Achieving visibility? Use of non‐verbal communication in interactions between patients and pharmacists who do not share a common language

Despite the seemingly insatiable interest in healthcare professional–patient communication, less attention has been paid to the use of non‐verbal communication in medical consultations. This article considers pharmacists' and patients' use of non‐verbal communication to interact directly in consultations in which they do not share a common language. In total, 12 video‐recorded, interpreted pharmacy consultations concerned with a newly prescribed medication or a change in medication were analysed in detail. The analysis focused on instances of direct communication initiated by either the patient or the pharmacist, despite the presence of a multilingual pharmacy assistant acting as an interpreter. Direct communication was shown to occur through (i) the demonstration of a medical device, (ii) the indication of relevant body parts and (iii) the use of limited English. These connections worked to make patients and pharmacists visible to each other and thus to maintain a sense of mutual involvement in consultations within which patients and pharmacists could enact professionally and socially appropriate roles. In a multicultural society this work is important in understanding the dynamics involved in consultations in situations in which language is not shared and thus in considering the development of future research and policy.     

‘If I can walk that far’: space and embodiment in stories of illness and recovery

Illness and recovery transform embodied experience, and transform the experience of space. Space, in turn, is a valuable resource in the telling of an illness narrative. Starting from a phenomenological perspective that takes the body to be the centre of experience, and hence of selfhood and storytelling, this article offers an argument for and an approach to analysing space as a narrative resource in stories about illness and recovery. Using a case study of one woman's stories about her amputation, it demonstrates how both narrated space and narrating space can be used as devices to structure the narrative and position its characters and interlocutors to construct the narrator's embodied experiences and identities. The article reveals intersections between embodied experience, space, and narrative identity construction, offering a new way of attending to illness narratives and a new way of engaging with narrative space.     

Dietetic students’ performance of activities in an objective structured clinical examination

Background: Objective structured clinical examinations (OSCEs) have been used to assess the key clinical skills of many health professions; however, this form of assessment is not reported to have been used extensively for dietetic students. The present study explored which key dietetic skills could be assessed by an OSCE and which activity students performed best. Methods: An OSCE of six activities, two involving simulated patients, was developed to assess key dietetic clinical skills. Thirty‐five level two dietetic students undertook the OSCE, which was marked using structured marking tools. A self‐administered questionnaire was also used to obtain data concerning student’s opinion on the OSCE process and the time allowed for each activity. Results: Six activities were incorporated into the OSCE, involving communication, discriminatory and interpretation and food knowledge skills. The OSCE activity students performed least well involved knowledge of portion sizes and the carbohydrate content of specific foods. The activities that students performed best were the two activities in which mainly communication skills were assessed in simulated dietetic consultations using actors as standardised patients. Conclusions: A dietetic OSCE was generally positively accepted by the students and offers a very effect form of assessment of key dietetic skills. Students performed better at activities requiring communication skills than those requiring greater discriminatory and interpretation and food knowledge skills. Students’ food knowledge skills require reinforcing to ensure that they acquire the knowledge and skills that are unique to dietitians.     

Communication skills for behaviour change in dietetic consultations

Background: Both the UK’s National Health Service (NHS) and the National Institute of health and Clinical Excellence (NICE) have recommended increased training for health professionals in communication skills. There is evidence to suggest that communication skills are important in helping people to change health‐related behaviour, which is a key role for dietitians. This study investigated the views of UK dietitians about their training needs and experience in relation to communication skills in dietetic practice. Methods: In October 2007, a cross‐sectional survey was mailed to all British Dietetic Association members (n = 6013). The survey gathered quantitative data and free‐text comments to ascertain the level, type and effect of communication skills training received by dietitians at both the pre‐ and post‐registration level. Results: There were 1158 respondents; a response rate of 19.3%. Ninety‐eight percent (n = 1117) rated communication skills as either very or extremely important in client consultations. Post‐registration training had been undertaken by 73% (n = 904). Of these, over 90% of respondents perceived that post‐registration training had led to improvements in their relationships with patients, their confidence in client interviews and their ability to cope with challenging clients. However, 248 (21.4%) felt time keeping in interviews had worsened. Lack of time for client interviews was also the most commonly identified barrier (19%, n = 216) to implementing the skills. Conclusions: This study has explored an important and under‐researched area. Respondents strongly endorsed the importance of good communication skills and the benefits of post‐registration training in this area. Some felt that good communication was time consuming but others felt that time management had improved. Further research and training is required to support the implementation of these skills into dietetic practice.     

