Lindsay Macdonald

Challenges to alcohol and other drug discussions in the general practice consultation

Background. There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. Aim. To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. Design. Analysis of video-recorded primary care consultations Setting. New Zealand General Practice. Methods. Interactional content analysis of AOD consultations between 15 GP’s and 56 patients identified by keyword search from a bank of digital video consultation recordings. Results. AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. Conclusions. Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.

The (non) use of prioritisation protocols by surgeons

Priority setting and rationing is a dominant feature of contemporary health policy. In New Zealand, clinical priority assessment criteria (CPAC) tools have been developed to make access to elective surgery more equitable and efficient. Research was undertaken to identify how surgeons used these tools in the consultation. Forty-seven consultations with 15 different surgeons have to date been video- and audio-recorded. There were no instances where CPAC tools were explicitly used in the consultation. Drawing on the methodology of conversation analysis and the concept of news delivery as developed by Maynard, this paper argues that the delivery of diagnoses and treatment plans can usefully be seen in part as the delivery of bad or good news. Using three case studies to illustrate the argument, it is suggested that the interactional work required in the delivery of such news challenges the ability of clinicians to use protocols such as CPAC. The analysis sheds light on important consultation processes that need to be more carefully considered when designing interventions to influence clinician behaviour. In order to influence the behaviour of clinicians to achieve policy goals, greater attention needs to be paid to the interactional demands of the consultation process.

Nurse-patient communication in primary care diabetes management: an exploratory study

BackgroundDiabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management.MethodsThirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis.In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared.ResultsThis study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses’ clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations.ConclusionsConscientious nursing work was evident but at times misdirected in terms of optimal use of time. The misalignment of patient expectations and clinical protocols highlights a common dilemma in clinical practice and raises questions about the best ways to balance the needs of individuals with the needs of a health system. Video- recording can be a powerful tool for reflection and peer review.

Observation of interprofessional collaboration in primary care practice: A multiple case study

ABSTRACT Interprofessional collaboration (IPC) is known to improve and enhance care for people with complex healthcare and social care needs and is ideally anchored in primary care. Such care is complex, challenging, and often poorly undertaken. In countries such as Canada, the United Kingdom, the Netherlands, Australia, and New Zealand, primary care is provided predominantly via general practices, where groups of general practitioners and nurses typically work. Using a case study design, direct observations were made of interprofessional activity in three diverse general practices in New Zealand to determine how collaboration is achieved and maintained. Non-participant observation of health professional interaction was undertaken and recorded using field notes and video recordings. Observational data were subject to analysis prior to collection of interview data, subsequently gathered independently at each site. Case-specific themes were developed before determining cross-case themes. Cross-case themes revealed five key elements to IPC: the built environment, practice demographics and location, practice business models, shared goals, and team structure and climate. The combination of elements at each practice site indicated that strengths in one area helped offset challenges in others. The three practices (cases) collectively demonstrated the importance of an “all of practice” commitment to collaborative practice so that shared decision-making can occur.

'You just got to eat healthy': the topic of CAM in the general practice consultation

Abstract New Zealand research suggests that CAM use by GPs has decreased, while referral to CAM practitioners by GPs has increased, and that patients often do not tell their health practitioners when they are using CAM. The New Zealand Medical Council has developed guidelines for GPs who use CAM. However, there is no research in New Zealand that looks at how patients and GPs respond to CAM issues in the consultation. This paper uses data collected for two research projects on doctor – patient interaction. For this research, consultations between 105 patients and nine GPs were video-recorded. In this data set, all doctors but one were ‘orthodox’ and to some degree reserved judgement on CAM, albeit remaining cautious in how they made this evident. Patients on the other hand demonstrated a variety of strategies to get CAM on the agenda, and GPs were careful to couch any criticism in such a way as to protect the face’ of patients.

