Communication skills and psychological training in oncology

To Address Burnout in Oncology, We Must Look to Teams: Reflections on an Organizational Science Approach

PURPOSE

Despite decades of effort, burnout among physicians remains elevated compared with that of other working populations, and it yields catastrophic consequences, including medical errors and physician suicide. Burnout leaves oncologists feeling like they are alone, but this is not the case-it affects everyone. To effectively address burnout, it is not enough to look only at oncologists; instead, we must include all those involved in the delivery of cancer care. With this aim, we present an overview of the organizational science strategies and initial evidence for the value of a comprehensive, team-focused approach to addressing oncology provider burnout.

METHODS

We describe the development of a team-focused burnout intervention approach, implemented for oncology providers, which focuses on the importance of encouraging communication and psychological safety to reduce feelings of isolation and fragmentation. We discuss the initial findings from 1 such team-based initiative currently underway within an academic medical center, presenting data from 409 cancer care providers embedded in 30 oncology units participating in this intervention approach.

RESULTS

Preliminary results demonstrate that units that integrated a team-focused intervention for burnout reported significantly higher levels of teamwork and lower levels of burnout. We also describe lessons learned and recommendations for implementing this type of intervention on the basis of best practices from organizational science.

CONCLUSION

This approach can positively affect the delivery of cancer care, interprofessional relationships among oncology staff, and the well-being of both patients and providers. Treating physician burnout alone will treat 1 symptom of the overall issue of burnout in oncology. As burnout pulls oncology clinicians apart, our solution must be to bring them together.

French adaptation of the PO-Bado short form, an interview-based expert rating scale for distress screening

OBJECTIVE

Basic Documentation for Psycho-Oncology (PO-Bado) is a hetero-assessment and psychosocial burden documentation tool for cancer patient caregivers (across all types and stages). Recently, the psychometric properties of the standard 12-item version of PO-Bado were published. However, the standard version is relatively time-consuming for the caregivers. Here, we developed and examined psychometric properties of a French short-form of PO-Bado (PO-Bado-FSF) with seven items derived from the validated standard version.

METHODS

One hundred and twenty-one cancer patients (M age = 58.4 years, SD = 13.9 years; 68.6% were women) participated in this study during a supportive care following the first diagnosis of cancer or a relapse. All patients completed the Hospital Anxiety and Depression Scale (HADS) and General Health Questionnaire (GHQ), in addition to the PO-Bado-FSF.

RESULTS

PO-Bado-FSF scores exhibit sound psychometric qualities such as internal consistency, test-retest reliability, inter-rater reliability, and scalability (i.e. Mokken's scalability coefficients); all items loaded significantly on the single CFA factor and yielded coefficients 0.40 or higher.

CONCLUSIONS

The results of this study highlight the value of using PO-Bado-FSF to identify psychological distress in cancer patients in research and practice. PO-Bado-FSF presents good psychometric properties and is less time-consuming than the standard version.

Effect of Breaking Bad News on Patients’ Perceptions of Doctors

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the ‘breaking bad news’ event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings ‘most helpful’ and ‘less helpful’, and completed standardized psychological screening questionnaires.

In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as ‘most helpful’ when breaking bad news, 8 were general practitioners; of the 7 categorized as ‘less helpful’ all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners.

Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

A clinical review of communication training for haematologists and haemato-oncologists: a case of art versus science

The art of communication at times seems at odds with the science of medicine. Poor communication is associated with risks for patient and physician. Communication skills are highly relevant for haematologists and are associated with increased physician and patient satisfaction, positive psychosocial outcomes and possible health outcomes. Medical communication training has recently become widespread but is largely restricted to junior medical professionals. In haematology, the proliferation of high quality communication skills is low and there are few interventions catering for the required skillset. A review identified five applicable interventions for haematologists. There is variation in intervention length and structure, and most studies measure targeted skill fidelity rather than patient outcomes. Work on motivation and empowerment holds potential for haematological conditions, but is largely absent from care. This review highlights the need for new interventions for haematologists which focus on producing and maintaining positive patient outcomes.

The Effect of Empathy Training on the Empathic Skills of Nurses

Background

The profound impact of empathy training on quality nursing care has been recognized. Studies have shown that there has been little improvement in nurses’ communication skills, and that they should work to enhance this area. Relevant training will lead to an improvement in nurses’ empathic skills, which in turn, will enable them to understand their patients better, establish positive interpersonal relationships with them, and boost their professional satisfaction.

Objectives

To reveal the effect of empathy training on the empathic skills of nurses.

Patients and Methods

This study was conducted as an experimental design. The research sample consisted of 48 nurses working at the pediatric clinics of Farabi hospital of Karadeniz Technical University in Turkey (N = 83). Two groups, an experimental group (group 1) and a control group (group 2) were determined after questionnaires were supplied to all nurses in the study sample. At first, it was intended to select these groups using a random method. However, since this may have meant that the experimental and control groups were formed from nurses working in the same service, the two groups were selected from different services to avoid possible interaction between them. The nurses in the Group 1 were provided with empathy training through group and creative drama techniques. Pre-tests and post-tests were conducted on both groups. Data was collected via a questionnaire designed around the topic “empathic skill scale-ESS”, developed by Dokmen. The Kolmogorov Smirnov test was employed to assess whether the measurable data was suitable for normal distribution. Data was presented as numbers and percentage distributions, as mean ± standard deviation and Chi-square, and as student t tests and paired t tests. The level of significance was accepted as P < 0.05.

