Discussing prognosis in an oncology setting: initial evaluation of a communication skills training module

Communicating with LGBTQ+ persons at end of life: A case-based analysis of interdisciplinary palliative clinician perspectives

OBJECTIVE

Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons with serious illness and their families often experience end-of-life (EOL) care disparities, such as homophobia and transphobia, disrespect and mistreatment, and exclusion of significant others or life partners. The aim of the study was to explore interdisciplinary clinicians' communication knowledge and priorities using a case of a gay man at EOL and his same-sex, cisgender spouse.

METHODS

Interdisciplinary clinicians (n = 150) who participated in a national 3-day communication training program, rooted in Adult Learning Theory and supported by the National Cancer Institute, responded to open-ended questions about a composite case study emphasizing diversity challenges relevant to LGBTQ + communities in the EOL context. A thematic analysis of responses using an iterative, inductive approach was conducted until saturation was reached.

RESULTS

Participants from nursing (48%), social work (35%) and chaplaincy (17%) responded to the survey. Five themes emerged: 1) provision of patient-centered care; 2) legal and ethical factors inform care and decision making; 3) considerations of same-sex spouse or couple context; 4) dynamics and role of family of origin; and 5) elements of inclusive clinical care.

CONCLUSIONS

LGBTQ + inclusive communication training is essential for all palliative clinicians to deliver culturally safe care. Our findings have implications for identifying unconscious bias, addressing discriminatory care, filling clinician knowledge gaps, and informing educational interventions to support LGBTQ + inclusion. Future research must focus on micro- and macro-level communication issues that shape the quality of palliative and EOL care for patients and chosen family members.

Integrating evidence-based communication principles into routine cancer care

PURPOSE

The global incidence of cancer and available cancer-directed therapy options is increasing rapidly, presenting patients and clinicians with more complex treatment decisions than ever before. Despite the dissemination of evidence-based communication training tools and programs, clinicians cite barriers to employing effective communication in cancer care (e.g., discomfort of sharing serious news, concern about resource constraints to meet stated needs). We present two composite cases with significant communication challenges to guide clinicians through an application of evidence-based approaches to achieve quality communication.

METHODS

Composite cases, communication skills blueprint, and visual conceptualization.

RESULTS

High-stakes circumstances in each case are described, including end-of-life planning, advanced pediatric illness, strong emotions, and health inequities. Three overarching communication approaches are discussed: (1) content selection and delivery; (2) rapport development; and (3) empathic connection. The key takeaways following each case provide succinct summaries of challenges encountered and approaches used. A communication blueprint from the Memorial Sloan Kettering Cancer Center Communication Skills Training Program and Research Laboratory has been adapted and is comprised of strategies, skills, process tasks, and sample talking points. A visually concise tool - the Communication Blueprint Traffic Circle - illustrates these concepts and demonstrates the iterative, holistic, and agile considerations inherent to effective communication.

CONCLUSION

Evidence-based communication is foundational to person-centeredness, associated with improved clinician and patient/caregiver outcomes, and can be integrated throughout routine oncology care. When used by clinicians, evidence-based communication can improve patient and caregiver experiences and assist in ensuring goal-concordant cancer care delivery.

Addressing palliative care and end-of-life issues in patients with advanced cancer: a systematic review of communication interventions for physicians not specialised in palliative care

OBJECTIVE

To identify and summarise evaluated interventions aiming to improve the communication of palliative care (PC) and end-of-life (EoL) issues in physicians caring for cancer patients. Such interventions are needed with regard to the aim of an earlier communication of those issues in oncology daily practice, which is associated with a range of benefits for patients and caregivers but is often impeded by physicians' communication insecurities.

DESIGN

Systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Relevant publications were systematically searched in MEDLINE, PsycINFO, CINAHL and Web of Science databases in September 2020 with an update in July 2021.

ELIGIBILITY CRITERIA

We included publications reporting a quantitative evaluation of a communication intervention on one or more PC/EoL issues with a communication-related main outcome. Target group had to be physicians caring for cancer patients non-specialist in PC.

DATA EXTRACTION AND SYNTHESIS

Two independent raters extracted intervention characteristics, publication characteristics and publication quality. Results were narratively synthesised.

RESULTS

24 publications reporting 22 interventions were included. 13 publications reported randomised controlled trials. A majority of the interventions addressed one specific PC/EoL issue, most often breaking bad news. Teaching strategies mostly involved role-plays. Target group were mainly oncologists. In addition to self-reported outcome measurements for evaluation, most publications also reported the use of external rating data. All but one publication reported significant intervention effects on at least one outcome parameter. Publication quality was overall moderate.

