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Purpose:In this paper we examine how the intersection of various social and political influences shapes discharge planning and rehabilitation practices in ways that may not meet the espoused aims of rehabilitation programs or the preferences of older adults and their families. Methods:Taking a critical bioethics perspective, we used microethnographic case study methods to examine discharge-planning processes in a well-established older adult inpatient rehabilitation setting in Canada. The data included observations of discharge-planning family conferences and semi-structured interviews conducted with older adults facing discharge, their family members and rehabilitation professionals involved in discharge planning. Results:From the time of admission, a contextual push to focus on discharge superseded program aims of providing interventions to increase older adults’ functional capabilities. Professionals’ primary commitment to safety limited consideration of discharge options and resulted in costly and potentially unnecessary recommendations for 24-hour care. The resulting “rehabilitation” stay was more akin to an extended process of “destination triage” biased towards the promotion of physical safety than optimizing functioning. Conclusions:The resulting reduction of rehabilitation into “destination triage” has significant social, financial and occupational implications for older adults and their families, and broader implications for healthcare services and overarching healthcare systems. Implications for RehabilitationCurrent trends promoting consideration of discharge planning from the point of admission and prioritizing physical safety are shifting the focus of rehabilitation away from interventions to maximize recovery of function, which are the stated aims of rehabilitation.Such practices furthermore promote assessments to determine prognosis early in the rehabilitation stay when accurate prognosis is difficult, which can lead to overly conservative recommendations for discharge from rehabilitation services, thus further negating the impact of rehabilitation.Further work is required to examine the social, occupational and functional implications of superseding rehabilitation interventions to maximize capabilities with practices that prioritize safety over quality of life for older adults and their family members. [ABSTRACT FROM PUBLISHER]

Gypsies, Roma and Travellers (GRT) experience a significantly high number of measles cases and have low levels of measles, mumps and rubella (MMR) immunisation. There is little evidence on: why immunisation levels are low; beliefs and practices surrounding the MMR vaccine; or the factors that promote or hinder uptake. This paper presents data from five focus groups with 16 GRT mothers in Kent, South East England. Between them, they had 35 children of whom just under half had not received the course of vaccinations. Focus groups explored the issues GRT parents consider when making vaccination decisions in the context of wider social, ideological, material and practical considerations. Four interrelated themes were identified: way of life and access; engaging with health care staff; perceptions and evaluations of risk; and strategies to minimise MMR-related risks. Our findings provide little support for explanations that emphasise cultural values or practices in shaping immunisation behaviour. Poor service provision, situational constraints related to living circumstances, and multifaceted and severe health issues, which precede and inform decisions over childhood immunisation, were more significant in explaining low uptake. [ABSTRACT FROM PUBLISHER]

People with drug addictions have among the lowest rates of adherence to HIV medications (i.e. HAART) of any infected population, which is often explained through reference to the instability associated with problematic drug use and the ‘chaos’ that is assumed to characterize the lives of people with addictions. Many studies examine the links between addiction and adherence from the perspective of HIV-positive populations, but few explore how HIV care providers think about addictions, their impact on adherence, and how to incorporate the complex health needs of drug-using populations into comprehensive HIV care practices. Using qualitative data from a pilot study on adherence to HAART among people with drug addictions in Vancouver, British Columbia, this paper examines how eight HIV care providers (i.e. physicians, pharmacists, and community-based service providers) approach these interconnected issues. Our findings illustrate that while addictions often complicate adherence to HAART, this is not a universal reality, and the kinds of drugs used as well as the individual capacities of these patients also factor significantly in their adherence success. The organization of the HIV care environment, which is highly stratified and provides certain professionals with more resources and structural capabilities to deliver comprehensive care than others, also plays a large role in our participants’ abilities to address the health needs of their clients with addictions. We recommend that the current HIV care delivery system be adapted to ensure more integrated care and greater equity across the different groups of providers working in the field of HIV care. [ABSTRACT FROM PUBLISHER]

This paper reports on a qualitative study of UK mental health practitioners' experiences of working with the contested condition, dangerous and severe personality disorder (DSPD). Our interviews focused on the issues of treatability, risk assessment and decision-making in multi-disciplinary teams. We discuss the approach of values-based medicine (VBM) as a useful framework for interpreting the data: respondents cited both explicit values (based on occupational training) and implicit values (based on personal beliefs and subjective perceptions). There was evidence of conflicting values -- within individuals, between occupational groups, and between individuals in occupational groups -- which led to widespread uncertainty and caution about whether and how those with 'dangerous' personality disorders could be treated. These disputes were resolved by a 'slide to pragmatism', whereby practitioners, reluctantly acknowledging their own empowerment in the process, sought to make whichever choice was least risky for their own professional reputation, and most pragmatic, given the resources available. [ABSTRACT FROM AUTHOR]

