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Repetition in the Health History Segment of Spanish Language Clinical Consultations

A Conversation Analysis

Vickers, Caroline H.; Lindfelt, Christopher; Dodd-Butera, Teresa

doi: 10.1097/NNR.0000000000000166
POINT-OF-CARE RESEARCH SERIES
Free

Background Patient history-taking sequences may be repeated across medical speech events with different healthcare providers and subsequently co-constructed differently, which can lead to disparate patient history information with implications for patient care outcomes. Encounters that include language discordance between patients with limited English language proficiency and healthcare workers can also impact patient outcomes.

Objectives We examined the repetition of patient history-taking sequences in consultations in which healthcare providers used Spanish as a first and second language with monolingual Spanish-speaking patients. The aim was to understand how repetition affects patient care processes and outcomes.

Methods Conversation analysis was used. The target population was bilingual healthcare providers and monolingual Spanish-speaking patients. The accessible population was composed of healthcare providers and patients from an urban, low-income, community health clinic in Southern California. In three exemplar cases from among 50 that were studied, instances of repetition in the history-taking segment of clinical consultations were located. We identified which aspects of patient reports were repeated across intake nurse–patient consultations and nurse practitioner–patient consultations, as well as how patient reports were differently co-constructed across these events.

Results Information elicited during the intake nurse–patient history event may be elicited again when a nurse practitioner repeats the elicitation of particular aspects of the patient’s complaints and health history. Repetition of patient history information was co-constructed differently by different healthcare providers, sometimes led to seamless teamwork, and sometimes led to time wasting. Healthcare provider second language use of Spanish did not substantially impact how patient history information was co-constructed.

Discussion This analysis sheds light on the effects of repetition across medical events and assessed the effects of repetition on communication among members of a healthcare team and patient care outcomes. It also informs how medical provider second language use may affect how information is conveyed. Our study has implications for understandings of medical consultations that involve nurse triage prior to consultation time in multilingual settings.

Caroline H. Vickers, PhD, is Professor, Department of English, and Co-Director, Center for Health Equity, at California State University, San Bernardino.

Christopher Lindfelt, PsyD, is Associate Dean, Undergraduate Studies, at California State University, San Bernardino.

Teresa Dodd-Butera, PhD, RN/DABAT, is Associate Professor, Department of Nursing; Co-Director, Center for Health Equity; and Coordinator, CSUSB Graduate Nursing Program, at California State University, San Bernardino.

Accepted for publication February 25, 2016.

The authors acknowledge that this study was funded by the National Institute of Nursing Research (1R15NR 010630-01A1).

The authors have no conflicts of interest to report.

Corresponding author: Caroline H. Vickers, PhD, Department of English, California State University, San Bernardino, 5500 University Parkway, University Hall Room 352, San Bernardino, CA 92407 (e-mail: cvickers@csusb.edu).

A successful health assessment includes an interview that establishes a trusting dialogue between patient and provider to both gather and offer essential information for optimal health outcomes (Bird & Cohen-Cole, 1990; Cohen-Cole, 1991; Estrada, Reynolds, & Hilfinger Messias, 2015; Lazare, Putnam, & Lipkin, 1995). Comprehensive history taking (Bickley, 2008) is typically one aspect of a health assessment; it involves a series of questions asked by the provider (Stivers & Heritage, 2001). The comprehensive history-taking event is co-constructed by the provider and the patient (Jacoby & Ochs, 1995; Stivers & Heritage, 2001). The co-constructed nature of the event means that the contributions of the provider and the patient work to make health history taking “a recognizable and concerted undertaking” (Stivers & Heritage, 2001, p. 154)—as both parties contribute to the process of meaning making. However, the co-constructed nature of the event also means that provider questions and interpretations shade the information that patients give (Eggly, 2002). An additional challenge to the medical encounter includes language discordance between limited English-proficient patients and healthcare workers, which can impact patient outcomes (Hornberger et al., 1996; Nápoles, Santoyo-Olsson, Karliner, Gregorich, & Pérez-Stable, 2015). According to the U.S. Census, in 2011, 60.6 million people (21% of this population) spoke a language other than English in the home (Ryan, 2013). Language discordance in patient interviews underscores the need for teamwork when communicating patient history and information.

In previous work using the same data set that we study in this article (Vickers, Goble, & Lindfelt, 2012), we examined how different healthcare providers in separate medical consultations co-constructed patient history reports differently with the same patient leading to different diagnoses—an issue that affected patient care outcomes. However, in Vickers et al. (2012), we did not consider how first and second language Spanish use might have affected the different co-constructions of meaning. Moreover, because the consultations we examined in Vickers et al. (2012) occurred on separate days, how such differently co-constructed patient history reports might affect patient care outcomes in situations in which two healthcare providers worked as a team was not studied.

