Ethnomethodological studies of nurse-patient and nurse-relative interactions : A scoping review

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Ethnomethodological

studies

of

nurse-patient

and

nurse-relative

interactions:

A

scoping

review

Eric

Mayor

*

,

Lucas

Bietti

UniversitédeNeuchâtel,Switzerland

Keywords: Nurse-patientrelationship Conversationanalysis Ethnomethodology Review ABSTRACT

Objectives:Researchersinnursingscienceinterestedinthestudyofnurse-patientandnurse-relative

interactionshavedisplayedaneverincreasinginterestinethnomethodologyandconversationanalysis.

This reviewassessesthescope of this literature.Wecategorize thepapersin thematiccategories

determinedbothinductivelyanddeductivelyandsynthesizethemainﬁndingsofthisliteraturewithin

category. Finally we discuss the interactionaldeterminants of the lack patient participation, the

limitationsoftheﬁeld,andfocusonimplications.

Design:Ascopingreviewonnurse-patientandnurse-relativeinteractions.

Datasources:Fortyarticlesfocusingonnurse-patientinteractionsandnurse-relativeinteractions.Allthe

articlesreliedonethnomethodologyand/orconversationanalysis.

Review methods:A literature searchhasbeen carriedout onMedline (allarticles untilJune2016;

keywordswere:nurs*.ab. and “conversationanalysis”;nurs*.ab. andethnomethodology). Asimilar

searchwasperformedonotherplatforms.Thescopeoftheliteraturewasidentiﬁedbyinductivelyand

deductivelyanalyzingthethemesoftherelevantarticles.

Results:Sixthematiccategoriesemerged:Organizationofnurse-patientinteraction(elevenarticles);

Organizationofmediatednurse-patientinteraction(sevenarticles);Information,explanationandadvice

(eightarticles);Negotiationandinﬂuenceasymmetry(sixarticles);Managingemotionsincriticalillness

(twoarticles);andInteractingwithpatientspresentingreducedinteractionalcompetences(sixarticles).

Conclusions:Acrossmostthematiccategoriesitappearedthatpatientparticipationisfarfromidealas

interactionalasymmetrywasmostobservedinfavorofnurses.Whentheencountersoccurredatthe

patients’homesthispatternwasreversed.Computer-mediatedinteractionswereoftenreportedas

non-optimalasthestandardizedprocessconstrainedcommunicationanddelayedpatients’presentationof

theirailments.Micro-analysesofinteractionpresentaclearpotentialforthedevelopmentofguidelines

fornurse-patientinteractions.Implicationsforpracticearedescribed.

Whatisalreadyknownaboutthetopic?

Lackofpatientparticipationinnurse-patientencountersleadsto delayedcare.

Studies in nurse-patient interactions haveindicated a lack of user-centereddesignincomputertools.

Whatthispaperadds

Nurse-patient interactions are asymmetrical over multiple institutionalsettings.

Nursesexertmorecontroloverinteractions,whichlimitspatient participation.

Interactionsinhomevisitsfeaturemorebalanceddistributionof contributions between beneﬁciaries and nurses, i.e., social contextaffectshowrolesareinstantiated.

Computer-assistedcommunicationtoolsshouldmeettheneeds ofinteractingpartiesinnurse-patientencounters.

Nurses’interactions withpatients andpatients’relativesare pervasive andessential in clinicalsettings(e.g.,Fleischer etal., 2009;McCabe,2004).Theserelationshipshavebeenstudiedfor decades(e.g.,Aguilera,1967)undera varietyof theoreticaland methodologicalframeworks(Fleischeret al.,2009).Whilemost studieshavegroundedtheirﬁndingsinquantitativeaspects(e.g., quantiﬁcation of observed actions, interviewees’ statements or archivedmaterial;e.g.,HertzbergandEkman,2000;Sharacetal., 2010),somestudieshaverelieduponhermeneuticapproachesor otherqualitativeapproaches(e.g.,McCabe,2004).Mostliterature * Correspondingauthorat:InstitutdePsychologiedutravailetdesorganisations

UniversitédeNeuchâtel,EmileArgand11,2000Neuchâtel,Switzerland. E-mailaddress:eric.mayor@unine.ch(E.Mayor).

Published in International Journal of Nursing Studies 70, 46-57, 2017 which should be used for any reference to this work

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onnurse-patient interactionshaslackedproper investigationof patients’ contributions to these encounters (Jarrett and Payne, 1995).Andpriorto1990,mostofthisresearchprogramfailedto examinethe(re)productionofsocialorderthroughnurse-patient interactions (i.e., an interest in what is interpersonally accomplished; Bowers, 1992a). Therefore, the need to rely on ethnomethodology and conversation analysis to study nurse-patientinteractions hasbeensuggestedbyseveralauthors(e.g., Bowers,1992a;Dowling,2007;Jones,2003).

Inthisreview,weexaminethecontributionof ethnomethod-ology and conversation analysis to the nurse-patient and nurse-relative literature. What are the thematic categories of researchquestionsinthisliterature?Whatarethemainﬁndings, particularlywithregardstopatientparticipationandinteractional asymmetry? What is missing in the literature? We provide answerstothesequestionsafterbrie_ﬂyintroducingthetheoretical andepistemologicalgroundingofethnomethodologyand conver-sationanalysis.

1. Ethnomethodologyandconversationanalysis

Thestudyofinteractionsinvolvingnursesiscloselyrelatedto ethnomethodologyandconversationanalysis.Ethnomethodology aimstostudythewayspeoplecoordinateandmakesenseoftheir everydayactivities(DrewandHeritage,1992;HesterandFrancis, 2007;TenHave,2004).Ethnomethodologyhasproducedsigni fi-cantknowledgeabouthowpeopleinteractinclinicalsettings(e.g., Heath,1986;Mondada,2014).Theapproachistocarefullyexamine interactions, most of the time between people, but also with technology(e.g.,Suchman,1987).Conversationanalysisemerged fromethnomethodologyandfocusesonthewaypeoplenegotiate thesocialorderinnaturalandinstitutionalinteractions(Goodwin and Heritage, 1990). Among the differences between the two traditions,itcanbenotedthatethnomethodologistsdonotrequire any specific method for the documentation of interactions (Garfinkel,2002),whereasconversationanalystsrequirenaturally occurringdata,suchasrecordingsofconversations(Goodwinand Heritage,1990).Anotherdistinctionisthatconversationanalysis has no interest in the motives of the participants (although accountscanbeinvestigated),andtakesaninterestonlyinwhat occursintherecordedinteractions(Schegloff,1987).

Regularities are present in the routines people use to understand and enact those understandings (Garfinkel, 1967) and in the context in which they are embedded (Drew and Heritage,1992).Theaimofethnomethodologyistodescribethese routines.Fromthisperspective,people’smotivesand understand-ing are constantly accounted for by their actions or words (Attewell,1974).Thesocial orderis(re)producedatthelevelof theinteractionbytheco-participants(HesterandFrancis,2007).In otherwords,themeaningofasituationisnevergiven,butalways recursively co-constructed and negotiated by members of a communityasapartoftheirprocessofunderstandingandacting insituation(Attewell,1974;ZimmermanandPollner,1970).Any social situation can hence be described accurately by the inspection of routines – through visible and audible conduct, withoutaneedforhigherordertheories.Theethnomethodologist can study the way members organize their actions by the observationofthesepractices(Adleretal.,1987). Ethnomethod-ology can also take into consideration the motives of the individuals,andinsistsontheimportanceofknowledgeoftheir social context (Garfinkel, 1967). A concomitant weakness of ethnomethodology is that itdeals withobservations ofactions thatarenecessarilyindexical,i.e.,relatedtotheknowledgeofthe participants prior to the examined situation, which implies a requirement forcontext onthepartof theobserver(Garfinkel, 1967).Thisoftenleadstoextensivefieldwork.

