Displacement: Critical insights from flood-affected children

Little is known about how children and young people are affected by evacuation following flooding. Participatory research using creative methods allowed us to elicit flood stories and recovery pathways over time. We found that children's relationships with space and place were severely challenged following evacuation from home. They suffered losses, including loss of agency, friendship networks and familiar space. They experienced distress, anxiety and disillusionment with societal responses. Sustained attention by flood risk and recovery agencies is required to address children's ongoing needs following evacuation. From policymakers recognition is overdue that young people are citizens who already contribute to community flood response and so need to be more explicitly consulted and included in the development of flood risk management.

Principles for telemedicine and telecare: The perspective of a citizens’ panel

Ten delegates at the conference Voluntarism, Health and Social Care were recruited to form a panel of citizens to debate and offer direction for the future of technologically mediated health care. The panel suggested various principles for the development of telemedicine and telecare, concerning: patients, users and carers, approach to service delivery, research and knowledge, and conditions of use. Many of the principles echoed the founding values of the National Health Service, yet have arguably been absent from both policy pronouncements and the telemedicine literature, which largely views new health technologies themselves as ‘value free’, i.e. developed untouched by social and political relations. A programme of citizens’ panels should be developed so that an informed debate can take place about the development of telemedicine and telecare, to underpin policy and practice.

Factors affecting the adoption of telehealthcare in the United Kingdom: the policy context and the problem of evidence

The adoption of telehealthcare in the United Kingdom has been slow and fragmented. This paper presents a structural explanation for this by contrasting contending themes in recent UK health policy. It is argued that the conflict between trends towards modernizationand demands for evidence-based practicehave made it difficult for a major policy agency to emerge that can sponsor service development, and so proponents of telehealthcare have been forced to situate their work within the domain of R&D. This has led to a fragmented field of practice characterized by short-term and small-scale projects.

Evaluation of new technologies in health-care systems: what’s the context?

Evaluation is an essential component of the introduction of new technologies, treatment modalities and models of service delivery across the health-care sector. Such work attracts significant levels of public funding, but little attention has been paid to understanding evaluation as more than a set of applied methodological activities. This paper sets out an agenda for a more complex and richer understanding of evaluation as a set of professional and organizational dynamics.

Ethical implications of home telecare for older people: a framework derived from a multisited participative study

CONTEXT

Telecare and telehealth developments have recently attracted much attention in research and service development contexts, where their evaluation has predominantly concerned effectiveness and efficiency. Their social and ethical implications, in contrast, have received little scrutiny.

OBJECTIVE

To develop an ethical framework for telecare systems based on analysis of observations of telecare-in-use and citizens' panel deliberations.

DESIGN

Ethnographic study (observation, work shadowing), interviews, older citizens' panels and a participative conference.

SETTING

Participants' homes, workplaces and familiar community venues in England, Spain, the Netherlands and Norway 2008-2011.

RESULTS

Older respondents expressed concerns that telecare might be used to replace face-to-face/hands-on care to cut costs. Citizens' panels strongly advocated ethical and social questions being considered in tandem with technical and policy developments. Older people are too often excluded from telecare system design, and installation is often wrongly seen as a one-off event. Some systems enhance self-care by increasing self-awareness, while others shift agency away from the older person, introducing new forms of dependency.

CONCLUSIONS

Telecare has care limitations; it is not a solution, but a shift in networks of relations and responsibilities. Telecare cannot be meaningfully evaluated as an entity, but rather in the situated relations people and technologies create together. Characteristics of ethical telecare include on-going user/carer engagement in decision making about systems: in-home system evolution with feedback opportunities built into implementation. System design should be horizontal, 'two-way'/interactive rather than vertical or 'one-way'. An ethical framework for telecare has been developed from these conclusions (Table 1).

Ovulation monitoring and reproductive heterosex: living the conceptive imperative?

Using biosensors, or devices that provide biological information to users about their own bodies, to map ovulation and time intercourse is a practice of rising significance in economically privileged countries. Based on an ethnographic study of ovulation biosensing, this paper explores the contradictions between device manufacturers' figurations of reproductive heterosex as a natural and pleasurable experience facilitated by fertility monitoring technology, and heterosexual women users' accounts of the pleasures and difficulties of ovulation monitoring and associated sexual encounters. Drawing on Science and Technology Studies and the concept of 'script', we examine the frameworks of action defined by makers of ovulation biosensors and how these are accepted, refused or remade by users. Within the scientific romance configured by manufacturers, reproductive heterosex emerges as exciting and fun, whilst the hard, 'technical' work of conception is done by ovulation technologies. Yet ovulation monitoring is described by many heterosexual women users as an exciting and yet anxiety-producing practice through which they come to know their bodies differently, often through online discussions with other women. Living a 'conceptive imperative', women engaging with ovulation sensing reconfigure their reproductive embodiment and shift their relationship to male partners in ways that reveal heterosexual 'baby-making' as a complex and nuanced practice worthy of critical engagement.

