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Chachad N, Levy A, Kenon K, Nash R, Carter S, Padilla M, Mitchell-Williams J, Rajput V. Integrating the Teaching and Assessment of Moral Reasoning into Undergraduate Medical Education to Advance Health Equity. MEDICAL SCIENCE EDUCATOR 2024; 34:653-659. [PMID: 38887408 PMCID: PMC11180056 DOI: 10.1007/s40670-024-02019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 06/20/2024]
Abstract
Moral reasoning skills among medical students have regressed despite the implementation of ethics teachings in medical education curricula. This inability to retain moral reasoning capability is attributed to difficulty transitioning to the principled thinking stage of moral reasoning as well as worsening of ethical decision-making skills during clerkship education due to the "hidden curriculum." Prior studies have examined the efficacy of individual strategies for moral education, but there is insufficient analysis comparing multiple educational interventions and moral reasoning assessment tools. The role and impact of these instruments in medical curricula for the advancement of health equity is reviewed.
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Affiliation(s)
- Nisha Chachad
- Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova Southeastern University, Fort Lauderdale, FL USA
| | - Arkene Levy
- Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova Southeastern University, Fort Lauderdale, FL USA
| | - Katlynn Kenon
- Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova Southeastern University, Fort Lauderdale, FL USA
| | - Rachel Nash
- Cooper Medical School of Rowan University, Camden, NJ USA
| | - Stefanie Carter
- Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova Southeastern University, Fort Lauderdale, FL USA
| | - Maria Padilla
- Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova Southeastern University, Fort Lauderdale, FL USA
| | | | - Vijay Rajput
- Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova Southeastern University, Fort Lauderdale, FL USA
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Chesterfield A, Harvey J, Hendrie C, Wilkinson S, Vera San Juan N, Bell V. Meaning and role of functional-organic distinction: a study of clinicians in psychiatry and neurology services. MEDICAL HUMANITIES 2024; 50:170-178. [PMID: 37968099 DOI: 10.1136/medhum-2023-012667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/17/2023]
Abstract
The functional-organic distinction attempts to differentiate disorders with diagnosable biological causes from those without and is a central axis on which diagnoses, medical specialities and services are organised. Previous studies report poor agreement between clinicians regarding the meanings of the terms and the conditions to which they apply, as well as noting value-laden implications of relevant diagnoses. Consequently, we aimed to understand how clinicians working in psychiatry and neurology services navigate the functional-organic distinction in their work. Twenty clinicians (10 physicians, 10 psychologists) working in psychiatry and neurology services participated in semistructured interviews that were analysed applying a constructivist grounded theory approach. The distinction was described as often incongruent with how clinicians conceptualise patients' problems. Organic factors were considered to be objective, unambiguously identifiable and clearly causative, whereas functional causes were invisible and to be hypothesised through thinking and conversation. Contextual factors-including cultural assumptions, service demands, patient needs and colleagues' views-were key in how the distinction was deployed in practice. The distinction was considered theoretically unsatisfactory, eventually to be superseded, but clinical decision making required it to be used strategically. These uses included helping communicate medical problems, navigating services, hiding meaning by making psychological explanations more palatable, tackling stigma, giving hope, and giving access to illness identity. Clinicians cited moral issues at both individual and societal levels as integral to the conceptual basis and deployment of the functional-organic distinction and described actively navigating these as part of their work. There was a considerable distance between the status of the functional-organic distinction as a sound theoretical concept generalisable across conditions and its role as a gatekeeping tool within the structures of healthcare. Ambiguity and contradictions were considered as both obstacles and benefits when deployed in practice and strategic considerations were important in deciding which to lean on.
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Affiliation(s)
- Alice Chesterfield
- Clinical, Educational and Health Psychology, University College London, London, UK
| | - Jordan Harvey
- Clinical, Educational and Health Psychology, University College London, London, UK
| | - Callum Hendrie
- Community Support Work Service, Headway East London, London, UK
| | - Sam Wilkinson
- Dept of Sociology, Philosophy and Anthropology, Exeter University, London, UK
| | - Norha Vera San Juan
- Clinical, Educational and Health Psychology, University College London, London, UK
| | - Vaughan Bell
- Clinical, Educational and Health Psychology, University College London, London, UK
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, London, UK
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English W, Robinson J, Gott M. Rapport: A conceptual definition from the perspective of patients and families receiving palliative care. PATIENT EDUCATION AND COUNSELING 2023; 106:120-127. [PMID: 36328826 DOI: 10.1016/j.pec.2022.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To explore patient and family perceptions of rapport in interactions with health professionals and use the findings to develop a conceptual definition of rapport. METHODOLOGY We undertook a qualitative Interpretive Description study; semi-structured interviews were conducted between November 2020 and May 2021. Participants included 18 patients and 11 family members recruited using a random approach from four hospice locations in Aotearoa, New Zealand. Interviews were audio recorded, transcribed, and analysed to develop a conceptual definition of rapport using guidelines (Podsakoff et al., (2016). A COREQ checklist was completed. RESULTS Four dimensions of rapport were identified which formed the basis of a conceptual definition: 1) the type of relating, 2) the essence of rapport experienced, 3) key communication characteristics, and 4) the effect on interactions. CONCLUSION Based on patient and family experiences of rapport, this study formulated a conceptual definition of rapport. This definition will support clinical education and practice and inform future research related to rapport. PRACTICE IMPLICATIONS A conceptual definition of rapport can provide clarity for both research and clinical practice. It may be used as a tool for health professionals to reflect upon their experiences with rapport and develop expertise in this area.
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Affiliation(s)
- Wendy English
- School of Nursing, University of Auckland, Auckland, New Zealand.
| | - Jackie Robinson
- School of Nursing, University of Auckland, Auckland, New Zealand.
| | - Merryn Gott
- School of Nursing, University of Auckland, Auckland, New Zealand.
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McAloon T, Coates V, Fitzsimons D. Duty of care trumps utilitarianism in multi-professional obesity management decisions. Nurs Ethics 2022; 29:1401-1414. [PMID: 35623624 PMCID: PMC9527366 DOI: 10.1177/09697330221075764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Escalating levels of obesity place enormous and growing demands on Health
care provision in the (U.K.) United Kingdom. Resources are limited with
increasing and competing demands upon them. Ethical considerations underpin
clinical decision making generally, but there is limited evidence regarding
the relationship between these variables particularly in terms of treating
individuals with obesity. Research aim To investigate the views of National Health Service (NHS) clinicians on
navigating the ethical challenges and decision making associated with
obesity management in adults with chronic illness. Research design A cross-sectional, multi-site survey distributed electronically. Participants A consensus sample of nurses, doctors, dietitians and final year students in
two NHS Trusts and two Universities. Ethical considerations Ethical and governance approvals obtained from a National Ethics Committee
(11NIR035), two universities and two teaching hospitals. Results Of the total (n = 395) participants, the majority were
nurses (48%), female (79%) and qualified clinicians (59%). Participants
strongly considered the individual to have primary responsibility for a
healthy weight and an obligation to attempt to maintain that healthy weight
if they wish to access NHS care. Yet two thirds would not withhold treatment
for patients with obesity. Discussion While clinicians were clear about patient responsibility and obligations, the
majority prioritised their duty of care and would not invoke a utilitarian
approach to decision making. This may reflect awareness of obesity as a
multi-faceted entity, with responsibility for support and management shared
amongst society in general. Conclusions The attitudes of this sample of clinicians complemented the concept of the
health service as being built on a principle of community, with each treated
according to their need. However limited resources challenge the concept of
needs-based decisions consequently societal engagement is necessary to agree
a pragmatic way forward.
