Explanations, explanations, explanations: how do patients with limited English construct narrative accounts in multi-lingual, multi-ethnic settings, and how can GPs interpret them?

Background. The gap is widening between understanding the subtleways patients and GPs manage their talk, and superficial discussionof the ‘language barrier’ among linguistic minoritypatients. All patients have to explain themselves, not justthose for whom English is their first or main language. Patients'explanations reflect how they want the doctor to perceive themas a patient and as a person: they reveal patients' identities.Yet interpretations are not easy when patients' style of talkingEnglish is influenced by their first language and cultural background. Objective. To explore in detail how patients with limited Englishand GPs jointly overcome misunderstandings in explanations. Methods. Using discourse analysis and conversation analysis,we examine how GPs and their patients with limited English negotiateexplanations and collaborate to manage, repair or prevent understandingproblems. Results. 31% of patients said English was not their first language.Misunderstandings arise owing to a range of linguistic and culturalfactors, including stress and intonation patterns, vocabulary,the way a patient sequences their narrative, and patient andGP pursuing different agendas. Conclusion. When talk itself is the problem, patients' explanationscan lead to misunderstandings, which GPs have to repair if theycannot prevent. Careful interpretation by skilful GPs can revealpatients' knowledge, experience and perspective. Keywords. Communicative style, cultural differences, explanations, misunderstandings.     

"Symbiotic niceness": constructing a therapeutic relationship in psychosocial palliative care

The concept of symbiotic niceness illustrates a mutually shared advantage in the nurse-patient relationship. This relationship is premised on the co-production of niceness through the doing of psychosocial care. This paper presents an account of 'symbiotic niceness' produced in palliative care nurses' talk. The data are collected from two hospices and one general hospital for the dying. The analysis of talk demonstrates how psychosocial care can be understood as the collaborative practice of 'niceness' in the daily activities of participants, and how they collaboratively achieve reciprocal and therapeutic relevance for their talk. Participants co-engage in a 'selling game'. Through the activities of selling, a set of personal assets that constitute their personal Curriculum Vitae (CV) are revealed. It suggests that nurses' assets, when combined with patients' assets, function as marketable 'products' to produce an impression of nice patients and professionals. This in turn leads to the production of an impression of 'nice' organisations. Impression management is presented as a key strategy for the production of marketable niceness. Through the co-performance of niceness in talk, both nurses and patients are constructed as people who are somewhat charismatic, friendly, informal, understanding and concerned. This paper argues that underpinning the co-enactment of symbiotic niceness is the sharedness of patients' and nurses' experiences and a reciprocal notion of therapeutic help. It serves as a means of managing relations between palliative care nurses and dying patients. Symbiotic niceness thus represents a core component of professional and patient identity which works to maintain social orderliness as well as to advance personal, professional and organisational aspirations.     

Disclosure predicaments arising during the course of patient care: nurses' privacy management

At times, nurses receive patient disclosures that have the potential to create challenges resulting in needs for strategies to manage patient information and expectations. This study examines disclosure predicaments nurses experience in critical care and emergency units at a large urban hospital. Utilizing the constant comparative method to identify disclosure themes guided by the principles of communication privacy management (CPM), the findings show that nurses regulate patient privacy in the role of stakeholder confidants. Second, disclosure predicaments occur in three different contexts: during the course of nurses' professional routine; when the nurses created safe terminals or havens for patients to talk; and when family matters became an inseparable part of caring for the patient. Third, the results indicate that there are several specific strategies that nurses use to manage disclosure predicaments they encounter. The lens of CPM is used to interpret these findings and offers a context in which to better understand the needs of nurses concerning patient disclosive behavior and privacy issues for nurses.     

Evaluation of satisfaction of patients hospitalized at the Kairouan Hospital

The patients' satisfaction studies are more and more utilized to underline the health centers' deficiencies and consequently set improvement action plans. Our survey aims to measure inpatients' satisfaction in its different dimensions. A survey centered around a transversal inquiry has been conducted during a period going from February to April 2000 and reached a total number of 817 patients hospitalized in six service units at kairouan hospital. The data has been gathered by structured interviews led by a previously trained social worker. The investigation tool was a standardized questionnaire prepared by a group of experts from WHO in the Oriental Mediterranean region. The main results are as follow: High satisfaction level concerning the global evaluation of the hospital service units was recorded (score = 70%). The patient who are more satisfied are those who have the feeling that their health situation has considerably improved, and who will probably recommend this hospital to their surroundings. Big proportion of the patients (77%) was expecting better services. The main reason behind their unhappiness is the information emanated whether from the nurses or the doctors, the comfort and the cleanness of waiting room, linen, room comfort, food and the emergency. These results showed that the quality of care improvements priorities, according to patient expectations are especially in relation with the quality of information, the relational aspects and the hospital stay conditions.     

