Aim

To understand construction of healthcare practitioner atopic eczema mindlines in primary care.

Design

An ethnographic approach was employed. Ethnography is founded in anthropology and is concerned with the systematic study of people and cultures.34 Data is collected through extensive observation with informal conversations, field notes and interviews.35 36 Data was collected in one large general practice in England.

Setting, participants and process

Data were collected by the author, a nurse and researcher, from January 2017 to June 2017. The general practice was identified by a local clinical research network. It was a research and education active urban general practice in a demographically diverse and deprived area of England with a patient population of approximately 10 000. Observations were also conducted in a community pharmacy adjacent to the practice, which was used by most patients. No practitioners reported a special interest in dermatology. In preparation for data collection the researcher attended two practice meetings to outline conduct of the study. Data were collected in more than 250 hours of observation during all surgery opening hours. The role of social-participant-as-observer, that is, predominantly observer with some social functions such as cleaning couches was taken.37 Observation began with the reception team to understand the day-to-day working of the practice. Observation of consultations with GPs, GP trainees and locums, nurses, health visitors in baby clinics, held on the practice premises and pharmacy staff followed. GP telephone consultations were listened to and discussed with the practitioner. Field notes were documented and informal conversations either written contemporaneously or audio-recorded. Entire clinics were attended regardless of presenting complaint, to gain understanding in the context of other long-term conditions. Between consultations practitioners recounted recent eczema consultations. Available documentation was reviewed. Single, semi-structured interviews using a topic guide (box 1) were conducted with practitioners from each profession (n=16) (table 1) using maximum variation purposive sampling38 to ensure a mix of job role and level of experience. A predominance of female participants was reflective of the profile of the healthcare team. The complete data set is summarised in box 2.

Interviews were conducted in the workplace and lasted from 22 to 40 min. Data sufficiency was achieved when no new insights were forthcoming.39 For completeness documents and websites were reviewed including the National Institute for Health and Care Excellence (NICE) clinical guidance for eczema,17 the local emollient formulary and the Clinical Knowledge Summary40 and GP Notebook pages41 for eczema.

Data collection and analysis were iterative with initial findings being used to guide further collection.42 Audio-data were professionally transcribed and transcripts read against the recording by the researcher to confirm accuracy. Data analysis was completed independently by the researcher, through the lenses of mindlines and self-management. Transcripts and field notes were read in full to get a sense of the data as a whole, and then manually coded, categorised and merged into themes and annotated with researcher inductive interpretations (see table 2 for worked example). Post theme development, relevant sections of the data were revisited to ensure authentic interpretation and use of participant language.

Reflexivity

Reflexivity was maintained throughout the study with particular attention being paid to subjectivity and positioning as a nurse and skin health researcher; pre-understandings were consciously set aside.43

Patient and public involvement

Lay people, from an eczema support group, were involved in the development of the research question and in planning the design of the study. They contributed through one meeting and a series of email exchanges.

Theme 1: beliefs about eczema

Eczema was consistently viewed as a ‘bread and butter’ (GP) condition that accounted for many consultations. However, although 19.5% of the practice population was recorded as having some type of eczema few consultations primarily for this condition were observed. Analysis of patient reported reason for GP consultation for a typical week during observation revealed that 26/627 (4.1%) of reasons were skin related with none citing eczema as the primary complaint. No observed face-to-face consultations were primarily for eczema; it was reported as a secondary concern in a small number of GP consultations and more often to HVs in baby clinics. This resulted in eczema necessarily being given limited attention ‘it’s often a secondary problem and there’s only time to deal with one problem per consultation’ (GP). Telephone consultations with GPs were witnessed and patients were observed to consult with pharmacy staff about their eczema. Practitioners mainly viewed eczema as a nuisance condition requiring limited knowledge to treat effectively, ‘eczema is simple to treat, nothing much has changed over the years’ (GP) and ‘the recipe doesn’t change’ (GP).

Some GPs described eczema as a ‘catch up’ (GP) consultation when clinics were over-running. GPs and nurses noted the absence of specific external incentives for long-term eczema management and that it was a condition without the ‘red flags’ (GP) which trigger treatment escalation or referral. They described treatment options as straightforward involving emollients with or without intermittent topical steroids. Few mentioned calcineurin inhibitors or other available medications. Most practitioners considered emollients to be a homogenous group of preparations all with similar properties, although a few differentiated in terms of viscosity and texture. Pharmacy staff and HVs were familiar with a broader range of emollient products and were more likely to offer suggestions for over-the-counter preparations. This was in part because no HVs in this study were able to prescribe. GPs were reluctant to prescribe topical steroids or other treatments unless absolutely necessary. PNs rarely saw patients with atopic eczema.

