The increasing attention to patient engagement and related topics is clearly shown by the growing number of publications from 2002 to 2012 thus suggesting that empowering patients to take an active role and to be engaged in their care has been internationally identified as a key factor in the drives to improve health service delivery and quality [24
]. Moreover, it is interesting to note that all the academic communities involved in health research share an interest in studying patient engagement as a core condition in performing effective chronic illness coping and management [25
]. These data are relevant as they foster the need to critically assess the specific application of patient engagement to the health services specificities. The predominance in the number of publications within the medical and nursing areas may suggest that these fields are probably the most responsive to the debate on patient engagement by including it in the research agenda and, at the same time, by producing insights in order to implement change in healthcare organization processes [26
]. Regarding the trend of publications split by discipline, even though there is a general increasing of academic production over the years, in the period from 2002 to 2005, we can observe a prominent focalization on the mental health context which implies a conceptualization of engagement as alliance between patient and clinicians as a key factor in promoting treatment effectiveness. In the last years, from 2006 to 2012, a more specific focus on organic patients' care (by medical and nursing perspectives) provided evidence about the need for developing interventions to improve disease-specific self-management behaviors, such as medication, adherence, and condition monitoring in order to better allocate resources to manage the whole patient population. This shift in the ways of conceptualizing patient engagement does not facilitate the formulation of a shared definition across scientific communities thus supporting the idea that a comprehensive definition is a challenging but urgent task. Furthermore, the efforts in encouraging greater patient engagement seem to be founded, up to now, on research more focused on expected pragmatic impact on patients' health obtained by active partnering with them and not on the organizational process which sustains its achievement: as a consequence, the current academic debate seems to reveal a stronger interest in the clinical and organizational outcomes of patient engagement (may be due to the need for legitimizing it as a healthcare priority) [12
]. However, little importance is till now given to cast light on the intrinsic nature of engagement: despite the growing popularity of the term patient engagement in the everyday rhetoric of worldwide NHS—especially in the English-speaking countries—it remains conceptually underdeveloped. Few attempts to find empirical markers of engagement have been conducted [9
], probably due to the still fragile link between the empirical evidence and the theoretical foundation of this construct. As a consequence, in order to develop a robust evidence-based theoretical framework and to enable data comparison and evaluation to be made, there is the need for a common understanding of what is meant by patient engagement in practice and how it can be operationalized and measured.
The multifaced definition of patient engagement emerging from our data suggests the hypothesis for which this concept may have some unchanging and underlying dimensions that are discipline-unrelated and operationalizations that are, instead, idiographic and context based. Probably, patient engagement may be observed from multiple perspective thus suggesting the opportunity to reflect upon the interaction between its individual (i.e., emotional, cognitive and behavioral, etc.), relational (i.e., patient-health providers, patient-caregiver, patient-patient, etc.), and organizational (i.e., type of healthcare settings, admission process, shape and process of intervention, use of ICT, role and attitude of health professionals, etc.) dimensions across the specificities of each single disease. A recovery of a psychological view seems also to be necessary, in order to give a comprehensive theorization which may take into account the individuals' role in being engaged in their care as subjects involved into a relational context and into a specific health culture: this may lead to build an inductively founded theoretical framework based on empirically rooted data. Surely, to take into account the patients' perspective on their own engagement may be particularly relevant in order to better assess the full range of factors that may be involved in such engagement and to foster a more effective use of healthcare services [27
]. Given the complexity of the phenomenon and the relevance of its practical implications, our study may suggest that there is a pressing need for empirical research to deepen the components of patient engagement at various levels (individual, relational, organizational, etc.), their specific impact and their interconnection [28
]. Once these issues are addressed, targeted interventions could be developed and implemented.
On the other hand, the contributions of nursing research in valuing the central role of nursing practice in enhancing patient's engagement in the process of care should be encouraged. Nurses are often portrayed by patients as the health providers who most make them feel as full engaged partners in the process of care [29
]. The input of nursing research in highlighting factors which may shape the possible forms of patients participation really attuned to each patient's needs may offer useful insights to plan interventions which maximize opportunities for patient's to take an active part in their care, if they so whish.
In order to gain these aims, we think that to assemble a detailed picture of the underlying components of patient engagement is particularly urgent: this may allow to offer a holistic vision on patient engagement which takes into account its multidimensional nature which could better enable strategic tailoring and targeting of interventions to support the capacity of health organization to be “engager” and to make patients “engaged” in the care process. Finally, engaging patients in interventions which develop their skills and confidence in self-management might be a key strategy in order to address the necessity of policy makers for seeking ways to rationalize the use of resources in an effort to deal more effectively with long-term chronic conditions and disabilities [30
]. The growing claim for patients that are fully engaged and mobilized should be not only a declaration of intent, but also a strategic resource which could transform the quality and sustainability of health system [31
]. The implications of this study are likely to have relevance for international patient engagement intervention and to gain insights into its related body of knowledge in order to open viable avenues for further research.
4.1. Limits and Future Research Developments
This bibliometric exploration offered an interesting picture of the ongoing debate about patient engagement. However, further analysis is needed in order to deepen the definition of patient engagement and to systematically meta-analyze results achieved on the topics by scholars across disciplines [32
]. A deeper consideration of pathological areas and of how these impact on the different conceptualizations of patient engagement is also opportune. Moreover, empirical research is needed in order to ecologically explore what means for patients to feel engaged in the care and cure process and to collect stories and experiences of healthcare intervention fruitions that appeared successful in improving their engagement.