Health Promotion International, 2016;31:303–313 doi: 10.1093/heapro/dau103 Advance Access Publication Date: 10 December 2014
Implementing ‘self-help friendliness’ in German hospitals: a longitudinal study Alf Trojan, Stefan Nickel* and Christopher Kofahl
*Corresponding author. E-mail: [email protected]
Summary In Germany, the term ‘self-help friendliness’ (SHF) describes a strategy to institutionalize co-operation of healthcare institutions with mutual aid or self-help groups of chronically ill patients. After a short explanation of the SHF concept and its development, we will present findings from a longitudinal study on the implementation of SHF in three German hospitals. Specifically, we wanted to know (i) to what degree SHF had been put into practice after the initial development phase in the pilot hospitals, (ii) whether it was possible to maintain the level of implementation of SHF in the course of at least 1 year and (iii) which opinions exist about the inclusion of SHF criteria in quality management systems. With only minor restrictions, the findings provide support for the usefulness, practicability, sustainability and transferability of SHF. Limitations of our empirical study are the small number of hospitals, the above average motivation of their staff, the small response rate in the staff-survey and the inability to get enough data from members of self-help groups. The research instrument for measuring SHF was adequate and fulfils the most important scientific quality criteria in a German context. We conclude that the implementation of SHF leads to more patient-centredness in healthcare institutions and thus improves satisfaction, self-management, coping and health literacy of patients. SHF is considered as an adequate approach for reorienting healthcare institutions in the sense of the Ottawa Charta, and particularly suitable for health promoting hospitals. Key words: self-help friendliness, self-help groups, health promoting hospitals, reorienting health services
INTRODUCTION The fifth key action area ‘reorient health services’ of the Ottawa Charta from 1986 addresses the health promotion in health services as a shared responsibility among individuals, community groups, health professionals, health service institutions and governments, and postulates that these ‘must work together towards a health care system which contributes to the pursuit of health’ (www.who. int/healthpromotion/conferences/previous/ottawa/en). However, more than two decades later, De Leeuw (De
Leeuw, 2009) reasons that health services have not reoriented at all, and concludes that ‘the discourse on further reorientation of health services [. . .] should clearly be continued, especially in the health promotion community’ ( p. 107). Comparably critical comments can be found in the reflections of Ziglio et al. (Ziglio et al., 2011) who assess the fifth Ottawa key action area as an ‘unfinished business’. On the other hand, ‘voluntary and self-help organisations’ as mentioned in the WHO’s strategy Health 2020 (WHO,
© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
Department of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany
304
THE CONCEPT ‘SHF’ AND ITS INSTITUTIONALIZATION IN GERMANY In Germany, SHGs, the support system for SHGs, and patient participation and involvement have reached a considerably high standard (Matzat, 2006–2007; Kofahl
et al., 2014). The number of SHGs increased up to 100 000 with ∼3 million members (ca. 3.5% of the German population), the vast majority of them regional face-to-face groups. In addition, the self-help sector is supported by a nationwide self-help supporting infrastructure consisting of 290 self-help clearinghouses plus 49 smaller self-help offices (NAKOS, 2013). The collaboration with SHGs is considered a crucial instrument to foster patient participation and involvement in the German healthcare system (Loh et al., 2007; Matzat, 2013; Kofahl et al., 2014). The further development and growth of self-help and self-help support in the last decades is the context in which SHF was started as an approach of sustainable integration of self-help associations into health services. Concerning the latter ones, the hospital sector was the first area in which eight quality criteria for SHF were developed in 2004. The initial project was conducted in Hamburg, Northern Germany, and led to a consensus document that was developed and approved by self-help group members, representatives of the local self-help clearinghouse and quality managers from three hospitals (Bobzien, 2008). The quality criteria for hospitals read as follows: (i) (ii) (iii) (iv) (v) (vi) (vii)
(viii)
The hospital offers rooms, infrastructure and possibilities for public relations. Patients of the hospital are personally informed about self-help on a regular basis. The hospital supports public relations of the selfhelp group. The hospital appoints a staff member as a contact person for self-help. Staff and self-help group members meet regularly for information exchange. Self-help groups are involved in further education/ training of staff. Self-help groups are involved in professional working groups such as quality circles and ethical committees. The collaboration is formally agreed upon and the activities will be documented.
