Abstract
Objectives:
The study objective was to develop methodology for observational research within traditional acupuncture consultations in community-based practice, and to explore how traditional acupuncturists communicate with patients about lifestyle and self-care.
Design:
This was a mixed-method qualitative study, using audio-recording of consultations followed by telephone interviews of patients. The study was nested within a cooperative inquiry. As co-researchers, group members participated in framing the research questions, deciding methods to be used, and discussing the emergent findings.
Settings:
Four (4) experienced traditional acupuncture practitioners, registered with the British Acupuncture Council, contributed to the co-operative enquiry and recorded consultations in three clinics in Somerset.
Subjects:
Subjects comprised a convenience sample of patients attending 21 consultations. A purposive subsample of patients was selected for interview.
Results:
Audio-recording was challenging to some practitioners who felt that it might result in infrequent, but nevertheless worrying, withholding of personal information by patients. Patients, however, reported that they were generally positive about the audio-recording. Each consultation was analyzed as a trajectory in which eight categories of talk interwove with each other and with periods of physical examination, needling, and silence. Trajectories showed where talk about self-care (“self-care talk”) appeared in the consultations, the content of such talk, and who initiated it. The data confirmed that self-care advice arises from, and is explained in terms of, each person's individual Chinese Medicine diagnosis. The identification of different types of talk and the way that “self-care talk” is interwoven throughout the consultation emphasized the integral nature of self-care support and advice in the practice of traditional acupuncture. Some patients had difficulty putting self-care advice into practice, even when they were intellectually committed to it, suggesting that practitioners may need to follow up more carefully on the advice they have given.
Conclusions:
Self-care in traditional acupuncture consultations is integral, interactive, and individualized. This study has mapped out a potential agenda for research into self-care in traditional acupuncture consultations and illustrates the exciting opportunities that open up when observational and interview data are combined.
Introduction
The wheel of heaven turns, it mounts up and falls away; the track of human affairs is similarly unclear. Whenever we dwell, unknowingly, on the brink of disaster, there is nobody in the world, who, if they cannot take care of themselves, will be able to conquer its course. Therefore, no scholar pursuing his nature, who does not make a plan for himself concerning self-care, will ever be able to partake in any discussion on the path of nourishing life. For this reason we take self-care as fundamental.
—Sun Simiao, Chinese physician, 581–682
Acupuncture consultations are likely to present added challenges to observational research because of their length, the inclusion of periods of actual treatment, which may be silent, and the likely importance of nonverbal communication and touch. They are also mainly confined to the private sector, where the acceptability and feasibility of research may be problematic. The current study aimed to address these methodological issues and, in the process, begins to explore how traditional acupuncturists communicate with patients about lifestyle and self-help. The research design was developed by a group of acupuncture practitioners and academic researchers who decided to pilot audio-recording of consultations. The aim of the study was to explore the acceptability and feasibility of audio-recording acupuncture sessions, from the perspectives of patients and the acupuncturists, and to begin to understand more about how self-care is communicated within the consultations.
Materials and Methods
The study took place in 2009–2010 and it was approved by the Peninsula Medical School Research Ethics Committee. The design was a mixed-method qualitative study (nonparticipant observation and interviews) nested within a co-operative inquiry.
Definition of self-care
The UK Department of Health definition of self-care was used: “Self-care is a part of daily living. It is the care taken by individuals towards their own health and wellbeing: the actions people take to stay fit and maintain good physical and mental health.” 20
Co-operative inquiry
This research was carried out by an established research group of practitioners and researchers (South West Acupuncture Research Group) utilizing the method of co-operative inquiry. 21,22 In this method, all those involved work together as co-researchers. As co-researchers, all the group members participated in the thinking that went into the research: framing the questions to be explored, the methods to be used, and discussing the emergent findings. As co-subjects, the practitioners participated in what was being studied by recording their own consultations. Nested in this inquiry was a qualitative study that was led by an experienced, independent qualitative researcher, ME, who joined the team after the research questions and design had been established. The use of this external researcher enhanced methodological rigor and confidentiality of data. Recorded consultation and interview data were only available to the practitioners in anonymized form. Analysis of the data incorporated collaborative team discussions of emerging findings. Before and during data collection, anticipated and actual experiences and difficulties were discussed at co-operative inquiry meetings, which took place every 6 weeks.
