Using reflexivity to optimize teamwork in qualitative research

Parent-adolescent communication about sex in rural India: U.S.-India collaboration to prevent adolescent HIV

In this article, we examine parent-adolescent communication about sex among rural Indian youth and their parents. We conducted in-depth interviews (N = 40) with mothers, fathers, and adolescent boys and girls aged 14 to 18 years in a rural community in Maharashtra, India. In the context of key cultural factors, including gender-related norms, we explore issues of sexual health and critically assess widely held beliefs that Indian parents are unwilling or unable to discuss sex-related topics with their children. Our findings suggest that despite communication barriers, e.g., lack of knowledge and cultural proscriptions, Indian families are interested in and willing to communicate about sex-related topics. Future research should seek to determine the viability of family-based HIV prevention interventions for Indian adolescents.

The role of team leadership in Portuguese child protection teams

The majority of team leadership studies have ignored the specific context in which that leadership takes place and the cyclical correlation of inputs and processes on ongoing performance. It is our contention that leadership is a mediator of team processes and team effectiveness on ongoing functioning of multidisciplinary teams (MDT). The members of 126 multidisciplinary teams responded to a survey on several aspects related to the functioning and leadership of their teams. The results support the hypothesis that leadership does mediate the relationship between reflexivity and effectiveness (i.e. team management performance, boundary spanning and satisfaction) within the team. Theoretically, these findings challenge those of linear models that typically analyse the impact of leadership as something that happens in isolation. Future research should describe and consider not just the team type and tasks but also investigate the roles that context and time play in team leadership.

Life disruption, life continuation: contrasting themes in the lives of African-American elders with advanced heart failure

This study addresses the need for more information about how urban African-American elders experience advanced heart failure. Participants included 35 African Americans aged 60 and over with advanced heart failure, identified through records from a community hospital in Detroit, Michigan. Four focus groups (n = 13) and 22 individual interviews were conducted. We used thematic analysis to examine qualitative focus groups and interviews. Themes identified included life disruption, which encompassed the sub-themes of living scared, making sense of heart failure, and limiting activities. Resuming life was a contrasting theme involving culturally relevant coping strategies, and included the sub-themes of resiliency, spirituality, and self-care that helped patients regain and maintain a sense of self amid serious illness. Participants faced numerous challenges and invoked a variety of strategies to cope with their illness, and their stories of struggles, hardship, and resilience can serve as a model for others struggling with advanced illness.

Technology adoption and implementation in organisations: comparative case studies of 12 English NHS Trusts

OBJECTIVES

To understand organisational technology adoption (initiation, adoption decision, implementation) by looking at the different types of innovation knowledge used during this process.

DESIGN

Qualitative, multisite, comparative case study design.

SETTING

One primary care and 11 acute care organisations (trusts) across all health regions in England in the context of infection prevention and control. PARTICIPANTS AND DATA ANALYSIS: 121 semistructured individual and group interviews with 109 informants, involving clinical and non-clinical staff from all organisational levels and various professional groups. Documentary evidence and field notes were also used. 38 technology adoption processes were analysed using an integrated approach combining inductive and deductive reasoning.

MAIN FINDINGS

Those involved in the process variably accessed three types of innovation knowledge: 'awareness' (information that an innovation exists), 'principles' (information about an innovation's functioning principles) and 'how-to' (information required to use an innovation properly at individual and organisational levels). Centralised (national, government-led) and local sources were used to obtain this knowledge. Localised professional networks were preferred sources for all three types of knowledge. Professional backgrounds influenced an asymmetric attention to different types of innovation knowledge. When less attention was given to 'how-to' compared with 'principles' knowledge at the early stages of the process, this contributed to 12 cases of incomplete implementation or discontinuance after initial adoption.

CONCLUSIONS

Potential adopters and change agents often overlooked or undervalued 'how-to' knowledge. Balancing 'principles' and 'how-to' knowledge early in the innovation process enhanced successful technology adoption and implementation by considering efficacy as well as strategic, structural and cultural fit with the organisation's context. This learning is critical given the policy emphasis for health organisations to be innovation-ready.

Quality assurance of qualitative research: a review of the discourse

Background

Increasing demand for qualitative research within global health has emerged alongside increasing demand for demonstration of quality of research, in line with the evidence-based model of medicine. In quantitative health sciences research, in particular clinical trials, there exist clear and widely-recognised guidelines for conducting quality assurance of research. However, no comparable guidelines exist for qualitative research and although there are long-standing debates on what constitutes 'quality' in qualitative research, the concept of 'quality assurance' has not been explored widely. In acknowledgement of this gap, we sought to review discourses around quality assurance of qualitative research, as a first step towards developing guidance.

