Healthcare professionals' assertions and women's responses during labour: A conversation analytic study of data from One born every minute

Touch, communication and affect: a systematic review on the use of touch in healthcare professions

BACKGROUND

The following systematic review explores the uses and understandings of physical, human-to-human touch engagements in healthcare professions. Given its central importance as both a diagnostic tool and a form of non-verbal communication, this review sought to understand the communicative, social and affective dimensions of touches a part of healthcare, medical or nursing interventions. We attempt to understand how touch communication seems to be structured in the literature, and what tends to be communicated via touch, but also to highlight how the dogmatic distinction between 'instrumental' and 'expressive' touches might have obscured a socio-affective matrix within all touches.

METHODS

The synthesis produced was informed by 36 empirical studies involving either direct observation of touch practices, or recollection and discussion with healthcare professionals. The studies were selected from five databases in March 2022. In order to minimise risks of bias, the corpus was screened by two independent reviewers and underwent quality appraisal through the Mixed Methods Appraisal Tool. The final dataset was then analysed, synthesised and presented according to the principles of thematic synthesis.

RESULTS

We outline how medical touch has been mostly categorised as either 'instrumental' or 'expressive', with only the latter usually described as serving a communicative purpose, despite its lower incidence. We further highlight how touch seems to be operating across a fragile boundary between 'reassuring presence' and 'control', and thus requires carefulness by practitioners, and an understanding of boundaries. Then, we describe how the literature presented gender, cultural background and personal preference as elements influencing the use and perception of touch. Lastly, touch-mediated communication has been presented in some of the literature as a co-produced practice based on bodily, affective and contextual mutual attunement. Such an understanding radically reconfigures the patient as an active co-participant, as well as pushing against the conceptual boundary between instrumental and expressive touch, recognising how to affect cuts across human-made dichotomies.

CONCLUSION

We argue that communication might happen in all instances of touch, while also advocating for empirical work to outline and describe the adaptive physical dynamics (e.g. changes in speed, pressure, temperature) that regulate and alter even medical procedures for communicative purposes. We also discuss the need for social scientists to radically re-conceptualise not only the theoretical scaffolding behind medical touch, but also the methodologies deployed to investigate it-advocating for a renewed attention to bodily and interactional dynamics, particularly through the deployment of (micro-)phenomenological tools, broader ethnographical engagements, or sensors for automatic recognition of bio-signals.

LIMITATIONS

The review could be at risk of bias given it sampled only studies written in English, French, Italian, Spanish and Finnish, thus not highlighting potentially different cultural and theoretical perspectives emerging from non-EuroAmerican contexts. Moreover, only 36% of studies included discuss patients' perspectives.

SYSTEMATIC REVIEW REGISTRATION

This review was not registered.

Clinical decision-making during childbirth in health facilities from the perspectives of labouring women, relatives, and health care providers: A scoping review

PROBLEM

For health care providers to ensure appropriate decision-making in clinical settings during childbirth, facilitators and barriers must be identified.

BACKGROUND

Women who experience a sense of control by participating in the decision-making process, are more likely to have a positive birth experience. However, decision-making may involve hierarchies of close observation and control.

AIM

The aim of the scoping review was to map and summarise existing literature on the process of clinical decision-making during childbirth from the perspective of labouring women, relatives and health care providers.

METHODS

We carried out a scoping review in line with Joanna Briggs Institute scoping review methodology. The search identified studies in Scandinavian or English languages from 2010 - Jan 2023 comprising evidence at different levels of the pyramid, resulting in 18.227 hits. Following the PRISMA checklist, the final inclusion comprised 62 papers.

FINDINGS

Four main categories summarized the importance of the following factors: 1) Woman-caregiver relationship, with sub-categories The importance of communication and Midwifery care, 2) Consent and legal issues, 3) Organization, with sub-categories Medicalization, Working atmosphere, and Complexity, and 4) Decision-making tools and models, with sub-categories Shared decision-making, and Other tools and models for decision-making.