In the current article, we examine how repetition, defined as “the reiteration of information from patient history reports across two segments of the clinical consultation in the same clinic visit,” works in the overall co-construction of meaning that leads to patients’ diagnoses in a clinical context in which monolingual, Spanish-speaking patients move from triage with a nurse who speaks Spanish as a first language to consultations with nurse practitioners who use Spanish as a first and second language. First language means “the language spoken from childhood,” whereas second language means “a language learned beyond childhood.” It is important to consider how such repetition affects the construction of meaning, and whether it detracts from or enhances the health assessment. We specifically addressed which aspects of patient reports were repeated across intake nurse–patient consultations and nurse practitioner–patient consultations, as well as how patient reports were differently co-constructed across these events in a Spanish–English bilingual clinical setting in Southern California, in which healthcare providers use both first and second language Spanish and patients are monolingual Spanish speakers. In this study, the term “intake nurse” refers to the intake nurse–patient interactions, and the term “nurse practitioner” refers to the nurse practitioner–patient interactions. Nurses and nurse practitioners are referred to as healthcare providers.

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Healthcare Provider–Patient Interactions

Patient histories consist of narratives that allow healthcare providers a glimpse into patients’ medical conditions. However, healthcare providers’ contributions to patients’ narratives change the meanings of those narratives in important ways. For example, healthcare providers recontextualize patient narratives into professional terms, which can lead to a redefinition of the types of behaviors and symptoms that patients convey in these narratives (Sarangi, 2001). Because the healthcare provider is in a position of power over the patient, the healthcare provider tends to take control over patient narratives (Mishler, 1984; Stivers & Heritage, 2001; ten Have, 1991), shaping the constructed reality of the patient’s medical condition. Because of the power-laden nature of the medical consultation, healthcare provider perspectives during an encounter involving health history-taking become crucially important to patient care outcomes.

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Uses of Repetition in Medical Consultations

Repetition is an important linguistic strategy for the conduct of interactional work. For instance, Tannen (1989, p. 61) claimed that “repetition not only ties parts of discourse to other parts, but it bonds participants to the discourse and to each other, linking individual speakers in a conversation and in relationships.” Repetition acts to provide a sense of coherence that allows conversations to make sense and allows conversational participants to feel involved with each other and form relationships with each other. These functions of repetition have been identified through various approaches to discourse analysis as people interact within one cohesive conversational event or interview.

Repetition in the health assessment interview has been studied through conversation analytic methodology (Friedland & Penn, 2003; Park, 2011). These studies showed that repetition can be used to facilitate understanding and create specific meanings. In situations in which patients may have difficulty understanding what the medical provider says, such as the case of the head-injured clients that Friedland and Penn (2003) studied, a mediator who was culturally and linguistically matched to the patient used repetition to “slow down the tempo of the interview” (p. 101) and facilitate the head-injured patient’s understanding of the healthcare provider.

Healthcare providers also engage in repetition to make particular kinds of meanings. During history taking in Korean medical consultations, physicians used repetition to create specific meaning (Park, 2011). The physician asked a question, “Did you know you had high blood pressure?” The patient then responded, “No.” The physician then repeated the question but used negative rather than positive polarity, “You didn’t know that it was high?” Park’s argument was that reversed polarity repetitions constituted “diagnostic activity that indexes a patient’s answer as being diagnostically significant” (p. 1929). Repetition, then, became a crucial part of meaning making in the history-taking segment of the consultations that Park studied.

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Team Approach and Communication

Treatment teams usually consist of a group of interdisciplinary professionals who work collaboratively to provide patient care. By working as treatment teams, multiple perspectives are considered as treatment plans are established. The main contention of establishing treatment teams is to improve patient outcomes and treatment quality by collaboratively engaging in dialogue and discussion to establish the best possible course of treatment considering multiple perspectives.

Teamwork has been identified as a necessary requirement for both quality and safety in patient treatment and outcomes (Berwick, 2002; Edmondson, 1999; Ferlie, & Shortell, 2001; Leggat, 2007; National Coalition on Health Care & the Institute for Healthcare Improvement, 2002). Results from a number of studies suggest that interdisciplinary team-based care is highly correlated with enhancing the clinical outcomes (Sicotte, Pineault, & Lambert, 1993; Wake-Dyster, 2001). More specifically, studies examining patient treatment outcomes related to a team approach to patient care results in more accurate, more cost-efficient, and more effective treatment outcomes (Edmondson, 1999; Shortell et al., 2004; West et al., 2002).

