Nonverbal Research Articles

Artificial intelligence-generated feedback on social signals in patient-provider communication: technical performance, feedback usability, and impact.

Implicit bias perpetuates health care inequities and manifests in patient-provider interactions, particularly nonverbal social cues like dominance. We investigated the use of artificial intelligence (AI) for automated communication assessment and feedback during primary care visits to raise clinician awareness of bias in patient interactions. (1) Assessed the technical performance of our AI models by building a machine-learning pipeline that automatically detects social signals in patient-provider interactions from 145 primary care visits. (2) Engaged 24 clinicians to design usable AI-generated communication feedback for their workflow. (3) Evaluated the impact of our AI-based approach in a prospective cohort of 108 primary care visits. Findings demonstrate the feasibility of AI models to identify social signals, such as dominance, warmth, engagement, and interactivity, in nonverbal patient-provider communication. Although engaged clinicians preferred feedback delivered in personalized dashboards, they found nonverbal cues difficult to interpret, motivating social signals as an alternative feedback mechanism. Impact evaluation demonstrated fairness in all AI models with better generalizability of provider dominance, provider engagement, and patient warmth. Stronger clinician implicit race bias was associated with less provider dominance and warmth. Although clinicians expressed overall interest in our AI approach, they recommended improvements to enhance acceptability, feasibility, and implementation in telehealth and medical education contexts. Findings demonstrate promise for AI-driven communication assessment and feedback systems focused on social signals. Future work should improve the performance of this approach, personalize models, and contextualize feedback, and investigate system implementation in educational workflows. This work exemplifies a systematic, multistage approach for evaluating AI tools designed to raise clinician awareness of implicit bias and promote patient-centered, equitable health care interactions.

Examining the Transition from Single Words to Phrase Speech in Children with ASD: A Systematic Review.

"Functional speech" by 5years of age is widely established as increasing the probability of long-term positive outcomes across a range of domains for autistic individuals. While terms such as "functional" or "useful" speech are often used, what defines these terms is not well established. Furthermore, most research focusing on language development has emphasized the transition from little or no language to use of single words, but much less is known about the transition from single words to phrase speech, which could be equally important. The verb lexicon is foundational to the development of simple, generative phrases and has been linked to prosocial behaviors and general developmental outcomes including better social communication skills, socioemotional reciprocity, and nonverbal communication in autistic children. The current systematic review synthesized information from 20 independent samples to characterize autistic children who transitioned from single words to phrase speech. On average, 48% of the pooled sample transitioned to phrase speech during the study periods. Results were highly variable across studies. Participants under the age of 5years were more likely to transition to phrases than participants over the age of 5. Though average standard scores were above 50, children who transitioned to phrases generally demonstrated below average adaptive and cognitive skills and moderate-high ASD symptomatology. Variable measures of cognition made it difficult to ascertain patterns in cognitive skills; nonetheless, nonverbal IQ emerged as a salient predictor of the transition to phrases across studies. More research is needed to better understand who transitions beyond single words, clinical benchmarks on the way to generative phrase speech and the factors that predict this transition. Such information can be used to inform clinical decision making and develop or improve targeted interventions based on individual communication profiles. This could make the use of phrases more likely for a greater number of autistic individuals, increasing the likelihood that these individuals communicate independently and effectively with others.

Nonverbal Communication of In-Vehicle Humanoid Robot to Communicate Autonomous Vehicle Behavior

Nonverbal Communication of In-Vehicle Humanoid Robot to Communicate Autonomous Vehicle Behavior

Inferring social signals from the eyes in male schizophrenia.