CONCLUSIONS

The empirically tested communication interventions on PC/EoL issues seem to effectively improve physicians' communication. Future interventions should focus on other issues than breaking bad news, such as preparing for the future. Target group should also be organ-specific oncologists, as all primary caring physicians are responsible for timely communication. Our risk-of-bias assessment revealed some weaknesses, indicating that more high-quality studies for evaluation are needed.

PROSPERO REGISTRATION NUMBER

CRD42020191054.

Oncologists' experience with discussing cancer prognosis with patients and families: perspectives from India

Nondisclosure of prognosis of advanced cancer is commonly practiced in some Asian cultures including India; but research is limited. To describe experiences of Indian oncologists in discussing cancer prognosis with people with cancer and their caregivers, with a focus on barriers and facilitators of prognostic discussions. Thirty oncologists practicing in South India, Hyderabad participated in semi-structured interviews; and analyzed using Interpretative Phenomenological Analysis. Barriers included system-level, patient-level, and physician-level challenges as obstructions to open and honest interactions around cancer prognosis. Most of the barriers focused on communication-related challenges. Lack of communication skills training for providers coupled with over-reliance on use of euphemisms, hesitation in communicating with "weak" patient, and struggles to establish healthcare proxy described communication-related barriers. The study also described factors including family involvement in cancer care and empathic communication as facilitators of honest and open communication about prognosis. In particular, rapport building and getting to know the patient, use of empathic communication, engaging in gradual and individualized disclosure, and balancing hope with honesty were communication-related facilitators that aid open communication with patients with cancer and their caregivers about prognosis and plan of care. Results provide implications for development of communication skills trainings for oncology physicians in India. Adapting, delivering, and evaluating existing communication skills training programs, particularly around discussions of prognosis and goals of care is a requisite step for providing patient-centered and supportive care to patients with cancer and their caregiving families.

Teaching and assessing communication skills in the postgraduate medical setting: a systematic scoping review

BACKGROUND

Poor communication skills can potentially compromise patient care. However, as communication skills training (CST) programs are not seen as a priority to many clinical departments, there is a discernible absence of a standardised, recommended framework for these programs to be built upon. This systematic scoping review (SSR) aims to gather prevailing data on existing CSTs to identify key factors in teaching and assessing communication skills in the postgraduate medical setting.

METHODS

Independent searches across seven bibliographic databases (PubMed, PsycINFO, EMBASE, ERIC, CINAHL, Scopus and Google Scholar) were carried out. Krishna's Systematic Evidence-Based Approach (SEBA) was used to guide concurrent thematic and content analysis of the data. The themes and categories identified were compared and combined where possible in keeping with this approach and then compared with the tabulated summaries of the included articles.

RESULTS

Twenty-five thousand eight hundred ninety-four abstracts were identified, and 151 articles were included and analysed. The Split Approach revealed similar categories and themes: curriculum design, teaching methods, curriculum content, assessment methods, integration into curriculum, and facilitators and barriers to CST. Amidst a wide variety of curricula designs, efforts to develop the requisite knowledge, skills and attitudes set out by the ACGME current teaching and assessment methods in CST maybe categorised into didactic and interactive methods and assessed along Kirkpatrick's Four Levels of Learning Evaluation.

CONCLUSIONS

A major flaw in existing CSTs is a lack of curriculum structure, focus and standardisation. Based upon the findings and current design principles identified in this SSR in SEBA, we forward a stepwise approach to designing CST programs. These involve 1) defining goals and learning objectives, 2) identifying target population and ideal characteristics, 3) determining curriculum structure, 4) ensuring adequate resources and mitigating barriers, 5) determining curriculum content, and 6) assessing learners and adopting quality improvement processes.

'Difficult Conversations with Patients'-A Modified Group Objective Structured Clinical Experience for Medical Students

This study presents a modified Group Objective Structured Clinical Experience (GOSCE) focused on difficult conversations, in which, due to limited time and financial resources, only some students could actively participate in scenarios. We aimed to evaluate the intervention, including differences between them and observers. The intervention was organized for sixth-year medical students at a Polish medical university. The study protocol assumed a pre-post analysis of students' attitudes and self-efficacy of communication skills and their opinions about the intervention. Complete questionnaire pairs were returned by 126 students. The pre-post analysis revealed a significant improvement in their self-efficacy levels of almost all skills as well as their affective attitudes and belief in outcomes of communication learning. The improvement was significant among both the active participants and observers. It also showed a decrease in the motivation score, significant only in females. Regardless of their roles, students had positive opinions about the course and its particular aspects. The modified GOSCE may be an enjoyable and effective learning experience for students, especially in the light of limited resources. However, changes in their motivation score suggest the necessity to increase the importance of communication learning in the curriculum.

"Maintaining hope:" challenges in counseling latino patients with advanced cancer

BACKGROUND

Latino cancer patients are at risk of poor psychological adjustment. Therapeutic effectiveness in treating Latino cancer patients with advanced cancer requires managing distress, therapeutic skill, and cultural competency. This mixed-methods study explored mental health providers' perceptions of the challenging aspects of counseling and caring for Latino patients with advanced cancer.