Because no single professional can deliver a single episode of care, communication among the providers becomes even more important. Not only is communication essential to effective treatment, but collaborative communication is associated with positive patient, nurse, and physician outcomes as well (Boyle & Kochinda, 2004). When healthcare professionals are able to communicate and work effectively together, patients are more likely to receive safe, quality care (Greiner & Knebel, 2003). Moreover, effective teamwork has a beneficial effect on nurses’ job satisfaction and group cohesion among nurses (DiMeglio et al, 2005).

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METHODS

Study Context

The research site was a small community clinic that was located in an urban area in Southern California and provided services to low-income families. The clinic was located in a medically underserved area, with a population of many Spanish-speaking immigrants. It was not uncommon to see Spanish on store signs and advertisements in the area. However, this area was embedded in a larger English-dominant context. The clinic was a bilingual context. All signs and brochures were in Spanish and English. All clinic staff members were bilingual.

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Participants

At the time of our study, the clinic medical staff included an intake nurse, “Maria,” who was a first language user of Spanish, and two nurse practitioners, “Carrie” (second language user of Spanish) and “Laura” (first language user of Spanish). All healthcare providers were recruited to the study through a recruitment script delivered individually in their offices. Patients included Pamela, Manuela, and Ramon, all monolingual Spanish speakers. Patients were recruited in the waiting room of the clinic through the use of a recruitment script. All names used in this article are pseudonyms. Before conducting the study, the study, its procedures, and the informed consent process and forms were approved by the institutional review board. All participants in this study gave informed consent as approved by the institutional review board.

In terms of the flow of patients through the clinic, Maria, the intake nurse, called patients from the waiting room, weighed them, and then took them to a consultation room where she took their blood pressure and temperature. She then sat down at the computer, while the patient sat on the exam table and took the patient’s history, typing small amounts of information into the computer. If the patient was new, she took a comprehensive history. In the case of returning patients, she took a recent history since the last consultation. After the history taking with Maria was complete, the patient waited in the consultation room until one of the nurse practitioners, Carrie or Laura, came in to complete the consultation.

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Data Collection

This article is drawn from a corpus of transcribed audio-recorded Spanish language, medical consultations, written field notes of interactions, and audio-recorded and transcribed postconsultation interviews with providers and patients. This corpus was collected over a period of 9 months from October 2009 to July 2010 and includes approximately 150,000 words. The medical consultations that we recorded were mostly in Spanish. The data for the current article are a subset of this larger corpus. The purpose of the larger study was to examine how healthcare providers communicate with language minority patients in medical consultations and to assess the effectiveness of communicative strategies that healthcare providers use in these medical consultations. We set up portable digital audio recorders in the consultation rooms of participants who had granted informed consent. We turned the audio recorder on when the healthcare provider entered the consultation room and turned it off when the healthcare provider left the consultation room. We also observed the consultations and the taking of field notes.

The focus of this article is three consultations involving patients Manuela, Pamela, and Ramon, where Maria was the intake nurse and either Carrie or Laura carried out the clinical consultations. Among the larger study of 50 consultations, these three were chosen as exemplars because they clearly demonstrate particular patterns of repetition throughout the data set. Choosing three focus consultations allowed us to demonstrate through fine-grained conversation analysis how repetition affects patient care. Other studies that we have conducted involve Laura, Maria, and Carrie in their roles as intake nurse and nurse practitioners including their use of Spanish language discourse markers (Vickers & Goble, 2011), different approaches to patient history taking (Vickers et al., 2012), ways of constructing stances through the use of Spanish and English (Vickers, Deckert, & Goble, 2014), and the effect of bilingual third-party family members’ contributions to the interaction within the consultation (Vickers, Deckert, & Goble, 2015).

In our analysis, we focused on history-taking segments of the consultation. We conceptualized the consultation as containing two separate speech events. The first speech event was with Maria, the intake nurse, and the second speech event was with one of the two nurse practitioners (Carrie or Laura). It is important to note that Maria was primarily responsible for comprehensive history taking in these consultations and for entering patient responses into the computer. However, Carrie and Laura also engaged in history-taking sequences in their parts of the consultations, which also involved diagnosis and treatment prescription.

