A patient-centred approach to defining and assessing interviewing competency

Verona Coding Definitions of Emotional Sequences (VR-CoDES): Conceptual framework and future directions

OBJECTIVE

To discuss the theoretical and empirical framework of VR-CoDES and potential future direction in research based on the coding system.

METHODS

The paper is based on selective review of papers relevant to the construction and application of VR-CoDES.

RESULTS

VR-CoDES system is rooted in patient-centered and biopsychosocial model of healthcare consultations and on a functional approach to emotion theory. According to the VR-CoDES, emotional interaction is studied in terms of sequences consisting of an eliciting event, an emotional expression by the patient and the immediate response by the clinician. The rationale for the emphasis on sequences, on detailed classification of cues and concerns, and on the choices of explicit vs. non-explicit responses and providing vs. reducing room for further disclosure, as basic categories of the clinician responses, is described.

CONCLUSIONS

Results from research on VR-CoDES may help raise awareness of emotional sequences. Future directions in applying VR-CoDES in research may include studies on predicting patient and clinician behavior within the consultation, qualitative analyses of longer sequences including several VR-CoDES triads, and studies of effects of emotional communication on health outcomes.

PRACTICE IMPLICATIONS

VR-CoDES may be applied to develop interventions to promote good handling of patients' emotions in healthcare encounters.

Factors predicting emotional cue-responding behaviors of nurses in Taiwan: An observational study

OBJECTIVE

Responding to emotional cues is an essential element of therapeutic communication. The purpose of this study is to examine nurses' competence of responding to emotional cues (CRE) and related factors while interacting with standardized patients with cancer.

METHODS

This is an exploratory and predictive correlational study. A convenience sample of registered nurses who have passed the probationary period in southern Taiwan was recruited to participate in 15-minute videotaped interviews with standardized patients. The Medical Interview Aural Rating Scale was used to describe standardized patients' emotional cues and to measure nurses' CRE. The State-Trait Anxiety Inventory was used to evaluate nurses' anxiety level before the conversation. We used descriptive statistics to describe the data and stepwise regression to examine the predictors of nurses' CRE.

RESULTS

A total of 110 nurses participated in the study. Regardless of the emotional cue level, participants predominately responded to cues with inappropriate distancing strategies. Prior formal communication training, practice unit, length of nursing practice, and educational level together explain 36.3% variances of the nurses' CRE.

CONCLUSIONS

This study is the first to explore factors related to Taiwanese nurses' CRE. Compared to nurses in other countries, Taiwanese nurses tended to respond to patients' emotional cues with more inappropriate strategies. We also identified significant predictors of CRE that show the importance of communication training. Future research and education programs are needed to enhance nurses' CRE and to advocate for emotion-focused communication.

Breaking significant news: The experience of clinical nurse specialists in cancer and palliative care

PURPOSE

The aim of the research was to explore specialist cancer and palliative care nurses experience of delivering significant news to patients with advanced cancer.

METHOD

A qualitative phenomenological research study was conducted to capture nurses' experiences with the aim of understanding how cancer and palliative care clinical nurse specialists work towards disclosure of advanced and terminal cancer. Data were collected through semi-structured interviews with 10 clinical nurse specialists working in one acute NHS trust. Clinical nurse specialists were recruited from the following specialities: lung cancer, breast cancer, gynaecological cancer, upper and lower gastrointestinal cancer and palliative care.

RESULTS

Four themes emerged from the data: importance of relationships; perspective taking; ways to break significant news; feeling prepared and putting yourself forward. The findings revealed that highly experienced clinical nurse specialists (CNSs) felt confident in their skills in delivering significant news and they report using patient centred communication to build a trusting relationship so significant news was easier to share with patients. CNSs were aware of guidelines and protocols for breaking significant and bad news but reported that they used guidelines flexibly and it was their years of clinical experience that enabled them to be effective in disclosing significant news. Some areas of disclosure were found to be challenging in particular news of a terminal prognosis to patients who were of a younger age.

