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Nasir Hamid
Changing media depictions of remote consulting in COVID-19: Analysis of UK newspapers
Background Remote consulting was introduced quickly into UK general practice in March 2020 as an emergency response to COVID-19. In July 2020, ‘remote-first’ became long-term government policy. Aim To explore how this change was portrayed in national newspapers and how depictions changed over time. Design and setting Thematic analysis of newspaper articles referring to remote GP consultations from two time periods: 2 March–31 May 2020 (period 1) and 30 July–12 August 2020 (period 2). Method Articles were identified through, and extracted from, LexisNexis Academic UK. A coding system of themes and narrative devices was developed and applied to the data. The analysis was developed iteratively, amending the coding structure as new data were added. Results Remote consulting was widely covered in newspapers. Articles in period 1 depicted it positively, equating digital change with progress and linking novel technological solutions with improved efficiency and safety (for example, infection control) in a service that was overdue for modernisation. Articles in period 2 questioned the persistence of a remote-first service now that the pandemic was waning, emphasising, for example, missed diagnoses, challenges to the therapeutic relationship, and digital inequalities. Conclusion As the first wave of the pandemic came and went, media depictions of remote consulting evolved from an ‘efficiency and safety’ narrative to a ‘risks, inequalities, and lack of choice’ narrative. To restore public trust in general practice, public communication should emphasise the wide menu of consulting options now available to patients and measures being taken to assure safety and avoid inequity.
Video consultations between patients and clinicians in diabetes, cancer, and heart failure services: Linguistic ethnographic study of video-mediated interaction
Background: Video-mediated clinical consultations offer potential benefits over conventional face-to-face in terms of access, convenience, and sometimes cost. The improved technical quality and dependability of video-mediated consultations has opened up the possibility for more widespread use. However, questions remain regarding clinical quality and safety. Video-mediated consultations are sometimes criticized for being not as good as face-to-face, but there has been little previous in-depth research on their interactional dynamics, and no agreement on what a good video consultation looks like. Objective: Using conversation analysis, this study aimed to identify and analyze the communication strategies through which video-mediated consultations are accomplished and to produce recommendations for patients and clinicians to improve the communicative quality of such consultations. Methods: We conducted an in-depth analysis of the clinician-patient interaction in a sample of video-mediated consultations and a comparison sample of face-to-face consultations drawn from 4 clinical settings across 2 trusts (1 community and 1 acute care) in the UK National Health Service. The video dataset consisted of 37 recordings of video-mediated consultations (with diabetes, antenatal diabetes, cancer, and heart failure patients), 28 matched audio recordings of face-to-face consultations, and fieldnotes from before and after each consultation. We also conducted 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by 2 software platforms (Skype and FaceTime). Results: Patients had been selected by their clinician as appropriate for video-mediated consultation. Most consultations in our sample were technically and clinically unproblematic. However, we identified 3 interactional challenges: (1) opening the video consultation, (2) dealing with disruption to conversational flow (eg, technical issues with audio and/or video), and (3) conducting an examination. Operational and technological issues were the exception rather than the norm. In all but 1 case, both clinicians and patients (deliberately or intuitively) used established communication strategies to successfully negotiate these challenges. Remote physical examinations required the patient (and, in some cases, a relative) to simultaneously follow instructions and manipulate technology (eg, camera) to make it possible for the clinician to see and hear adequately. Conclusions: A remote video link alters how patients and clinicians interact and may adversely affect the flow of conversation. However, our data suggest that when such problems occur, clinicians and patients can work collaboratively to find ways to overcome them. There is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives. We offer preliminary guidance for patients and clinicians on what is and is not feasible when consulting via a video link.
Interrogating the promise of technology in epilepsy care: systematic, hermeneutic review
Technology development is gathering pace in epilepsy with seizure detection devices promising to transform self-care and service provision. However, such accounts often neglect the uncertainties, displacements and responsibilities that technology-supported care generates. This review brings together a heterogeneous literature, identified through systematic searches in 8 databases and snowball searching, to interrogate how technology becomes positioned in epilepsy care. We took a hermeneutic approach in our analysis of the 206 included articles, which resulted in the development of a conceptual framework surfacing the underlying logics by which technology-supported epilepsy care is organised. Each of these logics enacts different techno-scientific futures and carries specific assumptions about how (often imagined) ‘users’ and their bodies become co-constituted. Our review shows that studies in this area remain primarily deterministic and technology-focused. Few draw phenomenological insights on lived experiences with epilepsy or use social theory to problematise the role of technology. We propose future directions for sociotechnical, theory-driven studies of technology in epilepsy care and offer a framework transferable across other long-term conditions.
