The body projects of university students with type 1 diabetes

Calibrating logics: How adolescents and young adults calibrate often-competing logics in their daily self-management of type 1 diabetes

Adolescents and young adults with type 1 diabetes must manage a demanding chronic condition in their daily lives, but adequate self-management remains a major challenge. In this article, we explore the logics invoked in shaping daily type 1 diabetes self-management among adolescents and young adults and propose an analytical view of self-management as a matter of 'calibrating logics'. Drawing on Annemarie Mol's concept of logic, our analysis of in-depth interviews with 21 adolescents and young adults with type 1 diabetes suggested that three main logics collectively shaped their self-management: biomedical, embodied and social. Biomedical logics appeared in the form of routinised insulin therapy, frequent blood glucose testing, and carbohydrate counting, all of which emphasise controlling blood glucose levels. Embodied logics emerged as refined practices such as 'thinking insulin units' and 'listening' to blood glucose fluctuations. Finally, social logics were at play when discreet or postponed self-management practices were used to adjust to social situations. While these logics may complement each other, study participants invoked how these logics often competed in daily life, generating tensions. We therefore propose viewing self-management as a matter of calibrating logics in which often-competing logics are at play. This can provide nuanced insights into the effort and challenges related to the daily self-management of type 1 diabetes for adolescents and young adults, in contrast to the prevailing dichotomy of adherence versus nonadherence to prescribed treatment regimens.

Self-directed self-management interventions to prevent or address distress in young people with long-term physical conditions: A rapid review

BACKGROUND

Comorbid distress in adolescents and young adults with physical long-term conditions (LTCs) is common but can be difficult to identify and manage. Self-directed self-management interventions to reduce distress and improve wellbeing may be beneficial. It is unknown, however, which intervention characteristics are successful in supporting young people. This rapid review aimed to identify characteristics of self-directed self-management interventions that aimed, in whole or part, to address distress, wellbeing or self-efficacy in this population.

METHODS

A systematic search was conducted for relevant controlled studies in six databases. Data on study settings, population, intervention characteristics, outcome measures, process measures and summary effects were extracted. The risk of bias was assessed using the Cochrane Risk of Bias tool v1, and the strength of evidence was rated (informed by Grading of Recommendations, Assessment, Development and Evaluations). Patient and public involvement members supported the review process, including interpretation of results. The rapid review was registered with PROSPERO (ID: CRD42021285867).

RESULTS

Fourteen studies were included, all of which were randomised trials. Heterogeneity was identified in the health conditions targeted; type of intervention; outcome measures; duration of intervention and follow-up. Three had distress, wellbeing or self-efficacy as their primary outcome. Four modes of delivery were identified across interventions-websites, smartphone applications, text messages and workbooks; and within these, 38 individual components. Six interventions had a significant benefit in mental health, wellbeing or self-efficacy; however, intervention characteristics were similar for beneficial and non-beneficial interventions.

CONCLUSIONS

There is a paucity of interventions directly targeting distress and wellbeing in young people with physical LTCs. In those identified, the heterogeneity of interventions and study design makes it difficult to identify which characteristics result in positive outcomes. We propose the need for high-quality, evidence-based self-management interventions for this population; including (1) more detailed reporting of intervention design, content and delivery; (2) robust process evaluation; (3) a core outcome set for measuring mental health and wellbeing for self-management interventions and (4) consistency in follow up periods.

PUBLIC CONTRIBUTION

Seven young people with an LTC were involved throughout the rapid review, from the development of the review protocol where they informed the focus and aims, with a central role in the interpretation of findings.

The experiences and support needs of students with diabetes at university: An integrative literature review

AIMS

Commencing university presents particular challenges for young adults with diabetes. This integrative literature review aimed to synthesise the research exploring the experiences and support needs of university students with diabetes.

METHODS

Medline, CINAHL, PsychInfo and EMBASE databases were searched for quantitative and qualitative studies, among undergraduate and postgraduate students with type 1 or type 2 diabetes conducted in the university setting. Two reviewers independently screened titles, abstracts and full-text articles. Data were analysed thematically and synthesised narratively utilising the ecological model as a framework for interpreting findings and making recommendations.

