The New South Wales Allied Health Workplace Learning Study: barriers and enablers to learning in the workplace.

BACKGROUND: Workplace learning refers to continuing professional development that is stimulated by and occurs through participation in workplace activities. Workplace learning is essential for staff development and high quality clinical care. The purpose of this study was to explore the barriers to and enablers of workplace learning for allied health professionals within NSW Health. METHODS: A qualitative study was conducted with a purposively selected maximum variation sample (n =46) including 19 managers, 19 clinicians and eight educators from 10 allied health professions. Seven semi-structured interviews and nine focus groups were audio-recorded and transcribed. The 'framework approach' was used to guide the interviews and analysis. Textual data were coded and charted using an evolving thematic framework. RESULTS: Key enablers of workplace learning included having access to peers, expertise and 'learning networks', protected learning time, supportive management and positive staff attitudes. The absence of these key enablers including heavy workload and insufficient staffing were important barriers to workplace learning. CONCLUSION: Attention to these barriers and enablers may help organisations to more effectively optimise allied health workplace learning. Ultimately better workplace learning may lead to improved patient, staff and organisational outcomes.

Medical students' experiences learning intimate physical examination skills: a qualitative study.

BACKGROUND: Intimate physical examination skills are essential skills for any medical graduate to have mastered to an appropriate level for the safety of his or her future patients. Medical schools are entrusted with the complex task of teaching and assessing these skills for their students. The objectives of this study were to explore a range of medical students' experiences of learning intimate physical examination skills and to explore their perceptions of factors which impede or promote the learning of these skills. METHODS: Individual semi-structured interviews (N = 16) were conducted with medical students in years two to five from the University of Newcastle, as part of a larger research project investigating how medical students develop their attitudes to gender and health. This was a self-selected sample of the entire cohort who were all invited to participate. A thematic analysis of the transcribed data was performed. RESULTS: Students reported differing levels of discomfort with their learning experiences in the area of intimate physical examination and differing beliefs about the helpfulness of these experiences. The factors associated with levels of discomfort and the helpfulness of the experience for learning were: satisfaction with teaching techniques, dealing with an uncomfortable situation and perceived individual characteristics in both the patients and the students. The examination causing the greatest reported discomfort was the female pelvic examination by male students. CONCLUSIONS: Student discomfort with the experience of learning intimate physical examination skills may be common and has ongoing repercussions for students and patients. Recommendations are made of ways to modify teaching technique to more closely match students' perceived needs.

'Perfect skin', the media and patients with skin disease: a qualitative study of patients with acne, psoriasis and atopic eczema.

The relationship of skin disease with societal ideals of beauty, and the role of the media in this relationship, has not previously been researched. The overall objective of this study was to explore the psychological effects of skin disease. The theme of the ideal of perfect skin and the role of the media in generating this ideal arose via an inductive study methodology and was explored in the context of respondents' psychological morbidity. A qualitative study, 62 semi-structured interviews were conducted with respondents with acne, eczema or psoriasis recruited from both general practice and specialist dermatology practice in an Australian regional city. Interviews were audiotaped, transcribed and subjected to thematic analysis employing a process of constant comparison in which data collection and analysis were cumulative and concurrent. The themes of perfect skin, societal ideals and media influence emerged from this iterative process. Respondents identified a societal ideal of flawless skin, largely mediated by media portrayals of perfection. Failure to meet this ideal precipitated psychological morbidity in female, but not male, respondents. An appreciation of the pervasive pressures of society and media upon females with skin disease may inform management strategies, particularly psychological management strategies, in patients with skin disease.

A review and recommendations for optimal outcome measures of anxiety, depression and general distress in studies evaluating psychosocial interventions for English-speaking adults with heterogeneous cancer diagnoses.

