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Effective clinician listening and communicating directly affects patients' health, satisfaction with healthcare, and complaints. This influences healthcare policy and clinician training/assessment. Listening skills and consultation frameworks underpin training but are often poorly used in everyday clinical work. Primary care doctors provide continuity of care using listening skills to develop long term relationships. Additionally, they listen to patients and colleagues in other ways such as surveys, participation groups, and significant event reviews. All these factors challenge educators to offer systematic training which ensures that future primary care clinicians/leaders develop conscious competence in listening at different levels and in differing contexts.

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In UK health policy 'sharing good information is pivotal to improving care quality, safety, and effectiveness. Nevertheless, educators often neglect this vital communication skill. The consequences of brief communication education interventions for healthcare workers are not yet established. This study investigated a three-hour interprofessional experiential workshop (group work, theoretical input, rehearsal) training healthcare staff in sharing information using a clear structure (PARSLEY). Staff in one UK hospital participated. Questionnaires were completed before, immediately after, and eight weeks after training, with semistructured interviews seven weeks after training. Participants (n=76) were from assorted healthcare occupations (26% non-clinical). Knowledge significantly increased immediately after training. Self-efficacy, outcome expectancy, and motivation to use the structure taught were significantly increased immediately following training and at eight weeks. Respondents at eight weeks (n=35) reported their practice in sharing information had changed within seven days of training. Seven weeks after training, most interviewees (n=13) reported confidently using the PARSLEY structure regularly in varied settings. All had re-evaluated their communication practice. Brief training altered self-reported communication behaviour of healthcare staff, with sustained changes in everyday work. As sharing information is central to communication curricula, health policy, and shared decision-making, the effectiveness of brief teaching interventions has economic and educational implications.

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BACKGROUND: Good communication skills are integral to successful doctor-patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination). AIM: To explore GPs' and patients' experiences of using touch in consultations. DESIGN AND SETTING: Qualitative study in urban and semi-rural areas of north-west England. METHOD: Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis. RESULTS: All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations. CONCLUSION: Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.

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BACKGROUND: Ongoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. 'Holding', a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients. AIM: To explore urban GPs' and patients' experiences of the management of chronic illness, with a particular focus on holding relationships. DESIGN AND SETTING: A qualitative study in urban and suburban areas of north west England. METHOD: Participating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis. RESULTS: GP responders considered holding to be a small but routine part of their work. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access. CONCLUSION: Holding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.

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OBJECTIVE: To develop a model for addressing the emotional concerns of patients or their caregivers; to teach the model in a three-hour workshop and to assess the impact of that training on a wide range of health and social care staff. METHODS: A multi-specialty team, including a cancer patient, developed a model based on the evidence relating to emotional support and communication skills. The model (SAGE & THYME) consists of nine steps (see Box 1). The purpose of the model is to enable staff of all grades and roles to fulfil the most important objectives of support: enabling patients to describe their concerns and emotions if they wish to do so, holding and respecting those concerns; identifying the patients' support structures; exploring the patients' own ideas and solutions before offering advice or information. Over 800 health and social care staff of all grades and students have participated in the three-hour SAGE & THYME training workshops. RESULTS: Analysis from 412 participants suggests that the workshops had a significant positive effect on self-confidence (p<.0005), self-perception of competence (p<.0005) and willingness to explore the emotional concerns of patients (p<.0005). 95% felt that the workshop would be very likely to have an impact on their practice. CONCLUSIONS: The workshops have been successful in increasing the self-perceptions of confidence, competence and willingness to explore the emotional concerns of patients. The model 'SAGE & THYME' has been welcomed by participants. PRACTICE IMPLICATIONS: Staff groups will require training for patients or their caregivers to have their concerns heard without interruption and to be allowed to explore their own resolutions. The three-hour SAGE & THYME training may go some way towards helping patients and staff form sound partnerships which assist patients to participate constructively in their own care.

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Definitions of professional roles and appropriate care are increasingly inclusive in primary care but many subjective factors influence the care that is actually delivered. One such factor is the boundary a clinician puts on his or her self in interactions with patients. This qualitative study investigated doctors' perceptions of personal boundaries to primary care consultations by exploring two examples: touch and spiritual care. Respondents reported clear but contrasting boundaries: some neither used touch nor explored spiritual care; others regularly undertook both. Some interviewees deliberately varied these boundaries, irrespective of their own views, if they felt this was in their patients' best interests. Such subjective limits may affect the quality of primary health care offered to some patients and contrast with theoretical definitions which assume both all-encompassing primary care, and doctors' conscious awareness of themselves and their personal boundaries. The existence of these boundaries, and some doctors' lack of awareness of them, has educational implications if patient-centred professional role definitions are to be realistically delivered in everyday primary care.

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This paper analyses the effects of bringing together a small group of nursing and medical students to learn the skills needed to break bad news to patients. It outlines the qualitative and quantitative methods used, to provide the reader with a comprehensive account of the teaching, learning and research strategies drawn on during the study. The paper examines the evaluation phase, as this aspect is of greatest import if such initiatives are to flourish. The facet of the study analysed in detail concerns the students' responses to the open-ended qualitative questionnaires. In coding the data, three researchers independently highlighted a series of themes associated with the benefits and hazards of nursing and medical students learning and working together. Finally, the paper closes by arguing that trust and mutual respect are vital ingredients if collaborative working is to become part of the medical and nursing curriculum.

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BACKGROUND: As well as hearing a story at the start of an interaction, listening in medicine involves picking up and checking out patients' cues. Despite this, cues are frequently missed or ignored by doctors. AIM: To explore the perceptions of general practitioners (GPs) about initiating listening and choosing not to listen during interactions. STUDY DESIGN: Qualitative study constant comparison. Methods General practitioners with over 5 years' experience in practice in a semi-rural area of England took part in a single, semistructured, audiotaped interview which was piloted initially. Interviews were transcribed and analysed according to the precepts of constant comparison. RESULTS: In total, 23 of 24 eligible doctors participated. The data emphasise the importance of spotting cues during interactions. Factors influencing judgements on whether or not to attend to cues included pressure of work, the doctor's mood or feelings about the patient, and the context of the interaction. Methods of limiting, blocking or resisting listening included reassuring, changing the subject, interrupting, being directive or making a plan, reducing sympathy and using body language. A tramline metaphor of choice in listening emerged (the listening loop: a definite period of listening by the GP within the interaction, generally separate to hearing the patient's initial story). CONCLUSION: The listening loop offers a simple model of listening that emphasises choice and judgement in response to patients' cues within interactions. Emphasising this choice highlights both picking up cues and pragmatic limits and resistance to attending to them, with implications for teaching.

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OBJECTIVES: To understand family doctors' constructs of long-term therapeutic relationships with patients in primary care. METHODS: Semi-structured interviews were administered to general practitioners with > 5 years of experience (n = 28) working in an English semi-rural district, and the results were subjected to constant comparative qualitative analysis. RESULTS: Participants identified pastoral relationships as long-standing patterns of doctor-patient interaction aimed at providing reliable supportive care indirectly concerned with clinical medicine. Holding work was identified as a technique for structuring and delivering care within pastoral relationships. Pastoral relationships and holding work were seen as valuable in the affective management of people with long-standing chronic illness, especially mild-to-moderate depression and anxiety. DISCUSSION: At a time when primary care is undergoing significant structural change, respondents in this study laid emphasis on personal and continuing relationships with patients who had diffuse needs connected with the experience of complex and chronic problems, and their accounts intimately connected life events with health status. Importantly, these accounts suggest that such relationships are hard to define and therefore hard to measure, but have important therapeutic purposes.

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