Effective communication skills are the key to good cancer care

Cross-cultural adaptation and patients' judgments of a question prompt list for Italian-speaking cancer patients

BACKGROUND

Question Prompt Lists (QPLs) have proven very effective in encouraging cancer patients to ask questions, allowing them to take up a more active role during visits with the oncologist. As no such tool has yet been validated for Italian-speaking users, we carried out the cross-cultural adaptation and evaluation of an existing Australian Question Prompt List.

METHODS

Cross-cultural adaptation was performed in accordance with the five steps described by Guillemin and Beaton. Forward and back translations of the original tool were carried out, and the products discussed by an Expert Committee who agreed on a prefinal version of the Italian QPL, which was submitted to 30 volunteer patients for evaluation. They rated each question's adequacy of content, clarity of wording, usefulness, and generated anxiety, on a 3-point Likert scale. Based on the analysis of patient ratings, the final version of the Italian QPL was produced.

RESULTS

Few discrepancies between the two back translations and the original version of the instrument were noted, indicating that the Italian translation (synthesis of the 2 forward translations) was substantially accurate. Most volunteer patients felt that the questionnaire was adequate, easy to understand and useful. Only a few minor criticisms were expressed. Certain questions on diagnosis and prognosis generated the highest level of anxiety. Patient comments and ratings on clarity highlighted the need to clarify common health care terms which are not widely used by the public (i.e. guideline, multidisciplinary team and clinical trial)

CONCLUSIONS

This cross-cultural adaptation has produced an Italian Question Prompt List that is now available for multi-center international studies and can be safely used with Italian-speaking cancer patients.

The role of provider-patient communication and trust in online sources in Internet use for health-related activities

Provider-patient communication is an important factor influencing patients' satisfaction and health outcomes. This study draws upon the uses and gratification theory to examine how individuals' perception of communication with healthcare providers is associated with their Internet use for health-related activities. Using the data from the 2007 Health Information National Trends Survey (HINTS), we found that as individuals perceived their communication with providers to be less patient-centered, they were more likely to engage in various types of online health activities, such as using websites for healthy lifestyles, searching for healthcare providers, and seeking health information. Trust in online health information was also found to be a significant predictor of online health activities. The results of this study emphasized the important role of provider-patient communication in motivating individuals to turn to the Internet for health purposes.

Burn teams and burn centers: the importance of a comprehensive team approach to burn care

Remarkable advances in burn care have been made over recent decades, and it is recognized that the organized efforts of burn teams are required to continue enhancing survival rates and quality of life for patients. Patients with major burns are unique, representing one of the most severe models of trauma, and therefore necessitate treatment in the best specialized facilities available for that endeavor. Burn centers have developed to meet these intricate needs but can only function most productively and efficiently through well-organized, multifaceted, patient-centered teams in the areas of both clinical care and research.

Teaching medical interviewing to patients: the other side of the encounter

OBJECTIVES

This paper describes the development and pilot testing of a communication skills curriculum based on medical student curriculum and modified for use with patients.

METHODS

Six key concepts from our introductory medical education communication skills curriculum were identified. The core knowledge and skills related to these concepts were reorganized into six modules, including presentation materials, handouts and active learning components. The curriculum was pilot tested with three independent groups of non-medical participants, representing a broad cross-section of the community.

RESULTS

Participants reported a high level of satisfaction; over 80% found the program helpful for learning new information and skills, and 92% for working with their physicians. Over 90% would recommend the program to others. Participant self-assessments revealed the greatest change in knowledge of medical interviewing. Skill changes were greatest in expressing emotion and efficiently telling the medical story. The pilot tests also highlighted the importance of other issues related to recruitment and health literacy.

CONCLUSIONS

This project demonstrates that key concepts underlying doctor-patient communications can be simplified and repackaged for use from the patient's perspective.

PRACTICE IMPLICATIONS

Similar curricula can empower patients from all walks of life to better communicate with their health care providers and enhance their healthcare experience.

An assessment of the likelihood, frequency, and content of verbal communication between radiologists and women receiving screening and diagnostic mammography

RATIONALE AND OBJECTIVES

Research on communication between radiologists and women undergoing screening and diagnostic mammography is limited. We describe community radiologists' communication practices with patients regarding screening and diagnostic mammogram results and factors associated with frequency of communication.

MATERIALS AND METHODS

We received surveys from 257 radiologists (70% of those eligible) about the extent to which they talk to women as part of their health care visit for either screening or diagnostic mammograms, whether this occurs if the exam assessment is positive or negative, and how they use estimates of patient risk to convey information about an abnormal exam where the specific finding of cancer is not yet known. We also assessed characteristics of the radiologists to identify associations with more or less frequent communication at the time of the mammogram.

RESULTS

Two hundred and forty-three radiologists provided complete data (95%). Very few (<6%) reported routinely communicating with women when screening mammograms were either normal or abnormal. Fewer than half (47%) routinely communicated with women when their diagnostic mammograms were normal, whereas 77% often or always communicated with women when their diagnostic exams were abnormal. For positive diagnostic exams, female radiologists were more likely to be frequent communicators compared to males (87.1%-72.8%; P=.02) and those who spend 40%-79% of their time in breast imaging (94.6%) were more likely to be frequent communicators compared to those who spend less time (67.2%-78.9%; P=.02). Most radiologists convey risk information using general rather than numeric statements (57.7% vs. 28.5%).