CONCLUSION

CNSs have become more directly involved in breaking significant news to those with advanced cancer by putting themselves forward and feeling confident in their skills.

Improving communication in cancer pain management nursing: a randomized controlled study assessing the efficacy of a communication skills training program

PURPOSE

Effective communication is needed for optimal cancer pain management. This study assessed the efficacy of a general communication skills training program for oncology nurses on communication about pain management.

METHODS

A total of 115 nurses were randomly assigned to a training group (TG) or control group (CG). The assessment included the recording of interviews with a simulated cancer patient at baseline for both groups and after training (TG) or 3 months after baseline (CG). Two psychologists rated the content of interview transcripts to assess cancer pain management communication. Group-by-time effects were measured using a generalized estimating equation.

RESULTS

Trained nurses asked the simulated patient more questions about emotions associated with pain (relative rate [RR] = 4.28, p = 0.049) and cognitions associated with pain treatment (RR = 3.23, p < 0.001) and used less paternalistic statements about cancer pain management (RR = 0.40, p = 0.006) compared with untrained nurses.

CONCLUSIONS

The general communication skills training program improved only a few of the communication strategies needed for optimal cancer pain management in nursing. General communication skills training programs should be consolidated using specific modules focusing on communication skills related to cancer pain management.

How unique is continuity of care? A review of continuity and related concepts

BACKGROUND

The concept of 'continuity of care' has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear.

OBJECTIVE

In order to clarify the confusion of tongues and to identify core values of these patient-centred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management.

METHODS

We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary.

RESULTS

Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient's perspective.

CONCLUSIONS

The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.

Empathy in general practice consultations: A qualitative analysis

Aims — Empathy is an important basis of all provider-patient interaction, including general practice. Little has been known about the details of how general practitioners express empathy to their patients. In the present study, it was a main aim to carry out a detailed qualitative study of actual sequences through which empathy was achieved, by focusing on the form, function, and categorisation of such sequences. Methods — The study drew on the qualitative method of conversation analysis. Transcriptions of 77 British general-practitioner-patient interactions were analysed in detail in order to identify and characterise sequences in which empathy was achieved. Results — Four types of empathy were identified, described, and analysed: cognitive empathy, affective empathy, sharing empathy, and nurturant empathy. Although sequences involving empathy typically were brief and occurred relatively rarely, the analyses demonstrated that the sequences often concerned matters of great importance to the interactants. Conclusions — The study underlined the need to focus also on phenomena that occur relatively rarely in consultations. For this purpose, the method of conversation analysis was a useful tool.

Declaration of Interest: there was no conflict of interest.

Creativity in clinical communication: from communication skills to skilled communication

Medical Education 2011: 45: 217-226 Objectives  The view that training in communication skills produces skilled communication is sometimes criticised by those who argue that communication is individual and intuitive. We therefore examine the validity of the concept of communication as a skill and identify alternative principles to underpin future development of this field. Methods  We critically examine research evidence about the nature of clinical communication, and draw from theory and evidence concerning education and evaluation, particularly in creative disciplines. Results  Skilled communication cannot be fully described using the concept of communication skills. Attempts to do so risk constraining and distorting pedagogical development in communication. Current education practice often masks the difficulties with the concept by introducing subjectivity into the definition and assessment of skills. As all clinical situations differ to some extent, clinical communication is inherently creative. Because it is rarely possible to attribute specific effects to specific elements of communication, communication needs to be taught and evaluated holistically. Conclusions  For communication teaching to be pedagogically and clinically valid in supporting the inherent creativity of clinical communication, it will need to draw from education theory and practice that have been developed in explicitly creative disciplines.

