A qualitative study of National Health Service (NHS) complaint-responses.

BACKGROUND: Healthcare complaints are grievances that may be indicative of some system failures, individual failings, or a combination of both. Moreover, the experience of making a complaint, including its outcome, often falls short of patient expectations, particularly in relation to the interpersonal conduct of National Health Service (NHS) staff. Over half of unresolved (local) complaints are subsequently upheld by the ombudsman with others potentially resulting in costly litigation. METHOD: A nuanced discourse analytical approach to analysing the language choices within complaint-responses could potentially provide greater insight into why many local complaints continue to remain unresolved. Over a period of 1 month we collated a data corpus of written complaints and their responses (n = 60) from an NHS healthcare area in Scotland, United Kingdom (UK) following anonymisation by NHS complaint handling staff. We took a qualitative approach to analysing the data drawing upon Discourse Analysis with this paper reporting on the complaint-responses only (n = 59). We had undertaken a similar review of the initial written complaints and this is reported elsewhere. In this paper we examine how, and to what extent, the complaint-responses fully addressed the complainants' perceived grievances. RESULTS: The complaint-responses rarely acknowledged the amount of detail or 'work' involved in making the complaint. Complaint-responses constructed complainants' accounts as subjective by using specific discourse strategies. Further, complaint responses used unintentionality or exceptionality to mitigate sub-standard experiences of care. We also observed the 'fauxpology' - a non-apology or false apology (e.g. I am sorry you feel) which imputes the cause of distress to the subjective (and possibly misguided) impressions of the complainant. The complaint-responses thereby evade blame or responsibility for the complainable action by implying that the complainants' feelings do not align with the facts. CONCLUSIONS: Complainants and complaint-responders work to different frames of reference. Complaint responders need to engage and align with complainants from the outset to ensure more appropriate complaint- responses. Complaint resolution as opposed to complaint handling could be enhanced by the approach of linguistic analysis and reference to the consumer literature's justice-based approach to post-complaint behaviour.

Synthesizing core nursing skills to support behavioural-based interviews for nurses in the UAE: A nominal group study.

AIM: To develop a bank of core clinical and performance skills to inform the future development of structured interview questions to aid the recruitment of nurses in the United Arab Emirates (UAE). BACKGROUND: The UAE depends on expatriate nurses with variable clinical and educational backgrounds. Given the global shortage of nurses, the UAE requires innovative recruitment methods to attract and retain quality nurses and ensure high-quality health care services. METHOD: Three cycles of a virtual nominal group technique (NGT) were used to elicit consensus from thirty (n = 30) frontline nurses on the core clinical and performance skills needed to work in three specialty areas (paediatric, outpatient and telemetry/transitional care). RESULTS: Ten performance skills and ten clinical skills were identified for each specialty area. Performance skills included communication and critical thinking with key clinical skills being medication administration/use, cardiac monitoring troubleshooting and recognizing arrhythmias. CONCLUSION: The identified core performance and clinical nursing skills provide the basis for the future development of specialty-specific questions or scenarios to aid interviewers in achieving an informed selection process. IMPLICATIONS FOR NURSING MANAGEMENT: The identified core performance and clinical skills provide the foundations for an appropriate interviewing/selection process, staff orientation, staff appraisal and continuous professional development.

A National Scoping Study on Barriers to Conducting and Using Research Among Nurses in the United Arab Emirates.