METHODS

Mental health providers providing services to Latino or Hispanic cancer patients received an emailed web-based survey with open- and closed-ended questions. Providers included psychiatrists, psychologists, social workers, counselors, and other mental health professionals. We invited 154 providers to participate from July 2015 to January 2017. One hundred and four accessed the survey, and 66 eligible providers responded, for a response rate of 43%. Analyses were used to explore whether clinical experience factors and training characteristics were associated with perceiving conversations about cancer (diagnosis, prognosis, and end-of-life) as challenging. Second, the challenging aspects of these conversations were explored qualitatively. Four independent coders coded responses; an inductive content analysis was utilized to analyze the data.

RESULTS

Mental health providers describe encountering many challenges in their therapeutic discussions with Latino cancer patients.

CONCLUSIONS

It is imperative to understand the factors associated with the perceived difficulty of these conversations, as well as the characteristics of these conversations, to develop culturally sensitive interventions and programs for patients and training interventions for providers.

Improving implementation of psychological interventions to older adult patients with cancer: Convening older adults, caregivers, providers, researchers

INTRODUCTION

Older adults with cancer (OACs) are a large and growing population. Psychological distress is prevalent in this population yet few OACs receive evidence-based psychological care. The purpose of this project was to identify barriers and strategies for the implementation of psychological interventions to OACs from the perspective of OACs, OAC caregivers, researchers, clinicians, and advocacy organization members.

METHODS

The Cornell Research-to-Practice (RTP) Consensus Workshop Model was used to organize and convene a consensus conference. The one-day conference consisted of small and large group discussions regarding barriers, facilitators, and strategies for the implementation of psychological interventions targeting OACs. A half-day roundtable meeting was subsequently conducted to organize data generated at the conference. De-identified transcriptions of the small group discussions were uploaded into NVivo 11 software and qualitatively analyzed using standard methods.

RESULTS

Thirty-five participants attended the consensus conference from across stakeholder groups. Three themes related to implementation barriers were identified: lack of knowledge about psychological interventions in patients and providers; personal and social factors associated with being an OAC; and institutional-level factors. Themes related to implementation strategies focused on increasing awareness, tailoring interventions for older adults, and modifying institutional-level factors.

DISCUSSION

Effective implementation of psychological interventions to OACs is complex and barriers exist across multiple levels of care. However, this project indicates that implementation can be improved in various ways that include all members of the healthcare system. Further clarification of implementation strategies and rigorous evaluation of their effectiveness is vital to improving care and care outcomes of OACs.

Communication interventions in adult and pediatric oncology: A scoping review and analysis of behavioral targets

Background

Improving communication requires that clinicians and patients change their behaviors. Interventions might be more successful if they incorporate principles from behavioral change theories. We aimed to determine which behavioral domains are targeted by communication interventions in oncology.

Methods

Systematic search of literature indexed in Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov (2000–October 2018) for intervention studies targeting communication behaviors of clinicians and/or patients in oncology. Two authors extracted the following information: population, number of participants, country, number of sites, intervention target, type and context, study design. All included studies were coded based on which behavioral domains were targeted, as defined by Theoretical Domains Framework.

Findings

Eighty-eight studies met inclusion criteria. Interventions varied widely in which behavioral domains were engaged. Knowledge and skills were engaged most frequently (85%, 75/88 and 73%, 64/88, respectively). Fewer than 5% of studies engaged social influences (3%, 3/88) or environmental context/resources (5%, 4/88). No studies engaged reinforcement. Overall, 7/12 behavioral domains were engaged by fewer than 30% of included studies. We identified methodological concerns in many studies. These 88 studies reported 188 different outcome measures, of which 156 measures were reported by individual studies.

Conclusions

Most communication interventions target few behavioral domains. Increased engagement of behavioral domains in future studies could support communication needs in feasible, specific, and sustainable ways. This study is limited by only including interventions that directly facilitated communication interactions, which excluded stand-alone educational interventions and decision-aids. Also, we applied stringent coding criteria to allow for reproducible, consistent coding, potentially leading to underrepresentation of behavioral domains.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

Association between advanced cancer patient-caregiver agreement regarding prognosis and hospice enrollment

BACKGROUND

Patients with advanced, incurable cancer who understand their illness is incurable are more likely to prefer hospice care at the end of life compared with patients who believe their illness is curable. To the authors' knowledge, it is unclear whether patient-caregiver agreement regarding perceived prognosis is associated with hospice enrollment.

