Revealing moments: formulating understandings of adverse experiences in a health appraisal interview

Displaying concerns within telephone triage conversations of callers with chest discomfort in out-of-hours primary care: A conversation analytic study

OBJECTIVES

In primary care out of hours service (OHS-PC), triage nurses ask questions to assign urgency level for medical assessment. A semi-automatic decision tool (the Netherlands Triage Standard, NTS) facilitates triage nurses with key questions, but does not leave much room for paying attention to callers' concerns. We wanted to understand how callers with chest pain formulate their concerns and are helped further during telephone triage.

METHODS

We conducted a conversation analytic study of 68 triage calls from callers with chest discomfort who contacted OHS-PC of which we selected 35 transcripts in which concerns were raised. We analyzed expressions of concerns and the corresponding triage nurse response.

RESULTS

Due to the task-oriented nature of the NTS, callers' concerns were overlooked. For callers, however, discussing concerns was relevant, stressed by the finding that the majority of callers with chest discomfort expressed concerns.

CONCLUSIONS

Interactional difficulties in concern-related discussions arised directly after expressed concerns if not handled adequately, or during the switch to the counseling phase.

PRACTICE IMPLICATIONS

When callers display concerns during telephone triage, we recommend triage nurses to explore them briefly and then return to the sequence of tasks described in the NTS-assisted triage process.

GP laughter in lifestyle behaviour consultations: A conversation analytical study of general practice

OBJECTIVE

This study investigates laughter by General Practitioners (GPs) in response to patient laughter in lifestyle behaviour consultations.

METHOD

We examined video-recorded consultations involving 44 patients of four GPs in Australia. After identifying 33 cases of patient laughter, we examined whether GPs laughed in response. We used Conversation Analysis to explore the appropriateness of GP laughter and non-laughter by investigating the talk before and after the occurrence of patient laughter.

RESULTS

GP reciprocal laughter was found in thirteen occasions when patients unsolicitedly mentioned their behaviours, laughed and displayed their evaluative stances (whether the behaviours were positive or negative). On twenty occasions, patients laughed in response to GP enquiries, which worked to problematise particular behaviours. In this context, patient laughter was not usually reciprocated (19/20 cases) because reciprocal laughter may risk being interpreted as laughing at the patient, as evidenced by one deviant case.

CONCLUSION

GP reciprocal laughter may be problematic when the behaviour issues are raised by GPs and patients' evaluative stances regarding their behaviour have not yet been revealed.

PRACTICE IMPLICATIONS

To decide when it is appropriate to reciprocate laughter, GPs should consider the contexts that lead to patient laughter and patients' evaluative stances.

Qualitative and quantitative analysis of doctor-patient interactions during andrological consultations

INTRODUCTION

Although a trustworthy connection between doctor and patient is crucial in clinical practice, it could be hindered by different cultural and linguistic backgrounds. Moreover, an effective doctor-patient interaction could be even more challenging in andrological fields, in which psychological and social components are predominant.

AIM

To analyse the doctor-patient relationship in the andrological field, applying both qualitative and quantitative analyses.

METHODS

monocentric, cross-sectional, observational study was performed between May and December 2018. During the study, all patients aged >18 years attending the Modena Andrology Unit for couple infertility or erectile dysfunction were enrolled and the doctor-patients interaction recorded. Patients were divided into two groups depending on their medical seeking and were further divided between native and non-native speakers of Italian. All patients underwent a routine andrological examination. Every first medical consultation was audio-recorded and transcribed using "ELAN" software for socio-linguistic analysis. Transcriptions underwent qualitative analysis through conversation analysis. Then, quantitative analyses were performed, and interaction parameters underwent correlation analyses.

