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  • 00:00

    [MUSIC][Researching Communication in Clinical EncountersUsing Interaction Analysis]

  • 00:10

    DR. CAROL RIVAS: Hi.My name is Dr. Carol Rivas and I'ma Senior Researcher at the University of Southampton.I specialize in interaction analyses.[DR.CAROL RIVAS, SENIOR RESEARCH FELLOW, UNIVERSITYOF SOUTHAMPTON] And today I'm going to talk about a studythat I've undertaken using interaction analysis.The objectives of the video todayare to show you the richness of the datathat you can obtain from such analyses,

  • 00:31

    DR. CAROL RIVAS [continued]: and also to highlight some of the issuesin doing this research.So the research I'm going to talk aboutwas undertaken when I worked at the University of Londonat Queen Mary.And the area around Queen Mary is populated by South Asians.And so we were interested in problems in communication

  • 00:51

    DR. CAROL RIVAS [continued]: in clinical encounters between South Asiansand the clinicians.We were also interested in diabetesbecause a recent audit, national audit,had shown that South Asian peopleand people from ethnic minorities in generalwere less efficiently treated for diabetes,and therefore, were more likely to have problems.

  • 01:13

    DR. CAROL RIVAS [continued]: To achieve the aims of our study, whichwas to look at the communication in a clinical encounter,we decided to make video recordings of the naturallyoccurring encounters.And because we were interested in South Asians' communication,we decided to look at 20 patients whowere fluent in English, 20 who were not fluent in English

  • 01:34

    DR. CAROL RIVAS [continued]: but had their consultations in English,and 20 who needed an interpreter.[Practical Issues in Data Collection]So I'm going to talk about some of the issues,first, of doing this study.The first and most important issue, perhaps, is aroundthe use of the video cameras.So if you're filming a naturally occurring incident,

  • 01:58

    DR. CAROL RIVAS [continued]: you need to make sure that the cameras are unobtrusiveand don't put people off with whatshould be a natural encounter.So, that's very hard when you're taking film in a clinic, whichisn't designed for that.You also need to make sure that the cameras aren't in the wayphysically, so that people don't trip over them

  • 02:18

    DR. CAROL RIVAS [continued]: however they move around the room,and, indeed, that the cables aren't trailing as a hazard.And on top of that, we wanted to use two cameras,making it even more difficult, sothat we could film the patient and the clinician separately.And also, because people might move around the room,and you cannot be in the room or you will influence what

  • 02:40

    DR. CAROL RIVAS [continued]: happens, you need to keep a wide angle lens,so that if they happen to move around the room,you're still going to capture them.The second important issue is around who controlswhen the camera is on and off.Ideally, I like to go into the consultation room,turn the camera on, give the control to the nurse in case

  • 03:01

    DR. CAROL RIVAS [continued]: she needs to turn it off or the patient wants it turned off,and then leave the room.And then at the end of the consultation,go back and turn the camera off.However, some nurses wanted to make surethat they had full control of the process.And they were doing this to protect the patient,but ironically, it had the opposite effect.And so some nurses recorded the wrong patients because of this.

  • 03:24

    DR. CAROL RIVAS [continued]: So the moral there is to make surethat if someone does that, that you train them properly.Some further issues related to the consent process,so if you are taking video recordings,people can be easily identified in them.And you need to make sure that you manage the data securely,but also so that people are fully aware of the risks.

  • 03:45

    DR. CAROL RIVAS [continued]: So this affected recruitment because wehad several pages of consent documentation to get through.We also found that because we were studyinga population that's very community-facing, that theytended to do what they thought was best for the communityrather than themselves.I saw a particular incidence of this when I just asked someone

  • 04:07

    DR. CAROL RIVAS [continued]: whether they wanted to take part.And they went to the receptionist,who was also South Asian, and asked her opinion.So you have to be careful that you'rerecruiting people who actually understand and wantto do the study.Another issue is around overzealous gatekeepers.So many of the nurses were very keen for the study

  • 04:29

    DR. CAROL RIVAS [continued]: to succeed because they really cared for their patients.But because of that, they wanted to encouragepatients who they thought would give a good story.And I had to train them in not doing thisbecause it was very important to do a scientific study.It's considered to be good for your data quality

