‘What is it?’: findings on preschoolers’ responses to play with medical equipment

When young people enter a hospital they are exposed to a foreign world of unfamiliar people, medical equipment and language. Children diagnosed with leukaemia are particularly vulnerable to repeated exposure to these distressing hospital visits. Assessing a child's understanding of the stresses associated with treatment during hospitalization is now seen as a key element of caring for the paediatric patient. A population particularly vulnerable to the effects of the stress of intensive treatments during hospitalization are preschool children. In order to understand the impact on leukaemia preschool children of intensive hospital treatment it is necessary to have comparative information on healthy peers who have not been exposed to such treatment experiences. This article presents findings from recent qualitative research that explored the beliefs held by healthy preschoolers about what happens in hospital, what it means to be sick, their reactions to and knowledge of medical equipment and their level of knowledge regarding cancer and leukaemia. It is the hope and expectation that the findings will be used comparatively to contribute to a deeper understanding of the world of the child coping with leukaemia and related disorders.     

What constitutes ‘good care’ and ‘good carers’? The normative implications of introducing reablement in Danish home care

As populations worldwide are ageing, Western welfare states are currently implementing welfare reforms aimed at curbing the rising need for social and healthcare services for ageing populations. A central element in home‐care reforms in several welfare countries is reablement: short‐term home‐based training programmes aimed at re‐enabling older people to live in their own homes independently of care. In this paper, we explore how transitioning from compensatory care to reablement care is not merely a practical process, but also a deeply normative one. Drawing on Annemarie Mol's concept of ‘ontonorms’ we analyse the normative dynamics involved in transitioning from one form of care to another as reflected in reablement professionals' practices and discourses. The paper draws on 10 months of multisited ethnographic fieldwork carried out from April 2015 to February 2016 in a Danish municipality, including participant observations of reablement practices as well as qualitative interviews with 13 professionals working with reablement. We demonstrate that professionals generally consider reablement to represent a desirable shift in home care from ‘bad care’ practices of making people passive through compensatory care, towards ‘good care’ practices of ‘keeping people going’ despite their limitations. Moreover, we demonstrate that while therapists are valued as ‘good carers’ due to their ability to focus on development and training, nurses and in particular home helpers are devalued as ‘bad carers’ due to their ‘caring genes’ and lack of technical and theoretical skills necessary for documentation work. Finally, we discuss the implications of these normative dynamics, which may risk stigmatising compensating care practices, although this form of care to a large extent continues to coexist with reablement practices. In conclusion, we argue for a more nuanced approach to care, recognising compensatory care and reablement as complementary forms of care, each doing good under different circumstances.     

Faculty development: a ‘Field of Dreams’?

Objectives  Participants in faculty development workshops often comment that 'those who need faculty development the most attend the least'. The goals of this study were to explore the reasons why some clinical teachers do not participate in centralised faculty development activities and to learn how we can make faculty development programmes more relevant to teachers' needs.
Methods  In 2006, we conducted focus groups with 16 clinical teachers, who had not participated in faculty development activities, to ascertain their perceptions of faculty development, reasons for non-participation and perceived barriers to involvement. Content analysis and team consensus guided the data interpretation.
Results  Focus group participants were aware of faculty development offerings and valued the goals of these activities. Important reasons for non-participation emerged: clinical reality, which included volume of work and lack of (protected) time; logistical issues, such as timing and the central location of organised activities; a perceived lack of financial reward and recognition for teaching, and a perceived lack of direction from, and connection to, the university.
Conclusions  Clinical reality and logistical issues appeared to be greater deterrents to participation than faculty development goals, content or strategies. Moreover, when asked to discuss faculty development, teachers referred to their development as faculty members in the broadest sense, which included personal and career development. They also expressed the desire for clear guidance from the university, financial rewards and recognition for teaching, and a sense of 'belonging'. Faculty development programmes should try to address these organisational issues as well as teachers' personal and professional needs.     

