Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care.

BACKGROUND: Healthcare providers are the vital link between evidence-based policies and women receiving high quality maternity care. Explanations for suboptimal care often include poor working conditions for staff and a lack of essential supplies. Other explanations suggest that doctors, midwives and care assistants might lack essential skills or be unaware of the rights of the women for whom they care. This ethnography examined the everyday lives of maternal healthcare providers working in a tertiary maternity hospital in Kabul, Afghanistan between 2010 and 2012. The aim was to understand their notions of care, varying levels of commitment, and the obstacles and dilemmas that affected standards. METHODS: The culture of care was explored through six weeks of observation, 41 background interviews, 23 semi-structured interviews with doctors, midwives and care assistants. Focus groups were held with two diverse groups of women in community settings to understand their experiences and desires regarding care in maternity hospitals. Data were analysed thematically. RESULTS: Women related many instances of neglect, verbal abuse and demands for bribes from staff. Doctors and midwives concurred that they did not provide care as they had been taught and blamed the workload, lack of a shift system, insufficient supplies and inadequate support from management. Closer inspection revealed a complex reality where care was impeded by low levels of supplies and medicines but theft reduced them further; where staff were unfairly blamed by management but others flouted rules with impunity; and where motivated staff tried hard to work well but, when overwhelmed with the workload, admitted that they lost patience and shouted at women in childbirth. In addition there were extreme examples of both abusive and vulnerable staff. CONCLUSIONS: Providing respectful quality maternity care for women in Afghanistan requires multifaceted initiatives because the factors leading to suboptimal care or mistreatment are complex and interrelated. Standards need enforcing and abusive practices confronting to provide a supportive, facilitating environment for both staff and childbearing women. Polarized perspectives such as 'villain' or 'victim' are unhelpful as they exclude the complex realities of human behaviour and consequently limit the scope of problem solving.

Parallel worlds: An ethnography of care in an Afghan maternity hospital.

Aspirations of quality, equitable and respectful care for all women in childbirth have, so far, been unrealised. Sub-optimal care remains the norm in many settings despite decades of substantial investment, the introduction of evidence-based policies, procedures and training programmes. Improving the standard of facility-based care for childbearing women in Afghanistan is an example. This ethnography of a large public Afghan maternity hospital explored the experiences, motivations and constraints of healthcare providers. The aim was to identify barriers and facilitators in the delivery of care. Participant observation, semi-structured interviews, and focus group discussions were used to gather diverse perspectives on childbirth and care between 2010 and 2012. The influences of the sociocultural setting and political economy on facility-based care are discussed in this paper. Under the surface of this maternity hospital, social norms were in conflict with the principles of biomedicine. Contested areas included the control of knowledge, equity and the primary goal of work. The institutional culture was further complicated by pressure from powerful elites. These unseen values and pressures explain much of the disconnection between policy and implementation, education and the everyday behaviours of healthcare providers. Improving the quality of care and equity in Afghan public maternity hospitals will require political will from all stakeholders to acknowledge these issues and find culturally attuned ways to address them. Furthermore, the notion of competing world-views on healthcare has relevance beyond Afghanistan.

Living with a long-term condition: Understanding well-being for individuals with thrombophilia or asthma.

A range of literature has explored the experience of living with a long-term condition (LTC), and frequently treats such experiences and conditions as problematic. In contrast, other research has demonstrated that it may be possible to adapt and achieve well-being, even when living with such a condition. This tends to focus on meaning and the qualitative experience of living with an LTC, and offers alternative perspectives, often of the same or similar conditions. As a result of these conflicting views, this study chose to consider two conditions which, though they may lead to life-threatening illness on occasion, do not appear to impact significantly the lives of all those affected on a daily basis. The aim of this research was to explore and explain how people make sense of two long-term, potentially life-threatening health conditions, namely, thrombophilia and asthma. In doing so, it specifically considered the contribution made by information about the condition. A constructivist grounded theory approach was adopted; this enabled the generation of a theory regarding how people make sense of their LTC, whilst acknowledging the social circumstances in which this was situated. Semi-structured interviews were conducted with 16 participants who had given consent to take part in the research. The findings demonstrate that participants undergo a two-stage process-gaining knowledge and living with a long-term condition. The theory based on these findings indicates that those who are knowledgeable about their condition, making informed decisions in relation to it, and accept their condition are able to live with it, whilst those who do not accept their condition do not fully adapt to it or integrate it into their lives.

Comfort vs risk: a grounded theory about female adolescent behaviour in the sun.

