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Information Authority
Patient-Led Learning
For The Clinical
Professions:
Fulfilling the Information
Needs of Patients
Final Report submitted to the
NHS Information Authority¡¯s
National Education, Training and
Development Programme
National ETD Programme,
First Floor,
Westerleigh House,
Blackberry Hill Hospital,
Manor Road,
Fishponds,
Bristol BS16 2EW
Tel: 0117 901 6162
Fax: 0117 975 4804
http://www.nhsia.nhs.uk
http://nww.nhsia.nhs.uk
NHS Information Authority ref: 2000-IA-280
Increasing opportunities for patients to obtain information led to
a reappraisal of the learning needs of all the clinical professions.
A multi-centre multi-disciplinary study, based initially on
interviews and surveys of clinicians, identified 46 learning
outcomes in eight areas to be addressed in planning curricula,
and 30 organisational challenges for health service and
educational managers. This report describes how this study
was carried out, its results and recommendations. Educational
methods, some of which have been piloted, that could be used
in tackling the learning outcomes are described.
Jones R, Tweddle S, Hampshire M, Hill A, Moult B et al
June 2000
This project was commissioned by the National Education Training & Development Programme of the
NHS Information Authority, formerly the NHS Executive.s .Enabling People Programme..
Project team
Project Board
University of Glasgow:
Ray Jones (Co-ordinator)
Sandra McGregor
Jill Morrison
Great Ormond Street Hospital:
Beki Moult
King.s Fund, London:
Alison Hill
Sarah Thompson
Juan Baeza
Dr Rebecca Dunn,
University of Nottingham:
Mandy Hampshire
Daphne Boot
University of Birmingham:
Sally Tweddle
Allan Marr
Consultant Geriatrician, St. Martins Hospital, Bath
Elaine Ballard,
Senior Lecturer, School of Nursing & Midwifery, University of Wolverhampton
Gillian Jordan,
Principal Lecturer Open Learning, University of Greenwich
Glenda Kenchington,
Head of Projects and Planning, University Hospitals NHS Trust, Birmingham
Paul Lawton,
Programme Manager, National Education, Training and Development
Programme, NHS Information Authority
Chris Pearson,
Programme Manager, National Education, Training and Development
Programme, NHS Information Authority
Marcel Pooke,
Chair, Healthcare Professions Steering Group, National Education, Training
and Development Programme, NHS Information Authority
Administrative Support Caryl Plewes,
National Education, Training and Development Programme,
NHS Information Authority
Correspondence should be Ray Jones
addressed to the main Mandy Hampshire
authors and grant holders Alison Hill
Beki Moult
Other Acknowledgements
r.b.jones@udcf.gla.ac.uk
mandy.hampshire@nottingham.ac.uk
ahill@kehf.org.uk
beki.moult@gosh-tr.nthames.nhs.uk
Dr Robbie Robertson for permission to reproduce the simulated patient exercise; Mark Duman who was
the original King.s Fund collaborator before leaving for another job; Academic colleagues and students
who participated in the Internet discussion group .comparative-health-systems..
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8
10
11
12
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36
37
41
Contents
Summary
Background
Note on Terminology
Aims and Methods
Results
Page
1. Learning Objectives and Organisational Challenges 13
LO/1-LO/8 Learning Objectives
OC/1-OC-3 Organisational Challenges 23
2. The Theoretical Framework 29
Transmission Model versus Transaction Model
3. Piloting of Learning Materials 33
LM/1 Sessions with Third Year Students 33
LM/2 Internet Discussion
LM/3 Simulated Patient Session
Discussion and Recommendations
References
Appendices
1. Implications for .Learning to Manage Health Information. 44
2. Further Reading 45
6
Summary
Aims:
The aims of this multi-centre study involving Glasgow,
Birmingham, Nottingham, and London, were to identify
learning outcomes and desired organisational changes
to fulfil the information needs of patients and to .make
use of. well informed patients in the professional
development of all clinicians.
Methods:
There were seven steps:
1. An interview schedule was developed and 20
clinicians were interviewed in Glasgow.
2. A revised interview was used with 52 clinicians
(Nottingham and London).
3. A Delphi exercise was carried out by post among a
further 37 clinicians concerning the relative
importance of the identified aims.
4. Educational sessions on this topic, for medical and
nursing undergraduates, were piloted in Glasgow.
5. An Internet-based international discussion between
postgraduate students was conducted on the
broader topic of the effect of IT based information for
patients.
6. A national workshop with 42 invited delegates and
speakers, at the King.s Fund, discussed the
meaning, utility and importance of the identified
learning outcomes, and the organisational changes
needed to implement them. The conference is
reported in a separate publication from the King.s
Fund.
7. A meeting was held to review the workshop
discussion and finalise a .checklist. of 46 learning
outcomes in eight areas for use by curriculum
planners, and 30 action points for health service and
educational managers.
Results:
There are three main outputs:
1. A list of 46 learning outcomes in eight areas to be
addressed in planning curricula, and 30 action
points for health service and educational managers.
2. An underlying theoretical model to put these
learning outcomes into perspective.
3. Three examples of learning materials which have
been piloted:
! A seminar and email follow-up amongst third
year students
! An Internet international discussion group
! A simulated patient scenario used by third year
medical students
Discussion:
We need to change our thinking about the relative roles
of clinicians and patients in the information gathering
process of health care. Many patients obtain their
information from a number of sources and build their
understanding of their situation over time. The clinicianpatient
consultation, and hence good communication
skills, is only one part of this process. Clinicians need
to learn how best to help patients gather and assimilate
information and how they themselves can best learn
from the patient and from this process.
Recommendations:
! The NHS Information Authority should facilitate
the funding of:
! Research projects to examine the impact of
innovations in patient information on
clinicians. learning
! Research projects to examine clinician
behaviours and organisational processes in
relation to the achievement of the outcomes
listed in this report
! Educational projects which involve the
development and evaluation of learning
packages which can be used by many centres
to address this topic across undergraduate,
postgraduate and continuing education curricula
7
! Audit projects which use the learning
objectives and organisational .action points.
developed here as the starting point for
developing standards and reviewing and
improving practice against those standards
! A review of the report .Learning to Manage Health
Information.1
! The Royal Colleges and Professional Bodies
should review their professional examinations to see
if these learning objectives are being addressed
! NHS Trusts, Primary Health Care Groups, Health
Authorities and Health Boards should review the 30
organisational challenges
8
Background
Patients have increasing expectations for health
information and can draw on a widening range of
resources2-3. Patients have been offered information in
newspapers, magazines and television for a long time.