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Transcription

The audio recordings were transcribed using the Express Scribe computer program. The transcriptions allowed us to examine a written and linguistically coded corpus of the interactions within the medical consultations. Transcripts of audio recordings allowed the fine-grained conversation analysis of consultations.

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Approach to Analysis

In the analysis of the data, we employed a particular discourse analytic method—conversation analysis—to allow a fine-grained examination of the interactional co-construction of all aspects of the medical consultation (Goodwin & Heritage, 1990). Conversation analysis involves making transcripts of audio-recorded data through the use of fine-grained conventions that attend to speaker turns, the words speakers say, as well as intricate features of talk, such as when speakers pause, overlap with each other, exhale, and lengthen words. We specifically examined talk in interaction (Schegloff, 2007), paying particular attention to the interdependency between patient and healthcare provider contributions and how the two together co-constructed (Jacoby & Ochs, 1995) meaning within the medical consultation. Patient contributions took on meaning within a conversational format because of the way that they were contextualized as the conversation unfolded. In our data, we considered how patient turns were linked to the larger conversation/interview that occurred throughout the entire healthcare interaction. Therefore, our analysis included fine-grained, turn-by-turn analysis, coding the data using fine-grained discourse analytic transcription conventions (Du Bois, 2005). Two researchers engaged in coding. Any disagreements were resolved through discussion.

We approached the analysis with a particular eye toward two separate conversations: one with the intake nurse and another with the nurse practitioner. We then examined those aspects of the two components of the consultation that were conveyed in the conversation with the intake nurse and then conveyed again with the nurse practitioner. Therefore, we examined situations in which patient information is repeated across intake nurse and nurse practitioner events and how such information was differentially conveyed when co-constructed with Maria as opposed to Carrie or Laura. Our focus was on how meaning was co-constructed with the different healthcare team members.

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RESULTS

Patient History Information That Tends to Be Repeated

When repetition occurred in the data, it tended to be the medical issue for which the patient had come to the clinic that was repeated. This seemed to be the case because the intake nurse often opened her part of the consultation with “¿porqué venía hoy?” (why did you come today?) or “¿cómo te has sentido?” (how have you been feeling?), unless the patient offered such information without being asked. Therefore, the nurse and the patient tended to discuss the patient’s primary medical complaint. In addition, new patients were asked a series of scripted questions regarding their medical history with a shorter version used for all returning patients. Then, the discussion of the primary medical complaint occurred again with the nurse practitioner.

However, regardless of the primary medical complaint of each individual patient, two medical issues tended to be repeated with some frequency in the triage and the clinical consultation—the two speech events that we studied. These included discussions of high blood pressure and diabetes management. High blood pressure discussions were repeated across the two speech events in about half of the consultations (24/50; 48%). Discussions of diabetes management were repeated in 14/50 or 28% of consultations. It seemed that if the patients had high blood pressure or a history of diabetes, not only were they discussed in the consultation but the discussions were repeated across the two speech events. In our data, these two medical issues were discussed repeatedly—whether or not they were the primary medical concern of the patient at the time of the clinic visit.

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Analysis of Repetition in Discourse

As we continue, we will examine discourse data that demonstrate how meaning was at times differently co-constructed when medical issues were repeated across the two speech events. We present six different excerpts; they were selected because they are representative of the three types of repetition that we found.

The first type of repetition we found is when all of the team members elicited the same information from the patient across the two speech events but co-constructed the meaning of the information differently (Excerpts 1 and 2). The second type of repetition was when healthcare team members and patients repeated critical information related to their histories across the two speech events. This second type of repetition seemed to be the basis for effective teamwork when the quality of the information fit well into the patient history computer program that Maria used (Excerpts 3 and 4) but could also lead to wasting time—a third category of repetition—when the quality of information did not fit easily into the patient history program (Excerpts 5 and 6).

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Elicitation of the Same Information: Different Co-construction of Meaning

As we said, the intake nurse Maria sometimes elicited particular information that the nurse practitioner then again elicited. However, it is interesting to note subtle differences in the way that each provider constructed the patient’s identity, as well as what constituted important information. In Excerpt 1, for instance, Maria discussed glucose self-monitoring with the patient Pamela. Following in Excerpt 2, nurse practitioner Carrie then discussed the same information.

Maria asked Pamela a two-pronged question (Excerpt 1, Line1). The first question focused on the level of the blood glucose, and the second question focused on whether or not Pamela checked her blood glucose today. Pamela answered that she did not check it today, and in Excerpt 1, Lines 3–6, Maria inquired about the last time Pamela checked it. Pamela seemed unsure and hesitated through the use of pauses and restarts, which constructed Pamela as uncertain of her own self-care.

