Workplace safety in healthcare settings

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Workplace_safety_in_healthcare_settings

Workplace safety in healthcare settings is similar to the workplace safety concerns in most occupations, but there are some unique risk factors, such as chemical exposures, and the distribution of injuries is somewhat different from the average of all occupations. Injuries to workers in healthcare settings usually involve overexertion or falling, such as strained muscles from lifting a patient or slipping on a wet floor. There is a higher than average risk of violence from other people, and a lower than average risk of transportation-related injuries.

Aggression in the healthcare

About one injury in eight is due to patients being aggressive or violent towards healthcare professionals (or towards other patients). Sometimes staff members being aggressive against patients. Patient-on-professional aggression commonly involves verbal abuse, although deliberate physical violence has been documented sometimes severe. Staff-on-staff aggression may be passive, such as a failure to return a telephone call from a disliked colleague, or indirect, such as engaging in backbiting and gossip.

Aggression was, in 1968, described by Moyer as "a behaviour that causes or leads to harm, damage or destruction of another organism". Human aggression has more recently been defined as "any behaviour directed toward another individual that is carried out with the proximate intent to cause harm".

The definition can be extended to include the fact that aggression can be physical, verbal, active or passive and be directly or indirectly focused at the victim–with or without the use of a weapon, and possibly incorporating psychological or emotional tactics. It requires the perpetrator to have intent, and the victim to attempt evasion of the actions. Hence harm that is accidental cannot be considered aggressive as it does not incorporate intent, nor can harm implicated with intent to help (for example the pain experienced by a patient during dental treatment) be classed as aggression as there is no motivation to evade the action. A description of workplace violence by Wynne, Clarkin, Cox, & Griffiths (1997), define workplace violence to be incidents resulting in abuse, assault or threats directed towards staff with regard to work–including an explicit or implicit challenge to their safety, well-being or health.

The rate of aggression within the health care varies by country, globally 24% of healthcare workers experience physical violence each year and 42% experience verbal or sexual abuse. This rate has been decreasing in North America and increasing in Australasia. In Europe, rates of verbal abuse have decreased and physical violence have remained stable over the past decade.

Aggression and violence negatively impact both the workplace and its employees. For the organisation, greater financial costs can be incurred due increased absences, early retirement and reduced quality of care. For the healthcare worker however, psychological damage such as post-traumatic stress can result, in addition to a decrease in job motivation. Aggression also harms patient care. Rude remarks from patients or their family members can distract healthcare professionals and cause them to make mistakes during a medical procedure.

A survey from the British National Audit Office (2003) stated that aggression and violence accounted for 40% of reported health and safety incidents amongst healthcare workers. Another survey looking into the abuse and violence experienced in 3078 general dental practices over a period of three years found that 80% of practice personnel had experienced self-reported verbal abuse, abuse or violence. It was reported that, over 12 months in Australian hospitals, 95% of staff had experienced verbal aggression. In the UK over 50% of nurses had experienced aggression or violence over a 12-month period. In the United States, the annual rate of nonfatal, job-related violent crime against mental healthcare workers was 68.2 per 1,000 workers compared to 12.6 per 1,000 workers in all other occupations.

In the United States, the emergency department is one of the most high-risk places to work in a hospital, which makes sense because most individuals in the emergency room are people who have just been injured and need to be rushed to the hospital. That situation is very stressful and scary for most people, so it may lead to emotions that are not truly meant, including aggressive emotions. Nurses' reports of patient aggression is not always taken seriously, which can make nurses less likely to report, ultimately leading to mental health issues.

It was stated that nonfatal injuries because of aggression were three times more frequent against health care professionals than private industry workers. With nurses dealing with these situations on a daily basis, it has led to many issues in their personal lives. It was stated that nurse suicide is the 10th leading cause of death in the United States.

Causes

Many factors are correlated with an increased risk of violence. Regarding workplace design, poor delineation of staff only areas, overcrowding, poor access to amenities and unsecured furnishing increase the risks of violence. Regarding work practices, waiting times, poor customer service, working alone, lack of training, low level of staff empowerment, lack of deescalation training, lack of straff training in the cause of violence, the use of physical restraint and the presence of cash on-site is correlated with violence. Physicians who are unprepared, lacking in education about violence including descalation, lacking in medical skills of social skills, less experienced, overworked are more likely to be involved in violence. The physicians interpersonal style, personality and emotional state are correlated with violence.

Patients who experience poverty or social exclusion, or lack the language of cultural competence to interact with physicians are more likely to be involved in violence. As well as those with certain injuries or disorders, such as head injuries, some psychiatric disorders, or thyroid disorders. Stressors, lack of respect and perceived respect, experience of poor healthcare historically, and intoxication are also risks for violence.

Regarding the interactions that preceded aggression, misunderstandings or disputes about medical issues, patients being or feeling dismissed, dissatisfaction with care, physical contact, frustration with the patients intention, and involuntary treatment are correlated with violence.

Ways of classifying aggression and violence

Most studies on violence in nursing are empirical in nature with little theoretical analysis. A systematic review on theoretical framings suggested an indisciplinary approach to capture the nuances of violence in a healthcare setting.

Classification

Patient-on-professional aggression can be classified as Type II; where the perpetrator commits a violent act whilst being served by the organisation, with which they have a legitimate relationship. It is uncommon for such attacks to result in death, however they are evidently responsible for approximately 60% of non-fatal assaults at work. Within this classification that is based on the relationship between the perpetrator and victim, Type I aggression involves the perpetrator entering the workplace to commit a crime–having no relationship to the organisation or its employees. Type III deals with a current/former employee targeting a co-worker or supervisor for what they perceive to be wrong-doing. Type IV aggression involves the perpetrator having an ongoing/previous relationship with an employee within the organisation.

Internal Model

The internal model associates aggression with factors within the person, including mental illness or personality. This model is supported by the numerous studies correlating a link between aggression and illness. A person's traits can relate to their expression of aggression–narcissists for example, tend to become angry and aggressive if their image is threatened. Sex tends to affect aggression–with certain provocations affecting each sex differently. It was found that males tend to prefer direct aggression, and females indirect. A study by Hobbs and Keane, 1996 says that patient factors commonly related to or causative of patient violence include; male sex, relative youth or the effects of alcohol or drug consumption. A study conducted amongst General Medical Practitioners in the West Midlands found that men were involved in 66% of aggression cases; rising to 76% with regard to assault/injury–the main male perpetrator being aged under 40 years of age. Patient anxiety, a particular problem associated with dentistry, tended to be the most likely instigator for verbal abuse and the second most likely reason for threatening verbal abuse.

