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Objective To explore the processes by which therapeutic alliance develops in mental health consultations with Sign Language interpreters. Method Semi-structured interviews with 7 qualified interpreters were transcribed and analysed with interpretative phenomenological analysis. Results Two key themes were generated: (1) Nurturing the triangle of care, where the therapeutic process relied on collaboration, continuity, and trust; and (2) Shared vision and knowledge, in which participants felt misunderstood and unsupported; there was a lack of deaf awareness and clinicians appeared to feel deskilled. Conclusions Interpreters should be viewed as valued members of clinical teams and have access to clinical supervision so that they can be supported in interpreting emotional distressing content. Clinicians can aim to be collaborative with interpreters and improve their knowledge of mental health issues that are relevant to deaf people. Practice Implications An aide-memoire of the role and practicalities of working with SL interpreters should be developed and disseminated to relevant services to support collaborative working with clinicians. A core competence in SL interpreter training is reflexivity. This should be embedded in educational curricula and facilitated through clinical supervision. Funding by commissioning services should be subject to services being deaf aware and interpreters being mental health aware., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: This study explored the perspectives of people affected by Huntington's disease (HD) on their own communicative abilities., Methods: Qualitative semi-structured interviews were carried out with eight people with early HD. The data were analysed through thematic analysis., Results: Four themes were constructed from the data, characterised by the following core topics: How HD directs and mediates communication; Regaining control to improve communication; Emotional outflows into communication and the struggle for separation; Sheltering as a way to boost confidence in communication., Discussion: Separating patients' identity as individuals from that of a person with a disease can help increase communicative control. Consistent with the general theory and model of self-regulation, patients should be allowed a wider range of choices to regain control over communication. Achieving better emotion regulation is of paramount importance for communication, and factors such as medication regimes, relationships and existing coping strategies should be strengthened. Consistent with previous research, feelings of safety and the idea of a safe place ('sheltering') represent an effective coping mechanism. Practical implications include the refinement of communication and relationships among clinicians, caregivers, and patients with HD by considering a wider range of medical, psychological and socio-environmental factors.

Objective: To investigate whether and how doctors' attachment styles and emotional intelligence (EI) might influence patients' emotional expressions in general practice consultations., Methods: Video recordings of 26 junior doctors consulting with 173 patients were coded using the Verona Coding Definition of Emotional Sequences (VR-CoDES). Doctors' attachment style was scored across two dimensions, avoidance and anxiety, using the Experiences in Close Relationships: Short Form questionnaire. EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. Multilevel Poisson regressions modelled the probability of patients' expressing emotional distress, considering doctors' attachment styles and EI and demographic and contextual factors., Results: Both attachment styles and EI were significantly associated with frequency of patients' cues, with patient- and doctor-level explanatory variables accounting for 42% of the variance in patients' cues. The relative contribution of attachment styles and EI varied depending on whether patients' presenting complaints were physical or psychosocial in nature., Conclusion: Doctors' attachment styles and levels of EI are associated with patients' emotional expressions in primary care consultations. Further research is needed to investigate how these two variables interact and influence provider responses and patient outcomes., Practice Implications: Understanding how doctors' psychological characteristics influence PPC may help to optimise undergraduate and postgraduate medical education., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To investigate the relationship between trainee doctors' attachment style and their performance in qualifying clinical and communication skills assessments., Methods: Participants were 