The first three criteria shall ensure that information on self-help is available for all patients. The next five criteria aim at systematic and sustainable patient involvement and participation. The integration of these quality criteria into the internal quality management of healthcare institutions is crucial for sustainability. After this last step, an institution can be awarded a certification which is based on a self-assessment confirmed by the collaborating self-help groups. Until the beginning of 2014, 18 hospitals had completely put the quality criteria into practice.
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
2012, section No. 51; cf. No. 21, p. 5 and No. 19, p. 5) have increasingly become an acknowledged actor in changing and improving health services (Baggott and Forster, 2008). They are the organized, but non-professional counterpart of professional carers. In Germany, the most common collective term for these groups is ‘Selbsthilfegruppen’ (self-help groups or SHGs). In the following, we use ‘SHG’ as a synonym for ‘mutual help’, ‘mutual aid’ or ‘support group’, for all self-help associations, and all types of patient groups/ organizations. Emphasizing the relevance of collaboration between professional services and these groups has a long tradition (Hatch and Kickbusch, 1983; Borkman, 1990). More recently, patient involvement, respectively, user or public involvement have become key concepts for closer collaboration and a stronger voice of patients in health services. These concepts are widely discussed as promising approaches to improve the quality and responsiveness of healthcare services (Conklin et al., 2010). Corresponding key notions for enhancing the quality of healthcare systems are ‘patient participation’, ‘patient integration’ and ‘patient centredness’ (Taylor, 2009). Although these similar concepts differ slightly in definitions and emphasis of their approaches, most literature concordantly concludes that closer collaboration with patients is highly relevant for quality improvement in healthcare provision at the individual level, the institutional level and the system level (Institute of Medicine, 2001; Rabeharisoa, 2003; Baggott and Forster, 2008). Yet, the realization of such cooperation usually lacks a systematic approach to sustainable institutionalization. The concept of self-help friendliness (SHF) is a new development to foster collaborative interaction between healthcare institutions and patients ‘on the collective level’ (Forster and Gabe, 2008). A self-help friendly healthcare institution is characterized by a formally implemented co-operation with SHGs of chronically ill patients. As the implementation implies structural changes of healthcare institutions, we also consider our paper as a contribution to the debate on reorienting health services. After a short explanation of the SHF concept, and its context and development in Germany, we will provide and discuss findings from a longitudinal study on the implementation of SHF in three German hospitals.
A. Trojan et al.
Implementing ‘self-help friendliness’ in German hospitals
– First, the German social insurance system has established substantial support measures for self-help groups and their systematic support by self-help clearinghouses (Geene et al., 2009). – Secondly, since 2004, Germany is pursuing a general policy (including legal provisions) for more patient centredness and, especially, the participation on the federal level in working groups of the ‘Federal Joint Committee of Physicians and Statutory Health Insurances’ (Matzat, 2006/2007; www.g-ba.de). – Thirdly, in 2009, the German Network ‘Self-help Friendliness and Patient Centredness in the Health Care System’ was founded (www.selbsthilfefreund lichkeit.de). This network pursues a nationwide strategy to promote the co-operation between healthcare professionals and self-help groups by developing and disseminating training materials, conducting and supporting pilot projects, and by integrating self-help friendly criteria into quality management and accreditation programmes (www. selbsthilfefreundlichkeit.de).
Finally, we have to stress that the dissemination of SHF in Germany (Nickel et al., 2012; Trojan et al., 2013; Kofahl et al., 2014) did not follow a comprehensive ‘master plan’. Based on a partnership ‘philosophy’ in an action research framework (Nelson et al., 1998), the process is better described as a step-by-step development of co-operating selfhelp representatives, professional self-help supporters, social scientists and staff from both healthcare insurances and healthcare institutions.