However, over the last few years many new resources
have become available such as the World Wide Web4-5,
email discussion groups6-7, touch-screen information
points8-11, and telephone services12-13 in particular
NHSdirect14. In some areas patients are given copies of
their medical summaries or some other patient-held
records15-19, others have been offered online access to
their medical record20-21. Along with a general trend in
society towards involvement in decisions, there have
been specific programmes to encourage the patient.s
role in reaching clinical decisions in partnership with
clinicians22-23.
Much of the research effort in patient information has
been in the development or evaluation of innovations.
There is, for example, mounting evidence of benefits of
well-informed patients for health outcomes and cost
(e.g.24-26). Clearly more work with patients is still needed
to identify their information needs27-28. However, many
innovations in patient information fail to remain in
routine use beyond the research stage because of
educational or organisational barriers and there was
concern that the learning needs of clinicians to deal
with the .well-informed. patients were not being
addressed.
The National Education Training & Development
Programme of the NHS Information Authority (formerly
the NHS Executive.s .Enabling People Programme.)
invited proposals to address the learning needs of
clinicians and .patient-led. learning in January 1998. A
multi-centre bid co-ordinated by the University of
Glasgow and including the Universities of Birmingham
and Nottingham, Great Ormond Street Hospital and the
King.s Fund was awarded funding and work started in
April 1998.
Scenarios 1 to 5 show examples of how technology
could be used routinely in the near future.
Scenario 1
Mary Smith is shopping in a supermarket. On her way
out she notices a .kiosk. which has a screen with a
.rolling display.. It tells her that by picking up the
telephone next to the screen she can get a wide range
of free health information. Mary picks up the phone.
She hears a welcoming message, while the screen has
changed to offer a menu of options including General
Health Information, Support groups and useful
contacts, Pre-recorded tapes on a range of topics, and
a number of others. She touches the screen to choose
General Health Information and then Back Pain. A
series of screens is displayed, describing the likely
causes of back pain and ways to try to prevent and
alleviate it. The final screen offers her the chance to
telephone NHSdirect and talk to somebody. Mary
touches this option and the computer dials NHSdirect.
The operator at NHSdirect suggests that she thinks
about replacing her mattress if it does not support her
comfortably. She is also told about special exercise
classes at her local leisure centre for people with back
problems. However, she is advised to contact her GP
first. When she is finished she touches the print button
and obtains a printout of the addresses. She uses the
phone to book an appointment with her GP and takes
the printout with her.
Scenario 2
Adam Smith has access to the Internet on his home
computer. His GP suspects that he has a rare blood
disorder but they are awaiting the results of the blood
tests. Adam searches the World Wide Web and
Bibliographic Databases for information on the
condition. He prints out the information and takes it
with him when he sees his GP. The GP has the results
of the blood test and is now 90% certain that Adam has
the condition. They review the material that Adam has
found. The GP says that some of it is not at all relevant
to Adam, other material however is. It includes results
of some new randomised controlled trials that the GP
was not aware of. The GP keeps the printouts to review
and they book another appointment to review treatment
options.
Scenario 3
A few years ago Carol Jones nearly died as a result of
a rare type of brain tumour. It was successfully
removed but she has had to adapt her lifestyle to her
condition. She gets tired quite easily, she has problems
with some bright neon lights, in periods of mild relapse
she gets a bit muddled. Her GP is aware of a
discussion group on the Internet. Knowing that Carol
has access to the internet on her home computer, the
GP suggests that she see if it is of any help. Carol
joins the discussion group and now corresponds with
fellow sufferers in the USA and New Zealand. The
emotional support that she gets from these links helps
9
her greatly in facing and dealing with her condition.
She goes to see her GP less!
Scenario 4
Fiona Robertson has had abdominal pain now for some
weeks. Her GP has referred her to see a specialist.
She has been asked by the specialist to go to use a
touchscreen .Healthpoint. in her local public library. The
Healthpoint gives her secure access over the Internet
to a hospital web page. She logs on to the clinic page
using the password sent to her by the specialist. She
is taken through a comprehensive interview about her
symptoms over the last few weeks. She is able to stop
the interview at various points to find out why these
questions are being asked and to get further
explanations. When she finally attends the clinic,
Fiona has had time to think about any further
questions she has and the specialist already has a
detailed history. The time spent in the clinic can be
kept to a minimum and the consultation is more
.productive. for both patient and professional.
Scenario 5
Elsie Stewart has breast cancer. She is to have
radiotherapy treatment. On the day she first attends
the treatment centre she is able to use a touch screen
computer to find out information from her own medical
record with explanations, find out about the treatment
centre and its staff, and find out about radiotherapy
treatment and its likely outcome. Two days later a
printout of all the information she has seen arrives at
home so that she can show her partner and family.
She has some doubts and worries about some of the
information in the printout and raises these with the
specialist breast cancer nurse at her next visit.
10
way:
Note About Our Terminology
In this report, we have used the terms .learning need.,
.learning objective. and .learning outcome. in the following
Learning Need:
Recognition of a topic or area in which clinicians needed to
acquire new skills or knowledge.
Learning Objective:
A behaviour that clinicians should be able to demonstrate.
For example, clinicians should be able to do X.
Learning Outcome:
It was quite clear that there were skills which clinicians
had but, because of various barriers, did not practise. We
felt it more appropriate to express the main output of this
report in terms of learning outcomes. For example,
clinicians should do X.
11
Aims and Methods
The original motivation for this study was to investigate
what the learning needs were when faced with a .well
informed. patient and to pilot some learning materials.
However, it soon became clear, when constructing our
initial interview schedule, and in our pilot study, that we
needed to take a broader perspective. Rather than just
consider the .well informed. patient we interviewed
clinicians about how they helped ALL patients meet
their information needs, and tried to identify those areas
which they found difficult or which they identified as
important. This study was therefore deliberately
clinician-centred, and involved a range of clinicians
(doctors, nurses, and professions allied to medicine) in
hospital, primary and community care. It also aimed to
be geographically inclusive, with interviews conducted
in Glasgow, Nottingham, and London, and postal
questionnaires involving clinicians over a wide area.
The development of learning objectives had four stages.
First, an interview schedule was developed and 20
clinicians (Glasgow) were interviewed. The taped
interviews were analysed thematically, to identify
learning needs and organisational changes that would
help in meeting patient information needs, mostly as
perceived by the clinicians. Second, a revised interview
was used with 52 clinicians (Nottingham and London).