  • 04:49

    DR. CAROL RIVAS [continued]: if you do member validation, so sharing your interpretationto people who have taken part.So we thought we would do this.And the first person we selected to try it outwas this absolutely fantastically performing nurse.We couldn't really find any fault with her.So we brought her into a room in the university.We started playing back a recording of one of her really

  • 05:11

    DR. CAROL RIVAS [continued]: good consultations.And within 30 seconds, she had run out of the room crying.And we asked her what was wrong, and she said,I didn't know I was so dreadful at doing consultations.So again this is something to always be aware of, that peoplereally do critique themselves.And you need to get around this with member validation.It's an issue, in general.

  • 05:32

    DR. CAROL RIVAS [continued]: [Data Analysis]The first thing I want to talk aboutis the qualitative content analysisthat we undertook of the data.So the first thing we did was group the data into themes,and then we did a count of the number of words thatwere spoken for each theme.And one of the significant findingswe found that has been published is

  • 05:54

    DR. CAROL RIVAS [continued]: that there was a greater social distancebetween interpreted consultation participantsand participants in fluent English consultations.So in the interpreted consultations,there was very little humor.There was very little social talk, very little talkabout the patient's lifeworld that is,the context in which their diabetes is lived-- and very

  • 06:18

    DR. CAROL RIVAS [continued]: little question-asking.And all these things are really important in a diabetesconsultation because diabetes managementneeds a good understanding of the patient.You have to understand how they can change their lifestyle,and only way you can do that is by understanding it.Humor is also important because humorallows patients to talk about lapses

  • 06:40

    DR. CAROL RIVAS [continued]: in the management of their diabeteswithout it seeming too bad.So that was one very important finding we found.I had some students looking at the data, as well,and one student decided to look at the question-asking.Now in the ideal consultation, the communicationshould always be triadic, so three people should

  • 07:03

    DR. CAROL RIVAS [continued]: be involved, the patient, the nurse, and the interpreter,as a mediator or a channel through whom allthe conversation goes.But what my student found was that very often theywere dyadic conversations.So in other words, either the nurse or the patientgot left out.Now if the nurse got left out, that

  • 07:23

    DR. CAROL RIVAS [continued]: means that she couldn't get a full understandingof the patient.So, for example, the patient mightask about how to take their medication,and the interpreter would know the answer so would providethe answer without translating.But this meant the nurse didn't knowthat the patient had a problem taking their medication.And then if the patient was left out,they could feel marginalized.

  • 07:45

    DR. CAROL RIVAS [continued]: But it also meant they couldn't use these strategies,such as humor or explaining away what theyhad done when they had lapses.And so that was also very important.And my student also found out that sometimes they onlypartially translated things, and sometimes the interpreterwould mistranslate things, which alsohad important consequences.

  • 08:07

    DR. CAROL RIVAS [continued]: Another student decided to look at the video itself,and at the way that the nurses used the computer.So she considered when they looked at the patientand when they looked at the computer.And what she found was that in the interpreted consultations,the nurse often felt marginalized,and so she would look at the computer

  • 08:28

    DR. CAROL RIVAS [continued]: or, indeed, fiddle with bits of paperjust because she felt redundant.But at the same time, the nurse would be keeping an ear outfor the patient.And this is something that some other studiesof the computer and the clinician haven't commented on.So she would be able to detect when changes in the way people

  • 08:48

    DR. CAROL RIVAS [continued]: spoke meant that there might be a problem, so quickening voice,for example.And sometimes problem words weren't translated.So for example, the word croissantwasn't translated into Bangladeshi,and so she was able to pick up that the patient was eatingcroissants, and would then turn around at those moments

  • 09:09

    DR. CAROL RIVAS [continued]: and face the patient, which is good communication.So I did an analysis in which I looked at the way foodwas talked about in the consultations.And I used the technique of conversation analysis, whichlooks at the fine details of the conversation and the waythat words are used.So in this extract, what I can show

  • 09:29

    DR. CAROL RIVAS [continued]: you is how the nurse and the interpreterwould stereotype patients.And I have to have the caveat here that both nursesand interpreters were really keen on helping the patients.So this was something that they couldn't help.And this was something that is very important to feedbackfor them so that they can really understandthat patients are individuals and shouldn't be stereotyped.

