The Four Habits Coding Scheme: validation of an instrument to assess clinicians' communication behavior

Effects of a shared decision-making implementation programme on patient-centred communication in oncology-Secondary analysis of a randomised controlled trial

BACKGROUND

There is a need for better implementation of patient-centred (PC) communication and shared decision-making (SDM) in routine cancer care.

OBJECTIVE

The aim of this study was to assess whether a programme to implement SDM in oncology had effects on PC communication in clinical encounters.

DESIGN

This study constitutes a secondary analysis of data derived from an implementation trial applying a stepped wedge design that, among other strategies, incorporated training and coaching to enhance the PC communication skills of physicians.

SETTING AND PARTICIPANTS

We analysed audio recordings of clinical encounters collected in three departments of a comprehensive cancer centre in Germany before and after rolling out the implementation programme.

MAIN VARIABLES STUDIED

We assessed the PC communication skills of physicians.

MAIN OUTCOME MEASURES

Each recording was rated by two researchers using the German version of the Four Habits Coding Scheme (4HCS), an observer-based measure of PC communication. Interrater reliability of the outcome measure was acceptable but moderate. Demographic data of patients participating in audio recordings were analysed.

METHODS

Data were analysed using descriptive statistics and linear mixed-effects models.

RESULTS

In total, 146 encounters, 74 before and 72 after implementation, were evaluated. The mean age of patients was 57.1 years (SD = 13.8), 70.3% were female, the largest portion of patients had medium formal education (32.4%) and were (self-) employed (37.8%). No statistically significant effect of the implementation programme on the physicians' PC communication skills was found.

DISCUSSION

The results indicate that the investigated programme to implement SDM in oncology, including training and coaching, had no effects on PC communication in clinical encounters. These results are in contrast to other studies that report the effects of specific training or coaching on PC communication. Reasons for the lack of effect include the short duration of our training compared to other studies, limited reliability and moderate interrater reliability of the 4HCS scale, limited reach of the intervention programme as well as the inclusion of physicians regardless of their exposure to the interventions.

CONCLUSION

Further research is needed to develop implementation strategies that improve physicians' PC communication skills.

PATIENT CONTRIBUTION

Data on patients and clinical encounters with patients and physicians were analysed. There was no other patient or public involvement.

Impact of a Mock OSCE on Student Confidence in Applying the Pharmacists' Patient Care Process

The Medical and Pharmacy Student Collaboration (MAPSC) student organization at the University of Southern California, Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, created an extracurricular, peer-led, virtual group mock objective structured clinical examination (MOSCE) to expose first-year pharmacy students (P1s) to the Pharmacists' Patient Care Process (PPCP). The purpose of this study is to evaluate the impact of a MAPSC MOSCE on P1s self-reported confidence in applying the PPCP and on patient communication, medication knowledge, and clinical skills. An anonymous, optional, self-reported survey was administered to P1s before and after the event, where they rated their confidence on a scale of 0-100 (0 = not confident, 100 = certainly confident). The statistical analysis was a paired two-tailed t-test with a significance level of p < 0.05. A total of 152 P1s and 30 facilitators attended the MOSCE. One hundred thirty-nine students met the inclusion criteria and were included in the data analysis. There was a statistically significant difference in the change in self-reported confidence for all PPCP components and learning outcomes. The results of our study strongly indicate that introducing P1 students to the PPCP through a MAPSC MOSCE format is a valuable experience.

Medical encounters with patients diagnosed with cancer: The association between physicians' behavior and perceived patient centered care and anxiety

PURPOSE

To evaluate the association between physicians' behavior and cancer patients' perceived patient-centered care (PCC) and anxiety following medical encounters.

METHODS

A prospective study design with 100 encounters, including 100 cancer patients and 22 oncology/surgery physicians, was performed between November 2019 and July 2021. Before the medical encounters, patients were asked to complete the validated State-Trait Anxiety Inventory (STAI), and physicians and patients completed sociodemographic and clinical data. During the medical encounters, structured 'real-time' observations of the physicians' behaviors were performed using the Four Habits Coding Scheme (4HCS). Following the medical encounters, patients were asked to re-complete the STAI and to fill the validated Perceived PCC questionnaire.

RESULTS

Mean 4HCS was positively associated with perceived PCC (β = 0.351, p < 0.001) and contributed 10.5% to the total 25.3% explained variance beyond the sociodemographic and clinical variables. Of the 4HCS sub scales, 'Demonstrate Empathy' displayed the lowest correlation with perceived PCC as compared to informational behaviors. In contrast, mean 4HCS was not associated with post-meeting anxiety (p > 0.05).

CONCLUSION

Our 'in-vivo' observations of medical encounters expands on previous studies in educational settings in showing how physicians' behaviors impact real patients' experience. The findings may provide a more accurate picture of physicians' supportive and unsupportive behaviors that impact on perceived PCC and anxiety. Patients may prefer their physicians to focus on the informational content related to their disease trajectory rather than focusing on empathy with their emotions. Physicians should be trained in ways to support patients on how to regain emotional control in stressful medical situations.

Evaluating the efficacy of a digital App to enhance patient-centred nursing handover: A simulation study

AIM

The study aim was to evaluate the feasibility and efficacy of a digital App developed to enhance patient communication with nurses during bedside nursing handover at shift change.

METHODS

Six nurses and 11 patient actors/volunteers participated in 12 simulated nursing handovers across six simulation workshops. Over half the patients were aged 70+ years (55%); majority were female (82%). Handover video recordings were analysed using a structured observation tool and a revised Four Habits Coding Scheme to assess nurses' handover communication skills. Patient and nurse feedback was also sought. The STROBE checklist (Data S1) guided preparation of the study.

RESULTS

For all simulated handovers (n = 12): Nurses greeted the patient at commencement; nurses made eye contact with the patient; patients were given opportunity to ask questions; and all patient questions were answered. Nurses explained the handover process for less than half the handovers (42%). Familiarity with the patient's history was evident in every handover. Communication behaviours identified in most handovers included: good nonverbal behaviour; allowing time for the patient to absorb information; giving clear explanations; involving the patient in decisions; and exploring acceptability of the care plan. Patient and nurse feedback on the App included: The App was easy to navigate, features were well-liked, with some improvements suggested.

CONCLUSION

Patients and nurses provided positive feedback for the App during hospital stay and at handover. The App has the potential to enhance existing handover processes and increase safety of hospital care by using technology to educate and empower patients/carers to be active partners in communication with nurses during change-of-shift handover.

RELEVANCE TO CLINICAL PRACTICE

The App empowers and enables patients/carers to actively participate in nursing handover and allows patients to communicate concerns and provide information to their nursing team, facilitating a new approach.

PATIENT OR PUBLIC CONTRIBUTION

Patients and carers were involved in the research from the original co-design workshops that guided the development of the handover App. The research aims and outcome measures were informed by the experiences and preferences of patients/carers. Two patient representatives were involved in writing and submission of the grant application for the study to evaluate the efficacy of the App and were listed as co-authors on this paper. Patient volunteers were involved in the current study to pilot test the handover App. Patient volunteers were recruited through a consumer representative and volunteer registry at the health service. They participated in simulated nursing handovers with two nurses to assess the feasibility and acceptability of the handover App and then provided feedback and suggestions for improvement.

Impact of a training program on hospital pharmacists' patient-centered communication attitudes and behaviors

Background

Effective communication that integrates the value of patient-centered care is important in healthcare encounters. Communication skills training (CST) has been indicated as effective in improving patient-centered communication behaviors. However, there is a paucity of studies on the impact of CST among Malaysian hospital pharmacists.

Objective

This study aimed to evaluate the effects of a patient-centered CST program on patient-centered communication scores, communication self-efficacy, and attitudes toward concordance among pharmacists in public hospitals.

Methods

A communication skills training (CST) program was conducted among hospital pharmacists. This training intervention was developed based on patient-centered communication frameworks and techniques, namely the Four Habits Model and motivational interviewing. A pre-test/post-test quasi-experimental design was implemented for the evaluation. Pharmacists underwent pre-test/post-test audiotaped simulated consultations and completed questionnaires, including the Revised United States-Leeds Attitudes Toward Concordance scale (RUS-LATCon) and Communication Self-Efficacy scale. The Four Habits Coding Scheme (FHCS) was used to evaluate patient-centered communication scores from the audiotapes, and the Wilcoxon signed-rank test was used to analyze for differences in the pre- and post-intervention scores.

Results

A total of 38 pharmacists from four tertiary hospitals participated in this study and completed the pre-test. However, due to the impact of COVID-19, only 23 pharmacists completed the post-test data collection. Improvements were noted in the FHCS scores post-training, including items related to exploring patients' concerns, acceptability, and barriers to treatment. Based on the questionnaire, there was an improvement in recognizing patients' needs and potential medication uncertainty and an increase in the overall communication self-efficacy scores after the training.

