How Can We Meet the Diverse Needs of Patients, Their Families and Their Communities? A Qualitative Study Including Clinicians, Consumer Representatives, Patients, and Community Stakeholders.

How Can We Meet the Diverse Needs of Patients, Their Families and Their Communities? 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A Qualitative Study Including Clinicians, Consumer Representatives, Patients, and Community Stakeholders. Natasha Roberts, Helene Jacmon, Brighid Scanlon, Chrissy Battersby, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1714661/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Jul, 2023 Read the published version in BMC Health Services Research → Version 1 posted 6 You are reading this latest preprint version Abstract Background: The Diversity Working Group was formed to provide guidance to implement hospital health services strategies that could better address the diverse needs of patients and communities, with particular attention to those at greater risk of harm. It was identified that a better understanding of gaps in patient facing areas was required. Methods: A qualitative study was conducted by an experienced team from varied professional backgrounds including a clinician researcher, a nurse researcher with expertise in culturally and linguistically diverse community care and a consumer representative with expertise in advocacy and carer representation. Qualitative questions were co-designed, aiming to identify enablers and barriers to person-centred care. Community stakeholders, and clinical staff and patients from both ambulatory and inpatient areas were approached to participate. Responses were coded independently and synthesised using a Framework Approach. Results In total 3 community stakeholders, 40 clinical staff and 30 patients consented to participate in the qualitative study over a period of three weeks. There were three key themes across responses, ‘ What are diverse needs? ’; ‘ Assigning people to a group does not identify a diverse need ’; ‘ Unplanned care amplifies diverse needs’ . Those patients who were isolated, for any number of reasons, were identified as at greatest risk of harm. Conclusion: Taking a person-centred approach can potentially ensure that the diverse needs of patients and communities will be better identified and responded to. Resources are needed to support patients and their families at times of transition care, particularly when care is unplanned. Key Implications - A person centred approach can potentially meet the needs of diverse patient populations, especially those at risk of harm - Transitioning between services was a time when patients feel most vulnerable -Quality care that meets the diverse needs of patients, families and communities requires multi-layered approach which includes the health services level, the local clinical area, with local clinical teams, and directed individually for each patient and their supports Background Three years ago, the Diversity Working Group was formed to evaluate and improve service provision for patients within the largest public hospital health service in Australia. The perceived need for the Diversity Working Group was in part driven by the Australian National Safety and Quality Health Service Standards (v2) (1) requiring organisations to identify the diversity of the consumers using its services; planning and delivering care accordingly, especially for those at a higher risk of harm. The other driver was that the membership of the Diversity Working Group was actively seeking organisational support for the patients across their various clinical areas. As a first step, expert stakeholders were engaged to identify those patient groups of greatest priority. Identified as at greater risk of harm were Aboriginal and Torres Strait Islander peoples, Culturally and Linguistically Diverse people, those living with a disability (physical or cognitive), patients from rural/ remote areas, people experiencing homelessness or social disadvantage, those with a mental health issue, and people who identify as Lesbian, Gay, Bisexual, Trans, intersex, Queer and other sexuality, gender, and bodily diverse people and communities (LGBTIQ+). Local demographic census data for residents in the hospital health service had been completed and compared to Australian averages (2). This data assessment identified that there was a higher prevalence of at-risk populations compared to national averages and further work was warranted. A rapid review of the literature confirmed that diversity in itself does not make a person and/or their community vulnerable. However, it was broadly acknowledged that at-risk populations have specific perspectives and healthcare needs (3). State and federal government resources highlighted that if these are ignored, poorer health outcomes may result (4). Internationally there was a call for targeted and culturally responsive healthcare to address disparities and achieve greater health equity (6–10). At a national level, there were five publications identifying determinants of diverse patient populations, including enablers and barriers to service delivery (11–15). Two publications identified improvements from supporting care coordination and navigation of health services for those groups identified as at risk of harm (16,17). However, across the work identified, there were no evaluations or pragmatic guidance on how to guide health services to directly address the diverse needs of patients and their communities. For this reason, the working group initiated a qualitative gap analysis to primarily answer the question, How can diverse needs of patients and communities be met in our hospital health service? Methods The qualitative project was designed to better understand enablers and barriers, and the mechanisms already in play within the health service (18). We proposed that by qualitatively exploring the potential factors impacting health service delivery, the Diversity Working Group could plan future directions. A Diversity Officer role was funded for this work and increments of the available full-time equivalent three positions, including two nurses with qualitative research expertise and clinical experience working in diverse patient communities, and a consumer advisor with expertise in advocacy and health ethics (NR, HJ, BS). The team had initiated the preliminary rapid review of the literature and by consensus determined that diverse needs could be addressed by using a person-centred care approach, defined by the Australian Commission on Safety and Quality in Healthcare as being “…respectful of, and responsive to, the preferences, needs and values of patients and consumers” (1). The term diversity was not well-supported in the literature, but “people-centred care” featured strongly. The Diversity Working Group had worked with stakeholders to identify groups at risk of harm in the hospital health service and wanted to explore how services could be directed to meet the diverse needs of every person (and their family and community) who walked through the doors of the hospital. A “people-centred care” approach supported this aim. The three Diversity Officers co-designed sets of qualitative open-ended questions, specifically for this study, to ask staff members, patients and community groups. Qualitative questions for staff aimed to explore enablers and barriers for meeting the diverse needs , to ensure “people-centred care” of patients and their communities, and potential groups at greater risk of harm. Qualitative questions for patients also aimed to better explore what diverse needs patients meant to patients, what diverse groups they identified with, and the perceived enablers and barriers for having needs met. The sets of qualitative questions were disseminated to members of the Diversity Working Group for feedback and improvement. Patients and carers were approached in both outpatient and inpatient areas to participate. The project was explained, the voluntary nature of participation was reinforced, and the independent role of Diversity Officers to clinical areas. Staff