The moral discourse of HIV providers within their organizational context: An ethnographic case study. Issue 12 (December 2018)

• Record Type: Journal Article
• Authors: Fix, Gemmae M.; Hyde, Justeen K.; Bolton, Rendelle E.; Parker, Victoria A.; Dvorin, Kelly; Wu, Juliet; Skolnik, Avy A.; McInnes, D. Keith; Midboe, Amanda M.; Asch, Steven M.; Gifford, Allen L.; Bokhour, Barbara G.
• Is Part Of: Patient education and counseling. Volume 101:Issue 12(2018)
• Page Start: 2226
• Page End: 2232
• Publication Date: 2018-12
• Subjects: Ethnography -- Qualitative methods -- HIV -- Healthcare organization -- Morals -- Discourse -- Communication; Patient education -- Periodicals; Health counseling -- Periodicals; Health education -- Periodicals; Counseling -- Periodicals; Patient Education -- Periodicals; Éducation des patients -- Périodiques; Counseling -- Périodiques; Éducation sanitaire -- Périodiques; 615.5071
• DOI: 10.1016/j.pec.2018.08.018
• Languages: English
• ISSNs: 0738-3991

Abstract

Highlights: HIV care organization may inform how providers conceptualize and treat patients. Providers who work independently see self-management as individual responsibility. Multidisciplinary teams see patients as socio-culturally embedded. If providers see self-management as individual responsibility, nonadherence is a moral failure. When providers see behavior as socially embedded, they can better plan care. Abstract: 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 fieldnotes 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' life-contexts. 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.