Conclusions

CST may help improve the adoption of patient-centered communication in pharmacists' consultations with patients.

A Direct Observation Form for Evaluation of the Psychiatric Interview: Pilot Testing During the Psychiatry Clerkship

OBJECTIVES

The authors evaluated the validity of a structured direct observation form (DOF) to assess medical student performance on psychiatric interviews for use in the psychiatry clerkship.

METHODS

One hundred and forty-eight third-year medical students were evaluated by two DOFs completed by a supervising resident, fellow, attending, or another team member. One DOF was completed early (time 1) and the other late (time 2) during a 4-week psychiatry clerkship.

RESULTS

The DOF showed good internal consistency (Cronbach's alpha = 0.88-0.89). DOFs submitted at time 2 were positively associated with end-of-course clinical grades (p < 0.001); this association remained significant while controlling for time of academic year the course was completed, rater rank, complexity of the case, and difficulty of the interview (time 2 p < 0.001). Mean scores from the DOF were associated with the time of year students took the course with students assessed early in the academic year having lower average scores (p-values = 0.01 at time 1, 0.002 at time 2). Scores on time 1 DOFs were positively associated with rater rank (p = 0.005; residents gave higher scores than faculty). DOFs also correlated with an Entrustable Professional Activity (EPA) assessment of the interview (time 1 r = 0.76, p < 0.001; time 2 r = 0.79, p < 0.001), but not with shelf exam scores (time 1 r = 0.10, p = 0.24; time 2 r = 0.11, p = 0.21).

CONCLUSIONS

A brief structured form evaluating medical student performance on psychiatric interviews provided valid information about performance by third-year medical students during the psychiatry clerkship.

Video review of family medicine resident clinical encounters: a tool for building emotional intelligence

Video Review (VR) is a well established educational tool for developing the practice of patient-centered care in family medicine residents. There are a number of behaviorally-based checklists that can be use in both live observation as well as VR of clinical encounters to identify and promote behaviors associated with patient-centered care, most of which also overlap with behaviors associated with Emotional Intelligence (EI). We propose a VR that is structured less on a seek-and-find of clinician behaviors and more as a self-reflective exercise of how the clinician presents in the room alongside how they were feeling during that encounter. We believe that this exercise promotes the first two skills of EI (self-awareness and self-management) and then provides a foundation on which to build the second pair of skills (social awareness and relationship management). This perspective paper offers guidance, including stepwise instruction, on how to facilitate such a VR curriculum.

Behavioural observation tool for patient involvement and collaboration in emergency care teams (PIC-ET-tool)

BACKGROUND

Patient participation is advocated in various healthcare settings. Instruments for assessment and feedback have been developed to strengthen clinician-patient interaction. In an emergency department context, such instruments are still missing. The study aimed to develop and test an observation tool for emergency teams' behaviour regarding patient involvement and collaboration.

METHODS

The development of the behavioural observation tool followed a systematic approach. The tool's content was based on various data sources, i.e., published literature, interview and observational data, and expert consensus. An international expert panel reviewed the content and the rating scale and rated its importance for patient involvement and collaboration in a Delphi process. The feasibility and reliability of the tool were tested by trained observers using video recordings of simulated emergencies. Intraclass correlation (ICC) and Kappa-statistics were performed to test the tool's inter-rater reliability.

RESULTS

The PIC-ET tool, a 22-item observation instrument was developed in which patient involvement and collaboration behaviours are rated from 'no' to 'high' using behavioural anchors. Expert agreement was obtained after three Delphi rounds on the tool content, the behavioural anchors and its importance for patient involvement and collaboration. The content validity was assessed as high, and the tool was found feasible for research. Overall inter-rater reliability was fair (Kappa 0.52).

CONCLUSIONS

A novel tool for assessing emergency teams' behaviour regarding patient involvement and collaboration is introduced. The tool's psychometric properties were fair to good. Further validation of the PIC-ET tool is recommended for more robust evidence. Future adaptation to different contexts and areas of use, as well as further validity testing may be of value.

Validity and reliability of standardized instruments measuring physician communication and interpersonal skills in video-recorded medical consultations - A systematic review

OBJECTIVE

To identify standardized instruments measuring physician communication and interpersonal skills based on video-recorded consultations.

METHODS

We searched electronic databases for primary studies published from 1950 to 2022. Eligible studies had to report the validation of standardized instruments dedicated to the assessment of physician interpersonal skills based on video-recorded consultations with adult patients.

RESULTS

Of 7155 studies retrieved, 13 primary studies involving nine standardized instruments were included. The median number of physicians and participants was 23 (range, 1-200) and 71 (range, 1-950), respectively. Seven out of nine instruments were multidimensional and comprised a median number of 23 items (range, 7-95). The conceptual framework was reported for two instruments only. Content analysis identified 12 key behaviors with substantial overlap across instruments. The Four Habits Coding Scheme (4-HCS) yielded satisfactory validity and reliability while the evidence on psychometric properties was limited for other instruments.

CONCLUSION

Limited evidence supports the psychometric attributes for most of the published standardized instruments dedicated to assessing physician communication and interpersonal skills.

PRACTICE IMPLICATIONS

Although the decision to use a specific instrument depends on the study aims, the 4-HCS appears to be the most reliable instrument for assessing physician communication and interpersonal skills based on video-recorded consultations.

Measurement of person-centred consultation skills among healthcare practitioners: a systematic review of reviews of validation studies

BACKGROUND

Person-centred care is integral to high-quality health service provision, though concepts vary and the literature is complex. Validated instruments that measure person-centred practitioner skills, and behaviours within consultations, are needed for many reasons, including in training programmes. We aimed to provide a high-level synthesis of what was expected to be a large and diverse literature through a systematic review of existing reviews of validation studies a of instruments that measure person-centred practitioner skills and behaviours in consultations. The objectives were to undertake a critical appraisal of these reviews, and to summarise the available validated instruments and the evidence underpinning them.

METHODS

A systematic search of Medline, EMBASE, PsycINFO and CINAHL was conducted in September 2020. Systematic reviews of validation studies of instruments measuring individual practitioner person-centred consultation skills or behaviours which report measurement properties were included. Review quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Details of the reviews, the included validation studies, and the instruments themselves are tabulated, including psychometric data, and a narrative overview of the reviews is provided.

RESULTS

Four reviews were eligible for inclusion. These used different conceptualisations of person-centredness and targeted distinct, sometimes mutually exclusive, practitioners and settings. The four reviews included 68 unique validation studies examining 42 instruments, but with very few overlaps. The critical appraisal shows there is a need for improvements in the design of reviews in this area. The instruments included within these reviews have not been subject to extensive validation study.

DISCUSSION

There are many instruments available which measure person-centred skills in healthcare practitioners and this study offers a guide to what is available to researchers and research users. The most relevant and promising instruments that have already been developed, or items within them, should be further studied rigorously. Validation study of existing material is needed, not the development of new measures.

Treatment decision making in psychiatry: Formulating patients’ perspectives in outpatient psychiatric consultations

Seeking and understanding patients’ values and preferences is one of the essential elements in shared decision making, which is associated with treatment adherence in psychiatry. However, negotiating treatment in psychiatric contexts can be challenging with patients whose ability to evaluate treatment recommendations rationally may be impaired. This article attempts to examine a conversational practice that psychiatrists use to deal with patients’ views and perspectives by formulating what the patients have said related to treatment. Taking the naturally occurring, face-to-face outpatient psychiatric consultations as the data, the present study uses conversation analysis (CA) as a method to demonstrate in a fine-grained detail what functions formulations of patients’ perspectives serve in psychiatric contexts. We found that by eliciting patients’ views and perspectives toward treatment, this type of formulation is not only used to achieve mutual understanding and establish the grounds for treatment decisions, but may also be used to challenge the legitimacy of patients’ position, steering treatment decision to the direction preferred by the psychiatrists. We argue that in the process of treatment decision making, psychiatrists do not simply impose their perspectives upon the patients, instead, they attempt to achieve consensus with patients by balancing their institutional authority and orientation to the patients’ perspectives. Data are in Chinese with English translation.

