"I am not frustrated anymore". Family doctors' evaluation of a comprehensive training on partner abuse

OBJECTIVE: The aim of this study was to discover the ways in which a training program on intimate partner abuse affected a doctor's daily practice. METHODS: Eighteen family doctors who participated in a training program on partner abuse were interviewed. RESULTS: The interviewees evaluated the training program to be useful in raising their awareness and suspect criteria on partner abuse. Any questions and frustrations they had concerning the subject were resolved. They felt more confident and equipped to discuss and aid abused patients after the training. CONCLUSION: In order to improve doctors' awareness of partner abuse in daily practice, they must need first realize the scale of the problem and then become more comfortable in their own attitude and finally more confident in their ability to aid these patients. PRACTICE IMPLICATIONS: Training on partner abuse should be specifically tailored to change awareness, attitudes and consultation skills.     

Aggregation of qualitative studies--From theory to practice: Patient priorities and family medicine/general practice evaluations

OBJECTIVE: Aggregation (i.e., meta-ethnography or meta-synthesis) of qualitative studies remains relatively rare and controversial. We have attempted this procedure within an investigation of patient priorities and evaluations of primary care in order to triangulate an instrument development process as well as explore associated dilemmas. METHODS: The procedures included a literature search of qualitative research on patient priorities and evaluations and creation of a framework for quality assessment of retrieved papers. The tool for the evaluation of quality in qualitative studies was piloted, refined, and applied to the retrieved literature. The articles were equally distributed between two teams in random fashion, and inter-rater agreement calculated. Finally, we formulated and applied a strategy for aggregation of data from included papers that allowed comparison to a systematic review of quantitative studies on the topic. RESULTS: Thirty-seven articles met inclusion criteria. Twenty-four of these articles were of sufficient quality to be included in the qualitative aggregation. Inter-rater agreement ranged from 0.22 to 0.77 and 0.38 to 0.60 for pair and assessor comparisons, respectively. The aggregation strategy enabled synthesis within sub-categories of the heterogeneous papers. CONCLUSIONS: We have devised a modestly reliable instrument to assess the quality of qualitative work. The procedure for quality assessment and aggregation appears to be both feasible and potentially useful, though both theoretical and practical problems underline the need for further refinement prior to widespread utilization of this approach. PRACTICE IMPLICATIONS: An instrument to assess the quality of qualitative work within the context of aggregation efforts is described. Calculating inter-rater reliability in this framework can support future quality assessments. A method of breaking a heterogeneous collection of included papers into sub-categories to enable aggregation of qualitative studies is applied and demonstrates its feasibility and potential usefulness.     

Technology-mediated awareness: Facilitating the handling of (un)wanted interruptions in a hospital setting

IntroductionNurses’ work in hospital departments is highly collaborative and includes communication with a variety of actors. To further support nurses’ communications, wireless phones, on which nurses receive both nurse calls and ordinary phone calls, have been introduced. However, while they ensure high availability among the mobile nurses, these phones also contribute to an increased number of interruptions.PurposeThis paper aims to discover whether all interruptions caused by the wireless phones are unwanted. Further, it investigates how nurses handle these interruptions in a hospital setting in order to construct a foundation for guidelines to use in designing these types of systems.MethodsQualitative and ethnographically inspired fieldwork, including workshops with both ordinary and student nurses from a Norwegian hospital, was undertaken. Patients from two hospital departments were interviewed.ResultsNurses struggle to handle interruptions caused by the wireless nurse call system. Deciding whether to abort an activity or not to respond to an interruption is regarded as stressful. The decision is further complicated by the complex nature of the interruptions. At the same time, patients anticipate that nurses are able to make these judgements with limited information. Nurses’ work is highly collaborative, and nurses depend on one another to carry out their work and manage interruptions.ConclusionThe dual nature of the interruptions is complex, and whether an interruption is wanted or unwanted depends on many factors. Nurses manage interruptions mainly by making their own activities visible and monitoring colleagues’ work. Therefore, nurses’ awareness of colleagues’ activities is a key factor in how they handle interruptions in the form of nurse calls.     

Paternalism, participation and partnership - the evolution of patient centeredness in the consultation

Objective

There is much discussion at present on the need for a more patient-centered health service. However, it is not always clear what exactly this means for patients or healthcare providers. Furthermore many current trends in healthcare and society may in fact move the consultation further from the patient-centered model. In this article I shall critically review the current state of the consultation.