RESULTS

Twenty-five patients were enrolled. The analysis of the andrological interview allowed to recognize five consecutive phases, following a semi-standardized pattern. Patients without linguistic barriers and with infertility problems showed more autonomous contribution during the consultation. No difference arose in sexual dysfunctions group. Doctor's explanations were frequent, but when linguistic barrier was present or Italian patients seemed less talkative, explanations were shorter, and doctors tried to use other conversational mechanisms to promote understanding. Patient's variables were significantly lower compared to the doctor, considering the number of turns (p = 0.025) and their minimum (p = 0.032), maximum (p<0.001), and average durations (p<0.001). Only patient's latency was significantly higher than the doctor's (p = 0.001).

CONCLUSION

This is the first attempt to analyse the doctor-patient relationship in andrology using authentic audio-recorded consultations. The results confirmed that a patient-centred communication must be applied also in andrological consultations. However, the topics discussed may require more "medical formulation" to be acceptable to the participants in this context. This article is protected by copyright. All rights reserved.

The first steps towards professional distance: A sequential analysis of students' interactions with patients expressing emotional issues in medical interviews

OBJECTIVE

Explore sequential patterns in students' interactions with patients expressing emotional concerns in a medical interview.

METHODS

Concepts and principles from conversation analysis (CA) were used to examine the turn-by-turn sequential organization of student actions in eleven video-taped medical interviews. We used results from an earlier coding with an interaction analysis system (VR-CoDES) in a previously published paper as a point of reference.

RESULTS

By using CA instead of VR-CoDES as our primary investigative method we observed that student turns previously coded as elicitations to simulated patients' expressions of emotion were often preceded by subtle patient initiatives. Students encouraged further elaboration by displaying their understanding of the emotional issue as a story telling still in progress. Students' expressions of understanding however, gave little room for further elaboration. Finally, students often addressed emotional issues as a medical issue and offered professional advice.

CONCLUSIONS

Students' actions seemed specifically designed to display interest in the patients' initiatives to talk about emotional experiences without departing from their initial interview task or violating norms for professional conduct.

PRACTICE IMPLICATIONS

Educators and practitioners should reconsider how the medical interview may shape expectations for professional conduct and can thereby unintentionally restrict students' empathy development.

How General Practitioners Raise Psychosocial Concerns as a Potential Cause of Medically Unexplained Symptoms: A Conversation Analysis

A common explanation for medically unexplained symptoms (MUS) relates patients' psychosocial concerns to their physical ailments. The present study used conversation analysis to examine how general practitioners (GPs) ascribe psychosocial causes to patients' unexplained symptoms during medical consultations. Our data consisted of 36 recorded consultations from Dutch general practice. We found that GPs raise psychosocial concerns as a potential cause of MUS in 14 consultations, either captured in 1) history-taking questions, or 2) diagnostic explanations. Whereas questions invited patient ideas, explanations did not make relevant patient responses in adjacent turns and subordinated patients' knowledge in symptom experiences to the GP's medical expertise. By questioning patients whether their symptoms may have psychosocial causes GPs enabled symptom explanations to be constructed collaboratively. Furthermore, additional data exploration showed that GPs lay ground for psychosocial ascriptions by first introducing psychosocial concerns as a consequence rather than a cause of complaints. Such preliminary activities allowed GPs to initiate rather delicate psychosocial ascriptions later in the consultation.

Empathic Validation in Physician-Patient Communication: An Approach to Conveying Empathy for Problems With Uncertain Solutions

Interest in systematic approaches to improving clinical empathy has increased. However, conceptualizations of empathy are inconsistent and difficult to operationalize. Drawing on video recordings of primary care visits with older adults, I describe one particular communication strategy for conveying empathy-empathic validation. Using conversation analysis, I show that the design of empathic validations and the context in which they are delivered are critical to positive patient responses. Effective empathic validations must (a) demonstrate shared understanding and (b) support the patient's position. Physicians provided empathic validation when there was no medical solution to offer and within this context, for three purposes: (1) normalizing changes in health, (2) acknowledging individual difficulty, and (3) recognizing actions or choices. Empathic validation is a useful approach because it does not rely on patients' ability to create an "empathic opportunity" and has particular relevance for older adults.

