Official recommendations and actual practice in physiotherapy: Managing troubles of physical performance

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

Distribution of agency across body and self

Distributed Agency presents an interdisciplinary inroad into the latest thinking about the distributed nature of agency: what it's like, what are its conditions of possibility, and what are its consequences. The book's 25 chapters are written by a wide range of scholars, from anthropology, biology, cognitive science, linguistics, philosophy, psychology, geography, law, economics, and sociology. While each chapter takes up different materials using different methods, they all chart relations between the key elements of agency: intentionality, causality, flexibility and accountability. Each chapter seeks to explain how and why such relations are distributed-not just across individuals, but also across bodies and minds, people and things, spaces and times. To do this, the authors work through empirical studies of particular cases, while also offering reviews and syntheses of key ideas from the authors' respective research traditions. Our goals with this collection of essays are to assemble insights from new research on the anatomy of human agency, to address divergent framings of the issues from different disciplines, and to suggest directions for new debates and lines of research. We hope that it will be a resource for researchers working on allied topics, and for students learning about the elements of human-specific modes of shared action, from causality, intentionality, and personhood to ethics, punishment, and accountability

How and when do patients request life-expectancy estimates? Evidence from hospice medical consultations and insights for practice

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

Systematically reviewing and synthesizing evidence from conversation analytic and related discursive research to inform healthcare communication practice and policy: an illustrated guide

Background: Healthcare delivery is largely accomplished in and through conversations between people, and healthcare quality and effectiveness depend enormously upon the communication practices employed within these conversations. An important body of evidence about these practices has been generated by conversation analysis and related discourse analytic approaches, but there has been very little systematic reviewing of this evidence. Methods. We developed an approach to reviewing evidence from conversation analytic and related discursive research through the following procedures:.• reviewing existing systematic review methods and our own prior experience of applying these.• clarifying distinctive features of conversation analytic and related discursive work which must be taken into account when reviewing.• holding discussions within a review advisory team that included members with expertise in healthcare research, conversation analytic research, and systematic reviewing.• attempting and then refining procedures through conducting an actual review which examined evidence about how people talk about difficult future issues including illness progression and dying. Results: We produced a step-by-step guide which we describe here in terms of eight stages, and which we illustrate from our 'Review of Future Talk'. The guide incorporates both established procedures for systematic reviewing, and new techniques designed for working with conversation analytic evidence. Conclusions: The guide is designed to inform systematic reviews of conversation analytic and related discursive evidence on specific domains and topics. Whilst we designed it for reviews that aim at informing healthcare practice and policy, it is flexible and could be used for reviews with other aims, for instance those aiming to underpin research programmes and projects. We advocate systematically reviewing conversation analytic and related discursive findings using this approach in order to translate them into a form that is credible and useful to healthcare practitioners, educators and policy-makers

Training and assessment of physiotherapy assistants

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

Blame attributions and mitigated confessions: The discursive construction of guilty admissions in celebrity TV confessionals

Drawing on insights from conversation analysis, discursive psychology and social psychology, this paper 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, i.e. 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, whilst simultaneously inviting the celebrity guest to tell their side of the story. We also show how celebrity guests produce descriptions which minimise 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

Talking about death and dying: Findings and insights from five conversation analytic studies (Editorial)

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

Communication practices that encourage and constrain shared decision making in health-care encounters: Systematic review of conversation analytic research

© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd 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)

What do displays of empathy do in palliative care consultations?

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

"What do you expect from physiotherapy?": a detailed analysis of goal setting in physiotherapy

Purpose: Health care practice guidelines require physiotherapists to include patients in goal-setting. However, not much is known about how this process is accomplished in practice. The purpose of this study is to analyse patient–physiotherapist consultations and to identify how physiotherapists enquire about goals and how patients respond to these enquiries. Method: 37 consenting patients and their physiotherapist from outpatient physiotherapy practice settings were videotaped. Conversation analysis was used to transcribe and analyse the data. Results: In 11 cases, physiotherapists enquire explicitly about goals. Patients’ responses indicate that problems can arise when therapists’ questions treat it as expected that the patient has a goal already in mind, and has sufficient understanding about “physiotherapy-relevant” goals. Patients’ difficulties with stating a goal are related to patients’ knowledge to propose a goal and whether they treat consultations as one in which it is appropriate to claim knowledge about goals. Conclusions: Goal-setting is not a straightforward process. Practices that entail asking patients to state their goals neither take into consideration the fact that patients may not know what an achievable goal is nor do they consider so-called social reasons for patients not to make claims to their physiotherapist about what the goals should be