The Pathways to Prevention program: nutrition as prevention for improved cancer outcomes

Adequate nutrition is central to well-being and health and can enhance recovery during illness. Although it is well known that malnutrition, both undernutrition and overnutrition, poses an added challenge for patients with cancer diagnoses, it remains unclear when and how to intervene and if such nutritional interventions improve clinical outcomes. In July 2022, the National Institutes of Health convened a workshop to examine key questions, identify related knowledge gaps, and provide recommendations to advance understanding about the effects of nutritional interventions. Evidence presented at the workshop found substantial heterogeneity among published randomized clinical trials, with a majority rated as low quality and yielding mostly inconsistent results. Other research cited trials in limited populations that showed potential for nutritional interventions to reduce the adverse effects associated with malnutrition in people with cancer. After review of the relevant literature and expert presentations, an independent expert panel recommends baseline screening for malnutrition risk using a validated instrument following cancer diagnosis and repeated screening during and after treatment to monitor nutritional well-being. Those at risk of malnutrition should be referred to registered dietitians for more in-depth nutritional assessment and intervention. The panel emphasizes the need for further rigorous, well-defined nutritional intervention studies to evaluate the effects on symptoms and cancer-specific outcomes as well as effects of intentional weight loss before or during treatment in people with overweight or obesity. Finally, although data on intervention effectiveness are needed first, robust data collection during trials is recommended to assess cost-effectiveness and inform coverage and implementation decisions.

Posttraumatic Growth Among Older Adults With Age-Related Macular Degeneration

Introduction: The term “post-traumatic growth” describes positive outcomes that accrue from the struggle with highly challenging life circumstances. The purpose of this study is to describe post-traumatic growth accruing from experience with vision loss caused by age-related macular degeneration (AMD) and to identify the relationships between depression, cognitive processing, social support, and post-traumatic growth. Methods: Individuals with vision loss caused by AMD completed an interviewer-administered composite questionnaire to identify elements of Tedeschi and Calhoun’s theoretical model of the process of posttraumatic growth, including measures of distress (depression), intrusive and deliberate rumination (cognitive processing), and social support (quality and quantity of social ties). Relationships were examined using path analysis. Results: Eighty-nine participants completed the questionnaire (mean age = 85.3 years, range = 74–98 years). All paths, including from depression to social support (β = –.363, p < .001), from social support to deliberate rumination (β = .233; p ≤ .01), and from intrusive rumination to deliberate rumination (β = .514, p < .01), were significant and consistent with the posttraumatic growth theoretical model. Deliberate rumination had a significant direct path to post-traumatic growth (β = .38, p = .001). Discussion: The findings may illuminate elements of the process of post-traumatic growth among those with AMD. We found that as social support increased, depression decreased. Increased social support seemed to encourage positive deliberate rumination, which led directly to post-traumatic growth. Although intrusive rumination is often associated with negative outcomes, the model demonstrates that it also stimulates engagement in deliberate attempts to process one’s experience. Deliberate cognitive processing is a direct precursor to post-traumatic growth. Implications for Practitioners: A focus on the process of growth and thriving can offer a broader view of the experience of living with vision loss. Interventions that foster post-traumatic growth among those with AMD should focus on enhancing social support and facilitating deliberate cognitive processing.

Fostering Interdisciplinary Boundary Spanning in Health Communication: A Call for a Paradigm Shift

Scholarship in the field of health communication is broad, with interdisciplinary contributions from researchers trained in a variety of fields including communication, nursing, medicine, pharmacy, public health, and social work. In this paper, we explore the role of "health communication boundary spanners" (HCBS), individuals whose scholarly work and academic appointment reflect dual citizenship in both the communication discipline and the health professions or public health. Using a process of critical reflective inquiry, we elucidate opportunities and challenges associated with HCBS across the spectrum of health communication in order to provide guidance for individuals pursuing boundary spanning roles and those who supervise and mentor them. This dual citizen role suggests that HCBS have unique skills, identities, perspectives, and practices that contribute new ways of being and knowing that transcend traditional disciplinary boundaries. The health communication field is evolving in response to the need to address significant healthcare and policy problems. No one discipline has the ability to single-handedly fix our current healthcare systems. Narrative data from this study illustrate the importance of seeing HCBS work beyond simply being informed by disciplinary knowledge. Rather, we suggest that adapting ways of knowing and definitions of expertise is an integral part of the solution to solving persistent health problems.

Balancing Work and Hospice Caregiving-A Closer Look at Burden, Preparedness, and Mental Health

CONTEXT

Navigating end-of-life is stressful and many caregivers feel unprepared for caregiving tasks. Being employed may further increase caregiver burden.

OBJECTIVES

Study objectives were 1) to examine the relationships among caregiver burden (financial burden, daily schedule disruption, lack of family support) and mental health (depression and anxiety), and 2) explore if preparedness for caregiving mediates these relationships in employed hospice caregivers.