To expand understanding of patient-clinician interactions in management reasoning. We reviewed 10 videos of simulated patient-clinician encounters to identify instances of problematic and successful communication, then reviewed the videos again through the lens of two models of shared decision-making (SDM): an 'involvement-focused' model and a 'problem-focused' model. Using constant comparative qualitative analysis we explored the connections between these patient-clinician interactions and management reasoning. Problems in patient-clinician interactions included failures to: encourage patient autonomy; invite the patient's involvement in decision-making; convey the health impact of the problem; explore and address concerns and questions; explore the context of decision-making (including patient preferences); meet the patient where they are; integrate situational preferences and priorities; offer >1 viable option; work with the patient to solve a problem of mutual concern; explicitly agree to a final care plan; and build the patient-clinician relationship. Clinicians' 'management scripts' varied along a continuum of prioritizing clinician vs patient needs. Patients also have their own cognitive scripts that guide their interactions with clinicians. The involvement-focused and problem-focused SDM models illuminated distinct, complementary issues. Management reasoning is a deliberative interaction occurring in the space between individuals. Juxtaposing management reasoning alongside SDM generated numerous insights. [ABSTRACT FROM AUTHOR]

Ample research suggests that uncertainty is a major concern for individuals undergoing genetic testing and for genetic mutation carriers, and that their management of uncertainty is largely influenced by healthcare providers, including genetic counselors (GCs). Indeed, uncertainty is inherent in genetic testing results. To help patients grapple with uncertainty, GCs need to effectively manage the uncertainty inherent in genetic testing and communicate it appropriately to patients. The present study aimed to identify GCs' strategies for managing uncertainty and communicating uncertainty to patients. Eighteen GCs participated in five focus group interviews, and the data were analyzed using a grounded theory approach. Findings indicated that GCs used three main strategies to manage uncertainty: becoming lifelong learners, normalizing uncertainty, and seeking social support. To communicate uncertainty to patients, GCs also used three different strategies: engaging in open and honest communication, adapting to patients' needs, and focusing on known information. The implications of these findings for uncertainty theories and for conceptual frameworks of GCs' clinical communication are discussed. [ABSTRACT FROM AUTHOR]

Purpose:This systematic literature review aimed to (1) summarize and explain the concept of Burden of Treatment (BoT) using the International Classification of Functioning, Disability and Health (ICF) terminology, and (2) inform the development of a future Comprehensive ICF Core Set for BoT. Method:Searches on EMbase, Medline, CINAHL and PsycINFO were conducted. Only qualitative studies were considered for inclusion. The screening and data extraction stages were followed by a “Best-fit” framework synthesis and content analysis, using the established ICF linking rules. Screening, data extraction, quality appraisal and data analysis were performed by two independent researchers. Results:Seventeen studies were included in this review. The “Best–fit” framework synthesis generated 179 subthemes which identified that BoT impacts negatively on body functions and structures, restricts valued activities and participation and influences contextual factors through life roles, self-identify and relationships. The identified subthemes were linked to 77 ICF categories. Conclusions:This study is part of the preparatory phase of a Comprehensive ICF Core Set for BoT and our findings will inform the further needed studies on this phase. The use of ICF terminology to describe BoT provides an accessible route for understanding this complex concept, which is pivotal for rethinking clinical practice.Implications for rehabilitationHealth professionals applying the ICF should consider the negative impact of interventions on patient’s life roles and self-identity, body functions and structures and on valued activities and participation.Health professionals who may be concerned about the treatment burden being experienced by their patients can now use the ICF terminology to discuss this with the multidisciplinary team.Poor adherence to rehabilitation programs may be explained by an increased BoT. This phenomenon can now be mapped to the ICF, and coded using a framework well known by multidisciplinary teams. [ABSTRACT FROM PUBLISHER]

In many contemporary healthcare systems, individuals are expected to be rational actors – weighing up available knowledge and making choices about their healthcare needs. In the policy context, this has been most explicitly applied to the financing of healthcare where there is encouragement for the purchase of private health insurance. However, perceptions of public and private healthcare provision, knowledge about healthcare needs, and the types of services people choose, are far from straightforward. Drawing on Bourdieu's concepts of habitus, field, and capital, and a study of individual experiences of choice in Australian healthcare, we explore the knowledges used by people as they navigate through the healthcare system. Such navigation takes place in a milieu where authoritative medical knowledge intersects with knowledge from other sources, including the Internet and lived experience. However, our study reveals that navigation of healthcare is assisted most of all by the capacity to draw on 'system knowledge'. System knowledge takes two, sometimes overlapping, forms. First, acquired system knowledge is produced through drawing on experience, formal knowledge and the capacity to undertake research (primarily cultural capital). Second, assumed system knowledge enables navigation of the healthcare system through accessing and utilising networks of privilege (primarily economic and social capital). [ABSTRACT FROM AUTHOR]

