Depression in Primary Care - Story of a PhD

Australia 2009 - ICCHNR Conference

Penny Louch — Sun, 12 Jul 2009 11:35:22 +0100

At last - tickets booked! Flights confirmed and off to Adelaide for the ICCHNR Conference. My presentation is scheduled for the Wednesday and I now need to get it prepared.....most of the work is done.

Should be a great trip - 6 days in Adelaide, then off to Melbourne for the weekend and then off to Sydney for 10 days. Flight home is via Singapore with a stopover there for 3 days.........

Can't wait!!

UCL Seminar

Penny Louch — Sun, 12 Jul 2009 11:32:12 +0100

UCL lunchtime seminar last Monday - it went well I think. There was a reasonable number of people attending and they all appeared interested in the work. The post presentation discussion raised some interesting points for further thought and consideration:

- Actor network theory (Callon and Latour, 1986)
- Self - if people can cope in public, then why not continue to cope when in private?
- Restoration or Cure? What is the difference? The difference in this study appears to be antidepressants, no cure if still needing antidepressants.~
- What are the messages to clinicians from this work? An understanding of the problems some people have in stopping antidepressants after long-term use.
- Methodological questions: clarification around the inclusion and exclusion criteria; those groups not included in the interviews may have had a view to discuss; cultural issues.

Thanks to all for attending and for your feedback.

Publications

Penny Louch — Sun, 21 Jun 2009 17:05:57 +0100

Two articles published as advanced practice pieces in May editions of Practice Nurse. Good to see work undertaken in my literature review transformed into publications. Will be able to add them to my thesis appendix too.

Can I do it?

Penny Louch — Wed, 13 May 2009 13:09:21 +0100

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 Planning

Penny Louch — Wed, 06 May 2009 16:01:27 +0100

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!

Thesis Progress

Penny Louch — Wed, 06 May 2009 15:50:32 +0100

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.

Theoretical Thoughts

Penny Louch — Mon, 04 May 2009 16:02:15 +0100

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.

Chapter Colours

Penny Louch — Sun, 03 May 2009 12:40:13 +0100

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....

Australia Booked

Penny Louch — Wed, 22 Apr 2009 12:34:32 +0100

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.

Chapter(s) Away!

Penny Louch — Wed, 07 Jan 2009 22:56:40 +0000

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..........

Australia 2009

Penny Louch — Tue, 02 Dec 2008 22:36:04 +0000

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

Writing a Thesis.....

Penny Louch — Thu, 20 Nov 2008 22:00:00 +0000

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........

Health Foundation

Penny Louch — Wed, 19 Nov 2008 22:30:48 +0000

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

Penny Louch — Sat, 05 Jul 2008 23:20:33 +0100

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.

NVivo 8

Penny Louch — Tue, 01 Jul 2008 19:12:01 +0100

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.

Reflections on Framework

Penny Louch — Wed, 25 Jun 2008 21:49:58 +0100

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

June.......

Penny Louch — Sat, 21 Jun 2008 22:17:52 +0100

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.

Charting finished

Penny Louch — Wed, 21 May 2008 23:44:57 +0100

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.

Health Foundation Event

Penny Louch — Mon, 19 May 2008 20:39:31 +0100

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.

Nursing Standard

Penny Louch — Mon, 28 Apr 2008 23:37:35 +0100

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.

Liverpool Learning

Penny Louch — Sun, 27 Apr 2008 23:32:00 +0100

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

RCN Research Conference - Liverpool 2008

Penny Louch — Tue, 15 Apr 2008 20:43:56 +0100

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.

Light at the end of a tunnel

Penny Louch — Tue, 08 Apr 2008 18:38:02 +0100

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!!

New Look

Penny Louch — Sun, 30 Mar 2008 18:59:37 +0100

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........

Settling in at Brick Lane

Penny Louch — Sun, 06 Jan 2008 14:22:39 +0000

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.

Health Foundation - Extension to Award Time

Penny Louch — Sun, 21 Oct 2007 20:43:50 +0100

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.

Granada

Penny Louch — Sun, 14 Oct 2007 19:43:59 +0100

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.......

Charting

Penny Louch — Fri, 12 Oct 2007 20:17:57 +0100

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?

Data Analysis Continues

Penny Louch — Fri, 31 Aug 2007 11:22:31 +0100

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.

