Communication study
Development of the Verona coding definitions of emotional sequences to code health providers’ responses (VR-CoDES-P) to patient cues and concerns

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Abstract

Objective

To present a method to classify health provider responses to patient cues and concerns according to the VR-CoDES-CC (Del Piccolo et al. (2009) [2] and Zimmermann et al. (submitted for publication) [3]). The system permits sequence analysis and a detailed description of how providers handle patient's expressions of emotion.

Methods

The Verona-CoDES-P system has been developed based on consensus views within the “Verona Network of Sequence Analysis”. The different phases of the creation process are described in detail. A reliability study has been conducted on 20 interviews from a convenience sample of 104 psychiatric consultations.

Results

The VR-CoDES-P has two main classes of provider responses, corresponding to the degree of explicitness (yes/no) and space (yes/no) that is given by the health provider to each cue/concern expressed by the patient. The system can be further subdivided into 17 individual categories. Statistical analyses showed that the VR-CoDES-P is reliable (agreement 92.86%, Cohen's kappa 0.90 (±0.04) p < 0.0001).

Conclusion

Once validity and reliability are tested in different settings, the system should be applied to investigate the relationship between provider responses to patients’ expression of emotions and outcome variables.

Practice implications

Research employing the VR-CoDES-P should be applied to develop research-based approaches to maximize appropriate responses to patients’ indirect and overt expressions of emotional needs.

Introduction

In a recent review on the literature on cues and concerns by patients in medical consultations, a high variability emerged in the definition of methodological approaches to these two types of patient expressions [1]. Definitions varied widely in detail and covered more or less different content areas, impeding a fruitful comparison of results and data. Hence an international group of experts in health communication research, “The Verona Network on Sequence Analysis” (authors of the present paper) decided to meet annually in Verona to find common ground and a shared language to define cues, concerns and the linked micro-behaviours expressed by physicians. This collaborative convention gave rise to the elaboration of a new coding system, the VR-CoDES (Verona coding definitions of emotional sequences), where both patient cues and concerns are defined (VR-CoDES-CC) along with health provider responses to them (VR-CoDES-P). In the VR-CoDES-CC cues are defined as “verbal or nonverbal hints, which suggest an underlying unpleasant emotion and that lack clarity” [2], [3]. Concerns, are defined as “clear and unambiguous expressions of an unpleasant current or recent emotion that are explicitly verbalised with or without a stated issue of importance” [2], [3].

In terms of health provider responses, cues and concerns constitute a source of information that may be distanced from, explored or acknowledged [4], [5]. Yet, patients’ cues and concerns are often under-detected and missed [1], [5], [6]. They may be either not perceived or consciously ignored by health providers in order to hold control over their own agenda [7]. Still, many authors suggest that cues and concerns should be recognised and explored by health care providers, using information gathering skills as well as skills to help the patients expressing their concerns [2], [4], [5], [6], [8].

Communication teachers assume that health providers should be open to cues and concerns and explore their content. However, little empirical evidence supporting the effectiveness of specific responses to cues is available. Zimmermann et al. cite in their recent review [1] only one study by Butow et al. looking at patient satisfaction and anxiety as related to cue responses with cancer patients [9]. Patient satisfaction and state anxiety turned out to be unaffected by physicians’ reactions to informational and emotional cues. However, Uitterhoeve et al. found that cue response by oncology nurses was independently and positively related to patient satisfaction [4].

One can imagine that in some situations, exploring concerns might be counterproductive. Some patients might be less appreciative of empathic behaviour and might prefer a more directive style [10]. Thus a facilitating response which is effective in one context can be ineffective in another. For example, follow up care may be different from emergency medicine. If so, the health provider would need to adopt a tailored approach rather than uniformly exploring such patient concerns. Indeed, Floyd et al. found that, depending on the way patients expected to present a symptom, i.e., with or without a cue and/or concern, they preferred a different response style on the part of the physician: some favoured a biomedical response whereas others preferred facilitation and even exploration [11]. The question of under what circumstances, with which patients, what reactions to patient cues and concerns are adequate and effective has to be settled empirically to support clinical teaching and practice. To substantiate these processes one has to identify certain reactions of providers to cues and concerns under given conditions and to associate these to outcomes.

A prerequisite for this is to have a coding system for health provider responses to patient emotional cues and concerns. Such a system should provide a neutral perspective for coding provider responses. Criteria of appropriateness should not be built into the definition of the codes to avoid circularity in the associations between provider responses and outcome measures. Also, such a system should distinguish provider responses that are relevant according to theoretical and clinical knowledge. There are some coding systems that are partly based on these principles [12], [13], [14], [15]. However, there is little consensus in definitions among these coding systems and the theoretical background is not always the same. The VR-CoDES-P represents the result of a shared effort in finding a general consensus among different experts in health communication research. The present paper aims to show the conceptual and the procedural outcomes that the “Verona Network on Sequence Analysis” has reached on evaluating health provider's behaviour in response to emotional talking by the patient as described in the VR-CoDES-CC system for patient cues and concerns [2], [3].

Section snippets

Methods

The development process has involved a number of steps. First, a position paper was written within the group in 2006 to formulate the basic considerations underlying the development process [16]. It was decided not to code “appropriateness” in order to avoid value judgments inherent in the terms appropriate and inappropriate, and to focus instead on what seems to be the function of the utterance. Moreover it was also underlined that appropriateness should not be specified a priori, but should

Results: description of the coding system

The coding system is specified in detail in the Coding Manual [18] and in a separate memorandum on units of analysis [19]. It can be accessed on the EACH web site (http://www.each.nl). The core feature of the system is that it intends to be descriptive and not normative in the sense that it does not distinguish between good and bad responses.

Discussion

We have introduced a new coding system, the VR-CoDES-P, devised to investigate health care providers’ responses to cues and concerns, as defined by the VR-CoDES-CC. Four criteria were formulated. The system: (1) is limited to provider responses to cues and concerns. It is not designed to code all provider utterances, (2) builds on a precise definition of cues and concerns, (3) provides a neutral perspective for coding provider responses, (4) can provide data suitable for sequence analysis.

The

Acknowledgements

The VR-CoDES-P is the result of the combined efforts of a group of European and American researchers from the “Verona Network on Sequence Analysis”.

Contributors: Jozien Bensing, Utrecht NL; Svein Bergvik, Tromso NO; Lidia Del Piccolo, Verona IT; Claudia Goss, Verona IT; Hanneke de Haes, Amsterdam NL; Stephanie Demaesschalck, Gent BE; Hilde Eide, Oslo NO; Tom Eide, Oslo NO; Arnstein Finset, Oslo NO; Ian Fletcher, Liverpool UK; Cathy Heaven, Manchester UK; Gerry Humphris, St. Andrews UK; Wolf

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