AIMS AND OBJECTIVES: To generate a grounded theory about female adolescent behaviour in the sun. BACKGROUND: Nurses have key roles in health promotion and skin cancer prevention. Adolescents' resistance to sun safety messages and their vulnerability to sunburn are of concern internationally. Understanding why young women do as they do in the sun may enhance skin cancer prevention, but their behaviour has not been explained before in the UK. DESIGN: The study incorporated a qualitative grounded theory design using the approach of Glaser. METHODS: Qualitative data were gleaned from group and one-to-one, semi-structured interviews with 20 female participants aged 14-17, research memos and literature. Sampling was purposive and theoretical. Data collection, analysis and theory generation occurred concurrently. Data were analysed using the constant comparative method. Data collection ended when a substantive theory had been generated. RESULTS: Data analysis revealed five categories of findings: fitting in, being myself, being physically comfortable, slipping up and being comfortable (the core category). The theory generated around the core explains how young women direct their sun-related activities towards meeting their physical and psychosocial comfort needs. CONCLUSIONS: A contribution of this research is the grounded theory explaining the behaviour of young women in the sun. Further, the theory challenges assumptions that female adolescents necessarily take risks; it explains their sun-related activities in terms of comfort. The theory extends findings from other researchers' descriptive qualitative studies and also appears to apply to young people in countries other than the UK. RELEVANCE TO CLINICAL PRACTICE: Understanding the sun-related activity of young women in terms of physical and psychosocial comfort may help nurses to develop new approaches to skin cancer prevention. These could complement existing messages and humanise health promotion.

Being a qualitative researcher.

This article, from a keynote address, is the result of some of the things which I learned about qualitative research during my many years of doing and teaching it. The main point I make is that qualitative researchers should present a good story which is based on evidence but focused on meaning rather than measurement. In qualitative inquiry, the researchers' selves are involved, their experiences become a resource. Researchers cannot distance themselves from the other participants, although they cannot fully present their meaning and experience. I also discuss voice, paradigm, and innovation as potentially problematic issues in qualitative research. These are terms often used but not always examined for their meaning in qualitative inquiry. If researchers are aware and sensitive, rather than overemotional or self-absorbed, qualitative research can be enlightening, person-centered, and humanistic.

Running free: embracing a healthy lifestyle through distance running.

Sport and leisure activity contribute to both health and quality of life. There is a dearth of qualitative studies on the lived experiences of active people, so the aim of this paper is to develop a deeper understanding of the experiences of one particular group of active leisure participants, distance runners, and to highlight the associated health and well-being benefits that result from participating in this increasingly popular form of active leisure. In doing so, this paper will briefly explore the potential opportunities and implications for sport and leisure policy and provision, and highlight examples of how distance running could positively contribute towards government objectives linked to tackling obesity levels, healthy living and physical well-being. It is suggested that similar benefits also exist across other forms of physical activity, exercise and sport. Qualitative methods of enquiry were adopted to understand the nature of the social world of long distance runners through interviews and observations, which were thematically analyzed. One of the key themes emerging from the data was the desire to embrace a healthy lifestyle, which then led to the emergence of four main sub-themes. The first was linked to the importance of seeking self-esteem and confirmation through running; second, an investigation of a selection of negative aspects associated with exercise addiction; third, the need to exercise among sport and leisure participants; and finally, an understanding of the concept of the 'running body'. Cautionary notes also identified negative aspects associated with exercise and physical activity. The findings highlight the potential role that distance running can play as an easily accessible and enjoyable leisure activity, one that can help facilitate increased participation in exercise and physical activity as an integral part of an active and healthy lifestyle.

Parental distress around supplementing breastfed babies using nasogastric tubes on the post-natal ward: a theme from an ethnographic study.

There is abundant evidence of the benefits of breastfeeding. In the UK, supplementation in hospital has consistently been shown to be associated with shortened duration of breastfeeding. This paper reports on a subset of the data from an ethnographic study that explored the expectations, beliefs and experiences of mothers and health professionals concerning supplementation, using a variety of methods, of breastfed babies in an English maternity unit in 2002. This paper aims to describe the expectations, beliefs and experiences of mothers and health professionals concerning supplementation by nasogastric (NG) tube on the post-natal ward. Participant observation was carried out on day and night shifts and at weekends over 9 months. Mothers, midwives, neonatal nurses, health care assistants and senior paediatricians were interviewed. Categories and themes were generated. The researchers' constructs of 'the essential method', when the tube was the method needed for medical reasons, and 'the chosen method', when other methods of oral feeding should have been possible, emerged. The latter included time pressures and the avoidance of any form of oral activity that might perhaps make return to the breast more difficult. The data concerning the use of NG tubes for supplementation yielded the specific theme of parental distress. In the absence of evidence that supplementation by NG tube on the post-natal ward is associated with greater breastfeeding success than other methods, the use of the tube to avoid any form of 'oral confusion' should be discontinued. Its use primarily to save time should not be considered acceptable.

