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Create a "special night" each week to be together and let your kids help decide how to spend the time. Look for other ways to connect — put a note or something special in your kid's lunchbox. Adolescents seem to need less undivided attention from their parents than younger kids. Because there are fewer windows of opportunity for parents and teens to get together, parents should do their best to be available when their teen does express a desire to talk or participate in family activities.

Attending concerts, games, and other events with your teen communicates caring and lets you get to know more about your child and his or her friends in important ways. Don't feel guilty if you're a working parent.

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It is the many little things you do — making popcorn, playing cards, window shopping — that kids will remember. Young kids learn a lot about how to act by watching their parents. The younger they are, the more cues they take from you. Before you lash out or blow your top in front of your child, think about this: Is that how you want your child to behave when angry?

Be aware that you're constantly being watched by your kids. Studies have shown that children who hit usually have a role model for aggression at home.

Nine Steps to More Effective Parenting

Model the traits you wish to see in your kids: respect, friendliness, honesty, kindness, tolerance. Exhibit unselfish behavior. Do things for other people without expecting a reward. Express thanks and offer compliments. Above all, treat your kids the way you expect other people to treat you. You can't expect kids to do everything simply because you, as a parent, "say so.

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If we don't take time to explain, kids will begin to wonder about our values and motives and whether they have any basis. Parents who reason with their kids allow them to understand and learn in a nonjudgmental way. Make your expectations clear. If there is a problem, describe it, express your feelings, and invite your child to work on a solution with you. Be sure to include consequences. Make suggestions and offer choices. Be open to your child's suggestions as well. Kids who participate in decisions are more motivated to carry them out. If you often feel "let down" by your child's behavior, perhaps you have unrealistic expectations.

Parents who think in "shoulds" for example, "My kid should be potty-trained by now" might find it helpful to read up on the matter or to talk to other parents or child development specialists. Pragmatic multicentre randomized controlled trials RCTs are acknowledged to be the best design for evaluating the effectiveness of health care interventions but often encounter recruitment difficulties [1] , [2] , [3] , [4]. RCTs in surgery face particular challenges, including that many surgeons have limited experience of participating in RCTs, often face learning curves for particular surgical procedures, and sometimes develop individualized rather than standardized techniques.

In addition, the comparator for a surgical procedure can often be a very different and more conservative option, such as physiotherapy in orthopedic trials, or no immediate intervention [5] , [6].


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To participate in an RCT comparing surgery and physiotherapy, all clinicians involved need to accept the possibility that their usual preferred treatment is no more effective than the comparator; and it is particularly difficult for recruiting surgeons to accept this [7]. In addition, discussions about trials are difficult because they may be perceived as disturbing the usual expectations of both patients and clinicians surrounding routine diagnostic and treatment consultations, where shared decisions about best treatment are the intended aim.

For patients, the idea that there is uncertainty over the comparative effectiveness of different treatments can also be very difficult to accept [8] , [9]. Discussions about trials are therefore awkward and may be avoided, leading to lack of accruals and insufficiently informed patients [7] , [10] , [11] , [12]. Qualitative research methods can be used to understand and inform the development of strategies to improve recruitment to RCTs [13] , [14] , [15]. An innovative approach to observing trial information exchange within clinician—patient consultations and giving formative feedback to recruiters based on those observations was among the strategies developed in this study and tested in other RCTs since [10] , [13] , [17].

The aim was to investigate the conduct of recruitment consultations that led to patients agreeing to participate in the pilot, including the order and manner in which the trial information is presented, and comparing this with the content and strategies used in consultations where they did not. Further, we aimed to derive a model from these findings, to offer a simple structure for a recruitment consultation that can be used in RCTs, and also inform the training of clinicians interested in conducting surgical RCTs.

An integrated qualitative research study was set up to observe recruitment processes with the objective of understanding how any difficulties related to design or conduct could be addressed early, and solutions implemented [16]. Sites were asked to audio record these two consultations for each potential trial participant and were provided with protocols for how to record them and about audio file transfer to the research team. The recordings enabled assessment of the content of information exchanged by recruiters and patients during these two key consultations.

Furthermore, the TMG provided standard training about recruiting patients during site visits. This training included the opportunity for a new recruiter to shadow an experienced recruiter talking about the trial to a potential participant. Recruiters were provided with crib sheets containing ideas for model answers to frequently asked patient questions about the trial, drawing on what had been learned during prepilot work and best recruitment practice identified by others.

As the six-step model gradually emerged from concurrent consultation data analysis throughout the trial, learning about this was ploughed back into recruiter training iteratively. Regarding the patient's experience, Fig. Collaborating surgeons identified potential FAI patients from referral letters. Before their appointment, patients were approached for consent for audio recording of their clinic consultations. Recruiting surgeons assessed patients as usual, taking a history, examining the patient, and performing appropriate imaging investigations.

