An institutional ethnography of chronic pain management in family medicine (COPE) study protocol

Rhetorics and Realities of Access in Community Mental Health Care

Recent discourse emphasizes the need to integrate social and structural determinants of health-such as poverty, violence, houselessness, and discrimination-into mental health care service design and delivery. This study investigates how psychiatric-mental health nurse practitioners (PMHNPs) navigate the conflicting demands of an efficiently organized clinic and the realities of patients experiencing chronic mental illness along with structural adversity. Using an institutional ethnographic approach, this research focused on the everyday work practices of nine PMHNPs in outpatient community mental health clinics in a major American city. The findings revealed disjunctures within two powerful discourses related to patient access to care that circulate in mental health settings: (1) "every door is an open door," and (2) "meeting people where they are." PMHNPs believe in the values promoted by the rhetoric while also being required to work outside institutional structures to meet real patient needs. By illustrating how the institutional coordination expected to improve health systems overlooks PMHNPs' expert knowledge, we highlight how addressing the "structural determinants of health" in clinical care for people with serious mental illnesses remains an ideological aspiration. We call for a reevaluation of mental health care practices and systemic transformation through the informed, ground-level interventions of PMHNPs.

Surgical safety checklist compliance process as a moral hazard: An institutional ethnography

BACKGROUND

Charting is an essential component of professional nursing practice and is arguably a key element of patient safety in surgery: without proper, objective, and timely documentation, both benign and tragical errors can occur. From surgery on wrong patients to wrong limbs, to the omission of antibiotics administration, many harms can happen in the operating room. Documentation has thus served as a safeguard for patient safety, professional responsibility, and professional accountability. In this context, we were puzzled by the practices we observed with respect to charting compliance with the surgical safety checklist (SSC) during a study of surgical teams in a large, urban teaching hospital in Canada (pseudonym 'C&C').

METHODS

This article leverages institutional ethnography and a subset of data from a larger study to describe and explain the social organisation of the system that monitored surgical safety compliance at C&C from the standpoint of operating room nurses. This data included fieldnotes from observations of 51 surgical cases, on-the-spot interviews with nurses, formal interviews with individuals who were involved in the design and implementation of the SSC, and open-ended questions from two rounds of survey of OR teams.

FINDINGS

We found that the compliance form and not the SSC itself formed the basis for reporting. To meet hospital accuracy in charting goals and legislated compliance documentation reporting requirements nurses 'pre-charted' compliance with the surgical checklist. The adoption of this workaround technically violated nursing charting principles and put them in ethically untenable positions.

CONCLUSIONS

Documenting compliance of the SSC constituted a moral hazard, constrained nurses' autonomy and moral agency, and obscured poor checklist adherence. The findings highlight how local and extra local texts, technologies and relations create ethical issues, raise questions about the effectiveness of resulting data for decision-making and contribute to ongoing conversations about nursing workarounds.

Chronic Struggle: An Institutional Ethnography of Chronic Pain and Marginalization

There have been several recent calls to re-think chronic pain in response to the growing awareness of social inequities that impact the prevalence of chronic pain and its management. This in turn has resulted in new explorations of suffering as it relates to pain. While laudable, many of these clinically oriented accounts are abstract and often fail to offer a critical theoretical understanding of social and structural inequities. To truly rethink pain, we must also reconsider suffering, beginning in the everyday expert knowledge of people with chronic pain who can offer insights in relation to their bodies and also the organization of the social circumstances in which they live. Our team undertook a sociological approach known as institutional ethnography (IE) to explicate the work of people in managing lives beset by chronic pain and the inequities that stem from marginalization. In keeping with our critical paradigm, we describe participant accounts as situated, rather than lived, to de-emphasize the individual in favour of the social and relational. Through our analysis, we offer a new concept of chronic struggle to capture how pain, illness, economic deprivation, and suffering constitute a knot of experience that people living with chronic pain are obliged to simplify in order to fit existing logics of medicine. Our goal is to identify the social organization of chronic pain care which underpins experience in order to situate the social as political rather than medical or individual. PERSPECTIVE: This article explicates the health work of people living with chronic pain and marginalization, drawing on their situated experience. We offer the concept of chronic struggle as a conceptualization that allows us to bring into clear view the social organization of chronic pain in which the social is visible as political and structural rather than medical or individual.

Ethnography in health professions education: Slowing down and thinking deeply

CONTEXT

Ethnography has been gaining appreciation in the field of health professions education (HPE) research, yet it remains misunderstood. Our article contributes to this growing literature by describing some of the key tensions with which both aspiring and seasoned ethnographers should productively struggle.