Achieving normality: the key to status passage to motherhood after a caesarean section.

OBJECTIVE: to explore women's experiences of caesarean section. DESIGN: a qualitative study using a grounded theory approach. Data were collected using unstructured, tape-recorded interviews which took place between 1999 and 2000. SETTING: the South West of England. PARTICIPANTS: twenty-one women who had experienced a caesarean section-either by choice or of necessity-and who were first- or second-time mothers. FINDINGS: four main categories emerged: expectations and reality, being in control, feelings of failure as a woman and feeling different. These all linked to the core category of achieving normality. Women strove to achieve normality after having a caesarean section. If they did not gain this sense of normality, the status passage to motherhood appeared to be more difficult. IMPLICATIONS FOR PRACTICE: it is important for health-care professionals to identify and acknowledge the emotional and physical needs of women who experience a caesarean section. Improving communication and support antenatally and postnatally may have positive benefits for maternal well-being.

The efficacy of midwifery role models.

AIM: to explore the influence of midwifery role models on the role that student midwives learn. DESIGN: a qualitative approach using specifically grounded theory, was adopted. Data were collected by means of unstructured tape-recorded interviews, and analysed using the constant comparative method. SETTING: South of England. PARTICIPANTS: 20 student midwives undertaking either an 18-month pre-registration shortened programme or a 3-4-year long programme were included in the study, along with 17 midwives practising in a variety of settings. FINDINGS: students learn the role of midwife in a changing culture, in which some midwives practise autonomously and others continue to rely on doctors to make their decisions. Students emulate the role of the midwife with whom they work. This suggests that all midwives are effective role models. Midwives who demonstrate the role of handmaiden to the doctor are inappropriate role models. They perpetuate a culture of midwifery that neither meets professional expectations nor the needs of women. Because they have power, students emulate these role models when in their presence. Midwives who practise autonomously are appropriate and influential role models. From these role models, students learn how to become autonomous practitioners. They emulate the practice of these role models because they want to, and intimate that they will continue to do so when their name is entered on the Nursing and Midwifery Council Professional Register. IMPLICATIONS: if learning inappropriate behaviours are to be avoided, attention needs to be paid to role modelling.

The stigmatisation of people with chronic back pain.

PURPOSE: This study responded to the need for better theoretical understanding of experiences that shape the beliefs, attitudes and needs of chronic back patients attending pain clinics. The aim was explore and conceptualise the experiences of people of working age who seek help from pain clinics for chronic back pain. METHODS: This was a qualitative study, based on an interpretative phenomenological approach (IPA). During in-depth interviews in their homes, participants were invited to 'tell their story' from the time their pain began. Participants were twelve male and six female patients, aged between 28 and 62 years, diagnosed as having chronic benign back pain. All had recently attended one of two pain clinics as new referrals. The interview transcripts were analysed thematically. FINDINGS: Stigmatisation emerged as a key theme from the narrative accounts of participants. The findings expose subtle as well as overt stigmatising responses by family, friends, health professionals and the general public which appeared to have a profound effect on the perceptions, self esteem and behaviours of those interviewed. CONCLUSIONS: The findings suggest that patients with chronic back pain feel stigmatised by the time they attend pain clinics and this may affect their attitudes and behaviours towards those offering professional help. Theories of chronic pain need to accommodate these responses, while pain management programmes need to address the realities and practicalities of dealing with stigma in everyday life.

Perseverance by older people in their management of chronic pain: a qualitative study.

INTRODUCTION: Many older people suffer from degenerative and chronic diseases resulting in chronic pain. It is important for health professionals and researchers to gain insights into experiences of chronic pain sufferers, so that they may understand the patient's perspective and instigate appropriate treatments. AIM: This study set out to gain insights into older people's perceptions about the effect of chronic pain on their lives and how they self-manage it. DESIGN: A qualitative approach to generating data based on Grounded Theory was chosen. Sixty-three people between the ages of 60 and 87 years participated and were interviewed using audiotape. The interviews were transcribed and subsequently analyzed, and the material was coded and collapsed into themes constituting the final grounded theory. RESULTS: As the data collection progressed, a major theme of perseverance emerged, supported by two subthemes: * keeping occupied, and * a focus on social activities. It became apparent that the participants were determined to get on with their lives. Those with strong social links appeared to have a more positive outlook on life. CONCLUSIONS: "Keeping going" was a priority for most of the participants. It may be beneficial to identify the ways in which older people persevere despite chronic pain. It is important for health professionals to appreciate the social factors which are important to, and valued by, older people who experience chronic pain.

