In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings. Existing work has tended to be based on hospital or hospice settings.
As a first contact point, many consultations are mainly initiated by patients, and medical expertise in primary care is of a generalist nature unlike for example, more specialised hospital care. Yet little sociologically informed work has examined this topic. Various studies have used Weick's concept of sensemaking as a lens through which to view professional behaviours and actions in relation to patient safety. According to Weick, sensemaking is the process by which people enact their environments.
Sensemaking is a social process with individuals interacting with people and objects to interpret their surroundings. Whilst some have depicted this as a cognitive information processing activity Weick , more recently there has been an emphasis on the emotional and embodied aspects of sensemaking Cunliffe and Coupland As we discuss later, not everybody has a fully formed set of views on safety in primary care.
Indeed, for many, an assumption that primary healthcare settings are safe Fotaki may indicate lack of prior reflection on the topic of their safety. Asking people to talk about their experiences and perceptions in this context is a way of tapping into and prompting their sensemaking processes. Sensemaking is about action, as much as it is about talk.
Yet being able to articulate one's perceptions is a key part of the sensemaking process. Sensemaking has implications not just for how we see the world around us, but also for our understanding of who we are. In the context of knowledge asymmetry, there may be a readiness to defer to medical professionals. A breach or disruption to normal activities, which means that available cues and frameworks are insufficient to facilitate immediate understanding, is likely to prompt sensemaking of a more episodic nature Weick This has been seen to occur when individuals spend time as hospital inpatients, a setting which is largely unfamiliar to them, and where control has to be surrendered to medical protocols and treatment procedures.
Compared with hospital settings, people have much more experience of primary medical care encounters, with visits to the local general practice following routines and patterns, which are to some extent predictable. The nature of primary care then, arguably offers more opportunities for action than is the case in secondary care.
In this paper, therefore, we ask how individuals make sense of their experiences of primary medical care and how that sensemaking shapes and reshapes their conceptualisation of safety. Participants were initially recruited through five general practices in the northwest of England. We aimed to have a maximum variation sample according to age, education level, carer status, socioeconomic and ethnic background.
Fifteen people were recruited through their practice, the remainder through snowballing.
Participants were registered with 19 practices across the northwest of England. A topic guide was developed and interviews began with broad questions, e. As it became apparent that perceptions of quality and safety were often interlinked, later interviews sought to unpick the distinction. Where there was ambiguity, the interviewer sought clarification. Transcripts were entered into NVivo10 qualitative data software package; Brisbane, QS International and analysed thematically and iteratively, drawing on grounded theory techniques to generate open codes which were constantly compared across cases Corbin and Strauss We used memos and team discussions to distil the core themes and to identify and discuss unusual cases.
Initial coding was carried out by one author PR and selected transcripts were read and coded by additional authors to identify key themes. Sixty four first order codes were categorised within seven main themes comprising: physical, psychological and interpersonal safety; medical safety; communication safety; systems safety; timely access; holistic care and relationship continuity; flexibility in the interpretation of rules.
However, for this paper, we have reanalysed the data using Weick's framework to understand sensemaking around primary care patient safety amongst primary care patients. The narratives in policy and academic literatures about safety in primary care tend to focus on designing and maintaining safe systems and disseminating guidelines aimed at reducing error. The accounts of patients suggested a somewhat different conceptualisation of safety, as we describe below. When initially asked how they understood safety in primary care, people were unsure how to respond and would throw the question back: What do you mean by safety issues?
Many responses seemed to be suggestive of the work to make sense of this concept that they had not previously thought about in any depth: To be honest you never really think about it, do you, until asked. And also, when people get very uptight in a GP surgery, it can be a bit unnerving. Before my practice moved to where they are now, they were in an old house with a very, very steep a staircase with very short treads. It was designed to suit people in the s when people were much smaller.
The reason that I go to the doctor is because I trust that he is able to deal with me confidently. Participants found it difficult to disentangle safety from quality. Many aspects of care or service appreciated in terms of quality were also aspects that made them feel safe.
Accessibility embraced more than the ease or difficulty of obtaining an appointment. Many participants for example, described a need for doctors to take time in a context of patient vulnerability: So I don't want to be with someone that just palms me off, because they haven't got the time … for someone who comes in and is projecting as fragile and vulnerable. So I felt kind of unsupported, if you like, as a result. The one time I did see him before the cancer diagnosis he had me in and out of the surgery that fast that I didn't even manage to bring up the reason I'd gone in.