CONCLUSIONS

Radiologists are most likely to convey information about diagnostic mammographic findings when results are abnormal. Most radiologists convey risk information using general rather than numeric statements.

Psychosocial care for patients and their families is integral to supportive care in cancer: MASCC position statement

This position paper, written on behalf of the MASCC Psychosocial Study Group, reviews the most common psychosocial concerns and needs of cancer patients during all phases of the cancer continuum, from diagnosis to death or survivorship. Developments in psychosocial care at both individual and systems levels are surveyed and summarized, along with gaps in knowledge and research and needed improvements in the dissemination and application of acquired knowledge and expertise. The roles of culture, spirituality, and religion as part of psychosocial care are reviewed, along with families' and caregivers' specific psychosocial concerns and needs, and areas of needed psychosocial interventions in supportive cancer care. Deficits in recognizing and meeting patients' psychosocial needs at the system level are examined, and international guidelines and models of psychosocial care are reviewed, including their potential applications to local contexts. The paper calls for a shift to a new paradigm of care through adoption of an integrated approach to identify and meet the psychosocial needs of cancer patients and survivors as part of supportive care worldwide.

Nurse responsiveness to cancer patient expressions of emotion

OBJECTIVE

This theoretically based study examined nurse responses to cancer patient expressions of emotion using a videotaped, simulated cancer patient.

METHODS

This study used an experimental crossover design with a videotaped patient expressing anger, sadness, and neutral emotion to elicit nurse responses. Seventy-four nurses from eight sites participated. Responses were coded using Roter interaction analysis system. Correlations explored relationships between variables that impact communication (age, gender, work experience, trait anxiety, work stress, self-efficacy). Regression models explored the effect of variables on nurse affective responsiveness.

RESULTS

Patient expressions of sadness elicited more affective responses than anger. Expressions of anger or neutral emotion elicited more instrumental behaviors than sadness. Variables such as age, work stress and work experience were significantly correlated. No variables predicted affective responsiveness to patient expressions of anger or sadness.

CONCLUSION

Nurse communication showed significant variation in response to patient emotional expressions. Understanding the relationships between demographic, personality, and work variables, and identification of new variables that influence nurse-patient communication, has implications for interventional studies.

PRACTICE IMPLICATIONS

Over 90% of the participants indicated that the videotape simulation would be a useful method for teaching and practicing communication skills with patients expressing emotions.

The self-management of uncertainty among men undertaking active surveillance for low-risk prostate cancer

Asymptomatic men with low-risk, early-stage prostate cancer are eligible for active surveillance (AS), which offers a means to monitor the cancer while delaying treatment. However, AS operates within a unique set of circumstances that advocate monitoring, rather than immediate treatment, and men's health practices are central to coping with the inherent uncertainty of living with an untreated cancer. A qualitative study was completed to describe the range of men's self-management strategies used to overcome AS-related uncertainty. The study findings reveal two strategies. First, positioning prostate cancer as benign through stoicism and solitary discourses were common to men intent on "living a normal life." Second, men committed to "doing something extra" complemented AS protocols, and often collaborated with their wives to focus on diet as an adjunct therapy. Although most participants exhibited typical men's health practices, it is clear that tailored AS psychosocial interventions will benefit men and their families.

Cancer patient preferences for quality and length of life

BACKGROUND

Optimal patient decision making requires integration of patient values, goals, and preferences with information received from the physician. In the case of a life-threatening illness such as cancer, the weights placed on quality of life (QOL) and length of life (LOL) represent critical values. The objective of the current study was to describe cancer patient values regarding QOL and LOL and explore associations with communication preferences.

METHODS

Patients with advanced cancer completed a computer-based survey before the initial consultation with a medical oncologist. Assessments included sociodemographics, physical and mental health state, values regarding quality and length of life, communication preferences, and cancer-related distress.

RESULTS

Among 459 patients with advanced cancer, 55% placed equal valued on QOL and LOL, 27% preferred QOL, and 18% preferred LOL. Patients with a QOL preference had lower levels of cancer-related distress (P < .001). A QOL preference was also associated with older age (P = .001), male sex (P = .003), and higher educational level (P = .062). Patients who preferred LOL over QOL desired a more supportive and less pessimistic communication style from their oncologists.

CONCLUSIONS

These data indicate that a values preference for LOL versus QOL may be simply measured, and is associated with wishes regarding the nature of oncologist communication. Awareness of these values during the clinical encounter could improve decision making by influencing the style and content of the communication between oncologists and their patients.

Factors Associated With Work Stress and Professional Satisfaction in Oncology Staff

Cancer care professionals work in a stressful environment, but it is not clear what factors contribute to this stress. We surveyed 60 oncology personnel on an inpatient unit and a palliative care unit regarding levels of perceived work stress and its potential contributors. Logistic regression analyses were performed to determine predictors of staff stress. A total of 63% of staff reported experiencing ``a great deal'' of stress at work, which was predicted by greater perceived workload (odds ratio = 32.2; P < .0001), insufficient time to grieve patients' death (odds ratio = 9.75; P = .0007), lack of institutional support (odds ratio = 0.16; P = .009), perceived lack of resources (odds ratio = 0.06; P = .007), and lack of control over the choice of workplace (odds ratio = 0.10; P = .03). Measures to address work-related stress should be included in the planning of cancer programs.