Byrepeatedand‘unmotivated’(Sacks,1984,p.27)scrutinyof fragmentsofinteraction,conversationanalysisdealswiththeway participants structure the interaction in an orderly manner, accordingtothesociallyconstructedrulestheyorientto(Schegloff andSacks,1973).Theaimistorevealtheserulesineverydayand institutional conversations fromthe scrutiny of multiple inter-actions(Sacks,1984)andsometimessinglecases(Schegloff,1987). Interactional routines are often standardized, which makes frequently occurring types of interactions predictable (e.g., Coulmas,1981). Conversation analysis aims at thediscoveryof regularitiesintalk-in-interactionthroughtheexplorationofthe natural and sequential unfolding of events as they occur in everydayencounters.Fromanearlyinterestincasualconversation (Sacksetal.,1974),conversationanalysishasevolvedtoamethod allowingthestudyofallkindsofinstitutionalinteractionswithan interest in the way people routinely accomplish work-related activitiescollaboratively throughconversation (fora review,see Drew and Heritage, 1992), including the study of clinical interactions(e.g.,MaynardandHeritage,2005).

Some approaches in conversationalanalysis have adopteda multimodal perspective to the study of naturally occurring interaction (e.g., Goodwin, 1994; Mondada, 2007). Human coordinationreliesnotonlyonspeechbutalsoonbodilyactions, posture, and prosody. Multimodal analysis is a subﬁeld of conversation analysis that takes into account not only speech butalsobodilyconductandtheirinterplay(e.g.,Goodwin,2000). The importanceof studyingmultimodal aspectsin professional settingshasbeenrepeatedlyshownintheliterature(e.g.,Heath,

1986; Maynard and Heritage, 2005; Goodwin,1994; Mondada,

2007; Streekand Kallmeyer,2001).However,this hasbeenless frequentinthestudyofnursing(e.g.,seeGonzález-Martínezetal., 2016;MayorandBangerter,2015).

2. Nurse-beneﬁciaryinteractions

Interactions between nurses and beneﬁciaries (patients and relatives)havebeenstudiedfordecades.Intheirthoroughreview, Fleischer et al. (2009) note that nurse-patient interactions are deﬁnedasmutualandintersubjective,andstresstheimportance of:

-patientparticipation,

-nurses’displayofempathy,and

-thepromotionofpatients’competences.

We refer the reader to the aforementioned article for an excellentoverviewoftheﬁeld,andfocusonthecontributionof ethnomethodologyandconversationanalysis.

Thegoalsofourstudyarepresentedbelow.

a) Ourprincipalaimistoexaminethemainthemesthatarefound in the international literature on nurse-patient and nurse-relativeinteractionsrelyingonethnomethodologyand conver-sationanalysisasmethods.

b) Inthediscussion,weaimtoexaminetheextenttowhichthe criteriamentionedabove(Fleischeretal.,2009)arediscussedin theliteratureonnurse-patientandnurse-relativeinteraction, andhowwellthecriteriaareattainedinpracticethroughthe lensofthestudieswereview.

c) We also aim at commenting on thelimitations of the ﬁeld (limitationsinscope,samplesize,diversityofmethodological andanalyticchoices,regionswherethedatawascollected),and describeimplicationsforpractice.

Thetypeofstudywhichbestallowstomeetthesegoalsisthe scopingreview.Contrarytoasystematicreview,ascopingreview

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reportsonpublicationsfeaturingawiderangeofstudyobjectsand designs(ArkseyandO’Malley,2005).Ratherthanexaminingthe robustness of results of studies relating to specific research questions,scopingreviewscanaimtoexploremultipleaspectsofa specific field:“(...)examine the extent, range and nature of researchactivity(...),determinethevalueofundertakingafull systematic review (...), summarize and disseminate research findings (...), [or] identify research gaps in the existing literature”(ArkseyandO’Malley,2005,p.21).

2.1.Method

Publicationswereidentifiedbysearchingthrougha)electronic databases, b) the reference lists of the articles identified in electronicdatabases,andc)thearticlescitingthearticlesidentified inelectronicdatabases.Wedecidednottobespeci_ficinthesearch in ordertoavoid thepotentialrisk of missingrelevantarticles.

Irrelevantarticleswereofcourseexcludedatalaterstep,basedon readingoftitlesandabstracts.Theexclusioncriteriaareindicated onFig.1which presentstheoverallprocessofidentiﬁcationof relevantpublications.

2.1.1.Electronicdatabases

InJune2016,weperformedasystematicandinclusivesearchof theliterature onMedline,inawaysimilartoJones(2003).Our searchincludedthefollowingterms:

-nurs*.ab.and“conversationanalysis”.af(41recordsfound) -nurs*.ab.andethnomethodology.af(13recordsfound)

WesearchedfornursontheEthnomethodologyand Conversa-tion analysis bibliography database (35 records found; http://emcawiki.net/EMCA_bibliography_database).

Fig.1.Identiﬁcation,exclusionandinclusionofstudies.

