain following surgery may have had an impact on a patient’s PCS measure (Hodgson & Given 2004). The SF-36 measure asked patients to recall their general health over the last 4 weeks. Previous studies that have shown a positive association between patient activation levels and physical functional health status were conducted with medical patients who did not have the same restrictions and pain as postsurgical patients (Hibbard et al. 2007, Green et al. 2010). In future studies, increasing the measurement interval to allow for recovery from surgery and the 4-week recall period used in the SF-36, or measuring a baseline physical functional health status before the surgery, may produce a more accurate assess- ment of physical functional health status after discharge.
The patients in this study had high patient activation levels, with 57% of the sample being in level 4 at baseline and 56% being in level 4, 6 weeks postdischarge, whereas previous studies found that between 17-2% and 41-4% were in level 4 (Hibbard & Cunningham 2008, Skolasky et al. 2011b, Shively et al. 2013). Patients were predomi- nantly Caucasian and well educated, factors that have been associated with higher patient activation levels in previous studies (Hibbard et al. 2005, 2008, Alegria et al. 2008, Lubetkin et al. 2010). Replicating this study in individuals with lower baseline activation may generate different results, given that pre-discharge activation level was a significant predictor of 6-week postdischarge activation.
Meleis’ Transitions Theory and the IFSMT provided useful theoretical frameworks to evaluate the relationships between patient perceptions of patient-empowering nurse behaviours, patient activation and functional health status (Meleis et al. 2000, Ryan & Sawin 2009). The study find- ings supported the proposition by Meleis et al. (2000) that nursing therapeutics, represented by patient-empowering nurse behaviours, can have an impact on patterns of response, measured as 6-week postdischarge patient activation and functional health status. Conceptualizing nursing therapeutics from the perspective of the patient’s experience, with empowering nursing behaviours targeted towards three process domains of self-management theory (Ryan & Sawin 2009), provided a mechanism for integrating patient-centred care concepts into the study model. The notion that transition is a process over time was evident in the improvements in patient activation and mental functional health status as early postsurgical outcomes. The lack of concurrent measurable improvement in physical functional status may indicate that, in this patient population, physical functional status improvements may be later outcomes.
Strengths and limitations
Strengths of this study include linking nursing behaviours during hospitalization with patient outcomes following discharge using a theory-guided approach. Examining the experience of two different patient types captured a broad range of postsurgical experiences. Using simultaneous equation modelling to test the complete sequential path of influence from nurse behaviours during hospitalization to patient activation and to functional health status 6-weeks postdischarge, in a prospective design, was also a significant methodological strength.
There were limitations in the design. This study was conducted at one academic Magnet-designated hospital in the USA. This designation recognizes exemplary nursing practice, strong leadership and empowered professionals (American Nurses Credentialing Center (ANCC) 2011). The study sample was a convenience sample of predominantly Caucasian participants and was heterogeneous in inclusion of cancer and cardiac patients with numerous diagnoses of varying severities. The sample was not of adequate size for subgroup analyses by diagnosis or severity. The follow-up period was 6 weeks in duration, which represented a point in time related to surgical recovery, but not the completion of transition to long-term illness management. Replication at other sites using a random, cohort or stratified sampling approach is recommended for future studies to achieve a more representative sample. Lengthening the follow-up period in future studies would allow the researchers to mea- sure more distal outcomes.
The process of patient empowerment was measured with the PPPNBS, a patient-reported measure of nursing behaviours. The instrument asked patients to recall the patient-empowering behaviours of the nursing staff, so that the unique contribution of nursing care to patient activation and functional health status could be determined. Difficulty differentiating nurses from other health care providers or focusing on one nurse who may have been particularly empowering or disempowering, may have influenced patient responses. The PPPNBS has demonstrated acceptable reli- ability and validity in pilot testing and in this study; how- ever, it should be subjected to comprehensive testing with other patient populations, including non-surgical patients.
In this non-intervention study, PPPNBS was measured in the context of usual care practices. Future studies should include both direct measures of deliberate use of patient- empowering nurse behaviours by nurses as well as patient perceptions. Patient perceptions of nurse behaviours are an important patient-reported outcome measure of patient experience and are consistent with healthcare priorities for improving patient-centred care.
