Using conversation analytic methods to assess fidelity to a talk-based healthcare intervention for frequently attending patients

Abstract

The study aim was to assess implementation fidelity (i.e., adherence) to a talk-based primary care intervention using Conversation Analytic (CA) methods. The context was a UK feasibility trial where General Practitioners (GPs) were trained to use "BATHE" (Background,Affect,Trouble,Handling,Empathy) - a technique to screen for psychosocial issues during consultations - with frequently attending patients. 35 GPs received BATHE training between July-October 2015. 15 GPs across six practices self-selected to record a sample of their consultations with study patients at three and six months. 31 consultations were recorded. 21/26 patients in four intervention practices gave permission for analysis. The recordings were transcribed and initially coded for the presence or absence of the five BATHE components. CA methods were applied to assess delivery, focusing on position and composition of each component, and patients' responses. Initial coding showed most of the BATHE components to be present in most contacts. However the CA analysis revealed unplanned deviations in position and adaptations in composition. Frequently the intervention was initiated too early in the consultation, and the BATHE questions misunderstood by patients as pertaining to their presenting problems rather than the psychosocial context for their problems. Often these deviations resulted in reducing theoretical fidelity of the intervention as a whole. A CA approach enabled a dynamic assessment of the delivery and receipt of BATHE in situ revealing common pitfalls in delivery and provided valuable examples of more and less efficacious implementations. During the trial this evidence was used in top-up trainings to address problems in delivery and to improve GP engagement. Using CA methods enabled a more accurate assessment of implementation fidelity, a fuller description of the intervention itself, and enhanced resources for future training. When positioned appropriately, BATHE can be a useful tool for eliciting information about the wider context of the medical visit.

‘Primary care sensitive’ situations that result in an ambulance attendance: a conversation analytic study of UK emergency ‘999’ call recordings

“…Further work is needed to explore the triage structure specifically for third-party callers. With increasing evidence that healthcare staff can be successfully trained in more effective talk practices using the lens of CA, 55 there may be ways that call-takers can be trained to design probing questions that are most congruent with third party callers’ own epistemic domain, and therefore avoid some of the interactional troubles that can delay triage progression.…”

Acceptability of the BATHE technique amongst GPs and frequently attending patients in primary care: a nested qualitative study

“…The findings presented in this paper, in combination with other evidence collected during the wider feasibility study [4], [15], suggests BATHE is acceptable and potentially beneficial when used in Tables Table 1. The five elements of the BATHE technique and their related questions [5] 18.0 (0 -60.0)…”

“…Insights into these difficulties are valuable, and when combined with other findings from the pilot RCT and process evaluation [4] [15], help us to understand our quantitative findings regarding overall use of BATHE. Whilst feedback from study GPs suggested there was some under-reporting of its use, the extent of BATHE use was still lower than we might have hoped.…”

A consultation-level intervention to improve care of frequently attending patients: a cluster randomised controlled feasibility trial

“…Analysis of recorded BATHE consultations ( n = 21) revealed adaptations in question composition and deviations from the training protocol. 25 Tailoring of questions to individual patient circumstances were considered successful adaptations. However, adaptations changing the nature of the questions and deviations in question location were consequential for theoretical fidelity to BATHE, and thereby its potential effectiveness.…”