What about the children? Adult mental health practitioners' experiences and views of family-focused practice in Early Intervention Services

Background

There is a significant risk of negative outcomes for families when a parent experiences serious mental illness. Family-focused practice (FFP) emphasises the “whole family” as the unit of care and has been found to improve outcomes for service users and their families. Despite its benefits, FFP is not routinely implemented in UK adult mental health services. This study explores adult mental health practitioners' experiences and views of FFP within Early Intervention Psychosis Services in the UK.

Methods

Sixteen adult mental health practitioners employed in three Early Intervention Psychosis teams in the Northwest of England were interviewed. Interview data were analysed using thematic analysis.

Results

Five core themes were generated: (1) A limited understanding of FFP, (2) Our practitioners, (3) Our approach, (4) Our families and (5) Our services. Practitioners' understanding of FFP was limited and typically excluded dependent children. Practitioners' age, professional and personal experience, and preconceptions of families influenced delivery, and in turn, the engagement approach they adopted impacted families' responsiveness. The diversity and dynamics of service user families such as age, socioeconomic status, culture and stigma impacted FFP. An operational context characterised by insufficient resources reduced FFP; however, organisational structures such as leadership, clinical supervision and multi-disciplinary teams facilitated FFP.

Conclusions

FFP is not yet embedded within Early Intervention Services. Practice recommendations include agreeing on a formal definition of FFP and its scope; the development of FFP policy; clarity in relation to staff responsibilities and identities; the adoption of a collaborative approach which encourages service user choice and for time to be ring-fenced to prioritise FFP. Future research should ascertain service user and family views on the facilitators and barriers to engaging with FFP in Early Intervention Services.     

Introduction to the article collection ‘Translation in healthcare: ethical,legal, and social implications’

New technologies are transforming and reconfiguring the boundaries between patients, research participants and consumers, between research and clinical practice, and between public and private domains. From personalised medicine to big data and social media, these platforms facilitate new kinds of interactions, challenge longstanding understandings of privacy and consent, and raise fundamental questions about how the translational patient pathway should be organised.This editorial introduces the cross-journal article collection "Translation in healthcare: ethical, legal, and social implications", briefly outlining the genesis of the collection in the 2015 Translation in healthcare conference in Oxford, UK and providing an introduction to the contemporary ethical challenges of translational research in biology and medicine accompanied by a summary of the papers included in this collection.     

Physicians,emotion, and the clinical encounter: A survey of physicians’ experiences

ObjectivesTraining in emotion management is not a standard part of medical education. This study’s objective was to understand physicians’ challenges navigating emotion (their own and their patients’) and identify areas for intervention to support physician wellness and enhance patient care.MethodsIn 2019, we surveyed 103 physicians in emergency medicine, internal medicine, family medicine, and neurology. Participants quantitatively reported emotion training, emotions that were challenging, and barriers to addressing emotion. They provided qualitative examples of emotion challenges and successes that we analyzed using an inductive thematic analysis.ResultsThere were no significant differences in responses by specialty. Only 10% reported receiving emotion management training, with no evidence that more recently trained physicians received more. Those who had received training on emotion reported greater comfort in dealing with patients’ emotions and were more likely to engage in teaching on emotion. There were gender and career stage differences regarding which emotions physicians found most challenging. The authors identified central themes of emotion-related challenges and successes.ConclusionsTargeted educational initiatives are needed to advance physicians’ ability to navigate emotion in clinical encounters.Practice implicationsDeveloping strategies for managing patients’ emotions may better prepare physicians for navigating the emotional demands of practicing medicine.     

Do changes in mood and concerns about weight relate to smoking relapse in the postpartum period?

Summary The majority of women who quit smoking during pregnancy will resume smoking during the postpartum period. Little is known, however, about the predictors of postpartum relapses to smoking. Changes in mood and increases in concerns about weight are common during the postpartum period, and these factors may affect womens postpartum smoking behavior. In this paper, we present a model of the relationship among mood, weight concerns and postpartum smoking. Data from previous postpartum relapse prevention trials are reviewed and evidence of a connection between changes in mood and weight concerns to postpartum relapse is presented. Directions for future research on the prevention of smoking relapses during the postpartum period, and the roles of mood and weight concerns in smoking relapse are presented.     

Women's and residents’ experiences of communication in the diagnostic mammography suite

ObjectiveTo gain understanding of radiology residents’ and women's experiences, concerns, information needs, coping strategies and perspectives about optimal communication during diagnostic mammography.MethodsQualitative analysis of focus groups of radiology residents and women who had undergone diagnostic mammograms.ResultsFive categories of themes emerged from our analysis: information needs, perspectives and ideals, emotional experiences and observations, working together, individual experiences, and others’ roles. Women preferred continuous orientation, clear explanations and emotional support by physicians and radiology technologists throughout diagnostic processes. Communication about diagnostic mammogram results evoked the threat of breast cancer and was experienced as “bad news” by women, but not necessarily by all radiology residents. Lack of collaboration among radiologists, technologists and other healthcare professionals engendered confusion and anxiety in patients. Radiology residents felt inadequately prepared to meet the communication challenges of providing information and emotional support tailored to women's needs in this context.ConclusionWomen's experiences are influenced by the extent to which they receive clear information and support, and perceive collaboration among professionals involved in the diagnostic mammography process.Practice implicationsRadiology education must address communication with patients and among healthcare professionals involved in the care of patients undergoing diagnostic procedures and interventions.     