were approached in groups at unit meetings, and the qualitative questions were also emailed to staff who worked outside standard business hours. Other patient facing services, such as social work, allied health, discharge facilitation were approached. Community group members were also identified by patients, staff and the broader working group, and then contacted by telephone. Verbal consents were obtained, and no identifying information was collected about participants. Diversity Officers kept memos during data collections. Over three weeks, the Diversity Officers collated responses to the qualitative questions in writing. A Framework Analysis Approach was used to organise and synthesise the resulting qualitative information (19). Codes/constructs were assigned by each Diversity Officer independently. These were put into matrices and the Diversity Officers then came together and the data were discussed further as the key themes emerged from the matrices. All responses were cross-coded independently by the Diversity Officers , and memos were used to better understand any diverging data and commonalities across themes. Data were discussed in two rounds, at which time consensus was achieved. After a 12-month time-period, a final revision of the data and themes was repeated for the preparation of this manuscript. COREQ guidelines were followed for reporting (20). Results In total three community stakeholders, 40 staff members and 30 patients consented to participate in the qualitative study over a period of three weeks. There were three key themes bringing together the responses. These were titled, ‘ What are diverse needs? ’; ‘ Assigning people to a group does not identify a diverse need ’; ‘ Unplanned care amplifies diverse needs’ . What are diverse needs? Some staff reported that they identified diverse needs by directly by asking patients, and/or families and carers on admission. Others reported that diverse needs were taken from risk assessments, admission notes, emergency department notes, previous medical records, discharge letters and from the family or friends of patients. Whilst some staff said that simply asking patients would be the best way to identify their diversity , others reported that they felt uncomfortable asking patients to ‘pigeonhole’ themselves. …you are asking people to tell you how they are different, it is a hard question.. (clinician) some people carry trauma about this sort of stuff… (clinician) And, patients did not feel comfortable either: ..I don’t know about the groups, I don’t know what the answer means for me (patient) people don’t want to be ‘different’ (patient) Existing organisational structures to communicate such diverse needs were available at various timepoints on the patient journey; including on admission (Risk assessment, Booking form), during care (Structured Interdisciplinary Bedside Rounding (SIBR), Multidisciplinary teams (MDTs)), and at discharge (discharge facilitators, referrals, follow-up appointments, general practitioner letters). However, some participants said that the term diversity was tokenistic and lacking commitment to really addressing patient needs in day-to-day care. They reported past experiences contributing to other pieces of work that did not result in any observed changes within the health service: We see this sometimes, diversity, what is that, it’s tokenistic (community stakeholder) There were responses across all participant groups on the importance of acknowledging that diverse needs exist, and that they could be both overt or invisible. Staff and patients raised concerns about relying on appearances at the risk of more pressing needs that may put patients at greater risk of harm: ..you can’t see diversity (stakeholder) Interestingly, no patient participants identified with any of the “at risk” groups when asked if they had any diverse needs. Instead, it was reported that their unique needs came from their own health experiences: “I have bad veins. I don’t like it when they are rude, I get scared they will be rude. I have no veins, I cannot help it, they keep poking thinking one will appear. I tell them. It hurts, and they get angry at me because I have no veins. That only happens every now and then, mostly everyone is very friendly, but it makes me feel shy” (patient) Assigning people to a group does not identify diverse needs Assigning patients to an “at risk” group, such as homelessness for example, as a mechanism to identify diverse needs was reported to be problematic. Participants said that this had the potential to generate unwarranted assumptions based on the group a patient may be assigned, rather than their own specific health needs. There were responses across all participant groups that emphasised a need to see a person as a person, as a part of a community, but not as a member of an “at-risk” group. In each clinical area, staff quickly identified resources available for patients, as well as gaps in needed resources. Each ward or department also presented unique patient groups, unique resources and unique service needs. All participant groups expressed frustration at the barriers to accessing resources they perceived were used routinely in other institutions. Staff reported evidence-based practices that could be used in their areas to reduce unmet needs. Patients explained that if their diverse needs were met, they felt “cared for”, in turn being included in their health care: …I saw an Obstetrician who took the time to really listen and explain; caring like a mother and I really appreciate that (patient) That they wanted to be treated like a person: We are not customers or consumers you know. We are people with families that love us. We are loved by people. Not someone coming in to buy something, you know. It is like they don’t care about who we are (patient) Patients described their experiences of communication and said they actively worked hard to build relationships with staff caring for them, that this was most important to them. For some patients, limitations with health services were perceived as a breakdown in trust. Many patients said that waiting for long periods in the waiting room makes you feel uncared for. And uncared for because of their diverse needs: ..ignoring you because you are inconvenient.. (patient) There were many patients who reported that they were very happy with their care, that they have no concerns, that there was nothing to be improved, and that their needs are always met. Many said that they trusted staff when they thought they actually cared about them. If they did not feel trust through a relationship with their team, they struggled to engage. Staff reported that patient engagement needed work. They gave examples of when they would actively seek out those who they thought would struggle to engage with the hospital service: ..you got to persist, don’t give up on anyone (nurse) There was this lady, she was really anxious. So we changed her appointments so that they worked for her, did extra follow-ups. My manager is very supportive. Being flexible was what helped her anxiety (staff) Patient reports reinforced that this was important, that they felt cared for when people fought for them: ..when the staff fight for you.. (patient) To be heard: ..taking on what I say, taking it on board.. (patient) Staff identified that patients who were at greater risk of harm were those who were isolated, for whatever reason. Isolation could be for social, cultural or spatial reasons. For example, those who are from culturally and linguistically diverse backgrounds, those from rural and remote locations, young mothers with a history of addiction without family supports. Isolation resulted in inequities that came from difficulties accessing information and to physically access services in the hospital: I don’t have a car, so normally I just would not go, its hard with all the kids on the bus. We make it work. I have had to learn to do things for myself, by myself, you learn to do it on your own. You just don’t know to ask for help, you actually don’t know how (patient) Those with mental health issues