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PubMed1991

[Incoherence as an interaction phenomenon. Results of a single case study].

Traditionally psychiatric patients' change of topic occurring in interviews e.g. with a doctor are construed as a psychopathologically relevant type of incoherence (formal thought-disorder). In a single case study it can be shown, however, that more than half of the patient's changes of topic occur after a specific class of interactionally meaningful paraverbal features. These may be interpreted as signals of the patient's being ready to relinquish the speaker's role. Therefore, rather than interpreting this type of change of topic as thought-disordered incoherence it should be considered as a consequence of the patient's unsuccessful trying to take over the listener's role. In contrast to interactively unmarked (thought-disordered) changes of topic the occurrence of this phenomenon may be determined by the asymmetric doctor-patient relationship.

Attention↗
PubMed2005

The interpretation and application of the three Rs by animal ethics committee members.

The Three Rs form the basis of review of animal-use protocols by Animal Ethics Committees (AECs), but little research has examined how AECs actually interpret and implement the Three Rs. This topic was explored through in-depth, open-ended interviews with 28 members of AECs at four Canadian universities. In describing protocol review, AEC members rarely mentioned the Three Rs, but most reported applying some aspects of the basic concepts. Comments identified several factors that could impede full application of the Three Rs: incomplete understanding of the Three Rs (especially Refinement), trust that researchers implement Replacement and Reduction themselves, belief by some members that granting agency review covers the Three Rs, focus on sample size rather than experimental design to achieve Reduction, focus on harm caused by procedures to the exclusion of housing and husbandry, and lack of consensus on key issues, notably on the nature and moral significance of animal pain and suffering, and on whether AECs should minimise overall harm to animals. The study suggests ways to achieve more consistent application of the Three Rs, by providing AECs with up-to-date information on the Three Rs and with access to statistical expertise, by consensus-building on divisive issues, and by training on the scope and implementation of the Three Rs.

Animal Experimentation↗
PubMed2001

Turning tapes into text: issues surrounding the transcription of interviews.

Transcription of interview data is a common practice in qualitative health research. However, there has been little discussion of the techniques of transcription and the issues inherent in the use of transcription as a strategy for managing qualitative data in nursing publications. The process of transcription may disclose or obscure certain information. Researchers need to question practices of transcription that have been taken for granted and make transparent the processes used to preserve the integrity of data. This paperfirst examines research reported in nursing and allied health journals employing interviews for data collection and the attention given to the transcription phase. It then deals with issues of concern regarding the transcription of interviews, and offers suggestions for promoting validity.

Ethics↗
PubMed1998

Psychophysiological effects of interviews about emotional events on offspring of hypertensives and normotensives.

Normotensive individuals with a parental history of hypertension have been found to exhibit greater cardiovascular reactivity to a variety of laboratory stressors than offspring of normotensives. To examine the possible generalization of these differences to real-life stressors, subjects were administered four brief interviews about different emotional events in their lives. Regardless of emotional content, offspring of hypertensives displayed greater systolic blood pressure responses to the non-verbal recollection and verbal description of personal emotional events, but not to the imagination of standardized emotional scenes or reading a non-emotional advertisement. This suggests that group differences in reactivity may generalize to real-world situations. Evidence of significantly greater vasoconstriction during interviews about sad topics was also observed, contributing to the literature on the physiological differentiation of emotional states.

Adolescent↗
PubMed1998

The effectiveness of intensive training for residents in interviewing. A randomized, controlled study.

