Group supervision for healthcare professionals within primary care for patients with psychosomatic health problems: a pilot intervention study.

BACKGROUND: In primary health care, efficacious treatment strategies are lacking for these patients, although the most prominent symptoms accounting for consultation in primary care often cannot be related to any biological causes. AIM: The aim was to explore whether group supervision from a specific phenomenological theory of psychosomatics could provide healthcare professionals treating patients with psychosomatic health issues within primary care a deeper understanding of these conditions and stimulate profession-specific treatment strategies. Our research questions were as follows: (i) What is the healthcare professionals' understanding of psychosomatics before and after the intervention? (ii) What are the treatment strategies for this group of patients before and after the intervention? METHODS: The study was an explorative qualitative intervention pilot study. The six participants from a primary healthcare setting in a medium-sized city in Sweden participated in the study. A supervision group was formed, based on a mix of professions, age, gender and years of clinical experience. Supervision consisted of one 75-minutes meeting every month during the course of 6 months. Participants were interviewed before and after the supervision intervention. FINDINGS: The study showed two distinct categories emerged from the data. One category of healthcare professionals espoused a psycho-educative approach, while the other lacked a cohesive approach. The supervision improved the second category of healthcare professionals' understanding of psychosomatics. The psycho-educative group did not change their understanding of psychosomatics, although they felt strengthened in their approach by the supervision. Profession-specific strategies were not developed. IMPLICATIONS: This pilot study indicates that a relatively short supervision intervention can aid clinicians in their clinical encounters with these patients; however, further research is necessary to ascertain the value of the specific phenomenologically based supervision intervention.

Communication skills in nursing: A phenomenologically-based communication training approach.

The aim of this article is to present a communication skills training curriculum for nursing students, based upon phenomenology. Research shows that nurses have difficulty prioritizing dialogue with patients, due to lack of time, organizational and cultural factors. Like other health care professionals, nurses may also have difficulties communicating with patients due to personal fears and shortcomings. The communication training curriculum based upon phenomenology aims at systematically training students to stay focused upon patients' and relatives' narratives, allowing them to reflect upon and better understand their current situation. This approach to communication is applicable in any clinical situation where it important to provide space for the patients' experiences. The philosophical principles guiding the training are presented here as well as the practical steps in the program. Finally, the approach is compared to other common communication methods used in nursing (motivational interviewing, caring conversations, empathy training). The authors hope that the article will highlight the nurses' role as dialogue partner as well as emphasize the importance of communication skills training in nursing education. This approach can be refined, tested and modified in future research and may serve as an inspirational model for creating a generic communicative competence for nurses. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Adaptation to a changed body. Experiences of living with long-term pelvic girdle pain after childbirth.

PURPOSE: To explore how women experience living with long-term pregnancy-related pelvic girdle pain. MATERIALS AND METHODS: Nine women with persistent pregnancy-related pelvic girdle pain of 2-13 years were recruited by means of purposive sampling from long-term follow-up studies. The women were 28-42 years of age and had given birth to 2-3 children. Audio-taped in-depth interview with open-ended questions were used with the guiding question 'How do you experience living with pregnancy-related pelvic girdle pain?'. The Empirical Phenomenological Psychological method was chosen for analysis. RESULTS: The pregnancy-related pelvic girdle pain syndrome has a profound impact on everyday life for many years after pregnancy. Three constituents were identified as central to the experience of living with pregnancy-related pelvic girdle pain: (1) the importance of the body for identity, (2) the understanding of pain, and (3) stages of change. The manner in which the women experienced their pain was interpreted in terms of two typologies: the ongoing struggle against the pain, and adaptation and acceptance. CONCLUSION: The participants' narratives highlighted that the pain led to severe functional limitations that threatened their capability to perform meaningful daily activities, and interfered with their sense of identity. It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome. IMPLICATIONS FOR REHABILITATION Chronic pregnancy-related pelvic girdle pain • Pregnancy-related pelvic girdle pain impairs women's capacity to perform meaningful activities of daily life for many years after pregnancy. • The participants' narratives highlighted that the pain interfered with their sense of identity. • It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome.

Experiences of moving with persistent pain--a qualitative study from a patient perspective.