Methods

This article is based on a critical review of the literature. I shall firstly outline what is meant by the terms ‘patient centeredness’ and ‘participation’. I shall then examine what wider factors may facilitate or impede effective communication within the consultation.

Results

Patient centeredness and participation is challenged by several factors including the ‘co-modification’ of healthcare, the information revolution, the tension between choice and continuity, the process of medicalisation, population health strategies and the availability of resources.

Conclusion

I will argue that precisely because of these wider trends in society the consultation is now more important than ever as a point of access, communication, understanding and delivery of healthcare.

Practice implications

The structure and aims of the consultation must be re-visited in the light of the rapid pace of change in service delivery. As such, healthcare professionals may need to advocate for the continuing role of the patient-centered consultation.     

Effectiveness of the ‘availability,current issues and anticipation’ (ACA) training programme for general practice trainees on communication with palliative care patients: A controlled trial

Objective

This study aimed to evaluate the effectiveness of a new palliative care ‘availability, current issues and anticipation’ (ACA) training programme to improve communication skills of general practice trainees (GPTs).

Methods

In a controlled trial among third-year GPTs, we videotaped one 20-min consultation between each GPT and a simulated palliative care patient at baseline and at six months follow-up. We measured the number of issues discussed and the quality of communication skills and analysed between-group differences using linear mixed models and logistic regression.

Results

Fifty-four GPTs were assigned to the intervention and 64 to the control group. We found no effect of the programme on the number of issues discussed or on the quality of GPT communicative behaviour. GPTs infrequently addressed ‘spiritual/existential issues’ and ‘unfinished business’. In a selection of the consultations, simulated patients brought up more issues than the GPTs did.

Conclusion

The ACA training programme was not effective in the way it was carried out and evaluated in this trial.

Practice implications

The ACA programme should focus on the issues that scored low in this trial. Future research on GPT–patient communication in palliative care should consider using real patients in a series of consultations to evaluate effectiveness.     

Shame,honor and responsibility in clinical dialog about lifestyle issues: A qualitative study about patients’ presentations of self

Objective

To explore how patients enact presentations of self in consultations dealing with lifestyle in general practice.

Methods

We conducted a qualitative observational study with thematic, cross-case analysis of video-recorded consultations inspired by discourse analysis.

Results

Patients presented themselves with an orientation toward responsibility in dialog about lifestyle. They described how they were taking care of themselves and doing their best. In this respect, they demonstrated their achievements as matters of honor. If one lifestyle issue was considered problematic, in some cases patients shifted attention to another, of which they were more proud. In areas where they were not doing well, some patients revealed shame for not acting responsibly. In such cases, patients spoke of themselves in terms of self-deprecation or admitted not living up to expected standards.

Conclusion

Negotiations of shame and honor, revolving around personal responsibility, are embedded in clinical discourse about lifestyle. Patients take a proactive role in presenting and defending the self against shame.

Practice implications

GPs should pay more attention to the tacit role of shame in consultations. Failure to do so could lead to distance and hostility while a strategy to acknowledge the impact of shame could help develop and strengthen the doctor–patient relationship.     

Assessment of motivational interviewing with the VASE-(Mental) Healthcare: Mixed-methods study to examine feasibility and validity in the general practice setting

ObjectiveThe VASE-(M)HC is an instrument to evaluate Motivational Interviewing (MI) skills. We adjusted the previous version for use in the broader (mental) healthcare context, incorporated new MI insights, expanded the scoring system and created a parallel version. Feasibility and validity evidence in the general practice setting was explored.MethodsThe teaching staff of the GP specialty-training, GP-, and PN-trainees (N = 156) completed the VASE-(M)HC. In this mixed-methods study, we examined psychometric characteristics, compared parallel versions, and interviewed assessors.ResultsOur adjustments enable assessment of a wider range of MI skills, and allow differentiation of basic and advanced skills. Inter-rater reliability was excellent and internal consistency of the total scale was good for both versions. The parallel versions are comparable in terms of difficulty.ConclusionThe VASE-(M)HC is improved by our revisions and adds multiple advantages to the domain of available MI assessment tools.Practice implicationsDue to the adjustments, the instrument can be used in the GP setting (instead of sole focus on substance abuse). The parallel version is useful for research (pretest/posttest) and selective assessment (retake of a test). It is promising to further explore its applicability in the broader (mental) healthcare context and as training material.     

