What is the Impact of Point of Care Diagnostics?

• 
  Nicolas Piperno
  

Multi-stakeholder approach to market for Point of Care Diagnostics in Canada

Point of care diagnostics, otherwise referred to point of care testing (POCT), is a form of in vitro medical testing that is performed near the site of patient care, and does not involve the use of laboratory staff and facilities to provide the result. Point of carecan mean, for example, on the wards in a hospital, at a patient’s bedside, in their home, in a consulting room in a doctor’s office or using tele-health technologies. This concept is not new. Urine testing or blood glucose tests, for example, have been traditionally done at the bedside. Over the past few years, however, analytical systems have been developed that enable a wide range of tests to be done quickly and simply without the need for pre-preparation or sophisticated laboratory equipment.

[1]
These tests are designed to sample blood, saliva, urine, or other bodily fluids in order to measure proteins, nucleic acids, metabolites, drugs, dissolved ions and gases, human cells, or microbes.

[2]
The tests require only elementary instruction to use and some can measure multiple bodily agents.

[3]
Interpretation may be as simple as viewing a stripe or spot of color on a strip of paper or polymer.

The key objective of POCT is to generate a result quickly so that appropriate treatment can be implemented. As technology plays a bigger role within healthcare, POCT and accompanying decision-making toolssuch as medical databases arebecoming more prominent. Other major benefits are obtained when POCT is linked directly with an electronic medical record. Results can be shared instantaneously with all members of the patient’s circle of care through a software interface enhancing communication among its members. All of these benefits can eventually lead to improved clinical and economic outcomes.

With the increasing availability and use of POCT, many stakeholders stand to be impacted by its innovation, application, and market opportunities. More specifically, physicians and patients would be impacted by the clinical outcomes, and the provincial government and pharmaceutical companies would be mainly impacted by the economic outcomes. This paper seeks to evaluate how each stakeholder plays a role in the increased use of POCT, and if there are points of resistance or leverage for this idea.

Physicians

POCT have the greatest potential for facilitating faster decision making and therefore more effective patient triage in the emergency department or reduced operation time in the operating room. For example, assessment of the coagulation status via POCT during cardiopulmonary bypass surgery reduces the requirement for blood products, postoperative blood loss, and the time spent in postoperative high dependency care.

[4]
Little evidence, however, supports the use of point of care testing in primary care.

[5]
Hence, physicians would be able to start treatment earlier because they would not need to wait for laboratory test results to come in before they can perform any subsequent treatments. Any POCT, however, will only be beneficial if appropriate action is taken on the result. Thus, the rate limiting step in reducing length of hospital stay may not be delivery of a test result

[6]
, but acknowledgement and communication of the result, and the appropriate action that follows.

[7]

Physicians, as well as nurses that would actually be the main administrators of POCT, just want to be able to do their job effectively. POCT would allow them to do that, and would therefore be a welcoming new tool for them. Challenges remain, however, in the training of staff. Even with the most sophisticated device, reliable results can be obtained only if the patient is prepared appropriately and the correct technique is used. As POCT is likely to be done by staff with limited technical background, training and quality control are critical.

[8]
If the POCT is linked to an online database, an opportunity arises where technicians can monitor if the POCT is being used properly and realistic results are being uploaded to the patient record. Obviously, privacy issues come into play when more than one person has access to a patient’s medical record.

Medical practitioners would be strong advocates for POCT, because they are the ones that would see the on-the-field benefits of its use. The only point of resistance would be the fact that they would need to be trained every time a new POCT is put into use. A way to mitigate this would be to make the POCT device as simple as possible. This becomes less obvious when POCT devices become more sophisticated with options to measure many things at once. Additionally, medical databases will eventually become more sophisticated, and users will need to adapt to changes with the system.

Not listed as a key stakeholder, but just as important is the laboratory personnel that could potentially lose their jobs because the POCT will be replacing what they do. This might also be a point of resistance. However, as stated above, there might be a possibility to reassign them as technicians that ensure the quality of the POCT results.

Patients

POCT will also allow patients to perform the tests themselves in the comfort of their own home. This is the case for diabetics, however POCT can also be performed for patients taking anticoagulants. A major challenge in this scenario would be compliance. Getting patients to perform POCT on their own time might result in them forgetting, especially with older patients. There are however technological tools that can correct for this such as apps that remind the patient when to perform the next test.

[9]
However, this requires the patient to be comfortable with technological devices.

