Conversation analysis: a method for research into interactions between patients and health-care professionals

The pervasive relevance of COVID-19 within routine paediatric palliative care consultations during the pandemic: A conversation analytic study

BACKGROUND

The importance of caring for children with complex and serious conditions means that paediatric palliative care must continue during pandemics. The recent pandemic of Coronavirus Disease 2019 (COVID-19) provides a natural experiment to study health communication during pandemic times. However, it is unknown how communication within consultations might change during pandemics.

AIM

This study, a sub-study of a larger project, aimed to examine real-world instances of communication in paediatric palliative care consultations prior to and during the COVID-19 pandemic to understand how clinicians and families talk about the pandemic.

DESIGN

Paediatric palliative care consultations prior to, during, and immediately following the initial peak of COVID-19 cases in Australia were video recorded and analysed using Conversation Analysis methods.

SETTING/PARTICIPANTS

Twenty-five paediatric palliative care consultations (including face-to-face outpatient, telehealth outpatient and inpatient consultations) were video recorded within a public children's hospital in Australia. Participants included 14 health professionals, 15 child patients, 23 adult family members and 5 child siblings.

RESULTS

There was a pervasive relevance of both serious and non-serious talk about COVID-19 within the consultations recorded during the pandemic. Topics typical of a standard paediatric palliative care consultation often led to discussion of the pandemic. Clinicians (55%) and parents (45%) initiated talk about the pandemic.

CONCLUSIONS

Clinicians should not be surprised by the pervasiveness of COVID-19 or other pandemic talk within standard paediatric palliative care consultations. This awareness will enable clinicians to flexibly address family needs and concerns about pandemic-related matters that may impact health and wellbeing.

Physician-patient shared decision making, patient satisfaction, and adoption of new health technology in China

OBJECTIVE

To examine the association between physician-patient treatments shared decision making (SDM), patient satisfaction, and adoption of a new health technology.

METHODS

A cross-sectional study was conducted from July 2016 to October 2016 in Fujian Province and Shanghai, in Eastern China. A total of 542 physicians and 619 patients in eleven hospitals were surveyed. Patients and their treating physicians completed self-reported questionnaires on patient-physician SDM, satisfaction with treatment decision making and adoption of a new health technology. Correlation analysis, multivariate logistic regression and multivariate linear regression were performed.

RESULTS

The majority (68.20 percent) of patients preferred SDM. Involvement of patients in SDM was positively associated with their satisfaction with treatment decision making (p < .001) and adoption of a new health technology (p < .05). Better concordance between their preference and actual SDM was positively associated with patients' adoption behavior (p < .05), but no statistically significant association was found between concordance and satisfaction.

CONCLUSION

SDM was the most important predictor of patients' satisfaction with decision making and adoption of a new health technology. Therefore, better communication between physicians and patients is recommended to improve their SDM, increase patient satisfaction and to assist with the adoption of new technologies. Training healthcare provider and teaching communication skills in working with patients in the initial stage of technology diffusion is required.

Pain talk in hospice care: a conversation analysis

BACKGROUND

A large number of the hospice patients have been reported to be with symptoms of pain. Thus, managing the patient's pain is one aspect of hospice care provision. The delivery of pain care services could be facilitated through effective communication. However, little has been done to explore the interactional details of the delivery of pain care services in palliative care.

METHODS

Conversation analysis is a useful method to explore the interactional details of interaction by hospice care providers and terminally ill patients. Using the method of Conversation Analysis (CA), this study aims to demonstrate how the hospice care provider employs different types of interactional practices to address the patient's pain concerns. The data showed in this study are collected from the Alexander St website http://ctiv.alexanderstreet.com , an educational resource presenting a large collection of psycho-therapeutic videos.

RESULTS

In this study, an illustrative analysis is demonstrated to show the potential of conversation analysis for research on pain talk in palliative care. It has been shown that conversation analysis could contribute to unfolding the interactional details regarding "pain talk" in hospice care settings. Specifically, conversation analysis could provide a detailed description and interpretation of the conversational practices, which are used to construct hospice care provider participation in delivering pain talk. In addition, conversation analysis could also demonstrate the interactional resources by which patients disclose their experiences of physical or spiritual pain to the hospice care provider and the way how the hospice care provider responds to the patient's troubles talk or feelings talk.

CONCLUSIONS

This study identifies five types of interactional resources which are used to deal with the patient's pain concerns in hospice care setting. A conversation analytical study of pain talk in hospice care could provide a turn-by-turn description of how the hospice care provider communicates with the terminally ill patient in terms of the patient's pain concerns. The findings in this study could inform how the hospice care provider initiates, delivers and develops a pain talk with the terminally ill patient effectively.

Linguistic and interactional aspects that characterize consultations about medically unexplained symptoms: A systematic review

OBJECTIVE

The apparent absence of any specific underlying diseases challenges patient-provider communication about medically unexplained symptoms (MUS). Previous research focused on general communication patterns in these interactions; however, an overview of more detailed interactional and linguistic aspects is lacking. This review aims to gain a detailed understanding of communicative challenges in MUS consultations by synthesizing evidence from conversation and discourse analytic research.

METHODS

A systematic review of publications using eight databases (PubMed, Embase, CINAHL, PsychINFO, Web of Science, MLA International Bibliography, LLBA and Communication Abstracts). Search terms included 'MUS', 'linguistics' and 'communication'. Additional studies were identified by contacting experts and searching bibliographies. We included linguistic and/or interactional analyses of natural patient-provider interactions about MUS. Two authors independently extracted the data, and quality appraisal was based on internal and external validity.

RESULTS

We identified 18 publications that met the inclusion criteria. The linguistic and interactional features of MUS consultations pertained to three dimensions: 1) symptom recognition, 2) double trouble potential (i.e. patients and providers may have differing views on symptoms and differing knowledge domains), and 3) negotiation and persuasion (in terms of acceptable explanations and subsequent psychological treatment). We describe the recurrent linguistic and interactional features of these interactions.

CONCLUSIONS

Despite the presence of a double trouble potential in MUS consultations, validation of symptoms and subtle persuasive conduct may facilitate agreement on illness models and subsequent (psychological) treatment.

Advanced informatics understanding of clinician-patient communication: A mixed-method approach to oral health literacy talk in interpreter-mediated pediatric dentistry

Background

In the clinical dental consultation, multi-party configurations predominate with the presence of parents/ primary caregivers in pediatric dentistry adding another layer of complexity. In managing child oral healthcare, parents/ primary caregivers are critical, especially in dental caries prevention. This study aimed (1) to identify the structure of oral health literacy (OHL) talk in interpreter-mediated pediatric dentistry and (2) to analyze interpreter contributions to the communication strategies: patient-centered direct interpreting (PC-DI), patient-centered mediated interpreting (PC-MI), clinician-centered direct interpreting (CC-DI), and clinician-centered mediated interpreting (CC-MI).

