UHRINN301

Week 5 - Influences on Care Delivery

Learning Objectives

• Discuss individual and social factors that influence health and care provision.

• Critically analyze the influence of organizational factors on person-centred care.

• Comprehend and critically explore the national and international differences

that influence care.

• Demonstrate an in depth understanding of the challenges of person-centred care

delivery that emerge due to influencing factors.

• Propose recommendations to address the challenges posed by influencing

factors.

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Content List

Introduction ................................................................................................................ 3

Physical, emotional, occupational, cultural, spiritual, intellectual and social

influences on care ....................................................................................................... 3

Influence of organizational factors on person-centred care ....................................... 9

Influence of care context e.g. acute and community settings, national and

international differences ........................................................................................... 11

Challenges of person-centred care delivery in the presence of the influencing

factors ....................................................................................................................... 15

Solutions to address the challenges posed by influencing factors ........................... 17

References ................................................................................................................ 19

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Introduction

People use medical services to diagnose, cure, or alleviate illnesses and injuries with

the aim of improving their health or maintaining function. A number of factors affect

the need of using healthcare services (JRF, 2022). The political, social and economic

context that results in national and international differences need also to be explored in

order to better understand how care and care interventions are envisioned and

completed. Influencing factors may cause challenges of person-centred care delivery

and proper solutions need to be put into practice. Social determinants of health may

determine the risk of developing a disease in the future and various individual,

organizational and social factors will influence care provision and person-centred care.

Physical, emotional, occupational, cultural, spiritual, intellectual and social

influences on care

There is a plethora of factors which play a crucial part in people’s health. Maintenance

of wellbeing and the delivery of care are related to a variety of factors: physical,

emotional, occupational, cultural, spiritual, intellectual and social. The environment,

the abundance of healthcare professionals and healthcare settings and the accessibility

to healthcare facilities as well as the relationships and everyday interactions with others

are of paramount importance and can influence health and care (Figure 1).

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Figure 1. Social Determinants of Health. (Alliance for strong families and communities,

nd)

Occupation and financial status

In more detail occupation, and financial status can play a major role in health and care

delivery as high status and welfare can result in better health outcomes and high quality

care. There is evidence that income has a strong correlation with risk factors that lead

to chronic disease: for example, people who experience poverty have higher rates of

heart disease, stroke, diabetes, or hypertension, and have multiple co-morbidities

(National Academies of Sciences, Engineering and Medicine, Health and Medicine

Division, Board on Healthcare Services, and Committee on Healthcare Utilization and

Adults with Disabilities, 2018). Economic resources (such as income and wealth)

enable access to material goods and services, including health-care services. Health

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inequalities can be frequently observed in socioeconomic disadvantaged people who

have higher risk of getting seriously ill and suffer from poor health outcomes compared

to socially advantaged people (Jegede, Muvvala, Katehis, Paul et al. 2021). In spite of

the high use of medical services by low-income earners, adults below poverty may not

receive or delay medical care, drug prescribing and dental care due to non-affordable

costs. Therefore, despite the high turnout in emergency and hospital services, the health

needs of people below the poverty line cannot be met (National Academies of Sciences,

Engineering, and Medicine, Health and Medicine Division, Board on Healthcare

Services, and Committee on Healthcare Utilization and Adults with Disabilities, 2018).

Place of birth and living

People who live in rural areas have higher risk factors that can lead to illness comparing

to people living in cities. Surgical rates vary widely by geographic area, especially in

hospital areas, and represent both outcome study gaps and poor patient decision-making

(National Academies of Sciences, Engineering, and Medicine, Health and Medicine

Division, Board on Healthcare Services, and Committee on Healthcare Utilization and

Adults with Disabilities, 2018). Also, in communities facing limited resources and food

shortages, culturally inclined families may choose to prioritize the nutritional needs of

a disabled boy over those of a disabled girl (Groce, Challenger, Berman-Bieler, Farkas

et al. 2014). It is also reported that African Americans in the USA receive less care for

cardiovascular diseases and post-operative pain, and are more likely to be diagnosed

with psychotic disorders, and more likely to be obese as they live in marginalized

neighborhoods (Jegede, Muvvala, Katehis, Paul et al. 2021).

