Ged Murtagh

Learning about maternal death and grief in the profession: a pilot qualitative study

The aim of this study was to explore the impact of maternal death on maternity professionals, and their related professional and personal needs.

Surgical decision making in a teaching hospital: a linguistic analysis

The aim of the study was to gain insight in the involvement of non‐operating surgeons in intraoperative surgical decision making at a teaching hospital. The decision to proceed to clip and cut the cystic duct during laparoscopic cholecystectomy was investigated through direct observation of team work.

Patient-initiated questions: How can doctors encourage them and improve the consultation process? A qualitative study.

Objective To investigate the circumstances under which patients initiate direct questions in oncology consultations. Design Conversation analysis of 47 consultations between oncologists and patients with cancer. Setting An oncology clinic at a teaching hospital in the East Midlands. Participants 16 Oncologists and 67 cancer patients. Outcome measure Patient initiated direct questions. Results On the whole patients’ direct questions are designed to seek specific information regarding, the cancer itself, treatment options or their experience of symptoms. When patients do ask direct questions they typically follow the announcement of test results where some reference to the details of those results, is provided. More specifically, there seems to be a relation between showing the patient their scan/X-ray results, patient involvement and patient-initiated direct questions. Higher levels of patient-initiated direct questions were clustered around occasions where doctors provided information and explanations of test results (12 consultations) sometimes with direct reference to scan or X-ray results (7 consultations). Conclusions This study highlights the importance of careful explanation of diagnostic evidence as a factor contributing to increased patient involvement. More specifically, the findings suggest that, when appropriate, invoking diagnostic evidence (eg, scan or X-ray results) is an effective way of increasing levels of patient question asking. Doctors need to be able to encourage patient question asking to ensure that patients have at their disposal an important means through which they can determine their information needs. Although these results come from a study of oncology consultations, the findings may be transferable to other clinical contexts.

Limited impact on patient experience of access of a pay for performance scheme in England in the first year.

Abstract Background: Improvement of access to general practice is a priority in England. In 2006/07 an annual national survey of patient experience of access was introduced, with financial incentives to practices based on the findings of the survey among their own patients. Objectives: To describe changes in patient experience of access over the first two years of the survey and incentive scheme, and identify respondent and practice characteristics associated with patient experience of access. Design and methods: The study included 222 general practices in the east of England, which had completed the access survey in 2006/07 and 2007/08. We compared proportions of patients reporting satisfaction with different aspects of access in each year. In explanatory regression models, we investigated the associations between improvement of reported access and respondent and practice characteristics. Results: There were some small improvements in reported access between the two surveys, although satisfaction with opening hours declined marginally. The explanatory analysis showed that larger practices, a higher proportion of respondents from ethnic minority groups, and higher deprivation were associated with patient reports of worse access. These variables and practice response rates did not explain the amount of change between the two years. Conclusions: The launch of the incentive scheme was not followed by convincing improvements in patient experience of access. Practices with deprived populations or with a high proportion of ethnic minority survey respondents are perceived as offering worse access, were not more likely to achieve improvements, and additional support should be considered to help these practices.

Improving consultations in oncology: the development of a novel consultation aid

Background:The way in which patients receive bad news in a consultation can have a profound effect in terms of anxiety, depression and subsequent adjustment. Despite investment in well-researched communication skills training and availability of decision-making aids, communication problems in oncology continue to be encountered.Methods:We conducted a mixed-methods study in a large UK Cancer Centre to develop a novel consultation aid that could be used jointly by patients and doctors. Consultations were audio-recorded and both the doctors and the patients were interviewed. We used conversation analysis to analyse the consultation encounter and interpretative phenomenological analysis to analyse the interviews. Key themes were generated to inform the design of the aid.Results:A total of 16 doctors were recruited into the study along with 77 patients. Detailed analysis from 36 consultations identified key themes (including preparation, information exchange, question-asking and decision making), which were subsequently addressed in the design of the paper-based aid.Conclusions:Using detailed analysis and observation of oncology consultations, we have designed a novel consultation aid that can be used jointly by doctors and patients. It is not tumour-site specific and can potentially be utilised by new and follow-up consultations.

Management of smokers motivated to quit: a qualitative study of smokers and GPs

BACKGROUND The National Institute for Health and Clinical Excellence (NICE) guidelines state that GPs should manage smokers motivated to quit by offering referral to Stop Smoking Services (SSS) and that nicotine addiction treatment (NAT) should be offered only to those who decline referral. OBJECTIVE To explore how smokers motivated to quit are managed in the GP consultation, specifically how treatment and referral are negotiated from the perspectives of both parties. METHODS Twenty patients, identified in a consultation with their GP as motivated to quit smoking, and 10 participating GPs were interviewed. Interviews were recorded, transcribed, coded and analysed using the framework approach. RESULTS Three strategies (treatment and follow-up by the GP, referral to SSS without treatment and immediate treatment with referral for follow-up) were evidenced in patient and GP accounts. Most patients were satisfied with their management and how this was negotiated, but some expressed surprise or dissatisfaction with lack of immediate treatment and questioned the need for referral to SSS. GPs welcomed the availability of SSS but some felt it important that they themselves also continued to support a quit attempt. Several saw advantages in offering NAT at the time the patient was motivated to stop. CONCLUSIONS Smokers appear less convinced than GPs about the value of referral to SSS, although these differences may be resolved through negotiation. An alternative strategy to that proposed by NICE, which may be more acceptable to some smokers, is immediate treatment with subsequent support from SSS.