The total of 72 clinicians comprised 24 hospital
doctors, 13 GPs, 14 hospital nurses, 12 health visitors,
7 PAMS, and 2 other clinicians. Third, consensus
among a further 37 (13 nurses, 12 doctors, 12 PAMS)
clinicians concerning the relative importance of the
identified aims, was investigated by postal
questionnaire. Lastly, a workshop with 42 invited
delegates and speakers discussed the meaning, utility
and importance of the identified learning outcomes, and
the organisational changes needed to implement them.
This discussion was used to further re-word, refine and
regroup a .checklist. of 46 learning outcomes in eight
areas for use by curriculum planners, and 30 action
points for health service and educational managers.
Educational sessions on this topic, for medical and
nursing undergraduates, were piloted in Glasgow.
Aims
! To identify learning outcomes for clinicians and
organisational challenges in fulfilling the
information needs of patients
! To pilot some learning materials, and suggest
others, which could be used to help meet the
learning outcomes set for clinicians
12
Results
The results of this study are presented in three
sections:
1. A list of learning outcomes of clinicians and
organisational challenges.
2. A description of how we should move from a
transmissive to a transactional model.
3. Three examples of learning materials which have
been piloted:
(a) a seminar and email follow-up amongst third year
students,
(b) an Internet international discussion group,
(c) a simulated patient session used with third year
medical students.
13
(2)
(5)
14
15
16
16
18
20
21
22
23
23
23
25
26
27
28
Results 1:
Learning Outcomes And
Organisational Challenges
Forty-six learning outcomes were grouped under the
eight headings shown in the Table. Thirty organisational
challenges were grouped into those for health care
organisations, those for research institutions, and for
those planning and managing curricula.
Learning Objectives:
LO/1. Placing a higher priority on patient information
and education (6)
LO/2. Understanding the patient.s information needs
and environment (7)
LO/3. Understanding the emotional aspects of learning
LO/4. Developing patient understanding (3)
LO/5. Helping patients to understand about health care
and health care information (10)
LO/6. Learning from the patient (5)
LO/7. Knowing about information sources and their use
LO/8. Issues of multi-disciplinary working (8)
Organisational Challenges For:
OC/1. Health Care Organisations (20)
OC/1-1 Strategy and corporate aims
OC/1-2 Quality Assurance
OC/1-3 Resources
OC/1-4 Medical Records
OC/2. Research and Development (7)
OC/3. Educational and Professional Institutions (3)
page no.
14
Learning Objectives
LO/1
Placing A Higher Priority On Patient
Information And Education
Clinicians should:
1. Take a patient-centred approach by (e.g.) enabling
the patient to lead the agenda in the consultation.
! Yes, I think making decisions in a shared way
with the patient is a slightly more complex
area. Often a patient will want you to make a
decision for them, and you have to be very
careful that you don.t actually fall into that trap.
.You said it was all right for me to go abroad:
my mother died while I was away.. So that
kind of decision making you have to be very
careful about, but still that.s part of our job, to
help the patient make the decision.
GP, Glasgow.
! The fact that the diabetes unit provided
patients with a print out of all their medical
records and were happy to discuss these was
an indication of the general philosophy of the
unit to encourage an active role by patients.
Diabetes Consultant, Nottingham
2. Know that the aim of patient education is the
development of the patient.s understanding and not
the transmission of information.
! Only 3 out of 37 respondents in the Delphi
exercise had attended a communication skills
course in the last 12 months.
3. Know the effectiveness of different methods of
helping patients to obtain information.
! Many Glasgow and London interviewees had
not read any literature on patient information or
undertaken any formal training. In contrast, all
12 interviewees in the Nottingham Diabetes
Unit had read recent articles about patient
information and seven had undertaken courses
on dealing with informed patients. (Interpreted
learning outcome.)
4. Find ways of handling their own discomfort caused
by a patient.s reaction (e.g. to uncertainty) or by
interaction with an informed patient.
! Clinicians should be able to react to requests
for information without being defensive.
Nurse Practitioner, Delphi Exercise.
! Be able to communicate this [Lack of
Knowledge] to the patient without guilt, but to
try and obtain answers.
Physiotherapist, Delphi Exercise.
! If I feel that somebody is coming in to the
consultation informed but generally interested
in what I think...then I.m very happy to sit and
discuss it but when I feel that I.m being...on
trial in a way then they.re testing me out as
to whether I know what I.m talking about,
then I find that I start to get annoyed.
GP, Nottingham
5. Make efficient use of their time and prioritise their
activities to spend sufficient time on meeting
patients. information needs.
! Body language is everything. An important
man who is in a rush and is too busy won.t
get asked any questions.
Consultant Paediatrician, London
6. Make it clear to patients that their information
needs are important.
! I.m quite happy to discuss <press cuttings>
with them...I say .please send me the stuff
so I can have a look at it, so I know what
you.re doing..
15
Learning Objectives
LO/2
Understanding The Patient¡¯s Information Needs
And Environment
Clinicians should:
1. Know how to establish what the patient knows at
the beginning and at the end of a consultation.
2. Give patients the opportunity to show their level of
knowledge and understanding and try to identify
misconceptions.
! She was a well-educated woman...so
everybody was presuming that because she
used the medical terminology appropriately...
that she understood the implications,
treatment and on going prognosis of the
condition. She didn.t.
Specialist Nurse, London
! I think they.ve misinterpreted it in a number of
ways, sometimes they misinterpret something
that.s very uncommon they think it.s very
common, something that.s not at all serious
they think it.s very serious and some things
which they think are curable are incurable,
those are the kinds of misguided ideas people
often have.
GP, Nottingham
! Several nurses in the diabetes unit said
patients who received copies of the letter
.owned. their condition more and became more
involved in their own care. They often asked for
clarification of points they did not understand
or chose to act on information about the result
of their blood test. Another nurse thought that
the patients of the only one consultant who did
not send them a copy of the letter, seemed to
be less informed than the patients of the other
consultants.
Nottingham Diabetes Unit
3. Know when and how to include the patient.s family
in information exchange.
! Well I will often, from the parents, get an idea
of what they think they.ve been told and then I
will check if that.s what the professional
concerned thought they.d told them and I get
the feedback saying the other way round.
GP, Nottingham
4. Be able to judge the level of knowledge held by the
family and the role of different family members in
information exchange within the family.
