Providing medically assisted dying in Canada: a qualitative study of emotional and moral impact.

PURPOSE: Medical assistance in dying (MAiD) in Canada places the medical provider at the centre of the process. The MAiD provider holds primary responsibility for determining eligibility and becomes acquainted with patients' inner desires and expressions of suffering. This is followed by the MAiD procedure of administering the lethal agent and being present at the death of eligible patients. We report participants' perceptions of the emotional and moral impacts of this role. METHODOLOGY: Two years after MAiD was legalised in Canada, 22 early-adopting physician providers were interviewed. Data were examined using both phenomenological analysis and a novel ChatGPT-enhanced analysis of an anonymised subset of interview excerpts. FINDINGS: Participants described MAiD as emotionally provocative with both challenges and rewards. Providers expressed a positive moral impact when helping to optimise a patient's autonomy and moral comfort with their role in relieving suffering. Providers experienced tensions around professional duty and balancing self with service to others. Personal choice and patient gratitude enhanced the provider experience, while uncertainty and conflict added difficulty. CONCLUSIONS: Participants described MAiD provision as strongly aligned with a patient-centred ethos of practice. This study suggests that, despite challenges, providing MAiD can be a meaningful and satisfying practice for physicians. Understanding the emotional and moral impact and factors that enhance or detract from the providers' experience allows future stakeholders to design and regulate assisted dying in ways congruent with the interests of patients, providers, families and society.

Estimating the prevalence of drawing in clinical practice among kiwi doctors.

Drawing has played a key role in the development and dissemination of Medicine and Surgery, such as to share anatomy, pathology, and techniques for clinical interventions. While many of the visuals used in medicine today are created by medical illustration professionals, and by imaging techniques such as photography and radiography; many doctors continue to draw routinely in their clinical practice. This is known to be valued by patients, for example when making informed decisions about care. We surveyed doctors in New Zealand online regarding their use of drawing to explore the prevalence of this practice. 472 complete responses were obtained over 3 months. There were very high rates of drawing among responding doctors practicing in both medical and surgical specialties. Reasons for drawing are explored and included professional, collegial, and patient communication, supporting informed consent, clinical documentation, and for planning procedures. Widespread use of drawing in clinical practice, almost non-existent training or support for this in digital workflows, and high interest in resources to develop clinical drawing skills, suggest unmet training needs for this practical clinical communication tool.

Medical student learner neglect in the clinical learning environment: Applying Glaser's theoretical model.

INTRODUCTION: Learner neglect is a relatively new concept in education, and no suitable framework for its exploration has been devised. The aim of this study was to determine whether an existing framework, Glaser's framework of child neglect, could be applied to learner neglect in clinical learning environments. This was a retrospective analysis of data obtained as part of a related study. METHOD: Six focus groups were conducted with medical students in their early clinical years to explore their views of what experiences in medical education were challenging and why they presented a challenge. The transcript data were analysed using inductive content analysis, within an interpretivist approach in the development of categories. The identified categories were cross referenced with Glaser's framework categories replacing the carer with the teacher and the child with the learner. RESULTS: Glaser's classifications of teacher (parent) behaviours were all identified in the negative aspects of medical learner clinical education including emotional unavailability/unresponsiveness, acting in a hostile manner, inappropriate inconsistent developmental interaction, failure to recognise individuality and failure to promote social adaption. Physical unavailability was identified as an additional category and is included in our proposed framework of learner neglect. DISCUSSION: Adapting Glaser's framework was useful in considering learner neglect. Medical schools have a role in ensuring learning experiences are positive across contexts and to make explicit to teachers any behaviours that may appear as learner neglect. Applying this framework has the potential to make more explicit any subtle undermining teacher behaviours. Once explicit, there is a greater likelihood that behaviours may be reappraised both by the teacher and learner and modified to promote a more effective clinical learning experience.

The people speak: social media on euthanasia/assisted dying.

In New Zealand, aiding and abetting a person to commit suicide or euthanasia even with consent is unlawful. The introduction of a third Bill on assisted dying to the House of Representatives following a high-profile court case afforded an opportunity for examining how assisted dying was discussed in the public sphere. In this article, we report on a discourse analysis of a selection of social media to illustrate the ways in which citizens participate in the voluntary euthanasia debate. The volume of social media posts that made up our data set suggests that the legalisation of assisted dying is a highly topical and deeply salient societal issue. Social media postings represent the voices of ordinary citizens who may not participate in formal public consultation processes. Based on our analysis, the assignment of binary conclusions about public opinion is simplistic and fails to adequately represent the intricacies of public debate. Contributors' posts reveal deeply held sociocultural values, as well as tensions about the relationship between citizens and the apparatus of government.

