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 2007 SAPC Annual Conference held at Kensington Town Hall was once again a great opportunity to meet up with with colleagues old and new. My presentation slot was scheduled for the first afternoon on Wednesday; it was good to get it done. It went well and stopping antidepressant medication seems to be a topic of interest to others as well as to me..... A copy of the presentation can be found on my website in the research outputs section.
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.
Done.....the upgrade went well, the presentation and the timing worked, and feedback from both reviewers was excellent. So although a bit stressful it was a really worthwhile occasion.
Useful aspects of the feedback were to confirm that my work to date is good enough to continue as a PhD (great relief!); but also that I need to broaden my perspectives within the literature review even further to include more of the lay literature on depression. Looking back now on my first draft literature review chapter makes me realise how far my knowledge and thinking has expanded in only a few months, that first attempt was very narrow in perspective and essentially 100% biomedical. It has made me understand how easy it is to become very narrow in ones perspectives when working within a particular clinical/professional area.
What now? Well, I think the suggestion of one of the reviewers to have a second literature review chapter dedicated to illness/disease/sickness, with the first literature review chapter looking at depression and treatments, is an excellent idea which will help to encompass much of the folklore/lay literature on illness etc. So am now off to review that part of the literature and sort out the chapters.
Chapters written, transfer report completed and presentation almost there; the end is in sight, just the hurdle of the Upgrade to get through. It is now the end of many weeks of intense work, every spare waking moment spent searching, reading, writing, tweaking to produce the literature review and methodology chapters. The past 10 days have been spent preparing the PowerPoint presentation - trying to locate the raw data in order to create accurate pie charts, bar graphs etc. It is amazing how badly some of the data in papers and reports is referenced, "where did they get that from!!"; so easy to quote percentages but to transpose them into a pictorial image has been a different story. A useful exercise though as I have found a huge amount of original data - especially on the WHO site, WHO Statistics 2006, the 2001 Mental Health Report contains lots of data on DALYs. Prescription data and costs by BNF categories can be found on the DH website.
The other key tools I have really learnt how to use more efficiently is Web of Science and Reference Manager - two powerful tools which make my life so much easier; I have learnt to ensure I import every reference WITH its abstract into Reference Manager, and the link to the site goes too; I can then search within Reference Manager to find relevant references and as long as I am logged into UCL with my Athens code I can then link straight back to the article; so much easier than scrabbling around looking for the paper.......the one which is never there when you want it!
Not possible.....too much to do and not enough time to do it justice, the upgrade date has been deferred from16th November to 4 December; it will still be tight to get everything done but should be possible. The literature needs lots more work, needs to be more balanced, still too biomedical in approach.......all going well though. Trouble is that I cannot work on the chapters and get interviews done too so all a bit slow on the interview front at present.
Reflecting on the interviews I have undertaken to date has made me increasingly aware of my responsibilities within the interview. Responsibility lies both to the participant and their well being, and also to the data and what I do with it through the analytic process, and also ultimately to myself and my well-being.
The standard mantra is that interviewing is a process of data generation rather than simply data gathering, true but not quite so simplistic. The interaction between interviewer and interviewee creates a number of outputs: new insights and perspectives for both parties; new knowledge; a memory long since forgotten; links between memories creating a new previously unthought of connection. The list of possibilities goes on; and what of my input? Is the interview one person's story or is it an interaction between two people? If I am asked for an answer to a question, do I decline or is it in fact part of the interview process that adds to the data generation, making facts meet in a logical and sensible way? If I expect them to 'expose' themselves within an interview, is it not a 2 way process to a certain degree where I have a responsibility to feed back to them too, is it just 'take' or is it 'give and take'?
Probing in the interview - some areas of the participants stories are traumatic, often to do with childhood abuse, certainly a cause defined by them for their depression and as the interview progresses and as trust and comfort with the process increases, interviewees often tell much in detail. What is my role? - I think to listen and let them tell their story, surely to probe too much into traumatic life stories borders on the voyeuristic as is the detail relevant to the research question, no I do not think so. However, having got the participant to a place to tell their story, I must allow them to tell their story, to cut them short or tell them that part of their story is irrelevant is surely irresponsible and will damage the interviewer-interviewee relationship if nothing else.
