Unraveling triadic communication in hospital consultations with adolescents with chronic conditions: The added value of mixed methods research

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Abstract

Objective

To integrate findings of a mixed methods research (MMR) into adolescents’ preferences and competencies for communication during consultations, in order to demonstrate the added value of MMR for health communication research.

Methods

Sequential MMR with adolescents (12–19 years) with various chronic conditions in a university hospital. Methods comprised: (1) 31 face-to-face interviews; (2) Q-methodology; (3) 39 observations of outpatient consultations; (4) three focus groups with 27 healthcare providers; (5) web-based questionnaire in 960 adolescents.

Results

Adolescents had different preferences regarding health communication, but all wished to be involved as partners. Yet, their actual participation during consultations was low. They often acted as bystanders rather than main characters because their participation was neither requested nor encouraged. Parents filled the gap, to healthcare providers’ frustration. The questionnaire confirmed the discrepancy between self-efficacy and self-reported independent behavior during consultations.

Conclusion

Triadic communication was all but multi-party-talk and adolescents did not act and were not considered as main partners. MMR was of pivotal importance for our understanding.

Practice implications

As chronically ill adolescents need to prepare themselves for transition to adult care, healthcare providers should encourage them to take the lead in communication by initiating independent visits and changing the parents’ roles.

Introduction

Medical interaction should be studied in the context of time, setting and participants [1], [2]. This plea is particularly relevant in pediatric consultations, where at least one parent is likely to be present next to the child and the doctor. Triadic communication and opportunity for partnership is framed, first and foremost, by the ‘ceremonial order of the clinic’ [2], [3]: the organizational and legal setting of pediatric clinics [4].

Research into triadic communication in the past decades has shown that the child's contribution is rather limited, seeing that doctors control the turn-taking and parents control their child's participation [4], [5], [6], [7], [8], [9], [10], [11]. Doctors [5], nurses [12], [13] or dieticians [5], [9] appear to address the parent more than the child; parents frequently take over when the doctor turns to the child [11], [14], whereas children have very little say [5]. Parental speaking for the child is institutionally co-constructed: it is hardly ever questioned by children and ratified by doctors [15]. So, children's communication competence is not only dependent upon their own capacity, but also on parents’ and healthcare professionals’ attitudes [16], [17].

Most studies on triadic communication were conducted in general practice [14], [15], [17], [18], [19]; some in outpatient settings [4], [6], [10], [11] or in-patient wards [20], [21]. Improving doctor–patient communication and establishing patient partnership is especially relevant in the context of chronic illness [22]. Youth with chronic conditions are rarely consulted, however, about their views on and preferences for involvement in communication [23], [24]. Most research has focused on school-aged children (6–12 years) [5], [6], [11], [14], [15], [17], [19], [25], [26], while relatively few observational studies involved adolescents (e.g. children over 12 years of age) [10], [11], [20], [23], [27]. As children mature, they achieve greater competence for making independent decisions [16] and increasingly want to be involved in decision-making [28], [29]. Also, the Dutch Medical Treatment Act (WGBO; 1995) grants adolescents aged 12–15 the right to co-decide with parents in treatment decisions and to decide for themselves when they are over 16. Adolescents with chronic conditions on the way to adult care should be trained and empowered to become effective partners in their own healthcare communication [30]. This does not only improve interaction, but is also enhances diagnostic and therapeutic processes [1].

In a project entitled “On Your Own Feet” we studied these adolescents’ preferences and competencies for healthcare communication. We chose a flexible, multi-method design to account for the complexity of a multi-party context. Mixed methods research (MMR) has the potential to access knowledge or insights unavailable to a qualitative study or a quantitative study undertaken independently. MMR is defined as a single study in which qualitative data collection and/or analysis is combined with quantitative data collection and/or analysis either in a concurrent or sequential design [31]. MMR has become popular [32], but the basic requirements for a good MMR study are much debated [33]. MMR has even been designated the third methodological paradigm: an intellectual and practical synthesis based on qualitative and quantitative research [34]. Integration of different strands of research is the biggest methodological challenge [35]. The key issue is whether the end product is really more than the sum of the individual quantitative and qualitative parts.

We chose MMR for several reasons. First, comprehensiveness: using different methods to address different aspects of the overall research question. Second, improvement of validity and generalizability of findings: by combining qualitative and quantitative methods, inherent weaknesses of each methodology could be compensated for [31], [32]. Third, as our ultimate aim was to give adolescents a voice, patient-centeredness was another justification for MMR [32].

The objective of this paper is twofold: (1) to integrate findings of a MMR study into preferences and competencies for hospital consultations of adolescents with chronic conditions; (2) to demonstrate whether the mixed methods approach has added value in triadic health communication research in pediatric settings. We followed the guidelines for Good Reporting of A Mixed Methods Study [33] (Box 1).

Section snippets

General design and setting

The research project “On Your Own Feet” employed a sequential strategy of inquiry [31]. All studies were performed in the Erasmus MC-Sophia Children's Hospital, the largest tertiary referral center in the Netherlands. The project was originally designed as a participatory, multi-method qualitative study, but later extended with a follow-up a questionnaire to strengthen the outcomes. Overall aim of “On Your Own Feet” was to map preferences for healthcare delivery and competencies required to

Interviews: adolescents’ views of healthcare communication

Young people found routine hospital consultations little interesting and often boring (“always the same”). The pediatrician takes the lead and sets the agenda, the adolescent follows, answers questions if asked to do so and only rarely poses questions. The younger adolescents (under 16) reported that parents and doctors do most of the talking. Yet, most interviewees maintained they are very well capable of playing a more active role. There are two reasons why they do not do this:

  • -

    it is not

Discussion

This study confirmed that adolescents with chronic conditions desire to participate in their own care and have their viewpoints taken seriously [24], [28]. A higher age was associated with a preference for communication directly to the adolescent [24]. Several qualitative studies found that preferences with regard to parents’ role differ between adolescents [20], [23], [27]. The four Q-Care Profiles we described show that such preferences are closely related to (perceived) healthcare

Conflict of interest

The author has no actual or potential conflict of interests.

Acknowledgements

The author thanks the other members of the On Your Own Feet Research Group (particularly Susan Jedeloo, Heleen van der Stege, Sander Hilberink, Marijn Kuijper, and Jos Latour) for their invaluable contribution to data collection and analyses and their helpful comments on earlier drafts of this paper. Nurse specialists Annelies Kok, Trudi Taat, Caro Fonkert, Linda van der Knaap, Patricia van Deventer, and Clementine Dekkers are thanked for their participation as co-researchers in the

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