Goal SettingGoal setting was used by physiotherapists to activate and motivate patients, to determine what meaningful therapy would be for the patient and to set discharge limits (Leach, Cornwell, Fleming, and Haines, 2010Leach E, Cornwell P, Fleming J, Haines T 2010 Patient centered goal-setting in a subacute rehabilitation setting Disability and Rehabilitation 32: 159–172. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Rindflesch, 2009Rindflesch AB 2009 A grounded-theory investigation of patient education in physical therapy practice Physiotherapy Theory and Practice 25: 193–202. [Taylor & Francis Online], [Google Scholar]; Thomson, 2008Thomson D 2008 An ethnographic study of physiotherapists’ perceptions of their interactions with patients on a chronic pain unit Physiotherapy Theory and Practice 24: 408–422. [Taylor & Francis Online], [Google Scholar]). Goal setting seemed particular of physiotherapists’ interest, as patients did not spontaneously mention goal setting as important for patient-centered physiotherapy. Patient-centered physiotherapists, however, tried to allow the patients to define their own goals in collaboration (Larsson, Liljedahl, and Gard, 2010Larsson I, Liljedahl K, Gard G 2010 Physiotherapists’ experience of client participation in physiotherapy interventions: A phenomenographic study Advances in Physiotherapy 12: 217–223. [Taylor & Francis Online], [Google Scholar]; Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Thomson, 2008Thomson D 2008 An ethnographic study of physiotherapists’ perceptions of their interactions with patients on a chronic pain unit Physiotherapy Theory and Practice 24: 408–422. [Taylor & Francis Online], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). This was done by facilitating them and guiding them, using education and dialogue to determine the patients’ goals (Larsson, Liljedahl, and Gard, 2010Larsson I, Liljedahl K, Gard G 2010 Physiotherapists’ experience of client participation in physiotherapy interventions: A phenomenographic study Advances in Physiotherapy 12: 217–223. [Taylor & Francis Online], [Google Scholar]; Leach, Cornwell, Fleming, and Haines, 2010Leach E, Cornwell P, Fleming J, Haines T 2010 Patient centered goal-setting in a subacute rehabilitation setting Disability and Rehabilitation 32: 159–172. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Rindflesch, 2009Rindflesch AB 2009 A grounded-theory investigation of patient education in physical therapy practice Physiotherapy Theory and Practice 25: 193–202. [Taylor & Francis Online], [Google Scholar]; Thomson, 2008Thomson D 2008 An ethnographic study of physiotherapists’ perceptions of their interactions with patients on a chronic pain unit Physiotherapy Theory and Practice 24: 408–422. [Taylor & Francis Online], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). Goals were mostly created in collaboration between the physiotherapist and the patient (Leach, Cornwell, Fleming, and Haines, 2010Leach E, Cornwell P, Fleming J, Haines T 2010 Patient centered goal-setting in a subacute rehabilitation setting Disability and Rehabilitation 32: 159–172. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). However, some physiotherapists made no or little mention of patient-centered goals (Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]).

Communicative abilities of a patient-centered physiotherapist meant being receptive to what the patient has to say, correctly interpreted, and giving explanations in a way patients understand (Fleiss and Cohen, 1973Fleiss JL, Cohen J 1973 The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability Educational and Psychological Measurement 33: 613–619. [Crossref], [Web of Science ®], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). Purposefully changing communication styles depending on the patient (Hiller, Guillemin, and Delany, 2015Hiller A, Guillemin M, Delany C 2015 Exploring healthcare communication models in private physiotherapy practice Patient Education and Counseling 98: 1222–1228. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]). Having the ability to explain in lay terms, directly speaking to the patient, listening, and asking appropriate questions were of importance (Cooper, Smith, and Hancock, 2008Cooper K, Smith BH, Hancock E 2008 Patient-centredness in physiotherapy from the perspective of the chronic low back pain patient Physiotherapy 94: 244–252. [Crossref], [Web of Science ®], [Google Scholar]; Kidd, Bond, and Bell, 2011Kidd MO, Bond CH, Bell ML 2011 Patients’ perspectives of patient-centredness as important in musculoskeletal physiotherapy interactions: A qualitative study Physiotherapy 97: 154–162. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Potter, Gordon, and Hamer, 2003Potter M, Gordon S, Hamer P 2003 The physiotherapy experience in private practice: The patients’ perspective Australian Journal of Physiotherapy 49: 195–202. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]).

