It is no surprise there is often confusion between the concepts of experience and engagement. Tack the word “patient” to the front of either, and you’ll likely become even more confused as to the difference in meaning between the two. The difference, however, becomes significant when we look at the current state of health care. The reality is, participants in the health care industry are dedicating significant resources to enhancing the patient experience.
Equally, investments in technology and labor are being made to
improve engagement with patients, both prospective and current. This shift in
patient engagement has stemmed from an increasing number of patients playing a
more active role in managing their health affairs through digital platforms. While
both patient experience and patient engagement contribute equally
to patient loyalty, there are key differences worth noting.
Patient experience can be summed up as the cumulative experiences a patient encounters throughout their dealings with a health care provider. This begins with the initial phone call and continues right through administering care to the patient and the routine after-care checkups. A patient’s experience is a journey that is often comprised of:
The initial phone conversation or online booking made to schedule an appointment with the health care provider.
The patient’s visit to the premises, including the interaction between the receptionist staff and the patient upon arrival and departure.
The level of care provided by the health care provider to the patient, and the quality of the health care staff who administered the care.
Whether the patient’s experience was comfortable, this includes the gown they were provided with and the appropriateness of the uniforms worn by the health care provider.
The patient’s billing experience, such as the ease, convenience, and flexibility of payment.
The after-stay experience with the health care provider—for example, did they make a follow-up call to the patient to gauge how they were feeling and whether the provider could have improved on any aspect of care?
In summary, every encounter the health care provider has with the patient contributes to the overall patient experience. Patient experience places the onus of care mostly on the health care provider, meaning the provider is responsible and accountable for the patient’s experience from start to finish. Understanding the touchpoints of this experience is critical to enhancing the overall relationship between the patient and the provider.
The Center for Advancing Health defines patient engagement as the “… actions individuals must take to obtain the greatest benefit from the health care services available to them.” Patient engagement puts the onus of health care back on the patient. Patients are afforded an opportunity to enhance their health and well-being through various health care services on offer. However, the patient must act for engagement to take place. This shift in onus from provider to patient is the main differentiating factor between patient experience and patient engagement. Some examples of patient engagement are:
1. Patients and their families engaging in wellness programs, health-based courses, and initiatives provided by health care providers.
2. Patients registering for, updating, and regularly using online health care records. The introduction of online health care records offers significant convenience and control for patients who traditionally would not have documented their health history.
records enable patients to manage their health information,
including advanced care plans or custodian details.
Online health records also allow patients to add personal notes regarding any allergies and allergic reactions they may have previously had and set up text or email notifications to notify the patient that a health care provider has viewed their record.
Patients concerned about security can configure their security settings to restrict access to their records and who can and can’t view their health records online.
3. Provide input into patient engagement surveys or broader initiatives. Surveys on patient engagement have been used previously to gauge the services that can be undertaken by a patient as opposed to health care providers. This, in turn, allows the health care provider to devote resources to segments of the patient experience cycle that require more attention.
Achieving Both Patient
Satisfaction and Engagement – Is It Possible?
Patient experience focuses on the steps taken by the health care provider to enrich a patient’s experience, whereas patient engagement centers on the actions taken by a patient to engage in the services provided by the health care professional. While differences between patient experience and engagement are apparent, the two operate hand in hand when understanding the full gambit of a patient’s interaction with health care providers in the modern-day health care landscape. The question is, can a health care provider serve both sides of the spectrum? Can this utopia of patient interaction be achieved? Essentially, the answer is yes, it can, but only by understanding some fundamental levers. Some of these levers are:
Defining the patient. Is the patient one person or should this comprise the patient’s family, friends, and caregivers? When assessing experience and engagement, should experience be focused on the individual’s experience with the provider or on how a patient and his/her family interact with health and wellness programs?
Defining the degree of control. What control does a patient under the “patient engagement” umbrella have in determining their quality of care and level of engagement? When we speak about engagement, how much choice does the patient have? Conversely, does the patient experience relinquish all control, or can there be some middle ground, where the patient can provide input into the patient experience cycle by, for example, completing surveys?
The degree of engagement. If a health care provider has patients who are highly engaged, completing most tasks themselves, is this the ideal degree of engagement? For example, is having patients schedule appointments themselves, leverage technology to pay for bills, and update their health care records the proper amount of engagement? Some believe so and argue patient engagement allows that other elements of care, such as the actual health care service, should be left to the patient experience cycle.