! ...more articulate fathers I.ve noticed probably
often take the role of wanting to find out lots of
information. Professional fathers might be the
ones that are searching the Internet and
bringing in bits of information.
Specialist Nurse, London
5. Use their assessment of what the patient knows to
discuss with the patient how much information they
want, and in what form they need it.
! ...I feel I.ve got to start off by finding out what
they know and then building on that...and if
they haven.t got the basic information I have
to fill that in first, and that is where I worry
because in a sense that may be as much as
they can take in first time around.
Oncologist, Glasgow
6. Know the different communication and information
needs of patients from different cultural, ethnic, and
language groups, and those unable to access
information in a spoken or written form.
! If they.re not literate, I mean I.ve certainly
worked with families who can.t read...
everything has to be done at a personal level.
Health Visitor, Nottingham
7. Re-assess what the patient knows and what
information is required over time.
! Another thing a lot of the parents find helpful is
that because they have repeated surgery and
repeated visits then I will write down the dates
of surgery and release of syndactyly, index
middle finger. I don.t go into great detail, just
put what they have done, and they find that
helpful for other professionals and schools and
things.
Specialist Nurse, London
16
Learning Objectives
LO/3
Understanding The Emotional Aspects Of
Learning
Clinicians should:
1. Know that emotion may be a barrier to, or may
drive, learning.
! I find that a lot of patients will ask questions
to those that they gel with or get on with,
regardless. Often they won.t ask a question if
that person they get on with isn.t working that
day, or isn.t around, if it.s lunch time and they
would wait to ask the question the next day.
Radiographer, Glasgow
! ...I.m thinking of particular cases who perhaps
don.t even know what their diagnosis is...you
still get that...and you think .my goodness.
...you wonder how they.ve got to this particular
stage, but it does happen. Then again the
particular individual may be in denial, they may
have been told...it.s very difficult...
Nurse, Glasgow
2. Know how to respond to and build upon an
emotional response.
! I think people who have naturally high levels
of anxiety...can be made a lot worse by having
information...It comes back to the question of
how much do you tell patients about, for
instance, side effects of the drugs that you.re
prescribing, it.s easy to say .I tell everybody
everything., that.s a facile way out of a difficult
situation, yes I think it.s difficult but I think that
some people would be made worse and some
people would be impaired by that.
Nottingham GP
LO/4
Developing Patient
Understanding
Clinicians should:
1. Take advantage wherever possible of a continuing
relationship with the patient to introduce new ideas
in manageable amounts over a period of time.
! And if you.re not actually seeing them very
often you.re under pressure to unload quite
a lot of information in a single consultation,
which might be better given in stages.
Consultant Oncologist, Glasgow
! ...picking up three or five years later on what
somebody knows...things have changed in that
interim.
Consultant Diabetologist, Nottingham
2. Guide patients in their gathering and assimilation of
information outside of the consultation.
! We have lots of booklets and would dish them
out to parents if asked. Sometimes we use
them as a gift to children. When the condition
is laser treatment for port wine stains in the
Puss Puss books, so we would give them as a
gift.
Paediatrician, London
continued...
17
Learning Objectives
LO/4
Developing Patient Understanding
...continued from previous page
3. Ensure that patients are given or can acquire
appropriate information from a variety of available
sources.
! .We should certainly be involved in any
literature that.s produced, I.d be very unhappy
with literature I.d never seen..
Consultant Paediatrician, London (Interpreted
learning outcome).
! In the conference there was discussion about
clinicians not having confidence in good
sources of information .not invented here. but
which could be very useful for patients.
! Health visitors in Nottingham gave examples of
photocopying DoH guidance on immunisations
or (eg) the COMA report, for mothers.
Health Visitors, Nottingham
! ....I have got a patient that.s autistic and there
was all this stoushy about the measles
vaccine...and I gave her a full copy of a BMJ
editorial about it..
GP, Glasgow
18
Learning Objectives
LO/5
Helping Patients To Understand About Health
Care And Health Care Information
Clinicians should:
1. Acknowledge what they do not know, should
explain the uncertainty in their own diagnosis
or treatment and how this may be resolved, but
taking into consideration the psychological
state of the patients and their ability to handle
uncertainty.
2. Be able to help patients understand concepts
of risk.
! My main worry, from the television, the media
generally and I include the Net, is that
information is rarely put to them in terms of
risk factors, so they get an inordinate fear of
consequence, complication, the risks of
medication, all things like that without putting it
into context about the risks of daily living.
Nottingham GP
3. Be able to explain how therapies should be
based on the assessment of evidence.
! There was a patient with a magazine
article looking at cachexia and cancer
patients...I.m reading the article...the way they
were putting forward their case, there was no
hard evidence to back it up. This particular
lady looked at it and she thought .isn.t this
wonderful, there was this wonderful injection
that was going to cure all weight loss for all
cancer patients..
Nurse, Glasgow
4. Help patients understand how the health care
team works. Help patients understand that
although they may get different information
from different members of the team it should be
consistent.
! The Arabs say, .you don.t go to any doctor,
you.ve got to go the doctor with grey hairs
because he has seen it all.. I suppose it
depends on the confidence you instil in
parents.
Consultant Paediatrician, London
5. Help patients and their families understand how
the assessment of diagnosis or need for
treatment may change as information about the
patient (e.g. tests) or about new treatments
becomes available.
! ...you can be in the situation where, for
instance, an x-ray report isn.t in. You.re told
the patient has no metastases, you go along,
you find a report that says lung metastases.
You spoke to the surgeon who said there were
no metastases, you say .oh well in that case
some pre-operative radiotherapy would be
okay.. They tell the patient Dr X is going to give
you some radiotherapy, you come along you
find the metastases and you tell the patient
.we can.t..
Oncologist, Glasgow
6. Help patients and their families understand that
information they have accessed may be aimed
at a different group of people with the same
condition and that the information may not be
applicable in their case. This is particularly the
case with the special needs of children.
! Parents came up and said, .can we have this?.
and in fact they weren.t available to children. It
was a trial for adults but as yet it hadn.t been
fully approved for paediatrics.
Specialist Nurse, London
7. Employ effective and tactful methods for guiding
patients through good and poor sources of
information.
19
Learning Objectives
8. Share their own guidelines for judging the
quality of information with patients.