Physiotherapists' Approaches to Patients' Concerns in Back Pain Consultations Following a Psychologically Informed Training Program

Guidelines advocate a combined physical and psychological approach to managing non-specific chronic low back pain (NSCLBP), referred to as psychologically informed practice (PIP). PIP is underpinned by patient-centered principles and skilled communication. Evidence suggests that a physiotherapist-focused style of communication prevails in physiotherapy. There is a recognized need for observational research to identify specific communication practices in physiotherapy interactions. This observational study explored the interactional negotiation of agenda setting following a PIP training intervention, by identifying and describing how physiotherapists solicit and respond to the agenda of concerns that patients with NSCLBP bring to primary care initial encounters. The research setting was primary care. Nineteen initial physiotherapy consultations were video-recorded, transcribed, and analyzed using conversation analysis, a qualitative observational method. These data revealed a patient-focused style of communication where trained physiotherapists demonstrated a collaborative and responsive style of verbal and nonverbal communication to solicit, explore, and validate patients' concerns.

Effective Communication and Knowledge Distribution in Healthcare Interaction with Migrants

Modern patient-centered approaches increasingly recognize the contribution of patients' knowledge in interactions with health-care personnel. Effective involvement is exceptionally difficult when patients are migrants with limited command of specialized language. Interactional practices that promote effective distribution of knowledge and access to it are needed: by doctors interacting directly with patients in a shared language and by mediators providing interpreting services across different languages. In this paper, we look at two types of sequence which seem to be effective in involving (migrant) patients. The first concerns clinicians' reactions to spontaneous patients' initiatives, like claims to knowledge or personal narratives. The second concerns interpreters' explanations when they render the clinicians' instructions to the patients. While both sequences are clearly designed to promote patients' participation, they need particular communicative competence on the part of staff, clinicians, and interpreters.

Empathy in nurse-patient interaction: a conversation analysis

BACKGROUND

Considerable attention has been drawn to empathy in nursing and the concept of empathy has firmly been embedded in nursing discourse. However, little has been known about the details of how nurses express empathy to their patients. In this study, we aim to conduct a qualitative study of actual nurse-patient conversations through which empathy was achieved.

METHODS

The data in this study was based on audio-recording of sessions of conversations between participating nurses and patients in two Chinese hospitals. The participants in this study involved 6 female nurses and 14 patients. Based on Bachelor's (1988) categorization of empathy, this study described and analyzed the actual empathic sequences in nursing conversations in an attempt to demonstrate how nursing empathy was interactionally achieved using the method of conversation analysis. Conversation analysis (CA), focusing on the study of talk in interaction, is a useful method for the qualitative analysis of empathic talk in nursing.

RESULTS

By drawing on prior theoretical work as well as on empathic sequence in nursing, this study described and analyzed some of the conversational resources nurses and patients used in achieving empathy. It has been shown that empathy can be interactionally and sequentially achieved in actual sequences of talk. Specifically, nursing empathy is a collaboratively constructed action instead of the nurse's own committed action, which is produced in specific interactional contexts.

CONCLUSION

Conversation analysis is a very useful method for describing and analyzing the nurse-patient interaction, especially for studying empathy in nursing care. The sequences in this study present example of exemplary empathic interaction between nurses and patients, which might shed some light on how nurses express empathy to their patients. Also, this study could help to increase the understanding of the mirco-process of empathy in nursing and contribute to improving nursing communicative skills.

Managing Distress Over Time in Psychotherapy: Guiding the Client in and Through Intense Emotional Work

Clients who seek psychotherapeutic treatment have had personal experiences involving some form of distress. Although research has shown that the client's ability to experience and express painful emotions during therapy can have a therapeutic benefit, it has also been argued that displaying distress may convey a form of helplessness and vulnerability, and thus, clients may be reluctant to cast themselves in this light. Using the methods of conversation analysis, this paper explores how a client's upsetting experience is managed over the course of a single session of client-centered therapy. The main analytic focus will be on (1) the different therapist practices used to orient to the client's distress, (2) the varying forms of client opposition to the therapist's attempts to work with the distress, and (3) the context sensitivity of orienting to distress and how certain practices may be uniquely shaped by what had occurred in prior talk. It was found that, whereas certain types of therapist responses tended to be endorsed by the client, others were forcefully rejected as inappropriate displays of understanding or empathy. By focusing on repeated sequential episodes over time in which a client conveys distress, followed by the therapist's response, this paper sheds light on the interactional trajectory through which a client and therapist are able to resolve impasses to emotional exploration and to successfully secure extended and intense emotional work.

