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ABSTRACT: The development of a high-quality primary healthcare system requires multidisciplinary perspectives and collaborations between clinicians and non-clinicians. Academic primary care departments across the United Kingdom and Ireland employ academics from a range of disciplines. However, questions remain about the parity of opportunity for career progression with a consistent trend to focus more on clinicians than non-clinicians. In this paper, we analyse the employment and careers of non-clinical primary care academics working in Ireland and Scotland. We draw on survey data from the island of Ireland and conference workshop discussions among Irish- and Scottish-based academics. We highlight problems with career progression and identify some strategic actions. We argue for a renewed attempt to ensure that all academics who are contributing to the discipline of primary care are appropriately acknowledged and supported to continue their endeavours to develop high-quality primary care health systems.
Primary Health Care Research & Development 02/2013;
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ABSTRACT: Modernization policies in primary care, such as the introduction of out-of-hours general practice cooperatives, signify a marked departure from many service users' traditional experiences of continuity of care. We report on a case study of accounts of service users with chronic conditions and their caregivers of continuity of care in an out-of-hours general practice cooperative in Ireland. Using Strauss and colleagues' Chronic Illness Trajectory Framework, we explored users' and caregivers' experiences of continuity in this context. Whereas those dealing with "routine trajectories" were largely satisfied with their experiences, those dealing with "problematic trajectories" (characterized by the presence of, for example, multimorbidity and complex care regimes) had considerable concerns about continuity of experiences in this service. Results highlight that modernization policies that have given rise to out-of-hours cooperatives have had a differential impact on service users with chronic conditions and their caregivers, with serious consequences for those who have "problematic" trajectories.
Qualitative Health Research 12/2012; · 2.19 Impact Factor
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ABSTRACT: Implementation researchers have attempted to overcome the research-practice gap in e-health by developing tools that summarize and synthesize research evidence of factors that impede or facilitate implementation of innovation in healthcare settings. The e-Health Implementation Toolkit (e-HIT) is an example of such a tool that was designed within the context of the United Kingdom National Health Service to promote implementation of e-health services. Its utility in international settings is unknown.
We conducted a qualitative evaluation of the e-HIT in use across four countries--Finland, Norway, Scotland, and Sweden. Data were generated using a combination of interview approaches (n = 22) to document e-HIT users' experiences of the tool to guide decision making about the selection of e-health pilot services and to monitor their progress over time.
e-HIT users evaluated the tool positively in terms of its scope to organize and enhance their critical thinking about their implementation work and, importantly, to facilitate discussion between those involved in that work. It was easy to use in either its paper- or web-based format, and its visual elements were positively received. There were some minor criticisms of the e-HIT with some suggestions for content changes and comments about its design as a generic tool (rather than specific to sites and e-health services). However, overall, e-HIT users considered it to be a highly workable tool that they found useful, which they would use again, and which they would recommend to other e-health implementers.
The use of the e-HIT is feasible and acceptable in a range of international contexts by a range of professionals for a range of different e-health systems.
Implementation Science 11/2011; 6:122. · 3.10 Impact Factor
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ABSTRACT: Normalization Process Theory (NPT) can be used to explain implementation processes in health care relating to new technologies and complex interventions. This paper describes the processes by which we developed a simplified version of NPT for use by clinicians, managers, and policy makers, and which could be embedded in a web-enabled toolkit and on-line users manual.
Between 2006 and 2010 we undertook four tasks. (i) We presented NPT to potential and actual users in multiple workshops, seminars, and presentations. (ii) Using what we discovered from these meetings, we decided to create a simplified set of statements and explanations expressing core constructs of the theory (iii) We circulated these statements to a criterion sample of 60 researchers, clinicians and others, using SurveyMonkey to collect qualitative textual data about their criticisms of the statements. (iv) We then reconstructed the statements and explanations to meet users' criticisms, embedded them in a web-enabled toolkit, and beta tested this 'in the wild'.
On-line data collection was effective: over a four week period 50/60 participants responded using SurveyMonkey (40/60) or direct phone and email contact (10/60). An additional nine responses were received from people who had been sent the SurveyMonkey form by other respondents. Beta testing of the web enabled toolkit produced 13 responses, from 327 visits to http://www.normalizationprocess.org. Qualitative analysis of both sets of responses showed a high level of support for the statements but also showed that some statements poorly expressed their underlying constructs or overlapped with others. These were rewritten to take account of users' criticisms and then embedded in a web-enabled toolkit. As a result we were able translate the core constructs into a simplified set of statements that could be utilized by non-experts.