Personal communication and communication skills were far more important than the provision of scientific facts (Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). By personal communication, a bond was established and the therapy shifted from therapist to patient centered (Hiller, Guillemin, and Delany, 2015Hiller A, Guillemin M, Delany C 2015 Exploring healthcare communication models in private physiotherapy practice Patient Education and Counseling 98: 1222–1228. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]).

Figure 2. Proposed framework for patient-centeredness in physiotherapy.

McAllister et al. highlighted the importance of the clinical consultation as a conversation, paced and directed by both participants [5McAllister M, Matarasso B, Dixon B, et al. Conversation starters: re-examining and reconstructing first encounters within the therapeutic relationship. J Psychiatr Ment Health Nurs. 2004;11:575–582. doi: 10.1111/j.1365-2850.2004.00763.x [Crossref], [PubMed], [Google Scholar]]. Sacks et al. maintain that people take turns to talk by following a set of conventional rules that assign speaker time and direction, and any deviation could indicate a person's attempt to display power, status or influence [6Sacks H, Schegloff EA, Jefferson G. A simplest systematics for the organization of turn-taking for conversation. Language. 1974;50(4):696–735. doi: 10.1353/lan.1974.0010 [Crossref], [Web of Science ®], [Google Scholar]]. Interruptions may not simply be a reflection of status or dominance however, they may reflect a speaker's enthusiasm, interest or spontaneity [22Irish JT, Hall JA. Interruptive patterns in medical visits: the effects of role, status and gender. Soc Sci Med. 1995;41(6):873–881. doi: 10.1016/0277-9536(94)00399-E [Crossref], [PubMed], [Web of Science ®], [Google Scholar]]. Furthermore, it is important they are not interpreted as signs of power, control or dominance, rather they are indicative of interpersonal relationships, such as neutrality, power or rapport [39Goldberg JA. Interrupting the discourse on interruptions. J Pragmat. 1990;14:883–903. doi: 10.1016/0378-2166(90)90045-F [Crossref], [Google Scholar]], which is particularly pertinent to healthcare where power differentials prevail. This was seen in the current study, both in theme 3, and when the patient interjects with humour in the penultimate quote. Practical guides to clinical communication skills concur with Sacks’ model and the two most important skills have been identified as: the ability to allow the patient to speak without interruption; and the ability to truly hear what the patient is trying to say [40Jackson C. Shut up and listen. A brief guide to clinical communication skills. Dundee: Dundee University Press; 2006; p. 1. [Google Scholar]].

McAllister et al. highlighted the importance of the clinical consultation as a conversation, paced and directed by both participants [5McAllister M, Matarasso B, Dixon B, et al. Conversation starters: re-examining and reconstructing first encounters within the therapeutic relationship. J Psychiatr Ment Health Nurs. 2004;11:575–582. doi: 10.1111/j.1365-2850.2004.00763.x [Crossref], [PubMed], [Google Scholar]]. Sacks et al. maintain that people take turns to talk by following a set of conventional rules that assign speaker time and direction, and any deviation could indicate a person's attempt to display power, status or influence [6Sacks H, Schegloff EA, Jefferson G. A simplest systematics for the organization of turn-taking for conversation. Language. 1974;50(4):696–735. doi: 10.1353/lan.1974.0010 [Crossref], [Web of Science ®], [Google Scholar]]. Interruptions may not simply be a reflection of status or dominance however, they may reflect a speaker's enthusiasm, interest or spontaneity [22Irish JT, Hall JA. Interruptive patterns in medical visits: the effects of role, status and gender. Soc Sci Med. 1995;41(6):873–881. doi: 10.1016/0277-9536(94)00399-E [Crossref], [PubMed], [Web of Science ®], [Google Scholar]]. Furthermore, it is important they are not interpreted as signs of power, control or dominance, rather they are indicative of interpersonal relationships, such as neutrality, power or rapport [39Goldberg JA. Interrupting the discourse on interruptions. J Pragmat. 1990;14:883–903. doi: 10.1016/0378-2166(90)90045-F [Crossref], [Google Scholar]], which is particularly pertinent to healthcare where power differentials prevail. This was seen in the current study, both in theme 3, and when the patient interjects with humour in the penultimate quote. Practical guides to clinical communication skills concur with Sacks’ model and the two most important skills have been identified as: the ability to allow the patient to speak without interruption; and the ability to truly hear what the patient is trying to say [40Jackson C. Shut up and listen. A brief guide to clinical communication skills. Dundee: Dundee University Press; 2006; p. 1. [Google Scholar]].