The following types of data were collected: audio-recorded consultations, postconsultation telephone interviews with patients, and audio-recorded discussion on acupuncturists' experience of the research as part of a co-operative inquiry meeting.
Audio-recording consultations
Following group discussion, audio-recording was considered to be the most feasible and acceptable method for this research. Video-recording and/or direct observation were highlighted as methods worth investigating in the future but were perceived to be potentially more intrusive and also more costly to undertake. An additional objective was to investigate the strengths and limitations of audio-recording in this context. Four (4) experienced traditional acupuncture practitioners, who were registered with the British Acupuncture Council and working in four private clinics in Somerset, audio-recorded a convenience sample of 21 routine consultations, using a digital recorder. As co-researchers, the practitioners were aware of the need to sample a range of types of consultation (for example recent versus long-standing patients and different conditions) and to behave as normally as possible. All recorded consultations were submitted to the researcher.
Patients were provided with written information about the study (either face-to-face or by mail) prior to the index consultation. Written informed consent was gained before audio-recording commenced. At the end of the consultation, patients were given the opportunity to withdraw from the study, in which case the record would be deleted. Practitioners were encouraged to record, if possible, an initial consultation and follow-up appointments with the same patient, across a number of cases.
Patient interviews
A purposive subsample of patients was selected for an audio-recorded semistructured telephone interview. Patients were chosen to give a range of age, therapist, and presenting problem. The interview took place within 2 weeks of their audio-recorded consultation. The audio-recording of the consultation was listened to prior to the telephone interview with that patient. In this way, paired data were obtained about the event itself (the consultation) and the patients' experience and perception of it. The interview topic guide covered basic information, such as age, main health problems, and history of acupuncture treatment, followed by a more open exploration of the patient perspective. This included (1) the acceptability of the recruitment process and of audio-recording consultations, and (2) the extent to which patients perceive audio-recording as changing or interfering with their communication in the consultation. The topic of self-help was introduced near the end of the interview if it had not emerged spontaneously before that time.
Data analysis
Interviews were professionally transcribed. Framework analysis was used to condense and analyze the key topic areas relevant to the research aims. 23 Using a constant comparative method, data from early consultations and interviews were subjected to a preliminary analysis, which fed into later data collection. The development of themes and codes and the emerging analysis was discussed on two occasions by ME and CP. Within these themes, cases were highlighted that confirmed and contradicted the emerging hypotheses.
Resources were not available to make verbatim typed transcriptions of the audiotapes of the consultations, and ME used the following analytic strategies to make a preliminary analysis of the consultation data: ME transcribed all of the first 18 consultations (out of a total of 21) by hand, noting the key elements of the recording line by line, and transcribing verbatim those sections specifically related to self-care communication; periods of silence were noted and timed Content analysis was applied to the consultation data, and a coding strategy was developed that showed the different types of talk occurring in the consultation A table was constructed for the trajectory of each consultation, showing the types of talk, who initiates each section of talk, and the duration of each section of talk (for further explanation see the Results section) Trajectories focusing on self-care talk were drawn to show visually where self-care talk appears in the consultations, the content of such talk, and who initiates it Techniques drawn from conversation analysis were applied to the consultation data by looking in more detail at sections of self-care talk
Drafts of the main findings were discussed at three co-operative inquiry meetings over a 6-month period.
In this article, some examples are presented from these different analyses and a list of the preliminary hypotheses that are supported by the data and inquiry. The aim is to map out the range of methods and hypotheses, all of which could form the basis of further work by the current authors and others.
Results
Two (2) male and 2 female acupuncture practitioners participated in the research, recording a total of 21 consultations with 18 individual patients. Ten (10) telephone interviews were carried out with patients. Table 1 shows the number and characteristics of research participants. Some practitioners were cautious in recruiting patients, only approaching those that they felt were likely to agree. One (1) practitioner stopped recruiting and audio-recording after three consultations. Others, however, took the approach of recruiting all patients attending on 1 or 2 typical clinic days. Despite encouragement from the researchers, only 1 practitioner recruited a new patient and audio-recorded their first consultation. Within the sample, 3 patients, from 3 different practitioners, had a series of two or more consultations recorded.