Practitioners recognised that eczema could have a negative impact on well-being and quality of life but this was not often reflected in the care offered. Treatment was mainly in reaction to a flare rather than there being a long-term plan of care. Generally patients were able to access regular repeat prescriptions for emollients and practitioners expressed a level of frustration when they presented with a flare having not requested or used the prescribed treatments. Although ‘safety netting’ was always in place, planned follow-up consultations were not suggested. Empathy for patients was most evident in practitioners who had personal experience of eczema, they articulated a varying level of understanding about the differences between products, regardless of available empirical evidence, and the extent to which personal preference influenced concordance. Pharmacy counter staff were the most conversant with the differences between emollient products having tried samples, and they were most likely to share this knowledge with patients/customers verbally and in leaflets.

Although eczema was viewed as a frequent reason for consultation, it was mainly presented as a secondary concern and so dealt with swiftly. Eczema was considered simple to treat with little change over time although practitioners with personal experience of eczema were more aware of the challenges of self-management and tolerant of personal treatment preferences.

Theme 2: atopic eczema knowledge

Beliefs about eczema influenced the formation of mindlines and for most mindlines were set against a backdrop of eczema being a low priority condition and a perception of unchanging treatment options which were constrained by local prescribing guidelines (figure 1). Many practitioners described atopic eczema as a common conditions for which you ‘know (treatment) by heart (GP)’ and likened his response to using a ‘satnav …………you stop thinking, the little NHS boxes (on the computer) tell you what to prescribe’ (GP).

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Figure 1

Practitioner eczema mindlines. Sources of information underpinning practitioner eczema mindlines.

Most practitioners reported that their eczema knowledge was based on their initial education and recognised ‘pre-reg derm education was very, very basic’ (GP). A few had completed dermatology placements during GP training but reported seeing little eczema. One experienced GP recounted learning from a consultant, her practice was unchanged as she had ‘learnt from a consultant many years ago and never heard anything to contradict it’ (GP). PNs and GPs were aware of available dermatology education but did not attend as it was a low priority and costly, ‘there is training but you have to pay’ (PN) and they preferred to ‘avoid reps and sponsored sessions’ (GP). HVs reported that skin health was never an educational priority. Pharmacist’s knowledge was updated through e-bulletins from different sources and covered only changes in, and availability of, medications. Only PCS received eczema specific education by attending regular seasonal sessions provided by their employer. Although deemed to be useful, particularly as they tried products and were advised on correct application, the educational experience was sometimes suboptimal as one reported how she was ‘shamed into remembering’ (PCS) session content.

Local emollient guidelines underpinned many prescribing decisions so practitioners did not need to think as ‘software will fire up a message if another product should be used’ (CP). Changes to guidelines were ascribed to cost and ‘what was in vogue’ (GP). Practitioners were not concerned about these changes stating for example, ‘aqueous cream, they’ve gone off that idea for some reason’ (PCS) and ‘Zero products are the ones that are currently on trend’ (GP trainee). While some prescribers stuck rigidly to prescribing the cheapest product, ‘I try to be good and prescribe the cheaper side of things’ (GP trainee), others were more flexible according to their own or the patient’s preference. However, deviations from the formulary were rare on the basis that ‘local formulary is very constraining and you’d have to be able to justify why you’d prescribed anything else’ (GP). Exceptions were observed in the baby clinic and in pharmacy practice where patients were often informed about a wider range of emollients that could be purchased over-the-counter. For those who paid a prescription charge this could often be more cost effective. PCS suggested that they were able to advise patients readily as they had ‘tried samples so you can tell the customers what they feel like’ (PCS).

Other knowledge sources contributed to eczema mindlines. All staff, with the exception of experienced GPs, used internet searches most commonly the online resources GP Notebook and Clinical Knowledge Summaries. Useful websites were often bookmarked and visited in preparation for a consultation rather than alongside the patient. If information was not located almost immediately the practitioner switched to another website ‘we’re hard wired for speed now’ (GP) and ‘dipped into what’s relevant’ (GP) as and when required. None mentioned existing NICE eczema guidance. Local emollient guidelines existed and influenced the prescribing practice of most practitioners, however others were unaware of these and some found them hard to access. GPs and HVs used different emollient guidelines and this caused confusion for patients when they consulted both. A member of pharmacy staff noted the need for ‘a synchronised approach so patients don’t get confused’ (PCS). Practitioners also experienced confusion when offering advice on treatment application, for example ‘treatment is a bit arbitrary – for example should you advise steroid or emollient first?’ (HV).