The conversation continued (Excerpt 1, Lines 7–14). Maria directed Pamela to always bring the machine (blood glucose monitoring machine) or to write down the numbers and bring those. The directive constructed Pamela as somewhat negligent in her way of maintaining her diabetes because the premise was that she should have brought the machine to the appointment but failed to do so. Moreover, Maria’s directive emphasized the need for systematic data so that medical personnel could properly monitor the state of Pamela’s disease. In response to Maria’s direction, Pamela provided information about her blood glucose level on Monday (5 days before the current consultation) in Lines 12 and 14, but she again hesitated by drawing out words and restarting, as well as by showing that she was approximating through her use of the word “like.” The conversation related to Pamela’s blood glucose continued in Excerpt 1, Lines 15–30.

Maria and Pamela co-constructed a specific account of Pamela’s blood glucose on Monday, including Maria’s medical opinion that Pamela’s blood glucose was high. Maria then asked Pamela about her blood glucose 2 days ago, and Pamela responded. Finally, Maria repeated the need to bring the blood glucose monitoring machine. This repetition functioned to emphasize the importance of the machine and the need for medical personnel to have access to systematic data, as well as Pamela’s negligence in not bringing the machine. It is interesting that Pamela provided an excuse in Line 28, which served to co-construct her as negligent in her diabetes self-care.

The series of questions that Maria asked throughout Excerpt 1 allowed Maria to gain some systematic information about Pamela’s blood sugar levels throughout the week. The interaction between Maria and Pamela placed emphasis on Pamela’s responsibility to provide medical personnel with systematic data regarding her blood sugar levels and Pamela’s negligence in providing the proper information.

Immediately after the triage with Maria, conversation between Pamela and nurse practitioner Carrie began (Excerpt 2). The excerpted interaction occurred about 1 minute into the consultation with Carrie and as in the interaction in Excerpt 1 with Maria, the patient and nurse practitioner discussed Pamela’s blood glucose levels.

Carrie asked a series of questions that elicited from Pamela her fasting blood glucose, which she claimed to have checked the day before yesterday. In contrast to Maria, Carrie’s first question focused on the blood glucose level. It is interesting to consider the linguistic framing of Maria’s question (Excerpt 1, Line 1) and Carrie’s question (Excerpt 2, Line 1). Maria asked “¿cuánto fue? ¿hoy se la checkió?” (how much was it? did you check it today?) as opposed to Carrie’s question, “¿la última vez que había checkiado su azúcar..cuánto estaba?” (the last time you had checked it…how much was it?). Maria’s question placed more emphasis on the actual amount of the blood glucose measurement or even a list of measurements as events that happened at particular points in time (today). Carrie’s question placed emphasis on a particular measurement as indicative of a habitual state of being as Pamela could have chosen any past measurement to report to Carrie. It is possible that Carrie’s phrasing of the question was indicative of her status as a second language user of Spanish, but her phrasing was clearly comprehensible to the patient and seemed to be in line with the larger way that she conceptualized blood glucose measurements in the ongoing consultation. In any case, Maria and Carrie’s questions carried different meanings while essentially getting at the same information—the blood glucose measurement.

The conversation between Carrie and Pamela continued as Carrie probed for more specificity (Excerpt 2, Lines 9–10). Carrie inquired about whether Pamela’s blood glucose was sometimes higher, and Pamela indicated without hesitation that it was higher on Monday.

Carrie then continued the conversation, asking about Pamela’s dietary habits in the time before she measured the high blood sugar level (Excerpt 2, Lines 12–17). Pamela indicated that she sometimes had soda (Excerpt 2, Line 15). Carrie and Pamela co-constructed soda as a bad dietary choice. Within that frame, Pamela said “pues,” which like the discourse marker “well” in English (Lam, 2010), framed the response as dispreferred (Serrano, 2001). Framing the utterance as dispreferred expressed Pamela’s disalignment with her tendency to drink soda. Pamela also hedged her answer by saying “a veces” (sometimes) and “uno sabe que” (one knows) to mitigate her rather face-threatening confession to not following dietary regimen for a person with diabetes. Throughout Excerpt 2, Carrie’s particular questions were ones that Pamela could answer without confessing that she had not engaged in some aspect of her diabetes management. Therefore, Pamela was constructed as competent, able to supply the requested information.