IVF, in vitro fertilization.
Acceptability and feasibility of audio-recording acupuncture consultations
Patients reported at interview that they were generally positive about the audio-recording for the following reasons: trust in their therapist; support for the research process; previous experience of research or training; and experiencing audio-recording as nonintrusive. Practitioners, however, had a number of practical and professional concerns that not everyone could overcome. Initial practical issues included using the digital recorder and sending recordings to the researcher in a safe and confidential manner. More enduring concerns included feeling personally uneasy about being recorded, in ways they felt might affect their interaction and relationship with their patients, and the limitations of missing nonverbal data. Some acupuncturists said that they had been told in subsequent consultations that some patients had failed to disclose some information while being audio-recorded. Despite this, practitioners found the data and analysis useful, interesting, and worth pursuing.
Analysis of the recorded consultations
In order to address the questions of how to analyze data from long consultations with periods of nonverbal behavior and silence, a number of analytic strategies were explored. The findings of two strategies are presented here: analyzing “types of talk” within the trajectory of the consultation and analyzing the content of the “self-care talk.”
“Types of talk” within the trajectory of the consultation
Each consultation was analyzed as a trajectory in which eight categories of talk interwove with each other and with periods of physical examination, needling, and silence. These categories were self-care talk, biomedical talk, symptoms talk, acupuncture talk, social talk, therapeutic talk, complementary therapy talk, introductory talk, and ending talk. Table 2 provides some examples of the main categories of talk. Every consultation contained an element of self-care talk that was woven into the consultation. Analysis of all the consultations indicated that it was contingent on other types of talk, especially “social talk” and “acupuncture talk.” These were the types of talk that most frequently preceded and followed self-care talk. Although practitioners each had their own style of trajectory, the types of talk were common across all practitioners. Table 3 is an example of one consultation trajectory (shorter than most).
P numbers refer to patient number; see Table 1.
Self-care talk could be initiated by either practitioner or patient, and it often demonstrated mutuality in terms of an overlapping interest in self-care. Mutuality was sometimes established during periods of “social talk,” which led into “self-care talk.” Table 4 provides examples of some of the ways that communication about self-care was introduced into the consultation. Strategies used by practitioners include giving advice, modeling self-care behaviors, inviting feedback on self-care, empathizing with self-care difficulties, and researching self-care activity. Some of these strategies are illustrated in Table 4. Patients initiated self-care talk by asking for advice, volunteering feedback on self-care, discussing their self-care needs, researching self-care, and indicating self-reliance, skepticism, or guilt about self-care. In addition to demonstrating mutuality, this communication about self-care was often, but not always, directed at supporting patients as active agents with their own priorities and choices. This theme of agency is returned to in the interview analysis below.
P numbers refer to patient number; see Table 1.
Self-care talk: Content and explanations
The main topics included in self-care talk (and who usually initiated these topics) are as follows: exercise (initiated by either patient or practitioner) dietary (initiated by either patient or practitioner) herbal and other supplements (usually initiated by practitioner) rest and relaxation (always initiated by practitioner) protection from the elements (usually initiated by the practitioner)
Tables 3 and 4 include examples of these topics. The authors' analysis suggests that the self-care advice usually arose out of each person's individual Chinese Medicine diagnosis, and there were a number of examples of the advice being explained with reference to that diagnosis, using interpretations based on lay concepts and metaphors. In the example given in Table 5, the acupuncture practitioner (A) has noted that the patients tongue is “still rather pale,” and the patient (P) has volunteered that they had tried taking an iron and vitamin supplement but had stopped due to side-effects.
P number refers to patient number; see Table 1.
Thematic analysis of the patient interviews
The interview data were analyzed inductively alongside the recorded consultations, focusing on understanding the patient's perspective on communication about self-care in the consultation. Three (3) key themes emerged as central in describing and interpreting the dataset. They are detailed below.