METHODS

We respond to the injunction made by Varpio et al (2017) that HPE researchers should ground their methodological ventures in their historical and philosophical tenets. To do so, we first review core ethnographic texts that provide a background for ethnographic research in HPE, then provide an orienting definition to bind the specificities of ethnographic research. Finally, we review core theoretical and practical considerations for ethnographic research.

RESULTS

Ethnography is a slow and deep approach to knowledge production, and as such it requires careful engagement with theory and deliberate choice of methods. Core theoretical tensions include the ontological, epistemological and axiological dimensions of ethnography, and concerns with quality and rigour. Practical tensions include the scope and remit of ethnography, the importance of observing naturally occurring behaviour and the crafting of rich field notes.

CONCLUSIONS

We encourage ethnographers to pursue scholarship that challenges the status quo. Ethnographers should favour deep encounters with research participants, dig deep into the cultural and structural aspects of HPE and be reflexive about knowledge outputs. At a time in HPE when the pressures to publish are high, using ethnography as a research methodology offers an opportunity to slow down and think deeply.

The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings

Purpose

Chronic disease is a global concern. While ample research has aimed to identify the epidemiology of multimorbidity and patient complexity using administrative data, little attention has been paid to the processes of care that treating complex patients entail. Consequently, the concept of patient complexity itself does not directly speak to how challenging it may be to care for a given patient. The purpose of this study was to investigate how primary care providers define, encounter, and manage complex patients, especially those with chronic pain. To our knowledge, this is the first study to move beyond general narrative descriptions of complexity towards an interrogation that is grounded in the work practices of caring for these patients.

Methods

We undertook an institutional ethnography (IE) in Ontario, Canada. IE uses people’s everyday work problems as the starting point for an exploration of the often-invisible social relations that orient experiences. Grounded in the everyday experience of primary care providers, we draw here on 51 interviews that were collected as part of our larger IE study, to interrogate the utility of definitions of patient complexity as medical multimorbidity.

Findings

Care providers consider patients challenging due to their socio-economic status more so than their medical problems alone. Our data shows that patients’ issues are often bound up with poverty, trauma, and mental health concerns, and are challenging for health care providers in part because the interventions needed exceed the scope of their medical expertise, while social issues render the treatment of potentially straightforward medical problems complicated. This was especially so for patients with chronic pain.

Conclusion

Defining patient complexity as morbidity alone is inadequate; such models neglect syndromes and conditions that are not included in formal disease classifications. Chronic pain should be included among the chronic conditions that are considered to constitute multimorbidity. In order to provide effective patient-centered care, discussions of patient complexity must also attend to the complex social and economic circumstances in which many patients live and include broader issues of inequity and social justice. This approach would enable policies to better support primary care providers who struggle to manage their patients with complex needs across domains of physiological health, mental health, and the quality of their living conditions, and in so doing improve the care that patients receive.

Promoting healthy eating in primary health care from the perspective of health professionals: a qualitative comparative study in the context of South America

BACKGROUND

Educational interventions designed to promote healthy eating are essential in primary health care. Nevertheless, given the nutrition controversies about what is healthy, the contradictions created by the media, and the situation of users with complex needs, the prioritization of the themes to be addressed in the services has scarcely been described in the planning process. This study aimed to identify the process of implementing the themes discussed by health professionals in nutrition education groups in two primary health care models.

METHODS

Our study followed a qualitative comparative approach. It included the systematic observation of nutrition education group meetings to identify the key messages addressed and semi-structured interviews with health professionals in São Paulo, Brazil, and in Bogotá, Colombia. We used thematic networks to classify the messages and the collective subject discourse technique to organize the information obtained from interviews. We observed 28 nutrition education groups in São Paulo, and 13 in Bogotá, and conducted 27 interviews with nutritionists in each city.

RESULTS

The messages identified were grouped into four global themes: feeding habits, life cycle, disease, and "being a multiplier". The process of implementing the themes, understood as identification, selection, consultation, and application of themes, is intermediated by social representations of the health professionals about service requirements, training and professional performance, and the relationship with users. Two notions shape these representations: Control, although the time and the physical space dedicated to health services are restricted to the disease in São Paulo, in Bogotá only limited health promotion is provided; and specificity, which is portrayed as therapeutic support within a more educational model in São Paulo and as health promotion training courses within a prescriptive model in Bogotá.

