Saying no to the staff: an analysis of refusals in a home for people with severe communication difficulties.

People with severe communication difficulties may attempt to exercise control over their lives by verbally or non-verbally refusing an activity proposed by supporters. We detail examples in which such refusals are treated by care home staff as a temporary reluctance, warranting further attempts to persuade the individual to co-operate. We identify the following conversational (and bodily) practices by which staff achieve their institutional ends: appreciating a resident's behaviour as something other than refusal; formulating the invitation again in a no-blame format; minimising the task required; escalating the invitation to a request and an order; moving the person bodily; and positively glossing the proceedings. Dealing with refusals illustrates the dilemma faced by institutional personnel in health and care settings in accepting choices which might disrupt the efficient management of the service.