Service user perspectives of community mental health services for people with complex emotional needs: a co-produced qualitative interview study.

BACKGROUND: There is consensus that services supporting people with complex emotional needs are part of a mental health care system in which change is needed. To date, service users' views and co-production initiatives have had little impact on the development of interventions and care. This needs to change, and our paper evidences the experiences and perspectives of a diverse range of people on how community services can best address the needs of people with complex emotional needs. METHODS: A co-produced qualitative research study. Lived experience researchers led data collection and analysis. Individual interviews were conducted with 30 people across England who had a diverse range of experiences and perspectives of using community services for complex emotional needs. Participants were asked about their experiences of using community services for their mental health, and views on how community services can best address their needs. Thematic analysis was used to analyse the data. RESULTS: Participants reported some experiences of good practice but also of experiences of severely stigmatising interventions, a lack of effective support and service fragmentation. Relational Practice was identified as the central overarching theme and describes how community services can best support people with complex emotional needs. This approach involves care delivered in a non-stigmatising, individualised and compassionate way and care that is trauma-informed. It involves care that is planned collaboratively with service users to ensure their multiple needs are addressed in a flexible, holistic and consistent way which accounts for the long-term and fluctuating nature of their needs. CONCLUSIONS: Relational practice approaches have potential to facilitate better community care for people with complex emotional needs. Research and service development are needed to examine how best to implement such approaches across the mental health service system. This work must be co-produced with people with relevant lived experience, their carers and the professionals who support them.

Fragmented care and whole-person illness: Decision-making for people with chronic end-stage kidney disease.

PURPOSE: The study reported herein sought to better understand how patients with multi-morbid, chronic illness-who receive care in institutions designed for treatment of acute illness-experience and engage in health-related decisions. METHODS: In an urban Canadian teaching hospital, we studied the interactions of six hemodialysis patients and 11 of the health professionals involved in their care. For 1 year (September 2009 to September 2010), we conducted ethnographic observation and interviews of six cases each comprising one hemodialysis patient and various health professionals including medical specialists, nurses, a social worker, and a dietician. RESULTS: We found that the ubiquity and complexity of health-related decision-making in the lives of these patients suggests the need for a more holistic interpretation of health-related decision-making. DISCUSSION: We propose an interpretation of decision-making as an ongoing process of integrating illness and life; as frequently open-ended, cumulative, and relational; and as fundamentally shaped by the fragmented delivery of care for patients with multiple morbidities. CONCLUSION: Our understanding of decision-making suggests that people living with complex chronic illness need to receive care from institutions that recognize and address their multi-morbidity as a whole illness that is constantly being integrated into the life of a whole person.

The wounding path to becoming healers: medical students' apprenticeship experiences.

BACKGROUND: This article responds to repeated calls in the literature to teach medical students how to treat the whole patient, not just the disease. It focuses on the educational experiences of medical students in a Canadian university in an effort to clarify the determinants of "caring" in medical education. METHOD: Nineteen (19) second-year medical students volunteered to keep weekly journal entries during the first five months of their medical apprenticeship. In journal entry analyses, the authors identified themes through a consensus-building coding process detailed in the work of Maykut and Morehouse (1994) and Huckin (2004). For this article, the authors focus on those themes most closely related to the students' caring experiences during their apprenticeship. RESULTS: The data highlight components of the medical system which made it difficult for students to engage in caring practices during their apprenticeship: the competing discourses of empathy and efficiency, the objectification of patients, the power of the medical hierarchy, and the institutionalized practice of wounding. CONCLUSION: The authors argue that returning medical care and students' experience to a balance of attention to curing and caring is a complex undertaking requiring a re-conceptualization of the process and goals of medical care.