featured as being at higher risk of harm, and it was identified by many staff and stakeholders as a pressing need. Patients that experienced mental health barriers could be from any “at risk” diverse group and often had difficulties engaging with health services generally. Other groups “at risk” of harm were also those that fall between services. Examples include those that do not have a Medicare card, or those awaiting assessment or approval for services such as National Disability Insurance Scheme or My Aged Care. These groups were those that had been identified as having specific health needs but were waiting for a place in a supported service. Staff reported that they had developed solutions at local unit or ward levels. Having the autonomy to be flexible with services to accommodate individual patient needs was valued by clinical staff and this support from hospital management kept them engaged with their work and with health service. Unplanned care amplifies diverse needs Patients told stories of their experiences when their health status changed, or there was a change of plan. It was often these experiences that they drew on to describe their own diverse needs. It was also a time when they said they felt vulnerable and isolated: …changing the plan without telling you. Little things are like pulling pieces out of the puzzle. I know what it is like, I get it, but sometimes you wonder what else you have missed, is everything ok? (patient) Patients perceived that it was their fault, it was from their own unique diverse needs, and that they were not involved in decision making. Patients told stories of finding out after the fact why decisions were made, and questioned why they were not included: …sometimes they communicate to themselves but not to the patients. I see them talking to each other in the corridor… (patient) It was from these experiences that patients developed an understanding that they had unique need, their d iverse need, and that they needed to monitor these to control any unexpected changes in the future. For example, waiting for results, or hearing about them after a decision was made was described as a time when patients felt they were not considered, that they could not advocate for what they needed: It is hard to make decisions without all the information. (patient) Patients said that they wanted to be involved in making decisions. This need featured strongly across responses: All I care about is my family, my partner and my child. When the plan changes, it’s on them. It means where will I go, what will I have to do, what will they have to do. (patient) In particular, patients said that they did not want their lack of understanding and knowledge to be a barrier in participating in decision making: And be patient with me, sometimes I don’t understand everything the first time (patient) Patients said that their diverse needs were met when they were included in decision-making: …when I am a member of the team (patient) Discussion This work identified key areas a large hospital health service can target to better address the diverse needs of patients and community, including patient assessment, health care planning and transition care. These touchpoints are particularly important for those who are isolated, as they are at most risk of harm. There were varying ways staff reported that they identify the diverse needs of the patients in their care, and patients rarely fall into the well-defined categories. Patients in this study reported that they were best equipped to identify and share their needs when they were in a trusting relationship with their health care providers, which they characterised by being heard and feeling cared about. Those who were isolated struggled to engage with services, for any number of reasons. Across participant groups, it was acknowledged that diverse needs may be invisible, and what may appear to be a priority to clinical teams, may not be the pressing need for a patient. A key finding of this work, bringing new knowledge, was that unplanned care and points of transition are when diverse needs have the greatest impact. A strength of this study was a co-designed qualitative approach. Responses were collected from both clinical inpatient and ambulatory spaces, including a wide breadth of stakeholders who are engaged with day-to-day patient care day. These participants brought to light some of the strategies in place day to day within the hospital health service. However, it is likely that there are vulnerable people who struggle to engage with health services did not participate in this study, as they may not be accessing or connecting with the health service, so these findings are limited to those who are engaged with the health service in some capacity. Organisational executive and health administrators were also not included in this study, but this is an area where much of the current literature is focussed. Studies investigating the characteristics of successful organisations have identified that by acknowledging unique needs exist and facilitate a flexible approach to health service delivery is both practical and effective, consistent with our findings where staff felt that they were able to provide optimal care when a flexible approach was supported (24). The literature has identified that patients’ needs are met when strategies are responsive to their preferences and values, so decisions support what is important to patients, with staff training a facilitator (24–32). The evidence also supports our findings which identified that it is when planned healthcare changes, it is a time when patients, and their families, felt most vulnerable (24, 32). For transition care to be effectively provided, services should be coordinated using robust care pathways and appropriate referrals, as it is the point in the patient’s journey of care when a cohesive multi-disciplinary team is most needed (34). When unplanned changes happen for patients with complex needs and diverse needs, transitions between providers or healthcare settings often result in fragmentation, low value care and poor patient outcomes (24, 35). Such outcomes include functional decline, adverse events, medication events, unplanned hospital admissions and patient dissatisfaction. Established strategies to respond include anticipating needs, providing actionable information and the provision of uninterrupted care, with unmet needs and under-utilisation of services a key barrier (33–34). Mitchell and colleagues reported that transition care this could be optimised by ensuring patients had a sense of feeling cared for, being accountable and optimising collaboration between teams (33). Velligan and colleagues report that key facilitators come with structured organisational support to ensure training and an adaptable approach (27). Across the available evidence, the evidence base is more comprehensive in the mental health context, which was identified as an area of particular concern in our study. These qualitative study results support a layered strategy for addressing diverse needs accommodating the multiple levels of a health service. Diverse needs must be approached not just an organisational level, but also purposively directly adapted to accommodate clinical teams and patients and their communities. Considering the literature tells us that both patient outcomes and health service outcomes are improved when we address individual health needs, such an approach likely has many benefits (21). Within the context of our study, it was broadly accepted that there were specific groups of patients “at risk” of harm at a health service level. A needs assessment at a population level can ensure the capacity of a health service to ensure adequate processes in place (22,23). However, how to consistently tailor services at an individual level remains a gap in evidence (36–39). Organisational strategies can include implementation of shared decision-making structures, use of patient reported outcome measures and an organisational philosophy that aligns with person-centred care (24–26). Shared decision