CONCLUSION

Balancing intuition and expertise of caregivers with evidence-based practices, is crucial to ensure women's participation in decision-making. Furthermore, a trusting relationship between the mother, partner, and health care provider is of utmost importance. Shared decision-making, which appeared to be the primary model for clinical decision-making regardless context, requires reflective practice and is a communication strategy.

Assertiveness in physicians' interpersonal professional encounters: A scoping review

PURPOSE

Good relationships between physicians, patients, families and the healthcare team are essential for high-quality care. Medical encounters are sometimes challenging. They may include conflicts, requiring physicians to be assertive: that is to share and protect their needs, rights and values while preserving those of others. Whereas assertiveness has been studied in patients and nursing staff (those with less power in healthcare), physicians' assertiveness, which must be mindful of these power differences, lacks a comprehensive review. Thus, this scoping review focuses on assertive communication in physicians' encounters.

METHODS

A literature search of four online databases: MEDLINE, Embase, PsycINFO and WoS, seeking articles on physicians' assertiveness as a communication style published until February 2022. The Joanna Briggs Institute approach and the Preferred Reporting Items for Systematic Reviews checklist underpinned the review protocol.

RESULTS

We identified 1513 articles relating to assertiveness, reviewed 153 full-text articles and selected 22 for full review, 68% from the last decade. The articles focused mainly on assertive communication and relationships with medical staff, with 54% focusing on bottom-up power relations. In 40% of the articles, no clear definition of assertiveness was included. Definitions included had varied focus: on self, on the other or both. Overall, assertiveness measures varied widely, precluding a methodical comparison.

CONCLUSIONS

Despite the growing interest in physicians' assertiveness, a clearer definition and in-depth exploration of assertiveness are needed alongside development of valid measures of assertiveness appropriate to physicians. Based on the review, we offer a relational definition of assertiveness as the capacity to communicate one's views, concerns, rights and needs while respecting others and preserving therapeutic, collegial and educational professional alliances. This definition may serve to expand research in the field while offering a professional alternative to problematic communication styles-passive and self-denying or paternalistic and aggressive -that obfuscate and thus undermine physician-patient relationships.

'It must be right, I saw it on TV!': An observational study of third stage birth practices in popular television programmes

Objectives

To examine modern media depictions of the third stage of birth in a selection of UK television representations.

Design

Observational study of a sample of televised fictional and real births, audited against current National Institute of Health and Social Care Excellence (NICE) guidance.

Setting

UK television channels BBC (Call The Midwife and This Is Going To Hurt) and Channel 4 (One Born Every Minute).

Participants

87 births from 48 episodes, sampled from the three shows.

Main outcome measures

The primary outcome was the number of births where the cord was clamped at more than 1 min after birth. Secondary outcomes included place and type of birth, measures of dignity and paternal involvement.

Results

Overall, the timing of cord clamping was clearly shown in 25/87 (29%) of births, of which only 4/25 (16%) occurred at more than 1 min in screen time. The place of birth and caesarean section (CS) rate changed according to the series perspective and era; graphic explicit images were shown, but these related to CS detail.

Conclusions

UK television shows have accurately depicted changes in place, culture and type of birth over the last century. They provide the public with a view of new rituals but an inaccurate picture of good quality care. Early cord clamping was shown in most births, even those set after 2014. No programme informed viewers about the safety aspects. When showing outdated practices, broadcasters have a public health duty to inform viewers that this is no longer recommended.