SAPC 2007

Penny Louch — Sun, 08 Jul 2007 22:52:41 +0100

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.

Back from the wilderness......

Penny Louch — Sun, 08 Jul 2007 20:12:51 +0100

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.....

Data Analysis Begins.....

Penny Louch — Sun, 22 Apr 2007 19:01:10 +0100

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.

An ISTJ!

Penny Louch — Tue, 06 Mar 2007 09:49:24 +0000

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.

Transcribed Interviews

Penny Louch — Tue, 06 Mar 2007 09:33:45 +0000

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.

My Reflections on 30 Interviews

Penny Louch — Sun, 21 Jan 2007 21:00:58 +0000

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.

Plans for 2007

Penny Louch — Fri, 05 Jan 2007 10:19:57 +0000

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.

Upgraded!

Penny Louch — Fri, 15 Dec 2006 09:35:26 +0000

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.

Preparing for the MPhil/PhD Upgrade

Penny Louch — Sat, 02 Dec 2006 07:57:27 +0000

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!

Deferring the Upgrade Date

Penny Louch — Sun, 29 Oct 2006 22:18:08 +0000

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.

Ramblings re. Responsibilities

Penny Louch — Fri, 06 Oct 2006 11:57:49 +0100

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...........

Transfer - Update about the Upgrade

Penny Louch — Thu, 05 Oct 2006 20:58:35 +0100

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......

Penny Louch — Tue, 26 Sep 2006 08:58:53 +0100

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........

Presentation Skills

Penny Louch — Tue, 19 Sep 2006 09:00:19 +0100

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.

Dundee 2007

Penny Louch — Tue, 08 Aug 2006 17:02:39 +0100

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......

Upgrade

Penny Louch — Tue, 08 Aug 2006 16:58:37 +0100

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 Tensions

Penny Louch — Sat, 15 Jul 2006 18:21:23 +0100

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.

Poster for the SAPC Conference 2006

Penny Louch — Sun, 09 Jul 2006 16:13:40 +0100

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.

http://www.depression-primarycare.co.uk/images/SAPC%20Depression%20Poster%207-06.pdf

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.

Questionnaire Responses - Preliminary Analysis

Penny Louch — Sat, 01 Jul 2006 15:22:13 +0100

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.

Lack of control

Loss

Self

Family

Illness trajectory

Senility, alzheimers

Inability to cope

Being incapacitated

That it may get worse

Suffering from dementia as I get older

It getting worse

Losing my mind

It will come back, perhaps worse than before

Dementia

StudioSkills - Presenting to others

Penny Louch — Mon, 26 Jun 2006 21:59:46 +0100

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.

Research Audit by R&D

Penny Louch — Thu, 22 Jun 2006 23:22:37 +0100

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.

Chinese Depression

Penny Louch — Fri, 16 Jun 2006 09:44:44 +0100

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.

Interview Issues

Penny Louch — Tue, 13 Jun 2006 23:45:27 +0100

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.

Planning for my upgrade....

Penny Louch — Sun, 04 Jun 2006 23:20:39 +0100

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.

Business Psychologist

Penny Louch — Fri, 19 May 2006 22:48:00 +0100

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

Sounds good to me!

Managing the Literature

Penny Louch — Wed, 17 May 2006 22:56:31 +0100

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.

A Lesson Learnt!

Penny Louch — Sat, 06 May 2006 10:11:38 +0100

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!

Thanks for the feedback

Penny Louch — Fri, 05 May 2006 09:35:10 +0100

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".

What a simple suggestion, excellent! Thanks.

Research Conference - York 2006

Penny Louch — Sun, 26 Mar 2006 11:20:36 +0100

A great week at York, good not only to meet up with a few familiar faces from last year but also to meet new people; other people working in Primary Care, other people doing part-time PhDs, and finally to put faces to names of people from the Primary Care Nursing Research Unit at UCL. As much as I value the concurrent sessions, workshops, symposia etc, for me the greatest asset of the week is to meet and share ideas, problems, solutions with colleagues especially as I am fairly isolated here in Norfolk and UCL is in London! There was one name on the delegate list of a nurse from Norwich who is doing a PhD.......I will endeavour to make contact as it will be good local peer support with a like-minded person.

