Holding space and transitional space: stroke survivors' lived experience of being on an acute stroke unit. A hermeneutic phenomenological study.

Despite substantial reorganisation of stroke unit provision in the United Kingdom, limited qualitative research has explored how stroke survivors experience the acute stroke unit. This hermeneutic phenomenological study used accounts from four stroke survivors who experienced one of two acute stroke units. Through detailed analysis, the acute stroke unit emerged as a meaningful space, in two distinct but interconnected forms. As holding space, the unit was understood to offer protection and safe haven, as the stroke survivors looked to cope and respond to the temporal, bodily, biographical disruption and significant vulnerability brought about by stroke and by being in hospital. Holding was fulfilled by different people (including their fellow stroke survivors) and reflected a human response to human need and existential vulnerability. This space, and the practices within it, functioned to hold them intimately but also at a distance from their prestroke lifeworld. As such, the acute stroke unit holding space was intertwined with how it supported, encouraged or provoked transition. In the transitional space of the acute stroke unit, stroke survivors described how they survived the hospital-healthcare space, stroke unit and poststroke space. This paper articulates how transition was meaningfully signified through its absence or presence, as they transformed, relinquished or re-asserted their 'self', and in one case, recovered whilst 'in there'. The findings of this study provide phenomenological insight into stroke survivors' lived experience, the meaningful holding and transitional contribution of the unit, and how these spatial forms were intertwined. These insights are discussed in relation to the existing evidence base and stroke unit provision.

Patients' expectations of osteopathic care: a qualitative study.

BACKGROUND: Research has shown that patients' expectations of health care and health-care practitioners are complex and may have a significant impact on outcomes of care. Little is known about the expectations of osteopathic patients. OBJECTIVES: To explore osteopathic patients' expectations of private sector care. DESIGN: Focus groups and individual interviews with purposively selected patients; this was the qualitative phase of a mixed methods study, the final phase being a patient survey. SETTING AND PARTICIPANTS: A total of 34 adult patients currently attending for treatment at private osteopathic practices across the United Kingdom. INTERVENTION: Focus group discussions and individual interviews around expectations before, during and after osteopathic care. OUTCOME MEASURES: Thematic analysis of text data to identify topics raised by patients and to group these into broad themes. RESULTS: Many components of expectation were identified. A preliminary conceptual framework describing the way the therapeutic encounter is approached in osteopathy comprised five themes: individual agency, professional expertise, customer experience, therapeutic process and interpersonal relationship. DISCUSSION AND CONCLUSION: The components of expectation identified in this phase of the study provided potential question topics for the survey questionnaire in the subsequent phase of the investigation. The model developed in this study may add a new perspective to existing evidence on expectations. Further research is recommended to test the findings both within private practice and the National Health Service.

Glaucoma awareness and access to healthcare: perceptions among glaucoma patients in Tanzania.

OBJECTIVE: To investigate the barriers to access to eye health services for patients with glaucoma in Tanzania with the aim of identifying key areas for improvement and further research. DESIGN: Qualitative investigation using face-to-face semi-structured interviews with patients recruited from the Kilimanjaro Christian Medical Centre (KCMC) outpatient eye clinic. This project is part of the international strategy of the Research into Glaucoma and Ethnicity (ReGAE) programme. METHODS: Interviews were conducted with the help of a translator; all data were transcribed in Swahili and then translated into English. Manual coding and qualitative analysis was used to identify major themes and relevant concepts. Data were collected during May and June 2013. MAIN OUTCOME MEASURES: Qualitative data on glaucoma awareness and access to healthcare. RESULTS: 12 patients (7 men, 5 women) of mean age 67.5 years (range 53-86 years) were interviewed. All participants had a previous diagnosis of glaucoma and no other eye conditions. The understanding of glaucoma was limited and the capacity for healthcare providers to improve glaucoma knowledge seemed underused. Participants had particular difficulty in understanding the aetiology and chronicity of the disease. Socioeconomic factors also posed significant barriers to service usage. CONCLUSIONS: Among many barriers to access to health services for patients with glaucoma, knowledge of the condition was identified as a key issue. Enhancing the understanding of glaucoma may improve access by triggering earlier presentation, informing those at risk and improving adherence to treatment. This is an area for further research with potential for improving service provision.

Social media use by patients with glaucoma: what can we learn?

