Challenging questions and ethical obligations: the ethics of everyday practice > 21 January 2015

Carol Rivas


How patient identity is actively shaped within diabetes review consultations and the implications for goal-setting, self-management, and key indicator exploration


Patient-centred care is embedded within UK National Health Service policy. Te aim in diabetes is to optimise self-management through interactional strategies that include motivational interviewing and individualised goal-setting arrived at through negotiation between clinician and patient. Evidence suggests poorer awareness of diabetes and its complications in ethnic minority patients and the tackling of fewer of the key indicatorsof disease progression at annual diabetes review.


We analysed the sequential nature of talk of 48 nurse-led video- and audio-recorded diabetes consultations in inner London primary care settings, supported by member validation interviews.   We compared consultations with fluent English speakers and those where an interpreter was present, largely involving patients of Bangladeshi origin.


Interpreted encounters are essentially triadic. But frequently, dyadic (untranslated) moments are shared between patient and interpreter or interpreter and provider. This usually consists of: small talk about mundane topics; explanations of bureaucratic procedures or service access; or explanation or clarifications of what one person said to aid further understanding. Some interpreters decided to omit some translation to help the consultation flow to the supposed advantage of the patient, when they were familiar with the patients from encounters in the local community or previous appointments, and considered they could answer for the patient, to maximise efficiency. However, since the decision as to whether to move from dyadic to triadic moments does not tend to rest with the patient, we found there was great potential for ethical dilemmas and concerns in practice. Contrary to interpreter and clinician understandings around the efficiency of dyadic moments, we found these meant the 12 non-English speakers often had difficulty in raising issues that concerned them. These difficulties were not shared by the 24 fluent English speakers, who also found it easier to convey a positive moral reputation as ‘worthy’ patients and to excuse behaviour that deviated from recommended self-management practices. Interpreters at times also acted as moral mediators, not translating statements that appear to convey a negative moral judgement of another participant. Hence problems with the service went unmarked. Further, dyadic talk may lead to some marginalisation of the person left out of the dyad, who has no idea what is going on, what is being kept from him or her or whether it is indeed irrelevant from their perspective.


Nurses and other clinicians need to be aware of the way that dyadic moments in the interpreted consultation disempower the patient, even though sometimes increasing efficiency of the consultation. This can have unseen ethical and moral implications. It can affect the way that patient identities are actively shaped in the consultation (as good/compliant or bad/non-compliant, or in terms of capacity to speak English and therefore demonstrate knowledge) and therefore the way the consultation and advice and management decisions are progressed. This has particular implications for key indicator exploration, self-management talk and experience of minority groups with health services.



Carol is a Senior Research Fellow at the University of Southampton and an Honorary Senior Research Fellow at Queen Mary University of London.  She has expertise across a range of quantitative and qualitative methods, disciplines and approaches which she primarily uses to explore her interests in communication and the patient experience.  She is particularly attentive to inequities within healthcare.  In 2012 she undertook an ethnographic, video-based study of clinical encounters in diabetes which sought to elucidate some of the difficulties healthcare service users experience when they are not fluent in English.


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