This article explores processes of legitimising health knowledge in three different spaces: the clinic, the home and the multidisciplinary meeting. It considers the ways in which categorisation work, health understandings and therapeutic actions are intertwined. The analysis draws on ethnomethodology and actor-network theory to suggest that in the clinic consultation room, a number of interactional elements in talk about side effects and talk about unorthodox interventions attempt to stabilise the categories used by health experts. In contrast, the household is a centre of knowledge production that may subvert, manipulate or align with expert systems. Fixed and stable expert knowledge becomes flexible and hybridised inside the home. In the multidisciplinary team meeting different forms of authority are called upon in hospital-based cancer care meetings, where health professionals mix scientific understandings with other ways of knowing in determining treatment options. From these empirical observations it is argued that therapeutic actions are not subject in any simplistic way to a dominant mode of understanding, but there are many means of understanding that selectively come into play in relation to the specifics of the interaction that is occurring between patients, health professionals and therapeutic spaces. [ABSTRACT FROM AUTHOR]

Some vaccine supporters interpret vaccine uncertainties as a form of public ignorance caused by patients’ online research, failed physician–patient relationships, or inadequate knowledge translation. These interpretations often portray health professionals as homogeneously accepting of all scheduled vaccines for all patients. Nonetheless, health professionals may have limited knowledge about vaccines because the demands of their profession require them to have a broad understanding of a variety of health topics. In this article, I draw on data from interviews with twenty-six physicians and seven nurses in Alberta, Canada between 2013 and 2014, to examine how they used narratives to convey confidence, uncertainty, or doubts in vaccines. All interviewees supported the culturally dominant vaccine narrative that vaccines are essential to population health, yet they also spoke about uncertainties. Interviewees managed their uncertainties through tactics that confirmed accepting vaccination was the most desirable course of action. With each of these tactics, interviewees shared narratives about communicable diseases, vaccine benefits and risks to individual patients, and their reasons for trusting in medical science. When these narratives did not fully resolve medical uncertainties, health professionals often explained that either vaccination was beyond their professional responsibilities or that their uncertainties were irrelevant. [ABSTRACT FROM PUBLISHER]

Background:Stewardship is an important aspect of medical care to which little formal attention is paid during training.Purpose:The goal is to evaluate stewardship practices of internal medicine residents and the relationship of resident refusal to provide requested nonindicated care with levels of confidence and bother.Methods:Cross-sectional survey of residents in one training program, containing four hypothetical clinical scenarios asking residents whether they would provide nonindicated tests and treatments, and to report confidence in the decision and bother.Results:Sixty-seven of 105 residents completed the survey. Most residents prescribed a requested brand-name expensive medication when a generic was available and hospitalized a patient with no expected clinical benefit, but few were willing to repeat imaging for quicker availability or perform an unnecessary diagnostic evaluation. Residents ordering nonindicated tests and treatments reported lower confidence in their decision and more bother. PGY level was not associated with clinical decision or bother.Conclusions:Internal medicine residents, at least on hypothetical scenarios, demonstrate inconsistent stewardship practices. Findings support room for improvement in confidence when faced with requests for nonindicated care and suggest the need for greater curricular emphasis on stewardship. [ABSTRACT FROM PUBLISHER]

Most shared decision-making (SDM) models within healthcare have been limited to the patient-physician dyad. As a first step towards promoting an interprofessional approach to SDM in primary care, this article reports how an interprofessional and interdisciplinary group developed and achieved consensus on a new interprofessional SDM model. The key concepts within published reviews of SDM models and interprofessionalism were identified, analysed, and discussed by the group in order to reach consensus on the new interprofessional SDM (IP-SDM) model. The IP-SDM model comprises three levels: the individual (micro) level and two healthcare system (meso and macro) levels. At the individual level, the patient presents with a health condition that requires decision-making and follows a structured process to make an informed, value-based decision in concert with a team of healthcare professionals. The model acknowledges (at the meso level) the influence of individual team members' professional roles including the decision coach and organizational routines. At the macro level it acknowledges the influence of system level factors (i.e. health policies, professional organisations, and social context) on the meso and individual levels. Subsequently, the IP-SDM model will be validated with other stakeholders. [ABSTRACT FROM AUTHOR]

The study addresses how recent reforms of the Sickness Benefit Act in Denmark are put into practice. A single case study embedded with five subunits of analysis based on 'real life' cases has been conducted in a Danish municipality. Five 'sick-listed' citizens and their respective municipal case manager and general practitioner (GP) were interviewed. Two key persons within the municipality were interviewed as background informants. The GPs and case managers ability to co-operate was hampered by lack of time, frequent staff turnover, lack of financial resources, and low accessibility. The motivation for co-operation was low due to low status of social medical issues, lack of feedback and lack of trust. The co-operation was characterized by sequential task integration. The stakeholders encountered difficulties when reciprocal task integration was needed. The decision making was affected by legal constraints and conflicting paradigms of key stakeholders. Rather than forcing co-operation, policymakers should increase the stakeholders' abilities and improve the conditions that create the low level of trust and hamper the willingness to co-operate. [ABSTRACT FROM AUTHOR]