Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework

An international field study for the reliability and validity of the EORTC communication questionnaire EORTC QLQ-COMU26

BACKGROUND

The EORTC Quality of Life Group has developed a questionnaire to evaluate cancer patients' perception of their communication with healthcare professionals (HCPs): the EORTC QLQ-COMU26. In this study we test the validity and reliability of this novel measure in an international and culturally diverse sample of cancer patients.

METHODS

Cancer patients completed the following EORTC questionnaires at two time points (before and during treatment): the QLQ-COMU26 (including a debriefing questionnaire), the QLQ-C30, and specific IN-PATSAT32 scales. These data were used to assess: the cross-cultural applicability, acceptability, scale structure, reliability, convergent/divergent validity, known-groups validity, and responsiveness to change of the QLQ-COMU26.

RESULTS

Data were collected from 498 patients with various cancer diagnoses in 10 European countries, Japan, Jordan and India (overall 5 cultural regions). At most, only 3% of patients identified an item as confusing and 0.6% as upsetting, which indicates that the questionnaire was clear and did not trigger negative emotional responses. Confirmatory factor analysis and multi-trait scaling confirmed the hypothesised QLQ-COMU26 scale structure comprising six multi-item scales and four single items (RMSEA = 0.025). Reliability was good for all scales (internal consistency > 0.70; test-retest reliability > 0.85). Convergent validity was supported by correlations of ≥ 0.50 with related scales of the IN-PATSAT32 and correlations < 0.30 with unrelated QLQ-C30 scales. Known-groups validity was shown according to sex, education, levels of anxiety and depression, satisfaction with communication, disease stage and treatment intention, professional evaluated, and having a companion during the visit. The QLQ-COMU26 captured changes over time in groups that were defined based on changes in the item of satisfaction with communication.

CONCLUSION

The EORTC QLQ-COMU26 is a reliable and valid measure of patients' perceptions of their communication with HCPs. The EORTC QLQ-COMU26 can be used in daily clinical practice and research and in various cancer patient groups from different cultures. This questionnaire can help to improve communication between patients and healthcare professionals.

Preparedness for colorectal cancer surgery and recovery through a person-centred information and communication intervention - A quasi-experimental longitudinal design

To meet patients’ information and communication needs over time in order to improve their recovery is particularly challenging for patients undergoing cancer surgery. The aim of the study was to evaluate whether an intervention with a person-centred approach to information and communication for patients diagnosed with colorectal cancer undergoing surgery can improve the patients’ preparedness for surgery, discharge and recovery during six months following diagnosis and initial treatment. The intervention components involving a novel written interactive patient education material and person-centred communication was based on critical analysis of conventional information and communication for these patients. During 2014–2016, 488 consecutive patients undergoing elective surgery for colorectal cancer were enrolled in a quasi-experimental longitudinal study. In three hospitals, first a conventional care group (n = 250) was recruited, then the intervention was introduced, and finally the intervention group was recruited (n = 238). Patients’ trajectories of preparedness for surgery and recovery (Preparedness for Colorectal Cancer Surgery Questionnaire—PCSQ) health related quality of life (EORTC QLQ-C30) and distress (NCCS Distress Thermometer) were evaluated based on self-reported data at five time points, from pre-surgery to 6 months. Length of hospital stay and patients’ behavior in seeking health care pre- and post-surgery were extracted from patient records. Longitudinal structural equation models were used to test the hypothesized effects over time. Statistically significant positive effects were detected for two of the four PCSQ domains (patients searching for and making use of information, and making sense of the recovery) and for the role functioning domain of the EORTC QLQ-C30. Patients in the intervention group were also more likely to contact their assigned cancer “contact nurse” (a.k.a. nurse navigator) instead of contacting a nurse on duty at the ward or visiting the emergency department. In conclusion, the overall hypothesis was not confirmed. Further research is recommended on written and oral support tools to facilitate person-centred communication.

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.

