(F02)
Health professionals' adaptation to societal and economic uncertainties, intensifying demands and growing challenges to healthcare provision
Location Bowland North Seminar Room 7
Date and Start Time 26 Jul, 2018 at 09:00
Sessions 3

Convenors

  • Assaf Givati (University of Portsmouth) email
  • Mick Harper (University of Portsmouth) email

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Short abstract

This panel is looking to bring together studies that explore how health professionals in pre-hospital care adapt to societal and economic uncertainties, intensifying demands and growing challenges to healthcare provision.

Long abstract

Health professionals' disciplinary boundaries are dynamic in nature and are defined in relation to fluid circumstances such as societal expectations, cultural perceptions and technological advancements. This panel is looking to bring together studies that explore how health professionals in pre-hospital care adapt to societal and economic uncertainties, intensifying demands and growing challenges to healthcare provision.

The healthcare workforce in high-income countries is experiencing an ongoing adaptation to increasing and unmet demands, including staffing shortages and consumers' changing expectations, all leading to the introduction of tight shifts and strict performance indicators.

Whilst the driving forces for the increasing pressure on health services are not fully understood, it appears to involve the impact of demographic changes and an ageing population, as well as organisational and practice-related changes to the already-complex and technologically advanced system of unplanned care with its ambulance services, A&E departments, emergency mental health services, emergency telephone helpline and walk-in centres.

We invite papers exploring:

- Professional and organisational strategies of health professionals in response to the aforementioned challenges.

- The changing roles and enhanced medicalisation of pre-hospital health and care professionals in relation to increasing demands and financial burden.

- The impact of the changing healthcare landscape on health professionals' well-being.

- The impact of reforms to professional organisation and practice on pre-hospital healthcare provision and on practitioners' performance and well-being.

This panel is closed to new paper proposals.

Papers

Meeting uncertainty in next generation clinical genetics

Author: Kathleen Job (Cardiff University) email
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Short abstract

Incorporating technological advancements into UK clinical genetics services has increased the potential for discovery of sequence variants of unknown or uncertain significance. These clinical uncertainties are discussed and interpreted in practices of shared decision making between professionals.

Long abstract

As technological advancements have shifted genetics into 'Next Generation' practices, integration into clinical genetics services has received strong governmental support but limited resources. Incorporation of these technological 'solutions' has the potential to create more complexity and uncertainty when genetic sequence variants are found that have not yet been classified as either benign or pathogenic, but as variants of unknown or uncertain significance (VUS). Discussion of this clinically uncertain information and the decision-making processes surrounding it, challenges those involved to disentangle the concept of uncertainty from that of risk. How these decision-making processes are enacted by professionals in the creation, review and interpretation of these clinical uncertainties can be observed during the various multifaceted, and often multidisciplinary, team meetings.

This presentation draws on the preliminary results of an ethnographic study of professional decision making around uncertainty in clinical genetics in the UK NHS.

Health professionals responses to demands for medical solutions to emotional distress in Uruguay

Authors: Gabriela Bruno (Universidad de la República, Uruguay) email
Andrea Bielli (Universidad de la República, Uruguay) email
María Pilar Bacci Mañaricua (Universidad de la República, Uruguay) email
Santiago Navarro (Universidad de la República, Uruguay) email
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Short abstract

This presentation analyzes the strategies that primary care health professionals deploy to respond to demands coming from health services institutions and health systems users to provide medical solutions to emotional distress in Uruguay, a middle-income country universal health coverage.

Long abstract

This paper analyzes strategies that primary care health professionals deploy to respond to demands of health services institutions and users to provide solutions to emotional distress in Uruguay, a middle-income country that has recently undergone a health system reform.

The presentation draws on findings from two projects, one conducted in 2013-2015 which explored health professionals perceptions on the role of benzodiazepines in their clinical practice, and another one conducted in 2015-2017 on benzodiazepines' users practices on psychopharmaceuticals consumption. In the first project we interviewed general practitioners, family doctors, psychiatrists and psychologist while in the second we interviewed benzodiazepines users.

