Communication and patient involvement in decision making : examples from consultations on atrial fibrillation

Background: Further knowledge is needed regarding communication that occurs in practice between patients with atrial fibrillation (AF) and health professionals in consultations to understand the issue of patient involvement in treatment decisions. Overall aim: The overall aim of this thesis is to contribute knowledge on communication between patients and health professionals (cardiology nurses and cardiologists), focussing on how they create involvement in decision making in consultations. Specific aims: (1) To describe (i) the topics that patients with AF discuss with cardiology nurses and cardiologists; (ii) the use of discursive space in consultations between these participants; and (iii) the frequency at which patients, cardiology nurses, and cardiologists introduce identified topics. (2) To describe the different types of resistance by patients to treatment with warfarin and how cardiologists respond to such resistance. (3) To examine how patients describe involvement and communication in decision making regarding treatment in consultations with cardiology nurses and cardiologists. (4) To examine how cardiologists describe their views on patient involvement in AF treatment decisions, their perceptions regarding efforts to involve patients, and how they handle decisions. Methods: A qualitative design was used. In study I, the sample consisted of 23 videotaped consultations between patients with AF and cardiology nurses and cardiologists at six nurse-led cardiology outpatient clinics. Content analysis was used to obtain a description of topics that were discussed. The patterns of dominance for the various topics and participants were examined. In study II, the sample consisted of 11 videotaped consultations between patients with AF and cardiologists. Conversation analysis was used to describe interactions concerning resistance to treatment with warfarin. In study III, 22 patients with AF were interviewed directly after their consultations with cardiology nurses and cardiologists. Content analysis was used for the resulting data. In study IV, 10 cardiologists were interviewed in cardiology clinics at four Swedish hospitals and qualitative content analysis was used. Findings: In study I, a medically driven agenda dominated the patient-driven agenda. However, when the patients initiated conversations about their life with AF (the topic that received the least amount of space on the agenda), involvement was created. In study II, the patients’ resistance could be viewed as a source of knowledge about patients’ real-life situations and what motivates them. In study III, despite not being actively involved in the decision-making process, the patients experienced a sense of involvement when they felt understood and were listened to. In study IV, by taking into account the patients’ feelings in the consultations, and by actively encouraging the patients to be involved, the cardiologists contributed to patient involvement. Conclusions: Patients, cardiology nurses, and cardiologists create involvement in decision making in consultations as communicative projects. Patients strive for space and create involvement by showing resistance to the decisions suggested by health professionals. However, involvement is not only an issue about obtaining space in the consultations, but is also associated with obtaining clarification, building confidence, feeling understood, trusting cardiology nurses and cardiologists, and having confidence in receiving consistent care within an established relationship. On a theoretical level, this thesis sheds light on the interaction between the concepts of communication, involvement, and decision making

Interactional resistance between patients with atrial fibrillation and cardiologists in consultation on treatment with warfarin: the value of shared decision-making

Rationale: Atrial fibrillation (AF) increases the risk of stroke and it can be reduced by treatment with warfarin. Some patients consider that warfarin is a stressful treatment with undesired effects and the perceived barriers include unwillingness to take it. Knowledge of patients resisting warfarin treatment may be useful for the potential threat to maintaining shared decision-making in the consultation as a central tenet of person-centered medicine. Aims and objectives: To identify how patients resist treatment with warfarin and how cardiologists respond to patients’ resistance. The co-constructive perspective of this work analyses the consultations by emphasizing the clinical communication strategies of both patients and cardiologists. Method: Eleven videotaped consultations, in 4 different hospitals, were selected for analysis. Treatment interactions regarding warfarin between patients with AF and cardiologists were analysed, according to the methodology of conversation analysis. Results: There were 4 types of resistance from patients for accepting treatment with warfarin. These included “Giving reasons for their resistance”, “Suggestion of another treatment option by the patient”, “Stating a treatment preference” and “Questioning or challenging the cardiologist’s treatment recommendation”. The cardiologists’ responses to the patients’ resistance included “Repeating the treatment recommendation”, “Negotiation with the patient”, “Providing additional information on the recommended treatment” and “Extending the explanation for the purpose of taking the treatment”. Conclusions: By showing resistance, patients are thought to want to participate in their treatment decisions and an awareness of patients’ resistance to treatment enables cardiologists to address the patients’ experience-based views on their treatment and individual concerns as part of clinical strategies to increase the person-centeredness of medical intervention

Communicative constructions of person-centred and non-person-centred caring in nurse-led consultations

Purpose Nursing is theorised to be a component of person-centred care. Communicative constructions of person-centred caring are a topic that needs to be studied in consultations. The study aimed to explore how person-centred caring and non-person- centred caring are verbally constructed in consultations between patients and nurse. Method This study was qualitative using audio-recorded observations from consultations with advanced nurse practitioners in nurse-led chemotherapy clinics from four hospitals in the UK through purposive sampling. Discourse analysis was used to identify communicative patterns in 45 non-participant observations of nurse consultations. Results The dominant discourse was a non-person-centred oriented discourse framed by the biomedical model. It was also possible to identify fragments of an alternative discourse—a person-oriented discourse localising health problems within the patient's personal and sociocultural context. Conclusions The prominent use of a non-person-oriented discourse focusing on the medical/technical aspects of a patient's assessment/evaluation in consultations may make it difficult for patients to raise questions and concerns from their daily lives during consultations. However, fragments of a person-oriented discourse show that it is possible for nurses to allow a person-centred approach to the consultation. The pedagogical implications have to do with raising nurses' awareness of the role of evaluative language in enhancing person-centred communication with patients in clinical interactions