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Affiliation(s)
- Toni McAloon
- Department of Nursing, 42259Ulster University - Jordanstown Campus, Newtownabbey, UK
| | - Vivien Coates
- Department of Nursing, 2596Ulster University - Coleraine Campus, Coleraine, UK
| | - Donna Fitzsimons
- Department of Nursing, 1596Queen's University Belfast, Belfast, UK
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Traina G, Feiring E. Priority setting and personal health responsibility: an analysis of Norwegian key policy documents. JOURNAL OF MEDICAL ETHICS 2022; 48:39-45. [PMID: 32122963 PMCID: PMC8717478 DOI: 10.1136/medethics-2019-105612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 02/11/2020] [Accepted: 02/17/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND The idea that individuals are responsible for their health has been the focus of debate in the theoretical literature and in its concrete application to healthcare policy in many countries. Controversies persist regarding the form, substance and fairness of allocating health responsibility to the individual, particularly in universal, need-based healthcare systems. OBJECTIVE To examine how personal health responsibility has been framed and rationalised in Norwegian key policy documents on priority setting. METHODS Documents issued or published by the Ministry of Health and Care Services between 1987 and 2018 were thematically analysed (n=14). We developed a predefined conceptual framework that guided the analysis. The framework included: (1) the subject and object of responsibility, (2) the level of conceptual abstraction, (3) temporality, (4) normative justificatory arguments and (5) objections to the application of personal health responsibility. RESULTS As an additional criterion, personal health responsibility has been interpreted as relevant if: (A) the patient's harmful behaviour is repeated after receiving treatment (retrospectively), and if (B) the success of the treatment is conditional on the patient's behavioural change (prospectively). When discussed as a retrospective criterion, considerations of reciprocal fairness have been dominant. When discussed as a prospective criterion, the expected benefit of treatment justified its relevance. CONCLUSION Personal health responsibility appears to challenge core values of equality, inclusion and solidarity in the Norwegian context and has been repeatedly rejected as a necessary criterion for priority setting. However, the responsibility criterion seems to have some relevance in particular priority setting decisions.
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Affiliation(s)
- Gloria Traina
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Eli Feiring
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Demant D, Carroll JA, Saliba B, Bourne A. Information-seeking behaviours in Australian sexual minority men engaged in chemsex. Addict Behav Rep 2021; 16:100399. [PMID: 35712328 PMCID: PMC9193851 DOI: 10.1016/j.abrep.2021.100399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/28/2021] [Accepted: 12/08/2021] [Indexed: 12/01/2022] Open
Abstract
Participants engaged in chemsex over long periods of time and on a regular basis. Most know where to seek professional help and access harm reduction information. Many worry about being judged by health professionals and few seek out assistance. Participants feel uncomfortable discussing chemsex with most health professionals. Information from sexual health professionals is trusted the most.
Introduction Chemsex refers to using illicit substances to facilitate sexual experiences in men who have sex with men. Chemsex has been linked to significant negative impacts on psychological, social, and physical wellbeing. Little is known about information-seeking behaviours in this population. This study aims to provide an in-depth understanding of seeking and engaging with health information. Methods Self-identified Australian sexual minority men who engage in chemsex (N = 184) participated in an anonymous cross-sectional survey. Variables included chemsex engagement, knowledge, perception and use of harm-reduction information, and associated health and support services. Pearson correlation and ANOVAs were conducted. Wilcoxon-Signed-Rank and Friedman tests were applied to analyse the perceived trustworthiness of information sources. Results Chemsex represented a meaningful part of sexual events. Most participants knew where to access professional help and harm-reduction information but worried about being judged. Most did not feel comfortable discussing chemsex with health professionals except with sexual health doctors/counsellors. Few users discussed health risks with a professional. Information on chemsex was received through multiple sources with significant differences in perceived relevance and trustworthiness, with sexual health doctors/nurses ranked the most trustworthy information. Interest in non-traditional sources of information was low except for formal peer networks and anonymous personal expert advice. Conclusion Engagement with health professionals and harm-reduction information is limited in this population, despite high risk and potentially significant adverse health outcomes. Results suggest that new and combined approaches are necessary to reach this population, including peer support networks, anonymous personal advice and changing community attitudes towards chemsex.
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Affiliation(s)
- Daniel Demant
- School of Public Health, University of Technology Sydney, Ultimo, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
- Corresponding author at: School of Public Health, Faculty of Health, University of Technology Sydney, 235-253 Jones Street, Ultimo, New South Wales 2007, Australia.
| | - Julie-Anne Carroll
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Bernard Saliba
- School of Public Health, University of Technology Sydney, Ultimo, Australia
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Adam Bourne
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia
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Paroz S, Daeppen JB, Monnat M, Saraga M, Panese F. Exploring Clinical Practice and Developing Clinician Self-Reflection Through Cross Self-Confrontation Methodology: An Application Within an Addiction Medicine Unit. Glob Qual Nurs Res 2021; 8:23333936211054800. [PMID: 34761077 PMCID: PMC8573618 DOI: 10.1177/23333936211054800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 09/22/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
Use of the methodology of cross self-confrontation (CSC) is limited in the field of healthcare and in the context of clinical practice. We applied this methodology within an addiction medicine unit of a university hospital, as part of an exploration of addiction-related clinical difficulties. Cross self-confrontation was used according to a 3-phase design based on video recorded clinical interviews with pairs of nurses and medical doctors. The article reports and discusses the application of CSC in a specific clinical context and illustrates the methodological process through one result. Findings suggest two major strengths of CSC in the context of clinical practice research and education: (1) the capacity to elicit tacit knowledge from daily clinical practice and (2) the ability to enhance self-reflection by questioning professionals both individually and collectively. Further use of CSC in nursing surroundings and clinical settings should be encouraged.
