The moral discourse of HIV providers within their organizational context: An ethnographic case study

PATIENT EDUCATION AND COUNSELING

卷:101

Article

Fix, Gemmae M.^1,2  Hyde, Justeen K.^1,3  Bolton, Rendelle E.^1,4  Parker, Victoria A.^1,5  Dvorin, Kelly¹  Wu, Juliet¹  Skolnik, Avy A.¹  McInnes, D. Keith^1,2  Midboe, Amanda M.⁶  Asch, Steven M.^6,7  Gifford, Allen L.^1,8  Bokhour, Barbara G.^1,2 

[1] ENRM Vet Affairs Med Ctr & VA Boston Healthcare S, CHOIR, Bedford, MA USA

[2] Boston Univ, Sch Publ Hlth, Dept Hlth Law Policy & Management, Boston, MA USA

[3] Harvard Med Sch, Boston, MA USA

[4] Brandeis Univ, Heller Sch Social Policy & Management, Waltham, MA USA

[5] Univ New Hampshire, Peter T Paul Coll Business & Econ, Durham, NH 03824 USA

[6] VA Palo Alto HCS, Ctr Innovat Implementat Ci2i, Palo Alto, CA USA

[7] Stanford Univ, Div Primary Care & Populat Hlth, Stanford, CA 94305 USA

[8] Boston Univ, Sch Med, Dept Med, Gen Internal Med Sect, Boston, MA 02118 USA

关键词: Ethnography;    Qualitative methods;    HIV;    Healthcare organization;    Morals;    Discourse;    Communication;   

DOI  :  10.1016/j.pec.2018.08.018

来源: Elsevier

【 摘 要 】

Objective: Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts. Methods: Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes. Results: We interviewed 30 providers, observed 43 clinical encounters, and recorded fleldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as good, behaving, or socio-paths, and flakes. Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' lifecontexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges. Conclusions and Practice Implications: When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded. Published by Elsevier B.V.

【 授权许可】

Free