Communication patterns in nurse-led chemotherapy clinics:A mixed-method study

Objective: To determine patterns of nurse-patient communication in fulfilling patients’ informational/psychosocial needs, effects of longer consultation/operational aspects on person-centred care experiences. Methods: Mixed-method design; secondary analysis of transcripts of nurse-patient communication within nurse-led chemotherapy clinics in UK [3]. Purposive sampling (13 nurses); non-participant observations (61 consultations). Qualitative content analysis of audio-recorded transcripts. Quantitative analysis using the Medical Interview Aural Rating Scale [14] to compare mean differences in the number of cues and level of responding using one-way ANOVA, and correlational analyses of discursive spaces. Results: Nurses responded positively to informational cues, but not psychosocial cues. Longer consultations associated with more informational and psychosocial cues (p < .0001), but not nurses’ cue-responding behaviours. Four main themes emerged: challenges/opportunities for person-centred communication in biomedical contexts; patients’ “life world” versus the “medical world”; three-way communication: nurse, patient and family; implications of continuity of care. Conclusions: The challenges/opportunities for cue-responding in nurse-led chemotherapy clinics were evident for informational and psychosocial support of patients. Shifting from a biomedical to biopsychosocial focus is difficult. Practice implications: Further evaluation is needed to integrate biopsychosocial elements into communication education/training. Careful planning is required to ensure continuity and effective use of time for person-centred care

Communication Patterns in Consultations Between Patients with Atrial Fibrillation and Health Professionals

Background Patients’ preferences, needs and desires are important when discussing treatment. In consultations between patients with atrial fibrillation (AF) and health professionals, knowledge, understanding and insight about communication patterns are of vital importance for strengthening patient involvement in decision-making about their care and treatment. Aim The general aim of this thesis was to describe communication patterns in consultations between patients with AF and health professionals. Specific aims (1) To describe (i) the topics patients with AF and their nurses and physicians discuss; (ii) the use of discursive space in consultations between these participants; and (iii) the frequencies with which patients and nurses/physicians introduce the identified topics. (2) To describe the types of patient resistance to accepting treatment with warfarin and how cardiologists respond to such resistance. Methods An inductive design was used. In study I, the sample consisted of 23 consultations between patients with AF (13 women and 10 men) and health professionals (5 women and 5 men) who were employed in six different cardiologic outpatient clinics. Content analysis was used to obtain a description of topics discussed. The patterns of dominance for the various topics and participant were explored from the framework of an analysis of dominance (I). In study II, the sample consisted of 11 consultations between patients with AF (7 women and 4 men) and cardiologists (2 women and 3 men). Conversation analysis was used to describe interactions concerning resistance to treatment with warfarin. Findings Study I. Four topics were introduced by both nurses and physicians during the consultations. These were “pathophysiology”, “treatment”, “diagnostic procedures”, and “activity”. In the nurse–patient consultations an additional topic, “routines related to the physician’s responsibilities”, emerged. With respect to the number of words and turns, the distribution of the discourse space was almost equal between nurses and patients, and unequal between physicians and patients. The patients were the dominant initiators of the topic “activity”, which refers to adaptation of activities in daily life in relation to AF. Study II. There were four types of patient resistance to accepting treatment with warfarin. These included “Giving reasons for their resistance”, “Suggesting other treatment options”, “Stating treatment preferences” and “Questioning or challenging the cardiologist’s treatment recommendations”. The cardiologists’ responses to the patients’ resistance included “Repeating the treatment recommendation”, “Negotiation with the patient”, “Providing additional information about the recommended treatment” and “Extending their explanation of the purpose of the treatment”. Conclusions The medical-driven agenda dominated over the patient-driven agenda in consultations between health care professionals and patients with AF. During conversations in consultations with nurses, the patients initiated discussion of living with AF and were more talkative than they were with physicians. An awareness of types of patient resistance to treatment would enable cardiologists to consider patients’ experience-based views about their treatment

Patient centeredness from a perspective of history of the present : A genealogical analysis

