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Background: Palliative care is a support system to help people live actively until they die. Current policy aims to integrate rehabilitation and goal setting as mechanisms to help professionals to support patients to do this, but there is little agreement about what this means in practice. No theory based framework currently exists to help palliative care professionals consistently work with patients to identify and work towards goals. This thesis describes how a framework for goal setting and action planning in palliative care (G-AP PC) was developed and implemented systematically in one hospice. Research aims: 1. To synthesise published literature regarding goal setting in palliative care settings. 2. To investigate current goal setting practice in one hospice setting. 3. To develop and evaluate a theory and evidence-based goal setting intervention for palliative care settings. Study design This study is placed in the ‘development and feasibility’ phases of the Medical Research Council (MRC) framework for developing and evaluating complex interventions. The intervention (G-AP PC) was systematically developed. Firstly a rigorous investigation of current practice was conducted by synthesising the literature on the subject, and investigating current goal setting practice in one hospice setting. These findings informed the development of a theory-based Goal setting and Action Planning practice framework (G-AP PC) which was then implemented and evaluated in one hospice in-patient unit. Normalization Process Theory (NPT) was used to structure the development and evaluation of the intervention. Findings: Goal setting with patients is recognised as important within palliative care, but is poorly conceptualised and lacks a theory and evidence-base for its practice. G-AP PC was successfully developed, implemented and evaluated in one hospice setting. Findings demonstrate that G-AP PC is acceptable and feasible for use by professionals and patients alike. It helped professionals to work as a team; shift their attention from symptoms/problems/risk to patient’s goals; act on what patients wanted to achieve, within short timescales and document patients goals appropriately. Patients reported that use of G-AP PC allowed them to focus on goals that were important to them. There was also evidence that goal setting helped increase patients’ motivation and self-efficacy. Conclusions: G-AP PC is a feasible and acceptable intervention. The study has demonstrated that the interventions can increase patient centred goal setting and motivates both patients and staff to work towards and achieve patient goals that are not only about controlling symptoms but also about engaging in meaningful activities, enabling patients to live actively until they die.

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Introduction: Conversation treatment for individuals with aphasia (IwAs) aims to enhance language and communication skills within naturalistic settings. Group dynamics, including psychosocial support (PSS) and vicarious learning (VL), are important components of this treatment. However, the lack of established aphasia-friendly methods for quantifying group dynamics impedes understanding of its contribution to treatment efficacy. This study addresses three key research goals: (1) Can group dynamics be reliably quantified? (2) Do measures of group dynamics vary with group size or time? (3) Are group dynamics linked to changes in self-reported psychosocial health measures? Methods: IwAs were assigned to participate in either a large group or dyadic condition as part of a larger study. Participants completed multiple standardized assessments before and after receiving conversation treatment for one hour twice a week for ten weeks. A coding system was developed to track PSS and VL during sessions. Video recordings of sessions at the start (Session 2) and end (Session 19) of the treatment period were analyzed for five large groups and six dyads, with seven additional dyads coded for Session 19 after reliability was confirmed. Intrarater and interrater reliability were assessed by recoding 21% of the videos randomly. Results: To address the first research goal, group dynamics were defined and then a code was created to represent occurrences of PSS and VL. After establishing a reliable coding system, instances of PSS and VL were compared across size conditions to address the second research goal. The results suggested that PSS differed between conditions later in treatment, but VL did not. For research goal three, the data suggest that large groups experience larger gains in quality of life measures, possibly due to increased exposure to PSS. Conclusion: Findings indicate that group dynamics can be reliably tracked and used for quantitative analysis. PSS was more common in groups than dyads later in the 10 week treatment period, but VL did not vary across conditions or at the start or end of treatment. Further, there is some evidence that PSS in larger groups contributes to improvements in quality of life measures. / Communication Sciences

Background: Aphasia is an acquired language disorder, usually due to stroke, that affects the social functioning and the quality of life of the person with aphasia as well as the quality of life of his or her family and caregivers. Traditional aphasia therapy has tended to focus on decontextualized tasks and discrete elements of language functioning. The Life Participation Approach to Aphasia (LPAA) focuses on the collaborative nature of communication and addresses communication within personally relevant contexts. Joint decision-making is one type of social interaction that occurs frequently between married couples and has received considerable attention in the literature. To date, no study has investigated how married couples affected by aphasia collaboratively make decisions. Aim: The present study aims to provide foundational information on joint decision-making by married couples affected by aphasia. Methods and Procedures: Fourteen married couples in which one of the spouses had aphasia volunteered to participate in the study. A variety of assessment measures were administered to the participants with aphasia to characterize their speech and language deficits and all participants were administered a non-verbal reasoning test and a marital quality scale. The primary task of interest in this study involved a joint decision-making activity in which spouses were read two hypothetical ‘survival-type’ scenarios and were given a list of items for each scenario. The spouses were instructed to decide on six items and then rank their selected items in order of importance in terms of their value in helping them survive the scenarios. Participants’ interactions were audio- and video-recorded, and their verbal communication transcribed verbatim. The participants’ communicative interactions were coded for speech functions and analyzed by comparing differences in communication behaviors between the spouses with and without aphasia. Results: Findings showed that participants with and without aphasia utilized a variety of speech functions but that the participants with aphasia made far fewer attempts to persuade their spouse to agree with them and that the spouses without aphasia tended to dominate the interaction, resulting in an imbalance of power in the decision-making process. Despite the differences in communication behaviors, both groups of spouses were supportive of the ideas suggested by their significant other and conflicts were typically resolved quickly. Conclusion: Findings from this study revealed potential discrepancies in the balance of power between the spouses with and without aphasia in decision-making communication. Suggestions are provided for tailoring interventions and guiding future research in joint decision-making in couples affected by aphasia.

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In Scotland, further education colleges provide 28% of all higher education; this includes over half of part-time undergraduate higher education. This provision has contributed to wider participation in higher education in Scotland by “non traditional” students and to progress towards a mass system of higher education within a learning society. This thesis is a case study of higher education students in a Scottish further education college. It explores the nature of the students’ experience and its relevance to institutional management and higher education policy. Evidence is drawn from the college’s records, from focus groups and from a questionnaire survey of whole year groups (full-time and part-time students) over three successive years. The theoretical focus is upon a new definition of lifelong learning as learning integrated with life, drawn from literature on motive, motivation, participation and retention. The research explores the students’ experiences of combining study with work and family life. The student experience is found to be heterogeneous, complex and distinct from the stereotype of a young full-time university student. Vocational motives predominate and there is evidence of a significant investment of meaning, expectation and purpose in the experience of higher education. The students’ ability to balance and integrate learning with life is a determining factor in the achievement of sustained participation. The quality of support networks both in college and in the students’ work and family lives are found to be more significant than personal or demographic characteristics. The case study contributes to current thinking about the professional role of college senior managers in creating a student-centred institutional culture that responds to the complexity of the students’ experience. A case is made for a review of the current inequity of financial support for full-time and part-time higher education students and of the marginal status of colleges in the development of higher education policy.