making has been demonstrated to improve patient and carer engagement to positively impact patient outcomes (27). Implementation theory focussed research helps to better understand the mechanisms at play of the complex impacts in a health setting (18) with calls to establish comprehensive datasets to guide future directions of health service innovation and care delivery (40, 41). New theoretical approaches can then assist in solving modern health care challenges (18). How we move from talking about person centred care to investigating how to create structures that ensure it is operationalised day to day remains challenging and It is apparent, from the evidence, that we are still trying to understand how large health organisations can incorporate services that are able to respond to diverse needs (42–43). As a priority more work is needed to better identify and understand the experiences of those who struggle to engage with health services. Those organisations that are reported to have the best quality patient experience data also have the highest quality and safety outcomes (36). Directions for the future work could aim to better understand how to predict and understand diverse needs, especially for those at risk of harm, not just relying on heuristic clinician assessment alone. Future research directions could potentially better understand how to use data to better model those who are isolated and at risk of harm. Such an endeavour may ensure appropriate resources are readily available for clinical teams to better anticipate and directly meet the diverse needs of patients, their families, and their communities. Conclusion Taking a person-centred approach can potentially ensure that the diverse needs of patients and communities will be better identified and responded to. Resources are needed to support patients and their families at times of transition care, particularly when care is unplanned. Abbreviations Lesbian, Gay, Bisexual, Trans, intersex, Queer and other sexuality, gender, and bodily diverse people and communities (LGBTIQ+) Declarations Ethics approval and consent to participate: This work was approved, including the use of verbal consent, after review by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee, approval number: LNR/2019/QRBW/54984 Consent for publication: Not applicable Funding: There was no funding of this project. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests: The authors do not have any financial or non-financial competing interests to declare. Funding: Not applicable Author contributions: All authors have approved the submitted version. 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Supplementary Files ISSMCOREQChecklist.pdf Cite Share Download PDF Status: Published Journal Publication published 28 Jul, 2023 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Major revision 05 Oct, 2022 Reviewers agreed at journal 27 Jul, 2022 Reviewers invited by journal 26 Jul, 2022 Editor invited by journal 14 Jul, 2022 Editor assigned by journal 01 Jul, 2022 First submitted to journal 31 May, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1714661","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":124153863,"identity":"010f5daf-14a4-48aa-9a33-3c13ea9d438f","order_by":0,"name":"Natasha Roberts","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIie3RsUrDQBjA8S8cpEvifCHSvkJCIRWM+ioXDuxiV0GEeCCcU90L+g4ZHRMyZDmSNW6VrAp26+FiGigtpWdxE7n/cBzH/biDD0Cn+4N5absYbLW1uoM+bPb7O0nRNiEwPEjCXRKxg6SosoV8OYfRwzRrbpbxOCmIMf/gMOj+vKdAUOTagsKxKKkvSD5JxBz5zxz8REVSCq7BEWB8FTiMpJOkJqZrczBUZFg1SEp+tyIjyUg89mrS+2rJhYr4NTWxzfPuFYMRRFpiopZEatIEpzYvLGyV1GGXuT8Tb/fOU4npTEG8KmpeJb/t4940W7AwHhwVNPt8vw7PHhVk3fYgutHgn+/vRH51W6fT6f5/33AYX8o65rKsAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-0534-8084","institution":"University Of Queensland UQCCR: The University of Queensland Centre for Clinical Research","correspondingAuthor":true,"prefix":"","firstName":"Natasha","middleName":"","lastName":"Roberts","suffix":""},{"id":124153864,"identity":"ac1b4cc6-5ade-43e7-be62-155b4db437f2","order_by":1,"name":"Helene Jacmon","email":"","orcid":"","institution":"Royal Brisbane and Woman's Hospital Health Service District: Royal Brisbane and Women's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Helene","middleName":"","lastName":"Jacmon","suffix":""},{"id":124153865,"identity":"8622e117-e7bd-4be8-bd74-3ccd860ba001","order_by":2,"name":"Brighid Scanlon","email":"","orcid":"","institution":"Royal Brisbane and Woman's Hospital Health Service District: Royal Brisbane and Women's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Brighid","middleName":"","lastName":"Scanlon","suffix":""},{"id":124153866,"identity":"260cd7c2-2936-4e83-b95d-a9cb83cf42a7","order_by":3,"name":"Chrissy Battersby","email":"","orcid":"","institution":"Royal Brisbane and Woman's Hospital Health Service District: Royal Brisbane and Women's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chrissy","middleName":"","lastName":"Battersby","suffix":""},{"id":124153867,"identity":"bbd6af6a-3dc3-4021-8fac-247641118c1b","order_by":4,"name":"Peter Buttrum","email":"","orcid":"","institution":"Royal Brisbane and Woman's Hospital Health Service District: Royal Brisbane and Women's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Buttrum","suffix":""},{"id":124153868,"identity":"b990bfc6-1499-42d2-9942-9a0fd467da67","order_by":5,"name":"Christine James","email":"","orcid":"","institution":"Royal Brisbane Hospital: Royal Brisbane and Women's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"James","suffix":""}],"badges":[],"createdAt":"2022-06-01 07:28:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1714661/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1714661/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-023-09814-9","type":"published","date":"2023-07-28T21:48:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44734167,"identity":"cd6d2df4-8565-4969-bdfc-3dd8b7938bb0","added_by":"auto","created_at":"2023-10-16 22:15:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":264764,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1714661/v1/62503dd9-af23-45ce-84ed-8444dfae56fd.pdf"},{"id":24611472,"identity":"dc6a502b-6f5a-4aa6-b897-5372bb75a2d2","added_by":"auto","created_at":"2022-08-01 17:06:40","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":426266,"visible":true,"origin":"","legend":"","description":"","filename":"ISSMCOREQChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1714661/v1/5f8a912ec0f6743909c5e7f6.pdf"}],"financialInterests":"","formattedTitle":"How Can We Meet the Diverse Needs of Patients, Their Families and Their Communities? A Qualitative Study Including Clinicians, Consumer Representatives, Patients, and Community Stakeholders.","fulltext":[{"header":"Key Implications","content":"\u003cp\u003e- A person centred approach can potentially meet the needs of diverse patient populations, especially those at risk of harm\u003c/p\u003e\n\u003cp\u003e- Transitioning between services was a time when patients feel most vulnerable\u003c/p\u003e\n\u003cp\u003e-Quality care that meets the diverse needs of patients, families and communities requires multi-layered approach which includes the health services level, the local clinical area, with local clinical teams, and directed individually for each patient and their supports\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eThree years ago, the \u003cem\u003eDiversity Working Group\u003c/em\u003e was formed to evaluate and improve service provision for patients within the largest public hospital health service in Australia. The perceived need for the \u003cem\u003eDiversity Working Group\u003c/em\u003e was in part driven by the Australian National Safety and Quality Health Service Standards (v2) (1) requiring organisations to identify the \u003cem\u003ediversity\u003c/em\u003e of the consumers using its services; planning and delivering care accordingly, especially for those at a higher risk of harm. The other driver was that the membership of the \u003cem\u003eDiversity Working Group\u003c/em\u003e was actively seeking organisational support for the patients across their various clinical areas.