Emotions in primary care: Are there cultural differences in the expression of cues and concerns?

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations

BACKGROUND

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress.

AIM

To examine how emotional concerns are engaged with during routine GP consultations.

DESIGN & SETTING

Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018.

METHOD

The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes.

RESULTS

The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised.

CONCLUSION

Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Doctors, Patients, and Interpreters' Views on the Co-Construction of Empathic Communication in Interpreter-Mediated Consultations: A Qualitative Content Analysis of Video Stimulated Recall Interviews

Doctors and patients rely on verbal and nonverbal resources to co-construct clinical empathy. In language-discordant consultations, interpreters' communicative actions might compromise this process. We aim to explore doctors, patients, and professional interpreters' perspectives on their own and others' actions during their empathic interaction in interpreter-mediated consultations (IMCs). We analyzed 20 video stimulated recall interviews with doctors, patients, and interpreters using qualitative content analysis. Doctors and patients found ways to connect with each other on the level of empathic communication (EC) that is not limited by interpreters' alterations or disengaged demeanor. Some aspects of doctors and interpreters' professional practices might jeopardize the co-construction of EC in IMCs. The co-construction of EC in IMCs is not only subject to participants' communicative (inter)actions, but also to organizational and subjective factors. These results provide evidence of the transactional process between the behavioral, cognitive, and affective components of clinical empathy in the context of IMCs.

Enhancing patient participation of older migrant cancer patients: needs, barriers, and eHealth

OBJECTIVES

To gain insight into (1) the unfulfilled instrumental and affective needs of Turkish-Dutch and Moroccan-Dutch older cancer patients/survivors, (2) the barriers perceived by healthcare professionals in fulfilling these needs, and (3) how the Health Communicator, a multilingual eHealth tool, can support the fulfillment of patients'/survivors' needs, and decrease professionals' barriers.

DESIGN

We conducted a pre-implementation study of the Health Communicator using semi-structured interviews with Turkish-Dutch (n = 10; mean age = 69.10) and Moroccan-Dutch (n = 9; mean age = 69.33) older cancer patients/survivors, and held two focus groups with general practitioners (GPs; n = 7; mean age 45.14) and oncology nurses (ONs; n = 5; mean age = 49.60). Topic list consisted of questions related to needs and perceived barriers. Analysis was based on grounded theory. The acceptance of the Health Communicator was inquired by questions based on the concepts of the Technology Acceptance Model, and analyzed deductively.

RESULTS

Patients/survivors reported unfulfilled needs concerning: (1) information about cancer (treatment), (2) information about the healthcare system, (3) possibilities regarding psychosocial support, and (4) doctor-patient relationship. Among professionals, the main perceived barriers were: (1) patients'/survivors' low health literacy and language barrier, (2) cultural taboo, (3) lack of insight into patients' instrumental needs, and (4) patients'/survivors' lack of trust in Dutch healthcare. Both patients/survivors and professionals thought that implementing the Health Communicator could be effective in fulfilling most of the needs and decreasing the barriers. However, a majority of the patients/survivors were hesitant regarding the use of it, because they found it too difficult to use. Professionals showed a positive intention towards using the Health Communicator.

CONCLUSIONS

To enhance patient participation among older migrant cancer patients/survivors, the Health Communicator is, under certain conditions, a promising tool for fulfilling patients'/survivors' unfulfilled instrumental and affective needs and for bridging barriers perceived by professionals.

Emotional Health Work of Women With Female Genital Cutting Prior to Reproductive Health Care Encounters

We used institutional ethnography to explore the social relations that shaped the reproductive health care experiences of women with female genital cutting. Interviews with eight women revealed that they engaged in discourse that opposed the practices of cutting female genitals as a human-rights violation. This discourse worked to protect those affected by the practices, but also stigmatized female genital cutting, making participants anticipate experiencing stigmatization during health care. Women's engagement in this discourse shaped their emotional health work to prepare for such encounters. This work included navigating feelings of worry, shame, and courage to understand what to expect during their own appointment; learning from family/friends' experiences; and seeking a clinic with the reputation of best care for women with female genital cutting. It is important to strive for more inclusive health care in which women do not have to engage in emotional health work to prepare for their clinical encounters.

Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length

PURPOSE

It is widely cited-based on limited evidence-that attending to a patient's emotions results in shorter visits because patients are less likely to repeat themselves if they feel understood. We evaluated the association of clinician responses to patient emotions with subsequent communication and visit length.

METHODS

We audio-recorded 41 clinicians with 342 unique patients and used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to time stamp patient emotional expressions and categorize clinician responses. We used random-intercept multilevel-regression models to evaluate the associations of clinician responses with timing of the expressed emotion, patient repetition, and subsequent length of visit.

