Unpacking gatekeeping in medical institutions: A case study of access to end-of-life patients

Spencer, Karen Lutfey; Mrig, Emily Hammad; Bouchard, Elizabeth G.

doi:10.1177/14687941211034975

Cited by 5 publications

(3 citation statements)

References 28 publications

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“…Data collection continued until data saturation was reached. Additional details of the study have been published previously (Spencer et al, 2021). All interviews were digitally recorded and transcribed verbatim.…”

Section: Methodsmentioning

confidence: 99%

The many faces of medical treatment imperatives: Biopower and the cultural authority of medicine in late‐life treatment decisions in the United States

Spencer

Mrig

Talaie

2022

Sociology Health & Illness

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Despite changes in specific features of the US health‐care system and policy environment in the past 50 years, professional dominance of medicine remains consistent. Extant social science research has considered how the cultural authority of medicine manifests and persists, sometimes emphasizing institutional structural influences and other times focusing on how individuals’ agentic behaviour shapes their decisions and strategies regarding the consumption of health‐care. We build on and extend these literatures using qualitative in‐depth interview data to explore a typology of ways palliative care patients and their caregivers experience medical treatment imperatives across a range of social contexts. Rather than viewing or validating these lived experiences through a medical lens, we foreground the accounts of patients and caregivers as they describe their experiences of where, when, and how they perceive pressure to engage in medical treatment in late life. We adopt a Foucauldian lens to examine how this biopower is both an internal and external experience in our modern biomedicalized society. Our work reveals how treatment imperatives are generated within clinical medical encounters, but also coproduced through multiple and overlapping forces that compel individuals to pursue medical solutions to bodily problems.

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Section: Methodsmentioning

confidence: 99%

The many faces of medical treatment imperatives: Biopower and the cultural authority of medicine in late‐life treatment decisions in the United States

Spencer

Mrig

Talaie

2022

Sociology Health & Illness

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“…Although care homes were asked to invite residents to take part, we received no response from residents. This is likely due to a combination of gatekeeping, and the complexity of residents' compromised cognitive status/health needs, meaning many would be unable to take part (33,34).…”

Section: Samplementioning

confidence: 99%

Supporting care home residents in the last year of life through ‘Needs Rounds’: Development of a pre-implementation programme theory through a rapid collaborative online approach

et al. 2023

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BackgroundRealist evaluation aims to address the knowledge to practice gap by explaining how an intervention is expected to work, as well as what is likely to impact upon the success of its implementation, by developing programme theories that link contexts, mechanisms and outcomes. Co-production approaches to the development of programme theories offer substantial benefits in addressing power relations, including and valuing different types of knowledge, and promoting buy-in from stakeholders while navigating the complex social systems in which innovations are embedded. This paper describes the co-production of an initial programme theory of how an evidence based intervention developed in Australia - called ‘Palliative Care Needs Rounds’ – might work in England and Scotland to support care home residents approaching their end of life.MethodsUsing realist evaluation and iPARIHS (integrated Promoting Action on Research Implementation in Health Services) we sought to determine how contexts and mechanisms of change might shape implementation outcomes. Pre-intervention online interviews (n = 28) were conducted (February-April 2021), followed by four co-design online workshops with 43 participants (April-June 2021). The online interviews and workshops included a range of stakeholders, including care home staff, specialist palliative care staff, paramedics, general practitioners, and relatives of people living in care homes.ResultsThis methodology paper reports developments in realist evaluation and co-production methodologies, and how they were used to develop context, mechanisms, outcomes (CMOs) configurations, and chains of inference. The initial (pre-intervention) programme theory is used to illustrate this process. Two developments to iPARIHS are described. First, involving stakeholders in the collaborative co-design workshops created opportunities to commence facilitation. Second, we describe developing iPARIHS’ innovation component, to include novel stakeholder interpretations, perceptions and anticipated use of the intervention as they participated in workshop discussions.ConclusionsThis rapid and robust co-production methodology draws on interactive collaborative research practices (interviews, workshop discussions of data, illustrative vignettes and visual methods). These innovative and engaging methods can be packaged for online processes to develop, describe and interrogate the CMOs in order to co-produce a programme theory. These approaches also commence facilitation and innovation, and can be adopted in other implementation science and realist studies.

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“…Gatekeeping refers to the act of restricting access by key actors in the field (Calvey, 2008). Such actors may exist at different organizational levels, with varying degrees of influence (Spencer et al, 2021). Gatekeeping is different from wasta, but the two are inextricably linked.…”

Section: Wasta In a Middle Eastern Contextmentioning

confidence: 99%

Cultural practices and organizational ethnography: implications for fieldwork and research ethics

Alshallaqi

2022

JOE

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PurposeThis study focuses on the practical and ethical implications of the cultural practice of wasta for organizational ethnography in the Middle East. Wasta is a form of intercession rooted in the Middle Eastern cultural context and is similar to other cultural practices such as “guanxi” in China. Such practices do not only shape organizational lives in those contexts, but also how organizational ethnographies are designed and carried out.Design/methodology/approachThe data in this study are derived from field notes and the author’s reflections on the fieldwork of an organizational ethnography aimed to investigate a digital transformation project.FindingsThis study draws on the lens of positionality to illustrate how wasta helps favourably reconfigure a researcher’s positionality during interactions with gatekeepers and participants, thereby facilitating access and data collection. The study also presents the ethical concerns related to reciprocity triggered by wasta. Finally, this study demonstrates how wasta functions as a situated system to ensure ethical research practices.Originality/valueThe study demonstrates that it is inevitable that organizational ethnographers engage with cultural practices such as wasta or guanxi during fieldwork in such cultural contexts. Furthermore, the study provides theoretical and methodological contributions for future researchers by engaging in a reflexive exercise to present a more nuanced and theoretically informed understanding of wasta. Moreover, it shows how it is exercised during fieldwork, the ethical concerns inherent in its exercise and how they can be mitigated. The paper concludes with practical recommendations derived from this fieldwork experience for future research.

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Unpacking gatekeeping in medical institutions: A case study of access to end-of-life patients

Cited by 5 publications

References 28 publications

The many faces of medical treatment imperatives: Biopower and the cultural authority of medicine in late‐life treatment decisions in the United States

The many faces of medical treatment imperatives: Biopower and the cultural authority of medicine in late‐life treatment decisions in the United States

Supporting care home residents in the last year of life through ‘Needs Rounds’: Development of a pre-implementation programme theory through a rapid collaborative online approach

Cultural practices and organizational ethnography: implications for fieldwork and research ethics

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