External Model

This model is based on the idea that social and physical environmental influences affect aggression. This includes the provisions for privacy, space and location. Motivation for aversion, possibly due to pain during dental treatment, can increase aggression–as can general discomfort, such as that resulting from sitting in a hot waiting room or in an uncomfortable position (for example in a reclined dental chair). Alcohol intoxication or excessive caffeine intake tends to indirectly exacerbate aggression. The Hobbs & Keane (1996) study states the involvement of drugs and alcohol; in 65% of cases at one Accident & Emergency Department and in 27% of all general practice cases. The study denotes intoxication to be the main reason for assaults and injury (along with mental illness). Frustration, defined by Anderson and Bushman as "the blockage of goal attainment", can also contribute to aggression–whether the frustrations are fully justified or not. Such frustration-related aggression tended to be against the perpetrator and persons not involved in failure to reach the goal. Prolonged waiting times in A&E departments and general practice led to aggression due to frustration; it generally being directed towards receptionists–with approximately 73% of doctors becoming involved.

Situational/Interactional Model

This deals with factors involved in the immediate situation, for example interactions between patients and staff. There are numerous studies that support the correlation between staff with a negative attitude and patient aggression. Provocation has been said to be the most important cause of human aggression –examples include verbal and physical aggression against the individual. It was found that perceived injustice, in the context of equality amongst staff for example, positively correlated to workplace aggression.

Expressions of Hostility

This is related to "behaviours that are primarily verbal or symbolic in nature". In terms of Staff-on-Staff hostility, this can involve he perpetrator talking behind the targets back. With Patient-on-Professional hostility however, this can deal with the patient assuming false knowledge over the professional–with the patient belittling their opinions.

Obstructionism

This involves the perpetrator conducting actions that aim to "obstruct or impede the target's performance". Failures to pass on information or respond to phone calls for example, are ways in which Staff-on-Staff obstructionism can be demonstrated. Patient-on-Professional obstructionism can be demonstrated by a failure on behalf of the patient to comply with the professional conducting a certain task. An unwillingness to allow the professional to diagnose the patient and a failure to turn up to appointments are examples of such obstructionism.

Overt Aggression

This normally relates to workplace aggression, and involves behaviours including; threatening abuse, physical assault and vandalism. This again can occur with regard to both, Staff-on-Staff and Patient-on-Professional aggression.

Buss' Three-Dimensional Model of Aggression

Buss differentiated aggression into a three-dimensional model; physical-verbal, active-passive and direct-indirect–active-passive being removed in 1995 when Buss refined the categories. Physical assault would come under the category physical-direct-active, whereas obstructionism relates to physical-passive–be it direct or indirect. Verbal abuse or insults relate to verbal-active-direct aggression, whereas the failure to answer a question when asked, for example with regard to lifestyle choices or habits, can come under the verbal-passive-direct category–providing the reasons for not answering are directed at the healthcare worker (e.g. hostility), as opposed to fear for example.

Struggle for recognition theory

A theory of violence based on struggle for recognition has been applied in healthcare settings. In this theory, nonrecognition and misrecognition of facts about the patient are causes of interpersonal conflict and violence. In a study of the interpersonal factors preceding violent incidents, healthcare workers identified unmet needs, involuntary assessment and unsolicited touch as correlated.

Mental Health issues due to abuse

Nurses dealing with more mental health issues is something that has come from dealing with workplace violence. In a study, it was found that somewhere between sixty and ninety percent of nurses are exposed to physical or verbal violence at some point in their work. This shows how real it is within a nurse's daily work life. The violence can severely take a toll on someone's mental health. The article states, "A systematic review of 68 studies found workplace violence was most strongly associated with negative psychological outcomes, including post-traumatic stress disorder, depression, anxiety, sleep disturbances and fatigue". With this being stated, it gives the readers a good idea of why workplace violence is so dangerous for healthcare workers.

Interventions

When dealing with aggression and violence in the workplace, training and education are the primary strategy for resolution. There are a number or personal factors that can help reduce aggression within the healthcare setting, which include improved interpersonal skills, with an awareness of patient aggression and knowledge regarding dealing with emotional patients. Although assertiveness is crucial when it comes to the interpersonal skills possessed by healthcare workers, it has been shown by numerous studies that nurses tend not to be very assertive. Training is therefore usually offered by organizations with regard to assertiveness, and deals mainly with improving self-esteem, self-confidence and interpersonal communication.

The Health Services Advisory Committee (HSAC) recommends a three-dimensional foundation by which to deal with violence in the workplace. It involves "researching the problem and assessing the risk, reducing the risk and checking what has been done".

In 1997, HSAC provided the following guidelines as to what good training involves:

• Theory: To understand the aggression within the workplace
• Prevention: To assess the danger and take precautions
• Interaction: With aggressive individuals
• Post-Incident Action: To report, investigate, counsel, and follow up the incident

Identifying whether patients are currently at risk of violence

The STAMP violence assessment framework lists elements of patient behaviour that are correlated with violence, and was developed in 2005 by Luck, Jackson and Usher. This model was later extended by the authours into an 18-point violence assessment tool. Looking at the predictors in the violence assessment tool, resisting nonconsensual healthcare was found to be the best predictory of violence, followed by aggressive language and yelling.

Assertiveness training

Although many studies looking at the effectiveness of training have provided inconclusive results, a study by Lin et al. positively correlated the improvement of assertiveness and self-esteem with an assertiveness training programme. The programme targets difficult interactions that we may face in day-to-day life and includes both, behavioural and cognitive techniques. The effectiveness of training is measured using the Assertive Scale, Esteem Scale, and Interpersonal Communication Satisfaction Inventory.

Evaluating the effectiveness of training

It remains that training is not universally or consistently offered to healthcare workers. Beale et al. found that the levels of training offered ranged from nothing to high-level restraint/self-defense training. A report by the National Audit Office (NAO) in 2003 found that, within mental health trusts, a reactionary approach tends to prioritise over prevention. Although criticised by many; restraint, seclusion and medication are used (Wright 1999, Gudjonsson et al. 2004). Breakaway techniques, restraint, rapid tranquilisation or isolation tend to be recommended when violence is instigated with a failure to prevent aggression. This correlates to the level of training offered, which dominates in these areas, however lacks in situation risk assessment and customer care–methods that are vital in a preventative approach to prevent escalation of the situation, causing for reactionary measures to be brought into play.

The study by Beale et al. therefore provides the following advice as to good practice:

• Training should emphasise prevention, calming and negotiation skills as opposed to confrontation
• Training should be offered in modules, ranging initially from basic customer care and handling difficult patients to full control and restraint of patients.
• Material relating to the causes of aggression, how to reduce risks, anticipation of violence, resolving conflict and dealing with post-incident circumstances should be provided to staff.
• Physical breakaway skills should be taught–however an understanding as to situations in which such skills should be practiced must be appreciated.
• Staff should be taught to control their own feelings
• An understanding of normal/abnormal post-trauma reactions should be reached
• Staff should be familiar with local arrangements and policies

How to cope with abuse

• Nurses should properly report their abuse to their supervisors
• If it is not properly dealt with go to individuals who are higher-up
• It is completely up to the individual who is dealing with the abuse to report it, no one else
• Try to contribute to a more positive work environment
• Nurses can go to informational meetings to deal with the abuse

The American Nursing Association provides sources to be used if nurses are dealing with abuse, however, it is up to the individuals to report the incidents. Some more resources to help deal with abuse are going to informational classes if the place in which you work offers them.

