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Interactional resistance between patients with atrial fibrillation and cardiologists in consultation on treatment with warfarin: The value of shared decision-making
2012 (English)In: The International Journal of Person Centered Medicine, ISSN 2043-7730, E-ISSN 2043-7749, Vol. 2, no 3, 427-436 p.Article in journal (Refereed) Published
Abstract [en]

Rationale: Atrial fibrillation (AF) increases the risk of stroke and it can be reduced by treatment with warfarin. Some patients consider that warfarin is a stressful treatment with undesired effects and the perceived barriers include unwillingness to take it. Knowledge of patients resisting warfarin treatment may be useful for the potential threat to maintaining shared decision-making in the consultation as a central tenet of person-centered medicine.

Aims and objectives: To identify how patients resist treatment with warfarin and how cardiologists respond to patients’ resistance. The co-constructive perspective of this work analyses the consultations by emphasizing the clinical communication strategies of both patients and cardiologists.

Method: Eleven videotaped consultations, in 4 different hospitals, were selected for analysis. Treatment interactions regarding warfarin between patients with AF and cardiologists were analysed, according to the methodology of conversation analysis.

Results: There were 4 types of resistance from patients for accepting treatment with warfarin. These included “Giving reasons for their resistance”, “Suggestion of another treatment option by the patient”, “Stating a treatment preference” and “Questioning or challenging the cardiologist’s treatment recommendation”. The cardiologists’ responses to the patients’ resistance included “Repeating the treatment recommendation”, “Negotiation with the patient”, “Providing additional information on the recommended treatment” and “Extending the explanation for the purpose of taking the treatment”.

Conclusions: By showing resistance, patients are thought to want to participate in their treatment decisions and an awareness of patients’ resistance to treatment enables cardiologists to address the patients’ experience-based views on their treatment and individual concerns as part of clinical strategies to increase the person-centeredness of medical intervention.

Place, publisher, year, edition, pages
2012. Vol. 2, no 3, 427-436 p.
Keyword [en]
Atrial fibrillation, Communication, Patient choice, Patient participation, Person-centered medicine, Resistance interaction, Shared decision-making, Warfarin
National Category
Nursing
Identifiers
URN: urn:nbn:se:shh:diva-2164OAI: oai:DiVA.org:shh-2164DiVA: diva2:916213
Available from: 2016-04-01 Created: 2016-04-01 Last updated: 2017-11-30Bibliographically approved
In thesis
1. Communication in Patient Involvement in Decision making: Examples from consultations on atrial fibrillation
Open this publication in new window or tab >>Communication in Patient Involvement in Decision making: Examples from consultations on atrial fibrillation
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Abstract

Background: Further knowledge is needed regarding communication that occurs in practice between patients with atrial fibrillation (AF) and health professionals in consultations to understand the issue of patient involvement in treatment decisions.

Overall aim: The overall aim of this thesis is to contribute knowledge on communication between patients and health professionals (cardiology nurses and cardiologists), focussing on how they create involvement in decision making in consultations.

Specific aims: (1) To describe (i) the topics that patients with AF discuss with cardiology nurses and cardiologists; (ii) the use of discursive space in consultations between these participants; and (iii) the frequency at which patients, cardiology nurses, and cardiologists introduce identified topics. (2) To describe the different types of resistance by patients to treatment with warfarin and how cardiologists respond to such resistance. (3) To examine how patients describe involvement and communication in decision making regarding treatment in consultations with cardiology nurses and cardiologists. (4) To examine how cardiologists describe their views on patient involvement in AF treatment decisions, their perceptions regarding efforts to involve patients, and how they handle decisions.

Methods: A qualitative design was used. In study I, the sample consisted of 23 videotaped consultations between patients with AF and cardiology nurses and cardiologists at six nurse-led cardiology outpatient clinics. Content analysis was used to obtain a description of topics that were discussed. The patterns of dominance for the various topics and participants were examined. In study II, the sample consisted of 11 videotaped consultations between patients with AF and cardiologists. Conversation analysis was used to describe interactions concerning resistance to treatment with warfarin. In study III, 22 patients with AF were interviewed directly after their consultations with cardiology nurses and cardiologists. Content analysis was used for the resulting data. In study IV, 10 cardiologists were interviewed in cardiology clinics at four Swedish hospitals and qualitative content analysis was used.

Findings: In study I, a medically driven agenda dominated the patient-driven agenda. However, when the patients initiated conversations about their life with AF (the topic that received the least amount of space on the agenda), involvement was created. In study II, the patients’ resistance could be viewed as a source of knowledge about patients’ real-life situations and what motivates them. In study III, despite not being actively involved in the decision-making process, the patients experienced a sense of involvement when they felt understood and were listened to. In study IV, by taking into account the patients’ feelings in the consultations, and by actively encouraging the patients to be involved, the cardiologists contributed to patient involvement.Conclusions: Patients, cardiology nurses, and cardiologists create involvement in decision making in consultations as communicative projects. Patients strive for space and create involvement by showing resistance to the decisions suggested by health professionals. However, involvement is not only an issue about obtaining space in the consultations, but is also associated with obtaining clarification, building confidence, feeling understood, trusting cardiology nurses and cardiologists, and having confidence in receiving consistent care within an established relationship. On a theoretical level, this thesis sheds light on the interaction between the concepts of communication, involvement, and decision making.

Place, publisher, year, edition, pages
Stockholm: Karolinska Institutet, 2016. 81 p.
Keyword
Communication, Patient involvement, Shared decision making, Atrial fibrillation, Interaction, Patient participation, Person-centered care, Resistance, Discursive space, Consultation
National Category
Nursing
Identifiers
urn:nbn:se:shh:diva-2171 (URN)978-91-7676-042-0 (ISBN)
Public defence
2016-01-22, Weitnersalen, Sophiahemmet University, Valhallavägen 91, Hus R, Stockholm, 09:30 (English)
Opponent
Supervisors
Available from: 2016-06-15 Created: 2016-04-01 Last updated: 2016-06-15Bibliographically approved

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