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Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of the individual (e.g. age and ethnicity), interpersonal (e.g. healthcare provider trust), and organisational (e.g. perceived workload) factors on general practitioners (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with or without a MB. An experimental study was carried out in which GPs were shown one of two video vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797, response rate was 13%) had to decide on their diagnosis, treatment, and referral. Analysis of variance and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables. Overall, we found that there were ethnic differences in GPs' decisions regarding diagnosis and treatment recommendations. GPs perceived the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and demonstrated a reduced likelihood to prescribe a combination of medical and non-medical treatments (F = 11.55, p < 0.001). Those differences increased in accordance with the GP's age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was exaggerating his distress. This paper showed that lower levels of trust among GPs' towards their migrant patients and high GP workloads contribute to an increased ethnic bias in medical decision-making. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs' trust in their migrant and ethnic minority patients. [ABSTRACT FROM AUTHOR]

Private primary care providers are usually the first site where afflictions come under institutional view. In the context of poverty, the relationship between illness and care is more complex than a simple division of responsibilities between various actors--with care given by kin, and diagnosis and treatment being the purview of providers. Since patients would often visit the provider with family members, providers are attuned to the patients' web of kinship. Providers would take patients' kinship arrangements into account when prescribing diagnostic tests and treatments. This paper terms this aspect of the clinical encounter as 'kin testing' to refer to situations/clinical encounters when providers take into consideration that care provided by kin was conditional. 'Kin testing' allowed providers to manage the episode of illness that had brought the patient to the clinic by relying on clinical judgment rather than confirmed laboratory tests. Furthermore, since complaints of poor health also were an idiom to communicate kin neglect, providers had to also discern how to negotiate diagnoses and treatments. Kinship determined whether the afflicted bodies brought to the clinics were diagnosed, whether medicines reached the body, and adherence maintained. The providers' actions make visible the difference that kinship made in how health is imagined in the clinic and in standardized protocols. Focusing on primary care clinics in Patna, India, we contribute to research that shows that kinship determines care and management of illnesses at home by showing that relatedness of patients gets folded in the clinic by providers as well. [ABSTRACT FROM AUTHOR]

In 2020, the New Zealand (NZ) Parliament voted to decriminalise abortion. Although NZ's abortion law formally opposes sex selective abortions, there is considerable complexity in the gender politics of 'choice' and 'agency' in multi-ethnic societies, and interpretations of reproductive rights for ethnic minority women and for the girl child, respectively. This paper explores these complexities through the perspectives of reproductive and maternity care practitioners who are situated at the interface of legal systems, health service provision, and delivery of culturally sensitive care. Thirteen practitioners were interviewed as part of this study. The analysis highlights strains in framings of 'reproductive choice' (underpinned by western liberal notions of rights) and 'gender equality' (abortion rights that acknowledge the complexity of cultural son-preference) for ethnic minority women. These tensions are played out in three aspects of the post-reform landscape: (a) everyday practice and accountability; (b) consumerism and choice; (c) custodianship and gender rights. The findings point to the limitations in operationalising choices for ethnic women in health systems wherein trust deficit prevails, and cultural dynamics render complex responses to abortion. They also highlight reconfigurations of client-expert relationships that may have implications for practitioners' abilities to advocate for ethnic women's rights against cultural influences. [ABSTRACT FROM AUTHOR]

Although oncology is a major site for clinician‒patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients and what the manner of promotion tells us about the oncologist‒patient relationship. Utilizing an already-established schema of coding treatment recommendations, I draw on 61 treatment recommendations to examine treatment decision-making in oncology. This paper investigates how physicians balance asserting their authority while at the same time attending to patient agency and involvement in decision-making. Taking this one step further, this paper explores how physicians negotiate decision-making with patients given that they occupy a liminal state between obligations to policy imperatives and commitments to their professional knowledge and technical expertise. How do they do this, and what accounts for this? To answer these questions, this paper analyzes the ways in which physicians present treatment recommendations and the treatment contexts in which they are made. [ABSTRACT FROM AUTHOR]