'There is no sick leave at the university': how sick leave constructs the good employee.

This paper examines the role of sick leave in constructing the identity of a good worker. The setting is a public funded New Zealand university. Within a qualitative research design, interviews were conducted with a range of employees and managers about their use and management of sick leave. Sick leave entitlements, use, and management encompass moral discourses that impact upon worker identity. Normalising discourses generated by compliance to bureaucratic demands and norms of productivity and performance in the neoliberalised workplace are constitutive to the construct of the good employee as reflected by the appropriate use and recording of sick leave. Conversely, the respectful, authentic, compliant and productive worker is constitutive of its opposite - the difficult employee. The construct of the difficult employee positions conformity and self-management of sick leave as strong moral imperatives. Managers were generally supportive of workers' efforts to self-manage sick leave with consideration for university commitments and were flexible around work hours, but this would in turn position them as deviant to institutional pathways of managing sick leave, with tensions between humanistic and authoritarian management.

A citizens' jury on euthanasia/assisted dying: Does informed deliberation change people's views?

Euthanasia or assisted dying (EAD) remains a highly contentious issue internationally. Although polls report that a majority New Zealanders support EAD, there are concerns about the framing of the polling questions, and that those responding to the questions do not know enough about the situations described, the options available and the potential implications of EAD policy. One way to address these concerns is through a citizens' jury, which is a method of learning how a group of people view an issue following informed deliberation. This citizens' jury was conducted to learn whether a group of 15 New Zealanders thought the law should be changed to allow some form of EAD and the reasons for their view, having been informed about the issue, heard arguments for and against, and having deliberated together. The jury met for two and a half days. They did not reach a consensus, but become polarized in their positions, with several changing their positions to either strong opposition or strong support. The reasons why people support or oppose EAD were not reducible to particular principles or arguments, but reflected an integrated assessment of a range of considerations, informed by personal priorities and experiences. These results suggest that views on EAD may change in response to informed deliberation that the EAD debate involves a range of value judgments and is not likely to be resolved through deliberation alone. These results may inform international debate on EAD policy.

Moral Economy and Moral Capital in the Community of Clinical Practice.

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

Shared care requires a shared vision: communities of clinical practice in a primary care setting.

AIMS AND OBJECTIVES: To understand how a vision of care is formed and shared by patients and the primary care professionals involved in their care. BACKGROUND: To achieve the best health outcomes, it is important for patients and those who care for them to have a mutual understanding about what is important to the patient in their everyday life and why, and what care is necessary to realise this vision. Shared or team care does not necessarily translate to a consistent and integrated approach to a patient's care. An individual patient's care network of clinical and lay participants can be conceptualised as the patient's own 'Community of Clinical Practice' of which they are the central member. DESIGN: Working alongside a long-term conditions nursing team, we conducted a focused ethnography of nine 'Communities of Clinical Practice' in one general practice setting. METHOD: Participant observation, in-depth qualitative interviews with 24 participants including nine patients, and the patients' medical records. Data were analysed using a template organising style. FINDINGS: Primary care professionals' insight into a patient's vision of care evolves through a deep knowing of the patient over time; this is shared between 'Community of Clinical Practice' members, frequently through informal communication and realised through respectful dialogue. These common values - respect, authenticity, autonomy, compassion, trust, care ethics, holism - underpin the development of a shared vision of care. CONCLUSIONS: A patient's vision of care, if shared, provides a focus around which 'Community of Clinical Practice' members cohere. Nurses play an important role in sharing the patient's vision of care with other participants. RELEVANCE TO CLINICAL PRACTICE: A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a 'Community of Clinical Practice'.

Spiritual beliefs, practices, and needs at the end of life: Results from a New Zealand national hospice study.

OBJECTIVE: International studies have shown that patients want their spiritual needs attended to at the end of life. The present authors developed a project to investigate people's understanding of spirituality and spiritual care practices in New Zealand (NZ) hospices. METHOD: A mixed-methods approach included 52 semistructured interviews and a survey of 642 patients, family members, and staff from 25 (78%) of NZ's hospices. We employed a generic qualitative design and analysis to capture the experiences and understandings of participants' spirituality and spiritual care, while a cross-sectional survey yielded population level information. RESULTS: Our findings suggest that spirituality is broadly understood and considered important for all three of the populations studied. The patient and family populations had high spiritual needs that included a search for (1) meaning, (2) peace of mind, and (3) a degree of certainty in an uncertain world. The healthcare professionals in the hospices surveyed seldom explicitly met the needs of patients and families. Staff had spiritual needs, but organizational support was sometimes lacking in attending to these needs. SIGNIFICANCE OF RESULTS: As a result of our study, which was the first nationwide study in NZ to examine spirituality in hospice care, Hospice New Zealand has developed a spirituality professional development program. Given that spirituality was found to be important to the majority of our participants, it is hoped that the adoption of such an approach will impact on spiritual care for patients and families in NZ hospices.

