Emma Pitchforth

An ethnographic study of classifying and accounting for risk at the sharp end of medical wards.

An understanding of how staff identify, classify, narrativise and orient to patient safety risks is important in understanding responses to efforts to effect change. We report an ethnographic study of four medical wards in the UK, in hospitals that were participating in the Health Foundations Safer Patients Initiative, an organisation-wide patient safety programme. Data analysis of observations and 49 interviews with staff was based on the constant comparative method. We found that staff engaged routinely in practices of determining what gets to count as a risk, how such risks should properly be managed, and how to account for what they do. Staff practices and reasoning in relation to risk emerged through their practical engagement in the everyday work of the wards, but were also shaped by social imperatives. Risks, in the environment we studied, were not simply risks to patient safety; when things went wrong, professional identity was at risk too. Staff oriented to risks in the context of busy and complex ward environments, which influenced how they accounted for risk. Reasoning about risk was influenced by judgements about which values should be promoted when caring for patients, by social norms, by risk-spreading logics, and by perceptions of the extent to which particular behaviours and actions were coupled to outcomes and were blameworthy. These ways of identifying, evaluating and addressing risks are likely to be highly influential in staff responses to efforts to effect change, and highlight the challenges in designing and implementing patient safety interventions.

The analysis of qualitative research data in family planning and reproductive health care

This is the third in a series of four papers on the use of qualitative methods in family planning and reproductive health care research. The first paper outlined the three main methods used in qualitative studies and the second explored how we can assess the ‘quality’ of qualitative research. This paper addresses issues related to the analysis of qualitative data. It begins by discussing the nature of qualitative data and its management followed by an outline of the main theoretical assumption pertaining to its analysis that of ‘coding up’ (versus ‘coding down’). Next we describe some of the major approaches to qualitative data analysis and discuss why you may choose one approach over another. The paper ends by highlighting some general issues in qualitative data analysis. (authors)

Models of intrapartum care and women’s trade‐offs in remote and rural Scotland: a mixed‐methods study

Objective  To explore women’s preferences for, and trade‐offs between, key attributes of intrapartum care models.

Delphi method and nominal group technique in family planning and reproductive health research

This is the authors final draft, not as published in The Journal of Family Planning and Reproductive Health Care, 2006, 32(4), pp.249-252

Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh

Objective: To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. Design: Mixed methods qualitative study. Setting: Large government medical college hospital in Bangladesh. Sample: Providers and users of EmOC. Methods: Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. Results: Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal “poor fund” system to help the poorest women. There was no formal assessment of poverty; rather, doctors made “adjudications” of women’s need for support based on severity of condition and presence of friends and relatives. Limited resources led to a “wait and see” policy that meant women’s condition could deteriorate before help was provided. Conclusions: Greater consideration must be given to what happens at health facilities to ensure that (1) using EmOC does not further impoverish families; and (2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity.

Participating in a trial in a critical situation: a qualitative study in pregnancy

Background: Randomised controlled trials of interventions in critical situations are necessary to establish safety and evaluate outcomes. Pregnant women have been identified as a potentially vulnerable population. Objective: To explore women’s experiences of being recruited to ORACLE, a randomised controlled trial of antibiotics in pre-term labour. Methods: Twenty qualitative interviews were conducted with women who had participated in ORACLE. Analysis was based on the constant comparative method. Results: Women gave prominence to the socioemotional aspects of their interactions with healthcare professionals in making decisions on trial participation. Comments on the quality of written and spoken information were generally favourable, but women’s accounts suggest that the stressful nature of the situation affected their ability to absorb the information. Women generally had poor understanding of trial design and practices. The main motivation for trial participation was the possibility of an improved outcome for the baby. The second and less prominent motivation was the opportunity to help others, but this was conditional on there being no risks associated with trial participation. In judging the risks of participation, women seemed to draw on “common sense” understandings including a perception that antibiotics were risk free. Discussion: Recruitment to trials in critical situations raises important questions. Future studies should explore how rigorous governance arrangements for trials, particularly in critical situations, can protect participants rather than relying on ideals of informed consent that may be impossible to achieve. Future research should include a focus on interactions between research candidates and professionals involved in recruitment.

Characteristics of Effective Interventions in Improving Young People's Sexual Health: A Review of Reviews.

The purpose of this paper is to conduct a review of reviews to identify characteristics of effective sex and relationship education (SRE) interventions and/or programmes in young people to improve sexual health and identify barriers and facilitators for implementation. Six bibliographic databases were searched from 1986 to 2006 for systematic reviews that assessed SRE interventions or programmes in participants between 10 and 18 years old and their partners. All outcomes of improvement in sexual health were assessed and 30 systematic reviews were included. Effective interventions and/or programmes tended to be those targeting younger age groups before they become sexually active, focused interventions tailored to the physical and biological development stages, theory based, and abstinence education programmes that incorporate values of relationships and provide skills training and links to contraceptive services. Adequate training of personnel delivering the interventions and culturally sensitive programmes were identified as important facilitators of effectiveness. Future research should explore the appropriate age for initiating sex education and investigate targeting specific behaviour compared with multiple-outcome targeting. Research exploring the reasons for interventions focusing on specific populations (i.e. African and Hispanic origins), even if they were conducted in countries dominated by Caucasians, is warranted.

“Choice” and place of delivery: a qualitative study of women in remote and rural Scotland

Objective: To explore women’s perceptions of “choice” of place of delivery in remote and rural areas where different models of maternity services are available. Setting and methods: Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services. Results: Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from “acceptors” to “active choosers.” The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in “choice.” Conclusions: Provision of different models of maternity services may not be sufficient to convince women they have “choice.” The paper raises fundamental questions about the meaning of “choice” within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

Focus group research in family planning and reproductive health care

This paper discusses how to conduct focus groups in family planning and reproductive research and follows a four-part series outlining the general principles of qualitative research. Originating in market research and through development as a more general social science research method focus groups now have wide application in many areas of research including health and health care. Focus groups are often regarded as a quick and convenient way to collect data from several people simultaneously but this is an oversimplification. Our paper considers the reasons for choosing to use focus groups and the strengths and weaknesses of the focus group method. Moreover it highlights some of the practical issues in planning and conducting focus groups as well as particular considerations in the analysis and presentation of focus group data. (excerpt)

Access to specialist cancer care: is it equitable?

The first principle of the Calman–Hine reports recommendations on cancer services was that all patients should have access to a uniformly high quality of care wherever they may live. This study aimed to assess whether the uptake of chemotherapy for colorectal cancer varied by hospital type in Scotland. Hospitals were classified according to cancer specialisation rather than volume of patients. To indicate cancer specialisation, hospitals were classified as ‘cancer centres’, ‘cancer units’ and ‘non-cancer’ hospitals. Colorectal cancer cases were obtained from cancer registrations linked to hospital discharge data for the period January 1992 to December 1996. Multilevel logistic regression was used to model the binary outcome, namely whether or not a patient received chemotherapy within 6 months of first admission to any hospital. The results showed that patients admitted first to a ‘non-cancer’ hospital were less than half as likely to go on to receive chemotherapy as those first admitted to a cancer unit or centre (OR=0.28). This result was not explained by distance between hospital of first admission and nearest cancer centre, nor by increasing age or severity of illness. The study covers the period immediately preceding the introduction of the Calman–Hine report in Scotland and should serve as a baseline for future monitoring of access to specialist care.