Communication with the therapist
Participants described their relationship with their acupuncture practitioner as confiding, and this was held in sharp contrast to their relationship with National Health Service (NHS) health professionals. For example, 1 participant described how she felt “guarded” and “unrelaxed” with her general practitioner (GP) compared to her acupuncturist. Another recounted how an NHS physiotherapist had used acupuncture for pain relief but it was a matter of “just sticking the needles in” with no sense of a therapeutic relationship. All participants described their therapist as easy to talk to and comfortable to be with and a sense of a close, confiding relationship emerged, such as “I can talk about anything with my therapist,” “My therapist takes my problems seriously,” “He knows me beyond my notes,” “We have a bit of a giggle.” One (1) participant described the importance of feeling relaxed in this way in order to properly “receive the treatment,” and the interview quote given in Table 6 illustrates how such a relationship might influence communication about self-care.
I, interviewer; P, patient.
Agency in self-care
The concept of agency or “purposeful action” refers to a sense that individuals have the freedom to create, change, and influence events. 24 The idea of agency is encompassed by the way in which patients themselves sometimes initiated dialogue about self-care by asking for advice or referring to self-care activities, rather than simply responding to the acupuncturist. Participants also embraced a commitment to self-care and a holistic view of health and healing that was striking. Typical comments were: “The only person who can care for you is you,” “I'm that sort of a person anyway … vegan, I exercise, I am body aware,” “The body is self-healing,” “It's a combined effort (you and the acupuncturist),” “It's a two-way street, you've got to put in effort,” “If you feel good about yourself you heal.”
Such comments suggest several aspects to self-care: a belief in a holistic approach to health that goes beyond simply treating an illness, an awareness that attitude and state of mind can allow healing to take place, and a recognition of the part that you as an individual play. Every participant embraced such views, which appeared to reflect a general philosophy of health that was prevalent in this sample of men and women. Many had worked out their own self-care strategy over the preceding years, and all of the participants interviewed were either currently using other types of complementary medicine or had done so in the past.
Despite the above comments, there was no great evidence, in this sample, of commitment to specific self-care advice or recommendations offered by therapists. Many participants already had their own self-care activities in place (such as diet, exercise, and the use of other complementary modalities such as herbal medicine or homeopathy), which were often actively encouraged by their acupuncturist. Recommendations about avoiding cold and damp were generally acted on, with some participants saying they had altered their behavior as a result of such advice, as shown in the quote in Table 7. Similarly, specific dietary advice relating to their diagnosis was followed, although individuals reported struggles with adherence to such advice. One (1) woman reported being helped by some advice on self-massage. Another reported how acupuncture helped him to take fewer conventional tablets. One (1) woman who in her consultation had responded positively when her therapist gave her an herbal sore throat remedy and an herbal liniment said at interview that she had used neither, since the use of herbal medicine conflicted with her Christian faith. Some therapists offered specific exercises in support of their treatment. These were perceived by patients as T'ai Chi movements. Adherence to such exercise regimens at home was low, with only 1 participant appearing to positively incorporate them. Another participant (who exercises regularly in the gym) had forgotten all about them until the research interview. More generic advice to exercise or eat healthily was not received particularly positively: “Everyone tells you that!”
P number refers to patient number; see Table 1.
P, patient; I, interviewer
MS, multiple sclerosis; GP, general practitioner.
Chinese medicine versus conventional understanding of illness and self-care
All participants accepted their therapists' Chinese medicine diagnosis of their state of health or well-being. It was welcomed as a more holistic construct than conventional medical diagnoses that tend, as 1 participant described it, “to put patients in particular boxes.” One (1) patient with multiple sclerosis described her initial resistance to the Chinese interpretation of her condition and how this had changed because of the success of self-care recommendations based on this interpretation. An extract from the interview is shown in Table 7. (The matching consultation with this interviewee is included in Table 4, quote 2).
Most participants reported their therapist talking to them in “lay” or “everyday” language, translating Chinese terminology into easily understood concepts. These interpretations were supported in many cases by patients' own experiential evidence of energy channels.
