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

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)

Healthcare professionals’ assertions and women's responses during labour: A conversation analytic study of data from One born every minute

© 2016 Elsevier Ireland Ltd Objective Communication during labour is consequential for women's experience yet analyses of situated labour-ward interaction are rare. This study demonstrates the value of explicating the interactional practices used to initiate ‘decisions’ during labour. Methods Interactions between 26 labouring women, their birth partners and HCPs were transcribed from the British television programme, One Born Every Minute. Conversation analysis was used to examine how decisions were initiated and accomplished in interaction. Findings HCPs initiate decision-making using interactional practices that vary the ‘optionality’ afforded labouring women in the responsive turn. Our focus here is on the minimisation of optionality through ‘assertions’. An ‘assertive’ turn-design (e.g. ‘we need to…’) conveys strong expectation of agreement. HCPs assert decisions in contexts of risk but also in contexts of routine activities. Labouring women tend to acquiesce to assertions. Conclusion The expectation of agreement set up by an assertive initiating turn can reduce women's opportunities to participate in shared decision-making (SDM). Practice implications When decisions are asserted by HCPs there is a possible dissonance between the tenets of SDM in British health policy and what occurs in situ. This highlights an educational need for HCPs in how best to afford labouring women more optionality, particularly in low-risk contexts

How companions speak on patients’ behalf without undermining their autonomy: Findings from a conversation analytic study of palliative care consultations

Companions are individuals who support patients and attend healthcare appointments with them. Several studies characterised companions’ participation in broad terms, glossing over the details of how they time and design their actions, and how patients and healthcare practitioners (HCPs) respond to them. This paper aims to examine these aspects in detail by using conversation analysis, focusing on actions whereby companions speak on patients’ behalf—mentioning delicate aspects of patients’ experience (specifically, by alluding to patients’ thoughts or feelings about dying). Some studies suggest that these actions undermine patients’ autonomy. By contrast, through examination of palliative care consultations in a UK hospice, we found that these interventions are warranted by contextual circumstances: they are either invited by patients or HCPs (through questions or gaze) or volunteered to help with the progression of an activity (e.g., when a patient does not answer an HCP’s question). Additionally, all parties collaborate in constructing these companion interventions as temporary departures from an otherwise prevailing normative orientation to patients’ right to speak for themselves. The study contributes to the sociology of health an illness by characterising how companions contribute to the ways in participant coordinate their relative rights and responsibilities, and ultimately their relationships, within healthcare interactions

Real Talk facilitator manual

Real Talk comprises resources for teaching communication skills relevant to palliative and end of life care. Real Talk has been developed as part of a research programme, and aims to enhance the quality and effectiveness of evidence-based communication skills training in the area of end of life care. The research programme is called VERDIS, which refers to video-based research and training on supportive and end of life care interactions. The research approach we use is called Conversation Analysis. VERDIS has been supported by Loughborough University, the University of Nottingham, and grant funding from The Health Foundation and the NIHR

Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice

Background: There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care; effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions. Methods: The current rapid review updates findings of the 2014 systematic review focussing more specifically on evidence related to illness progression and end-oflife conversations. Literature searches were conducted in nine bibliographic databases. Studies using conversation analysis or discourse analysis to examine recordings of actual conversations about illness progression or end of life were eligible for inclusion in the review. An aggregative approach was used to synthesise the findings of included studies. Results: Following screening, 26 sources were deemed to meet eligibility criteria. Synthesis of study findings identified the structure and functioning of ten communication practices used in illness progression and end-of-life discussions. Conclusion: The ten practices identified underpin five evidence-based recommendations for communicating with patients or family members about illness progression and end of life

End of Award Report February 17TH 2016: VERDIS: Video-based communication research and training in supportive and palliative care

High quality staff-patient communication is central to compassionate, effective healthcare. There has been limited progress towards generating robust evidence about the precise structure and functioning of healthcare communication. This impedes development of effective interventions and their evaluation. Conversation analysis, which relies on audio- and video-recordings of naturally occurring healthcare episodes is making rapid advances, particularly in generating evidence about communication in primary care medicine. The conversation analytic approach was used in this study to generate underpinning knowledge about the structures and functioning of healthcare communication behaviours in specialist palliative care, and to design associated staff communication skills training materials. In this study, we focused on communication in specialist palliative care provided in a hospice. Good communication is central to high quality effective care for people nearing the end of life and their friends and relatives [1, 2]. Poor communication is associated with distress and complaints [3, 4]. Also, we know that one particular element of communication in this domain - discussing and making plans and decisions about future care - influences place of death, and aggressiveness of care [5, 6], but little is known about precisely how staff can support patients to engage with such sensitive, challenging discussions, and about how to do so in an empathic manner. Thus we studied decision-making communication and communication associated with empathy – a quality highly valued by patients and their companions [7]. We know that patients and professionals are reluctant to address sensitive issues and decisions about the future and that practitioners’ uncertainty about how to talk with patients and family members about these is an important obstacle [8]. In an international survey of 90 palliative care experts, 80% wanted more evidence-based guidance on optimal communication strategies to improve decision-making practice [9]. There is already an established communication skills training programme for healthcare professionals – the ‘Connected’ advanced communication skills training programme, which is based within regional cancer networks, and funded through local commissioning [10, 11]. This kind of training is primarily delivered to staff who work in oncology and specialist palliative care. Systematic reviews indicate these courses have some positive effects [3], but that these are confined to two particular behaviours: trainees’ expression of empathy and question-asking behaviours. Unfortunately, no benefits have been shown in terms of patients’ communication behaviours and their perceptions of communication quality; also evidence about long-term effectiveness is contradictory [3]. Furthermore, current training is based upon limited evidence: little derives from direct observations [10], and most is specific to cancer patients [11]. There is good reason to anticipate stronger effects were it grounded in more detailed evidence about communication behaviours and skills [10, 12-14]. This study aimed to generate such detailed evidence, with data and analysis not solely confined to discussions with people with cancer. Video-based research on communication is relatively new within healthcare research, but is already developing a track record of yielding useful findings, for instance, it has identified specific communication practices that enhance patient satisfaction [15], and that increase vaccine uptake rates [16]. Video-based conversation analytic research has also led to design of communication training and interventions that have been shown to be effective in improving healthcare consultations – for instance in enabling primary care patients to express more of their concerns within consultations with doctors [12], and people attending HIV clinics to express their concerns more succinctly and readily [17]. Thus we know that video-based research on recordings of ‘real’ patients and professionals yields benefits to patients. However, it is not yet known whether using video-recordings of ‘real’ rather than simulated interactions in communication training increases its effectiveness and thus leads 5 to improvements in staff-patient communication; we will address this important question within the research programme of which the current study forms part. In this study we sought to generate evidence about how experienced, specialist hospice doctors communicate with patients and their accompanying friends/relatives, and design staff communication training materials aiming to pass on those skills to less experienced, less specialist staff. The resultant materials include video-clips of real interactions (where all participants permitted this use of their recordings); these were piloted in communication skills training at 11 sites and a preliminary evaluation conducted on trainees’ and trainers’ perspectives on perceived value, acceptability and usability