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Objective Assessing pain intensity is an important palliative care task. Self-report pain intensity scales are frequently used within assessment. In contrast to formal studies of validity and reliability, we examine administration of, and responses to these scales in everyday palliative care. Methods We searched episodes of pain scale use in a dataset of (video/audio-recorded) UK palliative care consultations involving five doctors, 37 terminally ill patients and their companions. We found five, and applied the techniques and tools of conversation analysis to characterise scales’ administration and functioning. Results Generally, the patients responded to scales by reporting multiple aspects of pain; the doctors supported and encouraged this. In two episodes, the scales generated misunderstandings. The doctors worked to resolve these in ways that avoided implying the patient was at fault. Conclusion Pain intensity scales can yield richer information than just intensity. They can also generate misunderstandings and social friction which take skill and effort to resolve. Practice implications Patients tend to respond to pain intensity scales by reporting on multiple aspects of pain, professionals should support them in this. These scales sometimes generate misunderstandings. To preserve the therapeutic relationship, professionals should work to resolve these without implying the patient is to blame.

As the main symptom in palliative care, pain requires careful assessment. Repeating patient answers is one recommended communication technique for helping convey to patients that they have been heard, and to encourage them to say more. We examined 23 episodes where experienced doctors repeat patients' answers with mirrored rhythm and downward-final intonation, captured in pain assessments video-recorded in 37 consultations in a large UK hospice. Using conversation analysis, our aim was to determine whether or not the repeats invite additional talk, and if so, how they do so. Our findings reveal lexical and prosodic features of doctors’ repeated pain answers that signal completion of the sequence. At the same time, because the patient has greater epistemic access to their own pain, a repeat can also invite confirmation or disconfirmation. The patients in our data sometimes—but not always—respond to the repeat with confirmation or further talk. We conclude that repeating patient answers with mirrored rhythm and downward-final intonation provides a no-obligation opportunity for patient-led confirmation, disconfirmation, or expansion of pain descriptions, particularly when the pain matter is new, revised, or has been problematic to report.

BACKGROUNDCommunication skills training for professionals caring for people with life-limiting conditions is in demand. Evidence shows that transfer of skills into practice is limited. Training can be improved by building on in-depth evidence and reflecting the complexity of actual interactions. Scientific advances from direct observational ‘conversation analytic’ studies of conversations in healthcare and beyond provide this evidence, but the linguistic complexities are often inaccessible to clinical trainers. We address this dilemma via a novel training initiative, ‘RealTalk’, designed to support trainers by increasing the authenticity and evidence base of end-of-life communication training for health and social care staff and trainees.METHODSWe conducted a development study to create a communication intervention for testing. In collaboration with stakeholders, we identified the rationale for the content and mode of delivery, converted research findings into an applied intervention, and tested and refined the intervention prior to launching the finished product. RESULTSUsing a conversation analytic approach, we made and analysed video recordings of real-life palliative care consultations in a large UK hospice. We transformed our findings into preliminary training resources comprising clips from the video recordings and accompanying written materials. We shared the materials with an advisory group of clinicians, educators and researchers. Based on feedback, we modified the materials. Trainers in UK higher education institutions, healthcare organisations and independent hospices piloted our materials within their own training and fed back. Further modifications followed in readiness for evaluation of acceptability, usability and effects on practice. The first version of RealTalk comprised two training modules, on ‘Broaching Dying’ and ‘Life Expectancy Enquiries’. Each module includes video clips from several patient cases, alongside written transcripts, case synopses and evidence-based learning points. CONCLUSIONSThe authentic and evidence-based RealTalk resources support experiential and reflective learning, focused on a range of communication problems and practices, for trainees from a wide range of backgrounds. Our process for developing RealTalk can serve as a prototype for developing other communication training resources based on data and findings from observational research on (recordings of) real-life interpersonal interactions.

Training to enhance healthcare practitioners’ capabilities in engaging people in sensitive and end-of life-related conversations is in demand. However, evaluations have either not measured, or found very limited impact on actual practice and patient experience. Training effectiveness is improved when it is based on in-depth evidence, reflects the complexity of real-life interactions, and instils principles adaptable to everyday practice. A relatively new source of in-depth evidence and practice-relevant insights on healthcare interactions is conversation analytic research, a form of observational analysis of real-life interactions. However, conversation analytic research findings have largely been disseminated by and for scientists, rather than clinicians and trainers. We used conversation analytic evidence to develop resources for use by healthcare trainers. The aim was to increase training’s evidence-base and authenticity. We further aimed to develop resources applicable to working with learners ranging from novices to advanced practitioners.Methods: Using an intervention development approach, we created online video-clips and supplementary written materials for professionals who deliver training, supervision, and support in healthcare communication for staff and students. The materials were reviewed by an advisory group comprising clinicians, lay consultees, educators, and researchers, and piloted by trainers in UK universities, NHS organisations and independent hospices. We refined materials based on their feedback.Results: The resulting ‘RealTalk’ resources focus on practices for communicating with patients and their companions about end-of-life and prognosis. Two core training modules were developed, each comprising several patient case studies featuring video-clips from real-life healthcare consultations. The clips featured practices that patients and experienced practitioners use in approaching end-of-life matters. The case studies also included evidence-based descriptions of observable practices and the principles underlying these, alongside transcripts and case synopses.Conclusions: RealTalk training resources aim to facilitate evidence-based, experiential and reflective learning, focusing on communication challenges, practices and principles for end-of-life-related interactions. The resources are designed for use by trainers for delivering all levels of training, from introductory to advanced, in both formal and informal training settings. Our development process may serve as a blueprint for the production of future evidence-based training resources based on conversation analytic research.

Drawing on insights from conversation analysis, discursive psychology and social psychology, this article describes some interactional features of two celebrity TV confessionals and the resources used by the TV interviewers and celebrity guests to attribute, accept or deny responsibility for their transgressions. The analytic interest lies in how confessions are locally and interactionally managed, that is, how ‘doing confessing’ is achieved in the television interview context. We show how the host’s opening turn constrains the celebrity guest’s contribution and secures overt admission of guilt, while simultaneously inviting the celebrity guest to tell their side of the story. We also show how celebrity guests produce descriptions which minimize the extent and severity of their transgressions, reduce agency and transform the character of their transgression. In doing so, we argue that celebrity interviewees can convey mitigations and extenuations which diminish the extent of their responsibility – calling into question the very nature of their confession. We propose that our findings demonstrate the hybrid nature of interviewing in the celebrity TV confessional and contribute to our understanding of how ‘doing confessing’ in the public eye is discursively and interactionally negotiated.