What do I leave the participant with? Has it been a good experience to retell their story? Has it churned up old memories? In the aftermath of the interview, was it worthwhile for them? My immediate response is that yes I think it is from their responses at the end of the interview; many people underestimate their depression experience; comments such as 'I hope there was something useful in there that will help', 'I hope I haven't wasted your time', or 'I had forgotten lot's of that' are frequently said. So, yes, in the immediate period after the interview, participants seem to be grateful for having the opportunity of talking about their depression; does that feeling stay or change as they have more time to reflect upon what they have said and possibly my responses to them?
The data - what I do with that, how I tell their stories and make my story, my report, my thesis is so important - all this time and effort - a huge responsibility to ensure I do the participants and the data justice.
In-depth interviews - run of the mill qualitative stuff, or is it? Something to think about; something to look into, to see what research has been done about the impact of interviewing on the participants...........
It's a bit like having a baby! The due date has arrived, and only 2 days overdue..... Sounds a bit dramatic but that was what it felt like Tuesday evening when the last document was emailed to my PhD Supervisors, there is life beyond the 2nd October (or 4th October as it happened)!!
The 2 chapters winged their virtual way Sunday night but there was still the transfer report to go......difficult to do, probably not helped by feeling pressured by time and although I have really enjoyed writing the draft chapters it is still tiring and I was left feeling fairly drained, so to then have to write the transfer report was 'hard'. However, it is done now and what a relief - until next week when I get the feedback, but that's another day.
For now - back to doing more interviews, and of course there is always the transcribing............
Time? Where does it go? I know doing a part-time PhD is never easy so I am not complaining, but time is so limited. Reading and writing.......that's several more hours gone by; a quick bit of research, finding out about that 'fact' that may have relevance to the work, tracking down and looking up that reference - why does it take so long? Do I just get side tracked, but all that other stuff is so interesting too and I am sure adds to the breadth of knowledge even if a bit irrelevant for that precise moment in time! The most difficult aspect though is getting immersed in the work, the mindset, the thinking and then next day going back to my clinical role and having to 'lose' my place.....it then takes more time to get back to where I was and be able to carry on constructively, 3 steps forward and 2 steps back sometimes but progress nevertheless. So time is of the essence, that methodology chapter awaits but time doesn't, I'm off........
So.....an opportunity to practise those skills I learnt on the Presentation Skills course back in June. I have been asked to do a short presentation at the BA Festival of Science here in Norwich, the session is about research which is going on in the community and involves the public.
Midweek, mid-morning, early September, in a venue in the middle of Norwich; a reasonable turnout of approximately 50 people, a mix of academics, PCT R&D, local researchers and members of the public. My 5 minute slot was mid session, amazingly I felt reasonably calm; I remembered my lessons about how to stand i.e. not to wobble on intertwined legs in a nervous sort of way! I had to hold a mike which helped to occupy my hands and I talked.......I had no PowerPoint other than some background images so it was just down to me, I told the story of what my depression research is about and how it involves the patients plus a brief feedback on some of the preliminary findings from the questionnaire analysis. Questions flowed, people seemed interested; there was also an opportunity for continued discussion at the coffee break and I had a fascinating conversation with a very knowledgeable gentleman who gave me some valuable information about a piece of work recently published on the SSRIs and the usefulness of the free online journal PLoS Medicine (I have now signed up for my e-alerts!). I found it very reassuring to think that the research is considered to be of value by colleagues and depression sufferers as well as being an academic exercise to achieve a PhD; after all, I think research's foremost aim should be of clinical benefit.
As a result of that presentation I have now been asked to go along to PPIRes in mid-October to give the presentation again, this time though I will have a slightly longer slot. Great news, means more practise for my presentation skills and also dissemination of the research.
The abstract is written and has been submitted on-line for the RCN International Nurse Conference in Dundee; the paper/poster will present the results of the early analysis of the questionnaire responses as outlined in the blog entry for 1st July. I will know by the 21st November whether I have been successful or not......
The date and time for my MPhil/PhD upgrade are fixed for Thursday 16th November at 1pm and the invited guest list is agreed.
My timetable is also planned, I need to write 2 chapters - literature review and methodology, map out the remainder of the PhD, draw a gantt chart, and write a transfer report. All sounds easy, but is rather daunting.......the time will slip by all too quickly and I am still trying to get my interviews done and transcribe the recordings as well.
I am currently revisiting the literature review I wrote for the research proposal; the structure of the chapter needs to start with breadth and explore the relevant literature on depression and antidepressants, and then to narrow the focus in a logical way to provide the necessary depth and insight into the research question.
My methodology chapter (as I understand it) will need to identify my chosen research methods and methodology based on the chosen theoretical framework; discussion will need to focus on reasons for choosing Kleinman and for not selecting alternative frameworks.