Due to the individual being the one experiencing the violence, researchers can not fully understand the extent of the abuse. Future researchers could make a survey asking nurses about where most of the abuse occurred and ways it would be easier for them to report the abuse.

Doctor–patient relationship

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Doctor%E2%80%93patient_relationship

The doctor–patient relationship is a central part of health care and the practice of medicine. A doctor–patient relationship is formed when a doctor attends to a patient's medical needs and is usually through consent. This relationship is built on trust, respect, communication, and a common understanding of both the doctor and patients' sides. The trust aspect of this relationship goes is mutual: the doctor trusts the patient to reveal any information that may be relevant to the case, and in turn, the patient trusts the doctor to respect their privacy and not disclose this information to outside parties.

An important dynamic of the doctor–patient relationship is that the doctor is bonded by oath to follow certain ethical guidelines (Hippocratic Oath) whereas the patient is not. Additionally, the healthiness of a doctor–patient relationship is essential to keep the quality of the patient's healthcare high as well as to ensure that the doctor is functioning at their optimum. In more recent times, healthcare has become more patient-centered and this has brought a new dynamic to this ancient relationship.

Importance

A medical practitioner explains an x-ray to the patient.

 

The doctor is providing medical advice to this patient.

 

A physician performs a standard physical examination on his patient.

A patient must have confidence in the competence of their physician and must feel that they can confide in them. For most physicians, the establishment of good rapport with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the physician–patient relationship more than others, such as pathology or radiology, which have very little contact with patients.

The quality of the patient–physician relationship is important to both parties. The doctor and patient's values and perspectives about disease, life, and time available play a role in building up this relationship. A strong relationship between the doctor and patient may lead to frequent, freely-offered quality information about the patient's disease and as a result, better healthcare for the patient and their family. Enhancing both the accuracy of the diagnosis and the patient's knowledge about the disease contributes to a good relationship between the doctor and the patient. In a poor doctor–patient relationship, the physician's ability to make a full assessment may be compromised and the patient may be more likely to distrust the diagnosis and proposed treatment. The downstream effects of this mistrust may include decreased patient adherence to the physician's medical advice, which could result in poorer health outcomes for the patient. In these circumstances, and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought, or the patient may choose to go to another physician that they trust more. Additionally, the benefits of any placebo effect are also based upon the patient's subjective assessment (conscious or unconscious) of the physician's credibility and skills.

Michael and Enid Balint together pioneered the study of the physician patient relationship in the UK. Michael Balint's "The Doctor, His Patient and the Illness" (1957) outlined several case histories in detail and became a seminal text. Their work is continued by the Balint Society, The International Balint Federation and other national Balint societies in other countries. It is one of the most influential works on the topic of doctor–patient relationships. In addition, a Canadian physician known as Sir William Osler was known as one of the "Big Four" professors at the time that the Johns Hopkins Hospital was first founded. At the Johns Hopkins Hospital, Osler had invented the world's first medical residency system. In terms of efficacy (i.e. the outcome of treatment), the doctor–patient relationship seems to have a "small, but statistically significant impact on healthcare outcomes". However, due to a relatively small sample size and a minimally effective test, researchers concluded additional research on this topic is necessary. Recognizing that patients receive the best care when they work in partnership with doctors, the UK General Medical Council issued guidance for both of doctors named "Ethical guidance for doctors", as well as for patients "What to expect from your doctor" in April 2013.

Aspects of relationship

Informed consent

Main article: Informed consent

The default medical practice for showing respect to patients and their families is for the doctor to be truthful in informing the patient of their health and to be direct in asking for the patient's consent before giving treatment. Historically in many cultures there has been a shift from paternalism, the view that the "doctor always knows best", to the idea that patients must have a choice in the provision of their care and be given the right to provide informed consent to medical procedures. There can be issues with how to handle informed consent in a doctor–patient relationship; for instance, with patients who do not want to know the truth about their condition. Furthermore, there are ethical concerns regarding the use of placebo. Does giving a sugar pill lead to an undermining of trust between doctor and patient? Is deceiving a patient for his or her own good compatible with a respectful and consent-based doctor–patient relationship? These types of questions come up frequently in the healthcare system and the answers to all of these questions are usually far from clear but should be informed by medical ethics.

Shared decision making

Health advocacy messages such as this one encourage patients to talk with their doctors about their healthcare.

 

Main article: Shared decision making

Shared decision-making involves both the doctor and patient being involved in decisions about treatment. There are varied perspective on what shared decision making involves, but the most commonly used definition involves the sharing of information by both parties, both parties taking steps to build consensus, and reaching an agreement about treatment.

The doctor does not recommend what the patient should do, rather the patient's autonomy is respected and they choose what medical treatment they want to have done. A practice which is an alternative to this is for the doctor to make a person's health decisions without considering that person's treatment goals or having that person's input into the decision-making process is grossly unethical and against the idea of personal autonomy and freedom.

The spectrum of a physician's inclusion of a patient into treatment decisions is well represented in Ulrich Beck's World at Risk. At one end of this spectrum is Beck's Negotiated Approach to risk communication, in which the communicator maintains an open dialogue with the patient and settles on a compromise on which both patient and physician agree. A majority of physicians employ a variation of this communication model to some degree, as it is only with this technique that a doctor can maintain the open cooperation of his or her patient. At the opposite end of this spectrum is the Technocratic Approach to risk communication, in which the physician exerts authoritarian control over the patient's treatment and pushes the patient to accept the treatment plan with which they are presented in a paternalistic manner. This communication model places the physician in a position of omniscience and omnipotence over the patient and leaves little room for patient contribution to a treatment plan.

Physician communication style

Physician communication style is crucial to the quality and strength of the doctor–patient relationship. Patient-centered communication, which involves asking open-ended questions, having a warm disposition, encouraging emotional expression, and demonstrating interest in the patient's life, has been shown to positively affect the doctor–patient relationship. Additionally, this type of communication has been shown to decrease other negative attitudes or assumptions the patient might have about doctors or healthcare as a whole, and has even been shown to improve treatment compliance. Another form of communication beneficial to the patient-provider relationship is self-disclosure by the physician in particular. Historically, medical teaching institutions have discouraged physicians from disclosing personal or emotional information to patients, as neutrality and professionalism were prioritized. However, self-disclosure by physicians has been shown to increase rapport, the patient's trust, their intention to disclose information, and the patient's desire to continue with the physician. These effects were shown to be associated with empathy, which is another important dimension which is often under-emphasized in physician training. A physician's response to emotional expression by their patient can also determine the quality of the relationship, and influence how comfortable patients are in discussing sensitive issues, feelings, or information that may be critical for their diagnosis or care. More passive, neutral response styles which allow for patients to elaborate on their feelings have been shown to be more beneficial for patients, and make them feel more comfortable. Physician avoidance or dismissal of a patient's emotional expression may discourage the patient from opening up, and may be harmful to their relationship with their provider.