METHODS

The current study examined the prospective relationship between patient-caregiver agreement concerning perceived prognosis and hospice enrollment in the last 30 days of life. Data were collected during a cluster randomized controlled trial examining a communication intervention for oncologists and patients with advanced cancer and their caregivers. At the time of study entry, patients and caregivers (141 dyads) were categorized as endorsing a "good" prognosis if they: 1) reported a >50% chance of surviving ≥2 years; or if they 2) predicted that the patient's quality of life 3 months into the future would be ≥7 on an 11-point scale.

RESULTS

Approximately one-fifth of dyads agreed on a poor prognosis whereas approximately one-half disagreed regarding prognosis. In approximately one-third of dyads, patients and caregivers both believed the patient's future quality of life would be good (34%) and that the patient would live for ≥2 years (30%). Patients in these dyads were less likely to enroll in hospice compared with patients in dyads who disagreed and those who agreed on a shorter life expectancy and poor future quality of life.

CONCLUSIONS

Dyadic understanding of patients' projected life expectancy and future quality of life appears to be predictive of care received at the end of life. Improving rates of hospice enrollment may be best achieved with dyadic interventions.

COMSKIL Communication Training in Oncology-Adaptation to German Cancer Care Settings

Medical communication is a skill which can be learned and taught and which can substantially improve treatment outcomes, especially if patients' communication preferences are taken into account. Here, we give an overview of communication training research and outline the COMSKIL program as a state-of-the-art communication skills training in oncology. COMSKIL has a solid theoretical foundation and teaches core elements of medical communication in up to ten fully operationalized modules. These address typical situations ranging from breaking bad news to responding to difficult emotions, shared decision-making, and communicating via interpreters.

Addressing communication challenges in older patients with cancer and geriatric syndromes: a communication skills training module for health care providers

PURPOSE

Older adults frequently suffer from functional decline and sensory changes which, in turn, may trigger ageism, i.e., stereotyping and discriminating against individuals based on their age. Ageism commonly interferes with medical care. Communication strategies can be used to counteract ageism and to engage in optimal patient-centered care. This study describes the development, application, and evaluation of a communication skills training (CST) module (Geriatrics 101) designed to familiarize health care providers (HCPs) with the concept of ageism, and the frequent sensory and physical impairments in older patients with cancer, and to teach practical communication skills to effectively communicate with these patients.

METHODS

Geriatrics 101 is one of three modules in a 1-day CST program for HCPs, intended to improve the outcome of consultations through utilization of a set of clinically meaningful strategies. Study measures included post-training module evaluation, self-efficacy measured pre- and post-training, and communication skills uptake assessed pre- and post-training.

RESULTS

97 clinicians participated over 2 years. Over 90% of participants rated the module favorably. Participants' self-efficacy to communicate efficiently with older patients with impairments improved significantly from pre- (M = 3.52, SD 0.85) to post-module training (M = 4.26, SD 0.50). Participants also demonstrated significant uptake of three skills-invite agenda, transition, and normalize.

CONCLUSION

The successful development and application of our program paves the way for future research that focuses on the evaluation of such geriatric-focused communication training in clinical settings, assessing patient-reported outcomes.

Feasibility of a team based prognosis and treatment goal discussion (T-PAT) with women diagnosed with advanced breast cancer

OBJECTIVE

To assess the feasibility of a team-based prognosis and treatment goal discussion for women living with advanced breast cancer.

METHODS

Female patients diagnosed with advanced breast cancer (n = 25) participated in a mixed methods study that evaluated the feasibility and effects of a planned and structured prognosis discussion. Audio analysis of the intervention appointments was conducted to assess intervention feasibility. Patient self-reports of prognosis related beliefs and treatment preferences were compared across intervention and usual care groups.

RESULTS

Most patients found the T-PAT appointment challenging but worthwhile. Intervention uptake by clinicians was good, but some fidelity disruptions were noted. T-PAT participants were more likely to hold realistic beliefs about disease curability after the appointment.

CONCLUSION

Productive prognosis discussions can be delivered effectively by a practice-based clinical team within a semi-structured patient education appointment. It was perceived by patients with advanced breast cancer as both valuable and acceptable. T-PAT clinicians found the intervention easy to deliver.

PRACTICE IMPLICATIONS

Regular implementation of T-PAT may help clinicians' build prognosis discussion communication skills. T-PAT documentation provides valuable information that can be used to tailor ongoing care.

A rigorous evaluation of an institutionally-based communication skills program for post-graduate oncology trainees

OBJECTIVE

Integrating education about physician-patient communication into oncology specialists' education is important to improve quality of care. Our aim was to rigorously evaluate a 4-year institutionally-based patient communication skills program for oncology post-graduate trainees.

METHODS

Trainees from 10 specialties in the U.S. participated in patient communication skills modules tailored to sub-specialties. The program was evaluated by comparing pre-post scores on hierarchical outcomes: course evaluation, self-confidence, skills uptake in standardized and real patient encounters, and patient evaluations of satisfaction with communication. We examined breadth of skill usage as key outcome. Generalized estimating equations were used in data analysis.