After some discussion of the circumstances surrounding the high measurement (Excerpt 1), Maria requested that the patient bring the self-monitoring data to her appointments. Maria’s request seemed to be in line with her conceptualization of blood glucose measurements as representing discrete points in time. Carrie, on the other hand, asked if Pamela had eaten something that might have increased her blood glucose to which Pamela responded that she had drunk soda (Excerpt 2). Carrie’s question about dietary behavior seemed to be in line with her conceptualization of blood glucose as a state of being; in this case, affected by behavior.

What is interesting is that Pamela might have walked away from the consultation with an important, salient message about giving her healthcare team members access to her blood glucose self-monitoring data (Maria) as well as an important, salient message about the effect of drinking soda on her blood glucose level (Carrie). Either one of these interactions in isolation would have left Pamela with a less comprehensive take-home message. Therefore, we conclude that repetition across the two speech events associated with the consultation was potentially beneficial to patient care outcomes in this case.

However, in the consultation with Maria, linguistic features employed by Pamela (false starts, statements of uncertainty) indicated that Pamela was uncertain of both when she checked her blood glucose and what the precise levels were. This uncertainty could be a reason that Maria focused on the need for Pamela to supply systematic data as Pamela was constructed as somewhat negligent in this area.

In contrast, Pamela’s responses seemed rather more certain in the part of the consultation conducted by Carrie. It raises the question whether the part of the consultation with Maria allowed Pamela a rehearsal, which then meant that she could speak with more certainty with Carrie only because she had already experienced a very similar interaction with Maria. This is important to consider because the interaction with Maria became erased in the process of the consultation so that it is the interaction with Carrie that carried weight toward diagnosis and prescribed regimen. Pamela seemed more competent in taking and reporting her blood glucose levels with Carrie than she did with Maria, which could have a negative effect on patient care outcomes because the uncertainty she expressed with Maria did not have a bearing on the diagnosis and prescribed regimen. Pamela’s display of competence in taking and reporting her blood glucose levels may actually have been the result of a rehearsed performance of competence allowed by the fact that the interaction was repeated. Carrie, then, would not have seen her as negligent in the way Maria did.

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Repetition of Critical Patient Information: Seamless Teamwork

During some consultations, patients revealed crucial information related to their conditions to Maria during the triage event. When such information fit easily into the standard patient history questions prompted on the computer, it transferred seamlessly from triage with Maria to the clinical consultation with the nurse practitioner. For example, in a consultation with patient Manuela, Maria took the blood pressure as part of the intake event and informed the patient that it was high (Excerpt 3); then, nurse practitioner Carrie prescribed a treatment (Excerpt 4). Excerpt 3 occurs right after Maria had taken Manuela’s blood pressure. As the excerpt begins, Maria informed Manuela that her blood pressure was still high. Manuela asked “¿todavia?” (still?), and Maria confirmed. Then Manuela mentioned that she took the blood pressure pill in the morning (Excerpt 3, Lines 4–5). Manuela indicated that she took her blood pressure medication in the morning, and Maria entered the patient’s blood pressure and the information that she took her medication in the morning into the electronic health record (EHR) as indicated by “CLICK” in line (Excerpt 3, Line 5). In the clinical consultation with Carrie (Excerpt 4), the information that Maria had entered then came up on the computer, allowing Carrie to move directly into a treatment plan for Manuela. Carrie confirmed with Manuela that her blood pressure was still high and then revised Manuela’s treatment plan.

The repetition between the two speech events associated with the consultation highlights the benefit of teamwork (Excerpts 3 and 4). Carrie and the patient co-constructed a confirmation (Excerpt 4) of the information that Maria had discussed with the patient (Excerpt 3). Then Carrie used the information on the computer to quickly move to revise the treatment plan.

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Repetition of Critical Patient Information: Time Wasting

However, in some cases of patient history taking, patients revealed information to Maria that did not easily fit as an answer to a patient history question as prompted by the computer. In these cases, such information was either lost or did not reenter the conversation with the nurse practitioner until after the nurse practitioner had already engaged in a series of questions aimed at figuring out the source of the patients’ conditions. Such is the case with one patient, Ramon, who had contracted a skin rash after going into trash bins to retrieve recyclables.

At the end of the initial consultation with Maria, Ramon revealed that he had been going through trash bins (Excerpt 5). Moreover, he told Maria that he had contracted the same rash after jumping into dumpsters in the past. Ramon’s narrative account occurred after Maria had spent 5 minutes interviewing him about the cause of the rash.