The communication between patient relatives and physicians in intensive care units

BACKGROUND

Patients in intensive care units (ICUs) are often physically unable to communicate with their physicians. Thus, the sharing of information about the on-going treatment of the patients in ICUs is directly related to the communication attitudes governing a patient's relatives and the physician. This study aims to analyze the attitudes displayed by the relatives of patients and the physician with the purpose of determining the communication between the two parties.

METHODS

For data collection, two similar survey forms were created in context of the study; one for the relatives of the patients and one for the ICU physicians. The questionnaire included three sub-dimensions: informing, empathy and trust. The study included 181 patient relatives and 103 ICU physicians from three different cities and six hospitals.

RESULTS

Based on the results of the questionnaire, identification of the mutual expectations and substance of the messages involved in the communication process between the ICU patients' relatives and physicians was made. The gender and various disciplines of the physicians and the time of the conversation with the patients' relatives were found to affect the communication attitude towards the patient. Moreover, the age of the patient's relatives, the level of education, the physician's perception, and the contact frequency with the patient when he/she was healthy were also proven to have an impact on the communication attitude of the physician.

CONCLUSION

This study demonstrates the mutual expectations and substance of messages in the informing, empathy and trust sub-dimensions of the communication process between patient relatives and physicians in the ICU. The communication between patient relatives and physicians can be strengthened through a variety of training programs to improve communication skills.

Communicating shared decision-making: cancer patient perspectives

OBJECTIVE

To contribute to the evolving dialogue on optimizing cancer care communication through systematic analyzes of patients' perspectives.

METHODS

Using constant comparative analysis, inductively derived thematic patterns of communication preferences for shared decision-making were drawn from individual interviews with 60 cancer patients.

RESULTS

Thematic patterns in how patients understand barriers and facilitators to communication within shared decision-making illuminate the basis for distinctive patient preferences and needs. Prevailing cancer communication considerations included focusing attention on the tone and setting of the consultation environment, the attitudinal climate within the consult, the specific approach to handling numerical/statistical information, and the critical messaging around hope. The patient accounts surfaced complex dynamics whereby the experiences of living with cancer permeated interpretations and enactment of the shared decision-making that is emerging as a dominant ideal of cancer care.

CONCLUSION

In our efforts to move beyond traditional paternalism, shared decision-making has been widely advocated as best practice in cancer communication. However, patient experiential evidence suggests the necessity of a careful balance between standardized approaches and respect for diversities.

PRACTICE IMPLICATIONS

Shared decision-making as a practice standard must be balanced against individual patient preferences.

Education in patient-physician communication: how to improve effectiveness?

OBJECTIVE

Despite educational efforts expertise in communication as required by the CanMEDS competency framework is not achieved by medical students and residents. Several factors complicate the learning of professional communication.

METHODS

We adapted the reflective-impulsive model of social behaviour to explain the complexities of learning professional communication behaviour. We formulated recommendations for the learning objectives and teaching methods of communication education. Our recommendations are based on the reflective-impulsive model and on the model of deliberate practice which complements the reflective-impulsive model. Our recommendations are substantiated by those we found in the literature.

RESULTS

The reflective-impulsive model explains why the results of communication education fall below expectations and how expertise in communication can be attained by deliberate practice. The model of deliberate practice specifies learning conditions which are insufficiently fulfilled in current communication programmes.

CONCLUSION

The implementation of our recommendations would require a great deal of effort. Therefore we doubt whether expertise in professional communication can be fully attained during medical training.

PRACTICE IMPLICATIONS

We propose that the CanMEDS communication competencies not be regarded as endpoints in medical education but as guidelines to improve communication competency through deliberate practice throughout a professional career.

