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Negotiation Strategies and patient empowerment in Spanish and British medical consultations

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Negotiation Strategies and patient empowerment in Spanish and British medical consultations
  Abstract  Making a decision is not only one of the physician’s most important responsibilities but also one of pa-tients’ most sensitive moments in medical encoun-ters. Drawing from pragmatics studies, this paper explores rapport maintenance and/or enhancement (Spencer-Oatey 2000, 2008) in the decision-making  strategies that General Practitioners (GPs) and pa-tients employ in 80 encounters in various areas of  England and Spain. Te results show that such strat-egies are context-bound and subject to role specifi-cations: while patients may make use of (dis)agree-ment strategies and initiate decisions and/or self-diagnosis, doctors give options, show empathy, ex- pand explanations or show explicit or implicit (dis)agreement. In relation to this, notable findings were revealed: first, these communicative strategies may vary not only in terms of frequency but also quality and distribution; second, the Spanish interlocutors in the data gathered tend to negotiate through the explicit expression of opinions, while the British in-terlocutors prefer the discussion of different alterna-tives and value the other’s freedom to act. Tird, there is higher tolerance of disagreement in the Spanish data. Fourth, negotiation may be undertaken on the basis of either self-affirmation or consensus-seeking beliefs. Finally, patient empowerment is displayed in divergent ways in both sets of data. In short, the decision-making processes examined are subject to  social and psychological factors with a direct impact on communicative styles.  Keywords: negotiation; decision-making; cross-cul-tural communication; patient empowerment; self-affirmation; consensus 1. Introduction Research on doctor-patient communication and decision-making processes has generated well-grounded evidence that effective interpersonal skills in healthcare contexts may not only improve patient satisfaction and adherence to treatment, but also the doctor’s adequate provision of information, adequacy of diagnosis and success in treatment related deci-sions (cf. Hall et al  . 1994; Iedema 2007; Kalbfleisch 2009; Rivadeneyra et al  . 2000; Street 1991; Street et al  .   1993, among many others). In fact, given that cultural assumptions, institutional values, professional experi-ences and communicative styles are all in full display in doctor-patient events (Candlin and Candlin 2003; Cordella and Musgrave 2009; Roberts and Sarangi 2002), the mismanagement of decision-making epi-sodes may constitute a serious threat to the quality of patient care (Hewett et al  . 2009). What is not so clear is what we mean by ‘adequate’ or whether there is an expected communicative pattern to follow. In other words, the decision-making process in medical consultations involves willingness to maintain and/or enhance rapport but, given the sensitive nature of the encounter, the interlocutors will endeavour by all means to avoid the so-called rapport-threat (Camp-bell 2005; Spencer-Oatey 2000, 2008).   Moreover, the impact of culture-specific communicative styles in negotiation on effective doctor-patient communica-tion still needs further investigation (Long Feather 2007; Pesquera et al  . 2008). On the other hand, since medical decisions are very sensitive for patients, it is expected that negotiation and interpersonal work will be developed (Campbell 2005; Mullany 2009). In this sense, and also considering that negotiation skills  vary considerably from context to context (Fant 1989, 1995, 2007; Kalbfleisch 2009; Valbuena de la Fuente 2003; Van Wieringen et al  . 2002), how both doctor Communication & Medicine Volume 8(2) (2011), 169–180Copyright © Equinox Publishing LtdSheffieldhttp://equinoxpub.comDOI: 10.1558/cam.v8i2.169 Negotiation strategies and patient empowerment in Spanish and British medical consultations MARÍA DE LA O HERNÁNDEZ󰀭LÓPEZ  Pablo de Olavide University, Spain  170  María de la O Hernández-López  and patient make decisions and deal with treatment-related issues is expected to vary as well. In this vein, when doctors and patients make a decision, they may adopt different attitudes, ranging from expressing an opinion after internal and individual consideration, to a process of mapping the likely consequences of decisions, working out the importance of individual factors collaboratively, and choosing the best course of action to take. With the exception of a few studies (cf. Hewett et al  . 2009; Street 1991), decision-making research has largely been limited to clinical decisions made by phy-sicians, who usually assume responsibility for health care decisions. However, as indicated by Broadstock and Michie (2000), patient participation in the deci-sion making process should be addressed in current research, as ‘physicians who have not established a relationship with the patient or with someone the patient knows may not be able to fruitfully ask ques-tions and gain useful answers’ (Kalbfleisch 2009). Tis study will examine both doctors’ and patients’ decision-making strategies as a cooperative process in which both interlocutors influence each other in interaction (Cordella 2007; Young and Flower 2002). Te initial assumption will be that negotiation encompasses a wide range of strategies and commu-nicative styles that are intrinsic to each situation. It is a move from doctor- or patient-centred examination of communication towards interpersonal communi-cation as a dynamically shaped activity. Contrary to some recent findings (cf. Bissel et al  . 