Non-disclosure of cancer diagnosis: an examination of personal, medical, and psychosocial factors

OBJECTIVES

In recent psycho-oncological literature, few studies are concerned with the consequences of cancer diagnosis non-disclosure. The aims of this study were to analyze factors that may explain the non-disclosure of cancer diagnosis to patients by physicians and to compare personal characteristics of cancer patients, on the basis of cancer diagnosis disclosure versus non-disclosure.

METHODS

A total of 420 hospitalized cancer patients were included in our study; 342 with malignant and 78 with benign tumors. Two hundred thirty-eight women and 185 men completed a self-report questionnaire that included standardized measures of depressive symptoms (BDI), hopelessness, ways of coping, negative life events and anomie. Data were controlled for demographic, medical, and psychosocial factors.

RESULTS

Malignant cancer (OR:11.88), severe and moderate depression (OR:10.57 and OR:4.81), lack of chemotherapy (OR:4.20) and low anomie (OR:2.77) after overall adjustment predicted cancer diagnosis non-disclosure to patients.

CONCLUSION

Our results underline the persistent need for delivering patient-focused health services in oncological care based on respect for the patients' right to autonomy.

Breast cancer: unique communication challenges and strategies to address them

Women with breast cancer have become increasingly more involved on a national and local level in advocating for resources to fight cancer. However, in the context of the relationship with their physicians and other cancer caregivers, much remains to be done in providing them with adequate support. In this paper, we highlight the difficulties in communication related to breast cancer and describe strategies and approaches that may be helpful in improving the communication throughout the cancer trajectory. Specifically, breast cancer patients have high unmet information needs relevant to health information and dissatisfaction with the actual information they receive from their providers. These needs seem even more pronounced when patients are older, of lower socio-economic class and from differing cultural backgrounds which may affect their ability to express their desires for information and desire to be involved in decision-making about their treatment. Other communication challenges can be envisioned as occurring at key points across the cancer trajectory: diagnosis disclosure, treatment failure, transition to palliative care, and end of life discussions. These involve techniques as basic as how to establish trust and rapport and determine a patient's information and decision-making preferences and as complex as giving bad news. These strategies are now viewed as essential skills in that they can affect patient distress and quality of life, satisfaction, and malpractice litigation as well as practitioner stress and burnout.

Do available questionnaires measure the communication factors that patients and families consider important at end of life?

Patients with advanced cancer report wanting better communication. Our previous research identified five specific communication domains important to end-of-life (EOL) cancer care: communicating information, interpersonal communication, communicating available supportive care services, communicating a transition in the objectives of care, and interprofessional communication. A literature review was conducted to identify patient-, family member-, or heath professional-reported questionnaires to measure these specific communication domains. On the basis of specific criteria, including validity and evidence base, 10 questionnaires were identified that have the potential to measure and monitor the quality of communication during EOL cancer care. No single questionnaire measured all five domains. There is a need to further develop questionnaires that have the capacity to specifically measure those communication domains that are important to patients with cancer and their families at EOL.

Interventions before consultations to help patients address their information needs by encouraging question asking: systematic review

OBJECTIVE

To assess the effects on patients, clinicians, and the healthcare system of interventions before consultations to help patients or their representatives gather information in consultations by question asking.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Electronic literature searches of seven databases and hand searching of one journal and bibliographies of relevant articles. Review methods Inclusion criteria included randomised controlled trials.

MAIN OUTCOME MEASURES

Primary outcomes were question asking; patients' anxiety, knowledge, and satisfaction; and length of consultation.

RESULTS

33 randomised trials of variable quality involving 8244 patients were identified. A few studies showed positive effects. Meta-analyses showed small and statistically significantly increases in question asking (standardised mean difference 0.27, 95% confidence interval 0.19 to 0.36) and patients' satisfaction (0.09, 0.03 to 0.16). Non-statistically significant changes occurred in patients' anxiety before consultations (weighted mean difference -1.56, -7.10 to 3.97), patients' anxiety after consultations (standardised mean difference -0.08, -0.22 to 0.06), patients' knowledge (-0.34, -0.94 to 0.25), and length of consultation (0.10, -0.05 to 0.25). Interventions comprising written materials had similar effects on question asking, consultation length, and patients' satisfaction as those comprising the coaching of patients. Interventions with additional training of clinicians had little further effect than those targeted at patients alone for patients' satisfaction and consultation length.

CONCLUSIONS

Interventions for patients before consultations produce small benefits for patients. This may be because patients and clinicians have established behaviours in consultations that are difficult to change. Alternatively small increases in question asking may not be sufficient to make notable changes to other outcomes.

Effectiveness of a three-day communication skills course in changing nurses' communication skills with cancer/palliative care patients: a randomised controlled trial

This multi-centre, two-armed parallel-group pragmatic randomised controlled trial (RCT) evaluated the effectiveness of a 3-day communication skills course in changing nurses' communication skills. The primary outcome was the change in the nurses' communication skills score from pre-course to 12 weeks post-course. The main secondary outcome was the change in the nurses' level of confidence in communicating with patients. A total of 172 nurses were randomised to the course or control. The communication skills score for the intervention group increased by 3.4 points post-course but decreased in the control by 0.05 points (between-group difference in change: 3.41, 95% CI: 2.16-4.66, P < 0.001). Confidence scores increased by 18.16 points for the intervention group but decreased 0.7 points in the control (between-group difference in change: 18.86, 95% CI: 13.39-24.34, P < 0.001). This RCT contributes to the evidence base on the effectiveness of communication skills training in cancer and palliative care.