  • 09:51

    DR. CAROL RIVAS [continued]: [Stereotyping and interpreted patients]So in this extract what you can seeis that the patient says that theyhave rich tea biscuits for breakfast,at which the interpreter translates.The nurse then says that she knowsthat this is a problem here.So the word, here, means that sheis including this patient in the local community,

  • 10:12

    DR. CAROL RIVAS [continued]: and that she considers that all the local South Asians tendto do this because they are not educated about good foodhabits.And she then goes on to point out that she is educated,and even though she doesn't have diabetes,she doesn't have biscuits.So she's setting herself up as more knowing than the patient.

  • 10:34

    DR. CAROL RIVAS [continued]: And the interpreter, interestingly,does exactly the same thing.Interestingly, because the interpreter comesfrom exactly the same community as the patient, but clearlyconsiders himself to be more educated.So he aligns with the nurse and says that they do, don't they.So using the word, they, he's setting himself apart.

  • 10:55

    DR. CAROL RIVAS [continued]: And because the nurse and the interpreter held this view,they believed that there needed to be mass educationof the local population.But perhaps what they might have doneis actually ask the patient why he was doing that,why he felt it was OK to eat the biscuits.And to just show you how the nurses were trying

  • 11:16

    DR. CAROL RIVAS [continued]: to do their best for the patients,I've got another extract to show you from the same study.Now in interaction analysis, one of the key conceptsis that you should keep the conversation going,because if conversations break down,that's a problem socially.Now in a review consultation, the nurseswant to get through all the important things.

  • 11:38

    DR. CAROL RIVAS [continued]: So after food, they normally consider exercise.This is an extract from a patientwho is not fluent in English.And clearly, if someone isn't fluent in English,you might think that there's more problem communicatingwith them.And the nurses clearly felt that they might notbe able to get all the messages across.So sometimes they spoke on behalf of the patient,

  • 11:60

    DR. CAROL RIVAS [continued]: in order to get to the next important bitof the consultation.And so this is an example, in which the nurse finds outthat the patient has a high blood sugar level.And she doesn't want to give him terribly bad newsbecause, with the language barrier,he might not be able to cope with it, in her view.And so she says to him, well, it's winter and people

  • 12:23

    DR. CAROL RIVAS [continued]: tend to put on weight in winter.So she's just providing an excuse for himso that he doesn't have to spend time strugglingto think of one, and she can then move on to the next topic.But again, it might be better if shewas able to actually say to the patientand get out of him what was going on that ledto his high blood sugar level.

  • 12:43

    DR. CAROL RIVAS [continued]: And so from all of these data, wecan see explanations for why South Asians aren't beingtreated as effectively even though theymight be going for their diabetes consultations.[Conclusion]So I hope I've shown from this video how naturally occurring

  • 13:03

    DR. CAROL RIVAS [continued]: consultations, or naturally occurring data, in general,can give you very rich information to work from,and how you can do different types of analyses using it,and also the type of information it can give you that youmight not even expect to find.Also, I hope I've shown you some of the issuesthat you might need to deal with in collecting this data.

Video Info

Publisher: SAGE Publications Ltd

Publication Year: 2017

Video Type:Video Case

Methods: Naturally occurring data, Video research, Content analysis

Keywords: consultation; diabetes; diet; food; hospital visitors; humor; interpreters; language; language and communication; listening; nurses; South asian people; Stereotypes; translators ... Show More

Segment Info

Segment Num.: 1

Persons Discussed:

Events Discussed:



Professor Carol Rivas discusses how to conduct interaction analysis by observing a natural setting. She includes accounts from a personal research project involving nurse and patient interactions during medical consultations.

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Researching Communication in Clinical Encounters Using Interaction Analysis

Professor Carol Rivas discusses how to conduct interaction analysis by observing a natural setting. She includes accounts from a personal research project involving nurse and patient interactions during medical consultations.

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