Results

The nurses in the experimental group had a mean score of 146.7 ± 38.8 and 169.5 ± 22.1 in the ESS pre-test and post-test, respectively. Although the nurses in the control group had a pre-test mean score of 133.7 ± 37.1, which increased to 135.1 ± 51.7 after the training, no statistically significant difference was found (P = 0.886). A comparison of the groups indicated that they scored similarly in the pre-test. However, the experimental group scored significantly higher than the control group in the post-test (P = 0.270 and P = 0.015, respectively).

Conclusions

In the light of these findings, it is recommended that communication skills should be widely included in in-service training programs; similar studies should be conducted on broader control groups formed through randomization; and a comparison should be made between the findings.

Assessing the impact of diagnosis and the related supportive care needs in patients with cutaneous melanoma

PURPOSE

Despite the large number of people affected by melanoma, little is known about the specific needs of melanoma patients. Understanding the effects of melanoma diagnosis and the specific supportive care needs of this group of patients is a necessary step towards provision of effective psychosocial care.

METHODS

Semi-structured interviews were carried out with 15 patients with malignant melanoma of the skin. The sample size, which was purposive, included 8 females and 7 males from 27 to 78 years old. Data were analysed using the NVIVO 8 software and principles of thematic analysis.

RESULTS

Four major areas were identified: (a) Emotional effects due to body image, fear of the sun and uncertainty for the future; (b) Effects on Relationships, with some patients in need of more support than others from family and work colleagues; (c) Functional effects due to on-going symptoms such as pain and lymphedema; and (d) Health System and Information Needs, around the clarity, quality and timing of the information received from the health care professionals.

CONCLUSIONS

The findings suggest that we often fail to pick up melanoma patients' health and psychosocial needs and fail to refer them appropriately, rather than the services not being available. Interventions should focus on patient and carer education about melanoma and sun protection, psychosocial support and effective information giving. Patient-reported outcome measures should routinely be collected to identify issues of specific concerns to the patients and directing them to the right services based on their individual needs.

Oncology staff: burnout, job satisfaction and coping with stress

OBJECTIVE

The oncology staff is at high risk for developing psychological disorders and burnout. In this study, we aimed to evaluate their burnout levels, job satisfaction, psychological statement and ways of coping with stress and the relationship between these variables and their sociodemographic and occupational characteristics.

METHODS

Among all health workers at the Istanbul University Institute, of Oncology, 159 were included in the study. A sociodemographic data form, the Maslach Burnout Inventory, the Minnesota Job Satisfaction Questionnaire, the General Health Questionnaire (GHQ) and the Styles of Coping Inventory-Short Form were used to evaluate burnout and its contributing factors.

RESULTS

High levels of 'emotional exhaustion', 'depersonalization' and 'low sense of personal accomplishment' were determined in 30.2%, 8.2% and 44% of all participants, respectively. The variables that affected emotional exhaustion were assessed by logistic regression analysis. Accordingly, the ratio of emotional exhaustion was approximately 10 times higher in those for whom job stress was the most important stress factor compared with those who indicated nonjob stress for each one point increase on the GHQ and depersonalization scores, which were other predictors, with odds ratio (OR) : 1.23, p = 0.006 and OR : 1.67, p < 0.001, respectively. A negative correlation was detected between adaptive coping styles and 'burnout,' and a positive correlation was found between maladaptive coping strategies and exhaustion.

CONCLUSIONS

It is necessary to monitor the psychological status of employees in oncology units with scanning tools such as GHQ to understand their job stress perceptions and to help them develop adaptive coping methods.

A 3-stage model of patient-centered communication for addressing cancer patients' emotional distress

OBJECTIVE

To describe pathways through which clinicians can more effectively respond to patients' emotions in ways that contribute to betterment of the patient's health and well-being.

METHODS

A representative review of literature on managing emotions in clinical consultations was conducted.

RESULTS

A three-stage, conceptual model for assisting clinicians to more effectively address the challenges of recognizing, exploring, and managing cancer patients' emotional distress in the clinical encounter was developed. To enhance and enact recognition of patients' emotions, clinicians can engage in mindfulness, self-situational awareness, active listening, and facilitative communication. To enact exploration, clinicians can acknowledge and validate emotions and provide empathy. Finally, clinicians can provide information empathetically, identify therapeutic resources, and give referrals and interventions as needed to help lessen patients' emotional distress.

CONCLUSION

This model serves as a framework for future research examining pathways that link clinicians' emotional cue recognition to patient-centered responses exploring a patient's emotional distress to therapeutic actions that contribute to improved psychological and emotional health.

PRACTICAL IMPLICATIONS

Specific communicative and cognitive strategies are presented that can help clinicians better recognize a patient's emotional distress and respond in ways that have therapeutic value.

[Psycho-oncology for speech therapists: establishment and conception of the course PSYKOL]

OBJECTIVE

Head and neck cancer patients show a high psychiatric comorbidity, yet receive only little psychosocial support. Therefore, a specific psychosocial qualification for speech therapists working with head and neck cancer patients seems necessary.

