The roles of companions in geriatric patient–interdisciplinary oncology team interactions

Healthcare provider assessments of caregiver communication behaviors during gynecologic Cancer treatment appointments

Objective

Caregivers often accompany patients to cancer-related medical appointments. Limited research exists on healthcare providers' (HCPs) evaluation of how caregiver communication influences interactions between healthcare providers and patients, particularly during gynecologic treatment visits. HCPs may perceive caregiver communication as helpful or challenging, and these triadic interactions may influence patient outcomes.

Methods

Interviews with ten cancer specialist HCPs (medical assistants/technicians, nurse practitioners/registered nurses, oncologists) addressed experiences interacting with patients and caregivers.

Results

Analyses revealed two themes concerning helpful communication: caregivers managing information and managing patient emotions. Three challenging themes include caregiver communication unsettling healthcare interactions, caregiver presence limiting patient communication, and caregiver engagement challenges.

Conclusion

HCPs evaluate caregiver communication as helpful and challenging. Findings suggest benefits of communication training for gynecologic cancer patients such as requesting privacy when interacting with HCPs, for caregivers to promote awareness of effects of their behavior, and for HCPs to help manage triadic interactions while supporting patient needs.

Innovation

HCP assessment of caregiver communication during gynecologic treatment visits offers unique insights regarding helpful and challenging behaviors contributing to implications for patient care and well-being. Applications may extend to other triadic interactions and cancer settings.

Adult Children as Companions in Geriatric Consultations: An Interpersonal Perspective from China

Despite the prevalence of accompanied medical visits all over the world, most literature on triadic medical communication shares an Anglo-American background; little is known about non-dyadic medical interactions in Asian societies such as China. This article explores triadic interactions in Chinese geriatric outpatient consultations, focusing on the interpersonal dynamics between doctors, older patients, and the adult children who accompany them throughout the consultation. From an interpersonal pragmatic approach, we conduct a conversation analysis of the transcription of 36 audio-recorded encounters. Our findings demonstrate three patterns of companions' communicative actions during geriatric visits: enhancing rapport, mitigating face threats, and adding tension. These patterns reveal the multi-faceted nature of adult children's participation in geriatric care, highlighting their capacity to simultaneously facilitate a positive interpersonal atmosphere and pose challenges to their older parents' face. Delving into the nuanced mechanisms through which these patterns of engagement are triggered, warranted, and negotiated by all participants in the local contingencies, we further illuminate the institutional and cultural context that informs companions' intervention. Our analysis demonstrates that the influence of Chinese familial values and institutional constraints in Chinese tertiary hospitals, including restricted time and limited privacy within the clinic room, have shaped the interpersonal dynamic in triadic geriatric care. Our research calls for the development of nuanced and targeted interventions and training for healthcare professionals and companions of older patients alike.

Geriatric Communication Skills Training Program for Oncology Healthcare Providers: a Secondary Analysis of Patient and Caregiver Outcomes

Geriatric cancer patients and their caregivers have unique needs that make it difficult for their healthcare providers (HCPs) to effectively communicate with them. As ineffective communication can lead to negative health outcomes, it is important that oncology HCPs receive specialized training on communication with older adult patients and their caregivers. We conducted a small pilot study examining audio recordings of clinical encounters between HCPs and older adult cancer patients/caregivers and questionnaires completed by the patients and their caregivers before and after the HCPs participated in a geriatric communication skills training program. Eleven HCPs completed the 6-h Geriatric Comskil Training. Two clinic consultations with unique geriatric patients (n = 44) and their caregivers (n = 29) were recorded before and after training and coded for HCPs' use of communication skills. Patients and caregivers also completed surveys measuring their satisfaction with HCP communication and perceived empathy. Analysis of the audio recordings revealed that HCPs did not increase their use of communication skills after training. Although our sample was too small to detect statistical significance, measures of effect size showed trending improvements in patients' and caregivers' perceptions of HCPs' empathy and satisfaction with their communication after training. Our findings build on previous studies evaluating the feasibility and effectiveness of the Geriatric Comskil Training in real world setting and indicate that the training may have improved HCPs' communication with older adult patients and their caregivers even if their use of their observable communication skills did not change.