Health professionals narratives show that they see themselves facing an increasing demand from health users to solve emotional problems that they consider rooted in social and economical factors and for which psychopharmaceuticals is the only means they have to respond. They also show how institutional demands and regulations of health services force them to resolve mental health consultations on the primary care level starting and following up psychopharmaceutical treatments until referral to specialist is possible. Paradoxically, benzodiazepines users narratives show that even though they ask health professionals to provide rapid solutions to emotional problems, they regulate themselves medication treatments deciding when and how to take psychoparmaceuticals and how to access to them without health professionals participation.

We discuss that the role of health professionals is challenged both by institution and users and that in order to face this situation they trace a dividing line between legitimate and non legitimate psycopharmaceutical consumption practices.

Negotiating medicalisation: the clinical practice of ADHD in paediatric psychiatry

Author: Fan-Tzu Tseng (Academia Sinica) email
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Short abstract

This study explores the clinical practices of childhood ADHD, and focuses on how psychiatrists react to the related medical and social controversies. Whilst considering back and forth between psychiatry as an imperfect science and as a contentious aid, practitioners manage to negotiate competing concerns in a constantly medicalising society.

Long abstract

While the rate of diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) has been growing rapidly since the turn of the twenty-first century in Taiwan, the public debate around the over-diagnosis and over-medication treatment in children has prevailed throughout this decade, and has been challenging the authority and credibility of child psychiatry as a latecomer to the local field of medical specialties. Based upon analyses of interview data collected from seventeen psychiatrists, this study explores how every day clinical practices react to social controversies, and how psychiatrists, very aware of the marked skepticism surrounds ADHD, negotiate the standardised label of disorder and clinical practice guideline while considering the characteristics of the child and his/her situations. This study finds that psychiatrists interviewed put more emphasis on the clinical logic -- whether this case is “treatable”—than the ambivalent nature of ADHD as a “real” disorder (on constructed). Although psychiatrists understand children with a biopsychosocial framework, it is usually the child, rather than the environment itself, that become the prior object of medical interventions given capacity and resource limitations. However, psychiatrists try to interpret these interventions as means of empowering the suffering child to develop his ability to manage himself and his social relationships. This study unveils that the process the clinical practitioners negotiate back and forth between psychiatry as an imperfect science and as a contentious aid, and will contribute the literature of medicalisation, diagnosis and the social control of childhood behavior.

Ecology of care. A more-than-institutional analysis of healthcare in the urban space of Trieste, Italy, and London, UK

Author: Francesco Salvini (University of Kent) email
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Short abstract

This paper aims to develop a more-than-institutional analysis of contemporary healthcare systems, immersing the roles and responsibilities of caring and healing in a broader urban system done of actants, sites, relations, memories, protocols. The paper results from a collaborative analysis.

Long abstract

This paper aims to develop a more-than-institutional analysis of contemporary healthcare systems, immersing the roles and responsibilities of caring and healing in a broader urban system. This critical analysis of social healthcare systems not only refers to the multiplicity of agencies and roles that participate in the contemporary endeavours of care; but also it attempts to place the responsibility of healing and caring beyond the field of competence, within the complex ecology of urban life.

Following the recent development by Franco Rotelli (2013) of "the city that heals/cares", as ulterior step of Franco Basaglia's critique of institutionalisation of healthcare (since the 1960s), the paper employs different streams of ecological critique, to engage with institutional practices in healthcare: the ecological perception of Henri Lefebvre; the transversal ecological understanding of Felix Guattari; and Susan Leigh Star's ecological institutional approach.

These streams of critique allows us to construct a novel concept, the "ecology of care", and to investigate and expose it through an ethnographic research in concrete sites of Europe. The _territorial medicine_ in Trieste and the _social prescription_ in London will serve to enquire different more-than-social tendencies; between emancipation and abandonment, commoning and individualisation, blossoming and desertification.