RESULTS

The mean visit length was 30.4 minutes, with 1,028 emotional expressions total. The majority of clinician responses provided space for the patient to elaborate on the emotion (81%) and were nonexplicit (56%). As each minute passed, clinicians had lower odds of providing space (odds ratio [OR] = 0.96; 95% CI, 0.95-0.98) and higher odds of being explicit (OR = 1.02; 95% CI, 1.00-1.03). Emotions were more likely to be repeated when clinicians provided space (OR = 2.33; 95% CI, 1.66-3.27), and less likely to be repeated when clinicians were explicit (OR = 0.61; 95% CI, 0.47-0.80). Visits were shorter (β = -0.98 minutes; 95% CI, -2.19 to 0.23) when clinicians' responses explicitly focused on patient affect.

CONCLUSION

If saving time is a goal, clinicians should consider responses that explicitly address a patient's emotion. Arguments for providing space for patients to discuss emotional issues should focus on other benefits, including patients' well-being.

Midwives' perceived barriers in communicating about depression with ethnic minority clients

OBJECTIVE

This study aimed to assess the most influential barriers midwives perceive in communicating about depression-related symptoms with ethnic minority clients.

METHODS

In-depth interviews were held with midwives (N = 8) and Moroccan-Dutch women (N = 6) suffering from perinatal depression to identify the most salient communication barriers. Subsequently, an online survey among midwives (N = 60) assessing their perceived barriers and the occurrence of these barriers in practice was administered. Composite scores using the QUOTE methodology were calculated to determine influential barriers.

RESULTS

Three types of barriers emerged from the interviews. Educational-related barriers, client-related barriers and midwife-related barriers. Results of the survey showed that the most influential barriers were educational-related barriers (e.g. lack of culturally sensitive depression screening instruments) and client-related barriers (e.g. cultural taboo about talking about depression).

CONCLUSION

Culturally sensitive screening instruments for depression and patient education materials should be developed to mitigate the educational-related barriers to communicating about depression. Patient education materials should also target the clients' social environment (e.g. husbands) to help break the cultural taboo about depression.

PRACTICE IMPLICATIONS

Based on this study's results, communication strategies to empower both midwives and ethnic minority clients with depression can be developed in a collaborative approach.

Applying Chinese Verona Coding Definitions of Emotional Sequences (VR-CoDES) in ophthalmic consultations: An observational study

OBJECTIVE

Apply Chinese VR-CoDES in ophthalmic setting and describe patients' worries and the doctor's responses. Explore cultural differences in coding.

METHODS

102 audio-taped consultations of 84 patients were coded by Chinese version of VR-CoDES. The intra-class correlation coefficient (ICC) was used to test inter/intra-rater reliability, and inductive content analysis was conducted.

RESULTS

The ICCs of inter-rater reliability for cues/concerns and responses were 0.78 and 0.81, and intra-rater reliability were 0.87 and 0.99, respectively. Cues were more frequent than concerns and elicited often by patients. Explicit Reduce Space (ER) was the most frequent response. Interruptions and the doctor's repetitions were evident. Some expressions were not specified in the coding manual. Patients concerned about treatment effect (22 %), expenses (18 %), risk of operation (14 %), and pain (10 %).

CONCLUSION

The Chinese VR-CoDES can be applied to clinical consultations in China. Ophthalmic patients often expressed cues which were frequently elicited by themselves. The ophthalmologist preferred to give ER response. Interruptions and the ophthalmologist's repetitions were difficult to code. More Chinese expressions should be collected to reduce cultural difference when coding.

PRACTICE IMPLICATION

VR-CoDES will be helpful in doctor-patient communication and medical education. VR-CoDES should undergo cultural adaptions in China.

What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an Australian healthcare setting

Background

Culturally competent health care service delivery can improve health outcomes, increasing the efficiency of clinical staff, and greater patient satisfaction. We aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting.

Methods

In-depth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus group with professional interpreters working. Data were analysed using an inductive thematic approach with constant comparison.

Results

Individual interviews were conducted with 12 patients from Greek, Chinese, Dari and Vietnamese backgrounds. Focus groups were conducted with 11 professional interpreters. Key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients. Interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with them.

Conclusions

In an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice. This can be enhanced by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don’t fall through the gaps with regards to the provision of culturally competent care.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7378-9) contains supplementary material, which is available to authorized users.

Can Verona Coding Definitions of Emotional Sequences (VR-CoDES) be applied to standardized Chinese medical consultations? - A reliability and validity investigation

OBJECTIVE

To investigate the reliability and validity of the Chinese version of VR-CoDES.

METHODS

The VR-CoDES was translated into Chinese, and a focus group was held to discuss its cultural adaptation. Video consultations between 75 fourth-year medical students and 2 standardized patients (SPs) were coded by two raters with the Chinese VR-CoDES. Inter-rater reliability was tested by using ICC. To obtain validity, the SPs reviewed the video consultations to confirm the cues and concerns.