Companion responses to diagnosis in Chinese outpatient clinical interaction

Patients regularly attend clinical consultations with companions in Chinese outpatient clinics. Despite companions' significant influence on clinical consultations, how companions respond to diagnosis and their contributions to the activity of diagnosis in Chinese outpatient clinical interaction remain under-researched. The present study, by adopting the method of conversation analysis, investigated clinicians' diagnostic deliveries and companions' subsequent responses in Chinese outpatient clinical interaction. The data for this study consisted of 79 video recordings of clinical consultations in the Chinese orthopedic outpatient clinic, approximately lasting 12 h and involving three male clinicians, 79 patients (37 male/42 female), and 91 companions (51 male/40 female). Three basic categories of companion responses to diagnosis were identified: minimal verbal responses, embodied responses, and extended responses. It was demonstrated that these distinct responses allowed companions to challenge clinicians' medical authority in the activity of diagnosis by delivering their own diagnostic judgments, resisting clinicians' diagnoses, and orienting to clinicians' accounts for their diagnostic statements and reasoning, thus displaying companion agency in the Chinese outpatient clinical decision-making and indicating a transition from a paternalistic model to a family-centered model of the doctor-patient relationship in the Chinese orthopedic outpatient interaction. This study furthers current knowledge of companion involvement across healthcare contexts and contributes to raising clinicians' awareness of the significance of companions' contributions in Chinese outpatient clinical interaction.

Partner presence in clinical conversations about sexual health: Breast cancer survivors', partners', and providers' perspectives of triadic interactions

PURPOSE

Breast cancer survivors' (BCSs') sexual health (SH) clinical conversations are rarely studied from a dyadic perspective let alone from a triadic perspective. Using a triadic approach, we evaluated BCSs' comfort discussing SH with partners present and identified factors that can contribute to their comfort level.

DESIGN

Qualitative approach using in-depth interviews.

PARTICIPANTS

93 BCSs, partners, and providers involved in BCS care.

METHODS

In-depth interviews with BCSs, partners, and providers explored triadic perspectives to understand factors informing BCSs' comfort level. Thematic analysis was used to analyze data.

FINDINGS

Four themes characterize potential benefits of partner presence: 1) partner facilitates information exchange, 2) partner realizes BCS's SH concerns are "a real thing," 3) partner better understands SH challenges, and 4) partner presence encourages relational communication about SH. Five themes illustrate potential complications of partner presence: 1) partner feels/becomes embarrassed, 2) partner is/becomes defensive, 3) partner presence constrains BCS's agency in clinical conversations, 4) partner presence threatens partner's view of BCS as a sexual being, and 5) partner presence increases partner burden.

IMPLICATIONS FOR PSYCHOSOCIAL ONCOLOGY

Providers should (1) initiate conversations about BCS comfort with partner presence, (2) be aware of the interaction between BCS primary and secondary goals, (3) consider how BCS/partner goal conflicts obstruct BCS agency and sexual/relational health, and (4) offer opportunities to clarify goals and expectations, and coordinate therapeutic options.

Communicating with Companions. The Impact of Companion Empowerment and Companion Literacy on the Well-being of Elderly Patients

The complexity of the current healthcare ecosystem justifies the convenience of targeting patients' companions in health communication strategies. Designing successful interventions requires taking into account which keys should be pressed in companions in order to generate positive outcomes in the accompanied patients. In particular, this paper explores how companion health empowerment and companion health literacy affect the well-being of chronically-ill elderly patients. Data for this research come from a cross-sectional quantitative study including 1,814 individuals (907 chronically-ill elderly patients and their 907 companions). Data were collected through two online questionnaires, one for patients and one for companions. The findings suggest that companion health empowerment is defined by the dimensions information search empowerment and knowledge development and decision participation empowerment. Furthermore, the distinction between functional, interactive and critical health literacy has revealed to be useful for comprehending companion health literacy. A structural equation model shows that critical health literacy sets the threshold above which companion health literacy improves accompanied patient well-being, even more so when it is backed up by companion information search empowerment and by companion knowledge development and decision participation empowerment.