RESEARCH QUESTIONS AND METHODS In this paper, we will show and discuss results from a longitudinal quantitative survey in three hospitals in Hamburg, Northern Germany, conducted between January 2009 and June 2011. Two of these were ‘pilot’ hospitals whose managerial staff agreed to participate in the development of SHF already in 2004. Between 2005 and 2008, they took part in identifying and defining the above-mentioned eight quality criteria and how to put them into practice. After a self-assessment according to the ‘Plan-Do-Check-Act’ cycle and a following formal audit consisting of eight SHG-representatives and two selfhelp supporters, the pilot hospitals A and B received a certification (‘quality seal’) as ‘self-help friendly health care institutions’ by the Hamburg clearinghouse for self-help in 2006 (Bobzien, 2008). A few months later Hospital C adopted the quality criteria as well, however ‘invested’ less effort in implementing the strategy, and thus did not run through the certification procedure. In January 2008, we started a research project to test the criteria, their acceptability and the sustainability of SHF. In this paper, we focus on the following research questions of this study: – To which extent did the three pilot hospitals implement SHF after the initial development phase? (feasibility) – Was it possible to maintain the level of integration of SHF in the course of 12–15 months? (sustainability) – Which opinions exist about the inclusion of SHF criteria in quality management systems? (acceptability) The study had two measure points at intervals of 12 (Hospital A) to 15 (Hospitals B and C) months (Nickel, 2012). The first data collection started about 2.5 years after the certification in 2006. In all hospitals, only those medical departments were involved which actively cooperated with SHGs (Hospital A: rheumatology and psychiatry: B: five psychiatric departments; C: paediatrics, otorhinolaryngology, gynaecology, obstetrics). The
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
The second area in which SHF criteria have been developed is the ambulatory care sector. A cross-sectional survey among moderators of quality circles of doctors in ambulatory care showed a large willingness of officebased physicians to co-operate with patient groups (Nickel et al., 2012). A pilot project was successfully completed, but only few practices showed interest to adopt the approach. Thus, a second pilot project is planned to develop a more promising approach which will be related to new care concepts and organizational forms (e.g. integrated healthcare or medical care centres). In the third area, the in-patient rehabilitation sector, a successful pilot project with two rehabilitation hospitals has just been completed. Finally, specific SHF criteria for public health departments, as the fourth area, were defined and published (Trojan and Nickel, 2011). In total, 17 hospitals, 10 practices and 2 rehabilitation hospitals were awarded a certification as self-help friendly healthcare institutions so far. More than 140 regional selfhelp groups, 40 self-help organizations and 15 regional selfhelp clearinghouses participated in the development and implementation of SHF (www.selbsthilfefreundlichkeit.de). Considering that participation was voluntary, these figures are indicative of the acceptability of the SHF approach. On the whole, however, the dissemination of the concept is still in the beginning. At least three characteristics of the German healthcare system have facilitated the present state of development and implementation:
305
306
comprehensive survey included all doctors and nurses of these 11 participating departments. Additionally, we tried to encompass the collaborating SHGs as well.
Research instrument
A: informing patients (four items) (α = 0.85) B: involving patients (four items) (α = 0.72) C: empowering patients (four items) (α = 0.81) D: involving self-help groups (10 items) (α = 0.93) All 22 items have the same four-point answer scale: very true—rather true—rather not true—not true at all. Additionally, users can tick the box ‘cannot assess’. Dimensions A to C represent SHF on the individual level. The dimension D ‘involving self-help groups’ measures collaboration on the collective level and fully includes the quality criteria of SHF as mentioned above (two more items were needed to cover all aspects of the eight criteria). Every dimension is transformed to a scale from ‘0’ for not true at all to ‘100’ for very true over all items of the relevant dimension.
Recruitment and data collection Respondent recruitment was carried out by our contact persons in the hospitals (i.e. the quality manager and/or self-help agent) who personally distributed and collected all questionnaires. For data protection and confidentiality, the participants administered the questionnaires anonymously, put them in closed envelopes which were collected and then sent to the evaluating department. In the first survey (t1), 189 out of 650 employees participated (overall response rate: 29%), in the follow-up
study (t2), we had a response rate of 151 out of 644 (23%). Response rates differed between the three hospitals: A: 48/50%, B: 23/20%, C: 41/25%. In Hospitals A and B, the response rates were relatively constant because of the good and long-lasting co-operation with the quality managers. Hospital C consisted of more departments than A and B which increased the complexity in co-operation and procedures, and thus reduced the response rate at t2 compared with t1. Fifty-four per cent of all participants were working in a psychiatric ward, 64% were women, 78% worked in the nursing service and 54% were between 30 and 49 years old.
Data analysis Mainly descriptive analyses were performed using frequency distributions, cross tables and mean comparisons. The psychometric testing was based on methods of classical test theory. In addition, statistical significance was calculated to detect differences by hospital, time and/or individual characteristics of the respondents (i.e. age, sex, medical speciality, occupational group). To analyse the open-ended questions of the survey, we used quantitative content analysis.