RESULTS

We identified 25 eligible papers (20 studies) utilising various methods: individual interview, focus group, survey, online forum. Four themes were identified: barriers to self-care (e.g. lack of structure and routine); living with diabetes as a student; identity, stigma and disclosure; and strategies for managing diabetes at university. Students in the early years at university, recently diagnosed or moved away from home, reported more self-care difficulties, yet few accessed university support services. Risky alcohol-related behaviours, perceived stigma and reluctance to disclose diabetes inhibited optimal diabetes management.

CONCLUSION

Despite the heterogeneity of studies, consistent themes related to diabetes self-care difficulties and risky behaviours were reported by young adults with diabetes transitioning to university life. No effective interventions to support students with diabetes were identified in this setting. Multilevel approaches to support students to balance the competing demands of study and diabetes self-care are needed, particularly in the early years of university life.

Biographical accounts of the impact of fatigue in young people with sickle cell disease

Children and young people (CYP) with sickle cell disease (SCD) are a 'missing voice' in the debate on biography and sociology of chronic illness, meaning we know little about the social consequences of the illness for CYP. This paper examines the meaning of fatigue (a common symptom) for adolescents with SCD. Analysing 24 in-depth interviews with adolescents aged 12-17 years in Ghana, we draw on the distinction proposed by Bury (1988) between 'meanings as significance' and 'meanings as consequence' to examine biographical aspects of fatigue. We argue that concepts of 'biographical disruption' and 'normal illness' do not easily accommodate the experience of CYP with congenital chronic illnesses like SCD, as their sense of (un)disruption and normality/continuity is contextualised relative to normative expectations about what it is to be a young person. At biographical transition points, illness/symptoms present from birth may evolve, shift and become experienced as 'new', 'different', or 'non-normal'. They may become restrictive rather than continuous or disruptive. These experiences are influenced primarily by normative biographical expectations and the pursuit of identity affirmations. We propose that biographical restriction, biographical enactment, biographical abandonment and biographical reframing are more relevant concepts for understanding the experiences of CYP living with SCD.

The mental health support needs of university students with long-term physical health conditions

Purpose

Supporting the mental health of university students is a key priority for higher education. Students living with long-term health conditions are at increased risk of poor mental health; yet little work has focused on their particular mental health needs or indeed, the implications for health education in the university setting. This study sought to identify the mental health support needs of students with long-term conditions, including best ways for universities to support these students.

Design/methodology/approach

A UK national online survey of 200 university students living with long-term physical health conditions (e.g. asthma, endometriosis, epilepsy) was conducted in 2019.

Findings

95% of respondents reported that their long-term condition/s had at least a moderate impact on their mental wellbeing, with 81% reporting that they felt depressed and anxious at least once a month because of their health. The most common suggestion for how universities can better support their mental wellbeing was to raise awareness about long-term conditions on campuses, with many reporting a lack of understanding about long-term conditions from academic and support services staff members – with negative impacts on their mental health. Because of this, some respondents reported a reluctance to come forward and seek help from university services, with 25% not formally disclosing their conditions.

Originality/value

These reported concerns underscore the need to develop health education amongst university staff about long-term conditions and to ensure these students are supported with their health at university.

"The Rest of my Childhood was Lost": Canadian Children and Adolescents' Experiences Navigating Inflammatory Bowel Disease

Children and adolescents with Inflammatory Bowel Disease (IBD) face significant and unique challenges related to their condition. The aim of this study was to better understand some of these challenges, and to explore how Canadian youth respond to them. We interviewed 25 pediatric patients with IBD, ranging in age from 10-17, to find out about their illness experiences. Using a thematic analysis, we discerned three themes: challenges related to diagnosis, making sense of change, and navigating sociability. Taken together, they paint a picture of young people facing great uncertainty prior to diagnosis, pronounced changes to selfhood as they make lifestyle adjustments, and facing difficulties with the implications of reduced sociability because of their disease. We conclude by providing recommendations for the development of resources aimed at helping newly diagnosed pediatric patients navigate these issues.

Supporting disengaged children and young people living with diabetes to self-care: a qualitative study in a socially disadvantaged and ethnically diverse urban area

OBJECTIVE

To explore how to enhance services to support the self-care of children and young people (CYP) clinically considered 'disengaged' by diabetes services.

DESIGN

Qualitative study.

