Doubting my abilities and capacity to take this forward....can I really dig deep into the data and come up with meaningful conclusions?  Finding it difficult to find the time to think and focus and then when I do to get my head into gear and think and concentrate........  Hmmm.........

Seminar booked for Monday 6 July at the RFMS.  Need to get my title and abstract submitted and then put together a presentation for the session.  The key aims of the seminar will be to test my theory of what the data is saying and get feedback from my audience.  Hopefully I will be asked pertinent questions and have any omissions highlighted.  Best to get asked the difficult questions now and have any errors and omissions pointed out now rather than at the viva!

Good supervision session today.  Really beginning to feel that I am putting a thesis together now.  Plan now is to revisit the Yellow Chapter and interrogate the data further and to summarise the chapter in my own words.  Supervisors suggestion is that I do that before pressing on further with the Turquoise Chapter.  The intention then is for me to compare and contrast my conclusions from the Yellow Chapter with Kleinman's 5 Parts of the Illness Experience which is the Turquoise Chapter.

Whilst reading Kleinman's book 'Pateints and Healers in the Context of Culture' in preparation for writing my Turquoise Chapeter, I came upon a series of concepts that I found both interesting and relevant to the PhD.  I have recorded them here as a way of being able to re-access them in the future:

~ Healthcare activities need to be studied holistically in the context that they are socially organised responses to disease
~ Medicine is a cultural system - a system of symbolic meanings anchored in particular arrangements of soical institutions and patterns of interpersonal interactions
~ In every culture, the responses to illness by the individuals experiencing it, those treating it and the social institutions relating to it are all systematically interconnected
~ The totality of the relationships is the healthcare system

Two key writers I need to visit/revisit are Zola (1972) and Illich (1975) who both write about the medicalisation of society.

Giddens (1976) also has something to say: the cultural analysis of any concrete aspect of the social world should attend to the effects produced by the interplay of 3 types of forces:

~ Meaning
~ Norms
~ Power

The power differential between the sick role and the therapeutic role is an ideal example of this.

Yellow Chapter first draft finished and now half way through Turquoise Chapter.......the colours really are meaningful at this stage of the write-up - needless to say they will not be the final chapter names......  The colours for chapters came about from an earlier mind map which identified what I needed to develop in the thesis and which bit linked to what etc.  Colours to follow are the Blue and the Red Chapters....

Have now registered for the ICCHNR conference in Adelaide and booked hotel for the week.  Just need to plan the rest of the trip following on from the conference - will go to Melbourne for first weekend and then onto Sydney for 7-10 days.  Once planned I can then book flights.......will be an interesting trip, especially as I have never been to Australia before.

Yay!!!  PhD supervision today - ramblings re. first 2 questions in draft 'yellow chapter' described by one supervisor as 'intriguing' - feels great, thankfully not told they were rubbish.......  Really enjoyed the writing - well more a stream of consciousness at this stage but feels good to be putting a thesis together at long last.  Now need to get down to writing up questions 3-8, have until beginning of March to get this done but hope to be finished with this first chapter draft well before then.

Really exciting to be getting ideas out for discussion - exploring what might be new and what simply reinforces known knowledge - debates with supervisors good too - all of a sudden beginning to feel as if on same level and can hold my own..........

......abstract accepted.........Health Foundation monies secure - am off to Adelaide in August 2009!!

The time has come to start to put a story together.  The previous months and years since 2005 when I started this PhD have been spent getting the data and then breaking it down, finally the time has come to tentatively put words together to create a story that does justice to people's  narratives about the depression in their lives.  Small steps initially, so will be starting with the first two of Kleinman's 8 questions - feedback from my PhD Supervisors will give me an indication as to whether I am on the right track.

Christmas is the deadline for this first piece of writing........

At last........my final monies from the LPTR Award are secure and can be accessed for ongoing dissemination.  The Health Foundation have been brilliant and have come to an agreement within their organisation to let me access the final monies via them rather than via the original contracted arrangement.  Great news and thanks to them - means that my dissemination plans for 2009 and beyond should hopefully materialise.