PURPOSE: Much health-related information is available on the internet but its quality is known to be variable. This research aimed to analyse the ophthalmic content of social media platforms which has yet to be formally assessed. METHODS: Five online social media platforms were selected, the International Glaucoma Association (IGA) forum, Facebook, Twitter, YouTube and Patient Opinion.org.uk. A total of 3785 items were scraped from the sites, collated and analysed using simple thematic analysis by two coders. RESULTS: Fourteen themes were identified. The most commonly discussed topics included treatments, care experiences, promotions and support. Un-moderated sites contain more misleading information. Complementary therapies and treatments with a poor evidence base are presented more positively than established, evidence-based treatments. CONCLUSION: Online forums give patients a space to air questions, grievances, suggestions and to provide mutual support. The information they contain may be of use to physicians by flagging adverse drug reactions, areas for service improvement or topics about which patients require more information. There is a risk of exposure to misleading content which is heightened in un-moderated sites. Social media platforms may be an adjunct to current care models by providing a supportive and educational online community if these risks are understood.

What do patients with glaucoma think about personal health records?

PURPOSE: Putting patients in control of their records is one way of promoting patient centred care and patients with chronic health problems may benefit most from personal health records (PHRs). Glaucoma management is often complicated by incomplete understanding and poor adherence to treatment, two areas which a PHR may help to address. This study aimed to discover what patients with glaucoma think about PHRs and what type of information a glaucoma PHR should contain. METHODS: A consultation exercise using a focus group approach involving 71 participants was undertaken to discuss if a PHR would be useful and what it would be like. Narrative data were collected through written notes and an online forum in addition to transcripts of the focus group feedback session and individual interviews. Recordings were transcribed and analysed with simple thematic analysis facilitated by NVivo software (www.qsrinternational.com). RESULTS: The consultation exercise indicated enthusiasm for PHRs. Views varied on the best format, some participants strongly favoured electronic records and others preferred a low-tech, paper based format. A comprehensive dataset of 24 items was developed which highlighted areas which are not covered by existing guidance to developers. A model for how PHRs may be useful as an education tool in clinical practice was devised. CONCLUSIONS: Asking patients what they thought about a glaucoma PHR raised challenging questions and adds perspective to predominantly clinician led development. Listening and responding to such viewpoints is fundamental to developing more patient centred PHRs which may act both as health record and self-care educational tool to promote more holistic, efficient glaucoma care.

Patients' expectations of private osteopathic care in the UK: a national survey of patients.

BACKGROUND: Patients' expectations of osteopathic care have been little researched. The aim of this study was to quantify the most important expectations of patients in private UK osteopathic practices, and the extent to which those expectations were met or unmet. METHODS: The study involved development and application of a questionnaire about patients' expectations of osteopathic care. The questionnaire drew on an extensive review of the literature and the findings of a prior qualitative study involving focus groups exploring the expectations of osteopathic patients. A questionnaire survey of osteopathic patients in the UK was then conducted. Patients were recruited from a random sample of 800 registered osteopaths in private practice across the UK. Patients were asked to complete the questionnaire which asked about 51 aspects of expectation, and post it to the researchers for analysis.The main outcome measures were the patients-perceived level of expectation as assessed by the percentage of positive responses for each aspect of expectation, and unmet expectation as computed from the proportion responding that their expectation "did not happen". RESULTS: 1649 sets of patient data were included in the analysis. Thirty five (69%) of the 51 aspects of expectation were prevalent, with listening, respect and information-giving ranking highest. Only 11 expectations were unmet, the most often unmet were to be made aware that there was a complaints procedure, to find it difficult to pay for osteopathic treatment, and perceiving a lack of communication between the osteopath and their GP. CONCLUSIONS: The findings reflected the complexity of providing osteopathic care and meeting patients' expectations. The results provided a generally positive message about private osteopathic practice. The study identified certain gaps between expectations and delivery of care, which can be used to improve the quality of care. The questionnaire is a resource for future research.

Using vignettes to teach stroke care.

Although nurses are best placed to meet the needs of patients with stroke and their carers, evidence suggests they are inadequately prepared for this role. This article discusses the use of vignettes as a teaching and learning tool to develop pre-registration student nurses' knowledge of stroke management. An evaluation found they could be a useful learning tool for use throughout the nurse education programme.