People often drew on their own experiences to substantiate or validate their views. For example, one woman justified her lack of confidence in GPs in general by describing a catalogue of examples of in her view poor and unsafe care. A succession of different doctors and their failure to take her concerns seriously compromised both her physical and psychological safety, and undermined her confidence in GPs in general. The negative consequences extended beyond the problem that was misdiagnosed to future relationships with GPs and future consulting behaviour: I knew there was a problem and I needed to go and see a specialist but that still didn't happen.
One respondent had moved practices due to negative experiences and problems with access, and described the reasons why he felt safe in the new practice: Why I feel safe … well, the main concern about going to places like that would be, you know, spread of a virus, maybe, or something like that, so it's always clean, you know, people are prompted to wash their hands when they go in, you know, the gel.
People, like my father, he's in a wheelchair, you know, he's got a ramp provided, stair lifts, people look after you if you need anything, straight away, you know, one of the receptionists will come out and say, do you need anything? So the whole environment is, you know, and it is a very small house if you go in, you know, it's not very clinical, it's, like, a house basically.
Although a good physician will have the ability to make patients feel both psychologically and physically safe, patients recognised that these two dimensions draw on different qualities and skills and not all doctors will be proficient in both: a doctor's poor interpersonal skills, for example, might be balanced by greater technical competence. Some patients therefore had preferred doctors for different types of problem: At my previous practice, there were two doctors.
One of whom was lovely, and everybody wanted to see, and the other was grumpy and nobody wanted to see. So, if you wanted to see the first doctor, you might have to wait weeks. To see this other doctor, you could see him any time, but I came to the conclusion that, actually, the one that nobody liked was a better diagnostician. An example of the latter can be illustrated by the case of a woman who persisted with her familiar GP until she was eventually diagnosed with cancer by a new doctor.
In reflecting back on these events, she felt her original GP had misattributed her symptoms of cancer to the natural processes of aging. Some participants distinguished between feeling and being safe, in the recognition that a sense of psychological security could be misleading and trust misplaced: I don't know if that's, you know, in the end, more safe or not, because, if you trust somebody more, you might not check them properly, check what they do … But you feel safe, definitely.
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Patients had to balance not only the different dimensions of safety but to weigh them against other priorities and social imperatives. Examples where other social imperatives took precedence include a Muslim woman with diabetes who chose to fast during Ramadan against her doctor's advice, and a man who delayed visiting the GP about his abdominal pain because he could not take time off work.
Perceptions of safety were thus open to multiple interpretations, and achieving safe care was often a matter of negotiation between patient and GP. In some cases, patients tried to persuade GPs of their own rival interpretation: for example, the person with a misdiagnosed ear condition quoted above who refused more antibiotics and insisted on a hospital referral. I've been to see a GP in my practice who doesn't know me and he's said something, and I knew that wasn't the way to treat somebody who'd got renal failure and so I just ignored what he said F.
Participants were often drawing attention to the emotions engendered in related healthcare encounters:. And I remember I came back to see her before she left and, you know, there was some actual physical contact. She put her hand on my shoulder. I can't quite remember whether I actually hugged her, but you know, I really felt like she really cared about what was going to happen to me, and there was that human element.
It wasn't that I'm a little minion on a conveyor belt through your practice. But then on the day that I was at my worst, literally it was at the worst you could imagine, she said to me … I'm going to close the book on your physical health because there's nothing wrong with you, and I'm going to open the book on your psychological because it's all psychologically based.
So I was like in tears at that point … I could easily have taken my life at that point , because I was at my lowest. Because I knew something wasn't right and this woman was just ignoring me … I feel so angry about … even to this day. Trust was not just engendered at cognitive level but at an emotional and affective level.
And, for many people, it was this emotional response that was most potent in inspiring more generalised confidence in a doctor's medical knowledge and skill. Feeling safe, in the sense of avoidance or minimisation of emotional harm was important to patients, but is not articulated in policy guidance and represents a very different conceptualisation of safety from that espoused in official safety discourse: I would say it was fine, but not personal at all, you know, you didn't feel that connection.
Interviewer: Do you think that connection is just a, sort of, something you like, a quality of service issue or do you think it might have or had safety implications? Good question that — you feel more safe, I don't know if it has a safety implication, but you feel, as a person, you feel more safe, you feel you trust the other person more. The following comment typified the views of many: I think your care and approach is just as much part of what you are expecting from a GP or any doctor, really, as the actual medical judgement.
