Lars E.F. Johannessen

Prestige rankings of chronic diseases and disabilities. A survey among professionals in the disability field

Disabled people constitute the worlds largest minority; too little is known about the internal structure and valuations of that minority. We investigate whether prestige rankings of different chronic diseases and disabilities can be elicited from a community of disability non-governmental organizations (NGOs). A survey was performed in a sample of NGO professionals in Norway in late 2013 and early 2014. Two copies of a questionnaire was sent to 92 national and regional offices of disability NGOs requesting a response from either senior employees or elected officials, preferably one of each. Outcome measures were ratings on a 1-9 scale of the prestige these respondents believed most professionals in their field would accord to a sample of 38 different conditions. We find that there is a prestige hierarchy of chronic diseases and disabilities in the disability field. In this hierarchy, somatic conditions that are strongly associated with medical treatment were placed higher than either conditions that are characterized by permanence, or conditions are associated with psychosomatic etiologies. The elicited prestige hierarchy is at odds with prevalent normative positions in the disability field; there is a lack of fit between some of the fields central political goals and its internal evaluations. We propose that its structure can be explained through a) influence from the medical field, b) organization history, size, and prominence, and c) issues of credibility, shame and blame. Further research should be conducted into the structure and valuations of the disability field in general and people with disabilities and chronic diseases in particular.

Stability and change in disease prestige: A comparative analysis of three surveys spanning a quarter of a century

In this paper, we present a comparative analysis of three survey studies of disease prestige in medical culture. The studies were conducted in 1990, 2002 and 2014 using the same research design. In each of the three rounds, a sample of Norwegian physicians was asked to rate a set of 38 diseases on a scale from 1 to 9 according to the prestige they believed health personnel in general would award them. The results show a remarkable stability in the prestige rank order over 25 years. The top three diseases in all three surveys were leukaemia, brain tumour and myocardial infarction. The four lowest ranked were fibromyalgia, depressive neurosis, anxiety neurosis and hepatocirrhosis. The most notable change concerns apoplexy (brain stroke), which moved from a rank of 33 to 29 and then to 23 over the three rounds. We argue that the stable pattern, as well as this change, substantiate the interpretation of previous research, i.e. that the prestige of a disease is affected by the localization of the affected organ or body part, the effect and style of its typical treatment, and the social attributes of the typical patient. Analysing physicians shared evaluations of different diseases, the paper contributes to the cultural understanding of disease conceptions in medicine. Understanding these conceptions is important because disease prestige may influence decision-making in the healthcare sector.

The narrative (re)production of prestige: How neurosurgeons teach medical students to valorise diseases

It is well documented that doctors rate diseases in a prestige hierarchy, in which some diseases are valued more than others. However, little is known about how doctors acquire the knowledge to do this rating. Based on a fieldwork study of the teaching of neurosurgery at a Norwegian university hospital, this paper shows how notions of disease prestige are (re)produced through neurosurgeons telling of disease narratives in medical education. The analysis presents their prestigious narrative of subarachnoid haemorrhage (SAH), a rare form of stroke, which neurosurgeons presented as an acute and potentially lethal but curable disease. In contrast to perceivably more ordinary diseases, their portrayal of SAH references heroic narratives on a more abstract cultural level, casting neurosurgeons as masculine and extraordinary lifesavers, able to act where others fall short. By shedding light on how neurosurgeons teach students to evaluate diseases, the paper lays a foundation for reflecting upon the means and conditions that (re)produce their notions of disease prestige and contributes more generally to our understanding of medical culture.

Beyond guidelines: discretionary practice in face‐to‐face triage nursing

This article draws on ethnographic data from a Norwegian emergency primary care clinic (EPCC) to explore nurses discretionary application of guidelines. Specifically, it analyses nurses discretionary use of the Manchester Triage System (MTS) when performing face-to-face triage, that is, assessing the urgency of patients complaints. The analysis shows how nurses assessed patients at odds with MTS prescriptions by collecting supplementary data, engaging in differential diagnostic and holistic reasoning, relying on emotion and intuition, and allowing colleagues and patients to influence their reasoning. The findings also show how nurses reasoning led them to override guidelines both overtly and covertly. Based on this evidence, it is argued that nurses assessments relied more on internalised triage mindlines than on codified triage guidelines, although the MTS did function as a support system, checklist and system for supervisory control. The study complements existing research on standardisation in nursing by providing an in-depth analysis of nurses methods for navigating guidelines and by detailing how deviations from those guidelines spring from their clinical reasoning. The challenges of imposing a managerial logic on professional labour are also highlighted, which is of particular relevance in light of the drive towards standardisation in modern healthcare.

Workplace assimilation and professional jurisdiction: How nurses learn to blur the nursing-medical boundary

In theorising the system of professions, Andrew Abbott emphasised how jurisdictional boundaries in the workplace are far fuzzier than those specified in law. A key reason for this fuzziness is the process he characterised as workplace assimilation, involving on the job learning of a craft version of another professions knowledge system. However, despite its centrality, workplace assimilation remains poorly elaborated in the scholarly literature. To address this shortcoming, this study explores the workplace assimilation of nurses in a Norwegian emergency primary care clinic. Using an ethnographic approach, the study shows how nurses learned to blur the nursing-medical boundary by (1) doing physician-like work; (2) interacting with their colleagues; (3) comparing their own clinical assessments to those of physicians (as codified in the patient record) and (4) using medical reference works to guide their clinical decision making. In detailing these aspects of workplace assimilation, the study illuminates how and why workers come to blur jurisdictional boundaries in the workplace.

Narratives and gatekeeping: making sense of triage nurses’ practice

It is well documented that emergency service staff consider some patients to be inappropriate attenders. A central example is trivia, denoting patients with medical problems considered too trivial to warrant attention. Although research has repeatedly shown that frontline staff violate guidelines in turning away trivial patients, existing research has paid insufficient attention to why staff are willing to engage in guideline-violating gatekeeping, which may put both themselves and trivial patients at risk. To address this issue, the present article explores nurses narratives about trivial patients - referred to in this context as GP patients - drawing on fieldwork data from a Norwegian emergency service. The article reconstructs three narrative clusters, showing that nurses gatekeeping is motivated by concerns for the patient being turned away, for nurses and more critically ill patients, and for the service they work for. Some of the issues embedded in these narratives have been under-analysed in previous research - most importantly, the role of identity and emotion in nurses gatekeeping, and how patient narratives can function as social prognoses in nurses assessments. Analysis of these narratives also reveals an antagonistic relationship between nurses and trivial patients that contradicts nurses ethical guidelines and indicates a need for healthcare reform.