Aim: To describe what is currently known about nurses' assessment decisions when providing care to patients at home or in their usual place of residence. Methods: In August 2018, an integrative literature review using a systematic approach was conducted using specific search terms to search Informit, MEDLINE and Cumulative Index of Nursing and Allied Health Literature (CINAHL). The literature search was not limited by date, and included published papers or unpublished dissertations written between 1980 and 2018. Results: In total 25 full papers were assessed for inclusion in this review; seven met the inclusion criteria. Three themes were identified from this review: i) nurse education and experience; ii) assessment informing decision-making and iii) knowing the patient. Conclusion: Nurses' education, experience, abilities, prior learning, beliefs, attitudes and values are key factors in the delivery of home-based nursing care, and strongly influence how assessments, clinical judgements and decisions are made. Impact Statement: An understanding of home based nurses' decisions and response to clinical deterioration is needed to inform Hospital in the Home nursing-specific curricula. [ABSTRACT FROM AUTHOR]

Background: Clinical reasoning has been proposed to be a key attribute of health professionals. We hypothesized that clinical reasoning may be one explicit way to further the understanding of each other’s roles in interprofessional learning activities, for nurse students and physiotherapy students. Objectives: The first part of this paper was a literature review. In the second part of the paper, we described a case study with an action-based approach. Major Findings: The literature review showed that, although sparse, clinical reasoning has been used as a conceptual framework for students learning in interprofessional activities. Through a collaboration between clinicians and university staff, we developed a structure for interprofessional student collaboration based on narratives in combination with a clinical reasoning structure as proposed by Levett-Jones, adapted to identify the different roles. The interprofessional collaboration was found crucial for development of authentic and useful narratives to work from, where both professions had important roles. The use of a reasoning framework could scaffold student discussions to learn with, from and about each other. Conclusions: We concluded that interprofessional learning can take place in theory courses and the use of clinical reasoning as a conceptual framework may facilitate to clarify professional similarities and differences. [ABSTRACT FROM AUTHOR]

The roles that rapid, point-of-care tests will play in healthcare in low-income settings are likely to expand over the coming years. Yet, very little is known about how they are incorporated into practice, and what it means to use and rely upon them. This paper focuses on the rapid diagnostic test for malaria (mRDT), examining its introduction into low-level public health facilities in Tanzania within an intervention to improve the targeting of costly malaria medication. We interviewed 26 health workers to explore how a participatory training programme, mobile phone messages, posters and leaflets shaped the use and interpretation of the test. Drawing on notions of biopolitics, this paper examines how technologies of the self and mechanisms of surveillance bolstered the role mRDT in clinical decision-making. It shows how the significance of the test interacted with local knowledge, the availability of other medication, and local understandings of good clinical practice. Our findings suggest that in a context in which care is reduced to the provision of medicines, strict adherence to mRDT results may be underpinned by increasing the use of other pharmaceuticals or may leave health workers with patients for whom they are unable to provide care. [ABSTRACT FROM PUBLISHER]

In this paper we examine how traditional views of normality are negotiated, indorsed and resisted when talking about children with heart defects. Having as a starting point an ethnographic project that aimed to study knowledge construction when being pregnant or having a child with a heart defect, we focus on argumentation put forward by clinicians and parents in order to understand the forms that normality takes in relation to children's health and illness and the way that it is constructed argumentatively and linguistically. More specifically, we draw data from recorded doctor-patient consultations, ethnographic interviews and entries from family blogs and forums and focus on those instances where normality is negotiated as a means of providing a medical consultation or of taking and motivating decisions about the child's health and everyday life. The analysis is conducted by identifying content and logical topics in the data and showing how constructions of normality and alternative conceptions are constructed in discourse. Discourses are additionally related to discursive, semiotic framing and the realization of norms. Our results highlight a duality that is being painted both in the clinicians and in the parents' discourse when negotiating the illness and the accompanying risks in the child's everyday life. Some of the traditional norms being re-constructed and re-negotiated in the data are those of stigmatization, diversity, responsibility and freedom of choice. [ABSTRACT FROM AUTHOR]

