Obzornik zdravstvene nege, 58(2), pp. 84–87. https://doi.org/10.14528/snr.2024.58.2.3287 Regularly, healthcare providers distribute brochures detailing treatment options to enhance patient self- management or encourage the use of apps for symptom tracking. We also strive for shared decision-making by inquiring about patients' therapy preferences. There are many of these positive initiatives In literature to optimize healthcare, and more specifically pharmaceutical care. Statements that patient engagement is as a viable strategy to improve healthcare sustainability have sparked my interest. The question arises: Can patient brochures, digital applications, shared decision- making processes, or other investments in patient engagement genuinely foster sustainability? While such interventions may boost patient satisfaction, knowledge, and even improve clinical parameters like HbA1c or blood pressure, their impact on sustainability remains debatable. Sustainability encompasses environmental, economic, and social dimensions. The World Health Organization [WHO] describes an environmentally sustainable healthcare system as a health system that improves, maintains, or restores health, while minimizing negative impacts on the environment and leveraging opportunities to restore and improve it, to the benefit of the health and well- being of current and future generations (WHO, 2017). In the domain of pharmaceutical care, an explorative literature search did not show strong evidence or mixed results for the impact on costs, efficiency, waste, health care consumption, planetary health, pollution, diversity, equity, inclusion, climate change, carbon, health resources, or health expenditures. These effects might be a consequence of improved medication adherence, patient self-management, quality of life or a reduction in errors, yet, also for these outcomes results are inconclusive. However this uncertainty should not deter us from pursuing patient engagement. On the contrary, it should prompt us to refine our approach to address several challenges. A first challenge is the correct use of the concept patient engagement. It is often incorrectly used interchangeable with other concepts such as patient empowerment or patient involvement. Higgins et al. (2017) and Hickmann et al. (2022) have done a great job in the conceptualization of patient engagement. Patient engagement is the behavior of a patient, where the patient shows active partnership with health care providers in personal health care. It requires the patient to be empowered to do so and to have the competencies. This means you cannot just invest in enabling the patient, making him competent to participate in care, or investing in empowering the patient to have the attitude to participate in care. As healthcare providers we need to respect all critical attributes of patient engagement and address all of them if we want substantial impact: establishing a partnership with the patient, pursuing shared health goals, perform shared decision-making, enabling patients to engage in their health care by making resources available and motivating the patient. A nice example is the study of Laura Mortelmans to facilitate self-management by patients in hospital. Patients are empowered being given the opportunity to self-manage. Healthcare providers receive tools to go through the process and to support patients in case of self-management problems. Patients receive tools, such as a medication diary, to have medication information available and to stimulate shared decision making. Error detection systems and feedback systems allow for coaching and training patients. A continuous partnership between patient and health care providers is required (Mortelmans et al., 2023, 2024; Mortelmans & Diller, 2024; Mortelmans & Dilles, 2024). A second challenge, a very essential one, is to make every step of the patient engagement process person- centered (Dilles, 2023). Not all patients will need and Editorial/Uvodnik Challenges to make patient engagement result in more sustainable pharmaceutical care Izzivi spodbujanja vključenosti pacientov za bolj trajnostno farmacevtsko oskrbo Tinne Dilles1, * 1 University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium; Chair of Centre for Research and Innovation in Care, Antwerp, Belgium and Chair of NuPhaC - Nurse and Pharmaceutical Care * Corresponding author/Korespondenčni avtor: Tinne.Dilles@UAntwerpen.be Received/Prejeto: 9. 