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Affiliation(s)
- Sophie Paroz
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Martine Monnat
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Public Health Service of Canton of Vaud, Lausanne, Switzerland
| | - Michael Saraga
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Francesco Panese
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Rowley J, Richards N, Carduff E, Gott M. The impact of poverty and deprivation at the end of life: a critical review. Palliat Care Soc Pract 2021; 15:26323524211033873. [PMID: 34541536 PMCID: PMC8442481 DOI: 10.1177/26323524211033873] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/01/2021] [Indexed: 11/22/2022] Open
Abstract
This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.
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Affiliation(s)
- Jane Rowley
- End of Life Studies Group, School of
Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Naomi Richards
- End of Life Studies Group, School of
Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | | | - Merryn Gott
- Professor, Te Ārai Palliative Care and End of
Life Research Group, School of Nursing, The University of Auckland, Private
Bag 92019, Auckland 1142, New Zealand
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Hawking MKD, Robson J, Taylor SJC, Swinglehurst D. Adherence and the Moral Construction of the Self: A Narrative Analysis of Anticoagulant Medication. QUALITATIVE HEALTH RESEARCH 2020; 30:2316-2330. [PMID: 32856537 PMCID: PMC7649927 DOI: 10.1177/1049732320951772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
In this article, we examine illness narratives to illuminate the discursive work that patients undertake to construct themselves as "good" and adherent. Biographical narrative interviews were undertaken with 17 patients receiving anticoagulation for stroke prevention in atrial fibrillation, from five English hospitals (May 2016-June 2017). Through pluralistic narrative analysis, we highlight the discursive tensions narrators face when sharing accounts of their medicine-taking. They undertake challenging linguistic and performative work to reconcile apparently paradoxical positions. We show how the adherent patient is co-constructed through dialogue at the intersection of discourses including authority of doctors, personal responsibility for health, scarcity of resources, and deservingness. We conclude that the notion of medication adherence places a hidden moral and discursive burden of treatment on patients which they must negotiate when invited into conversations about their medications. This discursive work reveals, constitutes, and upholds medicine-taking as a profoundly moral practice.
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Affiliation(s)
- Meredith K. D. Hawking
- Queen Mary University of London, London, United Kingdom
- Meredith K. D. Hawking, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK.
| | - John Robson
- Queen Mary University of London, London, United Kingdom
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Barbosa P, Huchital MJ, Weiss JJ. Empathy in Podiatric Medical Education: Challenges and Opportunities for Comprehensive Care. J Am Podiatr Med Assoc 2020; 110:447706. [PMID: 33179063 DOI: 10.7547/18-187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Many regard empathy as a critical component of comprehensive health care. Much interest has been generated in the field of medical empathy, in particular as it relates to education. Many desirable outcomes correlate with perceived empathy during the patient encounter, but paradoxically, empathy levels have been reported to decline during the years of medical education. Several new approaches have been described in the literature that intend to teach or develop empathy skills in health-care students. METHODS PubMed, PsycINFO, and Google Scholar databases were searched for the terms empathy education, medical education, medical student, podiatric medical education, medical empathy, compassion, emotional intelligence, biopsychosocial model, and bedside manner. After implementing inclusion and exclusion criteria, articles were selected for preparation of a literature review. Analysis of the podiatric medical education on empathy was conducted by reviewing descriptions of all courses listed on each of the nine US podiatric medical schools' Web sites. The 2018 Curricular Guide for Podiatric Medical Education was analyzed. RESULTS In this review, we examine the current state of empathy from a context of medical education in general, followed by a specific analysis in podiatric medicine. We define key terms, describe the measuring of empathy in medicine, explore outcomes of empathy in the health-care setting, review the reports of a decline in medical education, and highlight some of the current efforts to develop the skill in education. An overview of empathy in the podiatric medical curriculum is presented. CONCLUSIONS To improve the quality of care that physicians provide, a transformation in podiatric medical education is necessary. A variety of tools are available for education reform with the target of developing empathy skills in podiatric medical students.
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Traina G, Feiring E. 'There is no such thing as getting sick justly or unjustly' - a qualitative study of clinicians' beliefs on the relevance of personal responsibility as a basis for health prioritisation. BMC Health Serv Res 2020; 20:497. [PMID: 32493300 PMCID: PMC7268691 DOI: 10.1186/s12913-020-05364-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/25/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Concerns have been raised regarding the reasonableness of using personal health responsibility as a principle or criterion for setting priorities in healthcare. While this debate continues, little is known about clinicians' views on the role of patient responsibility in clinical contexts. This paper contributes to the knowledge on the empirical relevance of personal responsibility for priority setting at the clinical level. METHODS A qualitative study of Norwegian clinicians (n = 15) was designed, using semi-structured interviews with vignettes to elicit beliefs on the relevance of personal responsibility as a basis for health prioritisation. Sampling was undertaken purposefully. The interviews were conducted in three hospital trusts in South-Eastern Norway between May 2018 and February 2019 and were analysed with conceptually driven thematic analysis. RESULTS The findings suggest that clinicians endorsed a general principle of personal health responsibility but were reluctant to introduce personal health responsibility as a formal priority setting criterion. Five main objections were cited, relating to avoidability, causality, harshness, intrusiveness, and inequity. Still, both retrospective and prospective attributions of personal responsibility were perceived as relevant in specific clinical settings. The most prominent argument in favour of personal health responsibility was grounded in the idea that holding patients responsible for their conduct would contribute to the efficient use of healthcare resources. Other arguments included fairness to others, desert and autonomy, but such standpoints were controversial and held only marginal relevance. CONCLUSIONS Our study provides important novel insights into the clinicians' beliefs about personal health responsibility improving the empirical knowledge concerning its fairness and potential applications to healthcare prioritisation. These findings suggest that although personal health responsibility would be difficult to implement as a steering criterion within the main priority setting framework, there might be clinical contexts where it could figure in prioritisation practices. Additional research on personal health responsibility would benefit from considering the multiple clinical encounters that shape doctor-patient relationships and that create the information basis for eligibility and prioritisation for treatment.