BACKGROUND: Interviewing and the physician-patient relationship are crucial elements of medical care, but residencies provide little formal instruction in these areas. OBJECTIVE: To determine the effects of a training program in interviewing on 1) residents' attitudes toward and skills in interviewing and 2) patients' physical and psychosocial well-being and satisfaction with care. DESIGN: Randomized, controlled study. SETTING: Two university-based primary care residencies. PARTICIPANTS: 63 primary care residents in postgraduate year 1. INTERVENTION: A 1-month, full-time rotation in interviewing and related psychosocial topics. MEASUREMENTS: Residents and their patients were assessed before and after the 1-month rotation. Questionnaires were used to assess residents' commitment to interviewing and psychosocial medicine, estimate of the importance of such care, and confidence in their ability to provide such care. Knowledge of interviewing and psychosocial medicine was assessed with a multiple-choice test. Audiotaped interviews with real patients and videotaped interviews with simulated patients were rated for specific interviewing behaviors. Patients' anxiety, depression, and social dysfunction; role limitations; somatic symptom status; and levels of satisfaction with medical visits were assessed by questionnaires and telephone interviews. RESULTS: Trained residents were superior to untrained residents in knowledge (difference in adjusted post-test mean scores, 15.7% [95% CI, 11% to 20%]); attitudes, such as confidence in psychological sensitivity (difference, 0.61 points on a 7-point scale [CI, 0.32 to 0.91 points]); somatization management (difference, 0.99 points [CI, 0.64 to 1.35 points]); interviewing of real patients (difference, 1.39 points on an 11-point scale [CI, 0.32 to 2.45 points]); and interviewing (data gathering) of simulated patients (difference, 2.67 points [CI, 1.77 to 3.56 points]). Mean differences between the study groups were consistently in the appropriate direction for patient satisfaction and patient well-being, but effect sizes were too small to be considered meaningful. CONCLUSION: An intensive 1-month training rotation in interviewing improved residents' knowledge about, attitudes toward, and skills in interviewing.

Attitude of Health Personnel↗
PubMed2006

Beyond needling--therapeutic processes in acupuncture care: a qualitative study nested within a low-back pain trial.

BACKGROUND: In the medical and scientific literature, there is a dearth of reports about how acupuncturists work and deliver care in practice. An informed characterization of the treatment process is needed to support the appropriate design of evaluative studies in acupuncture. METHODS: The design was that of a nested qualitative study within a pragmatic clinical trial. Six acupuncturists who treated up to 25 patients each were interviewed after the treatment phase of the trial to obtain an account of their experiences of providing acupuncture care to patients with low back pain referred by their GP. Using semistructured interviews and a topic guide, data were collected and analyzed for both a priori and emergent themes. This paper focuses on practitioners' accounts of the goals and processes of care, and describes the strategies employed in addition to needling and other hands-on treatments. RESULTS: From the interview data, it is clear that a coherent body of theoretical knowledge informed clinical decisions and practice, and that the goals of treatment went beyond the alleviation of immediate pain-related symptoms. Acupuncturists in this study all described a pattern of patient-centered care based on a therapeutic partnership. Study participants confirmed the importance of three processes that characterized acupuncture care in this trial, each contributing to the goal of a positive long-term outcome; building a therapeutic relationship; individualizing care; and facilitating the active engagement of patients in their own recovery. Acupuncturists described elements of care that characterized these processes including establishing rapport, facilitating communication throughout the period of care, using an interactive diagnostic process, matching treatment to the individual patient, and the use of explanatory models from Chinese medicine to aid the development of a shared understanding of the patient's condition and to motivate lifestyle changes that reinforce the potential for a recovery of health. Acupuncturists did not view these therapeutic goals, processes, and strategies as a departure from their usual practice. CONCLUSIONS: This study suggests that acupuncture care for patients with chronic conditions such as low back pain is likely to be a complex intervention that utilizes a number of patient-centered strategies to elicit longterm therapeutic benefits. Research designed to evaluate the effectiveness of acupuncture as it is practiced in the UK needs to accommodate the full range of therapeutic goals and related treatment processes.

Acupuncture↗
PubMed2004

Implementing and using quality measures for children's health care: perspectives on the state of the practice.

