Maintaining face in the presentation of depression: constraining the therapeutic potential of the consultation

This article discusses the concerns of patients diagnosed with depression to preserve 'face' in social and medical encounters. The findings are from a qualitative study of patient and GP accounts of the presentation, recognition and treatment of depression. Medical consultations are difficult encounters to accomplish successfully, especially for patients, who often strive to protect their privacy and personal integrity through the maintenance of face. Face work reveals the concern of participants to contribute to the success of the consultation as a social interaction. Patients' strategy of maintaining face helps to account for the commonly reported underdetection of psychosocial distress in general practice consultations. Many people do not regard the experience of psychosocial distress as an appropriate topic for medical consultation or scrutiny. In this case, face work can function as a means of maintaining privacy and resisting medical diagnosis and intervention. The concept of face has relevance in other areas of clinical care, including chronic and enduring pain, functional disorders, medically unexplained symptoms and even terminal illness. Consideration of face work reveals the extent to which the pressure to contribute to the success of the consultation as a social encounter may constrain participants' capacity to realize its therapeutic potential. The extent to which clinical interactions are governed by social etiquette also helps to explain the continuing inertia of the formal health care system and the difficulty of changing the ways that patients and doctors communicate with each other, and of increasing patients' involvement in medical consultations

A case study exploring the experience of graduate entry nursing students when learning in practice

Aim. To explore how Graduate Entry Nursing students present and position themselves in practice in response to anti-intellectualist stereotypes and assessment structures. Background. A complex background turbulence exists in nurse education which incorporates both pro- and anti-intellectualist positions. This represents a potentially challenging learning environment for students who are recruited onto pre-registration programmes designed to attract graduates into the nursing profession on the basis of the specific attributes they bring known as ‘graduateness’. Design. A longitudinal qualitative case study conducted over 2 years. Methods. Data were collected from eight Graduate Entry Nursing students at 6 monthly points between 2009–2011 via diaries, clinical assessment documentation and interviews. Forty interviews took place over 2 years. Additionally, three focus groups involving 12 practice assessors were conducted at the end of the study period. Data were analysed through a social constructivist lens and compared with a set of suppositions informed by existing empirical and theoretical debates. Findings. Demonstrated the interplay of performance strategies adopted by Graduate Entry Nursing students to challenge or pre-empt actual or perceived negative stereotypes held by established practitioners to gain acceptance, reduce threat and be judged as appropriately competent. Conclusion. Students interpreted and responded to, perceived stereotypes of nursing practice they encountered in ways which facilitated the most advantageous outcome for themselves as individuals. The data present the creative and self-affirming strategies which students adopted in response to the expectations generated by these stereotypes. They also depict how such strategies commonly involved suppression of the attributes associated with ‘graduateness’

Co-construction of consent and counselling during Provider Initiated Counselling and Testing (PITC) in Nairobi Kenya

Background: The global policy focus of today’s HIV efforts and strategies is to reverse the spread of HIV/AIDS and provide care, treatment and support. A key component of this strategy is to increase individual HIV status awareness through expansion of HIV testing and counselling (HTC). However, the numbers tested still remain and evidence suggests that there are significant missed opportunities for HIV testing in clinical settings. One key strategy to expand HTC in clinical settings has been to implement a policy of ‘provider initiated counselling and testing’ (PITC) in which all patients accessing health facilities for treatment are routinely offered a HIV test. The introduction of PITC has brought with it a ‘dilution’ of the previously lengthy and stringent testing process by doing away with signed informed consent and extensive pre and post-test counselling. The previous process was recognised as a barrier to public health gains of HIV testing expansion, particularly as it differentiated an HIV test from other routine medical tests resulting in a sense of HIV exceptionalism. In its place, the PITC policy recommends an opt-out approach and replaces the extensive pre-test counselling with an information giving session placing more emphasis on post-test counselling in cases where the result is positive. This change has given rise to debates about the potential for PITC to infringe patients’ rights to informed consent and counselling especially in developing countries. Emerging evidence from the exploration of the PITC process within antenatal settings in the Sub Saharan Africa has revealed some of the complexities of implementing PITC guidelines in different cultural and healthcare contexts.These studies suggest that information giving and consent are difficult to apply in contexts characterized by healthcare worker dominance, lack of sufficient resources and time constraints. This study aims to specifically investigate how patients [and counsellors] co-construct informed consent and perform counselling during the PITC consultation. Thus it examined ‘real time’ patient-counselor interaction within hospital outpatient and inpatient settings in Kenya; to explore the patient’s experience of a routine HIV test and to evaluate how sociocultural norms influence the PITC process in this context. Methods: In order to explore the context of the routine testing consultation and the way the interaction played out, a qualitative research approach was adopted, utilizing multiple data collection methods (interviews, observations and audio recording of consultations). The study was carried out in two government run health facilities in Kenya’s capital, Nairobi. The intention was to follow patients through the PITC process, i.e. before testing, during the HIV test and (whenever possible) after the HIV test. To get a broader picture of the events during the routine HIV testing consultation, additional interviews were conducted with 5 nurse-counsellors whose consultations had been observed. Ethical approval was obtained from the Kenya National Research Council, Kenya Medical Research Institute and the Aga Khan University Ethics Committee. The data were analysed using Charmaz’s constructivist grounded theory approach which allowed for a systematic yet flexible approach to analysis. This method facilitated immersion and engagement with the data, and provided a means of managing the different data sets in the study and undertaking a process of constant comparison within and between data sets. Findings: Results from the study suggest that HIV remains a highly stigmatised illness in Kenyan society and is associated with death and perceived lack of morality. This is still the case in spite of years of health promotion and high profile media campaigns raising awareness about HIV and the availability and effectiveness of treatment. The context of stigma shaped the consultation so that both patients and counsellors worked together to help patients to maintain a ‘moral face’. Patients tended to withhold information on risky sexual behaviour whilst the counsellors avoided inquiring into this domain. The PITC consultation was characterised by a counsellor dominated approach to communication and health promotion. Counsellor inputs were generic, highly scripted and didactic rather than patient-centred. As a result, the counsellors’ style of communication allowed little space for personalised risk assessment or for patients to ask questions or to express concerns. Further on, the findings suggest that informed consent requiring explicit refusal of the test offer was difficult to achieve in an environment where the HIV test was not framed as a choice and patients came to the health facility expecting to be told what to do. Nevertheless, in spite of the obvious lack of explicit informed consent and the counsellor dominated interaction, post-test interviews revealed that patients were satisfied with the nature of the interaction. Implications: The study concludes that there is a considerable distance between the policy recommendations and their implementation on the ground due to the complexity of real world practice. This distance does not necessarily constitute a disregard for the guideline recommendations but, rather, is an attempt to adapt to the prevailing environment. Lay constructions about HIV (HIV stigma) and the existing norms of patient-provider interaction that are characterised by a passive patient and a dominant health care provider shape the way the consultation unfolds. PITC training programs and manuals need to include skills and strategies that can support counsellors to navigate the consultation and provide quality care within this prevailing context