It is important that nurses fully engage with the development and use of evidence-based practice so they can influence policy and improve patient care. There are significant challenges in developing nursing research and evidence-based practice in the United Arab Emirates (UAE). Therefore, the UAE Nursing and Midwifery Council formed a Scientific Research Subcommittee to lead the development of nursing research. Following a literature review to assess the status of nursing research in the UAE, the Subcommittee initiated a study to clarify UAE nurses' perceptions of barriers to implementing research. The results were expected to enable comparisons with other countries and establish a baseline on which to build and prioritize initiatives to address identified barriers. A cross-sectional design with convenience sampling was used to survey 606 nurses from across the UAE. The survey included the BARRIERS questionnaire and was administered online and in paper-based formats. The top three nurse-perceived barriers that affected nurses' use of research in the UAE (in descending order) were as follows: lack of authority to change patient care procedures, insufficient time to read research, and insufficient time on the job to implement new ideas. The highest ranked barriers to nurses conducting research in the UAE were lack of time and competing demands for time. The findings of this survey and a published literature review informed development of a strategy to address identified barriers to nurses in the UAE using and conducting research. This multifaceted strategy includes initiatives to reform policy and practice at local and national levels.

Traumatic journeys; understanding the rhetoric of patients' complaints.

BACKGROUND: Research on patients' complaints about healthcare has tended to focus on the typology of complaints and complainants to homogenise complaints and better understand safety implications. Nonetheless, complaints speak to a broader spectrum of harm and suffering that go beyond formal adverse events. Complaints about care episodes can take considerable time and effort, generate negative energy and may leave a dogged 'minority' embittered. METHODS: This study provides an overview of the process and rhetoric of how patients formulate written complaints. We collated a data corpus comprising 60 letters of complaints and their responses over a period of one month. This paper focuses on the complaint letters only. National Health Service (NHS) Complaint Department staff in a healthcare area in the United Kingdom (UK) anonymized the letters. We took a broad qualitative approach to analysing the data drawing upon Discourse Analysis focusing on the rhetorical and persuasive strategies employed by the complainants. RESULTS: What patients complained about related to how they complained, with complainants expending considerable effort in persuasive rhetoric that sought to legitimise the complaint drawing upon different sources of epistemic authority. The complainants struggle to be an 'objective' witness as the complaint evolves from an implicit neglect narrative to increasing 'noise' with other features such as Direct Reported Speech used to animate and authenticate the narrative. Many of the complex complaints appeared to evidence some psychological distress. This was associated with the complainants' reports of experiencing cumulative poor health care and their repeated failure to resolve the complaint. The subsequent delicate and potentially stigmatized formal act of complaining was a source of additional distress. CONCLUSIONS: Complaints are involved narratives often predicated on the expectation they will not be given due credence. Health care staff may benefit from understanding how complaints are formulated to be able to more appropriately address the focus and extent of patients' grievances from the outset and therefore, reduce the considerable associated harm.

Quality of life and well-being of people receiving haemodialysis treatment in Scotland: a cross-sectional survey.

End-stage renal disease is a complex, progressive and debilitating illness that affects patients' quality of life, physical and mental health, well-being, social functioning and emotional health. A cross-sectional survey was carried out in renal dialysis centres in Scotland to assess patients' health status and the impact of haemodialysis treatment on quality of life and well-being. Participants scored considerably lower than the UK general population in all domains of health-related quality of life, although mental health components were nearer to general population norms than physical health components. However, nearly half of the participants achieved a score on a general well-being questionnaire that was indicative of stress and anxiety. Increasing age was associated with better overall mental health but worse physical functioning. Increasing levels of hope and support were associated with improved general well-being.

Humour in health-care interactions: a risk worth taking.

BACKGROUND: Humour is a complex, dynamic phenomenon that mainly occurs in social situations between two or more people. Most humour research reviews rehearsed as opposed to spontaneous humour and rarely review the patients' perspective. AIM: We explore patients' perspectives on the use of humour in health care. We discuss the asymmetrical and divergent humour use between patients and clinical nurse specialists and posit nurses' approaches to risk as a contributing factor. DESIGN: A constructivist grounded theory collated researcher-provoked (interviews, observation, field notes, pre-and post-interaction audio diaries) and non-researcher-provoked data (naturally occurring interactions) over 18 months. This paper is based upon four patient focus groups. A constant comparison approach to data collection and analyses was applied using interpretative and illustrative frameworks that balanced what was 'known' and 'unknown' about humour. SETTING AND PARTICIPANTS: Patients were recruited from four patient-peer groups. Three audio-taped (n = 20) and one observed focus group interactions (n = 12) were undertaken at the groups' regular meeting places. RESULTS: Patients hold a broad appreciation of humour and recognize it as being evident in subtle and nuanced forms. Patients wish health-care staff to initiate and reciprocate humour. CONCLUSION: A chasm exists between what patients apparently want with regard to humour use in health-care interactions and what actually transpires. Initiating humour involves risk, and risk-taking requires a degree of self-esteem and confidence. Nurses are, arguably, risk-averse and have low self-esteem. Future research could review confidence and self-esteem markers with observed humour use in nurses and their interactions across a range of specialities.