METHODS

This was a secondary analysis of baseline data from a prospective multi-site project of hospice family caregivers of cancer patients. Employed hospice caregivers (n = 166) completed items assessing burden, mental health, and preparedness for caregiving. Hierarchical linear regression and mediation analysis were conducted.

RESULTS

Caregivers were primarily White (n = 155, 93%) and female (n = 116, 70%), with a mean age of 55 (SD = 11.7). After controlling for demographic variables, financial burden was significantly related to anxiety (b =.16[.001, .32], P <.05), lack of family support was significantly related to depression (b = 1.27[.76, 1.79], P <.01), and daily schedule disruption was significantly related to both anxiety (b = 1.92[1.07, 2.77], P <.01), and depression (b =.70[.14, 1.26], P <.05) in regression analyses. In mediation analysis, financial burden, daily schedule disruption, and lack of family support were indirectly related to both depression and anxiety through preparedness for caregiving.

CONCLUSION

To better support employed caregivers, hospice team members should be ready to address concerns about finances, daily schedule changes, and family support and screen for preparedness for caregiving. Developing strategies to help employed hospice caregivers feel more prepared may mitigate adverse mental health outcomes.

Shared Medication PLanning In (SIMPLIfy) Home Hospice: An Educational Program to Enable Goal-Concordant Prescribing In Home Hospice

CONTEXT

Simplifying medication regimens by tapering and/or withdrawing unnecessary drugs is important to optimize quality of life and safety for patients with serious illness. Few resources are available to educate clinicians, patients and family caregivers about this process.

OBJECTIVE

To describe the development of an educational program called Shared Medication PLanning In (SIMPLIfy) Home Hospice.

METHODS

An environmental scan identified a state-of-the-art educational program for home hospice deprescribing that we adapted using a stakeholder panel engagement process. The stakeholder panel (two hospice administrators, three nurses, two physicians, two pharmacists, and two former family caregivers) drawn from two geographically diverse hospice agencies reviewed the educational program and recommended additional content.

RESULTS

Iterative rounds of review and feedback resulted in: 1) a three-part clinician educational program (total duration = 1.5 hour) that presents a standardized, goal-concordant, medication review approach to align medications and conversations about regimen simplification with patient and family caregiver goals of care; 2) a patient-family caregiver medication management educational notebook that presents common symptoms, hospice medications, and medication regimen simplification principles; and 3) a brief guide including helpful phrases to use as conversation starters for key steps in the program. A professional designer created thematic coherence for all materials that was well received by stakeholder panelists and hospice staff.

CONCLUSION

Educational materials can support hospice programs' and clinicians' efforts to implement goal-concordant medication simplification that optimizes end-of-life outcomes for patients and family caregivers. Evaluation of outcomes including medication appropriateness and family caregiver medication administration burden are not yet available.

Live hospice discharge: Experiences of families, and hospice staff

OBJECTIVE

To examine live hospice discharge prevalence and experiences of families and hospice staff. Hospice eligibility is based on a cancer model where decline and death are predicable. Decline is less predictable for diagnoses such as dementia, frequently resulting in involuntary live hospice discharge.

METHODS

A mixed-method integration of hospice 2013-17 admission/discharge data, 5 family interviews, hospice discipline-specific focus groups (3 aides, 2 nurses, 1 administrator interview) and a discipline-combined focus group (all 6 staff; each staff participant engaged in two data collection experiences).

RESULTS

5648 hospice admissions occurred between 2013-17; 795 patients experienced live discharge. The most prevalent admitting diagnosis was cancer, the most prevalent live discharge diagnosis was dementia. Family caregiver themes were Attitude and experience with hospice, Discharge experience, and Continued need/desire for hospice following discharge. Staff themes were Discharge circumstances, Regulatory guidelines, and Changing practice to meet regulatory guidelines.

CONCLUSION

Involuntary live hospice discharge precludes patient-centered care due to policy constraints, especially for those with noncancer diagnoses. Families and staff noted the paradox of beneficial hospice care, yet this care resulted in ineligibility for continued hospice services.

PRACTICE IMPLICATIONS

Transparent, patient-family-staff communication (including CNAs) facilitates hospice live discharge planning. Hospice service eligibility policy changes are needed.

The Me in We dyadic communication intervention is feasible and acceptable among advanced cancer patients and their family caregivers

BACKGROUND

Advanced cancer affects the emotional and physical well-being of both patients and family caregivers in profound ways and is experienced both dyadically and individually. Dyadic interventions address the concerns of both members of the dyad. A critical gap exists in advanced cancer research, which is a failure of goals research and dyadic research to fully account for the reciprocal and synergistic effects of patients' and caregivers' individual perspectives, and those they share.

AIM

We describe the feasibility and acceptability of the Me in We dyadic intervention, which is aimed at facilitating communication and goals-sharing among caregiver and patient dyads while integrating family context and individual/shared perspectives.

DESIGN

Pilot study of a participant-generated goals communication intervention, guided by multiple goals theory, with 13 patient-caregiver dyads over two sessions.