Mind the gap: Disclosure of dietary supplement use to hospital and family physicians

ObjectiveWe aim to compare patients’ perspectives on communication with their hospital physicians (HPs) and primary care physicians (PCPs) on patients' dietary and herbal supplements (DHS) use.MethodsWe conducted a cross-sectional prospective study among in-patients using structured questionnaires on DHS use. Multivariate logistic regression models assessed variables influencing doctor-related reasons for patients' nondisclosure of supplement use.ResultsOf 452 DHS users identified, 133 (29.4%) used herbs and 319 (70.6%) used non-herbal supplements. DHS users reported that PCPs were more aware of DHS consumption than HPs (70.1% vs. 34.1%, P < 0.0001). PCPs initiative to detect supplement use was higher compared with HPs (P < 0.0001). Doctor-related reasons for non-disclosure of DHS use were more prominent in a hospital setting. Multivariate logistic regression model suggested association between older patient age and doctor-related non-disclosure (p = 0.03). DHS use was recorded in only 33 patients medical files.ConclusionsDoctor-patient communication concerning DHS use is significantly poorer during hospitalization compared with primary-care settings. A significant barrier for in-hospital disclosure is doctor-related.Practice implicationsContinuity of care between community and hospital physicians regarding patients' DHS use should be improved due to the safety implications of such use. Educating physicians on DHS and improving communication could bridge this gap.     

Communication about euthanasia in general practice: opinions and experiences of patients and their general practitioners

OBJECTIVE: Public opinion and professional organisations dominate the euthanasia debate, and there is a need to understand the opinions of people confronted with euthanasia. The aim of this study was to investigate whether patients and their GPs talk about euthanasia, and if so, how they communicate about this. METHODS: Qualitative, semi-structured interviews were held with 20 GPs and 30 of their patients in primary care in the Netherlands, where euthanasia is legalised. The patients had a life expectancy of less than 6 months, and cancer, heart failure or chronic obstructive pulmonary disease as underlying disease. RESULTS: Many patients did not communicate about euthanasia with their GP. Neither the patient nor the GP were clear in formulating their expectations concerning future decision making. CONCLUSION: The initial patient-GP communication consisted of an exchange of opinions about situations in which euthanasia would be desirable. GPs had different opinions about who should initiate communication, and found it difficult to judge the right moment to talk. PRACTICE IMPLICATIONS: It is essential to pay attention to education in communication about dying and euthanasia and to train the GPs to gain insight in the patient's end-of-life preferences, and to direct care at the best possible quality of life.     

The patient, the doctor and the emergency department: a cross-sectional study of patient-centredness in 1990 and 2005

OBJECTIVE: To compare and contrast the duration and content of physician-patient interaction for patients presenting to an emergency department with problems of low acuity in 1990 and 2005 treated by different grades of physician. METHODS: Observational study with data collection in May-July 1990 and May-July 2005. Patients identified at nurse triage as presenting with 'primary care' problems were allocated by time of arrival to senior house officers (1990, n=7; 2005, n=10), specialist registrars/staff grades (1990, n=4; 2005, n=7) or sessionally employed general practitioners (1990, n=8; 2005, n=12) randomly rostered to work in a consulting room that had a wall-mounted video camera. A stratified sample of 430 video-taped consultations (180 (42%) from 1990 and 250 (58%) from 2005) was analysed using the Roter Interaction Analysis System. Main outcome measures -- length of consultation; numbers of utterances of physician and patient talk related to building a relationship, data gathering, activating/partnering (i.e. actively encouraging the patient's involvement in decision-making), and patient education/counselling. RESULTS: On average consultation length was 251s (95% CI for difference: 185-316) longer in 2005 than in 1990. The difference was especially marked for senior house officers (mean duration 385s in 1990 and 778s in 2005; 95% CI of difference: 286-518). All groups of physician showed increased communication related to activating and partnering and building a therapeutic relationship with the patient. While senior house officers demonstrated a greatly increased focus on data gathering, only general practitioners substantially increased the amount of talk centred on patient education and counselling; compared to senior house officers, the odds ratio for the number of such utterances included in consultations was 2.8 (95% CI: 1.4, 5.3). CONCLUSION: Although patient-centredness together with consultation length increased for all three physician groups over the duration of this study, senior house officers and specialist registrars/staff grades continued to place less emphasis on advice-giving and counselling than did general practitioners. The extent to which these observed changes in practice were determined by policy, management and training initiatives, and their impact on patient outcome, needs further study. PRACTICE IMPLICATIONS: Video-recording consultations is feasible in an acute hospital setting, and could be used to support training and workforce development. General practitioners can make a distinctive contribution to the workforce of emergency departments. Their consulting style differs from that of hospital physicians and may benefit patient care through a greater focus on patient education and counselling.     

