Addressing the needs of terminally-ill patients in Bosnia-Herzegovina: patients' perceptions and expectations.

BACKGROUND: Many terminally ill patients in Bosnia-Herzegovina (BiH) fail to receive needed medical attention and social support. In 2016 a primary healthcare centreer (PHCC) in Doboj (BiH) requested the methodological and technical support of a local partner (Fondacija fami) and the Geneva University Hospitals to address the needs of terminally ill patients living at home. In order to design acceptable, affordable and sustainable solutions, we involved patients and their families in exploring needs, barriers and available resources. METHODS: We conducted interviews with 62 purposely selected patients using a semi-structured interview guide designed to elicit patients' experiences, needs and expectations. Both qualitative and quantitative analyses were conducted, using an inductive thematic approach. RESULTS: While patients were aware that their illnesses were incurable, they were poorly informed about medical and social support resources available to them. Family members appeared to be patients' main source of support, and often suffered from exhaustion and financial strain. Patients expressed feelings of helplessness and lack of control over their health. They wanted more support from health professionals for pain and other symptom management, as well as for anxiety and depression. Patients who were bedridden or with reduced mobility expressed strong feelings of loneliness, social exclusion, and stigma from community members and - occasionally - from health workers. CONCLUSIONS: Our findings suggest a wide gap between patients' end-of-life care needs and existing services. In order to address the medical, psychological and social needs of terminally ill patients, a multi-pronged approach is called for, including not only better symptom management through training of health professionals and improved access to medication and equipment, but also a coordinated inter-professional, inter-institutional and multi-stakeholder effort aimed at offering comprehensive medical, psycho-social, educational and spiritual support.

Interprofessional collaborative reasoning by residents and nurses in internal medicine: Evidence from a simulation study.

Clinical reasoning has been studied in residents or nurses, using interviews or patient-provider encounters. Despite a growing interest in interprofessional collaboration, the notion of collaborative reasoning has not been well studied in clinical settings. Our study aims at exploring resident-nurse collaborative reasoning in a simulation setting. We enrolled 14 resident-nurse teams from a general internal medicine division in a mixed methods study. Teams each managed one of four acute case scenarios, followed by a stimulated-recall session. A qualitative, inductive analysis of the transcripts identified five dimensions of collaborative reasoning: diagnostic reasoning, patient management, patient monitoring, communication with the patient, and team communication. Three investigators (two senior physicians, one nurse) assessed individual and team performances using a five-point Likert scale, and further extracted elements supporting the collaborative reasoning process. Global assessment of the resident-nurse team was not simply an average of individual performances. Qualitative results underlined the need to improve situational awareness, particularly for task overload. Team communication helped team members stay abreast of each other's thoughts and improve their efficiency. Residents and nurses differed in their reasoning processes, and awareness of this difference may contribute to improving interprofessional collaboration. Understanding collaborative reasoning can provide an additional dimension to interprofessional education.

The primary care physician/psychiatrist joint consultation: A paradigm shift in caring for patients with mental health problems?

OBJECTIVE: Thirty to forty percent of patients seen in primary care medicine suffer from mental health problems, but primary care physicians (PCPs) often feel unprepared to deal with their patients' mental health problems. Joint consultations conducted with a liaison psychiatrist can help. The purpose of this study was to evaluate the experience of joint consultations in a primary care service in Geneva, Switzerland. METHODS: We retrospectively analyzed reports of psychiatric evaluations conducted between October 2010 and August 2012 (n=182), in the Primary Care Service of the Geneva University Hospitals. We also carried out 4 focus groups with 23 physicians-in-training to explore their experiences and perceptions of the joint consultations. RESULTS: Seventy two percent of the evaluations resulted in a psychiatric diagnosis. Psychiatric follow-up was not considered necessary in 61% of cases. Focus groups revealed that prior to experiencing joint consultations, PCPs considered mental health problems to be the domain of psychiatrists and outside their own area of competence. Joint consultations helped to demystify the role of psychiatrists, reduce their anxiety and increase PCPs' confidence in dealing with patients' mental health problems. CONCLUSION: Joint consultations enabled PCPs to shift away from a dichotomous view of somatic versus mental health problems and their management, and towards a more integrated view. IMPLICATIONS FOR PRACTICE: Joint consultations provide a useful strategy for training primary care physicians in the management of mental health problems. Integrated management of somatic and mental health problems can lead to a better understanding of the patient and improve the therapeutic relationship.

