Background
Methods
Literature search & study selection
Data extraction
Critical appraisal
Data synthesis
Results
Consultation sample | ||||||||||
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Primary Reference | Associated publications | Focus | Data collection methods | Analysis methods | No. | Paediatric or mixed | Illness | Location | Consultation participants | Study quality |
Elwyn 1999 [33] | [34] | Shared decision making in situations of conflict | Two case studies. Audio recorded consultations. | Discourse analysis | 2 | Paediatric | URTI | UK | 2 Children (2–8 yrs) 3 Parents 1 GP from 1 clinic | High credibility. Insufficient information to assess typicality. Transferability limited to similar cases. |
Stivers 2000 [35] | Communication practices used by parents and paediatricians | Convenience sample. 295 audio recorded & 65 video recorded consultations. 1996–1997. | Conversation analysis | 360 | Paediatric | RTI | USA | Children (2–10 yrs) Parents (Demographic data for 295: avg. age: 38 yrs; avg. edu: 16 yrs; 75% affluent households; 69% White; all English speakers) 14 Clinicians from 6 clinics | High credibility. Likely to be typical. Limited transferability to similar populations. | |
Rollnick 2001 [41] | Language, skills and strategies used in everyday URTI consultations | Audio recorded consultations. | Verbal ‘moves’ used by doctors identified. | 29 | Paediatric | URTI | UK | Children (<11 yrs) Parents 5 GPs from 1 clinic | Insufficient information to assess credibility, transferability and dependability. | |
Main 2001 [42] | Effects of family context on care and physician-patient communication | Purposive selection of clinics. Direct observation of consultations. 1996 & 1999 | Emerging patterns of physician-patient interaction were identified. | 37 | Mixed | Acute RTI | USA | Children (<16 yrs) Parents >50 Clinicians from >18 clinics | High credibility. Insufficient information to assess transferability of these findings. | |
Barry 2001 [45] | Patient expectations, consultation behaviour and prescription | Purposive sample of clinicians. Audio recorded consultations & interviews with parents and clinicians. 1996–1998. | Conversation analysis | 35 | Mix | Mix | UK | 6 Children (<12 yrs) Parents 20 GPs from 20 clinics | High credibility. Insufficient information to assess typicality and transferability. | |
Tates 2002 [48] | Co-construction of roles and interaction | Video recorded. 3 time periods: 1975–78; 1988–89; 1993 | Conversation analysis | 106 | Paediatric | Mix | Netherlands | 106 Children (<12 yrs) 106 Parents (88 mothers) 58 Clinicians | High credibility. Insufficient information to assess transferability. | |
Butler 2004 [51] | GPs’ current practice regarding prognosis | Convenience sample. Audio recorded consultations. | Prognosis communication extracted. | 59 | Paediatric | RTI | UK | Children (<11 yrs) Parents 9 GPs from 2 clinics | Insufficient information to assess credibility, typicality or transferability. | |
Roberts 2005 [52] | Method of theme oriented discourse analysis | Two case studies. Audio or video recorded consultations. | Discourse analysis | 2 | Mix | Mix | Not stated | 1 Child 1 Parent 1 Clinician | High credibility. Insufficient information to assess transferability or typicality. | |
Nova 2005 [53] | Quality of the paediatric interaction. | Videos recorded consultations. 2003. | Discourse analysis | 10 | Paediatric | Mix | Italy | 10 Children (2–6 yrs) >6 Parents Clinicians (no information given) | High credibility. Insufficient information to assess transferability or typicality. | |
Stivers 2005 [16] | Parent resistance to no antibiotic treatment | Cross-sectional sample. Video recorded consultations. 2000 & 2001. | Conversation analysis | 309 | Paediatric | URTI | USA | Children (6 m to 10 yrs) 543 Parents (avg. age: 34 yrs; 53% latino; 28% white; 12% African-American; 7% Asian; 16% high school not completed; 60% high school completed; 24% graduates) 38 Paediatricians from 27 clinics | High credibility. Insufficient information to assess transferability or typicality. | |
Cahill 2007 [11] | Child participation in consultations | Purposive sample of practices. Video recorded consultations. 2004 & 2005 | Conversation analysis | 31 | Paediatric | Not stated | UK | 31 Children (6–12 yrs) Parents 16 GPs | High credibility. Limited transferability to similar populations is likely. | |
Butler 2009 [60] | How nurses deliver advice on telehealth line | Purposive selection of calls. Audio recorded. 2005 –2006. | Conversation analysis | 6 | Paediatric | Mix | Australia | 6 Children 6 Parents 12 Nurses | High credibility. Likely to be transferable to other similar interactions. | |
