Understanding Suicide and Help-seeking in Urban and Rural Areas in Northern Ireland

Funded by HSC R&D Division, Public Health Agency Why did we start? Most people who complete suicide are in contact with their family doctors or other services in the months prior to death. A better understanding of the nature of these contacts and the various pathways experienced by suicidal people should reveal the gaps and barriers to effective service provision. We also need better information about the difficulties experienced by family carers, both prior to the death and afterwards. Of particular interest to policy makers in Northern Ireland was a concern that people from rural areas may be at increasing risk of suicide. We were commissioned by the Health and Social Care R&D Division of the Northern Ireland Public Health Agency to address the gaps in our understanding of suicide in NI. What did we do? We undertook a mixed methods study in which we examined the records of 403 people who took their own lives over a two-year period between March 2007 and February 2009. We linked these data to GP records and then examined help-seeking pathways of people and their contacts with services. We did in-depth face-to-face interviews with 72 bereaved relatives and friends who discussed their understanding of the events and circumstances surrounding the death, the experience of seeking help for the family member, the personal impact of the suicide, and use of support services. Additionally, we interviewed 19 General Practitioners about their experiences of managing people who died by suicide.            

Using Social Worlds Theory to Explore Influences on Community Nurses’ Experiences of Providing Out of Hours Paediatric Palliative Care

Abstract Background: Paediatric oncology palliative care in the community is rare and nationally there is a lack of standardisation of out of hours nursing service provision. Objectives: This paper seeks to explore influences on the experiences of paediatric nurses providing out of hours palliative care within the family home to children with cancer. The study used social worlds theory to aid identification and demonstration of the findings. Methods: Twelve community-based palliative cases were purposively selected from children with cancer treated at one regional centre. Tape-recorded interviews were undertaken with 54 health professionals (general practitioners, community nurses and allied health professionals) involved in providing their palliative care and five facilitated case discussions completed. Data analysis followed a grounded theory approach; chronological comparative data analysis identifying generated themes. Social worlds theory was used as a framework to examine the data. Results: Nurses’ experiences are shaped by their social world and those of the nursing team,child and family and the inter-professional team providing the care. The lack of a formalised service, sub-optimal inter-professional working and impact of social worlds influence the experience of the nurse. Conclusions: Social worlds theory provided a new perspective in understanding these experiences based within a paediatric palliative care setting, knowledge that can be used to inform service provision.

What do GPs and Bereaved Parents Think About Paediatric Oncologists and Palliative Care?

Aim The aim of the study was to examine the experiences of bereaved parents and general practitioners (GPs) following the death of a child with cancer within the family home. This presenta-tion focuses on one of the findings; the parent and GP views on the hospital consultants’ involvement in the palliative care. Design A community based qualitative study.Setting West Midlands region, UK. Participants Purposeful sample of 18 GPs and 11 bereaved families. The sample was drawn from the families and GPs of children who had been treated for cancer at a regional childhood cancer centre and who subsequently died within the family home. Methods One-to-one semi-structured tape-recorded interviews were undertaken with GPs and bereaved parents following the death at home of a child with cancer. GPs were contacted three months after the death of the child and the parents at six months. Thematic analysis of the transcriptions was undertaken. Findings Parents described feeling abandoned at the transition to palliation when management of care transferred to the GP. Families did not perceive a seamless service of medical care between hospital and community. Where offered consultant contact was valued by families and GPs. Text and email were used by families as a means of asking the consultant questions. The GPs lacked role clarity where the consultant continued involvement in the care. Conclusions The transition to palliation and the transfer of care to community services needs to be sensitively and actively man-aged for the family and the GP. Medical care between tertiary andprimary care should be seen as a continuum. Improving GP: consultant communication could aid role clarity, identify mecha-nisms for support and advice, and promote the active engagement of the GP in the care. Exploring opportunities for integrated con-sultant: GP working could maximise mutual learning and support and enhance care provision. The level, access and duration of ongoing contact between consultants and families/GPs require clarity.