\u003c/p\u003e \u003cp\u003eAs a first step, expert stakeholders were engaged to identify those patient groups of greatest priority. Identified as at greater risk of harm were Aboriginal and Torres Strait Islander peoples, Culturally and Linguistically Diverse people, those living with a disability (physical or cognitive), patients from rural/ remote areas, people experiencing homelessness or social disadvantage, those with a mental health issue, and people who identify as Lesbian, Gay, Bisexual, Trans, intersex, Queer and other sexuality, gender, and bodily diverse people and communities (LGBTIQ+). Local demographic census data for residents in the hospital health service had been completed and compared to Australian averages (2). This data assessment identified that there was a higher prevalence of at-risk populations compared to national averages and further work was warranted.\u003c/p\u003e \u003cp\u003eA rapid review of the literature confirmed that \u003cem\u003ediversity\u003c/em\u003e in itself does not make a person and/or their community vulnerable. However, it was broadly acknowledged that at-risk populations have specific perspectives and healthcare needs (3). State and federal government resources highlighted that if these are ignored, poorer health outcomes may result (4). Internationally there was a call for targeted and culturally responsive healthcare to address disparities and achieve greater health equity (6\u0026ndash;10). At a national level, there were five publications identifying determinants of \u003cem\u003ediverse\u003c/em\u003e patient populations, including enablers and barriers to service delivery (11\u0026ndash;15). Two publications identified improvements from supporting care coordination and navigation of health services for those groups identified as at risk of harm (16,17). However, across the work identified, there were no evaluations or pragmatic guidance on how to guide health services to directly address the \u003cem\u003ediverse\u003c/em\u003e needs of patients and their communities. For this reason, the working group initiated a qualitative gap analysis to primarily answer the question, \u003cem\u003eHow can diverse needs of patients and communities be met in our hospital health service?\u003c/em\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe qualitative project was designed to better understand enablers and barriers, and the mechanisms already in play within the health service (18). We proposed that by qualitatively exploring the potential factors impacting health service delivery, the \u003cem\u003eDiversity Working Group\u003c/em\u003e could plan future directions.\u003c/p\u003e \u003cp\u003eA \u003cem\u003eDiversity Officer\u003c/em\u003e role was funded for this work and increments of the available full-time equivalent three positions, including two nurses with qualitative research expertise and clinical experience working in diverse patient communities, and a consumer advisor with expertise in advocacy and health ethics (NR, HJ, BS). The team had initiated the preliminary rapid review of the literature and by consensus determined that \u003cem\u003ediverse\u003c/em\u003e needs could be addressed by using a person-centred care approach, defined by the Australian Commission on Safety and Quality in Healthcare as being \u0026ldquo;\u0026hellip;respectful of, and responsive to, the preferences, needs and values of patients and consumers\u0026rdquo; (1). The term \u003cem\u003ediversity\u003c/em\u003e was not well-supported in the literature, but \u0026ldquo;people-centred care\u0026rdquo; featured strongly. The \u003cem\u003eDiversity Working Group\u003c/em\u003e had worked with stakeholders to identify groups at risk of harm in the hospital health service and wanted to explore how services could be directed to meet the \u003cem\u003ediverse needs\u003c/em\u003e of every person (and their family and community) who walked through the doors of the hospital. A \u0026ldquo;people-centred care\u0026rdquo; approach supported this aim.\u003c/p\u003e \u003cp\u003eThe three \u003cem\u003eDiversity Officers\u003c/em\u003e co-designed sets of qualitative open-ended questions, specifically for this study, to ask staff members, patients and community groups. Qualitative questions for staff aimed to explore enablers and barriers for meeting the \u003cem\u003ediverse needs\u003c/em\u003e, to ensure \u0026ldquo;people-centred care\u0026rdquo; of patients and their communities, and potential groups at greater risk of harm. Qualitative questions for patients also aimed to better explore what \u003cem\u003ediverse needs\u003c/em\u003e patients meant to patients, what \u003cem\u003ediverse\u003c/em\u003e groups they identified with, and the perceived enablers and barriers for having needs met. The sets of qualitative questions were disseminated to members of the \u003cem\u003eDiversity Working Group\u003c/em\u003e for feedback and improvement.\u003c/p\u003e \u003cp\u003ePatients and carers were approached in both outpatient and inpatient areas to participate. The project was explained, the voluntary nature of participation was reinforced, and the independent role of \u003cem\u003eDiversity Officers\u003c/em\u003e to clinical areas. Staff were approached in groups at unit meetings, and the qualitative questions were also emailed to staff who worked outside standard business hours. Other patient facing services, such as social work, allied health, discharge facilitation were approached. Community group members were also identified by patients, staff and the broader working group, and then contacted by telephone.\u003c/p\u003e \u003cp\u003e Verbal consents were obtained, and no identifying information was collected about participants. \u003cem\u003eDiversity Officers\u003c/em\u003e kept memos during data collections. Over three weeks, the \u003cem\u003eDiversity Officers\u003c/em\u003e collated responses to the qualitative questions in writing.\u003c/p\u003e \u003cp\u003eA Framework Analysis Approach was used to organise and synthesise the resulting qualitative information (19). Codes/constructs were assigned by each \u003cem\u003eDiversity Officer\u003c/em\u003e independently. These were put into matrices and the \u003cem\u003eDiversity Officers\u003c/em\u003e then came together and the data were discussed further as the key themes emerged from the matrices. All responses were cross-coded independently by the \u003cem\u003eDiversity Officers\u003c/em\u003e, and memos were used to better understand any diverging data and commonalities across themes. Data were discussed in two rounds, at which time consensus was achieved. After a 12-month time-period, a final revision of the data and themes was repeated for the preparation of this manuscript. COREQ guidelines were followed for reporting (20).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total three community stakeholders, 40 staff members and 30 patients consented to participate in the qualitative study over a period of three weeks.\u003c/p\u003e \u003cp\u003eThere were three key themes bringing together the responses. These were titled, \u0026lsquo;\u003cem\u003eWhat are diverse needs?\u003c/em\u003e\u0026rsquo;; \u0026lsquo;\u003cem\u003eAssigning people to a group does not identify a diverse need\u003c/em\u003e\u0026rsquo;; \u0026lsquo;\u003cem\u003eUnplanned care amplifies diverse needs\u0026rsquo;\u003c/em\u003e.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eWhat are diverse needs?\u003c/h2\u003e \u003cp\u003eSome staff reported that they identified \u003cem\u003ediverse\u003c/em\u003e needs by directly by asking patients, and/or families and carers on admission. Others reported that \u003cem\u003ediverse\u003c/em\u003e needs were taken from risk assessments, admission notes, emergency department notes, previous medical records, discharge letters and from the family or friends of patients. Whilst some staff said that simply asking patients would be the best way to identify their \u003cem\u003ediversity\u003c/em\u003e, others reported that they felt uncomfortable asking patients to \u0026lsquo;pigeonhole\u0026rsquo; themselves.