Recruitment, selection and retention of nursing and midwifery students in Scottish Universities.

BACKGROUND: High attrition rates from pre-registration nursing and midwifery programmes have been reported in both the UK and in other countries. OBJECTIVES: A study was conducted to identify best practice in recruitment, selection and retention across Scottish Universities providing pre-registration programmes. DESIGN: A survey of all universities providing pre-registration programmes in Scotland was conducted. Semi-structured interviews were conducted with key personnel in each university. Documentary evidence was collected to supplement interview data and evidence recruitment, selection and retention practices. SETTINGS: All universities in Scotland providing pre-registration nursing and/or midwifery programmes. PARTICIPANTS: All 10 identified universities agreed to take part and a total of 18 interviews were conducted. METHODS: Semi-structured face to face and telephone interviews were conducted. Relevant documentary evidence was collected. All data were subject to thematic analysis. FINDINGS: Universities are predominantly concerned with recruiting to the institution and not to the professions. Interviews are widely used, and are a requirement in the United Kingdom. However, there is no evidence base within the literature that they have predictive validity despite creating scales and scoring systems which are largely unvalidated. The study identified initiatives aimed at addressing attrition/retention, however most had not been evaluated often due to the multi-factorial nature of attrition/retention and difficulties with measurement. CONCLUSIONS: Recruitment selection and retention initiatives were rarely evaluated, and if so, adopted a relatively superficial approach. Evidence from existing studies to support practices was mostly weakly supportive or absent. The study highlights the need for a coordinated approach, supporting the development of a robust evidence base through the evaluation of local initiatives, and evaluation of new strategies. Evaluation strategies must take account of the local context to facilitate transferability of findings across different settings.

The isolating and insulating effects of hepatitis C: a substantive grounded theory.

Hepatitis C has a global prevalence of 3%, causing chronic infection in 75% of cases, and is currently the main cause of liver transplant in the United Kingdom. This study reviewed patients' and service providers' perspectives on hepatitis C as an enduring condition, using a constructivist grounded theory approach. A constant comparative approach to data collection and analyses incorporating a coding paradigm was applied to semistructured interviews, focus groups, and memos. Sixteen patients and three focus groups of staff (n = 17) were recruited via purposive theoretical sampling (February through August 2008). A negative synergistic relationship between the condition hepatitis C, patients, and service providers that creates isolating and insulating effects for the relevant parties emerged from the data as a middle-range theory. Stigma and contagion create a "real" or perceived sense of isolation for hepatitis C comorbid and itinerant patients, who require the right support at the right time. Healthcare staff adhere to professional demarcation lines to manage potentially untenable patient caseloads. In turn, patients and professionals perceive that a crisis may be required to bring about successful therapeutic intervention. A service that incorporates seamless outreach services and facilitates interdisciplinary working is needed to manage complex patients with this enduring condition.

Routines and rituals: a grounded theory of the pain management of drug users in acute care settings.