Methods

A range of databases, journals and grey literature sources were searched, and papers were included if they explicitly addressed quality assurance within a qualitative paradigm. A meta-narrative approach was used to review and synthesise the literature.

Results

Among the 37 papers included in the review, two dominant narratives were interpreted from the literature, reflecting contrasting approaches to quality assurance. The first focuses on demonstrating quality within research outputs; the second focuses on principles for quality practice throughout the research process. The second narrative appears to offer an approach to quality assurance that befits the values of qualitative research, emphasising the need to consider quality throughout the research process.

Conclusions

The paper identifies the strengths of the approaches represented in each narrative and recommend these are brought together in the development of a flexible framework to help qualitative researchers to define, apply and demonstrate principles of quality in their research.

The e-Health Implementation Toolkit: qualitative evaluation across four European countries

BACKGROUND

Implementation researchers have attempted to overcome the research-practice gap in e-health by developing tools that summarize and synthesize research evidence of factors that impede or facilitate implementation of innovation in healthcare settings. The e-Health Implementation Toolkit (e-HIT) is an example of such a tool that was designed within the context of the United Kingdom National Health Service to promote implementation of e-health services. Its utility in international settings is unknown.

METHODS

We conducted a qualitative evaluation of the e-HIT in use across four countries--Finland, Norway, Scotland, and Sweden. Data were generated using a combination of interview approaches (n = 22) to document e-HIT users' experiences of the tool to guide decision making about the selection of e-health pilot services and to monitor their progress over time.

RESULTS

e-HIT users evaluated the tool positively in terms of its scope to organize and enhance their critical thinking about their implementation work and, importantly, to facilitate discussion between those involved in that work. It was easy to use in either its paper- or web-based format, and its visual elements were positively received. There were some minor criticisms of the e-HIT with some suggestions for content changes and comments about its design as a generic tool (rather than specific to sites and e-health services). However, overall, e-HIT users considered it to be a highly workable tool that they found useful, which they would use again, and which they would recommend to other e-health implementers.

CONCLUSION

The use of the e-HIT is feasible and acceptable in a range of international contexts by a range of professionals for a range of different e-health systems.

Conducting qualitative research in audiology: a tutorial

OBJECTIVE

Qualitative research methodologies are being used more frequently in audiology as it allows for a better understanding of the perspectives of people with hearing impairment. This article describes why and how international interdisciplinary qualitative research can be conducted.

DESIGN

This paper is based on a literature review and our recent experience with the conduction of an international interdisciplinary qualitative study in audiology.

RESULTS

We describe some available qualitative methods for sampling, data collection, and analysis and we discuss the rationale for choosing particular methods. The focus is on four approaches which have all previously been applied to audiologic research: grounded theory, interpretative phenomenological analysis, conversational analysis, and qualitative content analysis.

CONCLUSIONS

This article provides a review of methodological issues useful for those designing qualitative research projects in audiology or needing assistance in the interpretation of qualitative literature.

Latino families' experiences with family-centered rounds at an academic children's hospital

OBJECTIVE

To characterize Latino families' experiences with family-centered rounds at an academic children's hospital to identify areas for improvement.

METHODS

Five focus groups of families of Latino children hospitalized on a general medical ward were conducted in Spanish by a single bilingual facilitator. Participants were recruited from a convenience sample of Spanish-speaking Latino family members present at the patients' bedside. Data were transcribed verbatim, content coded, and analyzed in Spanish for emergent themes.

RESULTS

Twenty-eight Latino family members of 21 hospitalized children participated in the 5 focus groups. Most spoke only Spanish (75%), and Spanish was the preferred language of all focus group participants. Qualitative data analysis indicated that families reported positive experiences with rounds involving a Spanish-speaking provider. Thematic issues focused on family-physician communication problems, lack of family empowerment, family and provider participants for family-centered rounds, and cultural needs. Parents were dissatisfied with telephonic interpretation services and preferred a live interpreter in the absence of a fluent, bilingual physician. Many families did not feel empowered to request interpretation assistance or health information; parents often felt embarrassed as a result of their inability to understand the primary language (English) of the care providers. Some parents felt inhibited to express themselves in the presence of other family members. Addressing cultural needs (e.g., chaplain support) was appreciated by families.

CONCLUSIONS

Spanish-speaking Latino families are not consistently receiving optimal family-centered rounds. Different strategies are needed to fully engage and empower Latino families.