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;you are asking people to tell you how they are different, it is a hard question..\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(clinician)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003esome people carry trauma about this sort of stuff\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(clinician)\u003c/p\u003e \u003cp\u003eAnd, patients did not feel comfortable either:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e..I don\u0026rsquo;t know about the groups, I don\u0026rsquo;t know what the answer means for me\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003epeople don\u0026rsquo;t want to be \u0026lsquo;different\u0026rsquo;\u003c/p\u003e\u003cp\u003e(patient)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eExisting organisational structures to communicate such \u003cem\u003ediverse\u003c/em\u003e needs were available at various timepoints on the patient journey; including on admission (Risk assessment, Booking form), during care (Structured Interdisciplinary Bedside Rounding (SIBR), Multidisciplinary teams (MDTs)), and at discharge (discharge facilitators, referrals, follow-up appointments, general practitioner letters). However, some participants said that the term \u003cem\u003ediversity\u003c/em\u003e was tokenistic and lacking commitment to really addressing patient needs in day-to-day care. They reported past experiences contributing to other pieces of work that did not result in any observed changes within the health service:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe see this sometimes, diversity, what is that, it\u0026rsquo;s tokenistic\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(community stakeholder)\u003c/p\u003e \u003cp\u003eThere were responses across all participant groups on the importance of acknowledging that \u003cem\u003ediverse\u003c/em\u003e needs exist, and that they could be both overt or invisible. Staff and patients raised concerns about relying on appearances at the risk of more pressing needs that may put patients at greater risk of harm:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e..you can\u0026rsquo;t see diversity\u003c/p\u003e\u003cp\u003e(stakeholder)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterestingly, no patient participants identified with any of the \u0026ldquo;at risk\u0026rdquo; groups when asked if they had any \u003cem\u003ediverse\u003c/em\u003e needs. Instead, it was reported that their unique needs came from their own health experiences:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have bad veins. I don\u0026rsquo;t like it when they are rude, I get scared they will be rude. I have no veins, I cannot help it, they keep poking thinking one will appear. I tell them. It hurts, and they get angry at me because I have no veins. That only happens every now and then, mostly everyone is very friendly, but it makes me feel shy\u0026rdquo;\u003c/em\u003e (patient)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssigning people to a group does not identify diverse needs\u003c/h2\u003e \u003cp\u003eAssigning patients to an \u0026ldquo;at risk\u0026rdquo; group, such as homelessness for example, as a mechanism to identify \u003cem\u003ediverse\u003c/em\u003e needs was reported to be problematic. Participants said that this had the potential to generate unwarranted assumptions based on the group a patient may be assigned, rather than their own specific health needs. There were responses across all participant groups that emphasised a need to see a person as a person, as a part of a community, but not as a member of an \u0026ldquo;at-risk\u0026rdquo; group.\u003c/p\u003e \u003cp\u003eIn each clinical area, staff quickly identified resources available for patients, as well as gaps in needed resources. Each ward or department also presented unique patient groups, unique resources and unique service needs. All participant groups expressed frustration at the barriers to accessing resources they perceived were used routinely in other institutions. Staff reported evidence-based practices that could be used in their areas to reduce unmet needs.\u003c/p\u003e \u003cp\u003ePatients explained that if their \u003cem\u003ediverse\u003c/em\u003e needs were met, they felt \u0026ldquo;cared for\u0026rdquo;, in turn being included in their health care:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;I saw an Obstetrician who took the time to really listen and explain; caring like a mother and I really appreciate that\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003cp\u003eThat they wanted to be treated like a person:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe are not customers or consumers you know. We are people with families that love us. We are loved by people. Not someone coming in to buy something, you know. It is like they don\u0026rsquo;t care about who we are\u003c/p\u003e\u003cp\u003e(patient)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatients described their experiences of communication and said they actively worked hard to build relationships with staff caring for them, that this was most important to them. For some patients, limitations with health services were perceived as a breakdown in trust. Many patients said that waiting for long periods in the waiting room makes you feel uncared for.\u003c/p\u003e \u003cp\u003eAnd uncared for because of their \u003cem\u003ediverse\u003c/em\u003e needs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e..ignoring you because you are inconvenient..\u003c/p\u003e\u003cp\u003e(patient)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere were many patients who reported that they were very happy with their care, that they have no concerns, that there was nothing to be improved, and that their needs are always met. Many said that they trusted staff when they thought they actually cared about them. If they did not feel trust through a relationship with their team, they struggled to engage. Staff reported that patient engagement needed work. They gave examples of when they would actively seek out those who they thought would struggle to engage with the hospital service:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e..you got to persist, don\u0026rsquo;t give up on anyone\u003c/p\u003e\u003cp\u003e(nurse)\u003c/p\u003e\u003cp\u003eThere was this lady, she was really anxious. So we changed her appointments so that they worked for her, did extra follow-ups. My manager is very supportive. Being flexible was what helped her anxiety\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(staff)\u003c/p\u003e \u003cp\u003ePatient reports reinforced that this was important, that they felt cared for when people fought for them:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e..when the staff fight for you..\u003c/p\u003e\u003cp\u003e(patient)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTo be heard:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e..taking on what I say, taking it on board..\u003c/p\u003e\u003cp\u003e(patient)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStaff identified that patients who were at greater risk of harm were those who were isolated, for whatever reason. Isolation could be for social, cultural or spatial reasons. For example, those who are from culturally and linguistically diverse backgrounds, those from rural and remote locations, young mothers with a history of addiction without family supports. Isolation resulted in inequities that came from difficulties accessing information and to physically access services in the hospital:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI don\u0026rsquo;t have a car, so normally I just would not go, its hard with all the kids on the bus. We make it work. I have had to learn to do things for myself, by myself, you learn to do it on your own. You just don\u0026rsquo;t know to ask for help, you actually don\u0026rsquo;t know how\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003cp\u003eThose with mental health issues featured as being at higher risk of harm, and it was identified by many staff and stakeholders as a pressing need. Patients that experienced mental health barriers could be from any \u0026ldquo;at risk\u0026rdquo; \u003cem\u003ediverse\u003c/em\u003e group and often had difficulties engaging with health services generally.