MATERIAL AND METHODS

A course was developed based on a process model. Questionnaires were completed by speech therapists (self-evaluation of working situation; n = 15) as well as therapists interested in further training (collection of issues in the work with head and neck patients who are under psychological pressure assessed as problematic by the therapists; n = 27), whose competence in communication was also evaluated. In addition, a literature research was conducted and a focus group was formed.

RESULTS

High psychosocial demands within the therapists' work with tumor patients and difficulties in communication became obvious. Nearly all interviewees frequently used nonconducive communication patterns, yet implicit knowledge existed (usage of a favorable conversational style in multiple choice test: 68 %). The content and concept of the curriculum were discussed within the focus group and led to the final version of the training.

CONCLUSION

A customised psycho-social training curriculum for speech therapists has been developed.

Missed opportunities for advance care planning communication during outpatient clinic visits

BACKGROUND

Early provider-patient communication about future care is critical for patients with heart failure (HF); however, advance care planning (ACP) discussions are often avoided or occur too late to usefully inform care over the course of the disease.

OBJECTIVE

To identify opportunities for physicians to engage in ACP discussions and to characterize physicians' responses to these opportunities.

DESIGN

Qualitative study of audio-recorded outpatient clinic visits.

PARTICIPANTS

Fifty-two patients ≥ 65 years recently hospitalized for HF with one or more post-discharge follow-up outpatient visits, and their physicians (n = 44), at two Veterans Affairs Medical Centers.

APPROACH

Using content analysis methods, we analyzed and coded transcripts of outpatient follow-up visits for 1) patient statements pertaining to their future health or their future physical, psychosocial and spiritual/existential care needs, and 2) subsequent physician responses to patient statements, using an iterative consensus-based coding process.

RESULTS

In 13 of 71 consultations, patients expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians responded by terminating the conversation, hedging their responses, denying the patient's expressed emotion, or inadequately acknowledging the sentiment underlying the patient's statement.

CONCLUSIONS

Physicians often missed the opportunity to engage in ACP despite openers patients provided that could have prompted such discussions. Communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses; in order to successfully leverage opportunities to engage in ACP discussions.

Evaluation of psycho-social training for speech therapists in oncology. Impact on general communication skills and empathy. A qualitative pilot study

The aim of this study was to evaluate the impact of a psychosocial training programme for speech therapists on their performance skills in patient-therapist communication in general and empathy in particular. Twenty-three speech therapists were interviewed in a pseudo-randomised controlled trial. Communication skills were tested using questionnaires with open questions. Respondents were asked to find adequate replies to clinical vignettes. The vignettes briefly described a patient's physical state and contained a statement from the patient expressing some distress. Answers were coded with qualitative content analysis. Communication skills improved considerably in terms of frequency of conducive communication (especially empathy) and width of conducive communicative repertoire. Negative communication preferences were reduced. Psychosocial training for speech therapists can improve communication skills manifestly and is therefore recommended for further use.

Optimising methods for communicating survival data to patients undergoing cancer surgery

BACKGROUND

Patients undergoing cancer surgery require outcome data to inform decisions, but communication of numerical risk is difficult. This study assessed patient understanding of survival data presented in different formats.

METHODS

Semi-structured interviews in which patients interpreted four presentation formats of survival data (three graphical and one narrative) were audio-recorded. The interviewer and a blinded observer (listening to the audio-recordings) scored patients' understanding of each format. Logistic regression examined associations between understanding and clinical and socio-demographic details.

RESULTS

Seventy participants with colorectal cancer were interviewed and 67 [95.7%, 95% confidence intervals (CIs) 90.9-100%] correctly interpreted a simplified Kaplan-Meier survival curve. A high proportion accurately understood data presented as a bar chart or pictograph (94.3%, 95% CIs 88.7-99.9% and 92.9%, 95% CIs 86.7-99.0% respectively). Standard narrative alone was least well understood (n = 53, 75.7%, 95% CIs 65.4-86.0%). Multivariable analyses demonstrated that older and female patients had poorer overall understanding (OR 0.93 per year, 95% CIs 0.87-0.98, p = 0.01 and OR 0.24, 95% CIs 0.07-0.86, p = 0.03).

CONCLUSION

Patient understanding of survival data was higher when presented with graphs compared to narrative alone. Further work examining understanding in the clinical context and before surgery is recommended before this can be used routinely.

Satisfaction with mammography in the National Cancer Screening Programme participants of age 40s in Korea

The aim of this study was to evaluate satisfaction with the National Cancer Screening Programme of mammography in Korea and to examine the association between subscales of satisfaction and general satisfaction. We conducted a cross-sectional telephone survey for women who had obtained a National Cancer Screening Programme mammographic screening at general hospitals between May and October 2008. The present study included 2005 women in their forties. We performed multivariate linear regression using dependent variable as general satisfaction and independent variables as subscales of satisfaction, such as pre-screening information transfer, staff interpersonal skills, physical surroundings and results reporting. Participants were stratified according to the result of their mammogram as negative or positive. Mean score of satisfaction was above 2.5 of 4 for all subscales. Women who received positive results were less satisfied with all of subscale factors. Staff interpersonal skills were the most important factor that contributed to general satisfaction. Future efforts such as staff training programme of communication/attitude skills, ensuring privacy and explanation of possible discomfort of the screening would be needed.

Swiss Cancer League communication skills training programme for oncology nurses: an evaluation

AIM

This paper is a report of an evaluation of the effectiveness of a communication skills training programme for oncology nurses.