Application of the skills network approach to measure physician competence in shared decision making based on self-assessment

Several approaches to and definitions of 'shared decision making' (SDM) exist, which makes measurement challenging. Recently, a skills network approach was proposed, which conceptualizes SDM competence as an organized network of interacting SDM skills. With this approach, it was possible to accurately predict observer-rated SDM competence of physicians from the patients' assessments of the physician's SDM skills. The aim of this study was to assess whether using the skills network approach allows to predict observer-rated SDM competence of physicians from their self-reported SDM skills. We conducted a secondary data analysis of an observational study, in which outpatient care physicians rated their use of SDM skills with the physician version of the 9-item Shared Decision Making Questionnaire (SDM-Q-Doc) during consultations with chronically ill adult patients. Based on the estimated association of each skill with all other skills, an SDM skills network for each physician was constructed. Network parameters were used to predict observer-rated SDM competence, which was determined from audio-recorded consultations using three widely used measures (OPTION-12, OPTION-5, Four Habits Coding Scheme). In our study, 28 physicians rated consultations with 308 patients. The skill 'deliberating the decision' was central in the population skills network averaged across physicians. The correlation between parameters of the skills networks and observer-rated competence ranged from 0.65 to 0.82 across analyses. The use and connectedness of the skill 'eliciting treatment preference of the patient' showed the strongest unique association with observer-rated competence. Thus, we found evidence that processing SDM skill ratings from the physicians' perspective according to the skills network approach offers new theoretically and empirically grounded opportunities for the assessment of SDM competence. A feasible and robust measurement of SDM competence is essential for research on SDM and can be applied for evaluating SDM competence during medical education, for training evaluation, and for quality management purposes. [A plain language summary of the study is available at https://osf.io/3wy4v.].

Effects of a 16-Week Digital Intervention on Sports Nutrition Knowledge and Behavior in Female Endurance Athletes with Risk of Relative Energy Deficiency in Sport (REDs)

Female endurance athletes are considered a high-risk group for developing Relative Energy Deficiency in Sport (REDs). Due to the lack of educational and behavioral intervention studies, targeting and evaluating the effects of the practical daily management of REDs, we developed the Food and nUtrition for Endurance athletes-a Learning (FUEL) program, consisting of 16 weekly online lectures and individual athlete-centered nutrition counseling every other week. We recruited female endurance athletes from Norway (n = 60), Sweden (n = 84), Ireland (n = 17), and Germany (n = 47). Fifty athletes with symptoms of REDs and with low risk of eating disorders, with no use of hormonal contraceptives and no chronic diseases, were allocated to either the FUEL intervention (n = 32) (FUEL) or a 16-week control period (n = 18) (CON). All but one completed FUEL, while 15 completed CON. We found strong evidence for improvements in sports nutrition knowledge, assessed via interviews, and moderate to strong evidence in the ratings concerning self-perceived sports nutrition knowledge in FUEL versus CON. Analyses of the seven-day prospective weighed food record and questions related to sports nutrition habits, suggested weak evidence for improvements in FUEL versus CON. The FUEL intervention improved sports nutrition knowledge and suggested weak evidence for improved sports nutrition behavior in female endurance athletes with symptoms of REDs.

The priorities, challenges, and scope of clinical communication teaching perceived by clinicians from different disciplines: a Hong Kong case study

Background

In the absence of a well-rounded syllabus that emphasises both interpersonal and medical dimensions in clinical communication, medical students in the early stages of their career may find it challenging to effectively communicate with patients, especially when dealing with perceived priorities and challenges across different disciplines.

Methods

To explore the priorities, challenges, and scope of clinical communication teaching as perceived by clinicians from different clinical disciplines, we recruited nine medical educators, all experienced frontline clinicians, from eight disciplines across seven hospitals and two medical schools in Hong Kong. They were interviewed on their clinical communication teaching in the Hong Kong context, specifically its priorities, challenges, and scope. We then performed interpretative phenomenological analysis of the interview data.

Results

The interview data revealed five themes related to the priorities, challenges, and scope of clinical communication teaching across a wide range of disciplines in the Hong Kong context, namely (1) empathising with patients; (2) using technology to teach both the medical and interpersonal dimensions of clinical communication; (3) shared decision-making with patients and their families: the influence of Chinese collectivism and cultural attitudes towards death; (4) interdisciplinary communication between medical departments; and (5) the role of language in clinician–patient communication.

Conclusions

Coming from different clinical disciplines, the clinicians in this study approached the complex nature of clinical communication teaching in the Hong Kong context differently. The findings illustrate the need to teach clinical communication both specifically for a discipline as well as generically. This is particularly important in the intensive care unit, where clinicians from different departments frequently cooperate. This study also highlights how communication strategies, non-verbal social cues, and the understanding of clinical communication in the Hong Kong Chinese context operate differently from those in the West, because of differences in sociocultural factors such as family dynamics and hierarchical social structures. We recommend a dynamic teaching approach that uses role-playing tasks, scenario-based exercises, and similar activities to help medical students establish well-rounded clinical communication skills in preparation for their future clinical practice.

Twelve tips to manage a breaking bad news process: Using S-P-w-ICE-S - A revised version of the SPIKES protocol

Breaking bad news (BBN) is a difficult task that requires multiple professional competencies. The way it is managed has implications for all involved in the encounter: the patient, family members, and the news provider. Existing guidelines were developed mainly at the turn of the millennium and require updating based on identification of daily clinical needs and pedagogical challenges while teaching the current protocols. Furthermore, there is a need to provide an overview of BBN encounters as a process, rather than a subdivided event, to help practitioners adopt an approach that might serve them in their daily routines. This twelve tips article summarizes research and practical experience for handling BBN encounters, from their preparation, through delivering the news while attending patients and family members' needs, toward documenting the news, and critically reflecting on the interaction. The tips are structured and explained to serve both practitioners and medical educators.

Assuring patient participation and care continuity in intermediate care: Getting the most out of family meetings using the four habits model

Introduction

As a transitional care intervention, intermediate care (IC) bridges the pathway for older patients from hospital to home. Within family meetings in IC, the older patient, his or her relatives, the interdisciplinary team and the municipal case manager come together to discuss goals and interventions during the IC stay, including follow‐up services after discharge. Although family meetings are a common aspect of teamwork in IC, it is unclear how the voices of older people and their relatives are coming across. The aim of this study is to explore how patient participation is framed and negotiated within family meetings in IC.

Methods

This study is based on qualitative data from the observation of 14 interdisciplinary family meetings in Norwegian IC services. As a theoretical framework, the authors have used the four habits model developed by Frankel and Stein as a lens to understand the interrelated sequence of events that typically takes place during a family meeting and the importance of communication skills to promote patient participation.

Results

The thematic analysis resulted in 16 categories and 4 main themes related to the 4 habits model: (i) grounding the family meetings, (ii) what matters to you?, (iii) being empathically present and (iv) the power of a final closure.

Conclusion

There was considerable variation in the way current family meetings were conducted. It seemed crucial to start the meeting with a proper introduction and explanation of the purpose of the meeting to establish trust and to be able to successfully move to the next stage of eliciting the patients' preferences, views and goals via the ‘what matters to you?’ question. There were examples of empathetic communication among meeting participants perceived to facilitate patient participation. Finally, to successfully end the meeting and agree on a shared plan, it seemed crucial for case managers who held the decision‐making power to attend the meetings. Framing family meetings in line with the four habits sequential approach may have the potential to assure patient participation and care continuity in IC services.

Patient or Public Contribution

This article is part of a larger project based on a James Lind Alliance process that brings patients, relatives, health care professionals and researchers together in priority setting partnerships to identify and prioritize evidence uncertainties that they agree are the most important. Accordingly, the design and content of this article have been initiated and discussed in the project's stakeholder group consisting of one patient representative, one relative representative, two health care professionals from IC settings, two representatives from the Norwegian Health Association and two representatives from the Agency of Health in Norway.

Shared decision making, patient-centered communication and patient satisfaction - A cross-sectional analysis

OBJECTIVES

The integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication.

METHODS

In 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION⁵ score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores.

RESULTS

In comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION⁵ scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores.

CONCLUSION

Shared decision making and patient-centered communication are not synonymous and do not always co-exist.

PRACTICE IMPLICATIONS

The value of integrated training of shared decision making and patient-centered communication should be further explored.

Assessing Physician's Motivational Communication Skills: 5-Step Mixed Methods Development Study of the Motivational Communication Competency Assessment Test

BACKGROUND

Training physicians to provide effective behavior change counseling using approaches such as motivational communication (MC) is an important aspect of noncommunicable chronic disease prevention and management. However, existing evaluation tools for MC skills are complex, invasive, time consuming, and impractical for use within the medical context.

OBJECTIVE

The objective of this study is to develop and validate a short web-based tool for evaluating health care provider (HCP) skills in MC-the Motivational Communication Competency Assessment Test (MC-CAT).

METHODS

Between 2016 and 2021, starting with a set of 11 previously identified core MC competencies and using a 5-step, mixed methods, integrated knowledge translation approach, the MC-CAT was created by developing a series of 4 base cases and a scoring scheme, validating the base cases and scoring scheme with international experts, creating 3 alternative versions of the 4 base cases (to create a bank of 16 cases, 4 of each type of base case) and translating the cases into French, integrating the cases into the web-based MC-CAT platform, and conducting initial internal validity assessments with university health students.