The outcome variables used in the analysis were nega- tively skewed and normality was not achieved using loga- rithmic and square root transformations. The simultaneous equation modelling proceeded using robust standard errors with recognition of the need for cautious interpretation in the presence of violation of the normality assumption. In addition, patient activation and functional health status were not measured prior to the hospitalization or exposure to patient-empowering nurse behaviours; therefore, the impact of the surgery and patient-empowering nurse behav- iours on change in patient activation and functional health status was not known. Overall, this study looked at associ- ations between variables and not causality. While some other known factors that have an impact on the outcome variables are included in the modelling of associations, all competing explanations were not fully specified in the model and further research will be needed to explore the relationships in more depth.
Conclusion
Examining the relationship of patient reports of patientempowering nurse behaviours with patient activa- tion and functional health status 6-weeks postdischarge provides further quantitative evidence supporting the relationship between quality nursing care and postdischarge patient outcomes. Patient empowerment is an important concept to nursing because nurses are responsible for discharge preparation and ensuring that patients have the skills and knowledge they need before discharge to navigate their way through their transition from hospital to home (Foust 2007, Weiss et al. 2007, Nosbusch et al. 2011). Patient empowerment should be practised not only in out- patient settings but also in inpatient settings, as postsurgical patients with life-threatening long-term illnesses demon- strated that they are receptive to patient-empowering nurse behaviours.
Nurses should be educated about the importance of being intentional in their methods of delivering care to postsurgi- cal patients through patient-empowering nurse behaviours with the goal of promoting patient activation. Nurses should not only provide education about long-term illness self-management but also encourage patients to be active participants in their care, while offering them access to information, support, resources, opportunities to build on prior knowledge and skills, helping them to establish collaboration with other providers and family or friends and giving them flexibility and autonomy in decision-mak- ing. Patient-empowering nurse behaviours can be used to facilitate engagement in self-management behaviour, improve functional health status and ultimately improve the cost of long-term illness care through improved patient activation. Measuring patient activation level at admission should be considered as a method to assist in tailoring patient-empowering nurse behaviours to patients’ baseline knowledge, skill and confidence in self-management, to sig-
nificantly have an impact on patient activation, engagement in self-management behaviours, functional health status and healthcare use following hospital discharge.
Acknowledgements
The authors sincerely thank Beth Showalter, BSN, for her assistance with gathering and entering the data, and Polly Ryan, PhD, RN, Kathleen Bobay, PhD, RN, and Jessica Pruszynski, PhD, for their insightful review and critique.
Funding
This research was funded through a small grant from Sigma Theta Tau International.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the IC- MJE (http://www.icmje.org/ethical_1author.html)]: • substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;
• drafting the article or revising it critically for important intellectual content.
References
Alegria M., Polo A., Gao S., Santana L., Rothstein D., Jimenez
A., Hunter M.L., Mendieta F., Oddo V. & Normand S. (2008) Evaluation of a patient activation and empowerment intervention in mental health care. Medical Care 46(3), 247– 256.
American Heart Association (2013) Classes of Heart Failure. Retrieved from http://www.heart.org/HEARTORG/Conditions/ HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_ 306328_Article.jsp on 24 February 2013.
American Nurses Credentialing Center (ANCC) (2011) Magnet Recognition Program Model. Retrieved from http://www. nursecredentialing.org/Magnet/ProgramOverview/New-Magnet- Model.aspx on 20 February 2013.
Aujoulat I., Luminet O. & Deccache A. (2007) The perspective of patients on their experience of powerlessness. Qualitative Health Research 17(6), 772–785.
Australian Commission on Safety and Quality in Healthcare (2010) Patient-Centred Care: Improving Quality and Safety by Focusing Care on patients and Consumers Discussion Paper. Department of Health and Ageing, Sydney.
Bakitas M., Lyons K.D., Hegel M.T., Balan S., Brokaw F.D., Seville J., Hull J.G., Li Z., Tosteson T.D., Byock I.R. & Ahles T.A. (2009) Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The project ENABLE II randomized control trial. Journal of American Medical Association 302(7), 741–749.
Barnason S., Zimmerman L., Nieveen J., Schulz P. & Young L. (2012) Patient recovery and transitions after hospitalizastion for acute cardiac events: an integrative review. Journal of Cardiovascular Nursing 27(2), 175–191.
Bupa (2011) Realising the Potential of Patient Empowerment for Tackling Chronic Disease. Retrieved from http://www.bupa.com/ media/289194/realising_the_potential_of_patient_empowerment_-_ final.pdf on 20 January 2013.
Chen Y. & Li I. (2009) Effectiveness of interventions using empowerment concept for patients with chronic disease: a systematic review. JBI Library of Systematic Reviews 7(27),
1177–1232.
Davidson R. & MacKinnon J.G. (1993) Estimation and Inference in Econometrics. Oxford University Press, USA.