Abortion stigma is experienced not only by women but also by providers and health professionals in a wide range of legal contexts. This paper analyses interviews with providers who work in the public health system in the Metropolitan Area of Buenos Aires, Argentina. A court ruling in 2012, FAL/12, changed the interpretation of abortion's legal status, clarifying the decriminalisation of abortion in cases of rape, and also requiring public policies and procedures to speed up access to legal abortion. Between 2014 and 2017, we conducted 27 in-depth, semi-structured interviews with abortion providers in public facilities across healthcare services in the Metropolitan Area of Buenos Aires. We found the way that health providers dealt with abortion stigma evolved over the course of time, as the abortion debate moved from the margins to the heart of political debate and public policies in Argentina between 2007 and 2017. Providers' experiences changed as the social and legal context changed. FAL/12 – as a clear, legal ruling – was a landmark and turning point in the way health professionals in public health facilities conduct their activities, making it possible for them to move from providing silent and hidden abortion care, to acknowledging it with pride. [ABSTRACT FROM AUTHOR]

Objectives:Whether and how patients should be told their dementia diagnosis, has been an area of much debate. While there is now recognition that early diagnosis is important for dementia care little research has looked at how dementia-related diagnostic information is actually verbally communicated. The limited previous research suggests that the absence of explicit terminology (e.g., use of the term Alzheimer's) is problematic. This paper interrogates this assumption through a conversation analysis of British naturalistic memory clinic interaction. Method:This paper is based on video-recordings of communication within a UK memory clinic. Appointments with 29 patients and accompanying persons were recorded, and the corpus was repeatedly listened to, in conjunction with the transcripts in order to identify the segments of talk where there was an action hearable as diagnostic delivery, that is where the clinician is evaluating the patient's condition. Results:Using a conversation analytic approach this analysis suggests that diagnostic communication, which is sensitive and responsive to the patient and their carers, is not predicated on the presence or absence of particular lexical choices. There is inherent complexity regarding dementia diagnosis, especially in the ‘early stages’, which is produced through and reflected in diagnostic talk in clinical encounters. Conclusion:In the context of continuity of dementia care, diagnostic information is communicated in a way that conforms to intersubjective norms of minimizing catastrophic reactions in medical communication, and is sensitive to problems associated with ‘insight’ in terms of delivery and receipt or non-receipt of diagnosis. [ABSTRACT FROM PUBLISHER]

Organ donation is constructed in the UK as a public responsibility, but more particularly as an obligation for members of minority ethnic communities. This paper draws attention to the ways in which ‘ethnicity’ has been made problematic by the allocation practices of transplant medicine, health promotion discourses and policy developments. Taken together, they have served to culturalise and racialise the procurement of organs. As the problem of organ donation is as much made inside medicine as outside it, this paper argues greater attention ought to be paid to these institutional practices and processes. Drawing on ethnographic work in the north of England, and with a specific focus on the organ consent encounter, this paper shows how categories of ethnicity in organ transplantation are an outcome of biopolitical and institutional practices. It argues that organ donation is best thought of, less as a discrete temporally-bounded act of decision-making, and more as a set of variegated situated practices that, in all manner of ways, problematically produce the publics that transplant medicine has come to rely upon so profoundly. [ABSTRACT FROM PUBLISHER]

This paper examines how physicians determine the quality and quantity of time to devote to each patient, and how these decisions are taught to physicians-in-training as part of the ‘hidden curriculum’ in medical education. The notion of moral economy is used to analyze how judgments of patient worth come to guide and influence interactions among physicians and physicians-in-training and patients, and how these interactions impact medical care. However, this paper also questions the notion of the hidden curriculum as a static or reified concept. Instead, the paper uses participant narratives to show how physicians-in-training are not simply passive recipients of the hidden curriculum but also actively resist judging patients based on perceptions of worth, even as they learn to operate within a moral economy of care. [ABSTRACT FROM PUBLISHER]