! There was a patient with a magazine
article looking at cachexia and cancer
patients...I.m reading the article...the way they
were putting forward their case, there was no
hard evidence to back it up. This particular
lady looked at it and she thought .isn.t this
wonderful, there was this wonderful injection
that was going to cure all weight loss for all
cancer patients..
Nurse, Glasgow
9. Be sensitive to the risk of damaging the self
esteem of a patient with wrong information.
! Nearly all health visitors had met parents who
appeared to have incorrect information from
reputable sources. Very often, however, the
HVs thought that parents had not received
misguided information but had misunderstood
what they had read or been told. Most HVs
would not directly contradict what parents said
but would try to deal with the situation .gently
and without being patronising..
Nottingham HVs.
10.Explain to patients how errors can occur in
medical records and how they can take action
to correct such errors.
! Eight of the nine professionals reported that
patients frequently pointed out mistakes in
their notes and that these were always
amended.
Nottingham Diabetes Unit.
20
Learning Objectives
LO/6
Learning From The Patient
Clinicians should know how to learn from the patient:
1. What it is like to have a condition so that they can
better understand other patients and can act as a
.clearing house. for coping strategies.
! A patient comes and gives their account of
their experiences, what could have been
better, what could have been different, the
effect it has on them. And I think to hear it
from the horse.s mouth like that always
impacts professional more than the other
professional standing up and saying
.you should do this or that..
Nurse Specialist, Glasgow
! An example was quoted by one nurse of a
seven year old girl attending the diabetic camp
who had shown the nurse how she had found
a way of injecting insulin into her arm by
herself, by bending down and squeezing her
arm between her knees. The nurse had been
able to pass the tip on to several other
patients. One doctor pointed out that he
learned from the life experiences of all patients
and not only from the better informed ones.
Patients were a source of information about
new diabetic food products in supermarkets,
new types of medication advertised in the
media and new meters or gadgets.
Nottingham Diabetes Unit.
2. The impact of treatment on the patient.s life and
strategies for dealing with it.
! They...get all this information and weed bits
out...sometimes they can say, Well when our
child was at this stage of its treatment we did
so and so and it worked really well. Then you
can make a note of that and say .I can
remember that.. Then if someone else asks
me that question I can say I haven.t actually
seen this work but I know that one of the
parents tried this. So I think yes, you can.
Clinical Nurse Specialist, London
3. New clinical knowledge through patients. information
gathering activity.
! This particularly holds true for alternative
medicine. I treat a number of conditions that
are simply not treatable by conventional
western medicine...one of the parents [is] a
Chinese practitioner and he had treated his
daughter with this concoction, a mixture of
things and apparently it.s very effective...I.ve
asked him to send the prescription of the
treatment to me. I.ve asked that because I
want to know, but I think it helps parents form
a bond with us because they don.t feel they.re
being ignored.
Consultant Paediatrician, London
! Twelve of the thirteen professionals who were
interviewed had had the experience of being
presented with information by a patient which
was either new or with which they were
unfamiliar - sometimes it was about alternative
therapies.
Nottingham Diabetes Unit.
4. What aspects of service provision matter most to
patients and how effectively services and systems
are working.
! One GP from Nottingham said that he learned
new clinical information about the
complications of the MMR vaccine from a
patient.
GP, Nottingham
5. New or different sources of information.
! It.s a learning experience because they.re
always making us think about the things that
are going on outside Great Ormond Street
(GOS)...it keeps us on our toes and makes
sure we don.t say, .we do it the GOS way..
Specialist Nurse, London
21
do..
Learning Objectives
LO/7
Knowing About Information Sources And Their
Use
Clinicians should:
1. Know where to look for information and when it is
most efficient and valid to use colleagues, books,
bibliographic databases, knowledge bases, or the
Internet to find information.
! Somebody came in recently with some ENT
condition which I.d never heard of, she.d
brought a piece of paper with a diagnosis
written on it, which she had been told by the
ENT Clinic that she had. I.d never heard of it,
neither had any of my colleagues, nor was it in
any of the books we had here. However we
did have a quick look on the Internet, found out
some surgical treatment for it. So I.m waiting
untill I get the confirmation.
GP, Glasgow
2. Know how to filter information and avoid the
irrelevant so allowing more time for meeting patient
information needs.
3. Know the range and effectiveness of different
methods for patients to obtain information and how
to promote the use of effective sources within their
clinical team.
! Every one of the ten interviewees who were
asked said it was common practice in the
diabetic unit to give out leaflets and
publications from the BDA or to give patients
the telephone number of the BDA care line.
Nottingham Diabetes Unit.
! ...I think with some parents it is quite difficult in
parents actually accessing...Going into local
libraries and things that the medical sections
aren.t always up to date. I do find that the
articles I.ve got, there are certain articles I can
send to parents, so I will actually photocopy
them and send them on to parents.
Specialist Nurse, London
! Obviously with the junior doctors, that.s not
always so. So I just say to them, if there.s any
information you want or find you need you can
always ask myself, there are the books on the
ward, there is the library.
Clinical Nurse Specialist, London
4. Have confidence in good sources of information
produced elsewhere.
! There should be, via your resource centre,
limited access to information. Information
that.s been screened for various things that is
enough information that is also friendly to the
docs, you know, it doesn.t put them in an
awkward position.
Consultant Paediatrician, London
5. Know when and how to make use of patient and
parent support groups and informal networks, both
in their own education and in referring patients or
families for information and support.
! Clinical nurse specialists in various areas have
a liaison with the parent associations...and
know...what sort of tune they play.
Consultant Paediatrician, London
! Some of them have wonderful counsellors...
some of the best...I have my own tame
counsellor [at the support group] who is not
employed by the NHS but probably works
longer hours for the Hospital than most people
Consultant Paediatrician, London
22
Learning Objectives
LO/8
Issues Of Multi-disciplinary Working
Clinicians should:
1. Explain to patients that different members of the
team will have different expertise and therefore will
be sources of different information.
! Doctors in primary care saw their working
relationship with nursing staff as giving the
opportunity to delegate some of the
responsibility on issues of communication with
patients and their carers.
2. Help patients understand the roles of different
members of the clinical team and how other
members of the team will be able to provide
information on other aspects of the condition or
treatment.
! ...patients are given expectations by the first
set of people they see...then as the specialists
and we say something different, they find this
quite hard...
Consultant Oncologist, Glasgow
3. Communicate well with colleagues over what a
patient has been told, what the patient seems to
understand or not, and what the patient.s fears and
concerns are.
! Parents. knowledge is recorded in the
admission assessment sheet so anybody
looking after that child can see how well the
parents understand.