Development of the Verona coding definitions of emotional sequences to code health providers' responses (VR-CoDES-P) to patient cues and concerns

OBJECTIVE

To present a method to classify health provider responses to patient cues and concerns according to the VR-CoDES-CC (Del Piccolo et al. (2009) [2] and Zimmermann et al. (submitted for publication) [3]). The system permits sequence analysis and a detailed description of how providers handle patient's expressions of emotion.

METHODS

The Verona-CoDES-P system has been developed based on consensus views within the "Verona Network of Sequence Analysis". The different phases of the creation process are described in detail. A reliability study has been conducted on 20 interviews from a convenience sample of 104 psychiatric consultations.

RESULTS

The VR-CoDES-P has two main classes of provider responses, corresponding to the degree of explicitness (yes/no) and space (yes/no) that is given by the health provider to each cue/concern expressed by the patient. The system can be further subdivided into 17 individual categories. Statistical analyses showed that the VR-CoDES-P is reliable (agreement 92.86%, Cohen's kappa 0.90 (±0.04) p<0.0001).

CONCLUSION

Once validity and reliability are tested in different settings, the system should be applied to investigate the relationship between provider responses to patients' expression of emotions and outcome variables.

PRACTICE IMPLICATIONS

Research employing the VR-CoDES-P should be applied to develop research-based approaches to maximize appropriate responses to patients' indirect and overt expressions of emotional needs.

Coding patient emotional cues and concerns in medical consultations: the Verona coding definitions of emotional sequences (VR-CoDES)

OBJECTIVE

To present the Verona Coding Definitions of Emotional Sequences (VR-CoDES CC), a consensus based system for coding patient expressions of emotional distress in medical consultations, defined as Cues or Concerns.

METHODS

The system was developed by an international group of communication researchers. First, consensus was reached in different steps. Second, a reliability study was conducted on 20 psychiatric consultations.

RESULTS

A Cue is defined as a verbal or non-verbal hint which suggests an underlying unpleasant emotion that lacks clarity. A Concern is defined as a clear and unambiguous expression of an unpleasant current or recent emotion that is explicitly verbalized with or without a stated issue of importance. The conceptual framework sets precise criteria for cues and concerns and for whom (health provider or patient) elicits the cue/concern. Inter-rater reliability proved satisfactory (agreement 81.5%, Cohen's Kappa 0.70).

CONCLUSION

The VR-CoDES CC will facilitate comparative research on provider-patient communication sequences in which patients express emotional distress.

PRACTICE IMPLICATIONS

The VR-CoDES CC may be used to help clinicians in recognizing or facilitating cues and concerns, thereby improving the recognition of patients' emotional distress, the therapeutic alliance and quality of care for these patients.

The analysis of verbal interaction sequences in dyadic clinical communication: a review of methods

OBJECTIVE

To identify methods available for sequential analysis of dyadic verbal clinical communication and to review their methodological and conceptual differences.

METHODS

Critical review, based on literature describing sequential analyses of clinical and other relevant social interaction.

RESULTS

Dominant approaches are based on analysis of communication according to its precise position in the series of utterances that constitute event-coded dialogue. For practical reasons, methods focus on very short-term processes, typically the influence of one party's speech on what the other says next. Studies of longer-term influences are rare. Some analyses have statistical limitations, particularly in disregarding heterogeneity between consultations, patients or practitioners. Additional techniques, including ones that can use information about timing and duration of speech from interval-coding are becoming available.

CONCLUSION

There is a danger that constraints of commonly used methods shape research questions and divert researchers from potentially important communication processes including ones that operate over a longer-term than one or two speech turns. Given that no one method can model the complexity of clinical communication, multiple methods, both quantitative and qualitative, are necessary.

PRACTICE IMPLICATIONS

Broadening the range of methods will allow the current emphasis on exploratory studies to be balanced by tests of hypotheses about clinically important communication processes.

A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045

BACKGROUND

Disparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons.

OBJECTIVE

This paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control.

METHODS

A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs.

CONCLUSION

The Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.