Objective Giving terminally ill people opportunities to participate in advance care planning involves tensions between: endorsing and supporting patients’ expectations, plans and decisions, and addressing how realistic these are. The latter risks exerting undue pressure to change plans; undermining autonomy; jeopardising therapeutic relationships. Our objective is to describe how experienced hospice doctors raise potential/actual problems with patients’ expectations, plans or decisions. Methods Conversation analysis of video-recorded consultations between five UK hospice consultants, 37 patients and their companions. Results Eleven episodes involving five doctors were found. In all of these we identified a ‘Hypothetical Scenario Sequence’ where doctors raise a hypothetical future scenario wherein current plans/expectations turn out to be problematic, then engage patients in discussing what could be done about this. We describe features of this sequence and how it can circumvent the risks of addressing problems with patients’ expectations and plans. Conclusion Our research breaks new ground, showing that by treating expectations, plans and decisions as potentially not actually problematic, practitioners can recognise and support patients’ preferences whilst preparing them for possible difficulties and inevitable uncertainties. Practice Implications Where professionals judge it appropriate to raise problems about patients’ preferences, plans and decisions, this sequence can manage the associated risks.

Empathy is an important way for doctors to demonstrate their understanding of patients’ subjective experiences. This research considers the role of empathy in 37 doctor–patient palliative or end-of-life care consultations recorded in a hospice. Specifically, it focuses on four contexts in which there is a disparity between patients’ displayed experience of their illness and the doctor’s biomedical, expertise-driven perspective on their illness. These include cases in which the patient is sceptical of the medical perspective, cases in which the patient’s expectations exceed what can realistically be provided and cases in which patients have an overly pessimistic view of their condition. The analysis shows how doctors can use empathic statements to display that they are attentive to the patient’s subjective experience even when the task at hand is, ostensibly, an expertise-driven, biomedical one. It thus demonstrates that empathy is of importance throughout palliative care consultations, even in those phases which might seem biomedical or task-driven.

BackgroundTwenty-five per cent of hospital beds are occupied by a person living with dementia. Dementia affects expressive communication and understanding. Health-care professionals report a lack of communication skills training.ObjectivesTo identify teachable, effective strategies for communication between health-care professionals and people living with dementia, and to develop and evaluate a communication skills training course.DesignWe undertook a systematic literature review, video-recorded 41 encounters between staff and people with dementia, and used conversation analysis to investigate communication problems and solutions. We designed a communication skills training course using coproduction and multiple pedagogic approaches. We ran a pilot, followed by six courses for health-care professionals. We measured knowledge, confidence and communication behaviours before, immediately after and 1 month after the course, and undertook interviews with participants and managers. Behaviours were measured using blind-rated videos of simulations.SettingGeneral hospital acute geriatric medical wards and two hospital clinical skills centres.ParticipantsWe video-recorded 26 people with dementia and 26 professionals. Ten experts in dementia care, education, simulation and communication contributed to intervention development. Six health-care professionals took part in a pilot course, and 45 took part in the training.ResultsThe literature review identified 26 studies describing 10 communication strategies, with modest evidence of effectiveness. Health-care professional-initiated encounters followed a predictable phase structure. Problems were apparent in requests (with frequent refusals) and in closings. Success was more likely when requests were made directly, with high entitlement (authority to ask) and with lowered contingencies (made to sound less difficult, by minimising the extent or duration of the task, asking patients ‘to try’, offering help or proposing collaborative action). Closings were more successful if the health-care professional announced the end of the task, made a specific arrangement, body language matched talk, and through use of ‘closing idioms’. The training course comprised 2 days, 1 month apart, using experiential learning, including lectures, video workshops, small group discussions, simulations (with specially trained actors) and reflections. We emphasised the incorporation of previous expertise and commitment to person-centred care. Forty-four participants returned for the second training day and 43 provided complete evaluation data. Knowledge and confidence both increased. Some behaviours, especially relating to closings, were more commonly used after training. The course was rated highly in interviews, especially the use of simulations, real-life video clips and interdisciplinary learning. Participants reported that they found the methods useful in practice and were using them 1 month after the course finished.LimitationsData were from people with moderate to severe dementia, in an acute hospital, during health-care professional-initiated interactions. Analysis was limited to problems and solutions that were likely to be ‘trainable’. Actors required careful preparation to simulate people with dementia. Communication skills training course participants were volunteers, unlikely to be representative of the general workforce, who displayed high levels of baseline knowledge, confidence and skills. Before-and-after evaluations, and qualitative interviews, are prone to bias.ConclusionsRequests and closings pose particular difficulties for professionals communicating with people with dementia. We identified solutions to these problems and incorporated them into communication skills training, which improved knowledge, confidence and some communication behaviours. Simulation was an effective training modality.Future workFurther research should investigate a wider range of health, social care and family carers. Conversation analysis should be used to investigate other aspects of health-care communication.Study registrationThe systematic literature review is registered as CRD42015023437.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

The presence of companions adds complexity to healthcare interactions. Few studies have characterized challenges arising when interactions involve healthcare professionals (HCPs), patients, and companions, or how those challenges are managed. Using conversation analysis, we examined recorded episodes where patients and companions adopt divergent positions on healthcare measures (e.g., walking aids, homecare, medications). We found nine such episodes within a dataset of 37 palliative care consultations with 37 patients, their companions, and ten healthcare practitioners (HCPs) - doctors, physiotherapists and occupational therapists. Palliative care is one of several healthcare domains where companions substantially contribute to care, consultations, and decision making. We propose that, when patients and companions adopt divergent positions, HCPs face a 'dilemma of affiliation' wherein taking a position on the healthcare measure (e.g., recommending it) entails siding with one party, against the other. By examining what happens in the face of patient-companion divergence, we characterize HCPs' strategies and substantiate our proposal that these reflect an underlying dilemma. We show that: HCPs do not immediately take a position on the healthcare measure after patient-companion divergence emerges; and when HCPs take a position later in the consultation, they do so without ostensibly siding with the party who previously supported the healthcare measure. Further, once an HCP takes a position, the party who supports the measure can treat the HCP as an ally. We offer insights and propose implications for: palliative care; the interactional complexities of healthcare decision-making; and consultations in which companions participate.