Age and Disability

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It is evident that disability and age increase the use of health-care services. Working-

age people and elderly are more in demand of healthcare facilities and medical

treatment (JRF, 2022). People who live alone and rely on caregivers to prepare meals

may find that the caregiver's scheduled visits do not coincide with their meal times. The

caregiver may not have time to shop for fresh food or may choose foods that are easy

to prepare, such as canned food, soups, and processed meats that may be high in fat and

salt. It should be noted that although most survey participants in Australia were

overweight or obese, the majority had minimal food choices and were generally low in

food intake (Australian Bureau of Statistics, 2014). Since the majority of participants

lived in the family home or in group homes, and not independently, these results

indicate that others made food choices for them (Kennedy, McCombie, Dawes,

McConnell et al. 1997). The access to healthcare facilities for disabled people can also

be challenging. Even though the use of care services are higher people who have

disabilities often have worse overall health status, and have higher risk factors such as

obesity, malnutrition, inactivity etc. (Everest, Marshall, Fraser, and Briggs, 2022). They

also face provider’s bias, discrimination and inadequate communication skills (National

Academies of Sciences, Engineering, and Medicine, Health and Medicine Division,

Board on Healthcare Services, and Committee on Healthcare Utilization and Adults

with Disabilities, 2018).

Environment

In addition, the physical environment is of utmost importance (WHO, nd). Adequate

primary care settings, hospitals and rehabilitation centres and the accessibility to these

facilities that are affected by geopolitical factors and transportation can have an impact

on the successful delivery of care. Access to clean water and clear air, safe workplaces,

houses and public infrastructure are also linked with better health (National Academies

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of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on

Healthcare Services, and Committee on Healthcare Utilization and Adults with

Disabilities, 2018). It is also supported that inequalities in the quality of care can exist.

People in cities can have higher quality of care comparing to people living in rural areas

(Haemmerli, Powell-Jackson, Goodman et al. 2021).

Physiology and gender

Physiological factors, such as genetics and gender can also contribute in the expression

of an illness and the care people are going to receive. Adult women may postpone or

not receive care or drug prescriptions at all as they cannot afford to cover the expenses.

However, women are more likely to use healthcare services than men and to have a

hospitalization, visits at the emergency department, primary care visits and receive

more diagnostic services, screening services, diet and nutrition counseling, and sexual

healthcare than men even though men generally have higher rates of obesity and

cardiovascular diseases. Women during and after menopause are more likely to use

healthcare services comparing to women in a reproductive age. Women at menopause

ask for care related to cardiovascular disease and osteoporosis issues. Adult women are

affected by a disability more frequently resulting in poor health (National Academies

of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on

Healthcare Services, and Committee on Healthcare Utilization and Adults with

Disabilities, 2018). Disabled females are likely to receive less quality care that that of

the male counterparts (Karami, Kamali, Williamson, Moradi et al. 2019). It is generally

reported that although women utilize health-care resources at greater rates (National

Academies of Sciences, Engineering, and Medicine, Health and Medicine Division,

Board on Healthcare Services, and Committee on Healthcare Utilization and Adults

with Disabilities, 2018).

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Furthermore, transgender people face difficulties and bias when receiving healthcare.

It is reported that clinicians avoided contact with transgender people which is a basic

element of care. Also, in the past, providers required transgender people patients to

“live as” a woman or man for a year or more before starting a gender-affirming medical

intervention (Alpert and Cicero, 2020).

Culture, Ethnicity and Language

Cultural factors including traditions and beliefs can have a severe impact on health and

care by influencing self-determination, defining discriminating behaviours, and

expressing differences in understanding human rights (PHAA, nd). Cultural beliefs may

determine how patients will ask for medical care and from whom, if they act according

to self-care principles, what are the health choices that make, and the compliance to

certain treatments. Providers believe that language and culture play a crucial role in the

delivery of care as. Patients are likely to non-complying with the recommended regime

due to cultural or linguistic barriers (IOM, 2013).

Ethnicity also plays an important role in the use and availability of healthcare services.

African Americans face obstacles to accessing affordable care. They use inadequate

health services and they frequently drop-out from therapy regime leading to poor health

outcomes. Few African Americans receive treatment for alcohol and drug misuse

(Jegede, Muvvala, Katehis, Paul et al. 2021).

Education and Social Support

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As long as education is concerned it is believed that people of both genders who drop

out of school have poor health and limited care options. Regarding the social

perspective, interaction with others is linked to better health and prompt care and more

precisely women can highly benefit from social support through the healthcare delivery.

For example, in USA, women with breast cancer who showed low levels of social

integration had higher mortality rates and lower odds of therapy commencement

(Teshome, Trabitzsch, Afework, Addissie et al. 2021).

In literature, the influence of close relationships on the quality and safety in healthcare

are reported. Family relations and its impact on therapy is the cornerstone of humanistic

care. For example, in Eastern countries strong family

ties and commitments can be observed. In case one member of the family gets sick, all

of them try to ensure that the patient is going to be treated well and receive the best care

through relations, authorities, and access to healthcare professionals (Asl, Khademi,

Mohammadi, 2022).