Nonverbal communication habitually leaks out in ways that expose underlying thoughts, true feelings, and integrity of a counterpart. Social cognition is deficient in a wide range of mental disorders, including schizophrenia (SZ). Inferring social signals through the eyes is pivotal for social interaction but remains poorly investigated. The present work aims to fill this gap by examining whether and, if so, how reading language of the eyes is altered in SZ. We focused on male SZ, primarily because the disorder manifests a gender-specific profile. Patients and matched typically developing (TD) individuals were administered the Reading the Mind in the Eyes Test-Modified (RMET-M) and Emotions in Masked Faces (EMF) task that provide comparable visual information. The findings indicate that in SZ, the emotion recognition profile is similar to TD, with a more accurate recognition of some emotions such as fear, neutral expressions, and happiness than the others (sadness and disgust). In SZ, however, this profile is shifted down: all emotions are recognized less accurately than in TD. On the RMET-M, patients are also less precise, albeit they perform better on items with positive valence. In SZ only, recognition accuracy on both tasks is tightly linked to each other. The outcome reveals global challenges for males with SZ in inferring social information in the eyes and calls for remediation programs to shape social cognition. This work offers novel insights into the profiles of social cognitive deficits in mental disorders that differ in their gender prevalence.

Linguistic Accommodation in English-Medium Instruction: Investigating Adjustments by Non-Native English Speakers

This study explores how non-native English-speaking students and teachers accommodate each other linguistically in EMI classrooms. The research explores the features of these strategies, including language simplification, visual aids, code-switching, and non-verbal cues, in terms of their frequency and types to identify how they impact communication/learning.Structured questionnaires were used to collect data from 200 students and 50 teachers. The study found that both students and teachers used simplification in language and visual aids to show what was being discussed.These are also well-documented, underscoring their importance in multilingual classrooms.The Pearson correlation analysis in Table 2 suggests significant positive correlations between the use of simplification and non-verbal cues language proficiency scores, which reveals that more proficient learners can employ these strategies better.This article highlights the importance of linguistic accommodation in EMI. It offers suggestions for targeted intervention programs as well as professional development to improve successful educational outcomes through English medium instruction.

Assessing language barriers in health facilities in Malawi.

Language barriers in healthcare lead to miscommunication between professionals and patients, thereby reducing the quality of and equitable access to healthcare. In African countries, the recognition and formal study of these barriers is severely limited despite Africa having more languages than any other continent. Our study investigates language barriers in healthcare facilities in Zomba district in Malawi, where three major local languages are spoken. We employed a mixed methods approach and conducted a questionnaire-led study. Data were gathered at 22 health facilities, from 79 healthcare professionals and 312 outpatients using a semi-structured questionnaire. Findings were corroborated using document analysis to review legislation and policies, curriculum documents and patient notes. Language discordance emerged as a problem for professionals and patients. Both faced challenges due to vocabulary limitations for medical terms in English and Chichewa. Professionals did not receive training on how to effectively communicate medical concepts in local languages. Most patients did not speak English, which was used for all written records. Patient understanding of the information given to them verbally during consultations or in written health notes was very low, and this diminished their confidence in the diagnosis or treatment they received. Social factors including gender, age or patient experience, as well as patient literacy or perceived low literacy, poor rapport between healthcare professionals and patients, and a lack of privacy during consultations all exacerbated communication issues. Consequences of language barriers included unsatisfactory care experiences and compromised exchanges of health information. Strategies used by professionals to cope with these challenges were flexibility in the choice of language, reliance on physical checks and non-verbal communication indicators and the occasional use of ad-hoc interpretations. Language barriers in healthcare facilities in Malawi have serious implications on the quality of healthcare provided. We propose solutions such as the development of dictionaries with phrases for symptoms and conditions, sensitisation courses that incorporate language considerations for both professionals and patients. Policies such as the provision of interpreters and staff allocation are discussed. We recognise that coordinated efforts at national and international levels are key to securing significant funding for effective interventions.