"Wrong, but useful": negotiating uncertainty in infectious disease modelling

For infectious disease dynamical models to inform policy for containment of infectious diseases the models must be able to predict; however, it is well recognised that such prediction will never be perfect. Nevertheless, the consensus is that although models are uncertain, some may yet inform effective action. This assumes that the quality of a model can be ascertained in order to evaluate sufficiently model uncertainties, and to decide whether or not, or in what ways or under what conditions, the model should be 'used'. We examined uncertainty in modelling, utilising a range of data: interviews with scientists, policy-makers and advisors, and analysis of policy documents, scientific publications and reports of major inquiries into key livestock epidemics. We show that the discourse of uncertainty in infectious disease models is multi-layered, flexible, contingent, embedded in context and plays a critical role in negotiating model credibility. We argue that usability and stability of a model is an outcome of the negotiation that occurs within the networks and discourses surrounding it. This negotiation employs a range of discursive devices that renders uncertainty in infectious disease modelling a plastic quality that is amenable to 'interpretive flexibility'. The utility of models in the face of uncertainty is a function of this flexibility, the negotiation this allows, and the contexts in which model outputs are framed and interpreted in the decision making process. We contend that rather than being based predominantly on beliefs about quality, the usefulness and authority of a model may at times be primarily based on its functional status within the broad social and political environment in which it acts.

Ageing with telecare: care or coercion in austerity?

In recent years images of independence, active ageing and staying at home have come to characterise a successful old age in western societies. 'Telecare' technologies are heavily promoted to assist ageing-in-place and a nexus of demographic ageing, shrinking healthcare and social care budgets and technological ambition has come to promote the 'telehome' as the solution to the problem of the 'age dependency ratio'. Through the adoption of a range of monitoring and telecare devices, it seems that the normative vision of independence will also be achieved. But with falling incomes and pressure for economies of scale, what kind of independence is experienced in the telehome? In this article we engage with the concepts of 'technogenarians' and 'shared work' to illuminate our analysis of telecare in use. Drawing on European-funded research we argue that home-monitoring based telecare has the potential to coerce older people unless we are able to recognise and respect a range of responses including non-use and 'misuse' in daily practice. We propose that re-imagining the aims of telecare and redesigning systems to allow for creative engagement with technologies and the co-production of care relations would help to avoid the application of coercive forms of care technology in times of austerity.

A new paradigm emerges from the study of de novo mutations in the context of neurodevelopmental disease

The study of de novo point mutations (new germline mutations arising from the gametes of the parents) remained largely static until the arrival of next-generation sequencing technologies, which made both whole-exome sequencing (WES) and whole-genome sequencing (WGS) feasible in practical terms. Single nucleotide polymorphism genotyping arrays have been used to identify de novo copy-number variants in a number of common neurodevelopmental conditions such as schizophrenia and autism. By contrast, as point mutations and microlesions occurring de novo are refractory to analysis by these microarray-based methods, little was known about either their frequency or impact upon neurodevelopmental disease, until the advent of WES. De novo point mutations have recently been implicated in schizophrenia, autism and mental retardation through the WES of case-parent trios. Taken together, these findings strengthen the hypothesis that the occurrence of de novo mutations could account for the high prevalence of such diseases that are associated with a marked reduction in fecundity. De novo point mutations are also known to be responsible for many sporadic cases of rare dominant mendelian disorders such as Kabuki syndrome, Schinzel-Giedion syndrome and Bohring-Opitz syndrome. These disorders share a common feature in that they are all characterized by intellectual disability. In summary, recent WES studies of neurodevelopmental and neuropsychiatric disease have provided new insights into the role of de novo mutations in these disorders. Our knowledge of de novo mutations is likely to be further accelerated by WGS. However, the collection of case-parent trios will be a prerequisite for such studies. This review aims to discuss recent developments in the study of de novo mutations made possible by technological advances in DNA sequencing.

