Patients' participation in decision‐making in the medical field – ‘projectification’ of patients in a neoliberal framed healthcare system

This article focuses on patients' participation in decision‐making in meetings with healthcare professionals in a healthcare system, based on neoliberal regulations and ideas. Drawing on two constructed empirical cases, primarily from the perspective of patients, this article analyses and discusses the clinical practice around decision‐making meetings within a Foucauldian perspective. Patients' participation in decision‐making can be seen as an offshoot of respect for patient autonomy. A treatment must be chosen, when patients consult physicians. From the perspective of patients, there is a tendency for healthcare professionals to supply the patients with the information that they think are necessary for them to make their own decision. But patients do not always want to be a ‘customer’ in the healthcare system; they want to be a patient, consulting an expert for help and advice, which creates resistance to some parts of the decision‐making process. Both professionals and patients are subject to the structural frame of the medical field, formed of both neoliberal framework and medical logic. The decision‐making competence in relation to the choice of treatment is placed away from the professionals and seen as belonging to the patient. A ‘projectification’ of the patient occurs, whereby the patient becomes responsible for his/her choices in treatment and care and the professionals support him/her with knowledge, preferences, and alternative views, out of which he/she must make his/her own choices, and the responsibility for those choices now and in the future. At the same time, there is a tendency towards de‐professionalization. In that light, participation of patients in decision‐making can be regarded as a tacit governmentality strategy that shapes the location of responsibility between individual and society, and independent patients and healthcare professionals, despite the basically desirable, appropriate, and necessary idea of involving patients in their own situations from a humanistic perspective.     

Language and stigmatization of individuals with mental health problems or substance addiction in the Netherlands: An experimental vignette study

Persons with mental health problems and/or substance addictions (MHPSA) are stigmatised more than persons with physical conditions. This includes stigmatisation by care professionals. Stigma is considered one of the most important barriers for recovery from these conditions. There is an ongoing debate that use of language can exacerbate or diminish stigmatisation. Therefore, we conducted an experiment examining how four different ways of referring to a person with (a) alcohol addiction, (b) drug addiction, (c) depression and (d) schizophrenia are related to stigmatising attitudes by care professionals in the Netherlands. We partially replicated two studies performed in the United States and used surveys with vignettes containing either ‘disorder‐first’, ‘person‐first’, ‘victim’ and ‘recovery’ language, which were randomly assigned to participants (n = 361). No significant differences between language conditions were found for any of the vignettes. Our findings suggest that subtle differences in language to refer to persons with mental health problems or substance addictions have no effect on stigmatising attitudes by care professionals in the Netherlands. However, more research is needed to determine the effect of language use on other groups, such as individuals with MHPSA.     

Integrating mental health services within primary care settings: the Hamilton Family Health Team

For 16 years, the Hamilton Family Health Team Mental Health Program has successfully integrated mental health counselors, addiction specialists, child mental health professionals, and psychiatrists into 81 offices of 150 family physicians in Hamilton, Ontario. Maximising the potential of a "shared care" model requires changes within the primary care setting, to support the addition of mental health and addiction professionals, active involvement of primary care staff in managing mental health problems of patients, and collaborative practice. This coordinated effort allow mental health treatment through onsite support from a mental health team and supplants the need to refer most patients to the mental health setting. This article reviews the evolution of the program and the changes made by practices with key lessons learnt.     

Twenty years of care for persons living with HIV/AIDS in Brazil: the health professionals' perspective

The aim of this study was to describe the meaning ascribed by health professionals to the care they provide for persons with HIV/AIDS. Data were collected through recorded interviews with 10 health professionals providing care to AIDS patients in different institutions in S?o Paulo State, Brazil. Three themes emerged from the analysis: (a) the overall scenario of healthcare provision for AIDS patients; (b) the relationship between healthcare professionals and patients; and (c) ethical aspects related to care. Despite significant advances, the study identified discriminatory behavior in the treatment. Such behaviors were related to feelings of insecurity and fear of infection on the part of healthcare professionals, which could be explained by the lack of appropriate training in general services and hospitals. Specific training for treating the patients mainly targeted health professionals in centers specializing in HIV/AIDS, resulting in difficulties for integrating the care of these patients with other services under the Unified National Health System. The data related to characteristics of professional training in the health field as a whole, leading one to reflect on the skills expected of health professionals in caring for (and relating to) persons with HIV/AIDS, as well as the impact on AIDS prevention.     