Breast cancer patients' narratives about positive and negative communication experiences

Health staff-patient communication is increasingly considered an important issue in cancer research. However, questionnaires addressing satisfaction with communication limit the issues patients can raise, do not address the context of communication and often show a strong positive skew in responses. Thus, qualitative studies of communication are also needed. Fifteen breast cancer patients were interviewed 3 months after finishing adjuvant treatment. They were asked to tell a 10 minute narrative and recall five experiences from treatment. Themes were extracted using categories derived from previous research while at the same time being sensitive to new elaborations and categories. The participants reported both positive and negative communication-related experiences from a wide range of treatment situations. Two major themes emerged: Information giving as professional care-giving and meeting emotional needs. The analysis suggests that appropriate information giving may have several functions, such as re-establishing the patient's future and reducing worst-case fantasies. Meeting emotional needs was seldom reported as directly talking about negative emotions, but rather through a variety of health staff behaviours. Also, the analysis points to problems in expecting or even pressurizing patients to feel and display negative emotions. The results highlight that meeting medical and emotional needs of patients may be closely intertwined in concrete treatment situations.

Cancer care communication: the power to harm and the power to heal?

OBJECTIVE

This study was designed to examine the belief held by many cancer patients that communication with their care providers has a meaningful part to play in shaping their disease outcomes.

METHODS

From a large qualitative interview data set in which cancer patients described their perceptions of helpful and unhelpful heath care communication; we extracted the accounts of 69 patients and 13 focus group participants who specifically articulated a perceived relationship between communication and cancer outcomes. Through secondary analysis of that subset, we generated an interpretive description of patterns and themes within their accounts of a relationship between communication and cancer survivorship.

RESULTS

Our findings document patient perceptions of the mechanisms involved in indirect and, some instances, direct relationships between communication encounters and cancer outcomes.

CONCLUSION

Some cancer patients believe that, by virtue of its influence upon comfort, inclusion, clarity and hope, communication can influence cancer outcomes.

PRACTICE IMPLICATIONS

While competing discourses exist within the patient population with regard to such associations, the perception that communication may influence clinical outcomes seems sufficiently pervasive and persistent that it warrants serious attention within care systems and by the psychosocial cancer research community.

Information needs and decision-making preferences: Comparing findings for gynaecological, breast and colorectal cancer

This study examined information needs and decision-making preferences for women with gynaecological cancers (n=53) using structured interviews and compared findings to previous work involving breast and colorectal cancer patients. Measures of information needs (Information Needs Questionnaire) and decision-making preferences (Control Preferences Scale) were administered to women with gynaecological cancers, consistent with measures previously administered to breast (n=150) and colorectal (n=42) cancer patients. Therefore, statistical comparisons could be made across study groups. Priority information needs were similar across the three cancer groups and related to information about likelihood of cure, spread of disease and treatment options. Patients across study groups preferred to share or delegate decision-making to doctors, rather than make decisions themselves. However, patients with gynaecological and colorectal cancers were more likely to have achieved their preferred role in decision-making than women with breast cancer. There were clear similarities in priority information needs across cancer patients groups. However, decision-making preferences need to be established on an individual basis to ensure that patients are involved in the decision-making process to the extent that they prefer. The research instruments used in this study have potential as clinical guides to enable health professionals to make an individual assessment of needs and preferences.

Consent and information giving in radiotherapy

This paper explores some of the issues around implementing a consent policy within the radiotherapy department. Consent can be defined as a patient’s agreement for a health care professional to provide care. The NHS Plan1 highlighted the need for quality care centred around the patient and for changes in the way patients are asked to give their consent to treatment. This led to the Department of Health (DoH) publishing a Good Practice in Consent Implementation Guide (2001)2 for use within all NHS Trusts from 1 April 2002, which aimed to provide consistency across the NHS and provides a policy model and generic consent forms.

The policy recommends that the health professional carrying out the procedure is ultimately responsible for ensuring that the patient is genuinely consenting to what is being done, as it is they who would be held responsible in law should a case be made by a patient against a health professional. In radiotherapy, it is the Clinical Oncologist who obtains consent as they are responsible for prescribing courses of treatment; however, it is the Radiographer’s role to deliver this treatment. This paper discusses some of the issues around implementing a consent policy in terms of who can give and confirm consent, and what are the requirements for training if the patient is to receive the appropriate information before making the decision to consent to treatment.

Ways to obtain a breast cancer diagnosis, consistency of information, patient satisfaction, and the presence of relatives

GOALS OF WORK

What physicians told breast cancer patients about their diagnosis, who informed them, and how this information was conveyed were examined in this study. Finally, the relatives' role in this communication process was considered.

MATERIALS AND METHODS

Women with primary breast cancer (N = 222) below the age of 70 were interviewed after surgery and after they were informed about their diagnosis.

MAIN RESULTS

One hundred twenty-one women consulted their primary gynecologist first, then they were referred to a radiologist, and finally to the secondary care gynecologist. Forty-seven women omitted the radiologist and only five went directly to the hospital for treatment. In most cases (N = 199), the general practitioner was not involved. Receiving inconsistent information was associated with patient dissatisfaction. This also applies to women who received their diagnosis on the phone. Women awaiting a worse diagnosis were more likely to be accompanied by another person.