Influence of organizational factors on person-centred care

Organizational factors that influence person-centred care are the levels of nursing and

medical staff, work resources, and work-related training. Adequate healthcare

professionals are linked with better health outcomes. Optimal staffing levels, adequate

resources and frequent educational programs result in higher levels of patient safety

and quality care and satisfaction as well. Factors such as coordination, frequency of unit

rounds and proper handover have been linked with improved quality of care, shorter

stays, and high patient safety (Clarke, and Donaldson, 2008). Alignment between unit

and hospital goals has also been associated with improved outcomes for patients. Shift

coverage by experts in intensive care has been associated with shorter stays, lower

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resource utilization, and lower patient mortality. Communication between the

interdisciplinary team, proper conflict resolution and shared decision-making with

patients may have a positive effect on patient outcomes and high satisfaction (McIntosh,

Oppel, Mohr, and Meterko, nd). The ability to access care including whether it is

available, timely and convenient, and affordable.

All the aforementioned factors can influence healthcare use (National Academies of

Sciences, Engineering, and Medicine, Health and Medicine Division, Board on

Healthcare Services, and Committee on Healthcare Utilization and Adults with

Disabilities, 2018). Another factor that may influence person-centred care is time

constraints and the workload pressure that healthcare professionals have to deal with

(Karstad, Rasmussen, Rasmussen, Rugulies et al. 2022). Person-centred care might be

omitted due to time constrains and the urgency of the job especially when dealing with

critical cases (Asl, Khademi, and Mohammadi, 2022).

Common language promotes person-centred care and contributes to better understating

the patient’s condition, opinions and wishes. Proper training of open-minded healthcare

professionals that is targeted to improve care for people with different cultural

backgrounds is also considered important. However, this does not ensure the realization

of humanistic person-centred care. Thus, the institution should cultivate an

organizational culture that encourages person-centred care practices and provides all

the requirements for nurses, patients, and their families to contribute to the overall

endeavor of person-centred care.

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Influence of care context e.g. acute and community settings, national and

international differences

Even though there is no unique definition, generally context entails two aspects: a focal

event and a field of action within which that event is embedded (Duranti and Goodwin,

1992). There are four core context dimensions, which identify factors that affect the

interaction:

• Setting which includes the social and geographical setting.

• Behaviour as a resource for envision and expression.

• Language which invokes context and promotes discussion.

• Extra-situational which is knowledge that extends far beyond the local talk and

its immediate setting (Thomsen, Soelver, and Holge-Hazelton, 2017).

According to Pawson, Greenhalgh, Harvey, and Walshe (2005) context is framed by:

individuals, interpersonal relations, institution and infrastructure. This includes the

relationships between stakeholders, the organizational setting, and the wider societal,

financial and cultural background. This definition presents the complex emergence of

interventions which are the result of the context as mentioned above.

This co-production that is based on the different elements of the context and constitutes

the final intervention limits transferability to other settings. In more depth, factors

within contexts enable certain mechanisms to trigger outcomes and therefore

interventions cannot simply be transferred from one context to another and be expected

to achieve the same results.

However, an understanding of the ad hoc aspect of ‘what works, for whom and where”

can result in valuable lessons (Coles, Anderson, Maxwell, Harris et al. 2020). As a

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result, differences in outcomes on national and international basis or acute and

community settings are likely to occur.

Acute Services

Acute services (Figure 2) given their emergency nature are time-sensitive. However,

acute care has been poorly defined and inadequately supported in most developing

health systems. A brief definition of acute care includes time-sensitive, person-centred

prevention, diagnosis, treatment, rehabilitation, and care towards the wellbeing of

people or populations. It also incorporates health system elements, used to deal with

life threatening situations. Acute care can be delivered in variety of healthcare settings

and situations, for example emergency medicine, trauma care, pre-hospital emergency

care, acute care surgery, critical care, and short-term inpatient acute care (Hirshon,

Risko, Calvello, Stewart de Ramirez et al. 2013).

Figure 2. Acute Care. (Hirshon, Risko, Calvello, Stewart de Ramirez et al. 2013)

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According to Alberta Context Tool (Estabrooks, et al. 2009) the factors that influence

organizational context are: leadership, culture, evaluation, social capital, informal and

formal interactions, resources, and organizational slack. Organizational context is

important in the creation of multidisciplinary relationships, the care provision as well

as the successful knowledge dissemination and translation into practice. Aspects of

organizational context that are positively noted are linked with high numbers of patients

receiving care. Creating unit-based multidisciplinary groups of healthcare

professionals, balancing staff shortages, and promoting successful leadership and

coordination can have a beneficial effect on few aspects of the organizational context

for example on social capital. Strong social capital may also improve knowledge

translation through information exchange and expertise of the multidisciplinary team.