Health matters and Healthmatters is an excellent quarterly publication that publishes pertinent articles relative to the current health agenda.  I was asked to submit an article I wrote about the Kirsch paper in PLoS regarding antidepressants and their benefit in depression.

"Antidepressant Medication Data: Why has something that was already known become a media circus years later?

The recent article published in PLoS by Kirsch et al (1) which reported the results of a meta-analysis of the evidence submitted to the Food and Drug Administration (FDA) re efficacy of the SSRIs is not new news.  This is the third article published by Kirsch which has focused on meta-analyses of antidepressant medication, the first article was published in 1998 and the second article published in 2002.  So why did the recent publication in PLoS create such media interest with coverage on national radio, TV and the press?"

If you want to know the answer to that question you can either find yourself a copy of the Spring edition of Healthmatters or patiently wait for me to attach a copy of the article to this blog.......I am still waiting for the pdf...........it's here now.....see attachment.

 

 

Why NVivo 8?

NVivo 8 - computer aided qualitative data analysis software (CAQDAS) - has been bought as an upgrade to N6 which I already have and had used for the analysis of my questionnaire data many moons ago.  Having completed the charting I was somewhat daunted by the numerous charts and data embedded within them - how on earth was I going to be able to get my head round all this data particularly considering the fractured way in which I have to work i.e. the norm of a part-time PhD, and then to do the data justice as well as the interviewees who had given of their time as well as their illness/depression stories.  So....after thought and consideration and discussion with my PhD supervisors I decided that using NVivo would enable me to more easily work with my data in a structured and consistent way and it would help me work within the constraints I currently have.

Benefits of NVivo 8

- Provides a recognised and consistent method to underpin my data analysis
- It is a logical process that I can track back to understand how and why I have got to where I have in the analysis
- It facilitates a rigorous analysis process

As a tool, NVivo is a complexity aid to assist with the process of the data analysis; it will allow me to maintain the momentum of the data analysis as I will be able to revisit and regroup my thought processes and assumptions over time.  The ability to complete a journal within NVivo will also allow me to document my thoughts and actions as they develop throughout the process; I will be able to identify personal goals and hopefully recognise assumptions and experiential knowledge and thus allow me to develop a critical subjectivity towards the data and its analysis.  It is important to remember that prior assumptions do exist so by recognising them and recording them I can become more aware of their influence on the way I am thinking and subsequently then assess their impact on the analysis.

 

Framework was developed by Ritchie and Spencer in 1994 (see below for full reference); it is a systematic approach to data analysis which is transparent and reproducible - the data is sifted and charted according to key issues and themes to facilitate the determination of meaning, salience and connections from the data. Framework is useful when the questions of a study are clearly known and it is an approach to data analysis that has been validated in studies of this kind.  Framework has certainly provided me with a structured tool with which to undertake my data analysis.  Having already previously worked with Framework it has been useful to understand how it works  form the outset.  Listed below is a summary of the stages of Framework; I have also attached the Framework flowchart which shows how all the parts link together.

Familiarisation

- Read proposal
- Read transcripts
- Review topic guide

Identify Recurring & Important Themes

- Develop a working framework of key themes and sub-topics

Indexing

- Apply a numerical series to working framework
- Label or code transcripts numerically
- Adapt framework in light of gaps or overlap

Pilot Charting

- Chart a few transcripts using working framework
- Adapt framework in light of gaps or overlap

Charting

- Summarise / synthesise verbatim data within finalised thematic framework

Abstraction

- Analyse and theorise using NVivo 8

Investigation & Interpretation

Having got to the abstraction stage I realised that I was going to struggle to continue working with my data now that it was in the form of the charts - either electronically as spreadsheets or in A3 paper format  - too much information to try and work with in an intermittent way..........I knew I needed help and decided to look into putting my spreadsheets into NVivo 8.  NVivo 8 is QSRs latest software that is able to embed all Word format documents and also pdfs - sadly though not Excel.  However, I worked out a way to save my spreadsheets as Word docs and these can then be imported into NVivo - NVivo seems to be the answer.........