Patients are another stakeholder that would be able to see the on-the-field benefits of POCT use. They will be able to take ownership of their disease if they do the POCT themselves, be able to receive feedback immediately, and not have to wait for laboratory results in which the waiting time can be often a very stressful scenario. POCT will give the impression of a faster access to healthcare in a country where wait times make it seem that the healthcare process is incredibly slow. This will increase patient satisfaction, and thus will be a reason that POCT will be favourable for them.

Other ways that POCT will increase patient satisfaction would be with fewer journeys to the hospital as some tests can be done in the comfort of their own home. Furthermore, POCT can be used to figure out an optimal treatment for them. Quicker optimization of treatment, without the need for trial and error, can lead to less adverse side effects and a more comfortable healthcare experience.

As for physicians and nurses, training becomes an issue because the average patient does not have technical knowledge. Again, the answer lies in the simplicity and ease of use of the POCT device.

Provincial government

One of the main objectives of the provincial government when it comes to healthcare is the control of its increasing costs. Healthcare has become really expensive in Canada, and it risks being not sustainable if we maintain the status quo. Innovative technologies such as POCT and the complementary medical databases can serve to reduce costs in many ways.

The economic benefit of POCT can be looked at from a short term point of view or a long term one. In the short term, POCT can gain from a more effective use of resources. For example, one study comparing laboratory and POCT suggested that certain tests might be used to rule out the need for other tests as in the case of suspected urinary tract infection.

[10]
Fenwick et al argued that urine leucocyte esterase and nitrite tests can effectively rule out patients with suspected urinary tract infection, which could reduce the inappropriate use of antibiotics as well as laboratory workload.

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Providing a more rapid result, however, does not always save time and money. No savings can occur unless the result is acknowledged and action taken because of this result.

Other short term savings involve a reduction in the length of hospital stay. The rapid availability of a result reduces the time to make decisions, thereby allowing more rapid triage, treatment, or discharge. In addition, POCT can be used to know whether a patient needs admitting to hospital.

[12]
This saves the hospital, and subsequently, the provincial government a huge amount of money because resources are spent more efficiently.

When it comes to long term savings, societal benefits, measured through quality of life indices can be seen as a gain for the government since this would allow less sick days, and more working hours, thus, more tax revenue. There is also an option for POCT via medical databases to become an important resource for public health officials. Big data can be used to guide preventative health policy and possibly save the government millions of dollars in the avoidable healthcare costs.

The government could potentially be favourable of POCT because of all of its economic benefits, however risks arise when considering the reliably of POCT results, which can negate the cost savings, and the potential for infection outbreaks – since we exposing bodily fluids to perform such tests. Furthermore, because POCT allows for testing to be decentralized from the traditional laboratory, data management and privacy becomes an issue. Provincial Governments will have to consider these risks and may impose certain regulations that might prevent the extent of the economic benefits of POCT.

Pharmaceutical Companies

This stakeholder comes in two types. The first type is the pharmaceutical company that is involved in diagnostics equipment. This type of stakeholder stands to gain a lot from POCT because it opens up market opportunities and additional revenue streams. The second type of pharmaceutical company is the one that is involved in drug R&D and sales. These pharmaceutical companies might lose revenue as a result of a more efficient healthcare system and less inappropriate use of drugs.

Pharmaceutical companies that do both might have to evaluate whether the loss in drug sales is less than the profit made from POCT device sales. Furthermore, because POCT devices will still need to go through a lot of R&D, the sale price might be so high that the provincial government might not see the economic value in it. Laboratories already profit from economies of scale, and POCT would be less likely to profit from such economies since its use is decentralized.

In general, lobby groups from drug companies risk being the biggest threat to the proliferation of POCT if they see it as a risk to their bottom line. Their lobby groups tend to influence government decisions on regulation and application of certain healthcare devices. Getting them on board would be critical to the widespread of POCT.

Conclusion

In general, the biggest wins come from doing healthcare differently. Because of the huge labour and pharmaceutical costs involved in healthcare, having the practice of medicine shift towards individuals outside of hospitals might be more economically viable. Rapid delivery of results can facilitate better clinical decision making, improved patient adherence, and greater patient satisfaction, all of which lead to improved clinical outcomes. Most stakeholders stand to benefit from POCT albeit with some concerns, however pharmaceutical companies and laboratory testing companies would be the biggest opponents of POCT. Finding ways to appease their concerns without sacrificing the added benefits of POCT would be the best way to proceed.

