How potentially serious symptom changes are talked about and managed in COPD clinical review consultations: A micro-analysis

Abstract

a b s t r a c tPeople with Chronic Obstructive Pulmonary Disease (COPD) are at heightened risk of developing lung cancer. Recent research has suggested that in people who have the disease, the time between symptom onset and consultation can be long enough to significantly affect prognosis. The regular and routine clinical encounters that people with COPD engage in provide an opportunity for them to highlight new symptoms of concern, and for clinicians to be watchful for new symptomatic indicators. We present a micro-analysis of naturalistic data from a corpus of such encounters with the aim of exploring the interactional factors within these routine consultations which influence when and how new symptoms of concern are raised. Our hypothesis is that although the underlying aim of the review consultation is the same in both settings, the different consultation structures oriented to by nurses and GPs have a tangible effect on how new and concerning symptomatic information is introduced. Conversation analysis (CA) was used to examine 39 naturalistic review consultation recordings in two clinical settings; GP led (n ¼ 16), and practice nurse led (n ¼ 23). We describe three interactional formats by which patients chose to present new symptomatic concerns; 'direct', 'embedded', and 'oblique'. Both settings provided interactional 'slots' for patients to offer new and concerning symptomatic information. However, the structure of nurse led encounters tended to limit opportunities for patients to develop extended symptom narratives which in turn facilitated 'oblique' formats. We suggest that the attenuation of the 'oblique' format in this particular clinical setting has implications relating to the psycho-social idiosyncrasies of lung cancer and the maintenance of interactional conditions that encourage patients to disclose new symptomatic concerns.

Ethnomethodological studies of nurse-patient and nurse-relative interactions: A scoping review

“…Higher patient participation results in better clinical outcomes (Chatwin, 2008;Chatwin et al, 2014;Elwyn et al, 2000). It also strengthens social bonds and promotes trust between nurses and beneficiaries of care (Adams, 2001a;Riva et al, 2014).…”

“…These studies particularly dealt with nurse-patient interactions. They included analyses of data taken from patient admissions (Jones, 2007) and discharge (Riva et al, 2014), check-ups (Edwall et al, 2009), child immunizations (Plumridge et al, 2009), and chronic obstructive pulmonary disease consultations (Chatwin et al, 2014). Despite the wide range of situations examined, the results reported in these studies highlight the importance and benefits of patient participation in nurse-patient interactions (Adams, 2001a) and the implications of the frequent lack thereof (Chatwin, 2008;Jones, 2007).…”

“…Interactions between nurses and patients are often bureaucratic, at odds with recommendations for increased patient participation (Jones, 2007). But the structure of the consultation can increase patient participation and understanding of their conditions (Chatwin et al, 2014;Edwall et al, 2009), and that of their relatives (Plumridge et al, 2009). Embracing a reciprocal interaction style leads to increased participation of patients in consultations (e.g.…”

Assessing risks to paediatric patients: conversation analysis of situation awareness in huddle meetings in England

“…Some huddlers spoke only about situations that concerned them and others used the time to speak briefly about each patient bed. The advantage of this latter method of huddling was that there were ‘slots’ created for nurses in the huddle to communicate potential changes in patients 13. Due to the tensions between providing opportunities for collaboration and expediency, huddlers may reflect on the best use of their time.…”

“…The method has been used to highlight important social-interactional moves in the accomplishment of medical tasks 10–12. In pulmonary medicine, Chatwin et al 13 noted the importance of medical staff providing ‘narrative slots’ in which patients could provide new information about potentially serious symptoms. In paediatrics, Stivers14 showed how through silence, questions and refusal to engage in shared laughter, parents resisted the treatment proposals of doctors who recommended against the use of antibiotics for viral infections.…”