The experience of chronic back pain: accounts of loss in those seeking help from pain clinics.

BACKGROUND: This study responded to the need for greater understanding of the experiences that help to shape the worldviews of chronic back patients as they seek help from pain clinics. AIM: To elaborate on the lived experience of chronic back pain in those actively seeking help from pain clinics. METHODS: This was a qualitative study, based on an interpretative phenomenological approach. As part of in-depth interviews, participants were invited to 'tell their story' from the time their pain began. Participants were twelve male and eight female patients, all of whom were diagnosed as having chronic benign back pain and had recently attended one of two pain clinics as new referrals. The data were analysed thematically. FINDINGS: Loss was one of five major themes to emerge. The narrative accounts revealed a catalogue of socio-economic and other material losses including loss of physical and mental abilities, occupational and social activities, job or role. In those of working age, these led to financial hardship and changes in interpersonal relationships, culminating in loss of self-worth, future and hope. CONCLUSIONS: The findings suggest that material losses, as well as perceptions of loss, are prominent issues for those of working age seeking help from pain clinics for chronic back pain, and may need to be acknowledged and addressed as part of therapeutic interventions. The possibility of age-related differences in pain-related loss may be worthy of further investigation.

The cup-versus-bottle debate: a theme from an ethnographic study of the supplementation of breastfed infants in hospital in the United kingdom.

This article reports 1 theme from an ethnographic study that aimed to describe the experiences, expectations, and beliefs of mothers and health care professionals concerning supplementation in a UK maternity unit. Observation was conducted on the postnatal ward and the newborn infant unit, and 30 mothers, 17 midwives, 4 neonatal nurses, 3 health care assistants, 3 senior house officers, and 3 senior pediatricians gave in-depth interviews during a 9-month period in 2002. One of the major themes that emerged was the cup-versus-bottle debate. There were 3 categories strongly linked to this theme: difficulties returning to the breast, ease of use, and necessary skills and knowledge. It appears there is an urgent need to determine which is the best method of giving supplementary feeds, so that full, accurate information can be given to mothers, appropriate policies be devised, and the necessary resources and staff training be provided.

Supplementing breast-fed babies in the UK to protect their mothers from tiredness or distress.

OBJECTIVE: To explore mothers' and healthcare professionals' beliefs, expectations and experiences in relation to supplementation of breast feeding in the postnatal ward and newborn-baby unit. DESIGN AND METHOD: A qualitative study using an ethnographic approach which involved participant observation and interviews. Analysis of the observation data informed who would be approached for interview and interviews also guided further observation work. Categories and themes were generated from the field notes and interviews. SETTING: A maternity unit in the South of England using six methods of supplementary feeding. PARTICIPANTS: 30 mothers, 17 midwives, four neonatal nurses, three paediatricians, three senior house officers and 3 healthcare assistants were interviewed in the postnatal ward and newborn-baby unit over a period of nine months in 2002. FINDINGS: A major theme was the healthcare professionals' desire to protect the mothers from tiredness or distress, although this at times conflicted with their role in promoting breast feeding. The categories 'protecting the mother from guilt', 'making it easy to give up' and 'protecting the mother from distress' were linked to this theme. Sometimes midwives suggested supplementation because they perceived mothers to be tired, sometimes mothers themselves made the request. Thus the researcher constructs of 'midwife led' and 'mother led' supplementation emerged. KEY CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Healthcare professionals need to be aware that they may not be helping mothers in the longer-term when supplementation is used as a quick 'solution' to a mother's tiredness or distress. However, other strategies such as providing emotional support or role modelling 'settling' skills are time consuming and have resource implications for the maternity services.

In the system: the lived experience of chronic back pain from the perspectives of those seeking help from pain clinics.

Narrative accounts of their lived experiences were collected from twenty back pain patients who were seeking help from two pain clinics in the UK. Following analysis using a phenomenological approach, five themes emerged which tell a typical story of back pain. One prominent emergent theme, 'in the system', is reported in which participants tell how they became entrapped within the medical, social security and legal systems. These systems, designed to treat or support those who are ill or disabled, effectively rendered participants powerless, helpless and angry. It is suggested that these accounts may help clinicians and researchers to gain a better understanding of the origins and nature of the negative attitudes exhibited by many back pain patients who seek help from pain treatment centres.