 

Framework Reference:

Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In Bryman A, Burgess RG, eds. Analysing Qualitative Data, pp 173-94. London: Routledge, 1994

 

A bit of a slow month - relative to the PhD anyway...... Life events have taken over to a considerable extent with the 'oldies' having an accident and weekends thus spent visiting etc.  Fortunately they are recovering well and should be back to some sort of normality over the next few weeks.  However, the events of end of May do highlight how little flexibility I have with my time, certainly no spare capacity - so PhD time has been taken over with needs of family.

I have been thinking through about how best to manage and cope with all my data I now need to analyse - part-time working means I have a disjointed approach to analysing my data and I need to somehow keep on top of my analysis and my thinking as to where the data is taking me.  This is not going to be easy to manage and is certainly a major concern I have.......

The NVivo workshop I attended last week (courtesy of NELCRAD) was excellent; NVivo 8 could well be the way forward and help to allay some of my concerns.

At last - the charting phase of Framework is now finished.  All 30 transcripts are now encapsulated/summarised within 5 charts/spreadsheets.  Seems to have been a long haul to get to this stage, but I can now start to look at drawing out themes.  Initially this will be those themes which fit into Kleinman's Semantic Illness Network and the 5 Parts of the Illness Experience.  It will then be possible to highlight which parts of the data do not fit within Kleinman's Explanatory Model Framework.  I will then be able to offer up a discussion as to whether Kleinman has provided a good theoretical framework for this qualitative study, or not; and then also draw out themes from the data.  So lots to do but so good to be moving on with the data analysis.

One year since I last attended a Health Foundation event.  The second event of 2007 was on the day after I started my new job at Health E1 so not a good time to go!  This time the Health Foundation fellows were asked to contribute 75% of the day - poster presentations summarising our work and the implications of it - see attachment for my efforts.

As always an excellent day - always so good to meet up with colleagues, the peer support and meeting of 'friends' is so supportive and necessary for my academic life.  The day was entitled 'Translating research into improvement' i.e. an opportunity for fellows to share their emerging research findings, explore their potential impact and create solutions to shared challenges.  The day was headed up by an excellent interactive presentation about leading and implementing service improvement within an organisation - Alder Hey - an organisation which has undergone a traumatic time but has learnt from its past to develop a future which looks promising and exciting.  There was also an opportunity to practise using action learning sets - something which I had previously learnt about and practised on the Kings Fund course - although I have to admit was something I had forgotten all about.  It is actually quite amazing how everything all seems to link up eventually - like lots of dots in a giant circle - all the disparate parts join up in the end in some way or another.

An editor from Nursing Standard listened to my presentation at the RCN Research Conference and has asked me to publish in the journal.  This poses a small dilemma in that I have not completed my data analysis and with all due respect the NS is probably not where I wish to publish my PhD research findings (fortunately PhD Supervisors agree).  I have replied to the NS editor and offered some work from my literature review regarding depression and antidepressant drug use.........so I now await her reply.

There were a number of excellent presentations which I listened to at the Research Conference which may be relevant to my ongoing work with my PhD:

Challenges and tensions in qualitative research (1.6.1):

- Look at the rhetoric and metaphors within the texts
- Narratives - remember the work of Frank
- If other people are present within the interview then their contribution within the interview will also need to be analysed, possibly as a joint story as dividing up the interviewee plus 3rd person may destroy the story
- Ethical conduct with distressed participants
-Look at the work by Scheurich (1997) - Research in the Post Modern; Goffman (1969) - The presentation of self in everyday life

Enhancing Rigour - Peshkin's Is (1.6.3):

- Peshkin states that researchers need to systematically identify their subjectivity throughout the course of the research
- Record my feelings as a researcher in order to capture subjectivity
- Is = him, me
- e.gs - Paladin I = champion to another group of people; Maverick I = unusual, unorthodox, looking for 'exciting' in the data which may represent the participants; Impatient I; Pragmatic I.....