[Managing diversity in Swiss Health care]. / Gérer la diversité en milieu clinique: compte rendu de la première Conference nationale des Migrant Friendly Hospitals.

The development of Migrant Friendly Hospitals is an important first step towards eliminating health care disparities in Switzerland and an important reminder to health policy makers and practitioners across the health care system of their responsibility to provide non-discriminatory quality health care to all patients.

Clinical supervisors' perceived needs for teaching communication skills in clinical practice.

BACKGROUND: Lack of faculty training is often cited as the main obstacle to post-graduate teaching in communication skills. AIMS: To explore clinical supervisors' needs and perceptions regarding their role as communication skills trainers. METHODS: Four focus group discussions were conducted with clinical supervisors from two in-patient and one out-patient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqda software for qualitative data analysis. RESULTS: Clinical supervisors said that they frequently addressed communication issues with residents but tended to intervene as rescuers, clinicians or coaches rather than as formal instructors. They felt their own training did not prepare them to teach communication skills. Other barriers to teach communication skills include lack of time, competing demands, lack of interest and experience on the part of residents, and lack of institutional priority given to communication issues. Respondents expressed a desire for experiential and reflective training in a work-based setting and emphasised the need for a non-judgmental learning atmosphere. CONCLUSIONS: Results suggest that organisational priorities, culture and climate strongly influence the degree to which clinical supervisors may feel comfortable to teach communication skills to residents. Attention must be given to these contextual factors in the development of an effective communication skills teaching program for clinical supervisors.

What is quality and how is it achieved? Practitioners' views versus quality models.

BACKGROUND: Quality improvement in healthcare organisations requires structural reorganisation and systems reform, and also the development of an appropriate organisational "culture". Beliefs and attitudes that are thought by experts to be conducive to quality improvement in hospitals include the understanding of healthcare as a complex system, recognition of the importance of coordination of healthcare processes, a positive attitude towards medical error, adherence to the concept of continuous improvement, and a central preoccupation with the patient's welfare. OBJECTIVES: To explore the ideas about quality held by hospital-based doctors and nurses in Geneva, Switzerland. METHODS: Semi-structured interviews were conducted with 21 doctors and nurses in five hospital departments to explore their ideas about the definition of quality in healthcare, their perceptions about the main barriers to achieving quality healthcare, the factors that facilitate delivery of quality healthcare, and notions of responsibility for ensuring quality healthcare. RESULTS AND CONCLUSIONS: Thematic analysis of the interview data suggested that doctors' and nurses' ideas bear little resemblance to models of quality developed by quality experts. Study participants considered quality of care to be primarily the responsibility of individual practitioners. Quality was seen as mainly dependent on the practitioners' mastery of the technical and interpersonal aspects of care. In contrast, the healthcare system was seen primarily as a source of obstacles to good quality care, providing insufficient resources and imposing an excessive administrative burden. The paper discusses the potential implications of these ideas for the implementation of quality management initiatives.

[Sociocultural diversity and medical education]. / Diversité socioculturelle et formation médicale.

Global migration patterns have led to increasingly diverse populations, and physicians must learn to work effectively with patients from diverse backgrounds. However, some aspects of medical education may actually reinforce the idea that physicians do not need to take social and cultural differences into consideration in their work. In order to train physicians who are capable of providing quality care to patients from diverse backgrounds, it will be important to integrate the concept of cultural competence into all aspects of medical training, such that it will cease to be perceived as an "optional" aspect of medicine.

Attention to gender issues in tuberculosis control.

Although a seventy per cent excess of male over female TB cases are reported globally each year, the reasons for this difference are unclear. Generally, women in poor countries confront more barriers than men in accessing health care services. Yet, research is lacking to explain the impact of gender inequalities in access to care on reported sex ratios for TB. A review of the limited available literature and field visits to TB programmes offered insights and suggested a framework to study gender differentials in TB. This paper considers the role of gender at various steps in effective TB care. A research strategy to study and account for gender differences in TB control is proposed.

Gender differentials in tuberculosis: the role of socio-economic and cultural factors.