Normalization Process Theory has been developed through transparent procedures at each stage of its life. The theory has been shown to be sufficiently robust to merit formal testing. This project has provided a user friendly version of NPT that can be embedded in a web-enabled toolkit and used as a heuristic device to think through implementation and integration problems.
BMC Health Services Research 09/2011; 11:245. · 1.66 Impact Factor
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ABSTRACT: Many western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre) for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue.
In 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied.
There was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for.
Direct provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations.
BMC Family Practice 05/2011; 12:32. · 1.80 Impact Factor
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ABSTRACT: It is widely accepted that medical undergraduate and postgraduate education should address issues related to human diversity. Despite the growth of guidelines and training resources, little is known about primary healthcare professionals' perceptions about their work with patients from diverse communities.
This research explored GP Registrars' views of their learning needs in relation to delivering effective healthcare to ethnically and culturally diverse patient populations.
The study was based on a naturalistic inquiry design, involving qualitative methods. Current GP Registrars of the postgraduate GP Western Training Programme, Galway, Ireland, were invited to participate in focus groups. Three different focus groups were conducted with a total of 31 GP Registrar participants. A thematic analysis following the principles of framework analysis was applied.
GP Registrars reported considerable professional uncertainty and occupational stress when consulting with patients from diverse communities. They perceived their training in relation to healthcare for patients from diverse backgrounds as inadequate and desired more training. They identified concrete learning needs, which were mainly related to factual knowledge, with less emphasis on communication skills and attitude awareness.
Educators should take GP Registrars' views into account in the development of diversity training in medical education. GP Registrars' attention to specific knowledge related to human diversity may, nonetheless, be too narrow. This training should also encourage acknowledgment of the doctor's professional uncertainty, awareness of the doctor's own attitudes, and development of generic skills such as a patient-centred approach to best meet the needs of diverse population groups.
Education for Health Change in Learning & Practice 04/2011; 24(1):494.
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Elizabeth Murray,
Shaun Treweek,
Catherine Pope, Anne MacFarlane,
Luciana Ballini,
Christopher Dowrick,
Tracy Finch,
Anne Kennedy,
Frances Mair,
Catherine O'Donnell,
Bie Nio Ong,
Tim Rapley,
Anne Rogers,
Carl May
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ABSTRACT: The past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation).
In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential.
The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial.
BMC Medicine 10/2010; 8:63. · 6.03 Impact Factor
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Elizabeth Murray,
Shaun Treweek,
Catherine Pope, Anne MacFarlane,
Luciana Ballini,
Christopher Dowrick,
Tracy Finch,
Anne Kennedy,
Frances Mair,
Catherine O&apos,
Donnell,
Bie Ong,
Tim Rapley,
Anne Rogers,
Carl May
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ABSTRACT: Abstract Background The past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation). Discussion In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential. Summary The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial.
BMC Medicine. 01/2010;
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ABSTRACT: This paper focuses on the work involved for service users in arranging and negotiating the use of informal interpreters from their social networks for general practice consultations. The data are drawn from a participatory learning and action research study, carried out in the west of Ireland. Qualitative data were gathered using a peer researcher model from a 'hard to reach' community of Serbo-Croat and Russian refugees and asylum seekers (n=26). The findings elucidate that there is a tension for service users between the experienced benefits of having a trusted friend/family member present to act as their interpreter and the burden of work and responsibility to manage the language barrier. Participants emphasize that, for them, the use of informal interpreters can be inadequate and problematic and can leave them worried, frustrated and with experiences of error and misdiagnosis. Overall, they state a clear preference for the use of professional, trained interpreters in general practice consultations which is currently unavailable to them in routine Irish general practice consultations.
Social Science [?] Medicine 07/2009; 69(2):210-4. · 2.70 Impact Factor
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ABSTRACT: Very little is known about the prevalence of acquired brain injury (ABI) in Ireland. ABI prevalence has previously been obtained from Belgian general practitioners using a postal survey. We attempted to ascertain the prevalence of ABI in County Mayo through a postal survey of all general practitioners in the county.The specific objectives of this project were to:1. identify whether general practitioners are a. aware of patients with ABI aged 18-65 in their practices b. able to provide prevalence data on ABI in patients aged 18-65 c. able to provide data on age, gender and patient diagnosis 2. analyse prevalence of ABI from any available data from general practitioners.
A pilot postal survey was performed initially in order to assess the feasibility of the study. It was established that general practitioners did have the necessary information required to complete the questionnaire. A main postal survey was then undertaken. A postal questionnaire was administered to all general practices in County Mayo in the west of Ireland (n = 59). The response rate was 32.2% (n = 19).