All to be done and emailed to my PhD Supervisors by the 2nd October in preparation for my next supervision on the 10th October.
Transcribing is not progressing at present due to time and work pressures; I have transcribed 2 + interviews but none recently. I discussed this at my supervision session this week and we agreed upon the following principles:
Transcribing needs to be undertaken as an ongoing process alongside the interviews as this will identify any new areas to be pursued in future interviews.
Transcribing my interviews will also enhance my interviewing skills by identifying what I do well, not so well and what I could do better.
I feel strongly that I should do the transcribing for a variety of reasons: - I have told my interviewees that I will transcribe the interviews. - The process of transcribing starts the familiarisation with the interview data process. - I can learn about my interview technique from listening and transcribing.
However, if the transcribing does become too burdensome then I will need to use a professional transcriber for some of the interview recordings. I consequently need re-prioritise my current workload and start getting on with transcribing, something I can do in the evenings as it is a task I can pick up easily and stop etc.
I designed a poster for the 2006 Keele SAPC Conference based on the preliminary analysis of the questionnaire responses. I was reasonably happy with the final product and thought it was quite a big poster.......I used the UCL square poster format....but the posters on display at Keele were probably twice the height of mine.....a lesson for next time I make a poster, it could be bigger.
The most interesting aspect of making the poster was incorporating an image to lighten the text; I decided to use the Chinese characters for depression which I had originally seen on the paper on culture and depression by Kleinman. I displayed the characters separately in order to show how they combine to make 'depression' i.e. worried + melancholy + illness/disease (disability) = depression.
The discussions I had with colleagues at the conference were about the use of the characters which was interesting to order my thoughts and consider how western medicine tends to increasingly label patients who present with single entities of this equation as depressed, but in fact they may be presenting with a normal response to a life event; or have a persona which tends to melancholia more than explicit happiness...... Certainly an area which will need to be discussed within the thesis.
I did not get the opportunity to discuss the use of Kleinman or the EM framework with colleagues; however I will submit the poster to appropriate conferences next year and may be able to find someone else who has used Kleinman as their theoretical framework for a research study.
The demographic data and the responses to the 8 questions in the short-answer questionnaire sent to 572 patients taking an SSRI or TCA antidepressant for at least 6 months was eneterd into the qualitative data analysis software programme, N6 (the programme formerly known as NUD*IST). I have undertaken a preliminary analysis of the responses and identified some initial themes which were used to present early data findings at the SAPC Annual Conference, Keele 2006, via a poster.
The phrases highlighted in bold are the themes that are beginning to be evident within the data and are accompanied by summarised respondents' comments.
Meaning of depression to patient
If I mention depression, people look down on me, treat me like a second class citizen.
Paradox of Medication
I have found the medication has helped me to recover.
I could not face work; I could not bother to cook, I cried until I had tablets.
With medication it is now controlled, but the course has been almost life-long, with peaks and troughs.
Would like to talk to someone about my fears.
Antidepressant is only a crutch - not a solution.
Without medication I could not lead a fairly normal life.
I am happy with the medication I am taking at present and pleased that my Doctor recommends it continue.
Coping without medication.
Fear about illness (depression)
I don't want to take medication forever.
If my medication is stopped.
The idea that I am perhaps very inadequate in not being able to cope and having to take an antidepressant.
That I will have to stay on medication for life. I don't want to come off them this time, not yet.
Scared to stop taking the tablets.
At the time, it is easy to fear that you will never feel 'normal' again and that your life will never recover its balance.
When feeling 'normal' you fear a return to depression, at times of low mood.
That I will be unable to cope if I were to come off medication.
Coming off medication and ending up at square one.
The possibility of stopping medication.
Recurrence.
The stigma of mental illness because you are judged
Hopes about illness
To eventually come off medication and cope on my own.
Come to terms with what caused the depression in the first place.
Locus of control
I do not fear it. I have got used to it and it can be controlled with medication.
If I don't work hard at my CBT and take my medication it can last a very long time.
Going mad, taking my own life.
I have got used to it, it can be controlled by medication.
I fear losing control of my emotions and being hospitalised.
The Health Foundation funding includes training for presentation skills; I accessed the first of these sessions mid-June. The session was delivered as a small group session with an excellent facilitator. It was a tiring and adrenaline filled day but extremely informative - its value (as seen as improvement in my presentation skills) remains to be revealed. With little ado we were all very quickly having to stand up in front of the rest of the group and present ourselves to the other group members - this was the opening for initial comments on our body language and style etc. Instruction and practise followed all day with a clear improvement in the presentation skills of all those present.