Talking to one colleague has made me realise that it is unrealistic to try and do everything myself, so my ideals have been put to one side and I accept the reality of finding someone to transcribe my interviews; the time freed up will allow me to try and get some of the reading and writing that I need to do done!

Next year is at Dundee - no excuses not to submit an abstract or two this time!!

Contacting Respondents

Penny Louch — Wed, 08 Mar 2006 23:14:46 +0000

Contacting the questionnaire respondents who are willing to be interviewed is a task which extends beyond my availability of time. For every person who I have made contact with there seems to be two people who are not in. Many are repeatedly not in within the normal working day, they need to be rung early evening when they get home from work. This creates a host of new issues, at the end of my day at the surgery I seem to fail to have the energy and will to start telephoning people, yet it needs to be done. Ringing respondents/patients from home does not seem right for a variety of reasons - ringing patients is what you do from the surgery, providing access to my home number by dialling 1471 etc. also makes me feel uneasy........but I need to contact these people in response to their willingness to be interviewed.......and this is the just the shortlisted group of 46 from whom I need to select my 30 interviews. What about the other 131 who are willing to be interviewed but who I do not need to interview? To telephone all this group is an unmanageable task, so we (PhD supervisors and I) have agreed to send them a postcard in an envelope thanking them etc. This has now become something achievable - I have had postcards printed and put a suitable message on the back and they were posted today. Hopefully, the recipients will find the postcard not only an agreeable form of contact but also an appreciation of their participation in the study.

Feedback from patients and interviewees has been incredibly supportive; there seems to be a universal view that it is research which is really worthwhile, that it is research into an area of health that perhaps has not been high profile, an area that is distressing for individuals to talk about but at the same time has a cathartic effect once they have.

Interviews Commence

Penny Louch — Tue, 28 Feb 2006 17:13:55 +0000

First interview done! It went reasonably well I think, not sure that I probed enough but the interview did last 58 minutes and 3 seconds and there was certainly breadth if not as much depth as I should have got out of it. My new digital recorder is dead neat - very easy to operate, my interviewee could easily have stopped the recording at any time if necessary, it is also quite a small gadget so sat discreetly on the side and was therefore relatively easy to forget about which is always a positive. The other advantage of having a digital recorder means no messing with audio tapes, and I can save the recording onto my laptop which is much more secure. So now onto the transcribing........

Several other interviews are now arranged, but the whole process to achieve 30 interviews will definitely take until October 2006. Trying to contact people by telephone is a lengthy task as so many people are not available and need to be contacted early evening I suspect. Those people who I have spoken to are all amazingly supportive and keen to take part which is wonderful. Nice to think the study is perceived as worthwhile.

Website Creation

Penny Louch — Fri, 24 Feb 2006 23:47:50 +0000

The website is coming along - FrontPage 2003 is excellent, and the book 'FrontPage 2003 in Easy Steps' is wonderful - it does make it all so easy! I have run through the tutorial and my colour scheme and format is now sorted - all very important!! Now 'just' the content to sort - not quite so easy, I plan to use Kipling's quote regarding his 6 honest serving-men - what, why, when, how, where and who - to provide the format.

The next 2-3 weeks will be spent getting the structure and content of the website correct. The logo links are defined, and I am now able to create PDF documents of relevant patient and clinical information which I will be able to attach to the website and which needs to be disseminated to the wider audience. I am aiming for mid-March - watch this space...................

Getting Ready to Interview

Penny Louch — Fri, 24 Feb 2006 23:34:06 +0000

My first interview is arranged, next week - exciting but daunting to be moving on to the next stage of the study - how will I do, will I probe enough, will I 'actively 'listen' - I know what I need to do but can I do it? It does all feel like a huge responsibility - this is real time research with real people with real problems, no longer the realms of theoretical possibilities.......I owe these respondents who are willing to expose their thoughts and feelings.........I need to listen, to understand and to tell a story from what they all tell me, it can make a difference.

The questionnaires have been a valuable tool to define a target population from whom I can select my 30 interviewees. Everyone who expressed a view about their medication has been included in the interview sample; those respondents who indicated they did not wish to proceed to interview were excluded, and my final interview target population equals 47. Finally, once this stage of the data analysis was complete I then revealed the identity of my target population to myself - their numbers became names.