Methods

Visual text analysis (VTA) of video recorded pediatric clinical consultations in Hong Kong utilized Discursis^™ software to illustrate temporal and topical structures and their distribution across turns-at-talk. Conversation analysis (CA) was applied to analyze turn-taking of the identified OHL talk qualitatively. The mixed-method approach of combining VTA and CA was applied to analyze the patterns and features of the recorded OHL talk.

Results

The conceptual recurrences of the 77 transcribed video recordings were plotted visually. CC- and PC-OHL talk were identified by the recurrence patterns of monochromatic and multi-colored triangular clusters formed by off-diagonal boxes, respectively. CA of interpreter-mediated turns supported earlier findings regarding patterns of MI in multilingual adult dental consultations; however, the role of the interpreter in parent/ primary caregiver education and patient management was more distinctive in the pediatric dentistry.

Conclusions

The mixed-method approach assisted in unpacking the complexities of the multi-party interactions, supported identification of effective communication strategies, and illustrated the roles of the dental professionals in initiating CC- and PC-OHL talk in pediatric dentistry. The intervention showed the implication of the professional education of evidence-based practices for clinicians in balancing agenda management and the communicative dimension of OHL with the help of VTA and CA in multilingual consultations.

Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies

BACKGROUND

Despite comparable clinical outcomes, therapists and patients express reservations about the delivery of psychological therapy by telephone. These concerns centre around the quality of the therapeutic relationship and the ability to exercise professional skill and judgement in the absence of visual cues. However, the empirical evidence base for such perceptions has not been clearly established.

METHODS

We conducted a systematic review to establish what is known empirically about interactional differences between psychotherapeutic encounters conducted face-to-face vs. by telephone.

RESULTS

The review identified 15 studies that used situated, comparative approaches to exploring interactional aspects of telephone and face-to-face psychological therapy. These studies revealed evidence of little difference between modes in terms of therapeutic alliance, disclosure, empathy, attentiveness or participation. However, telephone therapy sessions were significantly shorter than those conducted face-to-face.

LIMITATIONS

We identified only a small number of heterogeneous studies, many of which used non-randomised, opportunity samples and did not use validated measures to assess the constructs under investigation. Disparate therapeutic modalities were used across studies and samples included both clinically diagnosed and non-clinical populations.

CONCLUSIONS

Available evidence suggests a lack of support for the viewpoint that the telephone has a detrimental effect on interactional aspects of psychological therapy. The challenge for clinical practice is to translate this evidence into a change in practitioner and patient attitudes and behaviours. In order to do so, it is important to understand and address the breadth of factors that underpin ongoing ambivalence towards the telephone mode, which pose a barrier to wider implementation.

Identifying clients' readiness for hearing rehabilitation within initial audiology appointments: a pilot intervention study

Objective: The current study sought to explore audiologists' use of the Ida Institute Motivation Tools to help them identify clients' readiness for change within initial assessment appointments.Design: The study involved a mixed methods intervention design. Data were collected pre- and post-training audiologists to use the Ida Motivation tools in their appointments. Appointments were video-recorded and analysed using conversation analysis. Clients and audiologists also completed questionnaires within each appointment to measure clients' readiness-for-change.Study sample: Participants included 5 audiologists and 22 adult clients from two Audiology clinics.Results: Audiologists incorporated the Ida Motivation tools into the post-training appointments without a significant increase in appointment time. The Ida tools solicited responses from clients that displayed their ambivalence regarding hearing rehabilitation/aids within their talk. Post-training, audiologists' perceptions of clients' stage of readiness were not significantly more likely to match clients' self-reported stage on the URICA.Conclusions: The Ida Motivation tools may be useful to solicit clients' ambivalent feelings towards hearing rehabilitation/aids, however, it is important for audiologists to actively listen for ambivalence within clients' interactional responses to the tools in order judge clients' readiness.

Parents' questions to clinicians within paediatric hearing habilitation appointments for children with hearing impairment

OBJECTIVE

To examine parents' questions to clinicians and how clinicians respond in paediatric hearing healthcare appointments with children with hearing loss.

METHODS

The data consisted of 48 video-recorded hearing habilitation appointments. Participants included 22 clinicians, 41 children, and 48 parents/carers. Data were analysed using conversation analysis.

RESULTS

A total of 89 questions from parents were directed to the clinicians in the appointments. Parents' questions were mostly designed as polar (yes/no) questions. The questions covered several action and topical agendas, and in most instances functioned as something other than merely soliciting information. The most prominent action agenda of parents' questions involved questions that displayed parental concern. These questions sought reassurance as well as information from the clinician.

CONCLUSION

While parents in this study did not ask a large number of questions during the appointments their questions performed important functions. Parents' questions cannot be assumed to be only about seeking information. Often parents' questions are in pursuit of reassurance from the clinician about their child's progress.

PRACTICE IMPLICATIONS

Clinicians may need to provide encouragement to parents to ask questions during appointments. As part of delivering family-centred care, clinicians need to be aware that their responses may need to go beyond information provision.

Companions' dilemma of intervention when they mediate between patients with intellectual disabilities and health staff

OBJECTIVE

We analyse, for the first time, how companions intervene in the answers that an adult patient with intellectual disabilities gives to their medical practitioner in primary care.

METHODS

Video records of 25 health-check consultations in a large multi-ethnic city in the UK were analysed with the qualitative methods of Conversation Analysis.

RESULTS

We found that companions' interventions in patients' answers fell along a gradient of low to high entitlement, from mere hinting to outright direct take-over.

CONCLUSION

Companions have to manage the dilemma of displaying information which is the proper domain of the patient: encroachment on the patient's epistemic rights versus the needs of the medical practitioner.

PRACTICE IMPLICATIONS

Practitioners may need to check the patients themselves when their companions intervene at the most assertive end of the gradient of help.

Challenges in Collecting Big Data in A Clinical Environment with Vulnerable Population: Lessons Learned from A Study Using A Multi-modal Sensors Platform

Agitation is one of the most common behavioural and psychological symptoms in people living with dementia (PLwD). This behaviour can cause tremendous stress and anxiety on family caregivers and healthcare providers. Direct observation of PLwD is the traditional way to measure episodes of agitation. However, this method is subjective, bias-prone and timeconsuming. Importantly, it does not predict the onset of the agitation. Therefore, there is a need to develop a continuous monitoring system that can detect and/or predict the onset of agitation. In this study, a multi-modal sensor platform with video cameras, motion and door sensors, wristbands and pressure mats were set up in a hospital-based dementia behavioural care unit to develop a predictive system to identify the onset of agitation. The research team faced several barriers in the development and initiation of the study, namely addressing concerns about the study ethics, logistics and costs of study activities, device design for PLwD and limitations of its use in the hospital. In this paper, the strategies and methodologies that were implemented to address these challenges are discussed for consideration by future researchers who will conduct similar studies in a hospital setting.