Expanding the notion of researcher distress: the cumulative effects of coding

Qualitative researchers who explore the individual's experience of health, illness, death, and dying often experience emotional stress in their work. In this article, we describe the emotional stress we experienced while coding semistructured, after-death interviews conducted with 38 next of kin of deceased veterans. Coding sensitive topic data required an unexpected level of emotional labor, the impact of which has not been addressed in the literature. In writing this discussion article, we stepped back from our roles as interviewers/coders and reflected on how our work affected us individually and as a team, and how a sequence of exposures could exert a cumulative effect for researchers in such a dual role. Through this article, we hope to generate an expanded discourse on how qualitative inquiry impacts the emotional well-being of researchers.

The impact of direct provision accommodation for asylum seekers on organisation and delivery of local primary care and social care services: a case study

BACKGROUND

Many western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre) for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue.

METHODS

In 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied.

RESULTS

There was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for.

CONCLUSIONS

Direct provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations.

Workers’ Experiences of Crises in the Delivery of Home Support Services to Older Clients

In the provision of care to older clients, home support workers regularly confront, avert, and manage crises. Semistructured interviews were conducted to explore the nature, type, and management of crises from the perspective of home support workers ( N = 118) of older persons in British Columbia, Canada. The delivery of home health care occurs within a context of unpredictability related to scheduling, time constraints, variability of client need, and changing work environments. These events are experienced by 91% of home support workers and range from a serious medical incident (e.g., fall, death) to an interpersonal dilemma (e.g., client refusal of service, argument between worker and family member). Home support workers use a variety of strategies to manage these incidents. The analysis of crises enables us to better understand how agency and care policies may be more responsive to circumstances that challenge care work in home health settings.

Why is it difficult to implement e-health initiatives? A qualitative study

BACKGROUND

The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers -- the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives.

METHODS

We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT).

RESULTS

Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization.

CONCLUSIONS

Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners' attention to potential problems with a view to addressing them during implementation planning.

Valuing the Older Person in the Context of Delivery and Receipt of Home Support

Client perspectives of home support (i.e., assistance with daily activities that help to maintain a safe and supportive home) have not been considered in relation to personhood: “a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being.” Personhood and positive person work interactions conceptually guided our secondary analysis of data from a generic qualitative study including 82 semi-structured interviews with older adult home support clients in British Columbia, Canada. Findings revealed clients value a “focus on the person,” “preservation of autonomy,” and interactions characterized by recognition, validation, collaboration, and negotiation. Individuals involved in the delivery of home support services are in a key position to support the personhood of older adult clients.

Reflexivity and minimization of the impact of age-cohort differences between researcher and research participants

Reflexivity in research can be defined as (a) the acknowledgment and identification of one's place and presence in the research, and (b) the process of using these insights to critically examine the entire research process. Many authors implore qualitative researchers to be reflexive. Very few, however, specify how to do this in practice. Furthermore, in discussions of the presence and place of the researcher, the tendency has been to focus on such factors as gender and race or ethnicity with very little attention being given to age or cohort. In this article we seek to redress this deficiency by examining how reflexivity was practiced in a context in which there was a marked difference in age and cohort membership between researcher and research participants. Specifically, we describe the methodological challenges faced by a younger researcher conducting research with older study participants on the lived experience of the body, and how reflexivity was used to adapt the methodology employed so it became more appropriate and productive within this context.

Delusions and qualitative confusions: a dialogic collaborative exploration

In this article we describe the application of a dialogic collaborative process (DCP) to the exploration of issues arising from our own interview-based research in populations prone to delusions. We used the DCP to investigate and develop a shared understanding of ethical and epistemological tensions and their potential influence on the research process. Although our meaning making involved agreement to disagree in relation to specific issues, we are united in the view that full reporting and individual and team reflexivity are the hallmarks of quality for research with these populations. In a context in which qualitative research is increasingly conducted by multidisciplinary and hierarchical teams, we take the view that the DCP offers an effective and efficient means to construct evidence-based knowledge. However, we caution that to maximize benefits, the process must be underpinned by individual and collective active self-awareness and clarity about the commitment of each participant in the dialogue.

Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics

Physical therapist practice has a distinct focus that is holistic (ie, patient centered) and at the same time connected to a range of other providers within health care systems. Although there is a growing body of literature in physical therapy ethics knowledge, including clinical obligations and underlying philosophical principles, less is known about the unique ethical issues that physical therapists encounter, and how and why they make ethical decisions. As moral agents, physical therapists are required to make autonomous clinical and ethical decisions based on connections and relationships with their patients, other health care team members, and health institutions and policies. This article identifies specific ethical dimensions of physical therapist practice and highlights the development and focus of ethics knowledge in physical therapy over the last several decades. An applied ethics model, called the "active engagement model," is proposed to integrate clinical and ethical dimensions of practice with the theoretical knowledge and literature about ethics. The active engagement model has 3 practical steps: to listen actively, to think reflexively, and to reason critically. The model focuses on the underlying skills, attitudes, and actions that are required to build a sense of moral agency and purpose within physical therapist practice and to decrease gaps between the ethical dimensions of physical therapist practice and physical therapy ethics knowledge and scholarship. A clinical case study is provided to illustrate how the ethics engagement model might be used to analyze and provide insight into the ethical dimensions of physical therapist practice.