The acute stroke unit as a meaningful space: The lived experience of healthcare practitioners.

This hermeneutic phenomenological study was undertaken in response to the recent re-organization of stroke unit provision in the United Kingdom. Through the analysis of four acute stroke unit practitioners' subjective accounts, the acute stroke unit emerged as a dynamic, meaningful space, where they experienced authenticity and belonging. The findings showed how these practitioners navigated their way through the space, thriving, and/or surviving its' associated vulnerabilities. They offer a different gaze on which to attend to the complexity and challenge that is interwoven with health professionals' flourishing, the spatiality of healthcare practice, and perhaps other demanding places of work.

The construction of professional identity by physiotherapists: a qualitative study.

UNLABELLED: The U.K. Frances Report and increasing societal expectations of healthcare have challenged physiotherapists to reconsider professionalism. Physiotherapy has viewed identity as a fixed entity emphasising coherence, continuity and distinctiveness. Socialisation has required the acquisition of a professional identity as one necessary 'asset' for novices. Yet how do physiotherapists come to be the physiotherapists they are? DESIGN: Qualitative study using Collective Memory Work. Eight physiotherapists in South West England met for two hours, once a fortnight, for six months. Seventeen hours of group discussions were recorded and transcribed. Data were managed via the creation of crafted dialogues and analysed using narrative analysis. RESULTS: Participants shared ethical dilemmas: successes and unresolved anxiety about the limits of personal actions in social situations. These included matters of authenticity, role strain, morality, diversity. Participants made claims about their identity; claims made to support an attitude, belief, motivation or value. CONCLUSIONS: Professional identity in physiotherapy is more complex than traditionally thought; fluid across time and place, co-constructed within changing communities of practice. An ongoing and dynamic process, physiotherapists make sense and (re)interpret their professional self-concept based on evolving attributes, beliefs, values, and motives. Participants co-constructed the meaning of being a physiotherapist within intra-professional and inter-professional communities of practice. Patients informed this, and it was mediated by workplace and institutional discourses, boundaries and hierarchies, through an unfolding career and the contingencies of a life story. More empirical data are required to understand how physiotherapists negotiate the dilemmas they face and enact the values the profession espouses.

Psychophysical measures of visual function and everyday perceptual experience in a case of congenital stationary night blindness.

An appreciation of the relation between laboratory measures of visual deficit and everyday perceptual experience is fundamental to understanding the impact of a visual condition on patients and so to a fuller characterization of the disorder. This study aims to understand better the interpretative processes by which modified sensory information is perceived by a patient with congenital stationary night blindness and the adaptive strategies that are devised to deal with their measurable visual loss. Psychophysical measurements of temporal resolution, spectral sensitivity, and color discrimination were conducted on a 78-year-old male patient with the condition, who was also interviewed at length about the ways in which his diagnosis affected his daily life. Narrative analysis was employed to identify the relation between his subjective perceptual experiences and functional deficits in identifiable components of the visual system. Psychophysical measurements indicated a complete lack of rod perception and substantially reduced cone sensitivity. Two particular effects of this visual loss emerged during interviews: 1) the development of navigational techniques that relied on light reflections and point sources of light and 2) a reluctance to disclose the extent of visual loss and resulting lifelong psychosocial consequences. This study demonstrates the valuable complementary role that rich descriptive patient testimony can play, in conjunction with laboratory and clinical measurements, in more fully characterizing a disorder and in reaching a more complete understanding of the experience of vision loss. It also evidences the particular suitability of filmmaking techniques as a means of accessing and communicating subjective patient experience.

Integrating research into the culture of allied health professions: the background and a review of issues in the United Kingdom.

This article reviews the challenges and barriers to change associated with development of a research culture in allied health professions within the higher education sector. We address the cultural upheaval and alterations in ways of working experienced by higher education and the health professions in recent times as a result of government policy as it applies to education and the National Health Service in the United Kingdom. Cooperation between higher education and the National Health Service in developing a culture of research in the health professions is fundamental to achieving evidence-based practice in health care. Improving research capability is hampered, however, by lack of funding and institutional barriers to change and barriers within individuals. Engendering a sense of identity and ownership in relation to change and a strategic approach to the next Research Assessment Exercise are essential if allied health professional programs are to survive within higher education.

Sailing a safe ship: improving patient safety by enhancing the leadership skills of new consultant specialist surgeons.