Policy, practice and decision making for zoonotic disease management: water and Cryptosporidium

Decision making for zoonotic disease management should be based on many forms of appropriate data and sources of evidence. However, the criteria and timing for policy response and the resulting management decisions are often altered when a disease outbreak occurs and captures full media attention. In the case of waterborne disease, such as the robust protozoa, Cryptosporidium spp, exposure can cause significant human health risks and preventing exposure by maintaining high standards of biological and chemical water quality remains a priority for water companies in the UK. Little has been documented on how knowledge and information is translated between the many stakeholders involved in the management of Cryptosporidium, which is surprising given the different drivers that have shaped management decisions. Such information, coupled with the uncertainties that surround these data is essential for improving future management strategies that minimise disease outbreaks. Here, we examine the interplay between scientific information, the media, and emergent government and company policies to examine these issues using qualitative and quantitative data relating to Cryptosporidium management decisions by a water company in the North West of England. Our results show that political and media influences are powerful drivers of management decisions if fuelled by high profile outbreaks. Furthermore, the strength of the scientific evidence is often constrained by uncertainties in the data, and in the way knowledge is translated between policy levels during established risk management procedures. In particular, under or over-estimating risk during risk assessment procedures together with uncertainty regarding risk factors within the wider environment, was found to restrict the knowledge-base for decision-making in Cryptosporidium management. Our findings highlight some key current and future challenges facing the management of such diseases that are widely applicable to other risk management situations.

Uncertainties in the governance of animal disease: an interdisciplinary framework for analysis

Uncertainty is an inherent feature of strategies to contain animal disease. In this paper, an interdisciplinary framework for representing strategies of containment, and analysing how uncertainties are embedded and propagated through them, is developed and illustrated. Analysis centres on persistent, periodic and emerging disease threats, with a particular focus on cryptosporidiosis, foot and mouth disease and avian influenza. Uncertainty is shown to be produced at strategic, tactical and operational levels of containment, and across the different arenas of disease prevention, anticipation and alleviation. The paper argues for more critically reflexive assessments of uncertainty in containment policy and practice. An interdisciplinary approach has an important contribution to make, but is absent from current real-world containment policy.

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room

BACKGROUND

We aimed to describe how anaesthetists hand over information and professional responsibility to nurses in the operating theatre recovery room.

METHODS

We carried out non-participant practice observation and in-depth interviews with practitioners working in the recovery room of an English hospital and used qualitative methods to analyse the resulting transcripts.

RESULTS

We observed 45 handovers taking place between 17 anaesthetists and 15 nurses in the recovery room of the operating theatre suite. These took place in an environment that is event-driven, time-pressured, and prone to concurrent distractions. Anaesthetists and nurses often had differing expectations of the content and timing of information transfer. The point at which transfer of responsibility for the patient occurred during the handover process was variable and depended not only on the condition of the patient but also on the professional relationship between the nurse and doctor concerned. Handover also provided an 'audit point' in care where the patient's intraoperative progress was reviewed and plans were made for further management. Here, as in the transfer of responsibility, we found evidence that nurses play a greater role in defining the limits of anaesthetists' practice than might be expected.

CONCLUSIONS

Patient handovers in the recovery room are largely informal, but nevertheless show many inherent tensions, both professional and organizational. Although formalized handover procedures are often advocated for the promotion of safety, we suggest that they are likely to work best when the informal elements, and the cultural factors underlying them, are acknowledged.

Animal disease and human trauma: the psychosocial implications of the 2001 UK foot and mouth disease disaster

The 2001 UK foot and mouth disease (FMD) crisis is commonly understood to have been a nonhuman animal problem, an economic industrial crisis that was resolved after eradication. By using a different lens, a longitudinal ethnographic study of the health and social consequences of the epidemic, the research reported here indicates that 2001 was a human tragedy as well as an animal one. In a diary-based study, it can be seen that life after the FMD crisis was accompanied by distress, feelings of bereavement, fear of a new disaster, loss of trust in authority and systems of control, and the undermining of the value of local knowledge. Diverse groups experienced distress well beyond the farming community. Such distress remained largely invisible to the range of "official" inquiries into the disaster. That an FMD epidemic of the scale of 2001 could happen again in a developed country is a deeply worrying prospect, but it is to be hoped that contingency plans are evolving along with enhanced understanding of the human, animal, and financial cost.