The overall aim of this study, performed in Sweden, was to problematize the contemporary national and transnational discourse on patient centeredness, which during recent decades has become a given, having become established as a dogma in conversations, writing, and thinking about patients and health care. We did that by showing that ideas such as patient centeredness can be seen differently from the way they are depicted in contemporary discourses about health care. In the presented analysis, we drew on Foucault's concepts of governmentality, 'history of the present' and genealogy. This means that we reflected on contemporary conceptions of how phenomena, such as the care seeker, have been constructed within other discourses about health care. Empirically, we used different health policy documents-government reports from three different historical periods. The analysis showed that contemporary narratives about centeredness are neither more, nor less, care seeker-centered than the narratives of yesteryear. Rather, the phenomenon of the care seeker is given different frames and meanings within the framework of different economic and historical discourses about health care. Our analysis raised questions about the contemporary construction of patient centeredness. In a world with such huge economic differences between nations, as well as between citizens within most nations, the contemporary discourse may be limited as it does not problematize structural issues in the same way as previous discourses had done. Perhaps what is needed today are national and international patient-centered or person-centered discourses which also discuss policies and practices that are population- and social group-centered. In the final discussion of the analysis, we identified a new patient-centered discourse, which views the patient as a resource among other resources. The most important limitation of this type of study is that it is only about discourses and policy issues and not about daily practical activities

Communicative construction of native versus non-native Swedish speaking patients in consultation settings

In this paper, we examine patient-centered care through analyzing communicative constructions of patients, on the basis of their native language, in consultations with physicians. Whereas patient-centered care is of current interest in health care, research has not addressed its implications in this dimension. Previous studies indicate that non-native Swedish speaking patients, experience substandard interpersonal treatment far more than native Swedish speaking patients. Our findings show that the non-native Swedish speaking patients presented themselves as participating, whereas the native Swedish speaking patients presented themselves as amenable. The physicians responded in two different ways, argumentatively towards the non-native Swedish speaking patients and acknowledging vis-à-vis the native Swedish speaking patients. When decisions and conclusions were made by the patients and physicians, this resulted in preservation of the status quo in the consultations with the non-native Swedish speaking patients, while the corresponding result with the native Swedish speaking patients was monitoring of their health status. So, whereas the non-native Swedish speaking patients actually were model patient-centered care patients, physicians were more amenable towards the native Swedish speaking patients. We suggest that patient-centered care is desirable, but its practical application must be more thoroughly scrutinized from both a patient and a health care worker perspective

Nurses’ perceptions of patient involvement in shared decision-making in cardiovascular care

It is important for nurses to involve patients in their own care to enable shared decision-making. This study aimed to explore the perceptions of nurses regarding the degree to which involvement in shared decision-making takes place in clinical settings during consultations. Previous studies have shown that the use of shared decision-making by healthcare professionals can improve their caring practices and the quality of life of their patients. However, studies have also shown little evidence of the existence of shared decision-making in clinical practice. One step forward can be to clarify nurses’ perceptions of patient involvement in shared decision-making.Qualitative data were collected from 10 nurses at four Swedish hospitals using a semi-structured, open-ended interview guide. The data were analyzed using inductive latent content analysis. The results showed that the care practices described by the nurses in the study are clearly different from the healthcare policy and scientific vision of shared decision-making. The nurses in the study believe that, with some exceptions, both healthcare professionals and patients prefer to leave decision-making to medical experts. In order to take advantage of the existing potential for improvement of shared decision-making in cardiologic care, healthcare professionals must be given time to seriously listen to and develop an interest in their patients’ lifeworlds. Furthermore, the implementation of shared decision-making requires a mutual initiative and development of knowledge about the decision-making process from healthcare professionals and patients

The discharge process : From a patient's perspective

Inadequacy in discharge planning, preparation of readiness, and unplanned readmissions are closely linked and could cause misutilization of hospital services, creating higher costs to the health-care system. The information given before discharge is vital and of great importance for the well-being of the patient. The study's objective was to describe the patient's experience of their discharge process. A descriptive study was designed. Fifteen (n = 15) interviews with patients at one University Swedish hospital were held, and a qualitative content analysis was made from the collected data. The results show that accessibility, information, communication, confidence, and participation are pivotal in future development in the discharge process. The findings of this study indicate that in affirmation with the patient's experiences and desires, there is a great urgency for improvement in the discharge process. There is a need to focus on information and communication at discharge by initiating interaction from the nurses together with the doctors at a specific time in the discharge process. The discharge process needs to be more individualized and person-centered which could lead to better patient governance. Both accessibility and continuity need to be improved. The information given needs to be met with the patient's level of understanding

Parents' experiences of caring responsibility for their adult child with schizophrenia

As a consequence of the latest psychiatry-related reform in Sweden and its implementation, relatives and family members have taken over from the formal healthcare system significant responsibility for the care of persons with a mental disability and illness. The aim of this study was to systematically describe and analyze the experiences of parents' informal care responsibility. The questions were, what are the experiences around parents' informal care activities and responsibilities and how do parents construct and manage their caring responsibility and with what consequences? Semistructured in-depth interviews were conducted (16 hours of recorded material) with eight parents who were all members of the Interest Association for Schizophrenia (Intresseföreningen för Schizofreni (IFS)) in Sweden. A mixed hermeneutic deductive and inductive method was used for the interpretation of the material. The parents endow their informal caring responsibility with meaning of being a good, responsible, and accountable parent with respect to their social context and social relationships as well as with respect to the psychiatric care representatives. In this tense situation, parents compromise between elements of struggle, cooperation, avoidance, and adaption in their interaction with the world outside, meaning the world beyond the care provision for their child, as well as with the world inside themselves