'Waiting until they got home': gender, smoking and tobacco exposure in households in Scotland

The introduction in March 2006 of legislation banning smoking in public places in Scotland raised concerns that smokers would smoke more at home and so increase the exposure of those living with them to tobacco smoke. Drawing on interviews from two qualitative studies conducted after the implementation of the legislation, this article uses a gendered analysis to explore where and why smokers, who lived with non-smokers including children, continued to smoke in their homes. Although very few people attributed any increased home smoking to being a direct consequence of the legislation, many who already smoked there continued, and most women reported little or no disruption to their home smoking post-legislation. Also, because of the changing social environment of smoking, and other life circumstances, a minority of women had increased their levels of home smoking. Compared to the men in these studies, women, particularly those who didn't work outside the home, had restricted social lives and thus were less likely to have smoked in public places before the legislation and spent more time socialising in the homes of other people. In addition, women with children, including women who worked outside their homes, were more likely to spend sustained periods of time caring for children compared to fathers, who were more likely to leave the home to work or socialise. Although home smoking was linked to gendered caring responsibilities, other issues associated with being a smoker also meant that many women smokers chose to keep smoking in their homes.

‘At the moment it is just a couple of eccentrics doing it’: concordance in day-to-day practice

Objectives

To assess the feasibility and acceptability of concordance in pharmacy practice through examination of communication between customers and pharmacists in two community pharmacies in consultations for over-the-counter medicines.

Method

A qualitative pilot study involving data drawn from six sources: audiotaped training session with all the pharmacists involved, observational field work in the pharmacies, audiotaped consultations with pharmacists and customers, debriefing interviews with pharmacists after the consultation, and semi-structured interviews with customers a few days after their consultation.

Setting

Two community pharmacies that concentrate their services on medicine advice and dispensing, one in a deprived inner-city area, the other in a more affluent suburban area of London.

Key findings

The pharmacists developed a personal understanding of concordance which informed their practice. Customers reported a high level of satisfaction with services they received from the respective pharmacists. Their accounts of the consultations verified the pharmacists' patient-centredness in their day-to-day practice.

Conclusion

The implementation of a concordance model was possible through the development of a personalised, patient-centred model which drew on the model of concordance but was adapted in accordance with both structural constraints as well as the personal style of the pharmacists involved.

Review: Taking care of yourself in later life: A qualitative study into the use of non-prescription medicines by people aged 60+

The last 40 years have witnessed substantial changes to the experience of later life. Health and life expectancy have improved and the emergence of a putative third age has allowed post-working life to move beyond being a residual social category to become an arena in which later life lifestyles can be constructed. Greater emphasis is now placed on expectations of self-agency and choice. Allied to this is the growing role of consumerism as a way of organizing key aspects of social life. Not only do these changes place increased emphasis on individual responsibility for health, but they also engage individuals in various forms of health consumerism.This study draws on these aspects of contemporary society to provide an explanatory framework for understanding older people’s engagement with, and consumption of non-prescription medicines. We present a qualitative study in which we interviewed 22 men and women aged 60 plus who were purchasing or interested in purchasing non-prescription medicines, including complementary and alternative medicines. Our findings suggest that the use of non-prescription medicines is both pluralistic and makeshift. Moreover, while this pluralism led to tensions with conventional bio-medicine, conventional bio-medicine still maintained the legitimacy of its knowledge base. Self-care using non-prescription medicines appeared more governed by hope than by evidence or knowledge of the treatments concerned.We conclude that such pluralism of approach reflects the growing consumerism in health and self-care and that older people may in fact be similar to other age groups in terms of their approach to such commodification.

What biomedical science should be included in undergraduate medical courses and how is this decided?

This review aimed to determine the availability of core curricula for the biomedical sciences in the published literature and the approach taken to determining learning objectives. A systematic review was conducted searching three databases for articles containing the terms 'core curriculum', 'undergraduate' and 'medic*'. Fifty seven papers were read in full, of which 40 listed learning objectives. The authors used a consensus process to categorize the learning objectives according to the level of detail (high / medium / low) and the approach taken (either a top down approach using experts or a bottom up approach using key stakeholders). This paper directs the reader to publications that describe core curricula for the biomedical sciences. The review revealed that topic coverage was patchy and there was a variable level of detail of learning outcomes presented. Documents published by professional bodies tended to provide more detailed learning outcomes than those derived by experts associated with medical schools. Two thirds of the 40 publications used a top down approach and there was a temporal trend towards involving non-expert groups in some stage of the process of defining the learning objectives, regardless of whether a top down or bottom up approach was taken.