"Tiny Tiny Little Nothings": Minimization and Reassurance in the Face of Cancer

Drawing from a sub-sample of video recorded and transcribed oncology interviews, Conversation Analysis is used to examine moments when cancer is portrayed as absent or minimally present but not dangerously invasive. Though cancer patients and their doctors invest considerable efforts pursuing life-affirming and hopeful possibilities advancing the quality of living and healing outcomes, little is known about how"good news" and thus hopeful social actions get organized. An interactional practice is identified for depicting tumor sizes as small or shrinking - a displayed preference to tumors that are large, growing, and spreading (i.e., metastasizing). By relying on gestural depictions (e.g., pinched fingers and open hands), in precise unison with paired lexical affiliates (e.g., tiny, little, nothing), it is shown how patients seek to justify their wellness and doctors offer reassurance by demonstrating that tumor sizes are minimally threatening. These interactional practices provide a needed balance to deathly cancer stereotypes, criticisms of health-care bureaucracies as inhumane, and overreliance on biomedical authority enacted during clinical encounters. A need exists to verify the existence of a benign social order in the midst of cancer care, actions designed to address malignant diagnoses by curtailing uncontrolled cancer growth.

Empathically designed responses as a gateway to advice in Dutch counseling calls

Previous conversation analytic studies of institutional interaction included analyses of empathy in interaction. These studies revealed that professionals may use empathy displays not only to validate the client's worry, but also to perform actions oriented to other institutional goals and tasks such as closing off a troubles-telling sequence. In this article, we present an analysis of empathically designed responses in Dutch telephone counseling. The data consist of 36 calls from the Alcohol and Drugs Info Line. In some of the calls, clients' troubles-telling includes 'emotion discourse', that is, descriptions of their feelings/emotions. Counselors may respond to these descriptions using conventional empathy displays like 'I can imagine that' and 'I understand that' in a range of verbal and prosodic variations. The analysis reveals that these responses open up advice sequences that vary in the extent to which they treat the client's articulated feelings as valid. Most are affiliating, treating the client's feelings as the basis for advice, while some are less affiliative, putting the client's feelings into perspective or implicitly questioning their legitimacy. Hence, empathically designed responses are pivots to advice-giving.

Laughter, Humor, and Cancer: Delicate Moments and Poignant Interactional Circumstances

Conversation analysis is employed to examine transcribed excerpts drawn from a subsample of 75 naturally occurring and video recorded interviews between cancer patients and 30 doctors. Close examination is provided of how cancer patients initiate, and doctors respond, to laughter and humor during oncology interviews. Interactions demonstrate that communication about the disease "cancer" shares qualities similar to other medical areas (e.g., primary care): the tendency for patients to initiate laughter or humor to address troubling and challenging circumstances; and that during moments when patients address personal matters, doctors are not invited and do not reciprocate with shared laughter and humor. Prominent in talk about cancer are various precarious circumstances, awkward and delicate moments mirroring the lived experiences of cancer patients (e.g., when patients attempt to minimize fears, justify that they are well when threatened with sickness, claim normality in the midst of chronic conditions, and take stances that weight loss and gain are not problematic). These examples provide a compelling case that routine cancer care involves many poignant situations managed through laughter and humor. Implications are raised for how quality care might be improved through grounded understandings of laughter, humor, and cancer.