Specialist Paediatric Nurse, London
4. Know how to record and interpret information about
what the patient knows, understands and has been
told and about the patient.s approach to learning.
! I.ve admitted consultants in this ward...they
may not be an expert in this particular
treatment they.re getting...good to see what
their baseline knowledge is...obviously they
may take it into a lot more detail.
Nurse, Glasgow
5. Give patients the opportunity to contribute to their
own records.
! ...a mistake had been pointed out by a
patient, who borrowed a pen one day, changed
his notes. He went to the toilet and changed
his notes because a doctor had written that the
patient smoked.and he most definitely did not
smoke.
Radiographer, Glasgow
6. Know how to tactfully help other members of the
team to improve their patient information skills.
! We find that some parents are given the
[wrong] information by a well meaning
professional who.s tried to ease their anxieties
and in fact, they.re making the situation a lot
worse.
Specialist Nurse, London
! In response to the question .What would you
do if there was a colleague in the team who
was considered to have poor communication
skills?. several interviewees thought this was a
difficult issue which might be embarrassing to
deal with.
Nottingham Diabetes Unit.
7. Know the team.s policy, national or local guidelines
for patient information.
! An example was given from staff in the
Nottingham diabetes unit of junior staff not
knowing the unit.s policy or ethos.
Nottingham Diabetes Unit.
8. Give consistent (not necessarily uniform) messages
and use a similar patient-centred approach.
! If you have a multi-disciplinary clinic with
specialist nurse supporting the patient,
surgeons, pathologists, radiologists,
oncologists...if they meet regularly...then any
member of the team can support the patient.
Oncologist, Glasgow
23
Organisational Challenges
OC/1
Organisational Challenges For Health Care
Organisations
OC/1-1. Strategy And Corporate Aims
Health Care Organisations should:
1. Treat meeting patient information needs as a .core
activity. and not as a peripheral issue.
! 31 out of 37 in the Delphi Exercise felt that
communication skills were not given the right
priority in the NHS.
There are three offices and five nurses so
yesterday we were all having to swap rooms
and therefore everyone kept popping their head
round the door to see if the room was free and
we don.t have enough space and that.s one of
the things that creates interruptions.
Diabetes Nurse, Nottingham
2. Ensure that there is adequate funding, space and
time devoted to patient information.
! Conference delegates agreed that the provider
organisations should consider investing in
information management to facilitate patient
and clinician access to up to date and high
quality information.
3. Place a higher priority on continuity of care.
Continuity of care should be addressed through
(e.g.) shared-care schemes, patient-held records
and good record keeping.
! The problem arises when you don.t have an
integrated team, when the patient is a parcel
that.s passed from one individual to the
other...and then you lose it...if there.s an item
of information wrong, the extraction of data
hasn.t been correct...then confusion arises.
Oncologist, Glasgow
OC/1-2. Quality Assurance
Health Care Organisations should:
1. Produce, implement and review guidelines on
patient information and patient-centred
consultations. For example, many clinicians allow
themselves to be interrupted in the consultation. The
restriction of the use of bleeps and telephones and a
greater use of electronic mail and .asynchronous
communication. will allow clinicians to concentrate
on .the job in hand..
! One of the doctors thought that bleeps should
be left at a desk centrally and that queries
could then be answered after the consultation.
Nottingham Diabetes Unit.
! One of the drawbacks of my job is you.re
constantly interrupted by the telephone...it.s a
source of great annoyance to patients and to
parents.
Nottingham GP
2. Organise contacts between patients and clinicians
so that patients. information needs are met by
clinicians with good communication skills.
Communication skills should be subject to audit and
peer review.
! ...in terms of what is available for them to help
with their social and psychological needs, no I
don.t think the doctors are <good at helping>
...I don.t see any reason why a radiographer
couldn.t be.
Nurse Specialist, Glasgow
24
Organisational Challenges
3. Ensure that all staff have adequate opportunity to
learn about patient information needs.
! We try to keep SHOs out of the diabetic
clinic now because a lot of patients are better
informed.
Diabetes Consultant, Nottingham. (Interpreted
learning outcome, illustrates the limited
opportunities that may be available for
clinicians to learn or practice their skills.)
4. Audit methods of working to ensure that patients
have had adequate explanation and information
before attending for investigations or operations.
This is especially important if patients or families
are to be able to give truly informed consent.
! Quite often parents ring up and say they.re
coming in for a certain operation, but they don.t
really know what.s involved at that point...a lot
of information is not available until they get
here [the ward].
Nurse, London
5. Review methods of working to identify ways of
reducing workloads by making better use of wellinformed
patients or parents.
! ...it can cut down on the amount of outpatient
visits they need. Some of them just ring up.
They used to say, we need to see the doctor to
discuss so and so, whereas if they.re well
informed you can keep the outpatient
appointments to the necessity.
Nurse, London
! If you.ve got say a diagnosis of asthma or
something, I think the parent who is well
informed you probably are going to spend a lot
longer with than the one that you.re merely
going to teach the mechanics of .This is what
you do.. Ultimately...they will manage the child
better, they.ll probably consult you less and
when they do it will probably be an easier
consultation if you.ve got mutual respect and if
I know they know how to manage. If I do say a
6 month or an annual review of a child with
asthma and the parent is well informed...it can
actually be very, very quick.
GP, Nottingham
6. Ensure that the consultation process can
accommodate the family where appropriate and
meet their own information needs, as well as those
of the patient. This is particularly important where
the patient is a child or an incapacitated adult.
7. Implement a process of multi-professional review of
patient information to develop consistent messages
about diagnosis, treatment and care and how the
different professions view these.
! ...there has got to be a willingness to be open
and to talk amongst ourselves...one group
does one thing and one group another...we are
beginning to make inroads because we now
have multidisciplinary groups looking at patient
information issues.
Nurse, Glasgow
8. Ensure that, where available, patient information
supplied by the organisation is evidence based.
! ...what worries me...is the information they.ve
got, what they don.t have is the other missing
bits. That has been my main criticism of the
Bacup prostate bit, the leaflet, is that it missed
out two or three important things in its first
version. That.s why I brought it to their
attention...
Oncologist, Glasgow
25
Organisational Challenges
OC/1-3. Resources
Health Care Organisations should:
1. Consider whether it is appropriate to have
specialised staff (such as psychologists, play staff,
speech and language therapists) to ascertain the
level of knowledge and understanding of the patient,
if that patient is a child or an incapacitated adult.