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T able 1 Descript iv e information for the included studies. Cat. F ocus Country Setting F oundation Int er actions Data Linguistic resour ces Non-lingu istic re sour ces T ools Main fi ndings 1 Encount ers betwe en community psy chiatric nurses and patients ’ re lativ es at their homes ( Ad ams, 20 0 1 a ) UK Home visits (psy chiatry) CA; D A N-R: 48 A S Less inte ractionally asymmetric int er actions betwee n nurses and patients might help in crea ting bonds and pr omo ting trust betwe en the participants. 1 Con v ersational misalignments ( Chatwin, 20 08 ) UK Primary car e C A N-P: 1 A V S + P Con v ersational misalignment can lead to delay ed tre atment. 1 D ivulgation of symp to m chang es in C OPD ( Chatwin et al., 20 1 4 ) England Gener al pr actice CA N-P: 23 Ph-P: 1 6 (unspeci fi ed) S + P How nurses and ph y sicians conduct the int ervie w has po tential clinical impacts in the consultation. 1 P atient admission ( Jones, 20 07 ) U K Medicine, surg ery , neur ology , car diology CA, EGR N-P: 2 7 A + FN + A D S + W r + FN Clinical records N urses' admission pr actices do not allow patients to initiate topics. 1 P atient discharg e ( Ri v a et al., 20 1 4 ) Switzerla nd R ehabilitation CA N-P: 1 2 A V S + P G + N od R ecipr ocal int er action style fr om nurses enhances patient participation. 1 P atient and nurse participation in fi v e identi fi ed phases of annual check -ups of Type 2 diabet es patients ( Edw all et al., 20 09 ) Swe den Diabet es clinics CA N-P:20 A V S + P B M + N o d + T o u P resents w a y s in which nurses can structur e the ph y sical e xamination that can lead discussions that allow patients to e xpr ess their feelings and beliefs. The e xaminations pr omo tes patients' understanding of diabet es. 1 Int er actions during child immunizations ( Plumridg e et al., 20 09 ) Ne w Zealand Gener al pr actice CA N-R -P: 1 0 A V S + P G + B M N urses and pare nts ra re ly v erball y inte ract during immunization and rather addres s the child. N urses might re ly on baby talk to enrol mo thers in helping the immunization. 1 P articipation fr ames in int er action betw een nurses and taciturn patients ( K ettunen et al., 20 0 1 , 2 0 02a ) Finland Anesthesia, surg ery , gynecology , out-patient, ph y sio therap y , inte rnal medicine CA N-P: 1 8 A V S + P + W r + L Nod Pa perw ork Fou r differe nt participation fr ames ar e linked with taciturnity patients: i) in the hands of pr ofessional fr ame; ii) compliant fr ame; iii) guilty fr ame; and iv ) polit e fr ame. 1 P rogr ession of pare nt's e xpertise in their child's disease made e xplicit in int er action ( Niedel et al., 20 1 3 ) UK, US Diabet es consultations CA H-P: 55 A S + P Par ents deve lop an e xpertise of their child's diabete s that is manifeste d in the organization of nurse-patient inte ra ctions. As time unfolds, they become att enti v e to tw o types of symp toms: symp toms of normal childre n, and symp toms that might be relat ed to the w orsening of their child's condition. 1 Con v ersational pr actices when talking about death ( Wilainuch, 20 1 3 ) Thailand District hospital, public health cent er , patient home CA; EGR N-P: 40 N-R: N/A A V S G + N od + B M N urses initiate discussions about death to inform and pr o vide emot ional support. 2 Helpline call openings ( Le ydon et al., 20 1 3 ) UK Cancer helpline CA N-P: 52 A S + P Helpline calls ar e v astl y led b y the nurses. A uthors pr o vide a scrip t for ef fi cient call openings. 2 Int erpr et er mediat ed int er action ( Estr ada et al., 20 1 5 ) USA Clinics CA N-I-P: 3 A + S S + P + L Int erpr ete r mediat ed con v ersation can hinder or facilitate inte ra ction. Int erpr ete rs can help in recognizing and sol ving miscommunication issue. But patients can misconstrue br eaks in the inte rpre te r’ speech as turn completion points, which affects the unfolding of the inter action. Con v ersational str ate gies for meetings inv ol ving inte rpret ers ar e p ro vided. 2 P atient participation ( Jones, 20 09 ) UK A cute hospital sit es CA N-P: 2 7 A + FN + D S + P + W r + Typ N urses' use of assessment documents as a w ay to organize the inte rvie w leads to lo w patient participation. 2 Comput er -assist ed telephone triag e ( Mur doch et al., 20 1 5 ) England Gener al pr actice CA N-P: 22 A V S + P + L Comput er logs Compute r decision-support softw ar e leads to incr eased misalignments in con v ersation and reduced compre hension of patients' care needs. 2 Comput er -and art efact-mediat ed nurse-patient UK Primary car e CA; T A H-P: 50 A V S + P + Typ G Compute r check -lists structure the topics discussed and their ord er in consultations. This limits the

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T able 1 (Continued ) Cat. F ocus Country Setting F oundation Int er actions Data Linguistic resour ces Non-lingu istic re sour ces T ools Main ﬁ ndings int er action in routine diabete s consultations ( Rhodes et al., 20 06 ) Electr onic medical records possibilities for patients ’inte ra ctional in v o lv e ment in the encounters. 2 Constr ains of electr onic medical recor ds in inter actions about diabet es ( Rhodes et al., 20 08 ) UK Gener al pr actice CA N-P: 1 8 A V S + P + Typ G + BM + Nod Electr onic medical records N urses look at the computer scr een to disengag e fr o m the inter actions. Patie nts participat e more when nurses ’ gaze to w a rd s them. 2 N urses' medical advice in nurse-par ent phone con ve rsations about child health ( Butler et al., 20 09 ) A ustra lia Child health line CA N-P: 7 0 0 A S + P Although nurses ackno w ledg e paren ts ’accountability for the manag ement of their childre n, they display their pr ofessional authority backe d u p b y medical know ledg e. 3 Explanations in consultations ( Collins, 20 05 ) UK Primary car e diabet es consultations CA H-P: 38 A V S + P N urses and ph y sicians ha v e distinct communication patter ns. Both patter ns perform useful actions. Ther e ar e p ractical implications to combining nurses led and ph y sician led consultations. 3 R ole of ‘what about' q uestions in self-manag ement gro ups ( Fasulo et al., 20 1 6 ) England Self-manag ement meetings CA Sessions: 24 (N urse-led, 2 to 7 patients) A V S + P + W r Nod + B M + FE + M G What about' q uestions ar e used b y patients in gr oups as a device for selecting nurse as ne xt speaker and obtain information. 3 The deliv ery and recep tion of advice in health counselling sessions ( Poskiparta et al., 20 0 1 ) Finland

Health counselling sessions

CA N-P: 38 A V S + P G + B M + Nod + M G + Sm Guidebooks N urses alte rnat e betwe en patient-centr ed and nurse-centr ed communicati ve str ate gies. Such communicativ e str ate gies depend on nurses ’ g oals in their inte ractions with patients. 3 The social construction of risk in nurses and psy chiatric patients ’ relati v e s inter action ( A dams, 20 0 1 b ) UK Domiciliary meetings CA; D A N-P: 2 4 A S There ar e four stages in the social construction of risk during consultations: i) ﬁ shing stage; ii) identi ﬁ cation stage ; iii) risk assessment stage ; and iv ) risk manag ement stage manage . 3 N urse-par ent inter actions about child immunization ( Plumridg e et al., 20 08 ) Ne w Zealand Primary car e pr actices CA N-R -P: 1 0 A V S + P B M Par ents accep t and v alue nurses ’ medical kno w ledge and institutional role but often den y nurses an y know ledg e about their child. 3 Organization of the inter action betw een patients ’ relati v e s and health car e w or kers with regar ds to shar ed information ( Ma y e t al., 20 0 1 ) England R ehabilitation CA, EMG H-R: 30 A V S + P G + N od + B M + Point Pa tients' not es Ev en though health car e w orke rs remain in contro l o f the inte ractions, relati ve s can pr esent themselv es in a w a y that minimizes know ledg e asymmetry in inte ra ction. 3 Questions and advice in health counselling sessions. ( Poskiparta et al., 20 0 0 ) Finland

CA N-P: 38 gro ups A V S + P G + N od + B M + MG Patie nt participation is enhanced b y recipr ocal counselling (e.g., recourse to futur e orient ed and feeling orient ed q uestions by nurses, and advice seeking q uestions by patients). N on-re ciproc al counselling (e.g., the nurses pr o vides standard ized information) reduces patient participation. Health counselling sessions ar e g ener ally char act erized by bot h re ciproc al and non-r ecipr ocal counselling. 3 Empo werin g communication in health counselling sessions ( K ettunen et al., 20 03 ) Finland