Sociological refigurations of patient safety; ontologies of improvement and 'acting with' quality collaboratives in healthcare

The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of 'usefulness' in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of 'usefulness', this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of 'effective care' are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study. In order to explore these questions, this article draws on empirical material from an ongoing evaluation of a large quality improvement collaborative for the care sectors in the Netherlands. It addresses how issues like 'effectiveness' and 'client participation' are at present articulated in this collaborative and shows that alternative figurations of these notions dissolve many 'implementation problems' presently experienced. Further it analyzes how such a focus of medical sociology on multiple ontologies engenders new potential for exploring particular spaces for 'acting with' quality improvement agents.

A study of critical reflection in health professional education: 'learning where others are coming from'

A dominant focus of clinical education for health professional students is experiential learning through an apprentice model where students are exposed to a range of clinical scenarios and conditions through observation initially, and then through supervised clinical practice. However experiential learning may not be enough to meet the need for health professionals to be flexible, self-aware and understanding of alternative perspectives or 'where other people are coming from.' Critical reflection skills are recognised as a way of thinking and a process for analysing practice, that enables learning from, and redeveloping professional practice in an ongoing way. This paper describes and examines the effect of a three hour per week, six week critical reflection program, grounded in knowledge paradigms of postmodernism, reflexivity and critical theory, on third year undergraduate physiotherapy students' experience of their first clinical placements. The theoretical basis of the program provides a potential bridge with which to link and broaden the established framework of clinical reasoning theories. Within the program, students' critical reflection discourse focused on notions of power, hierarchies, connecting with others and relationships. Their feedback about the effects of the program highlighted themes of validation and sharing; a break in clinical performance and a broadening of their spheres of knowledge. These themes resonated with students' overall experiences of learning in clinical placements and provide some evidence for the inclusion of critical reflection as a valid and worthwhile component of early clinical education.

Ethnomethodological study of the values of Australian psychiatrists: towards an empirically derived RANZCP Code of Ethics

OBJECTIVE

The aim of the present study was to identify the core values of Australian psychiatrists to ascertain how these are reflected in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Code of Ethics.

METHOD

An ethnomethodological study was conducted on a non-purposive sample of Australian psychiatrists using a non-probabilistic theoretical sampling method. Data obtained at interview were analysed using a qualitative computer-assisted thematic analysis paradigm. The themes generated using this coding strategy were refined into a rich description of the core values held by Australian psychiatrists.

RESULTS

Four main values emerged from the data: the value of the patient, the value of sophisticated understanding, the value of reflexivity, and the value of advocacy.

CONCLUSIONS

The four main values identified in the present study were well reflected in the main principles of the RANZCP Code of Ethics. In the light of the data, some additional annotations to the document are suggested, to better reflect this value system.

Community-based tele-health systems for persons with diabetes: development of an outcomes model

The purpose of this study was to obtain information on the perceptions of persons with diabetes regarding participation in a tele-health program. We conducted three focus groups among diabetics who had used a monitoring and messaging device (MMD), a commonly used tele-health care system. Analysis involved open and axial coding to identify major themes and relationships. Results suggest that these systems enhance communication, care-manager relationships, self-discipline, and clinical follow-up. The results suggest mechanisms by which tele-health systems influence the health care system and point to areas for further tele-health development.

Experiences of appearance-related teasing and bullying in skin diseases and their psychological sequelae: results of a qualitative study

Acne, psoriasis and atopic eczema are common diseases and have been consistently associated with adverse psychological sequelae including stigmatization. Being teased on the basis of appearance has been associated with psychiatric morbidity in children and adolescents. The objective of this qualitative study was to explore the experiences of teasing and bullying in patients with acne, psoriasis and eczema, and the role of appearance-related teasing and bullying as mediators of psychological morbidity in these patients. Data collection consisted of 62 in-depth semi-structured interviews with patients with acne, psoriasis or atopic eczema recruited from both specialist dermatology and general practices. Data analysis was cumulative and concurrent throughout the data collection period reflecting a grounded theory approach. Analysis followed the analytic induction method, allowing themes to emerge from the data. Teasing, taunting or bullying was a considerable problem for a significant minority of acne, psoriasis and atopic eczema participants. Themes that emerged were the universally negative nature of the teasing, the use of teasing as an instrument of social exclusion, and as a means of establishing or enforcing power relationships, teasing related to contagion and fear, the emotional and psychological sequelae of teasing and the theme of 'insensate' teasing. For those who had suffered teasing or bullying, this was causally linked in respondents' accounts with psychological sequelae, especially self-consciousness and effects on self-image and self-esteem. Experiences of teasing and bullying were found to have principally occurred during the adolescence of participants and the perpetrators were other adolescents, but there were findings of respondents with psoriasis also having been subjected to ridicule or derogatory remarks by health professionals. Teasing, taunting and bullying may represent an underappreciated source of psychological morbidity in children and adolescents with these common skin diseases.