Appendix 1: Key Stakeholders with Regard to POCT

	Patients	Provincial Government	Pharmaceutical Companies	Physicians
Assumptions and definitions of health	Healthcare is supposed to be for their benefit	Health is a necessity for their constituents	Drug therapies needed to preserve population health	Hippocrates Oath They are the protectors of health
Values	Good health Quick feedback Answers to their questions	Do anything that garners public votes Prevent Healthcare costs from soaring (value for money) Increase public health	ROI Reputation Partnerships with other stakeholders Patent protection	Healthy patients Using best tools possible
Indicators (monitor/track)	Wait times Their own health	Popularity Health costs	Sales ROI Clinical Studies HTAs	Patient vital signs Information from patient visits Medical record
Definition of success	Access to healthcare in a reasonable amount of time Feeling healthier after hospital visit	Win re-election Healthcare budget under control Healthy economy with healthy people	ROI Winning government contracts Successfully bringing products to market	Patients leave hospital better than when they came in They are given medical devices/diagnostic tools that help them perform their job properly.
Role(s)	User of the healthcare system	Decider of provincial healthcare budget	Researcher, innovator, supplier	Provider of healthcare
Legitimate source of info	Media Physicians Nurses Wait times Reports	Opinion Polls Provincial Financial Reports Media	Market research R&D, literature Media	Patient reports Literature Media
Key questions	Will POCT help me heal faster?	Will POCT cut costs and increase public health?	Is POCT marketable and can I make money of it?	Will POCT allow me to do my job better?

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Postnatal Depression affects around 10-15% of mothers having their first baby. Depression during this time is seen as putting the mother at risk for the onset of a serious chronic mood disorder. Studies have indicated that women who do suffer from postnatal depression have a history of depression and psychosocial difficulties (Oates, 2004). Overall South Asians in Britain make up a total of 4% of the ethnic minority population living in the United Kingdom and 50% of the ethnic minority population (ONS 2004). Thus tackling the mental health needs of different cultures is a major public health concern for both commissioning and provider services. Overall research indicates the rates of suicide amongst South Asian women are higher than any other ethnic group (Bhugra, Desai & Baldwin,1999). Furthermore this rate is said to double for those women under the age of 30 (Bhugra, Desai & Baldwin 1999). Oates (2004) states that these factors are further exacerbated during the postnatal period. Thus the need to understand the causes and origins of depression amongst this cultural group is essential in order for health visitors to provide effective assessments and appropriate interventions.

However research looking at prevalence rates of Depression show little evidence of this illness amongst South Asians. For example this conclusion has arisen when looking at hospital admission rates. Cochrane (1977) found there to be lower admission rates for Pakistani Females and Males. This was further made evident in a follow up study conducted between 1971 -1981, which found that Pakistanis had low admission rates for all types of illness and disorders (Cochrane et al, 1989).

Similar findings have been found in G.P admission rates. Gillam et al (1989) provided more generalised findings in which he found that Asian women in general have low consultation rates for depression and various other mental disorders compared to white women. Thus it would be valid to conclude at this point that hospital admission rates suggest that Asians do not suffer from depression. However Nazroo (1997) disagrees with these findings. He points out that the instruments which are used in the study fail to accurately assess the prevalence of mental illness within Asians. Similarly Brewin (1980) found that there was no apparent difference in G.P consultation rates for Depression between Asian women and White women living in oxford. He also stated that the figures which have indicated low consultation and admission rates, do not reflect low rates of psychiatric treatments. One could therefore suggest that there are flaws in considering admission rates and identifying mental illness amongst South Asians. The consideration of prevalence rates is not the focus of the present review, however the possible causes of low admission rates amongst South Asians shall be considered throughout the review in relation to the research findings.

2.1 Role of the Health Visitor in assessing Postnatal Depression

The National Midwifery Council (2007) highlights Specialist Community Public Health Practitioner Nurses to be equipped with the skills and training to identify and assess mental health needs of mothers during the postnatal period. Furthermore, the National Institute of Clinical Excellence (2007) highlights the importance of health professionals identifying mental illness during the postnatal period and state:

“at a women’s first contact with primary care health care professionals (including midwives, obstetricians, health visitors and GP’S) should ask two questions to identify possible depression: During the past month, have you been bothered by feeling down , depressed or hopeless? During the past month have you often be bothered by having little interest or pleasure in doing things? A third question should be considered if a women answered yes to both clinical questions, such as is this something that you would want help with” .

Thus it is evident that identifying and assessing postnatal depression is pertinent to the role of the health visitor as they are in the frontline in providing early intervention and prevention. However, assessment of Postnatal Depression is challenging when faced with different cultural groups where behavioural, social, and cultural practices differ making assessment and treatments difficult.

Aim

The purpose of the present literature review is to examine the evidence regarding the causes of Postnatal Depression amongst South Asian Women. Thus through collecting and reviewing the research evidence is it proposed it will further expand our knowledge and understanding of Postnatal Depression amongst South Asian women. Furthermore, the review aims to make some recommendations for practice and identify some key areas in which the health visiting practice can further develop and propose various interventions which may be effective in addressing Postnatal depression amongst South Asian women.