CONCLUSIONS

Future studies should focus on the possible involvement of family doctors and relatives during the diagnostic process. Giving inconsistent information should be avoided.

Social support and coping in Turkish patients with cancer

This study was conducted with the aim of determining the relationship between social support and coping strategies in cancer patients and that between the sociodemographic and medical properties of patients. One hundred forty-eight cancer patients admitted to an oncology and hematology clinic in Erzurum were studied. The data were collected using a questionnaire that determines sociodemographic features: the Ways of Coping Inventory and the Perceived Social Support From Family Scale. Among the coping strategies, patients were found to use unconfident approach (emotion focused) (16.8 +/- 5.5) the most and seeking social support (problem focused) (8.3 +/- 2.6) the least. Mean +/- SD score for perceived social support from the family was 15.9 +/- 2.7. Significant correlations were found among social support and coping strategies. We found a negative correlation between social support and emotion-focused coping strategies (unconfident approach and submissive approach). As the social support scores increased, scores regarding emotion-focused coping strategies decreased. On the other hand, there was a positive correlation between social support and problem-focused coping strategies (confident approach, optimistic approach, and seeking social support); that is, mean social support scores increased as the mean problem-focused coping strategy scores increased. This result implies that families have important roles for patients and should be educated and supported by healthcare professionals in approaching patients in a knowing way. In addition to the results, this study could be used to help develop nursing interventions and efficient coping strategies. Patients may then be able to use the latter to solve symptom-associated distress, consequently enhancing their quality of life.

Screening for social difficulties in cancer patients: clinical utility of the Social Difficulties Inventory

Guidelines for psychosocial support have been developed, but there are no standard approaches in routine oncology practice to identify patients experiencing social difficulties. We have designed and evaluated a Social Difficulties Inventory (SDI) to identify patients requiring further assessment and, where appropriate, referral to support services. The purpose of this study was to develop a clinically meaningful SDI scoring system with guidance for oncology staff. Out of 189 patients, 183 completed the SDI and were interviewed by a social work researcher who scored the SDI independently. Comparison of patient/interviewer assessment was good (intraclass correlation 0.61, 95% confidence interval: 0.51, 0.70). Using top 10% of interviewer social distress (SD) scores to indicate 'SD case', the best 'cut-point' was a patient score of > or =10 (sensitivity=0.80; specificity=0.76; 56 out of 183 'cases'). Out of 127 patients, 72 with SD score <10 had individual SDI item rated at a higher level. Following interview, 32 patients were referred to specialist services, 46 given information and 112 had no action taken. An interpretation algorithm developed includes SD score, individual SDI item rating, and an additional general question, illustrated using four case scenarios. In conclusion, general guidance for interpreting the SDI has been developed to enhance health-care professional/patient consultations with a view to identifying patients who may benefit from support, advice or intervention.

Step by step development of clinical care pathways for older cancer patients: necessary or desirable?

Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.

Interventions before consultations for helping patients address their information needs

BACKGROUND

Patients often do not get the information they require from doctors and nurses. To address this problem, interventions directed at patients to help them gather information in their healthcare consultations have been proposed and tested.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions which are delivered before consultations, and which have been designed to help patients (and/or their representatives) address their information needs within consultations.

SEARCH STRATEGY

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library (issue 3 2006); MEDLINE (1966 to September 2006); EMBASE (1980 to September 2006); PsycINFO (1985 to September 2006); and other databases, with no language restriction. We also searched reference lists of articles and related reviews, and handsearched Patient Education and Counseling (1986 to September 2006).

SELECTION CRITERIA

Randomised controlled trials of interventions before consultations designed to encourage question asking and information gathering by the patient.

DATA COLLECTION AND ANALYSIS

Two researchers assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of five outcomes.

MAIN RESULTS

We identified 33 randomised controlled trials, from 6 countries and in a range of settings. A total of 8244 patients was randomised and entered into studies. The most common interventions were question checklists and patient coaching. Most interventions were delivered immediately before the consultations.Commonly-occurring outcomes were: question asking, patient participation, patient anxiety, knowledge, satisfaction and consultation length. A minority of studies showed positive effects for these outcomes. Meta-analyses, however, showed small and statistically significant increases for question asking (standardised mean difference (SMD) 0.27 (95% confidence interval (CI) 0.19 to 0.36)) and patient satisfaction (SMD 0.09 (95% CI 0.03 to 0.16)). There was a notable but not statistically significant decrease in patient anxiety before consultations (weighted mean difference (WMD) -1.56 (95% CI -7.10 to 3.97)). There were small and not statistically significant changes in patient anxiety after consultations (reduced) (SMD -0.08 (95%CI -0.22 to 0.06)), patient knowledge (reduced) (SMD -0.34 (95% CI -0.94 to 0.25)), and consultation length (increased) (SMD 0.10 (95% CI -0.05 to 0.25)). Further analyses showed that both coaching and written materials produced similar effects on question asking but that coaching produced a smaller increase in consultation length and a larger increase in patient satisfaction. Interventions immediately before consultations led to a small and statistically significant increase in consultation length, whereas those implemented some time before the consultation had no effect. Both interventions immediately before the consultation and those some time before it led to small increases in patient satisfaction, but this was only statistically significant for those immediately before the consultation. There appear to be no clear benefits from clinician training in addition to patient interventions, although the evidence is limited.