Physician superiority

Historically, in the paternalistic model, a physician tended to be viewed as dominant or superior to the patient due to the inherent power dynamic of physician's control over the patient's health, treatment course, and access to knowledge about their condition. In this model, physicians tended to convey only the information necessary to convince the patient of their proposed treatment course. The physician–patient relationship is also complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it without the physician's intervention, potentially resulting in a state of desperation and dependency on the physician. A physician should be aware of these disparities in order to establish a comfortable, trust-based environment and optimize communication with the patient. Additionally, it may be beneficial for the doctor–patient relationship to create a practice of shared care with increased emphasis on patient empowerment in taking a greater degree of responsibility for their care.

Patients who seek a doctor's help typically do not know or understand the medical science behind their condition, which is why they go to a doctor in the first place. A patient with no medical or scientific background may not be able to understand what is going on with their body without their doctor explaining it to them. As a result, this can be a frightening and frustrating experience, filled with a sense of powerlessness and uncertainty for the patient, though in rare conditions, this pattern tends not to be followed, and due to lack of expertise patients are forced to learn about their conditions.

An in-depth discussion of diagnosis, lab results, and treatment options and outcomes in Layman's terms that the patient can understand can be reassuring and give the patient a sense of agency over their condition. Concurrently, this type of strong communication between a doctor and their patient can strengthen the physician–patient relationship as well as promote better treatment adherence and health outcomes.

Coercion

Under certain conditions healthcare workers are able to treat patients involuntarily, imprison them, or involuntarily administer drugs to alter the patients' ability to think. They may also engage in forms of "informal coercion" where information or access to social services can be used to control a patient.

Deception

Lying in the doctor–patient relationship is common. Doctors provide minimal information to patients after medical errors. Doctors may lie to patients to displace culpability for poor outcomes and say they avoid giving patients information because it may confuse patients, cause pain, or undermine hope. They may lie to avoid uncomfortable conversation about disability or death, or to encourage patients to accept a particular treatment option. The experience of being lied to may undermine an individuals trust in others or themselves and reduce faith in one's church, community or society and result in avoidant behaviour to avoid being wounded. Patients may seek financial and legal retribution.

Patients may lie to doctors for financial reasons such as to receive disability payments, for access to medication, or to avoid incarceration. Patients may lie out of embarrassment or shame. Palmeira and Sterne suggest that healthcare workers acknowledging the motivations of patients to lie to appear in a positive light to reduce deception by patients.

Palmeira and Sterne offer different psychological framings and motivations for lying. From the perspective of attachment theory, lying may be used to avoid revealing information about an individual avoid intimacy and therefore the risk of rejection or shame, or to exaggerate to obtain protection or care. They also discuss the idea of protecting or maintaining an ego ideal.Generally, Palmeira and Sterne suggestion discussions about the amount of information and detail parties wish to discuss, viewing obtaining truth as an ongoing process to increase truthfulness in doctor–patient interactions. Palmeira and Sterne suggest that physicians acknowledge their lack of knowledge, and discuss the amount of detail they wish to discuss to avoid deception.

Physician bias

Physicians have a tendency of overestimating their communication skills, as well as the amount of information they provide their patients. Extensive research conducted on 700 orthopedic surgeons and 807 patients, for instance, found that 75% of the surgeons perceived they satisfactorily communicated with their patients, whereas only 21% of the patients were actually satisfied with their communication. Physicians also show a high likelihood of underestimating their patients' information needs and desires, especially for patients who were not college educated or from economically disadvantaged backgrounds. There is pervasive evidence that patients' personal attributes such as age, sex, and socioeconomic status may influence how informative physicians are with their patients. Patients who are better educated and from upper or upper middle-class positions generally receive higher quality and quantity of information from physicians than do those toward the other end of the social spectrum, although both sides have an equal desire for information.

Race, ethnicity and language has consistently proven to have a significant impact on how physicians perceive and interact with patients. According to a study of 618 medical encounters between mainly Caucasian physicians and Caucasian and African American patients, physicians perceived African Americans to be less intelligent and educated, less likely to be interested in an active lifestyle, and more likely to have substance abuse problems than Caucasians. A study of patients of color showed that having a white physician led to increased experience of microaggressions. Studies in Los Angeles emergency departments have found that Hispanic males and African Americans were less than half as likely to receive pain medication than Caucasians, despite physicians' estimates that patients were experiencing an equivalent level of pain. Another study showed that ethnic-minority groups of varying races reported lower-quality healthcare experiences than non-Hispanic Whites, specifically in treatment decision involvement and information received regarding medications. Other studies show that physicians exhibited substantially less rapport building and empathetic behavior with both Black and Hispanic patients than Caucasians, despite the absence of language barriers.

Medical mistrust

Mistrust of physicians or the healthcare system in general falls under the umbrella of medical mistrust. Medical mistrust negatively impacts the doctor–patient relationship, as a patient who has little faith in their physician is less likey to listen to their advice, follow their treatment plans, and feel comfortable disclosing information about themselves. Some forms of communication by the physician, such as self-disclosure and patient-centered communication, have been shown to decrease medical mistrust in patients.

Medical mistrust has been shown to be greater for minority group patients, and is associated with decreased compliance, which can contribute to poorer health outcomes. Research of breast cancer patients showed that African American women who received concerning mammogram results were less likely to discuss this with their doctor if they had greater medical mistrust. Another study showed that women with higher physician mistrust waited longer to report symptoms to a doctor and receive a diagnosis of ovarian cancer. Two studies showed that African American patients had more medical mistrust than white patients, and were less likely to undergo a recommended surgery as a result.

Benefiting or pleasing

A dilemma may arise in situations where determining the most efficient treatment, or encountering avoidance of treatment, creates a disagreement between the physician and the patient, for any number of reasons. In such cases, the physician needs strategies for presenting unfavorable treatment options or unwelcome information in a way that minimizes strain on the doctor–patient relationship while benefiting the patient's overall physical health and best interests. When the patient either can not or will not do what the physician knows is the correct course of treatment, the patient becomes non-adherent. Adherence management coaching becomes necessary to provide positive reinforcement of unpleasant options.

For example, according to a Scottish study, patients want to be addressed by their first name more often than is currently the case. In this study, most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 individuals disliked being called by their first name, most of whom were aged over 65. On the other hand, most patients do not want to call the doctor by his or her first name.

Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues.

Transitional care

Transitions of patients between health care practitioners may decrease the quality of care in the time it takes to reestablish proper doctor–patient relationships. Generally, the doctor–patient relationship is facilitated by continuity of care in regard to attending personnel. Special strategies of integrated care may be required where multiple health care providers are involved, including horizontal integration (linking similar levels of care, e.g. multiprofessional teams) and vertical integration (linking different levels of care, e.g. primary, secondary and tertiary care).