PhD to date

Penny Louch — Fri, 10 Feb 2006 23:46:35 +0000

I started my PhD in Primary Care at UCL, Dept. Primary Care & Population Sciences (PCPS), in April 2005. This is a part-time PhD as I also have a full-time clinical and management role as a Nurse Practitioner/Nurse Lead/Management Team member back in a general practice in Norfolk. My PhD research topic is the fears and concerns patients have when the time comes to stop their antidepressant medication. This research topic evolved from findings generated by my MSc Primary Care dissertation, also undertaken at UCL; the innovative web-based distance learning MSc organised by Trish Greenhalgh and her colleagues at PCPS, UCL.

By the time I came to register and start my PhD I was fortunate to have not only identified my research topic but also to have written the research protocol; this was because I had put in a submission for one of the Health Foundation 'Leading Practice Through Research' (LPTR) Awards in January 2005. This was a rigorous peer reviewed process, but in June 2005 I was informed that I was one of nine successful Award winners, all that effort had been worthwhile!. The LPTR Award provides me with significant research funding for 2 years; the aim of the LPTR Awards is to develop the leaders of the future. The Award explicitly does not fund PhDs, but clearly some of the costs involved in the PhD over the next 2 years will fall within the remit of this Award.

The LPTR Award was confirmed June 2005, it was time then to get the COREC and research governance applications sorted. They were submitted in August and approval granted at the beginning of November 2005, all in all not too bad!! The weekend that followed was hectic; 572 questionnaires, patient information sheets, consent forms, decline forms and SAEs were printed, collated, enveloped and stamped - this was a team effort - the family had little choice as until all was done they couldn't eat as the breakfast room table was covered in paper! The poor printer suffered too - it was making a very strange noise by the end of Sunday, fortunately a rest and period of light work has seen a full recovery!

So, 572 questionnaires were duly posted to all patients in the practice who were prescribed either an SSRI or TCA antidepressant. Kleinman's Explanatory Model Theory is my theoretical framework, the objectives being to identify patients' models of illness and recovery in order to understand their fears and concerns about stopping antidepressants within the context of their illness. I am using N6 (formerly called NUD*IST) to analyse the 201 returned questionnaires. The analysis will help identify the interview sample for the next stage of this study, the purposive sample of 30 in-depth interviews aims to explore the research topic in-depth.

Where am I at now? I think I have finally got to grips with N6 (never having used a CAQDAS package before) and am busy coding my questionnaire data. I am applying various coding approaches: the data from the questionnaires is being coded demographically; by question number; by Kleinman's 'Five Parts of an Illness Experience'; and also by themes that I am able to pull out from the data. I have a deadline, always guaranteed to clear the head and focus the mind! Tuesday I meet with my supervisors...........the weekend is going to be busy!

Why have a website?

Penny Louch — Fri, 10 Feb 2006 09:23:32 +0000

The idea for a website originated back last December and it is only now that I have had the time to move the idea forward. The Health Foundation organised a one day event 'Building Influence - How to influence more effectively in the health service' for all their Award holders. Everyone had to identify one thing that they would take away with them from the day - mine was the idea of having my own website where I could document not only my research but also the changes in clinical practice within my place of work that have resulted.

The website currently has a holding page but will hopefully become live very soon........I am awaiting delivery of my Frontpage 2003 CD, brand new, bargain price, off eBay! A recommended book 'Frontpage Made Easy' should also be winging its way here from Amazon - how did I ever manage shopping pre-internet! A whole new exciting challenge lies ahead - website design - I could get someone else to do it, but no fun in that. My basic grasp of HTML (plus the help of another excellent little book - 'HTML in 10 minutes') has enabled me to make some adaptations to both my blog and the website holding page, of which I'm very proud!

So, apart from learning something new, the website aims to be a useful resource to provide an additional and alternative way of disseminating information about depression in primary care.

Getting started!

Penny Louch — Tue, 07 Feb 2006 19:06:28 +0000

Well, with some considerable time and effort I have finally got the blog up and running, but still cannot change the colour!! This blog will be linked to my website which has yet to developed although I have just secured my own domain name, http://www.depression-primarycare.co.uk. I plan to use the blog as an on-line journal to chart the ups and downs of my PhD. For those of you who access this site I hope you find it interesting and possibly some of my experiences may reflect your own. Any feedback would be great.