Preliminary hypotheses about the content and form of lifestyle and self-care advice
Discussions of the data analysis, combining both the consultation and interview data, by the wider co-operative inquiry team led to formulating a list of preliminary hypotheses. The study findings suggest that promoting and supporting self-care in traditional acupuncture consultations is: integral to the practice of traditional acupuncture and woven in throughout the consultation; individualized; interactive, with different types of self-care talk tending to be initiated by patient and practitioner; based on supporting people's own agency and priorities; embedded in the Chinese diagnosis; sometimes explicitly explained with reference to that diagnosis, using interpretations based on lay concepts and metaphors; verbally communicated through “self-care talk,” which is contingent on other types of talk, especially “social talk” and “acupuncture talk”; and grounded in a mutual and confiding practitioner–patient relationship.
Discussion
Summary of findings
This study indicates that in traditional acupuncture, self-care is embedded in both the Chinese medicine diagnosis and a mutual and confiding relationship and is based on supporting people's own agency and priorities. Communication about self-care weaves through the consultation, such that there are many pathways and layers to promoting self-care. “Self-care talk” may include explanations that are based on the Chinese medicine diagnosis, which is interpreted and communicated through lay theories and metaphors. “Self-care talk” is contingent on other types of talk, especially “social talk” and “acupuncture talk,” and the type of self-care being discussed will influence whether the talk is initiated by the practitioner or the patient. As a result of these complex processes, self-care in traditional acupuncture consultations is integral, interactive, and individualized.
Methodological insights
This exploratory study also investigated the acceptability and feasibility of audio-recording acupuncture consultations and analyzing these data alongside linked patient interviews. The findings of this study suggest that even in the supportive context of a co-operative inquiry, audio-recording is challenging to some practitioners and may result in infrequent, but nevertheless worrying, withholding of personal information by patients in those consultations. In view of the current finding that patients were generally supportive of such research methods, it would appear that further research using this method is possible, provided practitioners are fully committed to the research question and given opportunities to develop skill and confidence in the technique.
Insights from the co-inquiry
Discussion of findings within the co-operative inquiry group meetings led to the development of deeper interpretations of the data. For example, the concept of “permeability” was developed to describe both the relationship between practitioner and patient and the flow and sequencing of the types of talk within the consultation. In the context of classical Chinese medicine, the present study uses the concept of permeability in a different way than in current everyday usage. It may signify that there are many layers of care contacted in treatment, and that there are many pathways leading to self-care, which can flow in many directions. The concept of permeability informs us of the qi-flow of the whole package of health delivery as it penetrates and permeates the bio-psycho-social-political world of the patient.
“Self-care talk,” for example, could arise from “symptom talk,” “therapeutic talk,” or “social talk,” and is facilitated by the mutual and confiding relationship. Another example of important co-inquiry discussions related to the category “social talk.” Practitioners suggested that “social talk” was not only used as a strategy to build mutuality and learn important factors about a person, but it could also be used as a place “to test emotion,” to “feed” emotions that were lacking, or promote self-regulation. Social talk is therefore integral to the diagnosis and treatment plan, providing the ground for the embedding of self-care. Such discussions promote the “model validity” of research, encompassing the need for the research to adequately address the unique healing theory and therapeutic context of the intervention that is being assessed. 25
Study strengths and limitations
Study limitations
The study sample mainly consisted of patients who were well known to the practitioners, thus reducing the number of first consultations in the dataset. In addition, the involvement of participating practitioners in designing and analyzing the research may have changed their “usual practice” regarding self-care support. The consultations we have studied are within the fee-paying sector which, although the most common way of accessing traditional acupuncture in the United Kingdom, may not be generalizable to consultations in the NHS.
The limited funding for this study influenced how data were collected. For example, the practitioners rather than the researcher took responsibility for consenting participants and setting up recordings. The lack of resources to transcribe consultation data limited the authors' ability to systematically examine the detail of the communication or to use the methods of conversation analysis. The use of audio-recording alone restricted the ability to analyze nonverbal communication and the interplay between physical examination, needling, and talk. However, given the difficulty in attracting research funds, successful exemplars of using such low-budget methods are important; the authors' experience is that they have both strengths and limitations.
The number of patient interviews carried out was limited owing to the lack of availability of some patients within the 2-week time frame. However, the sample of interviewees exhibits a range of gender, age, presenting complaint, and length of experience of acupuncture treatment.