Turn-taking and conversational dominance

Researchers have studied the doctor–patient relationship using the theory of conversation analysis. One of the key concepts in conversation analysis is turn-taking. The process of turn-taking between health care professionals and the patients has a profound impact on the relationship between them. In most scenarios, a doctor will walk into the room in which the patient is being held and will ask a variety of questions involving the patient's history, examination, and diagnosis. These are often the foundation of the relationship between the doctor and the patient as this interaction tends to be the first they have together. This can go a long way into impacting the future of the relationship throughout the patient's care. All speech acts between individuals seek to accomplish the same goal, sharing and exchanging information and meeting each participants conversational goals.

Research carried out in medical scenarios analyzed 188 situations in which an interruption occurred between a physician and a patient. Of these 188 analyzed situations, research found that the doctor is much more likely (67% of the time, 126 occasions) as compared to the patient (33% of the time, 62 occasions). This shows that physicians are practicing a form of conversational dominance in which they see themselves as far superior to the patient in terms of importance and knowledge and therefore dominate all aspects of the conversation. A question that comes to mind considering this is if interruptions hinder or improve the condition of the patient. Constant interruptions from the patient whilst the doctor is discussing treatment options and diagnoses can be detrimental or lead to less effective efforts in patient treatment. This is extremely important to take note of as it is something that can be addressed in quite a simple manner. This research conducted on doctor–patient interruptions also indicates that males are much more likely to interject out of turn in a conversation than women. Men's social predisposition to interject becomes problematic when it negatively impacts a woman physician's messages to her patients who are men: she may not be able to finish her statements and the patient will not benefit from what she was about to say, and the physician herself may fall prey to the socially conventional man's interjection by letting it cut short her professional commentary. Conversely, men physicians need to encourage women patients to articulate their reactions and questions, since women interrupt in conversations statistically less often than men do.

A hurdle can arise from how the thinking process goes: a patient typically relates their story in chronological order, where symptoms, test results, consulting opinions, diagnoses and treatment are intertwined. A provider tends to design their approach in a step-by-step analytical manner, extracting as much details out of symptomatology, then past medical and social history then tests then coming to a suggested diagnosis and management plan. Addressing this upfront and at the onset of the visit and carving enough time for both can help avoid unnecessary interruptions on either part, improve provider-patient relation and constructively facilitate care.

Other involved individuals

An example of where other people present in a doctor–patient encounter may influence their communication is one or more parents present at a minor's visit to a doctor. These may provide psychological support for the patient, but in some cases it may compromise the doctor–patient confidentiality and inhibit the patient from disclosing uncomfortable or intimate subjects.

When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.

Having family around when dealing with difficult medical circumstances or treatments can also lead to complications. Family members, in addition to the patient needing treatment may disagree on the treatment needing to be done. This can lead to tension and discomfort for the patient and the doctor, putting further strain on the relationship.

Telehealth

With the extensive use of technology in healthcare, a new dynamic has risen in this relationship. Telehealth is the use of telecommunications and/or electronic information to support a patient. This applies to clinical care, health-related education, and health administration. An important fact about telehealth is that it increases the quality of the doctor–patient relationship by making health resources more easily available, affordable, and more convenient for both parties. Challenges with using telehealth are that it is harder to get reimbursements, to acquire cross-state licensure, to have common standards, maintain privacy, and have proper guiding principles. The types of care that can be provided via telehealth include general health care (wellness visits), prescriptions for medicine, dermatology, eye exams, nutrition counseling, and mental health counseling. Just like with an in-person visit, it is important to prepare for a telehealth consultation beforehand and have good communication with the healthcare provider.

An interesting outcome of telehealth is that doctors have started to play a different role in the relationship. With patients having more access to information, medical knowledge, and their health data; doctors play the role of a translator between technical data and the patients. This has caused a shift in the way that the doctors see themselves concerning the doctor–patient relationship. Doctors who are engaged in telehealth see themselves as a guide to the patient and undertake the role of a guardian and information manager in the description, collection, and sharing of their patient's data. This is the new dynamic that has risen in this ancient relationship and one which will continue to evolve.

Bedside manner

A medical doctor, with a nurse by his side, performs a blood test at a hospital in 1980.

• A good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis.
• Vocal tones, body language, openness, presence, honesty, and concealment of attitude may all affect bedside manner.
• Poor bedside manner leaves the patient feeling unsatisfied, worried, frightened, or alone.
• Bedside manner becomes difficult when a healthcare professional must explain an unfavorable diagnosis to the patient, while keeping the patient from being alarmed.

Dr. Rita Charon launched the narrative medicine movement in 2001 with an article in the Journal of the American Medical Association. In the article she claimed that better understanding the patient's narrative could lead to better medical care.

Researchers and Ph.D.s in a BMC Medical Education journal conducted a recent study that resulted in five key conclusions about the needs of patients from their health care providers. First, patients want their providers to provide reassurance. Second, patients feel anxious asking their providers questions; they want their providers to tell them it is okay to ask questions. Third, patients want to see their lab results and for the doctor to explain what they mean. Fourth, patients simply do not want to feel judged by their providers. And fifth, patients want to be participants in medical decision-making; they want providers to ask them what they want.

An example of how body language affects patient perception of care is that the time spent with the patient in the emergency department is perceived as longer if the doctor sits down during the encounter.

Patient behavior

Rude behaviour by patients can have a negative effect on medical outcomes. A study showed that staff who received or witnessed rude behaviour by patients relatives had reduced ability to effectively carry out some of their simpler and more procedural tasks. This is important because if the medical staff are not performing sufficiently in what should be simple tasks, their ability to work effectively in critical conditions will also be impaired. This is consistent with research showing that rudness by medical staff to one another decreases effectiveness.

Examples in fiction

• Dr. Gregory House (of the show House) has an acerbic, insensitive bedside manner. However, this is an extension of his normal personality.
• In Grey's Anatomy, Dr. Burke compliments Dr. George O'Malley's ability to care for Dr. Bailey's baby by saying "it speaks to a good bedside manner."
• Doc Martin from the Doc Martin British TV series is a good example of a physician with a bad bedside manner.
• Dr Lily Chao from the British TV series Casualty is another example of a Foundation Doctor with a poor bedside manner, whereas her colleague, Dr Ethan Hardy has a better one.
• In Lost, Hurley tells Jack Shephard that his bedside manner "sucks". Later in the episode, Jack is told by his father to put more hope into his sayings, which he does when operating on his future wife. The comments continue in other episodes of the series with Benjamin Linus sarcastically telling Jack that his "bedside manner leaves something to be desired" after Jack gives him a harsh negative diagnosis.
• In Closer, Larry, the physician tells Anna when they first meet that he is famed for his bedside manner.
• In Scrubs, J.D is presented as an example of a physician with great bedside manner, while Elliot Reid is a physician with bad or non-existent bedside manner at first, until she evolves during her tenure at Sacred Heart. Dr. Cox is an interesting subversion, in that his manner is brash and undiplomatic while still inspiring patients to do their own best to aid in the healing process, akin to a drill sergeant. This show also comically remarked that the most time that a doctor needs to be in the presence of the patient before he finds out everything he needs to know is approximately 15 seconds.
• In Star Trek: Voyager, the Doctor often compliments himself on the charming bedside manner he developed with the help of Kes.
• In M*A*S*H, Hawkeye Pierce, Trapper John McIntyre, B.J. Hunnicutt, and Sherman Potter all possess a caring and humorous bedside manner meant to help patients cope with traumatic injuries. Charles Winchester initially possesses no real bedside manner, acting with detached professionalism, until the rigors of his job help him develop a sense of compassion for his patients. Frank Burns has a poor bedside manner, constantly minimizing the seriousness of his patients' injuries, accusing them of cowardice and goading them to return to the front lines.