“Let’s Sit Forward”: Investigating Interprofessional Communication,Collaboration, Professional Roles,and Physical Space at EmergiCare

Communication is key to hospital emergency department (ED) caregiving. Interventions in ED processes (and health care organizing in general) have struggled when they have ignored the professional role expectations that enable and constrain providers with patients and each other. Informed by a communication as design (CAD) approach, this study explored the intersections of professional roles, physical space, and communication at EmergiCare—an academic medical center and level-1 trauma center hospital. Based on an ethnographic analysis of field notes from 70 hours of shadowing at the EmergiCare ED, this study identified two specific communication patterns, “case talk” and “comfort talk,” that reflect different logics for communication in health care organizing. The findings indicate (a) that case and comfort talk have different status and therefore different influence in EmergiCare ED interprofessional communication and (b) that the arrangement of physical space at EmergiCare ED reflects the requirements of case talk more so than comfort talk. These findings have important implications for theory and practice, including the importance of considering the macro-discursive construction of professional roles reified in the arrangement of work space.     

Wage policy in the health care sector: a panel data analysis of nurses' labour supply

Shortage of nurses is a problem in several countries. It is an unsettled question whether increasing wages constitute a viable policy for extracting more labour supply from nurses. In this paper we use a unique matched panel data set of Norwegian nurses covering the period 1993-1998 to estimate wage elasticities. The data set includes detailed information on 19,638 individuals over 6 years totalling 69,122 observations. The estimated wage elasticity after controlling for individual heterogeneity, sample selection and instrumenting for possible endogeneity is 0.21. Individual and institutional features are statistically significant and important for working hours. Contractual arrangements as represented by shift work are also important for hours of work, and omitting information about this common phenomenon will underestimate the wage effect.     

Identifying second language speech tasks and ability levels for successful nurse oral interaction with patients in a linguistic minority setting: an instrument development project

One of the most demanding situations for members of linguistic minorities is a conversation between a health professional and a patient, a situation that frequently arises for linguistic minority groups in North America, Europe, and elsewhere. The present study reports on the construction of an oral interaction scale for nurses serving linguistic minorities in their second language (L2). A mixed methods approach was used to identify and validate a set of speech activities relating to nurse interactions with patients and to derive the L2 ability required to carry out those tasks. The research included an extensive literature review, the development of an initial list of speech tasks, and validation of this list with a nurse focus group. The retained speech tasks were then developed into a questionnaire and administered to 133 Quebec nurses who assessed each speech task for difficulty in an L2 context. Results were submitted to Rasch analysis and calibrated with reference to the Canadian Language Benchmarks, and the constructs underlying the speech tasks were identified through exploratory and confirmatory factor analyses. Results showed that speech tasks dealing with emotional aspects of caregiving and conveying health-specific information were reported as being the most demanding in terms of L2 ability, and the most strongly associated with L2 ability required for nurse-patient interactions. Implications are discussed with respect to the development and use of assessment instruments to facilitate L2 workplace training for health care professionals.     

Doing criticism in 'symbiotic niceness': a study of palliative care nurses' talk

This paper examines how palliative care nurses do criticism of other professionals in talk within settings for care of the dying (two hospices and one general hospital). Strategies for the production of moral identities include the use of direct criticism, indirect criticism and quoted speech, hence 'inverted comma criticism'. Criticism is done through the construction and reconstruction of 'atrocity stories'. Atrocity stories are used as a medium by nurses to express their opinions and feelings about doctors who might have behaved insensitively. At the same time, it allows doctors to redeem themselves. The analysis of talk reveals that the voices of absent patients are reactivated and co-opted into the nurses' talk. The stories serve to produce an image of nurses as caring, morally responsible patient advocates and loyal characters to their medical colleagues. Through the analysis of talk, the communication skills and strategies for the maintenance of interactional order are made visible and displayed. Skills for the production of the palliative care team work are also made visible. Emotional labour is analysed as a project for the production of particular kinds of niceness which in turn require particular types of emotional labour. This paper argues that educators should aim to identify and make conscious use of nurses' own available interactional skills, and focus on valuable cultural (rules of decorum) and material resources (the disease process) which are readily available and accessible for nurses, as a starting point in communication training. The theory of an account of co-production of niceness which benefits each other, hence, symbiotic niceness, reveals that being nice to each other can be rewarding and therapeutic in that it helps to smooth, distance and ameliorate problems occurring in the reality of palliative care nurses' and their patients' life-worlds.     