Emergency Dept. Research Symposium:

- Cochrane review re. methods to increase response rates to postal questionnaires (Edwards et al 2007)
- Practitioner research transition - 'Do I ever stop being a nurse' (Bailey 2007)

Framework (7.7.1):

- Tesch (1990) - Discourse, thematic, theory development
- Framework refs - Pope et al, 2000; Mulvaney, 2006; Prost, 2007.
- Coding index - remember to record all the initial themes and categories and how the linkages and final themes evolved i.e. initial themes -- categories -- final themes -- core concepts

The End Game:

- Think Donadedian - Structure -- Process -- Outcome
- Save thesis in several places - email accounts, flash drives etc
- Proof reading is important - think outside of discipline for proof reading
- Accept supervisor advice - they know best!
- Drafts - keep a track of drafts, name accurately, use coloured paper
- Remember the PhD thesis is a contribution to new knowledge, it is not a seminal work; only needs to be good enough; needs to be easy for the person who is going to read it - summarise sections, refer back to the introduction
VIVA:
- Normally a private event
- Get match fit 4-6 weeks prior to the viva - it is the opportunity to sell your knowledge
- Mock viva is really useful
- Internal examiner is there to ensure the standard is adequate and meets the university standards, usually want you to pass

Utility of the story (9.2.2):

- The essence of something is more than the factual account
- Stories are structured, contextual, chronological
- Themes may be reductionist
- There are risks of deconstructing an account and perhaps changing the story the person is trying to tell
- Refs - Weingraf, 2001 - qualitative research interview; Nemsley, 2000; Merleau Ponty
- Use 'tell me about.....' rather than 'what' in order to get more of a story or anecdote

Illness narratives (9.2.3):

- Alibris has a bookfinder search facility; able to search online bookstores
- Dogpile is a search engine
- Log of activity (Robinson 2001) - practical aspect of search processes
- NESH Guidelines (2003) - information in the public domain i.e. non-gatekeepered sites; need citing as normal (created commons)

Interviewing as a therapeutic activity - see paper (Burns et al 2008):

- Be aware of areas of distress for participant and try and limit this
- Can have therapeutic benefits for participant
- Therapeutic effect enhanced if interviewer leaves participant with a sense of well being at end of interview
- Planning and preparation in advance help to develop trust
- Be aware of the vulnerability of the interviewee; be skilled inactive listening
- Compassionate responses and emotional engagement by the interviewer who is focused on listening to the participant's story can benefit the participant

 

Just back from Liverpool 2008 - another excellent International Research Conference held by the RCN Research Society - it does rain a lot in Liverpool!

Having missed last year's conference in Dundee because of work, PhD and Nurse Prescribing course commitments it was good to be back.  Meeting up with 'old' colleagues from previous conferences and colleagues met via the Health Foundation was great, plus meeting and making new friends.  Networking, and sharing trials and tribulations of PhD study is always supportive - I think I had forgotten quite how supportive though.  Essentially my PhD journey is a lonely one (not complaining) so it is good to have the opportunity to share with others undertaking a similar journey.  Interestingly, I met a few other clinical nurses this year who are also undertaking PhDs - when I first went along to Belfast 2005 I don't think I met anyone who was interested in following a clinical/research pathway, so times are definitely changing.  Hopefully, it is no longer just the HEI nurses who have the monopoly on PhDs.

My presentation on the Wednesday went well, the audience was small but select and good questions were asked.  The Clinical Editor from the Nursing Standard approached me afterwards and has asked me to write something for their journal.  Certainly, I feel that my confidence, and hopefully also competence, at presenting is continuing to improve.

So thank you to Liverpool, it was a great week - an opportunity not only to work hard but also to play hard with all the social events that were organised for each evening, I had a great time and look forward to meeting up with colleagues old and new at Cardiff 2009 if not before.

All has been really quite blog-wise for the past few months - why you might ask?  Is it that I am not doing anything, have I forgotten about the blog or what?  Well if the truth be known I have been a bit stuck in the data analysis tunnel.  What does that mean?