Sometimes it's not an easy thing to go in there … because sometimes I feel like I'm wasting their time and feeling guilty about being there, that's how I felt. Interviewer: Am I putting words into your mouth by saying, if you think something's trivial you won't go, but you will take it once you get something else as well?
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Obviously I never saw him again. For example, one respondent talked about the difficulties of managing to get an appointment with a doctor who they had already consulted with, and with whom they wanted a further consultation. The interviewer clarified whether this was perceived to be a safety issue: Interviewer: Right, do you think that's mainly a convenience issue or do you think there are safety implications? I think they're safety implications … I don't necessarily mind which doctor I see, but if I've started to see one about a particular condition, then I'd like to continue to see that person, because then they have a better picture about how things are progressing, or whether they're progressing and I don't have to do the whole story again and spend time talking to them for too long to tell them the story, so I'd prefer to see the same person.
Participants were also anxious about their own performance during the consultation and concerned that they would not be able to express themselves adequately or understand and remember what was said to them: Not everybody explains themselves well, some people are nervous, it's like visiting a lawyer … you're frightened about the language they speak and I think it's the same with a lot of people with doctors. When you go to the doctor, it's like you know you've only got 5 mins and you've got to get it out, you know. The number of times you come away and you think, Oh no, I didn't mention that part about it or something, you know!
The degree to which individuals had reflected on the need to actively intervene to contribute to safe or safer encounters varied widely across our participants. People who were frequent users of health services both younger and older respondents had generally become more knowledgeable about the way they operated than those with less experience.
Hernan We've obviously got to go to the GP, we can't write prescriptions out ourselves, we don't have any formal medical training, it's just experience, really. So, when we go to the GP, it's pretty easy to spot whether they know what they are talking about, rather than just guessing at stuff. Wife: They're receptive to our knowledge and we respect their knowledge. Husband: We are very fortunate in that we are reasonably well educated and we kind of know how the system works and that we have been in it for a long time.
In consequence, some patients were more empowered and more capable of adopting a proactive role than others: I do feel I have to … sort of lead them, be clued up, be pushy and it's almost like I feel like there are trigger words that you have to say. Safety, and the capacity for agency individuals acting independently and making their own free choices , were therefore unequally distributed, and allusion to these fundamental inequalities was a common theme in many of the interviews.
Among the feats often enumerated or referred to are the ability to leap like a salmon, to run like a stag, to hurl great rocks incredible distances, to toss the wheel, and, like the Norse berserkers, when possessed with the fury of battle, to grow demoniac with fearsome rage. This last feat was especially valued, and was recognized as the "heroes' fury. So, when the slaughter begins in Etzel's hall, the writer of the Nibelung lay dwells with admiration on the vast strength of Diederick, as shown by the way in which his voice rang like a bison horn, resounding within and without the walls.
Many of the feats chronicled of the early Erse heroes are now wholly unintelligible to us; we can not even be sure what they were, still less why they should have been admired.
Among the heroes stood the men of wisdom, as wisdom was in the early world, a vulpine wisdom of craft and cunning and treachery and double-dealing. Druids, warlocks, sorcerers, magicians, witches appear, now as friends, now as unfriends, of the men of might. Fiercely the heroes fought and wide they wandered; yet their fights and their wanderings were not very different from those that we read about in many other primitive tales.
There is the usual incredible variety of incidents and character, and, together with the variety, an endless repetition. But these Erse tales differ markedly from the early Norse and Teutonic stories in more than one particular. A vein of the supernatural and a vein of the romantic run through them and relieve their grimness and harshness in a way very different from anything to be found in the Teutonic.
Of course the supernatural element often takes as grim a form in early Irish as in early Norse or German; the Goddess with red eyebrows who on stricken fields wooed the Erse heroes from life did not differ essentially from the Valkyrie; and there were land and water demons in Ireland as terrible as those against which Beowulf warred. But, in addition, there is in the Irish tales an unearthliness free from all that is monstrous and horrible; and their unearthly creatures could become in aftertime the fairies of the moonlight and the greenwood, so different from the trolls and gnomes and misshapen giants bequeathed to later generations by the Norse mythology.