Clinical implicationsTo the best of our knowledge, this is the first time the prevalence and nature of overlaps and interruptions have been reported in patients presenting with low back pain. This work has highlighted the complexity of evaluating the impact of communication during clinical encounters. Clinicians need to ensure that the pendulum of current clinical practice does not swing towards pathoanatomy and physiology, biomechanics and technological advances at the expense of treating the patient as a person and providing truly patient-centred care. Therefore, clinicians at the forefront of practice, whatever their profession, need to invest time evaluating and developing their own communication skills (for example by audio-recording consultations or engaging in peer observation, with patients’ consent) to optimize non-specific treatment effects and ultimately enhance patients’ experience and outcomes.

Whilst this study intended to explore participants’ perceptions of the impact of empathy on a clinical encounter, participants focused their discussion on how the attributes of both the clinician and patient, as well as external factors, could affect the delivery of empathy during a clinical encounter. Participants identified building rapport, active listening, verbal and non-verbal communication to be factors that could influence the patient-clinician relationship, which is supported in the literature, alongside empathy which has been shown to affect the patient-clinician relationship, improving clinical outcomes, diagnoses and adherence to therapy [3Hojat M, Mangione S, Kane G, et al. Relationships between scores of the Jefferson Scale of Physician Empathy (JSPE) and the Interpersonal Reactivity Index (IRI). Med Teach. 2005;27(7):625–628. doi: 10.1080/01421590500069744 [Taylor & Francis Online], [Web of Science ®], [Google Scholar],8–12Beck R, Daughtbridge R, Sloane P. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Med. 2002;15(1):25–38. [Google Scholar]Hojat M, Gonnella J, Nasca T, et al. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiat. 2002;159(9):1563–1569. doi: 10.1176/appi.ajp.159.9.1563 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]Shapiro J, Morrison E, Boker J. Teaching empathy to first year medical students: evaluation of an elective literature and medicine course. Educ Health: Change in Learn Practice. 2004;17(1):73–84. doi: 10.1080/13576280310001656196 [Crossref], [PubMed], [Google Scholar]Stepien K, Baernstein A. Educating for empathy. J Gen Intern Med. 2006;21(5):524–530. doi: 10.1111/j.1525-1497.2006.00443.x [Crossref], [PubMed], [Web of Science ®], [Google Scholar]Rakel D, Barrett B, Zhang Z, et al. Perception of empathy in the therapeutic encounter: effects on the common cold. Patient Educ Couns. 2011;85(3):390–397. doi: 10.1016/j.pec.2011.01.009 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]].