Deber R.B., Kraetschmer N., Urowitz S. & Sharpe N. (2007) Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expectations 10(3), 248–258.
Doran D.M. (2011) Functional status. In Nursing Outcomes: The State of The Science (Doran D.M., ed.), Jones & Bartlett Learning, Sudbury, MA, pp. 29–78.
Edge S.B., Byrd D.R., Compton C.C., Fritz A.G. & Greene F.L., eds. (2010) AJCC Cancer Staging Manual, 7th edn. Springer, New York, NY.
Elliott D., Lazarus R. & Leeder S.R. (2006) Health outcomes of patients undergoing cardiac surgery: repeated measures using Short-Form 36 and 15 Dimensions of Quality of Life questionnaire. Heart and Lung 35(4), 245–251.
Faul F., Erdfelder E., Lang A. & Buchner A. (2010) G*Power 3.0 [Software]. Retrieved from http://www.psycho.uni - duesseldorf.de/ abteilungen/aap/gpower3 on 15 March 2013.
Fawcett J. (1999) The Relationship of Theory and Research, 3rd edn. F.A. David Company, Philadelphia, PA.
Foust J.B. (2007) Discharge planning as part of daily nursing practice. Applied Nursing Research 20(2), 72–77.
Green C.A., Perrin N.A., Polen M.R., Leo M.C., Hibbard J.H. & Tusler M. (2010) Development of the Patient Activation Measure for mental health (PAM-MH). Adminstration & Policy in Mental Health & Mental Health Services Research 37(4),
327–333.
Halbert C.H., Armstrong K., Gandy O.H. & Shaker L. (2006) Racial differences in trust in health care providers. Archives of Internal Medicine 166, 896–901.
Herbert R.J., Gagnon A.J., Rennick J.E. & O’Loughlin J.L. (2009) A systematic review of questionnaires measuring health-related empowerment. Research and Theory for Nursing Practice 23(2),
107–132.
Hibbard J.H. & Cunningham P.J. (2008) How Engaged are
|
© 2013 John Wiley & Sons Ltd 1321 |
Consumers in Their Health and Healthcare and Why Does It Matter? Center for the Study of Health System Change Research Brief. Washington, DC. Retrieved from http://www.hschange. com/CONTENT/1019/ on 10 January 2013.
Hibbard J.H. & Greene J. (2013) What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Affairs 32(2), 207–214.
Hibbard J.H., Stockard J., Mahoney E.R. & Tusler M. (2004) Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Services Research 39(4 Part 1), 1005–1026.
Hibbard J.H., Mahoney E.R., Stockard J. & Tusler M. (2005) Development and testing of a short form of the patient activation measure. Health Services Research 40(6 Part 1), 1918–1930.
Hibbard J.H., Mahoney E.R., Stock R. & Tusler M. (2007) Do increases in patient activation result in improved self-management behaviors? Health Services Research 42(4), 1443–1463.
Hibbard J.H., Greene J., Becker E.R., Roblin D., Painter M.W., Perez D.J., Burbank-Schmitt E. & Tusler M. (2008) Racial/ethnic disparities and consumer activation in health. Health Affairs 27 (5), 1442–1453.
Hibbard J.H., Greene J. & Tusler M. (2009) Improving the outcomes of disease management by tailoring care to the patient’s level of activation. The American Journal of Managed Care 15(6), 353–360.
Hibbard J.H., Greene J. & Overton V. (2013) Patients with lower activation associated with higher costs; delivery systems should know their patients’ scores. Health Affairs 32(2), 216–222.
Hodgson N.A. & Given C.W. (2004) Determinants of functional recovery in older adults surgically treated for cancer. Cancer Nursing 27, 10–16.
Hollingshead A.B. (1975) Four Factor Index of Social Status. Yale
University, New Haven, CT.
Jerofke T.A. (2013) Concept analysis of empowerment from survivor and nurse perspectives within the context of cancer survivorship. Research and Theory for Nursing Practice 27(3),
157–172.
Kralik D. (2002) The quest for ordinariness: transition experienced by midlife women living with chronic illness. Journal of Advanced Nursing 39(2), 146–154.
Kralik D., Koch T., Price K. & Howard N. (2004) Chronic illness self-management, taking action to create order. Journal of Clinical Nursing 13(2), 259–267.
Lapum J., Angus J.E., Peter E. & Watt-Watson J. (2011) Patients’ discharge experiences: returning home after open-heart surgery. Heart and Lung 40(3), 226–235. doi:10.1016/j.hrtlng.2010.01.