This paper reviews current knowledge about the role that socio-economic and cultural factors play in determining gender differentials in tuberculosis (TB) and tuberculosis control. The studies reviewed suggest that socio-economic and cultural factors may be important in two ways: first, they may play a role in determining overall gender differences in rates of infection and progression to disease, and second, they may lead to gender differentials in barriers to detection and successful treatment of TB. Both have implications for successful TB control programmes. The literature reviewed in this paper suggests the following: Gender differentials in social and economic roles and activities may lead to differential exposure to tuberculosis bacilli; The general health/nutritional status of TB-infected persons affects their rate of progression to disease. In areas where women's health is worse than men's (especially in terms of nutrition and human immunodeficiency virus status), women's risk of disease may be increased; A number of studies suggest that responses to illness differ in women and men, and that barriers to early detection and treatment of TB vary (and are probably greater) for women than for men. Gender differences also exist in rates of compliance with treatment; The fear and stigma associated with TB seems to have a greater impact on women than on men, often placing them in an economically or socially precarious position. Because the health and welfare of children is closely linked to that of their mothers, TB in women can have serious repercussions for families and households. The review points to the many gaps that exist in our knowledge and understanding of gender differentials in TB and TB control, and argues for increased efforts to identify and address gender differentials in the control of TB.

Ethnographic studies of ARI in Bolivia and their use by the national ARI programme.

Acute respiratory infections (ARI) are responsible for one quarter to one third of all deaths in infants and young children, with most deaths being attributed to pneumonia. At present, few measures exist to prevent pneumonia. However, most pneumonia deaths can be averted by treatment with an appropriate antibiotic. The effectiveness of this strategy depends on families' ability to recognize the signs of pneumonia, and to promptly seek care from a trained health practitioner. In order for health workers to communicate effectively with families about how to care for children with ARI, what signs to watch for, and when to come back for care, they need to know how families perceive and respond to respiratory infections. The WHO ARI Programme has recently developed a research protocol for conducting ethnographic studies of community perceptions and practices related to ARI. The purpose of this protocol is describe communities' explanatory models for ARI, identify cultural and other factors that facilitate or constrain appropriate home care and careseeking for children with ARI, and make recommendations to national ARI programmes about how to develop effective communication activities. This paper reports on two studies conducted in Bolivia using the WHO/ARI Focused Ethnographic Study (FES) protocol, and describes the way in which the data were utilized by the national ARI programme.

The management of acute respiratory infections in Honduras: a field test of the Focused Ethnographic Study (FES).

The World Health Organization has recently developed an ethnographic research manual, The Focused Ethnographic Study (FES) for ARI, whose purpose is to facilitate Acute Respiratory Infection (ARI) program development by providing information about the context in which families perceive and respond to ARI, and by identifying factors that facilitate or impede prompt care-seeking for children with pneumonia. The methodology is focused around answering a set of pre-defined "Programme Managers' Questions" which represent the main concerns and needs of ARI programs. The FES is designed to address both the need for in-depth information about the household and community-level factors which affect the management of ARI, and the need for timely, program relevant, and focused information. A field test of this manual was conducted in Honduras, and a number of recommendations to the local ARI program were developed concerning improving communication about ARI with mothers of young children. The Honduran field-test of the FES shows how systematic ethnographic research can be conducted and translated into concrete recommendations for bridging the social and communication gap which so often exists between health workers and the communities they serve.

Improving the home management of childhood diarrhoea in bolivia.

This article reports on a rapid assessment of beliefs and practices related to child diarrhoea, conducted in the city of El Alto, Bolivia, and discusses its utility for developing communication activities aimed at improving home care of children with diarrhoea.

ORS and the treatment of childhood diarrhea in Managua, Nicaragua.

This paper discusses results from a study of the household management of childhood diarrhea in a poor, urban neighborhood of Managua, Nicaragua, carried out between February 1987 and April 1988. Eight key informants and a random sample of 109 mothers were interviewed. Appropriate use of ORS was not found to be a common feature of the household management of diarrhea despite health education efforts to change mothers' beliefs and practices, and the provision of oral rehydration solution (ORS) packets by state health facilities, pharmacies and informal drug vendors. Although mothers knew about dehydration and ORS, their explanatory models for diarrhea, as well as actual practices, reflected heavy reliance on self-prescribed pharmaceuticals and home remedies, while ORS use was associated with clinic attendance. These findings point to the difficulties inherent in changing people's explanatory models for illness and illness management, and the importance of understanding the context in which treatment options are assessed and utilized.