LOS TRUCOS DE RAMBAL

As I was talking with Jane, I realised that I didn’t understand why uncertainty was a key feature of prejudgement. It was apparent from other young people that past experiences of something ‘good’ or ‘bad’ were a key feature in the beliefs they formed; yet the role of uncertainty remained ambiguous. Jane clarified this when she explained why she always tried to get healthcare professionals she was familiar with. “I try to get the same ones [referring to obtaining GP appointments] because like I hate it when you get someone new and you’re not sure of them like. It’s not like you know what’s going to happen or if you can trust them or ‘owt. It’s like you know there’s bad ones ‘coz there’s ones like that nurse last year with the bags of drip, so I need to know them a bit before first, to like know what they’re like. So I’ll just sit there quiet until I’m sure.” New healthcare professionals were a source of uncertainty for her, related to the ambiguity surrounding what will happen, and feeling that it’s not possible to place trust. Jane explained that her fear was that she knew some healthcare professionals were ‘bad ones’. Jane made reference to the ‘nurse with the bags of drip’ who killed people, which was her justification of why uncertainty was difficult. Jane stated that, if she met a healthcare professional who was new, she would sit quietly and not engage. I realised that my focus throughout analyses has been on how young people create expectations from past events, but this approach disregards other factors that also influence beliefs. Jane made me realise that beliefs are not contained to the context of young people’s direct experiences, but can be derived from disparate sources. Analysis would benefit from exploring this in greater depth.

The discussion with Jane was influential as it identified anxiety surrounding the unknown could also influence future behaviour. In not having a basis for her anxiety, Jane rationalised that ‘bad ones’ existed, citing the 2011 Stepping Hill scandal where saline drips injected with insulin caused patient deaths. Jane drew on the information she saw as reliable, opting to withhold active involvement until she was able to ‘know what they’re like’. Jane’s wariness of healthcare professionals was complex and occurred due to a variety of factors. However, it

126 identified that prejudgement also occurred when uncertainty surrounded events, and that young people actively sought to anchor meaning to their interactions. This meaning-making process appeared to psychologically prepare young people, whilst enabling them to develop approaches for their interactions. To progress theoretical momentum, cluster diagramming was used to organise focussed codes and determine how prejudgement operated in terms of pre-engagement behaviour (Figure 10).

Codes were naturally arranged on a document, and free writing used to form meaningful associations between the data (Morse et al., 2009). The resulting ‘messy mapping’ exercise identified significant connections between codes and developed a wide-ranging theoretical

127 framework to understand the interrelationship between analyses. Circles were drawn around central codes and connected with lines, whilst numeric labels were used to comment on disparate codes to classify relationships. The circles joining codes together in the top left of the diagram tentatively identified the impact prejudgement held over the approaches young people used in their interactions. A significant relationship was identified between the expectations young people formed, and the approaches young people developed in their healthcare interactions, providing insight into the effect prejudgement had on actual engagement in interactions. Axial coding was used to provide structure to the category, ultimately establishing a framework by which the emerging concepts could be understood (Straus and Corbin, 1998). Properties, dimensions and the conditions that affected the prejudgement were clarified and compared against data sets until theoretical sufficiency was achieved. As prejudgement became a theoretically robust category, the components were charted to infer the interrelation between the different aspects of the category (Figure 11).

Properties were identified as ‘having frames of reference’ and ‘having expectations’, both of which were an essential feature of how young people formed prejudgements towards their

128 healthcare interactions and healthcare professionals. Properties were influenced by two conditions: the ‘confidence in self’ that the young person had, and the ‘pre-emptive strategies’ each young person employed to plan for upcoming interactions. Prejudgement was seen to exist on a dimension of ‘faith’ that the young person felt able to forward to their upcoming interactions. The following sections provide an account of these aspects of prejudgement, relating findings back to the participant’s narratives in order to convey the meaning that young people attached to their experiences.

5.3.1 Prejudgement: Properties, Conditions and the Dimension

The following section details the properties, condition and dimension of prejudgement.Two properties, ‘having frames of reference’ and ‘having expectations’, emerged from comparative analysis, elucidating characteristics of prejudgement and the influence on healthcare interactions. ‘Having frames of reference’ identified the means by which young people drew on a variety of information sources to frame the beliefs they held, and to articulate their perspectives about healthcare interactions.

