Expressing and negotiating face in community pharmacist-patient interactions.

BACKGROUND: A collaborative patient-pharmacist interaction is fundamental to greater patient satisfaction with pharmacy care and improved medication adherence. Effective pharmacist-patient communication occurs when both pharmacist and patient are able to successfully attend to not only the typical tasks and goals of the interaction but also basic face needs that underlie all social interaction; autonomy, competence or esteem, and fellowship. Addressing face needs occurs through conventional and strategic communication strategies that respond to the emerging needs throughout an interaction. Pharmacist-patient interactions are not just about transfer of information and medications. Both parties assess the situation, the others' intentions within the context of their own goals and this influences how they choose to act throughout the interaction. Face-work Theory provides a framework to understand these interaction processes in pharmacist-patient communication. OBJECTIVES: The aim of this study was to determine face needs, threats and the strategic communication strategies used to address these within community pharmacist-patient interactions. METHODS: This exploratory descriptive study drew upon principles of ethology to first describe naturally occurring behaviour and then to interpret this behaviour within the context of Face-work theory. Twenty-five audio-recorded community pharmacist-patient interactions were collected and analyzed. The average length of these interactions was 3:67 min with a range of 0.39 s-9:35 min. RESULTS: Multiple face needs for both pharmacist and patient were evident in most interactions. Autonomy, competence and fellowship face needs were negotiated in the following contexts: participative relationships, concordant role expectations, sensitive topics, and negotiating expertise and knowledge. Competence face needs for both parties were the most dominant need found in negotiating role expectations. The most common communication strategies used to support face were solidarity based strategies while indirect and depersonalized questions were commonly employed to mitigate face threat. IMPLICATIONS AND SIGNIFICANCE: Face-work Theory is a novel approach to understand processes and outcomes of patient-pharmacist interactions in community pharmacies. Linking speech acts with face needs and threats may help to elucidate how pharmacist-patient interactions achieve both task oriented and interpersonal goals.

Nurse Leaders' Perceptions of Influence of Organizational Restructuring on Evidence-Informed Decision-Making.

AIM: To describe how organizational context and restructuring influenced nurse leaders' use of evidence in decision-making in their management practice. METHOD: Qualitative descriptive study. Fifteen leaders at executive and front-line manager levels in one organization were interviewed using a semi-structured format. FINDINGS: Inductive content analysis generated five main themes: leaders strove to keep relationships that preserve best decision-making ability; and sought the best knowledge to inform their decisions. However, a context of constant change; more scope; less autonomy; and decisional inertia in a sea of change had profound effects on their ability to employ evidence in decision-making. IMPLICATIONS: Evidence-informed decision-making is a dynamic social process highly influenced by political instability in work environments. Organizational restructuring creates threats to common decision-making strategies, including information flow, relationships and priority setting. Healthcare restructuring is now a global constant, and there is a need for hospital leaders to understand and mitigate the effect restructuring has on the ability of leaders to engage in evidence-informed decision-making. Strategies are proposed to manage uncertainty and support nurse leaders in their evidence-informed decision-making to deliver quality health services. This research provides an in-depth examination of how evidence-informed decision-making is influenced in the context of instability and uncertainty due to ever-present organizational restructuring.

Opportunities and Constraints in Disseminating Qualitative Research in Web 2.0 Virtual Environments.

The Web 2.0 digital environment is revolutionizing how users communicate and relate to each other, and how information is shared, created, and recreated within user communities. The social media technologies in the Web 2.0 digital ecosystem are fundamentally changing the opportunities and dangers in disseminating qualitative health research. The social changes influenced by digital innovations shift dissemination from passive consumption to user-centered, apomediated cooperative approaches, the features of which are underutilized by many qualitative researchers. We identify opportunities new digital media presents for knowledge dissemination activities including access to wider audiences with few gatekeeper constraints, new perspectives, and symbiotic relationships between researchers and users. We also address some of the challenges in embracing these technologies including lack of control, potential for unethical co-optation of work, and cyberbullying. Finally, we offer solutions to enhance research dissemination in sustainable, ethical, and effective strategies.

Determinants of effective heart failure self-care: a systematic review of patients' and caregivers' perceptions.