SETTING

Two diabetes clinics in an ethnically diverse and socially disadvantaged urban area in the UK. Eligible participants were CYP living with type 1 or type 2 diabetes aged between 10 and 25 years who did not attend their last annual hospital appointment.

PARTICIPANTS

22 CYP (14 female and 8 male) aged between 10 and 19 years old took part. The sample was diverse in terms of ethnicity, age at diagnosis, family composition and presence of diabetes among other family members.

DATA COLLECTION

Semistructured interviews.

DATA ANALYSIS

Data were analysed thematically.

RESULTS

Analysis of participant accounts confirmed the crucial importance of non-medicalised care in CYP diabetes care. A life plan was considered as important to participants as a health plan. Participants valued the holistic support provided by friends, family members and school teachers. However, they found structural barriers in their health and educational pathways as well as disparities in the quality of support at critical moments along the life course. They actively tried to maximise their well-being by balancing life priorities against diabetes priorities. Combined, these features could undermine participants engagement with health services where personal strategies were often held back or edited out of clinical appointments in fear of condemnation.

CONCLUSION

We demonstrate why diabetes health teams need to appreciate the conflicting pressures experienced by CYP and to coproduce more nuanced health plans for addressing their concerns regarding identity and risk taking behaviours in the context of their life-worlds. Exploring these issues and identifying ways to better support CYP to address them more proactively should reduce disengagement and set realistic health outcomes that make best use of medical resources.

The agentic Self and uncontrollable body: Young people's management of chronic illness at university

Young people's experiences of living with a long-term health condition have been largely investigated from the perspective of developing autonomy and optimal self-management of treatment regimens. Little existing research explores how young people adjust to the experience of chronic illness within everyday social contexts. Drawing on sociocultural theories of healthism, in this article, we examine the everyday strategies students employed to manage their health condition at university. Data were drawn from a qualitative study with 16 undergraduate students in Australia. Findings from interviews highlight how participants took up discourses of the (hard-working, diligent) Self to discursively position themselves as 'health conscious' and 'in control'. This positioning was maintained through separating the controlled Self from the (uncontrollable) body. The unpredictability of the body posed a threat to young people's abilities to maintain control and denied them opportunities to exercise personal agency. Yet, participants also described a number of subversive strategies in order to take back control and resist the experience of ill health. These potential agentic practices often held unintended consequences, including loss of optimal medical control or (self) exclusion from university life - offering new insights into the differing ways young people concomitantly take-up, rework and resist the pursuit of healthism to 'successfully' manage their health conditions.

[Interdisciplinary multimodal inpatient pain treatment for young adults : Influence of autonomy on effectiveness]

BACKGROUND

Emerging adulthood between the ages of 18 and 25 are vulnerable years that offer many opportunities and simultaneously represent huge challenges for autonomy and identity development. Chronic pain in this vulnerable stage of life is associated with long-term negative consequences. So far, knowledge regarding the effectiveness of treatment offers for this patient group is scarce.

OBJECTIVE

The aim of this study is to examine the effectiveness of a multimodal inpatient pain therapy for young adults with chronic pain. In addition, the change and influence of the autonomy development will be investigated.

MATERIALS AND METHODS

The present longitudinal study examined the effectiveness of a 3-week multimodal inpatient pain treatment in young adults with chronic pain. Three-month follow-up data from 74 patients aged 18-25 years (75.7% female) were included in the study. Standardized questionnaires were used to investigate pain characteristics, pain-associated and emotional impairments quality of life, and various facets of autonomy.

RESULTS

The results show that pain-related and emotional impairments are significantly reduced after therapy. Furthermore, there is a significant improvement in the quality of life and resilience. The increased quality of life and reduced pain-related and emotional impairment are associated with a gain of autonomy convictions.

DISCUSSION

Multimodal inpatient pain treatment seems to be effective during emerging adulthood. Autonomy convictions seem to be an important starting point for therapeutic success and have a modulating importance in terms of positive changes in emotional impairment and quality of live. Therefore, this aspect should be considered when pain treatment offers are developed for this age group.

Making the leap and finding your feet: A qualitative study of disclosure and social support in university students with type 1 diabetes

University poses unique challenges surrounding disclosure for students living with type 1 diabetes, with implications for social support and self-management. Semi-structured interviews with students and peer interviewers living with type 1 diabetes explored university experiences of disclosure and social support. Thematic analysis identified three major themes: disclosure as a measured process, the need for lived experience for true understanding and personal growth and self-awareness. Findings emphasize the need to scaffold the university transition for individuals with type 1 diabetes as disclosure can elicit effective social support. In addition, the importance of lived experience suggests support from students with type 1 diabetes could considerably impact diabetes management.