Vested interest (communication theory)

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Vested_interest_(communication_theory) 

Vested interest (Crano, 1983; Crano & Prislin, 1995; Sivacek & Crano, 1982) is a communication theory that seeks to explain how certain hedonically relevant (Miller & Averbeck, 2013) attitudinal dimensions can influence and consistently predict behavior based on the degree of subjective investment an individual has in a particular attitude object. As defined by William Crano, vested interest refers to the degree to which an attitude object is deemed hedonically relevant by the attitude holder. According to Crano, "an attitude object that has important perceived personal consequences for the individual will be perceived as highly vested. Highly vested attitudes will be functionally related to behavior" (Crano, 1983). Simply put, when people have more at stake with the result of an object (like a law or policy) that will greatly affect them, they will behave in a way that will directly support or defy the object for the sake of their own self-interest.

For example, a 30-year-old learns that the legal driving age in his state is being raised from 16 to 17. While he may not agree with this proposed change, he is not affected as much as a 15-year-old would be and is unlikely to protest the change. A 15-year-old, however, has much to lose (waiting another year to get a driver license) and is more likely to vehemently oppose the new proposed law. To gather support for his position, a course of action the 15-year-old might take would be to tell other soon-to-be drivers about the new law, so that they collectively have a vested interest in perhaps changing the law. This example illustrates the point that highly vested attitudes concerning issues depend on the individual's point of view.

Another example of vested interest can be found in a study conducted by Berndsen, Spears and van der Pligt, which involves students from a University in Amsterdam where the teaching faculty proposed the use of English to teach the curriculum instead of Dutch. Vested interest, in this case, suggests that students would be opposed to the use of English rather than Dutch simply based on the potential impact lectures conducted in English might have on their grades.

Key Factors

Involvement

A key factor to consider with vested interest is the level or type of involvement the individual has with a particular attitude object. This can be broken up into three main involvement components: Value-relevant, Impression-relevant, and Outcome-relevant. Value-relevant involvement concerns behaviors which support/reinforce values of the individual. Impression-relevant involvement relates to those behaviors which serve to create or maintain a specific image of the individual. This could, in some ways, be compared to a low-self monitor. Outcome-relevant involvement concerns those behaviors which hold direct personal consequences at a premium for the individual and as a result, corresponds most closely to vested interest.

The concept of involvement closely relates to collaboration which encompasses value, impression and desired outcome. Vested interest is essential in achieving success in collaboration where two or more individuals have the potential to gain or lose. Organizations who strive for collaborative success benefit from understanding vested interest and that of other collaborators in order to maintain a supportive level of involvement.

Ego involvement

The way people view vested interest as distinct from ego involvement, is a construct that has been the topic of social psychological research for many years. In a study conducted by John Sivacek and William D. Crano, they prove that the aforementioned statement of ego involvement and vested interest are indeed separate. Sivacek and Crano state, "It was possible to have circumstances that an individual would perceive as involving but that it would not arouse his or her vested interest." Ego-involvement's main focus points are on individual's psychological attitudes that are experienced as being a part of “me”. The more emotionally connected people are to an idea, concept, or value, minor differences in beliefs can be viewed as significantly large and perhaps make harsh judgments or have stronger reactions. Conversely, a person with less emotional connectivity (low ego-involvement) will have more latitude in their reactions. It is important to note that while highly vested attitudes can be experienced as ego involving, the opposite is not always true. An individual can be ego involved in a certain attitude that has no hedonic consequence. For example, religious or political ideals with little or no hedonic value may still be ego-involved because individuals view those types of beliefs as part of who they are.

Ego-involvement, as it pertains to vested interest, is relative to Social Judgment Theory in that the concept of one's identity is the primary focus of efforts in continued involvement. Essential to social judgment theory is the idea of ego thus actions or ideas with a varying degree of ego involvement carry a commensurate amount of vested interest to the individual as detailed by Sherif, Kelly, Rogers, Sarup, and Tittler. Sherif, et al. conducted a series of studies to develop “indicators of ego involvement” (p. 311). One of the leading questions they sought to answer was how much ego involvement (vested interest) does an individual in a situation with no alternatives solutions have and does this ego involvement correlate to the number of options at hand. Sherif et al., suggest the question was answered by Beck and Nebergall in 1967 who stated that individuals with little to no options have corresponding vested interest indicating low ego involvement.

Attitude importance

The factor to consider with vested interest and its application towards attitude-consistent actions is attitude importance. Attitude (or issue) importance concerns not only matters of personal consequence, but also matters of national or international interest. While both of these can fall in line with each other, vested interest and attitude importance are not the same. For example, consider the plight of an African nation that has been ravaged by an influenza epidemic. Although an individual in America may consider this objectively important, because of the low probability of personal consequence—i.e., vested interest — his resultant behavior may not be indicative of his attitude towards the epidemic. In other words, since the issue is of little hedonic relevance to the perceiver, the amount of vested interest is low, and is therefore unlikely to produce attitude-consistent actions. Geographic distance and cultural differences are also a factor in attitude importance. Tragic circumstances halfway around the world or shocking behaviors by members of a culture different from the perceiver, will most likely never result in attitude change. The physical distance or cultural difference of an occurrence directly correlates to the vested interest of the perceiver. Things too far away or customs perceived to be too strange will almost never trigger a vested interest.

Indicators of vested interest can include attitude importance, as detailed by Jon Krosnick who defined this concept by stating that “central, ego-involved, and salient attitudes” often include attitudes significantly important to individual interests. In politics, for example, voters have a vested interest in candidates whose values (policy) align with their own to include attitudes toward these values. Due to the nature of politics, voters come to conclusions about one candidate over another based on perceived attitude importance (object) on these policies rather than vocal support alone placing a high value on this concept as it pertains to vested interest.

Attitude object continuously makes an issue salient which correlates to outcome relevant involvement. Two differences exist between vested interest and outcome relevant involvement where attitude objects remain highly important. Initially, outcome relevant objects retain a high degree of vested interest while not appearing to be. Secondly, outcome relevant involvement suggest interest ends once the goal is achieved whereas vested interest suggests a self-perpetuated interest.

