Measuring empathic, person-centred communication in primary care nurses:validity and reliability of the Consultation and Relational Empathy (CARE) Measure

Background Empathic patient-centred care is central to high quality health encounters. The Consultation and Relational Empathy (CARE) Measure is a patient-rated experience measure of the interpersonal quality of healthcare encounters. The measure has been extensively validated and is widely used by doctors in primary care but has not been validated in nursing. This study assessed the validity and reliability of the CARE Measure in routine nurse consultations in primary care. Methods Seventeen nurses from nine general medical practices located in three Scottish Health Boards participated in the study. Consecutive patients (aged 16 years or older) were asked to self-complete a questionnaire containing the CARE Measure immediately after their clinical encounter with the nurse. Statistical analysis included Spearman’s correlation and principal component analysis (construct validity), Cronbach’s alpha (internal consistency), and Generalisability theory (inter-rater reliability). Results A total of 774 patients (327 male and 447 female) completed the questionnaire. Almost three out of four patients (73 %) felt that the CARE Measure items were very important to their current consultation. The number of ‘not applicable’ responses and missing values were low overall (5.7 and 1.6 % respectively). The mean CARE Measure score in the consultations was 45.9 and 48 % achieved the maximum possible score of 50. CARE Measure scores correlated in predicted ways with overall satisfaction and patient enablement in support of convergent and divergent validity. Factor analysis found that the CARE Measure items loaded highly onto a single factor. The measure showed high internal consistency (Cronbach’s alpha coefficient = 0.97) and acceptable inter-rater reliability (G = 0.6 with 60 patients ratings per nurse). The scores were not affected by patients’ age, gender, self-perceived overall health, living arrangements, employment status or language spoken at home. Conclusions The CARE Measure has high face and construct validity, and internal reliability in nurse consultations in primary care. Its ability to discriminate between nurses is sufficient for educational and quality improvement purposes

Multimorbidity and socioeconomic deprivation in primary care consultations

Purpose: The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation. Methods: We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP’s empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups. Results: In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727). Conclusions: In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care

Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care

Growing demands on primary care services have led to policymakers promoting video consultations (VCs) to replace routine face-to-face consultations (FTFCs) in general practice. AIM: To explore the content, quality, and patient experience of VC, telephone (TC), and FTFCs in general practice. DESIGN AND SETTING: Comparison of audio-recordings of follow-up consultations in UK primary care. METHOD: Primary care clinicians were provided with video-consulting equipment. Participating patients required a smartphone, tablet, or computer with camera. Clinicians invited patients requiring a follow-up consultation to choose a VC, TC, or FTFC. Consultations were audio-recorded and analysed for content and quality. Participant experience was explored in post-consultation questionnaires. Case notes were reviewed for NHS resource use. RESULTS: Of the recordings, 149/163 were suitable for analysis. VC recruits were younger, and more experienced in communicating online. FTFCs were longer than VCs (mean difference +3.7 minutes, 95% confidence interval [CI] = 2.1 to 5.2) or TCs (+4.1 minutes, 95% CI = 2.6 to 5.5). On average, patients raised fewer problems in VCs (mean 1.5, standard deviation [SD] 0.8) compared with FTFCs (mean 2.1, SD 1.1) and demonstrated fewer instances of information giving by clinicians and patients. FTFCs scored higher than VCs and TCs on consultation-quality items. CONCLUSION: VC may be suitable for simple problems not requiring physical examination. VC, in terms of consultation length, content, and quality, appeared similar to TC. Both approaches appeared less 'information rich' than FTFC. Technical problems were common and, though patients really liked VC, infrastructure issues would need to be addressed before the technology and approach can be mainstreamed in primary care.Chief Scientist Office for Scotlan