RESULTS

The MC-CAT assesses MC competency in 20 minutes by presenting HCPs with 4 out of a possible 16 cases (randomly selected and ordered) addressing various behavioral targets (eg, smoking, physical activity, diet, and medication adherence). Individual and global competency scores were calculated automatically for the 11 competency items across the 4 cases, providing automatic scores out of 100. From the factorial analysis of variance for the difference in competency and ranking scores, no significant differences were identified between the different case versions across individual and global competency (P=.26 to P=.97) and ranking scores (P=.24 to P=.89). The initial tests of internal consistency for rank order among the 24 student participants were in the acceptable range (α=.78).

CONCLUSIONS

The results suggest that MC-CAT is an internally valid tool to facilitate the evaluation of MC competencies among HCPs and is ready to undergo comprehensive psychometric property analyses with a national sample of health care providers. Once psychometric property assessments have been completed, this tool is expected to facilitate the assessment of MC skills among HCPs, skills that will better support patients in adopting healthier lifestyles, which will significantly reduce the personal, social, and economic burdens of noncommunicable chronic diseases.

Student characteristics associated with interpersonal skills in medical consultations

BACKGROUND

The quality of medical care depends on effective physician-patient communication. Interpersonal skills can be improved through teaching, but the determinants are poorly understood. We therefore assessed the factors associated with the interpersonal skills of medical students during simulated medical consultations.

METHODS

We conducted a cross-sectional study of fourth-year medical students participating in simulated consultations with standardized patients. Each video-recorded medical consultation was independently assessed by two raters, using a cross-cultural adaptation of the Four Habits Coding Scheme (4-HCS) into French. We then collected information on demographics and education-related characteristics. The relationship between the overall 4-HCS score and student characteristics was modeled using univariable and multivariable linear regression.

RESULTS

Our analytical sample included 165 medical students for analysis. The factors significantly associated with 4-HCS score were gender (β = - 4.8, p = 0.011) and completion of an international clinical placement (β = 6.2, p = 0.002) or a research laboratory clerkship (β = 6.5, p = 0.005). Education-related characteristics, multiple-choice examinations in the first to third preclinical years, and number of medicine or surgery clerkships were not significantly associated with 4-HCS score.

CONCLUSIONS

Undergraduate students with higher level of interpersonal skills during video-recorded medical consultations with standardized patients are more likely to be female, to have completed international clinical placement as part of the ERASMUS exchange program or research laboratory clerkship.

Impact of a relationship-centered care communication curriculum on pediatric residents' practice, perspectives, and opportunities to Develop expertise

OBJECTIVES

To investigate the impacts of a Relationship-Centered Care (RCC) communication curriculum with coaching on pediatric residents 1) self-reported use of RCC strategies and perspectives, and 2) opportunities to develop adaptive expertise.

METHODS

Residents (n = 77) completed a 4 h RCC training and shared resultant RCC goals with Coaches (n = 15). Data included resident surveys and reflections immediately post-training, and resident and coach surveys 6-months later. Reported use of RCC strategies were compared over time with paired t-tests. Qualitative data were analyzed using open coding guided by sensitizing principles from the RCC framework and adaptive expertise.

RESULTS

Pediatric residents reported significant increases (p < 0.001) in use of 4/9 RCC strategies after 6 months: eliciting all concerns, chunking information, checking for understanding, and teach-back. Resident reflections highlighted shifts in perspective around RCC. Training combined with coaching provided opportunities for residents to develop adaptive expertise through adapting and innovating across settings and contexts.

CONCLUSION

Residents had significant increases in reported use of key RCC strategies after a training combined with coaching and demonstrated opportunities to develop adaptive expertise.

PRACTICE IMPLICATIONS

Residency programs should include RCC training with an emphasis on the new and challenging strategies and provide opportunities to practice and receive coaching.

Guidance on Providing Patient-Centered Care

This article explores the clinical applications of Audiology Practice Standards Organization (APSO) Standards 2 and 13, both of which keep us fully focused on the patient-as-person. The topics within Standard 2 include audiologists' interpersonal communication skills, specifically clarity (ensuring patient comprehension) and empathy (understanding the patient's experiences). Standard 2 also addresses the topic of health literacy, which has been recently expanded to consider not only the degree to which individuals are able to find, understand, and use information and services to inform health-related decisions but also how organizations equitably support those necessary skills. The characteristics and benefits of services provided in patient- and family-centered care contexts are also described. Standard 13 addresses audiologists' support toward overall successful adjustment as defined by the patient, including both technical and personal adjustment to amplification, nontechnical communication issues, and rehabilitation support using readily available technologies. A new assessment protocol that includes goal setting and intervention is described, as well as a patient-centered intervention strategy involving discussion of personally meaningful photographs. Both standards provide a necessary balance to our technology-reliant profession.

Impact of physician-patient relationship training on medical students' interpersonal skills during simulated medical consultations: a cross-sectional study

BACKGROUND

In medicine, the patient-centered approach is based on interpersonal skills, including communication, structuring the medical interview, and empathy, which have an impact on health professionals' interpersonal relationships and the quality of care. Training courses on this issue are therefore being developed in universities. We hypothesized that specific training courses in the physician-patient relationship could improve interpersonal skills among medical students during simulated consultations and the immediate satisfaction of standardized patients.

METHODS

This cross-sectional study enrolled fourth-year medical students who participated in a simulated medical consultation session with standardized patients. The evaluation of interpersonal skills was carried out using the Four Habits Coding Scheme, producing a synthetic score out of 115 points used as the primary endpoint. Some students benefited from the training courses offered by the university or by other organizations, mainly based on communication, active listening, or patient-centered approach. A comparison was made with students from the same graduating class who had not received any training.

RESULTS

The analysis of the primary endpoint showed a difference of 5 points between the group of students who had attended at least one training course and those who did not (p = 0.001). This difference was even more marked when the students had completed several training courses, up to 14 points higher with three training courses (p = 0.001), each with positive results in different areas of the care relationship.

CONCLUSIONS

Physician-patient relationship training currently provided in initial education appears to be effective in improving interpersonal skills. A repetition of this training is necessary to increase its impact.

Effectiveness of a multifaceted intervention to improve interpersonal skills of physicians in medical consultations (EPECREM): protocol for a randomised controlled trial

INTRODUCTION

Interpersonal skills, encompassing communication and empathy, are key components of effective medical consultations. Although many organisations have implemented structured training programmes, limited evidence exists on their effectiveness in improving physician interpersonal skills. This study aims to evaluate the effectiveness of a standardised, multifaceted, interpersonal skills development programme for hospital physicians.

METHODS AND ANALYSIS

This study is a prospective, randomised (with a 1:1 allocation ratio), controlled, open-label, two parallel arm, superiority trial conducted at a single university hospital. Physicians will be randomised to receive either a multifaceted training programme or no intervention. The experimental intervention combines two 4-hour training sessions, dissemination of interactive educational materials, review of video-recorded consultations and individual feedback. The primary outcome measure is the overall 4-Habits Coding Scheme score assessed by two independent raters blinded to the study arm, based on video-recorded consultations, before and after intervention. The secondary outcomes include patient satisfaction, therapeutic alliance, physician self-actualisation and the length of medical consultation.

ETHICS AND DISSEMINATION

The study protocol was approved on 21 October 2020 by the CECIC Rhône-Alpes Auvergne, Clermont-Ferrand, France (IRB 5891). All participants will provide written informed consent. Efforts will be made to release the primary results within 6 to 9 months of study completion, regardless of whether they confirm or deny the research hypothesis.

TRIAL REGISTRATION NUMBER

NCT04703816.

Addressing Hidden Curricula That Subvert the Patient-Centeredness "Hub" of the Pharmacists' Patient Care Process "Wheel"

Objective. This systematic review's purpose is to improve clarity for the meaning of patient-centered care in the JCPP Pharmacists' Patient Care Process and to provide an initial foothold for faculty to address "hidden curricula" that undermine the concept. Our corresponding objectives were to identify and describe the conceptualizations defining patient-centered care from the pharmacy literature; and compare the meaning of patient-centeredness in the pharmacy literature with the construct's seminal conceptualizations from other professional groups.Findings. The search protocol produced 61 unique sources from the pharmacy literature. More than two-thirds of these results lacked precise use of terminology consistent with the literature or operational depth or theoretical exploration of the term's meaning. The remaining sources yielded two separate conceptualizations of patient-centeredness with three commonalities but key differences between their grounding in the construct's seminal sources in the broader health care literature.Summary. The pharmacy literature clarifies the meaning of patient-centered care in the patient-pharmacist encounter, but additional understanding is needed at meso- (ie, health care) and macro-levels (ie, legislation, accreditation, payment, workforce dynamics) of care. This expansion of understanding may reduce dissonance between the formal and hidden curricula on patient-centeredness associated with health professional student disillusionment, contempt for faculty and institutions, and reductions in empathy and ethics. Increasing use of integrative case-based training, equitably blending patient-centeredness considerations with other curricular content, represents one strategy for reducing the presence and negative impact of hidden curricula.