BACKGROUND

Clinical care for patients with cancer is increasingly being divided between nurses and physicians, with nurses being responsible for the continuity of patient care, and oncologists choosing and explaining the basics of anti-cancer therapy. Therefore, oncology nurses will profit from evidence-based communication skills training to allow them to perform in a professional way.

METHODS

Between 2003 and 2006 pre- and post-intervention videos of interviews with simulated patients were compared using the Roter Interaction Analysis System. Patient centeredness was assessed by counting segments of appropriate mutual responding to cues and by calculating length of uninterrupted patient speech.

FINDINGS

Appropriate empathic (1.6% vs. 3.2%), reassuring statements (2.3% vs. 3.4%), questions concerning psychosocial information (2.8% vs. 4.0%) increased statistically significantly; utterances containing medical information decreased on the part of nurses (17.8% vs. 13.3%) and patients (8.1% vs. 6.7%); and patients provided more psychosocial information (3.3% vs. 5.7%). The level of congruence and empathic responses to patients' emotional cues increased statistically significantly, as did the length of uninterrupted speech (3.7-4.3 utterances; all P < 0.05).

CONCLUSION

The communication skills training of the Swiss Cancer League could be used as a model to achieve substantial improvements in patient-centred communication. Sequence analysis of utterances from patient-provider interaction should be used to assess the amount of patient-centred talk.

Improving patient education by an in-service communication training for health care providers at a cancer ward: communication climate, patient satisfaction and the need of lasting implementation

OBJECTIVE

To show the effects of an in-service communication training for health care providers at a cancer ward, to improve the quality and quantity of the patient education, and patient satisfaction with the care received.

METHODS

A 3-year in-service communication training was held at a cancer ward. Pre- and post-data were collected about the quality and quantity of the communication of nurses, physicians and other health care providers (HCPs) towards patients and colleagues (n=22) as well as the satisfaction of the patients with the quality of care (n=90).

RESULTS

The communication training raised significantly the quality and quantity of the communication towards patients and with colleagues. Also patient satisfaction with the quality of care increased. However, the long-term implementation of the benefits was proved disappointing.

CONCLUSION

In-service communication training is an important means for the long-term improvement of the quality of patient education at nursing departments in hospitals. Lasting implementation of the benefits however requires attention to organizational obstacles, budgetary conditions, leadership factors at the ward, and the application of an organizationally oriented theoretical framework.

PRACTICE IMPLICATIONS

Improvement of patient education at nursing wards does not only require educational means, organizational facilities and professional training, but can be improved too by in-service communication training, which increases the quality of the patient-centered care. An organizational oriented change-strategy is needed to ensure the implementation produces lasting effects.

Insight on variables leading to burnout in cancer physicians

Although communication skills training programs have been recommended to reduce physicians' burnout, few studies have investigated their efficacy. This study assessed the impact of two training programs on cancer physicians' burnout. Especially, it identified some variables leading to burnout in order to develop effective interventions. Burnout was assessed with the Maslach Burnout Inventory. No statistically significant impact of training programs on burnout was observed. The amount of clinical workload and the overuse of some facilitative communication skills were associated with cancer physicians' burnout. The content of such programs must be redefined to reduce burnout.

A qualitative study assessing mental health issues in two hospices in the UK

This study is a qualitative investigation into the experiences of assessing mental health issues by members of staff from two hospices in the UK. Nine individual interviews were held with doctors and nurses from the two hospices using semi-structured interviews. The research method used was grounded theory and the emerging data were analysed using the computer software Atlas.ti. The analysis was conducted around the four main research questions: 'How is mental health assessed in the hospices?', 'What are the staff members' feelings about doing these assessments?', 'How does assessment information inform clinical practice?' and 'What are the perceived training needs of staff?' The findings show that mental health is, to some extent, being assessed within these two hospices; however, no formal assessment strategy is in place. The majority of staff interviewed had very limited experience and/or training in the field of mental health and expressed a lack of confidence when dealing with mental health-related issues. A list of training needs has been identified. On the basis of these findings, recommendations have been made to improve the assessment procedures currently used within these two hospices.

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

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

CYP3A4 mediated in vitro metabolism of vinflunine in human liver microsomes

AIM

To study the metabolism of vinflunine and the effects of selective cytochrome P-450 (CYP450) inhibitors on the metabolism of vinflunine in human liver microsomes.

METHODS

Individual selective CYP450 inhibitors were used to investigate their effects on the metabolism of vinflunine and the principal CYP450 isoform involved in the formation of metabolites M(1) and M(2) in human liver microsomes.

RESULTS

Vinflunine was rapidly metabolized to 2 metabolites: M(1) and M(2) in human liver microsomes. M(1) and M(2) were tentatively presumed to be the N-oxide metabolite or hydroxylated metabolite and epoxide metabolite of vinflunine, respectively. Ketoconazole uncompetitively inhibited the formation of M(1), and competitively inhibited the formation of M(2), while alpha-naphthoflavone, sulfaphenazole, diethyl dithiocarbamate, tranylcypromine and quinidine had little or no inhibitory effect on the formation of M(1) and M(2).

CONCLUSION

Vinflunine is rapidly metabolized in human liver microsomes, and CYP3A4 is the major human CYP450 involved in the metabolism of vinflunine.