“Empathy” and “Sympathy” in Action: Attending to Patients' Troubles in Finnish Homeopathic and General Practice Consultations

This paper analyzes “empathy” and “sympathy” as situated practices, sequential processes that are coconstructed by the participants in the situation. The data consists of 228 sequences of patients' descriptions of their problematic experiences and professionals' responses to them in videorecorded general practice and homeopathic consultations. One deviant case, in which the practitioner shows compassion to the patient in an exceptional way, is subjected to detailed analysis. It is argued that both professionals and patients orient to a degree of professional neutrality in these situations, but also that affiliative practices can be adjusted to the otherwise problem-governed course of the consultation. These orientations seem to address questions similar to those of theoretical distinctions made between the terms empathy and sympathy.

Conversation analysis of the two-chair self-soothing task in emotion-focused therapy

OBJECTIVE

Despite an increasing recognition of the relevance and significance of self-compassion processes, little research has explored interventions that seek to enhance these in therapy. In this study, we examined the compassionate self-soothing task of emotion-focused therapy involving two-chair work, with seven clients.

METHOD

Conversation analysis was used to examine client-therapst interaction.

RESULTS

The analysis yielded a detailed description of interactional practices and processes involved in the accomplishment of self-soothing, drawing on Goffman's concept of the participation frame. We show how therapists and clients collaborate to move from the ordinary frame of therapeutic conversation to a self-soothing frame and back again by using various interactional practices: Therapists' instructions to clients, specific ways of sequencing actions in interaction, explanations and justification of the importance of the self-soothing task, pronouns as a way to distinguish among addressees (e.g., clients versus soothing agents), corrections of clients' talk, and response tokens (hm mm, yeah, good). These practices are used to help clients accomplish self-soothing in the form of self-praise, disclosing caring, and offering of helpful advice.

CONCLUSIONS

This study offers therapists a specific account of how to respond to clients at specific junctures in self-soothing dialogues and how to structure and accomplish the self-soothing task.

Prosody and empathic communication in psychotherapy interaction

OBJECTIVE

To investigate the prosodic aspects of therapists' empathic communication.

METHOD

70 audio-recorded sessions of cognitive psychotherapy and psychoanalysis were analysed using conversation analysis.

RESULTS

Two interactional trajectories where the therapists either validated the clients' emotions or challenged them were identified. The difference between these trajectories was not evident in the lexical composition of the therapists' formulations that initiated the trajectory. However, the prosodic features of the formulation already anticipated the direction of the trajectory. The formulations leading up to the validating trajectory were characterized by prosodic continuity and formulations leading up to the challenging trajectory by prosodic disjuncture. The choice between continuous and disjunctive prosody was a key resource for therapists in the construction of formulations as either validating or challenging.

CONCLUSIONS

The present article emphasizes the relational aspects of psychotherapy communication by considering the prosodic features of the therapist's talk in relation to the prosody of the client.

The Pragmatics of Emotions in Interlinguistic Healthcare Settings

Data-based studies on interlinguistic medical interaction show that frequently migrant patients encounter difficulties in expressing their emotions and concerns. Such difficulties are not always overcome through the intervention of an interpreter, as emotional expressions tend to “get missed” in translations which focus on problems and treatments in medical terms. The main question addressed here is: what types of interpreters’ actions cut out, or make relevant, migrant patients’ emotions? Our data is based on a corpus of 300 interlinguistic medical interactions in Arabic, Mandarin Chinese and Italian in two public hospitals in Italy. The conversations involve one Italian healthcare provider, an interpreter and a migrant patient. The corpus is analyzed drawing upon Conversation Analysis, studies on Dialogue Interpreting and Intercultural Pragmatics.

Narrative co-construction in the medical consultation: How agency and control affect the diagnosis

The purpose of this paper is to examine patient-provider narrative co-construction of symptoms, diagnosis and treatment in the medical consultation. Narrative scholarship has demonstrated that conversational narratives, including those that take place in medical consultations, are typically co-constructed by all participants within the conversation. In the context of the medical consultation, this means that patient narratives are co-constructed with providers, and that at times, provider contributions to the patient narrative can hide patient contributions. The inherent power asymmetry that exists between patient and provider facilitates the possibility for provider contributions to obscure those of the patient. Based on audio-recorded data from medical consultations between two different nurse practitioners and one patient, findings from this study demonstrate that such narrative co-construction leads to differential information regarding the patient’s symptoms, diagnosis and treatment. Implications include the need for providers to relinquish control over to the patient to allow the patient to fully articulate narrative accounts of their medical issues.