Framing of health information messages

BACKGROUND

The same information about the evidence on health effects can be framed either in positive words or in negative words. Some research suggests that positive versus negative framing can lead to different decisions, a phenomenon described as the framing effect. Attribute framing is the positive versus negative description of a specific attribute of a single item or a state, for example, "the chance of survival with cancer is 2/3" versus "the chance of mortality with cancer is 1/3". Goal framing is the description of the consequences of performing or not performing an act as a gain versus a loss, for example, "if you undergo a screening test for cancer, your survival will be prolonged" versus "if you don't undergo screening test for cancer, your survival will be shortened".

OBJECTIVES

To evaluate the effects of attribute (positive versus negative) framing and of goal (gain versus loss) framing of the same health information, on understanding, perception of effectiveness, persuasiveness, and behavior of health professionals, policy makers, and consumers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 3 2007), MEDLINE (Ovid) (1966 to October 2007), EMBASE (Ovid) (1980 to October 2007), PsycINFO (Ovid) (1887 to October 2007). There were no language restrictions. We reviewed the reference lists of related systematic reviews, included studies and of excluded but closely related studies. We also contacted experts in the field.

SELECTION CRITERIA

We included randomized controlled trials, quasi-randomised controlled trials, and cross-over studies with health professionals, policy makers, and consumers evaluating one of the two types of framing.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data in duplicate and independently. We graded the quality of evidence for each outcome using the GRADE approach. We standardized the outcome effects using standardized mean difference (SMD). We stratified the analysis by the type of framing (attribute, goal) and conducted pre-planned subgroup analyses based on the type of message (screening, prevention, and treatment). The primary outcome was behaviour. We did not assess any adverse outcomes.

MAIN RESULTS

We included 35 studies involving 16,342 participants (all health consumers) and reporting 51 comparisons.In the context of attribute framing, participants in one included study understood the message better when it was framed negatively than when it was framed positively (1 study; SMD -0.58 (95% confidence interval (CI) -0.94 to -0.22); moderate effect size; low quality evidence). Although positively-framed messages may have led to more positive perception of effectiveness than negatively-framed messages (2 studies; SMD 0.36 (95% CI -0.13 to 0.85); small effect size; low quality evidence), there was little or no difference in persuasiveness (11 studies; SMD 0.07 (95% CI -0.23 to 0.37); low quality evidence) and behavior (1 study; SMD 0.09 (95% CI -0.14 to 0.31); moderate quality evidence).In the context of goal framing, loss messages led to a more positive perception of effectiveness compared to gain messages for screening messages (5 studies; SMD -0.30 (95% CI -0.49 to -0.10); small effect size; moderate quality evidence) and may have been more persuasive for treatment messages (3 studies; SMD -0.50 (95% CI -1.04 to 0.04); moderate effect size; very low quality evidence). There was little or no difference in behavior (16 studies; SMD -0.06 (95% CI -0.15 to 0.03); low quality evidence). No study assessed the effect on understanding.

AUTHORS' CONCLUSIONS

Contrary to commonly held beliefs, the available low to moderate quality evidence suggests that both attribute and goal framing may have little if any consistent effect on health consumers' behaviour. The unexplained heterogeneity between studies suggests the possibility of a framing effect under specific conditions. Future research needs to investigate these conditions.

Patient-provider communication data: linking process and outcomes in oncology care

OVERVIEW

Patient-provider communication is vital to quality patient care in oncology settings and impacts health outcomes. Newer communication datasets contain patient symptom reports, real-time audiofiles of visits, coded communication data, and visit outcomes. The purpose of this paper is to: (1) review the complex communication processes during patient-provider interaction during oncology care; (2) describe methods of gathering and coding communication data; (3) suggest logical approaches to analyses; and (4) describe one new dataset that allows linking of patient symptoms and communication processes with visit outcomes.

CHALLENGES

Patient-provider communication research is complex due to numerous issues, including human subjects' concerns, methods of data collection, numerous coding schemes, and varying analytic techniques.

DATA COLLECTION AND CODING

Coding of communication data is determined by the research question(s) and variables of interest. Subsequent coding and timestamping the behaviors provides categorical data and determines the interval between and patterns of behaviors.