Evaluation of change in dietitians’ perceived comprehensibility and difficulty of the Patient‐Generated Subjective Global Assessment (PG‐SGA) after a single training in the use of the instrument

Background

The Patient‐Generated Subjective Global Assessment (PG‐SGA) is an instrument used to assess malnutrition and its risk factors. Some items of the PG‐SGA may be perceived as hard to comprehend or as difficult by healthcare professionals. The present study aimed to determine whether and how dietitians’ perceptions of comprehensibility and difficulty of the PG‐SGA change after a single training in PG‐SGA use.

Methods

In this prospective evaluation study, Dutch PG‐SGA‐naïve dietitians completed a questionnaire regarding perceived comprehensibility and difficulty of the PG‐SGA before (T0) and after (T1) receiving a single training in the use of the instrument. Perceived comprehensibility and difficulty were operationalised by calculating item and scale indices for comprehensibility (I‐CI, S‐CI) and difficulty (I‐DI, S‐DI) at T0 and T1. An item index of 0.78 was considered acceptable, a scale index of 0.80 was considered acceptable and a scale index of 0.90 was considered excellent.

Results

A total of 35 participants completed the questionnaire both at T0 and T1. All item indices related to comprehensibility and difficulty improved, although I‐DI for the items regarding food intake and physical examination remained below 0.78. Scale indices for difficulty and comprehensibility of the PG‐SGA changed significantly (P < 0.001) from not acceptable at T0 (S‐CI = 0.69; S‐DI = 0.57) to excellent for comprehensibility (S‐CI = 0.95) and acceptable for difficulty (S‐DI = 0.86) at T1.

Conclusions

The findings of the present study suggest that significant improvement in PG‐SGA‐naïve dietitians’ perception of comprehensibility and difficulty of the PG‐SGA can be achieved quickly by providing a 1 day of training in the use of the PG‐SGA.     

Verbal and non‐verbal development in SLI children after early intervention

Of all the developmental difficulties that may be present in childhood, language impairment is probably the most common. It is of vast importance to prevent cumulative negative consequences of these impairments. The present study evaluates the effects of a language and activity‐based intervention programme on verbal and non‐verbal performance and play behaviour in children diagnosed as having specific language impairment. Children with the same diagnosis and conventional early special education were used as controls. Verbal and non‐verbal abilities and play behaviour were evaluated before and after intervention in both groups. The intervention sessions, aimed to develop the children’s functional use of language and communication, were held in community day care centres. The sessions took place twice a week in groups of two to four children. The intervention had a positive influence on non‐verbal performance and play behaviour. However, the intervention did not have any significant effect on language measurements. The results are discussed in the context of language development as a dynamic process with circular causation between different aspects of development.     

Language background,English language proficiency and medical communication skills of medical students

Associations between language background, English language proficiency and medical communication skills were investigated in a group of 149 third year undergraduate medical students studying at an Australian university. Written and aural English proficiency were assessed with the Screening Test for Adolescent Language (STAL). Medical communication skills and the fluency of spoken language were scored during an Observed Structured Clinical Interview (OSCI), rated by a standardized patient and a clinician. An association was found between language background, performance on the STAL and spoken language proficiency. Satisfactory performance in medical communication skills was not associated with language background or overall performance on the STAL. In this study it was the global rating of unsatisfactory spoken language fluency that was associated with poorer performance in medical communication skills under examination conditions.     

Assessing communication skills of GP registrars: a comparison of patient and GP examiner ratings

CONTEXT: General practice. OBJECTIVES: To compare ratings of GP registrars' communication skills by patients and GP examiners. DESIGN: A comparative study where the communication skills of GP registrars were assessed both by patients, using a validated tool called the Doctors' Interpersonal Skills Questionnaire (DISQ), and by GP examiners as part of the Fellowship examination of the Royal Australian College of General Practitioners (RACGP). PARTICIPANTS: These included 138 GP registrars, 6075 patients, and more than 70 GP examiners. RESULTS: Spearman rank correlations were used to test the strength of the relationship between Fellowship examination and DISQ scores. Findings showed that there were several communication skills areas with mild (but significant) correlations between patient and GP examiner ratings. These areas included warmth of greeting, listening skills, respect, and concern for the patient as a person. No significant correlations were detected for explanation skills. Interestingly, the correlations between GP examiner and patient ratings were stronger for female GP registrars. CONCLUSION: There is some evidence that patients' ratings of GP registrars' communication skills is aligned to ratings made by GP examiners as part of the summative RACGP Fellowship examination. However, further work is required to assess the strength of this alignment, given that patient-doctor communication is assessed more widely through new components of the examination.     