001.
Laschinger H.K., Gilbert S., Smith L.M. & Leslie K. (2010) Towards a comprehensive theory of nurse/patient empowerment: applying Kanter’s empowerment theory to patient care. Journal of Nursing Management 18(1), 4–13. doi:10.1111/j.1365-2834. 2009.01046.x.
Lubetkin E.I., Lu W. & Gold M.R. (2010) Levels and correlates of patient activation in health center settings: building strategies for improving health outcomes. Journal of Health Care for the Poor and Underserved 21, 796–808.
Martin R.C., Brown R., Puffer L., Block S., Callender G., Quillo A., Scoggins C.R. & McMasters K.M. (2011) Readmission rates after abdominal surgery: the role of surgeon, primary caregiver, home health and subacute rehab. Annals of Surgery 254(4), 591–597.
McCorkle R., Ercolano E., Lazenby M., Schulman-Green D., Schilling L.S., Lorig K. & Wagner E.H. (2011) Self-management: enabling and empowering patients living with cancer as a chronic illness. CA: A Cancer Journal for Clinicians 61(1), 50–62. doi:10.
3322/caac.20093.
McMurray A., Johnson P., Wallis M., Patterson E. & Griffiths S. (2007) General surgical patients’ perspectives of the adequacy and appropriateness of discharge planning to facilitate health decision- making at home. Journal of Clinical Nursing 16(9), 1602–1609.
Meleis A.I., Sawyer L.M., Im E., Messias D.K.H. & Schumacher K. (2000) Experiencing transitions: an emerging middle-range theory. Advances in Nursing Science 23(1), 12–28.
Melnyk B.M. & Feinstein N.F. (2009) Reducing hospital expenditures with the COPE (Creating Opportunities for Parent Empowerment) program for parents and premature infants: an analysis of direct healthcare neonatal intensive care unit costs and savings. Nursing Administration Quarterly 33(1), 32–37.
Mosen D.M., Schmittdiel J., Hibbard J., Sobel D., Remmers C. & Bellows J. (2007) Is patient activation associated with outcomes of care for adults with chronic conditions? Journal of Ambulatory Care Management 30(1), 21–29.
Munn Z. (2010) Effectiveness of interventions using empowerment concept for patients with chronic disease: a systematic review. Journal of Advanced Nursing 66(7), 1446–1447. doi:10.1111/j. 1365-2648.2010.5346.x.
National Health Service (n.d.) The Expert Patients Programme. Retrieved from http://www.nhs.uk/NHSEngland/AboutNHSservi ces/doctors/Pages/expert-patients-programme.aspx on 20 February 2013.
Nosbusch J.M., Weiss M.E. & Bobay K.L. (2011) An integrated review of the literature on challenges confronting the acute care staff nurse in discharge planning. Journal of Clinical Nursing 20
(5/6), 754–774. doi:10.1111/j.1365-2702.2010.03257.x.
Okamoto I., Wright D. & Foster C. (2011) Impact of cancer on everyday life: a systematic appraisal of the research evidence. Health Expectations 15, 97–111.
Patient-Centered Outcomes Research Institute (PCORI) (2012) National Priorities for Research and Research Agenda. Retrieved from http://www.pcori.org/assets/PCORI - National - Priorities - and - Research-Agenda-2012-05-21-FINAL.pdf on 10 February 2013.
Remmers C., Hibbard J., Mosen D.M., Wagenfield M., Hoye R.E. & Jones C. (2009) Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? Journal of Ambulatory Care Management 32(4), 320–
327. doi:10.1097/JAC.0b013e3181ba6e77.
Ross C.E. & Mirowsky J. (2002) Age and the gender gap in the sense of personal control. Social Psychology Quarterly 65(2),
125–145.
Ryan R. & Lauver D.R. (2002) The efficacy of tailored interventions. Journal of Nursing Scholarship 34(4), 331–337.
Ryan P. & Sawin K.J. (2009) The Individual and Family Self- Management Theory: background and perspectives on context, process and outcomes. Nursing Outlook 57, 217–225.
Schumacher K.L. & Meleis A.I. (1994) Transitions: a central concept in nursing. Image: Journal of Nursing Scholarship 26(2),
119–127.
Shively M.J., Gardetto N.J., Kodiath M.F., Kelly A., Smith T.L.,
|
1320 © 2013 John Wiley & Sons Ltd |
Stepnowsky C., Maynard C. & Larson C.B. (2013) Effect of patient activation on self-management in patients with heart failure. Journal of Cardiovascular Nursing 28(1), 20–34.