Japanese women's reasons for accompaniment status to hereditary breast and ovarian cancer-focused genetic counseling

Genetic counselors routinely assess and understand clients' needs at the beginning of a session. Attending a genetic counseling session with or without companions is an objective sign that genetic counselors can easily notice. This study focused on clients' reasons for their accompaniment status for genetic counseling, which we categorize into attending with or without a companion(s). A questionnaire survey and interviews were conducted using snowball sampling, starting with the chief executive officer (CEO) of the Japanese hereditary breast and ovarian cancer (HBOC) support group. Of 32 participants, 19 continued with an in-depth interview after answering the questionnaire. Five themes were identified from the interview: (1) personal confidence, (2) decision-making style, (3) family members' habits and time availability, (4) considerations and conflicts with family members, and (5) healthcare provider's suggestion. Our data suggested that the clients expected their companion(s) to play certain roles. This indicates that the reasons of accompaniment status will be helpful for genetic counselors to understand both clients' and their families' motivations, personalities, habits, and psychosocial backgrounds. In a high-context culture such as that of Japan, accompaniment status may be a helpful sign to understand clients' true worries. In addition, some companions may be future clients in genetic counseling, due to the genetic nature of the disease. In conclusion, our study indicated that it is important for genetic counselors to record accompaniment status before the initial genetic counseling and to pay attention to its reasons at the beginning of the session, which may lead them to understand the client's psychosocial background to facilitate better client-centered genetic counseling.

Being in Place: A Multimodal Analysis of the Contribution of the Patient's Companion to "First Time" Oncological Visits

Companions to medical visits have been alternatively viewed as members who “support” or “inhibit” and “interfere” with the doctor-patient interaction. One way of looking at the companions' contribution to medical visits is by coding roles or functions of their communicative behavior. Our paper aims at reconsidering these findings and analyzing how the companion participation is a local and sequential accomplishment, changing from time to time in the consultation. The paper relies upon an overall collection of 58 videorecordings of first oncological visits. Visits were conducted in two different hospitals, one of which a University hospital, and by different oncologists, including both senior professionals and (in the second setting) medical students in oncology. Visits were fully transcribed according to the Jeffersonian conventions and authors examined the transcripts and video according to the methodology of Conversation Analysis. The aim of the paper focused on how patient's companions orient and contribute to the accomplishment of the different aims and activities at different stages of the visit as an institutional speech event. The multimodal analysis of turns and actions (such as, gaze shifts, prosodic modulation, bodily arrangements), and the close examination of the sequential and temporal arrangements of companions' and their co-participants' turns revealed that companions finely attune to the multiparty framework of the encounter and the institutional constraints that govern the oncological first visit. Overall, results show two relevant features: that companions act as to preserve the doctor-patient interaction and to maintain the patient as the most responsible and legitimate agent in the interaction; that companions' contributions are relevant to the activities that sequentially unfold at different stages in the consultation (e.g., history taking, problem presentation, treatment recommendation etc.). The study complements earlier findings on the companion's roles, showing how these are highly mobile, multimodal and multiparty accomplishments, and they are tied to the specific contingencies of the visit. The results solicit to consider the value of multimodal analysis in understanding the complexity of multiparty communication in medical setting, and make it usable also in medical education.

Decoding the Role of Companions in Supporting the Health Communication of Older African-American Men With Cancer

The objective of this study was to systematically characterize the content and patterning of companion’s communicative behavior during oncology consultations for older African-American male patients. Companions and family members often play an important role in patient-centered communication for patients with cancer. Despite their disproportionate cancer burden, little is known about how companions facilitate patient-provider communication for older African-American men with cancer. This study represents a secondary qualitative analysis of 14 video-recorded doctor patient-companion medical visits for African-American male patients with cancer. Videos were captured with consent and institutional review board approval at a Midwest comprehensive cancer center between 2002 and 2006. These medical visits were transcribed, deidentified, and analyzed for the content, frequency, co-occurrence, and thematic clustering of companions’ active participation behaviors during the interaction. Results were well aligned with existing studies on accompanied oncology visits. Patients were on average, 60.14 years old and all but one of the 16 companions was a woman. A total 782 companion behaviors were coded across 14 medical interactions. While companions communicated directly with providers (eg, asking questions, providing medical history) and directly with patients (eg, clarifying information, giving advice), there was a lack of triadic communication. This study clarifies the role of mainly spousal companions as important intermediaries in the patient-provider communication dynamic for older African-American men with cancer.

