By Maddie Tremblett, Jude McClellan, Charlotte Albury, Shoba Dawson, Brian McMillan, and Rebecca Goulding
Communication is central to the delivery of healthcare. From patients requesting an appointment, explaining what symptoms they have been experiencing and what they are concerned about, to staff asking for more information, delivering diagnoses and prognoses, and explaining different treatment options, clear understandable communication is core.
Most major investigations into failures in the UK NHS highlight communication as a key area where something has gone wrong1,2,3.
Researchers endeavour to improve healthcare communication, with journals dedicated to investigations into how this can be improved (e.g. Patient Education and Counselling, Qualitative Health Communication, Health Communication). However, so much of this research entails retrospective post hoc interviews on the experience of communication, which faces issues with our ability to effectively remember what happened in a conversation to build practical advice for change.
Government recommendations for healthcare delivery rarely cite the evidence base for any communication guidelines. The focus by researchers on retrospective accounts and lack of evidence in clinical guidelines is a puzzle. Methodology is available to systematically build evidence on effective communication practices in healthcare, based on actual clinical encounters – including conversation analysis.
Conversation analysis, with its origins in sociology, uncovers the normative rules and structures that we abide by during conversations. Unlike the messy disordered talk we all think we take part in, decades of research have demonstrated that talk is structured and ordered, with rules we tend to abide by (e.g. one speaker talks at a time4). This micro analytic technique has been harnessed by healthcare researchers and applied to clinical encounters as diverse as end of life care discussions5, healthy behaviour talk in primary care6 and medical emergency calls7.
At the same time as being a burgeoning field, it is a puzzle why the study of actual healthcare encounters is not embraced more often throughout healthcare research, and systematically used to develop solutions to known issues in healthcare communication.
We are a group of researchers and clinicians, who have, or have attempted to, examine actual healthcare encounters. We were bought together by a need to solve this puzzle – and help improve communication in healthcare, by enabling the generation of the gold standard of evidence through the recording and analysis of actual healthcare encounters.
Preliminary findings from our survey of UK researchers with experience of recording or attempting to record healthcare encounters for research speak to the causes of this puzzle. Content analysis was applied to responses from 24 participants, recruited between April – May 2024.
Time
Research projects are timebound. Funding is provided in a limited capacity with an expectation that goals are achieved in a quick and cost-effective way.
A lack of understanding by funders for how long it takes to build an in-depth analysis meant that time for analysis was often cut before the project even began, limiting the scope of the resulting evidence base.
Bureaucracy
Bureaucratic systems that researchers must navigate were perceived as a major hurdle for completing this type of research.
Ethical approval is essential for all research, but ethics committees often lack understanding of this methodology, and the ways of managing anonymity and confidentiality when voices can never be entirely anonymised. Explaining and answering queries on the methodology from committees takes significant time.
Information governance was an even bigger reported issue for most researchers. Each place that you want to do research in (e.g. hospital/primary care setting), has different gatekeepers that need extra applications for approval to conduct research there, eating up more projects time.
Along with impacting the time for the work, gatekeepers often demand changes to the way the project was designed. Compromises are often made, with researchers reporting that requirements imposed can be arbitrary, constraining, or even prohibitive.
“Governance offices in hospitals making us add a statement saying they could get access to the data if required, meaning clinicians refused to be recorded for fear of repercussions”
Participant 1, Academic Researcher
Approval processes used by different gatekeepers are perceived as overly subjective and open to variation according to the individual officer.
“I have found heterogeneity though across gatekeepers in IG in different provider trusts… so you have figured out what way of dealing with someone or a group that is more likely to enable … making videos in healthcare”
Participant 2, Clinician Researcher
As a result, there can be a variation in procedures dependent on the location, potentially effecting how the results can be interpreted.
Recruitment
Recruitment of patients was only perceived as problematic when there was a very limited pool of participants available due to the study focus (e.g. a focus on clinical communication about a rare condition). However, it was highlighted that clinicians were often reluctant to take part.
“Recruitment of clinicians has been the biggest challenge I’ve faced.”
Participant 3, Academic Researcher
Practicalities
Additional challenges were experienced due to the complexity of most healthcare settings, where multiple different parties may be present for the recording, and when appointments are ad hoc or in emergency settings.