Not only did I learn about how I should stand in front of an audience but also several key factors to try and remember about what to do and what NOT to do! Practise, practise, practise is the key - PowerPoint use should be minimal and should only back up the presentation and not be the presentation. Tools on how to structure the presentation are fundamental - a beginning, middle, end - with the middle structured in 3 parts; this format underpins the presentation so that it is logical and the structure should help me as presenter to always be able to keep the presentation on track.
Once I have gained some presentation experience I will access the follow-up course to develop my presentation skills further.
10% of all NHS research projects need to be audited as part of the DoH's Research Governance Framework; Norwich PCT is responsible for all research projects conducted within the East Norfolk and Waveney Research Consortium. My study was selected at random from all potentially auditable projects (apparently not many are suitable for audit due to the nature of the study, the location the study etc).
So what did the audit involve?
* all files held by R&D reviewed * meeting with Chief Investigator i.e. me * review of all my study documentation
.........and the audit findings?
* CI well organised and available to answer any questions from the auditor throughout the audit * all study documentation available and appropriate i.e. correct versions in use. * minor amendment to the study implemented without informing R&D (interestingly ethics do not need to be informed of minor amendments). * consent forms scanned and filed in patients medical records but lack of obvious clarity as to what the consent form related to. * some patients who were initially contacted were not on their TCA for depression and this required individual follow-up to address patient concerns about being labelled as having depression, it was really very emotive for some people. * training and supervision appropriate for the level of the study. * steering group meetings not happening but have been replaced with a quarterly newsletter, feedback to the clinical meetings, and my website which contains study updates. * lone working policy being adhered to satisfactorily. * storage is at my home so not reviewed; but confirmed that all computer records are password protected and all paperwork stored in a locked filing cabinet.
The audit recommendations?
* details of minor amendments sent to R&D for their files - done. * subject notes have further entry made to provide clarity that the subject has participated in this research on depression - in progress. * in any future study attempts should be made to eliminate any patient who might be on a medication for a reason other than the one under study; additionally the patient information sheet should include more detail to alleviate people's anxiety when asked to participate in the study.
Overall feedback indicates the audit went very well, no major findings/concerns arose and R&D generally happy with the way the study is being run. I need to confirm that I have actioned the minor recommendations. There is no need for any formal feedback process/further meeting to take place.
How did I find the process?
* threatening - this was an unexpected and interesting response, but having someone else go through all my documentation, and analyse the process of the study to date was quite stressful. * it was useful to pull everything together and look at it as a complete package. * reassuring in the aftermath (once report received!) that no major problems and an external audit process has reported favourably. * worthwhile too I think as I had to summarise what I am doing, and justify my actions. It also made me appreciate the input and support from the practice and from my supervisors.
You may wonder why Chinese depression? Kleinman, on his paper entitled 'Culture and Depression', uses an image which is the 3 Chinese symbols for depression. This intrigued me, more I think because there is very little imagery that can be associated with depression that is not stereotypical.
Knowing nothing about the Chinese language I researched further and found a website called www.chinese-tools.com and searched for depression in the Chinese-English dictionary. Depression (in psychological terms) consists of the 3 symbols that Kleinman had used as the image on his aforementioned paper. Each symbol has a meaning in its own right and together they form the construct of depression
The 3 symbols used by the Chinese to explain depression as an illness are 'you yu zheng.'
you = worried
yu = melancholy
zheng = illness / disease
you yu zheng = depression
Each symbol is an aspect of depression but it is only when you have the constructs of 'worried', together with 'melancholy' and illness / disease that you than get 'depression'. Within Chinese culture worry on its own, or melancholy alone do not make depression - it is a combination of these emotional experiences that create depression. I wonder how often in modern day western life worry or melancholy alone are assumed to be depression? If they are, is it important? Perhaps - if we then are guilty of medicalising the normal range of everyday life experiences .
Create an illness, the consequence of that means there must be a cure; if there is no cure then a cure needs to be found.......or invent a cure, then create the illness/disease......chicken and egg........big pharmas and the medicalisation of normality, is it healthy? This could be a whole new PhD!