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Affiliation(s)
- Gloria Traina
- Department of Health Management and Health Economics, University of Oslo, Post box 1089 Blindern, 0317, Oslo, Norway.
| | - Eli Feiring
- Department of Health Management and Health Economics, University of Oslo, Post box 1089 Blindern, 0317, Oslo, Norway
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Frescos N, Copnell B. Podiatrists' views of assessment and management of pain in diabetes-related foot ulcers: a focus group study. J Foot Ankle Res 2020; 13:29. [PMID: 32493455 PMCID: PMC7268326 DOI: 10.1186/s13047-020-00399-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/22/2020] [Indexed: 02/08/2023] Open
Abstract
Background Contrary to the belief that patients with diabetes-related foot ulcers (DRFU) do not experience wound related pain due to the presence of peripheral neuropathy there is increasing evidence that pain can be present. Subsequently, wound-related pain is often underestimated and undertreated. The aim of this study is to describe what influences pain assessment of DRFU. Methods A qualitative exploratory study was conducted with podiatrists who managed DRFU. Eight podiatrists were recruited through a professional organisation to participate in a focus group. A thematic analysis was conducted to identify themes that explored the barriers and enablers to pain assessment and management of DRFU. Results Three themes emerged. Observational and non-verbal cues were the preferred approaches used to assess wound pain. Assumptions and value judgments of the pain patients experienced and the relationships between podiatrists, patients and other health care practitioners were important influencers on the assessment and management of pain. Conclusion The perceived barriers to the assessment and management of wound related pain in DRFU were attitudes and beliefs about pain, lack of DRFU-specific validated assessment tools and lack of knowledge and skills to manage the pain.
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Affiliation(s)
- Nicoletta Frescos
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, 3086, Australia.
| | - Bev Copnell
- Northern Clinical School, School of Nursing and Midwifery, Northern Centre for Health Education and Research, College of Science, Health and Engineering, La Trobe University, Melbourne, 3086, Australia
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Bradby H, Lindenmeyer A, Phillimore J, Padilla B, Brand T. 'If there were doctors who could understand our problems, I would already be better': dissatisfactory health care and marginalisation in superdiverse neighbourhoods. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:739-757. [PMID: 32020646 PMCID: PMC7318273 DOI: 10.1111/1467-9566.13061] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.
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Affiliation(s)
| | | | - Jenny Phillimore
- Institute for Research into Superdiversity (IRiS)School of Social PolicyUniversity of BirminghamBirminghamUK
| | - Beatriz Padilla
- Department of SociologyUniversity of South FloridaTampaUSA
- Instituto Universitario de Lisboa (ISCTE‐IUL)LisbonPortugal
| | - Tilman Brand
- Department Prevention and EvaluationLeibniz Institute for Prevention Research and Epidemiology – BIPSBremenGermany
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Allen C, Vassilev I, Kennedy A, Rogers A. The work and relatedness of ties mediated online in supporting long-term condition self-management. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:579-595. [PMID: 31769045 PMCID: PMC7078997 DOI: 10.1111/1467-9566.13042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The 'care transition' is characterised by reduced state involvement in chronic illness management in response to socio-political movements aimed at meeting the challenges presented by an increased prevalence of chronic illness. Amongst these changes has been online communities' rising importance in everyday interactions and attention is being increasingly paid towards the ways online contacts might contribute to self-management. Whilst research has illuminated the relevance of personal networks in long-term condition management, it is relevant to extend this work to consider the place of ties mediated online in this bricolage of support, including better understanding the work drawn from them and the strategies involved in eliciting it. This study examined the work and relatedness of 30 participants, who used online communities. Participants were asked about the role of on and offline ties and ego network mapping was used to frame conversations about the nature of this support. The context of engagement followed three main themes. Participants drew from online communities in response to deficits in offline support, they used online ties to leverage support or action from offline ties and they used online ties to substitute offline support, with less intimate online ties.
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Affiliation(s)
- Chris Allen
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) WessexSchool of Health SciencesUniversity of SouthamptonSouthamptonUK
| | - Ivaylo Vassilev
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) WessexSchool of Health SciencesUniversity of SouthamptonSouthamptonUK
| | - Anne Kennedy
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) WessexSchool of Health SciencesUniversity of SouthamptonSouthamptonUK
| | - Anne Rogers
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) WessexSchool of Health SciencesUniversity of SouthamptonSouthamptonUK
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Glenn JE, Bennett AM, Hester RJ, Tajuddin NN, Hashmi A. "It's like heaven over there": medicine as discipline and the production of the carceral body. HEALTH & JUSTICE 2020; 8:5. [PMID: 32036547 PMCID: PMC7007681 DOI: 10.1186/s40352-020-00107-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/30/2020] [Indexed: 05/12/2023]
Abstract
BACKGROUND Correctional systems in several U.S. states have entered into partnerships with Academic Medical Centers (AMCs) to provide healthcare for people who are incarcerated. This project was initiated to better understand medical trainee perspectives on training and providing healthcare services to prison populations at one AMC specializing in the care of incarcerated patients: The University of Texas Medical Branch at Galveston (UTMB). We set out to characterize the attitudes and perceptions of medical trainees from the start of their training until the final year of Internal Medicine residency. Our goal was to analyze medical trainee perspectives on caring for incarcerated patients and to determine what specialized education and training is needed, if any, for the provision of ethical and appropriate healthcare to incarcerated patients. RESULTS We found that medical trainees grapple with being beneficiaries of a state and institutional power structure that exploits the neglected health of incarcerated patients for the benefit of medical education and research. The benefits include the training opportunities afforded by the advanced pathologies suffered by persons who are incarcerated, an institutional culture that generally allowed students more freedom to practice their skills on incarcerated patients as compared to free-world patients, and an easy compliance of incarcerated patients likely conditioned by their neglect. Most trainees failed to recognize the extreme power differential between provider and patient that facilitates such freedom. CONCLUSIONS Using a critical prison studies/Foucauldian theoretical framework, we identified how the provision/withholding of healthcare to and from persons who are incarcerated plays a major role in disciplining incarcerated bodies into becoming compliant medical patients and research subjects, complacent with and even grateful for delayed care, delivered sometimes below the standard best practices. Specialized vulnerable-population training is sorely needed for both medical trainees and attending physicians in order to not further contribute to this exploitation of incarcerated patients.
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Affiliation(s)
- Jason E. Glenn
- Department of History and Philosophy of Medicine, University of Kansas Medical Center, Kansas City, KS 66160 USA
| | - Alina M. Bennett
- Regional Ethicist, Kaiser Permanente, Northern California, Oakland, CA 94612 USA
| | - Rebecca J. Hester
- Department of Science, Technology and Society, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061 USA
| | - Nadeem N. Tajuddin
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX 77030 USA
| | - Ahmar Hashmi
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50220 Thailand
- Shoklo Malaria Research Unit, Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110 Thailand
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16
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Hill TE. Inadequate Health Care in U.S. Prisons. Ann Intern Med 2019; 171:523-524. [PMID: 31569238 DOI: 10.7326/l19-0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Terry E Hill
- Hill Physicians Medical Group, San Ramon, California (T.E.H.)