2004), this study supports the assumption that the doctor’s institutional and expert power (Erzinger 1991; Harrison and Barlow 2009) is in constant tension with regard to both the doctor’s and the patient’s interactional power (Mills 2003; Locher 2004). In other words, power is an ongoing process that is strategically developed (Guilfoyle 2005; Sarangi and Slembrouck 1997; Wang 2006) and so is empowerment. Power may be pre-established by the institution, because of the knowledge doctors have, achieved interactionally (i.e. usually patients may want to have power to make their own decisions) and even granted by the other interlocutor; in this latter case, doctors may, for instance, empower patients to temporarily be able to make decisions, negotiate and give opinions on health-related topics as a strategic empathic use of language (Cordella and Musgrave 2009). Studies like Brown et al  .’s (2006) support the idea that patients who can express their opinions, and get involved in treatment-related decisions, achieve more satisfactory communication with their doctors. A different issue would be how these pre-established power asymmetries, granted empowerment or inter-actionally self-acquired power rights are implied in communication. Cordella (2007) argues that health professionals tend to use reprimands when patients fail to adhere to a particular treatment as a sign of power asymmetries. In this sense, being assertive and direct in communication seems to be related to exerting power. Nonetheless, my study is undertaken under the assumption that power asymmetries may be linguisti-cally expressed in a wide range of strategies that may not be necessarily based on directness and assertive-ness. Additionally, it is worth noting that cultures hold  varying beliefs in terms of tolerance to disagreement and conflict (Locher 2004). One of the multiple devices used to express this communicatively is through the expression of either consensus (i.e. search of agree-ment) or self-affirmation as the expression of asser-tiveness (Cohen et al  . 2009; Fant 1989, 2007; Heine and Lehman 1997; Sherman and Cohen 2006; Steele 1988). Self-affirmation (Steele 1988) suggests that human beings are naturally predisposed to protect or enhance self-integrity and self-worth in various ways. One of the clearest manifestations of self-affirmation is assertiveness and the expression of one’s thoughts, i.e. a speaker-centered attitude in interaction. For these reasons, this study sought to examine the communicative styles displayed when making decisions in 80 British and Spanish medical consulta-tions. Tus, the goal of this study will be to answer the following questions: what decision-making dynamics and strategies are displayed between doctor and patient? What does this say about the cultural perception of doctors and patients? What is the relationship between decision-making styles and power expectations? In what ways do interlocutors seek agreement or self-affirmation attitudes when negotiating decisions? By answering these questions, implications for improvement in interpersonal com-munication management may be unravelled. 2. Data and approach Te data consist of 80 encounters between General Practitioners (GPs) and patients, audio recorded in different geographical areas in England and Spain. After eliminating those interactions with obscure or incomplete information, a set of 120 English interactions and 60 Spanish interactions related to minor physical illnesses were obtained. Following this, the 80 interactions examined for this study were randomly chosen.     Negotiation strategies in medical consultations  171 Te 40 Spanish interactions were recorded after obtaining permission in four different healthcare centres in Huelva, Seville, Badajoz and Madrid (centre and south of Spain). Te transcript notation utilized for the Spanish interactions was adapted from Atkin-son and Heritage (1984). Patients were previously informed of the research procedure and its goals, and only those who agreed to be recorded in successive consultations were included in this study. his means that the interactions recorded were not first time encounters between doctor and patient. Terefore, the type of rapport between interlocutors is relationship-renewing instead of relationship-shaping (Heritage 1984). Since all those involved had been told about the recording in advance, by the time the consultation took place the naturalness of the interactions did not appear to be distorted. Te English data belong to the  British National Corpus, characterised by being monolingual (it covers modern British English) and synchronic, on the one hand, and demographically and geographically rep-resentative, on the other. Te interactions