Person-centred care and self-efficacy - Experiences, measures and effects after an event of acute coronary syndrome

Abstract: Person-centred care (PCC) highlights the importance of knowing the patient as a person and is a key component in engaging the person as an active partner in health care and treatment to improve illness management. Self-efficacy is a closely related concept to PCC as it refers to peoples’ beliefs in their capability to influence events that affect their lives. Acute coronary syndrome (ACS) events are associated with arduous recovery and a PCC approach may facilitate self-efficacy beliefs and thereby improve health and clinical outcomes. The overall aim of this thesis was to build an understanding of patients’ prerequisites to collaborate as partners in their care after an event of ACS and to evaluate measures and the effects of a PCC intervention on self-efficacy and return to previous activity. Moreover, the goal was to identify if a person-centred approach can facilitate the care chain from hospital, outpatient and primary care for patients with ACS. A multi-method qualitative and quantitative approach was used to gather and analyse data. Study I involved 12 interviews with patients affected by ACS, which were analysed by the phenomenological hermeneutical method. Study II consisted of a confirmatory factor data analysis of cardiac self-efficacy scale (CSES) data from 288 patients with ACS. In Study III, 199 patients with ACS were enrolled in a randomised controlled trial (RCT) evaluating the effects of a PCC intervention in a composite score of changes, including general self-efficacy (GSE), return to work or prior activity level and rehospitalisation or death, which were followed up at 6 months post-discharge from the hospital. Descriptive statistics, non-parametric tests and logistic regression were used to analyse the data. In Study IV, the PCC intervention was evaluated against the CSES in 177 of the 199 patients, who were included in the RCT. Data were analysed with descriptive statistics and parametric tests. The results showed that patients with ACS formulated personal models built on their understanding of how they recognised, interpreted and responded to their illness early on during the hospitalisation. The Swedish CSES was shown to be a valid and reliable measure to evaluate cardiac self-efficacy (CSE) in patients with ACS. In the RCT, the composite score at 6 months showed that a higher number of participants in the PCC group improved in comparison with the usual care group (22.3%, n=21 versus 9.5%, n=10; Odds ratio=2.7, 95% CI: 1.2–6.2; P=0.015). Separation of the composite score into each individual component showed that GSE improved significantly in the PCC group (P=0.026). At the 4-week follow-up, the PCC group reported improved scores in the symptom control dimension, indicating higher CSE [mean change (standard deviation, SD)=0.81 (3.5)], while the control group reported worsening scores [mean change (SD)=−0.20 (3.0)]. The difference between groups was statistically significant (P=0.049). The conclusion from this thesis is that patients with ACS formulate personal models which can be integrated into a person-centred dialogue and the development of a personal health plan. Self-efficacy is a valuable concept in PCC that can be used as an outcome measure of PCC interventions. A PCC approach can advantageously be implemented in care of patients with ACS to encourage the improvement of patient self-efficacy without worsening the clinical events.