A double-blind trial of a new inactivated, trivalent, intra-nasal anti-influenza vaccine in general practice: relationship between immunogenicity and respiratory morbidity over the winter of 1997–98

Background: Influenza is responsible for considerable morbidity not only among older people but in younger age groups as well. However, most large-scale anti-influenza vaccination campaigns are still aimed principally at the elderly using injectable vaccines. Until now there has been much less emphasis on targeting younger populations or using intra-nasal vaccines in mass anti-influenza immunisation programmes. Objectives: To assess the immunogenicity of a new inactivated intra-nasal anti-influenza vaccine and to measure its effect on respiratory morbidity in a volunteer general practice population. Study design: A prospective, double-blind, placebo-controlled trial using the new vaccine was carried out over the winter of 1997–98 on 274 healthy patients aged 12–60 from three Israeli general practices, 182 in the vaccine group and 92 in the placebo group. Following vaccination the changes in the antigen levels and episodes of respiratory illness in the vaccine and placebo groups were measured. Results: Protective antibody levels occurred after a single dose of vaccine [influenza H1N1, 41% immune pre-vaccination to 73% post-vaccination; influenza H3N2, 35–66%; influenza B, 27–64%]. Between January and March 1998, when influenza activity was at a peak in Israel, the average number of respiratory illness events in the vaccine group [14 events/100 subjects per month] was significantly less than in the placebo group [22 events/100 subjects per month]; similarly, the average number of respiratory illness days in the vaccine group over the same period [69 days/100 subjects per month] was significantly less than in the placebo group [117 days/100 subjects per month]. Conclusions: The new vaccine possessed significant immunogenicity and was associated with a significant reduction in respiratory morbidity among a group of healthy older children and adults. Since intra-nasal vaccine's are simpler to administer and more acceptable to the public than injections the vaccine's potential for use in routine anti-influenza vaccination campaigns seems promising, especially if its beneficial effects are also reproducible in more medically vulnerable populations.     

GPs' views on the practice of physician-assisted suicide and their role in proposed UK legalisation: a qualitative study

Background

A bill to legalise assisted dying in the UK has been proposed in Parliament''s House of Lords three times since 2003. The House of Lords Select Committee concluded in 2005 that ‘the few attempts to understand the basis of doctors'' views have shown equivocal data varying over time’. Fresh research was recommended to gain a fuller understanding of health sector views.

Aim

To examine GPs'' views of the practice of physician-assisted suicide as defined by the 2005/2006 House of Lords (Joffe) Bill and views of their role in the proposed legislation; and to explore the influences determining GPs'' views on physician-assisted suicide.

Design of study

Qualitative interview study.

Setting

Primary care in South London, England.

Method

Semi-structured interviews with GPs were conducted by a lead interviewer and analysed in a search for themes, using the framework approach.

Results

Thirteen GPs were interviewed. GPs who had not personally witnessed terminal suffering that could justify assisted dying were against the legislation. Some GPs felt their personal religious views, which regarded assisted dying as morally wrong, could not be the basis of a generalisable medical ethic for others. GPs who had witnessed a person''s suffering that, in their opinion, justified physician-assisted suicide were in favour of legislative change. Some GPs felt a specialist referral pathway to provide assisted dying would help to ensure proper standards were met.

Conclusion

GPs'' views on physician-assisted suicide ranged from support to opposition, depending principally on their interpretation of their experience of patients'' suffering at the end of life. The goal to lessen suffering of the terminally ill, and apprehensions about patients being harmed, were common to both groups. Respect for autonomy and the right of self-determination versus the need to protect vulnerable people from the potential for harm from social coercion were the dominant themes.     