Employing imaginative rationality: using metaphor when discussing death.

The prevalence of metaphors in medicine is widely acknowledged. In a qualitative study exploring expectations of longevity, we observed repeated recourse to the imaginative rationality provided by metaphors to express perspectives on longevity and death. Bafflement, acceptance, uncertainty and distress were conveyed through metaphors, providing valuable insight into the internal healthcare frameworks of participants. Skilful use of imaginative rationality in the healthcare setting may illuminate the elusive and often eschewed topic of death in a way that fosters clarity and new understandings, and pave the way towards a better life, and death for patients. By becoming aware of the nuances contained within patients'-as well as their own-metaphors, clinicians may enhance patients' overall healthcare experience and avert unintended miscommunication.

Living into death: a case for an iterative, fortified and cross-sector approach to advance care planning.

Advance care planning (ACP) has been framed as best practice for quality palliative care, yet a growing body of literature affirms the need for an early iterative ACP process to begin when people are young and healthy. A significant gap appears to exist in the literature regarding the utility of death conversations outside the end-of-life context. Could 'death conversations' early in life be an effective tool by which doctor and patient can co-construct a more healthful way of life, and realistic relationship with death? And what variables must be taken into account for these conversations to proceed successfully? This paper provides a narrative exploration of the value of death conversations in the clinical context in New Zealand. Five exemplars are discussed, drawn from a sample of 21 semi-structured interviews with young older adults (54-65 years old) not receiving palliative care or diagnosed with a terminal illness. Together, these narratives indicate that further community consultation is required to determine culturally appropriate ways to initiate productive conversations around aging, death and dying and how to build patient/practitioner/family relationships which allow these conversations to happen safely. There is a need to acknowledge the important factor of culture related to age, generation, sex, faith and ethnicity when engaging in conversations about aging, death and dying. By doing so, health professionals will be best equipped to assist their patients to live well into death.

Moral economy and moral capital: A new approach to understanding health systems.

Healthcare systems can be considered moral economies in which moral capital in the form of expectations toward norms, values, and virtues are exchanged and traded. Moral capital, as a concept, is an extension of Bourdieu's forms of symbolic, and in particular, cultural capital. This research set out to identify forms of moral capital evident in the accounts of health professionals and patients within the distinctive healthcare systems of Germany, New Zealand, and the Unites States. Here, we provide an overview of 15 forms of moral capital that were identified. An important form of moral capital is equality. The global coronavirus pandemic has illuminated inequalities in healthcare systems across the world. We suggest considering moral capital as a useful tool to reform healthcare systems and make the provision of healthcare a more equitable enterprise.

GP obstetricians' views of the model of maternity care in New Zealand.

BACKGROUND: The Lead Maternity Carer (LMC) model of maternity care, and independent midwifery practice, was introduced to New Zealand in the 1990s. The LMC midwife or general practitioner obstetrician (GPO) has clinical and budgetary responsibility for women's primary maternity care. AIMS: To determine views of practising GPOs and former GPOs about the LMC model of care, its impact on maternity care in general practice, and future of maternity care in general practice. METHODS: 10 GPOs and 13 former GPOs were interviewed: one focus group (n = 3), 20 semi-structured interviews. The qualitative data analysis program ATLAS.ti assisted thematic analysis. RESULTS: Participants thought the LMC model isolates the LMC - particularly concerning during intrapartum care, in rural practice, and covering 24-hour call; Is not compatible with or adequately funded for GP participation; Excludes the GP from caring for their pregnant patients. Participants would like a flexible, locally adaptable, adequately funded maternity model, supporting shared care. Some thought work-life balance and low GPO numbers could deter future GPs from maternity practice. Others felt with political will, support of universities, and Royal New Zealand College of General Practice and Royal Australian and New Zealand College of Obstetrics and Gynaecology, GPs could become more involved in maternity care again. CONCLUSIONS: Participants thought the LMC model isolates maternity practitioners, is incompatible with general practice and causes loss of continuity of general practice care. They support provision of maternity care in general practice; however, for more GPs to become involved, the LMC model needs review.

