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Table 3 Second order constructs from included studies organised into major thematic groups

From: How communication affects prescription decisions in consultations for acute illness in children: a systematic review and meta-ethnography

Thematically related groups Translation or summary descriptions of second order constructs from included studies Studies which identify 2nd order construct
Communication during information exchange Parents displayed concern with establishing the ‘doctorability’ of the child’s illness by presenting a story of extreme or abnormal events, and seeking clinicians expertise. Elwyn 1999 [33]
Stivers 2000 [35]
Rollnick 2001 [41]
Four types of problem presentations have been identified and include ‘symptoms only’, ‘candidate diagnosis’, ‘diagnosis implicative symptoms descriptions’ and ‘candidate diagnosis as background information’. Stivers 2000 [35]
Ijas-Kallio 2011 [61]
Clinicians use problem minimising/normalising language or communication techniques during examination to communicate that an illness is not serious. Elwyn 1999 [33]
Stivers 2000 [35]
Rollnick 2001 [41]
Butler 2009 [60]
Clinicians justified ‘no antibiotic’ treatment decisions using problem minimising language as a pre-emptive move to signal a pending ‘no antibiotic’ treatment decision. Rollnick 2001 [41]
Parents and clinicians usually communicate purely in the voice of ‘strictly medicine’ (i.e. as though the problem was purely medical) in consultations for simple acute problems (communication phenomenon appears to be specific to these types of cases rather than clinician specific). Communicating only in the voice of medicine contributes to a failure of communication when parents have concerns that cannot be accommodated by this voice. Barry 2001 [45]
Clinicians’ communication may be based on an assumption of a patient-centred approach to decision making but parents who do not expect a patient centred approach may misunderstand it and in turn the confusion may contribute to a clinician assessment of a parent as anxious Roberts 2005 [52]
Clinician communication about prognosis varied, if duration was mentioned it was often too short or unclear, parents were invited to re-consult ‘if not happy’. Butler 2004 [51]
Communication during diagnosis delivery Clinicians responded to symptoms only problem presentations of simple acute illness with straightforward unilateral diagnosis announcements presented as being based on his/her own medical reasoning. Stivers 2000 [35]
Ijas-Kallio 2011 [61]
The parent’s problem presentation affects the trajectory of the interaction. When parents gave or implied a candidate diagnosis, the doctor designed his/her reply to be responsive to the parents’ own problem presentation, either confirming or disconfirming the candidate diagnosis. Stivers 2000 [35]
Ijas-Kallio 2011 [61]
Parents and clinicians alike oriented to diagnoses as within the clinician’s domain of expertise. Parents might respond minimally to simple unilateral diagnosis pronouncements but by doing so treat the unilateral decision as adequate. Stivers 2000 [35]
Ijas-Kallio 2011 [61]
Parents might also claim access to diagnostic reasoning by extended responses which might 1) assess the decision positively, 2) evaluate the grounds on which the doctor’s decision is acceptable, or 3) resist the decision. Ijas-Kallio 2011 [61]
Communication during treatment deliberation & decision Parents usually accepted treatment recommendations. Stivers 2000 [35]
Ijas-Kallio 2011 [61]
Parents resisted by withholding acceptance of treatment recommendations. Parents also drew on their own knowledge of symptoms, past experiences, previous medical advice and diagnostic expectations to contest clinicians’ interpretations. Stivers 2000 [35]
Main 20011[42]
Stivers 2005 [35]
Ijas-Kallio 2011 [61]
Overt requests or parent pressure for antibiotics were rare but included: parents making requests for or stating clear preference for antibiotic treatment and parents ’threatening’ to re-consult if antibiotics were not prescribed. More common were enquiries about antibiotics or mentions of positive past experience with antibiotic treatment. Elwyn 1999 [33]
Stivers 2000 [35]
Main 20011[42]
Clinicians sometimes presented the treatment decision (no antibiotics, delayed prescription, immediate prescription) as a choice to parents; clinician actively pursued parental acceptance of decisions; parents behaved as though they have the right to accept or reject treatment proposals. Elwyn 1999 [33]
Stivers 2000 [35]
Rollnick 2001 [41]
When parents gave or implied a candidate diagnosis as part of their problem presentation, these were responded to by clinicians in a way which indicated clinicians perceived an expectation for antibiotic treatment from parents, and their responses often included justifications of non-antibiotic treatment. Stivers 2000 [35]
Main 2001 [42]
Clinicians responded to parent resistance in a way which indicated clinicians perceived this as an indication of an expectation for antibiotic treatment from parents. Stivers 2000 [35]
Main 20011[42]
Parent's usually avoided open disagreement; rather they offered alternative or additional info and sought to further the shared understanding of the child’s condition. Ijas-Kallio 2011 [61]
Clinicians used various strategies to pursue parental agreement with non-antibiotic treatment including offering symptom relief, further testing, offering parent choice and invoking parental competence Stivers 2000 [35]
Rollnick 2001 [41]
Stivers 2005 [35]
When clinicians made affirmative, specific, non-minimised treatment recommendations e.g. for symptom relief, parents were less likely to resist and clinicians were more likely to gain acceptance than if clinicians made recommendations against a treatment. Rollnick 2001 [41]
Stivers 2005 [35]
Clinicians acknowledge uncertainty in diagnosis and treatment decision and prescribed antibiotics Elwyn 1999 [33]
Rollnick 2001 [41]
Clinicians met parents preference for antibiotic treatment or responded to parent pressure for antibiotics despite appearing to diagnose a viral condition. Elwyn 1999 [33]
Stivers 2000 [35]
Role of parent in consultation Parents gave and received information about their child’s health, illness and context, with parent’s involvement progressively decreasing through adolescence. Main 2001 [42]
Parents often asserted themselves during the consultation and until they had been able to express their concerns, would interrupt child-doctor interaction Main 2001 [42]
Cahill 2007 [11]
Role of child in consultation Children were notably quiet in these consultations Cahill 2007 [11]
Adults determined the degree of the child’s integration in the consultation interaction by the varying degree to which they oriented to or ignored the child. Clinicians affected child participation by varying how they arranged the room or how much they addressed the child rather than the parent or used appropriate communication techniques (asking closed questions, by giving children enough time to respond). Sometimes, both adults co-constructed a situation where the child was treated as a non-person (where child’s contributions were ignored or negated by adults). There was also an intermediate integration where child contributions were acknowledged but not integrated into the discussion. Tates 2005
Nova 2005 [53]
Cahill 2007 [11]
Where child was integrated he/she made relevant contributions and could influence diagnostic course Nova 2005 [53]
Child actively acquired knowledge of the illness and the consultation process during consultations Nova 2005 [53]
  1. 1reported in Scott 2001.