RESULTS

Two hundred and sixty-two trainees' data were analyzed, resulting in 984 standardized and 753 real patient encounters. Participants reported high satisfaction and demonstrated significant skill growth with standardized patients, but transfer of these skills into real patient encounters was incomplete. Participants with lower baseline scores had larger improvements with both standardized and real patients.

CONCLUSION

The program was well received and increased participant skills in the simulated setting without effective transfer to real patient encounters.

PRACTICE IMPLICATIONS

Future work should allocate proportionally greater resources to trainees with lower baseline scores and measure breadth of participant skill usage as an outcome.

The Use of Simulation to Teach Nursing Students and Clinicians Palliative Care and End-of-Life Communication: A Systematic Review

Objectives:

To present the findings of a systematic review on the use of simulation-based learning experiences (SBLEs) to teach communication skills to nursing students and clinicians who provide palliative and end-of-life care to patients and their families.

Background:

Palliative care communication skills are fundamental to providing holistic patient care. Since nurses have the greatest amount of direct exposure to patients, building such communication competencies is essential. However, exposure to patients and families receiving palliative and end-of-life care is often limited, resulting in few opportunities to learn these skills in the clinical setting. Simulation-based learning experiences can be used to supplement didactic teaching and clinical experiences to build the requisite communication skills.

Methods:

Searches of CINAHL, MEDLINE, PsychINFO, ERIC, and Web of Science electronic databases and Grey Literature returned 442 unique records. Thirty articles met the established criteria, including the SBLE must contain a nursing role.

Results:

Simulation-based learning experience are being used to teach palliative and end-of-life communication skills to nursing students and clinicians. Lack of standardization, poor evaluation methods, and limited exposure to the entire interprofessional team makes it difficult to identify and disseminate validated best practices.

Conclusion:

While the need for further research is acknowledged, we recommend this evidence be augmented by training programs that utilize SBLEs through (1) applying standards, (2) clearly specifying goals and objectives, (3) integrating externally validated scenarios, and (4) employing rigorous evaluation methods and measures that link the SBLE to the training objectives and desired clinician practice behaviors and patient outcomes.

A Communication Training Program to Encourage Speaking-Up Behavior in Surgical Oncology

Patient safety in the OR depends on effective communication. We developed and tested a communication training program for surgical oncology staff members to increase communication about patient safety concerns. In phase one, 34 staff members participated in focus groups to identify and rank factors that affect speaking-up behavior. We compiled ranked items into thematic categories that included role relations and hierarchy, staff rapport, perceived competence, perceived efficacy of speaking up, staff personality, fear of retaliation, institutional regulations, and time pressure. We then developed a communication training program that 42 participants completed during phase two. Participants offered favorable ratings of the usefulness and perceived effect of the training. Participants reported significant improvement in communicating patient safety concerns (t₄₀ = -2.76, P = .009, d = 0.48). Findings offer insight into communication challenges experienced by surgical oncology staff members and suggest that our training demonstrates the potential to improve team communication.

Caregiver burden in owners of a sick companion animal: a cross-sectional observational study

Much recent work has focused on occupational stress in veterinary medicine, although little is known about the possible contribution of client-based factors. Clients providing care for a companion animal with protracted illness are likely to experience 'caregiver burden' and reduced psychosocial functioning, which may ultimately lead to increased veterinarian stress. This cross-sectional observational study assessed caregiver burden and psychosocial function in 238 owners of a dog or cat, comparing owners of an animal with chronic or terminal diseases (n=119) with healthy controls blindly matched for owner age/sex and animal species (n=119). Results showed greater burden, stress and symptoms of depression/anxiety, as well as poorer quality of life, in owners of companion animals with chronic or terminal disease (p<0.001 for all). Higher burden was correlated with reduced psychosocial function (p<0.001 for all). Owners of a sick companion animal exhibit elevated caregiver burden, which is linked to poorer psychosocial functioning. This knowledge may help veterinarians understand and more effectively handle client distress in the context of managing the challenges of sick companion animal caregiving. Future work is needed to determine whether clients with this presentation impact veterinarian stress and how burden in this population might be reduced.

Discussing Death, Dying, and End-of-Life Goals of Care: A Communication Skills Training Module for Oncology Nurses

BACKGROUND

Effective communication, particularly at the end of life, is an essential skill for oncology nurses, but few receive formal training in this area.

OBJECTIVES

The aim of this article is to adapt an end-of-life care communication skills training (CST) module, originally developed for oncologists, for oncology nurses and to evaluate participants' confidence in using the communication skills learned and their satisfaction with the module.