General practitioners who replied on behalf of their practice could provide data on patient age, gender and diagnosis. In the nineteen practices, there were 57 patients with ABI. The age-specific prevalence of ABI in the area surveyed was estimated at 183.7 per 100,000. The mean patient population per practice was 2,833 (SD = 950). There were found to be significantly more patients with ABI in rural areas than urban areas (p = 0.006). There were also significant differences in the ages of patients in the different ABI categories. Patients whose ABI was of traumatic origin were significantly younger than those patients with ABI of haemorrhagic origin (p = 0.002).
Although this is a small-scale study, we have ascertained that general practitioners do have data on patients with ABI. Also, some prevalence data now exist where none was available before. These can be used to form the basis of a more substantial programme of university/community partnership research which could provide medical and psychosocial benefits for people with ABI and their families.
BMC Family Practice 06/2009; 10:36. · 1.80 Impact Factor
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Carl R May,
Frances Mair,
Tracy Finch, Anne MacFarlane,
Christopher Dowrick,
Shaun Treweek,
Tim Rapley,
Luciana Ballini,
Bie Nio Ong,
Anne Rogers,
Elizabeth Murray,
Glyn Elwyn,
France Légaré,
Jane Gunn,
Victor M Montori
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ABSTRACT: Theories are important tools in the social and natural sciences. The methods by which they are derived are rarely described and discussed. Normalization Process Theory explains how new technologies, ways of acting, and ways of working become routinely embedded in everyday practice, and has applications in the study of implementation processes. This paper describes the process by which it was built.
Between 1998 and 2008, we developed a theory. We derived a set of empirical generalizations from analysis of data collected in qualitative studies of healthcare work and organization. We developed an applied theoretical model through analysis of empirical generalizations. Finally, we built a formal theory through a process of extension and implication analysis of the applied theoretical model.
Each phase of theory development showed that the constructs of the theory did not conflict with each other, had explanatory power, and possessed sufficient robustness for formal testing. As the theory developed, its scope expanded from a set of observed regularities in data with procedural explanations, to an applied theoretical model, to a formal middle-range theory.
Normalization Process Theory has been developed through procedures that were properly sceptical and critical, and which were opened to review at each stage of development. The theory has been shown to merit formal testing.
Implementation Science 06/2009; 4:29. · 3.10 Impact Factor
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ABSTRACT: This paper focuses on the implications of migration for host health and social care systems in terms of linguistic diversity, language barriers and language supports. The objective is to compare Ireland, as a context responding to the new challenge of language barriers in healthcare, and England, as a context in which the management of language barriers is being re-assessed.
Empirical data from two action research studies in Ireland and England are compared. The combined data set is 146 data collection episodes with service users with limited English and their health and social care providers.
Key findings are that the same range of formal and informal responses to language barriers occurs in practice in both contexts but proportions of knowledge and use of these responses differ. English service providers have more awareness about the use of formal responses than Irish service providers but uptake of formal responses remains low in both contexts. Data from service users confirms these findings.
There is a need for more attention to the implementation of policies for language barriers in both Ireland and England, further research about the normalization processes associated with these consultations and knowledge transfer networks to facilitate on-going dialogue between all key stakeholders with an emphasis on supporting service users' involvement and participation.
Health Policy 05/2009; 92(2-3):203-10. · 1.51 Impact Factor
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ABSTRACT: Refugees and asylum seekers experience language barriers in general practice. Qualitative studies have found that responses to language barriers in general practice are ad hoc with use of both professional interpreters and informal interpreters (patients' relatives or friends). However, the scale of the issues involved is unknown. This study quantifies the need for language assistance in general practice consultations and examines the experience of, and satisfaction with, methods of language assistance utilized.
Data were collected by telephone survey with general practitioners in a regional health authority in Ireland between July-August 2004. Each respondent was asked a series of questions about consulting with refugees and asylum seekers, the need for language assistance and the kind of language assistance used.
There was a 70% (n = 56/80) response rate to the telephone survey. The majority of respondents (77%) said that they had experienced consultations with refugees and asylum seekers in which language assistance was required. Despite this, general practitioners in the majority of cases managed without an interpreter or used informal methods of interpretation. In fact, when given a choice general practitioners would more often choose informal over professional methods of interpretation despite the fact that confidentiality was a significant concern.
The need for language assistance in consultations with refugees and asylum seekers in Irish general practice is high. General practitioners rely on informal responses. It is necessary to improve knowledge about the organisational contexts that shape general practitioners responses. We also recommend dialogue between general practitioners, patients and interpreters about the relative merits of informal and professional methods of interpretation so that general practitioners' choices are responsive to the needs of patients with limited English.
