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Doctor-patient communication is fundamental to the therapeutic relationship necessary to achieve mutual understanding of the implications and impact of illness, diagnostic and treatment decisions, and health outcomes. It is recognised that both patient and doctor come with their own perspectives, beliefs and agendas. This quasi-ethnographic study explores the influence of the doctor’s own a priori assumptions on their communication with a new patient. Methods Cognitive interviewing was used prior to consultations to explore the doctor’s thoughts triggered by the referral information. The relevant subsequent consultations were audio recorded, as were loosely structured interviews after the consultation, during which the doctor reflected on what had been said and why. All data was subjected to qualitative thematic analysis. Conclusion The source, content and format of referrals are significant and doctors approach the information about the patient with their own perspectives, beliefs and experiences. The existence of assumptions and stereotypes appear to be triggered when processing the information. Doctors begin to develop the communication with the patient, based on their expectations of themselves and of the patient, before the patient is seen. During the consultation, some a priori assumptions were observed to be significant. A priori assumptions are influential to the communication with the patient and can result in communication not anticipated by the clinician. The relationship achieved with the patient during the consultation can be understood in the context of the concepts of recognition and presence.

Background: As the proportion of women in medicine draws towards parity, long-standing questions about gender differences in the way that doctors work become more pertinent. Gender differences in medical working patterns and career choices are well documented; but there is a lack of understanding of everyday differences in the working lives of male and female doctors, particularly in UK hospital medicine. In this thesis, potential sources of gender variations in activity rates, previously reported in the literature, are identified. Methods: Multiple methods were employed to explore potential gender differences in doctors’ working lives. Systematic review methods synthesised existing literature on gender differences in the communication style, content and length of medical consultations. Qualitative methods were used to develop in-depth and contextualised understanding of potential gender differences in UK hospital consultants’ working lives, using observation and interviews. Potential variations in clinic length data were analysed quantitatively and synthesised with the existing literature using meta-analysis. Finally, a pilot questionnaire was designed and tested to build on qualitative findings and investigate variations in a wider sample. Results: Doctors’ gender appears to influence their working lives, and the interface between home and work, and these influences may partly explain variations in activity rates. Specifically, female doctors appear to spend longer on consultations; adopt different styles of communication such as lowered dominance and greater use of psychosocial communication; experience greater barriers in their careers such as gender discrimination and problems with work-family conflict; and may experience lower levels of cooperation from colleagues. Conclusions: This research provides important and timely understanding about the sources of gender differences in the working lives of hospital consultants, which may affect both the quality and quantity of care provided by male and female doctors.

Research has well established the role of social support in coping with stressful and traumatic events, but has yet to examine how individuals cope with such events when social support is not available. In order to examine this question, research needed to indentify a naturally occurring, isolated group, who are exposed to stressful and traumatic events. The relatively recent expansion of remote medicine provided this opportunity. Remote Area Medics (RAM) are an occupational group who work autonomously to provide medical services in remote sites and thus their experiences include both professional and social isolation. In addition, RAMs share commonalities with paramedics and groups deployed to high threat areas, which suggests they could be exposed to similar experiences that are known to increase risk of Posttraumatic Stress Disorder (PTSD) and common mental health difficulties. Therefore RAMs provided this study the opportunity to explore how individuals cope with stressful and traumatic events when social support is not available. In addition, the inference that RAMs are at increased risk of PTSD and common mental health difficulties has yet to be researched, and therefore this study also explored the stressors and psychological impact associated with working as a RAM. The lived experiences of six RAMs working in Iraq were explored by conducting interviews and analysed using Interpretative Phenomenological Analysis. Three master themes emerged: the experience of, and coping with being remote; a different medic in a different culture; and the need to be heard, understood and validated. The analyses revealed a number of stressors unique to remote medicine and evidence that RAM could be at increased risk of depression. The study highlights the concept of virtual support as a way of coping with stressful and traumatic events when social support is no available. The concept and potential wider application of virtual support is discussed.

