Learning lessons from the analysis of patient complaints relating to staff attitudes, behaviour and communication, using the concept of emotional labour.

AIMS AND OBJECTIVES: This article explores the content of letters of complaint by patients and carers about the behaviour, attitudes and communication of healthcare staff. BACKGROUND: The most common focus of patient complaints in the UK and other high-income countries is staff attitudes, behaviour and communication. There is a move to learn lessons from patient complaints, which can be used to improve patient care and experience. METHODS: Fifty letters of complaint made by patients and carers relating to the behaviour, attitudes and communication of healthcare staff were analysed. RESULTS: Poor attitudes, behaviours and communication have significant negative impact on the emotional well-being of patients and carers. Many patients and carers have heightened sensitivities due to both health-related stresses and also other factors. The healthcare role is expected to include compassion and kindness. The concept of emotional labour is useful in explaining the skills and effort required of staff in this often invisible and undervalued aspect of health care. CONCLUSIONS: Given the increasing focus on patient experience, it is important that the importance of good staff attitudes, behaviours and communication is understood and that the emotional labour associated with this is recognised. RELEVANCE TO CLINICAL PRACTICE: An understanding of emotional intelligence can protect staff from burnout and other negative outcomes which those in a caring role can experience.

Transition to parenthood in the neonatal care unit: a qualitative study and conceptual model designed to illuminate parent and professional views of the impact of webcam technology.

BACKGROUND: Complications during pregnancy, childbirth and/or the postnatal period may result in the admission of a baby to a neonatal unit (NNU). While the survival and long-term prospects of high-risk infants are enhanced by admission, the enforced separation of the parent and child may have psychological consequences for both. There is a need to develop and evaluate interventions to help parents 'feel closer' to their infants in circumstances where they are physically separated from them. In this paper we present findings from an in-depth, theoretically-driven, evaluation of a technological innovation designed to address this need. The study sought to explore parent and professional views of the impact of the technology, which transmits real-time images of the baby via a webcam from the NNU to the mother's bedside in the post-natal care environment. METHODS: A qualitative approach was adopted, guided by a critical realist perspective. Participants were recruited purposively from a NNU located in East-central Scotland. Thirty-three parents and 18 professionals were recruited. Data were collected during individual, paired and small group interviews and were analysed thematically. Following the initial analysis process, abductive inference was used to consider contextual factors and mechanisms of action appearing to account for reported outcomes. RESULTS: Views on the technology were overwhelmingly positive. It was perceived as a much needed and important advancement in care delivery. Benefits centred on: enhanced feelings of closeness and responsiveness; emotional wellbeing; physical recovery; and the involvement of family/friends. These benefits appeared to function as important mechanisms in supporting the early bonding process and wider transition to parenthood. However, for a small number of the parents, use of the technology had not enhanced their experience and it is important, as with any intervention, that professionals monitor the parents' response and act accordingly. CONCLUSIONS: With a current global increase in premature births, the technology appears to offer an important solution to periods of enforced parent-infant separation in the early post-natal period. The current study is one of a few world-wide to have sought to evaluate this form of technology in the neonatal care environment.

Development of a cross-cultural HPV community engagement model within Scotland.

OBJECTIVE: To examine cultural barriers and participant solutions regarding acceptance and uptake of the human papillomavirus (HPV) vaccine from the perspective of Black African, White-Caribbean, Arab, Indian, Bangladeshi and Pakistani young people. METHODS: In total, 40 young people from minority ethnic communities in Scotland took part in a qualitative study, involving seven focus groups and four paired interviews, to explore their views and experiences of the HPV vaccine. Using critical discursive psychology, the analysis focused on young people's accounts of barriers and enablers to information, access and uptake of the HPV vaccination programme. RESULTS: Participants suggested innovative strategies to tackle intergenerational concerns, information design and accessibility, and public health communications across diverse contexts. A cross-cultural community engagement model was developed, embracing diversity and contradiction across different ethnic groups. This included four inter-related strategies: providing targeted and flexible information for young people, vaccine provision across the life-course, intergenerational information and specific cross-cultural communications. CONCLUSION: This is the first HPV cross-cultural model inductively derived from accounts of young people from different ethnic communities. We recommend public health practitioners and policymakers consider using the processes and strategies within this model to increase dialogue around public engagement, awareness and receptivity towards HPV vaccination.