OBJECTIVE: The aim of the present study was to use a phenomenological approach to explore how patients with persistent musculoskeletal pain experienced moving with their pain. DESIGN: In-depth interviews were performed by a physical therapy researcher with many years' experience with the rehabilitation of patients with persistent musculoskeletal pain. SETTING: The patients took part in individual rehabilitation at two different physical therapy departments. All but one patient opted to be interviewed in a room at the physical therapy department. METHOD: The sample was purposive and consisted of 10 Swedish outpatients with heterogeneous nonmalignant persistent musculoskeletal pain. SUBJECTS: The interviews were analyzed according to a qualitative method known as the Empirical Phenomenological Psychological (EPP) method. The results were coded, analyzed, and described in typologies. RESULTS: The experience of moving with pain implied much more than pure physical movement. Pain was a threatening challenge to the informants' existence and identity. Three typologies were identified: failed adaptation, identity restoration, and finding the way out. CONCLUSIONS: In conclusion, to move with persistent pain was described by the informants as having deep existential impact on the individual's life. It was also evident that all of the informants experienced a dramatic change in their identity. These experiences would most likely affect the patients' chances of recovery. To help him/her through the rehabilitation process, we need to extend our knowledge about what it means to the patient in an existential context to be unable to move as before.

Meanings of "acceptance" for patients with long-term pain when starting rehabilitation.

PURPOSE: The study aimed to elucidate the meaning of acceptance in relation to the lived body and sense of self when entering a pain rehabilitation programme. METHODS: Six women and three men with long-term pain were interviewed. The interviews were analysed according to interpretative phenomenological analysis. RESULTS: The analysis revealed three different meaning structures, first: acceptance as a process of personal empowerment, "the only way forward". Here, the individuals expressed that the body felt integrated: a trusting cooperation between self and body gave rise to hope. Second: acceptance as an equivocal project, a possible but challenging way forward. The hopeful insight was there, acknowledging that acceptance was the way to move forward, but there was also uncertainty and doubt about one's ability with a body ambiguous and confusing, difficult but important to understand. Third, in acceptance as a threat and a personal failure, "no way forward" the integration of the aching body in sense of self was impossible and pain was incomprehensible, unacceptable and unfair. Pain was the cause of feeling stuck in the body, affecting the sense of self and the person's entire life. CONCLUSIONS: The meaning of acceptance was related to acceptance of the persistency of pain, to how the individual related to the lived body and the need for changes in core aspects of self, and to the issue of whether to include others in the struggle of learning to move on with a meaningful life. IMPLICATIONS FOR REHABILITATION: Healthcare professionals should be aware that individuals with long-term pain conceptualize and hold different meanings of acceptance when starting rehabilitation; this should be considered and addressed in rehabilitation programmes. The meaning given to acceptance is related to the experience of the lived body and the sense of self, as well as to getting legitimization/acceptance by others; therefore these aspects need to be considered during rehabilitation. The process of achieving acceptance seems to embrace different processes which can be understood as, and facilitated by, an embodied learning process. The bodily existential challenges presented in the present study, for example to develop an integrated and cooperative relationship with the painful body, can inspire health professionals to develop interventions and communication strategies focusing on the lived body. A wide range of competencies in rehabilitation clinics seems to be needed.

Body awareness in persons diagnosed with rheumatoid arthritis.

Living with rheumatoid arthritis (RA) poses physiological and psychological demands on a person. RA is a autoimmune disease that can cause pain, disability, and suffering. The ability to notice bodily inner sensations and stimuli (body awareness, BA) is described in the literature in ways that could have either a positive or a negative impact on a person's health. The concept of BA is complex and a thorough understanding is needed about what BA means from the patient's perspective. This study was therefore conducted to acquire greater insight into this phenomenon. The study is grounded in a phenomenological life-world perspective. Eighteen narrative interviews were conducted in patients (age range 23-78 years) with RA. The interviews were analyzed using the Empirical Phenomenological Psychological method. General characteristics were found running through all 18 interviews, indicating that the disease resulted in a higher degree of negatively toned BA. BA was either a reactive process of searching or controlling after disease-related symptoms or a reactive process triggered by emotions. BA was an active process of taking an inventory of abilities. All participants had the ability to shift focus from BA to the outside world. Four typologies were identified: "A reactive process on symptoms," "A reactive process on emotional triggers," "An active process of taking an inventory of abilities," and "A shifting from BA to the outside world." In conclusion, because BA can be both positively and negatively toned, health care professionals must have a good understanding of when BA is positive and when it is negative in relation to the patient. RA had caused a higher degree of negatively toned BA. Thus, the ability to shift attention from BA to activity in the outside world could sometimes be beneficial for the patient's general health.

Regaining health and wellbeing after traumatic spinal cord injury.