RESULTS/FINDINGS As the focus of this paper is on the collective level of SHF, we only present results concerning scale D ‘involving selfhelp groups’. In the complementary survey on the collaborating self-help groups, however, only 73 members of SHGs participated in total, which turned out to be too small for quantitative analysis. At least, the reported views of patients did not contradict with the hospital staff survey.
Implementation of the various criteria of self-help-friendliness Table 1 shows the results of the first assessment (t1). For these purposes, the two positive response categories of the four-point scale (‘very true’ and ‘rather true’) were pooled into one category. On the whole, we see that those types of co-operation requiring ‘direct’ contacts between personnel and members of self-help groups usually are rated less positive (Items 7 and 9). For the criteria of ‘indirect’ collaboration (Items 1–3, 5, 6) with few exceptions, we find moderate to very positive assessments. Hospital A, which has already been the hospital with the longest experience in co-operation with self-help groups, achieved the best scores in all statements. However, as Hospital C began last with the implementation of SHF
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
As there was no instrument available for the measurement of SHF, we had to develop a new questionnaire. For this purpose, we conducted a qualitative study, comprising three parts: (i) expert interviews with 8 doctors, 3 psychologists, 12 nurses and 10 contact persons of co-operating self-help groups, (ii) group discussions within the Hamburg working group ‘Network Self-help-friendly Hospital’, and (iii) literature search and analysis (Trojan et al., 2009). These were the basis for defining and operationalizing the criteria for ‘self-help-oriented’ patientcentredness (SelP-K). The resulting questionnaire SelP-K consists of 22 standardized and four open-ended questions plus four socio-demographic items (Nickel, 2012). The questionnaire can be answered by any staff member as it is independent from qualification or position of staff. The core of 22 standardized statements (see Appendix) covers four dimensions of self-help-oriented patientcentredness (α-values are calculated on the data basis of the study as described below):
A. Trojan et al.
Implementing ‘self-help friendliness’ in German hospitals
307
Table 1: Criteria of SHF assessed by staff of three self-help friendly hospitals at t1 (‘very true’ and ‘rather true’ in per cent) Items of the dimension ‘involving self-help groups’
p-valuea
Hospital A (n = 20)
B (n = 97)
C (n = 72)
67
95
69
52
Implementing ‘self-help friendliness’ in German hospitals: a longitudinal study Alf Trojan, Stefan Nickel* and Christopher Kofahl
*Corresponding author. E-mail: [email protected]
Summary In Germany, the term ‘self-help friendliness’ (SHF) describes a strategy to institutionalize co-operation of healthcare institutions with mutual aid or self-help groups of chronically ill patients. After a short explanation of the SHF concept and its development, we will present findings from a longitudinal study on the implementation of SHF in three German hospitals. Specifically, we wanted to know (i) to what degree SHF had been put into practice after the initial development phase in the pilot hospitals, (ii) whether it was possible to maintain the level of implementation of SHF in the course of at least 1 year and (iii) which opinions exist about the inclusion of SHF criteria in quality management systems. With only minor restrictions, the findings provide support for the usefulness, practicability, sustainability and transferability of SHF. Limitations of our empirical study are the small number of hospitals, the above average motivation of their staff, the small response rate in the staff-survey and the inability to get enough data from members of self-help groups. The research instrument for measuring SHF was adequate and fulfils the most important scientific quality criteria in a German context. We conclude that the implementation of SHF leads to more patient-centredness in healthcare institutions and thus improves satisfaction, self-management, coping and health literacy of patients. SHF is considered as an adequate approach for reorienting healthcare institutions in the sense of the Ottawa Charta, and particularly suitable for health promoting hospitals. Key words: self-help friendliness, self-help groups, health promoting hospitals, reorienting health services
INTRODUCTION The fifth key action area ‘reorient health services’ of the Ottawa Charta from 1986 addresses the health promotion in health services as a shared responsibility among individuals, community groups, health professionals, health service institutions and governments, and postulates that these ‘must work together towards a health care system which contributes to the pursuit of health’ (www.who. int/healthpromotion/conferences/previous/ottawa/en). However, more than two decades later, De Leeuw (De
Leeuw, 2009) reasons that health services have not reoriented at all, and concludes that ‘the discourse on further reorientation of health services [. . .] should clearly be continued, especially in the health promotion community’ ( p. 107). Comparably critical comments can be found in the reflections of Ziglio et al. (Ziglio et al., 2011) who assess the fifth Ottawa key action area as an ‘unfinished business’. On the other hand, ‘voluntary and self-help organisations’ as mentioned in the WHO’s strategy Health 2020 (WHO,
© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
Department of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany
304
THE CONCEPT ‘SHF’ AND ITS INSTITUTIONALIZATION IN GERMANY In Germany, SHGs, the support system for SHGs, and patient participation and involvement have reached a considerably high standard (Matzat, 2006–2007; Kofahl
et al., 2014). The number of SHGs increased up to 100 000 with ∼3 million members (ca. 3.5% of the German population), the vast majority of them regional face-to-face groups. In addition, the self-help sector is supported by a nationwide self-help supporting infrastructure consisting of 290 self-help clearinghouses plus 49 smaller self-help offices (NAKOS, 2013). The collaboration with SHGs is considered a crucial instrument to foster patient participation and involvement in the German healthcare system (Loh et al., 2007; Matzat, 2013; Kofahl et al., 2014). The further development and growth of self-help and self-help support in the last decades is the context in which SHF was started as an approach of sustainable integration of self-help associations into health services. Concerning the latter ones, the hospital sector was the first area in which eight quality criteria for SHF were developed in 2004. The initial project was conducted in Hamburg, Northern Germany, and led to a consensus document that was developed and approved by self-help group members, representatives of the local self-help clearinghouse and quality managers from three hospitals (Bobzien, 2008). The quality criteria for hospitals read as follows: (i) (ii) (iii) (iv) (v) (vi) (vii)
(viii)
The hospital offers rooms, infrastructure and possibilities for public relations. Patients of the hospital are personally informed about self-help on a regular basis. The hospital supports public relations of the selfhelp group. The hospital appoints a staff member as a contact person for self-help. Staff and self-help group members meet regularly for information exchange. Self-help groups are involved in further education/ training of staff. Self-help groups are involved in professional working groups such as quality circles and ethical committees. The collaboration is formally agreed upon and the activities will be documented.
The first three criteria shall ensure that information on self-help is available for all patients. The next five criteria aim at systematic and sustainable patient involvement and participation. The integration of these quality criteria into the internal quality management of healthcare institutions is crucial for sustainability. After this last step, an institution can be awarded a certification which is based on a self-assessment confirmed by the collaborating self-help groups. Until the beginning of 2014, 18 hospitals had completely put the quality criteria into practice.
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
2012, section No. 51; cf. No. 21, p. 5 and No. 19, p. 5) have increasingly become an acknowledged actor in changing and improving health services (Baggott and Forster, 2008). They are the organized, but non-professional counterpart of professional carers. In Germany, the most common collective term for these groups is ‘Selbsthilfegruppen’ (self-help groups or SHGs). In the following, we use ‘SHG’ as a synonym for ‘mutual help’, ‘mutual aid’ or ‘support group’, for all self-help associations, and all types of patient groups/ organizations. Emphasizing the relevance of collaboration between professional services and these groups has a long tradition (Hatch and Kickbusch, 1983; Borkman, 1990). More recently, patient involvement, respectively, user or public involvement have become key concepts for closer collaboration and a stronger voice of patients in health services. These concepts are widely discussed as promising approaches to improve the quality and responsiveness of healthcare services (Conklin et al., 2010). Corresponding key notions for enhancing the quality of healthcare systems are ‘patient participation’, ‘patient integration’ and ‘patient centredness’ (Taylor, 2009). Although these similar concepts differ slightly in definitions and emphasis of their approaches, most literature concordantly concludes that closer collaboration with patients is highly relevant for quality improvement in healthcare provision at the individual level, the institutional level and the system level (Institute of Medicine, 2001; Rabeharisoa, 2003; Baggott and Forster, 2008). Yet, the realization of such cooperation usually lacks a systematic approach to sustainable institutionalization. The concept of self-help friendliness (SHF) is a new development to foster collaborative interaction between healthcare institutions and patients ‘on the collective level’ (Forster and Gabe, 2008). A self-help friendly healthcare institution is characterized by a formally implemented co-operation with SHGs of chronically ill patients. As the implementation implies structural changes of healthcare institutions, we also consider our paper as a contribution to the debate on reorienting health services. After a short explanation of the SHF concept, and its context and development in Germany, we will provide and discuss findings from a longitudinal study on the implementation of SHF in three German hospitals.
