Training interaction in primary care emergency teams: the role of the patient
AbstractObjective: “The needs of the patient” inform interactions in medical settings. Information regarding the role of the patient is, however, absent from emergency medicine guidelines and team training manuals. We sought to identify how we could introduce a greater focus on the needs of the patient in order to increase the person-centeredness of clinical services.Method: During the course of one year (May 2010-11), we applied a framework of action research to an exploration of the simulated patient’s role and participation in the context of interaction training in primary care emergency teams in Alta, a rural municipality in the county of Finnmark, Norway. All of the 10 rounds of team trainings we employed included 2 simulated scenarios. Each was followed by a de-briefing designed to elicit the participants’ reflections upon the simulations and moderated as a focus group. Our study material included: field notes; the transcribed audio-recordings from 18 de-briefings and the transcript of a follow-up focus group held with local stakeholders.Results: The analyses, bridging perspectives from ethnomethodology, conversation analysis and discourse analysis, revealed that participant reflections were dominated by language that objectified both the simulated patients and the participating professionals. When confronted with these findings, the local stakeholders expressed ambivalence about increasing the focus on the patient as a person when it was not of clear benefit to the patient and when it might impact negatively on “assessments and management” during the most critical phases.Discussion: Despite these results, the dominant objectifying language may well suppress insights that patient participation could provide and which could potentially prove beneficial both to patients and professionals as persons, those who share the crisis in emergencies.Conclusion: For future improvement, current emergency team trainings, characterised by increasing medical sophistication and professional competence, ought also to be enriched by increased focus on the role of the patient.
Ministry of Health and Care Services. (1999). LOV-1999-07-02-64: Act on Health Personnel.
Ministry of Health and Care Services. (1999). LOV-1999-07-02-63: Act on Patient's and Users Rights.
Ministry of Health and Care Services. (2005). FOR-2005-03-18-252 Regulation on demands for prehospital emergency medicine (Forskrift om krav til akuttmedisinske tjenester utenfor sykehus).
Chakravarthy, B., Ter Haar, E., Bhat, S.S., McCoy, C.E., Denmark, T.K. & Lotfipour, S. (2011). Simulation in medical school education: review for emergency medicine. Western Journal of Emergency Medicine 12 (4) 461-466.
Weaver, S.J., Salas, E., Lyons, R., Lazzara, E.H., Rosen, M.A., Diazgranados, D., Grim, J.G., Augenstein, J.S., Birnbach, D.J. & King, H. (2010). Simulation-based team training at the sharp end: A qualitative study of simulation-based team training design, implementation, and evaluation in healthcare. Journal of Emergencies, Trauma and Shock 3 (4) 369-377.
Austin, Z., Dolovich, L., Lau, E., Tabak, D., Sellors, C., Marini, A., Kennie, N. & Dan, L. (2005). Teaching and assessing primary care skills: the family practice simulator model. American Journal of Pharmaceutical Education 69 (4) 500-507.
Jacobsen, T. (2010). Fiction based communication training in medical education - with the use of theatrical tools (Fiksjonsbasert kommunikasjonstrening i medisinsk utdannelse - med bruk av teaterfaglige virkemidler). Bergen: University of Bergen.
Dieckmann, P., Friis, S.M., Lippert, A. & Østergaard, D. (2009). The art and science of debriefing in simulation: Ideal and practice. Medical Teacher 31, e287-e294.
Kneebone, R.L. (2006). Crossing the line: simulation and boundary areas. Simulation in Healthcare 1 (3) 160-163.
Nestel, D.F., Black, S.A., Kneebone, R.L. & Wetzel, C.M. (2008). Simulated anaesthetists in high fidelity simulations for surgical training: feasibility of a training programme for actors. Medical Teacher 30 (4) 407-413.
Wisborg, T., Brattebo, G., Brattebo, J. & Brinchmann-Hansen, A. (2006). Training multiprofessional trauma teams in Norwegian hospitals using simple and low cost local simulations. Education for Health 19 (1) 85-95.
Schön, D.A. (1983). The Reflective Practitioner. London, UK: Ashgate Publishing.
Utsi, R., Brandstorp, H., Johansen, K. & Wisborg, T. (2008). Training in multiprofessional emergency medicine in primary health care. Tidsskrift for Den Norske Legeforening 128 (9) 1057-1059.
Bardes, C.L. (2012). Defining "Patient-Centered Medicine". New England Journal of Medicine 366, 782-783.
Starfield, B. (2011). Is patient-centered care the same as person-focused care? The Permanente Journal 15 (2) 63-69.
Cassell, E.J. (2010). The person in medicine. International Journal of Integrated Care 10 (Supplement) e019.
Miles, A. & Mezzich, J.E. (2011). The care of the patient and the soul of the clinic: person-centered medicine as an emergent model of modern clinical practice. International Journal of Person Centered Medicine 1(2) 207-222.
Getz, L., Kirkengen, A.L. & Ulvestad, E. (2011). The human biology--saturated with experience. Tidsskrift for Den Norske Legeforening 131 (7) 683-687.