and their transcriptions are available for the research commu-nity. Tis study covers only those interactions that specify belonging to a GP medical consultation. In both corpora interactions with the elderly (85  years old and older), teenagers and children, as well as first time encounters, were not included as these factors may influence the way interaction evolves. Te Spanish doctors who participated in this study provided demographical information. Tis was not always available in the case of the BNC, though in the  vast majority of cases patients provided these data while interacting with the doctor. First, a deductive study, unravelled after the exami-nation of the data and the reactions interlocutors display in these interactions, will help classify the negotiation strategies found in the decision-making process in order to maintain or enhance rapport. Te focus and method of the analysis is the dynamics involved in decision making, i.e. who makes deci-sions, who takes initiatives, how frequently such situations occur and how assertive the interlocutors are in doing so. Whether there is explicit disagree-ment and, if so, how this is solved is also taken into consideration. Tis will lead to the creation of a taxonomy of strategies. Although it was the direct observation of data that led to the categories found, these have points in common with the main items of the OPION scale (Observing Patient Involvement) (cf. Elwyn et al  . 2003, 2005). However, the data were not measured by this method because the aims of this paper do not only cover concepts such as patient involvement, but also empowerment (Holmstrom and Roing 2010; Piper 2010; hesen 2005) and, drawing from psychology and pragmatics studies, degrees of self-affirmation or consensus (Cohen et al  . 2009; Fant 1989, 2007; Heine and Lehman 1997; Sherman and Cohen 2006; Steele 1988) expressed in language in order to maintain or enhance rapport (Spencer-Oatey 2000, 2008). Tus, the procedure is based on identifying those linguistic strategies directly linked to three catego-ries related to episodes in which the doctor 1) takes the lead; 2) displays affiliation or empathy (Cordella and Musgrave 2009; Pierce 1996); and 3) expresses disagreement (Locher 2004). In the same way, the patients’ linguistic choices analysed are those linked to three categories: 1) compliance or agreement; 2) initiative; and 3) non-compliance or disagreement (Cordella 2007). aking this into consideration, those patients’ and doctors’ linguistic strategies that express the aforemen-tioned categories will be first identified separately in the British and Spanish corpora, and later discussed with another researcher to ensure objectivity as much as possible. Repeated strategies within the same inter-action were not counted in this first step, as the aim was to disentangle whether some strategies are typical in each of the data sets, not whether these strategies are typical of some patients. Situational similarities and differences will be addressed subsequently. By cal-culating the frequency, mean and standard deviation,  variation in terms of communicative styles in negotia-tion will be measured, whereas a qualitative study will reveal the overall negotiation dynamics undertaken between doctor and patient in the two sociocultural contexts analysed. Finally, I will discuss the impact of negotiation styles and interactional dynamics on power asymmetry and cultural beliefs. 3. Negotiation strategies in the decision-making process Te quantitative results show specific communicative styles and variation in the dynamics involved in the decision-making process in both groups of doctors and patients. 3.1. Doctors’ initiative and negotiation Te analysis of the data led to the taxonomy of a series of linguistic strategies in the decision-making process – which could occur simultaneously or not – in doctors:  172  María de la O Hernández-López  1. Initiative.(a) Giving options: instead of imposing a specific treatment or action to be taken, the doctor suggests different possibilities and explains the advantages and disadvantages of each of them. (b) Expressing solution: the doctor tells the patient what to do without the patient’s direct involve-ment.2. Affiliation. (c) Empathy: the doctor shows solidarity with the patient’s opinions and feelings (Cordella and Mus-grave 2009). Tis could refer to expressions such as ‘I understand how you feel’, used to eventually gain patient’s cooperation in the decision-making process. (d) Expanded explanations: the doctor gives further arguments to support recommendations or in-structions that may make the patient feel good and/or to avoid disagreement. 3. Disagreement.(e) Implicit disagreement: sometimes what the doc-tor thinks is the best solution does not match the patient’s wants or needs, so the doctor tries to show how these are not suitable without explicitly contradicting the patient.(f) Explicit disagreement: the doctor’s open expres-sion of disagreement.  Te mean obtained in both data sets reveals that Spanish doctors (5,85) and British doctors (5,10) behave similarly in terms of initiative, disagreement and affiliation. Te standard deviation obtained (3,424 and 2,468 respectively) supports this fact. However, the frequency of decision-making strategies reveals some significant differences: Figure 1. Spanish and British negotiation strategies led by doctors, expressed in percentages.  