Future patients? Telehealthcare, roles and responsibilities

Increasing use of information and communication technologies is said to be transforming health care. Telehealthcare enables medical consultations to be conducted between patients and health professionals across different locations. Such technologies imply new relationships between patients and health professionals. This study aimed to understand how policy and practice in relation to telehealthcare suggests new conceptualisations of 'the patient'. In-depth semistructured interviews (n = 38) were conducted with key informants from across the UK, known to have involvement or interest in telehealthcare from a variety of perspectives: health professionals (n = 11), patient advocates (n = 7), telemedicine experts (n = 6), policy-makers (n = 4), administrators (n = 4), researchers (n = 3) and technologists (n = 3). Interviews were conducted either in person or over the telephone, and were audio-recorded. Data were analysed thematically with ongoing cross-validation of data interpretation between members of the research team. The results indicated divergent views about the role of the patient, although accounts of patients becoming 'educated self-managers', taking on a more active role in their healthcare, were predominant. Beliefs about the impact of telehealthcare on patients were focused on perceived 'priorities' such as access, location of services, confidentiality and choice; however, there remains little understanding of the trade-offs that patients are willing to make in the context of technologically mediated health care. The results also highlight ideas around how patients relate to technologies; the extent to which technologies might fragment care and medicine in new or unexpected ways, and participation and absence of patients in decision-making about policies and services. The results of this study have important implications for the ways in which relationships between health professionals and patients are managed in practice, and raise important questions for public participation in service development.

What defines expertise in regional anaesthesia? An observational analysis of practice †

BACKGROUND

Published work on knowledge in regional anaesthesia has focused on competence, for instance by identifying numbers of procedures required to achieve competence, or by defining criteria for successful performance of blocks. We aimed to define expertise in regional anaesthesia and examine how it is acquired.

METHODS

We observed anaesthetists performing 15 regional anaesthetic blocks and analysed the resulting transcripts qualitatively and in detail.

RESULTS

Expertise in regional anaesthesia encompasses technical fluency but also includes non-cognitive skills such as handling of the patient (communicating, anticipating and minimizing discomfort) and recognizing the limits of safe practice (particularly deciding when to stop trying to insert a block). Such elements may be underplayed by the experts who possess them. Focusing on a small number of regional anaesthetic procedures in detail (as is standard with such qualitative analytical approaches) has also allowed us to develop a model for the acquisition of expertise. In this model, trainees learn how to balance theoretical and practical knowledge by reflection on their clinical experiences, an iterative process which leads to the embedding of knowledge in the expert's personal repertoire of individual techniques.

CONCLUSIONS

Expertise in regional anaesthesia extends beyond competence at technical performance; non-cognitive elements are also vital. Further work is needed to test our learning model, and the hypothesis that learning can be enhanced by deliberate promotion of the tacit elements of 'expertise' we have described.

Different public health geographies of the 2001 foot and mouth disease epidemic: ‘citizen’ versus ‘professional’ epidemiology

Recently, there have been calls for health geographers to add critical and theoretical debate to 'post-medical' geographies, whilst at the same time informing 'new' public health strategies (Soc. Sci. Med. 50(9)1273; Area 33(4) (2002) 361). In this paper we reflect on how, alongside 'professional epidemiologies', 'citizen epidemiologies' can have credibility in informing public health policy and practice. We do this by drawing on mixed method and participatory research that used a citizens' panel to articulate the health and social outcomes of the 2001 foot and mouth disease disaster. We consider the difficulties of creating dialogue between on the one hand, time-limited, discrete, theoretical, visible and by implication legitimate, 'professional' knowledge and on the other, ongoing, holistic, experiential and often hidden 'citizen' knowledge of the foot and mouth disease epidemic. Despite significant evidence that in disaster and crisis situations, people need to be actively involved in key 'recovery' decisions (see for example At Risk Natural Hazards, People's Vulnerability, and Disasters, Routledge, London; A New Species of Trouble, Norton, New York), lay accounts, which may in themselves provide valuable evidence about the impact of the disaster, are often ignored. If health geographers are to critically inform 'new' public health policy then we need to consider research approaches that give voice to citizens' understanding of health outcomes as well as those of professionals. If 'new' public health is concerned with the material character of health inequalities, with fostering 'healthy' living and working environments, the promotion of community participation and individual empowerment (Area 33(4) (2002) 361), then we argue that situated, negotiated, everyday geographies of lay epidemiologies can and should inform public health policy.