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Abstract
BACKGROUND Positive organizational characteristics are conducive to healthy work environments. Hospitals with positive organizational characteristics and healthy work environments attract nurses. In turn, positive organizational characteristics and healthy work environments in hospitals will result in positive nurse, patient, and organizational outcomes. AIM The aim of this study was to assess hospital organizational characteristics from the viewpoint of registered nurses (RNs) in the country of Jordan. METHODS The researcher used a survey method to conduct the study; the Revised Nursing Work Index (NWI-R) was used to collect data, utilizing a convenience sample of 308 RNs with a total response rate of 75%. FINDINGS The strongest positive hospital organizational characteristic was the presence of adequate support services which allow nurses to spend time with their patients. The strongest negative hospital organizational characteristics were the nursing delivery systems-particularly in primary nursing where they result in nurses having to do things that are against their nursing judgment-and the limited opportunities and freedom over many aspects of nursing care and unit/ward decisions. CONCLUSIONS Positive hospital organizational characteristics should be maintained because these produce positive nurse, patient, and organizational outcomes. Fostering a positive hospital organizational environment is a continuous effort. The results have implications for practice, research, and education.
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Affiliation(s)
- Majd T Mrayyan
- Faculty of Nursing, The Hashemite University, Zarqa, Jordan
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18
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Individuals With Opioid Dependence Using Polysubstances: How Do They Experience Acute Hospital Care and What Are Their Needs? A Qualitative Study. J Addict Nurs 2019; 30:177-184. [PMID: 31478965 DOI: 10.1097/jan.0000000000000294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioid dependence accompanied by polysubstance use is a chronic illness with severe somatic, psychological and social consequences for those affected. International studies have shown that healthcare provision is inadequate for this population because of stigmatization and lack of expertise among medical professionals. It must be assumed that this is also the case in acute care settings of hospitals in German-speaking areas of Switzerland. To date, there are few studies addressing these patients' experiences that could provide data for targeted interventions. AIMS This qualitative study explored this patient population's perspective in terms of their experiences and needs regarding care provision in acute hospitals. The results should offer potential adaptations to care provision for this vulnerable group of individuals. METHODS Twelve individuals with opioid dependence using polysubstances were interviewed in two urban substitution centers. The data analysis of the material obtained was undertaken using qualitative content analysis according to Mayring. RESULTS As a whole, individuals with opioid dependence using polysubstances are not dissatisfied with care provided in acute hospitals as long as their relationship with health professionals is positive. Substitution medication is critically important to their treatment, but this group's experiences with its management during hospitalization continue to show widespread stigmatization along with inadequate knowledge and interprofessional collaboration and a failure to integrate these patients and their expertise into treatment and care. CONCLUSIONS AND FUTURE DIRECTIONS The treatment of individuals with substance-related disorders in acute hospitals requires staff with somatic and psychiatric training. In this regard, the principles of evidence-based models of reducing harm and multiprofessional treatment teams should be seen as particularly well suited and promising.
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Khatibi A, Mazidi M. Observers' impression of the person in pain influences their pain estimation and tendency to help. Eur J Pain 2019; 23:936-944. [PMID: 30620147 DOI: 10.1002/ejp.1361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Estimation of a patient's pain may have a considerable impact on the level of care that patient receives. Many studies have shown that contextual factors may influence an observer's pain estimation. Here, we investigate the effect of an observer's impression of a person in pain and justification of his/her pain on the observer's pain estimation, tendency to help and perceived empathy. METHODS Thirty healthy individuals (half females) read scenarios aimed to manipulate the reader's impression of characters who ultimately were fired from their work (four positive characters and four negative; half females). Then they observed 1-s videos of four levels of pain expression (neutral, mild, moderate, strong) in those characters during an examination. Subsequently, they rated pain estimation, tendency to help and perceived empathy. Afterwards, they rated their likability of characters and how just they find the end of story. RESULTS People rated pain in positive characters higher than the pain in negative characters. They also expressed more tendency to help and a higher level of perceived empathy towards positive characters than negative characters. For the highest level of pain in positive characters, perceived injustice towards that person was the best predictor of the observer's pain estimation, tendency to help and perceived empathy. For negative characters, dislikeability was the best predictor of tendency to help and perceived empathy. Justification of their pain was a predictor of pain estimation and tendency to help. CONCLUSION Observers used different information to evaluate pain in positive and negative individuals. SIGNIFICANCE Observers' estimation of pain, perceived empathy and tendency to help biases by their understanding of the characteristics of the person in pain. In clinical settings, these biases may influence the quality of care and well-being of patients. Understanding the underlying mechanisms of these biases can help us improve the quality of care and control the effect of prejudices on pain assessment.
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Affiliation(s)
- Ali Khatibi
- Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Mahdi Mazidi
- Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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20
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Fix GM, Hyde JK, Bolton RE, Parker VA, Dvorin K, Wu J, Skolnik AA, McInnes DK, Midboe AM, Asch SM, Gifford AL, Bokhour BG. The moral discourse of HIV providers within their organizational context: An ethnographic case study. PATIENT EDUCATION AND COUNSELING 2018; 101:2226-2232. [PMID: 30131263 PMCID: PMC7819576 DOI: 10.1016/j.pec.2018.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts. METHODS Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes. RESULTS We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges. CONCLUSIONS AND PRACTICE IMPLICATIONS When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Justeen K Hyde
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Brandeis University, The Heller School for Social Policy and Management, Waltham, MA, USA
| | - Victoria A Parker
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Peter T. Paul College of Business & Economics, University of New Hampshire, Durham, NH, USA
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - Juliet Wu
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - Avy A Skolnik
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (ci2i), VA Palo Alto HCS, Palo Alto, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (ci2i), VA Palo Alto HCS, Palo Alto, CA, USA; Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Theou O, Campbell S, Malone ML, Rockwood K. Older Adults in the Emergency Department with Frailty. Clin Geriatr Med 2018; 34:369-386. [DOI: 10.1016/j.cger.2018.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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22
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Blackwell CW. Reducing Risk: Counseling Men Infected with HIV Who Have Sex with Men on Safer Sex Practices with Seroconcordant Partners. SOCIAL WORK IN PUBLIC HEALTH 2018; 33:271-279. [PMID: 29634459 DOI: 10.1080/19371918.2018.1454869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The incidence of new HIV infections in the United States continues to be greatest among men who have sex with men (MSM). MSM infected with HIV often seek seroconcordant sexual partners based on intent to limit psychosocial, legal, and health risks they perceive as higher with serodiscordant sexual partners. However, the rationales for limiting sexual relationships exclusively with other MSM infected with HIV may be rooted in misinformation or misperception. Thus, these clients may have a unique sexual health knowledge deficit that nurses, social workers, and other clinicians need to address to help them reduce risk. This article focuses on sexually related health risks that are distinct to MSM infected with HIV seroconcordant partners. Data on the most recent HIV-infection incidence rates in MSM in the United States is provided. Discussion concentrates on the risk these individuals may have in communicating and acquiring sexually transmitted diseases other than HIV, the risk of HIV superinfection, and how sexually transmitted diseases affect persons who are immunocompromised differently than those who are immunocompetent. Finally, recommendations for healthcare professionals who counsel MSM infected with HIV in sexual decision making is provided.