Configuring the caller in ambiguous encounters: volunteer handling of calls to Samaritans emotional support services

This paper discusses volunteer strategies for handling and assessing calls to Samaritans emotional support services for the suicidal and despairing. It presents findings from the qualitative components of a two year mixed methods study based on an online caller survey, branch observations and interviews with volunteers and callers throughout the UK. A thematic analysis of the qualitative data analysis was undertaken using the principle of constant comparison. Many calls fell beyond the primary remit of a crisis service, and called for rapid attribution and assessment. Uncertainty about identifying ‘good’ calls and recognizing those which were not caused difficulty, frustration and negative attribution towards some callers. This paper presents our analysis of volunteers’ accounts of how they configure the caller in intrinsically uncertain and ambiguous encounters, and how such strategies relate to the formal principles of unconditional support and non-judgemental active listening espoused by the organization

GPs' decisions about prescribing end-of-life anticipatory medications: a qualitative study.

BACKGROUND: GPs have a central role in decisions about prescribing anticipatory medications to help control symptoms at the end of life. Little is known about GPs' decision-making processes in prescribing anticipatory medications, how they discuss this with patients and families, or the subsequent use of prescribed drugs. AIM: To explore GPs' decision-making processes in the prescribing and use of anticipatory medications for patients at the end of life. DESIGN AND SETTING: A qualitative interview study with GPs working in one English county. METHOD: Semi-structured interviews were conducted with a purposive sample of 13 GPs. Interview transcripts were analysed inductively using thematic analysis. RESULTS: Three themes were constructed from the data: something we can do, getting the timing right, and delegating care while retaining responsibility. Anticipatory medications were a tangible intervention GPs felt they could offer patients approaching death (something we can do). The prescribing of anticipatory medications was recognised as a harbinger of death for patients and their families. Nevertheless, GPs preferred to discuss and prescribe anticipatory medications weeks before death was expected whenever possible (getting the timing right). After prescribing medications, GPs relied on nurses to assess when to administer drugs and keep them updated about their use (delegating care while retaining responsibility). CONCLUSION: GPs view anticipatory medications as key to symptom management for patients at the end of life. The drugs are often presented as a clinical recommendation to ensure patients and families accept the prescription. GPs need regular access to nurses and rely on their skills to administer drugs appropriately. Patients' and families' experiences of anticipatory medications, and their preferences for involvement in decision making, warrant urgent investigation.National Institute for Health Research NIHR School for Primary Care Research. National Institute for Health Research Applied Research Collaboration East of England

Reappraising ‘the good death’ for populations in the age of ageing

This is the second in an occasional series of paired commentaries in Age and Ageing, the Journal of the British Geriatrics Society and the Journal of the American Geriatrics Society (JAGS). The aim is to address issues of current significance and to foster dialogue and increased understanding between academics and clinicians working in comparative international settings. Both commentaries address the urgent need to improve palliative care for older people, with a critique of some stereotypes surrounding palliative care and the ‘good death’. The companion commentary, published in JAGS, was written by Alexander Smith and Vyjeyanthi Periyakoil, and is grounded in their experience as academic clinicians (Smith AK, Periyakoil V. Should we bury ‘The Good Death’? Journal of the American Geriatrics Society 2018; in press). In the present paper, we offer a perspective on the outcome and wider consequences of misalignment between current UK policy and aspirations for end of life care in relation to epidemiological trends and patient experience of death and dying