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting

BACKGROUND

This study aimed to explore how critical and acceptable practice are defined in anaesthesia and how this influences the discussion and reporting of adverse incidents. Method. We conducted workplace observations of, and interviews with, anaesthetists and anaesthetic staff. Transcripts were analysed qualitatively for recurrent themes and quantitatively for adverse events in anaesthetic process witnessed. We also observed departmental audit meetings and analysed meeting minutes and report forms.

RESULTS

The educational value of discussing events was well-recognized; 28 events were discussed at departmental meetings, of which 5 (18%) were presented as 'critical incidents'. However, only one incident was reported formally. Our observations of anaesthetic practice revealed 103 minor events during the course of over 50 anaesthetic procedures, but none were acknowledged as offering the potential to improve safety, although some were direct violations of 'acceptable' practice. Formal reporting appears to be constrained by changing boundaries of what might be considered 'critical', by concerns of loss of control over formally reported incidents and by the perception that reporting schemes outside anaesthesia have purposes other than education.

CONCLUSIONS

Despite clear official definitions of criticality in anaesthesia, there is ambiguity in how these are applied in practice. Many educationally useful events fall outside critical incident reporting schemes. Professional expertise in anaesthesia brings its own implicit safety culture but the reluctance to adopt a more explicit 'systems approach' to adverse events may impede further gains in patient safety in anaesthesia.

Psychosocial effects of the 2001 UK foot and mouth disease epidemic in a rural population: qualitative diary based study

OBJECTIVES

To understand the health and social consequences of the 2001 foot and mouth disease epidemic for a rural population.

DESIGN

Longitudinal qualitative analysis.

SETTING

North Cumbria, the worst affected area in Britain.

SAMPLE

Purposive sample of 54 respondents divided in six demographically balanced rural occupational and population groups.

MAIN OUTCOME MEASURES

3071 weekly diaries contributed over 18 months; 72 semistructured interviews (with the 54 diarists and 18 others); 12 group discussions with diarists

RESULTS

The disease epidemic was a human tragedy, not just an animal one. Respondents' reports showed that life after the foot and mouth disease epidemic was accompanied by distress, feelings of bereavement, fear of a new disaster, loss of trust in authority and systems of control, and the undermining of the value of local knowledge. Distress was experienced across diverse groups well beyond the farming community. Many of these effects continued to feature in the diaries throughout the 18 month period.

CONCLUSIONS

The use of a rural citizens' panel allowed data capture from a wide spectrum of the rural population and showed that a greater number of workers and residents had traumatic experiences than has previously been reported. Recommendations for future disaster management include joint service reviews of what counts as a disaster, regular NHS and voluntary sector sharing of intelligence, debriefing and peer support for front line workers, increased community involvement in disposal site or disaster management, and wider, more flexible access to regeneration funding and rural health outreach work.

Telecare: perspectives on the changing role of patients and citizens

We conducted a qualitative study in the UK to examine perspectives about telemedicine, telecare and e-health for the changing roles of patients and citizens. We believe there are important differences between these applications, but for simplicity, the term 'telecare' is used broadly here to include all three. In-depth, semistructured interviews were conducted between September 2002 and May 2004. Participants were 38 key informants from the UK, known to have involvement or interest in telecare: policy-makers, clinicians, technologists, health service managers, researchers and patient advocates. Interviews were conducted either in person or over the telephone, and were audio-recorded with participants' consent. The most frequently cited priorities for patients included accessibility to services, locations of care and quality of care, with some respondents emphasizing the importance of choice for the patient (in terms of appointments and ways of accessing services). However, telecare has implications for patients that go beyond issues of access. A major problem is that 'priorities' are assumed rather than based on an empirical understanding; moreover, for individual patients, preferences for particular forms of service delivery are likely to represent trade-offs between multiple priorities. The findings of the present study confirm that concepts of the patient's rights and responsibilities are changing with the increasing use of new technologies to deliver health care.

Communication between anesthesiologists, patients and the anesthesia team: a descriptive study of induction and emergence

PURPOSE

Although the importance of communication skills in anesthetic practice is increasingly recognized, formal communication skills training has hitherto dealt only with limited aspects of this professional activity. We aimed to document and analyze the informally-learned communication that takes place between anesthesia personnel and patients at induction of and emergence from general anesthesia.

METHODS

We adopted an ethnographic approach based principally on observation of anesthesia personnel at work in the operating theatres with subsequent analysis of observation transcripts.