What doubts,concerns and fears about COVID-19 emerged during the first wave of the pandemic?

ObjectivesThe control of the COVID-19 pandemic depends strongly on effective communication, which must be grounded on the population’s perceptions and knowledge. We aimed to analyse the doubts, concerns and fears expressed by the Portuguese population about COVID-19.MethodsWe performed a content analysis of 293 questions submitted to online, radio, newspaper and TV channel forums during the first month of the pandemic in Portugal.ResultsMost questions contained doubts (n = 230), especially on how to prevent person-to-person transmission (n = 40) and how to proceed in case of symptoms (n = 37). Concerns and fears were also very commonly expressed (n = 144), mostly about which persons could be considered vulnerable (n = 53) and how to prevent transmission during daily life or normal activities (n = 37).ConclusionAs the pandemic evolved and suppression measures were put in place, doubts moved to concerns of vulnerability, quarantine and social isolation, and to doubts about transmission, transmission prevention, and on how to proceed in case of symptoms.Practice implicationsThese results may inform future communication strategies for a more adequate response in the next phases of the COVID-19 pandemic, as well as in future pandemics.     

Physicians’ views and experiences of discussing weight management within routine clinical consultations: A thematic synthesis

ObjectiveTo systematically search and synthesise qualitative studies of physicians’ views and experiences of discussing weight management within a routine consultation.MethodsA systematic search of four electronic databases identified 11,169 articles of which 16 studies met inclusion criteria. Quality was appraised using the Critical Appraisal Skills Programme tool and a thematic synthesis conducted of extracted data.ResultsFour analytical themes were found: (1) physicians’ pessimism about patients’ weight loss success (2) physicians’ feel hopeless and frustrated (3) the dual nature of the physician-patient relationship (4) who should take responsibility for weight management.ConclusionDespite clinical recommendations barriers remain during consultations between physicians and patients about weight management. Many of these barriers are potentially modifiable.Practice implicationsImproving training, providing clearer guidelines and placing a greater emphasis on collaboration within and between clinicians will help reduce barriers for both physicians and patients. In particular, there is an urgent need for more specialised training for physicians about weight management to promote knowledge and skills in behaviour change techniques and ways to broach sensitive topics without damaging patient relationships.     

Silenced: Patients’ experiences of voicelessness in head and neck cancer

ObjectivesThe objective of this qualitative study was to explore patients’ experiences of communicating with health professionals following a diagnosis of head and neck cancer (HNC).MethodsA qualitative research approach based on social constructionist theory was used. A total of 21 in-depth semi-structured interviews were conducted with people diagnosed with HNC. Thematic analysis was used to identify themes.ResultsThe experience of losing the capacity for speech was experienced by survivors of HNC as distressing and traumatic. Voicelessness was not just a loss of physical speech, but a holistic experience of silencing. A number of tensions emerged including patients’ experiences of losing their voice and then finding different ways to verbally express themselves; in interactions with health professionals there was a tension between abrupt, hurried communication and a slower, more mindful communication style. Sub-themes around communication style emerged where disparities between levels of health literacy were unaddressed, and patients’ experienced a lack of empathy. Another tension experienced was between an old style medical model and the ideal of person-centred care and the biopsychosocial model of health.ConclusionWhether HNC patients lose their voice temporarily, have periods of voicelessness, or are able to speak, but feel unheard, the treatment experience is too often one of disempowerment and silencing of their perspectives.Practice ImplicationsHealth professionals are challenged to find creative communication methods, to practice mindful listening, source speech pathology and adaptive technologies, and to facilitate communication that supports patients in expressing their values, preferences and needs.     

Promoting patients' rights at the end of life in a geriatric setting in France: The healthcare professionals’ level of knowledge about surrogate decision-makers and advance directives

ObjectiveTo assess levels of knowledge about patients’ rights, surrogate decision-makers, and advance directives among healthcare professionals at three hospitals in France.MethodsA multicenter, cross-sectional study in three geriatric hospitals in the Paris area (France) in 2015. The participants’ level of knowledge was assessed via an 18-item self-questionnaire on surrogate decision-makers, advance directives, and end-of-life decision-making. The characteristics associated with a good level of knowledge were assessed using logistic regression.ResultsAmong the 301 healthcare professionals (median ± standard deviation age: 40.4 ± 10.2 years; women: 73.4 %), only 15.0 % (95 % confidence interval (CI): [19.7–29.5]) correctly answered at least 75 % of the questions on patients’ rights. Respectively 24.6 % [19.7–29.5], 36.5 % [31.1–42.0] and 37.5 % [32.0–43.0] had sufficient knowledge regarding “surrogate decision-maker”, “advance directives”, and “decision-making at the end of life”. In a multivariable analysis, the only factor significantly associated with a good level of knowledge about end-of-life policy was employment in a university hospital, with a non-significant trend for status as a physician.ConclusionsOur survey of staff working in geriatric care units highlighted the poor overall level of knowledge about healthcare surrogates and advance directives; the results suggest that additional training in these concepts is required.Practice implicationsContinuing education of healthcare professionals on advance directives and surrogate decision-maker should be promoted to ensure rights of elderly patients at the end of life.     