ANALYTIC APPROACHES

Sequential analyses move from descriptive statistics to explanatory analyses to direct analyses and conditional probabilities. In the final stage, explanatory modeling is used to predict outcomes from communication elements. Examples of patient and provider communication in the ambulatory oncology setting are provided from the new Electronic Self Report Assessment-Cancer II dataset.

SUMMARY

More complex communication data sets provide opportunities to link elements of patient-provider communication with visit outcomes. Given more complex datasets, a step-wise approach is necessary to analyze and identify predictive variables. Sequential analyses move from descriptive results to predictive models with communication data, creating links between patient symptoms and concerns, real-time audiotaped communication, and visit outcomes. The results of these analyses will be useful in developing evidence-based interventions to enhance communication and improve psychosocial outcomes in oncology settings.

Studying physician-patient communication in the acute care setting: the hospitalist rapport study

OBJECTIVE

To assess the feasibility of studying physician-patient communication in the acute care setting.

METHODS

We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked.

RESULTS

Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians' primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: (1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities and (2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges.

CONCLUSION

Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection.

PRACTICE IMPLICATIONS

These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment.

How do interventions designed to improve provider-patient communication work? Illustrative applications of a framework for communication

In this broad overview for the Conference: "State of the Science in Cancer Care", we review a conceptual framework of physician-patient communication and use the framework to inform the application of theory regarding communication and patient preferences in clinical practice. Using a selection of research, we illustrate how problematic issues in communication can be represented by the framework. We further illustrate how interventions designed to improve communication or to elicit patients' preferences in a medical encounter may have their desired effect, or may be optimally evaluated.

Patient real-time and 12-month retrospective perceptions of difficult communications in the cancer diagnostic period

Communication is a notoriously complex challenge in the cancer care context. Our program of research involves exploration of patient-provider communications across the cancer trajectory from the patient perspective.Toward this end, we have been following a cohort of 60 cancer patients, representing a range of tumor sites, from immediately after diagnosis through to recovery, chronic, or advanced disease. Drawing on interpretive description analytic techniques, we documented patterns and themes related to various components of the cancer journey. In this article, we report on findings pertaining to poor communication during the initial diagnostic period, as described by patients at the time of diagnosis and 1 year later.These findings illuminate the dynamics of communication problems during that complex period, and depict the mechanisms by which patients sought to confront these challenges to optimize their cancer care experience. On the basis of these findings, considered in the context of the body of available evidence, suggestions are proposed as to appropriate directions for system-level solutions to the complex communication challenges within cancer care.

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.

Patients' and relatives' complaints about encounters and communication in health care: evidence for quality improvement

OBJECTIVE

The aim of this study was to describe patients' and relatives' complaints to the local Patients' Advisory Committee about their encounters and communication in health care.

METHODS

Complaints (n=105) regarding patients' and relatives' dissatisfaction with communication and encounters in health care, registered at a local Patients' Advisory Committee between 2002 and 2004, were included. The texts were analysed using content analysis.

RESULTS

Three categories were identified: "Not receiving information or being given the option to participate", "Not being met in a professional manner" and "Not receiving nursing or practical support". Insufficient information, insufficient respect and insufficient empathy were described as the most common reasons for a negative professional encounter.

CONCLUSION

Patients and relatives experienced unnecessary anxiety and reduced confidence in health care after negative professional encounters.

PRACTICE IMPLICATIONS

The complaints reported to the Patients' Advisory Committee could be used more effectively in health care and be regarded as important evidence when working with quality improvement. To systematically use patient stories, such as those obtained in this report, as a reflective tool in education and supervision could be one way to improve communication and bring new understanding about the patient's perspective in health care.