Art as a Form of Communication for Trauma Survivors

This study investigates the importance of art as a communicative tool for trauma survivors, offering a form of self-expression and healing when words fail. Art therapy allows trauma survivors to express their emotions and experiences in a nonverbal way, assisting them in processing their suffering, reducing psychological distress, and promoting recovery. By studying various types of traumas and the use of art therapy, this research demonstrates how generating visual and poetic representations of trauma can serve as a bridge to emotional resilience and healing. The study also looks at the therapeutic advantages and success stories of art-based interventions, illustrating how creative expression may alter mental health therapy for trauma survivors. Keywords: Art therapy, Trauma survivors, Non-verbal communication, Emotional healing, Post-traumatic stress disorder (PTSD).

Videos to study Interactions in AGEing (VIntAGE)

The Videos to study Interactions in AGEing (VIntAGE) corpus aims to investigate the complex relationship between language, cognition, and aging, focusing on verbal and non-verbal pragmatic markers in older persons with mild cognitive impairment (MCI). This multimodal and longitudinal corpus incorporates an analysis of gestural and verbal markers in discourse, aligned with neurolinguistic models. It provides a rich dataset for analyzing how aging impacts communicative competence in individuals with MCI. The VIntAGE corpus comprises approximately 18 hours of video recordings from 36 face-to-face interviews conducted by a close acquaintance of each of the nine women, all over 75 years old. Five participants were selected for in-depth analysis due to significant changes in their cognitive status. The participants underwent a series of semi-structured interviews over 15 months. The data were processed using transcription tools (for verbal discourse) and annotation tools (for gestures) and then subjected to Principal Component Analyses to manage each individual's diverse dataset and discursive modalities. The corpus includes the annotation of 6,351 verbal pragmatic markers (VPMs) and 8,044 non-verbal pragmatic markers (NVPMs). The data reveal an average decrease in MoCA scores from 23/30 to 20/30 over one year, highlighting cognitive decline's effects on verbal and non-verbal communication.

DIAGNOSTIC APPROACHES TO PAINFUL TEMPOROMANDIBULAR JOINT DYSFUNCTION: A LITERATURE REVIEW

Introduction. The temporomandibular joint (TMJ) is an anatomically and biomechanically complex structure, essential for critical functions such as chewing, breathing, verbal and non-verbal communication, and facial expressions. The term “temporomandibular joint disorders” encompasses a range of conditions characterized by pain with diverse, often polymorphic, manifestations. Purpose of this study is to analyze the trends and directions in publications on the diagnosis of painful temporomandibular joint disorders from 2017 to 2024 (up to March 31, 2024) across international and Ukrainian scientific resources. Materials and methods. We used the bibliosemantic method, the methods of the system approach and content analysis. We searched for scientific publications for the period from 2017 to 2024 as of 03/31/2024 in Google Academy and Medline (accessed via PubMed) using the following words and their combinations: “dysfunctional temporomandibular joint conditions” and “temporomandibular joint dysfunction”, “temporomandibular dysfunction and condylare position”, “temporomandibular dysfunction and classification”. Inclusion criteria were as follows: a) studies aimed at evaluating the anatomy of the temporomandibular joint; b) studies conducted with cone beam computed tomography images; c) research on humans; d) data of persons aged 18 to 60 years. Exclusion criteria were as follows: a) clinical cases; b) discussions; c) research with the participation of children and adolescents (under the age of 18). Results. For the period 2017-2024 (as of 31.03.2024), the main research topics on the painful form of temporomandibular joint dysfunction are the following: the prevalence of temporomandibular joint disorders (11 publications), the influence factors of the dysfunction development of the temporomandibular joint (42 publications), the improvement of existing and the search for new diagnostic criteria (17 publications); the anatomical and the morphological features of the temporomandibular join as the development predictors for the temporomandibular joint dysfunction (20 publications); search for new models for predicting the course and effectiveness of treatment for temporomandibular join dysfunction (4 publications). Conclusion. Researchers have primarily focused on examining factors influencing the clinical progression of temporomandibular joint dysfunction, accounting for 44.7% of all publications. Studies on anatomical and morphological features as predictors of temporomandibular joint dysfunction, along with new predictive models, remain contentious and highlight the need for further investigation.

