title: A multi-centre study of interactional style in nurse specialist- and physician-led Rheumatology clinics in the UK.
abstract: BACKGROUND
  Nurse-led care is well established in Rheumatology in the UK and provides follow-up care to people with inflammatory arthritis including treatment, monitoring, patient education and psychosocial support.
  
  
  OBJECTIVE
  The aim of this study is to compare and contrast interactional style with patients in physician-led and nurse-led Rheumatology clinics.
  
  
  METHODS
  A multi-centre mixed methods approach was adopted.
  
  
  METHODS
  Nine UK Rheumatology out-patient clinics were observed and audio-recorded May 2009-April 2010.
  
  
  METHODS
  Eighteen practitioners agreed to participate in clinic audio-recordings, researcher observations, and note-taking. Of 9 nurse specialists, 8 were female and 5 of 9 physicians were female. Eight practitioners in each group took part in audio-recorded post-clinic interviews. All patients on the clinic list for those practitioners were invited to participate and 107 were consented and observed. In the nurse specialist cohort 46% were female; 71% had a diagnosis of Rheumatoid Arthritis (RA). The physician cohort comprised 31% female; 40% with RA and 16% unconfirmed diagnosis. Nineteen (18%) of the patients observed were approached for an audio-recorded telephone interview and 15 participated (4 male, 11 female).
  
  
  METHODS
  Forty-four nurse specialist and 63 physician consultations with patients were recorded. Roter's Interactional Analysis System (RIAS) was used to code this data. Thirty-one semi-structured interviews were conducted (16 practitioner, 15 patients) within 24h of observed consultations and were analyzed using thematic analysis.
  
  
  RESULTS
  RIAS results illuminated differences between practitioners that can be classified as 'socio-emotional' versus 'task-focussed'. Specifically, nurse specialists and their patients engaged significantly more in the socio-emotional activity of 'building a relationship'. Across practitioners, the greatest proportion of 'patient initiations' were in 'giving medical information' and reflected what patients wanted the practitioner to know rather than giving insight into what patients wanted to know from practitioners. Interviews revealed that continuity of practitioner was highly valued by patients as offering the benefits of an established relationship and of emotional support beyond that of the clinical encounter. This fostered familiarity not only with their particular medical history, but also their individual personal circumstances, and this encouraged patient participation. In contrast, practitioners (mis)perceived waiting times to have a greater impact on patient satisfaction. However, practitioner interviews also revealed that clinic structure is often outside of the practitioner control and can undermine the possibility of maintaining patient-practitioner continuity.
  
  
  CONCLUSIONS
  This research enhances understanding of nurse specialist consultation styles in Rheumatology, specifically the value of their socio-emotional communication skills to enhance patient participation.
authors.affiliation: Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds LS2 9LJ, UK; Dental Public Health, School of Dentistry, University of Leeds, Worsley Building, Clarendon Road, Leeds LS2 9LU, UK. Electronic address: K.A.Vinall@leeds.ac.uk.
authors.forename: Karen
authors.initials: K
authors.lastname: Vinall-Collier
authors.affiliation: School of Psychology, University of Leeds, Leeds LS2 9JT, UK. Electronic address: A.L.Madill@leeds.ac.uk.
authors.forename: Anna
authors.initials: A
authors.lastname: Madill
authors.affiliation: Pennine MSK Partnership Ltd., Integrated Care Centre, New Radcliffe Street, Oldham OL1 1NL, UK; School of Healthcare, University of Leeds, Leeds LS2 9JT, UK. Electronic address: Jill.Firth@nhs.net.
authors.forename: Jill
authors.initials: J
authors.lastname: Firth
mesh_terms: D000554:Ambulatory Care Facilities / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000072184:Nurse Specialists; D009723:Nurse-Patient Relations; D010817:Physician-Patient Relations; D010820:Physicians; D012219:Rheumatology; D006113:United Kingdom
keywords: Communication; Consultation style; Continuity of care; Interview; Mixed method; Multi-centre; Nurse-led care; Patient activation; Qualitative; Roter's Interactional Analysis System