Developing empathy in nurses: an inservice training program

The purpose of this study was to determine whether inservice communication training enhanced the empathic skills of 263 nurses employed at Hacettepe University Hospital. Data were collected using a nurse information form, participants' satisfaction form, and the Empathic Communication Skill B (ECS-B) form developed by Dökmen [Dökmen, U. (1988). A new measurement model of the empathy and developing empathy by using psychodrama. Journal of Education Faculty of Ankara University, 21, 155-190]. The ECS-B was used as both a preintervention and a postintervention measure. The data were expressed as means, percentages, and standard deviations, and were analyzed using Pearson's chi-square test and repeated-measures analysis of variance. The posttest scores of nurses increased from 155.6 to 180.5, and training played a role in enhancing nurses' empathic skills with regard to all variables (P < .05). However, a more comprehensive and continuous training should be planned, and its impact on behavior and patient outcomes should be investigated.

An integrated psychological strategy for advanced colorectal cancer patients

Background

There is evidence regarding the usefulness of psychosocial intervention to improve health related quality of life (HRQOL) in adult cancer patients. The aim of this report is to describe an integrated approach and to evaluate its feasibility in routine clinical practice in 98 advanced colorectal cancer (ACC) patients during chronomodulated chemotherapy.

Methods

A prospective non-randomised design was developed and applied in a cancer out-patient setting. The intervention consisted of an integrated approach, whereby the psycho-oncologist had an active role in the health care team with the physician and routinely included psychological understanding in the medical treatment program. The psychological evaluation assessed: a) adaptation, awareness, psychopathological disorders through a psychodynamic interview; b) anxiety and depression using the HAD scale; c) subjective perception of care quality through a structured interview and d) HRQOL evaluation assessment with the EORTC QLQ C30. Outcomes data were collected before and after 18 weeks of chemotherapy.

Results

After 18 weeks of chemotherapy a significant improvement of adaptation and awareness was observed. The HADs results showed a significant decrease in anxiety when compared to pre-treatment. The structured interview showed a significant increase of patients who positively experienced the impact of medical treatment on HRQOL, anxiety, depression, interpersonal relationships, free-time and who positively experienced the care quality. Indeed, a majority of patients positively experienced the team relationship modality during the whole treatment. All scales on the EORTC questionnaire remained unchanged during the entire treatment.

Conclusion

Our results suggest that it is feasible to carry out an integrated approach during chemotherapy. These results seem to support the integrated approach as a tool in aiding advanced colorectal cancer patients' ability to cope with their diagnosis and treatment although an appropriately designed study is required to confirm this.

Teaching communication and stress management skills to junior physicians dealing with cancer patients: a Belgian Interuniversity Curriculum

BACKGROUND

Ineffective physicians' communication skills have detrimental consequences for patients and their relatives, such as insufficient detection of psychological disturbances, dissatisfaction with care, poor compliance, and increased risks of litigation for malpractice. These ineffective communication skills also contribute to everyday stress, lack of job satisfaction, and burnout among physicians. Literature shows that communication skills training programs may significantly improve physicians' key communication skills, contributing to improvements in patients' satisfaction with care and physicians' professional satisfaction. This paper describes a Belgian Interuniversity Curriculum (BIC) theoretical roots, principles, and techniques developed for junior physicians specializing in various disciplines dealing with cancer patients.

CURRICULUM DESCRIPTION

The 40-h training focuses on two domains: stress management skills and communication skills with cancer patients and their relatives. The teaching method is learner-centered and includes a cognitive, behavioral, and affective approach. The cognitive approach aims to improve physicians' knowledge and skills on the two domains cited. The behavioral approach offers learners the opportunity to practice these appropriate skills through practical exercises and role plays. The affective approach allows participants to express attitudes and feelings that communicating about difficult issues evoke. Such an intensive course seems to be necessary to facilitate the transfer of learned skills in clinical practice.

CONCLUSIONS

The BIC is the first attempt to bring together a stress management training course and a communication training course that could lead not only to communication skills improvements but also to burnout prevention.

Physician-patient communication among Southern European cancer physicians: the influence of psychosocial orientation and burnout

Physician-patient communication is a critical factor for comprehensive care in oncology. Although a number of studies have been carried out in Northern Europe and the US on this subject, no data are available in Southern European countries. As a part of a multicenter Southern European Psycho-Oncology study (SEPOS), the present investigation was conducted to examine communication skills and related variables (i.e. psychosocial orientation, and burnout) among 125 physicians from Italy, Portugal, and Spain. The Self-Confidence in Communication Skills (SCCS) scale was given to assess physicians' perception of their communication skills and the Expected Outcome of Communication (EOC) scale was administered to examine the physicians' expectations about the effects of communicating with their patients. Doctors' psychosocial orientation was measured by using the Physician Belief Scale (PBS) and burnout was measured by using the Maslach Burnout Inventory (MBI). Although the physicians reported receiving minimal training in communication during their education, they tended to perceive themselves as skilled in patient communication, apart from some areas (e.g. dealing with denial, managing uncertainty, assessing anxiety and depression, and promoting patient-family openness). Low psychosocial orientation and burnout symptoms (i.e. emotional exhaustion, depersonalization, and poor personal accomplishment in their job) were associated with lower confidence in communication skills and higher expectations of a negative outcome, following physician-patient communication. The results suggest that there is a need for training cancer physicians in communication and for increasing a more definite psychosocially oriented approach in cancer care in Mediterranean countries.