To be involved or not: factors that influence nurses' involvement in providing treatment decisional support in advanced cancer

Decisional support is a multifaceted process of facilitating patients' decision making regarding treatment choices. Effective decisional support practices of nurses in relation to the use of anticancer therapies in patients with advanced disease are central to quality cancer care. A recent qualitative descriptive study (n=21) exploring the decision making practices of doctors and nurses in one tertiary cancer centre in New Zealand identified many complexities associated with nurses and their participation in decisional support. The study revealed that cancer nurses had varied opinions about the meaning and importance of their roles in treatment related decision making. This variation was significant and led the researchers to undertake a detailed secondary exploration of factors that impacted on the nurses' involvement in the provision of decisional support. Four key groups of factors were identified. These were factors relating to degree of knowledge, level of experience, beliefs and understandings about nursing roles and cancer therapies, and structural interfaces in the work setting. Understanding these factors is important because it allows modification of the conditions which impact on the ability to provide effective decisional care. It also provides some understanding of clinical drivers associated with nurses' decisional support work with patients who have advanced cancer.

Recall in older cancer patients: measuring memory for medical information

PURPOSE

Remembering medical treatment information may be particularly taxing for older cancer patients, but to our knowledge this ability has never been assessed in this specific age group only. Our purpose in this study was to investigate older cancer patients' recall of information after patient education preceding chemotherapy.

DESIGN AND METHODS

We constructed a recall questionnaire consisting of multiple-choice questions, completion items, and open-ended questions related to information about treatment and recommendations on how to handle side effects. Immediately after a nursing consultation preceding chemotherapy treatment, 69 older patients (M = 71.8 years, SD = 4.1) completed the questionnaire. We checked recall against the actual communication in video recordings of the consultations.

RESULTS

On average, 82.2 items were discussed during the consultations. The mean percentage of information recalled correctly was 23.2% for open-ended questions, 68.0% for completion items, and 80.2% for multiple-choice questions.

IMPLICATIONS

Older cancer patients are confronted with a lot of information. Recall of information strongly depended on question format; especially active reproduction appeared to be poor. To improve treatment outcomes, it is important that cancer patients are able to actively retrieve knowledge about how to prevent and recognize adverse side effects and that this is checked by the health professional. We make suggestions on how to make information more memorable for older cancer patients.

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.

The content and effects of palliative care courses for nurses: A literature review

OBJECTIVES

The present literature review describes the literature (1990-2005) that concerns the effects of courses in palliative care at the pre- and postgraduate levels.

DATA SOURCES

A search was made for literature from the period between 1990 and 2005 using CINAHL, Pubmed and Psychlit, supplemented with a search for relevant systematic reviews from the Cochrane Library.

DESIGN

The research questions were directed on the areas of expertise and skills, the didactical methods, the effects of the courses and the standards to measure these effects.

RESULTS

The studies were all focused on general palliative care. Out of 27 studies 21 reported positive effects for communication, attitude, empathy and pain. Six of these 21 positive trails were studies with good quality designs, whereas 15 had moderate designs. The six studies with a lack of effects was one study with good quality and five studies with moderate quality designs. The effects on patients were described in only a few cases. There was still frequent use of self-constructed rating scales, where data about validity and reliability were lacking or where these aspects were not studied.

CONCLUSIONS

The most successful were integrated courses focused on several themes with a variety of didactical methods.

Exploration of communicative patterns of consultations in palliative cancer care

Building on the research conducted on institutional communication, and the analysis of actual communication taking place in clinical settings, this study describes and highlights features of palliative care consultations and focuses on the distribution of discursive space (i.e., share of words, lengths of turns), occurring topics and conversational frames. Six consultations between physicians, patients and significant others were videotaped and all participants took part in audio-taped interviews. The recordings were transcribed and analysed in regard to expectations of, the discursive space of, and topics addressed in the consultations. The distribution of the discursive space was unequal; the physicians had the greatest share of words and length of turns in all six consultations, and they mostly initiated discussion of medical issues connected to examinations and treatment, while only patients initiated the topic of the patient's future. During the consultations, institutional framing tended to dominate over client framing. There was found to be room for further study of the structure and content of palliative care consultations with emphasis on how the voice of the patient can manifest itself within the framework of the medical agenda of the consultation and its significance for palliative cancer team work.