Patient companions in the Turkish healthcare system: the role, expectations and problems

The purpose of this study was to determine the roles, expectations and problems of patient companions and to develop solutions to the difficulties encountered by the nurses, patients and their companions. A qualitative approach with semi-structured face-to-face interviews was used during May and June 2014 to collect data. A convenience sample of participants was selected from the nurses, patients and their companions. Content analysis was used for the data. The results of this study revealed that the need for companions is important to the current Turkish healthcare system, but it has many drawbacks. As companions are witness to a patient's declining health and family, social and financial problems, their role should be to support their patients emotionally or socially, but they should not perform medical tasks. Therefore, the agencies responsible for managing the use of patient companions should regularly review its function by communicating often with the patients and their caregivers. Open communication between patient companions and all those responsible for patient care could improve the present difficulties which exist.

Specialty-Specific Values Affecting the Management of Symptomatic Uterine Fibroids

PURPOSE

To better understand why interventional radiologists and gynecologists differ in their approaches to symptomatic uterine fibroids.

METHODS

Conversational interviews were conducted with 26 interventional radiologists and gynecologists about their professional roles, clinical reasoning, and practice variation within and outside their specialty. Interview transcripts were systematically analyzed using NVivo 10 software (QSR International, Burlington, Massachusetts) according to grounded theory and content analysis to identify key themes and compare themes across specialties and practice environments. Data were supplemented with retrospective analysis of 7,659 patients with symptomatic uterine fibroids treated at a large academic center over 11 years.

RESULTS

Interventional radiologists' shares of symptomatic uterine fibroid treatment and endovascular stent treatments have remained constant (P > .05) for 11 y at a large medical center, whereas minimally invasive gynecologic fibroid treatments and the percentage of interventional radiology (IR) procedures reimbursed by Medicaid/Medicare have increased significantly (r > .90, P < .001 and r = .93, P < .001). Interventional radiologists and gynecologists shared a commitment to do "the right thing" for patients, but each group possessed distinct professional values affecting how they viewed medical evidence, outcomes, and their colleagues. When differences were apparent and concerning, physicians tended to suspect ulterior motives not in patients' best interests.

CONCLUSIONS

Interventional radiologists and gynecologists demonstrated wide-ranging perspectives regarding their role in caring for patients with symptomatic uterine fibroids. To promote genuine collaboration and adoption of shared goals, stakeholders should seek and promote a deeper understanding of specialty-specific values and culture.

Social support plays a role in the attitude that people have towards taking an active role in medical decision-making

BACKGROUND

There is a growing emphasis towards including patients in medical decision-making. However, not all patients are actively involved in such decisions. Research has so far focused mainly on the influence of patient characteristics on preferences for active involvement. However, it can be argued that a patient's social context has to be taken into account as well, because social norms and resources affect behaviour. This study aims to examine the role of social resources, in the form of the availability of informational and emotional support, on the attitude towards taking an active role in medical decision-making.

METHODS

A questionnaire was sent to members of the Dutch Health Care Consumer Panel (response 70 %; n = 1300) in June 2013. A regression model was then used to estimate the relation between medical and lay informational support and emotional support and the attitude towards taking an active role in medical decision-making.

RESULTS

Availability of emotional support is positively related to the attitude towards taking an active role in medical decision-making only in people with a low level of education, not in persons with a middle and high level of education. The latter have a more positive attitude towards taking an active role in medical decision-making, irrespective of the level of emotional support available. People with better access to medical informational support have a more positive attitude towards taking an active role in medical decision-making; but no significant association was found for lay informational support.