CONTEXT: Disease management interventions for heart failure (HF) are inconsistent and very seldom incorporate the views and needs of patients and their caregivers into intervention design. OBJECTIVE AND DATA: To improve intervention effectiveness and consistency, a systematic review identified 49 studies which examined the views and needs of patients with HF and their caregivers about the nature and determinants of effective HF self-care. RESULTS: The findings identify key drivers of effective self-care, such as the capacity of patients to successfully integrate self-care practices with their preferred normal daily life patterns and recognise and respond to HF symptoms in a timely manner. CONCLUSIONS: Future interventions for HF self-care must involve family members throughout the intervention and harness patients' normal daily routines.

Worklife Improvement and Leadership Development study: a learning experience in leadership development and "planned" organizational change.

BACKGROUND: In response to increasing recognition of the importance of quality health care work environments, the Alberta Cancer Board initiated a province-wide leadership development program to plan for organizational change through a series of stages. In 2004, the Leadership Development Initiative (LDI) was implemented to facilitate organizational learning using a cohort-based leadership intervention based on a communities of practice framework. PURPOSES: The aim of the Worklife Improvement and Leadership Development study was to examine both the outcomes and experiences of participants of the LDI program to better understand leadership development, implementation, and its impact on worklife quality among 5 cohorts of health care managers and staff at the Alberta Cancer Board. METHODOLOGY/APPROACH: This study used both structured survey and interview methods, using a pretest-intervention-posttest quasi-experiment without a control group design, to assess the effects of LDI on worklife of leaders and staff. Surveys included the Leadership Practices Inventory and Areas of Worklife Scale, which looked at meaningfulness of work and organizational engagement. Interviews and focus group data provided a more detailed description of the experience of leadership development and perceptions of organizational worklife. FINDINGS: The study revealed layers of information about the complexity of individual and collective leadership in a cohort-based design, perceptions of leadership initiatives, organizational worklife, and planned organizational change. Our findings suggest that early changes in how leaders reflected on their own skills and practices (Leading Self) were positive; however, growing disengagement as the LDI continued was evident in the focus group data, particularly when change in behavior of others was not perceived to be evident. PRACTICE IMPLICATIONS: To support the effectiveness and success of a leadership initiative, managers and administrators need to implement strategies designed to help leaders grow and cope with ongoing flux of organizational change and stagnation.

Characteristics of patients and families who make early return visits to the pediatric emergency department.

OBJECTIVES: The primary objective of this study was to identify reasons why parents make early return visits, within 72 hours of discharge from a tertiary care pediatric emergency department (PED). A secondary objective was to investigate associated demographic and diagnostic variables. METHODS: A survey was conducted with a convenience sample of parents of children returning to the PED within 72 hours of discharge. A chart review was also completed for consented survey participants. Recruitment occurred from September 2005 to August 2006 at the Stollery Children's Hospital, Edmonton, Alberta, Canada. RESULTS: A total of 264 parents were approached to participate. Overall, 231 surveys were returned and 212 (92%) charts were reviewed. The overall rate of early return during the study period was 5.4%. More than half of parents stated that they returned because their child's condition worsened and many parents (66.7%) reported feeling stressed. Patients were typically under 6 years of age (67.4%), and most frequently diagnosed with infectious diseases (38.0%). Patients triaged with the Canadian Emergency Department Triage and Acuity Scale (CTAS) as CTAS 2 (emergent) for initial visits were more likely to be admitted on return, regardless of age (P < 0.001). CONCLUSION: Variables associated with early returns included young age, diagnosis, triage acuity, and parental stress. Future variable definition should include a deeper exploration of modifiable factors such as parental stress and patient education. These next steps may help direct interventions and resources to address needs in this group and possibly pre-empt the need to return.

Beliefs and expectations of Canadian parents who bring febrile children for medical care.

OBJECTIVES: The purpose of this survey was to study the beliefs, expectations, and satisfaction of Canadian parents regarding fever and the treatment of their febrile children. METHODS: A survey was developed exploring caregiver beliefs and treatment strategies, as well as expectations and satisfaction with medical care. Some items were modeled after previous studies to allow comparison. Caregivers with febrile children were recruited from 2005 to 2007 at 3 urgent care centers and emergency departments in Edmonton, Canada: a pediatric emergency department (n = 376), an urban urgent care center (n = 227), and a suburban urgent care clinic (n = 173). RESULTS: High and rapidly rising temperature, as well as physical symptoms associated with fever, caused concern in most parents surveyed. Seventy-four percent of parents felt that the elevated temperature from fever was dangerous and 90.3% always try to treat it. Forty degrees Celsius was the most commonly sited threshold for danger. Identifying the cause (80.6%) and seriousness (87.4%) of fever were the most com-mon stressors identified. Caregivers expected to receive information about the child's illness and appropriate treatment. The parents most often wanted information about febrile seizures and the potential dangers of febrile illness. Only 16.7% of caregivers expected anti-biotics. Nearly 92% of subjects were usually satisfied with medical care. CONCLUSIONS: Fever phobia continues to be a significant issue for Canadian parents. As a result, they treat fever aggressively and often seek medical attention. Good communication is important for medical staff caring for febrile children and typically leads to satisfied parents.

