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This research explores the experiences of UK NHS healthcare professionals working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic. Using a critical understanding of the concept of moral resilience as a theoretical framework, we explore how the difficult circumstances in which they worked were navigated, and the extent to which moral suffering led to moral transformation. Ten staff from a general practice participated in semistructured interviews. Encountering the harms endured by people seeking asylum prior to arrival in the UK and through the UK's 'Hostile Environment' caused healthcare staff moral suffering. They responded to this in several ways, including: (1) feeling grateful for their own fortunes; (2) defining the limitations of their professional obligations; (3) focusing on the rewards of work and (4) going above and beyond usual care. Although moral resilience is reflected in much of the data, some participants described how the work caused ideological transformations and motivated challenges to systems of oppression. We show how current moral resilience theory fails to capture these transformative political and social responses, warning of how, instead, it might encourage healthcare staff to maintain the status quo. We caution against the widespread endorsement of current formulations of moral resilience in contemporary social and political climates, where the hostile and austere systems causing suffering are the result of ideological political decisions. Future work should instead focus on enabling working conditions to support, and developing theory to capture, collective resistance.
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This paper explores how the rationing of medical care for older people by frailty score was justified and operationalised in the UK during the COVID-19 pandemic. COVID-19 was expected to overwhelm the National Health Service (NHS) in the UK. In March 2020, the National Institute for Health and Care Excellence (NICE) published the ‘COVID-19 rapid guideline: critical care in adults', which advised that clinicians use the Clinical Frailty Score (CFS) to inform decisions about which patients over the age of 65 should be offered ventilatory support. We present a Foucauldian Critical Discourse Analysis of this guidance and the supporting online resources. Analysis shows how the guidance merchandises the CFS as a quick and easy-to-use technology that reduces social and physical complexity into a clinical score. This stratifies older people by frailty score and permits the allocation of resources along these lines. We show how this is justified through epidemiological discourses of risk, which are merged with the language of individual mortality prediction. We discuss the proceduralisation of the CFS alongside a growing body of research that problematises its application in resource allocation. We argue that the pandemic has increased the use of the concept of frailty and that this effectively obfuscates the concept's limitations and ambiguities;the ageism implicit in the response to COVID-19 in the UK;and the relative resource scarcity facing the UK's NHS.
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What we knewPeople of African and Caribbean descent are less likely to access palliative and end of life care. It is unclear why they are so poorly served by our services and how COVID-19 has exacerbated this.What we wanted to knowWe sought bereaved relatives’, health and social care professionals’ and community workers’ views on experiences of and barriers to palliative and end of life care and suggestions for improvement.MethodsPublic recruitment was utilised. Over 150 diverse organisations throughout the UK were contacted. Qualitative semi-structured interviews were conducted with a diverse sample of 26 bereaved relatives and 13 professionals.FindingsThere were three key themes:Representation, encompassing discrimination and racism.Personalisation, including culture and the impact of COVID-19.Awareness and Access, including support before and after death and communication and involvement in decision-making.Participants recommend services shouldRepresentIdentify and acknowledge racism and discrimination in palliative care provision.Ensure better representation of African and Caribbean communities within services and in public facing material.PersonaliseAdapt services to ensure they are culturally and religiously competent:Recognise diversity in cultural and religious needs.Challenge racial and cultural stereotypes.Enable equitable remote engagement.Ensure awareness and educationBetter integrate services within communities by working with faith/community leaders.Raise awareness of the value of palliative care services in all communities.Provide training/education for professionals to build confidence and competence.ConclusionPalliative care was perceived as inadequate during the pandemic. Inequities in care provision were exacerbated, to the detriment of people of African and Caribbean descent who were disproportionately and uniquely effected. Palliative care services and local communities could and should learn from each other, to enhance equitable access to appropriate care for all. Significant investment in services and communities may be required.
ABSTRACT
BackgroundPolicymakers anticipated COVID-19 would overwhelm the National Health Service (NHS) in the UK with particular concern about critical care capacity. In March 2020, the National Institute for Health and Care Excellence (NICE) published guidance for clinicians treating people with COVID-19, which used the concept of frailty in its decision-making matrix for the care of people over the age of 65.MethodsThis research paper uses a Foucauldian theoretical approach to explore how the rationing of medical care for older people by frailty score was justified and operationalised in the UK during the COVID-19 pandemic. We present a Critical Discourse Analysis of this guidance and the supporting online resources.ResultsAnalysis shows in the guidance, the Clinical Frailty Score is merchandised as a quick and easy-to-use technology which reduces social and physical complexity into a clinical score. This process makes older people knowable within the biomedical sphere and allows them to be stratified based on frailty score. This is justified through epidemiological discourses of risk, merged with the language of individual mortality prediction. This facilitates the allocation of resources along the lines of CFS score. We discuss this proceduralisation of CFS alongside a growing body of research that problematises its application in resource allocation and frailty studies.DiscussionWe argue that the continuing dominance of frailty effectively obfuscates the concept’s limitations and ambiguities, the ageism implicit in the response to COVID-19 in the UK, and the relative resource scarcity facing the UK’s NHS.
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AimsThis research aims to understand relatives’ and carers’ experiences of discussions about resuscitation. Findings are needed to inform policy and practice about what works well and how discussions about resuscitation need to improve.BackgroundDo Not Attempt Cardiopulmonary Resuscitation (DNACPR) discussions have been especially challenging during the pandemic. Hospital visiting restrictions and untimely deaths due to COVID-19 have disrupted usual modes of communication between staff, patients and relatives. There have been reports of blanket DNACPR decisions being applied to older people and complaints about communication are common. This is distressing for patients and families and costly for the NHS.MethodsThis qualitative research uses semi-structured interviews to explore the experiences of people who discussed resuscitation on behalf of a relative during the COVID-19 pandemic. An interview topic guide was developed in collaboration with patients and public involvement partners. Interviews were transcribed verbatim, and analysed using framework analysis.Results18 semi-structured interviews have been undertaken to date. Analysis has identified the following themes:The importance of communication. This includes the timing of communication about DNACPR and examples of good practice and the lack of information about DNACPR for patients and families.The multiple dimensions of resuscitation and DNACPR, with misunderstanding about what resuscitation involves, how the decision about DNACPR is made, and by whom.Wide-ranging impacts of the DNACPR decision, feeling overlooked and disregarded by the medical team, guilt at not contesting a DNACPR decision, and consequent mistrust of the healthcare system.We aim to complete over 30 interviews by March 2022. Recruitment will continue until inductive thematic saturation.ConclusionUrgent action is needed to improve communication and ensure appropriate DNACPR discussions. Current practice results in frequent misunderstandings and lasting negative effects which may have detrimental consequences for bereavement reactions and future relationships with healthcare professionals.
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This commentary discusses the role and value of qualitative data when undertaking quality improvement (QI) focussing on the care of older adults. To illustrate this, we reflect on our own experiences of planning a QI project to improve the documentation of Clinical Frailty Scale (CFS) scores in the emergency department (ED) during the coronavirus disease of 2019 (COVID-19) pandemic. National clinical guidance for COVID-19 states that all adults over the age of 65 should be given a CFS at the first point of contact during hospital admission. Therefore, there is a need to improve CFS documentation, specifically in acute care settings. We describe how qualitative methods facilitated an understanding of the barriers to CFS documentation in ED. Staff see the CFS as a useful tool for inter-professional communication, though there are tensions between clinical guidance and their beliefs. Staff had moral concerns about how an ED-allocated CFS might limit available treatment options for older adults. Our findings demonstrate how qualitative methods can illuminate the important social and moral dimensions of why improvement does or does not occur.