General Practitioner's use of online resources during medical visits: managing the boundary between inside and outside the clinic

In an increasingly connected world, information about health can be exchanged at any time, in any location or direction, and is no longer dominated by traditional authoritative sources. We consider the ways information and advice given in consultations by doctors transcends the boundary between the clinic and the home. We explore how information that is widely accessible outside the consultation is transformed by General Practitioners (GPs) into a medical offering. Data comprise 18 consultations identified from 144 consultations between unselected patients and five GPs. We use conversation analytic methods to explore four ways in which GPs used online resources; (i) to check information; (ii) as an explanatory tool; (iii) to provide information for patients for outside the consultation; (iv) to signpost further explanation and self-help. We demonstrate the interactional delicacy with which resources from the Internet are introduced and discussed, developing and extending Nettleton's (2004) idea of 'e-scaped medicine' to argue that Internet resources may be 'recaptured' by GPs, with information transformed and translated into a medical offering so as to maintain the asymmetry between patients and practitioners necessary for the successful functioning of medical practice.

An Interactional Profile to Assist the Differential Diagnosis of Neurodegenerative and Functional Memory Disorders

OBJECTIVE

Specialist services for dementia are seeing an increasing number of patients. We investigated whether interactional and linguistic features in the communication behavior of patients with memory problems could help distinguish between those with problems secondary to neurological disorders (ND) and those with functional memory disorder (FMD).

METHODS

In part 1 of this study, a diagnostic scoring aid (DSA) was developed encouraging linguists to provide quantitative ratings for 14 interactional features. An optimal cut-off differentiating ND and FMD was established by applying the DSA to 30 initial patient-doctor memory clinic encounters. In part 2, the DSA was tested prospectively in 10 additional cases analyzed independently by 2 conversation analysts blinded to medical information.

RESULTS

In part 1, the median score of the DSA was +5 in ND and -5 in FMD (P<0.001). The optimal numeric DSA cut-off (+1) identified patients with ND with a sensitivity of 86.7% and a specificity of 100%. In part 2, DSA scores of rater 1 correctly predicted 10/10 and those of rater 2 predicted 9/10 diagnoses.

CONCLUSIONS

This study indicates that interactional and linguistic features can help distinguish between patients developing dementia and those with FMD and could aid the stratification of patients with memory problems.

Conversation Analysis (CA) as a tool for exploring interaction in an online video-conferencing based support service

Purpose

Around 60 per cent of people with dementia in the UK live at home. The experience of caring for a family member with dementia can be rewarding and positive, but it can also be significantly stressful. Current healthcare policy is encouraging greater provision to support family carers. Along with respite-care, day-care and support group-based initiatives, there has also been a focus on developing dementia-specific communication training. The paper discusses this issue.

Design/methodology/approach

The authors outline a new initiative “Empowered Carers” which is being piloted in the North of England. Empowered Carers is an online support and communication training service for family carers who are caring for someone with dementia at home. It utilises online video conference-calling technology to connect carers with support workers, and also allows for simultaneous interactions involving other family members. A central tenet of the approach is a theoretically grounded support model, based on the concept of mentalisation.

Findings

The authors describe the background to Empowered Carers, and how a conventional evaluation strategy for the initiative is being used alongside a socio-linguistic approach (Conversation Analysis – CA). This aims to provide empirical evidence about how the assimilation of mentalisation is reflected in the structuring of speech patterns in carers during support sessions.

Originality/value

The authors explain the CA method, how it has been applied to similar talk-based therapeutic settings, and why its ability to explore sequential linguistic patterns across extremely large data-sets is particularly suited to studying interaction in emerging online arenas.

How do physiotherapists solicit and explore patients' concerns in back pain consultations: a conversation analytic approach

Background: Guidelines advocate that non-specific chronic low back pain (NSCLBP) be considered within a multi-dimensional bio-psychosocial (BPS) framework. This BPS approach advocates incorporating the patient's perspective as part of the treatment process. 'Agenda setting' has been introduced as the key to understanding patients' concerns in medical encounters; however, this has received little attention in physiotherapy. This study explored how physiotherapists solicit and respond to the agenda of concerns that patients with NSCLBP bring to initial encounters. Method: The research setting was primary care. Twenty initial physiotherapy consultations were video-recorded, transcribed and analyzed using conversation analysis, a qualitative observational method. Both verbal and non-verbal features of the interaction were considered. Results: This data highlights a spectrum of communication styles ranging from more physiotherapist-focused, where the physiotherapists did not attend to patients' concerns, to a more patient-focused style, which provided greater opportunities for patients to voice their concerns. On occasions, patients were willing to pursue their own agenda when their concern was initially overlooked. Conclusion: This study provides empirical evidence on communication patterns in physiotherapy practice. A more collaborative style of communication with a shared conversational agenda provided patients with the conversational space to describe their concerns more fully.

The influence of subliminal crosstalk in dementia narratives

Ethnographic audio-visual research data recorded in a busy dementia care environment were initially considered to be ‘contaminated’ by unwanted background noise. This included a variety of elements: ambient sound, mechanical noise, non-narrative vocalisation and narrative fragments from parallel conversation. Using the methodological lens of conversation analysis, we present an exploration of the striking temporal and sequential resonances between the narrative of one man with dementia and a group of care staff holding a separate conversation some distance away. We suggest that in this and similar settings, where random and intrusive background sounds and conversation form a ubiquitous backdrop, the presence of such ‘noise’ can have a detectable influence on the content and direction of situated narratives. We argue that rather than attempting to filter out these apparently intrusive sounds from micro-interactional data, interference elements can usefully be incorporated into the analysis of interactions.

Designing Nursing Care Practices Complemented by Robots: Ethical Implications and Application of Caring Frameworks

The nurse of today must be able to master a variety of technologies. This article will discuss the current state of robots, explore the ethical framework of the Care-Centered Value Sensitive Design (CCVSD) and the caring theory of Nursing As Caring theory as it relates to the sacred nurse-patient relationship. Integrating both an ethical and caring framework will serve the nursing profession as it wrestles with the role and function robots can and will be used in clinical practice in order to protect the nurse–patient relationship. As technology advances, we must remember some human experiences are not programmable.

Can goal-setting for patients with multimorbidity improve outcomes in primary care? Cluster randomised feasibility trial

INTRODUCTION

Goal-setting is recommended for patients with multimorbidity, but there is little evidence to support its use in general practice.

OBJECTIVE

To assess the feasibility of goal-setting for patients with multimorbidity, before undertaking a definitive trial.

DESIGN AND SETTING

Cluster-randomised controlled feasibility trial of goal-setting compared with control in six general practices.

PARTICIPANTS

Adults with two or more long term health conditions and at risk of unplanned hospital admission.

INTERVENTIONS

General practitioners (GPs) underwent training and patients were asked to consider goals before an initial goal-setting consultation and a follow-up consultation 6 months later. The control group received usual care planning.

OUTCOME MEASURES

Health-related quality of life (EQ-5D-5L), capability (ICEpop CAPability measure for Older people), Patient Assessment of Chronic Illness Care and healthcare use. All consultations were video-recorded or audio-recorded, and focus groups were held with participating GPs and patients.