A meta‐ethnography of the facilitators and barriers to successful implementation of patient complaints processes in health‐care settings

Objective

To synthesize experiences of the patient complaints process for patients and health‐care professionals to identify facilitators and barriers in the successful implementation of patient complaints processes. This will assist the development of cultural change programmes, enabling complaints managers to incorporate stakeholder perspectives into future care.

Design

Systematic literature search and meta‐ethnography, comprising reciprocal syntheses of “patient” and “professional” qualitative studies, combined to form a “line‐of‐argument” embodying both perspectives.

Data sources

MEDLINE, CINAHL and PsycINFO (database inception to April 2015) were searched to identify international literature in primary and secondary health‐care settings, involving qualitative data collection and analysis. Further studies were identified from hand‐searching relevant journals, contacting authors, article reference lists and Google Scholar.

Results

A total of 13 papers, reporting 9 studies from the United Kingdom, Sweden, Australia and New Zealand, were included in the synthesis. Facilitators and barriers to the successful implementation of patient complaints processes were identified across the perspectives of both patients and health‐care professionals. Patients sought to individualize the complaints process by targeting specific professionals who engaged in practices that undermined the identity of patients. In contrast, professionals obscured their own individualism through maintaining a collective identity and withholding personal judgement in relation to patient complaints.

Conclusions

Complainants recognized health‐care professionals as bearers of individual accountability for unsatisfactory care, in opposition to the stance of collective responsibility endorsed by professionals. Implementation of patient complaints processes must reconcile the need for individualized resolution, whilst striving to improve the future provision of health care through a collaborative approach between patients and professionals.     

Is it time to abandon care planning in mental health services? A qualitative study exploring the views of professionals,service users and carers

Background

It has been established that mental health‐care planning does not adequately respond to the needs of those accessing services. Understanding the reasons for this and identifying whose needs care plans serve requires an exploration of the perspectives of service users, carers and professionals within the wider organizational context.

Objective

To explore the current operationalization of care planning and perceptions of its function within mental health services from the perspectives of multiple stakeholders.

Settings and participants

Participants included 21 mental health professionals, 29 service users and 4 carers from seven Mental Health Trusts in England. All participants had experience of care planning processes within secondary mental health‐care services.

Methods

Fifty‐four semi‐structured interviews were conducted with participants and analysed utilizing a qualitative framework approach.

Findings

Care plans and care planning were characterized by a failure to meet the complexity of mental health needs, and care planning processes were seen to prioritize organizational agendas and risk prevention which distanced care planning from the everyday lives of service users.

Discussion and conclusions

Care planning is recognized, embedded and well established in the practices of mental health professionals and service users. However, it is considered too superficial and mainly irrelevant to users for managing mental health in their everyday lives. Those responsible for the planning and delivery of mental health services should consider ways to increase the relevance of care planning to the everyday lives of service users including separating risk from holistic needs assessment, using support aids and utilizing a peer workforce in this regard.     

Citizenship, community participation, and health as seen by health care professionals: a case study in public health services

This paper deals with the subject of citizenship and people's participation in the health area through an analysis of ideas pertaining to a specific group: health care professionals working in Basic Health Care Clinics in the 3.1 Programmatic Area of the City of Rio de Janeiro (Brazil). The article analyzes their views on the subject and presents them in light of health-related legislation in the Brazilian constitution. It also analyzes the professionals' role vis-à-vis users in raising community awareness that health care is one of their basic rights. Field data from qualitative social research methodology showed a significant heterogeneity in the professionals' conceptions, dividing them into two groups: those belonging to teaching institutions and those working in institutions providing health care. This analysis shows the strategic role that day-to-day relationships between professionals and the community can play in the social change process and the establishment of social rights. It also discusses the viability of this process in view of the discovery of the subjective involvement of the health professionals who promote this process.     