Further challenges in measuring communication skills: accounting for actor effects in standardised patient assessments

Context  Subjective rating scales for communication skills may yield more personally meaningful responses than more standardised rating schemes. It is unclear, however, whether such evaluations may be overly biased by respondents' rating styles, which may lead to unreliable measurement of examinees' communication skills.
Methods  Our study involved 212 students from the classes of 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All students were rated by actors depicting standardised patients (SPs) on the same seven cases using the 19-item Rochester Communication Rating Scale (RCRS). Different students were assigned to different actors playing the same SP. We assessed the extent to which actors' personal rating styles influenced the scores they assigned to students. Main outcome measures were: between-actor variability in responses; the degree to which actors' response styles contribute to overall scores, and improvements in reliability achieved by standardising actors' ratings.
Results  There were statistically significant differences between actors in their mean assigned scores. Scores aggregated over 18 separate SP cases have an expected generalisability coefficient of 0.79. If raw RCRS scores are used, a total of 27 replications of the RCRS are required to achieve a Cronbach's alpha of 0.8; standardisation reduces this number to 18.
Conclusions  Although actors are variable in their use of a standardised subjective scale of communication, such differences contribute to an acceptably small proportion of the total variance if scores are combined across a large number of cases. Reliability can be markedly improved by standardising scores across raters.     

A disparity of words: racial differences in oncologist–patient communication about clinical trials

Background

African Americans are consistently underrepresented in cancer clinical trials. Minority under‐enrolment may be, in part, due to differences in the way clinical trials are discussed in oncology visits with African American vs. White patients.

Objective

To investigate differences in oncologist–patient communication during offers to participate in clinical trials in oncology visits with African American and White patients.

Methods

From an archive of video‐recorded oncology visits, we selected all visits with African American patients that included a trial offer (n = 11) and a matched sample of visits with demographically/medically comparable White patients (n = 11). Using mixed qualitative–quantitative methods, we assessed differences by patient race in (i) word count of entire visits and (ii) frequency of mentions and word count of discussions of clinical trials and key elements of consent.

Results

Visits with African American patients, compared to visits with White patients, were shorter overall and included fewer mentions of and less discussion of clinical trials. Also, visits with African Americans included less discussion of the purpose and risks of trials offered, but more discussion of voluntary participation.

Discussion and conclusions

African American patients may make decisions about clinical trial participation based on less discussion with oncologists than do White patients. Possible explanations include a less active communication style of African Americans in medical visits, oncologists'' concerns about patient mistrust, and/or oncologist racial bias. Findings suggest oncologists should pay more conscious attention to developing the topic of clinical trials with African American patients, particularly purpose and risks.     

Feasibility and Acceptability of ‘VitaVillage’: A Serious Game for Nutrition Education

Computer games have previously been used to improve nutrition knowledge in children. This paper describes the acceptability and feasibility of a serious game, “VitaVillage”, for improving child nutrition knowledge. VitaVillage is a farming-style game in which the player undertakes quests and completes questions aimed at increasing several aspects of nutrition and healthy eating knowledge. Children aged 9–12 years in two primary schools (control vs. intervention) completed a nutrition knowledge questionnaire at baseline (T1) and after 1 week (T2). Participants at the intervention school (n = 75) played VitaVillage for 20 minutes on two occasions. Control participants (n = 94) received no nutrition education. Likeability question scores and written feedback from intervention participants was reported qualitatively. Paired sample t-tests were used to compare T1 and T2 nutrition knowledge changes between control and intervention participants. Engagement with VitaVillage improved children’s overall nutrition knowledge (Mean increase of 2.25 points between T1 and T2, Standard Deviation (SD) 6.31, p = 0.035) compared to controls. The game was liked overall (mean score 77 (SD 24.6) on scale of 0–100) and positive feedback was given. Results indicate that VitaVillage has the potential to be successful as a nutrition education tool. In the future, VitaVillage’s content and gameplay will be revised, extended and evaluated for its long-term impact on eating behaviour and knowledge changes.