A paradigm of integrative care: healing with curing throughout life, "being with" and "doing to"

We are presenting an integrative paradigm of care. We will review the basis for its evolution from prior series and parallel models. In this paradigm, healing and palliation (when indicated) are introduced in parallel with curative measures as soon as any diagnosis, especially a critical one, is made. Frequently palliative measures address patient symptoms, such as pain, anxiety, delirium, or depression, and are geared towards comfort care at the end of life. Our view of healing care is that it actively addresses the cognitive, emotional and spiritual needs of the patient and family, and includes the elements of palliative care as a complement. Because a loss is often experienced in many conditions, even in the absence of death, bereavement is represented in our model as an ongoing, continual process throughout a disease process. While we will be drawing mainly from experiences with children, the proposed model is applicable to all ages. In order to implement this model most effectively, it will be important to shift from our mindset of "doing to" to one that includes "being with" our patients and their families. The uniqueness of this paradigm, in contrast to other models, is its comprehensiveness and universality. It is appropriate for patients of any age, at any stage of their disease or illness, regardless of the severity or duration of their condition.

Palliative information: Doctor-patient communication

Communication between doctors and patients allows the formation of a solid working relationship based on the recognition of mutual needs and expectations. It facilitates coping by providing the right amount of diagnostic and prognostic information that assists patients and families in making therapeutic choices consistent with their life goals. In order to provide quality care, the oncologist must take an active role in encouraging disclosure of concerns and formulate a treatment plan that addresses psychosocial needs. This accomplishes the dual purpose of knowing the patient and making the patient feel known and connected to his/her professional caregivers.

Evaluation of a counseling training program for nursing staff

One of the essential issues in nurses' daily work is interaction with patients, patients' families, and co-workers. However, in the Spanish academic programs for Nursing Schools, social interaction skills do not receive adequate attention and nurses often report communication problems. In order to diminish these difficulties and to train nursing staff to better manage interaction, an intensive counseling training program was designed and implemented in a General University Hospital. The main aim of this study was to evaluate the effects of a counseling training program and assessing the evolution of difficulties that professionals perceived in their work in three different periods: before the training, after the training, and at follow-up, 2 months after the program was delivered. According to the results, we can maintain the hypothesis that the counseling training program reduces perceived interaction difficulties in nursing staff. Consequently, we can expect a further improvement in the interaction performance with patients and their families after the training. These findings suggest that counseling training has to be taken into account to improve quality of care in health care providers, and it may also help to prevent professional burnout by increasing competence level at minimum personal cost.

[Communication in oncology]

Patient-doctor communication is an essential aspect of coping with cancer. In our "age of communication", information and data transfer often is mistaken for communication. Contrary to analogous or digital information transmission, a message received by the patient may widely differ from the message intended by the doctor. For in human communication, nonverbal and emotional contexts may extensively modify the perception, interpretation and processing of information. Moreover, in modern oncology patient-doctor communication is complicated by a growing incongruence between a patient's disease and his illness experience. To achieve satisfying doctor-patient communication, the setting, content and structure have to be directed towards a specific goal. Empirical data show that key elements and skills of efficient patient-doctor communication can be taught and learned.

Is there a cost to poor communication in cancer care?: a critical review of the literature

In this paper, the authors engage in a critical analysis of the existing empirical literature which addresses the impact of ineffective communication between cancer patients and clinicians. It is increasingly accepted that communication plays a significant role in many aspects of the care experience, and that poor communication can have a significantly negative influence on the patient's psychosocial experience, symptom management, treatment decisions, and quality of life. However, scant attention has been given to the idea that poor communication may also have an economic impact worthy of attention. This area has not been the focus of systematic inquiry or substantive critical consideration. On the basis of critical analysis of the limited empirical evidence that exists across a wide range of studies in related areas, the authors propose that the existential and material costs associated with poor communication in cancer care may well be considerable, and conclude with a call to mobilize a heightened enthusiasm for addressing the research challenges in this field.

Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach

BACKGROUND

This study aimed to determine the prevalence of psychiatric morbidity and distress among 189 consecutively recruited cancer patients upon admission to surgical oncology wards, and to investigate the recognition of distressed patients by medical staff.

PATIENTS AND METHODS

Assessment consisted of a diagnostic psychiatric interview (SCID, DSM-IV), patient-reported distress using a standardised questionnaire (Hospital Anxiety and Depression Scale), and physicians' and nurses' estimates of patients' distress. Twenty-eight per cent of patients were assigned a psychiatric diagnosis, with adjustment disorder predominating.

RESULTS

Surgeons accurately recognised marked distress in 77% of patients with a psychiatric disorder and nurses did so in 75%. Because of low specificity, the positive predictive value was only 39% in surgeons and 40% in nurses. However, recognition of distress translated into referral to the psychosocial liaison service for only a minor proportion of distressed patients.

CONCLUSIONS

Since a remarkable proportion of distressed patients remained unrecognised by the medical staff, only systematic screening of patients upon admission allows timely support to those who are most in need.

[Effects of a psychosocial education programme to improve doctor-patient interaction with cancer patients]

OBJECTIVES

The quality of medical care by somatically treating physicians has considerable influence on the coping process in cancer patients. In outpatient psychosocial care, information supply and doctor-patient interaction are often considered difficult by the patients. This study therefore investigates the effects of a teaching and training programme on interactional skills of experienced physicians in dealing with cancer patients.