OBJECTIVE: The objective of this paper is to inform choice of optimal patient-reported outcome measures (PROMs) of anxiety, depression and general distress for studies evaluating psychosocial interventions for English-speaking adults with heterogenous cancer diagnoses. METHODS: A systematic review was conducted to identify all PROMs used to assess anxiety, depression and general distress in randomised controlled trials (RCTs) of psychosocial interventions for people with cancer published between 1999 and May 2009. Candidate PROMs were evaluated for content, evidence of reliability and validity, clinical meaningfulness, comparison data, efficiency, ease of administration, cognitive burden and track record in identifying treatment effects in RCTs of psychosocial interventions. Property ratings were weighted and summed to give an overall score out of 100. RESULTS: The Hospital Anxiety and Depression Scale (HADS) scored highest overall (weighted score = 77.5), followed by the unofficial short-form of the Profile of Mood States (POMS), the POMS-37 (weighted score = 60), and the Centre for Epidemiological Studies Depression Scale (CES-D) and original POMS (weighted score = 55 each). CONCLUSIONS: The HADS' efficiency and substantial track record recommend its use where anxiety, mixed affective disorders or general distress are outcomes of interest. However, continuing controversy concerning the HADS depression scale cautions against dependence where depressive disorders are of primary interest. Where cost is a concern, the POMS-37 is recommended to measure anxiety or mixed affective disorders but does not offer a suitable index of general distress and, like the HADS, emphasises anhedonia in measuring depression. Where depression is the sole focus, the CES-D is recommended.

Sex and the skin: a qualitative study of patients with acne, psoriasis and atopic eczema.

Quantitative questionnaire-based research has suggested a considerable effect of skin disease on the sexual life of sufferers. In this study, we explored the effects of acne, psoriasis and atopic eczema upon sexual functioning and sexual relationships in the context of a wider exploration of the psychological sequelae of these diseases. We employed a qualitative methodology employing in-depth semi-structured interviews and involving thematic analysis and constant comparison. Participants were patients with currently active acne, psoriasis or atopic eczema. Purposive sampling aimed to obtain a sample reflecting a wide range of participant characteristics including skin disease severity, age, sex, and care by general practitioner or dermatologist. Sixty-two semi-structured interviews were conducted. Acne had adverse effects on participants' self-perceived sexual attractiveness and self-confidence, as did psoriasis and eczema. But psoriasis and eczema also had marked effects on sexual well-being and on capacity for intimacy. These were related to issues of self-esteem and sexual self-image and were often pervasive, resulting in marked behavioural avoidance of intimate situations and continuing effects on sexual well-being even in long-established sexual relationships. Effects of psoriasis and eczema on sexual well-being and sexual relationships were mediated more by appearance and texture of non-genital skin than by involvement of genital skin. We conclude that, while recognising the distressing effects of acne on self-perceived sexual attractiveness, clinicians should be especially aware of the capacity of psoriasis and eczema to profoundly affect patients' psychological and sexual well-being.

The psychological sequelae of psoriasis: results of a qualitative study.

Psoriasis is a common condition with recognised psychological comorbidity in specialist practice. The objective of this study was to investigate the psychological comorbidities in psoriasis in patients from general (family) practices and specialist dermatology practices, using a qualitative methodology. This was a qualitative study, utilising semi-structured interviews and thematic analysis. Twenty-nine patients with psoriasis were recruited from general practices and specialist dermatology practices in an Australian non-capital city. Respondents represented a broad range of ages and psoriasis severities. The principle study finding was that psychological morbidity in psoriasis is considerable. Though mood and anxiety symptoms were present in participants, and were occasionally severe, more prominent sequelae of psoriasis were embarrassment, shame, impaired self-image, low self-esteem, self-consciousness and stigmatisation. Psoriasis was associated with behavioural avoidance and effects on respondents' sexuality. The perception of psoriasis as an incurable disease beyond respondents' control, with consequent pessimism regarding prognosis and treatment efficacy, was a contributor to psychological morbidity. Some respondents reported psoriasis having permanently and adversely affected their personality - avoidant personality traits were ascribed to the experience of living with psoriasis. Our conclusion is that the psychological effects of psoriasis can be considerable and long-lasting and are evident across a broad range of psoriasis severities. Clinicians should be aware that psychological sequelae are complex and encompass a range of psychological morbidities beyond conventional psychiatric diagnoses.

Experiences of appearance-related teasing and bullying in skin diseases and their psychological sequelae: results of a qualitative study.