CA N-P: 38 gro ups A V S + P G + N od + L Documents Patie nt participation is facilitate d b y nurses ’ use of affecti v e q uestions, tentati ve speech and continuers. 4 Chr onic self-car e manag ement ( Carr et al., 20 1 4 ) UK & A ustra lia Primary car e EMG (3 focus gro ups: 1 0-1 5 participants each, 2 1 nurses in to tal; 36 inte rview s: including 5 nurses) FG, I S In fl uence of client-centr ed models of car e. Identi fi cation of facilitating facto rs and obstacles to self-manage ment. 4 M o ti v ational inte rvie w for smoking cessation ( Codern-Bo vé et al., 20 1 4 ) Spain Primary health car e CA, CoA H-P: 11 A V S Identi fi cation of str at egies that can impr o v e patient engage ment with smoking cessation. Most int ervie w s didn't follow guidelines. 4 Finland CA N-P: 38 A V S + P G 5

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Po w e r asymmetry in health counselling sessions ( K ettunen et al., 20 02b )

Health counselling practice

Po w e r is acti ve ly neg o tiat ed in nurse-patient inte ra ctions. N urses sho w their e xpertise while patients make use of their rights to int errup t, re q uest clari fi cations, etc. 4 Int er actional w ork during g oal setting ( Barnar d e t al., 20 1 0 ) England N eur ological rehabilitation CA H-P: 6 A V S + P G + BM Documents Patie nts do not ha v e much in fl uence in goal setting. N urses deploy much int er actional effort in ord er to sho w that the pr oposed course of action is non debatable. 4 N eg o tiation in lifetime counselling ( Karhil a e t al., 20 03 ) Finland Primary health car e CA N-P: 7 3 A V S + P + L G + B M + Nod + S m Documents N urses w ork with the patient to identify ar eas of life that can be impr o v ed. Most of the neg o tiation pr ocess is contro lled b y nurses. 4 Int er actions betw een psy chiatric nurses and patients at their home ( Bow ers, 1 992b ) England Home visits EMG N/A A S Patie nts ar e in inter actional contro l when the inte ra ctions take place at their home, e x cept for clearl y medical matt ers. 5 Manag ement of op timism in cancer car e ( Jarr ett and Pa yne, 20 0 0 ) UK Radio thera p y and/or chemo therap y EMG N-P: 9(26 inte rview s with patients, 22 inte rview s with nurses, 2 interv iew s with relati ve s) A S There is an int erplay of nurses' and patients' contributions. N urses rely upon inte ra ctional str ategies to render bad ne w s less thr eate ning. 5 F re q uency of humour and its use (Mallett & A ’hern, 1 996) UK Haemodial y sis CA, EMG N-P: 1 2 6 A V S + P + L G + N o d + BM + S m Par ticipants use humour to accomplish inte ractional g oals. Humour is collabor ati ve ly construct ed. Use of humour by participants does not v ary acr oss occasions. 6 Int er action with communication disability ( Gor don et al., 20 09 ) UK S troke _{rehabilitation} CA N-P: 5 A V + FN S + P G + B M + T o N urses focus con v ersation on nursing tasks when con v ersing with patients with communication disability . The int er action is highly asymmetrical (contro lled b y nurses). 6 Int er actions with older people and their aut onom y ( McCormac k, 20 0 1 ) UK Primary car e C A N-P: 1 4 A S + P + L N urses pla y a piv o tal role in their assessment of patients ’ needs and the w a y the y p resent patients with alte rnati ve s that fi t their limitations. 6 Int er actions with patients in palliati v e car e ( Li and Arber , 20 06 ) UK Pa lliativ e care CA, D A 8 team

meetings, shift hando

ve rs A + FN N urses addres s re q uests of ‘lucid' patients more readily . The y try to display positiv e emo tions in an y circ umstance, as w a y s to achieve inte ra ctional g oals. 6 A ccompan ying and relating to patients in end-of life car e ( Har aldsdo ttir , 2 0 11 ) Sco tland In-patient w a rd EMG (ﬁ eldw or k only) FN N urses lac k emo tional a v ailability to list en to end-of-life patients. They accompan y the patients b y pr o viding high q uality car e and an en viro nment as comfortable as possible. 6 Int er actions with post-aneasthetic patients ( Mallett, 1 990 ) England R eco ve ry unit CA N-P: 1 3 A V S + P + So G + BM N urses det ermine patients' lev el of consciousness fr om how the y react to summons and re q uests. They adap t their inter actional efforts to this assessment. 6 Maintaining the social or der in palliati v e car e ( K ell y , 1 998 ) England Pa lliativ e care CA, EMG N/A A S When patients ar e unr esponsiv e, the inte ra ctional ord er can still be maintained thr ough con v ersations that mimic the usual con v ersational rout ines. N o te : 1 = Organization of nurse-patient inte ract ion, 2 = Organization of mediat ed nurse-patient int er action, 3 = Information, e xplanation and advi ce, 4 = N ego tiation and in ﬂ uence asymmetry ,5 = Managing emo tions in critical illness, 6 = Inte ract ing with patients with red uced inte ract ional compete nces. CA: Con v ersation anal y sis; CoA: Cont ent anal y sis; D A : Discourse anal y sis; E GR: Ethnogr aph y ; EMG: Ethnomethodology ; T A: Thematic anal y sis; N-P: N urse-Pat ient, N-R: N urse-R elati v e ; N-R -P: N urse-R elativ e-P atient ; Ph-P: Ph y sician-Pa tient; H-P: Health pro fessionals-Pat ient ; A = A udio, A V = A udio -video, FG = Focu s g roup (audio); FN = Field no tes, AD = Assessment documents, I= Inte rview (audio). S = Speech, P = Pr osody . W r = W riting, L = Laught er , Typ = Typing, So = Sobbing. G = Gaze, N o d = N odding, BM = Body mov ement, Fe = Facial e xpr ession, MG = manual g esture , S m = Smile, T o u = T ouching.

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Wealsoperformedaliteraturesearchofallarticlesavailable through our university library network (explore.rero.ch). The searchplatformdoesnotallowsearchingspeciﬁcallyinabstracts: - nurs*inkeywordsand“conversationanalysis”inallﬁelds(61

recordsfound)

- nurs* in keywords and ethnomethodology in all ﬁelds (28 recordsfound)

Intotal,115uniquerecordswereidentiﬁed.Fromthereadingof thetitlesand/orabstracts,weexcludedrecordsthatwerenotin English (e.g.Korean,Portuguese,12records),werenot theﬁrst reportofempiricalstudies(e.g.,literaturereviews,editorials,study protocols, 20 records), did not focus on interactions including nurses(18records),didnotdrawonthemethodsof ethnometh-odologyandconversationanalysis(10records),orwerenotbased ondataaboutnursesclinicalactivitiesordidnotoccurinclinical settings(8records).

Forty-six records remained.Three records wereclassiﬁedas Nurse-to-physicianinteraction,andfourasNurse-to-nurse inter-actions. The remaining two were classiﬁed as “Other”. These recordswereexcluded.

ThirtyrecordswereclassiﬁedasNurse-to-patientinteractions, whetherornottheinteractionsalsoincludedathirdparty.Seven recordswereclassiﬁedasNurse-to-relativeinteractions.