Effective Leadership is also vital for successful delivery of evidence-based and person-

centred care as treatment in general requires good coordination beyond the unit,

including between ambulance services and the emergency department (Andrew,

Middleton, Grimley, Anderson et al. 2019).

Few acute care hospitals in UK and organization partnerships have already provided

community services to improve community wellbeing. For example, the Integrated

Care Academy (ICA, nd) which is a collaboration between the University of Suffolk,

the Suffolk and North East Essex Integrated Care System (ICS), Suffolk County

Council and Health watch Suffolk and others from the voluntary and community sector

aims at enhancing the social and health needs of the community through joint efforts.

In the near future it is expected that an increased number of care services will be

delivered beyond the hospital walls thus playing a vital part in the prevention and

population wellness and reducing bed numbers and length of stay in acute care

hospitals. These changes will occur due to the development of new care pathways,

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workforce arrangements and organizational models. Towards this end, measures that

can be applied in order to overcome the challenges faced by acute and community

services are proposed including:

• Effective internal governance systems that support integration across units.

• Opportunities for interaction and mutual training of acute and community

professionals.

• Job roles where acute and community care meets.

• Service changes and showcasing the importance of the integrated models of care

for patients’ outcomes (Naylor, Alderwick, and Honeyman, 2015).

Community Settings

Community health services (Figure 3) take place in a wide variety of settings with the

aim of promoting health, preventing diseases, maintaining health, restoration,

coordination, management and evaluation of care of individuals, families, and

aggregates, including communities. In the community settings, care focuses on

optimizing individual potential for self-care regardless of any injury or illness. The

main purpose of community care is to promote preventive interventions, and increase

the quality of life (EPHTI, 2006).

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 Figure 3. Community Services. (NHS confederation, nd)

The financial context can have an impact on community care as well as the performance

of healthcare professionals. Lack of adequate resources could lead to an inability to

provide basic care and prevent people from seeking care in general (Kok, Kane,

Tulloch, Ormel et al. 2015).

Challenges of person-centred care delivery in the presence of the influencing

factors

Time constraints

Time restrictions and pressure pose limitations to person-centred care delivery.

Education on the development of communication skills targeted to improving person-

centred care may be a time-consuming task. Due to urgent nature of the nursing

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profession such training activities are often omitted making person-centred care

implementation difficult. However, after such training interventions, person-centred

care patients could more easily took responsibility for their own care because of

successful guidance of the healthcare professionals and result in time reduction (Moore,

Britten, Lydahl, Naldemirci et al. 2017).

Professional attitudes

Healthcare Professionals’ attitudes that showed lack of interest, knowledge or

adherence hindered person-centred care practices. Keeping a professional yet person-

centred care approach needs self-awareness (Moore, Britten, Lydahl, Naldemirci et al.

2017).

Unclear responsibilities and lack of coordination

Lack of proper coordination, information exchange and unclear responsibilities led to

lower satisfaction by patients. According to literature patients and next of kins needs

clear cut instructions by healthcare professionals who take responsibility about their

condition. On the contrary, few patients were confused when they could not manage

properly their involvement in their care related decisions (Thomsen, Soelver, and

Holge-Hazelton, 2017).

Guidance primarily focused on treatment

Consultations focused on symptoms and physiology is common and the

recommendations are related to medication, diet, workout and follow-up tests and

appointments or referrals to other healthcare professionals or facilities. The

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involvement of patients was limited to factual, medical and health-related data

(Thomsen, Soelver, and Holge-Hazelton, 2017).

Solutions to address the challenges posed by influencing factors

The proposals to deal with the major challenges posed by influencing factors include

education and capacity building for healthcare professionals for example enhancing

communication skills and teamwork. Proper resources allocation to healthcare along

with political will and commitment could release the burden of financial restrictions in

healthcare settings. Health insurance coverage for everyone could mitigate health

inequalities and improve access to health. Improved leadership and coordination with

clear vision and focused on person-centred care could result in better outcomes for

patients and populations.

WHO (2010) has presented the six building blocks that contribute to the strengthening

of health systems (Figure 4).

Figure 4. The six building blocks of a healthcare system. (WHO, 2010)

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However, it seems that leadership and governance, staff, and healthcare financing in

particular, need to be further addressed with proper solutions. Authorities, policy

makers, managers and other stakeholders should prioritize interventions to improve the

access to healthcare system as well as the function, safety and quality of the services.

Public–private partnerships can also be encouraged if companies could devote a portion

of their profits to ensure that they meet the social responsibility requirements, in order

to cover health insurance for employees, their families and the communities in which

they work (Oleribe, Momoh, Uzochukwu, Mbofana et al. 2019).

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