Multidisciplinary, interdisciplinary, or dysfunctional? Team working in mixed-methods research

Combining qualitative and quantitative methods in a single study-otherwise known as mixed-methods research-is common. In health research these projects can be delivered by research teams. A typical scenario, for example, involves medical sociologists delivering qualitative components and researchers from medicine or health economics delivering quantitative components. We undertook semistructured interviews with 20 researchers who had worked on mixed-methods studies in health services research to explore the facilitators of and barriers to exploiting the potential of this approach. Team working emerged as a key issue, with three models of team working apparent: multidisciplinary, interdisciplinary, and dysfunctional. Interdisciplinary research was associated with integration of data or findings from the qualitative and quantitative components in both the final reports and the peer-reviewed publications. Methodological respect between team members and a principal investigator who valued integration emerged as essential to achieving integrated research outcomes.

Language and rigour in qualitative research: problems and principles in analyzing data collected in Mandarin

In collaborative qualitative research in Asia, data are usually collected in the national language, and this poses challenges for analysis. Translation of transcripts to a language common to the whole research team is time consuming and expensive; meaning can easily be lost in translation; and validity of the data may be compromised in this process. We draw on several published examples from public health research conducted in mainland China, to highlight how language can influence rigour in the qualitative research process; for each problem we suggest potential solutions based on the methods used in one of our research projects in China.

Problems we have encountered include obtaining sufficient depth and detail in qualitative data; deciding on language for data collection; managing data collected in Mandarin; and the influence of language on interpreting meaning.

We have suggested methods for overcoming problems associated with collecting, analysing, and interpreting qualitative data in a local language, that we think help maintain analytical openness in collaborative qualitative research. We developed these methods specifically in research conducted in Mandarin in mainland China; but they need further testing in other countries with data collected in other languages. Examples from other researchers are needed.

Performing stable angina pectoris: an ethnographic study

Symptoms play a crucial part in the formulation of medical diagnoses, yet the construction and interpretation of symptom narratives is not well understood. The diagnosis of angina is largely based on symptoms, but a substantial minority of patients diagnosed with "non-cardiac" chest pain go on to have a heart attack. In this ethnographic study our aims were to understand: (1) how the patients' accounts are performed or enacted in consultations with doctors; (2) the ways in which ambiguity in the symptom narrative is managed by doctors; and (3) how doctors reach or do not reach a diagnostic decision. We observed 59 consultations of patients in a UK teaching hospital with new onset chest pain who had been referred for a specialist opinion in ambulatory care. We found that patients rarely gave a history that, without further interrogation, satisfied the doctors, who actively restructured the complex narrative until it fitted a diagnostic canon, detaching it from the patient's interpretation and explanation. A minority of doctors asked about chest pain symptoms outside the canon. Re-structuring into the canonical classification was sometimes resisted by patients who contested key concepts, like exertion. Symptom narratives were sometimes unstable, with central features changing on interrogation and re-telling. When translation was required for South Asian patients, doctors considered the history less relevant to the diagnosis. Diagnosis and effective treatment could be enhanced by research on the diagnostic and prognostic value of the terms patients use to describe their symptoms.

Identifying and responding to ethical and methodological issues in after-death interviews with next-of-kin

After-death research with next-of-kin can enhance our understanding of end-of-life care and translate into better services for dying persons and their survivors. This article describes ethical and methodological issues that emerged in a pilot of a face-to-face interview guide designed to elicit next-of-kin's perceptions of end-of-life care. The pilot study was part of a larger Veterans Affairs (VA) Health Services Research protocol to improve end-of-life care in VA Medical Centers. By deconstructing the research process from an ethical perspective and engaging in critical self-assessment, the authors aim to inform other researchers of potential problems involved in after-death research with next-of-kin.