Understanding help-seeking decisions in people with heart failure: a qualitative systematic review.

OBJECTIVE: To understand the process of help-seeking among heart failure patients from the perspectives of patients, caregivers and health professionals. DESIGN: Systematic review using qualitative meta-synthesis. METHODS: A systematic search (20th May 2011) was conducted to identify studies published in English as full papers ≥1995 reporting primary qualitative data with extractable heart failure-specific data or themes related to help-seeking in patients, caregivers or health professionals. Databases searched were: CINAHL, Medline, PsycInfo, Social Science Citation Index, Embase, Social policy/Practice, SocIndex, Ageline, Health Source Nursing, Scopus; additionally, we consulted with experts and manually searched references. RESULTS: 58 studies (990 patients; 274 female, 527 male, 189 sex not described; 229 caregivers, 79 health professionals) were included. Heart failure help-seeking was embedded in daily experiences of heart failure but ongoing symptoms were confusing, ambiguous and disruptive; little support was available from professionals to interpret the presence and significance of fluctuations in symptoms for help-seeking. Other significant barriers to help-seeking were: avoidance-based coping, fear of hospitals and misplaced reluctance to be burdensome. Help-seeking was facilitated by good involvement and frank communication between patients, caregivers and health professionals and the presence of a sense of elevated personal risk. CONCLUSION: Health services should harness primary care providers and support patients and caregivers to prioritize development of objective symptom monitoring skills, recognize and personally assimilate the elevated risks of heart failure and help-seeking delays and discourage avoidance-based coping and unwarranted concerns that downplay the significance of heart failure and urgency to address symptoms.

Impact of leadership development on emotional health in healthcare managers.

AIM: To examine the effects of a Leadership Development Initiative (LDI) on the emotional health and well-being among five levels of healthcare managers. BACKGROUND: Increasingly dynamic, demanding healthcare environments result in highly stressful work atmospheres. METHODS: Using quasi-experimental and mixed methods, we used regression on pre- and post-LDI survey data with 86 managers, and individual/focus group interview data for focused ethnographic analysis. RESULTS: An increasing trend was observed in self-assessed leadership practices after the LDI with a significant increase in 'inspiring a shared vision' (P<0.01). However, a non-significant decreasing trend in areas of work life and a non-significant increase in cynicism (P=0.14) was observed. Before the LDI, participants' self-assessment of their practice to 'enable others to act' was negatively related to emotional exhaustion (P<0.01). Both before and after the LDI, 'modelling the way' was significantly related to professional efficacy (P<0.01 pre; P<0.05 post). Post-LDI, 'inspiring a shared vision' was negatively (P<0.01) and 'enabling others to act' was positively (P<0.05) related to cynicism. CONCLUSION: The LDI provided opportunities for healthcare managers to connect, strengthen leadership and social support networks and manage burnout. IMPLICATIONS FOR NURSING MANAGEMENT: Transformational leadership practices may influence managers' emotional health. Senior administrative support and communicating the structure and vision of developmental initiatives may help to achieve realistic expectations.

Building a therapeutic alliance in brief therapy: the experience of community mental health nurses.

Current mental health trends in brief therapy require a new understanding of the nurse--client relationship. This qualitative focused ethnography explored the perceptions and actions of community mental health nurses in building a therapeutic alliance in the context of brief therapy and the factors that facilitate or impede its development. Informants were 11 nurses with at least 3 years of experience in community mental health nursing primarily providing brief therapy or consulting practice. Participants described therapeutic alliance as the point at which the clients recognize that the nurse is fully attuned to "being in the moment" as they connect to their own issues in a positive way. Building an alliance consisted of three nonlinear overlapping phases: "establishing mutuality," "finding the fit in reciprocal exchange," and "activating the power of the client." Implications include recommendations to enhance intentional alliance building and directions for further research to explore differing world views among nurses on alliance formation within the context of brief therapy and consultations.