RESULTS

Fifty-two participants were recruited with a response rate of 12%. Full follow-up data were available for 41. In the goal-setting group, mean age was 80.4 years, 54% were female and the median number of prescribed medications was 13, compared with 77.2 years, 39% female and 11.5 medications in the control group. The mean initial consultation time was 23.0 min in the goal-setting group and 19.2 in the control group. Overall 28% of patient participants had no cognitive impairment. Participants set between one and three goals on a wide range of subjects, such as chronic disease management, walking, maintaining social and leisure interests, and weight management. Patient participants found goal-setting acceptable and would have liked more frequent follow-up. GPs unanimously liked goal-setting and felt it delivered more patient-centred care, and they highlighted the importance of training.

CONCLUSIONS

This goal-setting intervention was feasible to deliver in general practice. A larger, definitive study is needed to test its effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN13248305; Post-results.

A Tale of Two Inquiries (or, Doing Being Competent in a Clinical Skills Exam)

Phenomenon: In high-stakes evaluations of communicative competency, data-gathering skills are commonly assessed through the use of standardized patient encounters. This article seeks to document inquiry practices in 2 such encounters in a setting designed to emulate a consequential, clinical skills examination. Approach: Drawing on the methods and findings of Conversation Analysis, we examine selected fragments seeking to understand how, in the ways in which they are organized, they produce quite different outcomes. Findings: In the first encounter, the topic of the patient's history of depression arises naturally in the course of the interview. It happens to be a checklist item for the case and the examinee receives credit for having elicited it. In the second encounter, though the examinee was the more clinically experienced, the topic does not come up and the examinee fails to receive credit. Insights: When we examine how the two inquiry sequences develop on a turn-by-turn basis, it becomes clear that the differences between inquiry practices that carefully constrain patient responses and those that leave space for patient elaboration are subtle but evident. Both types of practice, however, are presumably a part of competent clinical performance. We argue that looking carefully at how specific interactional practices operate within clinical interviews can enable us to become more articulate as to what might count as communicative competence in the clinic.

Addressing possible problems with patients' expectations, plans and decisions for the future: One strategy used by experienced clinicians in advance care planning conversations

OBJECTIVE

Giving terminally ill people opportunities to participate in advance care planning involves tensions between: endorsing and supporting patients' expectations, plans and decisions, and addressing how realistic these are. The latter risks exerting undue pressure to change plans; undermining autonomy; jeopardising therapeutic relationships. Our objective is to describe how experienced hospice doctors raise potential/actual problems with patients' expectations, plans or decisions.

METHODS

Conversation analysis of video-recorded consultations between five UK hospice consultants, 37 patients and their companions.

RESULTS

Eleven episodes involving five doctors were found. In all of these we identified a 'Hypothetical Scenario Sequence' where doctors raise a hypothetical future scenario wherein current plans/expectations turn out to be problematic, then engage patients in discussing what could be done about this. We describe features of this sequence and how it can circumvent the risks of addressing problems with patients' expectations and plans.

CONCLUSION

Our research breaks new ground, showing that by treating expectations, plans and decisions as potentially not actually problematic, practitioners can recognise and support patients' preferences whilst preparing them for possible difficulties and inevitable uncertainties.

PRACTICE IMPLICATIONS

Where professionals judge it appropriate to raise problems about patients' preferences, plans and decisions, this sequence can manage the associated risks.

Patients' accounts of memory lapses in interactions between neurologists and patients with functional memory disorders

One of the most commonly made diagnoses in secondary care memory services is functional memory disorder (FMD). FMD is non-progressive and characterised by persistent worries about memory failures without objective evidence of cognitive impairment. This study explores how patients with FMD present their memory concerns. Utilizing video recordings of consultations between patients and neurologists in a memory clinic, we show that FMD patients account for their memory deficits as significant disruptions to their daily lives. Resonating with research which identified a dissonance between self-reports of memory functioning by FMD patients and the outcome of neuropsychological assessments, we demonstrate that, in giving a detailed account of their perceived memory problems, patients provide objective conversational evidence of their cognitive and memory capacity, implicitly undermining the claim of an objective problem. Using conversation analysis, we examine three of the more prominent interactional practices FMD patients draw on when attempting to communicate memory deficits to the doctor - they are (i) contrasts with a standard of 'normal'; (ii) third-party observations; and (iii) direct reported speech. These interactional features are recurrent devices for displaying memory concerns as legitimate problems, embedded within patients' accounts of their day-to-day lives.

Developing Methods That Facilitate Coding and Analysis of Synchronous Conversations via Virtual Environments

Programs via the Internet are uniquely positioned to capture qualitative data. One reason is because the Internet facilitates the creation of a community of similar individuals who can exchange information and support related to living with a chronic illness. Synchronous conversations via the Internet can provide insight into real-time social interaction and the exchange of social support. One way to analyze interactions among individuals is by using qualitative methods such as content, conversation, or discourse analysis. This manuscript describes how we used content analysis with aspects from conversation and discourse analysis to analyze synchronous conversations via the Internet to describe what individuals talk about and how individuals talk in an Internet-mediated interaction. With the increase in Internet interventions that facilitate collection of real-time conversational data, this article provides insight into how combining qualitative methods can facilitate the coding and analysis of these complex data.

The co-construction of medical disposals in emergency medicine consultations

Waiting times in Accident and Emergency (A&E) Departments are a key performance indicator for the UK National Health Service (NHS) and are linked to medical decision making. We use the concept of medical disposal to consider the ways in which patients' medical problems are remoulded and transformed into a solvable problem enabling what he refers to as 'medical disposal'. Drawing on a study of 16 video-recorded cases from a single A&E Department in the UK, collected in 2014 and 2015, conversation analysis is used to explore how options for disposal (referral and discharge) are constructed and received in interactions between junior doctors and consultants. We consider the potential impact of information imbalances between junior doctors and consultants, as well as orientation to organisation goals in the form of standardised procedures and guidelines and constraints on time. In this way we demonstrate the interactional delicacy of discussions between junior doctors and consultants concerning moving patients on from A&E. We show how when juniors discuss cases with consultants the resultant decision making may be viewed as co-constructed. We make a case for detailed and nuanced understanding of interactions in A&E departments in order to understand the complexity of decision-making in this highly politically visible setting.

Parent-directed commentaries during children's hearing habilitation appointments: a practice in family-centred care

BACKGROUND

Family-centred care (FCC) is recognized as best practice in the delivery of early intervention services for children with hearing loss (HL) and their families. However, there has been little research involving direct observation of family-centred communication practices in paediatric hearing habilitation appointments, which means little is currently known about how family members are involved within appointments, and how FCC is accomplished by health professionals through their interactions with families.

AIMS

To examine the interaction between hearing healthcare professionals, children with HL, and their parents within video-recorded paediatric hearing habilitation appointments (including both audiology and speech and language therapy appointments), with a particular focus on how parents were involved in the interaction.