'Just that little bit of doubt': Scottish parents', teenage girls' and health professionals' views of the MMR, H1N1 and HPV vaccines.

BACKGROUND: Parental decision making about childhood vaccinations is complex and the vaccination schedule ever-changing. Vaccination may be controversial even in countries with historically high vaccination rates such as Scotland. Health behaviour models have aided understanding of individual vaccine intentions for specific vaccines. These are limited in explaining actual behaviours and are divorced from the impact of socio-cultural contexts on vaccination decision making. PURPOSE: To explore vaccination views in Scotland amongst parents, teenage girls and health professionals across three controversial vaccines: the Measles, Mumps, Rubella (MMR), the Human Papilloma virus (HPV) and the Influenza A (H1N1) vaccine. METHOD: We used qualitative interviews and focus group discussions in a purposive sample of health professionals (n = 51), parents (n = 15) and teenage girls aged 12-15 years (n = 8) about their views of these vaccines. Discussions were analysed using thematic analysis. RESULTS: Two main themes are highlighted: 'vaccine risks revisited' in which we explored how the MMR legacy resurfaced and how worries about vaccine safety permeated the data. 'Vaccine responsibilities' indicated tensions regarding roles and responsibilities for vaccines. An overarching notion of 'just that little bit of doubt' referred to lingering doubts and uncertainties interwoven across the vaccines. CONCLUSIONS: Public health authorities should remain alert towards pervasive vaccine concerns. It is important for authorities to clarify vaccine roles and responsibilities in the face of new and existing vaccines and to acknowledge public concerns regarding vaccine safety.

Young women's constructions of the HPV vaccine: a cross-cultural, qualitative study in Scotland, Spain, Serbia and Bulgaria.

BACKGROUND: Following international trends, the HPV (human papilloma virus) vaccine was introduced in Europe for protection against infection from common strands of the HPV virus which can lead to cervical cancer. Young women aged 18-26 years are at greatest risk of infection by the HPV virus yet have been neglected in research, policy, and practice. PURPOSE: To explore young women's constructions of the HPV vaccine in four European countries with different implementation policies ranging from national school-based programmes, regarded as the gold standard, to regional on-demand and private provision. METHOD: Qualitative methods comprising 11 focus group discussions with 54 young women aged 18-26, in Scotland (n = 10), Spain (n = 25), Serbia (n = 9) and Bulgaria (n = 10). A discursive analysis was conducted, following an initial thematic analysis. RESULTS: Two competing discursive constructions were considered: the 'responsible young woman' discourse was constructed as someone with individual rights to health, choice and discretion along with responsibilities to protect health and make rational decisions. In 'the HPV vaccine: a discourse of exclusion', access to the vaccine, wider health promotion and knowledge was controlled by others which had the potential to undermine the young woman's health. We consider how young women managed this tension through recourse to being health vigilant. CONCLUSION: Qualitative, cross-cultural research highlighted common concerns amongst young European women towards being responsible citizens in the face of their health and highlighted socio-cultural constraints to knowledge and resources. We highlight cross-cultural implications particularly between Western and Eastern European contexts.

Patterns of primary care service use by families with young children.

BACKGROUND: In the UK, early years policy emphasizes that all families should have access to support tailored to their individual needs. Knowledge of the determinants of health service use should help to inform rational and equitable planning and delivery of services to parents. OBJECTIVES: We seek to investigate the determinants of primary care service use in families with preschool children. METHODS: Determinants of service use in two population cohorts (families with children aged 0-1 and 2-3 years) from the Growing Up in Scotland study are presented. Services related to use of the family doctor or health visitor for information on the child's health or behaviour in the last year. RESULTS: A range of socio-demographic determinants were significant predictors of service use on multivariate analysis. Determinants of service use differed between the health visitor and family doctor. CONCLUSIONS: The analysis provides an insight into the determinants and patterns of health service use by families with young children at two stages of development. While some of our findings are expected or supported by previous research, others highlight areas that require further investigation.