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Dominicé Dao M. Vulnerability in the clinic: case study of a transcultural consultation. JOURNAL OF MEDICAL ETHICS 2018; 44:167-170. [PMID: 27343284 DOI: 10.1136/medethics-2015-103337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/19/2016] [Accepted: 06/07/2016] [Indexed: 06/06/2023]
Abstract
Discrimination and inequalities in healthcare can be experienced by many patients due to many characteristics ranging from the obviously visible to the more subtly noticeable, such as race and ethnicity, legal status, social class, linguistic fluency, health literacy, age, gender and weight. Discrimination can take a number of forms including overt racist statement, stereotyping or explicit and implicit attitudes and biases. This paper presents the case study of a complex transcultural clinical encounter between the mother of a young infant in a highly vulnerable social situation and a hospital healthcare team. In this clinical setting, both parties experienced difficulties, generating explicit and implicit negative attitudes that heightened into reciprocal mistrust, conflict and distress. The different factors influencing their conscious and unconscious biases will be analysed and discussed to offer understanding of the complicated nature of human interactions when faced with vulnerability in clinical practice. This case vignette also illustrates how, even in institutions with long-standing experience and many internal resources to address diversity and vulnerability, cultural competence remains a constant challenge.
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Friesen P. Personal responsibility within health policy: unethical and ineffective. JOURNAL OF MEDICAL ETHICS 2018; 44:53-58. [PMID: 27660291 DOI: 10.1136/medethics-2016-103478] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 06/27/2016] [Accepted: 08/28/2016] [Indexed: 05/22/2023]
Abstract
This paper argues against incorporating assessments of individual responsibility into healthcare policies by expanding an existing argument and offering a rebuttal to an argument in favour of such policies. First, it is argued that what primarily underlies discussions surrounding personal responsibility and healthcare is not causal responsibility, moral responsibility or culpability, as one might expect, but biases towards particular highly stigmatised behaviours. A challenge is posed for proponents of taking personal responsibility into account within health policy to either expand the debate to also include socially accepted behaviours or to provide an alternative explanation of the narrowly focused discussion. Second, a critical response is offered to arguments that claim that policies based on personal responsibility would lead to several positive outcomes including healthy behaviour change, better health outcomes and decreases in healthcare spending. It is argued that using individual responsibility as a basis for resource allocation in healthcare is unlikely to motivate positive behaviour changes, and is likely to increase inequality which may lead to worse health outcomes overall. Finally, the case of West Virginia's Medicaid reform is examined, which raises a worry that policies focused on personal responsibility have the potential to lead to increases in medical spending overall.
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Supporting HIV prevention and reproductive goals in an HIV-endemic setting: taking safer conception services from policy to practice in South Africa. J Int AIDS Soc 2017; 20:21271. [PMID: 28361506 PMCID: PMC5577693 DOI: 10.7448/ias.20.2.21271] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction: Safer conception care encompasses HIV care, treatment and prevention for persons living with HIV and their partners who desire children. In 2012, South Africa endorsed a progressive safer conception policy supporting HIV-affected persons to safely meet reproductive goals. However, aside from select research-supported clinics, widespread implementation has not occurred. Using South Africa as a case study, we identify key obstacles to policy implementation and offer recommendations to catalyse expansion of these services throughout South Africa and further afield. Discussion: Four key implementation barriers were identified by combining authors’ safer conception service delivery experiences with available literature. First, strategic implementation frameworks stipulating where, and by whom, safer conception services should be provided are needed. Integrating safer conception services into universal test-and-treat (UTT) and elimination-of-mother-to-child-transmission (eMTCT) priority programmes would support HIV testing, ART initiation and management, viral suppression and early antenatal/eMTCT care engagement goals, reducing horizontal and vertical transmissions. Embedding measurable safer conception targets into these priority programmes would ensure accountability for implementation progress. Second, facing an organizational clinic culture that often undermines clients’ reproductive rights, healthcare providers’ (HCP) positive experiences with eMTCT and enthusiasm for UTT provide opportunities to shift facility-level and individual attitudes in favour of safer conception provision. Third, safer conception guidelines have not been incorporated into HCP training. Combining safer conception with “test-and-treat” training would efficiently ensure that providers are better equipped to discuss clients’ reproductive goals and support safer conception practices. Lastly, HIV-affected couples remain largely unaware of safer conception strategies. HIV-affected populations need to be mobilized to engage with safer conception options alongside other HIV-related healthcare services. Conclusion: Key barriers to widespread safer conception service provision in South Africa include poor translation of policy into practical and measurable implementation plans, inadequate training and limited community engagement. South Africa should leverage the momentum and accountability associated with high priority UTT and eMTCT programmes to reinvigorate implementation efforts by incorporating safer conception into implementation and monitoring frameworks and associated HCP training and community engagement activities. South Africa’s experiences should be used to inform policy development and implementation processes in other HIV high-burden countries.
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Stigma Reduction Training Improves Healthcare Provider Attitudes Toward, and Experiences of, Young Marginalized People in Bangladesh. J Adolesc Health 2017; 60:S35-S44. [PMID: 28109339 DOI: 10.1016/j.jadohealth.2016.09.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 09/15/2016] [Accepted: 09/28/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE Working with health providers to reduce HIV stigma in the healthcare setting is an important strategy to improve service utilization and quality of care, especially for young people who are sexually active before marriage, are sexual minorities, or who sell sex. A stigma reduction training program for health providers in Bangladesh was evaluated. METHODS A cohort of 300 healthcare providers were given a self-administered questionnaire, then attended a 2-day HIV and sexual and reproductive health and rights training (including a 90-minute session on stigma issues). Six months later, the cohort repeated the survey and participated in a 1-day supplemental training on stigma, which included reflection on personal values and negative impacts of stigma. A third survey was administered 6 months later. A cross-sectional survey of clients age 15-24 years was implemented before and after the second stigma training to assess client satisfaction with services. RESULTS Provider agreement that people living with HIV should be ashamed of themselves decreased substantially (35.3%-19.7%-16.3%; p < .001), as did agreement that sexually active young people (50.3%-36.0%-21.7%; p < .001) and men who have sex with men (49.3%-38.0%-24.0%; p < .001) engage in "immoral behavior." Young clients reported improvement in overall satisfaction with services after the stigma trainings (63.5%-97.6%; p < .001). CONCLUSIONS This study indicates that a targeted stigma reduction intervention can rapidly improve provider attitudes and increase service satisfaction among young people. More funding to scale up these interventions is needed.