4

RESULTS OF THE LITERATURE REVIEW

Overall the final results included a total of 11 studies (refer to appendix) . The results indicated there to be a limit in the research on Postnatal Depression amongst South Asian Women. A total of two studies were identified within the search which had specifically looked at the origins of Postnatal Depression amongst South Asian Women . Furthermore these studies were conducted in Goa India, therefore there was question the generalisability of these findings being applied to population living in Britain. Thus it was decided to incorporate studies looking at Depression amongst South Asian women as it would contribute to understanding the origins of mental illness within this community. A number of categories emerged from the studies . These categories were further combined into a further sub categoroes (refer to figure )? categories. As a result the diagram shown (refer to Figure 1, p ) represents how the data was organised and the categories that emerged.

The origins of Depression within South Asian Women

Assessment of Depression within South Asian Women

Diagram to show the how findings were analysed

ORIGINS OF POSTNATAL DEPRESSION IN SOUTH ASIAN WOMEN

a) Research Question:

CULTURAL VUNERABILITIESb) Core Theme:

c) Higher Order:

ASSESSMENT

CULTURAL EXPECTATIONS

d) Lower order:

Extended Family Living Cultural Expression of Depression

Gender of the Newborn Stigmatisation

5

Chapter 1:

THE ORIGINS OF POSTNATAL DEPRESSION IN SOUTH ASIAN WOMEN

This chapter will examine the evidence available regarding the causes or origins of depression in South Asian women. Overall the results have indicated that that the ’causes’ or ‘origins’ of depression are, due to the what the researcher describes as ‘Cultural Vulnerabilities’ which mean that they are a result of being exposed to an environment of which depression is a unavoidable response. The results are presented the following format, description of each theme along with the supporting evidence.

5.1.1 The theme of Cultural Expectations:

The theme of cultural expectations refers to those expectations formulated by the culture. Such expectations include conforming to cultural traditions. For instance living with the extended family aswell as pressures and expectations to have a male child. Living with the extended family largely refers to living with the mother and father inlaw, husbands brothers and sisters, which can lead to feeling oppressed with a number of family expectations. For example of the 11 articles reviewed the issue of extended family living occurred a total ? times within the studies as a cause of depression for South Asian Women. Shah-Sonuga-barke (2000) conducted a study looking at the relationship between the family structure and maternal mental health of two generations of Muslim and Hindu Women along with the influence this had on children’s behavioural problems. A total of 44 Muslim families and 42 Hindu families agreed to take part in the study. The mental health of the women was monitored using a Hospital Anxiety Depression Scale which is 14 item self report questionnaires. The results indicated that of 46% of the mothers and 40 % of the grandmothers scored above the scale for anxiety. Furthermore 29% of the mothers and 44 % of the grandmothers scored above the cut off point for depression, thus indicating that the majority of the randomly selected sample suffered from significant mental health issues. The findings indicated that grandmothers and children benefited from living in the extended family environment however it had detrimental effects on the maternal mother’s mental health status. Thus suggesting that the traditional extended family, amongst immigrant communities is not always of benefit to its members and in may in some circumstances contribute to the risk in mental health.

Similarly Hicks and Bhugra (2003) conducted a focus group study investigating the possible causes of suicide within South Asian women. A total of 180 South Asian women formed part of the convenience sample from 9 G.P practices and 24 South Asian community organisations in London area. The study was conducted in two parts the subjects were sent questionnaires focussing on the perceived causes of suicide and the findings from these results were formed the focus of discussion within the focus groups. The findings indicated that 90% stated a unhappy family situation to be causal factors. Thus further highlighting the family to be central in experiencing mental illness for South Asian Women.

The possible explanation for these results is that grandmothers that may have grown up in their country of origin where such traditions may have been easier to conform to as there is no exposure to the “western world”. Thus in some cases failure to understand this concept they may project the same values to a generations that is growing up and being exposed to different cultures. In contrast to this study, previous research which has looked at the benefits of extended family living have shown extended families to be a protective factor in alleviating depression in women. For example, Birchwood et al (1992) elaborates on how extended family living reduces the likelihood of suffering with depression and suggested that the support and practical advice offered in an extended family can moderate the risks associated with the development of mental illness.

Furthermore, on, Stainbrook (1954) suggested that the family structure plays a role in mediation of depression western cultures might be responsible for low levels of depression within South Asian Community . For example he stated that the frustrations and the problems which may be faced with in early life, for example marriage and new born are cushioned by the provision of many family members, who play a part in parenting within the extended family.