Background Assessing pain is a key palliative care task. Structured tools to assess pain intensity are commonly used, but patients report challenges in responding to these. Aims The study aimed to analyse real-life episodes of pain scale use within hospice care, and develop communication training resources based on the findings. Methods Pain scale use was identified in a dataset of video-recorded hospice consultations involving 37 patients and five doctors in a large UK hospice. The video data was subjected to Conversation Analysis - a direct observational approach to describing the challenges, structure and functioning of people’s interactional behaviours. Results Pain rating-scales were used in 5/37 consultations. We found that patients capitalise on scale use: taking it as an opportunity to communicate multiple aspects of pain - not just intensity. Video-clips exemplifying this are included within ‘Real Talk’ training materials (www.realtalktraining.co.uk), alongside learning points detailing how practitioners can support and encourage patients to do so. We found instances (2/5) of numerical scale misunderstandings. The experienced doctors we recorded handled these carefully. A video-clip demonstrating how a doctor and patient resolve a misunderstanding with caution and sensitivity is included in the Real Talk materials. Analysis-based learning points describe how practitioners can avoid resolving the misunderstanding in ways that imply the patient is to blame, and also consider how misunderstandings can take considerable time and interactional effort to resolve. Conclusions Our analysis shows that pain rating-scales get used to report features besides their official target. Our findings directly underpin communication training resources for face-to-face training events - showing how professionals can support patients‘ maximal responses and how they can handle numerical rating misunderstandings in ways that avoid demeaning or disempowering patients.

This special section of Patient Education and Counseling is dedicated to advancing knowledge on communication about the end of life in healthcare settings. The five studies in the special section use the theoretical tenets and the analytic techniques of conversation analysis (CA). In this editorial we briefly overview prior CA research on communication about death and dying, we illustrate how the studies in this special section advance this research, and we consider the potential of CA studies to contribute further to understandings of this area of social life.

Background: Shared decision making (SDM) is generally treated as good practice in health-care interactions. Conversation analytic research has yielded detailed findings about decision making in health-care encounters. Objective: To map decision making communication practices relevant to health-care outcomes in face-to-face interactions yielded by prior conversation analyses, and to examine their function in relation to SDM. Search strategy: We searched nine electronic databases (last search November 2016) and our own and other academics’ collections. Inclusion criteria: Published conversation analyses (no restriction on publication dates) using recordings of health-care encounters in English where the patient (and/or companion)was present and where the data and analysis focused on health/illness-related decision making. Data extraction and synthesis: We extracted study characteristics, aims, findings relating to communication practices, how these functioned in relation to SDM, and internal/external validity issues. We synthesised findings aggregatively. Results: Twenty-eight publications met the inclusion criteria. We sorted findings into 13 types of communication practices and organized these in relation to four elements of decision-making sequences: (i) broaching decision making; (ii) putting forward a course of action; (iii) committing or not (to the action put forward); and (iv) HCPs’ responses to patients’ resistance or withholding of commitment. Patients have limited opportunities to influence decision making. HCPs’ practices may constrain or encourage this participation. Conclusions: Patients, companions and HCPs together treat and undertake decision making as shared, though to varying degrees. Even for non-negotiable treatment trajectories, the spirit of SDM can be invoked through practices that encourage participation (eg by bringing the patient towards shared understanding of the decision’s rationale).

Objectives: To contribute to understandings about acceptability and risks entailed in video-based research on healthcare communication. To generate recommendations for non-covert video-based research on healthcare communication − with a focus on maximising its acceptability to participants, and managing and reducing its risks. Methods: A literature review and synthesis of (a) empirical research on participant acceptability and risks of video recording; (b) regulations of professional and governmental bodies; (c) reviews and commentaries; (d) guidance and recommendations. These were gathered across several academic and professional fields (including medical, educational, and social scientific). Results: 36 publications were included in the review and synthesis (7 regulatory documents, 7 empirical, 4 reviews/commentaries, 18 guidance/recommendations). In the context of research aiming in some way to improve healthcare communication: •Most people regard video-based research as acceptable and worthwhile, whilst also carrying risks. •Concerns that recording could be detrimental to healthcare delivery are not confirmed by existing evidence. •Numerous procedures to enhance acceptability and feasibility have been documented, and our recommendations collate these. Conclusion and practice implications: The recommendations are designed to support deliberations and decisions about individual studies and to support ethical scrutiny of proposed research studies. Whilst preliminary, it is nevertheless the most comprehensive and detailed currently available.

Introduction Despite clear compatibilities between the tenets of occupational therapy and re-ablement, there is limited research on occupational therapy in homecare reablement services. This article describes an occupational therapy intervention that was delivered as part of a feasibility randomised controlled trial (Occupational Therapy intervention in HomEcare Re-ablement Services), and evaluates whether the intervention was acceptable to participants. Method There were three phases: (1) a bespoke pro forma was completed, recording the activities undertaken after each therapy visit; (2) an acceptability questionnaire was sent to every intervention participant and (3) semi-structured interviews were completed with key informants who received the intervention. Results The principal activities undertaken were assessment, case management, goal-setting, advice and support, and practising activities in relation to bathing/showering or kitchen activities. Participants particularly valued the advice and support provided. However, there were difficulties due to fluctuations in circumstances and with activities of daily living outside the home within the 6 week timescale. Conclusion An intervention focusing on activities of daily living within the home was acceptable for participants and consistent with their goals; however, they also had goals beyond personal activities of daily living and the timescale of the re-ablement episode. Further research should focus on extended activities of daily living, beyond this time-limited period.