he most significant findings summarized in Figure 1 are that: 1) while 35 interactions (87,5%) contain agreement in British doctors’ turns, it only occurred in 6 Spanish interactions (15% of the inter-actions); 2) while the Spanish doctors use a range of disagreement strategies in 14 interactions (35%) that can be either explicit (17,5%) or implicit (17,5%), British doctors disagree more frequently in the data, but only implicitly, as found in 22 interactions (55%). Explicit disagreement was nonexistent in the British data; and 3) British doctors prefer giving options to the patient in 14 interactions (35%) while this only occurred in 1 Spanish interaction in the data. Tese strategies conform a role-related willingness to either seek consensus (full agreement, doctor-led decisions) or be assertive (i.e. showing disagree-ment, taking initiative). Extract 1 shows some of the doctors’ strategies: Extract 1D[1][2] ¿Le duele por aquí?  Does it hurt here?  […]P[3][4]ahí justamente en ese hueso de la cadera  Right there, in the hip bone [5][…]D[6]esto ya es el sacro, ¿eh? Tis is the sacrum, ok?  P[7][8] la verdad es que tengo un poco de osteoporosis o tell you the truth, I think I have a bit of osteoporosis D[9][10][11][12]no, pero esto no es eso. Aquíen las mujeres es muy frecuente una obusitis que seforma aquí  No, this is not the problem. It’s very  frequent to find bursitis in women  [13][…]D[14][…]P[15][16][17] y yo diciendo la hernia. Esto es que me irradia el problema lumbar que tengo hacia abajo and the whole time I was thinking it was a hernia. It may be that my lumbar problem irradiates downwards. D[18][19][20][21][22]en la mujer, con la estructuraque tiene el sacro es muy típico la (…) a nivel sacro(…) sea una obusitis o sea anivel artrosis negativa a nivel     Negotiation strategies in medical consultations  173 [23][24]sacro, lo cierto es que hay unnervio y por eso duele tanto  Due to female sacrum structure this is very frequent, either related to bursitis or to negative arthritis. What is true is that there’s a nerve affected and that’s why it’s painful. P[25][26]Claro yo tengo artrosis realmente en las manos y = Yeah, I actually have arthritis in my hands . D[27] [28][29][30][31][Aquí viene muy bien la rehabilitación / es decir /  yo lo que diría es que se pusiera calor local, eh / diez minutos nada más al día  Rehabilitation is very good for this. Tat is, my advice for you would be  you to apply heat to the affected area ten minutes each day. P[32][33]sí  yeah […]P[34] [35][36][37][38][39][40]¿Y protector me tomo? Porque yo me estaba tomando Omeoprazol porque tengo problemas de estómago y tenía dolores sobre todo cuando tomo Etamil Should I take some sort of stomach medicine?? I was taking Omeoprazol because I have problems with my  stomach and I had aches, mainly when taking Etamil  . D[41][42][43]Yo el Etamil no es santo de mi devoción por qué no decírselo  I’m not very fond of Etamil, I have to  say P[44][45][46] vamos que no me lo estoy tomando porque cuando tomo tomo ibuprofeno well, I’m not taking it now because  I’m taking Ibuprofen . Tis is an example of how patient’s self-diagnosis (lines [7] and [25]) and initiative to make decisions (line [34]) are combined with the doctor’s disagree-ment (strategy 3 in lines [9] and [41]) and the expan-sion of explanations (strategy 2 in lines [9] and [10]) in order to not only negotiate a treatment-related decision, but also to define the problem. Tis shows how these strategies do not operate in isolated ways but make sense in interaction. 3.2. Patients’ initiative and negotiation he strategies described occur in combination with a series of negotiation strategies identified in patients: 1. Compliance.(a) Full agreement: the patient is happy with the recommendations made by the doctor.2. Initiative.(b) Suggestion: the initiative is taken by the patient in order to suggest a particular treatment. (c) Self-diagnosis: the patient suggests a potential diagnosis and/or explains possible causes of their illness.3. Non-compliance.(d) Implicit disagreement: there is an attempt to change the course of the doctor’s decisions in an implicit way, for example, by suggesting other options, hesitating, objecting.(e) Explicit disagreement: the patient shows verbal disagreement and/or unwillingness to follow the doctor’s procedures.  Te results show a significant variation in terms of (non)compliance and initiative. Te mean obtained in Spanish patients (2.28) indicates much higher initia-tive and disagreement, and therefore more involve-ment in the decision-making process, than British patients (0.40). Te standard deviation obtained in each data set (3.266 and 1.355 respectively) supports this fact. In terms of frequency, this variation is even clearer: Figure 2.  British and Spanish patients’ strategies in negotia-tion, expressed in percentages.  Figure 2 reveals that agreement is typical in 36 British patients analysed (90%). Te Spanish data set is more varied in this respect: despite the importance
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