Organising work in neonatal transfer: Optimising place of care for babies born moderately preterm.

The organisation of neonatal units into geographically-based networks that offer different levels of care is intended to ensure babies receive the care they need via transfers between different units. In this article, we explore the significant organisational work required in practice to accomplish such transfers. Conducted within a wider study of optimal place of care for babies born between 27 and 31 weeks' gestation, we draw on ethnographic work exploring the accomplishment of transfers in this complex care context. We undertook fieldwork in six neonatal units across two networks in England, representing 280 hours of observation and formal interviews with 15 health-care professionals. Drawing on Strauss et al.'s concept of the social organisation of medicine and Allen's concept of 'organising work', we identify three distinct forms of such work central to the successful accomplishment of a neonatal transfer: (1) 'matchmaking', to identify a suitable transfer location; (2) 'transfer articulation', to successfully effect the planned transfer; and (3) 'parent engagement', to support parents through the transfer process. Our findings build on and extend Strauss et al. and Allen's work by both highlighting the different forms of 'organising work' undertaken in this clinical context and the distribution of such work across different professional groups.

Managerial thinking in neonatal care: a qualitative study of place of care decision-making for preterm babies born at 27-31 weeks gestation in England.

OBJECTIVES: Preterm babies born between 27 and 31 weeks of gestation in England are usually born and cared for in either a neonatal intensive care unit or a local neonatal unit-with such units forming part of Operational Delivery Networks. As part of a national project seeking to optimise service delivery for this group of babies (OPTI-PREM), we undertook qualitative research to better understand how decisions about place of birth and care are made and operationalised. DESIGN: Qualitative analysis of ethnographic observation data in neonatal units and semi-structured interviews with neonatal staff. SETTING: Six neonatal units across two neonatal networks in England. Two were neonatal intensive care units and four were local neonatal units. PARTICIPANTS: Clinical staff (n=15) working in neonatal units, and people present in neonatal units during periods of observation. RESULTS: In the context of real-world neonatal practice, with multiple (and rapidly-evolving) uncertainties relating to mothers, babies and unit/network capacity, 'best place of care' protocols were only one element of much more complex decision-making processes. Staff often made judgements from a less-than-ideal starting point, and were forced to respond to evolving clinical and organisational factors. In particular, we report that managerial considerations relating to demand and capacity organised decision-making; demand and capacity management was time-consuming and generated various pressures on families, and tensions between staff. CONCLUSIONS: Researchers and policymakers should take account of the organisational context within which place of care decisions are made. The dominance of demand and capacity management considerations is likely to limit the impact of other improvement interventions, such as initiatives to integrate families into the neonatal care provision. Demand and capacity management is an important element of neonatal care that may be overlooked, but significantly organises how care is delivered.

Public health in the making: Dietary innovators and their on-the-job sociology.

Diet is understood to be one of the most important influences on public health and chronic disease, and is particularly implicated in the so-called 'obesity epidemic'. Yet interventions aiming to improve the population's dietary habits have failed to translate into widespread health improvements. Simultaneously, the knowledge landscape has become increasingly contentious, with fat activism challenging dominant approaches to how obesity is framed and addressed. This paper is based on 24 ethnographic interviews, and explores the work of health practitioners promoting therapeutic carbohydrate restriction ('low-carb' diets) for people with metabolic health conditions. Drawing on Michel Callon's study of technological innovation, I show practitioners engaging in 'on-the-job sociology'-situated sociological work to justify, and forge a space for, innovative dietary intervention. These innovators employ physiological explanations of hormones, satiety (or hunger), and pleasure (or shame), supported with personal experience, to emphasise material connections between particular eating habits and the sustainability of dietary improvement in everyday life. They resist fat activist influence on healthcare practice (that has resulted in practitioners avoiding conversations about diet, fatness and health), as well as the more extensively critiqued practices of health promotion. Deflecting blame/shame from individuals, innovators spotlight the role of the food industry in undermining public understandings of food and physiology, and dietary improvement that is achievable and sustainable. Through on-the-job sociology, innovators forge a space to engage patients in collaborative dietary experimentation and improvement. This study highlights the importance of on-the-job sociology in the contemporary knowledge landscape, providing new insights about public health in the making.

A win-win scenario? Restrictive policies from alternative standpoints.