A purpose-based evaluation of information for patients: an approach to measuring effectiveness

OBJECTIVE

To assess the feasibility, internal reliability, and validity, of an assessment tool, purpose-based information assessment (PIA), that we had developed to evaluate how effectively information provided to patients addresses their individual purposes for the information. The study also demonstrated potential novel insight gained by the PIA assessment.

METHODS

One hundred and eighty-two patients and family members were provided with a booklet on early-stage prostate cancer and its treatment options, in the context of a clinical trial comparing two booklets. Using the PIA, participants rated the importance (4-point Likert scale) of each of six previously identified common purposes for such information: to organize their thoughts, to understand their situation, to decide on treatment, to plan their future, to provide emotional support to others, and to discuss issues. Participants then rated how much their booklet helped address each of their purposes (4-point Likert scale). Evaluations were returned by mail. This report assesses the PIA evaluation of one of the booklets.

RESULTS

One hundred and fifty-six (86%) participants returned evaluations. Participants wanted information for a mean of 5.8 purposes (range 2-7); 72.5% rated the booklet at different levels of helpfulness across their purposes. The assessment showed internal reliability on three constructs tested, and convergent validity on 10 of 11 tested. PIA's individualized purpose-based approach revealed how an overall assessment could be misleading: overall, the booklet was more effective at helping readers decide than at helping them plan (64.7% versus 55.8%, respectively, rated the booklet as "helpful" or better). However, among readers who rated the two purposes as "very important", the booklet had a mean helpfulness rating of 1.95 for deciding compared to a mean of 2.02 for planning. The result suggests that the booklet was not better at helping people decide than at helping them plan, for the readers who most needed the help.

CONCLUSION

The PIA seems reliable and valid and adequately sensitive. The individualized purpose-based approach to assessing information appears to provide more specific feedback and more insights into its effectiveness than a single, global evaluation.

PRACTICE IMPLICATIONS

Developers of information source or educational tools for patients can use an individualized purpose-based assessment, such as the PIA, to identify strengths and limitations of the tools more precisely than global assessments.

What do we know about facilitating patient communication in the cancer care setting?

Throughout the cancer diagnosis and treatment period, patients interact with multiple healthcare providers. In order to facilitate these communications, researchers have developed interventions primarily for providers, and, more recently, for patients. The aim of this paper is to conduct a critical examination of a sample of the empirical literature regarding current knowledge about the types of interventions that have been designed to facilitate cancer patients' communication with their healthcare providers. Overall, the empirical literature suggests that some types of patient-based interventions (e.g. prompt sheets, audiotapes, coaching sessions) may be beneficial in specific areas (e.g. increasing the number of questions asked, increased patient satisfaction). However, there are few consistent findings and the outcome measures that have been examined have varied substantially across studies. More controlled studies using carefully chosen outcome variables are needed. Increasing patients' communication skills so that their goals are met has the potential to positively affect the communication process.

The communication goals and needs of cancer patients: a review

The aim of this review paper is to critique the empirical literature pertaining to the communication needs and goals of cancer patients, and to provide direction for research in this area. According to the conceptual framework of Feldman-Stewart et al., patient-physician communication occurs for the fundamental purpose of addressing each participant's goal(s). This review is divided into two categories of goals: (a) optimal medical management of the cancer, and (b) optimal attention to the patient's psychosocial response to cancer. Optimal medical management includes discussions about disease status and the treatment plan, and the effectiveness of these discussions is frequently determined by assessing patient understanding, satisfaction, and well-being. The literature suggests that cancer patients continue to have unmet communication needs, and communication outcomes are enhanced when physicians attend to the emotional needs of patients. Research gaps in communication research are highlighted, including the need for additional study of several external factors affecting the patient and provider.