Acne, psoriasis and atopic eczema are common diseases and have been consistently associated with adverse psychological sequelae including stigmatization. Being teased on the basis of appearance has been associated with psychiatric morbidity in children and adolescents. The objective of this qualitative study was to explore the experiences of teasing and bullying in patients with acne, psoriasis and eczema, and the role of appearance-related teasing and bullying as mediators of psychological morbidity in these patients. Data collection consisted of 62 in-depth semi-structured interviews with patients with acne, psoriasis or atopic eczema recruited from both specialist dermatology and general practices. Data analysis was cumulative and concurrent throughout the data collection period reflecting a grounded theory approach. Analysis followed the analytic induction method, allowing themes to emerge from the data. Teasing, taunting or bullying was a considerable problem for a significant minority of acne, psoriasis and atopic eczema participants. Themes that emerged were the universally negative nature of the teasing, the use of teasing as an instrument of social exclusion, and as a means of establishing or enforcing power relationships, teasing related to contagion and fear, the emotional and psychological sequelae of teasing and the theme of 'insensate' teasing. For those who had suffered teasing or bullying, this was causally linked in respondents' accounts with psychological sequelae, especially self-consciousness and effects on self-image and self-esteem. Experiences of teasing and bullying were found to have principally occurred during the adolescence of participants and the perpetrators were other adolescents, but there were findings of respondents with psoriasis also having been subjected to ridicule or derogatory remarks by health professionals. Teasing, taunting and bullying may represent an underappreciated source of psychological morbidity in children and adolescents with these common skin diseases.

Rural obesity, healthy weight and perceptions of risk: struggles, strategies and motivation for change.

OBJECTIVE: To explore risk logics, embodiment (the interplay between the physical, social and subjective body) and issues related to adult obesity in remote New South Wales. DESIGN: Qualitative multiple-method design using semistructured interviews and visual aids (food and exercise palm cards) to explore the saliency of food and exercise options. A one-page demographic survey incorporated self-reported body mass index. PARTICIPANTS: A total of 19 rural adults (13 female; six male). SETTING: Community in remote New South Wales, Australia. RESULTS: Thematic analysis revealed 14 major weight-related themes. Respondents raised numerous explanations for their weight gain, reported struggles with weight loss, revealed a range of motivations for weight loss and a variety of approaches to risk, not all of which are aligned to dominant health discourse. The need for realistic interventions incorporating social meaning and pleasure seeking is revealed. CONCLUSION: Obesity interventions promoting 'easy' healthy choices also need to acknowledge embodiment and social status linked to consumption. Interventions that ignore the complexity surrounding consumption (e.g. the interplay of social taste, group distinction and embodiment) will have lower relevance and effectiveness.

Mobilising a rural community to lose weight: impact evaluation of the WellingTonne Challenge.

OBJECTIVE: To evaluate the impact of the WellingTonne Challenge. DESIGN: Before-after study. SETTING: The National Action Agenda for the prevention and control of obesity in Australia identified community action and development as a key theme. The WellingTonne Challenge was a whole-of-community project designed to support a small rural community to lose weight and reduce their risk of chronic disease. PARTICIPANTS: Adult residents of the Wellington Local Government Area who were overweight or obese. RESULTS: The project successfully engaged the community with around 10% of the target group formally participating in the Challenge. Participants achieved a weight reduction of around 3 kg each, as well as positive changes in diet and physical activity. A total of 59% of those who signed up for the Challenge achieved an accumulated loss of 687 kg at the end of the 12-week program--less than the community goal of 1000 kg. CONCLUSION: The WellingTonne Challenge is a promising intervention. Wider implementation of this approach in other small rural communities might make a significant contribution to the national effort. The opportunity should be taken to undertake a more rigorous evaluation to determine whether this approach benefits communities in the longer term.

Using problem-based learning in public health service based training.

OBJECTIVES: This study explored the suitability and benefits of problem-based learning (PBL) in competency-based postgraduate public health training. The PBL was delivered within a rural retreat and included site visits. METHODS: Qualitative semistructured interviews with trainee public health officers and key informants. RESULTS: The learning approach (retreat-PBL combination with site visits) was valuable and relevant. Trainees reported a high learning impact with increased knowledge about the problems examined and rural public health practice. They also expressed an openness to work rurally. CONCLUSION: Collaboratively developed and delivered, experiential rural public health PBL provides a positive learning experience for trainees undertaking competency-based training in public health and could play an important workforce role. PBL appears to be suitable in rural and non-rural public health training settings.

Couples' experiences of postnatal depression: a framing analysis of cultural identity, gender and communication.

Difficulties in communication have been associated with fathers' perceived lack of support for mothers suffering postnatal depression (PND). This paper investigates why the communication of the experience of PND is so difficult and considers how these difficulties might be linked, in part, to the diagnostic process. The study explores, through in-depth interviews, how six Australian couples talked about the new mothers' experience of mild to moderate PND. Framing analysis revealed discrepancies in the couples' explanations of the mothers' PND. The application of the concept of 'framing' has come to the study of mental health by way of Goffman's work on how experience becomes organised. Goffman used the technique of 'frame analysis' to identify and describe the taken-for-granted sociocultural elements that give meaning to a situation. This study identified that mothers and fathers used different frames, with mothers understanding their postnatal experience primarily from within an 'identity' frame and fathers understanding the mothers' experience primarily through a 'psychological' or 'physical hardship' frame. Implications for health service providers are considered.