Background Much palliative care communication training draws on sparse evidence about practice. Yet training’s effectiveness depends on the strength of its underpinning evidence. An empirical, observational science of language and social interaction – ‘Conversation Analysis’ holds great promise because: it is generating copious evidence on communication, and healthcare–communication specifically; shows role–played interactions differ from authentic ones in fundamentally important ways; recent quantitative evaluations of interventions based on conversation analytic findings have shown effectiveness. Within a research and training development programme, we designed novel training resources – ‘Real Talk’ incorporating research findings and clips from video-recorded hospice consultations. We designed Real Talk to complement rather than replace existing resources. We report a preliminary evaluation of Real Talk’s strengths and weaknesses. Method Mixed-methods, qualitative evaluation entailing observations, interviews, and participant-completed feedback questionnaires. Results We collected data from 11 events, 10 trainers across England, and 150 trainees. Conclusions Trainees and trainers alike appreciated the video clips and their authentic nature. Observations and reports indicated Real Talk was particularly effective for encouraging participants to both emotionally engage with the nature of palliative care, and actively engage in discussion and overall learning about communication practices. Trainers used the video clips more than they did the research findings components; with a similar pattern seen in most trainees’ feedback. Our decision to design Real Talk for trainers to use without initial intensive training meant we could rapidly and widely distribute the resources and evaluate their use. However, this also meant heavy reliance on trainers’ existing facilitation skills, and on their allocation of adequate time to familiarise themselves with the materials. We argue that this is also why the research findings-based components were not put to full use by trainers. We are revising Real Talk and its delivery on the basis of our evaluation.

Study objective Optimal practices for recruiting, consenting, and randomizing patients, and delivering treatment in out-of-hospital ultra-acute stroke trials, remain unclear. We aim to identify key barriers and facilitators relevant to the design and conduct of ambulance-based stroke trials and to formulate preliminary recommendations for the design of future trials. Methods Using semistructured interviews, we investigated the experiences and challenges faced by paramedics who took part in a randomized controlled trial in suspected ultra-acute stroke, the Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT), in which recruitment, consent, randomization, assessment, and treatment were delivered by paramedics before hospitalization. Results We purposively selected a diversity sample of 14 of the 78 paramedics who participated in RIGHT. We identified 13 themes (7 facilitators and 6 barriers to out-of-hospital stroke research). A simple stroke diagnostic tool, use of proxy consent on behalf of patients, and straightforward trial processes were identified as the main facilitators. Recruitment became easier with each new randomization attempt. Key barriers reported were informed consent in the emergency setting, lack of institutional support for research, learning curve and rarity (each paramedic treats only a few eligible patients), and difficulty in attending training sessions. Interviewed paramedics were motivated to participate in research. Conclusion Ultra-acute stroke research in the out-of-hospital environment is feasible, but important barriers need to be addressed. Proxy consent by paramedics addresses some of the difficulties with the consent process in the out-of-hospital setting.

Objective To break new ground by directly examining how patients seek life-expectancy estimates, and how doctors support them in doing so. Methods Conversation analytic examination of 10 recorded UK hospice consultations involving 3 palliative specialists. Results Life-expectancy estimate episodes frequently begin after a doctor has given a patient an opportunity to shape the consultation agenda. Rather than posing direct questions, patients cautiously display their interest in receiving an estimate using statements. These often contain preparatory information about: what they already know about their prognosis, their perspective on it, and readiness to hear more. When patients do not provide this information, doctors invite it before giving an estimate. Patients’ companions also contribute to this preparatory work. Conclusion Doctors, patients, and companions collaboratively work to prepare a conversational environment wherein emotional states and uncertainties have been addressed prior to delivery of the actual estimate. This helps manage both possible emotional distress, and prognostic uncertainty entailed in seeking and delivering estimates. Practice implications Clinicians should be mindful that rather than overtly requesting estimates, patients may seek them more cautiously. Before delivering estimates, doctors can support patients to articulate their existing understanding and perspective regarding prognosis, and their readiness to hear more.

Physiotherapists often have to ask their clients to move in a certain way, and they sometimes accompany such instructions with explanations. It turns out that these practitioners have an interesting resource—they can design their explanation to bear either upon the exact movement currently in play or on a more general or future case. I show that they make this distinction largely by how they deploy explanatory connectives like because, so, and so on—and, counterintuitively, how they omit such connectives. I finish by considering other datasets and discussing the pedagogical benefits, in any interaction, of being able to construct and convey different temporal domains that the account is meant to bear on.

OBJECTIVES: The objective of this study was to test the feasibility of conducting a randomised controlled trial (RCT) of an intervention targeted at activities of daily living (ADL), delivered by an occupational therapist, in homecare reablement.\ud \ud DESIGN: Feasibility parallel group RCT.\ud \ud SETTING: Single-site local authority homecare reablement service.\ud \ud PARTICIPANTS: People referred for homecare reablement with ability to consent. Exclusion criteria were as follows: inability to speak English, receiving other community therapy services, needing two or more to assist transfer and receiving end-of-life care.\ud \ud CONTROL: 'Usual care' was 6 weeks of homecare reablement delivered by social care workers (no routine health professional input).\ud \ud INTERVENTION: A targeted ADL programme, delivered by an occupational therapist incorporating goal setting, teaching/practising techniques, equipment/adaptations and provision of advice/support. This was in addition to usual care.\ud \ud OUTCOME MEASURES: Aspects of feasibility including eligibility, recruitment, intervention delivery, attrition and suitability and sensitivity of outcome measures. Participant outcomes were personal and extended ADL, quality of life, falls and use of health and social care services.\ud \ud RESULTS: 30 participants were recruited, 15 to each arm, which was 60% of those eligible. Data from 22 (73%) were analysed at 6 months. Of the 15 participants, 13 (86%) received the intervention and were able to set one or more ADL goals. There were improvements from baseline in both groups, although overall improvements were greater in the occupational therapy (OT) intervention group. The biggest threat to feasibility was a change in service configuration during the trial, involving additional occupational therapy input, affecting usual care and recruitment.\ud \ud CONCLUSIONS: Despite the service reconfiguration, it was feasible to recruit and retain participants, deliver the intervention and collect outcome data that were responsive to change. The choice of primary outcome measure remains unclear. A further powered study is feasible and warranted; however, the design will require careful consideration because of ongoing national changes in service configurations.\ud \ud TRIAL REGISTRATION NUMBER: ISRCTN21710246; Results.