OBJECTIVE: The objective of this study was to identify issues, obstacles, and priorities related to implementing and using child health care quality measures from the perspectives of 4 groups: 1) funders of quality-measurement development and implementation; 2) developers of quality measures; 3) users of quality measures (including Medicaid and the State Children's Health Insurance Program, employer coalitions, and consumer groups); and 4) health plans and providers (in their role as both subjects and users of quality measures). METHODS: A series of semistructured interviews was conducted with approximately 40 opinion leaders drawn from these 4 groups. The interviews were conducted by telephone between September and December of 2001. Major topic areas covered in the interviews were similar across the groups. Topic areas included 1) strategic vision and/or objectives for funding, developing, or using quality measures for children's health care; 2) a brief summary of the specific quality measures funded, developed, or used; 3) issues and challenges facing funders and developers of measures; 4) major successes achieved; 5) obstacles to implementation and use of measures; and 6) priority needs for future funding. RESULTS: Leaders from all 4 groups acknowledge the importance of developing a robust set of quality measures that can serve multiple objectives and multiple audiences. Standardization of measures is viewed as a critical feature related to all objectives. An assessment of specific quality measures funded, developed, or used by strategic objective shows a high correlation between the uses intended by funders and developers and the actual applications of the various users. The most commonly cited measures across all groups are the Consumer Assessment of Health Plans Survey and Health Plan Employer Data and Information Set, followed by the Child and Adolescent Health Measurement Initiative and special topic studies to support quality-improvement applications (eg, asthma, diabetes, etc). The major issues and challenges cited in common among funders and developers are 1) the lack of trained capacity in the field to conduct needed research and development, and 2) the difficulty in generating sustained interest and support among funders because of the complexity of quality-measurement issues, competing funding priorities in the face of limited funds available to allocate, and the lack of clear and compelling evidence that quality measurement and improvement actually result in better outcomes for children. The 3 most common successes cited across all 4 groups are 1) the growing consensus and collaboration among diverse stakeholder groups involved in measurement development and implementation; 2) the increasing collection and use of specific measures; and 3) early documentation of tangible results in terms of improved quality of care. Specific measurement tools cited as successes by funders and developers include the Medicaid Health Plan Employer Data and Information Set, Consumer Assessment of Health Plans Survey, the Child and Adolescent Health Measurement Initiative, and Rand QA Tools. The most important obstacle reported across all groups is the lack of a strong and compelling "business case" that clearly demonstrates the benefits of quality measurement relative to the costs of implementation. Strongly related to this barrier is the cost of implementing and using measures without a sustainable source of financing as well as the absence of strong public awareness and political support for children's health care quality measurement. Another major barrier cited is the lack of coordination among funders, which prevents the field from developing a unified approach to addressing the numerous technical, political, and administrative issues also cited at length by the leaders interviewed. The 5 top needs for future funding identified across all 4 groups follow directly from the major obstacles that they reported: 1) develop the business case for children's health care quality measurement and improvement based on rigorous cost-bigorous cost-benefit analysis and documentation of quantifiable successes; 2) develop new measures to fill the gaps in critical areas (including adolescent health care, behavioral health, and chronic conditions) that can be applied at the hospital and ambulatory care provider levels; 3) invest in building needed research capacity, a trained pool of users of quality measures, and the capacity among providers to understand and use quality-improvement methods and tools; 4) invest in developing an information infrastructure that will support the efficient collection and use of measures for multiple purposes, including clinical practice, quality measurement, and quality improvement; and 5) develop increased public awareness and support for quality measurement based on improved strategies for communicating with consumers, purchasers, providers, and policy makers. CONCLUSIONS: Several implications are suggested by these perspectives for the future direction of quality measurement in children's health care. First, to meet the funding needs identified, many funders must improve coordination to reduce the noise and fragmentation generated by numerous competing or redundant activities. Improved coordination among funders will help assure maximum impact and the efficient use of scarce resources. Second, the importance attached to standardization of measures by both users and developers may conflict at times with the need for innovation and flexibility. Child health quality leaders will need to manage this tension between standardization and innovation to maintain an appropriate balance between the benefits of both. Finally, many of the obstacles identified are not unique to children's health care. Child health quality leaders will need to determine to what extent their efforts to overcome these obstacles can be successfully undertaken independently as opposed to in concert with groups concerned about other populations and sectors in the health care system.

Child↗
PubMed2006

Women's experiences of three early miscarriage management options: a qualitative study.