Patients were not represented within the co-operative inquiry group, since the study developed within a pre-existing group of traditional acupuncture practitioners and resources were limited. However, in future their involvement would be beneficial.
Study strengths
Using a mixture of audio-recorded consultations and interviews allows for the process of “complementarity,” by uncovering different perspectives of the phenomenon under study. 26 Having access to recorded consultations and patients' views on those consultations adds to the debate concerning distinctions between what people say and what happens in reality. 27 Examples of both concordance and discontinuity between data were given above. In analyzing the consultation data, the reliance on repeated listening to audio data, rather than verbatim transcripts, was perceived as a strength as it promoted interest in the flow of talk and provided important clues to nonverbal interactions.
The use of a co-operative inquiry not only ensured that the research questions, design, and analysis reflected the perspective of acupuncture practitioners and several researchers, but it also provided a supportive environment for sharing experiences and solutions to the methodological challenges of researching consultations. The input of the practitioner perspective into the final analysis was especially important in respect to expanding understanding of “social talk” and suggesting new acupuncture-related concepts such as “permeability.” It is likely that this is similar to the communication strategies used to establish empathy patterns in homeopathic consultations. Further cross-disciplinary research in this area would be useful.
Conclusions: Findings in Relation to the Literature
Although some of the current findings break new ground, others confirm and extend previous results from interview studies. The consultation data confirmed that self-care advice arises from, and is explained in terms of, each person's individual Chinese Medicine diagnosis—previously found in an interview study of acupuncture practitioners 9 —and the patient interviews suggest that this is received more positively than more general advice. Another aspect of the individualized and interactive nature of the communication are the many examples of practitioners basing advice and support on the patient's own agency and priorities, a strategy that has been shown to improve communication and adherence to advice in studies of conventional medical consultations. 28,29 The importance of a mutual and confiding relationship has been evident from previous acupuncture patient interview studies 2,3 but has not previously been demonstrated in consultation data or linked so clearly with successful communication about self-care. Most novel in this analysis is the identification of different types of talk and the way that “self-care talk” is interwoven throughout the consultation, thus emphasizing the integral nature of self-care support and advice in the practice of traditional acupuncture.
This project adds to the research evidence about communication within consultations more widely. This study, combined with other research evidence, suggests that the link between the therapeutic relationship and successful communication about self-care may vary across different professional groups. There is evidence that in GP consultations, self-management advice is attenuated because it is seen to threaten the therapeutic relationship perhaps because of the more didactic nature of the advice offered in that setting. 30 Lifestyle discussions are often “shallow” and when advice is given it can have a “moral” tone. 31 Another study showed differences between homeopathic and conventional approaches to patients' eating and drinking habits. In homeopathy, questions on these topics assume a diagnostic significance as they are needed for defining the patients' idiosyncratic characteristics. 32
Implications and future research
This study has mapped out a potential agenda for research into self-care in traditional acupuncture consultations and illustrated the exciting opportunities that open up when observational and interview data are combined. Many of our findings offer opportunities for further research with different patient and practitioner populations and exploring different methods of data collection and analysis. In addition, this work has not yet explored the conditions (context such as private/NHS settings) or the consequences (the association between self-care communication in the consultation and change in patient behavior/cognition) except through preliminary analysis of the interviews.
To date, the authors' analysis indicates that patients had difficulty putting self-care advice into practice, even when they were intellectually committed to it—findings that suggest practitioners may need to follow up more carefully on the advice they have given. The current findings are potentially useful for the teaching and learning of acupuncture practice and may also be useful as a basis for developing an explicit role for acupuncture in health promotion and the everyday self-management of long-term conditions.
Footnotes
Acknowledgments
The study was funded by the Cyril and Eve Jumbo Trust and Warwick House Research Fund. CP initiated the original idea for the research, which was developed by all the authors. ME carried out the interviews and data analysis aided by the group. CP wrote the first draft of the article, which was commented on by all authors. ME wrote subsequent drafts and prepared the paper for submission. We wish to thank all the patients who took part in the study.
Disclosure Statement
No competing financial interests exist.