Such staff would be able to work with clinicians in
choosing good quality information.
! ...I don.t think we can go into a great deal of
counselling in the ward environment...as you
can see it.s a very open ward...counselling is a
private thing...there are nurses that we could
refer them to...
Nurse, Glasgow
2. Consider whether it is appropriate to have
specialised staff (such as librarians) to guide
patients through information sources such as
leaflets, computer-systems, videos, the Internet,
bibliographies.
! <talking about clinical nurse specialists>. That
is the best thing that has happened in clinical
medicine...because they have the permanence
that the junior staff don.t.
Consultant Paediatrician, London
3. Ensure that clinicians have access to reviews and
sources of information available to patients on the
Internet, leaflets, computer-systems, videos, etc.
! We have lots of booklets and would dish them
out to parents if asked. Sometimes we use
them as a gift to children. When the condition
is laser treatment for port wine stains in the
Puss Puss books, so we would give them as
a gift.
Paediatrician, London
! ...there was one in the newspapers about the
update on Tamoxifen, that can actually prevent
breast cancer in women who are genetically
prone to it, I.d like that to be available within
the department before a patient gets it to me. I
would prefer to be informed about it rationally
rather than a patient come in with a newspaper
article...
Radiographer, Glasgow
4. Ensure that clinicians have easy access to up-todate
information about patient and parent support
groups and networks
5. Assess and make use of innovations in patient
information such as touch-screen systems, patient
guidelines and checklists or patient-held records, if
there is evidence that they improve patient
information.
6. Ensure that all groups in society have sufficient
information resources and support, especially those
with special needs such as those with language
differences, ethnic groups with different cultural
needs, children, those with low literacy, and
incapacitated adults.
7. Provide information about how the organisation
works and which describes the roles of different
professionals and departments within the
organisation.
26
Organisational Challenges
OC/1 - 4. Medical records
Health Care Organisations should:
1. Implement record systems that support the
recording of how the patients. information needs are
being met.
! Mostly what I have told them is not recorded
unless I feel there may be a medical legal
situation in the future.
Paediatrician, London
! All the health professionals said they recorded
what information they had given to patients in
the patients. hospital medical notes and
diabetic summary sheets and, in the case of
nurses, chiropodists and the dietician, in their
own notes too. (In the case of dieticians there
is a legal obligation to do so).
Nottingham Diabetes Unit.
! Parents. knowledge is recorded in the
admission assessment sheet so anybody
looking after that child can see how well the
parents understand.
Specialist Paediatric Nurse, London
! ...we have got a big discrepancy where you.ve
got patients in a trial situation who have to
have a box ticked which says...received
informed consent...and others for whom it.s not
recorded in any way.
Nurse Specialist, Glasgow
2. Implement record systems and processes that give
patients the opportunity to contribute to, and audit
their medical records.
! This point was raised in group discussion at
the conference when considering how
clinicians were going to maintain the records
and the benefits of patient held records.
Conference.
27
4.
5.
6.
7.
Organisational Challenges
OC/2
Research And Development Challenges
Health service research and development should be
undertaken to:
1. Further develop and implement systems that filter
and present summaries of new research to
clinicians.
! To have a slightly more limited database, than
just looking at a whole wide range of...because
...Medline takes a year and a day, you really
want to have something that is kept up to date,
with a service to, let.s say general practitioners
who can tap into it.
GP, Glasgow
! What they need, I think, is information relevant
to them. If people want 5 year survival figures
for different stages of different cancers then
that.s okay. I would love it all be put together in
one short document, because I can never
remember.
Consultant Oncologist, Glasgow
2. Continue development of .gateways. to information
such as OMNI and provide local sources of
information through (for example) medical libraries
and decision support systems.
3. Examine the evidence about the effectiveness of
complementary and alternative therapies that are
favoured either by patients or are used in other parts
of the world (e.g. China or the East).
! ...sometimes, particularly in the realms of
complementary therapies and such like,
there.s a lot of things I don.t know the answers
to, and I don.t necessarily have the resources
for them. So quite often it will send me...trying
to find out things to pass back to them.
Nurse Specialist, Glasgow
Explore the relationship between information and
anxiety, depression and feelings of autonomy
! ...there is a group of patients who do want all
the information that you can give...equally
there are a lot of patients who are confused
when they are offered choices and it makes
things difficult for them and there are people
who actually say .no I don.t really want to
know that, I.m happy to let things go.. So it.s a
bit of a mixed bag.
Nurse Specialist, Glasgow
Develop and evaluate generic guides for patients
which explain
- Having a good relationship with your doctor,
nurse, or other health professional.
- How to assess the quality of information
- The role of the medical record and how the
patient can play a role in keeping that record up
to date and correct
- The ideas of risk in relation to treatment and
disease
- How diagnoses are developed and refined.
- That information they have accessed may be
aimed at different groups (e.g. adults and not
children).
! I would like to see a universality in the
information that is provided...across the
disciplines some agreement and some hard
protocols...have some protocols in each
division...
Nurse Specialist, Glasgow
Develop better clinical record systems that prompt
for and display information about the patients.
understanding and information needs and that do
not prevent the patient.s agenda being the basis of
the consultation.
Investigate the use of patient-held records to help in
the integration of information across members of the
multi-disciplinary team
28
Organisational Challenges
OC/3
Challenges For Educational Institutions And
Professional Organisations
1. Curricula need to be checked to see that patient
information receives appropriate priority and that all
educational outcomes are being addressed.
! ...the younger students are hopefully being
encouraged to come with a more open
approach to their patients...
Nurse Specialist, Glasgow
2. Patient information as well as communication skills
should be addressed in all curricula.
! I think if we are ever to get away from
compartmentalising nurses, radiographers and
doctors, and everyone be within their own
domain, I think the only way to do that is for us
to do training together. There are lots of areas,
like communication skills...that we could be
taught together, and I think that would go a
long way in breaking down barriers.
Nurse Specialist Glasgow.
(Note, however, that in the Delphi exercise
opinions were divided over this. It is clear that
patient information should be addressed in all
curricula but there is still debate about whether
this should be .together..)
3. Incentives and penalties should be employed to
ensure that those who need them attend courses.
! The sad thing about it is that the ones who are
good and interested are the ones who come on
all the courses, and the ones who could do
with coming on the courses don.t see that they
have a need to do it, because they don.t have
enough insight...