Researching in the community: the value and contribution of nurses to community based or primary health care research

AIM To describe the role, contribution and value of research nurses in New Zealand community-based or primary health care research. BACKGROUND Research nurses are increasingly recognised as having a key role in undertaking successful research in hospitals and clinical trial units however only limited work has been undertaken to examine their role in community-based research. Undertaking health research in the community has unique challenges particularly in relation to research design and recruitment and retention of participants. METHODS We describe four community-based research projects involving research nurses, each with particular recruitment, retention and logistical problems. Vignettes are used to illustrate the role, contribution and value of research nurses in a diverse range of community research projects. FINDINGS The knowledge and skills used by research nurses in these projects included familiarity with communities, cultural competence, health care systems and practice philosophies and in particular with vulnerable populations. Their research actions and activities include competence with a broad range of research methodologies, organisational efficiency, family-centred approach, along with advocacy and flexibility. These are underpinned by nursing knowledge and clinical expertise contributing to an ability to work autonomously. These four projects demonstrate that research nurses in community-based research possess specific attributes which facilitate successful study development, implementation and outcome.

Framing the Consultation: The Role of the Referral in Surgeon–Patient Consultations

This study describes and analyzes the impact of the referral process on communication at the beginning of surgeon–patient consultations. We used conversation analysis to analyze the opening interactional activities of surgeon–patient consultations in New Zealand. This study focuses on 20 video-recorded consultations recorded between 2004 and 2006. Participants in surgeon–patient consultations began referred consultations by discussing the referral letter in what we have termed “referral recognition sequences.” These sequences are coconstructed activities that can be implicit or explicit and address the minimized epistemic distance between surgeons and patients that is caused by the referral process. These sequences can be simple or complex, and this complexity may be determined by the quality of the referral letter received. Acknowledgment of the referral letter assists in achieving alignment between surgeon, patient, and referring doctor regarding the presenting problem. If this alignment is not achieved, progressivity of the consultation is affected, as there is disagreement as to why the patient is seeing the surgeon. This research shows that to assist in the progressivity of surgeon–patient consultations, referral letters should be clear and patients made aware of the reason for referral. Surgeons should also overtly address the minimized epistemic distance caused by the referral letter to ensure patients present their problems in full.

Case Study Observational Research: A Framework for Conducting Case Study Research Where Observation Data Are the Focus.

Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts. However, current models of case study research do not particularly distinguish the unique contribution observation data can make. Observation methods have the potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive characteristics of case study observational research, a modified form of Yin’s 2014 model of case study research the authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data are positioned as the central component of the research design. Case study observational research offers a promising approach for researchers in a wide range of health care settings seeking more complete understandings of complex topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the approach.

Understanding communication between surgeon and patient in outpatient consultations

There is an assumption that there is a similarity between surgeon‐patient and primary care consultations. Yet, surgeon communication has had far less analytic attention than its primary care counterparts. Therefore, this assumption of similarity (and the proposition here of dissimilarity) has yet to be evidenced through detailed interactional analysis.

It's complicated - talking about gout medicines in primary care consultations: a qualitative study

BackgroundGout is the most common form of inflammatory arthritis. It is associated with substantial co-morbidity and often managed in primary care. A greater understanding of the communication process between patients and healthcare professionals provides one way of improving the management of this condition. This paper describes communication about gout medicines and treatment between patients and primary care health professionals during routine consultations.MethodsVideo-recordings of 31 individual healthcare consultations between patients and a range of primary care practitioners (general practitioners, practice nurses, podiatrists, dietitians) from an archived database were reviewed. Consultations that encompassed any discussion about gout medicines and treatment were included (n = 27) and were not solely restricted to those where gout was the presenting complaint. Themes were derived from an inductive qualitative analysis, from clinical and linguistic perspectives, based on the conversation between patients and practitioners about medicines and visual observation of these interactions.ResultsA number of factors were identified that had the potential to impact on the optimal management of gout in primary care. These included level of patient knowledge, patient attitudes to medicines, and the attributes of practitioner communication with patients. The latter related to the style of delivery and content of the information provided, and the ability of practitioners to make use of opportunities that arose to discuss these issues.ConclusionsPatients with gout communicate at varying levels of complexity with a diverse range of primary care healthcare professionals about the treatment of their condition. It is important that all practitioners engaging with gout patients in this setting are knowledgeable about the current management of gout, provide clear, consistent and accurate messages, remain aware that these messages may need repeating over time, and are supportive of patients’ medicine-taking preferences.