CONCLUSIONS

This study shows that social resources are associated with the attitude towards taking an active role in medical decision-making. Strategies aimed at increasing patient involvement have to address this.

Physicians' professional identities: a roadmap to understanding "value" in cardiovascular imaging

BACKGROUND

Quality improvement efforts in cardiovascular imaging have been challenged by limited adoption of initiatives and policies. In order to better understand this limitation and inform future efforts, the range clinical values related to cardiovascular imaging at a large academic hospital was characterized.

MATERIALS AND METHODS

15 Northwestern Medicine physicians from internal medicine, cardiology, emergency medicine, cardiac/vascular surgery, and radiology were interviewed about their use of cardiovascular imaging and imaging guidelines. Interview transcripts were systemically analyzed according to constructivist grounded theory and combined with 56 previous interviews with interventional radiologists, interventional cardiologists, gynecologists, and vascular surgeons to develop a model describing specialty-specific values. This model was applied to the 15 pilot interviews focused on cardiovascular imaging, highlighting specialty specific differences in values and practice patterns. Transcripts were also reviewed independently by a cardiologist and 2 radiologists followed by a group discussion to assess reproducibility and achieve a consensus regarding the results.

RESULTS

Differences in perceived value of cardiovascular imaging and use of guidelines among physicians were well explained by three value-associated identity categories (managers, diagnosticians, and fixers) that were further differentiated along three axes (broad v. focused-thinkers, complex v. definitive-answer-seekers, and public visibility).

CONCLUSIONS

Quality improvement in cardiovascular imaging may be limited by a lack of understanding and incorporation of the complexity of medical culture into ongoing initiatives. Both individually and during policy development, it is important to first understand the complexity of stakeholders' diverse perceptions of "value," "quality," and "appropriateness."

Verbal Social Support for Newly Diagnosed Breast Cancer Patients during Surgical Decision-Making Visits

This study reports an analysis of verbal social support strategies directed by surgeons and patients' companions to breast cancer patients using the social support behavior code (SSBC). Additionally, the influence of companions on the provision of social support is examined. Forty-six videotapes of appointments where treatment regimens were being decided were analyzed. Results demonstrated that the majority of units spoken by surgeons were coded as verbal social support, primarily in the form of informational social support. Companions' social support was lower (relative to surgeons) in nearly every category of social support assessed. Patients who brought companions were found to receive more network social support from surgeons. Overall, these results point to low emotional support from surgeons and companions for patients during these appointments, which indicates a need for modifications in empathy training for medical providers.

"This Is a Partnership Between All of Us": Audiologists' Perceptions of Family Member Involvement in Hearing Rehabilitation

PURPOSE

The purpose of the study was to explore the perceptions of audiologists about the role of family members in hearing rehabilitation for older adults with hearing impairment (HI), the influence of family member involvement on outcomes, and factors affecting family members' involvement.

METHOD

A qualitative descriptive research study was undertaken. Using a purposeful sampling strategy, 9 audiologists were recruited. Audiologists participated in individual semistructured interviews. Interview transcripts were analyzed using thematic analysis, and a process of member checking was used to enhance the trustworthiness of findings reported.

RESULTS

The importance of promoting partnership emerged as the overarching theme. Audiologists valued promoting partnership with family members so that a shared understanding could be established, family members could be active participants with distinct roles in hearing rehabilitation, and the rehabilitation outcomes for the person with HI could be improved. Audiologists generally reported low attendance rates of family members to appointments and identified 5 major factors affecting family participation.

CONCLUSIONS

There is growing recognition among audiologists of the importance of promoting partnership with family members during the hearing rehabilitation process. More research is needed to develop and evaluate a family-centered model of hearing health care that considers the service-level barriers identified by audiologists in the present study.

Missed opportunity? Caregiver participation in the clinical encounter. A videographic analysis

OBJECTIVE

Although the assistance of caregivers is critical to patients undertaking self-care, little is known about their participation in visits and involvement in decision making. We sought to examine this caregiver participation in shared decision making through videographic analysis.