INTRODUCTION: The potential for "discontinuities in care" arising from the turbulent transition from specialist trainee to consultant specialist presents risks to patient safety. But it is easy to lose sight of the affective needs of individuals facing the burden of keeping patients safe. This article describes a 2-day program focused on new and prospective consultant specialist ophthalmic surgeons entitled "Sailing a Safe Ship" (SASS). The purpose was to facilitate understanding and analysis of their personal holistic learning needs and enhance individual agency in optimizing learning during the transition period. METHODS: The program used gaming, team challenges, meta-planning, role play and professional actors, interactive presentations, and self-analysis tools to portray the real world of consultant specialist practice in terms of ill-defined problems requiring "elite communication" and effective negotiation of value differences and priorities for their resolution. Participants' insights into their individual learning were recorded in scheduled reflective sessions. The immediate impact on their learning was also considered in terms of direct (instructional) and indirect (nurturant) effects. RESULTS: Participants' insights reflected 4 key themes: admitting vulnerability and uncertainty, taking responsibility for managing risk, being self-aware and reflexive, and internalizing authentic leadership. Four instructional and 4 nurturant effects were revealed. Preliminary findings on long-term impact on participants' practice are outlined. DISCUSSION: Evidence from the evaluation indicated that participants felt empowered to construct a personal strategic response to unfamiliar and unanticipated workplace demands and pressures, adopt a capability mindset that would accelerate their capacity to fulfill an enhanced leadership role, and take a holistic approach to their continuing self-directed development as leaders and educators.

Clinical reasoning and patient-centred care in musculoskeletal physiotherapy in Portugal--a qualitative study.

Clinical reasoning has been described as a common process that underpins the myriad of tasks in the clinicians' practice. To date clinical reasoning models have emerged from research developed in specific and well-developed health care and professional cultures, such as those in Australia and the United States, but there has been little discussion of their relevance and applicability to other cultural settings. The aim of this investigation was to explore clinical reasoning processes in a sample of experienced Portuguese musculoskeletal physiotherapists. The study focused on clinicians' interaction with their patients in order to define and manage clinical problems. Data were collected through non-participant observation, semi-structured interviews, memos and field notes, and analysed thematically to explore and interpret clinical practice and reasoning. Findings highlighted that the clinicians were more likely to carry out their reasoning approach as a purely cognitive and clinician centred process. Perspectives of clinical reasoning therefore differ between cultures and contexts of practice and this has potential implications in the way physiotherapists interpret health and illness, their role as clinicians, as well as the patient-physiotherapist relationship.

A qualitative study of physiotherapy final year undergraduate students' perceptions of clinical reasoning.

Clinical reasoning is a fundamental component of physiotherapists' clinical competence. However research examining how clinical reasoning is understood and developed in physiotherapy undergraduate courses is limited, particularly from the student's perspective. The aim of this study was to explore the current understanding of clinical reasoning held by final year undergraduate students, and how it is represented in the undergraduate musculoskeletal curriculum in Portugal. A qualitative research approach involving final year undergraduate students' from four different physiotherapy programmes was used. A total of 28 students participated in four focus group discussions, which were digitally recorded, transcribed verbatim, and analysed thematically. Four themes were identified: 1) an instrumental process; 2) a clinician centred process; 3) a knowledge dependent process; 4) a context dependent process. Findings of this study suggest that the primary purpose of clinical reasoning was to assist musculoskeletal physiotherapists in the diagnosis and treatment of clinical problems, and to facilitate efficient management of individual practices. The insights into the promotion of clinical reasoning in undergraduate musculoskeletal curricula may have important implications for curriculum design, teaching and learning strategies, and graduation profile in physiotherapy undergraduate courses.

Moving from PROMs to POEMs for glaucoma care: a qualitative scoping exercise.