METHODS

The adapted end-of-life care module consisted of a 45-minute didactic, exemplary video and 90 minutes of small group interaction and experiential role play with a simulated patient. Using a five-point Likert-type scale, 247 inpatient oncology nurses completed pre-/post-workshop surveys rating their confidence in discussing death, dying, and end-of-life goals of care with patients, as well as overall satisfaction with the module.

FINDINGS

Nurses' confidence in discussing death, dying, and end-of-life goals of care increased significantly after attending the workshop. Nurse participants indicated satisfaction with the module by agreeing or strongly agreeing to all six items assessing satisfaction 90%-98% of the time. Nurses' CST in discussing death, dying, and end-of-life care showed feasibility, acceptability, and potential benefit at improving confidence in having end-of-life care discussions.

Breaking bad news: Effects of forecasting diagnosis and framing prognosis

OBJECTIVE

Research to support guidelines for breaking bad news is lacking. This study used an experimental paradigm to test two communication strategies, forecasting bad news and framing prognosis, in the context of cancer.

METHODS

In a 2×2 design, 128 participants received bad news in a hypothetical consultation. A videotaped physician presented diagnostic and prognostic information, varying warning (warning shot vs. no warning), and framing (positive vs. negative). Effects on psychological distress, recall accuracy, and subjective interpretations of the news were assessed.

RESULTS

Warning was not associated with lower psychological distress or improved recall. Individuals who heard a positively-framed prognosis had significantly less psychological distress, rated their prognosis better, and were more hopeful than those who heard a negatively-framed prognosis. However, they also showed a trend toward reduced accuracy in recalling prognostic statistics.

CONCLUSIONS

Results contribute to a growing body of literature exploring optimal approaches for communicating bad news in health care.

PRACTICE IMPLICATIONS

Although research in clinical settings is needed to bolster results, findings suggest that when providers use positive framing to reduce distress about prognosis, they should also consider ways to overcome potential reductions in recall accuracy, such as repeating statistical information or supplementing with written information.

Goal Communication in Palliative Care Decision-Making Consultations

CONTEXT

Palliative care (PC) promotes patient-centered outcomes, but the mechanisms underlying these effects remain poorly understood. Identifying, clarifying, and prioritizing patients' goals are conceptually fundamental to the process of patient-centeredness and are the main reasons for PC referral. However, very little is empirically known about the content or process of goal expression in the natural setting of PC.

OBJECTIVES

To describe the frequency, types, and determinants of goal expression in PC consultations.

METHODS

This was a cross-sectional direct observational study of 72 audiorecorded PC consultations with hospitalized patients (and families) referred for PC goals of care clarification or end-of-life decision making. We coded digital audio files using reliable methods and linked conversation codes to clinical record and brief clinician interview data.

RESULTS

Goal expressions occurred frequently in PC consultations and addressed both length-of-life and quality-of-life domains. The presence of existential suffering in the conversation was associated with substantially more expressions and types of goals.

CONCLUSION

Goal communication is common in PC decision-making settings and strongly influenced by existential suffering.

Communication skills in psychiatry training

OBJECTIVE

Mental health clinicians can experience problems communicating distressing diagnostic information to patients and their families, especially about severe mental illnesses such as schizophrenia. Evidence suggests that interpersonal communication skills can be effectively taught, as has been demonstrated in the specialty of oncology. However, very little literature exists with respect to interpersonal communication skills training for psychiatry. This paper provides an overview of the communication skills training literature.

CONCLUSIONS

The report reveals significant gaps exist and highlights the need for advanced communication skills training for mental health clinicians, particularly about communicating a diagnosis and/or prognosis of schizophrenia. A new communication skills training framework for psychiatry is described, based on that used in oncology as a model. This model promotes applied skills and processes that are easily adapted for use in psychiatry, providing an effective platform for the development of similar training programs for psychiatric clinical practice.

Asking the Stakeholders: Perspectives of Individuals With Aphasia, Their Family Members, and Physicians Regarding Communication in Medical Interactions

PURPOSE

The purpose of this study was to explore the experiences of patients with aphasia, their family members, and physicians related to communication during medical interactions.

METHOD

Face-to-face, semistructured interviews were conducted with 18 participants—6 patients with aphasia, 6 family members involved in patient care, and 6 practicing physicians. A qualitative description approach was used to collect and summarize narratives from participants' perspectives and experiences. Participants were asked about experiences with communication during medical interactions in which the family member accompanied the patient. Interviews were audio- and/or video-recorded, transcribed, and then coded to identify main themes.

RESULTS

Patients and family members generally described their communication experiences as positive, yet all participants discussed challenges and frustrations. Three themes emerged: (a) patients and family members work as a team, (b) patients and family members want physicians to "just try" to communicate with the patient, and (c) physicians want to interact with patients but may not know how.