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Medical student communication with patients has been subject to scrutiny from educators and policy makers. Recommendations that treat medical student-patient talk as known and understandable have formed the basis for communication improvement. The aim of this thesis was to understand how undergraduate medical students talk with and about patients in the course of learning to communicate effectively and develop their clinical skills and knowledge. Following a review of the literature, a research question was developed to investigate how the information and experiences shared between student and patient in one encounter might shape, and be shaped by organisational tasks and goals. Data was collected at a large teaching hospital in the South West of the UK. Video recordings were made of medical student-patient clerking and patient case presentations involving 19 students, 34 patients and 9 clinical tutors. Paired recordings - where the same patients were clerked and presented to clinical tutors in assessed case presentations - were captured on 13 occasions. The resulting data was transcribed and analysed using conversation analytic methods (CA). It was found that in student-patient clerking encounters, features particular to the students’ ‘learning’ or ‘novice’ status were influential in communication with patients. In the case presentation; students were found to orient strongly to the educative assessment imperative. A comparative analysis of the paired data revealed specific stages of the case presentation exhibiting particular uses of patient talk from the prior clerking; demonstrated in transformation of ‘reused’ patient talk, This suggested a strong relationship between talk with and talk about the patient, and the management of this by medical students to demonstrate adherence to the imperative of medical education. This study uniquely offers a systematic comparative analysis of talk across these two learning encounters. The influence of assessment-driven learning on student talk with patients can be demonstrated in and through this analysis; detracting medical students from an opportunity for experiential learning. In understanding the relationship between these learning opportunities what students are actually taking away from patient encounters, as well as the role of patients as educators is clarified. Understanding and critical awareness of this by all parties may lead to a reimagining of the learning potential of these talk events.

The term agenda setting has been used variably across the healthcare literature, in particular in writings on doctor-patient communication, medical education, and behaviour change. No attempt has yet been made to integrate these different conceptualisations. This impacts both investigation and teaching of this communication skill. The studies in this thesis aim to clarify a conceptual foundation, and to develop a measure of agenda setting, for use in teaching clinicians. A context of long-term condition management was selected. In these clinical encounters clinician and patient agendas naturally intersect and may disagree, and patient participation is essential to effective management. Phase 1 of this thesis involved a structured literature review, and focus group study with clinicians in primary and secondary care to map components of agenda setting. These were refined through a consensus group study involving patients, clinicians, researchers and educators. An integrated model of agenda setting is proposed that adopts new terminology: agenda mapping involves establishing shared focus, and agenda navigation involves tracking natural shifts in focus throughout an interaction. Agenda mapping includes six core domains: (1) identifying patient talk topics, (2) identifying clinician talk topics, (3) agreeing shared priorities, (4) agreeing focus, (5) collaboration, and (6) engagement. Clarifying these domains established a foundation for measurement. Phase 2 of this thesis addresses measurement of agenda mapping. A review of measures confirmed that no existing measure includes all agenda mapping domains. The Evaluation of AGenda mapping skiL Instrument (EAGL-I) was developed, and tested in a study with third year medical students. EAGL-I scores were shown to represent reliable and valid assessment of agenda mapping. Conditions, under which reliable assessment may occur, are also discussed. Educators and researchers now have a tool for use in teaching agenda mapping to clinicians. Further investigation of agenda mapping in long-term condition management may also now progress.