It's a family affair: Confucian familist philosophy's potential to improve mental health care for ethnic Chinese in Aotearoa New Zealand.

Many ethnic groups traditionally value familism, which emphasises interdependence and the extended family unit. However, Aotearoa New Zealand's health system remains largely individual-oriented, with the implementation of family-centred care remaining inconsistent. This is known to have negative effects on Maori healthcare experiences and outcomes. Our research, exploring the experiences of ethnic Chinese using mental health services in Aotearoa New Zealand, indicated that this could also be a barrier for ethnic Chinese, who have similarly strong cultural links to familism, accessing mental health care. To balance the cultural importance of family involvement with the protection of individual patient autonomy, we propose a moderate Confucian familist approach, encouraging family involvement and participation in individual patients' care, with patients' consent. The approach acknowledges individual patients as interconnected members of a wider family unit, emphasising their reciprocal, mutual responsibility in maintaining a well-functioning, harmonious family. We highlight Whanau Ora as a potential exemplar for a culturally grounded, family-centred approach to mental health care which could be feasibly implemented and deliver positive outcomes. Parallels between Maori and ethnic Chinese cultural views around whanau, community, and collectivism suggest a Kaupapa Maori approach could also be beneficial to Aotearoa New Zealand's ethnic Chinese populations. However, ethnic Chinese lack the specific legal obligations empowering the implementation of interventions such as Whanau Ora. This is an obstacle which remains to be addressed before mental health services which are sensitive to the needs of ethnic Chinese or of other ethnicities can be effectively implemented.

The embodied liminalities of occupational overuse syndrome: Medical anthropology quarterly.

Drawing on interviews with sufferers of OOS (occupational overuse syndrome) in Aoteraoa/New Zealand, this article explores the liminalities associated with OOS and the ways in which this liminality is embodied. While successful rehabilitation could lead back to employment, the respondents' fragility while living with OOS and its accompanying social stigma render such rehabilitation both literally and symbolically "out of reach". Their situations reveal social isolation, loss of identities, pain, and functional disability that have been incorporated into renegotiated identities and biographies in which respondents have become exquisitely self-absorbed, exercising constant bodily surveillance and discipline in order to manage their symptoms. We suggest that this problematic extends beyond biographical disruption to encompass the concept of injury to an embodied sense of integrity for people who were notable prior to their affliction for their reputations as extremely competent and conscientious workers. The embodied meaning of OOS in this environment is not so much to have fallen "out of culture" as Hilbert (Ewan et al. 1991) suggests, but to be liminal in Turner's sense of "threshold people" (Turner 1969:56) "ground down to a uniform condition to be fashioned anew."

Winging it: a qualitative study of knowledge-acquisition experiences for early adopting providers of medical assistance in dying.

Background: Medical Assistance in Dying (MAID) was legalized in Canada without a designated period for implementation. Providers did not have access to customary alternatives for training and mentorship during the first 1-3 years after legalization. Objective: To report on how doctors prepared for their first provision of MAID in the early period after legalization in Canada. Design: Qualitative research design within an interpretive phenomenological theoretical framework. We asked participants to describe their experiences preparing for first MAID provision. Analysis of transcripts elicited themes regarding training and information desired by early adopters for provision of newly legalized MAID. Participants: Twenty-one early adopting physician-providers in five Canadian provinces were interviewed. Results: Few formal training opportunities were available. Many early-adopting providers learned about the procedure from novel sources using innovative methods. They employed a variety of strategies to meet their needs, including self-training and organizing provider education groups. They acknowledged and reflected on uncertainty and knowledge gained from unexpected experiences and missteps. Key phrases from participants indicated a desire for early training and mentorship. Limitations: This study included only the perspective of physicians who were providers of MAID. It does not address the training needs for all health practitioners who receive requests for assisted death nor report the patient/family experience. Conclusion: The Canadian experience demonstrates the importance of establishing accessible guidance and training opportunities for providers at the outset of implementation of newly legalized assisted dying.

Lessons learnt from the implementation of new models of care delivery through alliance governance in the Southern health region of New Zealand: a qualitative study.