'It seems like you're going around in circles': recurrent biographical disruption constructed through the past, present and anticipated future in the narratives of young adults with inflammatory bowel disease

Biographical disruption and related concepts continue to be widely drawn upon in explaining how individuals experience chronic illness. Through in-depth examination of the narrative experiences of two young adults with inflammatory bowel disease (IBD), this article aims to contribute to the continuing theoretical elaboration of biographical disruption, and in turn offer new insights into how young adults experience this condition. The cases are analysed from an interaction-based, constructionist perspective, through which it is argued that the relapse-remission nature of IBD can give rise to a particular form of recurrent biographical disruption, constructed in narrative through a complex configuration of past, present and anticipated future experiences. The two young adults are found to give different meaning to this recurrent disruption in terms of its significance and consequences - whilst Samuel represents an ongoing cycle of profound disruption and biographical reinstatement, Edith normalises the cycle of disruption and its role in her ongoing biography. Therefore, moving beyond the notion of 'normal illness' observed in previous research literature, the concept of 'normal recurrent disruption' is proposed. Finally, it is argued that this recurrent biographical disruption may be experienced particularly severely in young adulthood owing to the unique pressures and expectations of this lifestage.

Growing pains: understanding the needs of emerging adults with chronic pain

BACKGROUND

Emerging adulthood (18-30 years), in the Western world, is often a time of identity development and exploration, focusing on areas of work, relationships and education. Individuals with chronic illnesses, such as chronic pain, may be more vulnerable to facing challenges during this time. This study aims to investigate the needs of young adults (YAs) attending a tertiary level National Health Service (NHS) Pain Management Programme (PMP) Service in the United Kingdom; exploring how these needs may translate on to clinical assessment and the delivery of rehabilitation interventions.

METHOD

This is a descriptive qualitative study influenced by phenomenological approaches. YA with a diagnosis of chronic pain were recruited and assigned to one of four focus groups facilitated by a clinical psychologist and occupational therapist. A semi-structured interview guide was used to help facilitate the group discussion.

RESULTS

Qualitative analysis identified four key themes in understanding the needs of YAs with chronic pain: (1) thwarted opportunities, (2) peer separation, (3) perceived illness validity in the context of age and (4) dependency/parental enmeshment.

CONCLUSIONS

The emerging adulthood literature provides a valuable framework for examining a normal developmental trajectory and highlights the relevance of age-related processes in YAs with chronic pain. The idealisation of opportunity and the role of perception in this developmental phase both appear relevant. It is significant that emotional stability is not yet established in emerging adulthood and links to unhelpful management strategies that may be differentiated from older populations are identified.

Challenges of optimizing glycaemic control in children with Type 1 diabetes: a qualitative study of parents' experiences and views

AIMS

To explore the difficulties parents encounter in trying to achieve clinically recommended blood glucose levels and how they could be better supported to optimize their child's glycaemic control.

METHODS

In-depth interviews were conducted with 54 parents of children with Type 1 diabetes (≤ 12 years). Data were analysed thematically.

RESULTS

Parents described being reluctant and finding it difficult to keep their child's blood glucose levels consistently within clinically recommended ranges. As well as worrying about their child's ability to detect/report hypoglycaemia, parents highlighted a multitude of factors that had an impact on their child's blood glucose levels and over which they could exercise little control. These included: leaving their child with other caregivers who could not be trusted to detect hypoglycaemia; difficulties remotely monitoring and regulating their child's food consumption and activity; and physical and social changes accompanying childhood development. Most parents used two sets of blood glucose targets, with clinically recommended targets employed when their child was in their immediate care and higher targets when in the care of others. Parents described health professionals as lacking understanding of the difficulties they encountered keeping blood glucose within target ranges and needing more empathetic, tailored and realistic advice.

CONCLUSION

It is not parents' fear of hypoglycaemia in isolation that leads to decisions to raise their child's blood glucose but, rather, parental fear in conjunction with other factors and considerations. Hence, to improve diabetes management in children, these factors may need to be addressed; for instance, by training others in diabetes management and using new technologies. Changes to consultations are also recommended.

