RealTalk – promoting positive conversations about end of life

However, talking about dying is worthwhile.

According to The Royal College of Physicians: “Open conversations about prognosis, palliative care and end of life can often be welcomed by the patient or their family as a chance to gain more information about their prognosis and treatment options, and to exercise some choice and preference.”

In other words, sensitive and open conversations allow people and their loved ones to make decisions about their lives and future – minimising futile and unwanted care while reducing the suffering of the bereaved.

But the fact remains, these conversations can be extremely hard for everyone involved.

RealTalk provides training for health and social care practitioners to help them engage effectively in discussions about disease progression and end of life with patients and their companions.

Drawing on communication science research – specifically conversation analysis – it equips practitioners with the skills and knowledge they need to broach and sensitively guide these tough, but essential discussions.

Conversation analysis (CA) is the systematic study of social interactions – and can be applied to the many types of conversations that we have every day in both formal and casual situations.

Developed in the USA during the late 1960s and early 1970s – by the sociologist Harvey Sacks with fellow researchers Emanuel Schegloff and Gail Jefferson – it explores and highlights the practical problems we face in everyday communication.

Importantly for RealTalk, CA explores how we raise and talk about delicate subjects, and the ways we navigate the problems inherent in these kinds of conversations.

In addition to what is said and the language used, CA also examines how something is articulated – the precise timing, tone of voice and volume – as well as the accompanying non-verbal behaviour – facial expressions and gestures.

These details make a difference to how something we say is understood – and how effective it is in achieving our desired outcomes.

Conversation analysts make detailed transcriptions of video or audio recordings of actual conversations – including notes about the non-verbal elements – which they then analyse alongside the original recording.

By studying multiple conversations, researchers spot patterns and identify what elements of communication help or hinder progress to a positive outcome. From this, they can identify strategies and practices that constructively help conversations along.

Therefore, CA provides useful insights for people who engage in difficult interactions – including mediators and negotiators, police officers and the judiciary, educators and health practitioners.

However, in the past, the findings of CA research have largely been shared by and for scientists, rather than as practical toolkits for people in these professions. [A notable exception to this is CARM, developed at Loughborough by Professor Elizabeth Stokoe.]

RealTalk makes good on this omission for health and social care practitioners.

A set of evidence-based training resources, RealTalk teaches health and social care practitioners how to facilitate discussions about disease progression and end of life – as well as conversations about pain assessment and bereavement – with patients and their companions. 

The resources are freely available – via the RealTalk website – for use by communication skills trainers within the NHS, higher education institutions, hospices and other third sector organisations. Accompanied by guidance notes and safeguarding prerequisites, the resources can be embedded in existing training packages and the trainers need no CA expertise. 

Based on video of actual consultations in hospice settings and audio recordings of bereavement support group sessions, the RealTalk resources exemplify common communication problems and highlight the skills for dealing with them. 

Typically, training in this type of talk makes use of role play, but this approach does not always create scenarios that are true to life. By drawing on authentic conversations and real situations RealTalk reflects the complex, context-specific nature of actual healthcare conversations.

Rather than providing a set procedure or conversational script to follow, RealTalk highlights and teaches the basic principles that underpin a range of complex communication skills. Practitioners can draw on these to facilitate compassionate conversations that allow everyone involved to positively participate.

The research underpinning RealTalk was started by Professor Ruth Parry and the VERDIS project team which Loughborough’s Dr Marco Pino joined in 2013.

Their work was initially funded by the Health Foundation, and its development has been supported by several partnerships – including with LOROS and Cruse Bereavement Support – as well as via consultancy work with the NHS.

Since 2013, the RealTalk project has grown further – thanks to further support from the Health Foundation, the National Institute for Health and Care Research, Loughborough University, and the School of Social Sciences and Humanities.

RealTalk’s development has been iterative. The researchers analysed end-of-life conversations to create a foundation of robust, in-depth evidence of the features that promote constructive communication. Drawing on these findings, they created the original resources and guidance manual which were then piloted by trainers who provided feedback for revisions and improvements.

In September 2022, the University licensed RealTalk to Treetops Hospice, ensuring wider use and embedding the research evidence into practice.

Although Treetops will be responsible for the operational management of RealTalk, Marco and his team based at Loughborough will remain involved in the project – expanding its underpinning evidence, generating new training modules, and assessing the impact of the programme’s resources.

The license agreement means that financial support of RealTalk is secure, ensuring its long-term sustainability.

Thanks to Treetops’ experience in end-of-life care and communication skills training, RealTalk will be used more widely – benefitting practitioners, patients and their companions, as well as the bereaved across the UK.

RealTalk and is highly valued by the many trainers who use it to teach the facilitative skills necessary for compassionate conversations with patients who have palliative care needs, and their companions.

There are currently about 300 registered users – and their feedback is always extremely positive.

Trainers who recently attended a series of RealTalk workshops, said that they felt far better equipped to teach practitioners how to approach difficult conversations with compassion.

They highlighted the value of RealTalk’s unique video resources which allow trainees access to real patients and learn from actual conversations.

Similarly, practitioners who have undergone RealTalk training say that they feel more confident about broaching difficult conversations with patients and families – and are more aware of various techniques that can guide sensitive discussions to helpful outcomes.

RealTalk research is ongoing and the range of teaching materials continues to grow in response to user feedback and to support evolving training needs.

There are plans to expand the resources to include conversations recorded in other settings where discussions about disease progression and end of life form a crucial, but highly sensitive part of health and social care – including hospital emergency departments, drop-in information sessions for newly diagnosed patients and recently bereaved people, as well as hospice-at-home visits.

And, in response to the coronavirus pandemic, RealTalk now includes guidance for remote online training sessions.

To support the ongoing resource development, the RealTalk researchers have secured University funding to conduct a rigorous user evaluation.

This will include surveys and interviews with training professionals registered to use RealTalk as well as with the healthcare practitioners who attend their training events. Their feedback will help shape existing and new materials to further enhance RealTalk’s impact.