CONCLUSIONS

Participants discussed the need for successful accommodation, or changing how one communicates, to help facilitate the patients' increased understanding and ability to express themselves. Over- and underaccommodation with communication were commonly reported as problems. Speech-language pathologists have a role to play in helping to improve communication during medical interactions. Implications for current speech-language pathologist practice and future directions of research are discussed.

The Group Objective Structured Clinical Experience: building communication skills in the clinical reasoning context

OBJECTIVE

Students are rarely taught communication skills in the context of clinical reasoning training. The purpose of this project was to combine the teaching of communication skills using SPs with clinical reasoning exercises in a Group Objective Structured Clinical Experience (GOSCE) to study feasibility of the approach, the effect on learners' self-efficacy and attitude toward learning communication skills, and the effect of providing multiple sources of immediate, collaborative feedback.

METHODS

GOSCE sessions were piloted in Pediatrics and Medicine clerkships with students assessing their own performance and receiving formative feedback on communication skills from peers, standardized patients (SPs), and faculty. The sessions were evaluated using a retrospective pre/post-training questionnaire rating changes in self-efficacy and attitudes, and the value of the feedback.

RESULTS

Results indicate a positive impact on attitudes toward learning communication skills and self-efficacy regarding communication in the clinical setting. Also, learners considered feedback by peers, SPs, and faculty valuable in each GOSCE.

CONCLUSION

The GOSCE is an efficient and learner-centered method to attend to multiple goals of teaching communication skills, clinical reasoning, self-assessment, and giving feedback in a formative setting.

PRACTICE IMPLICATIONS

The GOSCE is a low-resource, feasible strategy for experiential learning in communication skills and clinical reasoning.

Latent classes of prognosis conversations in palliative care: a mixed-methods study

BACKGROUND

Prognosis conversations are complex phenomena of substantial importance to palliative care (PC), yet these remain poorly understood. This study empirically identifies and describes major types of prognosis conversations that occur in the natural setting of PC consultation.

METHODS

We audio-recorded and coded 71 inpatient "goals of care" PC consultations at a large academic medical center in the northeastern United States. We used quantitative Latent Class Analyses for identifying discrete prognosis conversation types and qualitative Dimensional Analyses for more fully describing the process and content of the latent classes.

RESULTS AND CONCLUSIONS

We observed three discrete types of prognosis conversations, each placing different communication demands upon all participants for achieving goal-concordant care: Navigating Options & Goals (56% of consultations), Facilitating New Goals (23%) and Preparing for End-of-Life (21%). This study provides the first step for developing educational and clinical prognosis communication interventions that are tailored to common decision-making contexts facing seriously ill patients, their families, and PC clinicians.

Direct observation of prognosis communication in palliative care: a descriptive study

CONTEXT

Palliative care (PC) consultations result in improved patient understanding of prognosis and better quality of life, yet the content and processes of prognosis communication during PC consultations remain unknown.

OBJECTIVES

To describe prognosis communication during PC consultation with seriously ill hospitalized patients.

METHODS

We audio recorded 71 sequential inpatient PC consultations (initial visit) with seriously ill patients and their families who were referred for "goals of care" clarification or help with "end-of-life decision making." Conversations were coded using reliable methods and we then linked conversation codes to clinical record and clinician interview data.

RESULTS

Ninety-three percent of consultations contained prognosis communication. Participants communicated prognoses regarding quality of life more frequently than survival; focused prognosis estimates on the unique patient more frequently than on a general population; and framed prognosis using pessimistic cues more frequently than optimistic ones. Prognoses were more commonly spoken by PC clinicians than by patients/families. The following two factors demonstrated an association with the rate of prognostic communication and with the pessimistic framing of that information: whether the patient, family, or both participated in the conversation, and shorter expected survival (as estimated by the attending physician).

CONCLUSION

Prognoses are routinely communicated in PC consultations with hospitalized patients and their families. The rate and characteristics of prognosis communication differ based on the length of time the patient is expected to live.

Employee to employer communication skills: balancing cancer treatment and employment

BACKGROUND

Cancer patients face difficulties in accessing legally mandated benefits and accommodations when they return to the workplace. Poor employer-employee communication inflates these difficulties. Although proven methods to facilitate physician-patient communication exist, these have not been applied to the workplace. Thus, we aimed to assess the feasibility and utility of applying these methods to educate patients about their workplace rights and provide them with communication skills training to aid their conversations with their employers.

METHODS

A DVD was produced to educate patients and facilitate workplace communication. Participants consisted of 28 solid tumor cancer patients (14 women and 14 men) who completed primary cancer treatment in the past 12 months and were employed at the time of diagnosis. Participants watched a communication skills training DVD and completed a telephone interview. The interview elicited information about workplace experiences and evaluation of the DVD training program.