An exploration of the experiences of professionals supporting patients approaching the end of life in medicines management at home. A qualitative study

BACKGROUND: The management of medicines towards the end of life can place increasing burdens and responsibilities on patients and families. This has received little attention yet it can be a source of great difficulty and distress patients and families. Dose administration aids can be useful for some patients but there is no evidence for their wide spread use or the implications for their use as patients become increasing unwell. The study aimed to explore how healthcare professionals describe the support they provide for patients to manage medications at home at end of life. METHODS: Qualitative interview study with thematic analysis. Participants were a purposive sample of 40 community healthcare professionals (including GPs, pharmacists, and specialist palliative care and community nurses) from across two English counties. RESULTS: Healthcare professionals reported a variety of ways in which they tried to support patients to take medications as prescribed. While the paper presents some solutions and strategies reported by professional respondents it was clear from both professional and patient/family caregiver accounts in the wider study that rather few professionals provided this kind of support. Standard solutions offered included: rationalising the number of medications; providing different formulations; explaining what medications were for and how best to take them. Dose administration aids were also regularly provided, and while useful for some, they posed a number of practical difficulties for palliative care. More challenging circumstances such as substance misuse and memory loss required more innovative strategies such as supporting ways to record medication taking; balancing restricted access to controlled drugs and appropriate pain management and supporting patient choice in medication use. CONCLUSIONS: The burdens and responsibilities of managing medicines at home for patients approaching the end of life has not been widely recognised or understood. This paper considers some of the strategies reported by professionals in the study, and points to the great potential for a more widely proactive stance in supporting patients and family carers to understand and take their medicines effectively. By adopting tailored, and sometimes, 'outside the box' thinking professionals can identify immediate, simple solutions to the problems patients and families experience with managing medicines

The rules of the game in graduate entry nursing: a longitudinal case study

Background Graduate Entry Nursing programmes are pre-registration nursing curricula designed for candidates who already have a health related degree. The programmes aim to attract highly motivated individuals who have a commitment to nursing and hold the cognitive abilities associated with studying in higher education including critical thinking styles and capability to study independently. These attributes are termed within the literature as “graduateness”. They are viewed by some as advantages to nursing. In contrast, however, there remains widespread scepticism amongst the public and some professionals towards those who are academically educated entering nursing. Objectives To explore how GEN students anticipate, experience, explain and respond to attitudes which imply resistance to those who are academically educated. Design Longitudinal case study informed by the conventions advocated by Yin (2014). Settings School of Health Sciences in a British University. Participants Eight GEN students participated over the two year duration of their programme. Twelve clinical assessors with a minimum of four months' experience of supporting GEN students in practice. Methods Students took part in individual interviews at six monthly periods which were informed by the content of diaries maintained throughout their clinical placements. Clinical assessors took part in focus group discussions. Practice documentation was accessed to identify the progression of clinical competency along with written feedback received by students from clinical assessors. Results Results demonstrate the ways in which GEN students position themselves performatively in order to pre-empt or challenge negative stereotypes relating to their competence, compassion and commitment. Conclusions Students employ a number of strategies to navigate the challenges of learning within an environment in which they are viewed with suspicion and distrust

Unwelcome memento mori or best clinical practice? Community end of life anticipatory medication prescribing practice: A mixed methods observational study.

Funder: RCN Foundation; Grant(s): RCN Foundation Professional Bursary Scheme: BB [grBACKGROUND: Anticipatory medications are injectable drugs prescribed ahead of possible need for administration if distressing symptoms arise in the final days of life. Little is known about how they are prescribed in primary care. AIM: To investigate the frequency, timing and recorded circumstances of anticipatory medications prescribing for patients living at home and in residential care. DESIGN: Retrospective mixed methods observational study using General Practitioner and community nursing clinical records. SETTING/PARTICIPANTS: 329 deceased adult patients registered with Eleven General Practitioner practices and two associated community nursing services in two English counties (30 most recent deaths per practice). Patients died from any cause except trauma, sudden death or suicide, between 4 March 2017 and 25 September 2019. RESULTS: Anticipatory medications were prescribed for 167/329 (50.8%) of the deceased patients, between 0 and 1212 days before death (median 17 days). The likelihood of prescribing was significantly higher for patients with a recorded preferred place of death (odds ratio [OR] 34; 95% CI 15-77; p < 0.001) and specialist palliative care involvement (OR 7; 95% CI 3-19; p < 0.001). For 66.5% of patients (111/167) anticipatory medications were recorded as being prescribed as part of a single end-of-life planning intervention. CONCLUSION: The variability in the timing of prescriptions highlights the challenges in diagnosing the end-of-life phase and the potential risks of prescribing far in advance of possible need. Patient and family views and experiences of anticipatory medication care, and their preferences for involvement in prescribing decision-making, warrant urgent investigation.National Institute for Health Research (NIHR) School for Primary Care Research; NIHR Applied Research Collaboration East of England (ARC EoE) programm