“We had multiple participants in any single recording. Some had given ‘higher’ levels of consent than others (e.g. consented (or note) to using anonymized photos, video, etc. in dissemination) …We had to decide how to use each recording based on the ‘lowest’ level of consent from participants in each recording.”
Participant 4, Academic Researcher
“Getting consent from the practices, all members of the [ ] team and the patients and their chaperones before audio recording of urgent [ ] appointments. This is a lot of people who all need to agree”
Participant 5, Academic Researcher
The logistics of getting good quality recordings in healthcare settings, which were at times chaotic, were perceived as further challenges. Funding may not stretch to the ‘best’ equipment, and the practicalities of setting up multiple cameras to fully capture all the interactions can be complex.
“one camera and little time to set up, getting good quality recordings with everyone’s face in them can be tricky… Multiple cameras of course helps this, but adds lots of levels of complexity”
Participant 6, Academic Researcher
“the suction pump kicking in upstairs can have a real impact”
Participant 5, Academic Researcher
Bringing researchers into the healthcare setting to help with the set up and the recording is one way to get better quality recordings but were reported as leading to other challenges that researchers were not sure on how to manage.
“Some patients would speak to the researcher within their consultations (despite instructions to act as if we were not there), particularly if they had spoken to us a few times before”
Participant 7, Academic Researcher
Equally the increasing use of telehealth consults were perceived to impact time on a project, as researchers had to learn how best to capture these interactions with new technology.
So, what next?
These preliminary findings give an idea of what might need to happen to make recording and analysing actual healthcare encounters an accessible method to build evidence based clinical guidelines.
Communication may be the key. Communication to regulatory authorities about this type of methodology, and how it can safely protect data, might speed up initial approval processes. Communicating to get consistency throughout healthcare settings for how requirements are applied would mean protocols can be easily transferred to different settings. Working with these bodies to establish a framework that everyone agrees on could be an option. Researchers using established ways of communicating the power of this type of research to clinicians and working with healthcare teams to enable suitable set up of equipment could make for good quality of recordings.
Our group hopes to establish further projects to show how this communication puzzle can be solved. Exploring these issues faced by researchers, but also in the future patients and those working in healthcare settings, we hope to establish a range of resources for researchers, funders and gatekeepers in the process. Establishing guidelines for smoother processes and methods will not only make researchers lives easier, it will have real world impact. Rather than relying on what we think might work to enable good communication in healthcare, we could rely on an evidence base of what is demonstrated to actually work. Healthcare communication, and its impact on patients’ lives, are too important to do otherwise.
References
1 Walsh, K. (2003). Inquiries: Learning from failure in the NHS? The Nuffield Trust. Retrieved from: https://www.nuffieldtrust.org.uk/sites/default/files/2017-01/inquiries-learning-from-failure-nhs-web-final.pdf
2 Powell, M. (2019), Learning from NHS Inquiries: Comparing the Recommendations of the Ely, Bristol and Mid Staffordshire Inquiries. The Political Quarterly, 90: 229-237. https://doi.org/10.1111/1467-923X.12697
3 NHS England, (n.d.). Improving safety critical spoken communication. Retrieved from: https://www.england.nhs.uk/patient-safety/improving-safety-critical-spoken-communication/
4 Sacks, H., Schegloff, E., & Jefferson, G. (1974). A Simplest Systematics for the Organization of Turn-Taking for Conversation. Language, 50(4), 696-735.
5 Parry, R. (2024). Communication in Palliative Care and About End of Life: A State-of-the-Art Literature Review of Conversation-Analytic Research in Healthcare. Research on Language and Social Interaction, 57(1), 127–148. https://doi.org/10.1080/08351813.2024.2305048
6 Albury, C., Hall, A., Syed, A., Ziebland, S., Stokoe, E., Roberts, N., Webb, H., & Aveyard, P. (2019). Communication practices for delivering health behaviour change conversations in primary care: a systematic review and thematic synthesis. BMC Family Practice, 20(1), 111. https://doi.org/10.1186/s12875-019-0992-x
7 Riou, M. (2024). Communication in Prehospital and Emergency Care: A State-of-the-Art Literature Review of Conversation-Analytic Research. Research on Language and Social Interaction, 57(1), 55–72. https://doi.org/10.1080/08351813.2024.2305044