Exploring Surgical Patient Engagement A Critical Realist Perspective

Abstract Our healthcare system is transitioning from disease-centred to patient-centred models, prioritising individual needs, preferences, and values. This shift emphasises the importance of patient engagement for high-quality, responsive care that aligns with the needs and values of the individual. Such engagement not only promotes personalised care but also empowers patients to play an active role in managing their health, leading to improved health outcomes, increased patient satisfaction, and a more sustainable healthcare system. In perioperative care, active patient engagement promises to enhance recovery experiences. Despite its importance, there is a gap in research focused on surgical patient engagement, indicating a need for enhanced understanding of engagement strategies in this critical area of healthcare. Underpinned by a critical realism, this thesis explores the perceptions, beliefs, and values of different stakeholders involved in surgical patient engagement. This perspective acknowledges these viewpoints as subjective yet significant interpretations of reality. Despite the potential fallibility of these viewpoints, they are valued as crucial insights into the shared meanings and norms that underpin patient engagement in surgical contexts. It allows for a nuanced exploration of the underlying mechanisms and social dynamics that shape engagement practices, fostering a deeper understanding of how these stakeholders collectively contribute to the patient engagement process, thereby enriching the understanding of its multifaceted nature. A mixed-methods approach is adopted, combining a mixed-methods systematic review from the perspective of patients and qualitative focus groups with clinicians, to provide a comprehensive exploration of patient engagement. This methodology allows for an in-depth exploration capturing both research discourse and clinical insights. The project aimed to (1) review existing research on how surgical patient engagement is conceptualised and operationalised during the perioperative period; and (2) explore the associated barriers and facilitators from the perspectives of clinicians involved in the perioperative period. The study was structured in two phases. Phase 1 systematically reviewed the literature on conceptualisations and operationalisations of surgical patient engagement. Searches in MEDLINE, EMBASE, CINAHL, and the Cochrane Library identified English-language studies focusing on surgical patient engagement during the perioperative period. The selection and assessment of studies were done by three reviewers using the Joanna Briggs Institute mixed methods review framework. Data analysis involved reflexive thematic analysis for qualitative studies and qualitisation of quantitative data. A total of 29 studies were included, comprising both qualitative (n=14) and quantitative (n=15) research. Sample sizes ranged from 7 to 1,315 participants. Every study included patient perspectives, some also included other stakeholders, predominantly nurses. Only 11 studies (38%) provided an explicit definition of patient engagement, revealing a conceptual void. Analysis identified four main themes related to operationalisation: provision of information, communication, decision-making, and action-taking, which were interrelated and mutually dependent. The review highlights the nuanced, multifaceted nature of surgical patient engagement. It underscores the need for more theoretically sound and comprehensive research to better understand surgical patient engagement. Phase 2 consists of qualitative focus groups with surgeons and anaesthetists. Despite initial intentions to include a broader range of medical professionals, recruitment was limited due to logistical and pandemic-related constraints. Purposive sampling was used. Two focus groups were conducted—one in-person and another online. Data analysis followed Braun and Clarke’s thematic analysis framework, emphasising the identification of key themes related to the facilitation and barriers of patient engagement, with an emphasis on reflexivity and transparency to maintain analytical integrity. Participants included 11 healthcare professionals, comprising five surgeons and six anaesthetists with 45.5% (n=5) female and 54.5% (n=6) male. Data resulted in identification of barriers to surgical patient and engagement, and strategies to overcome these barriers. The barriers to patient engagement include 'Patient interest and commitment', 'Time constraints', 'Language barriers and cultural differences', and 'Lack of Trust'. To address these challenges, the clinicians recommended several strategies: adopting a 'Collaborative interdisciplinary approach', 'Provision of information and education', and 'Fostering relationships with interpersonal skills'. This study contributes to a nuanced understanding of surgical patient engagement from the perspectives of healthcare professionals, highlighting both barriers to and opportunities to facilitate engagement. The findings from both phases of the study suggest a consensus on the conceptualisation of patient engagement, while highlighting interpretative differences. Both phases highlight the importance of providing information and education to patients, the importance of clinicians' communication skills, the necessity of shared decision-making, and patient’s capability for active engagement. Moreover, another key recommendation from focus groups included the role of a surgical coordinator to improve communication and continuity of patient care, underscoring the need for a multidisciplinary approach in perioperative engagement. This study defines surgical patient engagement as a multi-faceted, dynamic collaboration between patients and clinicians across all surgical phases, aimed at empowering patients to take an active role in their recovery. It proposes a conceptual framework that underscores continuous engagement and the need for responsiveness to feedback and adaptability in engagement strategies, as well as a collaborative interdisciplinary approach that includes patients as key decision-makers. The core elements of the framework include Meeting Needs, Education, Empowerment, and Trust (MEET), which address patient factors, provision of information, fostering patient autonomy, and building a rapport and trust for effective engagement. The framework emphasises interdisciplinary collaboration, personalisation, and technology to improve surgical outcomes and overall care quality by engaging patients in their health journey. This research acknowledges several limitations: the exclusion of grey literature and non-English publications in the systemic review may have limited the findings, although the review included a diverse international selection. Specific keyword use, focusing solely on major surgeries, and absence of subgroup analyses could limit the breadth and applicability of findings. The focus groups consisted of a small sample size of 11 participants from a single hospital and by not including nurses, due to constraints of the pandemic, leading to uncertainty on data saturation. However, the nurses’ views on patient engagement have been represented in the systematic review. Despite these challenges, the research provides valuable insights into perioperative surgical patient engagement and contributes to the field's theoretical and practical knowledge base. This research offers a nuanced understanding of surgical patient engagement and introduces a conceptual framework for systematic operationalisation of surgical patient engagement. It offers insights to guide clinicians and researchers in creating effective patient engagement strategies, particularly during the complex perioperative phase. This framework serves as a foundation for systematic study of patient engagement strategies for researchers, leading to the formulation of evidence-based practices. Clinically, it promotes a more empathetic, responsive, and personalised approach to healthcare, aiming to develop more targeted patient engagement strategies. The focus on continuous engagement, education, empowerment, and trust can enhance surgical care quality, creating a dynamic where patients are well-informed and active in their treatment, thus improving health outcomes and the efficiency of healthcare delivery. These insights not only advance our conceptual understanding but also have practical implications for training healthcare professionals, emphasising patient engagement as a pivotal element of effective health management.