Development and validation of the questionnaire to analyze the communication of nurses in nurse-patient therapeutic communication

OBJECTIVE

The purpose of this study was to develop and analyze the psychometric properties of an instrument that could analyze the communication of nursing professionals in nurse-patient therapeutic communication.

METHODS

A literature review and a panel of experts were used (N = 10) to develop the questionnaire to analyze the communication of nurses in nurse-patient therapeutic communication. The final version of the questionnaire was composed of 49 items and applied to a convenience sample of 370 nurses.

RESULTS

The construct validity was assessed by an exploratory factor analysis (EFA) and the reliability using Cronbach's Alpha. Three dimensions were identified that determine therapeutic communication: professional, contextual and/or situational and patient. The Cronbach's α total coefficient was 0.90, ranging from 0.71 to 0.81 for the dimensions.

CONCLUSION

The questionnaire to analyze the communication of nurses in nurse-patient therapeutic communication represents a valid and reliable questionnaire to measure nurses' communication with patients in the clinical setting.

IMPLICATIONS FOR PRACTICE

The use of the questionnaire enables the analysis of elements that interfere with effective communication. This can assist in developing interventions to improve nurses' therapeutic communication with patients.

From Observation to Action: Developing and Pilot-Testing a Communication Tool for Follow-up Consultations with Adolescent Cancer Survivors

Purpose: Efficient physician communication with adolescent cancer survivors (ACS) during follow-up consultations is important to enable survivors to take responsibility for their health. The present study had two aims: to develop a communication tool to enhance structured consultations and improve clinician communication in follow-up consultations, and to pilot-test the tool in physicians' consultations with ACS. Methods: Clinicians and communication experts collaborated closely to develop the 7 Memory Hooks (7MH) communication tool and a corresponding coding scheme for scoring communication behavior in consultations. Thirty-seven follow-up consultations between ACS and physicians were video-recorded (22 before intervention and 15 after intervention). The intervention consisted of a didactic lecture, a group workshop, and individual coaching to provide feedback to physicians on the communication skills observed in the pre-intervention videos. We then compared physicians' communication behavior both before and after intervention. Results: Fourteen physicians participated in the 7MH training. The mean total score on the 7MH scheme was significantly higher post-intervention compared with pre-intervention (p = 0.001). Six behaviors changed significantly after the intervention. At a group level, physicians were more likely to be alone with the adolescent (p = 0.004) and to prepare the patient for transition to adult heath care (p = 0.040). They asked more often about the patients' expectations (p = 0.007) and resources ((p = 0.019). And they acknowledged patients' concerns more often (p = 0.016) but talked significantly less about physical activity (p = 0.012). Conclusion: A physician communication tool, designed bottom-up and developed in collaboration with the clinic, shows promising effects on physicians' communication behavior at follow-up consultations with ACS.

Warding off a tyranny of reliability and validity

Researchers in the healthcare communication field come from many different educational backgrounds. Such diversity generally strengthens a field, but sometimes a set of beliefs or a particular orthodoxy may predominate in ways that are negative. We discuss one such example, noting how the research culture deriving from training in schools of education treats the concepts of reliability and validity. We note that some researchers working in fields such as medical education and healthcare communication use the terms "reliable" and "valid" loosely or even incorrectly, often referring to them as a single catch-phrase. More importantly, we caution healthcare communication researchers against a tyranny of reliability and validity in which researchers feel pressure to avoid creating unique instruments to study new questions, instead using instruments with previously demonstrated reliability and validity even when these may not directly capture the concept of interest. This practice is motivated by realistic fears that reviewers and editors will disapprove of their work because the instruments used are not known to be "reliable and valid." We encourage the research community to take a more balanced approach wherein originality is not stifled, and in which creativity and rigor exist side by side.

Spanish Medical Interpreters' Management of Challenges in End of Life Discussions

OBJECTIVE

Professional medical interpreters facilitate patient understanding of illness, prognosis, and treatment options. Facilitating end of life discussions can be challenging. Our objective was to better understand the challenges professional medical interpreters face and how they affect the accuracy of provider-patient communication during discussions of end of life.

METHODS

We conducted semi-structured interviews with professional Spanish medical interpreters. We asked about their experiences interpreting end of life discussions, including questions about values, professional and emotional challenges interpreting these conversations, and how those challenges might impact accuracy. We used a grounded theory, constant comparative method to analyze the data. Participants completed a short demographic questionnaire.

RESULTS

Seventeen Spanish language interpreters participated. Participants described intensive attention to communication accuracy during end of life discussions, even when discussions caused emotional or professional distress. Professional strains such as rapid discussion tempo contributed to unintentional alterations in discussion content. Perceived non-empathic behaviors of providers contributed to rare, intentional alterations in discussion flow and content.

CONCLUSION

We found that despite challenges, Spanish language interpreters focus intensively on accurate interpretation in discussions of end of life.

PRACTICE IMPLICATIONS

Provider training on how to best work with interpreters in these important conversations could support accurate and empathetic interpretation.

Teaching plain language to medical students: improving communication with disadvantaged patients

BACKGROUND

Low health literacy underpins health inequality and leads to poor adherence to medical care and higher risk of adverse events and rehospitalization. Communication in plain language, therefore, is an essential skill for health professionals to acquire. Most medical education communication skill programs focus on verbal communication, while written communication training is scarce. ETGAR is a student delivered service for vulnerable patients after hospital discharge in which, amongst other duties, students 'translate' the medical discharge letters into plain language and share them with patients at a home visit. This study ascertains how this plain language training impacted on students' written communication skills using a tool designed for purpose.

METHODS

Students, in pairs, wrote three plain language discharge letters over the course of a year for patients whom they encountered in hospital. The students handed over and shared the letters with the patients during a post-discharge home visit. Structured feedback from course instructors was given for each letter. An assessment tool was developed to evaluate students' ability to tell the hospitalization narrative using plain and clear language. First and last letters were blindly evaluated for the entire cohort (74 letters; 87 students).

RESULTS

Students scored higher in all assessment categories in the third letters, with significant improvement in overall score 3.5 ± 0.8 vs 4.1 ± 0.6 Z = -3.43, p = 0.001. The assessment tool's reliability was high α = 0.797, it successfully differentiated between plain language categories, and its score was not affected by letter length or patient's medical condition.

CONCLUSIONS

Plain language discharge letters written for real patients in the context of experience-based learning improved in quality, providing students with skills to work effectively in an environment where poor health literacy is prevalent. ETGAR may serve as a model for learning written communication skills during clinical years, using the assessment tool for formative or summative evaluation.

Development and national consensus finding on patient-centred high stakes communication skills assessments for the Swiss Federal Licensing Examination in Medicine

OBJECTIVE

To describe and evaluate a consensus finding and expert validation process for the development of patient-centred communication assessments for a national Licensing Exam in Medicine.

METHODS

A multi-professional team of clinicians and experts in communication, assessment and role-play developed communication assessments for the Swiss Federal Licensing Examination. The six-month process, informed by a preceding national needs-assessment, an expert symposium and a critical literature review covered the application of patient-centred communication frameworks, the development of assessment guides, concrete assessments and pilot-tests. The participants evaluated the process.

RESULTS

The multiple-step consensus process, based on expert validation of the medical and communication content, led to six high-stakes patient-centred communication OSCE-assessments. The process evaluation revealed areas of challenge such as calibrating rating-scales and case difficulty to the graduates' competencies and integrating differing opinions. Main success factors were attributed to the outcome-oriented process and the multi-professional exchange of expertise. A model for developing high stakes patient-centred communication OSCE-assessments was derived.

CONCLUSIONS

Consensus finding was facilitated by using well-established communication frameworks, by ensuring outcome-orientated knowledge exchange among multi-professional experts, and collaborative validation of content through experts.

PRACTICE IMPLICATIONS

We propose developing high-stakes communication assessments in a multi-professional expert consensus and provide a conceptual model.

A single, early aged care experience improves speech-language pathology students' attitudes towards older people, communication confidence, and career aspirations in aged care

PURPOSE

This study aimed to investigate if a single, early learning experience in an aged care setting could influence speech-language pathology students': (1) attitudes towards older people; (2) confidence in communicating with older people; and (3) career aspirations in aged care.