Still more striking is the difference between the women in the Irish sagas and those, for instance, of the Norse sagas. Their heirs of the spirit are the Arthurian heroines, and the heroines of the romances of the Middle Ages. In the "Song of Roland"—rather curiously, considering that it is the first great piece of French literature—woman plays absolutely no part at all; there is not a female figure which is more than a name, or which can be placed beside Roland and Oliver, Archbishop Turpin and the traitor Ganelon, and Charlemagne, the mighty emperor of the "barbe fleurie.
Emer, the daughter of Forgall the Wily, who was wooed by Cuchulain, had the "six gifts of a girl"—beauty, and a soft voice, and sweet speech, and wisdom, and needlework, and chastity. In their wooing the hero and heroine spoke to one another in riddles, those delights of the childhood of peoples.
She set him journeys to go and feats to perform, which he did in the manner of later knight errants. After long courting and many hardships, he took Emer to wife, and she was true to him and loved him and gloried in him and watched over him until the day he went out to meet his death. Even to us, reading the songs in an alien age and tongue, they are very beautiful. She dwells constantly on the unfailing tenderness of the three heroes; for her lover's two brothers cared for her as he did:.
She sings of their splendor in the foray, of their nobleness as they returned to their home, to bring fagots for the fire, to bear in an ox or a boar for the table; sweet though the pipes and flutes and horns were in the house of the king, sweeter yet was it to hearken to the songs sung by the sons of Usnach, for "like the sound of the wave was the voice of Naisi. There were other Irish heroines of a more common barbarian type. Such was the famous warrior-queen, Meave, tall and beautiful, with her white face and yellow hair, terrible in her battle chariot when she drove at full speed into the press of fighting men, and "fought over the ears of the horses.
Her husband was Ailill, the Connaught king, and, as Meave carefully explained to him in what the old Erse bards called a "bolster conversation," their marriage was literally a partnership wherein she demanded from her husband an exact equality of treatment according to her own views and on her own terms; the three essential qualities upon which she insisted being that he should be brave, generous, and completely devoid of jealousy! Fair-haired Queen Meave was a myth, a goddess, and her memory changed and dwindled until at last she reappeared as Queen Mab of fairyland. But among the ancient Celts her likeness was the likeness of many a historic warrior queen.
The descriptions given of her by the first writers or compilers of the famous romances of the foray for the Dun Bull of Cooley almost exactly match the descriptions given by the Latin historian of the British Queen Boadicea, tall and terrible-faced, her long, yellow hair flowing to her hips, spear in hand, golden collar on neck, her brightly colored mantle fastened across her breast with a brooch. But we must remember the surroundings, and think of what even the real women of history were, throughout European lands, until a far later period.
In the "Heimskringla" we read of Queen Sigrid, the wisest of women, who grew tired of the small kings who came to ask her hand, a request which she did not regard them as warranted to make either by position or extent of dominion. So one day when two kings had thus come to woo her, she lodged them in a separate wooden house, with all their company, and feasted them until they were all very drunk, and fell asleep; then in the middle of the night she had her men fall on them with fire and sword, burn those who stayed within the hall and slay those who broke out.
The incident is mentioned in the saga without the slightest condemnation; on the contrary, it evidently placed the queen on a higher social level than before, for, in concluding the account, the saga mentions that Sigrid said "that she would weary these small kings of coming from other lands to woo her; so she was called Sigrid Haughty thereafter. The story of the "Feast of Bricriu of the Bitter Tongue" is one of the most interesting of the tales of the Cuchulain cycle.
In all this cycle of tales, Bricriu appears as the cunning, malevolent mischief-maker, dreaded for his biting satire and his power of setting by the ears the boastful, truculent, reckless, and marvellously short-tempered heroes among whom he lived. This story is based upon the custom of the "champion's portion," which at a feast was allotted to the bravest man.
It was a custom which lasted far down into historic times, and was recognized in the Brehon laws, where a heavy fine was imposed upon any person who stole it from the one to whom it belonged. The story in its present form, like all of these stories, is doubtless somewhat changed from the story as it was originally recited among the pre-Christian Celts of Ireland, but it still commemorates customs of the most primitive kind, many of them akin to those of all the races of Aryan tongue in their earlier days.
The queens cause their maids to heat water for the warriors' baths when they return from war, and similarly made ready to greet their guests, as did the Homeric heroines. The feasts were Homeric feasts. The heroes boasted and sulked and fought as did the Greeks before Troy. At their feasts, when the pork and beef, the wheaten cakes and honey, had been eaten, and the beer, and sometimes the wine of Gaul, had been drunk in huge quantities, the heroes, vainglorious and quarrelsome, were always apt to fight.