A distributed brain response predicting the facial expression of acute nociceptive pain.

Pain is a private experience observable through various verbal and non-verbal behavioural manifestations, each of which may relate to different pain-related functions. Despite the importance of understanding the cerebral mechanisms underlying those manifestations, there is currently limited knowledge of the neural correlates of the facial expression of pain. In this functional magnetic resonance imaging (fMRI) study, noxious heat stimulation was applied in healthy volunteers and we tested if previously published brain signatures of pain were sensitive to pain expression. We then applied a multivariate pattern analysis to the fMRI data to predict the facial expression of pain. Results revealed the inability of previously developed pain neurosignatures to predict the facial expression of pain. We thus propose a facial expression of pain signature (FEPS) conveying distinctive information about the brain response to nociceptive stimulations with minimal or no overlap with other pain-relevant brain signatures associated with nociception, pain ratings, thermal pain aversiveness, or pain valuation. The FEPS may provide a distinctive functional characterization of the distributed cerebral response to nociceptive pain associated with the socio-communicative role of non-verbal pain expression. This underscores the complexity of pain phenomenology by reinforcing the view that neurosignatures conceived as biomarkers must be interpreted in relation to the specific pain manifestation(s) predicted and their underlying function(s). Future studies should explore other pain-relevant manifestations and assess the specificity of the FEPS against simulated pain expressions and other types of aversive or emotional states.

A distributed brain response predicting the facial expression of acute nociceptive pain

Pain is a private experience observable through various verbal and non-verbal behavioural manifestations, each of which may relate to different pain-related functions. Despite the importance of understanding the cerebral mechanisms underlying those manifestations, there is currently limited knowledge of the neural correlates of the facial expression of pain. In this functional magnetic resonance imaging (fMRI) study, noxious heat stimulation was applied in healthy volunteers and we tested if previously published brain signatures of pain were sensitive to pain expression. We then applied a multivariate pattern analysis to the fMRI data to predict the facial expression of pain. Results revealed the inability of previously developed pain neurosignatures to predict the facial expression of pain. We thus propose a facial expression of pain signature (FEPS) conveying distinctive information about the brain response to nociceptive stimulations with minimal or no overlap with other pain-relevant brain signatures associated with nociception, pain ratings, thermal pain aversiveness, or pain valuation. The FEPS may provide a distinctive functional characterization of the distributed cerebral response to nociceptive pain associated with the socio-communicative role of non-verbal pain expression. This underscores the complexity of pain phenomenology by reinforcing the view that neurosignatures conceived as biomarkers must be interpreted in relation to the specific pain manifestation(s) predicted and their underlying function(s). Future studies should explore other pain-relevant manifestations and assess the specificity of the FEPS against simulated pain expressions and other types of aversive or emotional states.

‘The Charismulator’ – charisma simulator: A study of a new VR intervention to improve charisma

Abstract Charisma, often seen as an innate trait, is now understood as leader signaling grounded in values, symbols, and emotions, suggesting it can be developed through interventions. However, the method for cultivating charisma remains unclear. This study examines nonverbal communication strategies, highlighting the potential of body language, facial expressions, and vocal modulation to enhance charisma. Additionally, we introduce a virtual reality training program focused on these cues and explore the role of audience presence in boosting the intervention’s effectiveness by fostering self-awareness and behavioral adjustments. Results of a controlled randomized experiment with virtual reality-trained participants and online charisma assessors demonstrated significant improvements in observer-rated charisma from pre- to post-training compared to the control group. Moreover, training in front of a virtual audience yielded the expected outcomes. This study sheds light on charisma theory, its potential virtual reality training application, and its implications for leadership development.