BMC Family Practice 01/2009; 9:68. · 1.80 Impact Factor
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ABSTRACT: Despite increased investment in primary care research and development (R&D), the level of engagement of primary healthcare professionals with research remains poor. The aim of this study is to assess the level of research activity and capacity for research among primary healthcare professionals in a health authority of over one million people in a mixed urban/rural setting in the West of Ireland.
A questionnaire, incorporating the R+D Culture Index, was sent to primary healthcare professionals in the HSE Western Region. Baseline characteristics were analysed with the use of one-way ANOVA and Chi-square test and the dependence of R&D Culture Index score on all sixteen available covariates was examined using multiple regression and regression tree modelling.
There was a 54% response rate to the questionnaire. Primary healthcare professionals appeared to have an interest in and awareness of the importance of research in primary care but just 15% were found to be research active in this study. A more positive attitude towards an R&D culture was associated with having had previous research training, being currently involved in research and with not being a general practitioner (GP) (p < 0.001), but much variability in the R&D culture index score remained unexplained.
Despite awareness of the importance of R&D in primary care and investment therein, primary healthcare professionals remain largely unengaged with the R&D process. This study highlights the issues that need to be addressed in order to encourage a shift towards a culture of R&D in primary care: lack of research training particularly in basic research skills and increased opportunities for research involvement. The use of the R&D Culture Index may enable groups to be identified that may be more research interested and can therefore be targeted in any future R&D strategy.
BMC Family Practice 01/2009; 10:33. · 1.80 Impact Factor
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ABSTRACT: The national health service in the Republic of Ireland is one of a number of European health services currently undergoing significant reform. Out-of-hours primary care has been at the forefront of this process of change, and although patients appear satisfied, the complexity of their response to changes in out-of-hours care has not been fully explored.
To conduct an analysis of qualitative data collected during a recent study of patients' satisfaction with out-of-hours care in order to explore the full range of patients' views and experiences.
All patients contacting a family-doctor out-of-hours cooperative over a designated 24-day period were forwarded a postal questionnaire. The questionnaire contained a section giving the patient the opportunity to add qualitative comments concerning their experience. The data were analysed according to the principles framework analysis using Nvivo software.
Analysis of the data resulted in the development of the following thematic categories: service availability, service accessibility, efficiency, continuity of care and quality of care. There was a range of views, both positive and negative, apparent around these themes, with evidence of patients engaging in careful decisions and "trade-offs" in respect of their options for out-of-hours care.
Patients hold a range of views that suggests the complexity around patient satisfaction with out-of-hours care. A qualitative methodological approach can compliment current approaches to the evaluation of patient satisfaction, facilitating the exploration of the full range of patients' views and experiences.
The European Journal of General Practice 02/2007; 13(2):83-8. · 1.13 Impact Factor
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Carl May,
Tracy Finch,
Frances Mair,
Luciana Ballini,
Christopher Dowrick,
Martin Eccles,
Linda Gask, Anne MacFarlane,
Elizabeth Murray,
Tim Rapley,
Anne Rogers,
Shaun Treweek,
Paul Wallace,
George Anderson,
Jo Burns,
Ben Heaven
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ABSTRACT: The Normalization Process Model is a theoretical model that assists in explaining the processes by which complex interventions become routinely embedded in health care practice. It offers a framework for process evaluation and also for comparative studies of complex interventions. It focuses on the factors that promote or inhibit the routine embedding of complex interventions in health care practice.
A formal theory structure is used to define the model, and its internal causal relations and mechanisms. The model is broken down to show that it is consistent and adequate in generating accurate description, systematic explanation, and the production of rational knowledge claims about the workability and integration of complex interventions.
The model explains the normalization of complex interventions by reference to four factors demonstrated to promote or inhibit the operationalization and embedding of complex interventions (interactional workability, relational integration, skill-set workability, and contextual integration).
The model is consistent and adequate. Repeated calls for theoretically sound process evaluations in randomized controlled trials of complex interventions, and policy-makers who call for a proper understanding of implementation processes, emphasize the value of conceptual tools like the Normalization Process Model.
BMC Health Services Research 02/2007; 7:148. · 1.66 Impact Factor
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ABSTRACT: To determine the factors that influence non-consultant hospital doctors (NCHDs) in their decision to prescribe antimicrobial agents.
A qualitative study using semi-structured interviews centred on a life grid tracking the medical career of 22 NCHDs employed by a university teaching hospital in the west of Ireland.