Objective\ud To examine how palliative medicine doctors engage patients in end-of-life (hereon, EoL)\ud talk. To examine whether the practice of “eliciting and responding to cues”, which has been\ud widely advocated in the EoL care literature, promotes EoL talk.\ud Design\ud Conversation analysis of video- and audio-recorded consultations.\ud Participants\ud Unselected terminally ill patients and their companions in consultation with experienced palliative\ud medicine doctors.\ud Setting\ud Outpatient clinic, day therapy clinic, and inpatient unit of a single English hospice.\ud Results\ud Doctors most commonly promoted EoL talk through open elaboration solicitations; these\ud created opportunities for patients to introduce–then later further articulate–EoL considerations\ud in such a way that doctors did not overtly ask about EoL matters. Importantly, the\ud wording of elaboration solicitations avoided assuming that patients had EoL concerns. If a\ud patient responded to open elaboration solicitations without introducing EoL considerations,\ud doctors sometimes pursued EoL talk by switching to a less participatory and more presumptive\ud type of solicitation, which suggested the patient might have EoL concerns. These more\ud overt solicitations were used only later in consultations, which indicates that doctors give precedence to patients volunteering EoL considerations, and offer them opportunities to\ud take the lead in initiating EoL talk. There is evidence that doctors treat elaboration of\ud patients’ talk as a resource for engaging them in EoL conversations. However, there are limitations\ud associated with labelling that talk as “cues” as is common in EoL communication\ud contexts. We examine these limitations and propose “possible EoL considerations” as a\ud descriptively more accurate term.\ud Conclusions\ud Through communicating–via open elaboration solicitations–in ways that create opportunities\ud for patients to volunteer EoL considerations, doctors navigate a core dilemma in promoting\ud EoL talk: giving patients opportunities to choose whether to engage in conversations\ud about EoL whilst being sensitive to their communication needs, preferences and state of\ud readiness for such dialogue.

Objectives To survey practice and opinion regarding school-based teaching of communication skills, to summarise relevant research evidence from physiotherapy and beyond, to reflect on practice in light of evidence, and to propose associated recommendations. Design Survey using customised questionnaires. Basic descriptive statistical analysis and thematic content analysis were used. The results were compared with evidence from systematic reviews to derive recommendations. Survey participants and setting Educators in all UK centres delivering physiotherapy qualifying programmes in 2006. Results A response rate of 69% was achieved. The majority of respondents reported delivering communication-specific modules. Lecturing was common, and more experiential methods were also used. Assessment was mainly by written work. Educators commented on challenges and strategies involved in student engagement, provision of authentic experiences, availability of teaching time and expertise, and physiotherapy-specific teaching resources. Evidence from allied health profession, medical and nursing education research emphasises the importance of experiential teaching, formative feedback, observational assessment and a substantial evidence base on which to ground course content. In physiotherapy, the latter is emerging but incomplete. There are also gaps in direct evidence about advantages or otherwise of stand-alone modules and benefits of pre-qualification communication training. Evidence suggests that effective training requires substantial teaching time, expertise and a body of empirical research on specific communication practices and their effects. Conclusion Curriculum designers and educators should endeavour to maximise the degree to which training in this area is experiential, provide training when students have already had some contact with patients, and assess students by observation if at all possible. Due to gaps in the evidence, some important questions about optimal practice remain unanswered.

This paper examines healthcare communication between physiotherapists and patients during treatment sessions, using the perspectives and methods of conversation analysis. In particular, it examines communication about reasons and rationale for treatment actions by analysing physiotherapists' accounts (explanations) for these actions during treatment sessions. Circumstances in which accounts arise are identified, structural aspects described and their functions demonstrated. These accounts can be persuasive, can foster mutuality, minimise resistance and provide education. They contribute to sensitive handling of patients' physical failures and of removing clothing. Questions arising, but as yet unanswered, include whether clinicians' accounts impact on patients' perceptions and their long-term outcomes. Analysis sheds some light on why observers have found accounts are uncommon in actual consultations. It thereby contributes to sociological understandings about why certain matters are and are not communicated during healthcare encounters, demonstrating the significance of practical and interactional constraints. The findings also provide clinically relevant information about when and how accounts can be provided, and what accounting can achieve in terms of both local procedures and the overall character of the consultation and relationship.

Background: Conversation and discourse analytic research has yielded important evidence about skills needed for effective, sensitive communication with patients about illness progression and end of life. Objectives To: Locate and synthesise observational evidence about how people communicate about sensitive future matters; Inform practice and policy on how to provide opportunities for talk about these matters; Identify evidence gaps. Design: Systematic review of conversation/ discourse analytic studies of recorded interactions in English, using a bespoke appraisal approach and aggregative synthesis. Results: 19 publications met the inclusion criteria. We summarised findings in terms of eight practices: fishing questions - open questions seeking patients’ perspectives (5/19); indirect references to difficult topics (6/19); linking to what a patient has already said — or noticeably not said (7/19); hypothetical questions (12/19); framing difficult matters as universal or general (4/19); conveying sensitivity via means other than words, for example, hesitancy, touch (4/19); encouraging further talk using means other than words, for example, long silences (2/19); and steering talk from difficult/negative to more optimistic aspects (3/19). Conclusions: Practices vary in how strongly they encourage patients to engage in talk about matters such as illness progression and dying. Fishing questions and indirect talk make it particularly easy to avoid engaging — this may be appropriate in some circumstances. Hypothetical questions are more effective in encouraging on- topic talk, as is linking questions to patients’ cues. Shifting towards more ‘optimistic’ aspects helps maintain hope but closes off further talk about difficulties: practitioners may want to delay doing so. There are substantial gaps in evidence.