Ijas-Kallio 2011 [61] | Patients participation in diagnosis and treatment decision | Audio or video recorded consultations. 2005–2006. | Conversation analysis | 46 | Mix | RTI | Finland | 46 Children Parents 11 Clinicians from 9 clinics | High credibility. Insufficient information to assess transferability or typicality. |
Studies characteristics & relatedness
Study quality
Translation of second order constructs
Study | Second order construct | Summary translation |
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Elwyn 1999 [33] | The doctor has attempted to use the concept of ‘normality’ as a means of persuading the patients to accept symptomatic treatment. It is to be expected that young children will develop upper RTI, and the doctor wants to avoid its medicalization. | Clinicians use problem minimising/normalising language or communication techniques during examination to communicate that an illness is not serious |
Stivers 2000 [35] | When doctors initiate closure of a minimal sequence (either by moving to a new sequence or with a minimal sequence expanding SCT) they convey that the response is routine, expectable, or unproblematic. | |
Rollnick 2001 [41] | The doctor in the example above (involving the ‘very rattle cough’) used minimizing words, not only to reassure a worried parent and to reduce the intrusiveness of the physical examination, but also to introduce the idea that the problem was not that serious. | |
Butler 2009 [60] | The nurse draws on her expertise in the area of child development and parenting to re-specify the problem as non-medical and as an expected and normal occurrence. | |
The nurse assures the caller that 37 is ‘normal’ and at ‘37.4 she’s probably feeling a little bit uncomfortable but that’s okay’. |
Thematically related groups | Translation or summary descriptions of second order constructs from included studies | Studies which identify 2nd order construct |
---|---|---|
Communication during information exchange
| Parents displayed concern with establishing the ‘doctorability’ of the child’s illness by presenting a story of extreme or abnormal events, and seeking clinicians expertise. | Elwyn 1999 [33] |
Stivers 2000 [35] | ||
Rollnick 2001 [41] | ||
Four types of problem presentations have been identified and include ‘symptoms only’, ‘candidate diagnosis’, ‘diagnosis implicative symptoms descriptions’ and ‘candidate diagnosis as background information’. | Stivers 2000 [35] | |
Ijas-Kallio 2011 [61] | ||
Clinicians use problem minimising/normalising language or communication techniques during examination to communicate that an illness is not serious. | Elwyn 1999 [33] | |
Stivers 2000 [35] | ||
Rollnick 2001 [41] | ||
Butler 2009 [60] | ||
Clinicians justified ‘no antibiotic’ treatment decisions using problem minimising language as a pre-emptive move to signal a pending ‘no antibiotic’ treatment decision. | Rollnick 2001 [41] | |
Parents and clinicians usually communicate purely in the voice of ‘strictly medicine’ (i.e. as though the problem was purely medical) in consultations for simple acute problems (communication phenomenon appears to be specific to these types of cases rather than clinician specific). Communicating only in the voice of medicine contributes to a failure of communication when parents have concerns that cannot be accommodated by this voice. | Barry 2001 [45] | |
Clinicians’ communication may be based on an assumption of a patient-centred approach to decision making but parents who do not expect a patient centred approach may misunderstand it and in turn the confusion may contribute to a clinician assessment of a parent as anxious | Roberts 2005 [52] | |
Clinician communication about prognosis varied, if duration was mentioned it was often too short or unclear, parents were invited to re-consult ‘if not happy’. | Butler 2004 [51] | |
Communication during diagnosis delivery
| Clinicians responded to symptoms only problem presentations of simple acute illness with straightforward unilateral diagnosis announcements presented as being based on his/her own medical reasoning. | Stivers 2000 [35] |
Ijas-Kallio 2011 [61] | ||
The parent’s problem presentation affects the trajectory of the interaction. When parents gave or implied a candidate diagnosis, the doctor designed his/her reply to be responsive to the parents’ own problem presentation, either confirming or disconfirming the candidate diagnosis. | Stivers 2000 [35] | |
Ijas-Kallio 2011 [61] | ||
Parents and clinicians alike oriented to diagnoses as within the clinician’s domain of expertise. Parents might respond minimally to simple unilateral diagnosis pronouncements but by doing so treat the unilateral decision as adequate. | Stivers 2000 [35] | |