Changing jobs mid PhD is not recommended - all the books tell you that but sometimes when the time comes to move jobs and the right job appears on the scene then one is left with no choice but to go for it and cope with the consequences.  Clearly changing jobs is in itself a major transition without relocating to London Monday-Friday!  Having said that, it has all gone well - the job is great, my flat is great and dividing time between London and Norfolk and the family is working well.  The occasional weekend in London is great - husband comes to me; daughter uses flat as London base for a few days when she is on hols from university - all working well there then.  However, what about the data analysis - has been verrrry slowwww.........  The indexing of all the transcripts was to say the least monotonous, dare I say boring (!) - talking to other qualitative researchers this is true and just the way it is - so I don't feel quite so guilty now about thinking those thoughts.  The charting is fascinating and enthuses me as I start to summarise and chart chunks of data in preparation for the next stage of analysis.  This phase now coincides with completion of 4 months in the new job/flat and I really feel that I can now take the PhD back on board properly instead of fiddling around the edges of it - hope that makes sense.  Also helped by getting all our 2007/08 QOF submissions finally in - the last 4-6 weeks has been a lot of hard work by not only me but also the HE1 Team to get all our QOF data maximised - looks like we will have our best QOF points ever - 50 points more than last year,  a 5% improvement which is great news.

So, I guess to summarise - I can see the light at the end of the data charting phase, only 11 transcripts and a few weeks away; the newness of working life is no longer there and normality and routine are beginning to fall back into place and I have got room in my head to think about the PhD and do justice to the data.

So should you change jobs mid PhD? The right answer is probably no, but if you must then it really is OK, and you do move through the PhD 'stuck' patch and get though to the other side OK.  So my advice - go for it!!

No not the shop but a new look for both the blog and my website - have a look.  Spring is here and I thought after 2 years a new brighter image was called for - probably just distraction therapy from getting on with data analysis but, I think, worth the time and effort.  I like the brighter colours, the more cleaner, crisper appearance........

One month on since starting at Health E1.............

As expected I have lots to learn about working with patients with substance misuse problems and homelessness, but already some areas are becoming a bit more familiar and thus less stressful.  Thankfully, whatever a patient's background they do all still have the same types of physical and psychological illnesses so at least I am an more familiar territory there! Much of the work involves dealing with the chaos and complexity of individual's lives as well as the health issues that arise.

Some of the more unexpected challenges have been getting used to how the practice uses EMIS - I had assumed that this would be one area I would not have to think about but no, Health E1 use EMIS differently!  They use it in its 'problem-focused' format so I have had to get used to using it slightly differently, not too much of a challenge but still something else that is not familiar.  Other little things like how notes are summarised is also different; but templates are still the same and they do need my skills to change templates so good to be useful there.

I spent most of my first 2 weeks out and about visiting the hostels and other agencies involved in the care and support of the homeless population in East London; I walked many miles from Hackney to Bethnal Green, to Shoreditch and down towards Docklands but at least I now know where places are in relation to each and to Health E1.  The support and infrastructure to meet the needs of people who are homeless and with substance misuse problems is amazing, there is a whole level of agency working that traditional general practice has little or no knowledge that exists and certainly does not need to engage with normally.  It has certainly been a fascinating learning journey so far.

Wasting no time, the practice was keen that I get onto the RCGP Substance Misuse Course Part 1 as soon as possible - I am now registered for the face -to-face session at the end of January and need to be getting on with the 2 on-line modules as well (something else that needs to fit in alongside the PhD.......).  The plan is then to complete the final Part 2 later in the year, probably July.

Moving back into my clinical comfort zone, I met with key people at the Diabetes Centre at Mile End Hospital last week with the aim of liaising and trying to improve the care of our patients with diabetes and to also continue with my own special interest in Type 2 diabetes in particular.  Great news is that I have been invited to represent primary care on the Diabetes NSF Group which meets monthly, so I look forward to joining them at next month's meeting.  I have also met with the Lead Nurse from the Whitechapel WIC who will also be a great resource and support in my new role within Tower Hamlets PCT, the PCT has suggested he would be ideal to provide me with my clinical supervision - I was really impressed that the PCT should be so proactive about arranging clinical supervision for me.