AIM: This study reviewed the perceptions and strategies of drug users and nurses with regard to pain management in acute care settings. BACKGROUND: Drug users present unique challenges in acute care settings with pain management noted to be at best suboptimal, at worst non-existent. Little is known about why and specifically how therapeutic effectiveness is compromised. DESIGN: Qualitative: constructivist grounded theory. METHOD: A constructivist grounded theory approach incorporating a constant comparative method of data collection and analysis was applied. The data corpus comprised interviews with drug users (n = 11) and five focus groups (n = 22) of nurses and recovering drug users. RESULTS: Moral relativism as the core category both represents the phenomenon and explains the basic social process. Nurses and drug users struggle with moral relativism when addressing the issue of pain management in the acute care setting. Drug users lay claim to expectations of compassionate care and moralise via narration. Paradoxically, nurses report that the caring ideal and mutuality of caring are diminished. Drug users' individual sensitivities, anxieties and felt stigma in conjunction with opioid-induced hyperalgesia complicate the processes. Nurses' and hospitals' organisational routines challenge drug user rituals and vice versa leading both protagonists to become disaffected. Consequently, key clinical issues such as preventing withdrawal and managing pain are left unaddressed and therapeutic effectiveness is compromised. CONCLUSION: This study provides a robust account of nurses' and drug users' struggle with pain management in the acute care setting. Quick technological fixes such as urine screens, checklists or the transient effects of (cognitive-based) education (or training) are not the answer. This study highlights the need for nurses to engage meaningfully with this perceptibly 'difficult' group of patients. RELEVANCE TO CLINICAL PRACTICE: The key aspects likely to contribute to problematic interactions with this patient cohort are outlined so that they can be prevented and, or addressed.

Harsh humour: a therapeutic discourse.

Humour research in healthcare has tended to focus on rehearsed as opposed to spontaneous humour. This paper reports an empirical example of spontaneous humour in healthcare interactions: a negative case analysis from a constructivist grounded theory study. Twenty Clinical Nurse Specialist (CNS)-patient interactions and CNS pre- and postinteraction audio diaries provided the baseline data corpus. Follow-up interviews, field notes, focus groups and observations serviced theory generation with a constant comparison approach to data collection and analyses. Interpretative and illustrative frameworks incorporating humour theories, non-laughter humour support, discursive features and prosodical features of speech were applied to all data. This paper is based upon the negative case comprising a 90-minute follow-up interview and 10 hours of field note observations. The negative case - a CNS working with female drug users' sexual and reproductive health needs - contradicted emerging findings from the baseline data corpus. First, the negative case had greater awareness of humour, deliberately initiated humour and recognised parameters and exclusion zones. Second, a good patient personal was evident in the baseline data corpus but the negative case worked with 'bad' patients. Accordingly, a specific type of humour - harsh humour - was evident in the negative case. Harsh humour used areas of potential discord (e.g. drug use) as a focus of humour creation and maintenance. The deliberate initiation of harsh humour enabled the negative case and her colleagues to achieve their aims by engaging effectively with unpredictable, reluctant and recalcitrant patients. The negative case demonstrates how humour can be used to therapeutically enhance healthcare interactions with disenfranchised individuals. Humour is not superficial but integral to the accomplishment of key aspects of interactions. Health and social care workers should consider the potential for therapeutic humour to engage and maintain all patients - disenfranchised or otherwise - in healthcare interactions.

Ensnared by positivity: a constructivist perspective on 'being positive' in cancer care.

BACKGROUND: The concept of 'positive thinking' emerged in cancer care in the 1990s. The usefulness of this approach in cancer care is under increasing scrutiny with existing research, definitions and approaches debated. Nurses may wish to judiciously examine the debate in context and consider its relevance in relation to their experience and clinical practice. PURPOSE: To offer a constructivist perspective on 'being positive' we extract data from a constructivist grounded theory study on humour in healthcare interactions in order to identify implications for practice and future research. METHODS: We offer three areas for consideration. First, we briefly review the emergence of 'positive thinking' within cancer care. Second, we present data from a grounded theory study on humour in healthcare interactions to highlight the prevalence of this discourse in cancer care and its contested domains. We conclude with implications for practice and future research. FINDINGS: Patients actively seek meaningful and therapeutic interactions with healthcare staff and 'being positive' may be part of that process. Being positive has multiple meanings at different time-points for different people at different stages of their cancer journey. Patients may become ensnared by positivity through its uncritical acceptance and enactment. CONCLUSION: Positive thinking does not exist in isolation but as part of a complex, dynamic, multi-faceted patient persona enacted to varying degrees in situated healthcare interactions. Nurses need to be aware of the potential multiplicity of meanings in interactions and be able (and willing) to respond appropriately.