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]

Coordination of perioperative work is challenging. Advancements in diagnostic and therapeutic possibilities have not been followed by similar advancements in the ability to coordinate care. In this paper, we report on a study that explored the nature of continuous coordination as practiced by perioperative staff in order to coordinate their own activities with respect to those of their colleagues. We conducted in-depth interviews ( n = 14), and combined observations and focused interviews ( n = 31) with perioperative staff (physicians, nurses, technicians, and cleaners) at a major university hospital in Norway. Data were analysed qualitatively with systematic text condensation. The results indicated that a surgical schedule was important for informing staff members about the cases and tasks they had been assigned. Staff also depended on ad hoc, explicit communication to ensure timeliness of particular perioperative activities. This, however, left little room for adjustments of other activities. Hence, to be able to proactively coordinate their own work some staff tried to predict future perioperative activities by observing the workplace, monitoring the surgical scheduling software for changes, and sharing their colleagues' progress updates and predictions. These findings could be important for those developing support for perioperative coordination. [ABSTRACT FROM AUTHOR]

The framing effect, identified by Tversky and Kahneman, is one of the most striking cognitive biases, in which people react differently to a particular choice depending whether it is presented as a loss or as a gain. Numerous studies have subsequently demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision-making. Compared to daily decisions, medical decisions are of low frequency but of paramount importance. The framing effect is a well-documented bias in a variety of studies, but research is inconsistent regarding whether and how variables influence framing effects in medical decision-making. To clarify the discrepancy in the previous literature, published literature in the English language concerning the framing effect was retrieved using electronic and bibliographic searches. Two reviewers examined each article for inclusion and evaluated the articles' methodological quality. The framing effect in medical decision-making was reviewed in these papers. No studies identified an influence of framing information upon compliance with health recommendations, and different studies demonstrate different orientations of the framing effect. Because so many variables influence the presence or absence of the framing effect, the unexplained heterogeneity between studies suggests the possibility of a framing effect under specific conditions. Further research is needed to determine why the framing effect is induced and how it can be precluded. [ABSTRACT FROM AUTHOR]

This paper arises from the analysis of data from a large Singapore-based survey and a complementary qualitative series of 17 individual interviews. Some results from both arms of the research have been previously analysed and are reported elsewhere. Answers to a series of questions within the questionnaire and the structured interviews have been drawn together under the umbrella of investigating of recent Singaporean graduates' views about the characteristics of a good nurse, a good day at work, and how they uphold ethical standards. Overall five themes emerged, these are: caring for others; respectful interpersonal interaction; rational clinical decision-making; the harsh reality of the workplace; and personal qualities (not easily influenced by formal education). Interviewees believed that potential nursing students should be made aware of the harsh realities they will face on graduation, which may seem counter-intuitive. However, graduates recalled their own struggles and perseverance and toughness to simply survive the early months as a key component of transition shock, indicating that an earlier awareness may be beneficial. [ABSTRACT FROM AUTHOR]

In contemporary times, evidence-based medicine is used as the basis for clinical decision-making. For a great number of diseases, surveillance guidelines, which are informed by evidence-based medicine, have been drawn up with much input from specialists in their relevant fields. However, these guidelines are implemented in general practice where different rationalities are brought to bear on clinical decision-making. This qualitative study interviewed both specialists and General Practitioners in New Zealand about their use of surveillance guidelines for colorectal cancer. Tension between both groups of medical professionals was apparent with regard to referral practices, with specialists advocating a rational approach to risk. However, the socio-cultural context within which General Practitioners' clinical decision-making takes place demands a more reflexive process. This paper argues the need to explore power within medical practice as the devolution of power to one group, specialists, who are constructed as the knowledge 'elite', sidelines other groups, in this case General Practitioners, who have to deal with the more qualitative aspects of health service delivery. [ABSTRACT FROM AUTHOR]

