The PACT of Patient Engagement

Patient engagement has become a widely used term, but remains a poorly understood concept in healthcare. Citations for the term during the past two decades have increased markedly throughout the healthcare-related disciplines without a common definition. Patient engagement has been credited for contributing to improved outcomes and experiences of care. Means of identifying and evaluating practices that facilitate patient engagement in care have become an ethical imperative for patient-centered care. This process begins with a definition of the concept. Concept analysis is a means of establishing a common definition of a concept through identification of its attributes, antecedents and consequences within the context of its use. Concept analysis is a methodology that has been used in social science and nursing as a means to resolve conceptual barriers to theory development in an evolving field. The methodological theory was based in the analytic philosophical tradition and sustained during the 20th century by the strength of philosophical positivism in the health sciences. This concept analysis is guided procedurally by Rogers’ evolutionary approach that incorporates postmodern philosophical principles and well-defined techniques. This dissertation is informed by the expanded and updated perspective of the neomodern era in nursing research, which advances the concept analysis methodology further. An analysis of the concept underlying the term patient engagement in the scientific literature revealed four defining attributes: personalization, access, commitment and therapeutic alliance. These defining attributes were derived through thematic analysis of over 100 individual attributes shared among six categories and three domains. The resultant definition revealed that patient engagement is both process and behavior shaped by the relationship between patient and provider and the environment where healthcare delivery takes place. Patient engagement is defined as the desire and capability to actively choose to participate in care in a way uniquely appropriate to the individual, in cooperation with a healthcare provider or institution, for the purposes of maximizing outcomes or improving experiences of care. In addition to the attributes of the concept identified in the literature, themes relevant to patient engagement were identified through inputs from six focus groups of persons living with HIV in New York City. The focus group participants were convened to inform the development of a mobile application designed to support their healthcare needs. Their experiences, insights and expectations were valuable in ascertaining those actions or behaviors that may serve to assist the patient in obtaining and adhering to care. The focus group transcripts were coded twice. The first round occurred prior to the concept analysis of the literature and used emergent coding methodology to capture meanings independent of the findings of the concept analysis. The second round occurred after the concept analysis of the literature and used the resultant attributes to perform a directed concept analysis of the transcripts. The content analyses of the transcripts from the patient perspective supported and reinforced the attributes from the concept analysis. The focus groups also highlighted another important aspect of patient engagement, that of privacy/confidentiality, which had not been specifically addressed in the concept analysis of the literature. The definition and the identified attributes serve as a heuristic in designing patient engagement strategies and as a basis for future development of the engagement concept in healthcare. The supporting concepts for engagement, especially the role of empathy in the therapeutic alliance, require further clarification and debate. While patient engagement may be promoted through face-to-face interactions or through health information technology, the defining attributes are invariable and should guide the design of engagement processes and tools. Finally, the value of understanding and exploring the defining attributes of patient engagement in medical and nursing education becomes clear, as is the need for continuing clinical training to support and encourage patient engagement skills.