Do the Quality and Outcomes Framework patient experience indicators reward practices that offer improved access

BACKGROUND The Quality and Outcomes Framework (QOF) includes indicators for patient experience, but there has been little research on whether the indicators identify practices that deliver good patient access. AIM To determine whether practices that achieved high QOF patient experience points in 2005/2006 or 2006/2007 also delivered good patient access. DESIGN OF STUDY Use of publicly available data to investigate two hypotheses: practices with more positive access survey findings in 2006/2007 will be more likely to have achieved maximum QOF patient experience points in the same year; and practices with maximum QOF patient experience points in 2005/2006 will have higher access survey findings in 2006/2007. SETTING Two-hundred and twenty-four East Midlands general practices. METHOD For hypothesis one, binary logistic regression was used, with achievement of maximum QOF points as the dependent variable, and access survey findings, responder variables, and practice variables as independent variables. For hypothesis two, general linear models were used, with access survey findings as the independent variables, and achievement of maximum QOF points and the responder and practice variables as dependent variables. RESULTS The findings did not support the first hypothesis. For the second hypothesis, achievement of maximum QOF points was only significantly associated with patient satisfaction with opening hours (positive correlation). QOF points were not associated with any other aspect of access. CONCLUSION The QOF patient experience indicators do not reward practices that offer good patient access. A standard patient survey with financial incentive may be more effective in identifying and rewarding practices that offer better access, including opportunity to book appointments with a particular doctor.

Microanalysis of video from the operating room: an underused approach to patient safety research

Video recording technologies offer a powerful way to document what happens in clinical areas.1 Cameras, and to a lesser extent, microphones, can be found in a growing number of modern operating rooms in the USA, UK and other parts of the world. While they could be used to create a detailed record of what happens in and around the operating table, this is still rarely being done; the vast majority of operations are still only documented in written operation notes. When operations are being recorded, it is primarily for educational purposes: for instance, to broadcast a live feed of a surgical demonstration to a remote audience; to provide an ‘adjunct’ to live observation;2 to collect authentic footage for edited, instructional videos on a surgical technique or procedure; to facilitate video enhanced debriefing and coaching; or to formally assess surgical skills. Recently, Makary et al 1 ,3 have proposed that video equipment in the operating room could be used as an auditing tool. They also argue that making video recording a routine occurrence would improve performance and make surgical care more transparent. They propose that a video archive of operations could prove useful for surgeons preparing to operate on a patient who had been operated on before—to check the anatomy and density of adhesions for example. It has also been suggested that when used routinely, video could be used to investigate adverse events.4–6 What has gone relatively unnoticed in these recent discussions about the potential of video in the operating room is the possibilities it opens up for empirical research . While videos can only provide a partial representation of what happened and are always open to interpretation, they do provide a relatively objective, shareable point of reference. Using video, clinical events can be looked at from …

Wearable technologies in osteoarthritis: a qualitative study of clinicians’ preferences

Objective This study investigates clinicians’ views of health-related wearable technologies in the context of supporting osteoarthritis (OA) long-term management. Clinicians’ preferences are critical in identifying realistic implementation strategies for such technologies. Design Qualitative study incorporating an inductive thematic analysis applied to identify key themes from clinicians’ responses. Participants Clinicians, including 4 general practitioners, 4 physiotherapists and 5 orthopaedic surgeons were interviewed. Setting The study was conducted in a University setting. Results Participants all agreed wearable technologies could positively complement their role and enhance their relationship with patients. Perceived benefits of wearable technologies included monitoring patients’ progress, treatment evaluation, monitoring compliance and informing clinical decision-making. The device should be designed to provide objective data of patients’ locomotion capability in an easy and timely fashion via a simple interface. Data should be available to both clinicians and patients to provide them with the motivation to achieve clinical goals and allow them to take ownership of their treatment. The use of technology was also seen as a way to more effectively plan treatment and manage patients’ contact time saving time and cost. Conclusions Findings support the use of wearable technologies to enhance current OA management and suggest clinical uses. Adoption of technologies could have implications on the effectiveness of treatment provided overcoming current barriers, in particular compliance with treatment.

Ethical reflection on the harm in reproductive decision-making.

Advances in reproductive technologies continue to present ethical problems concerning their implementation and use. These advances have preoccupied bioethicists in their bid to gauge our moral responsibilities and obligations when making reproductive decisions. The aim of this discussion is to highlight the importance of a sensibility to differences in moral perspective as part of our ethical inquiry in these matters. Its focal point is the work of John Harrisi, who has consistently addressed the ethical issues raised by advancing reproductive technologies. The discussion is aimed at a central tenet of Harris’s position on reproductive decision-making—namely, that in some instances, giving birth to a worthwhile life may cause harm and will therefore be morally wrong. It attempts to spell out some of the implications of Harris’s position that the author takes to involve a misplaced generality. To support this claim, some examples are explored that demonstrate the variety of ways in which concepts (such as harm) may manifest themselves as moral considerations within the context of reproductive decision-making. The purpose is to demonstrate that Harris’s general conception of the moral limits of reproductive autonomy obscures the issues raised by particular cases, which in themselves may reveal important directions for our ethical inquiry.