CONCLUSIONS

Understanding the process of implementing the themes discussed in nutrition education groups can reveal mechanisms that support the approach to themes on healthy eating, including communicative and educational adaptations of health professionals. This study contributes to the discussion about educational models in health care and their effects on the qualifications of health professionals within the service, especially those included in the context of low- and middle-income settings.

Medical Trainees' Experiences of Treating People With Chronic Pain: A Lost Opportunity for Medical Education

PURPOSE

Evidence suggests that physicians' opinions about patients with chronic pain become progressively negative over the course of medical training, leading to decline in empathy for these patients. Few qualitative studies have focused on this issue, and thus the experiences shaping this process remain unexplored. This study addressed how medical trainees learn about chronic pain management through informal and formal curricula.

METHOD

This study adopted a constructive qualitative approach informed by the theoretical lens of the hidden curriculum. Thirteen open-ended interviews were conducted with medical students and residents at various training stages; interviewees had experience treating patients with chronic pain, shadowing the care of these patients, or both. Interviews elicited information about stage of medical training, general descriptions of work, and concrete experiences of managing patients with chronic pain. All interviews were collected in Toronto between June and August 2015.

RESULTS

Most interviewees described the management of chronic pain as challenging and unrewarding and attributed this at least in part to their perception that pain was subjective. Trainees also recounted that their inability to cure chronic pain left them confused about how to provide care, and voiced a perception that preceptors seemed to view these patients as having little educational value.

CONCLUSIONS

Specifically because chronic pain is subjective and incurable, listening and communication become crucial for patient care. Instead of sheltering trainees, medical educators should be offered the opportunity to reflect on the skills that are required to provide patient-centered care for this population. This approach has the potential to greatly benefit both trainees and patients.

From Opiophobia to Overprescribing: A Critical Scoping Review of Medical Education Training for Chronic Pain

BACKGROUND

Chronic pain is a significant health problem strongly associated with a wide range of physical and mental health problems, including addiction. The widespread prevalence of pain and the increasing rate of opioid prescriptions have led to a focus on how physicians are educated about chronic pain. This critical scoping review describes the current literature in this important area, identifying gaps and suggesting avenues for further research starting from patients' standpoint.

METHODS

A search of the ERIC, MEDLINE, and Social Sciences Abstracts databases, as well as 10 journals related to medical education, was conducted to identify studies of the training of medical students, residents, and fellows in chronic noncancer pain.

RESULTS

The database and hand-searches identified 545 articles; of these, 39 articles met inclusion criteria and underwent full review. Findings were classified into four inter-related themes. We found that managing chronic pain has been described as stressful by trainees, but few studies have investigated implications for their well-being or ability to provide empathetic care. Even fewer studies have investigated how educational strategies impact patient care. We also note that the literature generally focuses on opioids and gives less attention to education in nonpharmacological approaches as well as nonopioid medications.

DISCUSSION

The findings highlight significant discrepancies between the prevalence of chronic pain in society and the low priority assigned to educating future physicians about the complexities of pain and the social context of those afflicted. This suggests the need for better pain education as well as attention to the "hidden curriculum."

Blurring the boundaries: using institutional ethnography to inquire into health professions education and practice

CONTEXT

Qualitative, social science approaches to research have surged in popularity within health professions education (HPE) over the past decade. Institutional ethnography (IE) offers the field another sociological approach to inquiry. Although widely used in nursing and health care research, IE remains relatively uncommon in the HPE research community. This article provides a brief introduction to IE and suggests why HPE researchers may wish to consider it for future studies.

METHODS

Part 1 of this paper presents IE's conceptual grounding in: (i) the entry point to inquiry ('materiality'), (ii) a generous definition of 'work' and (iii) a focus on how 'texts' such as policies, forms and written protocols influence activity. Part 2 of this paper outlines the method's key features through exemplars from our own research. Part 3 discusses the ways in which research that blurs the lines between educational and clinical practice can be both generative for HPE and accomplished using IE.

RESULTS

The authors demonstrate the usefulness of IE for studying complex social issues in HPE. It is posited that a key added value of IE is that it goes beyond individual-level explanations of problems and phenomena, yet also closely studies individuals' activities, rather than remaining at an abstract or distant level of analysis. Thereby, IE can result in feasible and meaningful social change at the nexus of health professions education and other social systems such as clinical practice.

CONCLUSIONS

IE adds to the growing qualitative research toolkit for HPE researchers. It is worth considering because it may enable change through the study of HPE in relation to other social processes, structures and systems, including the clinical practice world. A particular benefit may be found in blending HPE research with research on clinical practice, toward changing practice and policy through IE, given the interrelated nature of these fields.