2.1.2.Referencelists

Relevantstudiesmighthavebeenpublishedinjournalsthatare not indexed in theelectronic databaseswe used. Wetherefore examinedthereferencelistsofpapersweidentiﬁed.Astheobjects ofthisstudyarenurse-patientandnurse-relativeinteractions,we chose to search through the publications reporting on these interactions only.Wecollatedthereferencelistsof therelevant publications. Abstractsof journalarticlesfromtheresultinglist that werenot indexedinMedline werecollected. Wesearched through thetitlesand abstractsof thesepublications usingthe same keywordsas above. Two additional relevant publications werefound.

2.1.3.Citingpapers

Thesearchthroughreferencelistscannot,obviously,informon studies published after the papers we found. Therefore, we collected the references of the publications that cited the publications identiﬁedthrough electronicdatabasesin orderto identifypotentialadditionalstudies.Abstractsofjournalarticles from the resultinglist that werenot indexed in Medlinewere collected.Afterasearchthroughthetitlesandabstractsofthese publications (same keywords as above), one more relevant publicationwasfound.

2.1.4.Thematicanalysis

Weperformedathematicanalysisoftheincludedstudiesboth deductivelyandinductively(seeVaismoradietal.,2013).Wepaid particular attention to three potential themes of which the importancewasstressedintheliteratureonnurse-patient relation-ships (e.g., Fleischer et al.,2009), as we mentioned above:the importance of patient participation in clinical situations, the importance ofnurse’s displayof empathyandthepromotion of patients’ competences. As conversation analysis is primarily interestedinthe(re)productionofsocialorderatthelevelofthe interaction,itisaprivilegedmethodforinvestigatingthesethree potentialthemes(ofwhichonlytheﬁrstisthoroughlydiscussedin the literature, as we will see). We also expected mediated communication tobeanimportantthemeinthese publications, frompreviousresearchwecarriedoutinclinicalsettings,andother settings aswell (e.g., Bangerter et al.,2011; Bietti and

Galiana-Castelló,2013;Biettiet al.,2016;Mayor etal.,2012;Mayorand Bangerter,2015,2016).Wedecidednottofocusonlyontheseaspects inpreparingthisreviewasthecomplementarityofdeductiveand inductiveapproachesleads toanenrichmentoftheunderstanding of thestudiedobject(e.g.,Vaismoradietal.,2013).Inotherwords,we wereopentoemergingthemes.

Weconductedthethematicanalysisasdescribedbelow: a) We prepared summaries of each publication. These are

provided as Supplementary material,and a reduced version ofthesummariesispresentedinTable1.

b) Wemadeannotationsofthesesummaries.

c) We classiﬁed the summaries into thematic categories. This processwascarriedoutiterativelyuntilweweresatisﬁedwith thethematiccategorization.

d) We wrote a synthetic review for each category (see results section) along with a synthetic review of the ﬁeld (see the discussion).

2.1.5.Codingofthestudies

Wewereadditionallyinterestedindescribingandcommenting uponvariouscharacteristicsofthestudies(seethelimitations sub-sectioninthediscussion).WetooknoteofthefollowinginTable1 (alsoseeourcommentsinthediscussionsection):

thethematiccategoryappliedtothestudy thetopicandtheauthors

theyearofpublication thecountryofdatacollection thesettingofdatacollection themethodologicalfoundations

thesamplesize(numberofinteractions) thetypeofdata

thereportedlinguisticresources thereportednon-linguisticresources thereportedtoolsusedbyparticipants themainﬁndings

3. Results

Thethematiccategoriesofthepapersthatresultedfromour analysis were: 1- Organization of nurse-patient interaction; 2-Organizationofmediatednurse-patientinteraction;3- Informa-tion, explanation and advice; 4- Negotiation and inﬂuence asymmetry;5-Managingemotionsincriticalillness,6-Interacting withpatientspresentingreducedinteractionalcompetences.The thematic category membership of each paper is provided on Table1.Foreachofthethematiccategories,weprovideasynthesis of the _ﬁndings below, as well as summaries of each study as Supplementarymaterial,aspartoftheresults.TheSupplementary materials alsocontain a particularly illustrating data exemplar reproducedfromoneofthepublicationineachthematiccategory. The dataexemplar is commentedin a wayvery similarto the analysisperformedbytheauthorswhenreportingonthestudy. We standardized thetranscription conventionsfor the readers’ comfort.

3.1.Organizationofnurse-patientinteraction

Eleven papers were categorized as discussing the general organization(e.g.,turn-taking,topicsdiscussed,andphasesofthe interaction)ofnurse-patientornurse-relativeinteraction.These studies particularly dealt with nurse-patient interactions. They includedanalyses ofdatatakenfrompatientadmissions(Jones, 7

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2007)anddischarge(Rivaetal.,2014),check-ups(Edwalletal., 2009),childimmunizations(Plumridgeetal.,2009),andchronic obstructive pulmonary disease consultations (Chatwin et al., 2014).Despitethewiderangeofsituationsexamined,theresults reportedinthesestudieshighlighttheimportanceandbeneﬁtsof patientparticipationinnurse-patientinteractions(Adams,2001a) andtheimplicationsofthefrequentlackthereof(Chatwin,2008; Jones,2007).Interactionsbetweennursesandpatientsareoften bureaucratic,atoddswithrecommendationsforincreasedpatient participation(Jones,2007).Butthestructureoftheconsultation can increase patient participation and understanding of their conditions(Chatwinetal.,2014;Edwalletal.,2009),andthatof theirrelatives (Plumridge et al., 2009). Embracing a reciprocal interactionstyle leadsto increasedparticipation of patients in consultations(e.g. Rivaet al., 2014).Buttheinitialbehavior of patients is also related to their further participation and the progression of the encounter (Chatwin, 2008; Kettunen et al., 2001).Whennursesparticipateinconversationsoutsideaclinical setting(e.g.atthehomesofrelativesofpsychiatricpatients)their controlovertheinteractionsislimitedtoclinicaltopicsonly,and conversationaltopicsnotstrictlyrelatedtothehealthcarecreate theconditionsforthestrengtheningofsocialbondsbetweenthe interactingpartners(Adams,2001a).Niedeletal.(2013)showthat thedevelopmentofparents’understandingoftheillness(diabetes) oftheirchildisvisibleintheorganizationoftheirinteractionswith nurses.Announcing (imminent) deathtopatients and relatives requiresmuchinterpersonaleffort,deployedtoalleviatesuffering oftheconversationalpartner(Wilainuch,2013).Thesesituations focusmoreontherecipients’feelingsandlessonclinicalmatters. Hence, conversational contexts may affect the interactional instantiationofpre-existingsocialroles.