\u003c/p\u003e \u003cp\u003eOther groups \u0026ldquo;at risk\u0026rdquo; of harm were also those that fall between services. Examples include those that do not have a Medicare card, or those awaiting assessment or approval for services such as National Disability Insurance Scheme or My Aged Care. These groups were those that had been identified as having specific health needs but were waiting for a place in a supported service.\u003c/p\u003e \u003cp\u003e Staff reported that they had developed solutions at local unit or ward levels. Having the autonomy to be flexible with services to accommodate individual patient needs was valued by clinical staff and this support from hospital management kept them engaged with their work and with health service.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eUnplanned care amplifies diverse needs\u003c/h2\u003e \u003cp\u003ePatients told stories of their experiences when their health status changed, or there was a change of plan. It was often these experiences that they drew on to describe their own \u003cem\u003ediverse\u003c/em\u003e needs. It was also a time when they said they felt vulnerable and isolated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;changing the plan without telling you. Little things are like pulling pieces out of the puzzle. I know what it is like, I get it, but sometimes you wonder what else you have missed, is everything ok?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003cp\u003ePatients perceived that it was their fault, it was from their own unique \u003cem\u003ediverse\u003c/em\u003e needs, and that they were not involved in decision making. Patients told stories of finding out after the fact why decisions were made, and questioned why they were not included:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;sometimes they communicate to themselves but not to the patients. I see them talking to each other in the corridor\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003cp\u003eIt was from these experiences that patients developed an understanding that they had unique need, their d\u003cem\u003eiverse\u003c/em\u003e need, and that they needed to monitor these to control any unexpected changes in the future. For example, waiting for results, or hearing about them after a decision was made was described as a time when patients felt they were not considered, that they could not advocate for what they needed:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt is hard to make decisions without all the information.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003cp\u003ePatients said that they wanted to be involved in making decisions. This need featured strongly across responses:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll I care about is my family, my partner and my child. When the plan changes, it\u0026rsquo;s on them. It means where will I go, what will I have to do, what will they have to do.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003cp\u003eIn particular, patients said that they did not want their lack of understanding and knowledge to be a barrier in participating in decision making:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAnd be patient with me, sometimes I don\u0026rsquo;t understand everything the first time\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003cp\u003ePatients said that their \u003cem\u003ediverse\u003c/em\u003e needs were met when they were included in decision-making:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;when I am a member of the team\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e(patient)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis work identified key areas a large hospital health service can target to better address the \u003cem\u003ediverse\u003c/em\u003e needs of patients and community, including patient assessment, health care planning and transition care. These touchpoints are particularly important for those who are isolated, as they are at most risk of harm. There were varying ways staff reported that they identify the \u003cem\u003ediverse\u003c/em\u003e needs of the patients in their care, and patients rarely fall into the well-defined categories. Patients in this study reported that they were best equipped to identify and share their needs when they were in a trusting relationship with their health care providers, which they characterised by being heard and feeling cared about. Those who were isolated struggled to engage with services, for any number of reasons. Across participant groups, it was acknowledged that \u003cem\u003ediverse\u003c/em\u003e needs may be invisible, and what may appear to be a priority to clinical teams, may not be the pressing need for a patient. A key finding of this work, bringing new knowledge, was that unplanned care and points of transition are when \u003cem\u003ediverse\u003c/em\u003e needs have the greatest impact.\u003c/p\u003e \u003cp\u003eA strength of this study was a co-designed qualitative approach. Responses were collected from both clinical inpatient and ambulatory spaces, including a wide breadth of stakeholders who are engaged with day-to-day patient care day. These participants brought to light some of the strategies in place day to day within the hospital health service. However, it is likely that there are vulnerable people who struggle to engage with health services did not participate in this study, as they may not be accessing or connecting with the health service, so these findings are limited to those who are engaged with the health service in some capacity. Organisational executive and health administrators were also not included in this study, but this is an area where much of the current literature is focussed.\u003c/p\u003e \u003cp\u003e Studies investigating the characteristics of successful organisations have identified that by acknowledging unique needs exist and facilitate a flexible approach to health service delivery is both practical and effective, consistent with our findings where staff felt that they were able to provide optimal care when a flexible approach was supported (24). The literature has identified that patients\u0026rsquo; needs are met when strategies are responsive to their preferences and values, so decisions support what is important to patients, with staff training a facilitator (24\u0026ndash;32).\u003c/p\u003e \u003cp\u003eThe evidence also supports our findings which identified that it is when planned healthcare changes, it is a time when patients, and their families, felt most vulnerable (24, 32). For transition care to be effectively provided, services should be coordinated using robust care pathways and appropriate referrals, as it is the point in the patient\u0026rsquo;s journey of care when a cohesive multi-disciplinary team is most needed (34). When unplanned changes happen for patients with complex needs and \u003cem\u003ediverse\u003c/em\u003e needs, transitions between providers or healthcare settings often result in fragmentation, low value care and poor patient outcomes (24, 35). Such outcomes include functional decline, adverse events, medication events, unplanned hospital admissions and patient dissatisfaction. Established strategies to respond include anticipating needs, providing actionable information and the provision of uninterrupted care, with unmet needs and under-utilisation of services a key barrier (33\u0026ndash;34). Mitchell and colleagues reported that transition care this could be optimised by ensuring patients had a sense of feeling cared for, being accountable and optimising collaboration between teams (33). Velligan and colleagues report that key facilitators come with structured organisational support to ensure training and an adaptable approach (27). Across the available evidence, the evidence base is more comprehensive in the mental health context, which was identified as an area of particular concern in our study.