AUTHORS' CONCLUSIONS

Interventions before consultations designed to help patients address their information needs within consultations produce limited benefits to patients. Further research could explore whether the quality of questions is increased, whether anxiety before consultations is reduced, the effects on other outcomes and the impact of training and the timing of interventions. More studies need to consider the timing of interventions and possibly the type of training provided to clinicians.

Satisfaction with care among patients with non-metastatic breast cancer: development and first steps of validation of the REPERES-60 questionnaire

Background

The care itinerary for cancer involves difficulties that occur in several different areas, whether in the diagnostic procedures, in surgery, or in adjuvant treatment. The aim of this work was to obtain a valid instrument measuring satisfaction among patients with breast cancer and exploring their care itinerary overall.

Methods

Development phase: Patient focus groups were implemented in two French regions in order to identify areas of satisfaction in relation to the different phases of care provision in breast cancer. On the basis of the literature and the themes and wordings derived from the focus groups, the patients identified several areas of satisfaction, which they found to be partially covered in an American satisfaction measure that has been validated in the French general population (the Consumer Satisfaction Survey in its French version, CSS-VF, 39 items). The patient focus groups suggested adaptation of certain dimensions of this instrument to the potential care providers (37 items) and produced 45 new items in six areas.

Validation phase: Using a large sample of patients (cohort of 820 women with invasive non-metastatic breast cancer) approached one month after treatment, this phase selected items that were comprehensible (non-response rate < 10%), non-redundant (r < 0.80) and reproducible (test-retest conducted on a sub-sample of 166 patients). The dimensions were identified by factor analysis on the selected items. Divergent and discriminant validity were assessed (relationships with quality of life questionnaire, comparisons between extreme groups).

Results

Results were in favour of not inserting additional broken-down items into the CSS-VF and retaining 21 new items. The factor analysis found the initial structure of the CSS-VF (39 items in 9 dimensions) and the 21 new items divide up into four dimensions (listening abilities and information provided by doctors, organisation and follow-up of medical care provision, psychological support, material environment). No redundancy was observed between new items and CSS-VF items. Internal consistency was high. Divergent and discriminant validity were satisfactory.

Conclusion

Adding four new dimensions to the CSS-VF yielded a valid 60-item instrument for assessment of care provided in breast cancer. These promising results now require further investigations of its responsiveness and its robustness in other linguistic, cultural and healthcare settings.

Assessing the attitudes to prostate cancer treatment among European male patients

OBJECTIVES

To understand the attitudes of patients with prostate cancer toward the disease in general and to the use of hormone therapy as treatment; to assess unmet needs in the management of prostate cancer; and to gauge patient receptivity to a potential 6-month formulation of a luteinizing hormone-releasing hormone (LHRH) agonist.

PATIENTS AND METHODS

Face-to-face interviews, lasting 50 min on average, were conducted during January and February 2007 with 200 European men who had been diagnosed with prostate cancer.

RESULTS

Most patients were very satisfied with their physician, particularly with specialists, with 94% of men being satisfied with their expertise and 67% fully trusting the recommended treatment. Therapeutic efficacy was considered the most crucial aspect of treatment, although maintaining their lifestyle during treatment was also considered important (83% of patients). In all, 67% of patients believed that consideration should be given to lifestyle needs when selecting treatment; however, over half (55%) had never raised lifestyle issues with their physicians. Most patients would prefer fewer injections, with 68% preferring 6-monthly injections over 3- or 1-monthly depots. Perceived advantages of 6-monthly injections include less discomfort/pain, more quality of life, fewer reminders of the disease and more ability to undertake activities without restriction.

CONCLUSIONS

Patients with prostate cancer are generally very satisfied with their physicians and the information they receive, yet find it difficult to communicate their lifestyle needs. Most patients would prefer 6-monthly LHRH agonist therapy due to the many advantages associated with fewer injections, including its efficacy in reducing testosterone levels. Improving patients' willingness to raise lifestyle issues with their physicians, providing more effective patient-physician communication and less frequent injections might assist in achieving both optimal control of testosterone and optimal management of prostate cancer.

Evaluation of an integrated communication skills training program for nurses in cancer care in Beijing, China

BACKGROUND

Nurses have considerable needs for communication skills training in cancer care because of the general lack of education and training on oncology-specific communication skills in Mainland China.

OBJECTIVES

To evaluate the effectiveness of an integrated communication skills training program, in which an intensive learning session was combined with practice in the clinical unit to create a supportive ward atmosphere where nurses could practice skills in the workplace and obtain support of head nurses.

METHODS

To implement the communication skills training for 129 nurses, a quasi-experimental research design with a nonequivalent control group was used. Measures, including basic communication skills, self-efficacy in oncology-specific communication skills, communication outcome expectancies, and self-perceived support for communication, were administered at pretraining evaluation, formative evaluation (1 month after training), and summative evaluation (6 months after training) in the training group. Formative evaluation was not administered in the control group.

RESULTS

There was continued significant improvement in the overall basic communication skills, self-efficacy, outcome expectancy beliefs, and perceived support in the training group. No significant improvement was found in the control group over the same period.

DISCUSSION

Nurses' communication skills could be developed and consolidated under the integrated communication skills training model. Development of effective interventions to change nurses' negative outcome expectancies in communication with cancer patients is needed in further study.