This paper is a systematic review of empirical papers investigating preventative strategies and interventions for burnout among healthcare workers. The idea was borne out of a recommendation in the independent NHS Health and Well-being Review (Department of Health, 2009a) commissioned by the Department of Health and led by Dr Stephen Boorman, that is that there should be access to effective interventions for mental health problems faced by NHS staff in all NHS Trusts. 11 studies were included in the review which covered interventions ranging from brief psycho-education, peer-support, intensive residential courses involving individual counselling sessions and whole team-based interventions. Participants both within and between studies included a wide variety of healthcare professionals who worked in a variety of specialities and settings. Intensive residential courses for self-referring nurses and medics produced long-lasting reductions for those with initially high levels of burnout. Peer-support interventions were also valuable. The interventions reviewed tended to include more than one component and so future research should concentrate on determining which components of the interventions are most useful for which groups of healthcare professionals. This portfolio thesis comprises three parts: Part I is a systematic literature review of empirical papers investigating preventative strategies and interventions for burnout among healthcare workers. The idea was borne out of a recommendation in the independent NHS Health and Well-being Review (DoH, 2009a) commissioned by the Department of Health and led by Dr Stephen Boorman, that there should be access to effective interventions for mental health problems faced by NHS staff in all NHS Trusts. Part II is an empirical paper that has also arisen from a recommendation of the Boorman Review (DoH, 2009a), namely that the NHS should adopt a prevention-focused health and well-being strategy for staff. To help enable this, a clearer understanding of how healthcare professionals come to experience difficulties in the course of their work is required. To further this understanding a quantitative test was applied to the Positivity Negativity Ratio Model of the development of Compassion Satisfaction and Compassion Fatigue proposed by Radey & Figley (2007) as applied to mental health workers. Part III comprises the appendixes with additional information relevant to the systematic literature review and empirical paper, and a reflective statement of the research process.

Lay health workers have been widely used to deliver health improvement activities in developed and developing countries. Although there is some data to support their efficacy, reviews of the research literature have consistently found insufficient evidence to assess which intervention strategies are likely to be most effective. Furthermore, there is a dearth of research exploring service user views and experiences. This study contributes to evidence and theory in relation to lay-led models of promoting lifestyle change. By adopting a grounded theory methodology underpinned by a subtle realist perspective, the study aimed to understand better the experiences of users and the mechanisms underlying intervention outcomes. The focus for this research was the NHS Health Trainers Initiative, which is part of an attempt to shift the emphasis in UK public health from ‘advice on high to support from next door’. Participants were sampled from three heterogeneous health trainer services in northern England. Semi-structured interviews with service users (n=26) were conducted at 0, 3, 6 and 12 months, and with health trainers (n=13) and their managers (n=5) at 0 and 12 months. A longitudinal approach was chosen to allow for a more in-depth exploration of the processes involved in attempting to make and maintain health-related behaviour changes. Informal observations of selected health trainer activities were also undertaken in order to generate additional data for triangulation. All data were analysed using the constant comparative method. Health trainers were found to employ a tailored, holistic approach that takes into account the context of a person’s life and their access to resources for health. This builds upon the salutogenic theory of health, and is in direct contrast to the paternalistic, deficit model traditionally found in public health. It also draws on theories of ‘person-in-situation’ more commonly found in the social work literature, which present an alternative to the emphasis on person-centredness and psychological aspects of behaviour change. An integrated model is developed – called the theory of lay-led behaviour change in context – and contrasted with the logic models typically used to conceptualise similar interventions. This research is one of few qualitative studies to investigate the role of lay health workers in the UK. Furthermore, the use of a longitudinal approach to explore behaviour change has produced results that are likely to have high policy relevance. The research represents an important application of a user-focused perspective affording new insights, which may also be applied to other complex interventions.

The therapeutic relationship is the relationship between service users and staff, based on collaboratively working towards the service users’ goals. Within a secure hospital environment, staff sometimes have to physically restrain service users, as a last resort to manage risk. The aim of this research was to explore both service user and staff perspectives of the therapeutic relationship after physical restraint in a secure hospital environment. This was investigated in an independent sector medium-low secure hospital in Wales. Ten semi structured interviews were conducted with five service users and five staff members; all of whom had been involved in at least one incident of physical restraint. These participants described their experiences of therapeutic relationships with those that they had been involved in a physical restraint with. Interpretative Phenomenological Analysis was used to separately analyse the service user and staff member data. Four master themes emerged from the service user experiences: changes to the therapeutic relationship; appraisal of the necessity of physical restraint; emotional impact; and dependency and power. A further three master themes emerged from the staff member experiences: personal impact; conflicting professional roles and responsibilities; and making sense of the physical restraint. These findings are discussed in relation to implications for secure hospital services and recommendations for future research are outlined.