Living kidney donors' experiences with the health care system

The purpose of this study was to explore living kidney donors' perceived experiences with the health care system from the period prior to being tested as a potential donor, through to post donation discharge and follow-up. Qualitative methodology, using a phenomenological approach, explored the experiences, feelings, and ideas of 12 purposefully selected living kidney donors' interface with the health care system. Eight men and four women were interviewed four to 29 years post donation. Interviews were audio taped and transcribed verbatim. An iterative and interpretive analysis was conducted. Themes emerging from the data included factors influencing living kidney donors' decision to be tested as potential donors, the importance of emotional support, and humanistic care. This in turn impacted on their experience of: (1) the role of information in the decision-making process; (2) their tolerance of issues related to hospitalization and; (3) their perception of the quality of care. The findings of this study provide suggestions for the role of social work and improvement in the health care system to better address the needs of living kidney donors.

Making sense of mild cognitive impairment: a qualitative exploration of the patient's experience

PURPOSE

The proposed dementia precursor state of mild cognitive impairment is emerging as a primary target of aging research. Yet, little is known about the subjective experience of living with a diagnosis of mild cognitive impairment. This study examines, from the patient's perspective, the experience of living with and making sense of the diagnosis.

DESIGN AND METHODS

We recruited 12 older adults with amnestic or nonamnestic mild cognitive impairment from a university-based memory disorders clinic. We conducted in-home, semistructured interviews in order to elicit rich descriptions of the personal experience of having mild cognitive impairment. We used the qualitative method of grounded theory to analyze narrative data.

RESULTS

Understanding and coming to terms with the syndrome, or assigning meaning, constituted a fundamental aspect of living with a diagnosis of mild cognitive impairment. This process comprised interrelated emotional and cognitive dimensions. Participants employed a range of positive, neutral, and negative phrasing in order to depict their emotional reactions to receiving a diagnosis. Cognitive representations of mild cognitive impairment included both prognosis-focused and face-value appraisals. Expectations of normal aging, personal experience with dementia, and concurrent health problems were key contextual factors that provided the backdrop against which participants assigned meaning to a diagnosis of mild cognitive impairment.

IMPLICATIONS

Clinicians who disclose diagnoses of mild cognitive impairment need to be mindful of the potential for varying interpretations of the information that is conveyed. Future research needs to include systematic, longitudinal investigations of illness representation and its impact on health behaviors among individuals with mild cognitive impairment.

Reflexive journaling on emotional research topics: ethical issues for team researchers

Traditional epistemological concerns in qualitative research focus on the effects of researchers' values and emotions on choices of research topics, power relations with research participants, and the influence of researcher standpoints on data collection and analysis. However, the research process also affects the researchers' values, emotions, and standpoints. Drawing on reflexive journal entries of assistant researchers involved in emotionally demanding team research, this article explores issues of emotional fallout for research team members, the implications of hierarchical power imbalances on research teams, and the importance of providing ethical opportunities for reflexive writing about the challenges of doing emotional research. Such reflexive approaches ensure the emotional safety of research team members and foster opportunities for emancipatory consciousness among research team members.

Effectiveness of an improvement writing program according to students' reflexivity levels

After designing a writing program to enhance students' reflexivity and thus improve their compositions (García & de Caso, 2002a, 2002b), the aim of the research project was to show how reflexivity levels could influence the effectiveness of this program. This writing instruction through reflexivity was carried out with 5th and 6th grade students with learning disabilities (LD) and/or low achievement (LA) during 25 sessions. One hundred participants were assigned to either the experimental group (n=49), which received specific intervention in writing and reflexivity, or the control group (n=51), which simply received the ordinary curriculum. Both groups were assessed on the productivity and quality of their writing composition as well as their attitudes, self-efficacy, and reflexivity towards writing. The results show that coherence and reflexivity improved depending on the level of reflexivity, whereas the relationship with attitudes and self-efficacy is not so clear. Thus, it seems possible to improve LD and/or LA students' compositions by taking their reflexive style into account. Depending on the students' learning style, teachers should use either one or another technique.

Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study

BACKGROUND

National and international healthcare policy increasingly seeks technological solutions to the challenge of providing care for people with long-term conditions. Novel technologies, however, have the potential to change the dynamics of disease monitoring and self-management. We aimed to explore the opinions and concerns of people with asthma and primary care clinicians on the potential role of mobile phone monitoring technology (transmitting symptoms and peak flows, with immediate feedback of control and reminder of appropriate actions) in supporting asthma self-management.

METHODS

This qualitative study recruited 48 participants (34 adults and teenagers with asthma, 14 asthma nurses and doctors) from primary care in Lothian (Central Scotland) and Kent (South East England). Thirty-nine participated in six focus groups, which included a demonstration of the technology; nine gave in-depth interviews before and after a 4-week trial of the technology.