METHODS

We identified video recordings from outpatient visits in which a healthcare professional, patient, and caregiver participated, drawn from five practice-based randomized trials testing the efficacy of decision aids vs. usual care. Two reviewers, working independently, coded videos to explore caregiver engagement in the clinical encounter, clinician facilitation of that engagement, and the influence of decision aids in the engagement process.

RESULTS

In most of the 37 videos coded, caregivers' participation was self-triggered. We saw no impact of the use of decision aids on caregiver participation. Clinicians did not address the caregivers' preferred level of involvement in decision making in any of the video recorded encounters analyzed.

CONCLUSION

In this analysis, most clinicians did not engage caregivers in outpatient visits for chronic care. While the use of decision aids improves communication between patient and clinician, they do not appear to affect caregiver involvement during consultations.

PRACTICE IMPLICATIONS

Research on the comparative effectiveness of ways to engage caregivers to optimize patient-important outcomes, including enhancing the shared decision making process is necessary.

Using a Family-Centered Care Approach in Audiologic Rehabilitation for Adults with Hearing Impairment

Hearing problems are the most common communication disability in older people. The wide-ranging impact of hearing impairment means that not only does the person with hearing impairment experience the consequences, but also his or her family members. This impact on family members is referred to as a “third-party disability” (World Health Organization, 2001). Health professionals and researchers worldwide suggest that professionals can increase effectiveness of health care if they take into account the needs of the person with hearing impairment and the needs of family members (Dunst, 2002). This article discusses the important role of family-centered care in audiologic rehabilitation for adults with hearing impairment. Strategies for increased inclusion of family members in the rehabilitation process are proposed, with concepts from the field of psychology applied to audiologic rehabilitation.

Physician-patient-companion communication and decision-making: a systematic review of triadic medical consultations

OBJECTIVE

To systematically review quantitative and qualitative studies exploring physician-adult patient-adult companion (triadic) communication and/or decision-making within all medical encounters.

METHODS

Studies were identified via database searches and reference lists. One author assessed eligibility of studies, verified by two co-authors. Data were extracted by one author and cross-checked for accuracy. Two authors assessed the quality of included articles using standardized criteria.

RESULTS

Of the 8409 titles identified, 52 studies were included. Summary statements and tables were developed for each of five identified themes. Results indicated companions regularly attended consultations, were frequently perceived as helpful, and assumed a variety of roles. However, their involvement often raised challenges. Patients with increased need were more often accompanied. Some companion behaviours were felt to be more helpful (e.g. informational support) and less helpful (e.g. dominating/demanding behaviours), and preferences for involvement varied widely.

CONCLUSION

Triadic communication in medical encounters can be helpful but challenging. Based on analysis of included studies, preliminary strategies for health professionals are proposed.

PRACTICE IMPLICATIONS

Preliminary strategies for health professionals include (i) encourage/involve companions, (ii) highlight helpful companion behaviours, (iii) clarify and agree upon role preferences of patient/companions. Future studies should develop and evaluate specific strategies for optimizing triadic consultations.

The role of companions in aiding older cancer patients to recall medical information

OBJECTIVES

This study investigates information recall in unaccompanied and accompanied older cancer patients and their companions.

METHODS

One hundred cancer patients (aged > or = 65 years) and 71 companions completed a recall questionnaire after a nursing consultation preceding chemotherapy treatment. Recall was checked against the actual communication in video-recordings of the consultations. Patients also completed measures of anxiety and memory-related beliefs.

RESULTS

Findings revealed that recall in patient and companion couples together was higher than their separate recall scores (both proportional and absolute), indicating that they supplement each other. Proportionally, unaccompanied patients recalled almost as much as couples, whereas their absolute recall scores were lower. Younger age and higher education were associated with higher recall in both patients and companions. Patients' memory-related beliefs predicted the recall scores of their companions rather than their own recall score. When patients reported memory complaints, recall was lower in their companion. In contrast, when patients indicated that they did not understand all information, their companion recalled more.

CONCLUSIONS

These findings indicate that, although an interrelationship exists between recall in patients and their companions, accompanied patients are likely to benefit from the extra information that their companions remember.