There is undoubtedly an opportunity for health care providers and patients to work within the confines of the patient experience and patient engagement concepts. Advancements in technology, such as online health care records and increased availability of health programs, have created the platform for patient engagement and made it easier for a patient or a patient’s family member/caregiver to manage their health affairs. This has reduced administrative dependency on providers, who can now focus on more pressing facets of the patient experience, such as the level and quality of care provided to patients.
Overall, the outlook appears positive and, in time, health care providers and patients will likely find a comfortable medium between bearing the burden of patient engagement and patient experience.
A small sampling of these messages on Facebook found that “anti-vaxxers” had qualitatively different types of arguments that cater to a wide variety of audiences, reported Brian Primack, MD, of the University of Pittsburgh School of Medicine, and colleagues.
The World Health Organization (WHO) lists “vaccine hesitancy” as one of its 10 threats to global health in 2019, and indeed, Primack and colleagues cited the “considerable rise in the rate of nonmedical exemptions from school immunization requirements” in the U.S.
They noted that while prior research has focused on either anti-vaccination content on Twitter, comments in response to celebrity posts, and Facebook groups, the characteristics of individuals posting anti-vaccination content on Facebook has not been thoroughly examined.
Primack and colleagues examined the profiles of 197 individuals who posted anti-vaccination comments on a Pittsburgh pediatrics practice’s Facebook page in response to a video promoting the vaccine against HPV. These were among “thousands” posted over a period of 8 days considered anti-vaccination, “which we defined as being either (1) threatening (e.g., ‘you’ll burn in hell for killing babies’) and/or (2) extremist (e.g., ‘you have been brainwashed’),” the group explained.
Among the 197 randomly chosen for analysis (“in order to feasibly conduct in-depth quantitative assessment”), they found a large majority of these commenters were women, and almost 80% were parents. About 30% reported an occupation and a little under a quarter reported a post-secondary education. Of the 55 individuals whose political affiliation could be determined, 56% identified as supporters of Donald Trump, while 11% identified as supporters of Bernie Sanders.
There were 116 individuals who had at least one public anti-vaccination post from 2015-2017, with posts about “educational material,” or claims that doctors are uneducated and parents need to educate themselves were the most popular (73%), followed by “media, censorship, and ‘cover up'” or the suggestion that pharmaceutical manufacturers, government, and physicians deliberately fail to disclose adverse vaccine reactions (71%) and “vaccines cause idiopathic illness,” claiming kids who are not vaccinated get less illness (69%).
The four overarching themes were more specifically:
Trust: emphasizing suspicion about the scientific community, concerns about personal liberty
Alternatives: focusing on chemicals in vaccines, use of homeopathic remedies over vaccination
Safety: perceived risks and concerns about vaccination being immoral
Conspiracy: that government “hides” information that anti-vaccination groups believe to be facts
Co-author Beth Hoffman, BSc, also of the University of Pittsburgh, said that these groups “caution against a blanket approach to public health messages that encourage vaccination.”
Limitations to the data include that these only reflect commenters who responded to a single pro-vaccination video, and do not necessarily reflect “broader discussions of anti-vaccination issues on Facebook.” Demographic data was self-reported, and could not be authenticated, they noted.
The column about Nursing Knowledge Activities, is intended to inform readers about events and developments in nursing knowledge. Having had a long-term interest in theory and research I wrote a series of columns to showcase different professional organizations dedicated to nursing theory activities.
Usually I write the Nursing Knowledge Activities column about 4-6 months before it appears in print. In October 2017 I began writing the May 2018 column. Having already written about several nursing theory organizations, I wanted to write about the Transcultural Nursing Society started by Madeleine Leininger. That Fall, I was doing background reading about twentieth century American history for a book I am currently writing. Each evening, the national news mentioned Congress wanting to overturn the Affordable Care Act. Also, there were news stories about refugees fleeing crisis situations from several parts of the world. Our politicians seemed divided about wanting to help refugees. That news broke my heart since it seemed that some politicians were not interested in helping humanity.
My first column for May 2018 was focused on a different topic. But then things came together on December 12, 2017. I decided to write a completely different column for May 2018. That morning I had read President Kennedy’s speech during my background reading. It reminded me of Leininger’s approach to human beings that was so nurturing, caring, and respectful of human dignity. The stark contrast between Kennedy’s approach to humanity and current political conversations, created a clear insight. I then examined the Transcultural Nursing Society’s website equipped with that insight. Once I saw the rich treasures that the Transcultural Nursing Society has to offer nurses today, I scrapped my other column. Within a half hour I wrote May’s column from beginning to end.