METHODS & PROCEDURES

The data for this study involved a corpus of 48 video-recorded paediatric hearing habilitation appointments from three clinical sites (including 33 audiology appointments and 15 speech pathology appointments). Participants included 14 audiologists, 8 speech and language therapists, 41 children with HL (aged 18 months and over) and 48 of their attending family members (e.g., parents/carers). The data were analyzed using conversation analysis.

OUTCOMES & RESULTS

Analysis revealed one specific practice that health professionals used to engage parents in the interaction during child-directed assessment and therapy tasks: that of 'parent-directed commentaries', where health professionals shifted their attention to the parent(s) to describe or evaluate what they were observing during appointment tasks. Health professionals were observed to produce two types of parent-directed commentaries: (1) a positive evaluation of the child's just-prior response; and (2) an account for the child's prior behaviour (sometimes also accompanied by a positive evaluation). These commentaries appeared at systematic points in the interaction when the child had been displaying difficulty with their response to the health professional. The parent-directed commentaries accomplished several important functions: they engaged the parent's attention in the interaction; focused the parent's attention on positive responses from the child (while shrouding less positive responses); played down potential negative perceptions of the child's previous missed/incorrect responses; and provided parents with reassurance of their child's progress during the ongoing task.

CONCLUSIONS & IMPLICATIONS

The parent-directed commentaries identified in this study provide an example of the practical, interactional resources that health professionals can draw on within paediatric appointments to facilitate FCC with parents.

Evaluating nuanced practices for initiating decision-making in neurology clinics: a mixed-methods study

Background

We report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another.

Objectives

To (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making.

Design

A mixed-methods secondary analysis of recorded neurology consultations and associated questionnaire responses. We coded every recommendation, PVE and option-list together with a range of variables internal (e.g. patients’ responses) and external to the consultation (e.g. self-reported patient satisfaction). The resulting matrix captured the qualitative and quantitative data for every decision.

Setting and participants

The primary study was conducted in two neurology outpatient centres. A total of 14 neurologists, 223 patients and 114 accompanying others participated.

Results

Distribution of practices – recommending was the most common approach to decision-making. Patient demographics did not appear to play a key role in patterning decisional practices. Several clinical factors did show associations with practice, including (1) that neurologists were more likely to use option-lists or PVEs when making treatment rather than investigation decisions, (2) they were more certain about a diagnosis and (3) symptoms were medically explained. Consequences of practices – option-lists and PVEs (compared with recommendations) – were strongly associated with choice by neurologists and patients. However, there was no significant difference in overall patient satisfaction relating to practices employed. Recommendations were strongly associated with a course of action being agreed. Decisions containing PVEs were more likely to end in rejection. Option-lists often ended in the decision being deferred. There was no relationship between length of consultation and the practice employed.

Limitations

A main limitation is that we judged only outcomes based on the recorded consultations and the self-report data collected immediately thereafter. We do not know what happened beyond the consultation.

Conclusions

Patient choice is harder to enact than policy directives acknowledge. Although there is good evidence that neurologists are seeking to enact patient choice, they are still more likely to make recommendations. This appears to be partly due to concerns that ‘choice’ might conflict with doctors’ duty of care. Future guidance needs to draw on evidence regarding choice in practice to support doctors and patients to achieve the wider goal of shared decision-making.

Future research

To advance understanding of how interactional practices might have effects beyond the clinic, a priority is to investigate associations between decision-making practices and external outcomes (such as adherence).

Funding

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

Reflecting on what 'you said' as a way of reintroducing difficult topics in child mental health assessments

BACKGROUND

In child and adolescent mental health assessments, questions are integral to the process. There has been limited research focused on the assessment process, or on how questions are constructed within this clinical environment.

METHODS

We examined 28 naturally occurring initial assessments, with particular attention to how practitioners used questions in their communication with children and young people. We utilised conversation analysis to examine the data.

RESULTS

Analysis revealed a particular type of question preface used to reintroduce a prior topic. This was achieved through the use of 'you said x' as a foundation for asking a follow-up question and demonstrated active listening.

CONCLUSIONS

Arguably, this approach is a useful way of gathering assessment-relevant information in a child-centred way.

Agenda setting with children using the 'three wishes' technique

The National Health Service (UK) offers initial screening appointments for children referred to child and adolescent mental health services to determine clinical need and assess risk. Conversation analysis was utilized on 28 video recordings of these assessments, lasting approximately 90 minutes each with a multidisciplinary team. This article focuses on the agenda setting strategies used to establish relevant goals with children and adolescents; specifically, the technique of offering 'three wishes'. For example, ' if you had three wishes, what would you like to make happen?' In cases where children initially volunteered an assessment-relevant wish, they tended not to articulate further wishes. Non-assessment-relevant wishes (i.e. fantasy wishes, such as being 'rich') were treated as insufficient, with many approaches used to realign establishing assessment relevant goals. Where responses were not institutionally relevant, practitioners undertook considerable discursive work to realign the focus of the three wishes task to assessment relevance. In these cases, the wish responses were treated as irrelevant and tended to be dismissed, rather than explored for further detail. Such work with the children's contributions has implications for engaging children and child-centred practices.

GP-delivered brief weight loss interventions: a cohort study of patient responses and subsequent actions, using conversation analysis in UK primary care

Background

Guidelines encourage GPs to make brief opportunistic interventions to support weight loss. However, GPs fear that starting these discussions will lead to lengthy consultations. Recognising that patients are committed to take action could allow GPs to shorten brief interventions.

Aim

To examine which patient responses indicated commitment to action, and the time saved if these had been recognised and the consultation closed sooner.

Design and setting

A mixed-method cohort study of UK primary care patients participating in a trial of opportunistic weight management interventions.

Method

Conversation analysis was applied to 226 consultation audiorecordings to identify types of responses from patients that indicated that an offer of referral to weight management was well received. Odds ratios (OR) were calculated to examine associations between response types and likelihood of weight management programme attendance.

Results

Affirmative responses, for example ‘yes’, displayed no conversational evidence that the referral was well received and showed no association with attendance: ‘yes’ (OR 1.2, 95% confidence interval [CI] = 0.37 to 3.95, P = 0.97). However, ‘oh’-prefaced responses and marked positive responses, for example ‘lovely’, showed conversational evidence of enthusiasm and were associated with higher odds of commercial weight management service attendance. Recognising these could have saved doctors a mean of 31 seconds per consultation.

Conclusion

When doctors make brief opportunistic interventions that incorporate the offer of help, ‘oh’-prefaced or marked positive responses indicate enthusiastic acceptance of the offer and a higher likelihood of take-up. Recognising these responses and moving swiftly to facilitate patient action would shorten the brief intervention in many cases.