3.2.Organizationofmediatednurse-patientinteraction

Sevenpaperswereclassifiedasdiscussingtheorganizationof mediated (through documents, computer tools, or interpreters) nurse-patientornurse-relativeinteractions.Researchonmediated casesofnurse-patientinteractionshowstherolethatotherpeople (e.g.interpreters)andtoolsplayincommunicationbetweennurses andpatients.Thetopicscoveredbythearticlesrangedfrom phone-mediatedinteractions(Butleretal.,2009;Leydonetal.,2013),and theroleof interpreters(Estradaet al.,2015), totheinfluenceof medical records (Rhodes et al., 2008) and computer-assisted technologies(Murdochetal.,2015)innurse-patient interaction. Thesestudiessuggestthattechnologicalmediationhindersrather thanfacilitatesnurse-patientinteraction.Forexample,Leydonetal. (2013) show that missing elements in the opening of phone-mediatedinteractions have interpersonal consequences (Leydon et al., 2013). Nurses’ use of documents to structure their consultationscanreducepatientparticipation(Jones,2009;Rhodes etal.,2008).Rhodesetal.(2006)haveshownthatthenurses_’useof computercheck-listsandelectronicmedicalrecordssignificantly limitsthepossibilitiesforpatients’interactionalinvolvementinthe encounters. Computer-assisted triage creates a conversational organization that increases misalignment between participants (Rhodes et al.,2006). Eventhough phone-mediated conversation can beanopportunityfornurses’displayingofexpertise,thiscanreduce patient participant (Butler et al., 2009). In translator-mediated communication, Estrada et al. (2015) show that patients can misconstruebreaksinthetranslators’speechasturncompletion points,whichaffectstheunfoldingoftheinteraction.

3.3.Information,explanationandadvice

Eightpaperswereclassiﬁedasdiscussingtherequest,reception and provision of information, explanations and advice. The

organizationof nurse-patientornurse-relative interactions(see above)hasaneffectonhow informationis communicated,and howthenursesgiveexplanationsandadviceinclinicalsettings. Researchonphysiciansandnurses’explanationshasshownthat thesegroupsemploydifferentcommunicationstrategiestowards patients(Collins,2005).Inbothcases,communicationstrategies provetobeusefulandcomplementarywhengivingexplanations inconsultations.Examiningnurses’communicationstrategiesas they were giving advice to patients, Poskiparta et al. (2001) reported that the choice of strategies depends on the nurses’ interactionalgoals.However,patientsalsohaveanactiverole:for instance, they choose speciﬁc types of questions (what about questions) to efﬁciently elicit information from nurses (Fasulo et al., 2016). Reciprocal (vs non-reciprocal) interaction styles promotepatientparticipationinhealthcounselingsessions,i.e., rigidly following a procedure reduces patients_’ participation (Poskipartaetal.,2000;Kettunenet al.,2003).Withregardsto nurse-relativeinteractions,studieshaveshowntheactiveroleof relativesinriskassessments(Adams,2001b).Patientrelativesare reticent accepting nurses’ contributions on non-medical issues (Plumridgeetal.,2008).Asaresult,relativesseemtochallenge nurses’ institutional role when it is not restricted to giving information, explanations or advice based on their medical knowledge(Mayetal.,2001).

3.4.Negotiationandinﬂuenceasymmetry

Eight papers were classified as discussing negotiation and influenceasymmetry innurse-patient interactions. Researchon interactionsbetweennursesandpatientshasshownthatnurses havealeading rolewhensetting goalsinconsultationsand are seekingtomaketheirguidanceandplannedcourseofaction non-debatable(Barnardetal.,2010).Institutionalrolesandexpertise organize powerrelationshipsastheseareacknowledged by co-participants,i.e.,thecontrolovertheinteractionismostlyexerted bynurses(Karhilaetal.,2003).Butstill,patientsoftenparticipate tointerrupt,askquestionsandrequestforclarifications(Kettunen et al.,2002b).Patient participationis higher whennurses “use reiterations, declarations, and open-ended questions” ( Codern-Bovéetal.,2014,p.1).Interestingly,wheninteractionstakeplace outsidetheclinicalsettings(e.g.patients’homes),thepatientsand notthenursesareinchargeoftheinteractionalmanagement,with the exception of situations that require specialized medical knowledge (Bowers, 1992b). In cases in which strategies for patients’ self-management of chronic care are discussed, the nurses’ reliance upon rigid models of care (e.g., asymmetrical relations)isdetrimentalifthepatientsaretotakeonamoreactive roleintheirowncare(Carretal.,2014).

3.5.Managingemotionsincriticalillness

Twopapers wereclassiﬁedasdiscussingthemanagementof emotionsincriticalillness.Nursescraftcommunicativestrategies toconveycancerdiagnosistopatients ina less life-threatening fashion(JarrettandPayne,2000).Indoingso,nurses’expertise plays an important role in mitigating the patient’s pessimism about the future and the need for cancer care. Besides the management of expectations and optimism, the interactional moodbetweennursesandpatientshasalsobeenasubjectofstudy. Inastudyonmoodininteractionsbetweennursesandpatients withrenal failure on haemodialysis,Mallett and A’hern (1996) showedthatthesituationalatmosphereisjointlyand collabora-tivelyconstructedbynursesandpatientsininteractioninrelation totheinteractionalgoals(e.g.,themanagementofthepatients’ anxiety).

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3.6.Interactingwithpatientspresentingreducedinteractional competences

Six papers were classiﬁed as discussing interactions with patientswhoseinteractionalcompetencesarereduced, temporar-ily orpermanently.Patients’reduced interactionalcompetences shapetheirinteractionswithnurses,astheyincreaseinteractional asymmetry (e.g., Gordon et al., 2009). How nurses assess the interactionalcompetencesofpatientsdeterminestheinteractional effortstheydeployintheinteraction.Someoftheseassessments relyonnurses’perceptionsofpatients’reactionstosummonsand requests (Mallett, 1990).Even whenpatients are unresponsive, nursesmanagetosustainthesocialorderonthewardbytalkingto the patients and discussing withothercaregivers (Kelly,1998). Reducedinteractionalcompetencesdonotmeanthatpatientsare completely dependent. McCormack (2001) shows that through theirstay,patientsandnursesmanagetocollaborativelyfocuson both,theweaknessesofthepatientswheretheyrequirehelp(e.g., communicatingandresponding),butalsotheirstrengths,where they can be autonomous. Yet, patients’ reduced interactional competencescanaffectcordialityintheinteractions.Eventhough nursesstillprovidehighqualitycaretoterminallyillpatients,their communicativeefforts and emotionalavailabilitytowards them candiminishconsiderably(Haraldsdottir,2011).Nursesarealso less personally engaged in their communication with disabled strokepatients(Gordonetal.,2009).Dyingpatientsarealsoless cordialintheirinteractionswithnurses.Butthisdoesnotseemto be treated as a social transgression by the nurses, due tothe patients’healthconditions(LiandArber,2006).

4. Discussion

We furtherdiscuss theliterature by providingan additional synthesisthroughthelensofFleischerandcolleagues’criteriaand thereby confront the reality of nursing to these expectations. Fleischerandcolleagueshavesetcriteriafortheopportunitiesthat nurse-patient interactions shouldafford(Fleischeret al.,2009). Thesecriteriaincluded:i)opportunitiesforpatientparticipation; ii) nurses’ display of empathy; and iii) promotion of patients’ competences. In thenext sub-section, wewillfocus onpatient participation, and will only brieﬂy discuss nurses’ display of empathyandpromotionofpatients’competences,asthesehave not been much studied yet in the literature on nurse-patient interactions relying on ethnomethodology and conversation analysis.