RESULTS

The physician-patient communication skills training model utilized was successfully translated to the employer-employee setting. All but one participant found the DVD useful and easy to understand and indicated a high degree of confidence in using the communication skills to help them ask for workplace accommodations. All participants agreed that it would help newly diagnosed patients in discussions with their employers.

CONCLUSION

Our data provides promising preliminary evidence that patient communication skills training can be applied to the workplace setting and is a welcomed aid to newly diagnosed cancer patients in their discussions with employers regarding the impact of treatment on their work performance and needs for accommodations.

Information giving and receiving in hematological malignancy consultations

PURPOSE

Little is known about communication with patients suffering from hematologic malignancies, many of whom are seen by subspecialists in consultation at tertiary-care centers. These subspecialized consultations might provide the best examples of optimal physician-patient communication behaviors, given that these consultations tend to be lengthy, to occur between individuals who have not met before and may have no intention of an ongoing relationship, and which have a goal of providing treatment recommendations. The aim of this paper is to describe and quantify the content of the subspecialty consultation in regards to exchanging information and identify patient and provider characteristics associated with discussion elements.

METHODS

Audio-recorded consultations between 236 patients and 40 hematologists were coded for recommended communication practices. Multilevel models for dichotomous outcomes were created to test associations between patient, physician and consultation characteristics and key discussion elements.

RESULTS

Discussions about the purpose of the visit and patient's knowledge about their disease were common. Other elements such as patient's preference for his/her role in decision-making, preferences for information, or understanding of presented information were less common. Treatment recommendations were provided in 97% of the consultations and unambiguous presentations of prognosis occurred in 81% of the consultations. Unambiguous presentations of prognosis were associated with non-White patient race, lower educational status, greater number of questions asked, and specific physician provider.

CONCLUSION

Although some communication behaviors occur in most consultations, others are much less common and could help tailor the amount and type of information discussed. Approximately half of the patients are told unambiguous prognostic estimates for mortality or cure.

Patient Satisfaction in Obstetrics and Gynecology: Individualized Patient-centered Communication

Background

Patient satisfaction is becoming an increasingly prevalent topic in medicine, but little is known about patient satisfaction in women's health and other specialties. We review current methods of improving patient satisfaction in the field of obstetrics and gynecology with the intent to increase patient satisfaction even further by enhancing and combining previously used strategies.

Methods

A search from inception to June 2010 for electronic literature was performed using Medline. The search strategy used the medical subject heading terms “patient satisfaction”, “obstetrics”, “gynecology”, “patient-centered communication”, “communication training”, and “malpractice”. The company websites for Press Ganey Associates, Inc and Integrated Health Associates' were also reviewed. Studies in both general medicine and the field of obstetrics and gynecology were reviewed to emphasize disparities between patients' satisfaction in diverse medical specialties.

Results

Studies indicating the importance of patient satisfaction, the factors contributing to patient satisfaction, and an evaluation of current, evidence-based methods of increasing patient satisfaction were reviewed. The studies included suggest that current methods of assessing/improving patient satisfaction are effective, but may not be the most productive.

Conclusions

We expect that the combination of previously successful methods of improving patient satisfaction to allow physicians to employ individualized patient-centered communication may improve patient satisfaction even further. Studying the use of our proposed enhancements in physician-patient communication may be worthwhile tools to increase patient satisfaction and optimize the quality of women's healthcare.

Race/ethnicity-based concerns over understanding cancer diagnosis and treatment plan

BACKGROUND

Race/ethnicity and culture influence illness perceptions, health beliefs and behaviors, and communication with health care providers. However, information about the impact of race/ethnicity on the understanding of cancer diagnosis and treatment plan is limited.

METHODS

Nine hundred seventy-three cancer patients completed an information needs-assessment questionnaire prior to starting treatment at 20 geographically distinct clinical cancer sites within the University of Rochester Community Clinical Oncology Program network. Chi2 Test was used to examine the association between race/ethnicity and education, occupation, and perception and use of available information. T test and analysis of covariance were used to examine race/ethnicity-based differences in concerns over understanding cancer diagnosis/treatment plan and the effect of race/ethnicity controlling for demographics.

RESULTS

There were 904 non-Hispanic white and 69 nonwhite (blacks, Latinos, and others) patients in the sample. Whites and nonwhites were comparable in educational attainment and occupation. However, there was a statistically significant race/ethnicity-based difference in concerns over understanding the diagnosis and treatment plan for cancer, even after controlling for sex (male, female), age, education, and occupation (p < .001). More nonwhite patients indicated that additional information would have been helpful in dealing with these concerns (p <.001).

CONCLUSIONS

Nonwhite cancer patients reported more concerns about understanding their diagnosis and treatment plan and were more likely to indicate that additional information would have been helpful. The findings emphasize the need for oncology professionals to confirm patients' understanding and ensure patients' information needs have been met, particularly when working with racial/ethnic minorities.