Ahmad HIdayat Joshua Maringan PrIyo Nugroho

ABSTRACT :

Ineffective communication has been identified as the major cause of critical incidents in public hospitals in Australia. (Background) Critical incidents are adverse events leading to avoidable patient harm. (Background) This article discusses a study that focused on spoken interactions between clinicians and patients in the emergency department of a large, public teaching hospital in New South Wales, Australia. (Purpose)

 The purpose of the study was to identify successful and

unsuccessful communication encounters. (Purpose)

It combined two complementary modes of analysis:

qualitative ethnographic analysis of the social practices of emergency department healthcare and discourse analysis of the talk between clinicians and patients. (Method)
This allowed the researchers to analyse how talk is

socially organised around healthcare practices and how language and other factors impact on the effectiveness of communication. (Method)

 The complex, high stress, unpredictable and dynamic

work of emergency departments constructs particular challenges for effective communication. (Result)
The article analyses patientclinician interactions within the organizational and professional practices of the emergency department and highlights some systemic and communication issues. (Result) It concludes with some implications for the professional development of clinicians and an outline of ongoing research in emergency departments. (Findings)

INTRODUCTION :

Effective communication & interpersonal skills have long been recognized as fundamental to the delivery of quality healthcare. (background) However, there is mounting evidence that the pressure of communication in high-stress work areas such as hospital emergency departments present particular challenges for the delivery of quality care. (background)

 A report on incident management in the New South

Wales healthcare system (NSW Health 2005) cites poor & inadequate communication between clinicians and patients as the main cause of critical incidents. (background)
Communication in emergency departments is

particularly complex, as clinicians are now increasingly expected to work in teams to treat culturally diverse patients who present with multiple symptoms and problems. (background)

Inadequate communication is also the basis for many patient complaints about the healthcare system (Taylor, Wolfe and Cameron 2002; NHMRC 2004; Health Care Complaints Commission 2005). (background)
In their literature review, Flores et al (2002) demonstrate how failure to recognize the importance of language and culture can result in a range of health-related issues, including obtaining informed consent, failure to understand diagnosis and treatment, preventable morbidity and mortality, dissatisfaction with care and lower quality care in general. (background)

 These difficulties are perceived to be due, to a

large extent, to the numbers of practitioners and patients who are not proficient in English (Flores et al 2002). (background)
Currently, a considerable number of the health

professionals in New South Wales hospitals are from language backgrounds other than English, and the hospital in this study had a total of 25% overseas-trained doctors who had English as a second language. (background)

 However, the study has shown a significant number

of clinicianpatient communication difficulties and breakdowns are between people who believe they are communicating satisfactorily in English. (background)
Seminal cross-cultural communication research by

Gumperz (1982) and Roberts (2000) has demonstrated that serious communication problems can occur where there is no evident language barrier, and where it is assumed that there is a shared language. (background)

For example, misunderstandings and communication breakdowns can occur because of different cultural assumptions about how to structure information or an argument in conversation, how to signal connections and logic, or how to indicate the significance of what is being said in terms of overall meaning and attitude. (background)
Different ways of speaking, such as tone of voice and intonation patterns, can result in inaccurate inferences being drawn about knowledge, attitude or behaviour (Gumperz, Jupp and Roberts 1991). (background)

 For a number of decades now, studies of

communication between doctors and patients have been carried out using either linguistic or organizational approaches (Wodak 2006). (background)
Early work by Cicourel (1981, 1985), using a number

of case histories, showed the advantage of a conversation-analytical approach. (background)

Other studies have focused on healthcare

communication in general (Sarangi and Roberts 1999; Candlin 2000; Coiera et al 2002; Cordella 2004; Iedema 2005, 2006; Wodak 2006; Sarangi in press). (background)

However, to date, there has been no research that examines the dynamic complexity of interactions unfolding in real time in high-risk environments such as emergency departments. (background)
Healthcare contexts are now of increasing interest as social organisations because of the technologically more complex medicalised practices of modern healthcare and the interplay of professionals in changing organisations (Iedema 2007). (background)

 There have been a significant number of recent

complaints from patients in relation to their experiences in emergency departments in New South Wales, many involving inadequate communication. (background)
Practitioners are also expressing dissatisfaction

(Joseph 2007) and professional disquiet (BraggKingsford 2007). (background)

 Dr Sally McCarthy, Vice President of the

Australasian College for Emergency Medicine and Director of the Prince of Wales Emergency Department, cites lack of funding, inadequate staffing and overdependence on locums for the difficulties faced in emergency departments (Wallace 2007). (background)
This article outlines findings of a pilot study that

took place in the emergency department of a large teaching hospital in Sydney, Australia. (background)

The main aims of the project were to: describe, map and analyse the communication encounters that occurred between clinicians and patients in the emergency department in order to identify the features of both successful and unsuccessful encounters, identify ways in which clinicians can enhance their communicative practices to improve the quality of the patient journey through the emergency department.(purpose)

The project was cross-disciplinary and involved academics in applied linguistics and nursing from the University of Technology, Sydney, and Macquarie University, language educators from the New South Wales Adult Migrant English Service and healthcare professionals from the Area Health Service. (background)

The research focused on communication between clinicians and patients who were deemed to be able to communicate effectively in English. (purpose)

The patients were from language backgrounds other than English and English-speaking backgrounds, but patients who needed interpreters were not included. (method)
We believe this study to be unique in that, for the first time, patients were observed and recorded from the moment they entered the hospital emergency department (triage) to the moment a decision about further hospital treatment or release from the emergency department was made. (method)

 The study situated patient experiences and

communication exchanges within professional and institutional practices (Gumperz 1982; Sarangi and Roberts 1999; Iedema 2005; Kemmis in press) of the emergency department, and related the interactions between patients and clinicians to the broader, systemic exigencies and the roles and discourse practices of healthcare professionals, managers and policy-makers. (methods)
The research thus contributes to discourse

knowledge in the context of critical healthcare services. (purpose)

 The article begins by introducing the hospital in

terms of general demographics, followed by an outline of the research methods. (method)

It presents some examples of spoken data and

discusses some major findings. (method)

It concludes with implications for the

professional development of clinicians and a description of ongoing research in a further four hospitals. (finding)