The skill of summary in clinician-patient communication: a case study

OBJECTIVE

To investigate the use and impact of the micro-skill of summary in clinical encounters, a core skill that has little empirical investigation of its use and outcomes.

METHODS

This exploratory study used a mixed method design. Video recordings of ten consultations between simulated patients and medical-students were analysed to identify types of summary used. Two contrasting cases were then micro-analysed and follow up interviews held with the 2 students and simulated patients, involved in the consultations, using the video recording as a trigger.

RESULTS

Ninety-nine summaries were identified and grouped into six types: reflective, screening, clarifying, paraphrasing, interim and full. Summary appeared to aid accuracy. However, summaries about the patient's perspective were summarised less frequently than the biomedical perspective. When summaries were repeatedly incorrect they made the simulated patient feel they were not being listened to.

CONCLUSIONS

The use and effect of summary appears more complex than the medical literature suggests and may have both positive and negative attributes. Further research is needed to investigate whether these preliminary findings are replicated within doctor-patient consultations.

PRACTICE IMPLICATIONS

When teaching use of summary we need to address: type, purpose, accuracy, effect on patient and flexible use to suit the patient.

Creating history: documents and patient participation in nurse-patient interviews

Strongly worded directives regarding the need for increased patient participation during nursing interaction with patients have recently appeared in a range of 'best-practice' documents. This paper focuses on one area of nurse-patient communication, the hospital admission interview, which has been put forward as an ideal arena for increased patient participation. It uses data from a total of 27 admission interviews, extensive periods of participant observation and analysis of nursing records to examine how hospital admission interviews are performed by nurses and patients. Analysis shows that topics discussed during admission closely follow the layout of the admission document which nurses complete during the interview. Whilst it is tempting to describe the admission document as a 'super technological power' in influencing the interaction and restricting patient participation, this analysis attempts a more rounded reading of the data. Findings demonstrate that, whilst opportunities for patient participation were rare, admission interviews are complex interactional episodes that often belie simplistic or prescriptive guidance regarding interaction between nurses and patients. In particular, issue is taken with the lack of contextual and conceptual clarity with which best-practice guidelines are written.

Death, depression and 'defensive expansion': closing down smoking as an issue for discussion in GP consultations

This paper examines routine primary care consultations in the UK where smoking is discussed using data from a larger study of the factors influencing discussion of smoking between general practitioners (GPs) and patients. In this study, consultations have been analysed with a focus on the termination of discussion about smoking, using an approach that is informed by the conversation analytic (CA) literature on professional/client interaction. In interviews from the previous larger study, GPs suggested two main reasons for not pursuing discussion of smoking in consultations. One reason was an overarching fear of damaging the GP/patient relationship. The second reason related to clinical judgement, where it was feared that an attempt to stop smoking might exacerbate a patient's existing condition, particularly their mental health. This paper suggests that, while this latter scenario of clinical judgement is borne out by the consultation data, there are two more subtle patient behaviours which are associated with GPs abandoning further discussion of smoking: patients' 'troubles telling', where the issue of smoking is de-emphasised in the face of other 'troubles', and 'defensive expansion', where the patient over-emphasises deficiencies to curtail discussion. Greater awareness of the situations in which doctors end discussion of smoking will help GPs to develop ideas for alternative approaches in these circumstances which could result in more meaningful, effective engagement between doctors and their patients who smoke when smoking is discussed.