Providing Palliative Care for the Child with Cancer: The Experience of GPs

Background Childhood cancers are rare and general practitioners (GPs) have limited experience in caring for these children and even less in providing their palliative care. Most families prefer that their child is cared for at home in the palliative phase of their illness, with professional support from those known to them (Chambers and Oakhill 1995, Vickers and Carlisle 2000, Craft and Killen 2007). A community based qualitative study examined the experiences of ten GPs following their involvement in the care of a child with cancer receiving palliative care within the family home. Methods Data collection was through 1:1 in-depth interviews and facilitated case discussion supported by field notes and grounded theory analysis (chronological comparative data analysis identifying generated themes). Social worlds theory was used as a framework to aid examination, and facilitate critical understanding, of the experiences of the GPs. Findings This presentation focuses on five of the findings relating to the experiences of the GP; the impact of minimal contact; lack of knowledge and experience, uncertain role, out of hours service provision and the emotional toll. Findings highlighted that GPs often have to re-establish their role at the child’s transition to palliative care. Factors hindering the GP in this process include a deficit of specialist knowledge and experience of paediatric palliative care and lack of role clarity. Conclusions/points of interest Strategies for enhancing the role of the Macmillan team in supporting GPs have been identified by this study, such as enhanced collaborative working. Findings have also provided further confirmation of the substantial variation in out of hours medical palliative care provision; with evidence that some GPs work beyond their remit in providing informal out of hours care. This presentation details the findings of one aspect (the experiences of GPs) of a wider study that explored the experiences of 54 community based health professionals (GPs, community nurses and allied health professionals) who had been involved in caring for a dying with cancer receiving palliative care at home (Neilson 2009).

GPs Experience of Caring for Children with Cancer Receiving Palliative Care at Home

Background The study being undertaken builds on earlier work that found general practitioners (GPs) were at times uncertain of their role in paediatric palliative care and questioned whether their involvement had been beneficial to the child and family. The rarity of childhood cancer makes it difficult for GPs to develop or maintain palliative care knowledge and skills yet the GP is perceived by the family as the gatekeeper of care within the community. Aim The study is examining GPs perception of their role in caring for an individual child with cancer receiving palliative care and comparing this with families' perceptions of their GP's roles. Methodology The methodology incorporates tape-recorded semi-structured interviews, thematic framework analysis and Q methodology (QM) to capture the experiences of GPs who have cared for a child with cancer receiving palliative care as well as the perspectives of care experienced by the families. The semi-structured interview sample comprises 10 families (parents/guardians) whose child has been treated at a regional childhood cancer centre and their GPs. A further 40–60 GPs will be involved in the QM. Findings Findings detailing GP experiences from the initial study along with the preliminary findings of the semi-structured interviews with parents and GPs will be presented. Papers' contribution The results will identify and clarify GPs perceptions of their roles, and what families perceive their GPs role to be, enabling development of strategies to support GPs roles. It is anticipated that findings will inform the wider field of palliative care generally and the practice of both hospital and community paediatricians.

Undertaking Sensitive Interviews: a Researcher’s Experience of Interviewing Bereaved Parents and Family GPs

The presentation describes the researcher’s experience of undertaking sensitive interviews. Background The interviews form part of a current study that is examining bereaved parents’ experience of caring for their child at home as well as the experience of their GP. This study builds on earlier work that found general practitioners (GPs) were at times uncertain of their role in paediatric palliative care and questioned whether their involvement had been beneficial to the child and family. The rarity of childhood cancer deaths makes it difficult for GPs to develop or maintain palliative care knowledge and skills yet the GP is perceived as the gatekeeper for care within the community. Presentation aim To describe the process of both the preparation for, and undertaking of, sensitive interviews. Study methodology The methodology incorporates tape-recorded semi-structured interviews, thematic framework analysis and Q methodology (QM). QM will be used to capture the experiences of GPs who have cared for a child with cancer receiving palliative care as well the perspectives of care experienced by the families. The semi-structured interview sample comprises 10 families (parents/guardians) whose child has been treated at a regional childhood cancer centre and their GPs. A further 40-60 GPs will be involved in the QM. Findings The preparation for these interviews will be discussed and compared to the supportive bereavement visits undertaken within the researcher’s role as a paediatric Macmillan nurse. The experience of undertaking the interviews will be exemplified with findings from the initial and the current, study. Papers’ contribution The researcher’s experience of preparing for and undertaking sensitive interviews may prove beneficial to other researchers.

