Design and structuring of the task

In general, group participants appeared well engaged in the modified Delphi process evidenced by the high response rates, and the level of detail provided in participant responses. A challenge in the design of the survey was the diversity of modified Delphi participants. While all participants had expertise in agenda setting, they nonetheless were from different cultural backgrounds

(international group), working in diverse areas (primary care, prison service, addiction treatment), in different roles (expert patient tutors, researchers, clinicians, management) with different educational backgrounds (non-tertiary level to doctoral level). Ensuring that the survey was clear and accessible to all participants was important particularly as the survey design influences the judgments participants are likely to make (Murphy, Black et al. 1998, Hsu and Sandford 2007).

Murphy et al (1998) suggest a structured approach to content development of a Delphi round, e.g. through literature review, while at the same time giving participants many opportunities for stating their own views. This principle was followed in the design of the survey. In addition, as described earlier, attention

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was given to the design of the task with a number of pilot rounds and testing of questions. In particular attention was given to the phrasing being clear, and free of jargon or bias. Despite this attention to detail, it is probable that participant responses were moulded by the task designed to gather them. Therefore the findings should be interpreted in this light, i.e. that this is a consensus of opinion among a non-representative group of experts.

4.4.3 Modified Delphi findings and the teaching of agenda setting The modified Delphi exercise was an important activity for bridging the two research questions - (1) what is agenda setting? (2) is it measureable? From this study the conceptual model has been developed to embrace both the clinician and patient perspectives in defining agenda setting (Chapter 5). The inclusion of expert patients in the modified Delphi expert participant group prompted a shift in perspective when describing agenda setting. Domains were phrased in a more objective manner for example. In this way the model is intended to be useful for a wide range of activities. A measure of patient skilfulness in agenda setting might be developed from this platform for example. In this study the purpose of measure development was to produce a tool that can be used to teach clinicians.

It was necessary therefore to shift perspective again, this time to embrace the clinician perspective more fully. This shift from refining the content of domains to considering their measurement in teaching clinicians was a significant part of this consensus exercise.

Organising the information from round 1 to round 2 into three higher order categories defining agenda setting – i.e. the (1) conversation, (2) tasks, and (3) skills – was intended to create a simple framework that might be useful in teaching. Two domains were included as the “quality of conversation”. Four domains were rephrased as tasks as the task approach is a familiar to learners, allowing them to focus on a discrete action while retaining flexibility in being responsive to the patient and situation (Makoul 2001). Skills were also identified.

The consensus group was particularly useful in considering when in clinical training agenda setting should be taught, with some indication that it is a core

communication skill that should be taught in basic training. These findings are consistent with consensus statements that considered agenda setting as a one of a number of core clinical communication skills in medical education (Simpson, Buckman et al. 1991, Makoul 2001, von Fragstein, Silverman et al. 2008). Similar consensus statements in other professional disciplines were not identified.

Note: To clarify, the preceding paragraph refers to empirically based consensus statements of core communication skills, such as the Kalamzoo consensus

statement for medical communication (Makoul 2001, Duffy, Gordon et al. 2004).

A consensus statement of inter-disciplinary communication skills has recently been published and is the first of its kind (Bachmann, Abramovitch et al. 2013).

These authors also noted the lack of consensus statements that have been published in other disciplines. All professional groups have guidelines with regard to communication competence, and this is highlighted in Chapter 9, section 9.1.2.)

Given some recognition of its importance in educational settings two questions arise: (1) to what extent and in which way is agenda setting already included in undergraduate communication skills training; and (2) how might the findings from this study enhance teaching efforts both where agenda setting is already part of the curricula and where it is not? This last question will be revisited later in the PhD through the development of a measure based on this framework.

Equally however it could be argued – and was argued by some participants in this study - that evidence to support the impact of agenda setting on patient outcomes remains underdeveloped. This argument suggests that integration of agenda setting into teaching curricula is premature. The value of this framework is not undermined in this instance though as it may be used to teach agenda setting to clinicians when conducting research. As highlighted in the literature review presented in Chapter 2, the evidence for the usefulness of agenda setting is mixed, and meaningful conclusions are difficult to make.

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4.5 Conclusion

This consensus exercise provided a bridge between the primary research questions, allowing for clarification of the “what is agenda setting?” question from which to consider whether or not it is measureable. There was high degree of consensus across this expert group, suggesting that while agenda setting descriptions may be variable, there is nonetheless a considerable amount that unites these differences. The integrated model of agenda setting is an attempt to capture this and is presented in the following chapter. Measure development follows, and is described in Chapters 6, 7 and 8 of the thesis.