Tseng and Hsu (1969) identified how the extended family setting brings about low levels of depression. They conducted some research on Twianese family and found that living within the extended family creates a feeling of togetherness and stability and there is a feeling of belonging. Similarly Violtles et al (1967) stated that the role of the family is important in the sharing of loss, it reduces a sense of isolation which can result in depression.

It is acknowledged from the studies above that they were conducted on different cultural groups thus explaining the contrast in findings. However the implications of this in relation to health visiting practice and assessment of PND in South Asian women is that the perception of living with the extended family can be perceived as being positive it may be observed that these women living in a extended family setting are in a supportive environment however it is this environment which can initiate depression for South Asian women.

Furthermore previous research that has highlighted the benefits of the extended have been conducted in 50s, 60s and 70s which poses question on the historical validity of these findings to the present day. The question of whether the findings are applicable to todays population are brought to light. Further on, the research has been conducted on specific cultures therefore is not applicable to ‘all’ cultural groups, and further highlights the complexity of identifying ‘causal’ factors.

The limitations of the two studies are that they both used a small random sample thus posing questions on the generalisability of the findings. Furthermore the Hicks and Bhugra (2003) recruited only a English speaking sample thus the results are representative of those who are educated only , however recruiting from a sample that spoke little English would have increased the validity of the findings. However the validity of the study is increased as it is conducted in two parts using both a qualitative and quantitative approach thus increasing the validity of the findings.

In contrast Hussan and Cochrane (2002) conducted a qualitative study using the grounded theory approach to explore the perception and causes of depression in South Asian Women. The researchers interviewed 10 women in Punjabi, Urdu and English who were suffering from depression, along with their carers who were also interviewed about the causes of depression . The results of the study indicated that conflicting cultural expectations were initiators of depression. The women stated that moving from their country of origin had fragmented the family set up therefore there was a sense of loss and lack of support from the extended family. They stressed that the extended family provided them with support when carrying out daily activities however moving to England there was too many expectations placed upon the women to fulfil the role of the mother, and wife and carrying out all the duties to maintain the respect of the family. This finding contrasts to previous findings which highlight the extended families to be contributory in initiating depression for women. A possible explanation for these results are that migrating from their country of origin involves the individuals leaving behind their homes and their culture. It is a period of adjustment into a new environment which can inturn lead to experiencing a sense of loss and isolation. In some cases this sense of loss can be like a mourning process which can take place at least until the new culture begins to replace some of the old ties. These feelings of loss are expected to be a normal process but if a women for example emigrates from her country of origin and fails to find a substitute for what she has left behind then it interfers with the adaption process. Thus these feelings of loss can inturn result in psychological and distress and illness. Therefore the role of the extended family in this case is protective.

5.1.3. Gender of the new born

The gender of the new born has been highlighted to further initiate Depression for South women. Overall the studies indicated that there was a general preference for a male child. Being a female was considered to be a burden on the family. Thus the expectation to produce a male child places a huge expectation on the mother adding to her pressure to conform to these cultural expectations. Jambunathan (1992) studied 30 women in Madhuri India and examined social cultural factors in the development of depression. The interviews revealed that females were believed to be a curse on the family. For example one of the participants within the study stated that: “instead of being born a girl it is better to be born a free sparrow or a crow…or one should die…” (p264) . The participants within the study believed that females produced a burden on the family in relation to their marriage prospects aswell as financial stress in giving of dowries. The male was preferred as it was believed they would support them in old age and more importantly carry on the family name (Jambunathan 1992).

Furthermore, Patel et al (2002) examined the cultural specific factors such as the gender of the infant and the association with Postnatal Depression. Indian women were recruited who were mostly Hindu in origin (89%) from Goa India who participated within the study. The results of the study indicated that at 6-8 weeks 23 % of the women had postnatal depression. At 6 months a total of 22 % of the women were depressed. 14 % of the women were considered to be chronically depressed. The results indicated that gender of the newborn was significantly associated with the development of postnatal depression. The results also highlighted marital violence to be significantly higher if the infant was a girl but lower if the infant was a boy. The results suggested overall there is a preference for a male infant within this cultural group. The data was collated over a period of 6 months using two different measures. Firstly the General Health Questionniare was employed and the EPDS was used postpartum. The problem with using the two different scales were that they may both measure different aspects of depression this is not made clear within the study. Furthermore the Konki version of the scale was utilized. The validity of the scale was investigated using a two stage pilot study thus there was no confirmation this was only a pilot study. The sample was located from a hospital setting therefore it puts question on the reliability of these findings to be generalised to the population of Goa, even though thes study concludes it to be representative of the population in Goa.

