Epistemic injustices in clinical communication: the example of narrative elicitation in person‐centred care

Abstract

The increasing popularity of the term ‘person‐centred’ in the healthcare literature and a wide range of ideals and practices it implies point to the need for a more inclusive and holistic healthcare provision. A framework developed in a Swedish context suggested narrative elicitation as a key practice in transition to person‐centred care. Initiating clinical communication by inviting people to tell their stories makes persistent yet often subtle problems in clinical communication visible. By drawing upon an observational study on narrative elicitation and vignette‐based focus group interviews with nurses, our aim is to trace ‘credibility deficits’ (Fricker 2007. Epistemic Injustice. Power and the Ethics of Knowing. Oxford: Oxford University Press) and ‘credibility excesses’ (Medina 2011, Social Epistemology, 25, 1, 15–35, 2013, The Epistemology of Resistance: Gender and Racial Oppression, Epistemic Injustice, and the Social Imagination. Oxford: Oxford University Press) in narrative elicitation. We argue that narrative elicitation may be one way to tackle epistemic injustices by giving voice to previously silenced groups, yet it is not enough to erase the effects of ‘credibility deficits’ in clinical communication. Rather than judging individual professionals’ success or failure in eliciting narratives, we underline some extrinsic problems of narrative elicitation, namely structural and positional inequalities reflecting on narrative elicitation and the credibility of patients. ‘Credibility excesses’ can be useful and indicative to better understand where they are missing.

Developing new ways to listen: the value of narrative approaches in empirical (bio)ethics

“…Furthermore, factors such as age, gender, cultural and mental health background, expectations and powerimbalances in the doctor-patient relationship, and organizational factors have shown to profoundly influence what is being told by patients and how clinicians respond to it [25][26][27][28]. And even when a person-centered care approach is deliberately applied, some patients' stories are taken more seriously than others [29]. On a level transcending medicine and bioethics, both social scientists and philosophers have described (and criticized) dominant cultural narratives in Western countries that focus on the autonomous self, coherence, control and continuity [30][31][32][33].…”

The interactive work of narrative elicitation in person‐centred care: Analysis of phone conversations between health care professionals and patients with common mental disorders

“…When patients' experiences are given a prominent position in health care interactions, patients are likely to be more actively engaged and more satisfied with care 14–16 . Previous studies on narrative elicitation in PCC have highlighted it as a complex interactive process requiring communicative skills, sensitivity and openness to an array of potential stories 17,18 . Health care professionals (HCPs) have described different communicative strategies they employ to encourage patients to narrate their experiences, for example, sitting down, having a calm demeanour, listening attentively and asking open‐ended and follow‐up questions 16,17,19,20 .…”

“…Health care professionals (HCPs) have described different communicative strategies they employ to encourage patients to narrate their experiences, for example, sitting down, having a calm demeanour, listening attentively and asking open‐ended and follow‐up questions 16,17,19,20 . However, incorporating aspects outside the medical realm into the health care encounter can put both patients and HCPs in a position of unease and uncertainty as to what is expected of them as narrators and listeners to lifeworld concerns 18,21 . Through interaction analyses, such as conversation analysis (CA), the interactive processes underpinning narrative elicitation in person‐centred communication, and what it requires of participants, could be further explored.…”

“… 14 , 15 , 16 Previous studies on narrative elicitation in PCC have highlighted it as a complex interactive process requiring communicative skills, sensitivity and openness to an array of potential stories. 17 , 18 Health care professionals (HCPs) have described different communicative strategies they employ to encourage patients to narrate their experiences, for example, sitting down, having a calm demeanour, listening attentively and asking open‐ended and follow‐up questions. 16 , 17 , 19 , 20 However, incorporating aspects outside the medical realm into the health care encounter can put both patients and HCPs in a position of unease and uncertainty as to what is expected of them as narrators and listeners to lifeworld concerns.…”

“…tions directed both at the factual circumstances at work (Lines 1-2, 24,[26][27] and at the patient's understanding of what happened (Lines[18][19]29). Here the HCP does not use open-ended questions, which are traditionally seen as the ideal practice for encouraging narrating 29.…”