Evolving Grounded Theory Methodology: towards a discursive approach.

Grounded Theory Methodology (GTM) is a widely cited research approach based upon symbolic interaction with a focus on interaction, action and processes. Relatively recently, Discursive Psychology; a language-based interaction research approach also based on symbolic interaction, emerged. At present Discursive Psychology is principally cited in the social sciences literature. Given Discursive Psychology's symbolic interaction foundations, what relevance does this approach have for evolving GTM? A number of methodological challenges were posed by a study looking at humour in Clinical Nurse Specialist-patient interactions. This paper will use the phenomenon of spontaneous humour in healthcare interactions to illustrate the potential for a new form of GTM drawing on discursive approaches; Discursive GTM. First, the challenges presented by a study looking at spontaneous humour in Clinical Nurse Specialist-patient interactions are presented. Second, the research approach adopted to meet these challenges - Discursive GTM (DGTM) - is explicated and the results of the study are outlined. Third, the different GTM approaches and Discursive Psychology are compared and contrasted in relation to the DGTM approach adopted. Finally, the challenges and tensions of using DGTM as well as the opportunities afforded by the use of naturally occurring data are reviewed. The authors contend that a DGTM approach may be appropriate in analyzing certain phenomena. In particular, we highlight the potential contribution of naturally occurring data as an adjunct to researcher-elicited data. Thus, when exploring particular phenomena, a DGTM approach may address the potentially under-developed symbolic interaction tenet of language.

Reconciling the good patient persona with problematic and non-problematic humour: a grounded theory.

BACKGROUND: Humour is a complex phenomenon, incorporating cognitive, emotional, behavioural, physiological and social aspects. Research to date has concentrated on reviewing (rehearsed) humour and 'healthy' individuals via correlation studies using personality-trait based measurements, principally on psychology students in laboratory conditions. Nurses are key participants in modern healthcare interactions however, little is known about their (spontaneous) humour use. AIMS: A middle-range theory that accounted for humour use in CNS-patient interactions was the aim of the study. The study reviewed the antecedents of humour exploring the use of humour in relation to (motivational) humour theories. PARTICIPANTS AND SETTING: Twenty Clinical Nurse Specialist-patient interactions and their respective peer groups in a country of the United Kingdom. METHOD: An evolved constructivist grounded theory approach investigated a complex and dynamic phenomenon in situated contexts. Naturally occurring interactions provided the basis of the data corpus with follow-up interviews, focus groups, observation and field notes. A constant comparative approach to data collection and analysis was applied until theoretical sufficiency incorporating an innovative interpretative and illustrative framework. This paper reports the grounded theory and is principally based upon 20 CNS-patient interactions and follow-up data. The negative case analysis and peer group interactions will be reported in separate publications. FINDINGS: The theory purports that patients' use humour to reconcile a good patient persona. The core category of the good patient persona, two of its constituent elements (compliance, sycophancy), conditions under which it emerges and how this relates to the use of humour are outlined and discussed. In seeking to establish and maintain a meaningful and therapeutic interaction with the CNS, patients enact a good patient persona to varying degrees depending upon the situated context. The good patient persona needs to be maintained within the interaction and is therefore reconciled with potentially problematic or non-problematic humour use. Humour is therefore used to deferentially package concerns (potentially problematic humour) or affiliate (potentially non-problematic humour). This paper reviews the good patient persona (compliance, sycophancy), potentially problematic humour (self-disparaging, gallows) and briefly, non-problematic humour (incongruity). CONCLUSIONS: The middle-range theory differentiates potentially problematic humour from non-problematic humour and notes that how humour is identified and addressed is central to whether patients concerns are resolved or not. The study provides a robust review of humour in healthcare interactions with important implications for practice. Further, this study develops and extends humour research and contributes to an evolved application of constructivist grounded theory.