Objectives To describe and elucidate skilled practices by which physiotherapists communicate with patients about problems of ongoing or recent performance of physical treatment activities; to offer a sociological perspective on this area of practice; to examine relations between actual communication practice and official (Chartered Society of Physiotherapy) recommendations; to explore problems associated with formulating standards pertaining to communication and suggest how these might be addressed. Design Video recordings of physiotherapy treatment sessions (n = 74) were analysed using conversation analysis—an observational, inductive, social science methodology. Setting Inpatient rehabilitation units in four English hospitals. Participants Twenty-one stroke patients aged 52–86 years and 10 senior physiotherapists with 3–23 years of postqualification experience. Results and conclusions A variety of practices were identified. Managing shortcomings of performance often involves identifying and/or correcting the problem in a manner that deals sensitively with the negative connotations of physical non-competence. Characteristics of these practices include indirectness and ambiguity. As such, they do not conform to some official recommendations. However, good interactional reasons underlie the observed patterns. It is suggested that official guidance should acknowledge the complexity of communication and its measurement. Recommendations should be based upon a thorough understanding of the interactional tasks and practices entailed in physiotherapy. Recommendations should be explicitly tentative and refer to broad principles. By elucidating specific communication strategies, their consequences and the considerations that underlie them, conversation analytic research into physiotherapy communication has the potential to inform guidelines, and provide resources for developing and teaching communication skills.

Background: Homecare re-ablement services have been developed by local authorities in England in response to the government agenda for health and social care. These services aim to optimize users' independence and ability to cope at home, and reduce the need for ongoing health and social care services. However, there is currently limited evidence and guidance regarding the optimum configuration and delivery of re-ablement services. In particular, the impact of occupational therapy input on service user outcomes has been highlighted as a specific research priority. Methods/Design: This feasibility randomized controlled trial (RCT) will recruit 50 people from one local authority led homecare re-ablement service in England. Those who provide informed consent will be randomized to receive either usual homecare re-ablement (without routine occupational therapy input) or usual homecare re-ablement plus an enhanced program targeted at activities of daily living (ADL), delivered by an occupational therapist. The primary aim of this study is to assess the feasibility of conducting a further, powered study. The participant outcomes assessed will be independence in personal and extended ADL, health and social care-related quality of life, number of care support hours, falls, acute and residential admissions and use of health and social care services. These will be assessed at two weeks, three months and six months post-discharge from the re-ablement service. Discussion: To our knowledge, this is the first RCT of occupational therapy in homecare re-ablement services. The results of this study will lay the foundations for a further powered study. The findings will be relevant to researchers, clinicians, commissioners and users of adult social care services. Trial registration: Current Controlled Trials registration number: ISRCTN21710246 (registered on 31March 2014)

Objectives: To identify interventions that aim to reduce dependency in activities of daily living (ADL) in homecare service users. To determine: content; effectiveness in improving ability to perform ADL; and whether delivery by qualified occupational therapists influences effectiveness. Data sources: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, OTseeker, PEDro, Web of Science, CIRRIE, and ASSIA. Review methods: We included: randomised controlled trials, non-randomised controlled trials and controlled before and after studies. Two reviewers independently screened studies for inclusion, assessed risk of bias and extracted data. A narrative synthesis of the findings was conducted. Results: Thirteen studies were included, totalling 4975 participants. Ten (77%) were judged to have risk of bias. Interventions were categorised as those termed ‘re-ablement’ or ‘restorative homecare’ ( n=5/13); and those involving separate components which were not described using this terminology ( n=8/13). Content of the intervention and level of health professional input varied within and between studies. Effectiveness on ADL: eight studies included an ADL outcome, five favoured the intervention group, only two with statistical significance, both these were controlled before and after studies judged at high risk of bias. ADL outcome was reported using seven different measures. Occupational therapy: there was insufficient evidence to determine whether involvement of qualified occupational therapists influenced effectiveness. Conclusion: There is limited evidence that interventions targeted at personal ADL can reduce homecare service users’ dependency with activities, the content of evaluated interventions varies greatly.

Summary Evaluations of physiotherapy for stroke patients have been criticised for their lack of description of the content of treatments. The purpose of this paper is to describe in detail the physiotherapy approach employed in a recent trial ( Lincoln et al, 1999 ). The trial evaluated effects of early additional physiotherapy for the arm. The main outcome measures were the Rivermead Motor Assessment Arm Scale and the Action Research Arm Test. The trial included a comparison between treatments administered by a qualified physiotherapist and treatments delegated to a trained and closely supervised physiotherapy assistant. A post hoc subgroup analysis of the data from this trial suggested benefits in a small group of less severely impaired patients who had completed additional treatment in the assistant group ( Parry et al, 1999 ). This paper will discuss this finding in the light of differences in the content of treatment which was applied by the qualified and assistant therapists. Design The study was a randomised controlled trial. Outcome was compared between additional and routine amounts of physiotherapy, and between treatment given by a qualified physiotherapist and treatment given by a trained and supervised assistant. During the trial, descriptive data concerning the content of treatments were recorded. Following post hoc analysis which subdivided the patients into those who were more and less impaired, content of the treatments applied by the qualified therapist and by the trained supervised assistant were compared. Finding Treatment content differed between the assistant and qualified groups. Treatment in the less severe assistant subgroup included a greater proportion of repetitive supervised practice of movements and functional tasks. For all but one of the 93 patients randomised to the assistant's group, it was possible to construct a programme of treatment activities suitable for administration by a trained supervised assistant. There was no significant difference between the assistant and qualified groups in the number of patients who completed the treatment. Conclusions The findings from the subgroup analysis were the result of post hoc analysis of small groups and must therefore be viewed as speculative. However, previous research supports an argument that benefits in the milder patients treated by the assistant may have resulted from the emphasis on repetitive supervised practice in their therapy. We argue that it is appropriate to delegate this sort of treatment to trained and supervised physiotherapy assistants.