Patient participation in decision making: views of health professionals caring for people with colorectal cancer

AIM

The aim of this study was to explore views on patient participation in decision making, as described by health professionals caring for people with colorectal cancer.

BACKGROUND

Patient participation in health-care decision making is on the policy agenda at an international level. However, many aspects of cancer care and treatment are complex and it is unclear how health professionals view their role as promoters of patient participation.

DESIGN

A qualitative exploratory study.

METHODS

In depth interviews with 35 health professionals in clinical practice. Data were analysed using thematic content analysis, assisted by a computer software package for analysis of qualitative data (N-VIVO).

RESULTS

Choices in relation to surgical treatment were viewed as limited. Although it was perceived that patients could be more involved in decisions related to adjuvant treatment, providing information on various chemotherapy regimes was challenging. It was acknowledged that patients could be involved in treatment choices but there was far less clarity concerning aspects of physical and psychological care. Age was a factor when determining which patients should be offered treatment choices.

CONCLUSION

The availability and presentation of choices to patients is context specific and tailored to the preferences of individuals. If health professionals focus only on aspects of decision making related to treatment, the potential for shared partnerships with patients in relation to choices about physical and psychological care may be lost. This may be particularly pertinent for nurses and allied professions who engage with patients throughout the illness trajectory.

RELEVANCE TO CLINICAL PRACTICE

Policy makers should arguably appreciate that health professionals have an awareness of current thinking on patient participation, but may find policy recommendations challenging to implement in clinical practice when faced with the individual needs and preferences of patients and the complexities and uncertainties of disease management.

How do participants of a post registration oncology nursing course perceive that the course influences their practice?—A descriptive survey

The high incidence of cancer necessitates informed and skilled cancer care, a concept highlighted in a number of Government reports. However, there is little research, which explores the relationship between cancer education and practice. This paper reports a descriptive survey to explore the perceived impact of a post registration oncology-nursing course on practice. It aimed to determine how much the oncology nursing course impacted on practice and what aspects impacted the most. Postal questionnaires, using primarily closed questions, were sent to all post-registration nurses (n=171) who had undertaken an oncology-nursing course at one cancer centre between 1996 and 2003. The course was perceived to have a positive impact on practice and the subjects perceived to be most beneficial included those relating to communication skills, attitudes to cancer and psychological support. In conclusion, the study suggested that there is a positive relationship between oncology education and practice. This research may be used to inform discussions to support current and future investment in oncology education.

Communication in Oncology Care: The Effectiveness of Skills Training Workshops for Healthcare Providers

Communication skills are the cornerstone of the patient-provider relationship in cancer care. Lack of these skills can diminish patient disclosure, increase patient anxiety, and decrease satisfaction with care. The purpose of this article is to evaluate the literature regarding the efficacy and outcomes of communication skills training programs for healthcare providers in oncology. Using four databases, the author found 21 research articles about communication skills training programs for healthcare providers in oncology. The majority of published studies involved training programs for experienced clinicians (i.e., physicians, nurses, nurse practitioners, physician assistants) in oncology care. Programs varied in length from 18-105 hours and evaluated communication skills, patient satisfaction and anxiety, and provider confidence and perceived stress. Specific communication skills and provider confidence were statistically improved in 19 of 21 studies. Follow-up data showed maintenance of some skills and attrition of others. Longer programs with consolidation workshops are seen as more effective.

Information needs of the informal carers of women treated for breast cancer

Although the vital role of informal carers has been acknowledged in government policy documents in the UK, the information needs of informal carers are not well documented. There is also uncertainty about where carers get their information from and whether they are satisfied with the information they receive. This study aimed to examine the information needs and sources of information for informal carers in the acute cancer setting; the informal carers of a sample of women treated for breast cancer. Both quantitative and qualitative data were collected from semi-structured interviews with 50 informal carers. Measures of information needs and sources were administered in addition to an in-depth exploration of information needs. The priority information needs of carers related to cure, spread of disease and treatments, a similar profile to that found for women with breast cancer in previous work. The main source of information for carers was the person they were caring for, although written information was also valued. Health professionals need to ensure that patients are well informed so that patients can provide information for carers and also need to take advantage of any opportunities to directly assess the information needs of carers to enable them to be more effective in their caring role.

Palliative or curative treatment intent affects communication in radiation therapy consultations

OBJECTIVE

To assess whether communication in radiotherapy consultations is affected by palliative or curative treatment intent.

SUBJECTS AND METHODS

The study involved 160 patients and 8 radiation oncologists. Eighty patients visited the radiation oncologist (RO) for palliative treatment and 80 for curative treatment. The consultation prior to radiation treatment was analyzed with the Roter Interaction Analysis System (RIAS). Within three days, patients completed a quality of life questionnaire (EORTC-QLQ-C30).

RESULTS

In palliative radiotherapy (PRT) consultations, ROs asked more (closed-ended) biomedical and psychosocial questions and provided more information on prognosis than in consultations for curative radiotherapy (CRT). Patients in both groups provided a great deal of psychosocial information but asked few questions. The ROs expressed more concerns in the PRT consultations, while patients did not. PRT patients received fewer supportive remarks than CRT patients. In both groups, explicit decision-making received little attention. Proxies who accompanied the patients took a more active role in PRT than in CRT consultations.