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Le Roux E, Gottot S, Aupiais C, Girard T, Teixeira M, Alberti C. Professional's Perspectives on Care Management of Young People with Perinatally Acquired HIV during Transition: A Qualitative Study in Adult Care Setting. PLoS One 2017; 12:e0169782. [PMID: 28114376 PMCID: PMC5256933 DOI: 10.1371/journal.pone.0169782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/21/2016] [Indexed: 12/30/2022] Open
Abstract
Background Increasing numbers of young people with perinatally acquired HIV are surviving to adulthood. When they come of age, they leave pediatric services in which they were followed and have to be transferred to the adult health care system. Difficulties in adaptation to adult care and the numbers of young people lost to follow up after transfer to adult care have been reported. This transition phase and their retention in adult care are crucial in maintaining the clinical status of these young with HIV in adulthood. Our study aimed to explore how HIV professionals working in adult care perceive and adapt their practices to young people in transition. Methods Qualitative interviews were conducted with 18 health and social services professionals in hospitals or patient associations in France. A thematic analysis was conducted. Results Adult care professionals were found to be making a distinction between these young people and their patients who were infected during adulthood. On the basis of the healthcare teams’ experience, a simplified categorization of these young people into four levels can be used: those “who have everything good”; those who have some deficiencies that must be addressed; those “who have everything bad”; and those lost to follow up. Professionals interviewed highlighted the difficulties they encountered with young people in transition. Three types of problematic situations were identified: problems of acceptance of the disease; communication problems; and problems of disorientation in the new care environment. Conclusions Despite the lack of specific training or national policy recommendations for the integration of young people with perinatally acquired HIV into adult services, all the adult healthcare teams interviewed tried to adapt their practice to this population. The results suggested that professional involvement during transition should depend on the characteristics of the patient, not be limited to a single transition model and that a dedicated structure for transition care is not appropriate for all young people.
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Affiliation(s)
- Enora Le Roux
- Université Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris, France
- Inserm, ECEVE U1123 and CIC-EC, CIC 1426, Paris, France
- * E-mail:
| | - Serge Gottot
- Université Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris, France
- Inserm, ECEVE U1123 and CIC-EC, CIC 1426, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Unité d’épidémiologie clinique, Paris, France
| | - Camille Aupiais
- Université Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris, France
- Inserm, ECEVE U1123 and CIC-EC, CIC 1426, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Unité d’épidémiologie clinique, Paris, France
| | - Thomas Girard
- Assistance Publique-Hôpitaux de Paris, Hôpital de l'Hôtel-Dieu, Unité Guy Mocquet, Paris, France
| | - Maria Teixeira
- Université Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris, France
- Inserm, ECEVE U1123 and CIC-EC, CIC 1426, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Unité d’épidémiologie clinique, Paris, France
| | - Corinne Alberti
- Université Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris, France
- Inserm, ECEVE U1123 and CIC-EC, CIC 1426, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Unité d’épidémiologie clinique, Paris, France
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Attitudes and Behaviours of Health Workers and the Use of HIV/AIDS Health Care Services. Nurs Res Pract 2016; 2016:5172497. [PMID: 28116154 PMCID: PMC5225383 DOI: 10.1155/2016/5172497] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/07/2016] [Accepted: 09/20/2016] [Indexed: 11/21/2022] Open
Abstract
Background. This article discusses how health workers relate to and communicate with clients of VCT and ART treatment. It also looks at how health worker practices in the form of attitudes and behaviours towards clients influence the use of these services. Methods. In-depth interviews, informal conversations, and participant observation were used to collect data from health workers providing VCT and ART and clients who access these services in two Ghanaian hospitals. Results. The study found that health workers providing these services, with the exception of a few, generally showed positive attitudes and behaviours towards clients during clinical encounters. Health workers warmly received clients to the facilities, addressing clients with courtesy, advising clients on a wide range of issues, sometimes supporting clients financially, and comfortably interacting with them. This is contrary to the findings of most studies in the literature that health workers often do not communicate and relate to these patients well. Conclusion. It concludes that dealing with clients well during interactions in the centres and clinics is crucial for reducing the perceived stigma associated with the use of services and increasing use as part of the national effort to reduce the infection rate of the disease in Ghana.
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Shapiro J, Rakhra P, Wong A. The stories they tell: How third year medical students portray patients, family members, physicians, and themselves in difficult encounters. MEDICAL TEACHER 2016; 38:1033-1040. [PMID: 27010769 DOI: 10.3109/0142159x.2016.1147535] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Physicians have long had patients whom they have labeled "difficult", but little is known about how medical students perceive difficult encounters with patients. METHODS In this study, we analyzed 134 third year medical students' reflective essays written over an 18-month period about difficult student-patient encounters. We used a qualitative computerized software program, Atlas.ti to analyze students' observations and reflections. RESULTS Main findings include that students described patients who were angry and upset; noncompliant with treatment plans; discussed "nonmedical" problems; fearful, worried, withdrawn, or "disinterested" in their health. Students often described themselves as anxious, uncertain, confused, and frustrated. Nevertheless, they saw themselves behaving in empathic and patient-centered ways while also taking refuge in "standard" behaviors not necessarily appropriate to the circumstances. Students rarely mentioned receiving guidance from attendings regarding how to manage these challenging interactions. CONCLUSIONS These third-year medical students recognized the importance of behaving empathically in difficult situations and often did so. However, they often felt overwhelmed and frustrated, resorting to more reductive behaviors that did not match the needs of the patient. Students need more guidance from attending physicians in order to approach difficult interactions with specific problem-solving skills while maintaining an empathic, patient-centered context.
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Affiliation(s)
- Johanna Shapiro
- a Department of Family Medicine , University of California Irvine School of Medicine , Orange , CA , USA
| | - Pavandeep Rakhra
- b College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, College of Osteopathic Medicine , Kansas City , MO , USA
| | - Adrianne Wong
- c California State University , Fullerton , CA , USA
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Developing Brief Opportunistic Interactions: practitioners facilitate patients to identify and change health risk behaviours at an early preventive stage. Prim Health Care Res Dev 2015; 17:319-32. [PMID: 26586240 DOI: 10.1017/s1463423615000511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
UNLABELLED Aim To identify shortcomings in existing models of patient behaviour change, and present the development and testing of a novel approach using practitioner facilitation and person-focussed conversations that identifies and addresses behaviours at an earlier stage than current models. BACKGROUND Systematic strategies used by health professionals to change patient behaviours began with motivational interviewing and brief intervention approaches for serious addictive behaviours. Practitioners typically presume they should drive the process of patient behaviour change. Attempts to transfer these approaches to primary care, and a broader range of health risk behaviours, have been less successful. The TADS programme (Tobacco, Alcohol and Other Drugs, later Training and Development Services) began teaching motivational interviewing and brief interventions to practitioners in New Zealand in 1996. Formal and informal evaluations showed that practitioners used screening tools that patients rejected and that led to incomplete disclosure, used language that did not engage patients, failed to identify the behaviours patients wished to address and therefore misdirected interventions. METHODS Iterative development of new tools with input from patients and primary care clinicians. Findings The TADS programme developed a questionnaire whose results remained private to the patient, which enabled the patient to identify personal behaviours that they might choose to change (the TADS Personal Assessment Choice Tool). This was assisted by a brief conversation that facilitated and supported any change prioritised by the patient (the TADS Brief Opportunistic Interaction). The need for this approach, and its effectiveness, appeared to be similar across adults, youth, different ethnic groups and people in different socio-economic circumstances. Behaviours patients identified were often linked to other health risk behaviours or early-stage mental health disorders that were not easily detected by practitioner-driven screening or inquiry. The long-term effectiveness of this approach in different populations in primary health care settings requires further evaluation.