Components

There are five key components that may diminish or enhance the effects of vested interest on attitude-behavior consistency. These are (a) stake, (b) attitudinal salience, (c) the certainty of the attitude outcome link, (d) the immediacy of attitude-implicated consequences, and (e) the self-efficacy of the individual to perform an attitudinally implicated act. Attitudes affect behavior. However, social psychologists recognize that contextual, interpsychic, and intrapsychic sources of variation can drastically affect the strength of this relation. A factor that has been shown to strongly affect attitude-behavior consistency is self-interest or vested interest. The following sections explain each of these variables in greater detail.

Stake

Stake refers to the perceived personal consequence of an attitude that is directly related to the intensity of vested interest and influences components that contribute to attitude-behavior consistency. In its basic form, the more that is at stake concerning a particular issue, the stronger the attitude will be. Consequently, as attitude strength increases, the consistency of attitude-based actions also increases.

Referring to the concept of vested interest as it relates to attitude-behavior consistency, stake is an individual's macro involvement in a particular situation where the consequence is salient. In a situation where stake is operationalized using certainly and immediacy, one found the likely effect of this was behavior relative to the immediate consequence, positive or negative. For instance, in a study conducted to measure the relevance stake has on vested interest, students given a health assessment showed greater enthusiasm for items inquiring about donating blood when saving a life was salient (i.e. a child's life depends on my donation).

Stake may contribute to attitude-behavior consistency by inducing thoughts that support the attitude. This serves as the basis for future behavior. Stake may also strengthen the attitude-behavior relation by indirectly amplifying the awareness of stimuli associated with people's attitudes. Stake is the most powerful impression that comes from all the components of vested interest regarding attitude and behavior. Stake influences perceptions of attitude and action, but also of other action-relevant components as well. When stake is high, people also find the critical issue highly salient. Stake also affects the perception of immediacy. The greater the personal consequence of the issue, the more pressing the issue is perceived to be. Finally, stake was found to affect the perception of immediacy. The greater the personal consequence of the issue, the more pressing it was perceived to be. The phrases, "the stakes are/were high" or "high stakes", are used when issues of high salience or immediacy are raised, usually in regards to gambling or other high-risk activities involving vested interest.

Salience

Salience refers to the perceiver's awareness of the effects of an attitude upon himself. In other words, the prominence of an issue, as perceived by an individual, shapes the strength of his resulting attitude. Salient attitudes have a greater effect directly on subsequent behavior. Linking this discovery to vested interest, the research concluded that the salience effect was heightened when the attitude had important personal outcomes for someone. When the consequences of the behavior issuing from an attitude are highly salient, attitude-behavior consistency increases. If consequences are not salient, the consistency of the effects of vested interest on attitude behavior will be dramatically reduced. For instance, two people may have negative attitudes towards living near a prison. The first person lost a loved one at the hands of an inmate who escaped during a jailbreak. The second person simply does not like the eyesore the prison building creates in the area around his home. The first person's attitude towards inmates and prisons will probably be more salient than that of the second person who has not experienced a similar trauma. The first person's more salient attitude will foster the operation of vested interest, which will result in greater attitude-behavior consistency.

Attitudes that have been acquired through direct experience, such as the example just given, may be more salient than those acquired through vicarious processes. This greater salience results in greater consistency in attitude behavior. The attitude of someone who is non-salient reduces vested interest and weakens attitude-behavior consistency. The most powerful impression to emerge from all the analyses is the overwhelming effect of stake, or personal consequence, on attitude and behavior. When stake is high, people assume that a person would find the critical issue highly salient. Stake does not interact with, but enhances the perception of, issue salience. This is an important effect, because salience significantly affects actions that are expected to happen.

Additionally, salience can be described as the most recent and accessible memory associated with a specific object (i.e. idea) in which an individual has developed their own unique attitude. Mortality, for instance, would become salient when faced with a situation where death was probable or the known death of a friend, relative or an experienced event which resulting in someone's death. This death salience would then influence behavior for a short amount of time following the event.

Certainty

Certainty refers to perceived likelihood of personal consequences as a result of an attitude or action. Simply stated, if a certain course of action is taken, then the chances of a specific event occurring as a result of this action are evaluated by the perceiver to help shape his resultant attitudes and behaviors. Certainty can be easily applied to situations in which an individual knowingly takes a calculated risk. For instance, let's continue with our aforementioned example of people living near a prison. Although the chance of a prison escape is minimal, particularly in a maximum-security prison, it could occur and crimes against those living close by would increase. Those living further away from the prison might argue that a prison break is unlikely and that there is no real risk. Alternatively, those living close to the prison could make an equally valid argument about the dangers of living near the prison in the event of prisoners escaping. Still others might realize there to be a potential risk to their safety, but would not deem it risky enough to move elsewhere.

Certainty in attitude, relative to vested interest, remains difficult to define without an understanding of two particular concepts. One is the acceptance of truth in the events or idea requiring approximation of occurrence. Two requires that certainty is not dependent on external factors which can undermine its validity. Certainty must be a concept which is pushed onto us much like truth is a certainty beyond our immediate control.

If the consequences of an attitude consistent act are uncertain, attitude-consistent action is not likely to occur, due to the fact that vested interest will be reduced. An example of this is a person who has a negative attitude towards living near a prison. If the person assumes that the link between living near a prison and being a victim of a violent crime is minimal, then health and safety promoting behaviors consistent with this negative attitude are not likely. However, if someone believes that living near the prison and being a victim of a violent crime is almost certain, that person would be unlikely to move close to the prison, assuming the person has a positive attitude toward safety or a negative attitude toward prisons and inmates.

Immediacy

Immediacy refers to an individual's perceived amount of time between an action and its resulting consequences. Immediacy can be considered an extension of certainty, however, these two entities are completely separate. For instance, in our prison example, people in opposition to the construction of the prison in their neighborhood may have felt that the amount of time to build the prison to and the eventual housing of prisoners was not long enough to make an informed decision. They may also feel that it is only a matter of time before something negative happened to the local citizens as a result of having a prison nearby.

Immediacy refers to the apparent temporary lag between an attitudinally implicated action and its consequences. If the results of an attitude consistent action are thought to be immediate rather than delayed, the effects of stake, or vested interest, on attitude-behavior consistency will be more dramatic. In other words, if a person living near the prison in the previous example perceives the possibility of a jailbreak could occur at a much later time in life, he may act in manner that is not consistent. This is because the lack of immediate consequences reduces the perception of vested interest. Therefore, immediacy can help explain self-destructive behaviors.

Immediacy, in vested interest, can also be thought of in terms of positive or negative consequence disassociated from a timeline. Vested interest such as organ donation, for example, make life and death salient which brings about the concept of immediacy to decide not necessarily to act. This is seen in a mechanism which allows people to agree to donate organs in the event of their death (i.e. drivers licenses).