You must be joking.

Everyone likes a good laugh but is it appropriate to use humour with patients? The topic will be a matter for discussion at next week's RCN congress.

The purpose and function of humour in health, health care and nursing: a narrative review.

AIM: This paper is a report of a review conducted to identify, critically analyse and synthesize the humour literature across a number of fields related to health, health care and nursing. BACKGROUND: The humour-health hypothesis suggests that there is a positive link between humour and health. Humour has been a focus of much contention and deliberation for centuries, with three theories dominating the field: the superiority or tendentious theory, the incongruity theory and the relief theory. DATA SOURCES: A comprehensive literature search was carried out in January 2007 using a number of databases, keywords, manual recursive searching and journal alerts (January 1980-2007) cross-referenced with the bibliographic databases of the International Society of Humor Studies. An inclusion and exclusion criterion was identified. REVIEW METHODS: A narrative review of evidence- and non-evidence-based papers was conducted, using a relevant methodological framework with additional scrutiny of secondary data sources in the latter. Humour theories, incorporating definition, process and impact constituted a significant part of the appraisal process. RESULTS: A total of 1630 papers were identified, with 220 fully sourced and 88 included in the final review. There is a dearth of humour research within nursing yet, ironically, an abundance of non-evidence-based opinion citing prerequisites and exclusion zones. Examination of physician-patient interaction and the humour-health hypothesis demonstrates that use of humour by patients is both challenging and revealing, particularly with regard to self-deprecating humour. CONCLUSION: Nurses and nursing should adopt a circumspect and evidenced-based approach to humour use in their work.

The process of developing audiovisual patient information: challenges and opportunities.

AIM: The aim of this project was to produce audiovisual patient information, which was user friendly and fit for purpose. The purpose of the audiovisual patient information is to inform patients about randomized controlled trials, as a supplement to their trial-specific written information sheet. BACKGROUND: Audiovisual patient information is known to be an effective way of informing patients about treatment. User involvement is also recognized as being important in the development of service provision. The aim of this paper is (i) to describe and discuss the process of developing the audiovisual patient information and (ii) to highlight the challenges and opportunities, thereby identifying implications for practice. A future study will test the effectiveness of the audiovisual patient information in the cancer clinical trial setting. METHODS: An advisory group was set up to oversee the project and provide guidance in relation to information content, level and delivery. An expert panel of two patients provided additional guidance and a dedicated operational team dealt with the logistics of the project including: ethics; finance; scriptwriting; filming; editing and intellectual property rights. RESULTS: Challenges included the limitations of filming in a busy clinical environment, restricted technical and financial resources, ethical needs and issues around copyright. There were, however, substantial opportunities that included utilizing creative skills, meaningfully involving patients, teamworking and mutual appreciation of clinical, multidisciplinary and technical expertise. CONCLUSION: Developing audiovisual patient information is an important area for nurses to be involved with. However, this must be performed within the context of the multiprofessional team. Teamworking, including patient involvement, is crucial as a wide variety of expertise is required. RELEVANCE TO CLINICAL PRACTICE: Many aspects of the process are transferable and will provide information and guidance for nurses, regardless of specialty, considering developing this format of patient information.

Involving patients in teaching about blood-borne viruses.

Involving patients in the teaching of healthcare staff is not a new concept, but there is a shortage of literature on the subject. This article focuses on the experiences of staff on an established education and training programme for HIV and other blood-borne viruses. The programme involved four patients in the teaching of nurses and other health and social care staff. This article describes the recruitment, preparation and methods used, as well as the possibilities of transferring the methodology to other subject areas. The author concludes that there are advantages and disadvantages to be considered before embarking on such a programme.