Physician-patient communication in single-bedded versus four-bedded hospital rooms

OBJECTIVE

To examine whether physician-patient communication in multi-bedded rooms differs from communication in single rooms during ward rounds.

METHODS

Ward rounds in single-bedded patient rooms and ward rounds in four-bedded rooms were audiotaped and analyzed with an adapted version of MIARS. The researcher completed an observational checklist of each encounter. We measured: the duration of speech time, the types of verbal and nonverbal communication, the extent to which patients and physicians raise intimate subjects.

RESULTS

Encounters during ward rounds in single rooms significantly took up more time than encounters in four-bedded rooms. The patients asked more questions and made more remarks in single rooms compared to four-bedded rooms. Empathic reactions of the physician were scored significantly more often in single rooms than in four-bedded rooms. No differences were observed concerning the extent to which intimate subjects were brought up.

CONCLUSION

This study is the first that investigated this subject. Findings suggest that single rooms contribute positively to physician-patient communication.

PRACTICE IMPLICATIONS

The research findings indicate the relevance of taking account of the context in which physician-patient communication takes place.

The English version of the Verona medical interview classification system (VR-MICS). An assessment of its reliability and a comparative cross-cultural test of its validity

OBJECTIVE

This study aimed to assess the inter-rater and intra-rater reliability of the English translation of the original Italian version of the VR-MICS and to evaluate its sensitivity by comparing the coding of English and Italian general practice consultations with emotionally distressed and non-distressed patients, as defined by the 12-item General Health Questionnaire (GHQ-12).

METHOD

Six male GPs from Manchester (UK) and six from Verona (Italy) each contributed five consultations, which were coded using the VR-MICS. Intra-rater and inter-rater reliability were assessed both for the division of interviews into speech units and the speech unit coding. Interaction and main effects of GHQ-12 status and nationality on patient and GP expressions were assessed by two-way ANOVA.

RESULTS

Agreement indices for the division of speech units varied between 88-96 and 87-93% for GP and patient speech, respectively; those for coding categories between 88-91 and 82-86%, with Cohen's Kappa values between 0.86-0.91 and 0.80-0.85 for GP and patient speech, respectively. Cross-cultural comparisons of patient and GP speech showed no interaction effects between GHQ-12 status and nationality. The Italian GPs were more 'doctor-centred', while the UK GPs tended to use a more 'sharing' consulting style. Independent of nationality, distressed patients talked more, gave more psychosocial cues and increased amounts of positive talk compared to non-distressed patients. GPs in both settings, when interviewing distressed patients, reduced social conversation and increased psychosocial information-giving, checking questions and reassurance.

CONCLUSION

The English translation of the VR-MICS showed satisfactory reliability indices and similar sensitivity to patients' verbal behaviours in relation to their emotional state in the two settings.

PRACTICE IMPLICATIONS

The VR-MICS may be an useful coding instrument to support collaborative research on doctor-patient communication between the two countries.

Determinants of once-only contact in a community-based psychiatric service

BACKGROUND

This study examined variables associated with patients who had a once-only contact with the out-patient department of a Community Mental Health Service (CMHS).

METHODS

Using the South-Verona Psychiatric Case Register (PCR), an 8-year cohort of patients who had a new episode of care with the out-patient department of the South Verona CMHS was followed up for 3 months after the first contact, to identify those patients who had no further contact with the service. Potential determinants of once-only contact were analysed.

RESULTS

A total of 2,446 new episodes of care met the inclusion criteria of the study. Of those, 734 (30%) were once-only contacts with the service. Compared to patients with more than one contact, patients who had a once-only contact were older, more likely to be male, had a lower socio-economic status and less severe psychiatric diagnosis. They were more likely to be referred by consultation/liaison or emergency room.

CONCLUSIONS

Multivariate analysis revealed that having a less severe psychiatric diagnosis was the most significant determinant of once-only contact with a CMHS. The results suggest that the behaviour of referring agents in selecting patients and preparing them for treatment merits further investigation.