An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings

BACKGROUND

Type 1 diabetes occurs more frequently in younger children who are often pre-school age and enter the education system with diabetes-related support needs that evolve over time. It is important that children are supported to optimally manage their diet, exercise, blood glucose monitoring and insulin regime at school. Young people self-manage at college/university.

METHOD

Theory-informed mixed-method systematic review to determine intervention effectiveness and synthesise child/parent/professional views of barriers and facilitators to achieving optimal diabetes self-care and management for children and young people age 3-25 years in educational settings.

RESULTS

Eleven intervention and 55 views studies were included. Meta-analysis was not possible. Study foci broadly matched school diabetes guidance. Intervention studies were limited to specific contexts with mostly high risk of bias. Views studies were mostly moderate quality with common transferrable findings.Health plans, and school nurse support (various types) were effective. Telemedicine in school was effective for individual case management. Most educational interventions to increase knowledge and confidence of children or school staff had significant short-term effects but longer follow-up is required. Children, parents and staff said they struggled with many common structural, organisational, educational and attitudinal school barriers. Aspects of school guidance had not been generally implemented (e.g. individual health plans). Children recognized and appreciated school staff who were trained and confident in supporting diabetes management.Research with college/university students was lacking. Campus-based college/university student support significantly improved knowledge, attitudes and diabetes self-care. Self-management was easier for students who juggled diabetes-management with student lifestyle, such as adopting strategies to manage alcohol consumption.

CONCLUSION

This novel mixed-method systematic review is the first to integrate intervention effectiveness with views of children/parents/professionals mapped against school diabetes guidelines. Diabetes management could be generally improved by fully implementing and auditing guideline impact. Evidence is limited by quality and there are gaps in knowledge of what works. Telemedicine between healthcare providers and schools, and school nurse support for children is effective in specific contexts, but not all education systems employ onsite nurses. More innovative and sustainable solutions and robust evaluations are required. Comprehensive lifestyle approaches for college/university students warrant further development and evaluation.

Stigma, deviance and morality in young adults' accounts of inflammatory bowel disease

For young adults with inflammatory bowel disease (IBD), perceived stigma has been found to be a salient concern. Drawing on interviews with individuals with IBD aged 18-29 (n = 16), this article uses rhetorical discourse analysis to explore how stigma is discursively constructed by young adults, with a focus on the moral underpinnings of the participants' talk. Their representations showed both felt stigma and enacted stigma; principally related to the perceived taboo surrounding the symptoms of their condition, which often led to the non-disclosure or concealment of the condition. The different ways in which stigma is manifested in the accounts present a challenge to recent arguments questioning the relevance of this concept in chronic illness research, though it was found that it is not adequate to look at stigma alone and, given the unstable nature of IBD, negotiating stigma in relation to possible charges of deviance is a pertinent issue for these young adults. For instance, non-disclosure because of shame could result in individuals experiencing blame. Accounts were constructed through a range of discursive strategies, allowing the participants to present themselves in morally appropriate ways throughout. Suggestions are made about future directions in addressing stigma and deviance in relation to this cohort.

Developing and evaluating a child-centred intervention for diabetes medicine management using mixed methods and a multicentre randomised controlled trial

Aim

To develop and evaluate an individually tailored age-appropriate diabetes diary and information pack for children and young people aged 6–18 years with type 1 diabetes to support decision-making and self-care with a specific focus on insulin management and blood glucose monitoring, compared with available resources in routine clinical practice.

Design

Four-stage study following the Medical Research Council framework for designing and evaluating complex interventions. Stage 1: context – brief review of reviews and mixed-method systematic review; updating of database of children’s diabetes information; children’s diabetes information quality assessment and diabetes guideline analysis; and critical discourse analysis. Stage 2: intervention development – working with expert clinical advisory group; contextual qualitative interviews and focus groups with children and young people to ascertain their information preferences and self-care practices; ongoing consultation with children; development of intervention programme theory. Stage 3: randomised controlled trial (RCT) to evaluate the diabetes diaries and information packs in routine practice. Stage 4: process evaluation.