Objective: To investigate effect of initial severity of arm impairment on response to additional physiotherapy for the arm after stroke. Design: In this controlled trial, patients were randomized into one of three groups: routine physiotherapy (RPT) patients received no additional physiotherapy; qualified physiotherapy (QPT) patients received additional treatment from a qualified physiotherapist; assistant physiotherapy (APT) patients received additional treatment from a trained supervised assistant. Comparisons between the whole groups found no significant differences and have been reported elsewhere. In a post hoc analysis, the groups were subdivided according to severity of initial arm impairment. The subgroups were then compared. Setting: A general hospital with acute and rehabilitation facilities for stroke patients. Subjects: Patients (n= 282) between one and five weeks after stroke. Interventions: Ten hours additional physiotherapy were given over a five-week period. The treatment approach reflected current usual British practice. ‘Blind’ outcome assessment was performed after intervention, and at three and six months after stroke. Main outcome measures: Rivermead Motor Assessment Arm Scale, Action Research Arm Test. Results: In more severe patients, no benefits of additional treatment were detected. In less severe patients, significant benefits were found in those who completed treatment with the trained assistant. However, a considerable number of patients did not complete the additional treatment. The content of treatment differed between the QPT and APT groups. Treatment of less severe APT patients emphasized repetitive supervised practice of movements and functional tasks. No significant effects of additional treatment were found in terms of shoulder pain or spasticity. Conclusions: Regardless of whether additional physiotherapy was given or not, patients with severe arm impairment improved very little in arm function. Enabling adaptation to loss of arm function may be an appropriate rehabilitation strategy for some patients. Trends in the data confirm findings of some previous studies that intensive treatment for patients with some motor recovery of the upper limb is effective. Following patient assessment and treatment planning by a qualified physiotherapist, it may be appropriate for guidance of repetitive practice of motor and functional tasks to be delegated to trained and closely supervised assistant staff.

Background and Purpose —Many patients have impaired arm function after stroke, for which they receive physiotherapy. The aim of the study was to determine whether increasing the amount of physiotherapy early after stroke improved the recovery of arm function and to compare the effects of this therapy when administered by a qualified therapist or a trained, supervised assistant. The physiotherapy followed a typical British approach, which is Bobath derived. Ten hours of additional therapy were given over a 5-week period. Methods —The study design was a single-blind, randomized, controlled trial. Stroke patients were recruited from those admitted to the hospital in the 5 weeks after stroke. They were randomly allocated to routine physiotherapy, additional treatment by a qualified physiotherapist, or additional treatment by a physiotherapy assistant. Outcome was assessed after 5 weeks of treatment and at 3 and 6 months after stroke on measures of arm function and of independence in activities of daily living. Results —There were 282 patients recruited to the study. The median initial Barthel score was 6.5, and the median age of the patients was 73 years. The median initial Rivermead Motor Assessment Arm score was 1. There were no significant differences between the groups at randomization or on any of the outcome measures. Only half of the patients allocated to the 2 additional-therapy groups completed the program. Conclusions —This increase in the amount of physiotherapy for arm impairment with a typical British approach given early after stroke did not significantly improve the recovery of arm function in the patients studied. A number of other studies of interventions aimed at rehabilitation of arm function have reported positive results. Such findings may have been due to the content of these interventions, to the greater intensity of the interventions, or to the selection of patients to whom the treatments were applied.

This paper discusses some of the issues relevant to the role and training of physiotherapy assistants. It describes the processes of role definition, assessment and training of one particular assistant, developed in the context of a larger research study. A small survey of senior physiotherapists' views on task delegation, training and working with assistants was conducted, using semi-structured interviews. The method and findings are described; broad agreement between the physiotherapists was found. A training and assessment package was then developed and implemented. The training was specifically related to treatment of the upper limb of acute stroke patients. While delegation to assistants is part of everyday practice for many physiotherapists and the training of these staff a professional obligation, the structure and support to do so are often lacking. In the context of the description of a particular case, this paper provides some insights and points of interest for clinicians involved in training and task delegation to assistants.

There is a growing demand for services whereby individuals receive assistance from care workers for personal care within the home. This has led to the development of re-ablement or restorative homecare services that provide time-limited input aimed at reducing dependency in personal activities of daily living, and preventing or delaying the need for further homecare support. However, little is currently known about how such interventions are configured, or how they may affect individuals’ ability to carry out personal care independently. We will seek to identify studies that compare an intervention designed to reduce dependency in personal activities of daily living with routine input or usual care as the control. We will include randomised controlled trials, nonrandomised controlled trials, and controlled before and after studies. We will also include interrupted time series studies. We shall search electronic databases in addition to searching for ongoing and unpublished studies, and where appropriate will contact key authors. Two reviewers will independently screen articles for inclusion; will assess risk of bias using quality assessment tools; and will carry out data extraction using pre-prepared forms. Any disagreements, at any stage, will be resolved by discussion and the involvement of a third reviewer if needed. We will produce a narrative summary of the results. A meta-analysis will be conducted if sufficient data are available of appropriate quality and comparability. The findings from this review will inform future practice within homecare re-ablement services; will inform policy decisions about the structure, organisation and content of such services; and will identify areas where further research is warranted. This review protocol has been registered on the PROSPERO database ( CRD42013004163 ).

Background. Time from acute stroke to enrolment in clinical trials needs to be reduced to improve the chances of finding effective treatments. No completed randomised controlled trials of ambulance-based treatment for acute stroke have been reported in the UK, and the practicalities of recruiting, consenting, and treating patients are unknown.Methods. RIGHT is an ambulance based, single-blind, randomised controlled trial with blinded-outcome assessment. The trial will assess feasibility of using ambulance services to deliver ultra-acute stroke treatments; a secondary aim is to assess the effect of glyceryl trinitrate (GTN) on haemodynamic variables and functional outcomes. Initial consent, randomisation, and treatment are performed by paramedics prior to hospitalisation. Patients with ultra-acute stroke (≤4 hours of onset) are randomised to transdermal GTN (5 mg/24 hours) or gauze dressing daily for 7 days. The primary outcome is systolic blood pressure at 2 hours. Secondary outcomes include feasibility, haemodynamics, dependency, and other functional outcomes. A nested qualitative study is included.Trial Status. The trial has all relevant ethics and regulatory approvals and recruitment started on February 15, 2010. The trial stopped recruitment in December 2011 after 41 patients were recruited.Trial Registration. The trial registration number is ISRCTN66434824 and EudraCT number is 2007-004766-40.