RESULTS

We noted three main styles of communication on induction, commonly combined in a single induction. In order of frequency, these were: (1) descriptive, where the anesthesiologists explained to the patient what he/she might expect to feel; (2) functional, which seemed designed to help anesthesiologists maintain physiological stability or assess the changing depth of anesthesia and (3) evocative, which referred to images or metaphors. Although the talk we have described is nominally directed at the patient, it also signifies to other members of the anesthetic team how induction is progressing. The team may also contribute to the communication behaviour depending on the context. Communication on emergence usually focused on establishing that the patient was awake.

CONCLUSION

Communication at induction and emergence tends to fall into specific patterns with different emphases but similar functions. This communication work is shared across the anesthetic team. Further work could usefully explore the relationship between communication styles and team performance or indicators of patient safety or well-being.

Safe asleep? Human–machine relations in medical practice

In the process of anaesthesia the patient must surrender vital functions to the care of clinicians and machines who will act for, and advocate for the patient during the surgical procedure. In this paper, we discuss the practices and knowledge sources that underpin safety in a risky field in which many boundaries are crossed and dissolved. Anaesthetic practice is at the frontier not only of conscious/unconsciousness but is also at the human/machine frontier, where a range of technologies acts as both delegates and intermediaries between patient and practitioner. We are concerned with how practitioners accommodate and manage these shifting boundaries and what kinds of knowledge sources the 'expert' must employ to make decisions. Such sources include clinical, social and electronic which in their various forms demonstrate the hybrid and collective nature of anaesthetised patients. In managing this collective, the expert is one who is able to judge where the boundary lies between what is routine and what is critical in practice, while the junior must judge the personal limits of expertise in practice. In exploring the working of anaesthetic hybrids, we argue that recognising the changing distribution of agency between humans and machines itself illustrates important features of human authorship and expertise.

Towards a wireless patient: chronic illness, scarce care and technological innovation in the United Kingdom

'Modernization' is a key health policy objective in the UK. It extends across a range of public service delivery and organizational contexts, and also means there are radical changes in perspective on professional behaviour and practice. New information and communications technologies have been seen as one of the key mechanisms by which these changes can be engendered. In particular, massive investment in information technologies promises the rapid distribution and deployment of patient-centred information across internal organizational boundaries. While the National Health Service (NHS) sits on the edge of a pound sterling 6 billion investment in electronic patient records, other technologies find their status as innovative vehicles for professional behaviour change and service delivery in question. In this paper, we consider the ways that telemedicine and telehealthcare systems have been constructed first as a field of technological innovation, and more recently, as management solutions to problems around the distribution of health care. We use NHS responses to chronic illness as a medium for understanding these shifts. In particular, we draw attention to the shifting definitions of 'innovation' and to the ways that these shifts define a move away from notions of technological advance towards management control.

Access, boundaries and their effects: legitimate participation in anaesthesia

The distribution of work, knowledge and responsibilities in the delivery of anaesthesia has attained particular significance recently as attempts to meet the demands of the European Working Times Directive intensify existing pressures to reorganise anaesthetic services. Using Lave and Wenger's (1991) notions of 'legitimate peripheral participation' in 'communities of practice' (and Wenger 1998) to analyse ethnographic data of anaesthetic practice we illustrate how work and knowledge are currently configured, and when knowledge may legitimately be taken as the basis for action. The ability to initiate action, to prescribe healthcare interventions, we suggest, is a critical element in the organisation of anaesthetic practices and therefore central to any attempts to reshape the delivery of anaesthetic services.

Grounded citizens' juries: a tool for health activism?

Involving the public in decision-making has become a bureaucratic pre-occupation for every health agency in the UK. In this paper we offer an innovative approach for local participation in health decision-making through the development of a 'grounded' citizens' jury. We describe the process of one such jury commissioned by a Primary Care Group in the north-west of England, which was located in an area suffering intractable health inequalities. Twelve local people aged between 17 and 70 were recruited to come together for a week to hear evidence, ask questions and debate what they felt would improve the health and well-being of people living in the area. The jury process acted effectively as a grass-roots health needs assessment and amongst other outcomes, resulted in the setting up of a community health centre run by a board consisting of members of the community (including two jurors) together with local agencies. The methodology described here contrasts with that practiced by what we term 'the consultation industry', which is primarily interested in the use of fixed models to generate the public view as a standardized output, a product, developed to serve the needs of an established policy process, with little interest in effecting change. We outline four principles underpinning our approach: deliberation, integration, sustainability and accountability. We argue that citizens' juries and other consultation initiatives need to be reclaimed from that which merely serves the policy process and become 'grounded', a tool for activism, in which local people are agents in the development of policies affecting their lives.