Exploring the Attitudes of Health Professionals Providing Care to Patients Undergoing Treatment for Upper Gastrointestinal Cancers to Different Models of Nutrition Care Delivery: A Qualitative Investigation

Background: People with upper gastrointestinal cancer are at high risk for malnutrition without universal access to early nutrition interventions. Very little data exist on the attitudes and views of health professionals on providing nutrition care to this patient cohort delivered by electronic health methods. COVID-19 has fast-tracked the adoption of digital health care provision, so it is more important than ever to understand the needs of health professionals in providing health care via these modes. This study aimed to explore the perspectives of health professionals on providing nutrition care to upper gastrointestinal cancer patients by electronic methods to allow the future scaling-up of acceptable delivery methods. Methods: Semi-structured qualitative interviews were conducted face-to-face or by telephone and recorded, de-identified and transcribed. Thematic analysis was facilitated by NVivo Pro 12. Results: Interviews were conducted on 13 health professionals from a range of disciplines across several public and private health institutions. Thematic analysis revealed three main themes: (1) the ideal model, (2) barriers to the ideal model and (3) how to implement and translate the ideal model. Health professionals viewed the provision of nutrition interventions as an essential part of an upper gastrointestinal cancer patient’s treatment with synchronous, telephone-based internal health service models of nutrition care overwhelmingly seen as the most acceptable model of delivery. Mobile application-based delivery methods were deemed too challenging for the current population serviced by these clinicians. Conclusion: The use of novel technology for delivering nutrition care to people receiving treatment for upper gastrointestinal cancers was not widely accepted as the preferred method of delivery by health professionals. There is an opportunity, given the rapid uptake of digital health care delivery, to ensure that the views and attitudes of health professionals are understood and applied to develop acceptable, efficacious and sustainable technologies in our health care systems.     

Nurses’ elicitation of patient error as a practice in training end‐stage renal patients in automated home peritoneal dialysis

As part of a reorganisation of the delivery of health care in Denmark therapies for chronic medical conditions are moved out of hospitals and disease‐specific patient education programmes instituted to train patients to assume responsibility for treating their disease at home, that is, perform tasks and functions traditionally done by healthcare professionals. Drawing on video‐recordings (90:25h) from a programme for self‐management of end‐stage renal disease through automated home peritoneal dialysis, the study employs conversation analysis to examine nurses’ instructional practices for providing patients with the necessary knowledge, skill and competences. Showing training to rely on an error‐based monitoring strategy, the study demonstrates that rather than solely waiting for random errors to emerge, nurses on occasion steer patients towards specific errors to bring about particular instructional opportunities. Surprising given the seriousness of the therapy, this elicitation of error is shown to reflect a deliberate instructional choice; nurses promote select errors to impart patients with an understanding of the procedural logic behind the therapy and medical technology. The study argues that training patients for chronic disease self‐management and providing them with a proficiency level, normally associated with certified professionals, necessitates pushing patients beyond what is strictly accurate and exposing them to medically delicate events.     

Role of Family Physicians in Implementing Asthma Self-Management Programs

The reality of everyday asthma care differs substantially from guidelines. The fact that better possibilities for asthma care do not result in better outcomes remains an enigma and harms professional pride. Patient self-management has been presented as a tool to improve outcome of care. Based on published work thus far, it can be concluded that self-management of asthma can be beneficial from both the family physicians’ and the patients’ perspective and, under certain conditions, proves to be an efficient method of incorporating both interests. Health professionals play an important role in implementing self-care, but several barriers should be solved first: attitudes of health professionals and patients need to shift towards shared responsibilities and be patient-centered and organization of care should change accordingly. As reviewed in this article, the typical features of self-management of asthma may provide the means to overcome these barriers.     

Patients' and professionals' experiences and perspectives of obesity in health‐care settings: a synthesis of current research

Background Obesity‐related stigma likely influences how obese people interact with health‐care professionals and access health care. Aim To undertake a synthesis of studies examining the views and experiences of both obese people in relation to their health‐care provision and health‐care professionals in providing care to obese patients. Search strategy A systematic search of key electronic databases relating to professional or patient experiences of, or perspectives on, obesity was performed in 2008 and updated in 2010. Reference lists of article bibliographies were searched, along with hand searches of relevant journals. Inclusion Criteria Studies were screened against explicit inclusion criteria and published between 1990 and 2010. Findings were examined and organized thematically. Data Extraction Data were extracted focusing on obesity, stigma and access to health‐care services. All included studies were subject to critical appraisal to assess the quality of the research. Findings Thirty studies were identified. All the studies reported obesity impacting on health‐care interactions. Key themes identified were experiences of stigma and feelings of powerlessness, treatment avoidance, psycho‐emotional functioning, professional attitudes, confidence and training, variations in health contact time and finally, differences in treatment options and preventative measures. Conclusion Obesity is a stigmatized condition that impacts negatively on the relationship between patients and health‐care providers. Given the increasing prevalence of obesity and the range of therapeutic options available, further work is necessary to understand how the presence of obesity affects health‐care interactions and decision making.     