190 undergraduate medical students whose performance was assessed by examiners across two areas (communication and clinical skills) during their qualifying Objective Structured Clinical Examination (OSCE). Simulated patients also rated communication skills. Participants' attachment style was rated across two dimensions, avoidance and anxiety, using the Relationship Questionnaire (RQ)., Results: Lower levels of attachment avoidance and anxiety significantly predicted higher performance in both communication and clinical skills., Conclusion: Trainee doctors' attachment styles are associated with patient communication and clinical performance. Further research is needed to investigate the impact of attachment on consultations between doctors and patients within clinical settings., Practice Implication: Attachment theory can inform our understanding why, for some student doctors, interacting with patients may be particularly challenging and require additional support by medical educators., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Good doctor-patient communication may lead to better compliance, higher patient satisfaction, and finally, better health. Although the social variance in how physicians and patients communicate is clearly demonstrated, little is known about what patients with different educational attainments actually prefer in doctor-patient communication. In this study we describe patients' perspective in doctor-patient communication according to their educational level, and to what extent these perspectives lean towards the expert opinion on doctor-patient communication. In a multi-center study (Belgium, The Netherlands, UK and Italy), focus group discussions were organised using videotaped medical consultations. A mixed methods approach was used to analyse the data. Firstly, a difference in perspective in communication style was found between the lower educated participants versus the middle and higher educated participants. Secondly, lower educated participants referred positively most to aspects related to the affective/emotional area of the medical consultation, followed by the task-oriented/problem-focused area. Middle and higher educated participants positively referred most to the task-oriented/problem-focused area. The competency of the physician was an important category of communication for all participants, independent of social background. The results indicate that the preferences of lower educated participants lean more towards the expert opinion in doctor-patient communication than the middle and higher educated participants. Patients' educational level seems to influence their perspective on communication style and should be taken into account by physicians. Further quantitative research is needed to confirm these results.

Background: The literature shows that the quality of communication is usually determined from a professional perspective. Patients or lay people are seldom involved in the development of quality indicators or communication., Objective: To give voice to the lay people perspective on what constitutes 'good communication' by evoking their reactions to variations in physician communication., Design: Lay people from four different countries watched the same videotaped standardized medical encounters and discussed their preferences in gender-specific focus groups who were balanced in age groups., Setting and Participants: Two hundred and fifty-nine lay people (64 NL, 72 IT, 75 UK and 48 BE) distributed over 35 focus groups of 6-8 persons each., Main Variables Studied: Comments on doctors' behaviours were classified by the GULiVer framework in terms of contents and preferences., Results: Participants prevalently discussed 'task-oriented expressions' (39%: competency, self-confident, providing solutions), 'affective oriented/emotional expressions' (25%: empathy, listening, reassuring) and 'process-oriented expressions' (23%: flexibility, summarizing, verifying). 'Showing an affective attitude' was most appreciated (positive percentage within category: 93%, particularly facilitations and inviting attitude), followed by 'providing solution' (85%). Among disfavoured behaviour, repetitions (88%), 'writing and reading' (54%) and asking permission (42%) were found., Conclusions: Although an affective attitude is appreciated by nearly everybody, people may vary widely in their communication needs and preferences: what is 'good communication' for one person may be disliked or even a source of irritation for another. A physician should be flexible and capable of adapting the consultation to the different needs of different patients. This challenges the idea of general communication guidelines., (© 2013 John Wiley & Sons Ltd.)