RESULTS

Participants considered that mobile phone-based monitoring systems can facilitate guided self-management although, paradoxically, may engender dependence on professional/technological support. In the early phases, as patients are learning to accept, understand and control their asthma, this support was seen as providing much-needed confidence. During the maintenance phase, when self-management predominates, patient and professionals were concerned that increased dependence may be unhelpful, although they appreciated that maintaining an on-going record could facilitate consultations.

CONCLUSION

Mobile phone-based monitoring systems have the potential to support guided self-management by aiding transition from clinician-supported early phases to effective self-management during the maintenance phase. Continuing development, adoption and formal evaluation of these systems should take account of the insights provided by our data.

The complexity of patients' satisfaction with out-of-hours care: a qualitative study

BACKGROUND

The national health service in the Republic of Ireland is one of a number of European health services currently undergoing significant reform. Out-of-hours primary care has been at the forefront of this process of change, and although patients appear satisfied, the complexity of their response to changes in out-of-hours care has not been fully explored.

OBJECTIVE

To conduct an analysis of qualitative data collected during a recent study of patients' satisfaction with out-of-hours care in order to explore the full range of patients' views and experiences.

METHODS

All patients contacting a family-doctor out-of-hours cooperative over a designated 24-day period were forwarded a postal questionnaire. The questionnaire contained a section giving the patient the opportunity to add qualitative comments concerning their experience. The data were analysed according to the principles framework analysis using Nvivo software.

RESULTS

Analysis of the data resulted in the development of the following thematic categories: service availability, service accessibility, efficiency, continuity of care and quality of care. There was a range of views, both positive and negative, apparent around these themes, with evidence of patients engaging in careful decisions and "trade-offs" in respect of their options for out-of-hours care.

CONCLUSION

Patients hold a range of views that suggests the complexity around patient satisfaction with out-of-hours care. A qualitative methodological approach can compliment current approaches to the evaluation of patient satisfaction, facilitating the exploration of the full range of patients' views and experiences.

Australian rural adolescents' experiences of accessing psychological help for a mental health problem

OBJECTIVE

This study aims to explore Australian rural adolescents' experiences of accessing help for a mental health problem in the context of their rural communities.

DESIGN AND SETTING

A qualitative research design was used whereby university students who had sought help for a mental health problem during their adolescence were interviewed about their experiences. Interviews were conducted face-to-face at the university.

MAIN OUTCOME MEASURES

A semi-structured interview schedule was designed around the study's main research questions. Audio-taped interviews were transcribed and thematically coded using a constant comparative method.

PARTICIPANTS

Participants were first-year undergraduate psychology students between the ages of 17 and 21 years who sought help for a mental health issue during their adolescence and who at that time resided in a rural area.

RESULTS

Participants highlighted various barriers to seeking help for mental health problems in the context of a rural community, including: social visibility, lack of anonymity, a culture of self-reliance, and social stigma of mental illness. Participants' access to help was primarily school-based, and participants expressed a preference for supportive counselling over structured interventions. Characteristics of school-based helpers that made them approachable included: 'caring', 'nonjudgemental', 'genuine', 'young', and able to maintain confidentiality.

CONCLUSIONS

The findings support previous research that reveals barriers to help seeking for mental health problems that are unique to the culture of rural communities. The study raises questions about the merit of delivery of primary mental health care to young people via GPs alone and suggests that school-based counsellors be considered as the first step in a young person's access to mental health care.

Dilemmas in the (un)veiling of the diagnosis of Alzheimer's disease: walking an ethical and professional tight rope

OBJECTIVE

To enhance the understanding and effect of physician's difficulties, attitudes and communication styles on the disclosure of the diagnosis of AD in practice.

METHODS

Qualitative, phenomenological study, combining pre-encounter interviews with physicians, observations of actual encounters of diagnosis disclosure of AD, and post-encounter interviews.

RESULTS

There were various ways or tactics to (un)veil the bad news that may be perceived as different ways of dulling the impact and avoiding full and therefore problematic statements. In the actual encounters this was accomplished by keeping encounters short, avoiding elaboration, confirmation of comprehension and explicit terminology and using fractured sentences.

CONCLUSION

The present study's findings highlight the difficulties encountered in breaking the news about AD, in the way it is actually done, and the problems that may arise from this way of un/veiling the news. The main problem is that the reluctance to make a candid disclosure of the diagnosis as was demonstrated in this study may violate basic moral and legal rights and may also deprive patients and caregivers of some of the benefits of early disclosure of diagnosis.

PRACTICE IMPLICATIONS

There is a need for assisting physicians to cope with their personal difficulties, problems and pitfalls in breaking the news.