Stories of change in drug treatment: a narrative analysis of ‘whats’ and ‘hows’ in institutional storytelling

Addiction research has demonstrated how recovering individuals need narratives that make sense of past drug use and enable constructions of future, non‐addict identities. However, there has not been much investigation into how these recovery narratives actually develop moment‐to‐moment in drug treatment. Building on the sociology of storytelling and ethnographic fieldwork conducted at two drug treatment institutions for young people in Denmark, this article argues that studying stories in the context of their telling brings forth novel insights. Through a narrative analysis of both ‘the whats’ (story content) and ‘the hows’ (storying process) the article presents four findings: (1) stories of change function locally as an institutional requirement; (2) professional drug treatment providers edit young people's storytelling through different techniques; (3) the narrative environment of the drug treatment institution shapes how particular stories make sense of the past, present and future; and (4) storytelling in drug treatment is an interactive achievement. A fine‐grained analysis illuminates in particular how some stories on gender and drug use are silenced, while others are encouraged. The demonstration of how local narrative environments shape stories contributes to the general understanding of interactive storytelling in encounters between professionals and clients in treatment settings.     

Factors for Effective Identification of Patients at Nutritional Risk in Clinical Practice: Thematic Analysis of Qualitative Research

IntroductionDespite the high prevalence of malnutrition in patients at all levels of healthcare, early prevention and treatment of malnourished patients are often neglected and overlooked in clinical practice. The aim of this systematic literature review was to identify the factors considered most important by healthcare professionals in the identification and treatment of malnourished patients or those at risk of malnutrition.MethodsA systematic literature review of qualitative research was conducted. Documents published in scientific journals in English from 2011 to 2021 were searched in the PubMed (MEDLINE), CINAHL and ProQuest databases. The results were analysed with a thematic analysis of qualitative research findings.ResultsFrom the search set of 1010 results, 7 sources were included in the final analysis. Factors identified by health professionals as important in the identification and treatment of malnourished patients in clinical practice were grouped into five themes: unclear organizational structure; indefinite structure of nutritional care; poor continuity of nutritional care; lack of knowledge and skills of health professionals; lack of time and human resources.ConclusionsHealth policy must provide resources for nutritional care for patients at all levels of health care on the initiative of the highest professional bodies at the state level. To improve the nutritional care of patients in clinical practice, the management of health care institutions must promote and enable the professional and organizational establishment of clinical nutrition as a regular medical activity of the institution, develop clinical nutritional pathways, and promote evidence-based clinical practice and interprofessional collaboration.     

L’éducation thérapeutique pour les patients souffrant de troubles psychiatriques en France : psychoéducation ou éducation thérapeutique du patient ?

Context

Psychoeducation and therapeutic patient education can be effectively included in treatments for patients with psychiatric disorders. These two effective educational therapies have the common purpose of improving disorder-related morbidity, compliance with treatment and patients’ quality of life. While they have different methods of application, both teach patients to play an active role in their own care. However, it is still critical to combine them for care of patients with psychiatric and addiction disorders in a manner that allows for specificity. To do this, the differences between psychoeducation and therapeutic patient education must be considered, and their potential for the management of patients with psychiatric and addiction disorders must be determined.

‘Makes you wanna do treatment’: Benefits of a hepatitis C specialist clinic to clients in Christchurch,New Zealand