Supporting the case for 'progressive universalism' in health visiting: Scottish mothers and health visitors' perspectives on targeting and rationing health visiting services, with a focus on the Lothian Child Concern Model.

AIMS AND OBJECTIVES: To explore parents and professionals' experience of family assessment in health visiting (public health nursing), with a focus on the Lothian Child Concern Model. BACKGROUND: Health visitors currently assess families as requiring core, additional or intensive support, and offer support at a corresponding level. The majority of families are assessed as core and receive no pro-active support beyond the early days. Previous assessment tools, consisting of checklists, have been criticised as being ineffective in identifying a range of health needs and unacceptable to parents and health visitors. The Lothian Child Concern Model was developed and introduced in the study area to promote a partnership approach with parents and assess strengths as well as difficulties in parents' capacity to care for their child. METHODS: Qualitative methods were used. Ten mothers and 12 health visitors took part in individual semi-structured interviews. RESULTS: Most mothers were aware of the assessment process but some felt that they were not involved in the decision-making process. Explaining the assessment process to parents is problematic and not all health visitors do so. The assessment process was stressful for some mothers. Health visitors find the model useful for structuring and documenting the assessment process. Many believe that most families benefit from some support, using public health approaches. Health visitors said that families are often assessed as core because there are insufficient resources to support all those who meet the criteria of the additional category and that managers assess caseloads in terms of families with child protection concerns. CONCLUSIONS: The study findings significant the concept of 'progressive universalism' that provides a continuum that intensity of support to families, depending on need. Mothers would like better partnership working with health visitors. RELEVANCE TO CLINICAL PRACTICE: The study endorses proposed policy changes to re-establish the public health role of health visitors and to lower the threshold for families to qualify for support.

Parenting support for families with young children - a public health, user-focused study undertaken in a semi-rural area of Scotland.

AIMS AND OBJECTIVES: To work with parents and public health nurses (health visitors), to identify and design a range of public health interventions to provide support to parents of young children. BACKGROUND: In the UK, only vulnerable families are now eligible for pro-active health visiting interventions on an individual family basis beyond the early days. Public health approaches are recommended for the majority of families who are not eligible for one-to-one professional support. DESIGN: Focus groups were carried out with parents of young children, health visitors and other professionals working with them. METHODS: The study was carried out in a semi-rural area of Scotland, consisting of a small town, and the surrounding rural area, including one area of deprivation. The area is served by a team consisting of six health visitors and one health assistant, based in two health centres in the area. Nineteen parents, five members of the health visiting team and 11 other professionals from health, education and social work took part via an invitation to contact the research team. RESULTS: The needs of parents identified by both parents and professionals could best be met by social support, with skilled facilitation and suitable resources. The resolution of tensions between caseload-based and population-based health visiting, as well as the management of the tensions inherent in these changes, seems to be vital in order to implement these approaches. Many parents would like information made available online. CONCLUSIONS: Services to support families with young children need to be designed from the perspectives of parents and their needs. RELEVANCE TO CLINICAL PRACTICE: Services need to be set up in partnership with parents to provide them with information and access to peer and professional support, using public health approaches. Multiagency working, including among senior managers, may be the most effective way of providing this support.

Professional boundary work in the face of change to generalist working in community nursing in Scotland.