The mental distress of the birth relatives of adopted children: ‘disease’ or ‘unease’? Findings from a UK study

Parental mental distress may pre‐date or even precipitate a child’s adoption, but adoption can also cause birth family members psychological distress. There is a lack of research that has measured the mental distress of birth relatives in contemporary adoptions, most of which are initiated by the child welfare system. The objective of this study was to measure the mental health of birth relatives in contemporary UK adoptions using a self‐report measure, the Brief Symptom Inventory (BSI). 164 birth relatives (89 birthmothers, 32 birthfathers and 43 extended family members), drawn from three separate samples, completed the measure. Data were collected between 2002 and 2008. In 89% of cases, the child had been adopted from the public care system. The length of time since adoption varied from 0 to 12 years (M = 3.8). The scores of birth relatives on the nine symptom dimensions and three global indices of the BSI are reported and compared with previously published results from a community sample and a psychiatric outpatient sample. The scores of birth relatives were considerably higher than the community comparison sample. Fifty‐seven per cent of all birth relatives had scores on the global severity index within the clinical range. Separated into three groups (birth mothers, birth fathers and extended family members), these figures were 67%, 56% and 35% respectively. For all groups of birth relatives, scores on the ‘paranoid ideation’ subscale were particularly elevated, raising questions as to the meaning of this symptom dimension for this group of people. Social models for understanding mental distress are argued to be particularly relevant, and it is suggested that the distress of birth relatives is more usefully seen as ‘unease’ than ‘disease’ and that support services should draw on Recovery models of intervention. Practice suggestions for adult mental health service providers and adoption support services are discussed.     

‘Why must I wait?’ The performance of legitimacy in a hospital emergency department

This article examines the processes of negotiation that occur between patients and medical staff over accessing emergency medical resources. The field extracts are drawn from an ethnographic study of a UK emergency department (ED) in a large, inner city teaching hospital. The article focuses on the triage system for patient prioritisation as the first point of access to the ED. The processes of categorising patients for priority of treatment and care provide staff with the opportunities to maintain control over what defines the ED as a service, as types of work and as particular kinds of patients. Patients and relatives are implicated in this categorical work in the course of interactions with staff as they provide reasons and justifications for their attendance. Their success in legitimising their claim to treatment depends upon self‐presentation and identity work that (re)produces individual responsibility as a dominant moral order. The extent to which people attending the ED can successfully perform as legitimate is shown to contribute to their placement into positive or negative staff‐constituted patient categories, thus shaping their access to the resources of emergency medicine and their experience of care.     

‘What would my classmates say?’ An international study of the prediction‐based method of course evaluation

Objectives Traditional student feedback questionnaires are imperfect course evaluation tools, largely because they generate low response rates and are susceptible to response bias. Preliminary research suggests that prediction‐based methods of course evaluation ‐ in which students estimate their peers’ opinions rather than provide their own personal opinions ‐ require significantly fewer respondents to achieve comparable results and are less subject to biasing influences. This international study seeks further support for the validity of these findings by investigating: (i) the performance of the prediction‐based method, and (ii) its potential for bias. Methods Participants (210 Year 1 undergraduate medical students at McGill University, Montreal, Quebec, Canada, and 371 Year 1 and 385 Year 3 undergraduate medical students at the University Medical Center Groningen [UMCG], University of Groningen, Groningen, the Netherlands) were randomly assigned to complete course evaluations using either the prediction‐based or the traditional opinion‐based method. The numbers of respondents required to achieve stable outcomes were determined using an iterative process. Differences between the methods regarding the number of respondents required were analysed using t‐tests. Differences in evaluation outcomes between the methods and between groups of students stratified by four potentially biasing variables (gender, estimated general level of achievement, expected test result, satisfaction after examination completion) were analysed using multivariate analysis of variance (manova) . Results Overall response rates in the three student cohorts ranged from 70% to 94%. The prediction‐based method required significantly fewer respondents than the opinion‐based method (averages of 26–28 and 67–79 respondents, respectively) across all samples (p < 0.001), whereas the outcomes achieved were fairly similar. Bias was found in four of 12 opinion‐based condition comparisons (three sites, four variables), and in only one comparison in the prediction‐based condition. Conclusions Our study supports previous findings that prediction‐based methods require significantly fewer respondents to achieve results comparable with those obtained through traditional course evaluation methods. Moreover, our findings support the hypothesis that prediction‐based responses are less subject to bias than traditional opinion‐based responses. These findings lend credence to prediction‐based as an accurate and efficient method of course evaluation.     