Thus in the three houses which together made up the palace of the high king at Emain Macha, it was necessary that the arms of the heroes should all be kept in one place, so that they could not attack one another at the feasts. These three houses of the palace were the Royal House, in which the high king himself had his bronzed and jewelled room; the Speckled House, where the swords, the shields, and the spears of the heroes were kept; and the House of the Red Branch, where not only the weapons, but the heads of the beaten enemies were stored; and it was in connection with this last grewsome house that the heroes in the train of the High King Conchubar took their name of the "Heroes of the Red Branch.
When Bricriu gave his feast, he prepared for it by building a spacious house even handsomer than the House of the Red Branch; and it is described in great detail, as fashioned after "Tara's Mead Hall," and of great strength and magnificence; and it was stocked with quilts and blankets and beds and pillows, as well as with abundance of meat and drink. Then he invited the high king and all the nobles of Ulster to come to the feast.
An amusing touch in the saga is the frank consternation of the heroes who were thus asked. They felt themselves helpless before the wiles of Bricriu, and at first refused outright to go, because they were sure that he would contrive to set them to fighting with one another; and they went at all only after they had taken hostages from Bricriu and had arranged that he should himself leave the feast-hall as soon as the feast was spread. But their precautions were in vain, and Bricriu had no trouble in bringing about a furious dispute among the three leading chiefs, Loigaire the Triumphant, Conall the Victorious, and Cuchulain.
He promised to each the champion's portion, on condition that each should claim it. Nor did he rest here, but produced what the saga calls "the war of words of the women of Ulster," by persuading the three wives of the three heroes that each should tread first into the banquet-hall. Each of the ladies, in whose minds he thus raised visions of social precedence, had walked away from the palace with half a hundred women in her train, when they all three met. The saga describes how they started to return to the hall together, walking evenly, gracefully, and easily at first, and then with quicker steps, until, when they got near the house, they raised their robes "to the round of the leg" and ran at full speed.
When they got to the hall the doors were shut, and, as they stood outside, each wife chanted her own perfections, but, above all, the valor and ferocious prowess of her husband, scolding one another as did Brunhild and Krimhild in the quarrel that led to Siegfried's death at the hands of Hagen. Each husband, as in duty bound, helped his wife into the hall, and the bickering which had already taken place about the champion's portion was renewed. At last it was settled that the three rivals should drive in their chariots to the home of Ailill and Meave, who should adjudge between them; and the judgment given, after testing their prowess in many ways, and especially in encounters with demons and goblins, was finally in favor of Cuchulain.
One of the striking parts of the tale is that in which the three champions, following one another, arrive at the palace of Meave. The daughter of Meave goes to the sun-parlor over the high porch of the hold, and from there she is told by the queen to describe in turn each chariot and the color of the horses and how the hero looks and how the chariot courses. The girl obeys, and describes in detail each chariot as it comes up, and the queen in each case recognizes the champion from the description and speaks words of savage praise of each in turn. Loigaire, a fair man, driving two fiery dapple-grays, in a wickerwork chariot with silver-mounted yoke, is chanted by the queen as:.
Conall is described as driving a roan and a bay, in a chariot with two bright wheels of bronze, he himself fair, in face white and red, his mantle blue and crimson, and Meave describes him as:. Then Cuchulain is described, driving at a gallop a dapple-gray and a dark-gray, in a chariot with iron wheels and a bright silver pole. The hero himself is a dark, melancholy man, the comeliest of the men of Erin, in a crimson tunic, with gold-hilted sword, a blood-red spear, and over his shoulders a crimson shield rimmed with silver and gold.
Meave, on hearing the description, chants the hero as:. Bricriu lost his life as a sequel of the great raid for the Dun Bull of Cooley. This was undertaken by Queen Meave as the result of the "bolster conversation," the curtain quarrel, between her and Ailill as to which of the two, husband or wife, had the more treasure.
To settle the dispute, they compared their respective treasures, beginning with their wooden and iron vessels, going on with their rings and bracelets and brooches and fine clothes, and ending with their flocks of sheep, and herds of swine, horses, and cattle. The tally was even for both sides until they came to the cattle, when it appeared that Ailill had a huge, white-horned bull with which there was nothing of Meave's to compare. The chagrined queen learned from a herald that in Cooley there was a dun or brown bull which, it was asserted, was even larger and more formidable.