METHODS

In a pre-post comparison design, the effects of a 6-hour and a 24-hour interaction and teaching programme were compared. To measure the effects, interviews with standardised patients were carried out and analysed using the Medical Interaction Process System (Ford 1998).

RESULTS

About one third of all physicians practicing in the area of Mönchengladbach, Germany, could be motivated to participate in the programme. The physicians who received the 24-hour training showed a substantial improvement in interaction skills whereas no marked changes were seen in those physicians who had participated in the 6-hour training.

CONCLUSIONS

Interactional skills of experienced physicians can be improved by teaching and training programmes. Therefore, doctor-patient interaction training should be integrated into continuing medical education.

Communication, quality of life and age: results of a 5-year prospective study in breast cancer patients

BACKGROUND

Previous studies have employed short follow-up periods or examined only certain aspects of quality of life (QoL). This study aimed to examine the effect of communication on breast cancer patients' QoL and to investigate the role of age in this relationship.

PATIENTS AND METHODS

In a prospective, observational study breast cancer patients were sent questionnaires, including the European Organisation for Research and Treatment of Cancer QLQ-C30, over 5 years.

RESULTS

Forty-five per cent of the sample reported that some aspect of the communication they received was unclear and 59% wanted to speak with medical staff more. Patients under 50 years rated social and psychological help as more important, they were more aware of such services, had greater contact with support groups but were less satisfied with the information they received. Seventeen of the 27 QoL variables were significantly worse (P <0.01), up to 4 years after diagnosis, for those patients reporting unclear information. For patients over 50 years, QoL was significantly (P <0.001) worse when communication was unsatisfactory. Operation method or arm problems did not mitigate the association between communication and QoL.

CONCLUSIONS

Communication is clearly a vital clinical skill that may play a role in patient QoL.

Communication skills training for Japanese oncologists on how to break bad news

BACKGROUND

Despite significant communication gaps between patients and physicians, there has been little effort to initiate and evaluate teaching programs. We investigated whether a communication skills training (CST) could be effectively conducted for Japanese oncologists.

METHODS

Fifty-eight oncologists participated in the CST. We evaluated the program by measuring participant-rated confidence for communication with patients, burnout, and satisfaction of participants.

RESULTS

Immediately and at 3 months after CST, confidence in communication increased significantly compared with before. The providers' emotional-exhaustion 3 months after the workshop, however, worsened. The participants' satisfaction level with the program was high.

CONCLUSIONS

The CST is feasible for Japanese oncologists, but it needs to be modified to reduce emotional-exhaustion.

Healing the caregiver

When treating seriously ill patients, those working in the healing professions may be particularly vulnerable to their own stress symptoms. Left unattended, these professionals may go down the dark road leading to burnout, with impaired effectiveness as caregivers, diseases rooted in stress, as well as increased suicides, drug and alcohol addiction, and exacerbation of personality disorders. Early intervention may help reduce the associated problems. In this paper, we present an elementary debriefing system, a psychotherapeutic approach, to be used by the affected individual. While this methodology may be far more simplistic than those utilized in different schools of healing or caregiving, its appeal is its simplicity and practicality. We are proposing that the individual caregiver systematically consider the following: the Background of the situation; how it Affects thinking and feeling; the Troublesome element(s); how one is Handling element(s); and an Empathetic/empowering conclusion (BATHE). Ideally, these considerations may help alleviate caregivers' anguish in troublesome situations and may complement their awareness of their patients' suffering as well.

Breaking bad news: structured training for family medicine residents

Previous research has shown that physicians experience incompetence and difficulty in dealing with patients' feelings after they have broken bad news to them. During the past 10 years, we have implemented a longitudinal training program targeting these issues. The present article describes this training and discusses its contribution to doctors' skills at approaching distressed patients. In order to cope with breaking bad news to patients and their families, physicians should be skilled at crisis intervention and communication techniques. They should also be aware of their personal attitudes and emotional reactions when breaking bad news. Each session encompassed these areas, as well as the most prominent issues arising when breaking bad news. In a 1-5 Likert scale, the course received an overall score of 4.47 (S.D. 0.51). Participants noted that they had gained relevant communication skills for future patient encounters.

Effect of breaking bad news on patients' perceptions of doctors

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the 'breaking bad news' event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings 'most helpful' and 'less helpful', and completed standardized psychological screening questionnaires. In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as 'most helpful' when breaking bad news, 8 were general practitioners; of the 7 categorized as 'less helpful' all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners. Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

Does training increase the use of more emotionally laden words by nurses when talking with cancer patients? A randomised study