4. 2024 Accepted/Sprejeto: 20. 4. 2024 Dilles, T. (2024)/Obzornik zdravstvene nege, 58(2), pp. 84–87. 85 will respond to the same strategies for competency improvement or motivation. Furthermore, the extent of desired involvement varies among individuals. We do not consider social determinants of health enough in our interventions. In Sint Maartens hospital in the Netherlands an omnichannel strategy to provide patient education on medicines use was developed. Depending on the patient competences, preferences and needs, patients can for choose consulting information on the website reading text, watching videos, learning through gaming, using a chatbot, talking to a digital human, direct text messaging, videocalling with health care providers, or live encounters. In majority- minority city of Antwerp, Belgium, we study the impact of sociocultural diversity on the way people think about and deal with polypharmacy to facilitate personalization of interventions. The third challenge involves reaching out to the disengaged. If we want to make a difference we need to engage those who are not already engaged in their care. Studies indicate that patients who are already proactive in their care benefit less from additional resources, suggesting that targeting this group may not be the most sustainable approach. Studies often depend on the willingness of patients to participate in a study. Engagement in one's own health and engagement in study participation can be related. In many studies we see that patients who are already doing well are participating. Many studies report difficulties in implementing interventions for patient engagement with patients not being willing to participate in the interventions. A recent study shows that patients who are willing to share information about their medicines use with health care providers, were also more willing to participate in a follow-up study on adherence after discharge (Mortelmans et al., 2024). So, we need a tailored approach targeted at the most disengaged, respecting all steps of the patient engagement process. This can only be achieved in case of a strong interprofessional approach, which is the fourth challenge. With increasing staff shortages we need to work together, with the unique, complementary and common strengths we have, to care for the patients together, avoiding missed care and useless overlapping care. If we change our approach and tackle the challenges together, I believe the patient can become a stronger partner in care. The NuPhaC (Nurse and Pharmaceutical Care) EU frameworks can be used to discuss and agree on interprofessional collaboration with nurses in pharmaceutical care (De Baetselier et al., 2021). In conclusion, patient engagement is a cornerstone of healthcare. Its' Importance is expanding in view of paving the way for a healthcare system that is sustainable for generations to come. We need to set up interprofessional experimental studies that show the effects on sustainability outcomes. With a smart approach, dealing with the challenges, we hypothesize that more patient engagement in pharmaceutical care has the potential to improve sustainability related outcomes such as workload, patient self-management, to inclusiveness, medication adherence and decrease waste. Slovenian translation/Prevod v slovenščino Distribucija brošur z informacijami o različnih možnostih zdravljenja ter spodbujanje uporabe aplikacij za spremljanje simptomov sta temeljna ukrepa za izboljšanje samooskrbe