Complementary and alternative medicine therapies in acne, psoriasis, and atopic eczema: results of a qualitative study of patients' experiences and perceptions.

OBJECTIVES: The aim of this study was to explore the use of complementary and alternative medicine (CAM) therapies in patients with acne, psoriasis, or atopic eczema and the attitudes about CAM of these patients. DESIGN: This was a qualitative study, utilizing semistructured interviews and thematic analysis. SETTING: Patients were recruited from the practices of dermatologists and general practitioners in a noncapital Australian city. RESULTS: Twenty-six (26) interviews were conducted with patients with acne, 29 with psoriasis, and 7 with atopic eczema. Use of CAM therapies was common. Participants tended to value CAM over orthodox therapies because of their preference for natural approaches to their skin diseases and the perceived lesser potential for adverse effects of CAM therapies. Respondents with acne were more confident about the efficacy of CAM than were those with psoriasis or eczema. The resulting sense of control attenuated psychologic sequelae of acne. This was not apparent in psoriasis or eczema. CONCLUSIONS: Practitioners should be cognizant of the likely use of CAM and its implications (including the potential for attenuation of psychologic morbidity) in their patients who have skin diseases.

Psychological sequelae of acne vulgaris: results of a qualitative study.

OBJECTIVE: To investigate the psychological sequelae of acne vulgaris. DESIGN: Qualitative study using a grounded-theory approach. SETTING: General practices and specialty dermatology practices in Newcastle, Australia. PARTICIPANTS: Patients with current acne recruited from the practices. METHOD: We used semistructured interviews and recorded participants' comments verbatim. Data analysis was cumulative and concurrent throughout the data-collection period. Coding and analysis was done in the inductive tradition. MAIN FINDINGS: Interviews were conducted with 26 subjects who represented a range of ages and acne severity. Psychological morbidity was considerable. Though participants had mood and anxiety symptoms, these symptoms tended to be subsyndromal and evanescent. More prominent symptoms were embarrassment, impaired self-image, low self-esteem, self-consciousness, frustration, and anger. Some subjects thought that acne had affected their personalities permanently and adversely. Psychological sequelae were attributed to the effects of facial acne on appearance. CONCLUSION: The psychological effects of acne can be considerable. The psychological morbidity is complex and often does not conform to standard psychiatric disease criteria. Recognition and management of the psychological sequelae of acne by general practitioners is of considerable importance.

Patients' perceptions of isotretinoin, depression and suicide--a qualitative study.

BACKGROUND: Isotretinoin is an effective acne medication. The evidence for it causing depression and suicide, although widely publicised, remains uncertain. METHODS: Twenty-six semi-structured interviews with patients with acne were coded and subjected to thematic analysis. RESULTS: Isotretinoin was perceived to be effective but dangerous. The most well known adverse effects were depression and suicide. DISCUSSION: The overemphasis of serious psychological adverse events in patients might discourage the use of isotretinoin by those who might benefit from it.

Patients with skin disease and their relationships with their doctors: a qualitative study of patients with acne, psoriasis and eczema.

OBJECTIVE: To explore the experiences of patients with acne, psoriasis or atopic eczema in their relationships with their treating doctors. DESIGN: Qualitative study, using semi-structured interviews conducted between January 2004 and April 2005, thematic analysis and modified grounded theory methodology. SETTING AND PARTICIPANTS: Participants were patients with acne, psoriasis or atopic eczema recruited from urban general practices and urban dermatology practices. RESULTS: 62 semi-structured interviews were conducted. Reports of negative experiences with doctors treating participants' skin conditions were common. Both general practitioners and dermatologists were reported as having poor comprehension of the psychological implications of skin diseases, being insensitive to their patients' emotional suffering, and trivialising participants' disease. Participants acknowledged that time considerations and other pressures may explain these apparent deficiencies. Some participants perceived their doctors as medical technicians and sought treatment for their physical skin disease, not for its emotional or social aspects. CONCLUSION: We recommend education for GPs about the psychological effects of skin diseases, and education for dermatologists and GPs on how to elicit and manage, or appropriately refer, these problems.