The emotional content of health care professionals-cancer patient communication is often considered as poor and has to be improved by an enhancement of health care professionals empathy. One hundred and fifteen oncology nurses participating in a communication skills training workshop were assessed at three different periods. Nurses randomly allocated to a control group arm (waiting list) were assessed a first time and then 3 and 6 months later. Nurses allocated to the training group were assessed before training workshop, just after and 3 months later. Each nurse completed a 20-min clinical and simulated interview. Each interview was analysed by three content analysis systems: two computer-supported content analysis of emotional words, the Harvard Third Psychosocial Dictionary and the Martindale Regressive Imagery Dictionary and an observer rating system of utterances emotional depth level, the Cancer Research Campaign Workshop Evaluation Manual. The results show that in clinical interviews there is an increased use of emotional words by health care professionals right after having been trained (P=0.056): training group subjects use 4.3 (std: 3.7) emotional words per 1000 used before training workshop, and 7.0 (std: 5.8) right after training workshop and 5.9 (std: 4.3) 3 months later compared to control group subjects which use 4.5 (std: 4.8) emotional words at the first assessment point, 4.3 (std: 4.1) at the second and 4.4 (std: 3.3) at the third. The same trend is noticeable for emotional words used by health care professionals in simulated interviews (P=0.000). The emotional words registry used by health care professionals however remains stable over time in clinical interviews (P=0.141) and is enlarged in simulated interviews (P=0.041). This increased use of emotional words by trained health care professionals facilitates cancer patient emotion words expressions compared to untrained health care professionals especially 3 months after training (P=0.005). This study shows that health care professionals empathy may be improved by communication skills training workshop and that this improvement facilitates cancer patients emotions expression.

Assessment and treatment of psychosocial problems in cancer patients: an exploratory study of a course for nurses

A course in psychosocial oncology for nurses was developed and evaluated within the framework of a prospective randomised study. Six nurses participated. Areas covered were basic techniques for assessment of psychosocial problems, for relieving anxiety and depression, solving problems in conjunction with treatment and disease, and improving communication. Participants met for four 3h weekly lessons. Between meetings, they met to train assessment and techniques. Follow-up discussions were held at termination and 5 months later. Participants reported that the new knowledge and skills had made them feel more confident when handling patients' psychosocial situation. However, treatment of psychological problems did not prove to be a predominant aspect of their patient work. The evaluation of the course suggests that participants improved their skills for assessment of patient problems and, therefore, felt more confident when handling psychosocial issues.

Information needs of patients with cancer: results from a large study in UK cancer centres

As part of a multi-centred study evaluating a communication skills training model for clinicians, we collected information preferences using an adaptation of Cassileth's Information Needs questionnaire from a heterogeneous sample of 2331 patients. Results showed that 87% (2027) wanted all possible information, both good and bad news and 98% (2203) preferred to know whether or not their illness was cancer. Cross tabulation of responses revealed no significant differences in information preferences for tumour site or treatment aims but did show an effect of age and sex. The few 58/440 (13.2%) patients who stated that in general they preferred to leave disclosure of details up to the doctor, tended to be older patients more than 70 years of age (chi square = 26.01, df = 2, P< 0.0001), although paradoxically they still wanted to know certain specific details. In comparison to men women preferred to know the specific name of the illness (chi square = 4.9, df = 1, P< 0.02) and what were all the possible treatments (chi square = 8.26, df = 1, P< 0.004). The results from this very large sample provide conclusive evidence that the vast majority of patients with cancer want a great deal of specific information concerning their illness and treatment. Failure to disclose such information on the grounds that significant numbers of patients prefer not to know is untenable.

Testing health care professionals' communication skills: the usefulness of highly emotional standardized role-playing sessions with simulators

Although standardized role-playing sessions (SRPS) with simulators are increasingly used to assess health care professionals' (HCPs) communication skills (CS) and the effectiveness of training workshops (TWs), nothing has been done to date to define the optimal emotional content of SRPS. Three emotionally different SRPS contexts-weakly emotional (WE-), moderately emotional (ME-), and highly emotional (HE-SRPS)-were, therefore, tested in order to assess induced CS and sensitivity to TW-related changes. The study included 25 HCPs. Tape-recorded SRPS, scheduled before and after the TW, were retranscribed, and assessed according to the Cancer Research Campaign Workshop Evaluation Manual (CRCWEM), which provides a rating of form, function and structure for each utterance. Results show that induced CS are different in WE-, ME-, and HE-SRPS, regarding form (HE-SRPS induced more 'directing', 'leading' or 'multiple' questions; WE: 20.7%; ME: 19.7%; HE: 33.7% (p<0.001)); function (HE-SRPS induced more 'inappropriate' information; WE: 6. 5%; ME: 8.2%; HE: 15.6% (p<0.001)); and blocking (HE-SRPS induced more 'blocking' utterances; WE: 7.2%; ME: 13.8%; HE: 30.2% (p<0. 0001)). Finally, CS changes induced by TWs are the highest in HE-SRPS (14.8% increase of 'open' questions for the HE- versus 1.0% for the WE-SRPS; 11.6% decrease of 'inappropriate' information for the HE- versus 3.3% for the WE-SRPS; and 17.5% decrease of 'blocking' for the HE- versus 2.6% for the WE-SRPS). In conclusion, SRPS, with a HE content, induce more inappropriate CS. Moreover, they are more sensitive to TW effects. SRPS with a HE content should, thus, be recommended for the assessment of TW effectiveness.

Quality of life instruments in oncology

The objective of this article is to aid clinicians in understanding the current state of the development and application of quality of life (QOL) instruments as outcome measures in cancer clinical research and practice. As a result of the achievements of the past two decades, the concept of QOL has been defined and many reliable and valid measurement tools have been developed. The two main approaches to QOL assessment, psychometric-based and utility-based, are discussed together with a brief description of the strategies for meaningful interpretation of QOL profiles. QOL measures in oncology have the potential to be used to study populations in randomised clinical trials, to aid patient-clinician interactions in routine practice and to support policy decision making and economic evaluation of healthcare provision.