Early in their careers NCHD prescribing is based primarily on the immediate influence of more senior colleagues. Recollection of formalized undergraduate teaching and hospital guidelines are a very minor influence. As their career progressed and they exercise greater autonomy, personal experience becomes the major influence on prescribing decisions. Hospital guidelines are a minor influence. Participants consider that undergraduate teaching needs to be more practical and taught in a way that is easier to apply to on-ward situations and that hospital prescribing guidelines need to be presented in a 'user-friendly' format and adherence to the guidelines needs to be promoted.
The key influences on antimicrobial prescribing by NCHDs are informal. New approaches are required to ensure that formal training and hospital guidelines on antimicrobial prescribing are more influential in shaping antimicrobial prescribing practice.
Journal of Antimicrobial Chemotherapy 11/2006; 58(4):840-3. · 5.07 Impact Factor
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ABSTRACT: To explore the similarities and differences between patients and health professionals' perspectives on the sociocultural influences on secondary cardiac behaviour, and the implications in policy and practice.
Qualitative study using grounded theory research. We used a linked, phased study to ascertain the factors which helped shape patients' views about their heart problems and how these influence secondary cardiac behaviour. We also explored health professionals' perspectives on patients' views and interpretations. A total of 70 participants, 56 patients and 14 health professionals, took part in individual and group interviews and focus groups.
Patients seemed in control of their heart condition and communicated a sense of satisfaction in how they manage it. To interpret the sociocultural influences on secondary cardiac behaviour, patients used theirs and community knowledge of heart disease, personal constructions of cardiac illness, together with their individual belief systems, particularly relating to lay health beliefs. Individual interpretations were unique and contextual, but there were many common views which did not differ between patients.
Patients and health professionals reported similar areas of influence but there were important differences in emphasis. Providers described the ambivalence between being positive about the future health of patients to boost their recovery process, and recognition that this positive outlook could be construed as a 'cure'.
Family Practice 11/2006; 23(5):587-96. · 1.50 Impact Factor
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ABSTRACT: The Republic of Ireland is characterised by few urban conurbations and a high rural population, including significant numbers of island dwellers. Information communication technologies (ICT), including telemedicine, present opportunities to address rural health-service delivery issues. As in other countries, the recent National Health Information Strategy is regarded as pivotal to the modernisation of the Irish health care system. There is, however, a dearth of research about telemedicine in Ireland. This paper reports, to the best of our knowledge, the first systematic review of telemedicine in the two regional health boards in the Republic of Ireland. Details of 11 telemedicine services, all initiated by local policy, will be presented. Results of an interview study with service providers about their experiences of the practices and processes involved in telemedicine service delivery are also provided. The focus of our analysis is two-fold. We assess the resonance of these Irish data with the international literature with particular reference to a recently developed model for the normalisation of telemedicine. For the first time, this model which was developed in the United Kingdom is applied to a fresh set of empirical data in a different health care context. We then discuss a number of health information policy issues for Ireland and elsewhere arising from our analysis.
Health Policy 06/2006; 76(3):245-58. · 1.51 Impact Factor
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ABSTRACT: To determine patient perceptions of joint teleconsultations (JTC), with particular reference to reasons underlying, and factors contributing to, patient satisfaction and dissatisfaction with this mode of health delivery.
Telemedicine has been welcomed as one way of improving health-care delivery, by improving patient access to secondary care and specialist services hence widening patient choice, particularly for patients outside major conurbations. However, a recent systematic review found currently available data on patient satisfaction with telemedicine to be methodologically flawed. Qualitative evaluations offer the opportunity to elucidate the details of patient satisfaction with this mode of health-care delivery.
Qualitative study using semi-structured interviews.
Purposive sample of 28 participants of a major randomized controlled trial (Virtual Outreach study) of JTC conducted in one urban and one rural area in Britain.
Joint teleconferenced consultations with the patient, patient's general practitioner (GP), and a hospital specialist. The patient and GP were sited in the local practice, while the hospital specialist was in the hospital outpatient department, and the two parties were connected by an ISDN2 link and video-conferencing software.
Patient experiences of JTC, with particular reference to reasons underlying, and factors contributing to, overall satisfaction or dissatisfaction.
Two major themes were identified: customer care and doctor-patient interaction. Patients appreciated the customer care aspects of JTC, particularly the enhanced convenience, reduced costs and improved punctuality associated with JTC. However, there were divergent views about the doctor-patient interactions with some patients expressing a sense of alienation arising from the use of technology, and problems with doctor-patient communication.
These data add significantly to the existing literature on patient satisfaction with telemedicine, by elucidating the factors underlying overall satisfaction scores and hence have implications for future service delivery and implementation of telemedicine.
Health Expectations 04/2006; 9(1):81-90. · 2.32 Impact Factor
