appointment in an outpatient clinic or general practice setting. Such consultations are the most common healthcare encounter and there is evidence that their frequency is increasing on a yearly basis (HSCIC 2008, HSCIC 2013, NHS England 2013). Such characteristics thus enabled observation and understanding of the ways in which patients’ use of medicines was commonly managed in the health care setting.
The majority of patients were attending for a routine review appointment although the frequency of the appointments varied according to the condition experienced by the patients. Patients with diabetes and COPD were therefore attending for an annual review appointment whilst those with bronchiectasis and cancer were routinely reviewed on a three-monthly basis. Patients with renal disease were similarly reviewed in the out-patient clinic every three months although they were also seen by the nurse prescriber on a weekly basis when attending for dialysis. Three patients experiencing COPD were seen due to a referral by their general practitioner for consideration of their suitability for pulmonary rehabilitation or
Nurse prescriber
Sex Specialist area Length of experience in speciality
Length of experience as a prescriber Wendy Female Respiratory
conditions
Over 15 years 6 years
Yvonne Female Diabetes Over 15 years 3 years Angela Female Diabetes Over 15 years 5 years Becky Female Renal conditions 12 years 7 years Claire Female Bronchiectasis Over 15 years 5 years
Dawn Female Oncology Over 15 years 5 years
Edward Male Respiratory conditions
improved symptom control. Further examination of the nature of patients’ consultations is provided in section 5.1.
The role sought within the consultations was initially one of ‘complete observer’ to minimise any impact on the actual interaction (Gold 1958). Thus a position was taken in the room which allowed full observation of the encounter but which was not in the line of sight of either the prescriber or patient. No part was taken in the consultation unless engaged in social conversation by either party. As the consultations progressed however the challenges involved in such a simple classification of observer roles became apparent (Coffey 1999). Certain patients, for example, wished to explain their symptoms further or would seek the involvement of everyone in the room in humorous banter that was a feature of some interactions. A small number of prescribers also took the opportunity to explain the significance of certain aspects of the patient’s condition or their treatments. In such situations it was necessary to respond to patients and prescribers to respect social conventions and to foster rapport with participants. Sensitivity to the needs of the prescriber to continue with the consultation was however maintained and any instances of more direct participation was recorded in field notes to enable a reflexive approach when considering their impact on the nature of the encounter (Allen 2010, Mason 2006).
The whole encounter was observed, placing particular emphasis on the nature of the discussion that occurred between the patient and prescriber. Any physical examinations of patients that occurred were not observed. Field notes were not recorded during the consultation but were written as soon as possible after it ended and included information about the patient’s condition, their prescribed medicines and a summary of the main points discussed during the consultation, together with any personal thoughts or feelings that were stimulated by observation of the encounter. In most research sites only one patient encounter was observed at each visit to the site which meant that field notes could be recorded immediately after the consultation ended. In two sites, all of the patients who agreed to participate in the study had appointments immediately after each other during the same clinic session. Brief notes were maintained during the consultation and full field notes were then written at the end of the session.
Whilst many authors provide a detailed list of factors that should be included in an observation exercise, it was believed that the largely unstructured approach to observation used here would enable a focus on the interaction occurring within the
encounter as this was the key source for data collection. An unstructured approach would also enable a sensitivity to all that was happening within the encounter.
Audio-recording of the consultations was undertaken to ensure that all elements of the interaction were available for analysis. Encounters were recorded using two digital voice recorders to ensure any loss of data was minimised (Olympus VN- 8700PC™ and Philips Voice Tracer LFH0662™). Whilst some analysts argue for the use of video recording to ensure non-verbal data such as facial expression can be collected (e.g. Heath et al 2010) it was not believed to be a practical option in this study. The timeframe for the study meant that it was not possible, for example, to gain any knowledge of likely research settings prior to developing the application for research ethics approval and it was therefore difficult to be confident that video- recording was feasible.
Following observation of the encounters, individual, semi-structured interviews then took place with patients and prescribers and these are considered further below. Patient interviews occurred after their consultation and prescribers were interviewed once all of their consultations with participating patients had been observed.