Practitioners learnt from each other to a limited extent, most often within their professional groups. They recognised ‘we learn both good and bad habits from each other’ (PN). Opportunities for shared learning had reduced as there was little time to meet up and in-house teaching for GPs and PNs had ‘fallen by the wayside’ (GP) due to staff sickness and pressure of work. One GP reported ‘phoning a friend’, now a consultant dermatologist, when she needed advice. GPs reported learning from trainees during debrief sessions but could not recall ever having discussed eczema. Trainees exhausted all available information sources before seeking advice from a GP. HVs and PNs met more frequently and exchanged knowledge more regularly, although eczema was not a condition of interest.

Practitioners expressed varied views on the value of patient knowledge and experience and the extent to which it influenced care. PNs, HVs and pharmacy staff respectively reported that they routinely ‘ask patient what they have tried already’ (PN), ‘see what’s worked for them’ (HV) and ‘listen and learn from customers’ (PCS) and used this information as a basis for treatment advice. Others listened to patients with a degree of scepticism but acquiesced to patient preference, ‘patients often have fixed ideas (about emollients) and I try to accommodate these’ (GP). A few were less receptive, for example ‘I try to use guidelines and the formulary …………. patient experience stuff can be counterproductive’ (GP trainee) and others suggested that their wider experience overrode the patients personal preferences and experiences ‘experience wise I’ve found a lot of people get on with it (particular emollient)’ (GP) and therefore that was what would be prescribed.

Only the most experienced practitioners spontaneously articulated the existence of tacit knowledge stating, ‘it’s a perpetual exercise … adding on knowledge and skills’ (GP) and ‘built up knowledge over time’ (PN). Others pointed to more concrete sources of knowledge. All practitioners understood reliability of evidence to a greater or lesser extent.

Eczema knowledge was constructed from different sources by individual professions. Nursing and medical staff perceived a limited need to update their knowledge as eczema care was viewed as having changed little over time. Exceptions to this were practitioners who had personal experience of eczema and pharmacy staff who regularly updated their mindlines using informal and formal sources of knowledge.

Theme 3: approaches to self-management

In principle, all practitioners supported self-management of eczema but recognised the difficulties of achieving this in practice particularly without formal recognition as a long-term condition (LTC). Some practitioners routinely used techniques to support self-management for patients with other LTCs. Strategies included for example, ‘finding out patients’ expectations’ (PN), ‘tailoring knowledge to the person’ (GP), ‘start with what the patient understands and then fill in the gaps’ (GP), ‘give patients a map of management’ (GP), ‘instil confidence’ (GP) and ‘reinforce that self-management is good’ (GP trainee). A few GPs used specific techniques such as ‘short bursts of CBT’ (GP), ‘motivational interviewing techniques ……. compressed to fit in consultation’ (GP) and ‘behaviour modification ………… not a one consultation job’ (GP). Even practitioners who did not articulate using strategies to support self-management integrated them in practice for many LTCs. However they were rarely observed or discussed in relation to eczema.

Most eczema care was reactive when patients presented with a flare and talk of eczema care was almost exclusively about treatment options. Virtually no attention paid to ensuring that the patient understood the condition and actions they could take to avoid the relentless cycle of flares. The most tangible contribution to self-management was the availability of repeat prescriptions for emollients but advice to use these consistently was lacking. Barriers to self-management were observed, for example the appointment system often precluded patients seeing the same GP over time, so treatment could be altered without the benefit of fully understanding the patient journey to date. Contradictory advice given by practitioners and a lack of faith in patient’s ability to judge when they needed to use topical steroids and to use them safely presented significant barriers to successful self-management. Practitioners suggested they ‘need to see patients before prescribing (topical) steroids’ (GP). One GP stated that ‘sensible’ patients may get steroids on repeat but struggled to define sensible in this context. Pharmacy staff did not recognise their contribution to self-management per se, but recognised the positive impact they had on eczema management through ‘actually taking notice of what they’re telling me’ (PCS) and perceived ‘they do trust me ………………… I’m well known in the local community’ (PCS) and were therefore easy for customers to speak with.

While recognising the need for self-management the fact that eczema is not categorised as a long-term condition limited how much patients were supported to self-manage and at times healthcare systems could hinder attempts.