The dictionary definitions of each of the terms is also of interest:
Worried: WordWeb 2006 1. Afflicted with or marked by anxious uneasiness or trouble or grief Oxford Dictionary 1998 1. Anxious or disturbed tranquility. 2. Disturbed state of mind, anxiety. Nuttall's Dictionary 1905 1. Harrassed; fatigued
Melancholy: WordWeb 2006 1. A feeling of thoughtful sadness 2. A constitutional tendency to be gloomy and depressed 3. A humor that was once believed to be secreted by the kidneys or spleen and to cause sadness and melancholy. Oxford Dictionary 1998 1. Pensive sadness; mental depression; habitual or constitutional tendency to this. 2. Sad, gloomy. Nuttall's Dictionary 1905 1. A diseased state of the mind, characterised by great depression and gloomy apprehensions, so called as presumed to be due to an excess of black bile. 2. A gloomy state of mind. 3. Depression of spirits.
Illness: WordWeb 2006 1. Impairment of normal physiological function affecting part or all of an organism Oxford Dictionary 1998 1. Ill health, state of being ill. 2. Disease. Nuttall's Dictionary 1905 1. The state of being ill; indisposition; sickness; moral perversity.
Disease: WordWeb 2006 1. An impairment of health or a condition of abnormal functioning Oxford Dictionary 1998 1. Unhealthy condition of body or mind. 2. Illness, sickness; particular kind of this with special symptoms or location. Nuttall's Dictionary 1905 1. Derangement in the structure or the function of any organ belonging to a vegetable, an animal, or a spiritual organism, or to any organised body such as a state.
Depression: WordWeb 2006 1. A mental state characterized by a pessimistic sense of inadequacy and a despondent lack of activity 2. Sad feelings of gloom and inadequacy 3. A state of depression and anhedonia so severe as to require clinical intervention. Oxford Dictionary 1998 1. State of extreme dejection, often with physical symptoms. Nuttall's Dictionary 1905 1. State of being depressed; a low state 2. A sinking of the spirits.
Several key things have become apparent over the past few interviews. I have now learnt not to turn the audio recorder off as soon as I have thanked my interviewee for participating and sharing their story about depression; it seems that every time, as I stress the confidentiality aspects and anonymity of the data, they seem to then go on and continue to talk about their depression experience and if I turn the audio recorder off too soon then that data is lost. I now turn the recorder off at the very last minute so as not to lose any valuable data; once the interviewee starts to talk and share their story they seem to want to continue and think of more things to say. I do make it clear to the interviewee that I am now turning the recorder off so they do know they have been recorded at all times. I also always inform them again at the end of the interview that they can listen to the recording, I also ask them to confirm they are happy for me to transcribe the recording in full.
The interviewees clearly prepare themselves for their interview - they consider their explanation of what caused their depression, what it means to them and the effect it has (has had) on them; my awareness of this fact has made me realise the importance of my obligation to the interviewee to ensure the interview continues as planned i.e. the day as prearranged etc. as they have clearly prepared themselves for it and it is not an arrangement that can be lightly changed for convenience.
Therapeutic talking about life issues as the cause of depression was clearly demonstrated in a recent interview - the interviewee clearly linked life events to past and current depression but I was unable to perpetuate any conversation of depth or length about depression per se. The interviewee had a need to talk about events, family, colleagues/neighbours and was impossible to deviate from that line of conversation. To abruptly curtail the discussion would (I felt) have been discourteous and neglectful of the need to talk.......so could I have managed the interview differently? I really do not know, but I think not. I need to reflect upon how I can manage a long interview (3 hours) in the future in a different way; perhaps I should simply accept that within my role as researcher I have been able to provide a respondent with the opportunity to share feelings and experiences that are clearly not normally discussed in open forum? Does my responsibility as researcher extend beyond the role of data collection? I think it probably does as the interviewee knows me as clinician as well as a researcher.
My MPhil/PhD upgrade is planned for mid-Novemebr 2006, probably 16th. November but the exact date is still to be confirmed. Potential people to be invited to the upgrade seminar have been identified and need to be approached; the plan is to present to, and elicit feedback from, people with a nursing background, mental health background and possibily a medical anthropology background.
What do I need to do? I need to write 2 thesis chapters, the theoretical framework chapter and the methodology chapter; to present a plan for the PhD and a gantt chart of anticipated progress.
As part of the Health Foundation LPTR Award I am entitled to a session with a Leadership Development Consultant (business psychologist) in order to help identify my leadership development needs.The purpose of the session is to discuss leadership development in the context of my career, to identify appropriate activities/support for that development and to agree a time frame for starting the development.
