The concept of patient engagement is attracting growing attention from scholars working on doctor-patient interactions. It refers to the condition in which patients are fully aware of their medical condition and willing to be active both in the relationship with their caregivers and towards the health care institutions. However, the operative steps necessary to achieve patient engagement have not yet been fully described. This chapter focuses on the communicative dimension of engagement. Communication is shown to be a pivotal means to improve patient self-efficacy and commitment, both fundamental components of engagement. In particular, the authors take a closer look at the process of decision making in chronic care settings, and propose a normative model to analyze and evaluate the quality of decision making in consultations. It is argued that the model can also be used as a blueprint to create training materials for clinicians.
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Chronic illnesses such as diabetes, hypertension, and asthma - just to name a few - are nowadays common occurrences in the lives of many individuals. Modern Western lifestyle and the aging population will lead, in the next decades, to an increase in the number of people suffering from chronic diseases (Visser, 2000). Chronicity imposes new challenges to the clinician-patient relationship. As chronic diseases are by nature treatable but not curable, it becomes essential for healthcare providers to engage patients in their care and promote patients’ self-management and compliance to treatment in order to maintain a good health (Assal, 1999; Coleman, Austin, Brach, & Wagner, 2009; Nuño, Coleman, Bengoa, & Sauto, 2012).
Recently, the literature on chronic care has focused on the concept of patient engagement. Patient engagement has been generally described as a result of the relationship between patients and health care providers as they work together to “support active patient and public involvement in health and healthcare and to strengthen their influence on healthcare decisions, at both the individual and collective levels” (Coulter, 2011, p. 10). Engagement has also been described as a complex process of exchanges that occur between the patient and the health care system (Graffigna, Barello, Riva, & Bosio, 2014, p. 87), capable of producing positive psychosocial changes in patients and better quality of life (Barello & Graffigna, 2014). A recent model developed by Graffigna et al. (2014) defined patient engagement as a dynamic process, in which patients experience four phases (blackout, arousal, adhesion and eudaimonic project), each encompassing emotional, cognitive and behavioral dimensions. According to this model, engagement is the final outcome of a series of emotional, cognitive and behavioral reframing of the patient’s health condition (Barello & Graffigna, 2014). Specifically, fully engaged patients are able to integrate the disease into their identity and life, manage their own care and mobilize healthcare services proactively if needed. As characterized by the literature, patient engagement can be described as an emotional, cognitive and behavioral change. Patient engagement therefore implies a greater ability and motivation to solve health-related problems, the exchange of relevant information with clinicians, shared decision-making, the capacity to cope with complications and follow through with treatment (Barello & Graffigna, 2014).
In the literature, engagement has been mainly described at an individual level in terms of patient’s experience and patient’s behaviors. However, engagement is promoted and sustained in the verbal day-by-day interactions between the patient and the healthcare providers (Thompson, 2007). More specifically, as a process supporting a proactive role of patients regarding their own health, patient engagement is promoted in the relationships between patients and clinicians within the consultations (Charles, Gafni, & Whelan, 1997, 1999; Epstein & Street, 2011; Street, Elwyn, & Epstein, 2012).
The process of patient engagement, as proposed in the literature, seems to include at least three dimensions that can only be dealt with through communicative processes: motivation, the exchange of relevant information with clinicians, and shared decision-making (Barello & Graffigna, 2014). Several strategies have been identified for clinicians to help patients move along the process of engagement, such as offering clear information on their condition, strengthening motivation to adopt healthy lifestyles, promoting self-efficacy, reinforcing healthy behaviors, and valuing patients’ responsibility towards their own health (Graffigna et al., 2014). However, little is known about what specific clinician-patient communicative behaviors could sustain engagement in clinical consultations. In this contribution, we propose the model of the deliberation dialogue (Walton & Krabbe, 1995; Walton, 2006; Walton, Toniolo, & Norman, 2014) as a tool for the analysis of clinician-patient verbal interactions that can help distinguish and assess the components of engagement-oriented dialogues within chronic care consultations.