Ramon began a narrative account (De Fina, 2009) by telling Maria that he jumped into trash bins to gather bottles in 2008 because he was out of work and that, when he had done this, he developed the same rash. As De Fina (2009) noted, narrative accounts anticipate “why” or “how” questions from their interlocutors. His narrative account provided the how and why that explained the skin rash. He said, “mira la cuenta que” (look the story that). Through his narrative account, he indicated that his jumping into the trash bins was the cause of the rash. In what followed, Maria confirmed that Ramon had jumped into dumpsters (Excerpt 5, Lines 6–12).

When Ramon met with nurse practitioner Laura about 15 minutes after he met with Maria, she spent 4 minutes asking him questions about what might have caused the rash. Though she was clearly puzzled by what caused the rash and how to diagnose it, she had already prescribed an injection and the use of a cream before the conversation in Excerpt 6 commenced. In fact, she was washing her hands about to exit the consultation room when Ramon relayed a similar narrative account to Laura as the one he told Maria. It is interesting that Ramon began the narrative account by indexing his conversation with Maria, “le estaba diciendo” (I was telling her). This entry into his account indicated that he was aware that he was repeating himself.

After he related the story of jumping into the trash bins (Excerpt 6, Line 1), Laura responded with a high pitched and lengthened “oh” followed by the statement “algo debia saber” (something I should have known) (Excerpt 6, Lines 2–13). Clearly, she found this information to be relevant to her diagnosis and prescription. Ramon then continued the narrative account (Excerpt 6, Line 2), which was followed by a series of suggestions made by Laura to protect against a recurrence of the rash.

Laura’s series of suggestions was important because it allowed Laura and Ramon to negotiate what he could and could not do for prevention. In Excerpt 6, Line 4, Laura said “es que quieres en veranos en la basura” (it’s that you want in the trash in the summer), which Ramon seemed to interpret as advice not to enter the trash bins in the summer, which was not possible for Ramon because he earned his livelihood that way. Therefore, as Laura continued, she made recommendations about the type of clothing Ramon should wear when he jumps into trash bins. Ramon’s narrative account, then, gave Laura the information she needed to work to prevent a recurrence of the rash.

It was not until the part of the consultation with Laura was almost complete that Ramon repeated his narrative account to Laura, and Laura’s surprise at receiving this information indeed indicated that the account he told Maria did not transfer to the part of the consultation with Laura. It was not clear whether Maria had not entered the information into the computer or whether Laura had not looked carefully at the history that Maria documented on the computer. In any case, Laura almost missed the probable cause of Ramon’s rash and, therefore, the opportunity to help him take steps to prevent reoccurrence. Moreover, Laura used 4 minutes of time to interview Ramon to find out the cause of the rash that, in the end, was time wasted because it became clear that contact with materials in the trash bin likely caused the rash. Moreover, Maria used 5 minutes of time before Ramon relayed the crucial narrative account.

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DISCUSSION

In this article, we showed three patterns of repetition that occur as part of patient history taking between triage and the medical consultation. These three patterns were (a) repetition of the same information that is differently co-constructed with the two healthcare providers (Excerpts 1 and 2); (b) repetition that contributes to seamless teamwork (Excerpts 3 and 4); and (c) repetition that leads to time wasting (Excerpts 5 and 6).

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Repetition Leads to Differently Co-constructed Patient History

Our data revealed the co-constructed nature of patient history-taking sequences as shown by Stivers and Heritage (2001). However, our findings contribute to an understanding of the implications of the co-constructed nature of meaning when patients consult with multiple healthcare providers. Depending on how the healthcare provider elicits responses and how patients convey responses, the meanings that are created can be different because of the co-constructed ways of arriving at the information. Such variance of meaning across the two speech events associated with the consultation seems to have benefits and drawbacks associated with medical teamwork.

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Implications of Repetition for Teamwork

The findings bear on notions of teamwork in the medical context. In cases in which members of teams interact face to face in the same room, teamwork seems to be beneficial to patient care outcomes (Sicotte et al., 1993; Wake-Dyster, 2001). However, our data question the efficacy of members of medical teams working with patients separately in two separate interactions.

Because meanings co-constructed with Maria tended to be devalued in the sense that they may not contribute to eventual diagnoses and treatments, nuanced meanings co-constructed between the patient and Maria may be lost. This was the case with the co-construction of Pamela’s uncertainty with Maria. Because the uncertainty was not co-constructed with Carrie, it was not a factor in the eventual diagnosis and treatment—potentially a detrimental patient care outcome. However, repetition can also lead to the patient receiving more medical information as shown by the consultation with Maria and Carrie (Excerpts 1 and 2).