A. Trojan et al.
Implementing ‘self-help friendliness’ in German hospitals
– First, the German social insurance system has established substantial support measures for self-help groups and their systematic support by self-help clearinghouses (Geene et al., 2009). – Secondly, since 2004, Germany is pursuing a general policy (including legal provisions) for more patient centredness and, especially, the participation on the federal level in working groups of the ‘Federal Joint Committee of Physicians and Statutory Health Insurances’ (Matzat, 2006/2007; www.g-ba.de). – Thirdly, in 2009, the German Network ‘Self-help Friendliness and Patient Centredness in the Health Care System’ was founded (www.selbsthilfefreund lichkeit.de). This network pursues a nationwide strategy to promote the co-operation between healthcare professionals and self-help groups by developing and disseminating training materials, conducting and supporting pilot projects, and by integrating self-help friendly criteria into quality management and accreditation programmes (www. selbsthilfefreundlichkeit.de).
Finally, we have to stress that the dissemination of SHF in Germany (Nickel et al., 2012; Trojan et al., 2013; Kofahl et al., 2014) did not follow a comprehensive ‘master plan’. Based on a partnership ‘philosophy’ in an action research framework (Nelson et al., 1998), the process is better described as a step-by-step development of co-operating selfhelp representatives, professional self-help supporters, social scientists and staff from both healthcare insurances and healthcare institutions.
RESEARCH QUESTIONS AND METHODS In this paper, we will show and discuss results from a longitudinal quantitative survey in three hospitals in Hamburg, Northern Germany, conducted between January 2009 and June 2011. Two of these were ‘pilot’ hospitals whose managerial staff agreed to participate in the development of SHF already in 2004. Between 2005 and 2008, they took part in identifying and defining the above-mentioned eight quality criteria and how to put them into practice. After a self-assessment according to the ‘Plan-Do-Check-Act’ cycle and a following formal audit consisting of eight SHG-representatives and two selfhelp supporters, the pilot hospitals A and B received a certification (‘quality seal’) as ‘self-help friendly health care institutions’ by the Hamburg clearinghouse for self-help in 2006 (Bobzien, 2008). A few months later Hospital C adopted the quality criteria as well, however ‘invested’ less effort in implementing the strategy, and thus did not run through the certification procedure. In January 2008, we started a research project to test the criteria, their acceptability and the sustainability of SHF. In this paper, we focus on the following research questions of this study: – To which extent did the three pilot hospitals implement SHF after the initial development phase? (feasibility) – Was it possible to maintain the level of integration of SHF in the course of 12–15 months? (sustainability) – Which opinions exist about the inclusion of SHF criteria in quality management systems? (acceptability) The study had two measure points at intervals of 12 (Hospital A) to 15 (Hospitals B and C) months (Nickel, 2012). The first data collection started about 2.5 years after the certification in 2006. In all hospitals, only those medical departments were involved which actively cooperated with SHGs (Hospital A: rheumatology and psychiatry: B: five psychiatric departments; C: paediatrics, otorhinolaryngology, gynaecology, obstetrics). The
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
The second area in which SHF criteria have been developed is the ambulatory care sector. A cross-sectional survey among moderators of quality circles of doctors in ambulatory care showed a large willingness of officebased physicians to co-operate with patient groups (Nickel et al., 2012). A pilot project was successfully completed, but only few practices showed interest to adopt the approach. Thus, a second pilot project is planned to develop a more promising approach which will be related to new care concepts and organizational forms (e.g. integrated healthcare or medical care centres). In the third area, the in-patient rehabilitation sector, a successful pilot project with two rehabilitation hospitals has just been completed. Finally, specific SHF criteria for public health departments, as the fourth area, were defined and published (Trojan and Nickel, 2011). In total, 17 hospitals, 10 practices and 2 rehabilitation hospitals were awarded a certification as self-help friendly healthcare institutions so far. More than 140 regional selfhelp groups, 40 self-help organizations and 15 regional selfhelp clearinghouses participated in the development and implementation of SHF (www.selbsthilfefreundlichkeit.de). Considering that participation was voluntary, these figures are indicative of the acceptability of the SHF approach. On the whole, however, the dissemination of the concept is still in the beginning. At least three characteristics of the German healthcare system have facilitated the present state of development and implementation:
305
306
comprehensive survey included all doctors and nurses of these 11 participating departments. Additionally, we tried to encompass the collaborating SHGs as well.