Protocol paper for the 'Harnessing resources from the internet to maximise outcomes from GP consultations (HaRI)' study: a mixed qualitative methods study

INTRODUCTION

Many patients now turn to the internet as a resource for healthcare information and advice. However, patients' use of the internet to manage their health has been positioned as a potential source of strain on the doctor-patient relationship in primary care. The current evidence about what happens when internet-derived health information is introduced during consultations has relied on qualitative data derived from interview or questionnaire studies. The 'Harnessing resources from the internet to maximise outcomes from GP consultations (HaRI)' study combines questionnaire, interview and video-recorded consultation data to address this issue more fully.

METHODS AND ANALYSIS

Three data collection methods are employed: preconsultation patient questionnaires, video-recorded consultations between general practitioners (GP) and patients, and semistructured interviews with GPs and patients. We seek to recruit 10 GPs practising in Southeast England. We aim to collect up to 30 patient questionnaires and video-recorded consultations per GP, yielding up to 300. Up to 30 patients (approximately three per participating GP) will be selected for interviews sampled for a wide range of sociodemographic characteristics, and a variety of ways the use of, or information from, the internet was present or absent during their consultation. We will interview all 10 participating GPs about their views of online health information, reflecting on their own usage of online information during consultations and their patients' references to online health information. Descriptive, conversation and thematic analysis will be used respectively for the patient questionnaires, video-recorded consultations and interviews.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the London-Camden & Kings Cross Research Ethics Committee. Alongside journal publications, dissemination activities include the creation of a toolkit to be shared with patients and doctors, to guide discussions of material from the internet in consultations.

It takes two to tango: A dyadic approach to understanding the medication dialogue in patient-provider relationships

OBJECTIVE

To describe typologies of dyadic communication exchanges between primary care providers and their hypertensive patients about prescribed antihypertensive medications.

METHODS

Qualitative analysis of 94 audiotaped patient-provider encounters, using grounded theory methodology.

RESULTS

Four types of dyadic exchanges were identified: Interactive (53% of interactions), divergent-traditional (24% of interactions), convergent-traditional (17% of interactions) and disconnected (6% of interactions). In the interactive and convergent-traditional types, providers adopted a patient-centered approach and used communication behaviors to engage patients in the relationship. Patients in these interactions adopted either an active role in the visit (interactive), or a passive role (convergent-traditional). The divergent-traditional type was characterized by provider verbal dominance, which inhibited patients' ability to ask questions, seek information, or check understanding of information. In the disconnected types, providers used mainly closed-ended questions and terse directives to gather and convey information, which was often disregarded by patients who instead diverted the conversation to psychosocial issues.

CONCLUSIONS

This study identified interdependent patient-provider communication styles that can either facilitate or hinder discussions about prescribed medications.

PRACTICE IMPLICATIONS

Examining the processes that underlie dyadic communication in patient-provider interactions is an essential first step to developing interventions that can improve the patient-provider relationship and patient health behaviors.

Facilitating patient participation in physiotherapy: Symptom-talk during exercise therapy from an Asian context

Background and purpose: Patient participation is the cornerstone for effective physiotherapy intervention. The aim was to analyze how patients and physiotherapists negotiate symptoms during exercise therapy and describe patients' participation during this process. Methods: Nineteen consultations with sixteen patients and six physiotherapists were video-recorded in two Hong Kong outpatient settings. Conversation Analysis was used to uncover interactional aspects of symptom-talk, focusing on turn-taking, sequence organization, and vocabulary. Results: Physiotherapists explored patients' symptoms only minimally and their frequent use of closed-ended questions allowed limited opportunity for participation. For patient-initiated symptom-talk, less than half elicited actions from physiotherapists, whose minimal acknowledgments were often accepted. Yet, some patients achieved a more substantial contribution through: (1) pausing the exercise-in-progress; (2) gazing at the physiotherapist; (3) pointing at the painful area; and (4) interrupting the physiotherapist, thereby challenging the social order. While discussion about symptoms was often initiated by physiotherapists, some patients participated actively by engaging in certain communicative strategies. Conclusions: Patient participation can be improved by physiotherapists offering a supportive environment (i.e., question design, responding to patients' initiations, and promoting health literacy), and by patients embracing action-engendering communicative strategies. The fine details of interaction shed light onto the subtleties of symptom-talk initiated by patients or physiotherapists in physiotherapy.

Goal setting dynamics that facilitate or impede a client-centered approach

BACKGROUND

Client-centred goal setting is central to the process of enabling occupation. Yet, there are multiple barriers to incorporating client-centred goal setting in practice. We sought to determine what might facilitate or impede the formation of client-centred goals in a context highly supportive of client-centred goal setting Methods: We used conversational analysis to examine goal-setting conversations that took place during a pilot trial of Occupational Performance Coaching for stroke survivors. Twelve goal-setting sessions were purposively selected, transcribed, and analyzed according to conventions for conversation analysis.

RESULTS

Two main types of interactions were observed: introductory actions and goal selection actions. Introductory actions set the context for goal setting and involved sharing information and seeking clarification related to goal requirements and clients' occupational performance competencies. Goal selection actions were a series of interactions whereby the goals were explored, endorsed or dropped.

CONCLUSION

Client-centred occupational performance goals may be facilitated through placing goal-setting in the context of life changes and lifelong development of goals, and through listening to clients' stories. Therapists may improve consistency in adoption of client-suggested goals through clarifying meaning attached to goals and being attuned to power dynamics and underlying values and beliefs around risk and goal attainability.

Is it my turn to speak? An analysis of the dialogue in the family-physician intensive care unit conference

OBJECTIVE

Apply turn analysis to family conferences in the pediatric intensive care unit.

METHODS

We analyzed 39 audio-recorded family conferences using the Roter Interaction Analysis System. A turn was defined as a continuous block of uninterrupted statements by a speaker.

RESULTS

Opening turns by the healthcare team (HCT) averaged 207s, compared to 28s for families. Turn density (number of statements/turn) was 6 for the HCT versus 2 for families (p<0.0001). An average of 21 turns (26%) occurred between HCT members, resulting in substantial sections of dialogue excluding the family. Average HCT dialogue reflected a literacy demand of a 9th grade level, whereas family dialogue averaged a 5th grade level (p<0.0001). More HCT turns were related to higher reading level demand (r=0.34; p=0.03) and lower levels of patient-centeredness (r=-0.35, p=0.03).

CONCLUSION

The healthcare team can improve the communication experience for families by encouraging and facilitating family engagement in conference dialogue.

PRACTICE IMPLICATIONS

Changing how the healthcare team engages with families during communication events is vital to improving the experience for families. Our data suggests simple adjustments, such as limiting medical jargon and inter-team turns may lead to increased family participation and more family-centered care.