Objective: Attachment style and emotional intelligence (EI) have been highlighted as potential factors influencing the variation in medical students' and doctors' patient-provider communication (PPC), particularly in relation to emotive issues. The objective of this review is to systematically review and synthesise the published literature relating to the influence of medical students' and/or doctors' attachment style and EI on their PPC., Methods: Electronic and hand searches were conducted to identify all published literature relating to the aim of the review. Data were narratively synthesised., Results: 1597 studies were identified. 14 were included in the review, of which 5 assessed the influence of attachment style and 9 assessed the influence of EI on PPC. No studies assessed the impact of both attachment style and EI on PPC., Conclusion: Whilst tentative links were found between both PPC and both attachment style and EI, heterogeneity in study design, predictor variables and outcome measures made drawing conclusions difficult., Practice Implications: More research is needed to assess the influence of both attachment style and EI on PPC., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: to establish which kind of physician communicative responses to patient cues and concerns are appreciated by lay people., Methods: A balanced sample (259 people) was recruited in public places to participate in a full day observation of four videotaped standardized medical consultations. In a two-step procedure participants gave their individual quality ratings of the whole consultations and then of a set of four fragments from each consultation. They contained a patient negative emotional expression and the subsequent physician response, according to the VR-CoDES., Results: Higher quality ratings were given to physician responses which provided space to the patient to talk and to the explicit expressions of empathy. The explicit responses were favored above non-explicit responses. Participants' global evaluation of the whole consultation affected their quality assessments of the fragments (halo-effect). In a multivariate model, lay people's background characteristics appeared to be relevant: to be female, of lower educational level and living in Belgium or Italy predicted higher ratings., Conclusions: Providing space to patients is appreciated by all participants, combined with the need for tailor made communication., Practice Implications: To teach physicians listening skills and how to show empathy with distressed patients should be a core element in medical education., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: The project GULiVer explores how lay people in Belgium (Gent), the Netherlands (Utrecht), the UK (Liverpool) and Italy (Verona) evaluate physicians' communicative skills. The aims are to present the study design and to assess the quality of collected data., Methods: In each centre one out of two sets of four videotaped consultations involving medical students with varying communication skills were shown to eight lay panels of six to nine participants each (n = 259). The selection of lay participants was stratified by gender and age in order to obtain a heterogeneous sample. Background characteristics included socio-demographics, participants' general physical (COOP-WONCA) and mental health (GHQ), communication preferences (QUOTE-com) and trust in doctors (TMP). Participants were asked to give quantitative and qualitative evaluations of the student doctors' performance in a mixed-methods design. Quality assessment of the collected data and protocol adherence of the four centres was carried out by Generalized Linear Model (GLM)., Results: The overall sample comprised 259 participants. Participants were equally distributed among the centres and balanced in terms of age, gender and OSCE scenario, confirming the quality of collected data., Conclusion: The study design and the applied procedures will ensure a great richness of data allowing a wider European perspective on lay persons' views, assessed both individually and through focus group discussion.

Objectives: We reviewed papers describing the development of instruments for assessing clinical communication in undergraduate medical students. The instruments had important limitations: most lacked a theoretical basis, and their psychometric properties were often poor or inadequately investigated and reported. We therefore describe the development of a new instrument, the Liverpool Undergraduate Communication Assessment Scale (LUCAS), which is intended to overcome some of these limitations. We designed LUCAS to reflect the theory that communication is contextually dependent, inherently creative and cannot be fully described within a conceptual framework of discrete skills., Methods: We investigated the preliminary psychometric properties of LUCAS in two studies. To assess construct and external validity, we examined correlations between examiners' LUCAS ratings and simulated patients' ratings of their relationships with students in Year 1 formative (n = 384) and summative (n = 347) objective structured clinical examination (OSCE) samples. Item-total correlations and item difficulty analyses were also performed. The dimensionality of LUCAS was examined by confirmatory factor analysis. We also assessed inter-rater reliability; four raters used LUCAS to rate 40 video-recorded encounters between Year 1 students and simulated patients., Results: Simulated patient ratings correlated with examiner ratings across two OSCE datasets. All items correlated with the total score. Item difficulty showed LUCAS was able to discriminate between student performances. LUCAS had a two-dimensional factor structure: we labelled Factor 1 creative communication and Factor 2 procedural communication. The intraclass correlation coefficient was 0.73 (95% confidence interval 0.54-0.85), indicating acceptable reliability., Conclusions: We designed LUCAS to move the primary focus of examiners away from an assessment of students' enactment of behavioural skills to a judgement of how well students' communication met patients' needs. LUCAS demonstrated adequate reliability and validity. The instrument can be administered easily and efficiently and is therefore suitable for use in medical school examinations., (© Blackwell Publishing Ltd 2012.)