Myths and Realities of Inter-professional Working

Introduction: Childhood cancers are rare and community based health care professionals have limited experience in caring for these children and often even less experience in providing their palliative care. It is well recognised that the provision of palliative care falls beyond the remit of any one profession, thus inter professional working is the standard model. This qualitative study aims to examine the experiences of the range of health care professionals involved in providing palliative care at home for children with cancer, focusing on how knowledge is exchanged; the level of communication and support both interprofessionally and at the community/specialist interface. It also aims to examine interprofessional collaboration in palliative care; identifying healthcare professional's perceptions of problems involved, interprofessional boundaries, specific areas of the organisation or provision of care that could be enhanced through changes in practice, support issues and the educational needs of health professionals. Methods The study involves three types of data collection; in-depth interviews, facilitated case discussion (FCD) and field notes from up to 20 cases (a "case" refers to the provision of palliative care to one child). Cases are selected from children who were treated at one regional childhood caner centre. For each case the community based health care professionals (for example the GP, community nurse or health visitor) involved in the care of the child at home are invited to participate in a one-to-one tape recorded in-depth interview followed by a group discussion in the form of a FCD. Field notes are completed following each interview. Data analysis follows a grounded theory approach. The term "social worlds theory" (SWT) his used to define a type of social organisation with no fixed or formal boundaries (such as membership boundaries), for example the range of health professionals that work together to provide palliative care. The boundaries of SW's are determined by the interaction and communication between recognised organisations, such as community nursing teams and general practitioners. SWT examines encounters between different professional groups and can be used to extend knowledge in both the organisation (for example general practice) and the content of what is being provisioned (for example, palliative care). The use of SWT in the analysis of the data is through examining the ethos of the different professions and the associated individual approaches to palliative care, exploring how this determines their roles in the provision of palliative care. Results 10 cases have so far been completed: 47 1:1 interviews (with a range of between 2-7 health care professionals being involved in each case): ( 9 x GP, 19 x CCN, 4 x DN, 3 x HV, 1 x HV assistant 7 x paediatric palliative care nurses, 1 x home support worker, 1 x OT, 1 x physiotherapist, 1 x community paediatrician) and 5 x FCD. The range of participants in the FCDs reflected that of the individual interview sampler. Data obtained to date gives clear insight into the personal experience of the individual health care professional in providing palliative care. Two themes emerging from the data will be focused upon: the continuity of care provision throughout treatment and palliation and the emotional burden experiences by the health care professional. Conclusions SWT can provide a useful framework in examining the social worlds of a disparate group of health care professionals working together for the first and maybe, the only time. A wide variation in the continuity of care provision has been found not only between professions, but also within professions. The emotional burden is evident across the professions.

Do GPs Make Good Research Participants?

Background Childhood cancers cause the largest numbers of deaths by disease in children aged 0-14 years1 with more than 400 children a year dying from cancer in the UK.2 Parental preference for their child to die within the family home2 coupled with the speciality of children’s palliative care medicine being still in its infancy, highlights the importance of the GP’s role in this highly specialised area of clinical practice. An understanding of the GP’s role will help inform the development of this specialty and identify best collaborative practice. A NIHR/CAT CL funded study examined the role of the GP in paediatric oncology palliative and bereavement care from the perspective of both the GP and the bereaved parent. This presentation will detail how GPs were approached and recruited, the reasons GPs declined participation and factors influencing the actual data collection. Methods The mixed method study used both qualitative and quantitative data collection methods. Phase 1: Semi-structured interviews to explore the experiences of GPs and parents. Phase 2: Q methodology with GPs who had a child with cancer on their caseload. Q methodology is a research tool that uses statistical analysis to cluster participants’ experiences according to similarity of their viewpoint Results The method and effectiveness of recruiting GPs for both phases of the study will be presented. In addition factors influencing collecting such emotive and sensitive data will be discussed. Conclusions Researcher flexibility and perseverance in participant recruitment was rewarded by the rich data collected. Findings from this study have identified four different GP role viewpoints and have provided a new dimension in understanding GP viewpoints on their role in this arena.

Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the Dutch Transition Project

International audience

Inter-professional education unveiling significant association between asthma knowledge and inhaler technique

Objectives: To explore whether an association exists between health care professionals’ (HCPs) asthma knowledge and inhaler technique demonstration skills. Methods: HCPs’ asthma knowledge and inhaler technique demonstration skills were assessed at baseline at an inter-professional educational workshop focusing on asthma medication use. Asthma knowledge was assessed via a published questionnaire. Correct inhaler technique for the three inhalers, the Accuhaler, Turbuhaler and pressurized Metered Dose Inhaler (pMDI) was assessed using published checklists. Results: Two hundred HCPs agreed to participate: 10 specialists (medical doctors specialized in respiratory diseases) (5%), 46 general practitioners (23%), 79 pharmacists (39%), 15 pharmacists’ assistants (8%), 40 nurses (20%) and 10 respiratory therapists (5%). Backwards stepwise multiple regression conducted to determine predictors of HCPs’ inhaler technique, showed that out of many independent variables (asthma knowledge score, profession, age, gender, place of work, years in practice and previous personal use of the study inhaler/s), asthma knowledge score was the only variable showing significant association with inhaler technique (R²=0.162, p<0.001). Conclusion: This study revealed significant associations between asthma knowledge and inhaler technique scores for all HCPs. Providing inter-professional workshops for all HCPs involved integrating education on asthma knowledge and practice of inhaler technique skills are looked-for.