pacientov. Zdravstveni delavci si s pomočjo seznanjanja s pacientovimi željami prizadevamo tudi za skupno odločanje glede samega zdravljenja. V literaturi je najti veliko pozitivnih pobud za optimizacijo zdravstvenega varstva oziroma farmacevtske oskrbe. Zanimale so me predvsem trditve, da je spodbujanje vključenosti pacientov učinkovita strategija za izboljšanje vzdržnosti zdravstvenega varstva. Ključno vprašanje, ki se pri tem zastavlja, je, ali lahko brošure in digitalne aplikacije, namenjene pacientom, ter postopki skupnega odločanja in druge naložbe v vključenost pacientov resnično prispevajo k trajnostni farmacevtski oskrbi. Čeprav lahko tovrstni ukrepi povečajo zadovoljstvo bolnikov, poglobijo njihovo znanje in celo izboljšajo določene klinične parametre, kot sta HbA1c in krvni tlak, je njihov vpliv na trajnost še vedno vprašljiv. Trajnost namreč zajema okoljske, gospodarske in družbene razsežnosti. Svetovna zdravstvena organizacija [WHO] opredeljuje okoljsko trajnosten zdravstveni sistem kot zdravstveni sistem, ki ne le izboljšuje, ohranja ali obnavlja zdravje, ampak hkrati zmanjšuje negativne okoljske vplive ter izkorišča možnosti za njegovo obnovo in krepitev v korist zdravja in blagostanja sedanjih in prihodnjih generacij (WHO, 2017). Pregled literature s področja farmacevtske oskrbe ni podal ne trdnih dokazov niti mešanih rezultatov glede vplivov na stroške, učinkovitost, uporabo zdravstvenih storitev, zdravje planeta, zmanjševanje odpadkov in onesnaževanja, raznolikost, enakost, vključenost, podnebne spremembe, ogljik, zdravstvene vire ali zdravstvene izdatke. Ti učinki bi lahko bili posledica izboljšanega upoštevanja predpisanega zdravljenja, samooskrbe pacientov, kakovosti življenja in zmanjšanja napak, vendar so tudi glede teh izidov rezultati neprepričljivi. Ta negotovost pa nas ne sme odvrniti od prizadevanja za dejavno vključenost pacientov v proces zdravstvene oskrbe, ampak nas mora spodbuditi k izboljšanju svojega pristopa k spoprijemanju z izzivi, ki se pri tem porajajo. Prvi takšen izziv je pravilna uporaba termina 'vključenost pacientov'. Pogosto se namreč uporablja napačno in zamenjuje s termini, kot sta opolnomočenje pacienta in vključevanje pacienta. Higgins et al. (2017) in Hickmann et al. (2022) so ključno prispevali h konceptualizaciji vključenosti pacientov. Vključenost pacienta označuje aktivno sodelovanje pacienta z izvajalci zdravstvenih Dilles, T. (2024)/Obzornik zdravstvene nege, 58(2), pp. 84–87.86 storitev pri skrbi za lastno zdravje. Pacient mora biti za to opolnomočen in imeti ustrezne kompetence. To pomeni, da je potrebno več kot le usposobiti pacienta za sodelovanje pri oskrbi ali ga opolnomočiti za sodelovalni odnos pri oskrbi. Kot izvajalci zdravstvenih storitev moramo upoštevati vse ključne značilnosti vključenosti pacientov ter jih pravilno nasloviti, obenem pa pacientom omogočiti dostop do ustreznih virov in jih motivirati. Le tako bomo lahko vzpostavili partnerstvo s pacientom, si prizadevali za skupne zdravstvene cilje, skupaj odločali in jim omogočili aktivno vlogo pri zdravstveni oskrbi. Raziskave Laure Mortelmans predstavljajo dober primer omogočanja samooskrbe pacientom v bolnišnici. Pacienti se ob možnosti samooskrbe počutijo opolnomočeni. Zdravstveni delavci prejmejo orodja, s katerimi v primeru težav pacientom nudijo pomoč pri samooskrbi, pacienti pa prejmejo orodja, kot je dnevnik zdravil, ki jim omogoča dostop do informacij o zdravilih in spodbuja njihovo sodelovanje pri odločanju glede zdravljenja. Sistemi za odkrivanje napak in sistemi povratnih informacij omogočajo izvajanje coachinga in usposabljanja pacientov. Pri tem je potrebno zagotoviti stalno partnerstvo med pacientom in izvajalci zdravstvenih storitev (Mortelmans et al., 2023, 2024; Mortelmans & Diller, 2024). Drugi izjemno pomemben izziv v procesu zagotavljanja vključenosti pacienta je ohranjanje osredotočenosti na osebo (Dilles, 2023). Vsi pacienti namreč ne potrebujejo enakih strategij