Disclosing and responding to cancer “fears” during oncology interviews

Video-excerpts from routine oncology interviews are examined to reveal how patients demonstrate and doctors respond to "fears" about cancer. Vocally and visually, embodied impacts of dealing with dreaded consequences of cancer are apparent when addressing both good and potentially bad cancer news. Even a "brush" with cancer can promote negative and ongoing impacts provoking unresolved illness dilemmas. We reveal how, in the midst of extending answers and initiating concerns, patients exhibit trepidations when volunteering narrative information about their medical history and experience of symptoms. In response, doctors are shown to acknowledge yet exhibit minimal receptiveness to patients' lifeworld disclosures and demonstrations (e.g., redirecting attention away from patients' concerns by offering "textbook" symptoms and related pursuits of biomedical agendas). Discussion focuses on interactional criteria for identifying "fears", patients' lay orientations to medical visits, and implications for refining educational workshops for oncologists.

Competent patient care is dependent upon attending to empathic opportunities presented during interview sessions

OBJECTIVE

Core competencies in surgical education and clinical care rely on effective patient-physician communication. We aim to develop quantitative and empirical tools for understanding critical communication tasks during patient interviews.

METHODS

Residents in surgical training and attending physicians were separately video recorded during stressful, first visit oncology patient interview sessions. Taped sessions (n = 16) were analyzed in detail to identify and label patient-initiated actions (PIAs), or "empathic opportunities," that call for recognition or action from the caregiver. Doctor-responsive actions (DRAs) were labeled as matching to, or missing from, each empathic opportunity. Missed empathic opportunities occurred when a PIA did not have an associated DRA. Presession and postsession surveys queried the patient's perception of how well their health-care needs were met.

RESULTS

Resident trainees and attending physicians missed 70% of 160 clearly identified empathic opportunities. There was no clear association with the level of physician training. This pilot study did not have enough power to discern differences in patient satisfaction.

CONCLUSIONS

Physicians are often not very attentive to empathic opportunities offered by patients. Individual feedback and training regarding empathic opportunities in recorded patient communication encounters may improve resident and physician core competencies. These improvements may affect patient satisfaction related to these encounters.

Nurses talking to patients: exploring conversation analysis as a means of researching nurse-patient communication

As governmental priorities worldwide continue to emphasise the inclusion of patients in healthcare consultations, there is a pressing need for a research approach that accurately captures the contribution of both participants within nurse-patient interaction. With this in mind, this paper examines, via selective data extracts, the contribution that conversation analysis (CA) could make to this area of nursing research. In the United Kingdom (UK) over the last two decades, CA has been neglected as a method for exploring nurse-patient communication, and a case is made here for its entry into the mainstream of nursing research. The case is made particularly persuasive in the light of conversation analysts' use of naturally occurring research data, a form of data that is regrettably lacking in much of the published research on nurse-patient interaction.

Between dad and son: initiating, delivering, and assimilating bad cancer news

The opening moments of a phone call reveal how a father informs his son, for the 1st time, that his mom's tumor is malignant. An extended phone opening reveals how delaying talk about the mom's condition allows for important interactional work: Displaying resistance to announce the bad news directly, projecting and anticipating the valence of forthcoming news prior to its announcement, and delicately sharing ownership of a serious health condition at the outset of a family cancer journey. Enacting a biomedical demeanor, replete with technical language and withholdings of emotional and personal reactions, subsequent delivery and reception of the bad news is managed stoically-a normalized resource employed by consequential figures when managing and coping with dreaded news events. By closely examining how family members talk through cancer on the telephone, the scope of health communication research is extended beyond clinical settings into home environments, progress is made on the noticeable absence of interactional studies in psycho-oncology, and diverse implications arise for understanding how lay persons diagnose and manage illness dilemmas.

Closing medical encounters: two physician practices and their implications for the expression of patients' unstated concerns

When patients visit primary-care physicians, they frequently have more than one concern. Patients' first concerns are solicited by physicians at the beginnings of encounters. A challenge to health care is how to get patients' additional concerns raised as topics of discussion. If patients' additional concerns are addressed, it tends to occur at the end of encounters. Using the methodology of conversation analysis, this article identifies and describes the interactional organization of two physician-initiated communication practices that are used to negotiate the closure of the business of encounters and a transition into the activity of closing encounters themselves. These practices have different implications for the topicalization of patients' additional concerns.