The complex enterprise of modelling prenatal exposure to cigarettes: what is ‘enough’?

While there is a burgeoning body of research linking smoking during pregnancy to problem behaviour in offspring, a major criticism of this work has been the crude measurement of exposure in these studies (e.g. retrospective, self-reported only) that could lead to biased estimates. To address this issue, we used a pregnancy cohort with repeated prospective measures of exposure as well as biological assays to generate estimates of exposure patterns using a range of modelling techniques. In this paper we report on the analytical approaches we have developed, including patterns of exposure over time and best-estimate approaches that combine self-report and cotinine measures, and compare their predictive value in relation to different dimensions of fetal growth as a first step towards examining the utility of greater precision of exposure measurement.
Surprisingly, in this sample the more complex assessments of exposure, including biological measures, generally did not perform better than simple indicators of exposure based on repeated self-report measures, with one exception: a combined self-report cotinine 'best estimate' of third trimester exposure was uniquely associated with lower brain : body ratio. Further study is needed using more sophisticated cotinine assays and testing prediction of a range of outcomes to ascertain whether these findings represent true differences or are specific to the sample, methods and outcomes used. Such research will inform the development of guidelines for adequate exposure characterisation in developmental studies.     

Knowledge is power? The role of experiential knowledge in genetically ‘risky’ reproductive decisions

Knowledge of the condition being tested for is increasingly acknowledged as an important factor in prenatal testing and screening decisions. An analysis of the way in which family members living with an inheritable condition use and value this knowledge has much to add to debates about whether and how this type of knowledge could be made available to prospective parents facing screening decisions. This article reports on in‐depth interviews (conducted between 2007 and 2009) with 61 people with a genetic condition, spinal muscular atrophy (SMA) in their family. Many participants reported that their intimate familial knowledge of SMA offered them valuable insights with which they could imagine future lives. Other participants, however, found themselves trapped between their experiential knowledge of SMA and their (often) competing responsibility to maintain the wellbeing of their family. Still, others established a hierarchy of knowledge to rank the authenticity of different family member's accounts of SMA in order to discredit or justify their decisions. This article highlights the way in which experiential knowledge of the condition being tested for cannot be unproblematically assumed to be a useful resource in the context of prenatal testing decisions and may actually constrain reproductive decisions.     

The ‘demented other’ or simply ‘a person’? Extending the philosophical discourse of Naue and Kroll through the situated self

This article presents a critique of an article previously featured in Nursing Philosophy (10: 26-33) by Ursula Naue and Thilo Kroll, who suggested that people living with dementia are assigned a negative status upon receipt of a diagnosis, holding the identity of the 'demented other'. Specifically, in this critique, we suggest that unwitting use of the adjective 'demented' to define a person living with the condition is ill-informed and runs a risk of defining people through negative (self-)attributes, which has a deleterious impact upon that person's social and relational personae. Moreover, use of the locution 'demented' reinforces a divide between the 'demented' (them) and the 'healthy others' (us). Social constructionist theory, malignant positioning and viewing people with dementia as semiotic subjects are the philosophical pillars through which we construct the main arguments of the critique. The article concludes with the voice of one of the authors, a younger person with dementia, asking for language in dementia care to be carefully reconsidered and reframed and for the recognition of the diagnosed person's agency in the conduct of their day-to-day lives.     

What kind of healthcare ‘internal market’? A cross-europe view of the options

Many governments are trying to invent new types of 'internal' healthcare market that will expose health services to competitive pressures to innovate, contain costs, raise service quality, and respond better to consumer demands; but not expose them to 'market failures' which prejudice universal access to 'basic' health services. Policy debates in this area are muddled and constricted by a failure to differentiate the variants of internal market that are available. This article outlines a taxonomy of the main types of internal market: primary doctor purchasing; managed competition; competitive bidding; social insurance; and compulsory private insurance. It notes their main structural characteristics and differences. Although internal market reforms have been intended to support the commercialization of healthcare, the idea of designing new types of economic structure to avoid market failure in healthcare has wider and more radical implications than most policy-makers intend.