These dialogues are constructed through the participatory analysis of practices together with workers, users and activists. This collaborative analysis provides a series of analytical tools to widen our understanding of the responsibility of caring and healing, as a socio-material distributed invention of care in the complex urban environment, today.

How to be nudged, and be just at the same time? Exploring an innovation in the organisation of health care as a practice of justification and critique

Author: Willemine Willems (Maastricht University) email
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Short abstract

This paper explores an innovation in the delivery of health care. By holding specialized consultations in a primary care setting, patient and specialist are nudged towards making cheaper decisions. The presented ethnographic research shows how such a strategy turns out in practice.

Long abstract

This paper explores the response of an organization of primary care professionals to the widespread concerns about growing health care costs. With specialized consultations in a primary care setting instead of in a hospital, patient and specialist are 'nudged' toward making fewer expensive decisions that are medically redundant. By analyzing justification registers on the managerial and operational level, the paper aims to show how such a strategy to deal with the growing challenges of health care turns out in practice.

The paper first presents a short overview of the debate around nudging. A nudge is a policy tool used to change behavior of people by changing the decision environment, supposedly interfering in the so-called automatic thinking system instead of the deliberative system. Although not explicitly denoted a nudge by any of the people involved, I argue that understanding the innovation as such will give insight into the registers of justification applied when using such a tool. Secondly, I present the results of an ethnographic research into both managerial and operational levels of the innovation. On the managerial level I focus on how the innovation is presented internally and externally by looking at justification statements but also at the practices of evaluation. On the operational level, I describe how specialist and patient, dealing with the limitations of the environment, are engaged in intricate justification work. By analyzing both levels as practices of justification and critique, I show on which points registers clash and to what extent this is problematic.

The bargaining of professionalism in emergency care practice: NHS paramedics and higher education

Author: Assaf Givati (University of Portsmouth) email
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Short abstract

This article explores the impact on professional practice of reforms to the paramedic profession in the UK including the academization of training in order to accommodate for enhancing paramedics' public health roles and ability to utilize technological advancements and medical interventions.

Long abstract

Over the past 2 decades, as part of reforms to the National Health Service and with it organizational changes to ambulance work in the UK, paramedic education has undergone a process of 'academisation' and a shift from in-house, apprenticeship weeks-long occupational training, to university-based undergraduate programs. This change was designed to accommodate for enhancing paramedics' public health roles including the utilization of advanced medical and technological skills. While the professional regulation and standardization of Allied Health Professionals' education in high-income countries has captured scholarly attention, the study of paramedic practice is still in its infancy and there is a need to explore its evolvement in relation to the fluid societal-political circumstances affecting its provision and demand. Based on interviews with front-line paramedics, paramedic educators and paramedic science students in the South of England, this article examines how the reforms to paramedic education have impacted the professionalization of paramedics and their discourse of professionalism. Framed within to the 'new' sociology of professions, the case of British paramedics demonstrates the complex nature of the relationship between the university and professional practice. It appears that universities, the providers of paramedic education, are caught between two opposing discourses of professionalism: on the one hand, that of providing a platform for students' socialization and engagement with professionalism 'from within' practice which is based on students' common goals and mutual experiences, and, on the other hand, serving as a conduit for managerial/organizational strategies of professionalism which appear to undermine the role of university socialization.

Visible persons, invisible work? Exploring articulation work in person-centered care

Author: Doris Lydahl (University of Gothenburg) email
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Short abstract

Person-centered care is one of the many initiatives developed in response to new uncertainties and challenges in healthcare, promising to increase patient satisfaction while decreasing costs. This presentation explores the articulation- and invisible work involved in sustaining such care.