4.1.Patientparticipation

Atoddswiththeidealofincreasedpatientparticipation,the heavy workload of nurses, notably, can lead to bureaucratic interactions, (Jones, 2007), even when guidelines meant to increase patient participation are in place (Codern-Bové et al., 2014). There is a distribution of labor where most topics are initiatedbynurses,andanswersareprovidedbypatients(Jones, 2007;Leydonetal.,2013).Thisdoesnotmeanthatpatientsarenot activeintheinteractions,butthattheircontributionsaremainly elicited by the nurses, and fulﬁll the instrumental needs of a procedure in which nurses are in power (Edwall et al., 2009). Nursesmightvoluntarilyrestrictpatientparticipationasameans torendergoalsnondebatable(Barnardetal.,2010).

Reciprocalinteractionstylescanpromotepatientparticipation (Poskipartaetal.,2000;Kettunenetal.,2003;Rivaetal.,2014),but other interactional circumstances (participation frames) can inhibit deviation from a division of labor in which nurses are dominant(Kettunenetal.,2001,2002b).Externalresourcestendto interfere with the interactions and to lead to interactional

misalignment(Jones,2009; Murdochetal.,2015;Rhodesetal., 2006).Further,the alternationfrom less tomoreasymmetrical interactionsbetweennursesandpatientsisdeterminedbynurses ‘goals’(Poskipartaetal.,2001), asnursesadoptpatient-centred andnurse-centredcommunicativestrategiesdependingonthese goals(Poskipartaetal.,2001).

The structuring role of nurses is even more visible in their interactionswithpatientswithdecreasedinteractionalabilities. Nurse-centeredcommunicative strategies are more frequent in interactionswithpatientswithreducedautonomy(Gordonetal., 2009),patientsinpalliativecare(Kelly,1998;LiandArber,2006) andpost-anestheticpatients(Mallett,1990).

Despite the fact that nurses are vastly in control of their interactionswithpatients,powercanbeinteractionallynegotiated tosomeextent (e.g.Kettunen etal., 2002b).Verbal and bodily conversational devices can increase patients_’ participation. For instance, patients rely on ‘what about’ questions to request clariﬁcations(Fasulo et al., 2016), and nurses’ changes in gaze directiontowardsthemcanbetreatedbypatientsasopportunities toinitiatenewtopics(Rhodesetal.,2008).

The physical context of nurse-patient encounters plays an importantroleinreinforcingortransformingtheabovedescribed conversational asymmetries. When nurse-patient interactions occuratthepatients’homes,patientsareininteractionalcontrol with the exception of highly speciﬁc medical matters (e.g. Bowers, 1992b). Not only the setting where nurse-beneﬁciary interactionsoccurshapesinteractionstylesandpowerrelations, theidentityandrolesoftheinteractingpartnersarealsocrucial. Relatives can present themselves in a way that minimizes knowledge asymmetry in interaction(Butler et al., 2009; May etal.,2001;Plumridgeetal.,2009).Althoughpatients’relatives acknowledgenurses’medicalexpertisetheyoftendenynursesany othergeneralknowledgeabouttheirrelatives(Plumridgeetal., 2008).

Higherpatientparticipationisconsequentialasitleadstothe promotionoftheircompetences(Kettunenetal.,2002b),andtheir betterunderstandingoftheirdisease(Edwalletal.,2009),whereas low patient participation delays the identiﬁcation of pertinent information(Chatwin,2008;Jones,2009).Horizontalinteractional styles between nurses and patients’ relatives facilitate the collaborativeidentiﬁcationofriskinpsychiatricpatients(Adams, 2001b), and parents’ progressiveunderstandingof their child’s diabetessymptoms(Adams,2001a).

4.2.Nurses’empathy

Nurses display empathy through verbal and non-verbal communication(Poskipartaetal.,2001).Thishappenswhenthey initiatediscussionsaboutdeathtoinformandprovideemotional support (Wilainuch, 2013), when they use humor to reduce patients_’anxiety(MallettandA_’hern,1996)andfosteroptimismin cancerpatients(JarrettandPayne,2000).Nursesreadilydisplay empathyatthepatients’home(Adams,2001b).Buttheycanalso displayalackofemotionalavailabilitytowardspatient_’srequests inpalliativecare(Haraldsdottir,2011).

4.3.Thepromotionofpatients’competences

Theissueofthepromotionofpatients’competenceswasmostly discussedinstudiesconductedinthesettingofhealthcounselling and self-management groups (Poskiparta et al., 2000, 2001; Kettunenetal.,2002b,2003),butofcourseempoweringpatients isimportantinallencounterswithcaregivers(Lashingermetal., 2010).Several authorssuggested that patientparticipation is a prerequisitetothepromotionofpatients’competences.

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4.4.Limitations

Thisreviewhashighlightedseverallimitations,some method-ological,othersrelativetothescopeofthestudiesconsideredasa corpus(geographicalscope, disciplinaryscope, limited objects). Thesearediscussedbelow.

4.4.1.Limiteduseofmultimodalanalyses

Onlyabouthalfofthereviewedarticlesincludedatranscription ofnon-verbalresources(e.g.gaze,bodymovementsandnodding). Onlyaquarterexaminedtheuseofexternalresources(e.g.clinical records). Of thestudies featuring multimodal transcripts, most have not conducted actual multimodal analyses, where the interplayof speechand bodilyconduct is analyzed. Relying on multimodalanalyses couldbeneﬁt theunderstandingof nurse-patient interactions as much as it did for physician-patient interactions(e.g.,Heath,1986).

4.4.2.Limiteddiversityofsettings

Thesetting of data collectionwas mostly primary care.The limiteddiversityofsettingsrenderscomparisonsofinteractions across settings difﬁcult. We attempted to discuss interactional differences between primary care patients and other types of patients,butwereconfrontedwiththeproblemthatintheﬁrst caseweencounteredavarietyofstudies,whereasintheotheronly afew.

4.4.3.Limiteddiversityofregions

Twothirdsofthereviewedstudiesreliedupondatacollectedin theUK,andmostoftherestoriginatedinFinland.Thislimitation doesnotallowstudyingwhetherthereareuniversalpatternsin nurse-patientcommunication,orifthereexistculturaldifferences inthesepatterns.

4.4.4.Limitednumberofinteractionsanalyzed

The median number of interactions studiedwas 25. This is hardlyenoughtoproposerulesofinteractionsasSchegloff(1979) didforphoneinteractions,relyingonthescrutinyof500cases.Yet, therepetitionofﬁndingsacrossdifferentstudiesgivesconﬁdence intheiraccuracy.

4.4.5.Thelackofstudyofotherimportantinteractionalaspects Neither nurses’ display of empathy nor the promotion of patients’ competences were much discussed in the studies reviewed here. The lack of studies on these essential aspects (Fleischeretal.,2009)mightstemfromtheperceptionofalesser importanceamongresearchers,orfromtheinﬂuenceofcritical discourse analysis – which focuses on power relations – in qualitativenursingresearchonnurse-patientrelationships( Tray-nor,2006).Thisisdiscussedbelow.