PURPOSE: Patient-reported outcome measures (PROMs) are accepted widely as important outcomes in comparative effectiveness research. Over 30 PROMs have been described for use in glaucoma research, but their role in routine care is undefined. Our study explores the views of patients with glaucoma and their carers on the feasibility and content of a glaucoma PROM for use in day-to-day clinical practice. METHODS: Focus groups were held with 71 participants facilitated by 23 staff working in the field of ophthalmology. Comparisons were made among themes derived from this exercise using simple thematic analysis and currently available health-related quality of life (HRQoL) instruments. RESULTS: Participants were supportive of reporting their outcomes if the instrument was short, practical, and useful. Potential barriers to the use of PROMs, including bureaucratic overload and accessibility issues, were identified. Measuring health outcome and patient experience was important to participants. No freely available instrument covers all the domains identified, particularly knowledge and understanding. A novel instrument, a glaucoma patient-reported outcome and experience measure (POEM) is proposed. This addresses three aspects of outcome (fear of blindness, acceptability of treatment/side effects, and impact on daily life), and three aspects of experience (safety, respect, and understanding). CONCLUSIONS: Using PROMs routinely in the management of glaucoma presents significant challenges. Although current instruments (questionnaires) cover many of the participants' key domains, no single instrument covered them all. Further research is required to determine the feasibility (resources required), and validity and reliability of the proposed glaucoma POEM in clinical care.

Experiences of individuals with chronic low back pain during and after their participation in a spinal stabilisation exercise programme - a pilot qualitative study.

Spinal stabilisation exercises are commonly used in the management of low back pain (LBP). There is limited evidence relating to patients' experiences of their involvement in such programmes. The aim of this study was to explore the experiences of a sample of individuals with chronic LBP who participated in a randomised controlled trial (RCT) investigating the most efficacious dosage and frequency of spinal stabilisation exercises. The qualitative study involved nine participants who took part in focus group discussions. The data were analysed using thematic content analysis and provided insights into the experiences of the participants. Four themes emerged: Physical dimensions of the LBP experience, emotional and psychological dimensions of the LBP experience and perceived effects of the programme and lastly, the impact of the treatment programme on participants' knowledge, understanding and adherence. In conclusion participants' experiences were not limited to the positive effects of stabilisation exercises on pain, functional disability and quality of life, but also reflected increases in confidence, the formulation of self help strategies and the ability to exert better control over their LBP. The findings highlight the importance of well planned associated educational support packages in the treatment of LBP paving the way for future qualitative research.

ReGAE 5: Can we improve the surgical journey for African-Caribbean patients undergoing glaucoma filtration surgery? Some preliminary findings.

AIM: To explore the experiences of African-Caribbean patients who had undergone filtration surgery for advanced glaucoma. METHODS: Semi-structured qualitative interviews were used to collect the data and an interview guide was developed. Participants recounted when they first became aware of a problem with their eyes and their feelings at the time. Subsequently they were probed about their subjective experiences of becoming a glaucoma patient, receiving treatment, the decision to undergo surgery, and its aftermath. The perceptions of three participants from three different generations of African-Caribbean men were selected from the larger study for presentation in this paper. Interview transcripts were subjected to narrative analysis. RESULTS: The concept of patient-partnership was re-framed in terms of mentorship. Surgeon-patient relationships are central to developing effective coping strategies. Support to face the ordeals ahead, challenge to take on new responsibilities, and help to envision a meaningful life with glaucoma are fundamental to fostering trust and maintaining motivation to continue. CONCLUSIONS: The use of patient narratives provides a valuable a resource for enhancing communication skills and patient-centered care in the hospital eye service.

Perceptions of the learning environment in higher specialist training of doctors: implications for recruitment and retention.

INTRODUCTION: Career choice, sense of professional identity and career behaviour are influenced, subject to change and capable of development through interaction with the learning environment. In this paper workplace learning discourses are used to frame ongoing concerns associated with higher specialist training. Data from the first stage of a multimethods investigation into recruitment into and retention in specialties in the West Midlands is used to consider some possible effects of the specialist learning environment on recruitment and retention. METHODS: The aim of the study was to identify issues, through interviews with 6 consultants and questionnaires completed by specialist registrars from specialties representing a range of recruitment levels. These would inform subsequent study of attributes and dispositions relevant to specialist practice and recruitment. The data were analysed using NVivo software for qualitative data management. RESULTS: Participants' perceptions are presented as bipolar dimensions, associated with: curriculum structure, learning relationships, assessment of learning, and learning climate. They demonstrate ongoing struggle between different models of workplace learning. CONCLUSION: Changes in the postgraduate education of doctors seem set to continue well into the future. How these are reflected in the balance between workplace learning models, and how they influence doctors' sense of identity as specialists suggests a useful basis for examination of career satisfaction and recruitment to specialties.