Making monitoring 'work': human-machine interaction and patient safety in anaesthesia

This study aimed to explore the use of electronic monitoring within the context of anaesthetic practice. We conducted workplace observation of, and interviews with, anaesthetists and other anaesthetic staff in two UK hospitals. Transcripts were analysed inductively for recurrent themes. Whilst formal sources of knowledge in anaesthesia deal with the issue of monitoring in terms of theoretical principles and performance specifications of devices, anaesthetists in practice often 'disbelieve' monitoring information. They call on and integrate other sources of knowledge about the patient, especially from their clinical assessment. The ability to distinguish 'normal' and 'abnormal' findings is vital. Confidence in electronic information varies with experience, as does the degree to which electronic information may be considered 'redundant'. We conclude that electronic monitoring brings new dimensions of understanding but also the potential for new ways of misunderstanding. The tacit knowledge underlying the safe use of monitoring deserves greater acknowledgement in training and practice.

Integrating service development with evaluation in telehealthcare: an ethnographic study

OBJECTIVES

To identify issues that facilitate the successful integration of evaluation and development of telehealthcare services.

DESIGN

Ethnographic study using various qualitative research techniques to obtain data from several sources, including in-depth semistructured interviews, project steering group meetings, and public telehealthcare meetings.

SETTING

Seven telehealthcare evaluation projects (four randomised controlled trials and three pragmatic service evaluations) in the United Kingdom, studied over two years. Projects spanned a range of specialties-dermatology, psychiatry, respiratory medicine, cardiology, and oncology.

PARTICIPANTS

Clinicians, managers, technical experts, and researchers involved in the projects.

RESULTS AND DISCUSSION

Key problems in successfully integrating evaluation and service development in telehealthcare are, firstly, defining existing clinical practices (and anticipating changes) in ways that permit measurement; secondly, managing additional workload and conflicting responsibilities brought about by combining clinical and research responsibilities (including managing risk); and, thirdly, understanding various perspectives on effectiveness and the limitations of evaluation results beyond the context of the research study.

CONCLUSIONS

Combined implementation and evaluation of telehealthcare systems is complex, and is often underestimated. The distinction between quantitative outcomes and the workability of the system is important for producing evaluative knowledge that is of practical value. More pragmatic approaches to evaluation, that permit both quantitative and qualitative methods, are required to improve the quality of such research and its relevance for service provision in the NHS.

Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia

BACKGROUND

Expert professional practice in any field is known to rely on both explicit (formal) and tacit (personal) forms of knowledge. Current anaesthetic training programmes appear to favour explicit knowledge and measurable competencies. We aimed to describe and explore the way different types of knowledge are learned and used in anaesthetic practice.

METHOD

Qualitative approach using non-participant observation of, and semi-structured interviews with, anaesthetic staff in two English hospitals.

RESULTS

The development of expertise in anaesthesia rests on the ability to reconcile and interpret many sources of knowledge--clinical, social, electronic, and experiential--and formal theoretical learning. Experts have mastered technical skills but are also able to understand the dynamic and uncertain condition of the anaesthetized patient and respond to changes in it. This expertise is acquired by working with colleagues, and, importantly, by working independently, to develop personal routines. Routines mark the successful incorporation of new knowledge but also function as a defence against the inherent uncertainty of anaesthetic practice. The habits seen in experts' routines are preferred ways of working chosen from a larger repertoire of techniques which can also be mobilized as changing circumstances demand.

CONCLUSIONS

Opportunities for developing expertise are linked to the independent development of personal routines. Evidence-based approaches to professional practice may obscure the role played by the interpretation of knowledge. We suggest that the restriction of apprenticeship-style training threatens the acquisition of anaesthetic expertise as defined in this paper.