Another important implication of the data addressed in the article is the question of the purpose and efficacy of entering patient history information into a computer program in medical consultations that involve two separate speech events. For instance, the use of prescribed history-taking questions and slots for patient responses preclude the ability to enter unexpected kinds of information, such as the case with Ramon (Excerpts 5 and 6). However, repetition of information can also lead to more efficient consultations (Excerpts 3 and 4)—depending on how medical information is conveyed through electronic medical records.

This article then raises the question of the role of the intake nurse. As our data have shown, such a team works well when the nurse practitioner uptakes information that the intake nurse entered into the computer, repeats it, confirms it with the patient, and then uses the information to benefit the diagnosis and treatment. However, such teamwork is hindered by overly prescriptive history-taking regimens that do not allow for unexpected responses from patients to be entered for use by the nurse practitioner. It seems that the intake nurse works best as part of a medical team when information fits seamlessly into the patient history programmed questions. However, perhaps it would be more beneficial to patient care outcomes if the intake nurse could enter information in a more open-ended way tailored to the specific type of information gleaned from the particular patient—which can sometimes be unexpected. This might include information about the intake nurse’s assessment of issues, such as patient competence and compliance, as well as patient narratives that illuminate their conditions.

The findings, then, speak to the role of EHRs in teamwork. Varpio et al. (2015) present some of the qualitative obstacles to an intercollaborative practice with the use of EHR. Their data (p. 1) revealed that the use of an EHR limited narrative notes and inhibited sharing of team members’ interpretation, ultimately obstructing “clinicians’ ability to build the patient’s story by fragmenting data interconnections.” Our data indicate that narrative notes can be limited, specifically when patient information does not fit into the categories of information that EHR software includes. Narrative nursing notes can be useful in describing specific and qualitative information that can address specific patient needs and track the progression of online patient information (Long, 2003). Further research investigating the value of and necessity for integrating information of structured and free text are important for the next step. Salanterä (2015) pointed to the significance of nursing notes for populating EHR with patient information and also for eliciting the nurses “reasoning processes,” which inform actions and patient’s health status.

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Healthcare Providers Second Language Use

We also investigated how the health professionals’ use of a second language might affect the conveyance of information. We looked into whether or not provider second language use affected the co-constructed meaning within the medical consultation. In Excerpts 1 and 2, Carrie’s grammatical structure differed from Maria’s (the native speaker), which affected the information conveyed. After asking three native Spanish speakers, they agreed Carrie’s grammatical structure seemed less correct than Maria’s, though not unintelligible. However, correct or not, Carrie’s phrasing carried a different meaning than Maria’s.

Though we found that Carrie’s phrasing related to the blood glucose measurement differed from Maria’s, we do not typically find instances when lack of second language proficiency on the part of the healthcare provider caused miscommunication with patients or hindered the ability to clearly communicate with patients. In a globalized context in which second language use on the part of providers and patients is not uncommon, our data draw a positive light on medical provider second language use and language concordant consultations with language minority patients. A survey of U.S. hospitals (Huang, Jones, Reggenstein, & Ramos, 2009) found that approximately 90% employ bilingual clinicians. Andres, Wynia, Regenstein, and Maul (2013) note that interactions between patients and bilingual providers show increased medication compliance and overall higher satisfaction with healthcare treatments. Our data corroborate these findings as the healthcare provider who used a second language in our data was able to communicate clearly with her patient.

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Implications for Research

The fact that repetition seems common across the speech events associated with the medical consultation in our data indicates the need for further research on the role of repetition and the transferability of these findings to patient outcomes and other varied clinical encounters. The evidence specifically points to addressing conditions in ambulatory settings with triage and intake personnel that affect transmission of accurately reported information for patients and providers.

One important component in our data was a nurse practitioner who used a second language. Our data do not reveal that such second language use in any way hinders medical teamwork or patient care outcomes. However, it would be interesting to examine further—especially through examination of more than one healthcare provider—how second language use on the part of the patient or the provider affects the co-construction of meaning in the medical consultation.

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Conclusion

Our findings contribute to an understanding on how effective and ineffective teamwork is achieved. This article is an important step in identifying what effective teamwork is like on the ground by examining the interactions that take place within the consultation room. The article points to implications for further discourse analytic research in the medical context that centers around understanding how effective teamwork and ineffective teamwork are achieved in interactions in a variety of medical teamwork situations.

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      Keywords:

      bilingualism; health communication; Hispanic Americans; interviews; narration; nursing team; office visits

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