OBJECTIVE: Traumatic spinal cord injury is typically a devastating event, leading to permanent physical disability. Despite the severity of the condition, many persons with traumatic spinal cord injury manage to lead both active and independent lives. The aim of this study was to investigate the experience of health and wellbeing of persons living with a traumatic spinal cord injury for at least 20 years. DESIGN AND METHODS: A qualitative design was used. Data was analysed using a phenomenological-hermeneutical method. Rich narratives were obtained from 14 persons with paraplegia due to traumatic spinal cord injury sustained at least 20 years ago. RESULTS: The key finding was that health and wellbeing were attained when persons were able to perceive themselves as being "normal" in everyday relationships and circumstances. The normalization process involved learning to negotiate and/or prevent potentially embarrassing situations by acting in a "parallel world", covertly "behind the scenes". CONCLUSION: The subjective experience of wellbeing and health after traumatic spinal cord injury depends upon the ability to prevent or resolve potentially embarrassing situations without this being noticed by others. Performing this work "behind the scenes", enables persons with traumatic spinal cord injury to interact smoothly with others and thereby be perceived as normal, despite substantial disability.

My prosthesis as a part of me: a qualitative analysis of living with an osseointegrated prosthetic limb.

BACKGROUND: Bone-anchored prosthesis is still a rather unusual treatment for patients with limb loss. OBJECTIVES: The aim of this study was to improve our understanding about the experience of living with an osseointegrated prosthesis (OI-prosthesis) compared to one suspended with a socket, through the use of qualitative research methodology. STUDY DESIGN: A qualitative phenomenological research method. METHODS: Thirteen Swedish patients (37-67 years) with unilateral upper or lower limb amputation (10 transfemoral, 2 transhumeral, 1 transradial), who had been using OI-prostheses for 3 to 15 years, were recruited by means of purposive sampling. An audio-taped in-depth interview was performed. The guiding question was 'How do you experience living with your osseointegrated prosthesis compared to your earlier prostheses suspended with sockets?'. The empirical phenomenological psychological method was used for data analysis. RESULTS: The results showed that all participants described living with an OI-prosthesis as a revolutionary change. These experiences were described in terms of three typologies, called 'Practical prosthesis', 'Pretend limb' and 'A part of me'. CONCLUSIONS: The most important finding was that the change went beyond the functional improvements, integrating the existential implications in the concept of quality of life. CLINICAL RELEVANCE: This qualitative in-depth interview study on patients using bone-anchored prosthetic limbs showed that all described a revolutionary change in their lives as amputees and the meaning of that change went beyond the functional improvements, integrating existential implications in the concept of quality of life.

Embodiment and chronic pain: implications for rehabilitation practice.

Throughout the Western world people turn towards the health care system seeking help for a variety of psychosomatic/psychosocial health problems. They become "patients" and find themselves within a system of practises that conceptualizes their bodies as "objective" bodies, treats their ill health in terms of the malfunctioning machine, and compartmentalizes their lived experiences into medically interpreted symptoms and signs of underlying biological dysfunction. The aim of this article is to present an alternative way of describing ill health and rehabilitation using the philosophy of Maurice Merleau-Ponty in order to deepen our understanding of the rehabilitation process. I will explore how the experience of chronic pain ruptures the natural connection between body and world and how the rehabilitation process can be understood as the re-insertion of the body into the flow of experience, where the body "disappears" into its natural silence in order to allow the world to once again unfold. The experience of chronic pain places the painful body in focus, resulting in a diminished articulation of both self and world. Persons with illness suffer not only from the physical aspects of pain and discomfort but also from a loss of identity where one feels alienated and detached from things that used to give meaning to ones life. Rehabilitation must not only address the material (medical) body but also the diminished sense of self as well as the retreat from the world outside of the painful body.

Meaning out of chaos: a way to understand chronic pain.

Pain is a multidimensional phenomenon lying at the intersection between biology and culture. The modern understanding of pain takes into account emotional, psychological, socio-political and existential aspects of pain as well as physiological, anatomical factors. Our aim in this study was to deepen the understanding of psychosocial, existential aspects of pain and to discuss how clinicians can better understand and treat patients with chronic pain. A focus group was formed consisting of a researcher and a group of clinicians (n = 3) with various backgrounds working at a specialized pain clinic. The group met once a month during a 6-month period. Questions concerning the life-world of the pain patient as well as inquiries into the conditions for 'the good clinical encounter' were investigated. The results of this study consist of a systematization of the data (focus group meetings) collected and analysed in a collaborative effort between the researcher and group participants. The findings are presented in terms of themes. The main metaphor used to describe the path from the seeking of medical help to successful rehabilitation was order out of chaos. Ordering chaos was a process moving from diagnosis through a phase of heightened self-awareness towards responsibility-taking on the part of the patient. Related themes presented, illustrated and discussed in the paper concern problems of linkage, the role of flexibility and creativity in the healing process and the kind of clinical encounter conducive for the journey from chaos to the creation of new meaning.