Ijas-Kallio 2011 [61] | ||
Parents might also claim access to diagnostic reasoning by extended responses which might 1) assess the decision positively, 2) evaluate the grounds on which the doctor’s decision is acceptable, or 3) resist the decision. | Ijas-Kallio 2011 [61] | |
Communication during treatment deliberation & decision
| Parents usually accepted treatment recommendations. | Stivers 2000 [35] |
Ijas-Kallio 2011 [61] | ||
Parents resisted by withholding acceptance of treatment recommendations. Parents also drew on their own knowledge of symptoms, past experiences, previous medical advice and diagnostic expectations to contest clinicians’ interpretations. | Stivers 2000 [35] | |
Main 20011[42] | ||
Stivers 2005 [35] | ||
Ijas-Kallio 2011 [61] | ||
Overt requests or parent pressure for antibiotics were rare but included: parents making requests for or stating clear preference for antibiotic treatment and parents ’threatening’ to re-consult if antibiotics were not prescribed. More common were enquiries about antibiotics or mentions of positive past experience with antibiotic treatment. | Elwyn 1999 [33] | |
Stivers 2000 [35] | ||
Main 20011[42] | ||
Clinicians sometimes presented the treatment decision (no antibiotics, delayed prescription, immediate prescription) as a choice to parents; clinician actively pursued parental acceptance of decisions; parents behaved as though they have the right to accept or reject treatment proposals. | Elwyn 1999 [33] | |
Stivers 2000 [35] | ||
Rollnick 2001 [41] | ||
When parents gave or implied a candidate diagnosis as part of their problem presentation, these were responded to by clinicians in a way which indicated clinicians perceived an expectation for antibiotic treatment from parents, and their responses often included justifications of non-antibiotic treatment. | Stivers 2000 [35] | |
Main 2001 [42] | ||
Clinicians responded to parent resistance in a way which indicated clinicians perceived this as an indication of an expectation for antibiotic treatment from parents. | Stivers 2000 [35] | |
Main 20011[42] | ||
Parent's usually avoided open disagreement; rather they offered alternative or additional info and sought to further the shared understanding of the child’s condition. | Ijas-Kallio 2011 [61] | |
Clinicians used various strategies to pursue parental agreement with non-antibiotic treatment including offering symptom relief, further testing, offering parent choice and invoking parental competence | Stivers 2000 [35] | |
Rollnick 2001 [41] | ||
Stivers 2005 [35] | ||
When clinicians made affirmative, specific, non-minimised treatment recommendations e.g. for symptom relief, parents were less likely to resist and clinicians were more likely to gain acceptance than if clinicians made recommendations against a treatment. | Rollnick 2001 [41] | |
Stivers 2005 [35] | ||
Clinicians acknowledge uncertainty in diagnosis and treatment decision and prescribed antibiotics | Elwyn 1999 [33] | |
Rollnick 2001 [41] | ||
Clinicians met parents preference for antibiotic treatment or responded to parent pressure for antibiotics despite appearing to diagnose a viral condition. | Elwyn 1999 [33] | |
Stivers 2000 [35] | ||
Role of parent in consultation
| Parents gave and received information about their child’s health, illness and context, with parent’s involvement progressively decreasing through adolescence. | Main 2001 [42] |
Parents often asserted themselves during the consultation and until they had been able to express their concerns, would interrupt child-doctor interaction | Main 2001 [42] | |
Cahill 2007 [11] | ||
Role of child in consultation
| Children were notably quiet in these consultations | Cahill 2007 [11] |
Adults determined the degree of the child’s integration in the consultation interaction by the varying degree to which they oriented to or ignored the child. Clinicians affected child participation by varying how they arranged the room or how much they addressed the child rather than the parent or used appropriate communication techniques (asking closed questions, by giving children enough time to respond). Sometimes, both adults co-constructed a situation where the child was treated as a non-person (where child’s contributions were ignored or negated by adults). There was also an intermediate integration where child contributions were acknowledged but not integrated into the discussion. | Tates 2005 | |
Nova 2005 [53] | ||
Cahill 2007 [11] | ||
Where child was integrated he/she made relevant contributions and could influence diagnostic course | Nova 2005 [53] | |
Child actively acquired knowledge of the illness and the consultation process during consultations | Nova 2005 [53] |