Frameworks for supporting patient and public involvement in research: Systematic review and co-design pilot
BACKGROUND: Numerous frameworks for supporting, evaluating and reporting patient and public involvement in research exist. The literature is diverse and theoretically heterogeneous. OBJECTIVES: To identify and synthesize published frameworks, consider whether and how these have been used, and apply design principles to improve usability. SEARCH STRATEGY: Keyword search of six databases; hand search of eight journals; ancestry and snowball search; requests to experts. INCLUSION CRITERIA: Published, systematic approaches (frameworks) designed to support, evaluate or report on patient or public involvement in health-related research. DATA EXTRACTION AND SYNTHESIS: Data were extracted on provenance; collaborators and sponsors; theoretical basis; lay input; intended user(s) and use(s); topics covered; examples of use; critiques; and updates. We used the Canadian Centre for Excellence on Partnerships with Patients and Public (CEPPP) evaluation tool and hermeneutic methodology to grade and synthesize the frameworks. In five co-design workshops, we tested evidence-based resources based on the review findings. RESULTS: Our final data set consisted of 65 frameworks, most of which scored highly on the CEPPP tool. They had different provenances, intended purposes, strengths and limitations. We grouped them into five categories: power-focused; priority-setting; study-focused; report-focused; and partnership-focused. Frameworks were used mainly by the groups who developed them. The empirical component of our study generated a structured format and evidence-based facilitator notes for a "build your own framework" co-design workshop. CONCLUSION: The plethora of frameworks combined with evidence of limited transferability suggests that a single, off-the-shelf framework may be less useful than a menu of evidence-based resources which stakeholders can use to co-design their own frameworks.
Realist methods in medical education research: what are they and what can they contribute?
Education is a complex intervention which produces different outcomes in different circumstances. Education researchers have long recognised the need to supplement experimental studies of efficacy with a broader range of study designs that will help to unpack the 'how' and 'why' questions and illuminate the many, varied and interdependent mechanisms by which interventions may work (or fail to work) in different contexts. One promising approach is realist evaluation, which seeks to establish what works, for whom, in what circumstances, in what respects, to what extent, and why. This paper introduces the realist approach and explains why it is particularly suited to education research. It gives a brief introduction to the philosophical assumptions underlying realist methods and outlines key principles of realist evaluation (designed for empirical studies) and realist review (the application of realist methods to secondary research). The paper warns that realist approaches are not a panacea and lists the circumstances in which they are likely to be particularly useful. © Blackwell Publishing Ltd 2012.
New models of self-management education for minority ethnic groups: Pilot randomized trial of a story-sharing intervention
Objective: No model of self-management education or peer support has yet achieved widespread reach and acceptability with minority ethnic groups. We sought to refine and test a new complex intervention in diabetes education: informal story-sharing groups facilitated by bilingual health advocates. Methods: Pilot randomized trial with in-depth process evaluation in a socioeconomically deprived area. 157 people referred for diabetes education were randomized by concealed allocation to an intervention (story-sharing group in their own language) or control ('usual care' self-management education, through an interpreter if necessary) arm. Story-sharing groups were held in five ethnic languages and English (for African Caribbeans), and ran fortnightly for six months. Primary outcome was UKPDS (UK Prospective Diabetes Study) risk score. Secondary outcomes included attendance, HbA1c, well-being and enablement. Process measures included ethnographic observation, and qualitative interviews with staff and patients. Results: Some follow-up data were obtained on 87% of participants. There was no significant difference between intervention and control arms in biomedical outcomes. Attendance was 79% in the story-sharing arm and 35% in the control arm (p < 0.0001), and patient enablement scores were significantly higher (8.3 compared to 5.9, p < 0.005). The model was very popular with clinicians, managers and patients, which helped overcome numerous challenges to its successful embedding in a busy public sector diabetes service. Conclusion: People from minority ethnic groups in a socioeconomically deprived area were keen to attend informal story-sharing groups and felt empowered by them, but clinical outcomes were no better than with conventional education. Further research is needed to maximize the potential and evaluate the place of this appealing service model before it is introduced as a part of mainstream diabetes services. © The Royal Society of Medicine Press Ltd 2011.