Elevating Facial Expression Detection: Empowered by VGG-19 and Weight-Normalized Gradient Boost Algorithm

Facial expression recognition termed as FER, is one of the vital tasks which is able in mimicking the human ability and wellness. Face expression and other gestures delivered via face are some of the important aspects of conveying non-verbal communications which plays a vital role in interpersonal relations. This domain has a higher scope of research due to enhancing computer vision and human-computer interaction. With respect and consideration to these domain interest, DL has gained a reasonable approach in performing FER. Some of the state-of-art approaches encompassing the ML approaches have faced several cases of laybacks such as overfitting, computational complexity, less adaptable to higher and big datasets. Thus, considering these laybacks and in achieving accurate FER in aspects of bringing proximal levels of FER, the current approach deployed DL methods for both feature extraction from the input image and in classifying them. Deep multi-level feature extraction is performed using the VGG-19 model and Weight Normalized gradient boosting algorithm is adapted for classifying these expressions using the FER13 dataset. This dataset constitutes the input images, which are in ranges of 28,709 sample image data and about 3,589 image data for test. These input images are initially pre-processed for obtaining better accuracy rates when performing feature extraction and classifications. The complete model in effective FER is evaluated using the performance metrics comprising Accuracy (98%), Recall (99%), F1-score (98%) and the precision rates (97%). This analysis of the performance will aid in affirming the overall efficacy of the proposed system.

AI-Teacher Teaching Task Spectrum in Action

The AI-Teacher Teaching Tasks Spectrum (AITTTS) was conceived as a way to understand the relationship between human teachers and the ever-evolving AI technologies in education. This study demonstrates how the AITTTS framework can be operationalised into a tangible intervention, showcasing the design models and practical applications of the AITTTS in real-world educational settings. By categorising teaching tasks into a spectrum, the AITTTS delineates the roles that AI and human teachers can play, providing a structured and nuanced understanding of their collaboration. As a result of the practical application of the AITTTS, a design model was birthed in this study. It highlights various aspects of holistic student outcomes such as positive electronic nonverbal communication (eNVC) cues, adaptive learning paths, and interactive learning responses as elements by which AI should be designed. By providing a structured approach for educators to incorporate AI tools and interventions in their learning environments, this research lays the groundwork for further exploration of the synergistic relationship between AI and human teachers in modern education. This framework can serve as a guide for educators to develop and implement AI-enhanced teaching strategies, fostering a more dynamic and responsive educational landscape.

Development of a framework of interpersonal communication skills for MPharm students: a UK eDelphi study

Abstract Introduction The importance of communication skills for pharmacists in their daily activities, particularly in patient-centred care, is paramount. Effective healthcare, including complex tasks such as health promotion and medication reviews, heavily relies on quality communication. The GPhC emphasises the importance of graduates being able to employ communication skills in various settings1 although consensus on essential communication competencies in student pharmacist education is lacking. Aim To achieve consensus on a framework of interpersonal communication competencies for MPharm students. Method With approval from Keele University’s Research Ethics Committee, a draft interpersonal communication competency framework was developed after thorough literature review. Panellists with an interest in pharmacy education (including graduates, pharmacists and non-pharmacists) were invited to participate in an online three-round modified eDelphi study. Round 1 involved participants reviewing the draft framework, providing feedback on competency relevance/ wording and identifying missing competencies. Round 2 evaluated an updated framework for competency importance, with competencies needing 80% agreement to achieve consensus. Competencies without consensus underwent Round 3 review. Feedback was provided after each round. Results Panellists from across UK came from diverse pharmacy sectors like community, hospital, primary care, academia, industry, regulatory and education. In addition, there was as considerable participant experience, knowledge and expertise, which contributed distinct insights and viewpoints. The draft framework comprised 123 competencies across four Domains: Generic Communication (sub-divided into: organisation of an encounter, initiating and closing discussions, verbal and non-verbal communication, encouragement of person involvement, and adjusting communication based on contextual or cultural factors); Patient-Specific Communication (sub-divided into: gathering patient information and shared decision making); Peer Communication, and Other Communication (e.g., written). In total, 56, 49, and 47 participants completed each of the three consecutive rounds. In Round 1, over 500 comments prompted considerable amendments, including competency additions, removals, and mergers. This led to 126 competencies being rated for importance in Round 2 and 120 competencies (95%) were deemed important by at least 80% of eDelphi participants. Alongside competency ratings, an additional 130 comments were received, offering constructive insights. Six competencies that failed to achieve consensus in Round 2 underwent review again in Round 3. Subsequently, three more competencies failed to achieve consensus, resulting in a final agreed-upon framework of 123 competencies. Discussion This is the first competency framework developed for pharmacy student education. This study underscores the importance of interpersonal communication skills in pharmacy education and the experience of participants enriched the study, providing diverse and essential perspectives that were crucial in defining these competencies. The robustness of the iterative eDelphi process was instrumental in refining these competencies through multiple rounds. Although most competencies achieved consensus, a few contentious competencies underscored the challenges of aligning participant perspectives. The finalised framework, grounded in evidence-based development and stakeholder involvement, potentially serves as a flexible foundation for structuring pharmacy education curricula, but the scope of the study may face limitations, with the range of competencies either being too broad or too narrow, which could make implementation a challenge. Future research could focus on assessing these competencies across diverse healthcare settings. Reference 1. General Pharmaceutical Council, (2017). Standards for pharmacy professionals. Retrieved from https://www.pharmacyregulation.org/sites/default/files/standards_for_pharmacy_professionals_may_2017_0.pdf.