Objective (1) To systematically review direct evidence about effects of interventions to improve communication performance amongst allied health professionals (AHPs). (2) To summarise indirect evidence pertinent to design, delivery, effects, and evaluation of such interventions. Methods (1) Systematic search and narrative review of evaluations of interventions for AHPs. (2) Systematic search and narrative summary of reviews of corresponding interventions in medicine and nursing. Results Five reports of interventions for AHPs were included. All reported positive effects of training. Strongest evidence was from two small-n within-subjects controlled studies that evaluated highly specific training for qualified therapists in brain injury rehabilitation environments. Indirect evidence from nine systematic reviews in medicine and nursing indicated positive effects of communication training. Robust designs yielded smallest effect sizes. Interventions based on strong conceptual and empirical foundations and targeting specific areas of practice appeared more effective. Strongest evidence is for performance-based training for clinicians already working with patients. Conclusion More empirical and conceptual understandings about AHPs’ communication practices are required so as to improve the design, delivery and subsequent evaluation of communication training amongst these important healthcare workers. Practice implications Preliminary and indirect evidence suggest it is possible to positively influence AHP clinicians’ performance and patients’ outcomes if training interventions are specific, founded on evidence about effective practice and delivered using practical modalities.

This paper explores relations between official written recommendations for physiotherapists and actual practice. It does so by presenting and discussing findings from a conversation analytic study of 74 physiotherapy treatment sessions video-recorded in four English hospitals. Various practices are described by which therapists address troubles of ongoing or recent physical performance by patients during phases of sessions that are occupied with therapists' instructions in treatment activities and patients' physical responses. Divergence between practice and official guidance can be observed, particularly regarding recommendations that therapists always be unambiguous and clear in their communication with patients. Also, there seem to be conflicting demands between maintaining performance of physical treatment activities, whilst also spending time giving patients information and explanation about troubles of performance, and checking their understanding (as is recommended). There are also conflicting demands between individual recommendations. These observations inform a discussion of the wider challenges involved in formulating relevant, appropriate official guidance on communication practice. I argue that the difficulties of auditing actual conduct against official recommendations on interaction should be acknowledged, and that recommendations should be explicitly tentative and broad. Conversation analytic studies can provide resources and understandings to complement and augment such official guidance.

Patients' physical incompetence is a feature of many clinical interactions; the challenges it presents are not only technical but also interactional. This paper examines how interpretations and interactional consequences of physical incompetence are dealt with during stroke physiotherapy. A conversation analytic approach was used to examine video-recorded treatment sessions. Analysis demonstrated that managing physical incompetence forms an important element of the organisation of these interactions. Through their conduct, patients and therapists limit and counter its various negative implications, including those which attribute it to failure of a patient's efforts, co-operation and personal competence, and failure of therapy. Understanding orientations to incompetence and their influence upon interactions provides some explanations, or 'good reasons', for certain features of clinical interactions that have attracted criticism. Analysis also shows how management of incompetence is grounded in the clinician's authority and contributes to its maintenance. In the face of failures of physical competence, participants collaboratively and continually work to portray patients as deserving of treatment rather than sanction, and to convey that despite evident difficulties, the therapeutic process is a co-operative and successful endeavour. The paper examines how these meanings are addressed and accomplished through interaction.

Objective: To analyse in detail therapists' and patients' communication practices during physiotherapy goal-setting in stroke rehabilitation settings. To deduce explanations for observed practices. To contribute to understanding of the communication challenges entailed in goal-setting. Design: A conversation analytic study of video-recorded treatment sessions. Setting: Physiotherapy ‘gyms’ in four UK hospitals. Subjects: The 74 recorded sessions involved 21 patients (52-86 years, 11 female) and 10 senior physiotherapists. Patients' disabilities varied; none were severely aphasic. Nine of the therapists were female, post qualification experience ranged from 3 to 23 years. Findings: Eight goal-setting episodes were identified. In all but one, therapists supplied the target problems or abilities for which goals were subsequently set. The case in which the patient was asked to propose problems prior to goal-setting is examined in detail. Various interactional difficulties and delays arose both in eliciting the patient's views and incorporating them into agreed goals. Strategies by which the therapist dealt with difficulties included repeated and constraining questions, negotiation, and amending proposed goals. Conclusions: Findings of this small, detailed study might help explain previous observations of infrequent goal-setting and failure to maximize patients' involvement therein. Goal-setting, particularly where patients' views are elicited and incorporated, involves skill and effort, and is influenced by powerful social constraints. Developing detailed knowledge of both practices and constraints may contribute to improving professional practice, guidance and education. The paper demonstrates the utility of detailed analysis of rehabilitation communication using conversation analytic methods.

There are numerous contested issues in qualitative research, and its findings are difficult to condense. Thus, short, qualitative research abstracts are difficult both to compile and evaluate. The Society for Research in Rehabilitation has produced guidelines that aim to illuminate and inform the development and judging of such abstracts. These draw on an extensive Health Technology Assessment review of qualitative methods in health services research.

Introduction Communicating with patients about their feelings and preferences for the future is a challenging element of palliative care. Useful evidence exists, but most is embedded in social-scientific rather than clinical research. Aims and Methods To collate evidence about communication practices used in addressing sensitive future issues, from studies where patient/professional conversations have been recorded and analysed. To inform communication policy, practice and training. This innovative systematic review spanned social science, clinical and linguistics research. Using explicit criteria, we searched electronic databases and specialist sources. We used review and synthesis techniques appropriate for social-science research. Results 2203 publications were initially identified. Of the 18 meeting the inclusion criteria, 5 were social science, five clinical and eight linguistics publications. Strong evidence (11/18) indicates hypothetical questions are effective in encouraging people to address feelings and plans for uncertain and difficult futures. Moderate evidence (5/18) indicates that another way to create such opportunities entails using cautious, euphemistic language ; and that this provides distinctive opportunities for people to deflect or avoid the topic. Moderate evidence (3/21) indicates that people often steer such conversations towards more optimistic statements , which tends to stop further talk about difficult events. Conclusions Social-science, linguistic and clinical evidence is available to inform this skilled, often problematic element of care. There are different ways to provide opportunities to discuss feelings and plans in relation to end of life. Different ways have different results: better understandings of these will facilitate evidence-based communication. To fill gaps in knowledge, further research using recordings of authentic palliative care consultations is needed.