METHOD

Ninety first-year undergraduate speech-language pathology students participated in a single visit to an aged care community centre. Students participated in recreational activities alongside older people and engaged in conversation. Before and after the visit, students completed surveys which examined their attitudes towards older people (UCLA Geriatrics Attitudes Scale) and self-perceived communication confidence. A Learning Reactionnaire, examining satisfaction with the experience and career aspirations, was completed post-visit. Quantitative data were analysed using descriptive statistics and non-parametric tests. Qualitative data were analysed using inductive content analysis.

RESULT

Students demonstrated positive changes in their attitudes towards older people and increased communication confidence. Students reported increased interest in future employment in aged care. High satisfaction towards the learning experience was reported.

CONCLUSION

These preliminary findings indicate that a single, early learning experience in an aged care setting can positively shape the attitudes and self-perceived communication skills of first-year speech-language pathology students and help foster interest in pursuing a career in aged care.

Making the biopsychosocial model more scientific-its general and specific models

Some aver that the biopsychosocial (BPS) model is not fully scientific because it lacks a method to produce BPS information. To resolve this criticism, I propose that we think in terms of general and specific BPS models. What most understand to be the model is the general BPS model. It simply indicates that all patients be understood in biological, psychological, and social terms without specifying a method or sources of BPS information. Its fundamental function is to guide medicine away from the effete, 17^th century disease-only model in clinical care, teaching, and research. Considerable population-based research data also support its scientific status. Less well understood, but of greater relevance to the clinician, is the specific BPS model, which describes the BPS features unique to an individual patient. The specific model, however, requires an interviewing method to achieve this, the method critics believe lacking. In this article, I review how medical communication scholars have established a method to acquire individualized BPS data on each patient. Research identified the patient-centered interviewing (PCI) method to do this. After much progress over several decades, the field was able to test the PCI in several randomized controlled trials-and confirmed it to be evidence-based. Therefore, by definition, because the patient-centered interview defines the specific BPS model in each patient, the model itself is evidence-based. This means we now can, for the first time, identify a scientific BPS model for every individual patient. Joining this scientific support with much existing data for the general model, we now have a fully scientific BPS model.

Protocol for Symptom Experience, Management, Outcomes, and Adherence in Women Receiving Breast Cancer Chemotherapy

BACKGROUND

The 5-year survival for Black women with breast cancer in the United States is lower than White women for stage-matched disease. Our past and ongoing work and that of others suggest that symptom incidence, cancer-related distress, and ineffective communication contribute to racial disparity in dose reduction and early therapy termination. Although race is perhaps the most studied social determinant of health, it is clear that race alone does not account for all disparities.

OBJECTIVES

The aim of the study was to present a study protocol of Black and White women prescribed breast cancer chemotherapy. The aims are to (1) examine and compare chemotherapy received/prescribed over time and in total; (2a) examine and compare symptom incidence, distress, and management and clinical encounter, including patient-centeredness of care and management experience over time and (2b) correlate symptom incidence, distress, and management experience to Aim 1; and (3) explore the effects of social determinants of health, including age, income, education, zip code, and lifetime stress exposure, on Aims 1, 2a, and 2b.

METHODS

A longitudinal, repeated-measures (up to 18 time points), comparative, mixed-methods design is employed with 179 White and 179 Black women from 10 sites in Western Pennsylvania and Northeast Ohio over the course of chemotherapy and for 2 years following completion of therapy.

RESULTS

The study began in January 2018, with estimated complete data collection by late 2023.

DISCUSSION

This study is among the first to explore the mechanistic process for racial disparity in dosage and delay across the breast cancer chemotherapy course. It will be an important contribution to the explanatory model for breast cancer treatment disparity and may advance potential mitigation strategies for racial survival disparity.

Learning social determinants of health through a home visiting course in the clinical years

OBJECTIVE

The purpose of this study was to assess the impact of a new experience-based educational program aiming to teach social determinants of health (SDH) and health disparities, through a post-discharge home-visit conducted with patients recruited in hospital.

METHODS

105 clinical-year students visited 177 patients living in disadvantaged circumstances. Their home-visit reports were analyzed employing mixed methodology. Content analysis was conducted for classifying issues raised by students, and quantitative analysis to compare reports by level of elaboration, gender and class.

RESULTS

Fifteen taxonomy items were identified. Social support and patients' medical conditions were most prevalent, followed by personal-related and community-related issues. Analysis demonstrated students' understanding of the relationship between SDH and patient health, and challenges patients face following discharge. Women and mixed couples provided more elaborate reports, which contained significantly greater critique of medical care.

CONCLUSIONS

Meeting patients both in hospital and at home enhanced awareness of SDH. Students learned to view the patient comprehensively, and to understand the diverse factors affecting their health. Students, who had essentially sole responsibility for the home-visit, successfully integrated their skills to take action when needed.

PRACTICE IMPLICATIONS

The ETGAR experience provided a means for effective learning about how social determinants impact on health.

Caring Behavior Coding Scheme based on Swanson's Theory of Caring - development and testing among undergraduate nursing students

Rationale

To maintain patients’ dignity and well‐being and alleviate suffering, it is essential that healthcare providers engage in caring behaviours. Yet, every year patient boards receive an increasing number of complaints from patients and significant others regarding healthcare providers’ non‐caring behaviours. Defining and measuring both verbal and nonverbal caring and non‐caring behaviour in healthcare delivery is vital to address such complaints. However, no studies were found that incorporated a comprehensive theory of caring to code encounters between healthcare providers and patients.

Aim

The aim was to develop and test a Caring Behavior Coding Scheme based on Swanson’s Theory of Caring.

Method

An instrument development process was used for behavioural coding including observational data from thirty‐eight video recordings collected in an undergraduate nursing course at a Swedish University. The observational data involved interactions between undergraduate nursing students and a standardised patient.

Result

The Caring Behavior Coding Scheme (the CBCS), contains seventeen verbal and eight nonverbal behavioural codes, categorised as caring and non‐caring in accordance with Swanson’s Theory of Caring. Content and face validity were assessed. Timed‐event sequential continuous coding was performed in INTERACT software. The coder achieved excellent agreement with the developed gold standard (k = 0.87) and excellent mean inter‐rater reliability (k = 0.82). All domains in Swanson’s Theory of Caring were observed and coded in the interaction.

Discussion/Conclusion

The CBCS is a theory‐based instrument that contributes to research on healthcare providers’ behavioural encounters. It uses verbal and nonverbal caring and non‐caring behavioural codes to assess the alignment of both the theory and practice of caring. The CBCS can contribute to both development and measurement of interventions focused on improving healthcare providers’ caring behaviour with the intended outcome of patient well‐being.

A skills network approach to physicians' competence in shared decision making

BACKGROUND

Measurement of physicians' competence in shared decision making (SDM) remains challenging with frequent disagreement between assessment methods.

OBJECTIVE

To conceptualize and measure physicians' SDM competence as an organized network of behavioural skills and to determine whether processing patient-reported data according to this model can be used to predict observer-rated competence.

DESIGN

Secondary analysis of an observational study.

SETTING AND PARTICIPANTS

Primary and specialty outpatient care physicians and consecutively recruited adult patients with a chronic condition who faced a treatment decision with multiple acceptable choices.

MEASURES

Network parameters constructed from patients' assessment of physicians' SDM skills as measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) and observer-rated SDM competence of physicians measured by three widely used observer-rated instruments.

RESULTS

29 physicians (12 female, 17 male; mean age 50.3 years) recruited 310 patients (59.4% female, 40.6% male; mean age 54.0 years) facing a decision mainly regarding type 2 diabetes (36.4%), chronic back pain (32.8%) or depressive disorder (26.8%). Although most investigated skills were interrelated, elicitation of the patient's treatment preferences showed the strongest associations with the other skills. Network parameters of this skill were also decisive in predicting observer-rated competence. Correlation between predicted competence scores and observer-rated measurements ranged from 0.710 to 0.785.

CONCLUSIONS

Conceptualizing physicians' SDM competence as a network of interacting skills enables the measurement of observer-rated competence using patient-reported data. In addition to theoretical implications for defining and training medical competences, the findings open a new way to measure physicians' SDM competence under routine conditions.

Empathy of dental students towards children after behaviour guidance lectures and clinical experience

INTRODUCTION

The empathetic behaviour of dentists is essential for perfect patient care. Because the behaviour of child patients in a dental clinic differs from that exhibited by the adults, knowing of empathy of dental students towards the child in the dental clinic is an important concern.

METHODS

We distributed a modified form of the Health Professions Student version (HPS-version) of the Jefferson Scale of Empathy (JSE) to dental students in two rounds: (R1) before and (R2) after introducing behaviour guidance subcourse and exposure to 3 clinical experiences with children to measure changes in empathy of dental students towards child patients. The modifications include replacing the "patient" words with "child patients" and translation into Arabic. We checked the internal consistency of the modified form of HPS-version by Cronbach's coefficient alpha test. The significance level was set at 0.05 for all statistical analyses.