Findings

The RCT achieved 100% recruitment, was adequately powered and showed that the Evidence into Practice Information Counts (EPIC) packs and diabetes diaries were no more effective than receiving diabetes information in an ad hoc way. The cost per unit of producing the EPIC packs and diabetes diaries was low. Compared with treatment as usual information, the EPIC packs fulfilled all NHS policy imperatives that children and young people should receive high-quality, accurate and age-appropriate information about their condition, self-management and wider lifestyle and well-being issues. Diabetes guidelines recommend the use of a daily diabetes diary and EPIC diaries fill a gap in current provision. Irrespective of allocation, children and young people had a range of recorded glycated haemoglobin (HbA1c) levels, which showed that as a group their diabetes self-management would generally need to improve to achieve the HbA1clevels recommended in National Institute for Health and Care Excellence guidance. The process evaluation showed that promotion of the EPIC packs and diaries by diabetes professionals at randomisation did not happen as intended; the dominant ‘normalisation’ theory underpinning children’s diabetes information may be counterproductive; risk and long-term complications did not feature highly in children’s diabetes information; and children and young people engaged in risky behaviour and appeared not to care, and most did not use a diabetes diary or did not use the information to titrate their insulin as intended.

Limitations

Recruitment of ‘hard to reach’ children and young people living away from their families was not successful. The findings are therefore more relevant to diabetes management within a family context.

Conclusions

The findings indicate a need to rethink context and the hierarchical relationships between children, young people, parents and diabetes professionals with regard to ‘partnership and participation’ in diabetes decision-making, self-care and self-management. Additional research, implementation strategies and service redesign are needed to translate available information into optimal self-management knowledge and subsequent optimal diabetes self-management action, including to better understand the disconnection between children’s diabetes texts and context; develop age-appropriate Apps/e-records for recording blood glucose measurements and insulin management; develop interventions to reduce risk-taking behaviour by children and young people in relation to their diabetes management; reconsider what could work to optimise children’s self-management of diabetes; understand how best to reorganise current diabetes services for children to optimise child-centred delivery of children’s diabetes information.

Study registration

Current Controlled Trials ISRCTN17551624.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

I am many: the reconstruction of self following acquired brain injury

In this article we examine the construction of self following acquired brain injury from an experience-centered perspective. Life history and semistructured interview transcripts collected from four brain injury survivors were analyzed using thematic, syntactic, and deep structure analysis. Though notions of the "lost" or "shattered" self have dominated discussions of personhood in the acquired brain injury literature, we argue that this perspective is a crude representation of the postinjury experience of self, and that aspects of stability, recovery, transcendence, and moral growth are also involved in this process. We highlight the intersubjective nature of the self, and present the processes of delegitimation, invalidation, negotiation, and resistance as crucial aspects of the postinjury construction of personhood. We explore the implications of this complex process of construction of self for grief and bereavement theories, clinical practice, and professional discourse in the area of acquired brain injury.

Motivational narratives and assessments of the body after cosmetic surgery

Cosmetic surgery can be conceptualized as part of a spectrum of contemporary body projects whereby the individual uses body work to achieve some social and personal goal. In this article I examine individual motivations for undergoing cosmetic surgery as well as assessments of the outcomes of those surgeries. Drawing on in-depth interviews, I explore how cosmetic surgery patients understand and ascribe meaning to their own experiences and discover how the respondents evaluate their surgeries in both personal and social contexts. I found that motivations for undergoing surgery are often articulated in both physical and psychosocial terms, with the expectation that physical alterations will facilitate social or emotional changes. Additionally, outcomes are assessed in a similar fashion, with interviewees expressing not only their evaluations of the aesthetic changes to their bodies, but also how these changes made them feel about themselves and their relationships with others.

The role of creative expression in diabetes: an exploration into the meaning-making process

In this narrative exploration of meaning making through the use of creative arts, we recorded the experiences of 8 women with type 1 diabetes. Through a conceptual framework of creative expression as a way of knowing, we designed this study to evoke affective and metaphorical connections to the meaning of diabetes. The initial narrative interview findings reflected the experience of the participants, with three primary themes emerging: experiencing negative emotions about diabetes, putting a positive "spin" on the negative as a way to make meaning, and resisting against diabetes and the medical approach. During the creative arts process, we encouraged further exploration into the meaning-making process using imagery and photographs created by the participants. Final interview findings addressed the need for moving beyond numbers, and attention to the meaning-making process in patient care.