The key finding from this study indicates that teaching empathy per se, may be best done when working in a clinical setting, as clinicians are able to draw on their clinical experience and immediately take new ideas into their clinical encounters to further enhance their skills. Whilst methods of developing empathy in students have been shown to be successful [16Brunero S, Lamont S, Coates M. A review of empathy education in nursing. Nurs Inq. 2010;17(1):65–74. doi: 10.1111/j.1440-1800.2009.00482.x [Crossref], [PubMed], [Web of Science ®], [Google Scholar],20Bombeke K, Van Roosbroeck S, De Winter B, et al. Medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships. Patient Educ Couns. 2011;84(3):310–318. doi: 10.1016/j.pec.2011.03.007 [Crossref], [PubMed], [Web of Science ®], [Google Scholar],21Batt-Rawden S, Chisolm M, Anton B, et al. Teaching empathy to medical students. Acad Med. 2013;88(8):1171–1177. doi: 10.1097/ACM.0b013e318299f3e3 [Crossref], [PubMed], [Web of Science ®], [Google Scholar],27Fernández-Olano C, Montoya-Fernández J, Salinas-Sánchez A. Impact of clinical interview training on the empathy level of medical students and medical residents. Med Teach. 2008;30(3):322–324. doi: 10.1080/01421590701802299 [Taylor & Francis Online], [Web of Science ®], [Google Scholar],31Lim B, Moriarty H, Huthwaite M. “Being-in-role”: a teaching innovation to enhance empathic communication skills in medical students. Med Teach. 2011;33(12):e663–e669. doi: 10.3109/0142159X.2011.611193 [Taylor & Francis Online], [Web of Science ®], [Google Scholar],33–36Bayne H. Training medical students in empathic communication. J Spec Group Work. 2011;36:316–329. doi: 10.1080/01933922.2011.613899 [Taylor & Francis Online], [Google Scholar]Norfolk T, Birdi K, Walsh D. The role of empathy in establishing rapport in the consultation: a new model. Med Educ. 2007;41:690–697. doi: 10.1111/j.1365-2923.2007.02789.x [Crossref], [PubMed], [Web of Science ®], [Google Scholar]Das Gupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Acad Med. 2004;79:351–356. doi: 10.1097/00001888-200404000-00013 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]Tiuraniemi J, Läärä R, Kyrö T, et al. Medical and psychology students’ self-assessed communication skills: a pilot study. Patient Educ Couns. 2011;83:152–157. doi: 10.1016/j.pec.2010.05.013 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]], the increase in empathy levels has not been shown to have a carry over longer than 7 days following the intervention,[16Brunero S, Lamont S, Coates M. A review of empathy education in nursing. Nurs Inq. 2010;17(1):65–74. doi: 10.1111/j.1440-1800.2009.00482.x [Crossref], [PubMed], [Web of Science ®], [Google Scholar],35Das Gupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Acad Med. 2004;79:351–356. doi: 10.1097/00001888-200404000-00013 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]]. Multiple studies, however, have identified a decrease in empathy levels in medical and healthcare students over the duration of their education [6Nunes P, Williams S, Sa B, et al. A study of empathy decline in students from five health disciplines during their first year of training. Int J Med Educ. 2011;2:12–17. doi: 10.5116/ijme.4d47.ddb0 [Crossref], [Google Scholar],16Brunero S, Lamont S, Coates M. A review of empathy education in nursing. Nurs Inq. 2010;17(1):65–74. doi: 10.1111/j.1440-1800.2009.00482.x [Crossref], [PubMed], [Web of Science ®], [Google Scholar],19Hojat M, Vergare M, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182–1191. doi: 10.1097/ACM.0b013e3181b17e55 [Crossref], [PubMed], [Web of Science ®], [Google Scholar],20Bombeke K, Van Roosbroeck S, De Winter B, et al. Medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships. Patient Educ Couns. 2011;84(3):310–318. doi: 10.1016/j.pec.2011.03.007 [Crossref], [PubMed], [Web of Science ®], [Google Scholar],23Sherman J, Cramer A. Measurement of changes in empathy during dental school. J Dent Educ. 2005;69(3):338–345. [Crossref], [PubMed], [Google Scholar]], and in a review of these studies [24Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009. doi: 10.1097/ACM.0b013e318221e615 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]], the authors identified four possible reasons for this: negative experiences with clinical supervisors; a feeling of vulnerability as a student, resulting in reduced self-confidence; a lack of social support and increased workload combined with long clinical placement hours [24Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009. doi: 10.1097/ACM.0b013e318221e615 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]]. The student physiotherapists in this study stated that there were multiple factors to focus on whilst on clinical placement, and that their focus was more on their personal development and academic grades rather than their focus being on empathising and communicating with patients. Students did however acknowledge the importance of empathic communication during clinical encounters, but deemed other aspects of their education to be a priority. Neumann et al. [24Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009. doi: 10.1097/ACM.0b013e318221e615 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]] report similar findings, with medical students’ empathy levels showing a significant decline at the point that they enter clinical practice during their educational programme, due to their focus on academic work, improving clinical skills and lack of time to relax and de-stress.