Excerpt 3

“[When asked why he thought his next appointment would be ‘pointless’] I know because of what happened before at [hospital name]. They asked questions about breathing and health and how I’m feeling but I can’t bring up anything. They’ll have their plan and stick to it. It’ll be the same.”

Mark Excerpt 4

“I went to get the contraception rod put in my arm and like my sister went and got it a couple of weeks later and like with mine they just put a needle in and put it through. But on my sister’s, they’ve slit her arm a little bit, when they weren’t really meant to do that. I was thinking like, why’ve they done that? That’s wrong, they’re only supposed to put a needle in and then like pop it in.”

129 The above collection of quotes represent influences to data analysis. Initial codes from excerpt 3 such as ‘following their agenda’, ‘not having input’ and ‘sticking to their plan’ identified that Mark drew on past experiences of interactions which he perceived as being protocol-based to predict the future subjugation of his voice in the next appointment. In excerpt 4 Jane makes comparisons between the same procedure both she and her sister had. Initial codes such as ‘being able to compare’, ‘knowing what should happen’ and ‘being told about mistakes’ were influencing factors in Jane’s perception of wrong doing and unnecessary harm. Codes in excerpt 5, such as ‘knowing good practice’ and ‘seeing bad practice’, illiterate Rihanna’s judgement of practice based on what she had previously learnt. By drawing on previous health and social care lessons, she identified the infection control risk the ward doctor posed. Excerpt 6 draws on codes such as ‘hearing the worst in the paper’ and ‘nurses confirming the worst’ to identify that mediated stereotypes could influence a young person’s perception of his nurses. Individually, the above excerpts contained different narratives, consisting of contrasting beliefs and judgements formed about the interactions young people found themselves in. However, collectively they evidenced that the formation of judgement was a multifaceted

Excerpt 5

“When he came to mum [referring to the ward doctor] he was supposed to have his shirt rolled up, but he didn't have it rolled up, but he had his watch on and everything on when he shouldn't have, because we learnt in school that could have been infected and then he's passing on germs to everyone.”

Rihanna Excerpt 6

“It’s like it’s in the paper when they aren’t doing their job properly. Not slacking basically, but if someone was calling for the nurse and they just looked up and ignored them and got someone else to do it. And then you see them just standing around [referring to the ward nurses] and you think are you really as busy as you say you are?”

130 phenomenon, ‘constructed’ from a range of sources to confirm assumptions. The relationship between what young people knew, and what they assumed based on what they knew, highlighted a unique insight into the basis of expectation formation.

To develop sensitivity towards expectation, extant literature was explored to determine the theoretical resonance it held as a key concept. As acknowledged in Chapter 2, the introduction of extant literature requires justification to be philosophically aligned with the research approach; hence, constructivist grounded theory research explicitly acknowledges the role of literature in its contribution to theoretical development (Charmaz, 2006). Introduction to literature at this stage of the analysis is not problematic, as initial findings have been firmly grounded in the data; therefore, extant literature is viewed as additional data, incorporated into analysis to address the study research questions (Charmaz, ibid., p. 35). As such, the comparison of findings against a priori concepts is acknowledged as a useful tool to aid conceptual development and clarify ideas for theoretical maturation (Charmaz, 2014). In terms of ‘prejudgement’, the notion that young people’s interactions with healthcare professionals are influenced by preconceived feelings and assumptions has been recognised in the healthcare literature, and was useful to expound the role of expectation in young people’s engagement. For example, a recent literature review exploring children and young people’s participation in healthcare services identified that previous exposure to healthcare professionals and services could contribute to preconceptions and influence participation (Moore and Kirk, 2010). In the same vein, Beck (2006), in a survey of young people’s perceptions of mental health services, suggests that a negative preconception of services could be a deterrent to young people’s health-seeking behaviours. Bias and stigma can be understood to be a factor that influences participation, yet little is known of the role these

131 factors play in engagement. Exploration of how young people formed assumptions became a key concept that influenced theoretical progression. The below memo elucidates this concept.