BACKGROUND: Miscarriage affects around one in six pregnancies. Much research has taken place identifying the consequences of this for parents but is mainly quantitative. Of the limited qualitative studies, none have explored women's experiences of the methods of miscarriage management received. AIM: To assess the social and personal impact of different management methods (expectant, medical and surgical) on women's experience of first trimester miscarriage. DESIGN OF STUDY: Qualitative interviews using a topic guide with a purposive cohort of four categories of women (each management method plus non-participants) 6 months to 1 year after first trimester miscarriage. Focus groups with both research participants and health workers. SETTING: Women from three hospitals in the South West of England that participated in the Miscarriage Treatment (MIST) trial. METHOD: Seventy-two interviews were undertaken between September 1999 and June 2000. There were also five focus groups (47 participants) and two feedback sessions (8 participants) with written feedback from 12 women. Interviews lasted 0.5-2.5 hours generating over 2000 A4 pages of transcripts. The transcripts were analysed for common themes, using standard proformas, which were filled in by individual team members and then discussed by the whole research team. Iterative readings in the light of new emerging issues ensured that new themes could be identified throughout the analytical process. All transcripts were then encoded for the identified themes using NUDIST. RESULTS: Common themes emerged across all management options although some were specific to just one or two management options. The five major themes arising out of the data analysis were: intervention; experiences of care; finality; the 'baby'; and pain and bleeding. CONCLUSIONS: Women's experiences and beliefs vary widely and their preferences need to be considered in their early miscarriage management. The three methods have different benefits and problems from the women's point of view. Competence and caring from professionals are especially important.

Abortion, Spontaneous↗
PubMed1998

The ethics of narrative ethics: some teaching reflections.

Narrative is reemerging as a teaching tool. Narrative ethics is being seen as a rich endeavour both for clinical practice and academic teaching and research. Narrative helps put ethics into context. However, the use of narrative increasingly raises issues in teaching and research: for instance, how do we do justice to the people and narratives we utilise, and what does our practice reveal about our ethics? In this article examples are drawn from clinical practice, teaching and case notes to draw out some lessons to help further critical understanding.

Anecdotes as Topic↗
PubMed1990

Ethics and human values committee survey: (AMI Denver Hospitals: Saint Luke's, Presbyterian Denver, Presbyterian Aurora: Summer 1989). A study of physician attitudes and perceptions of a hospital ethics committee.

By studying physician perceptions of the Hospital Ethics Committee (HEC), the committee can determine (1) what areas the committee should concentrate on, and (2) how it is perceived by the physician community. The topics covered by the study included whether or not a HEC is needed in any hospital system, as well as the specific need within AMI Denver hospitals. In addition, the physician participants discussed what departments should be represented on the HEC and what topics it should study and discuss. By discussing the perceived effectiveness and the ideal function of HECs the physicians were able to provide the committee with many concrete suggestions to improve its effectiveness and visibility within the hospital community. Most of the advice is captured in one physician's words: "Be Visible and Credible."

Attitude of Health Personnel↗
PubMed2006

Addiction treatment agencies' use of data: a qualitative assessment.

Addiction treatment agencies typically do not prioritize data collection, management, and analysis, and these agencies may have barriers to integrating data in agency quality improvement. This article describes qualitative findings from an intervention designed to teach 23 addiction treatment agencies how to make data-driven decisions to improve client access to and retention in care. Agencies demonstrated success adopting process improvement and data-driven strategies to make improvements in care. Barriers to adding a process improvement and data-driven focus to care included a lack of a data-based decision making culture, lack of expertise and other resources, treatment system complexity, and resistance. Factors related to the successful adoption of process-focused data include agency leadership valuing data and providing resources, staff training on data collection and use, sharing of change results, and success in making data-driven decisions.

Behavior, Addictive↗
PubMed2005

Digging deep: using diary techniques to explore the place of health and well-being amongst older people.

To date, solicited diaries have been relatively neglected as a social science research method. This is particularly true within the field of health research. Yet, these narrative approaches can provide invaluable insights into the health behaviours of individuals and how these are played out across time and space. To illustrate this, we draw on recent research in the north west of England that investigated the potential benefits of communal gardening as opposed to other social activities in maintaining the health and emotional well-being of older people. As part of a wider study using largely qualitative techniques, our analysis revealed that, contrary to the findings of earlier studies, diaries can be used effectively over relatively long periods of time and are equally effective in exploring health issues amongst both older men and women. With the benefit of good researcher support, we argue that diary techniques can offer some unique insights into the ongoing health routines and coping strategies of older people and can prove invaluable in uncovering those, often hidden, aspects of their daily lives and routines that impact on their health histories. Through the gathering of chronologically organised data about daily activities, diaries can act as both a record and reflection of the health experiences, activities and life-worlds inhabited by older people.

Adaptation, Psychological↗