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Aultman J, Wurzel R. Recognizing and Alleviating Moral Distress Among Obstetrics and Gynecology Residents. J Grad Med Educ 2014; 6:457-62. [PMID: 26279769 PMCID: PMC4535208 DOI: 10.4300/jgme-d-13-00256.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 01/29/2014] [Accepted: 02/16/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Obstetrics and gynecology residents face difficult clinical situations and decisions that challenge their moral concepts. OBJECTIVE We examined how moral and nonmoral judgments about patients are formulated, confirmed, or modified and how moral distress may be alleviated among obstetrics-gynecology residents. METHODS Three focus groups, guided by open-ended interview questions, were conducted with 31 obstetrics-gynecology residents from 3 academic medical institutions in northeast Ohio. Each focus group contained 7 to 14 participants and was recorded. Two investigators independently coded and thematically analyzed the transcribed data. RESULTS Our participants struggled with 3 types of patients perceived as difficult: (1) patients with chronic pain, including patients who abuse narcotics; (2) demanding and entitled patients; and (3) irresponsible patients. Difficult clinical encounters with such patients contribute to unalleviated moral distress for residents and negative, and often inaccurate, judgment made about patients. The residents reported that they were able to prevent stigmatizing judgments about patients by keeping an open mind or recognizing the particular needs of patients, but they still felt unresolved moral distress. CONCLUSIONS Moral distress that is not addressed in residency education may contribute to career dissatisfaction and ineffective patient care. We recommend education and research on pedagogical approaches in residency education in a model that emphasizes ethics and professional identity development as well as the recognition and alleviation of moral distress.
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Bright FAS, Kayes NM, Worrall L, McPherson KM. A conceptual review of engagement in healthcare and rehabilitation. Disabil Rehabil 2014; 37:643-54. [DOI: 10.3109/09638288.2014.933899] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Fitzgerald RP, Legge M, Frank N. When biological scientists become health-care workers: emotional labour in embryology. Hum Reprod 2013; 28:1289-96. [PMID: 23508251 DOI: 10.1093/humrep/det051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY QUESTION Can biological scientists working in medically assisted reproduction (MAR) have a role as health-care workers and, if so, how do they engage in the emotional labour commonly associated with health-care work? SUMMARY ANSWER The scientists at Fertility Associates (FA) in New Zealand perform the technical and emotional cares associated with health-care work in an occupationally specific manner, which we refer to as a hybrid care style. Their emotional labour consists of managing difficult patients, 'talking up' bad news, finding strategies to sustain hope and meaning, and 'clicking' or 'not clicking' with individual patients. WHAT IS KNOWN ALREADY Effective emotional labour is a key component of patient-centred care and is as important to the experience of high-quality MAR as excellent clinical and scientific technique. STUDY DESIGN, SIZE, DURATION This is a qualitative study based on open-ended interviews and ethnographic observations with 14 staff in 2 laboratories conducted over 2 separate periods of 3 weeks duration in 2007. Analysis of fieldnotes and interviews was conducted using thematic analysis and an NVivo qualitative database and compared for consistency across each interviewer. PARTICIPANTS/MATERIALS, SETTING, METHODS The participants were consenting biological scientists working in one of the two laboratories. Semi-structured interviews were conducted in 'quiet' work times, and supervised access was allowed to all parts of the laboratories and meeting places. Opportunities for participant review of results and cross comparison of independent analysis by authors increases the faithfulness of fit of this account to laboratory life. MAIN RESULTS AND THE ROLE OF CHANCE The study suggests that emotional labour is a part of routinized scientific labour in MAR laboratories for FA. LIMITATIONS, REASONS FOR CAUTION This is a qualitative study and thus the findings are not generalizable to populations beyond the study participants. WIDER IMPLICATIONS OF THE FINDINGS While little has been published of the emotional component of scientist's working lives, there may be a New Zealand style of doing scientific work in MAR laboratories which is patient centred and which incorporates much higher patient contact and involvement than is experienced in other laboratories. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by a research grant from the University of Otago and was also partly funded by a Marsden Grant administered by the Royal Society of New Zealand. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- R P Fitzgerald
- Department of Anthropology and Archaeology, Te Tari Mātai Tikanga Tangata o Nāianei me Onamata, University of Otago, PO Box 56, Dunedin 9054, New Zealand.
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Monks R, Topping A, Newell R. The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: a grounded theory study. J Adv Nurs 2012; 69:935-46. [DOI: 10.1111/j.1365-2648.2012.06088.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Rob Monks
- School of Health; University of Central Lancashire; Preston; UK
| | - Annie Topping
- Centre for Health and Social Care Research; University of Huddersfield; UK
| | - Rob Newell
- Nursing Research & Knowledge Transfer; University of Bradford; UK
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Cohen M, Quintner J, Buchanan D, Nielsen M, Guy L. Stigmatization of Patients with Chronic Pain: The Extinction of Empathy. PAIN MEDICINE 2011; 12:1637-43. [DOI: 10.1111/j.1526-4637.2011.01264.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Quintner J, Buchanan D, Cohen M. Maldynia as a Moral Judgment? PAIN MEDICINE 2011; 12:1130; author reply 1131, 1132-3. [DOI: 10.1111/j.1526-4637.2011.01174.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Giordano J. Respice...prospice: philosophy, ethics and medical care- past, present, and future. Philos Ethics Humanit Med 2010; 5:17. [PMID: 21062432 PMCID: PMC2991273 DOI: 10.1186/1747-5341-5-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 11/09/2010] [Indexed: 05/20/2023] Open
Affiliation(s)
- James Giordano
- Potomac Institute for Policy Studies 901 N. Stuart St. Suite 900 Arlington, VA 22203, USA
- Oxford Centre for Neuroethics Uehiro Centre for Practical Philosophy University of Oxford OX1, 1PT Oxford, UK
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