Long abstract

Designed in response to new societal and economic uncertainties, intensifying demands and growing challenges to healthcare, a growing number of patient-focused initiatives have been developed in the last decades. Person-centred care is a particular approach to patient-focused care, in which it is argued that by centring care on the patient as a person, inviting them to share their stories and participate in the delivery of their own health care, patient satisfaction will increase, as well as efficiency furthering a more appropriate allocation of health care resources. Drawing on the concept of articulation work and invisible work, this presentation investigates the efforts involved in sustaining the realisation of person-centred care. The presentation builds on an ethnographic study conducted at a Swedish hospital ward implementing person-centred care. Following a nurse, and her patient, through a 'person-centred' admission process and its subsequent procedures, I argue that person-centred care depends on nurses performing many new tasks, which are rarely recognized and appreciated. Secondly, I argue that nurses are continually asked to perform articulation work, coordinating between these different new tasks and established duties. Thirdly, I discuss the tensions arising when implementing a formalized model of care, which builds on a critique of standardization and objectification, and the work that is excluded and invisible in such routinized operationalization. Finally, I conclude that while the successful implementation of person-centred care is often argued to rely on the willingness of nurses to surrender old habits, it seems rather to hinge on the skilled inven¬tiveness of these nurses.

Efficiency, standardization and the complexity of integrating care for old people in a primary care setting in Northen Italy

Author: Francesco Diodati (University of Milano-Bicocca) email
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Short abstract

This paper explores the relationship between Population Aging and Economic Restructuring in a primary care setting in Northen Italy. It highlights provider's perceptions of standardization and efficiency and the complexity of providing integrated care for old people.

Long abstract

In Italy, the increasing number of complex chronic conditions and the rising demand for long-term care have raised public and institutional concerns about the need to overcome National Health System's fragmentation by developing integrated primary care. However, the implementation of primary care has woven with the economic matter of providing time and cost-effective healthcare services.

This paper explores the relationship between Population Aging and Economic Restructuring and its effects on a primary care service to old people in Northen Italy. Drawing on interviews with different health and social professionals on the complexity of providing integrated health and social care for old people, I show the perception of the rhetoric of standardization and efficiency as an image too much mechanical, coherent and objective of health professional's disciplinary boundaries and user's needs. This vision can not acknowledge everyday work of reassembling and mediating fragmented, hid and ambivalent information and thoughts - as well as disciplinary landscapes - in the ongoing tinkering with pharmacological treatments, aids, and home-based care activities. I underline the providers place a high value on the personal and professional experience of cultivating patient-provider-caregiver relationships and negotiating health disciplinary boundaries in practice. And I highlight how all believe health authorities underestimate the effectiveness of time and effort spent due to economic concerns about quantification and standardization of care services.

The paper presents extracts from interviews gathered and analyzed by the author in an ethnographic study part of broader multidisciplinary research on primary care services in Northern Italy.

The contribution of internet use in personal networks of support for long-term condition self-management

Author: Chris Allen (University of Portsmouth ) email
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Short abstract

This research examines the role of offline support on the utilization of online health resources for long-term condition self management in a marginalized community.

The findings indicate the importance of supportive offline relationships on the uptake of online self-management resources.

Long abstract

Objectives: To describe the individual and network characteristics of the personal communities of people using the internet and the role of offline support, network resources and community participation in using the internet for condition management.

Methods: Secondary analysis of survey data using logistic regression analysis to determine the factors associated with differential internet use for condition management. This study involved 300 participants from 19 primary care providers in Manchester in 2010 and 2011.

Results: Using the internet is associated with age, deprivation, education and having access to a personal network member who understands how to fix computer problems. Those using the internet for condition management received more offline emotional work. No associations were found between using the internet for health and other types of offline support. Those using the internet for support reported lower levels of happiness.

Conclusion: Network processes and engagement shape online contact and use of resources for condition management. Those with access to personal networks who provide emotional work are likely to make use of online resources during non-crisis situations, suggesting that these resources act as an extension of offline network support. Those with greater levels of unhappiness may more frequently look to the internet for support.

This panel is closed to new paper proposals.