Slavery and jouissance: analysing complaints of suffering in UK and Australian nurses' talk about their work

Nursing has a gendered and religious history where ideas of duty and servitude are present and shape its professional identity. The profession also promotes idealized notions of relationships with patients and of professional autonomy both of which are, in practice, highly constrained or even impossible. This paper draws on psychoanalytic concepts in order to reconsider nursing's professional identity. It does this by presenting an analysis of data from two focus group studies involving nurses in England and Australia held between 2010 and 2012. The studies gave rise to data where extremely negative talk about nursing work seemed to produce, or to be expressed with, a high degree of energy, and a particular kind of enjoyment. In our analysis, we focus on the nurses' apparent enjoyment derived from their expression of a position of powerlessness in which they describe themselves as ‘slaves’ or ‘martyrs’ in the health care system. We interpret this as jouissance and suggest that the positions of slave or martyr provide a possible response to what we argue is the impossibility of the nurse's role. We argue that a remnant of a quasi‐religious ethic within the profession makes it acceptable for nurses to talk about self‐sacrifice and powerlessness as part of their working subjectivity. We further argue that this analysis offers a new consideration of the issue of power and professional identity in nursing that goes beyond seeing nurses as simply overpowered by, or engaged in, a gendered power struggle with other professional groups. We suggest that powerlessness and victimhood hold particular attractions and advantages for nurses and are positions that are more available to nurses than to other occupational groups. This research shows how psychoanalytic theory can help produce new insights into the problems and complexity of nursing and extend existing study of the professions.     

Disclosure Predicaments Arising During the Course of Patient Care: Nurses' Privacy Management

At times, nurses receive patient disclosures that have the potential to create challenges resulting in needs for strategies to manage patient information and expectations. This study examines disclosure predicaments nurses experience in critical care and emergency units at a large urban hospital. Utilizing the constant comparative method to identify disclosure themes guided by the principles of communication privacy management (CPM), the findings show that nurses regulate patient privacy in the role of stakeholder confidants. Second, disclosure predicaments occur in three different contexts: during the course of nurses' professional routine; when the nurses created safe terminals or havens for patients to talk; and when family matters became an inseparable part of caring for the patient. Third, the results indicate that there are several specific strategies that nurses use to manage disclosure predicaments they encounter. The lens of CPM is used to interpret these findings and offers a context in which to better understand the needs of nurses concerning patient disclosive behavior and privacy issues for nurses.     

Theme-oriented discourse analysis of medical encounters

APPROACH: Theme-oriented discourse analysis looks at how language constructs professional practice. Recordings of naturally occurring interactions are transcribed and combined with ethnographic knowledge. Analytic themes drawn primarily from sociology and linguistics shed light on how meaning is negotiated in interaction. Detailed features of talk, such as intonation and choice of vocabulary, trigger inferences about what is going on and being talked about. These affect how interactants judge each other and decisions are made. Interactions also have larger rhetorical patterns used by both patients and doctors to persuade each other. EXAMPLES: Two settings are used to illustrate this approach: genetic counselling and primary care consultations in multilingual areas. In genetic counselling, interactions are organised around the tension between the risks of knowing and the risks of occurrence. This can lead to a 'rhetorical duel' between health professionals and patients and their families. In intercultural primary care settings, talk itself may be the problem when interpretive processes cannot be taken for granted. Even widely held models of good practice can lead to misunderstandings under these conditions. CONCLUSION; Through discourse analysis, the talk under scrutiny can be slowed down to show the interpretive processes and overall patterns of an activity. Discourse analysts and health professionals, working together, can look at problems in new ways and develop interventions and tools for a better understanding of communication in medical life.     