CONCLUSION

Communication in radiotherapy is affected by treatment intent with respect to the main contents of the consultation.

An Internet method to assess cancer patient information needs and enhance doctor-patient communication: a pilot study

BACKGROUND

We previously reported that doctor-patient communication in the cancer context may be suboptimal. We therefore developed measures to assess patient communication preferences and established feasibility of an Internet-based intervention to improve communication.

METHODS

Cancer patients completed an Internet-based survey about communication preferences, with a summary provided to the physician before the consultation. Patients completed a follow-up survey to assess consultation content and satisfaction.

RESULTS

Study procedures were feasible, measures exhibited strong internal consistency, and patients expressed satisfaction with the intervention.

CONCLUSION

The Internet offers an opportunity to assess patient preferences and prompt physicians about individual patient informational needs prior to the clinical encounter.

Level of agreement between patient self-report and observer ratings of health-related quality of life communication in oncology

OBJECTIVE

To determine the level of agreement between patients and observers regarding the frequency with which health-related quality of life topics are discussed during outpatient clinical oncology visits.

METHODS

The sample (n=50) consisted of a consecutive series of cancer patients undergoing chemotherapy. Both the patients and observers used a checklist to report which HRQL topics had been discussed during the consultation. Percentage of agreement, kappa and adjust-kappa statistics were calculated.

RESULTS

The percentage agreement between patients' and observers' ratings was generally high, ranging from 74% for fatigue to 96% for sleep problems and cognitive functioning. The average percentage of agreement over the 13 HRQL topics rated was 86%. Cohen's kappa varied between 0.41 (for pain) and 0.78 (for sleep problems). Prevalence-adjusted kappa's were generally higher, ranging from 0.48 (for fatigue) to 0.92 (for sleep problems and social functioning). The average Cohen's kappa and prevalence-adjusted kappa over the 13 HRQL topics were 0.56 and 0.71, respectively. Level of agreement was not found to vary significantly as a function of patients' background characteristics.

CONCLUSION

Oncology patients' self-reports of the HRQL-related topics discussed during outpatient chemotherapy visits are in reasonably close agreement with those provided by observers.

PRACTICE IMPLICATIONS

Our results indicate that the patient is a legitimate source of information about the HRQL-related content of medical encounters, and thus can be used in communication studies where the collection of observational data (e.g., via audio- or videotaping) is either too costly or logistically impractical.

Current concepts of communication skills training in oncology

Too many patients leave their consultations with insufficient understanding about their diagnosis, prognosis, the need for further diagnostic tests, the management plans, or the therapeutic intent of treatment. This situation is not entirely due to paternalism or a lack of awareness that patients worldwide desire more information, but rather a reflection of the dismal communication skills training that most healthcare professionals receive. There have been many developments aimed at rectifying this situation, but there are still too few publications available demonstrating efficacy. Nevertheless, evidence shows that communication skills can be taught and that if taught well then the impact endures into the clinic. This chapter looks at some of the history of good evidence-based interventions to improve communication and makes a plea for more research-based evidence for improved patient outcomes following training. Unless attention and resources are given to help healthcare professionals in this core clinical skill then we will never be able to help patients and their families take an informed and educated role in their own cancer care.

Psychodynamic aspects of communication skills training: a pilot study

GOALS OF WORK

Communication between patients and oncology clinicians is a key element of cancer care. Emotionally charged consultations may trigger clinicians' defense mechanisms, protecting them from painful emotions. Defense mechanisms, however, may also hamper the recognition of patients' suffering. This pilot study aims to explore clinicians' defense mechanisms observed in communication skills training (CST).

PATIENTS AND METHODS

A verbatim transcription of videotaped interviews with simulated patients were evaluated before (N=10) and after CST (N=10) with the defense mechanism rating scales (DMRS).

MAIN RESULTS

A wide variety of defense mechanisms were observed such as obsessional (e.g. intellectualisation) or disavowal (e.g. denial or projection). Immature defense mechanisms decreased after CST.

CONCLUSIONS

A wide variety of defense mechanisms are operant in oncology clinicians facing challenging interviews with simulated patients. Defense mechanisms may be modified by CST.

Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians

BACKGROUND

No study has yet assessed the impact of physicians' skills acquisition after a communication skills training programme on the evolution of patients' anxiety following a medical consultation. This study aimed to compare the impact, on patients' anxiety, of a basic communication skills training programme (BT) and the same programme consolidated by consolidation workshops (CW), and to investigate physicians' communication variables associated with patients' anxiety.

PATIENTS AND METHODS

Physicians, after attending the BT, were randomly assigned to CW or to a waiting list. The control group was not a non-intervention group. Consultations with a cancer patient were recorded. Patients' anxiety was assessed with the State Trait Anxiety Inventory before and after a consultation. Communication skills were analysed according to the Cancer Research Campaign Workshop Evaluation Manual.

RESULTS

No statistically significant change over time and between groups was observed. Mixed-effects modelling showed that a decrease in patients' anxiety was linked with screening questions (P = 0.045), physicians' satisfaction about support given (P = 0.004) and with patients' distress (P < 0.001). An increase in anxiety was linked with breaking bad news (P = 0.050) and with supportive skills (P = 0.013). No impact of the training programme was observed.

CONCLUSIONS

This study shows the influence of some communication skills on the evolution of patients' anxiety. Physicians should be aware of these influences.