Men's experiences following laparoscopic radical prostatectomy: a qualitative descriptive study.

BACKGROUND: Laparoscopic radical prostatectomy is a less invasive surgical option to the open retropubic approach for prostate cancer that will likely grow in popularity commensurate with availability. However, since little is known about what men experience throughout the postoperative period, our ability to ensure informed decision-making remains compromised. OBJECTIVES: The aim of this study was to explore what men experience following laparoscopic radical prostatectomy and how adequately their pre- and postoperative needs are being met. DESIGN: This was a qualitative descriptive study. PARTICIPANTS: Nineteen men, aged 46-76, who had undergone laparoscopic radical prostatectomy within the previous 3-6 months period were recruited from the treatment and control arms of a randomized controlled trial. Men who were not in the trial were recruited via letters mailed from surgeons' offices. METHODS: Data were generated during loosely structured individual (n=5) and focus group interviews (n=3). Inductive content analysis helped to ensure that participants' perspectives were accurately represented. RESULTS: Men had actively sought information prior to surgery but seemed unprepared for the intensity of discomfort and incontinence they experienced. They particularly valued opportunities for informal discussion with former prostatectomy patients; however, erectile dysfunction remained a major concern and most did not know where to turn for help. CONCLUSION: Nurses could play a pivotal role in the laparoscopic radical prostatectomy experience by ensuring men are well informed both pre- and postoperatively. Facilitating contact with other men who have undergone laparoscopic radical prostatectomy (LRP) and initiating conversation about potential side-effects such as urinary incontinence and erectile dysfunction would be an important starting point. Particularly in light of early discharge and concerns regarding erectile dysfunction, additional follow-up seems warranted.

Expressing and responding to pain and stoicism in home-care nurse-patient interactions.

Addressing pain and suffering are critical issues for home-care nurses. Pain is frequently experienced by people living at home with chronic illnesses, as well as acutely ill people discharged early from hospitals. The purpose of this qualitative ethology study was to explore and describe the interactions and experiences expressing and responding to pain in home-care nurse-patient interactions. A qualitative video ethology design was appropriate to inductively describe micropatterns of communicative behaviour in natural settings. Ten home-care nurse-patient dyads were videotaped over multiple visits. Data consisted of 31 videotaped visits (over 19 hours) and accompanying participant interviews. Recursive and cyclical qualitative analysis was used to describe the patterns of communication with which stoicism or endurance of pain and suffering was supported or challenged. Dominant patterns of interaction were concerned with: negotiating appropriate forms of stoicism; negotiating ways to express, understand and measure pain and suffering; and dealing with intractable or inflicted pain. The methodology of this study allows an in-depth view of typical nurse-patient interactions. It explores the subtle communicative expertise of nurses by investigating the types of communication used in nursing encounters and by explicating behavioural patterns of expressing and responding to suffering. Observational research of interaction-as-it-occurs must continue to better understand how nurses and patients co-construct personal identities of suffering and stoicism.

Identifying signals of suffering by linking verbal and facial cues.

Here, the authors describe microanalytically the two main behavioral states in suffering (enduring and emotional suffering) so that in subsequent research, appropriate comforting responses to ease and relieve suffering can be identified for each behavioral state. Their objectives were to describe the facial expressions of enduring and emotional suffering, and to link them with verbal narrative and thus develop a microanalytic description of each behavioral state. Using Ekman's modified EMFACS, they videotaped interviews with 19 participants and coded co-occurring verbal text and expressions. They also documented differences between each behavioral state and the transitions from enduring to emotional suffering. Enduring and emotional suffering are distinct and identifiable behaviors. These formerly implicit behavioral cues can be used in clinical assessment and research.

The interpersonal contexts of negotiating care in home care nurse-patient interactions.

In this article, the author describes six interpersonal contexts within which care is negotiated between home care nurses and their patients, based on qualitative analysis of 31 videotaped visits. The interpersonal contexts were negotiation of (a) territoriality, (b) shared perceptions of the situation, (c) an amicable working relationship, (d) role synchronization, (e) knowledge, and (f) taboo topics. Analysis of moment-by-moment communication explored how social identity related to care activities is constructed, challenged, or threatened in the flow of events in the encounter. This approach does not problematize negotiation by assuming negative connotations of inequality of power; rather, it examines the therapeutic consequences of specific communication acts. It demonstrates how both nurse and patient are, paradoxically, both empowered and made vulnerable through everyday conversation.