Abbreviation: FAI, femoroacetabular hip impingement. Patients had the opportunity to read this document at the beginning of recruitment, engaged in the process of information sharing about the following: FAI and its possible treatments; the pilot RCT and its procedures, including randomization and research follow-up. Patients also had opportunity to ask questions. If considered in equipoise, patients were then invited to give their consent to become participants in the RCT and to be randomized to receive either hip arthroscopy or conservative care.

Consultation recordings were transcribed and analyzed using the combined techniques of thematic analysis and conversation analysis pioneered in previous studies [20]. The aim was to develop a deeper understanding of recruitment processes, and particularly of communication patterns that were linked to securing patients' informed consent to participate in the trial. The analysis consisted of listening to and reading the transcripts repeatedly to identify and document aspects of information provision that were clear or unclear, sensitive or insensitive to patients' needs, and that either hindered or facilitated recruitment.

Teaching Appropriate Behavior

The content of the consultations was further evaluated to assess whether a logical order and balanced presentation of the RCT arms and other treatment options was given; and whether participants appeared to understand the key issues of equipoise, randomization, participation in the RCT, the option to choose their treatment, and the option to withdraw from the research at any time.

Within this framework, common themes emerging from the data were identified, relating to good and bad recruitment consultation practices, and these informed the model's six steps described in the following paragraphs.

Personalized feedback was given to recruiters based on the findings, as in previous studies [16]. Data analysis was carried out prospectively, as consultation recordings became available. The first set of available consultations was analyzed in depth. The detailed analysis of these patients' recruitment consultations resulted in theoretical saturation where no new findings emerged for subsequent patient consultations , and so it was decided that further detailed analysis would not be required.

The remaining audio recordings were reviewed to check and validate the model described in the next section. However, one center did not start recruitment within the time frame of the pilot i. Analysis of the recruitment consultations provided evidence of a logical sequence for information sharing which seemed to facilitate recruitment for both recruiting clinicians and patients. It is a guide for recruiters to structure their consultations in such a way as to maximize the likelihood of successful patient recruitment.

A six-step model for recruitment to an RCT. The main principle underpinning the model is that recruitment consultations should enable patients to understand the uncertainty arising from a lack of clinical research evidence about the optimal treatment of FAI.

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This aspect of recruitment consultations is quite different from diagnostic and treatment consultations in routine clinical practice, where the usual aim is for the clinician to remove uncertainty and move toward a shared agreement about the best treatment option. However, in recruitment consultations, there is a need to explain and reiterate that there is uncertainty about the best treatment.

Previous research has shown that this is difficult and sometimes uncomfortable for recruiting clinicians [7]. The aim of the six-step model is to provide a framework to facilitate this process. Each step is now explained in more detail, with an emphasis on highlighting what has been learned about best recruitment practice.

Patients need to receive an explanation about FAI that is easy to understand. We found that successful recruiters tended to use lay terms to explain the morphologic abnormalities related to this condition. They also made use of metaphors from common everyday experiences when explaining, for example, referring to the piston heads in a car. These attempts to make sure the patient understood what is happening to their bodies were important investments in the relationship and appeared to help patients feel confident in the care they were receiving.

Explaining this permitted patients to make a logical link between their condition and nonsurgical therapy as a plausible treatment, which could be used later in the discussion.

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The following quote is an example of a helpful explanation provided by a recruiter:. Now, lots of people have that sort of shape but only a few people run into trouble with it … and my idea on this is if you've got the egg shape, and your muscles are not good at supporting it, then you run into trouble. Now that problem is called femoral acetabular impingement, it's quite a long word, it just means that the ball is rubbing irregularly on the socket.

Recruiters also introduced to the high incidence of FAI in the population, which supported the sense of urgency about answering the research question and increasing available knowledge about FAI. A direct invitation from the recruiting surgeon to the patient to listen to the recruiter seemed particularly effective in getting the person to consider participation in the trial. Statements that reassured patients were very powerful in generating trust and openness to joining the trial, for example, when recruiters were confident about having the right diagnosis and explaining their patients would receive the best treatment for their condition.

The following quote illustrates the kind of reassurance that patients appeared to value:. That rubbing is causing the pain, so there's not really any mystery; we know what the problem is. So, my suggestion is that we treat this problem; I don't think we should just leave it alone, I think we need to try and make you better. The first two steps of the model, explaining about the diagnosis and that patients will receive the best treatment, set the scene for the discussion about equipoise and the rationale for the RCT.

Uncertainty about which treatment is the best was mentioned early on in the diagnostic appointment and reinforced repeatedly during the consultation. This enabled patients to understand that although there was uncertainty about whether one treatment was better than the other, the two treatments being compared were both effective. This approach helped to reduce patients' uneasiness about not knowing which treatment is the best overall.

The following quote is an example of how a recruiter explained this to a patient:. And, I think you know that we are trying to find out which of those is better. We just genuinely don't know which one is better and which one we should recommend to people. Once uncertainty was established, explaining the purpose of the study followed logically. They also mentioned the need for evidence, emphasizing the real contribution patients could make to advancing science and health care, as illustrated in the following quote:.

So, here we're running the trial to see if we can work out what the best treatment is.