The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study

Background: There is international interest in the potential role of different forms of communicationtechnology to provide an alternative to face-to-face consultations in health care. There has beenconsiderable rhetoric about the need for general practices to offer consultations by telephone, e-mail orinternet video. However, little is understood about how, under what conditions, for which patients and inwhat ways these approaches may offer benefits to patients and practitioners in general practice.Objectives: Our objectives were to review existing evidence about alternatives to face-to-face consultation;conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives;recruit eight general practices as case studies for focused ethnographic research, exploring how practicecontext, patient characteristics, type of technology and the purpose of the consultation interact to determinethe impact of these alternatives; and synthesise the findings in order to develop a website resource about theimplementation of alternatives to face-to-face consultations and a framework for subsequent evaluation.Design: Mixed-methods case study.Setting: General practices in England and Scotland with varied experience of implementing alternatives toface-to-face consultations.Participants: Patients and practice staff.Interventions: Alternatives to face-to-face consultations include telephone consultations, e-mail,e-consultations and internet video.Main outcome measures: How context influenced the implementation and impact of alternatives to theface-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms ofconsultation by different patient groups; and the intended benefits/outcomes.Review methods: The conceptual review used an approach informed by realist review, a method forsynthesising research evidence regarding complex interventions.Results: Alternatives to the face-to-face consultation are not in mainstream use in general practice, withlow uptake in our case study practices. We identified the underlying rationales for the use of thesealternatives and have shown that different stakeholders have different perspectives on what they hope toachieve through the use of alternatives to the face-to-face consultation. Through the observation of real-lifeuse of different forms of alternative, we have a clearer understanding of how, under what circumstancesand for which patients alternatives might have a range of intended benefits and potential unintendedadverse consequences. We have also developed a framework for future evaluation.Limitations: The low uptake of alternatives to the face-to-face consultation means that our researchparticipants might be deemed to be early adopters. The case study approach provides an in-depthexamination of a small number of sites, each using alternatives in different ways. The findings aretherefore hypothesis-generating, rather than hypothesis-testing.Conclusions: The current low uptake of alternatives, lack of clarity about purpose and limited evidence ofbenefit may be at odds with current policy, which encourages the use of alternatives. We have highlightedkey issues for practices and policy-makers to consider and have made recommendations about priorities forfurther research to be conducted, before or alongside the future roll-out of alternatives to the face-to-faceconsultation, such as telephone consulting, e-consultation, e-mail and video consulting.Future work: We have synthesised our findings to develop a framework and recommendations aboutfuture evaluation of the use of alternatives to face-to-face consultations.Funding details: The National Institute for Health Research Health Services and DeliveryResearch programme.ABSTRACTNIH

Receptionists' role in new approaches to consultations in primary care: A focused ethnographic study

© British Journal of General Practice. Background The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. Aim The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. Design and setting The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. Method Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. Results Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to faceto-face consultations was minimal, despite the expectation that they would be involved in delivery. Conclusion A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations

Alternatives to the face-to-face consultation in general practice: Focused ethnographic case study

© British Journal of General Practice. Background NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives. Aim To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice. Design and setting Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016. Method Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the 'one sheet of paper' mind-map method to identify the line of argument in each thematic report. Results Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other's practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-toface consultation as the ideal. Conclusion Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team

Making sense of bodily sensations: Do shared cancer narratives influence symptom appraisal?

Though new or altered bodily sensations are a common occurrence they rarely transition to biomedically defined symptoms. When they do, sensations are subject to an appraisal process that can culminate in help-seeking. The transition has particular relevance for cancer diagnoses. Studies of 'symptom appraisal' in cancer patients typically conclude that failure to regard sensations as serious or 'symptom misattribution' results in lengthier help-seeking intervals. Though multiple influences on appraisal processes are acknowledged, including the socio-cultural context, detailed description and analyses of how socio-cultural factors shape appraisal is lacking. In this paper we explore one substantial component of the sociocultural context, namely, publicly recognised shared cancer narratives, and their impact on appraisal. We undertook a secondary analysis of 24 interviews with Scottish colorectal cancer patients originally completed in 2006–2007. Our analysis showed that fear, death and severity dominated cancer narratives and were frequently restated throughout interviews. Yet, early bodily changes were often mild and vague, were commonly experienced in the context of 'feeling well' and failed to match preconceived ideas of what cancer 'feels like'. Moreover, few perceived themselves to be 'at risk' of cancer and diagnoses were characterised as 'shocking' events. Participants engaged in self-monitoring strategies and severe or painful changes prompted help-seeking. Far from misattributing symptoms, responses to bodily changes were sensible and measured; responses are particularly apt in relation to current policy rhetoric, which urges measured use of services. Our findings have resonance across healthcare settings as patients are required to negotiate a narrow and challenging space when making decisions to seek help. There is a pressing need for a more realistic approach to symptom appraisal in order to reduce help-seeking intervals. Future awareness campaigns should emphasise the importance of vague/minor bodily changes although this will necessitate discussions with health professionals on referral thresholds to achieve earlier detection