Research instrument
A: informing patients (four items) (α = 0.85) B: involving patients (four items) (α = 0.72) C: empowering patients (four items) (α = 0.81) D: involving self-help groups (10 items) (α = 0.93) All 22 items have the same four-point answer scale: very true—rather true—rather not true—not true at all. Additionally, users can tick the box ‘cannot assess’. Dimensions A to C represent SHF on the individual level. The dimension D ‘involving self-help groups’ measures collaboration on the collective level and fully includes the quality criteria of SHF as mentioned above (two more items were needed to cover all aspects of the eight criteria). Every dimension is transformed to a scale from ‘0’ for not true at all to ‘100’ for very true over all items of the relevant dimension.
Recruitment and data collection Respondent recruitment was carried out by our contact persons in the hospitals (i.e. the quality manager and/or self-help agent) who personally distributed and collected all questionnaires. For data protection and confidentiality, the participants administered the questionnaires anonymously, put them in closed envelopes which were collected and then sent to the evaluating department. In the first survey (t1), 189 out of 650 employees participated (overall response rate: 29%), in the follow-up
study (t2), we had a response rate of 151 out of 644 (23%). Response rates differed between the three hospitals: A: 48/50%, B: 23/20%, C: 41/25%. In Hospitals A and B, the response rates were relatively constant because of the good and long-lasting co-operation with the quality managers. Hospital C consisted of more departments than A and B which increased the complexity in co-operation and procedures, and thus reduced the response rate at t2 compared with t1. Fifty-four per cent of all participants were working in a psychiatric ward, 64% were women, 78% worked in the nursing service and 54% were between 30 and 49 years old.
Data analysis Mainly descriptive analyses were performed using frequency distributions, cross tables and mean comparisons. The psychometric testing was based on methods of classical test theory. In addition, statistical significance was calculated to detect differences by hospital, time and/or individual characteristics of the respondents (i.e. age, sex, medical speciality, occupational group). To analyse the open-ended questions of the survey, we used quantitative content analysis.
RESULTS/FINDINGS As the focus of this paper is on the collective level of SHF, we only present results concerning scale D ‘involving selfhelp groups’. In the complementary survey on the collaborating self-help groups, however, only 73 members of SHGs participated in total, which turned out to be too small for quantitative analysis. At least, the reported views of patients did not contradict with the hospital staff survey.
Implementation of the various criteria of self-help-friendliness Table 1 shows the results of the first assessment (t1). For these purposes, the two positive response categories of the four-point scale (‘very true’ and ‘rather true’) were pooled into one category. On the whole, we see that those types of co-operation requiring ‘direct’ contacts between personnel and members of self-help groups usually are rated less positive (Items 7 and 9). For the criteria of ‘indirect’ collaboration (Items 1–3, 5, 6) with few exceptions, we find moderate to very positive assessments. Hospital A, which has already been the hospital with the longest experience in co-operation with self-help groups, achieved the best scores in all statements. However, as Hospital C began last with the implementation of SHF
Downloaded from http://heapro.oxfordjournals.org/ at Purdue University Libraries ADMN on June 7, 2016
As there was no instrument available for the measurement of SHF, we had to develop a new questionnaire. For this purpose, we conducted a qualitative study, comprising three parts: (i) expert interviews with 8 doctors, 3 psychologists, 12 nurses and 10 contact persons of co-operating self-help groups, (ii) group discussions within the Hamburg working group ‘Network Self-help-friendly Hospital’, and (iii) literature search and analysis (Trojan et al., 2009). These were the basis for defining and operationalizing the criteria for ‘self-help-oriented’ patientcentredness (SelP-K). The resulting questionnaire SelP-K consists of 22 standardized and four open-ended questions plus four socio-demographic items (Nickel, 2012). The questionnaire can be answered by any staff member as it is independent from qualification or position of staff. The core of 22 standardized statements (see Appendix) covers four dimensions of self-help-oriented patientcentredness (α-values are calculated on the data basis of the study as described below):
A. Trojan et al.
Implementing ‘self-help friendliness’ in German hospitals
307
Table 1: Criteria of SHF assessed by staff of three self-help friendly hospitals at t1 (‘very true’ and ‘rather true’ in per cent) Items of the dimension ‘involving self-help groups’
p-valuea
Hospital A (n = 20)
B (n = 97)
C (n = 72)
67
95
69
52
![[Distress Among Surgeons - a Study in German Hospitals.]](/assets/img/hold.png)