Chamberlain University College of Nursing students recently completed a two-week trip to Kenya as part of the Global Health Education Program. The program, which has been in existence for 23 years, provides Chamberlain nursing students the opportunity to put their nursing skills and education to use in different countries, like Haiti, Kenya, Brazil, and India.
Third year nursing student Christopher Monzon chose to travel to Kenya for his GHEP trip earlier this fall, working alongside local nurses and nursing students in five cities: Mukuru, Koch, Babadongo, Kamahuha, and Maasai Mara. The nursing groups helped provide healthcare and assistance in a variety of ways, treating around 400 patients per day. “Maasai Mara, located near the Tanzania and Kenya border, had a high number of patients with malaria so they needed anti-malarial medications and disease education,” Monzon said. “However, the tribe did not believe in vaccinations so we used a special plant called Artemisia annua to treat the patients. We also taught this tribe how to search for clean water, another serious issue in the region.”
Chamberlain’s Global Health Education Program partners with different organizations in each country, such as Family Hope Charity in Kenya and Hope for Hansan’s in India. Dr. Susan Fletcher, chair of the GHEP, works with her faculty to ensure that even with varying healthcare needs, every community is helped. Dr. Fletcher told DailyNurse.com: “The program’s focus across the board is health promotion and disease prevention with an emphasis on sustainability.”
Monzon and other students were partnered each day with translators and Thika medical students to diagnose patients, distribute treatment and medication, or travel to homes of bed-ridden patients. Because the students treated so many patients each day with limited time, they sharpened and honed their interview skills to figure out symptoms and appropriate treatments. But each team learned many valuable skills from working closely together. “For example, a Thika medical student taught me how to diagnose Rickets, a disease I had never encountered prior to the trip,” Monzon told DailyNurse.com. “Then I was able to teach the Thika students how to properly take a patient’s vital signs which they then took over for us while we were interviewing patients in clinics.”
These GHEP trips fill the Chamberlain College of Nursing requirement for the campus-based community health course, while providing students the opportunity to broaden their education outside of the United States. Program requirements include a 3.0 GPA, faculty recommendation letters, and an application with the campus president’s signature. Chamberlain also provides 10-12 scholarships annually for students requiring financial aid for these trips.
These trips are invaluable for Chamberlain students, as they not only practice their nursing skills and gain new healthcare skills, but get to treat patients from very different backgrounds. “Before leaving for Kenya, I wanted to be a travel nurse,” Monzon said. “Now I want to be an international nurse to help more people like those I met in Kenya.”
Concordia University Texas School of Nursing students are now utilizing a medical van to better serve their community. Their mobile Medical Missions Van operates as a pop-up clinic that provides free, basic healthcare to two counties and has plenty of space for medical supply storage and seating for clients and nurses.
Students first put the van to use last month to help individuals living under an Austin bridge, setting up foot-washing stations while a local ministry provided fellowship and food. Though these community healthcare activities are strongly helped by the use of the mobile medical clinic, nursing students have been working on projects like these since 2015, as part of their requirement for their Community Health course.
Concordia’s Nursing program director Dr. Greta Degen, RN, told CTX Blog: “The biggest impact the van has is that it allows Concordia nursing students to become the first stop for people in the community who are wrestling with a medical issue. Students can use their nursing knowledge to screen and educate individuals on their health issue or medication before needing to go see a doctor or visit an emergency room.”
Mobile medical clinics like this are used globally, especially in areas devastated by war, natural disasters, and humanitarian crises. The clinics provide a way for healthcare professionals to get medical treatments and supplies to people cut off or isolated from communities, and are especially helpful in areas lacking in public transportation.
To learn more about Concordia University Texas School of Nursing and their mobile Medical Missions Van, visit CTX Blog.
Andrew J. Johnson, APRN, CRNA, grew up in a rural area and always knew that it was the exact type of setting where he wanted to work. As the sole anesthesia provider for a critical access hospital in Olivia, Minnesota, Johnson loves what he does. But he does face quite a lot of challenges.
He took some time to tell us about his work. What follows is an edited version of our interview.
What kind of work do you do?