Health technology assessment in its local contexts: studies of telehealthcare

Health technology assessment (HTA) is one of the major research enterprises of late modernity, reaching into fields of previously autonomous professional practice, and critically interrogating the organisation and delivery of health care. The 'evaluation' of new health technologies within the field of HTA is increasingly a normative political expectation, as discourses of 'evidence-based' practice run through health policy in the UK and elsewhere. Despite its importance in governing the direction of innovation in health care delivery, there are hardly any empirical studies of HTA in practice. In this paper, we draw on two ethnographic studies of telehealthcare implementation and evaluation in the UK to explore the practical conduct of HTA, and we focus specifically on the social organisation and conduct of randomised controlled trials of these new technologies. The paper examines how evaluation forms a mediating set of practices that make the embedding or normalisation of a new technology possible; and present a simple model of the social and technical contingencies within the evaluation process.

Passing on tacit knowledge in anaesthesia: a qualitative study

OBJECTIVE

To explore the acquisition of knowledge in anaesthetic practice using qualitative methods.

METHODS

An ethnographic study examining the nature of expertise in anaesthesia in one English hospital. The study used qualitative research methods, including observation of anaesthetic practice and interviews with members of the anaesthetic team. An integral part of the study was a process of feedback to the anaesthetic team including presenting observational data and conducting debriefing interviews with individual team members.

RESULTS

The study highlights the continued importance of the clinical apprenticeship in passing on knowledge, but also emphasizes the central role of practising independently in the acquisition of skills. Anaesthetists who participated in debriefing interviews or read observational transcripts found the experience valuable for thinking about their own practice.

DISCUSSION

One suggestion arising from the use of qualitative methods in this setting is that the type of detailed, systematic observation and data recording used in this study could be beneficial in the training and, possibly, appraisal of anaesthetists. This novel and innovative application of qualitative methods in anaesthesia is described and discussed with a view to broadening the debate about specialist training.

Normative models of health technology assessment and the social production of evidence about telehealth care

Telehealthcare is a rapidly growing field of clinical activity and technical development. These new technologies have caught the attention of clinicians and policy makers because they seem to offer more rapid access to specialist care, and the potential to solve structural problems around inequalities of service provision and distribution. However, as a field of clinical practice, telehealthcare has consistently been criticised because of the poor quality of the clinical and technical evidence that its proponents have marshalled. The problem of "evidence" is not a local one. In this paper, we undertake two tasks: first, we critically contrast the normative expectations of the wider field of Health Technology Assessment (HTA) with those configured within debates about Telehealthcare Evaluation; and second, we critically review models that provide structures within which the production of evidence about telehealthcare can take place. Our analysis focuses on the political projects configured within a literature aimed at stabilising evaluative knowledge production about telehealthcare in the face of substantial political and methodological problems.

Ethics and ethnography: an experiential account

In this article, the authors discuss an ethical dilemma faced by the first author during the fieldwork of an ethnographic study of expertise in anesthesia. The example, written from the perspective of the first author, addresses a number of ethical issues commonly faced, namely, the researcher-researched relationship, anonymity and confidentiality, privacy, and exploitation. She deliberates on the influences that guided her decision and in doing so highlights some of the elements that combine to shape the data. The authors argue that this process of shaping the data is a symbiotic one in which the researcher and the community being studied construct the data together.

Dietary patterns and nutrient intakes of toddlers from low-income families in Denver, Colorado

Over a 2-year period, dietary and socioeconomic data were collected from 793 food records of 90 toddlers, aged 1 to 2 years, who were predominantly U.S. Hispanics living in low-income households in Denver, CO. This study was part of a larger investigation designed to assess the efficacy of vitamin and mineral supplements in young children. The toddlers were randomly assigned to one of five treatment groups: multivitamin; multivitamin and iron; multivitamin, iron, and zinc; multivitamin and zinc; or placebo. Three-day food records that were collected from the toddlers at the beginning of the study, at 3 months, and at 6 months were used to assess the dietary and nutrient intakes. Meal patterns were devised on the basis of the frequency of food consumption and common food combinations. Nutrient values were calculated using a diet analyzer program. Nutrient analysis of the toddlers' diets indicated that iron and magnesium were consumed least frequently, whereas more than adequate amounts of protein (193% of the Recommended Dietary Allowance) and sodium (207% of minimum requirements for healthy persons) were consumed. No significant differences in nutrient intakes were observed among the treatment groups, suggesting that the vitamin and mineral supplements had no effect. A difference in energy intake was observed over time with the 6-month and 3-month intakes significantly higher than the initial intakes. There was also a high consumption of carbonated beverages. Despite the low income levels of the families, these toddlers were consuming adequate amounts of food; however, an educational component aimed at reducing the toddlers' high intakes of protein, sodium, and carbonated drinks may help improve the present feeding practices of the mothers.