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]

Aims and objectives: This paper reports a study aimed at exploring the nursing practices associated with the administration of pro re nata (PRN) postoperative analgesia to children, and at gaining a preliminary understanding of the decisions that nurses make about this important intervention. Background: Nurses are responsible for assessing and administering the appropriate medication at the appropriate time to the child in pain. There was scant published research about the administration of postoperative PRN analgesia to children, or about the decision-making processes inherent in this aspect of clinical nursing care. Design: A sequential mixed methods explanatory study with two data collection phases -- quantitative followed by qualitative -- was conducted. Results: Nurses used multiple strategies to ascertain children's need for postoperative PRN analgesia, including reference to pain assessment tools, focussing on the behavioural cues of children, involving parents and children, and drawing upon personal and professional backgrounds and experience. Evaluation of the effectiveness of PRN postoperative analgesia was poorly communicated. Conclusions: Decision-making associated with the selection and administration of appropriate analgesia to children is complex. In-service education should be developed and offered to nurses working with children postoperatively to ensure the appropriate use of PRN pain relief. Relevance to clinical practice: Documentation surrounding this task is poor and needs to be addressed as a matter of urgency to ensure quality patient outcomes. [ABSTRACT FROM AUTHOR]

Currently, the life expectancy of black Americans is about five years shorter than that of white Americans when factoring for gender. Poor patient compliance is often used as an explanation for why black people have worse health outcomes. The proof, however, is anecdotal and relies primarily on discourses about black people's general dysfunction. Black patients often respond in kind to problems they experience with health care access. They often conclude that the medical professionals they work with are racist. In most cases, neither of these explanations is correct. This paper argues that behavioral explanations for health care disparities shift attention away from structural issues, namely health care rationing and the limits of therapeutic medicine. The lack of an open discussion about the structural issues is part of the reason the goal initiated by the Clinton administration to end racial disparities by 2010, Healthy People 2010, largely failed. [ABSTRACT FROM AUTHOR]

With the rapid adoption of electronic health records (EHR), there is a growing appreciation for the central role they play in clinical decision making and team communication, with many studies documenting new safety issues with integration of the EHR into the clinical enterprise. To study these issues, we created a high-fidelity simulation instance of our clinical EHR. In this paper, we describe the impact of integrating the EHR into high-fidelity, interprofessional intensive care unit (ICU) simulations, and the errors induced. We found a number of safety issues directly related to the EHR including alert fatigue, negative impacts on interprofessional communication, and problems with selective data gathering, and these issues were present for all members of the interprofessional team. Through successful integration of the EHR into high-fidelity team-based simulations, we now have an infrastructure to focus educational initiative and deploy informatics solutions to mitigate these safety issues. [ABSTRACT FROM PUBLISHER]

Objective: This paper aims to summarize published findings by the authors and integrate these within current literature to support clinical guidelines when choosing an ear for cochlear implantation in adults with long-term monaural sound deprivation. Study sample: Four retrospective cohort studies based on data collected in five cochlear implantation centres with adults with bilateral hearing loss who used a single hearing aid for at least 15 years prior to unilateral or bilateral cochlear implantation. Design: Review, integration and interpretation of retrospective cohort studies to support clinical recommendations. Results: In this population, the prelingual nature of the hearing loss and the duration of bilateral significant hearing loss were the most reliable predictors of cochlear implantation outcomes. Importantly, the duration of sound deprivation in the ear to be implanted was not a significant predictor of speech recognition scores after cochlear implantation and should carry less weight in making recommendations. Conclusions: In most adults with postlingual hearing loss and long-term monaural sound deprivation, the sound-deprived sound deprivation ear should be preferred for implantation. For adults with prelingual deafness and monaural sound deprivation, the decision should weigh the risks of obtaining poorer results with the cochlear implant compared to the benefits of accessing binaural hearing. [ABSTRACT FROM AUTHOR]