Consult, Negotiate, and Involve: Evaluation of an Advanced Communication Skills Program for Health Care Professionals

Effective communication is central to children, young people, and their families’ experiences of health care. Most patient complaints in developed health care systems result from ineffective communication, including inadequate information provision, not feeling listened to, failure to value patients concerns, and patients not feeling involved in care decisions. Advanced communication skills training is now embedded within cancer care policy in the United Kingdom and now features prominently within cancer education in many countries. Here, we share findings from a research evaluation of an advanced communication skills training program dedicated to health professionals caring for children and young people with cancer. We evaluated participants’ (n = 59) perceptions of the program, impact on their skills, knowledge, competence, and confidence. An appreciative inquiry design was adopted; data included interviews, precourse-postcourse evaluations, e-mail blog survey, and 360-degree reflective work records. The framework approach underpinned data analysis and triangulation of data sets. Key findings highlighted good and poor practice in health professionals’ engagement with children, young people, and their families; the purpose of communicating effectively was not always consistent with collaborative working. Attending a program helped participants expand their knowledge of communication theories and strategies. Participants valued using simulated scenarios to develop their skills and were keen to use their new skills to enhance care delivery. Our emphasis within this evaluation, however, remained on what was communicated, when and how, rather than to what effect. The impact of programs such as these must now be evaluated in terms of patient benefit.

Using physical objects with young children in 'face-to-face' and telehealth speech and language therapy

PURPOSE

Speech language therapists increasingly are using telehealth to enhance the accessibility of their services. It is unclear, however, how play-based therapy for children can be delivered via telehealth. In particular, modalities such as videoconferencing do not enable physical engagement between therapists and clients. The aim of our reported study was to understand how physical objects such as toys are used in similar and different ways across videoconferenced and "face-to-face" (hereafter, "in-person") therapy.

METHODS

We used conversation analytic methods to compare video-recorded therapy sessions for children delivered across in-person and telehealth settings. Utilising a broader corpus of materials, our analysis focused on four client-therapist dyads: two using videoconferencing, and two who met in-person.

RESULTS

Both videoconferencing and in-person sessions enabled routine affordances and challenges for delivering therapy. Within in-person therapy, therapists made access to objects contingent upon the client producing some target expression. This contingency usually was achieved by restricting physical access to these objects. Restricting access to a toy was not necessary in videoconferenced therapy; therapists instead used techniques to promote engagement.

CONCLUSIONS

When delivering play-based therapy via telehealth, our study demonstrates how practitioners adapt the intervention to suit the particular medium of its delivery. Implications for Rehabilitation Telehealth enhances equitable access for those who cannot physically access rehabilitation services. Telehealth modalities can create practical challenges, however, when delivering interventions such as play-based therapy. Practitioners should intentionally adapt telehealth interventions to suit the particular telehealth modality they are using.

A taboo topic? How General Practitioners talk about overweight and obesity in New Zealand

ABSTRACT INTRODUCTION Obesity is overtaking tobacco smoking in New Zealand as the leading potentially modifiable risk to health. International obesity guidelines recommend that health professionals opportunistically encourage weight management with their patients. However, research shows consistently low rates of weight management discussion, suggesting that health professionals may not be realising their full potential to address obesity. AIM To identify communication strategies used by General Practitioners (GPs) to open the topic of weight and weight management in routine consultations. METHODS A secondary analysis was conducted of 36 video-recorded consultations in general practices, selected for relevance from a database of 205 consultations. Content and interactional analysis was conducted in the context of the entire consultation. RESULTS The topic of weight was initiated more often by GPs than patients and was raised mostly once or twice in a consultation and occasionally as many as six times. GPs employed opportunistic strategies twice as often as they used structured strategies. DISCUSSION This study of naturally occurring consultations confirmed GPs do engage in opportunistic discussions about weight. However, such discussions are challenging and interactionally delicate. Highlighting the clinical relevance of weight appears to be effective. The high frequency of patient contact with GPs provides opportunity to reach and work with people at risk of chronic conditions associated with excess weight. Further research is required to identify suitable training and brief intervention tools for use in routine consultations that may be beneficial for both GPs and patients.

Managing risk and patient involvement in choosing treatment for cancer: an analysis of two communication practices

Drawing on conversation analyses of oncology consultations collected in Italy, the article examines the communication practices used to recommend treatments. We found that the oncologist formulates the treatment recommendation (TR) for high-risk patients in terms of a 'mandatory' choice and for low-risk patients as an 'optional' type of decision. In the first case the doctor presses to reach a decision during the visit while in the second case leaves the decision open-ended. Results show that high-risk patients have less time to decide, are pressured towards choosing an option, but have more opportunities for involvement in TR during the visit. Low-risk patients instead have more time and autonomy to make a choice, but they are also less involved in the decision-making in the visit time. Moreover, we document that TR is organised through sequential activities in which the oncologist informs the patient of alternative therapeutic options while at the same time building a case for the kind of treatment she/he believes to be best for the patient's health. We suggest that in this field risk plays a key role in decision-making which should be better understood with further studies and taken into account in the debate on shared decision-making and patient-centred communication.

The pattern of educator voice in clinical counseling in an educational hospital in Shiraz, Iran: a conversation analysis

Doctor-patient interaction (DPI) includes different voices, of which the educator voice is of considerable importance. Physicians employ this voice to educate patients and their caregivers by providing them with information in order to change the patients' behavior and improve their health status. The subject has not yet been fully understood, and therefore the present study was conducted to explore the pattern of educator voice. For this purpose, conversation analysis (CA) of 33 recorded clinical consultations was performed in outpatient educational clinics in Shiraz, Iran between April 2014 and September 2014. In this qualitative study, all utterances, repetitions, lexical forms, chuckles and speech particles were considered and interpreted as social actions. Interpretations were based on inductive data-driven analysis with the aim to find recurring patterns of educator voice. The results showed educator voice to have two general features: descriptive and prescriptive. However, the pattern of educator voice comprised characteristics such as superficiality, marginalization of patients, one-dimensional approach, ignoring a healthy lifestyle, and robotic nature. The findings of this study clearly demonstrated a deficiency in the educator voice and inadequacy in patient-centered dialogue. In this setting, the educator voice was related to a distortion of DPI through the physicians' dominance, leading them to ignore their professional obligation to educate patients. Therefore, policies in this regard should take more account of enriching the educator voice through training medical students and faculty members in communication skills.

Is it acceptable to video-record palliative care consultations for research and training purposes? A qualitative interview study exploring the views of hospice patients, carers and clinical staff

BACKGROUND

Research using video recordings can advance understanding of healthcare communication and improve care, but making and using video recordings carries risks.

AIM

To explore views of hospice patients, carers and clinical staff about whether videoing patient-doctor consultations is acceptable for research and training purposes.

DESIGN

We used semi-structured group and individual interviews to gather hospice patients, carers and clinical staff views. We used Braun and Clark's thematic analysis.

SETTING/PARTICIPANTS

Interviews were conducted at one English hospice to inform the development of a larger video-based study. We invited patients with capacity to consent and whom the care team judged were neither acutely unwell nor severely distressed (11), carers of current or past patients (5), palliative medicine doctors (7), senior nurses (4) and communication skills educators (5).