Crying in the Womb: Emotions, Sound, and Personhood in Early Modern England

ABSTRACT Crying in the womb (vagitus uterinus) was an extraordinary phenomenon or prodigy by which a foetus in the later stages of gestation could be heard to cry before its birth. This article traces the way that crying in the womb in early modern England was consistently interpreted, across religious, medical, and popular texts, as an emotional expression. Hearing crying in the womb affirmed the unseen presence of a body and soul, already miserable with sin and able to convey this humanness, and affect the emotions of others, with the sound of its voice. This article reveals that hearing non-verbal emotional expressions was central to the early configuration of English Protestant personhood.

Unveiling Layers of Interaction: An Investigation into the Behavioral Transformations of Preschoolers with Autism Spectrum Disorder Through Assistive Technology from a Caregiver’s Perspective

This qualitative study explores the impacts of assistive technology (AT) on preschoolers with autism spectrum disorder (ASD) from the perspective of caregivers who observe and experience these behavioral changes firsthand within the home environment. Utilizing a phenomenological research design, the study involved semi-structured interviews with 10 caregivers, including both mothers and grandmothers. The analysis revealed several key themes: enhanced communication, improved social interaction, learning and development, challenges and support needs, and the variety and everyday usefulness of AT. Caregivers reported significant advancements in both verbal and nonverbal communication, increased family and peer interactions, and the development of academic and life skills in their children. However, challenges such as technical difficulties and the need for professional support were also highlighted. The study underscores the potential of AT to significantly improve the quality of life for children with ASD while also emphasizing the importance of robust support systems to optimize AT utilization. These findings contribute to a deeper understanding of the nuanced impacts of AT on children with ASD, offering valuable insights for future research and intervention strategies. Received: 8 September 2024 / Accepted: 31 October 2024 / Published: 05 November 2024

The Impact and Future of Teletherapy in Mental Health Support

Teletherapy, a digital form of mental health support, has become an essential aspect of psychological care, driven by technological advancements and evolving societal needs. This paper examines the evolution, benefits, and challenges of teletherapy, emphasizing its accessibility, especially for underserved populations. It highlights innovations such as artificial intelligence (AI) and secure messaging and discusses ethical considerations like confidentiality and informed consent. Despite limitations, such as technical barriers and reduced non-verbal communication, teletherapy is poised to grow, offering flexible, accessible mental health services. The future of teletherapy will likely see further integration with emerging technologies, potentially reshaping the landscape of mental health care. Keywords: Teletherapy, mental health support, digital therapy, online therapy, telehealth, accessibility.