\u003c/p\u003e \u003cp\u003eThese qualitative study results support a layered strategy for addressing \u003cem\u003ediverse\u003c/em\u003e needs accommodating the multiple levels of a health service. \u003cem\u003eDiverse\u003c/em\u003e needs must be approached not just an organisational level, but also purposively directly adapted to accommodate clinical teams and patients and their communities. Considering the literature tells us that both patient outcomes and health service outcomes are improved when we address individual health needs, such an approach likely has many benefits (21). Within the context of our study, it was broadly accepted that there were specific groups of patients \u0026ldquo;at risk\u0026rdquo; of harm at a health service level. A needs assessment at a population level can ensure the capacity of a health service to ensure adequate processes in place (22,23). However, how to consistently tailor services at an individual level remains a gap in evidence (36\u0026ndash;39). Organisational strategies can include implementation of shared decision-making structures, use of patient reported outcome measures and an organisational philosophy that aligns with person-centred care (24\u0026ndash;26). Shared decision making has been demonstrated to improve patient and carer engagement to positively impact patient outcomes (27).\u003c/p\u003e \u003cp\u003eImplementation theory focussed research helps to better understand the mechanisms at play of the complex impacts in a health setting (18) with calls to establish comprehensive datasets to guide future directions of health service innovation and care delivery (40, 41). New theoretical approaches can then assist in solving modern health care challenges (18). How we move from talking about person centred care to investigating how to create structures that ensure it is operationalised day to day remains challenging and It is apparent, from the evidence, that we are still trying to understand how large health organisations can incorporate services that are able to respond to \u003cem\u003ediverse\u003c/em\u003e needs (42\u0026ndash;43). As a priority more work is needed to better identify and understand the experiences of those who struggle to engage with health services. Those organisations that are reported to have the best quality patient experience data also have the highest quality and safety outcomes (36).\u003c/p\u003e \u003cp\u003eDirections for the future work could aim to better understand how to predict and understand \u003cem\u003ediverse\u003c/em\u003e needs, especially for those at risk of harm, not just relying on heuristic clinician assessment alone. Future research directions could potentially better understand how to use data to better model those who are isolated and at risk of harm. Such an endeavour may ensure appropriate resources are readily available for clinical teams to better anticipate and directly meet the \u003cem\u003ediverse\u003c/em\u003e needs of patients, their families, and their communities.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTaking a person-centred approach can potentially ensure that the diverse needs of patients and communities will be better identified and responded to. Resources are needed to support patients and their families at times of transition care, particularly when care is unplanned.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLesbian, Gay, Bisexual, Trans, intersex, Queer and other sexuality, gender, and bodily diverse people and communities (LGBTIQ+) \u0026nbsp; \u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: This work was approved, including the use of verbal consent, after review by the Royal Brisbane and Women\u0026rsquo;s Hospital Human Research Ethics Committee, approval number: LNR/2019/QRBW/54984\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eFunding: There was no funding of this project.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors do not have any financial or non-financial competing interests to declare.\u003c/p\u003e\n\u003cp\u003eFunding: Not applicable\u003c/p\u003e\n\u003cp\u003eAuthor contributions: All authors have approved the submitted version. \u0026nbsp;Conception: NR, BS, HJ, CB, PB, CJ; Design of the work: NR; Acquisition and analysis: NR, BS, HJ; Writing: Draft of work: NR; Revision of draft: BS, HJ, CB, PB, CJ\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors would like to acknowledge the staff and patients that participated in this project.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAustralian Commission on Safety and Quality in Healthcare (2012). 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Journal of Clinical Oncology 35(18), 1978\u0026ndash;1981.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarly P, Johnston-Fleece M, Johnson M, Shifreen A, Clauser S (2021). Patient-centred approaches to transitional care research and implementation: Overview and insights from patient-centred Outcomes Research Institute\u0026rsquo;s Transitional Care Portfolio. Medical Care 59, pS330-S335.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGredndarova P, Yannitsos DH, Vaska M, Barbera LC (2019). Improving patient experience in health care and oncology: A scoping review. Journal of Clinical Oncology 37(27).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Diepen C, Wolf A. (2021). \u0026ldquo;Care is not care if it isn\u0026rsquo;t person-centred\u0026rdquo;: A content analysis of how Person-Centre Care is expressed on Twitter. Health Expectations 42(2), 548\u0026ndash;555.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-1714661/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1714661/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe Diversity Working Group was formed to provide guidance to implement hospital health services strategies that could better address the diverse needs of patients and communities, with particular attention to those at greater risk of harm.\u0026nbsp;It was identified that a better understanding of gaps in patient facing areas was required.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA qualitative study was conducted by an experienced team from varied professional backgrounds including a clinician researcher, a nurse researcher with expertise in culturally and linguistically diverse community care and a consumer representative with expertise in advocacy and carer representation.\u0026nbsp;\u0026nbsp;Qualitative questions were co-designed, aiming to identify enablers and barriers to person-centred care.\u0026nbsp;Community stakeholders, and clinical staff and patients from both ambulatory and inpatient areas were approached to participate.\u0026nbsp;Responses were coded independently and synthesised using a Framework Approach.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eIn total 3 community stakeholders, 40 clinical staff and 30 patients consented to participate in the qualitative study over a period of three weeks.\u0026nbsp;\u0026nbsp;There were three key themes across responses, ‘\u003cem\u003eWhat are diverse needs?\u003c/em\u003e’; ‘\u003cem\u003eAssigning people to a group does not identify a diverse need\u003c/em\u003e’; ‘\u003cem\u003eUnplanned care amplifies diverse needs’\u003c/em\u003e.\u0026nbsp;Those patients who were isolated, for any number of reasons, were identified as at greatest risk of harm. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eTaking a person-centred approach can potentially ensure that the diverse needs of patients and communities will be better identified and responded to.\u0026nbsp;Resources are needed to support patients and their families at times of transition care, particularly when care is unplanned.\t\t\t\u003c/p\u003e","manuscriptTitle":"How Can We Meet the Diverse Needs of Patients, Their Families and Their Communities? 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