Roderugues et al (2003) conducted a study which looked at the attitudes and perceptions of mothers towards childbirth. The results indicated that the poor relationships with the mother-inlaw, and husbands caused a great deal of distress for the women within the study. Furthermore the women in the study further claimed that the birth of a daughter further caused problems within their relationships with the family and the In-laws. Furthermore the gender of the infant was recognised by the fathers as being a possible cause of nerves for their wives. These findings further suggest that the cultural factors initiate depression. This study adds further strength to the previous study as the study incorporates the fathers and their perceptions. Furthermore the results are compared with depressed and non depressed women , increasing the generalisability of the findings to the general population.

In contrast to these findings Goyal et al (2005) investigated whether such cultural factors such as the gender of the infant and arranged marriages are associated with the development of Postnatal. This was a quantitative study which involved administering the PPDS a Postpartum Depression scale to 58 self selected immigrant Asian Indian women between 2 weeks and 12 months postpartum livin in the USA. The researchers attached additional 14 questions including the age ethnicity and education , occupation, marital status and whether it was arranged and the years living in the U.S. Furthermore medical information regarding the pregnancy, type and the gender of the newborn was recorded aswell as the gender of the previous children. 69 % of the women reported in having an arranged marriage. Women were well educated with at least 50% having a masters degree 43% were described as house makers. A total of 59 % gave birth to a male infant and 41% gave birth to a female infant. Previous history of depression was reported in 7% of the women. The results indicated that 24% screened positively for symptoms of depression and the results indicated that there was no statistically significant difference in the level of depression of those women that had an arranged marriage compared to those who had not had an arranged marriage. Furthermore there was no statistical significance in relation to the gender of the newborn and depression.

A possible explanation for the difference in these results are that three of the studies which have indicated gender of the offspring to be a initiator of depression were conducted in the participants country of origin, where such cultural traditions and beliefs maybe more prevalent. Whereas Goyal et al’s (1998) study was conducted on a sample of women who were educated and living in an environment where they were exposed to western beliefs and traditions thus such cultural beliefs were perhaps difficult for the participant to hold.

In relation to the practice implications of these studies suggest that if gender of the newborn is a factor then the antenatal visits perhaps should question whether there is a preference for male child and whether there are any expectations and pressures placed upon them by the extended family.

6

Chapter 2

Assessment of Postnatal Depression in South Asian Women

This chapter will examine the evidence available regarding the assessment of depression in South Asian women. Overall there is possible reasons as to why depression is difficult to assess these being the stigma surrounding the illness , the communication of distress, and the tools employed to assess depression in south asian women to be factors which can make assessment of cultural factors which have been discussed in the previous chapter difficult to detect. The results are presented the following format, description of each theme along with the supporting evidence.

5.1.1 Communication of Distress

Words that represent emotional status in many European languages have been found not exist within the South Asian culture. Wilson and McCarthy (1994) found that South Asians living in the UK express their depression somatically. The study screened a total of ? patients in G.P practices It was found that Asian patients reported having a physical problem alone rather that a mental problem compared to White patients. Thus this may lead to the indigenous population being correctly diagnosed as having depression that the Asian population. Similarly Odell et al (1997) suggested that Asian patients tended to focus much more on the physical symptoms, thus it therefore made it difficult for G.Ps to detect depression. Thus suggesting that if the G.P is unable to detect depression accurately in Asian women they are less likely to visit their G.P. This suggests a possible reason for low consultation rates between Asian patients and Health professionals. Rack (1979) found that in the Asian Culture there is no acknowledgement for the word of depression being a mental illness. It was found that in the Asian culture Asians perceived illness as being judged by the degree of social dysfunction. Therefore if a women failed in her social roles then her illness would become apparent. On the other hand if a women expresses internal distress it is not recognised.

Karaz (2005) compared depressive symptoms within two cultural groups. 36 South Asian immigrants and 37 European Americans were presented with vignette describing symptoms of depression along with a semi structured interview. The results indicated there were significant differences in the representation of depression. It was identified that depression for South Asian Women was measured through a breakdown of relationships within the family; in particular reference was made to their relationship with the extended family and husbands. In contrast European Americans characterised depression in relation to their biology and hormonal imbalances. This suggests that even if the symptoms of depression are prevalent . the recognition, and understanding and treatment of the illness is different across cultures.