Doctors’ views about training and future careers expressed one year after graduation by UK-trained doctors: questionnaire surveys undertaken in 2009 and 2010

Background

The UK medical graduates of 2008 and 2009 were among the first to experience a fully implemented, new, UK training programme, called the Foundation Training Programme, for junior doctors. We report doctors’ views of the first Foundation year, based on comments made as part of a questionnaire survey covering career choices, plans, and experiences.

Methods

Postal and email based questionnaires about career intentions, destinations and views were sent in 2009 and 2010 to all UK medical graduates of 2008 and 2009. This paper is a qualitative study of ‘free-text’ comments made by first-year doctors when invited to comment, if they wished, on any aspect of their work, education, training, and future.

Results

The response rate to the surveys was 48% (6220/12952); and 1616 doctors volunteered comments. Of these, 61% wrote about their first year of training, 35% about the working conditions they had experienced, 33% about how well their medical school had prepared them for work, 29% about their future career, 25% about support from peers and colleagues, 22% about working in medicine, and 15% about lifestyle issues. When concerns were expressed, they were commonly about the balance between service provision, administrative work, and training and education, with the latter often suffering when it conflicted with the needs of medical service provision. They also wrote that the quality of a training post often depended on the commitment of an individual senior doctor. Service support from seniors was variable and some respondents complained of a lack of team work and team ethic. Excessive hours and the lack of time for reflection and career planning before choices about the future had to be made were also mentioned. Some doctors wrote that their views were not sought by their hospital and that NHS management structures did not lend themselves to efficiency. UK graduates from non-UK homes felt insecure about their future career prospects in the UK. There were positive comments about opportunities to train flexibly.

Conclusions

Although reported problems should be considered in the wider context, in which the majority held favourable overall views, many who commented had been disappointed by aspects of their first year of work. We hope that the concerns raised by our respondents will prompt trainers, locally, to determine, by interaction with junior staff, whether or not these are concerns in their own training programme.

     

“When I feel safe,I dare to open up”: immigrant and refugee patients’ experiences with coproducing healthcare

ObjectiveInterest in the coproduction concept in healthcare is increasing. According to coproduction, services are, unlike goods, always coproduced by a user and a service provider. This study explored how immigrants and refugees perceive the coproduction of their healthcare service in clinical encounters.MethodsWe conducted semi-structured interviews with thirteen patients with varied backgrounds and health problems. Participants were purposefully recruited in an interdisciplinary clinic for immigrants and refugees at a Danish University Hospital. Interviews were transcribed, anonymized, and analyzed using meaning condensation.ResultsPatients emphasized the importance of a safe space where they could be themselves and feel supported. This encouraged them to be open and assume an active role in the coproduction of their health. A stable therapeutic alliance based on kindness and kinship helped them find strength and take responsibility for their own health.ConclusionsThis study improves our understanding of how immigrants and refugees experience the coproduction of healthcare services. Further studies, evaluating long-term outcomes of coproduction efforts, are required.Practice implicationsProviding a safe space in which health professionals have time to listen and empathically validate immigrant and refugee patients’ lived realities, can enable patients to open up and become agents of their own health.     

Oncologists’ and cancer patients’ views on whole-exome sequencing and incidental findings: results from the CanSeq study

PurposeAlthough targeted sequencing improves outcomes for many cancer patients, it remains uncertain how somatic and germ-line whole-exome sequencing (WES) will integrate into care.MethodsWe conducted surveys and interviews within a study of WES integration at an academic center to determine oncologists’ attitudes about WES and to identify lung and colorectal cancer patients’ preferences for learning WES findings.ResultsOne-hundred sixty-seven patients (85% white, 58% female, mean age 60) and 27 oncologists (22% female) participated. Although oncologists had extensive experience ordering somatic tests (median 100/year), they had little experience ordering germ-line tests. Oncologists intended to disclose most WES results to patients but anticipated numerous challenges in using WES. Patients had moderately low levels of genetic knowledge (mean 4 correct out of 7). Most patients chose to learn results that could help select a clinical trial, pharmacogenetic and positive prognostic results, and results suggesting inherited predisposition to cancer and treatable noncancer conditions (all ≥95%). Fewer chose to receive negative prognostic results (84%) and results suggesting predisposition to untreatable noncancer conditions (85%).ConclusionThe majority of patients want most cancer-related and incidental WES results. Patients’ low levels of genetic knowledge and oncologists’ inexperience with large-scale sequencing present challenges to implementing paired WES in practice.Genet Med18 10, 1011–1019.