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.