Gausia et al (2009) investigated the prevalence of PND amongst South Asian Women within the sub district of Bangladesh. A total of 346 women were followed from late pregnancy to early postpartum period. The risk factors identified were formulated using a questionnaire and women were followed up and administered the EPDS scale which was validated using the BANGLA version . they identified that PND could be predicted by a number of variables these being depression in pregnancy , prenatal death, poor relationship with mother in-law or husband mother or wife.

It is evident from the literature that there are clear differences in the way in which depression is expressed within cultures. In order to diagnose the symptoms it is essential to have an understanding of the language, culture beliefs and values as it appears that these values play a part in the attitude of the sufferer. Therefore due to this in-depth knowledge of the persons culture there is question on the western diagnostic tools when interpreting illness, it is questionable whether these western diagnostic tools can be used with non western populations? Research has indicated that there are a number of problems of interpreting depression in different cultural groups, they have all concluded that there is a need to be more culturally aware and to consider social, cultural and economic aspects of a person’s life as well as their attitudes and beliefs. Furthermore it highlights why depression rates are reported to be low in this community it is because of these cultural specific factors that rates of depression within this community may be lower or higher than originally assumed.

Communication of distress

Words that represent various emotions have been found not to be present within the some languages. Another possible reason for depression within the South Asian women is the issue of stigma Attached to illness within the Asian community. The illness of the mind is perceived as being madness within the culture and believed to be incurable. Therefore those suffering from the illness will not come forward for treatment. Furthermore those suffering from depression before marriage, their chances of getting married were reduced as the community was aware of this. I f the women however married and their depression arises there is pressure placed on the husband to remarry (Cochrane and Hussain 2002). Similalry Karaz (2005) further highlighted the stigma associated with the illness as South Asian women would refer to depression as being “pagal” or “crazy” which inturn affects her status within the family. These studies suggest depression is part of the living experience for these women for example migrating to a new country or family. Thus it appears that asian women have internalised these beliefs , it then acts as barrier to them seeking any treatment or making their illness known. For this reason depression is likely to be high amongst this group .

For example the role of the family again was a key instigator and asell a)s expectations placed upon the female to fufill the duties of a mother, wife and daughter -inlaw. Further areas identified to initate depression for women were migration from their country of origin

Thus it is evident at this point there is a issue of personal space when living in this environment. The women may feel their personal space is expected to be shared amongst this environment. Thus in moving away from such traditions she is forced into their way of living thus creating a conflict between the generations and cultures.

6

Assessment of Postnatal Depression in South Asian Women

Problems of measurement of depression across cultures:

It is evident from the literature that there are clear differences in the way in which depression is expressed within cultures. In order to diagnose the symptoms it is essential to have an understanding of the language, culture beliefs and values as it appears that these values play a part in the attitude of the sufferer. Therefore due to this in-depth knowledge of the persons culture, it is questionable whether these western diagnostic tools can be used with non western populations? Research has indicated that there are a number of problems of interpreting depression in different cultural groups, they have all concluded that there is a need to be more culturally aware and to consider social, cultural and economic aspects of a person’s life as well as their attitudes and beliefs. Furthermore it highlights why depression rates are reported to be low in this community it is because of these cultural specific factors that rates of depression within this community may be lower or higher than originally assumed. This Chapter will focuss on the the validity of such tools such as the EPDS in indentifying Depression amongst South Asian Women.

Brief Chapter Synopsis, and Change and Implementation Process Description

Chapter two of Change Leadership in Nursing (ChLN) explored the theory of focusing on the good aspects of nursing which totally breaks the myth that effective quality improvement is achieved from the analysis of wrongdoing. Chief Nursing Officer (CNO) Mairead Hickey enabled an interchange of ideas on the assessment and definition of nursing at Brigham and Women’s Hospital (BWH) and what nursing excellence really meant for the staff. This initiative was named “Finding and Defining the good of Nursing” and was implemented following philosophy and change strategy “appreciative inquiry” (Hickey & Kritech, 2012). This strategy targeted the identification of “the best” of an organization with the purpose of envisioning and achieving an ideal, or in other words, “what might be”. Based on this premise, nurses from all areas of the organizations were interviewed following a multistep process that encompassed unit-based focus groups, analysis, review, validation, clarification and refinement of data (Hickey & Kritech, 2012). Furthermore, the themes, definitions and descriptors utilized in the appreciative inquiry process provided a basic window into the excellence of nursing at BWH, and through a refinement process five excellent nursing practice characteristics were defined as standard of care. The initiative was considered a success since it received the constant engagement and support from the senior leadership team, it validated the results of focus groups and narrative sessions with staff nurses and findings from the literature highlighting the high level of research and rigorousness of the initiative (Hickey & Kritech, 2012).