Objective: The aim of this study is to generate empirically based 'tips' from lay people on how medical consultations could become more successful from a patient perspective., Methods: 258 Lay people in the United Kingdom, Italy, Belgium and the Netherlands, distributed over 32 focus groups, were invited to formulate 'tips' for doctors as well as patients after rating the quality of communication from videotaped consultations and discussing their arguments in focus groups., Results: Tips were remarkably similar across the four countries. Most tips reflect the professional literature, such as the importance of nonverbal communication, personal attention and empathy, but also addressed issues as how to deal with new technologies and new accessibility arrangements (triage). The tips were targeted to the consultation itself, its preparation and the aftercare. Tips for doctors were mirrored in tips for patients., Conclusion: Lay people seem to be competent in participating in quality-of-care debates. They are well aware of patients' own responsibilities. Besides, they have clear opinions about novel technology and healthcare arrangements (triage)., Practice Implications: Listening to patients, showing empathy and personal attention seem to have a universal value. Doctors should be trained to practice these behaviors, healthcare managers in involving patients in practice reorganisations., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To investigate whether different measures of inter-rater reliability will compute similar estimates with nominal data commonly encountered in communication studies. To make recommendations how reliability should be computed and described for communication coding instruments., Methods: The raw data from an inter-rater study with three coders were analysed with; Cohen's κ, sensitivity and specificity measures, Fleiss's multirater κj, and an intraclass correlation coefficient (ICC)., Results: Minor differences were found between Cohen's κ and an ICC model across paired data (largest margin=0.01). There were negligible differences between the multirater estimates e.g. κj (0.52) and ICC (0.53). Sensitivity analyses were in general agreement with the multirater estimates., Conclusion: It is more practical to analyse nominal data with >2 raters with an appropriate model ICC for inter-rater studies, and little difference exists between Cohen's κ or an ICC., Practice Implication: Alternatives to Cohen's κ are readily available, but researchers need to be aware of the different ICC definitions. An ICC model should be fully described in reports. Investigators are encouraged to supply confidence limits with inter-rater data, and to revisit guidance regarding the relative strengths of agreement of reliability coefficients., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To describe the methodological procedures of a multi-centre focus group research for obtaining content categories also suitable for categorical statistical analyses., Methods: Inductive content analyses were performed on a subsample of 27 focus groups conducted in three different countries, the Netherlands (Utrecht), the UK (Liverpool) and Italy (Verona). The analyses of the subsample of focus group discussions were performed in five steps: (1) independent development of content categories in each of the participating centres, (2) obtaining consensus categories, (3) creation of a manual with coding rules and defining criteria for categories and subcategories, (4) assessment of inter-rater reliability to identify unreliable categories to be revised, and (5) repetition of inter-rater reliability assessment., Results: The resulting coding system considers five areas: non verbal communication, process oriented expression, task oriented or problem focused expressions, affective or emotional expressions, and physician's personal characteristics. It contains 12 categories of acceptable inter-rater reliability and 41 subcategories., Conclusion: The coding procedures show how focus group data, obtained in an international multi-centre study can be analysed in a systematic way combining scientific rigour with the richness of data obtainable from qualitative methodologies., Practice Implication: The applied procedures may be helpful for multi-centre focus group research on other topics., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To present the Verona Coding Definitions of Emotional Sequences (VR-CoDES CC), a consensus based system for coding patient expressions of emotional distress in medical consultations, defined as Cues or Concerns., Methods: The system was developed by an international group of communication researchers. First, consensus was reached in different steps. Second, a reliability study was conducted on 20 psychiatric consultations., Results: A Cue is defined as a verbal or non-verbal hint which suggests an underlying unpleasant emotion that lacks clarity. A Concern is defined as a clear and unambiguous expression of an unpleasant current or recent emotion that is explicitly verbalized with or without a stated issue of importance. The conceptual framework sets precise criteria for cues and concerns and for whom (health provider or patient) elicits the cue/concern. Inter-rater reliability proved satisfactory (agreement 81.5%, Cohen's Kappa 0.70)., Conclusion: The VR-CoDES CC will facilitate comparative research on provider-patient communication sequences in which patients express emotional distress., Practice Implications: The VR-CoDES CC may be used to help clinicians in recognizing or facilitating cues and concerns, thereby improving the recognition of patients' emotional distress, the therapeutic alliance and quality of care for these patients., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)