Talking about Dr. Google: Communication strategies used by nurse practitioners and patients with inflammatory bowel disease in the Netherlands to discuss online health information

ObjectiveThis study explores how patients with Inflammatory Bowel Disease (IBD) and nurse practitioners (NPs) in the Netherlands communicate about online health information-seeking.MethodsWe analyzed 165 consultations of patients at the start of maintenance treatment using grounded theory. Consultations in which the words; internet, website, Google, Googled, webpages, online (forum/blog/platform) or a website was mentioned, were included. Segments were identified and analyzed that represented a discussion about online health information-seeking (n = 87). We coded the initiator, initiation and reaction communication strategy.ResultsHalf of the sample was female, most patients were moderately to highly educated and aged on average 48 years. One third of the consultations included a discussion about online health information-seeking. Seventeen communication initiation and reactions strategies were identified. Patients and NPs were equally as likely to initiate a neutral discussion about online health information-seeking. Patients repeatedly reacted with disclosing their concerns. NPs responded by taking patients’ online health information-seeking seriously or affirming patients’ beliefs.ConclusionThis exploration makes a unique contribution by demonstrating that NPs particularly adopt a patient-centered communication style while communicating about patients’ online health information-seeking.Practice implicationsResults of this study could guide interventions to train providers in talking about patients’ online health information-seeking.     

Context factors in consultations of general practitioner trainees and their impact on communication assessment in the authentic setting

ObjectiveAcquiring adequate communication skills is an essential part of general practice (GP) specialty training. In assessing trainee proficiency, the context in which trainees communicate is usually not taken into account. The present paper aims to explore what context factors can be found in regular GP trainee consultations and how these influence their communication performance.MethodsIn a randomly selected sample of 44 videotaped, real-life GP trainee consultations, we searched for context factors previously identified in GP consultations and explored how trainee ratings change if context factors are taken into account. Trainee performance was rated twice using the MAAS-Global, first without and then with incorporating context factors. Item score differences were calculated using a paired samples t-test and effect sizes were computed.ResultsAll previously identified context factors were again observed in GP trainee consultations. In communication assessment scores, we found a significant difference in 5 out of 13 MAAS-Global items, mostly in a positive direction. The effect size was moderate (0.57).ConclusionsGP trainee communication is influenced by contextual factors; they seem to adapt to context in a professional way.Practice implicationsGP specialty training needs to focus on a context-specific application of communication skills. Communication raters need to be taught how to incorporate context factors into their assessments.     

Communication about self-care in traditional acupuncture consultations: The co-construction of individualised support and advice

Objective

To analyse the co-construction of self-care advice in traditional acupuncture consultations.

Method

Analysis of 27 audio-recorded and transcribed consultations, involving 7 practitioners, augmented by integrating the data from 15 patient interviews and regular practitioner discussions.

Results

Self-care talk was initiated equally by practitioner and patient, and was threaded through and between acupuncture consultations. It involved interactive discussions that were interwoven with other types of talk, especially life-world and acupuncture talk. Practitioner engagement in self-care talk appeared to increase with experience. The self-care talk was co-constructed within the context of a relationship that was characterised by continuity, mutuality and trust.

Conclusion

Self-care support and advice was integral to the practice of traditional acupuncture and individualised in terms of the patient's life-world and/or the Chinese medicine diagnosis. The co-construction of self-care talk did not replicate the asymmetry of conventional medical consultations.

Practice implications

The active participation of both patients and acupuncture practitioners in self-care talk may be related to professional practice that is underpinned by a holistic theory base such as Chinese medicine and is delivered in the context of therapeutic relationships based on continuity, mutuality and trust. These findings may inform professional education and the design of multi-disciplinary care pathways.     

Context factors in consultations of general practitioner trainees and their impact on communication assessment in the authentic setting

Objective

Acquiring adequate communication skills is an essential part of general practice (GP) specialty training. In assessing trainee proficiency, the context in which trainees communicate is usually not taken into account. The present paper aims to explore what context factors can be found in regular GP trainee consultations and how these influence their communication performance.

Methods

In a randomly selected sample of 44 videotaped, real-life GP trainee consultations, we searched for context factors previously identified in GP consultations and explored how trainee ratings change if context factors are taken into account. Trainee performance was rated twice using the MAAS-Global, first without and then with incorporating context factors. Item score differences were calculated using a paired samples t-test and effect sizes were computed.

Results

All previously identified context factors were again observed in GP trainee consultations. In communication assessment scores, we found a significant difference in 5 out of 13 MAAS-Global items, mostly in a positive direction. The effect size was moderate (0.57).

Conclusions

GP trainee communication is influenced by contextual factors; they seem to adapt to context in a professional way.

Practice implications

GP specialty training needs to focus on a context-specific application of communication skills. Communication raters need to be taught how to incorporate context factors into their assessments.