PURPOSE: In this viewpoint article, the authors consider the challenges in implementing restrictive policies, with a particular focus on how these policies are experienced, in practice, from alternative standpoints. DESIGN/METHODOLOGY/APPROACH: The authors draw on social science studies of decommissioning work to highlight how patient and official versions of value often vary, creating difficulties and distrust as restrictive policies are implemented. Patients and the public are well aware that financial calculations are somehow embedded in concepts of "evidence" and "value" but are usually unfamiliar with the social infrastructures that produce and utilise such concepts. The authors discuss with reference to a contemporary restrictive programme in England. FINDINGS: While policymakers and researchers frequently present restrictive policies as "win-win" scenarios (achieving both cost-savings for healthcare services and improved patient care), social science analyses highlight the potential for tensions and controversies between stakeholders. The authors recognise that cost containment is a necessary component of policymaking work but argue that policymakers and researchers should seek to map (and make visible) the socially organised reasoning, systems and processes that are involved in enacting restrictive policies. Although transparency may pose challenges, it is important for informed democratic engagement, allowing legitimate scrutiny of whose voices are being heard and interests served (the "winners" and "losers"). ORIGINALITY/VALUE: The authors argue for social science analyses that explore overuse, value and restrictive practices from alternative (e.g. patient) standpoints. These can provide important insights to help identify priorities for intervention and support better communication.

Supporting people to implement a reduced carbohydrate diet: a qualitative study in family practice.

INTRODUCTION: Much of the science behind dietary guidelines for risk reduction and chronic disease management is equivocal, and there are well-accepted uncertainties and complexities relating to diet in everyday life, as well as physiological processes. Guidelines have therefore stopped short of aligning with one particular approach, instead highlighting several evidence-based options. However, reduced carbohydrate, or 'low-carb', diets have increasing traction in the media and with patients, practitioners and the general public. This qualitative study examines healthcare practitioner (HCP) experiences of implementing a reduced carbohydrate diet. METHODS: Semistructured, qualitative interviews were conducted with 19 HCPs in the UK family practice (including general practitioners, practice nurses and non-medical practitioners), recruited through a special interest forum, and social media. Data analysis employed social science theory and methods to produce key themes. RESULTS: All participants self-identified as 'low-carb practitioners' who, over time, had introduced a specific focus around carbohydrate reduction into their work. They reported transformations in patients' metabolic markers, patient enthusiasm for the approach and renewed job satisfaction. Key themes highlight experiences of: (1) discovering low-carb as a new 'tool-in-the-box'; (2) promoting and supporting incremental low-carb experimentation; and (3) diverging from established dietary guidelines. CONCLUSIONS: This study provides important experience-based evidence on a topical dietary intervention. Participants strongly advocated for the use of low-carb diets. The successes described draw attention to the need for pragmatic, formative evaluation of low-carb advice and support as a 'complex intervention' (alongside physiological research), to justify, challenge and/or shape low-carb intervention in clinical practice. The findings raise important questions about the contribution of particular care practices to the apparent success of low-carb. Social science analyses can elucidate how dietary intervention is carried out across different healthcare settings (eg, dietetics, endocrinology) and patient groups, how healthcare practices intersect with people's everyday self-management and how different forms of evidence are invoked and prioritised.

Overruling uncertainty about preventative medications: the social organisation of healthcare professionals' knowledge and practices.

In this article, we draw on an institutional ethnographic (IE) study of cardiovascular disease prevention in general practice, exploring the work of healthcare professionals who introduce a discussion of risk and preventative medications into consultations with patients. Our aim is to explicate, using IE's theoretical ontology and analytical tools, how troubling patient experiences in this clinical context are coordinated institutionally. We focus our attention on the social organisation of healthcare professionals' knowledge and front-line practices, highlighting the textual processes through which they overrule patients' concerns and uncertainties about taking preventative medication, such that some patients feel unable to openly discuss their health needs in preventative consultations. We show how healthcare professionals activate knowledge of 'evidence-based risk reduction' to frame patients' queries as 'barriers' to be overcome. Our analysis points not to deficiencies of healthcare professionals who lack the expertise or inclination to adequately 'share decisions' with patients, but to the ways in which their work is institutionally orientated towards performance measures which will demonstrate to local and national policymakers that they are tackling the 'burden of (cardiovascular) disease'.