Taken together, the Guidelines lead to the ultimate goal of UDL: to develop “expert learners” who are, each in their own way, resourceful and knowledgeable, strategic and goal-directed, purposeful and motivated.

10 Cultivating Change for Inclusive Practice: Creating a Community of Learners By Lisa Mauro-Bracken, Head of Department Health and Well-being; School of Allied Health and Community This case study illustrates an innovative, department-wide approach to learning and professional development of staff. Higher Education encounters increasing numbers of students from diverse linguistic, cultural and ethnic backgrounds requiring personalised learning (V1; V2). To cultivate a ‘new’ inclusive culture within the Department of Health and Well-being, I organised a workshop introducing Universal Design for Learning (UDL) as part of a team away day (K5). UDL is a framework to improve and optimize teaching and learning for all people based on scientific insights into how humans learn (CAST, 2019). The UDL framework supports inclusive practice and relies on multiple means of: ‘engagement,’ ‘representation’ and ‘action and expression.’ In other words, a focus on personalised learning and meaningful choice to ensure all students can access the curriculum in a way that develops their strengths. To embed this approach within the department, I delivered workshops on implementing University of Worcester’s Inclusive Assessment Policy. This was implemented using Technology Enhanced Learning and Blackboard in an inclusive way and auditing module resources using de Montfort University’s UDL self-assessment checklist. This proved to be an effective reflective tool to further inform learning, teaching and assessment (Bracken, 2019; Moriarty and Scarffe, 2019). The values underpinning our department are student-focused and this was reflected in our approach of implementing new ideas, as it required staff and student involvement and regular consultation with students about inclusive design for learning. Staff enthusiasm for the innovative approach was balanced against accepting a response of hesitancy and fear of change (Dasborough, Lamb and Suseno, 2015). However, one colleague stated ‘UDL allows me... [to] reflect, listen, change my pedagogical approach...getting input from colleagues and feel safe[ty] in questioning

Internationally, students with disabilities also have policy protections. Specifically, the Salamanca Statement cited a ‘necessity and urgency’ of providing students with a disability access to the regular education system (UNESCO 1994UNESCO. 1994. The Salamanca Statement and Framework for Action on Special Needs Education. Paris: UNES. [Google Scholar], viii). When the statement was issued, a few countries already had policies articulating the rights of students with disabilities in educational settings (de Bruin 2019de Bruin, K. 2019. “The Impact of Inclusive Education Reforms on Students with Disability: An International Comparison.” International Journal of Inclusive Education 23 (7–8): 811–826. doi:10.1080/13603116.2019.1623327. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]). Later, additional countries have clarified and amended their respective laws to align with the Convention on the Rights of Persons with Disabilities (United Nations 2006United Nations. 2006. “Convention on the Rights of Persons with Disabilities.” https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html [Google Scholar]). Thus, the need to invest in learning to teach students with disabilities is becoming more important internationally because of compliance issues and because there are more students with disabilities in these spaces who are paying for and deserve an education.

In this study, we drew on sociocultural notions of agency – where individual actions are entwined with community goals. A community is comprised of people with shared and individual goals, in their environments, in the midst of a historical context (Wenger 1998Wenger, E. 1998. Communities of Practice: Learning, Meaning, and Identity. New York, NY: Cambridge University Press. [Crossref], [Google Scholar]). Due to this web of relationships with people, environment, and history, people do not act autonomously, but according to possibilities within the community. Such possibilities for agency are negotiated over time; actions that strengthen ties to the community constitute investments in the self that in turn, have outcomes for the community as well (Peirce 1995Peirce, B. N. 1995. “Social Identity, Investment, and Language Learning.” TESOL Quarterly 29: 9–31. doi:10.2307/3587803. [Crossref], [Web of Science ®], [Google Scholar]). The financial metaphor in using the word investment is critical – it connotes spent effort that yields dividends. These dividends emerge immediately and over time.