Shmueli A. (1998) The SF-36 profile and health-related quality of life: an interpretative analysis. Quality of Life Research 7, 187– 195.
Skolasky R.K., Mackenzie E.J., Wegener S.T. & Riley L.H. (2008) Patient activation and adherence to physical therapy in persons undergoing spine surgery. Spine 33(21), E784–E791.
Skolasky R.L., Green A.F., Scharfstein D., Boult C., Reider L. & Wegener S.T. (2011a) Psychometric properties of the patient activation measure among multimorbid older adults. Health Services Research 46(2), 457–478. doi:10.1111/j.1475-6773. 2010.01210.x.
Skolasky R.L., Mackenzie E.J., Wegener S.T. & Riley L.H. (2011b) Patient activation and functional recovery in persons undergoing spine surgery. Journal of Bone and Joint Surgery
93, 1665–1671.
Slamowicz R., Erbas B., Sundararajan V. & Dharmage S. (2008) Predictors of readmission after elective coronary artery bypass graft surgery. Australian Health Review 32, 677–683.
Stanton A.L., Revenson T.A. & Tennen H. (2007) Health psychology: psychological adjustment to chronic disease. Annual Reviews in Psychology 58, 565–592.
StataCorp (2009a) Stata Statistical Software: Release 11. StataCorp
LP, College Station, TX.
StataCorp (2009b) Stata 11 Base Reference Manual. Stata Press, College Station, TX.
Suhonen R., Walimaki M., Katajisto J. & Leino-Kilpi H. (2007) Provision of individualized care improves hospital patient outcomes: an explanatory model using LISREL. International Journal of Nursing Studies 44, 197–207.
Suter P., Suter W.N. & Johnston D. (2011) Theory-based telehealth and patient empowerment. Population Health Management 14(2), 87–92. doi:10.1089/pop. 2010.0013.
Tabachnick B.G. & Fidell L.S. (2007) Using Multivariate Statistics, 5th edn. Pearson Education, Boston, MA.
Taylor C., Richardson A. & Cowley S. (2010) Restoring embodied control following surgical treatment for colorectal cancer: a longitudinal qualitative study. International Journal of Nursing Studies 47, 946–956.
Tu Y.-C., Wang R.-H. & Yeh S.-H. (2006) Relationship between perceived empowerment care and quality of life among elderly residents within nursing homes in Taiwan: a questionnaire survey. International Journal of Nursing Studies 43, 673–680.
Ware J.E. (n.d.) SF-36 Health Survey Update. Retrieved from http://www.sf36.org/tools/SF36.shtml on 20 February 2013.
Ware J.E. & Sherbourne C.D. (1992) The MOS 36-Item Short- Form Health Survey (SF-36): conceptual framework and item selection. Medical Care 30(6), 473–483.
Ware J.E., Kosinski M. & Keller S.D. (1994) SF-36 Physical and
Mental Health Summary Scales: A User’s Manual. The Health Institute, Boston, MA.
Weiss M.E., Piacentine L.B., Lokken L., Ancona J., Archer J., Gresser S., Holmes S.B., Toman S., Toy A. & Vega-Stromberg T. (2007) Perceived readiness for hospital discharge in adult medicalsurgical patients. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice 21(1), 31–42.
Weng L., Dai Y., Huang H. & Chiang Y. (2010) Self-efficacy, self- care behaviours and quality of life of kidney transplant recipients. Journal of Advanced Nursing 66(4), 828–838.
World Health Organization (2012) Noncommunicable Disease: Empowering Patients. Retrieved from http://www.euro.who.int/ en/what-we-do/health-topics/noncommunicable-diseases/sections/ news/2012/4/empowering-patients on 10 February 2013.
Yoo H., Kim C.J., Jang Y. & You M. (2011) Self-efficacy associated with self-management behaviours and health status of South Koreans with chronic diseases. International Journal of Nursing Practice 17, 599–606.
JAN: ORIGINAL RESEARCH Patient perceptions of patient-empowering nurse behaviours
JAN: ORIGINAL RESEARCH Patient perceptions of patient-empowering nurse behaviours
T. Jerofke et al.
The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan
Reasons to publish your work in JAN:
· High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour- nal Citation Reports © (Nursing (Social Science)).
· Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 3,500 in developing countries with free or low cost access).
· Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
· Positive publishing experience: rapid double-blind peer review with constructive feedback.
· Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
· Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).
© 2013 John Wiley & Sons Ltd 1321
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
1322 © 2013 John Wiley & Sons Ltd