RESULTS

Out of eighty-one, sixty-five dental students completed the survey and attended a behaviour guidance course and three clinical sessions. The questionnaire showed accepted reliability. There was a significant decrease in the empathy of dental students in R2 than R1 (P < .05). The level of empathy for males was less than female students in both rounds (P < .05).

CONCLUSIONS

The clinical interaction of children by dental students inhibits their empathy towards child patients, and a specific training course is needed to improve dental students' empathy towards children since learning behaviour guidance may not sufficient.

A state-of-the-art review of direct observation tools for assessing competency in person-centred care

BACKGROUND

Direct observation is a common assessment strategy in health education and training, in which trainees are observed and assessed while undertaking authentic patient care and clinical activities. A variety of direct observation tools have been developed for assessing competency in delivering person-centred care (PCC), yet to our knowledge no review of such tools exists.

OBJECTIVE

To review and evaluate direct observation tools developed to assess health professionals' competency in delivering PCC.

DESIGN

State-of-the-art review DATA SOURCES: Electronic literature searches were conducted in PubMed, ERIC, CINAHL, and Web of Science for English-language articles describing the development and testing of direct observation tools for assessing PCC published until March 2017.

REVIEW METHODS

Three authors independently assessed the records for eligibility. Duplicates were removed and articles were excluded that were irrelevant based on title and/or abstract. All remaining articles were read in full text. A data extraction form was developed to cover and extract information about the tools. The articles were examined for any conceptual or theoretical frameworks underlying tool development and coverage of recognized PCC dimensions was evaluated against a standard framework. The psychometric performance of the tools was obtained directly from the original articles.

RESULT

16 tools were identified: five assessed PCC holistically and 11 assessed PCC within specific skill domains. Conceptual/theoretical underpinnings of the tools were generally unclear. Coverage of PCC domains varied markedly between tools. Most tools reported assessments of inter-rater reliability, internal consistency reliability and concurrent validity; however, intra-rater reliability, content and construct validity were rarely reported. Predictive and discriminant validity were not assessed.

CONCLUSION

Differences in scope, coverage and content of the tools likely reflect the complexity of PCC and lack of consensus in defining this concept. Although all may serve formative purposes, evidence supporting their use in summative evaluations is limited. Patients were not involved in the development of any tool, which seems intrinsically paradoxical given the aims of PCC. The tools may be useful for providing trainee feedback; however, rigorously tested and patient-derived tools are needed for high-stakes use.

Patient affect, physician liking for the patient, physician behavior, and patient reported outcomes: A modeling approach

OBJECTIVE

To determine associations between patient affect and physician liking of the patient, and their associations with physician behavior and patient-reported outcomes.

METHODS

Structural equation modeling based on coding of 497 videotaped hospital encounters, with questionnaires assessing pre-visit patient affect, post-visit patient affect and encounter evaluations, and physician liking of the patient, involving 71 physicians.

RESULTS

In first visits, patient reported outcomes were strongly correlated with physician behavior and less so with physician liking, while in later visits, patient reported outcomes were directly related to physician liking and not mediated by physician behavior. Physician liking predicted physician behavior, more for female physicians in first visits. Patient negative affect before the visit was negatively associated with male physicians' liking. When acquainted, both patient positive and negative affect were associated with physician liking.

CONCLUSION

Physician liking of the patient plays a dynamic role in a consultation, is influenced by patient pre-encounter affect, and influences physician behavior. The dynamics are different in first and later visits, and influenced by physician gender.

PRACTICE IMPLICATIONS

Physicians should be aware how patient affect influences their behavior, and administrators should take any prior relationship between patient and physician into account when evaluating patient reported outcomes.

Evaluation of Communication Skills Among Physicians: A Systematic Review of Existing Assessment Tools

OBJECTIVE

The importance of physician training in communication skills for motivating patients to adopt a healthy life-style and optimize clinical outcomes is increasingly recognized. This study inventoried and systematically reviewed the psychometric properties of, and the skills assessed by, existing assessment tools used to evaluate communication skills among physicians.

METHODS

This review was conducted in accordance with the PRISMA guidelines (PROSPERO: CRD42018091932). Four databases (PUBMED, EMBASE, PsychINFO, and SCOPUS) were searched up to December 2018, generating 3902 unique articles, which were screened by two authors. A total of 57 articles met the inclusion criteria and underwent full data extraction.

RESULTS

Forty-five different assessment tools were identified. Only 47% of the studies mentioned underlying theories or models for designing the tool. Fifteen communication skills were assessed across the tools, the five most prevalent were information giving (46%) or gathering (40%), eliciting patients' perspectives (44%), planning/goal setting (37%), and closing the session (32%). Most tools (93%) assessed communication skills using in-person role play exercises with standardized (61%) or real (32%) patients, but only 54% described the expertise of the raters who performed the evaluations. Overall, reporting of the psychometric properties of the assessment tools was poor-moderate (4.5 ± 1.3 out of 9).

CONCLUSIONS

Despite identifying several existing physician communication assessment tools, a high degree of heterogeneity between these tools, in terms of skills assessed and study quality, was observed, and most have been poorly validated. Research is needed to rigorously develop and validate accessible, convenient, "user-friendly," and easy to administer and score communication assessment tools.

Cross-cultural adaptation of the 4-Habits Coding Scheme into French to assess physician communication skills

Background

The Four Habits Coding Scheme (4-HCS) is a standardized instrument designed to assess physicians’ communication skills from an external rater’s perspective, based on video-recorded consultations.

Objective

To perform the cross-cultural adaptation of the 4-HCS into French and to assess its psychometric properties.

Methods

The 4-HCS was cross-culturally adapted by conducting forward and backward translations with independent translators, following international guidelines. Four raters rated 200 video-recorded medical student consultations with standardized patients, using the French version of the 4-HCS. We examined the internal consistency, factor structure, construct validity, and reliability of the 4-HCS.

Results

The mean overall 4-HCS score was 76.44 (standard deviation, 12.34), with no floor or ceiling effects across subscales. The median rating duration of rating was 8 min (range, 4–19). Cronbach’s alpha was 0.94 for the overall 4-HCS, ranging from 0.72 to 0.88 across subscales. In confirmatory factor analysis, goodness-of-fit statistics did not corroborate the hypothesized 4-habit structure. Exploratory factor analysis resulted in two dimensions, with the merging of three conceptually related habits into a single dimension and substantial cross-loading for 15 out of 23 items. Median average absolute-agreement intra-class correlation coefficient estimates were 0.74 (range, 0.68–0.84) and 0.85 (range, 0.76–0.91) for inter- and intra-rater reliability of habit subscales, respectively.

Conclusion

The French version of the 4-HCS demonstrates satisfactory internal consistency but requires the use of two independent raters to achieve acceptable reliability. The underlying factor structure of the original US version and cross-cultural adaptations of the 4-HCS deserve further investigation.

Customizable Curriculum to Enhance Resident Communication Skills

Communication remains challenging to teach and evaluate. We designed an online patient survey to assess anesthesia residents' communication skills from August 2014 to July 2015. In December 2014, we implemented a customized, simulation-based curriculum. We calculated an overall rating for each survey by averaging the ratings for the individual questions. Based on the Hodges-Lehmann 2-sample aligned rank-sum test, overall ratings, reported as the median (interquartile range) of residents' average overall ratings, differed significantly between the preintervention (3.86 [3.76-3.94]) and postintervention (3.91 [3.84-3.95]) periods (P = .025). Future studies should assess the intervention's effectiveness and generalizability.

Meaningful shared decision-making: complex process demanding cognitive and emotional skills

BACKGROUND

Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences.

METHODS

The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM.

RESULTS

We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills.

CONCLUSIONS

We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

The development of PROmunication: a training-tool for clinicians using patient-reported outcomes to promote patient-centred communication in clinical cancer settings

BACKGROUND

The value of using real-time patient-reported outcome (PRO) measures in cancer communication has gained attention both in the clinic and in research. Despite this, no internationally accepted guidelines or training programs for clinicians on how to engage in patient-centred communication based on PROs exist. Lack of training may complicate implementation and systematic use of PROs in the clinic. We aimed to develop a short and feasible manual and training session in PRO-based dialogue rooted in patient-centred communication, coined PROmunication.

METHODS

PROmunication was implemented in two studies using PROs in different clinical cancer settings. We interviewed clinicians twice during the development phase. First, adopting a clinical perspective, they provided ideas for content, length and structure of the training session and the manual. Second, they approved the draft of the manual with minor adjustments on how to document clinician-patient communication. The final version of the PROmunication tool was built on clinicians' input, theory on patient-centred communication, a literature review, and didactic considerations.