Chapter three defined the importance of a healthy work environment. While exploring the good of nursing on the previous chapter, the author realized that a supportive work environment is a prerequisite for a professional practice environment and excellence in nursing. For the Department of Nursing (DON) at BWH the idea of nursing being seen as a unified collective core aimed to advance patient care and process development wasn’t too clear. Previous leadership fragmentation consisted in nurses and nursing leaders reporting to administrative vice-presidents outside the scope of the DON which resulted in inhibition of discipline and our identity as a nursing community. Based on these flaws, leadership at BWH road mapped a strategy that began with a deep assessment of what a healthy work environment means. This process was carried out by interviews at all levels of nursing within the organization, designation of Advanced Professional Nursing (ANP) meetings, and evidenced based support provided by the American Association of Critical Care Nurses (AACN). After a vigorous debate, dialogue, and literature review, several priority areas were identified and subsequently narrowed down to “collaboration, skilled communication, authentic leadership, and appropriate staffing” (Hickey & Kritech, 2012). According to the authors, in order to implement change, areas of priority needed to be realistic, clear, and achievable. On that note, a further refinement of the list of priority areas was identified based on previous experiences and accomplishments by the nursing department. These included “collaboration, authentic leadership, and practice excellence (Hickey & Kritech, 2012). Finally, engagement and presentation of the of the operational definition to nursing leaders was accomplished with great success. Work teams also disseminated the findings that made “commitment to authentic leadership, true collaboration, and practice excellence” available to clinical nurses and highlighted the evidence for evaluating the benefits of adding the priority areas into leadership practice (Hickey & Kritech, 2012).

Nurse Professionalism and Poor Collaboration among Nursing Departments

When we hear the word “professional” people colloquially link this vocable to high performance sport athletes or mastering of a specific branch of work. There is a tendency to use this term lightly in every aspect of our life. However, the truth is that professionalism means reuniting core skills that make an individual exceptional in seeing beyond expectations and representing a role model for our society. On that note, being a nurse professional means much more than healing the ill and nurturing the wounded. According to Walker, Clendon and Walton (2015), nurse professionalism in an individual is adherence to a code of ethics, honesty, integrity, trust, commitment to cultural safety, empathy, caring, compassion and owning up to mistakes among other characteristics (Walker, Clendon, & Walton, 2015).

In today’s healthcare landscape patient care demands for more than the mere act of treating a patient in order to provide a positive patient experience. The expectations not only require a new optic of thinking regarding the capabilities of a team but also the collaboration among those teams to deliver the best care possible. Lack of communication between hospital departments precipitates situations where medical errors can occurs resulting in patient injuries and team frustrations (O’Daniel & Rosenstein, 2008). Collaboration between nursing departments is defined by the interaction of multiple parties to achieve a common goal, it consists of an active and constant partnership of diverse background institutions and professionals who work together to provide services (Morley & Cashell, 2017). Collaboration is a process that includes effective communication, cooperation, respect, trust, and self-awareness to create a synergistic association that upgrades the contribution of each party involved (Morley & Cashell, 2017).

Based on the readings from Change Leadership in Nursing (2012) and a literature review of the topic, steps to improve true collaboration between nursing department start by self-awareness (Hickey & Kritech, 2012). A self-analysis of the individual, group, department or organization provides information about own triggers or hotspots which will help in developing techniques to avoid conflict (O’Daniel & Rosenstein, 2008). Another aspect of effective collaboration converges in creating a safe work environment. As stated in chapter two of ChLN this is an important factor in true collaboration since “a healthy work environment that is supportive and respectful is a necessary prerequisite of a professional practice environment and of nursing excellence (Hickey & Kritech, 2012). Moreover, according to experts, poor conflict management represents the single most critical barrier to safe collaboration between nursing teams. Although entire conflict avoidance isn’t necessarily suggested since standing on your opinion shows patient advocacy and character, having the ability to handle conflict with effective communication will ultimately promote collaboration and subsequent quality improvement and patient care (O’Daniel & Rosenstein, 2008).

References

• Hickey, M., & Kritech, P. B. (2012).
  
  Change Leadership in Nursing.
  
  New York: Springer Publishing Company.
• Morley, L., & Cashell, A. (2017). Collaboration in Healthcare.
  
  Journal of Medical Imaging and Radiation Services
  
  , 48(2017):207-216.
• O’Daniel, M., & Rosenstein, A. H. (2008).
  
  Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
  
  Rockville (MD): US Agency for Healthcare Research and Quality.
• Walker, L., Clendon, J., & Walton, J. (2015). What nurses think about professionalism.
  
  Kai Tiaki Nursing New Zealand
  
  , 21(1):12-13.