4.5.Theimportanceofcriticaldiscourseanalysis

Criticaldiscourseanalysis focusesontheinvestigationofthe ways in which social-power, dominance and inequality are practiced, reproduced, and sometimes resisted through the inspectionofseveralformsofcommunicationinrelationtosocial andpoliticalcontexts(vanDijk,2015).Criticaldiscourseanalysisis notaparticularmethodbutratheracriticalattitudetowardsthe useofdiscourse practices tomaintainthestatus quoin power relationships.Thus, critical discourseanalysis integratesstudies from different perspectives and methods in discourse studies, includingconversationanalysis,argumentationanalysis,discourse pragmatics,multimodaldiscourseanalysis,sociolinguistics,social semiotics,amongseveralothers(seevanDijk,2015;forageneral review;andTraynor,2006forareviewofnursingstudies).Critical

discourse analysis has provided a vast repertoire of studies focusing on the relationship of nurses with patients (Traynor, 2006).Thesearenotboundtothestudyofrecordednurse-patient interactionsasinconversationanalysis.Forinstance,Horsfalland Cleary (2000) examined a policy for constant observation of patients in psychiatric wards and showed how this document reproducesasymmetricalpowerrelationshipsbetweencaregivers and patients. Wilson(2001)analyzed interviewswithpediatric nursesandfoundthatsomeformsoffriendlysocialinteractions can beconstrued asdisguised surveillancepractices. Heartﬁeld (1996)analyzednursingdocumentation.Sheshowsthatnursing documentationdehumanizespatientsasitframesthemasobjects composedofbodyparts.Accordingtoherwork,althoughthemain goalofnursingisobviouslycuringpatients’ailments,itisalsoused to reproduce power relationships through interactions and procedures.Thistypeofresearchiscomplementarytowhathas beendiscussedhere.

4.6.Implicationsforpractice

Thisreviewshowsthatalthoughnurse-patientinteractionsare oftencharacterizedbyaninteractionalasymmetry,thereisroom forpatientparticipation.Theothermaincrucialaspectsmentioned by Fleischer et al. (2009) are not sufﬁciently studied in this literaturetobefurthercommentedupon.

Someofthereviewedstudieshavehighlightedconditionsthat foster or inhibit patient participation. Several types of nurse-patient interactions share a tendency for control by nurses (whereasthisisnotthecaseatpatients’home).Butthiscontrol might bestronger inmediated interactions.Patienttriageis an exampleofsuchinteractionsinwhichcomputer-mediationbrings contingencieswhichenhancenursescontrol thisalsoappliesto admissions and related interactions. Murdoch et al. (2015) has documentedhownursesstrictlyfollowtheitemsontheirscreen whentriagingpatients,andhowthisstructurestheirconversation, at theexpenseof patient participation– sometimesleading to misunderstandingsasaconsequence.Theredesignof computer-assisted technologycanbea straightforwardwaytosolve such issues. Such redesigns should fulﬁl conversational and clinical needs– notablyby takingintoaccount studiesin conversation analysis or other observational studies of clinical interactions (Coiera,2000).Redesignsareobviouslycostlyandmaynotbea mainconcernforadministrators.Therefore,anotherwaycouldbe forthenursestoﬁrstencouragethepatientstofullyexplaintheir ailments,andthentorelyonthetoolforprocessing.Theywould therebyavoidthereasonforthepatient’svisitbeingdelayedfora longtime(seeExcerpt2intheSupplementarymaterialswherethe reasonforadmissionisdiscussedafter12minutes,becauseofthe rigiduseofastandardizeddocument,fromJones,2009).Wedonot mean that no pre-established structure is better. Indeed, the outcomeof interactionscanbepositivelyaffectedbytheinitial structureofconversation(Chatwin,2008;Leydonetal.,2013).Our point is thatthe structureof conversation shouldbedriven by interactionalimperatives.Someguidelinesfor structuring inter-actionshavebeenproposed.Leydonetal.(2013)havefocusedon theimportanceofopeningsofinteractionsinoptimizingfurther interactionalwork.Poskiparta et al.(2000) and Kettunenetal. (2003)havediscussedtheroleofreciprocalinteractionalstylesin increasing patient participation. Poskiparta et al. (2001) have shownthatverbalandbodilymanifestationsofunderstandingand interestpromotepatientparticipation.

4.7.Furtherstudies

Futurestudieswouldneedtofurtherexamineandsystematize the communication strategies used by nurses and patients in

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relationtotheirinteractionalgoals, andmaterialenvironments. Having a systematic and comprehensive understandingof how nurses and patients interact will create the conditions for promoting interventions in existing forms of communication and interaction to improve parents’ care and well-being. In addition,acomprehensiveunderstandingofnurse-patient inter-actions in mostfrequent communicative situations (e.g. phone consultations; face-to-face interactions in clinical facilities and patients’homes;andcomputer-assistedconsultationseither face-to-faceoroverthephone)mayhelpcreatemoresolidtheoretical, methodological and practical grounds to assess the costs and benefits of new hybrid modes of consultations (e.g. virtual consultationsoverSkypeand/orothervideo-supportedelectronic media)andcontributetoamoreeffectiveregulationofsuchnovel practices(Greenhalghetal.,2016).Suchanunderstandingcanbe betteraccomplished byexamining indepththeweb of mutual dependenciesbetweenbehavioralmodalitiesincommunication. Collectionsincludingasufficientnumberofinteractionsshouldbe systematicallyanalyzed,contrarytowhathasbeendoneinsome studies so far (half of the ones we reviewed relied on 25 interactionsorless).Theliteraturewouldalsobenefitfromstudies in more countries. This would permit identifying cultural variationsontheone hand,andthediffusionofgood practices ontheother.

Havingabetterinsightintointeractionalpracticesastheyoccur inreal-timeiscrucialtodesigningprotocolsaimedatimproving communicationstrategiesbetweennurses,patientsandrelatives (Poskipartaetal.,2001).Studyinginteractionalpracticesinclinical settings might be of even greater importance as computer-mediated interactions are becoming a standard practice. The interactional impact of human-machine interfaces needs tobe assessed,astepthatisoftenforgottenduringtheimplementation ofinformationtechnologyinhospitals(Coiera,2000).

5. Conclusion

Higherpatientparticipationresultsinbetterclinicaloutcomes (Chatwin,2008;Chatwinetal.,2014;Elwynetal.,2000).Italso strengthenssocialbondsandpromotestrustbetweennursesand beneﬁciariesofcare(Adams,2001a;Rivaetal.,2014).Thisreview hasshownthatnursingresearchersrelyingonethnomethodology andconversationanalysishavestudiedthedeterminantsandthe consequencesofpatientparticipation,andthelackthereofacross several types of nurse-patient encounters. Maybe the most importantandrecurrentﬁndingintheliteratureisthat,despite repeated calls for heightenedpatientparticipation,nursesstill exertcontrolovermostoftheprogressoftheinteraction,including topicsetting.Recommendationshavebeenprovided.

Fleischeretal.(2009)havereportedthatotheraspects,suchas nurses’ display of empathy and the promotion of patients’ competence are very important in nurse-patient interactions, butthesehavenotbeenstudiedthoroughlyinstudiesrelyingon ethnomethodologyandconversationanalysis.

Conversation analysis and ethnomethodology have already showntheirpotentialfortheunderstandingandimprovementof nurse-patient interactions,openingupinterestingopportunities forfurtherresearch.

Conﬂictofinterest Noconﬂictofinterest. Funding

None.

Ethicalapproval None.

AppendixA.Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in the online version, at http://dx.doi.org/10.1016/j. ijnurstu.2017.01.015.

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