RESULTS

ICC was 0.79. Specificity and sensitivity were 0.99 and 0.96 respectively. The SPs expressed considerably more cues (mean = 7.00) than concerns (mean = 0.32). Half of the responses of medical students were explicit reducing space. Focus group participants raised some cultural considerations, and some interactions were difficult to code due to cultural differences.

CONCLUSION

The Chinese VR-CoDES obtained good reliability and validity. Due to differences in the expression of emotions and other differences such as different medical systems between China and Western countries, the Chinese VR-CoDES needs further cultural adaptation.

PRACTICE IMPLICATION

More consultations in real clinical settings need to be gathered to further support the Chinese VR-CoDES both on validation and cultural adaptation.

Verona Coding Definitions of Emotional Sequences (VR-CoDES): Conceptual framework and future directions

OBJECTIVE

To discuss the theoretical and empirical framework of VR-CoDES and potential future direction in research based on the coding system.

METHODS

The paper is based on selective review of papers relevant to the construction and application of VR-CoDES.

RESULTS

VR-CoDES system is rooted in patient-centered and biopsychosocial model of healthcare consultations and on a functional approach to emotion theory. According to the VR-CoDES, emotional interaction is studied in terms of sequences consisting of an eliciting event, an emotional expression by the patient and the immediate response by the clinician. The rationale for the emphasis on sequences, on detailed classification of cues and concerns, and on the choices of explicit vs. non-explicit responses and providing vs. reducing room for further disclosure, as basic categories of the clinician responses, is described.

CONCLUSIONS

Results from research on VR-CoDES may help raise awareness of emotional sequences. Future directions in applying VR-CoDES in research may include studies on predicting patient and clinician behavior within the consultation, qualitative analyses of longer sequences including several VR-CoDES triads, and studies of effects of emotional communication on health outcomes.

PRACTICE IMPLICATIONS

VR-CoDES may be applied to develop interventions to promote good handling of patients' emotions in healthcare encounters.

How family physicians respond to unpleasant emotions of ethnic minority patients

OBJECTIVE

The diversity in our society makes patient-centered care more difficult. In this study, we aim to describe how family physicians respond to unpleasant emotions of ethnic minority patients.

METHODS

One hundred ninety one consultations of family physicians with ethnic minority patients were video-recorded and analyzed using the Verona Codes for Provider Responses (VR-CoDES-P) to describe physicians' responses to patients' expressed unpleasant emotions or cues (implicit) and concerns (explicit).

RESULTS

42.4% (n=81) of all the consultations contained no cues or concerns, and thus no physician responses. Of the consultations containing at least one cue or concern, a mean of 3.45 cues and a mean of 1.82 concerns per consultation were found. Physicians are significantly (p≤0.001) more frequently stimulating further disclosure of patients' cues and concerns (providing space: n=339/494 or 68.6% versus reducing space: n=155/494 or 31.4%). However, these explorations are more often about the factual, medical content of the cue than about the emotion itself (n=110/494 or 22.3% versus n=79/494 or 16%). The inter-physician variation in response to patients' cues is larger than the variation in response to the patient's concerns.

CONCLUSIONS

Although family physicians are quite often providing room for patients' emotions, there is much room for improvement when it comes to explicitly talking about emotional issues with patients.

PRACTICE IMPLICATIONS

Further research should focus on a more qualitative in-depth analysis of the complex interplay between culture and language of ethnic minority patients in primary care and, consequently, create awareness among these healthcare providers about the importance of ethnic minority patients' emotions and how to respond accordingly.

Applying the Verona coding definitions of emotional sequences (VR-CoDES) to code medical students' written responses to written case scenarios: Some methodological and practical considerations

OBJECTIVE

To investigate whether the Verona Coding Definitions of Emotional Sequences to code health providers' responses (VR-CoDES-P) can be used for assessment of medical students' responses to patients' cues and concerns provided in written case vignettes.

METHODS

Student responses in direct speech to patient cues and concerns were analysed in 21 different case scenarios using VR-CoDES-P.

RESULTS

A total of 977 student responses were available for coding, and 857 responses were codable with the VR-CoDES-P. In 74.6% of responses, the students used either a "reducing space" statement only or a "providing space" statement immediately followed by a "reducing space" statement. Overall, the most frequent response was explicit information advice (ERIa) followed by content exploring (EPCEx) and content acknowledgement (EPCAc).

DISCUSSION

VR-CoDES-P were applicable to written responses of medical students when they were phrased in direct speech. The application of VR-CoDES-P is reliable and feasible when using the differentiation of "providing" and "reducing space" responses. Communication strategies described by students in non-direct speech were difficult to code and produced many missings.

PRACTICE IMPLICATIONS

VR-CoDES-P are useful for analysis of medical students' written responses when focusing on emotional issues. Students need precise instructions for their response in the given test format.