The past month has also seen me complete the mandatory 2-day PCT Induction Course - a huge amount of stuff was covered, almost too much in the time available and most was of a very good quality; interestingly the most interactive of all sessions was the one regarding NHS Pensions - everyone was most interested in what they could expect to get from their NHS Pension.

So all in all, the past month has been amazingly busy and very interesting, I am learning fast and it is good to be part of the team at Health E1; they are a great team who are very focused on providing quality patient care in sometimes very difficult circumstances.  I am grateful that they have all made me feel so welcome.

 

Amazingly my 2 years of the LPTR Award will be up mid November 2007.  I really cannot believe that the practical work for this PhD started 2 years ago, the time has gone so quickly.  In some respects this year has been slow in terms of getting on with the data analysis; undertaking my Independent/Supplementary Nurse Prescribing course from Jan-July 2007 was challenging but necessary to keep my clinical skills and career up to date and on track.

The recommendations are that one should not change jobs mid PhD.........nevertheless if a job comes by with all the right opportunities and challenges one cannot let it pass!  Consequently I am on the move and am off to a new Nurse-led medical practice as their new Lead Nurse Practitioner.  As from December 3rd I will be working at Health E1 Homeless Medical Practice on Brick Lane, in Tower Hamlets.  This new post will provide me with new clinical challenges as I have no prior experience of working with the homeless or with people with substance misuse problems; hopefully my managerial and leadership skills will be adequate; but importantly I hope I can link my own clinical and and research interests into the interests of the practice and develop close working relationships between the practice and primary care academic units in London.  Changing jobs and having to sort out accommodation in London for a Mon-Fri commute has also been a distraction to data analysis and added to a slowing of the overall progress.  However, hopefully when I am ensconced in my studio flat Mon-Fri I will have plenty of time to work on the PhD...no more excuses then!

The Health Foundation have been very supportive and extended my Award by 6 months to allow completion of the data analysis and production of a final report for them.  The Health Foundation are a great organisation to be involved with, the twice yearly days for Award holders are also excellent, it is a shame that I will be unable to attend the December day as it is the day after I start at Health E1.

The ICCHNR Symposium in Granada was the first international academic event I have attended.  The simultaneous translations (Spanish-English, English-Spanish) were fascinating - I have great admiration for the translators as it must be a very challenging job.  Despite the distractions of the act of translation, the debates were very good and provided much food for thought.

The many posters on display were also all of a high quality, it was good to get positive feedback on my poster.  It certainly seems that there is an interest in the aspect of the patient experience of stopping antidepressant medication, reassuring to say the least.

It was also a great opportunity to meet up with London colleagues, old and new, to be able to share PhD progress updates and forthcoming plans.

The next ICCHNR conference is in 2009, in Adelaide.......

My supervision session to review progress with my 7 Framework pilot charts went well.  We reviewed the index framework and charts, no changes were made and it was agreed I should continue charting using index framework as per pilot charts.

We identified that there was a need to map the methodology; to map Kleinman’s 8 questions to the recurrent/important themes, the 5 parts of an illness, and the semantic illness network.  This should show any gaps in Kleinman’s questions which do not cover the breadth of the illness experience of people with depression.

 

We also identified some themes to explore:

- Do the narratives of the patients fit with an acceptance of depression; are their narratives contradictory or complementary, both within narratives and across narratives?

- What models to the patients have to explain their depression?

- Kleinman’s research was carried out in China, is there a cultural explanation for his 8 questions not explaining the whole of the patient depression experience?

I am working through a quarter of my transcripts initially, this is to allow me to refine and adjust the framework I am using.  I have indexed 7 transcripts and already realised that applying Kleinman's Semantic Illness Network, and the 5 Parts of the Illness Experience at this stage are an analytical step too far.  I am therefore indexing the transcripts and creating charts for background information; Kleinman's 8 Questions; Depression themes; Antidepressant themes; and themes such as stigma, recovery, self etc. 