A linguistic framework for assessing the quality of written patient information: its use in assessing methotrexate information for rheumatoid arthritis

Patient information leaflets are an important adjunct to verbal exchange between doctor and patient. Their value is dependent upon whether they contain useful information from the viewpoint of the patient and are easily understood. We developed a framework based upon linguistic theory for assessing the quality of written patient information and applied it to a set of leaflets about methotrexate treatment. Items included the overall structure of the text, the technicality of the vocabulary used, the number of content words per clause ('lexical density'), and the clarity of the role relationship between author and reader. The leaflets consisted of up to nine identifiable sections (range 3-8): background information about the drug, summary of its use, dosage instructions, outline of benefits and side-effects, monitoring information, constraints on patient behavior, storage instructions, and clinical contact availability. Most leaflets contained a high number of content words per clause and the identity of the author was clear in only three (17%). Linguistic analysis provides highly relevant information about written patient information. Together with critical assessment of factual and visual aspects, consideration of key linguistic features should improve the quality of informational texts for our patients.     

Deathbed phenomena and their effect on a palliative care team: a pilot study

Anecdotal evidence suggests that death may be heralded by deathbed phenomena (DBP) such as visions that comfort the dying and prepare them spiritually for death. Medical practitioners have been slow to recognize DBP, and there has been little research into the spiritual effect that DBP have on caregivers or on how these phenomena influence their work. A pilot study looking into the occurrence of DBP was conducted by the palliative care team at Camden Primary Care Trust. Interviews revealed that patients regularly report these phenomena as an important part of their dying process, and that DBP are far broader than the traditional image of an apparition at the end of the bed. Results of the interviews raise concerns about the lack of education or training to help palliative care teams recognize the wider implications of DBP and deal with difficult questions or situations associated with them. Many DBP may go unreported because of this. Results of this pilot study also suggest that DBP are not drug-induced, and that patients would rather talk to nurses than doctors about their experiences.     

A cohort study on the active life expectancy of stroke patients using a community-based stroke registry in a Japanese rural district

In order to support patients with a history of stroke, public health nurses, hospitals and ambulance stations in and around the Oyabe Health District (49 000 population, rural area) provided initial information for a community-based stroke registry starting from 1966. This stroke registry was established by the present authors to record the patients' status and provide social services at home. The information from 1032 stroke patients was compiled into a register during the period 1966–79. Of 494 patients identified as living at home in 1980, we were able to maintain contact with 452 patients (91.5%) and these 452 stroke patients were defined as the study cohort. They were asked several questions on physical status, mobility status, central nervous function, emotional problems and living conditions. These data were used to construct the baseline of this study cohort and we gathered information on mobility status every year until 1993. The risk factors reducing their active life expectancy were investigated using Kaplan-Meier's method, log-rank test and Cox's proportional hazard model. For active life expectancy, the end point was defined as commencement of immobile status or death. Emotional problems ( P < 0.01), difficulty in bathing ( P < 0.05) and disorder of memory function ( P < 0.05) were shown to contribute to a reduction in their active life expectancy after adjustment for age, sex, years after stroke, types of stroke, mobility status and living with spouse.     

护患沟通技巧在急诊输液中的应用

目的掌握急诊输液中与不同类型,不同疾病患者进行有效沟通的技巧。方法加强护理人员的职业技术培训,了解急诊输液区的工作性质和特点,制定护理应对措施。结果安抚了因突然发病引起焦虑患者12000余人次,安慰了因家人生病而焦虑的家属5800余人次。结论良好的护患沟通可使患者及家属感到了急诊护士的人文关怀,有效地改善了护患关系。     

Nurses' Comfort Level With Emergency Interventions in the Rural Hospital Setting

ABSTRACT:  Context: One quarter of the persons living in the United States receive their emergency care in a rural hospital. Nurses employed in these hospitals see few emergencies but must be prepared to provide expert and efficient care when they do occur. Purpose: The purpose of this study was to determine the influence of registered nurses' certifications and years of experience on comfort level in emergencies. Methods: Data were collected using a survey design. The questionnaire gathered demographic data, number and type(s) of certifications held, and comfort level with 7 emergency interventions. The sample was recruited from registered nurses (RNs) working in 10 Critical Access Hospitals that represented different geographic locations and different distances to larger, more comprehensive hospitals in an upper Midwestern state. Findings: Mean comfort level of all respondents with the 7 selected emergency interventions ranged from 2.3 for assisting with thoracentesis to 3.6 for assisting with precipitous vaginal delivery, indicating only a moderate comfort level with the selected emergency interventions. While 70% of the 86 respondents answered "yes" when asked if they felt comfortable in emergency situations, the percentage of respondents who reported being comfortable ranged from 33% to 83%. Conclusions: Number and type(s) of certifications and years of experience as an RN were associated with higher comfort levels. Responses to open-ended questions provided insight into the realities of rural emergency nursing and strategies for improving comfort levels of rural nurses in emergency situations.