An Analysis of Linguistic Barriers Affecting Street Vendors’ Communication: A Study at Mandalika Special Economic Development Region of West Nusa Tenggara

This study explores the linguistic barriers faced by street vendors in Kuta Mandalika, a popular tourist destination in Indonesia, and their impact on communication, job performance, and customer satisfaction. Utilizing a qualitative case study approach, the research subject is 13 street vendors who has an ability to communicate with foreign customer, the research involved semi-structured interviews and observations of street vendors who interact regularly with international tourists, the data analysis will be conducting thematic analysis to analyze the data. The findings highlight several major challenges, including difficulties in understanding foreign accents, limited English vocabulary, pronunciation issues, and reliance on non-verbal communication. The noisy environment where vendors operate further complicates these communication barriers. These linguistic challenges lead to frequent misunderstandings, incorrect orders, and customer dissatisfaction, significantly affecting the vendors' business performance and customer relations. This research is rarely talked by researcher as in the previous study the researcher is focusing on semantic area but that’s quite too deep to learn by street vendors and an English beginner, this approach will contribute to the overall economic vitality of the Mandalika region, benefiting both vendors and the local community.

Challenges and guidance for implementing social distancing for COVID-19 in care homes: a mixed methods rapid review.

Older people living in care homes are at high risk of poor health outcomes and mortality if they contract coronavirus disease 2019. Protective measures include social distancing and isolation, although implementation is challenging. To explore the real-life experiences of social distancing and isolation in care homes for older people, and to develop a toolkit of guidance and resources. A mixed-methods, phased design. Six care homes in England caring for older adults. Care home staff (n = 31), residents (n = 17), family members (n = 17), senior health and care leaders (n = 13). A rapid review to assess the social distancing and isolation measures used by care homes to control the transmission of coronavirus disease 2019 and other infectious diseases (phase 1), in-depth case studies of six care homes, involving remote individual interviews with staff, residents and families, collection of policies, protocols and routinely collected care home data, remote focus groups with senior health and care leaders (phase 2) and stakeholder workshops to co-design the toolkit (phase 3). Interview and focus group data and care home documents were analysed using thematic analysis and care home data using descriptive statistics. The rapid review of 103 records demonstrated limited empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. The case studies found that social distancing and isolation measures presented moral dilemmas for staff and often were difficult, and sometimes impossible to implement. Social distancing and isolation measures made care homes feel like an institution and denied residents, staff and families of physical touch and other forms of non-verbal communication. This was particularly important for residents with cognitive impairment. Care homes developed new visiting modalities to work around social distancing measures. Residents and families valued the work of care homes to keep residents safe and support remote communication. Social distancing, isolation and related restrictions negatively impacted on residents' physical, psychological, social and cognitive well-being. There were feelings of powerlessness for families whose loved ones had moved into the care home during the pandemic. It was challenging for care homes to capture frequent updates in policy and guidance. Senior health and care leaders shared that the care home sector felt isolated from the National Health Service, communication from government was described as chaotic, and trauma was inflicted on care home staff, residents, families and friends. These multiple data sources have informed the co-design of a toolkit to care for residents, families, friends and care home staff. The review included papers published in English language only. The six care homes had a Care Quality Commission rating of either 'good' or 'outstanding'. There was a lack of ethnic diversity in resident and family participants. Care homes implemented innovative approaches to social distancing and isolation with varying degrees of success. A legacy of learning can help rebuild trust at multiple levels and address trauma-informed care for residents, families, friends and staff. Future work can include evaluation of the toolkit, research to develop a trauma-informed approach to caring for the care home sector and co-designing and evaluating an intervention to enable residents with different needs to transition to living well in a care home. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132541) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 45. See the NIHR Funding and Awards website for further award information.