Jessica Young

Finding the ‘self’ after weight loss surgery: Two women’s experiences.

Drawing on narratives derived from two women’s YouTube vlogs (video blogs), we examine what weight loss surgery offers as a mode of being in the world. In these vlogs, Divataunia and Thebandinme have kept a record of their weight loss surgery ‘journey’. We explore the multiple selves they express, drawing on notions of embodiment and post-structuralist conceptualisations of subjectivity, to examine the contradictory and shifting experiences of having weight loss surgery. We examine the work that subjectivity ‘does’, in how each woman enacts her subjectivity, in what they ‘choose’ to express, and in how their choices are related to their perceptions and lived experiences of their bodies. In particular we investigate one subject position that the women both take up – a ‘fat subjectivity’ – and discuss how each woman relates to this subject position as her body changes. The notion of a weight loss surgery journey from an ‘old’ self to a ‘new’ one is explored and we conclude that the idea of a simple trajectory from ‘old’ to ‘new’ fails to adequately account for the complex vagaries of each women’s experience.

Communities of clinical practice in action: Doing whatever it takes:

Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient’s well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients’ medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice’s repertoires are characterised by care and are driven by the moral imperative to care. They do ‘whatever it takes’, although there is a cost to this form of care. Well-functioning communities of clinical practice use patient’s well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the ‘messiness’ of community-based care.

An exercise to map patient-centred care networks

An interview study of participants in primary health carebased CoCPs highlighted their potential complexity. We found that the visual representation of CoCPs as maps facilitated the assimilation of this complexity. Each patient was shown their map to confirm whether they agreed that it represented their care world. The optimal care and wellbeing of the patient at the centre of the CoCP is the common purpose of its participants. CoCPs are dynamic: the composition changes as the patient’s needs change. Participants have varying roles and levels of engagement (Figure 1).5 CoCP maps include family, social clubs, community and health care services. They articulate the formal and informal care networks that sustain individuals in the community.

Students' reflections on the relationships between safe learning environments, learning challenge and positive experiences of learning in a simulated GP clinic.

Learning environments are a significant determinant of student behaviour, achievement and satisfaction. In this article we use students’ reflective essays to identify key features of the learning environment that contributed to positive and transformative learning experiences. We explore the relationships between these features, the students’ sense of safety in the learning environment (LE), the resulting learning challenge with which they could cope and their positive reports of the experience itself. Our students worked in a unique simulation of General Practice, the Safe and Effective Clinical Outcomes clinic, where they consistently reported positive experiences of learning. We analysed 77 essays from 2011 and 2012 using an immersion/crystallisation framework. Half of the students referred to the safety of the learning environment spontaneously. Students described deep learning experiences in their simulated consultations. Students valued features of the LE which contributed to a psychologically safe environment. Together with the provision of constructive support and immediate, individualised feedback this feeling of safety assisted students to find their own way through clinical dilemmas. These factors combine to make students feel relaxed and able to take on challenges that otherwise would have been overwhelming. Errors became learning opportunities and students could practice purposefully. We draw on literature from medical education, educational psychology and sociology to interpret our findings. Our results demonstrate relationships between safe learning environments, learning challenge and powerful learning experiences, justifying close attention to the construction of learning environments to promote student learning, confidence and motivation.

Moral Economy and Moral Capital in the Community of Clinical Practice

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient’s journey. The concept of moral capital offers another route into the “black box” of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

‘Why worry about something you can’t control?’ Negotiated risk, longevity and health behaviours:

While we know about lay attitudes towards death and dying, we understand little about the ways people estimate their overall personal risk of life-limiting disease and/or death. This study contributes to the limited literature on lay longevity reckonings, with a particular focus on how these reckonings may influence health behaviours. Semi-structured interviews were held with 21 young older adults (54–65 years), addressing the core questions of ‘What do you think you will die from, and how long do you expect to live?’ Participants indicated their longevity estimation was guided by three key frameworks: family history, environment and lifestyle factors and lived experience. The reckoning process was also moderated by assumptions about loci of control and self-efficacy and the information available to participants. A tripartite model of death risk assessment is proposed, extending the idea of ‘negotiated risk’ beyond the scope of family history where it has received most attention. We argue that by drawing on the three risk-assessment frameworks, determining patients’ predisposition for external/internal attributions of control and perceptions of self-efficacy, clinicians will be better equipped to understand – and thus guide – patients’ reckonings of longevity and health behaviours that are influenced by it.

Living into death: a case for an iterative, fortified and cross-sector approach to advance care planning

ABSTRACT Advance care planning (ACP) has been framed as best practice for quality palliative care, yet a growing body of literature affirms the need for an early iterative ACP process to begin when people are young and healthy. A significant gap appears to exist in the literature regarding the utility of death conversations outside the end-of-life context. Could ‘death conversations’ early in life be an effective tool by which doctor and patient can co-construct a more healthful way of life, and realistic relationship with death? And what variables must be taken into account for these conversations to proceed successfully? This paper provides a narrative exploration of the value of death conversations in the clinical context in New Zealand. Five exemplars are discussed, drawn from a sample of 21 semi-structured interviews with young older adults (54–65 years old) not receiving palliative care or diagnosed with a terminal illness. Together, these narratives indicate that further community consultation is required to determine culturally appropriate ways to initiate productive conversations around aging, death and dying and how to build patient/practitioner/family relationships which allow these conversations to happen safely. There is a need to acknowledge the important factor of culture related to age, generation, sex, faith and ethnicity when engaging in conversations about aging, death and dying. By doing so, health professionals will be best equipped to assist their patients to live well into death.

General practitioners’ ethical decision-making: Does being a patient themselves make a difference?

There is very little literature on the actual decision-making frameworks used by general practitioners with respect to ethical issues and virtually none on the impact of personal experiences of illness on this. This study aimed to investigate what these frameworks might be and if and how they were altered by doctors’ own illness experience. Twenty general practitioners were recruited, 10 having had a previous serious medical illness and 10 having no such history. They participated in a semi-structured interview, including case vignettes, recorded and analysed using qualitative thematic analysis. Being a patient themselves altered general practitioners’ decision-making by enhancing physician empathy, increasing ease at discussing difficult topics, having a greater willingness to support patient choice and a wider ability to provide a greater diversity of therapeutic strategies, with the role of empathy being the most noticeable difference between the groups. Doctors who had not had a severe personal illness showed difficulty in anticipating how this might change their decision-making. Virtue ethics was most commonly used for decision-making by both groups. There was considerable divergence of opinion on the ethics and usefulness of self-disclosure of personal illness in both groups of doctors. These findings have implications for the teaching and learning of medical ethics at both undergraduate and postgraduate level.

Putting social care on the map

McCartney’s call for reflection on the status of social care and its integration with the health system will resonate with many.1 Our recent, modest innovation might facilitate mutual awareness of the various people who support and care for patients. We have been investigating the concept of a “community of clinical practice”2 (adapted from Wegner’s community of practice …