GP, Glasgow
29
Results 2:
The Theoretical Framework
Towards a transaction model of patient -
professional interaction in the consultation.
Introduction
A model has been developed to provide a tool for use
by health professionals. It takes the form of a
framework for analysing how they inform and educate
patients, how they obtain informed consent and how
they encourage patient participation or responsibility. It
has been developed within the context of an increasing
emphasis on patient professional partnership and the
growing recognition of the impact of information and
information technologies on patient/professional
relationships30-33.
The approach taken is informed by research into the
ways in which .novices. can become .experts.34. One of
the outcomes of the study reported here is the
recognition that while the patient may traditionally have
been regarded as the novice and the professional as
the expert, there are areas of knowledge and
experience in which the relationship is reversed. It has
been argued that distinctions between equal
partnership and equal responsibility in the medical
consultation have been insufficiently clarified35. The
framework presented here should act as a focus for
discussion of issues to do with sharing control, risk and
responsibility and the function of information exchange
between professionals and patients.
The framework can be used by individuals or by groups
within a multi-disciplinary team. It is based in activity
theory, which is a multi-disciplinary approach to
development and change. The theory has been applied
to work within a range of professions including medical,
scientific and legal and has particularly examined the
nature of team work36-37.
The focus of the model is the kind of practice described
by participants in the study. The range of approaches
detailed in the interviews has been represented in the
framework by sets of continua. The continua represent
the constituent elements of the activity involved in
informing or educating patients.
It is envisaged that certain of the elements in the
framework may be identified as focuses for
developmental change by individual health professionals
or a multi-disciplinary team. Such change might be
addressed through training, change in institutional
practices or policies and/or additional resourcing.
Nevertheless, as noted later, all elements of the
framework need ultimately to be addressed in order to
achieve a transformation of practice.
The framework deals with the activity of the health
professional and the outcomes for the health
professional. A different framework would be needed to
examine the reciprocal activity of the patient. Our
proposition is that if patient partnership and patient as
decision maker are the overall goals of health
professionals. activity, a .transaction. mode of
interaction is needed to replace the more traditional
.transmission. mode38-39. The differences between the
two modes is not elaborated here but is illustrated
through the framework.
The framework
In any patient-professional interaction, the health
professional may act in different ways within each of six
elements of the activity. These are subject, tools/
means, object, rules, community and division of labour
as explicated by Engestr.m and Cole40-41. The .subject.
is the health professional and the .object. is his or her
goals, or aims and objectives. .Tools. or .means. are
used by the subject to achieve aims and objectives, so
for the health professional whose aim is to develop the
patients. understanding, the tools and means might be
discussion and resources such as information leaflets
or Web site addresses. .Rules., .community. and
.division of labour. are cultural, contextual factors which
affect any activity. In the case of the medical
consultation .rules. would include the conventions and
procedures of outpatients. clinics both outside and
within the consulting room. .Community. would include
the professionals and non-professionals who have an
involvement or effect on the clinician/patient interaction.
.Division of labour. would represent the
compartmentalisation responsibilities of different
professionals and of patients in the clinician/patient
interaction.
Figure 1 represents the elements of activity theory, the
double headed arrows being used to indicate their interdependence.
Descriptors for each element of the
activity of the health professional in the consultation are
given in Figure 2.
Two different modes of patient/professional interaction
are presented in the framework, the transmission mode
and the transaction mode (Fig.1). They are envisaged
as being at the opposite ends of continua for each
element of the health professional.s activity. They are
explicated with examples of characteristic practices.
30
The Theoretical Framework
Activity theory assumes that all elements of the activity
need to be addressed. Therefore in determining whether
the mode of interaction is transmissive or transactional,
all elements needed to be examined.
The evidence of the study suggested that no clinician.s
practice was consistently and entirely typical of one
mode or the other. This is to some extent inevitable
because however successful the professional is in
adopting a particular approach within the consultation,
the elements of .community., .rules. and .division of
labour. are located within the wider context for the
activity. They will include the kind of factors that need
to be addressed through collective, institutional,
strategic and/or societal change. However the argument
advanced here is that attendance to all dimensions of
the activity will help to identify aspects of practice that
can be changed in order to move towards a more
transactional mode.
Related references for further reading include42-45.
Figure 1:
Engestrom.s activity theory triangle showing all dimensions of activity as related to and dependent upon each other
31
The Theoretical Framework
Transaction between patient and
professional directed towards development
of the patient
The health professional acts as guide and
supporter, active participant, evaluator, facilitator
of development and learner
Development is mediated through dialogue with
the patient, recommendation and provisions of
other sources of information and discussion of
sources used by the patient, over time.
The goal of the professional is to bring about
patient construction of knowledge, understanding
and appropriation of meaning over time.
The professional is a partner with the patient and
his/her family in the consultation and addresses
his/her own agenda and the patient.s. Guided by
the patient, the professional makes judgements
about the complexity of information, and how
much, is discussed. The professional indicates
how much time is available for the consultation.
The professional enables and encourages the
patient to actively construct meaning through
dialogue with him/herself. The professional has a
role and responsibility for information within a
multi-disciplinary team. The professional is
supported by non-professionals, including the
family, in development of patient understanding.
The professional develops his or her own
understanding.
The activity takes place in a community which
depends upon the interactions of professionals
from different disciplines and non-professionals.
The cultural and organisational practices and
structures reflect the value afforded to different
types of knowledge and experience. The
community is comprised of participants with
differing educational, linguistic and racial
characteristics which determine the actions and
resources which are employed.
Transmission of knowledge by the
professional to the patient
The health professional acts as provider,
gatekeeper, communicator of medical and
scientific knowledge
Knowledge is mediated through the consultation
and through provision and recommendation of
other sources of information, human and textual
The goal of the professional is to convey
appropriate information to the patient
The professional is the expert who controls the
activity and the patient is a novice who conforms
to the rules of the consultation. The professional
determines who talks and when. In response to
the patient the professional decides what
information, and at what level of complexity,
should be discussed.
The professional acts autonomously, focusing on
the patient as recipient of information. S/he is
aware of the information practices of other
professionals in the team. S/he recommends
certain non-professional information providers.
The activity takes place in a community which
comprises professionals from different disciplines
and non-professionals. They operate within
cultural and organisational practices and
structures which emphasise the value afforded to
medical knowledge and experience. The
community is comprised of participants with
differing educational, linguistic and racial
characteristics
Activity
Subject
Tools /
Means
Object
Rules
Divisio |
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