Horvath, A. (2006). The alliance in context: accomplishments, callenges, and futuure directions. Psychotherapy: Theory, Research, Practice, Training 43 (3) 258-263.
Martin, D.J., Garske, J.P. & Davis, K.M. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology 68, 438-450.
Spiegel, D. (2011). Mind matters in cancer survival. Journal of the American Medical Association 305 (5) 502-503.
Blaxter, M. (2004). Health. Cambridge:Polity press.
Getz, L. (2006). Sustainable and responsible prevetive health. Conceptualising ethical dilemmas arising from clinical implementation of advancing medical technology. Trondheim: Department of Public Helath and General Practice, Faculty of Medicine, Norwegian University of Science and Technology.
The Norwegian Medical Association. (2002). Ethical regulations for physicians.
Naess, A.C., Foerde, R. & Steen, P.A. (2001). Patient autonomy in emergency medicine. Medicine Health Care and Philosophy 4 (1) 71-77.
Nordby, H. (2010). Ethics and communication in prehospital medical work. Oslo: Gyldendal norsk forlag.
Tham, V., Rydning, E.L. & Christensson, K. (2010). Experience of support among mothers with and without post-traumatic stress symptoms following emergency caesarean section. Sexual & Reproductive Healthcare 1 (4) 175-180.
Roertveit, S. & Hunskaar, S. (2009). Medical emergencies in a rural district. Tidsskrift for Den Norske Legeforening 129, 738-742.
Zakariassen, E., Burman, R.A. & Hunskaar, S. (2010). The epidemiology of medical emergency contacts outside hospitals in Norway - a prospective population based study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 18, 9.
Finnmark health trust. (2006). Plan for ambulance services in Finnmark county.
Arentz-Hansen, C. & Moen, K. (2007). Handbook of primary care emergency medicine (Legevakthåndboken). 3rd edn. Oslo: Gyldendal Akademisk.
The Mom-collaboration. (2009). Medical operative manual.
Greenwood, D.J. & Levin, M. (2006). Introduction to action research: social research for social change. 2.edm. rev edn. Thousand Oaks, Califoria: SAGE.
Miller, G. & Fox, K.J. (2004). Building bridges. The posibility of analytic dialogue between ethnography, conversation analysis and Foucault. In: Qualitative Research: Theory, Method and Practice. 2.edn., pp. 35-55. Silverman D, ed. London, UK: SAGE.
Silverman, D. (2007). A very short, fairly interesting and reasonable cheap book about qualitative research. London, UK: SAGE.
Garfinkel, H. (1984). Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice Hall.
Skjervheim, H. (2002). Mennesket (The human being). Oslo: Universitetsforlaget.
Wilkilson, S. (2004). Focus group research. In: Qualitative research. Theory, Method and Practice. 2nd edn., pp. 175-199. Silverman, D. ed. London, UK: SAGE.
Davidson, J.E., Buenavista, R., Hobbs, K. & Kracht, K. (2011). Identifying factors inhibiting or enhancing family presence during resuscitation in the emergency department. Advanced Emergency Nursing Journal 33 (4) 336-343.
Struckman, T. (2011). Best evidence topic 3: Effect of family presence on paediatric trauma resuscitation. Emergency Medicine Journal 28 (11) 993-994.
Glaser, R. & Kiecolt-Glaser, J.K. (2005). Stress-induced immune dysfunction: implications for health. Nature Reviews: Immunology 5, 243-251.
Höglund, A.T., Winblad, U., Arentz, B. & Arentz, J.E. (2010). Patient participation during hospitalization for myocardial infarction: perceptions among patients and personnel. Scandinavian Journal of Caring Sciences 24, 482-489.
Webster Marketon, J.I. & Glaser, R. (2008). Stress hormones and immune respons. Cellular Immunology 252, 16-26.
Chochinov, H., Hack, T., Hassard, T., Kristjanson, L., McClement, S. & Harlos, M. (2005). Understanding the will to live in patients nearing death. Psychosomatics 45 (1) 7-10.
Parchman, M., Zeber, J. & Palmer, R. (2010). Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study. Annals of Family Medicine 8 (5) 410-417.
Wilson, S.R., Strub, P., Buist, A.S., Knowles, S.B., Lavori, P.W., Lapidu, J. & Better Outcomes of Asthma Treatment (BOAT) Study Group. (2010). Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. American Journal of Respiratory and Critical Care Medicine 181, 566-577.
Eid, J. & Johnsen, B.H. (2006). Operativ psykologi (Operative psychology). 2nd edn. Bergen: Fagbokforlaget.
Pettersen, B. & Johnsen, R. (2007). Physicians' experience with and attitudes to interaction between health care levels (abstract in English). Tidsskrift for Den Norske Legeforening 127, 565-568.
Mishler, E.G. (1984). The Discourse of Medicine: The Dialectic of Medical Interviews. New Jersey: Norwood.
Mishler, E.G. (2005). Patient stories, narratives of resistance and the ethics of human care: á la recherche du temps perdu. Health 9 (4) 431-451.
Geertz, C. (1973). The interpretation of Cultures: Selected Essays. New York: Basic Books.