Before the patient is released, the nurse will once again speak with the patient and ask, on a scale of ten, how important do they think it is to wear the appliance post-surgically. The nurse will also ask how likely the patient himself or herself thinks it is that compliance will be virtually 100%. The nurse will ascertain that the patient is competent to apply the device, removing it only for cleaning the teeth and the appliance, and that there are no other factors in the patient's home/work environment that would preclude compliance.

The nurse will then personally assess the likelihood she ascribes to the patient's 100% compliance.

When the patient is seen by the surgeon for his or her first follow-up visit, the same questions will be asked/answered. This will be true at each follow-up visit, no matter how many there are, and also at the end of the healing/follow-up period.

In addition, at the end of this period, the nurse will access information from the orthodontist regarding:

What the patient told the orthodontist regarding the patient's compliance.

What the orthodontist has concluded medically that the patient did about compliance (i.e., if there was non-compliance to a great extent, it should be revealed in the less acceptable outcome of the surgery.)

In notating the outcomes, National Quality Measures Clearinghouse Convention 3 will be used. That convention looks like this:

An additional area of study will be that of adverse effects. These will be tabulated separately, and matched against a control group that has not gotten the nursing patient care originally, nor the follow-up.

Patients in the study will be asked about negative outcomes and will also be asked to determine whether they thought the outcome was due to their own non-compliance, or other reasons. If non-compliance is ascribed to 'other reasons,' the patient's orthodontist will be queried to see if this is an accurate assessment by the patient. If it is, the patient will be eliminated from the study. If the orthodontist believes that the noncompliance caused a problem, the patient's information will be tabulated.

It is not possible to ascertain whether compliance made a difference to the outcome of the surgery/orthodontic treatment per se; it is only possible to ascertain whether shifting the burden of information regarding patient self-care and patient follow up in that self-care improved under the new process. Therefore, a control group will be needed that is not provided with the physician/nurse 'drama' to reinforce the need for compliance. This group will be asked the same questions at before discharge, and again when he or she is released from the surgeon's care.

For both groups, the orthodontist in the case will be asked to apply a numerical value to his assessment of the patient's compliance with the post-surgical need for wearing of the orthodontic headgear.

The results from the control group and from the three subgroups in the Change of Process study will be compared.

Resources required

Very few resources will be required for this change in the process of patient care in this instance. The results, however, will be suggestive across a broad range of patient care events and issues, and this project will add valuable insights into the need for and value of shifting the burden of obtaining patient commitment to compliance from physician to nurse, and for using relatively dramatic, not simply informative, means for gaining a commitment to compliance and possible compliance per se.

Conclusion

Kreps (1988) found that patients want information, trust and a close personal relationship with their physician. In the current managed care setting, a close, personal relationship with a physician is the exception, arguably, rather then the rule. In the case of oral and maxillofacial surgery, especially as an adjunct to orthodontia, it is...

Because of that, it is necessary to find other ways to enhance the process of patient care in order to produce the best outcome. Shifting the burden to a nurse who works with the surgeon and who can (theoretically) spend time with the patient building such a relationship would seem to be logical and workable. In addition, by involving both the nurse and the physician, it is possible to provide the sort of dramatic transfer of information several earlier researchers deemed essential to gaining a commitment by the patient to act on that information.
Moreover, it is likely that this process will also contribute to the patient's asking questions, in short, actively participating, which will help them fulfill their own expectations concerning the experience, or at the very least, understand logically why some of their expectations may not be met: either purely medical reasons, or for reasons of their own non-compliance.

Finally, Street and Weimann (1987) showed that patients prefer more egalitarian relationships in their heath care, relationships in which both sides contribute equally. Removing the process from that of a physician speaking to the patient 'from on high' to one in which physician, nurse and patient form a team dedicated to bringing the patient the best possible outcome, would seem to be an avenue of the patient care process well worth exploring.

References

Ballard-Reisch, D.S. (1990). "A model of participative decision making for physician- patient interaction." Health Communication, 2, 91-104.

Davis, M.S. (1968). "Variations in patients' compliance with doctors' advice: Empirical analysis of patterns of communication." American Journal of Public Health, 58, 274-286.

Fazio, R.H., & Zanna, M.P. (1981). Direct experience and attitude-behavior consistency. In L. Berkowitz (Ed.), Advances in Experimental Social Psychology, 14, (pp. 161-202). New York: Academic Press.

Forchuck, C., B. Mound and M. Yama*****a. (2005) Nurse case management: Negotiating care together with developing a relationship. Perspectives in Psychiatric Care, 41(2), 62+/

Greenwald, A.G., & Albert, R.D. (1968). "Acceptance and recall of improvised arguments." Journal of Personality and Social Psychology, 8, 31-34.

Gross, A.M. (1987). "A behavioral approach to the compliance problems of young diabetics." The Journal of Compliance in Health Care, 2, 7-21.

Himmelhoch, A. (1980). "Patient adherence in the treatment of hypertension." Australian Family Physician, 9, 229-234.

Hoffman, L.R., Burke, R., & Maier, N. (1970). "Participation, influence, and satisfaction among members of problem-solving groups." In N. Maier (Ed.), Problem solving and creativity in individuals and groups (pp. 279-285). Belmont, CA: Brooks/Cole.

Janis, I.L., & King, B.T. (1954). "The influence of role-playing on opinion change." Journal of Abnormal and Social Psychology, 49, 211-218.

Kim, M.S., & Hunter, J.E. (1993). "Relationships among attitudes, behavioral intentions, and behavior: A meta-analysis of past research, Part 2." Communication Research, 20, 331-364.

Slamecka, N.J., & Graf, P. (1978). "The generation effect: Delineation of a phenomenon." Journal of Experimental Psychology: Human Learning and Memory, 4, 592-604.

Young, M. And R.S. Klingle. (1006) Silent partners in medical care: A cross-cultural study of patient participation. Health Communications, 8(1), 33-39.

Convention 3

Patient group: metric plus treatment/intervention

Patient group refers to a specific patient population such as the Frail Elderly, Medically Uninsured, or Children. NQMC has not yet encountered a process measure that does not address a disease/condition or a clinical topic.