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

Clinicians navigating moral accountability when discussing parental behaviors in the care of the child in the hospital

OBJECTIVE

The purpose of this study was to explore how moral accountability is navigated when clinicians talk about parental behaviors to support the health of the hospitalized child.

METHODS

We conducted a secondary data analysis of 74 conversations during daily rounds video recorded as part of a randomized controlled trial of an intervention to advance family-centered rounds in one children's hospital. Conversations involving children under the age 18 who were cared for by a pediatric hospitalist service, pulmonary service, or hematology/oncology service were recorded. We used conversation analysis to analyze sequences in which physicians engaged in talk that had implications for parent behavior.

RESULTS

Two phenomena were apparent in how physicians and parents navigated moral accountability. First, physicians avoided or delayed parental agency in their references to parent behaviors. Second, parents demonstrated and clinicians reassured parental competence of parents caring for their children.

CONCLUSION

Physicians appeared to be oriented toward the potential moral implications of asking about parental behavior.

PRACTICE IMPLICATIONS

Avoiding attributions of agency and moral accountability as well as providing reassurance for the parents' competence may be useful for clinicians to maintain a good relationship with the parents of children in their care in the hospital setting.

Communicative Practices Clinicians Use to Correct Patient Misconceptions in Primary Care Visits

To investigate how clinicians correct patient misconceptions, we analyzed 23 video recordings of primary care visits. Analysis focused on operationalizing, identifying, and characterizing clinician corrections, integrating two inductive approaches: microanalysis of clinical interaction and conversation analysis. According to our definition, patient misconception-clinician correction episodes met three essential criteria: (1) the clinician refuted something the patient had said, (2) which the patient had presented without uncertainty, and (3) which contained a proposition that was factually incorrect. We identified 59 such episodes; the patient misconceptions most commonly related to medication issues; fewer than half had foreseeable implications for patients' future actions. We identified seven clinician correction practices: Three direct practices (displaying surprise, marking disagreement, contradicting the patient) and four indirect practices (presenting the correct proposition, providing explanations, invoking an outside authority, demonstrating with evidence). We found an almost equal distribution of these direct and indirect practices.

Audiovisual Recording in the Inpatient Setting: A Method for Studying Parent-Nurse Communication

Audiovisual recordings are under-utilized for capturing interactions in inpatient settings. Standardized procedures and methods improve observation and conclusion validity drawn from audiovisual data. This article provides specific approaches for collecting, standardizing, and maintaining audiovisual data based on a study of parent-nurse communication and child and family outcomes. Data were collected using audio and video recorders at defined time points simplifying its collection. Data were downloaded, edited for size and privacy, and securely stored, then transcribed, and subsequently reviewed to ensure accuracy. Positive working relationships with families and nurses facilitated successful study recruitment, data collection, and transcript cleaning. Barriers to recruitment and data collection, such as privacy concerns and technical issues, were successfully overcome. When carefully coordinated and obtained, audiovisual recordings are a rich source of research data. Thoughtful protocol design for the successful capture, storage, and use of recordings enables researchers to take quick action to preserve data integrity when unexpected situations arise.

"I was gonna ask you": How patients use agency framing to display engagement in primary care

The message that patients should be responsible for their health is pervasive. Health promotion campaigns encourage patients to "ask your doctor" about potential illnesses and treatments, preventive medicine guidelines call for patients to self-monitor to avoid future health problems, and models like shared decision-making advocate for greater patient involvement in medical decisions. Research shows that patients can participate in medical dialogue by asking questions, but that doing so is difficult due to the structure and social norms of medical visits. In this article, we ask: how can patients participate more actively in medical care? Drawing on video recordings of older patients (aged 65 and older) and primary care physicians, we use conversation analysis to describe one practice that patients use to demonstrate personal responsibility for their health; agency framing. This involves prefacing questions to the doctor with phrases that project a prior intended action, such as "I was gonna ask you", "I was gonna tell you" or "I wanted to ask you". Patients use agency framing to cast their questions as 1) independently motivated, 2) well-informed, and 3) personally responsible. Consequently, patients exert agency within the confines of the medical visit structure to resist the potential interpretation that their question was responsive to the doctor or to the local interactional context. Rather, agency framing allows patients to show that their question was considered independently. Questions designed with agency framing work to portray the speaker as a responsible patient who is not only meeting the bare minimum of expected health maintenance, but is staying ahead of medical problems. This article discusses the particular importance of this practice among older patients, for whom demonstrating a willingness and ability to cope with medical problems may be significant for maintaining independence.