Reconfiguring or reproducing intra-professional boundaries? Specialist expertise, generalist knowledge and the ‘modernization’ of the medical workforce

Efforts to ‘modernize’ the clinical workforce of the English National Health Service have sought to reconfigure the responsibilities of professional groups in pursuit of more effective, joined-up service provision. Such efforts have met resistance from professions eager to protect their jurisdictions, deploying legitimacy claims familiar from the insights of the sociology of professions. Yet to date few studies of professional boundaries have grounded these insights in the specific context of policy challenges to the inter- and intra-professional division of labour, in relation the medical profession and other health-related occupations. In this paper we address this gap by considering the experience of newly instituted general practitioners (family physicians) with a special interest (GPSIs) in genetics, introduced to improve genetics knowledge and practice in primary care. Using qualitative data from four comparative case studies, we discuss how an established intra-professional division of labour within medicine—between clinical geneticists and GPs—was opened, negotiated and reclosed in these sites. We discuss the contrasting attitudes towards the nature of genetics knowledge and its application of GPSIs and geneticists, and how these were used to advance conflicting visions of what the nascent GPSI role should involve. In particular, we show how the claims to knowledge of geneticists and GPSIs interacted with wider policy pressures to produce a rather more conservative redistribution of power and responsibility across the intra-professional boundary than the rhetoric of modernization might suggest.

Estímulos, barreiras e experiências na procura de ajuda para a disfunção sexual : estudo com utentes dos cuidados de saúde primários

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Perforación de la membrana timpánica: características clínicas, epidemiológicas y modalidades de manejo. Hospital José Carrasco Arteaga. Cuenca – Ecuador. 2011 - 2015

En el Ecuador la discapacidad auditiva afecta al 5% de la población y pese a ser susceptible de tratamiento es la segunda causa de discapacidad. Muchas de estas patologías alteran el tímpano y disminuyen la capacidad auditiva, afectando la calidad de vida y generando problemas de adaptación y cognición particularmente en niños. El tímpano tiene capacidad regenerativa por lo que la conducta inicial es expectante, sin embargo cuando el defecto no involuciona se inicia el tratamiento. La mayoría de los pacientes recuperan la audición cuando reciben atención médica oportuna. En nuestro medio son escasos los estudios del tema, por lo que el objetivo de este trabajo descriptivo y retrospectivo fue determinar las características clínicas, epidemiológicas y las modalidades de manejo de la perforación timpánica en el Hospital José Carrasco Arteaga de Cuenca durante los años 2011-2015. RESULTADOS: el 50.50% de pacientes fueron mujeres y el 65.20% de la población tuvo entre 20 y 59 años. El 80% de los casos fueron secundarios a infección; la otitis media crónica supurativa se encontró en el 56% de los pacientes y los traumatismos en el 14%. La perforación central fue la más frecuente. El 43.7% de los individuos se realizaron una timpanoplastia, con una tasa de éxito del 58%. CONCLUSIONES: La patología timpánica tiene importantes repercusiones sobre la calidad de vida. Pese a ser una entidad frecuente y susceptible de tratamiento, poco se conoce sobre su manejo. Conocimientos más amplios del tema permitirá al médico general un abordaje apropiado con mejores resultados

Clinical diagnosis and management of suspicious pigmented skin lesions: A survey of GPs

BACKGROUND The ability of general practitioners to make important clinical decisions about the diagnosis and management of skin lesions is poorly understood.METHODS A questionnaire on the diagnosis and management of eight photographed skin lesions was sent to 150 GPs in southeast Queensland.RESULTS The questionnaire was completed by 114 GPs (response rate 77%). General practitioners’ provisional diagnoses and management of photographed skin lesions were mostly or always correct, and there was general high consistency between diagnosis and intended management. Pigmented seborrhoeic keratoses were the most difficult lesions for GPs to diagnose correctly. Whether a lesion was different to usual moles appears to have the strongest association with clinical diagnosis.DISCUSSION The high ability of GPs as measured in this artificial study is encouraging. The strong association between identifying moles that appear different to usual and correct clinical diagnoses suggest that unless GPs can increase the number of skin lesions they see as part of their typical workload, their clinical ability may not increase further. Article in Australian family physician 34(1) · January 2005