OBJECTIVES: To explore the process of implementation of the primary and community care strategy (new models of care delivery) through alliance governance in the Southern health region of New Zealand (NZ). DESIGN: Qualitative semistructured interviews were undertaken. A framework-guided rapid analysis was conducted, informed by implementation science theory-the Consolidated Framework for Implementation Research. SETTING: Southern health region of NZ (Otago and Southland). PARTICIPANTS: Eleven key informants (Alliance Leadership Team members and senior health professionals) who were involved in the development and/or implementation of the strategy. RESULTS: The large number of strategy action plans and interdependencies of activities made implementation of the strategy complex. In the inner setting, communication and relationships between individuals and organisations were identified as an important factor for joint and integrated working. Key elements of a positive implementation climate were not adequately addressed to better align the interests of health providers, and there were multiple competing priorities for the project leaders. A perceived low level of commitment from the leadership of both organisations to joint working and resourcing indicated poor organisational readiness. Gaps in the implementation process included no detailed implementation plan (reflected in poor execution), ambitious targets, the lack of a clear performance measurement framework and an inadequate feedback mechanism. CONCLUSIONS: This study identified factors for the successful implementation of the PCSS using an alliancing approach in Southern NZ. A key enabler is the presence of a stable and committed senior leadership team working through high trust relationships and open communication across all partner organisations. With alliances, partnerships and networks increasingly held up as models for integration, this evaluation identifies important lessons for policy makers, managers and services providers both in NZ and internationally.

"There is a huge need, and it's growing endlessly": perspectives of mental health service providers to ethnic Chinese in Aotearoa New Zealand.

AIM: Little is known about the experiences of ethnic Chinese accessing mental health services in Aotearoa New Zealand, resulting in uncertainty around their service preferences, and facilitators or barriers to their mental health help-seeking. This paper investigated the experiences of providers of specific mental health services for ethnic Chinese in Aotearoa, their opinions regarding their patients' experience, and their suggestions to improve the system. METHOD: Sixteen health professionals with experience and expertise delivering mental health services for ethnic Chinese were interviewed at 12 organisations across Aotearoa. Interviews were recorded, transcribed and analysed using general inductive methods and thematic analysis. RESULTS: Practitioners' experiences revolved heavily around cultural brokerage, which is vital for culturally appropriate care, but this is time-consuming and receives little formal support. Practitioners thought the patient experience was inadequate, with a lack of language- and culturally appropriate services leading to delays in help-seeking. Practitioners' suggestions for system improvement included increasing resourcing for research, and for expanding the availability of language and culturally appropriate services. CONCLUSION: Current mental health service provision is inadequate for ethnic Chinese seeking help in Aotearoa, and is causing harm by delaying mental health help-seeking. Decisive Government leadership and deeper collaboration between non-Government organisations (NGOs) will be key to improving mental health service accessibility and outcomes.

Defining decision making: a qualitative study of international experts' views on surgical trainee decision making.

BACKGROUND: Decision making is a key competency of surgeons; however, how best to assess decisions and decision makers is not clearly established. The aim of the present study was to identify criteria that inform judgments about surgical trainees' decision-making skills. METHODS: A qualitative free text web-based survey was distributed to recognized international experts in Surgery, Medical Education, and Cognitive Research. Half the participants were asked to identify features of good decisions, characteristics of good decision makers, and essential factors for developing good decision-making skills. The other half were asked to consider these areas in relation to poor decision making. Template analysis of free text responses was performed. RESULTS: Twenty-nine (52%) experts responded to the survey, identifying 13 categories for judging a decision and 14 for judging a decision maker. Twelve features/characteristics overlapped (considered, informed, well timed, aware of limitations, communicated, knowledgeable, collaborative, patient-focused, flexible, able to act on the decision, evidence-based, and coherent). Fifteen categories were generated for essential factors leading to development of decision-making skills that fall into three major themes (personal qualities, training, and culture). The categories compiled from the perspectives of good/poor were predominantly the inverse of each other; however, the weighting given to some categories varied. CONCLUSIONS: This study provides criteria described by experts when considering surgical decisions, decision makers, and development of decision-making skills. It proposes a working definition of a good decision maker. Understanding these criteria will enable clinical teachers to better recognize and encourage good decision-making skills and identify poor decision-making skills for remediation.

Occupational overuse syndrome: moral ambiguities of New Zealand health professionals.

In this article we examine the moral ambiguities expressed by New Zealand health professionals regarding their clients and patients who have occupational overuse syndrome (OOS). Workers with OOS were described as being hard working and dedicated, but also undisciplined in their work and personal lives. The goal of rehabilitation in such cases is a return to full work duties and to this end, health professionals represent the disciplinary and normalizing technologies of the neoliberal state which, in New Zealand, provides financial support and treatment for injured workers. According to the health professionals in this study, the disciplinary technologies exercised through rehabilitation require that clients and patients internalize key values associated with the rhetoric of healthism; primarily self-discipline, self-control, self-denial, and willpower. These underpin successful rehabilitation and ongoing management of OOS, and at the same time represent the central values of the neoliberal capitalist workplace.