This appears to be working well; the plan is to then review these charts which will have been derived from the 7 transcripts with my PhD Supervisors in early October where we can further refine the Framework process.  From these initial charts I think I will then be more easily able to create second level charts for the Semantic Illness Network and also Illness Experience.

What has been interesting though is the indexing process.  I have been through the transcripts and indexed them numerically section by section, but now when I go back through the transcripts to chart them according to the indexing theme I have become more aware of deeper meanings and linkages in the data and have in some places had to revise my initial index category to something else. 

So far, I have found Framework a very useful data analysis tool which is not only adaptable but also provides a way of being able to index and chart all the data.

The past 3 months have been barren weeks in terms of the PhD but I have not been idle!  Anything but.....my Nurse Prescribing course started in January and ended with the final exam last Tuesday and since April I have had to concentrate on writing my assignment and producing a portfolio of learning to include prescribing episodes, practice learning, consultation assessment, formative and summative assessments and reflections.  It has been a lengthy task but it has been worthwhile regarding clinical practice, not so much for the PhD though.

I have missed the PhD and am looking forward to getting 'stuck in' to the start of my data analysis this week.  I need to review the learning and course details re Framework from the NatCen course and get started on creating the Framework charts; hopefully I will have something to show by next weekend.  As always getting started is always the hardest thing; it is difficult to know what sort of time frame this is all going to take.....

I have begun to identify the early themes from each interview and draw these together into topic areas.  The next stage is to begin to create the Framework charts in Excel.  Initially I intend to create a chart for each of Kleinman's 8 questions and also for each aspect of his Semantic Illness Model; I suspect that after this I will need to create charts to highlight deeper meanings and subtleties within the data.

I still need to change all my transcripts into the format required to feed them into my CAQDAS software, N6.  Using N6 will not only help with data analysis and interpretation but will also provide an opportunity to compare Framework v. CAQDAS; this will form part of my discussion chapter in the thesis alongside a discussion regarding the utility of Kleinman's EM as a data analysis tool in primary care research of this type.

Without hesitation I recommend the Kings Fund 'Management and Leadership for Clinicians' 5 day course to anyone who wants to become a better leader and manager of people; to do this one needs to know and understand oneself first, to explore your individual strengths and weaknesses, only then can one go on to lead and manage within organisations.  There is no cookbook recipe to become a leader but everyone can identify their potential and direct their development in a positive way.  The week was spent in the company of 23 NHS colleagues from a multidisciplinary environment, there were Consultants, SpRs, Psychologists, Nurses, Dentists and Scientists attending and the 3 course leaders were of the highest calibre.

So now I know - I am an ISTJ, knowing this is really very empowering, I know what and who I am and can now work towards strengthening my strengths and weaknesses, I can address those things I am not so good at, seek support and advice from colleagues who have a different world view and encourage and embrace diversity - I will never look at a champagne bottle in the same way ever again!!!!  Sounds all very grand, but it really is very enabling to get this view and understanding of oneself.

The course is not cheap but is worth every penny, and the lunches each day were 5*****...........many thanks to the Health Foundation who funded my place as part of the LPTR Award and provided the opportunity to spend a week at the Kings Fund.

All 30 interviews are now transcribed and I am going through them one by one.  I am listening to and editing each transcription to ensure the accuracy of transcription, to put it into the paper format that I want to work with and importantly to increase my familiarity with the data. 

I am beginning to identify early themes from each transcript, a lot of stuff around causes of depression, acceptance of the biochemical cause of depression as presented by the GP as an acceptable reason for taking antidepressants, fear of stopping antidepressants, fascinating analogies relating antidepressants to a 'crutch', a 'friend' or a 'foe' depending on their role in the illness trajectory, depression as a positive life experience, depression as the beginning of a trajectory towards dementia and/or madness, recovery models which may or may not include continued use of antidepressants.  Ideas that are beginning to emerge which I want to explore further are the need to have a physical reason for a mental illness, individuals recovery models, and constructs of self and the effect of depression and antidepressants on personal constructs.