Making Conversation Analysis Accessible: A Conceptual Guide for Health Services Researchers

The quality of healthcare communication can impact both experiences and outcomes. We highlight aspects of communication that can be systematically examined using Conversation Analysis (CA) and provide guidance about how researchers can incorporate CA into healthcare studies. CA is a qualitative method for studying naturally occurring communication by analyzing recurrent, systematic practices of verbal and nonverbal behavior. CA involves examining audio- or video-recorded conversations and their transcriptions to identify practices speakers use to communicate and interpret behavior. We explain what distinguishes CA from other methods that study communication and highlight three accessible CA approaches that researchers can use in their research design, analysis, or implementation of communication interventions. Specifically, these approaches focus on how talk is produced (specific words, framing, and syntax), by whom, and when it occurs in the conversation. These approaches can be leveraged to generate hypotheses and to identify patterns of behavior that inform empirically driven communication interventions.

Forms of resistance in people with severe and profound intellectual disabilities

Government policy in the UK emphasises that people with intellectual disabilities should have the opportunity to make choices and exert control over their own lives as much as possible. The ability of a person to resist activities and offers is therefore important, particularly for people with severe and profound intellectual disabilities, who are likely to have language impairments and need to communicate their choices non-verbally. Video and ethnographic data were collected from two services for people with severe and profound intellectual disabilities. Examples of resistance by people with severe and profound intellectual disabilities and responses to that resistance by support workers were collected and examined using conversation analysis and ethnographic description. A range of non-verbal resistance behaviours are described, and the difficulty for support workers in identifying resistance when behaviour is ambiguous is discussed. The importance of understanding these behaviours as examples of decision-making is stressed.

Communication in high risk ante-natal consultations: a direct observational study of interactions between patients and obstetricians

Background

Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where the outcome affects more than one person. While higher levels of patient participation and shared decision making are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective communication practices in a high-risk ante-natal clinic.

Methods

We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13 obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in conjunction with thematic analysis of interview transcripts.

Results

Most patients reported high quality communication and high levels of satisfaction; the detailed consultation analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations, acknowledgement of the patient’s experience, consideration of patient wishes, and realistic and honest answers to patient questions. On the patient side, these included a high level of engagement with technical aspects of events and procedures, and appropriate questioning of obstetricians.

Conclusions

This study has demonstrated the utility of combining direct observation of consultations with data from patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care. The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.

Women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour

OBJECTIVE

To explore and synthesise evidence of women's information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour.

DESIGN

A systematic review following the Joanna Briggs Institute (JBI) meta-aggregative approach to qualitative evidence synthesis. Relevant databases were searched for literature published in English between 2000-19. Study quality was assessed using the JBI quality assessment tool for qualitative studies.

SETTING

Qualitative research conducted in OECD countries describing women's information needs, decision-making and/or experiences of membrane sweeping to promote spontaneous labour.

FINDINGS

One article met the criteria for inclusion. This article describes the experience of a membrane sweep given without consent.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a lack of evidence around women's information needs, decision-making and experiences of membrane sweeping. This is concerning, especially in the context of rising rates of formal induction of labour. Further research is needed to investigate how women are being offered membrane sweeping and what information women need to make informed choices about membrane sweeping to promote spontaneous labour.

Quantitative insights into televised birth: a content analysis of One Born Every Minute

This article explores birth representations through a content analysis of two seasons of the U.K. program, One Born Every Minute (OBEM) (Channel 4, 2010-). Reality television (RTV) has been a fertile ground for the mediation of birth, but has also stoked controversy among feminist critics and the birth community about how birth is represented and the impacts this might have for women and society. International research has explored problematic over-representation of white, heterosexual couples, as well as noting a predominance of medicalized birth experiences. However, this research is formed largely of qualitative studies that are necessarily based on small samples of episodes. To contribute to this literature, we apply a quantitative and interdisciplinary lens through a content analysis of two seasons of the U.K. version of OBEM. Paying attention to the geographical and temporal context of OBEM, this article confirms over-representation of white, heterosexual couples and medicalized birth on RTV birth shows while also providing novel insights into the ambiguous representation of birthplace and lead caregivers, the medicalization of birth through the routinization of supposedly minor birth interventions, and the absence of the representation of women's choice over such interventions.