RESULTS

The one-page manual gave clinicians a brief and clear overview of how to prepare for, undergo and document a PRO-based consultation. Illustrations and verbal phrases were offered to operationalize and facilitate patient-centred communication. The training session included elements like evidence-based knowledge about the rationale, benefits and challenges of using PROs and comprised theory, experimental training and instructions for the use of the manual in clinical practice. Ad hoc training and feedback in the clinic followed the training session.

CONCLUSIONS

This paper presents the development of a short, theory-driven manual and training session intended to support and engage clinicians in PRO-based dialogue leading to patient-centred communication. Further testing of the tool is necessary and adjustments may be required if the PROmunication tool should be applied in other clinical settings were patients are seen regularly. An evaluation of the tool is planned to be performed in future studies. Training in PROmunication may further systematic and consistent use of PRO data in the consultation, leading to patient-centred consultations and increased patient involvement.

The Community Pharmacist: Perceived Barriers and Patient-Centered Care Communication

Nowadays, the classic perception of the pharmaceutical profession in community pharmacies is facing worldwide extinction due to many factors. Among the numerous factors, online pharmacies are increasingly gaining ground thanks to their ability to facilitate customer demand. Nevertheless, they are endangering “face-to-face” contact, affecting the building of customer loyalty based on direct “human” interaction, and consequently reducing pharmacists to mere commercial figures. Patient-centered care communication is emphasized as the essential element to build a solid and appropriate interpersonal relationship with the patient, to make the consultancy process effective, and to strengthen the pharmacist’s professionalism in community pharmacy. This paper presents a narrative review of existing literature with the first aim of pinpointing the factors affecting pharmacy professional practice, and secondly, of how to improve patient-centered communication skills. A more widespread introduction of in-depth study and practice of behavioral, communication, educational, and sociological methodologies and techniques would allow for the development of more effective skills used for providing an efficient consultancy service, improving the capacity of future professionals to approach public relations.

Single-Day Simulation-Based Training Improves Communication and Psychiatric Skills of Medical Students

BACKGROUND

Use of standardized (or simulated) patients (SP) is considered an effective teaching method for improving clinical and communication skills. This study assesses the effect of a single-day simulated patients (SP)-based training course on medical students' communication and basic skills in clinical psychiatry during their psychiatry rotation in a university-affiliated tertiary medical center.

METHODS

Forty-two third-year medical students participated. Communication and basic skills in clinical psychiatry were evaluated by a modified Four Habits Coding Scale (4HCS) and the psychiatric interview coding scale before and after SP training. An actual patient interview by the students 1 week after the training was evaluated by an attending psychiatrist blinded to the student's score during the SP-based training. Self-report questionnaires on satisfaction from the training and its impact on their self-confidence were administered at the end of training.

FINDINGS

The mean pre-training 4HCS score of 33.9 increased to 52.3 post-training (p < 0.001). The mean psychiatric interview coding scale score increased from 4.33 to 5.36 (p = 0.002). The self-report questionnaire yielded a mean score of 4.21 on a 1-5 Likert scale, implying high levels of satisfaction and self-confidence.

CONCLUSIONS

A single SP-based training course of medical students sufficed to improve clinical and communication skills in psychiatric settings and enhance their subjective perception of those skills.

[Questionnaires of person centered care in primary care. A systematic review]

Objetivo

Pese a la importancia de la «atención centrada en la persona» (ACP), hay evidentes limitaciones para valorarla y medirla, debidas probablemente a la dificultad para definirla. El objetivo del estudio fue identificar herramientas validadas que midiesen la ACP o algunos de sus aspectos en el ámbito de la atención primaria.

Diseño

Revisión sistemática.

Fuentes de datos

MEDLINE, Embase, Cochrane, PSYCinfo, IME-Biomedicina, LILACS y TESEO hasta del 31 de mayo de 2018.

Selección de estudios

Los criterios de inclusión fueron: a) estudios de validación de cuestionarios, revisiones sistemáticas sobre estudios de validación u otros estudios descriptivos, b) realizados todos ellos en el ámbito de la atención primaria y c) que midieran aspectos de la ACP en profesionales y/o pacientes. Dos investigadores revisaron de forma independiente los artículos y sus discrepancias fueron resueltas por un tercer investigador.

Extracción de datos

Se recogieron datos sobre los aspectos de la ACP medidos, población a la que se dirige, tipo de cuestionario, y datos sobre validez y fiabilidad.

Resultados

Se localizaron 1.415 artículos a los que se añadieron 54 referencias adicionales identificadas a través de referencias de los artículos de la revisión sistemática. Tras una depuración finalmente fueron 75 los artículos que cumplieron todos los criterios y 39 las herramientas identificadas y clasificadas según las dimensiones analizadas.

Conclusiones

Debido a la dificultad de medir la ACP en su conjunto, la mayor parte de los artículos hacen referencia solo a alguno de sus aspectos o dimensiones, predominando la perspectiva del paciente frente a la del profesional. Estas herramientas son, no obstante, un importante punto de partida para futuros cuestionarios que intenten valorar de forma integral la ACP.

Effectiveness of a Comprehensive Health Literacy Consultation Skills Training for Undergraduate Medical Students: A Randomized Controlled Trial

Comprehensible communication by itself is not sufficient to overcome health literacy related problems. Future doctors need a larger scope of capacities in order to strengthen a patient’s autonomy, participation, and self-management abilities. To date, such comprehensive training-interventions are rarely embedded in curricula, nor systematically evaluated. We assessed whether comprehensive training increased these health literacy competencies, in a randomized controlled trial (RCT), with a waiting list condition. Participants were international undergraduate medical students of a Dutch medical faculty (intervention: 39; control: 40). The 11-h-training-intervention encompassed a health literacy lecture and five interactive small-group sessions to practise gathering information and providing comprehensible information, shared decision-making, and enabling of self-management using role-play and videotaped conversations. We assessed self-reported competencies (knowledge and awareness of health literacy, attitude, self-efficacy, and ability to use patient-centred communication techniques) at baseline, after a five and ten-week follow-up. We compared students’ competencies using multi-level analysis, adjusted for baseline. As validation, we evaluated demonstrated skills in videotaped consultations for a subsample. The group of students who received the training intervention reported significantly greater health literacy competencies, which persisted up to five weeks afterwards. Increase was greatest for providing comprehensible information (B: 1.50; 95% confidence interval, CI 1.15 to 1.84), shared decision-making (B: 1.08; 95% CI 0.60 to 1.55), and self-management (B: 1.21; 95% CI 0.61 to 1.80). Effects regarding demonstrated skills confirmed self-rated competency improvement. This training enhanced a larger scope of health literacy competences and was well received by medical students. Implementation and further evaluation of this training in education and clinical practice can support sustainable health literacy capacity building of future doctors and contribute to better patient empowerment and outcomes of consultations.

Introducing the System for Observing Medical Alliances (SOMA): A Tool for Studying Concordance in Patient-Physician Relationships

We developed the System for Observing Medical Alliances (SOMA) to study relationships between medical providers and patients with medically unexplained symptoms (MUS). Based on literature in health psychology, medicine, and the psychotherapeutic alliance, the SOMA operationalizes three medical alliance dimensions: Engagement in the Consultation Process, Trust in the Provider, and Concordance of Illness Beliefs and Treatment Recommendations. Specific behavioral indicators, tallied as observed by trained judges, are used as the basis for rating each dimension. In a sample of 33 medical consultations with veterans who had MUS, interrater reliabilities ranged from .79 to .94. Notably, the other dimension ratings accounted for 40% of the variability in Concordance, with Trust in the Provider contributing unique variance. In addition to research, psychologists in integrated health settings can use the SOMA to consult and train medical providers on communication skills that enhance concordance.

Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training

Since publication of Unequal Treatment by the Institute of Medicine in 2003, there has been a growing recognition of the role of provider implicit racial bias in patient care. Provider implicit racial bias has been consistently negatively associated with both care satisfaction and provider trust among racial/ethnic minority patients. This suggests provider implicit racial bias likely manifests through their communication behaviors, which in turn may offer a means of addressing racial disparities in healthcare and ultimately in health. However, identifying provider communication behaviors that mediate the links between provider implicit racial bias and patient outcomes is challenging. In this paper, we argue that identifying these provider communication behaviors requires (1) taking into account findings from social psychology research of implicit racial bias and (2) incorporating the perspectives of racial/ethnic minority patients into patient-provider communication research. We discuss the utility of mixed methods research designs as a framework for resolving this complex scientific question. Research that draws on social psychology research of implicit racial bias and incorporates the racial/ethnic minority patient perspectives can inform the development of communication skills training programs for students and residents in various healthcare fields. Such programs are one element of a broader effort to reduce racial/ethnic disparities in healthcare.