People with hepatitis C virus (HCV) are a marginalised population that may experience discrimination in everyday contexts, including health‐care, due to the association of HCV with injecting drug use. Stigma and discrimination are known to have a range of negative effects on people with HCV, including diminished quality of life and avoidance of health‐care. The Hepatitis C Community Clinic is an integrated care service established in 2008 in Christchurch, New Zealand to provide alternative access to health‐care that is non‐judgemental and supportive. As an integrated care service, the clinic aims to improve health outcomes and quality of life through a holistic approach to health‐care for people with HCV and people who inject drugs. This qualitative study forms part of a broader mixed‐methods evaluation of the clinic, and aims to assess the role of the clinic in improving health outcomes, knowledge, lifestyle practices and psychosocial functioning of the target population. Interviews were conducted with 24 health professionals and 24 clients of the clinic between April and November 2010. Findings illustrate that the clinic is a novel model of care that is effective in accessing a hard‐to‐reach and marginalised population in part due to the non‐judgemental, caring and supportive environment that engenders trust with clients. Based on participant reports, the clinic assists clients in managing their HCV and other health concerns and in increasing their readiness for HCV treatment. Given the benefits of this community clinic to clients, it is proposed that future research investigate the feasibility and benefits of administering HCV treatment through community‐based integrated care networks.     

Bioethical differences between drug addiction treatment professionals inside and outside the Russian Federation

This article provides an overview of a sociological study of the views of 338 drug addiction treatment professionals. A comparison is drawn between the bioethical approaches of Russian and foreign experts from 18 countries. It is concluded that the bioethical priorities of Russian and foreign experts differ significantly. Differences involve attitudes toward confidentiality, informed consent, compulsory treatment, opioid agonist therapy, mandatory testing of students for psychoactive substances, the prevention of mental patients from having children, harm reduction programs (needle and syringe exchange), euthanasia, and abortion. It is proposed that the cardinal dissimilarity between models for providing drug treatment in the Russian Federation versus the majority of the countries of the world stems from differing bioethical attitudes among drug addiction treatment experts.     

Mental health professionals’ views of the parents of patients with psychotic disorders: a participant observation study

As a consequence of the deinstitutionalisation of mental health services, family members have become an important part of the care system. However, little is known about mental health professionals’ perceptions of these family members. The aim of this study was to explore professionals’ views of one particular group, the parents of patients with psychotic disorders. Because sensitive issues such as professionals’ perceptions of parents can be difficult to capture via interviews or self‐report instruments, we conducted participant observation of 20 multi‐professional team meetings. The observations were carried out during 2011 at a psychiatric care unit specialised in working with patients with psychosis. Approximately 10 inpatients and outpatients were discussed in each team meeting. All conversations about the patients’ parents were documented with field notes that were later analysed using inductive thematic analysis. Through the analysis, a complex and multi‐faceted image emerged of parents as seen by mental health professionals. Some parents were described as a helpful resource, but others were thought to hinder treatment. Conflicts between staff members and parents were commonly due to their differing views on the treatment, particularly the medical treatment, of the patient. Other parents were described as causing the patient emotional pain and some parents were perceived as neglectful or abusive. These findings highlight the crucial role mental health professionals play in identifying families’ particular needs and capacities to provide interventions that effectively address each specific situation. Professionals should also recognise families with adverse experiences and help parents fulfil their potential to become resources for their children with psychosis.     

The uses of ultrasonography in relation to foetal malformations in Rio de Janeiro,Brazil

The world-wide diffusion of prenatal ultrasound has encountered local historical, cultural and political particularities. The purpose of this article is to study the varied uses of this technology in cases of detection of a foetal anomaly, in Rio de Janeiro, in a context of generalized access to ultrasound, restrictive legislation on abortion and major social inequalities. An ethnographic approach was chosen combining from 2009 to 2011, observations of prenatal consultations and interviews with specialist physicians and pregnant women, in both public and private sector institutions. Analysis of the data allowed us to identify three ideal-typical moments in the trajectory of the pregnant women when a foetal malformation was detected. The first moment occurs before the detection of the anomaly, when an initial ultrasound is carried out, essentially in private centres. The standardized actions of pregnancy monitoring are performed in the background while practitioners use the technology to support the local culture of praise to motherhood and the family. The second ideal-typical moment shows how detection of an anomaly leads to fragmentation of the foetus at the public referral centre for foetal malformations. But far from depersonalizing the consultation, the formalism of the diagnostic procedure is considered by some professionals as a political lever to empower women from poor neighbourhoods as they acquire knowledge and comprehension of the situation despite their lack of decisional autonomy. During the third ideal-typical moment, professionals put the data produced by the image into the larger perspective of the logic of care: the focus is no longer on access to knowledge and autonomy, but on the joint collaboration of women and professionals towards solving the problems of everyday life. The combination of these three moments in time illustrates a process whereby the malformed foetus is humanised, dehumanised and re-humanised with respect to the technological tool.