I am the sole anesthesia provider for our critical access hospital. I opened a pain clinic at our facility because access to care for those suffering with chronic pain was lacking. Fortunately, I was able to find an incredible mentor, Keith Barnhill, to teach me chronic pain management. I was then accepted into the post master’s advanced pain certificate program through Hamline University. The pain clinic has definitely benefitted our community.
I also provide anesthesia for obstetrics, emergency room, and surgical cases including general, podiatry, gynecological, ENT, orthopedics, and urology. In 2017, we became the first critical access hospital in Minnesota to get a Da Vinci surgical robot. This has definitely increased the number and complexity of general surgical cases we are able to do at our facility. We have been performing total hip and knee replacements the last 2 years, which was a much-needed service in our community.
Working in a rural area is quite different from what most nurses do. Have you worked in a more urban or suburban area before this? If so, how does working in a rural area differ from those places? If the facility you work in large or small?
Rural anesthesia is much different from that in urban and suburban facilities. Although the anesthesia doesn’t change, the number of resources available to trouble shoot and help in difficult situations is severely limited. I have always found that the toughest decision I make is what cases I shouldn’t perform at my facility.
What kinds of patients do you tend to see? How are they different from those you saw in a more urban setting?
I feel like the patients and staff have closer relationships in small communities. We all know each other, and many times are related to each other. I hear weekly from patients that they feel so comfortable knowing I will be doing their anesthesia because of our relationships in the community.
What have you learned from working as a nurse in a rural area?
There are many individuals and organizations that want to limit scope of practice for advanced practice nurses, especially nurse anesthetists, and thereby limit access to care for rural comminutes. It is easy to get busy with work and family and lose track of the politics of anesthesia, but it is vitally important to stay vigilant about what is going on in the medical and political arena.
Because it’s a rural setting, do you tend to know more of the patients or their families, as in a small-town? Do you get a lot of patients who have to travel a long way to get to you? How many miles might some patients travel? Are people ever helicoptered in? Brought by ambulance? How far?
I know most of the patients that I see for anesthesia and pain injections. In a town with a population of about 2,500, it is no surprise to run into people I have seen in the community. Most patients do not need to travel more than 45 miles to see us. There are about six hospitals in a 45-mile radius of Olivia. Some of these facilities provide a higher level of care, so we are able to transport to these facilities if we are unable to provide the level of care needed. For bad traumas, often the flight crews will land at the scene of the accident and evacuate the patient from the scene instead of delaying high-level care by coming through our emergency room. Certainly, there are times when these patients need to come to our emergency room for stabilization prior to transport.
What are the biggest challenges of working in a rural setting?
Call is always tough in rural settings. If can be tough to achieve a work/life balance because of the need to be available and within call range of the hospital. Because of this, my family has several hobbies that we can do together on our acreage including gardening, yard work, blacksmithing, exercising, hunting, and sports.
What are the greatest rewards?
It’s fun to be recognized in the community by patients that have been through the surgery department or pain clinic. They are appreciative of being able to be cared for in their hometown where they have friends and family to help with their recovery. I feel that community recognition makes it easier for my family to accept me not being home. My wife and kids can become frustrated with me getting called to work, but when they find out later I was helping one of their friends, they understand the importance of my job and are happy that I do what I do.
What would you say to someone considering moving to work in a rural area? What do they need to be willing to do or deal with?
Deciding to work in a rural facility is not a decision that can be made lightly. It is not just a job, but a lifestyle. My family has to take two vehicles to the movies, dinner, church, etc. Calling in sick to work is not an option. There is no additional help when emergencies arise.
Personally, I think there is no better place to raise a family that in a rural community, but I may be a little biased. To work in the setting, confidence is an absolute requirement. Someone will always try to challenge your decisions. As long as you can always make decisions with the patient’s best interest in mind, you will have the respect of your medical staff, and this will make for a satisfying career.
Also, you can’t decide not to see particular patients because there are no other options. As an example, I had to do the anesthesia for my wife’s caesarian section. I had someone hired to do her case, but her water broke a week before her schedule C-section. Another example of an interesting rural experience is when the locum I had hired to do my colonoscopy got the schedule confused and didn’t show up for the day. I had to do anesthesia for 6 procedures and was finally able to get someone to do my anesthesia in the afternoon.
The Frontier Nurse Practitioner
A Conceptual Model for Remote-Rural Practice
This pioneering text is the first to present a framework for remote-rural and frontier nurse practitioners (NPs), with a focus on the political and contextual forces that influence practice.