Another example of immediacy is that of marketing companies who implement immediacy to encourage consumers to act or remain inactive. If what they market is something a person is highly vested in and the marketing firm has simultaneously created an immediate need, then they have done their job to get consumers to behave as they desired. This use of immediacy can be both helpful and harmful. Consumers who are not well versed in how marketing works may find themselves situations they did not wish to be in. However, consumers who are cognizant of how marketing works may find this very useful in how they do or do not expend their resources.

Self-efficacy

Self-efficacy in regards to vested interest, is the amount that an individual believes that they are capable of performing an action associated with an attitude or advocated position. In short, it is a person's sense of competence in regards to a specific task. Continuing with our prison example, residents with high vested interest that was covered by the other four components would need self-efficacy to protest the location of the new prison. In other words, the residents opposing the prison would have to believe in their abilities to effectively stop the construction. Conversely, if they lacked self-efficacy and therefore believed there was nothing they could do, then they would not act on their held attitude and vested interest will not have been attained. Variations in self-efficacy will produce differences in perceptions of the likelihood of someone working against the opposed plan. Higher levels of manipulated self-efficacy result in higher levels of expected action. However, variations in stake also influence perceptions of self-efficacy. When the stakes are high, people assume higher levels of perceived self-efficacy.

Another way the concept of self-efficacy can be described is using social cognitive theory to understand the role thought, drive and emotion have on self-efficacy (20). Cognitively, one works to quantify actions, emotion, and drive resulting in self-efficacy. However, this concept remains volatile as a change in one or more of these influences degrades self-efficacy. An example of this would be physical fitness, in that, elevated or decreased self-efficacy will cause one to accept or deny a strenuous task daily.

Relevant research

Drinking age experiment

Various studies have been conducted to determine the effects of vested interest on attitude strengths. In one such study, Crano and Sivacek visited a university in Michigan and gathered the results of a proposed drinking-age referendum. The referendum sought to increase the legal drinking age from 18 to 21. The respondents were divided into three categories: 1. high vested interest (those who would be significantly and immediately affected as a result of the referendum), 2. low vested interest (those who would be unaffected by the law change at the time of its inception), and 3. moderate vested interest (those who fell between the first two extremes). Although 80% of the subjects were opposed to the referendum, their respective levels of vested interest clearly indicated that the strength of their attitudes significantly affected their resultant behaviors. Half of the highly vested interest groups joined the anti-referendum campaign, but only a quarter of the moderately vested interest group and an eighth of the low vested interest group joined the campaign. These results support Crano's theory of vested interest and reinforce the implications and considerations of stake, salience, certainty, immediacy, and self-efficacy discussed above. It also proves the correlation between vested interest and action, based on what level of involvement the three types of students were willing to participate in.

Comprehensive exam experiment

In a second study, Sivacek and Crano visited Michigan State University. In this experiment, subjects were informed that the university was considering the addition of a senior comprehensive examination to the graduate prerequisites. Respondents were given the following options:

1. Do nothing
2. Sign an opposing petition
3. Join a group that opposed the referendum
4. Volunteer specific numbers of hours to the opposing group's activities

The respondents were grouped into the same three categories as the drinking age study: high, moderate, and low vested interest. The study found that those with the highest levels of vested interest were significantly more inclined to take action based on their attitudes concerning the issue; that is, their resultant behaviors (signing the petition, joining the group, pledging multiple hours with the group) occurred much more consistently and prevalently than that of the other two vested interest groups.

Assumed consensus

Crano conducted another study to prove that vested interest may affect people's belief that a majority of a population will support their attitude on an issue. This bias is known as false-consensus or assumed-consensus effect. Under the guise of a public opinion survey, Crano created high and low vested interest groups by identifying whether upper- or lower-classmen would pay a surcharge to subsidize lost funding from the government. The class who was selected to pay the surcharge had a high degree of vested interest while the student body not required to pay exhibited a lower degree of vested interest. The study then determined the participants estimate of what percentage of the student body would support their beliefs regardless of impact. Crano found that vested interest influenced assumed consensus and students believed that a majority of the university's population would support their plight even though only half would be affected.

The effect of smoking on attitudes toward cigarette tax and smoking restrictions

Dale Miller and Rebecca Ratner conducted this study utilizing 81 male and female students at the University of Yale. In this experiment the objective was for half of the participants to show their own attitude toward smoking policies and the other half to show their thoughts on others attitudes toward smoking policies. The group with the questionnaire regarding their personal attitude about smoking were asked: 1. if they were a smoker or a nonsmoker, 2. how heavy or light a smoker they were, 3. whether they would support an increase on cigarette tax, 4. would they do away with smoking advertisements, and 5. their thoughts on smoking restrictions in public places. The second half of the participants were asked what percentage they thought smokers would support the previously mentioned policies for smokers or nonsmokers. They were not asked whether or not they smoked. The results of this study replicated Green and Gerkin's 1989 study that nonsmokers had more support for smoking restrictions than did those that smoke. These results supported the hypothesis: "Smokers in this study were more opposed to policies that regulated smoking than were nonsmokers, but the effect of smoking status on expressed attitudes was significantly less than that predicted by respondents". The smokers had a higher vested interest in smoking policies because they were directly affected. This study also revealed a direct correlation between vested interest and attitudes.

Voter Registration

Barbara Lehman and William Crano conducted a study regarding the persuasive effects of vested interest on attitude concerning political judgment which was published in 2001. In this study, they utilized data from 1976 national election studies concentrating on three areas (e.g. living conditions, health insurance and school integration). Their discoveries were such that self-interest was a significant contributor to values placed on all three areas of concern. Further, outside analysis of the study revealed self-interest had a direct correlation to ideologies, affiliation, and intolerance. Additionally, respondents with vested interest in any one of the three areas were more than likely to endorse candidates whose focus was in that particular area.

These findings, set in 1976, show a significant relationship between vested interest and aligned values associated with electoral candidates which can be either perceived or marketed. Understanding these values, one can conclude, would allow for use of vested interest harvested by surveys to decide which values to champion for use in maximizing voter endorsement.

Issues

Vested interest appears to affect people's tendency to overestimate the extent to which others agree with their beliefs, a bias known variously as the false-consensus or assumed-consensus effect. If people tend to overestimate the number of others who share their beliefs, this tendency should be exacerbated in situations involving personally consequential, or highly vested, beliefs. Research supports this expectation. College student participants who thought that a new university policy would disadvantage them personally assumed that the great majority of the student body would evaluate the policy as they had, despite the fact that only half the student population would be similarly disadvantaged.

Summary

Each of the five components (stake, salience, certainty, immediacy, and self-efficacy) co-exist within an individual's realm of conscious judgment. If it creates a sufficiently strong attitude, any of these components can cause an individual to adopt or reject a certain position. All five are considered any time an individual is presented with a message that attempts to influence or persuade him to adopt a certain position or perform an action. The process of evaluating these components can range from almost instantly to taking several years. At any rate, all five are considered (consciously or subconsciously) before making a decision with implications of vested interest.