usposabljanja ali motivacije in se nanje tudi ne odzivajo enako, prav tako pa se posamezniki razlikujejo tudi glede na stopnjo želene vključenosti. Pri intervencijah se družbena determinanta zdravja pogosto ne upošteva v zadostni meri. V bolnišnici Sint Maartens na Nizozemskem so razvili strategijo izobraževanja pacientov o uporabi zdravil, temelječo na kombinaciji različnih virov. Pacienti lahko v skladu s svojimi kompetencami, željami in potrebami na spletni strani iščejo informacije z branjem besedila, gledanjem videoposnetkov, igranjem poučnih iger, uporabo klepetalnika, izmenjavo besedilnih sporočil, videoklicev z izvajalci zdravstvenih storitev ali srečanji v živo. V Antwerpnu v Belgiji preučujemo učinke družbeno-kulturne raznolikosti na dojemanje in mehanizme obvladovanja polifarmacije z namenom spodbujanja personalizacije zdravstvenih intervencij. Tretji izziv je navezovanje stikov s pacienti, ki niso dejavno vključeni v proces svojega zdravljenja. Če želimo spremeniti trenutno situacijo, moramo nasloviti tiste, ki v svojo zdravstveno oskrbo še niso vključeni. Raziskave kažejo, da imajo pacienti, ki so že proaktivno vključeni v svojo oskrbo, manj koristi od dodatnih sredstev, kar nakazuje, da usmerjanje v to skupino morda ne predstavlja najbolj trajnostnega pristopa. Glede na to, da so raziskave pogosto odvisne od pacientove pripravljenosti za sodelovanje, je zelo verjetno, da obstaja določena povezava med aktivno skrbjo za lastno zdravje in pripravljenostjo za sodelovanje v raziskavah. V številnih študijah namreč sodelujejo pacienti zadovoljivega zdravstvenega stanja, po drugi strani pa mnoge študije poročajo o težavah pri izvajanju intervencij za povečanje vključenosti pacientov, saj ti v intervencijah niso pripravljeni sodelovati. V nedavni raziskavi so se bili pacienti, ki so bili pripravljeni deliti informacije o uporabi zdravil z zdravstvenimi delavci, tudi bolj pripravljeni udeležiti nadaljevanja raziskave o upoštevanju predpisanega zdravljenja po odpustu iz bolnišnice (Mortelmans et al., 2024). Iz tega razloga je pristop nujno potrebno prilagoditi najmanj angažiranim pacientom, pri čemer moramo upoštevati vse korake procesa vključevanja pacientov. To je mogoče doseči le z močnim medpoklicnim pristopom, ki je hkrati tudi četrti izziv. Kot odgovor na naraščajoče pomanjkanje zdravstvenega osebja moramo spodbujati sodelovanje in uporabo svojih edinstvenih in komplementarnih sposobnosti za skupno zdravstveno nego pacientov ter se izogniti zamudam v oskrbi in neproduktivnem podvajanju nege. S tovrstnimi spremembami v pristopu in skupnim spopadanjem z izzivi lahko pacient postane močan partner pri izvajanju zdravstvene nege. Okvire NuPhaC (Nurse and Pharmaceutical Care) EU je mogoče uporabiti za razpravo in dogovor o medpoklicnem sodelovanju z medicinskimi sestrami pri farmacevtski oskrbi (De Baetselier et al., 2021). Vključevanje pacientov je temelj zdravstvenega varstva. Njegov pomen je pri utiranju poti trajnostnemu zdravstvenemu sistemu za prihodnje generacije še toliko večji. Vzpostaviti moramo medpoklicne eksperimentalne raziskave, rezultati katerih bodo osvetlili trajnostne učinke. Verjamemo, da lahko s pametnim pristopom k spopadanju z naštetimi izzivi in z dejavnejšo vključenostjo pacientov v farmacevtsko oskrbo izboljšamo rezultate, povezane s trajnostjo, kot so delovna obremenitev, samooskrba pacientov, inkluzivnost, upoštevanje predpisanega zdravljenja in zmanjšanje količine odpadkov. Conflict of interest/Nasprotje interesov The author confirms that there are no conflict of interest./Avtorica izjavlja, da ni nasprotja interestov. Literature De Baetselier, E., Van Rompaey, B., Dijkstra, N. E., Sino, C. G., Akerman, K., Batalha, L. M., Fernandez, M. I. D., Filov, I., Grøndahl, V. A., Heczkova, J., Helgesen, A. K., Keeley S, Kolovos, P., Langer, G, Ličen, S., Lillo-Crespo, M., Malara, A., Padyšáková, H., Prosen, M., Pusztai, D., … Dilles, T. (2021). 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