RESULTS

Participants viewed video-based research on communication as valuable because of its potential to improve communication, care and staff training. Video-based research raised concerns including its potential to affect the nature and content of the consultation and threats to confidentiality; however, these were not seen as sufficient grounds for rejecting video-based research. Video-based research was seen as acceptable and useful providing that measures are taken to reduce possible risks across the recruitment, recording and dissemination phases of the research process.

CONCLUSION

Video-based research is an acceptable and worthwhile way of investigating communication in palliative medicine. Situated judgements should be made about when it is appropriate to involve individual patients and carers in video-based research on the basis of their level of vulnerability and ability to freely consent.

Patient involvement and language barriers: Problems of agreement or understanding?

OBJECTIVE

This study aims to explicate efforts for realizing patient-centeredness (PCC) and involvement (SDM) in a difficult decision-making situation. It investigates what communicative strategies a physician used and the immediate, observable consequences for patient participation.

METHODS

From a corpus of videotaped hospital encounters, one case in which the physician and patient used Norwegian as lingua franca was selected for analysis using conversation analysis (CA). Secondary data were measures of PCC and SDM.

RESULTS

Though the physician did extensive interactional work to secure the patient's understanding and acceptance of a treatment recommendation, his persistent attempts did not succeed in generating the patient's participation. In ratings of PCC and SDM, this case scored well above average.

CONCLUSION

Despite the fact that this encounter displays some of the 'best actual practice' of PCC and SDM within the corpus, our analysis of the interaction shows why the strategies were insufficient in the context of a language barrier and possible disagreement.

PRACTICE IMPLICATIONS

When facing problems of understanding, agreement and participation in treatment decision-making, relatively good patient centered skills may not suffice. Knowledge about the interactional realization of key activities is needed for developing training targeted at overcoming such challenges.

Communication practices that encourage and constrain shared decision making in health-care encounters: Systematic review of conversation analytic research

Background

Shared decision making (SDM) is generally treated as good practice in health‐care interactions. Conversation analytic research has yielded detailed findings about decision making in health‐care encounters.

Objective

To map decision making communication practices relevant to health‐care outcomes in face‐to‐face interactions yielded by prior conversation analyses, and to examine their function in relation to SDM.

Search strategy

We searched nine electronic databases (last search November 2016) and our own and other academics' collections.

Inclusion criteria

Published conversation analyses (no restriction on publication dates) using recordings of health‐care encounters in English where the patient (and/or companion) was present and where the data and analysis focused on health/illness‐related decision making.

Data extraction and synthesis

We extracted study characteristics, aims, findings relating to communication practices, how these functioned in relation to SDM, and internal/external validity issues. We synthesised findings aggregatively.

Results

Twenty‐eight publications met the inclusion criteria. We sorted findings into 13 types of communication practices and organized these in relation to four elements of decision‐making sequences: (i) broaching decision making; (ii) putting forward a course of action; (iii) committing or not (to the action put forward); and (iv) HCPs' responses to patients' resistance or withholding of commitment. Patients have limited opportunities to influence decision making. HCPs' practices may constrain or encourage this participation.

Conclusions

Patients, companions and HCPs together treat and undertake decision making as shared, though to varying degrees. Even for non‐negotiable treatment trajectories, the spirit of SDM can be invoked through practices that encourage participation (eg by bringing the patient towards shared understanding of the decision's rationale).

Using a patient decision aid for insulin initiation in patients with type 2 diabetes: a qualitative analysis of doctor-patient conversations in primary care consultations in Malaysia

OBJECTIVE

To investigate whether the use of apatient decision aid (PDA) for insulin initiation fulfils its purpose of facilitating patient-centred decision-making through identifying how doctors and patients interact when using the PDA during primary care consultations.

DESIGN

Conversation analysis of seven single cases of audio-recorded/video-recorded consultations between doctors and patients with type 2 diabetes, using a PDA on starting insulin.

SETTING

Primary care in three healthcare settings: (1) one private clinic; (2) two public community clinics and (3) one primary care clinic in a public university hospital, in Negeri Sembilan and the Klang Valley in Malaysia.

PARTICIPANTS

Clinicians and seven patients with type 2 diabetes to whom insulin had been recommended. Purposive sampling was used to select a sample high in variance across healthcare settings, participant demographics and perspectives on insulin.

PRIMARY OUTCOME MEASURES

Interaction between doctors and patients in a clinical consultation involving the use of a PDA about starting insulin.

RESULTS

Doctors brought the PDA into the conversation mainly by asking information-focused 'yes/no' questions, and used the PDA for information exchange only if patients said they had not read it. While their contributions were limited by doctors' questions, some patients disclosed issues or concerns. Although doctors' PDA-related questions acted as a presequence to deliberation on starting insulin, their interactional practices raised questions on whether patients were informed and their preferences prioritised.

CONCLUSIONS

Interactional practices can hinder effective PDA implementation, with habits from ordinary conversation potentially influencing doctors' practices and complicating their implementation of patient-centred decision-making. Effective interaction should therefore be emphasised in the design and delivery of PDAs and in training clinicians to use them.

Conversation breakdowns in the audiology clinic: the importance of mutual gaze

BACKGROUND

Conversational breakdowns are a persistent concern for older adults with hearing impairment (HI). Previous studies in experimental settings have investigated potential causes of breakdowns in conversations with a person with HI, and effective strategies for repairing these breakdowns. However, little research has explored the causes of hearing-related communication breakdowns, and their repairs, in extended, naturally occurring conversations in a healthcare setting.

AIMS

To analyse systematically instances of clients' initiations of repair within video-recorded initial audiology appointments, and to examine the interactional environment in which they occurred.

METHODS & PROCEDURES

Participants included 26 audiologists and their older adult clients (aged 55+ years). Companions were present in 17 of the 63 appointments. Conversation analysis (CA) was used to examine the video-recorded audiology appointments with older adults with HI. The corpus was systematically analysed for all instances of 'other-initiated repair' by clients (initiation of repair targeting the prior speakers' turn). A collection of 51 instances of other-initiated repair were identified. These instances were analysed in detail for: (1) the interactional environment in which they occurred; (2) the strategy by which the client initiated repair; and (3) the strategies used by the audiologist to repair the communication breakdown.

OUTCOMES & RESULTS

In 76% (n = 39) of the 51 cases of other-initiated repair from the client, there was a lack of mutual gaze between participants (i.e., either the audiologist or the client were looking away or facing in another direction during the prior turn). More specifically, many of these instances occurred when the audiologist was speaking to the client while multitasking. Audiologists used multiple-repair strategies in their responsive turn in an attempt to repair the communication breakdown efficiently.

CONCLUSIONS & IMPLICATIONS

These findings, from extended, naturally occurring conversations with older adults with HI in clinic settings, highlight the importance of face-to-face communication even in quiet one-to-one settings. Clinicians should remain aware of their movements and gaze when speaking to clients during appointments. The findings also provide further support for the importance of communication programs in hearing rehabilitation.