I met up with my designated Leadership Development Consultant at the Health Foundation offices in Convent Garden last Tuesday. It was a useful session which took me back over my career pathway to date and identified my anticipated career trajectory to 5 years hence; it was also reassuring to have my choice of previously identified leadership development course (selected as part of the LPTR Award application process) confirmed as the best choice to meet my leadership development needs. Within the session we identified where I am at now in 2006 and where I want to be in my career in 2011:
2006 'Now'
Nurse Practitioner and Nurse Lead for a Nurse-led Surgery Memebr of Practice Management Team Manage the Nurse Dept. PhD Student
2007
LPTR Award finishes at the end of the year Kings Fund Managment and Leadership for Clinicians Course
2008
One-to-one mentoring to improve my networking skills
2010
Finish my PhD
2011 'Where I Want To Be'
Busy Content Balance working as a member of both an academic and a clinical team Living in Norfolk Develop what I do with UEA & the PCT Working in a Dept. Primary Care Working as an NP in primary care
One year into the PhD and I finally feel that I am getting a grip on the literature. I have read papers, filed them in organised, labelled box files and then have either forgotten them or, at best, had a vague memory of their content. I have been aware that other people have a 'system' for managing their literature but, for whatever reason, I have not quite been able to achieve my own 'system'...until now.
One of my outcomes from my supervision meeting earlier in the year was to draw up a grid of all the work by Kleinman and also all the work I could find on Explanatory Model Theory. I have spent the past few weeks doing just that - I have set up an Excel spreadsheet within which I have several worksheets, each worksheet has a separate heading e.g. Kleinman, illness/disease, methodology, explanatory model theory etc. This process has revolutionised how I am now managing my literature and has set up a system that is not only useful for now but is adaptable and can be built upon as the PhD progresses.
I now consider that I have started to achieve what I thought I wanted to achieve way back last summer when I attended a PhD RCN day in Swansea. I came away from the day enthused, and had a desire to set up some sort of logical system for managing the relevant literature so that I could not only build upon it but also access it easily and meaningfully. For several months I held that thought and did not really have the time or impetus to move forward with it. However, the supervision process identified this as something I needed to do, it also coincided with my own awareness that I needed to somehow find time to read and document a summary of the papers I was reading in such a way as to make the reading of the literature a useful and valuable exercise. I thought of using Reference Manager as a way of documenting a paper's key content, but then the question was one of how would I be able to access all relevant literature easily? Answer - to set up an Excel literature grid; this works well thus far. I can, of course, add to it and adapt it as my needs and knowledge broaden.
Could I, should I, have started this process earlier? I don't know really, I think probably not. I think the fact I now 'need' to set up a system has helped me to define what it is I want, and how I want the information to be presented. Certainly, revisiting some of the earlier papers I have amassed and rereading them has been enlightening; I have an understanding that I did not have a year ago simply because I now have a greater knowledge of the subject area.
The answer, I guess, is that there is no correct answer; it is whatever is right for the individual.........I would say that the process of learning about how to manage the literature accompanied by the need to manage it has been a worthwhile exercise and has helped defined what is useful for me.
Never assume anything! The 3 interviews that I have undertaken over the past couple of weeks were arranged a few weeks back when I made my initial telephone calls to the interview sample population. At that time I confirmed with each prospective interviewee the day, date and time of the planned interview and confirmed with each one that they were happy for me to visit them at home (rather than them coming to the surgery).
I decided that as a few weeks had passed since the initial arrangements were made that I ought to contact them to reconfirm the arrangements. Each one, without exception, was expecting to attend at the surgery - I guess that is where they always see me! Once explained that I was willing and would like to undertake the interview in the home, they were very happy for this to occur.
For me, the moral of this story is do not assume anything, irrespective of how well you think someone has taken on board the details of the prospective arrangement. I will be contacting each and everyone in future prior to going along to interview them to ensure our paths do not cross as I head towards their home and they head in the opposite direction to the surgery!
Feedback is really helpful, so anyone reading this blog who has any helpful suggestions or insights please do not hesitate to email me or post a comment. A colleague who recently looked at my blog has come up with a brilliant suggestion regarding the contacting of respondents. He said:
"If you have not found a solution to your phone problem I strongly suggest what we did. Although we already established a dedicated BT phone line for the research it is no longer terribly useful. Use some of the Health Foundation money to buy a dedicated mobile. Then wherever you are and whatever you are doing it controls the access that your clients/participants have. If they need to cancel the appointment with you - they can with no hassle of GP receptionists. 1471 does not matter. All the related expenses are easily tracked. etc etc".
you = worried
yu = melancholy
zheng = illness / disease
you yu zheng = depression