Done!!  The 30 interviews are completed as of 12th January, a bit later than the timeline which had aimed for end October but I am there now........  A fantastic journey, and a very privileged one where interviewees have told me their very personal stories to help depression research.  The overriding wish of everyone has been that their experiences be used to try and help other people avoid going through the same horrors of depression that they have faced.  Thank you.

So what are some of my reflections on this stage of the study?

- Finding homes in remote rural Norfolk is not easy; having my SatNav was a great help, I could not have managed without it.  Even so, evening interviews were still difficult as although the SatNav got me to the right area, finding the correct house in the dark, often with no streetlights and with houses set right back off the road posed some problems; a phone call to the waiting interviewee got me there finally....

- Telephone calls are very time consuming, people are never in when you want them.  Early evening was generally the best time to speak with people and arrange the interview.

- Confirming the interview time, date and place on the day preceding the pre-arranged time was also essential, many people assumed they were coming to the surgery as that is where they would normally expect to see me if I am wearing my clinical 'hat'; this was despite being quite clear when arranging the interview that they were happy for me to go to them....

- 29 out of the 30 interviews occurred in the interviewees home, only one took place in the surgery.  However, this was fine as it occurred on a day I would not normally be in the surgery and I used a room upstairs which I would not normally use, consequently I had no interruptions.

- Interview recording was brilliant using the digital recorder, an extremely worthwhile investment.  It was so much more preferable than having to use and worry about tapes.  There was only one recording disaster when not a word was taped........ Why did it happen?  I am not sure but I suspect I must have knocked the record button as I positioned the mike.  The lesson to learn from this is to always make sure I can see the red light on the mike which confirms recording is taking place.  I wrote up the unrecorded interview as soon as I got home and made 4 pages of notes, clearly not as good as the real thing but it will do and I think I have remembered all the key aspects of the interview.

- 25 interviews have been sent to a recommended professional transcriber - my long 3 hour interview is back, she transcribed the interview in one working day, amazing as it would have taken me days and days........

- My skills as an intervieiwer have evolved, the NatCen Course has really benefitted me; I think my active listening skills and ability to probe have developed, they are certainly skills which I am aware I apply to other areas of my life too now.  Reading through the transcripts will continue my learining too.

So now onto the next stage of data analysis, I am now about to start applying Framework to the transcripts as they all become available, I think I will also enter them into N6 to help with identifying themes.  Exciting to be getting on and progressing with the next stage of the study.

 

Nearly there with the interviews, the final 2 interviews of the planned 30 are scheduled for next week.  These have taken a lot longer than I had planned for as I had hoped to complete them by the end of October originally and then by the end of December.......  Why has it taken me so long?  The work I needed to do for the Upgrade put everything else on hold without a doubt; plus the day job at the practice is very busy with all sorts of ongoing additional issues to resolve as a result of the Norfolk PCT Turnaround Plan which aims to saves £50 million by March 2008, so lots of distractions and long working days there have meant that even just arranging the interviews is not always as easy as one would think.

I have also accepted that to do all my own transcribing is unrealistic and not the best use of my time, I have transcribed 5 of my interviews myself but have arranged for a professional transcriber (recommended by one of my PhD Supervisors) to transcribe the remaining 25 interviews.  I will be sending her the interview recordings mid January when she is available to work on them, she estimates it will take her about a month to transcribe them all.  In the meantime I will work on my second literature review chapter.  Once the transcripts are back I will need to listen and go through them all as the starting point of my data analysis; a process which will take me several months.

I have got meetings set up with various researchers at UEA throughout January to liaise and network with them with a view to developing contacts for not only the present but also for a postdoc future.  End of February will see me on the Kings Fund Clinical Leadership and Management Course which is part of the Health Foundation funding; that reminds me - I need to get my report written and sent to the Health Foundation now that I have completed my first year.

Not forgetting my clinical role - I am about to embark on the Nurse Prescribing course also - distance learning at Winchester University - it has now reached the point where I cannot defer doing this any longer as my inability to prescribe is becoming very limiting to my NP role; I hope it will not be too arduous, it really should be underpinning what I already do using practice protocols/PGDs, but as always it is getting through the various hoops.