Storylines of self-management: Narratives of people with diabetes from a multiethnic inner city population
Objectives: To analyse the narratives of people with diabetes to inform the design of culturally congruent self-management education programmes. Methods: The study was based on quasi-naturalistic story-gathering; i.e. making real-time field notes of stories shared spontaneously in diabetes self-management education groups in a socioeconomically deprived London borough. Eighty-two adults aged 25-86, from six minority ethnic groups who were in the intervention arm of a randomized controlled trial of story-sharing, participated. Stories were translated in real time by the facilitator or group members. Ethnographic field notes were transcribed, and analysed thematically (to identify self-management domains raised by participants) and interpretively for over-arching storylines (i.e. considering how self-management domains were contextualized and made meaningful in personal narratives). Analysis was informed by both biomedical and sociological theories of self-management. Results: People with diabetes identified seven self-management domains: knowledge; diet; exercise; medication; foot care; self-monitoring; and attending check-ups. Interpretive analysis revealed eight illness storylines within which these practical issues acquired social meaning and moral worth: becoming sick; rebuilding spoiled identity; becoming a practitioner of self-management; living a disciplined and balanced life; mobilizing a care network; navigating and negotiating in the health care system; managing the micro-morality of self-management 'choices'; and taking collective action. Conclusion: Living with diabetes involves both medically recommended behaviours and complex biographical work to make sense of and cope with illness. Self-management education programmes should take closer account of over-arching storylines that pattern experience of chronic illness and recognize that some elements of self-management knowledge cannot be pre-specified in a structured curriculum. © The Royal Society of Medicine Press Ltd 2011.
Being 'rational' and being 'human': How National Health Service rationing decisions are constructed as rational by resource allocation panels
© The Author(s) 2013. The English National Health Service Constitution states that patients have the right to expect all decisions about access to medicines and treatments to be made 'rationally'. Rationality in health care can be framed as instrumental, institutional or practical. In this article, we present a case example from an ethnographic study of the work of 'Individual Funding Request' panels to explore how rationality is enacted and accounted for in deliberations about the rationing of health care in the National Health Service. Our rhetorical analysis highlights how an embodied, practical rationality emerges as a significant aspect of rationality in practice, but at the same time has a problematic status in formal accounts of decision-making. We suggest that being both 'human' and 'rational' is a 'delicate balance' and creates a dilemma for Individual Funding Request panels. Aristotle's notion of phronesis provides a useful lens for theorising our observation of panel deliberations, and we argue for greater attention to the value of narrative ethics in helping us understand the challenges faced by resource allocators.
How to Read a Paper The Basics of Evidence-Based Medicine
This fifth edition has been fully updated with new examples and references to reflect recent developments and current practice.
User Involvement in Health Care
How can the needs and perspective of patients be incorporated in the design and redesign of health services?. Health organizations are focusing more and more on patients - and requiring their employees to practise patient focused care. The Modernisation Initiative described in this book explores in three health service areas (kidney, stroke and sexual health services) how patients' and carers' involvement may inform and shape quality improvement work. This book guides you through the issues and challenges that teams seeking to involve users in changing health services are likely to face. It offers a wealth of practical knowledge about involving users. Those undertaking similar programmes, whether in primary care or hospital based, will find ideas and examples in this book to inspire and guide them. © 2011 Blackwell Publishing Ltd.
Opening up the 'black box' of the electronic patient record: A linguistic ethnographic study in general practice
One of the most pervasive changes in general practice is the introduction of the electronic patient record (EPR). The EPR supports both immediate clinical and anticipatory care (e.g. management of risk factors). Incorporating the EPR into social interaction is a complex task which is achieved discursively, clinician and patient responding to interactional contingencies as the consultation unfolds. Clinicians are presented with a 'dilemma of attention' as they seek to deal with the immediacy ('here and now') of the interpersonal interaction and the institutional demands ('there and then') of the EPR. We present data analysis which illuminates the EPR as an important presence in the clinic consultation context, one which places material and textual demands. Developing previous work on the triadic (three party) consultation, our novel multimodal analysis of the EPR-in-use suggests there is value in considering the EPR as a collection of silent but consequential voices. Micro-analytic attention to the way in which these different voices are managed, combined with understandings drawn from ethnographic observation of the primary care context, reveals the EPR as exhibiting a previously under-explored kind of 'agency' within the consultation. Copyright © Equinox Publishing Ltd.