AIM: The present study explored how community nurses and managers constituted changes towards generalist working. BACKGROUND: Following international trends moving from acute care towards community care, changes within community nursing in the United Kingdom have been subject to debate in recent years. Sociological insights into 'boundary work' in professional disciplines are informative for understandings about proposed new roles in community nursing. Recently, radical changes to the role of the community nurse from specialist disciplines to a generalist community health nurse model were proposed in Scotland and tested in four health boards. METHODS: Focus group discussions were held with 27 community nurses and semi-structured interviews with three managers during January-March 2009 in a purposive sample from one health board. Discussions were audio-recorded and transcribed verbatim. Initial thematic analysis was used to highlight key themes from the data and later a discursive analysis focused on the rhetorical strategies used by participants. FINDINGS: Four key themes were identified along with the rhetorical devices associated with these including: the undermining of the generalist model through the 'jack of all trades, master of none' metaphor through associations of loss of specialisms; how the re-establishment of specialist discipline boundaries occurred; how current roles were validated and how managers and nurses accounted for future changes to the profession. CONCLUSION: The qualitative study explored here has implications for discussions about future role change debates within community nursing as well as the specialist-generalist debate internationally. Managers and policy-makers involved in organizational changes are required to give greater credence to the perceived professional status of community nursing.

What support do parents of young children need? A user-focused study.

Health visiting practice has moved away from surveillance and screening of children to support for parents, especially those assessed as vulnerable. This paper explores parents' perspectives of factors that determine their need for support and the perceived usefulness of the support they receive. Parents of 44 children took part in small group discussions in convenient local venues or individual interviews in their homes. The early days of parenthood appeared particularly problematic for parents. Self-confidence, previous experience of caring for children and an effective social network of family and friends were seen as being essential for successful childrearing. Social isolation was highlighted as the main cause of difficulty. Establishing new social networks appeared important for many parents to learn childrearing skills and as a source of emotional support.

Supporting children and families facing the death of a parent: part 1.

AIM: To present findings from a review of key literature and from a scoping of current provision of support for children facing the death of a parent. A summary of the findings from these is reported here. METHODS: To set out the background and context to the evaluation of a new service aimed at supporting children and families facing the loss of a parent from cancer, key literature was reviewed and a scoping of current bereavement support for children and families was conducted using online searching, telephone and face-to-face communications. FINDINGS: The review processes uncovered a range of national and local bereavement services. Bereavement was reported as a normal life event and part of human experience. Health, education and social services personnel need to respond to individual needs, accepting that not all bereaved children require complex, long-term interventions. CONCLUSIONS: At national and global levels there was recognition that the needs of bereaved children require careful assessment. A complex range of initiatives have been developed across the UK aimed at supporting children facing the death of a family member. The fragmented nature of provision makes it difficult to be comprehensive or all-inclusive when describing service provision in this area.

Supporting children and families facing the death of a parent: part 2.

AIM: To report on the views of children, parents and key stakeholders of a new bereavement support service for families where a parent is dying from cancer. STUDY DESIGN: A qualitative pre- and post-intervention evaluation design was used. Case study methods allowed multiple perspectives to be accessed so broadening the scope of the evaluation. SAMPLE AND SETTING: A purposeful sample of six families was recruited from the community palliative care service. Each case study comprised a family, a health professional and the family support worker. Six key stakeholders also contributed data. METHODS: Data gathering included individual and family group interviews, non-participant observation and interviews with nominated health professionals, key stakeholders and the family support worker. Analysis of pre- and post-intervention data were supported by QSR NVivo. FINDINGS: Children and families with complex and/or enduring needs benefited from the specialist expertise and interventions provided by this service. CONCLUSIONS: Risk assessment procedures should be used to identify need and ensure limited resources are directed appropriately. Many children and families can be supported within the community drawing on their own social networks.

Community development in primary care: opportunities and challenges.

This qualitative study aimed to explore primary health care professionals' views on community development, and to identify the opportunities and barriers associated with using this approach in practice. Participants in community development training--mainly health visitors--took part in small group discussions before, after, and six months following the training course. Opportunities for using a community development approach were identified, but were restricted by lack of interest from some communities, lack of leadership and support within health visiting, and by the increasing medicalisation of health promotion. There is a potential conflict between the ethos of community development and the aim of the national, policy-driven public agenda. Recommendations are suggested to change the organisation of health visiting in order to facilitate the adoption of public health approaches, including community development. These changes would enable health visitors to make use of the help which is readily available from recently appointed public health practitioners, whose role is to promote public health practice in primary health care.