SETTING/PARTICIPANTS

Patients with advanced cancer and their self-identified family caregivers were recruited from an academic cancer center. Dyads did not have to live together, but both had to consent to participate and all participants had to speak and read English and be at least 18 years or age.

RESULTS

Of those approached, 54.8% dyads agreed to participate and completed both sessions. Participants generated and openly discussed their personal and shared goals and experienced positive emotions during the sessions.

CONCLUSIONS

This intervention showed feasibility and acceptability using participant-generated goals as personalized points of communication for advanced cancer dyads. This model shows promise as a communication intervention for dyads in discussing and working towards individual and shared goals when facing life-limiting or end-of-life cancer.

Health Care Provider Knowledge and Perceptions of FDA-Approved and Do-It-Yourself Automated Insulin Delivery

BACKGROUND

Automated insulin delivery (AID) technology may reduce variability in blood glucose, resulting in lower risk for hypoglycemia and associated complications, and by extension improve quality of life. While clinical trials, research, and patient experience have consistently demonstrated the value of AID, this technology is still inaccessible to many patients. Patient-driven innovation has resulted in alternative do-it-yourself (DIY) solutions to available off-the-shelf AID devices.

METHOD

This two-phase cross-sectional observational study addressed health care provider (HCP) perceptions of AID as well as the perceived need for, development of, and evaluation of an AID fact sheet comparing the most commonly used Federal Drug Administration approved AID and DIY AID devices.

RESULTS

Negative attitudes toward the use of DIY AID were low. The majority of HCPs saw their lack of knowledge about how DIY AID work to be the greatest barrier to answering patient questions about what is available (74.4%). Additionally, the majority of HCPs (64.5%) indicated they were either "likely" or "very likely" to use the fact sheet when answering patient questions about AID options.

CONCLUSION

Increased awareness and utilization of AID technology offer hope to further reduce the burden of diabetes, but there is a need to bridge the knowledge gap about DIY AID. A fact sheet provides a way to facilitate discussions of this emerging technology between HCPs and patients. Next steps could investigate additional ways to put needed information in the hands of HCPs.

"In Eight Minutes We Talked More About Our Goals, Relationship, Than We Have in Years": A Pilot of Patient-Caregiver Discussions in a Neuro-Oncology Clinic

Primary brain cancer is a diagnosis that can have drastic health impacts on patient and caregiver alike. In high-stress situations, dyadic coping can improve psychosocial and health outcomes and communication about personal life goals maybe one way to facilitate this coping. In this study, we describe the feasibility and accessibility of a one-time, self-directed goal discussion pilot intervention for neuro-oncology patients and their primary caregivers. Ten dyads were taken to a private room to complete a pre-discussion questionnaire, a worksheet to elicit personal goals, complete an 8-min discussion of goals, a post-discussion questionnaire, and provided open-ended feedback about the process. Post-discussion, dyads reported that the intervention was not stressful. In open-ended feedback, dyads overwhelmingly reported that the intervention was a positive experience, providing a safe, calm environment to have difficult conversations. This intervention provides a positive framework for improving communication and discussion of goals between patient-caregiver dyads.

Health communication roles in Latino, Pacific Islander, and Caucasian Families: A qualitative investigation

Family communication about health is critical for the dissemination of information that may improve health management of all family members. Communication about health issues, attitudes, and behaviors in families is associated with life expectancy as well as quality of life for family members. This study addresses family communication about health by examining individual roles for family health communication and factors related to these roles, among families of three different racial/ethnic groups: Caucasians, Latinos, and Pacific Islanders. Data were collected from 60 participants recruited as 30 family dyads, 10 from each group, through qualitative semistructured interviews. Interviews were conducted with each participant separately and then together in a dyadic interview. Two coders independently coded interview transcripts using NVivo 11. Results identified the family health communication roles of collector, disseminator, health educator, and researcher. We also identified several factors related to these roles using the lens of family systems theory-the presence of chronic conditions in the family, previous experience, medical education, and family hierarchy. Findings demonstrate many similarities and relatively few differences in the family health communication roles and the related factors among the families of different race/ethnicity. Conclusions highlight implications for future research and intervention development.

Does family communication matter? Exploring knowledge of breast cancer genetics in cancer families

Knowledge of breast cancer genetics is critical for those at increased hereditary risk who must make decisions about breast cancer screening options. This descriptive study explored theory-based relationships among cognitive and emotional variables related to knowledge of breast cancer genetics in cancer families. Participants included first-degree relatives of women with breast cancer who had received genetic counseling and testing. Study participants themselves did not have breast cancer and had not received genetic counseling or testing. Data were collected by telephone interviews and surveys. Variables analyzed included numeracy, health literacy, cancer-related distress, age, education, and the reported amount of information shared by the participants' family members about genetic counseling. The multiple regression model explained 13.9% of variance in knowledge of breast cancer genetics (p = 0.03). Best fit of the multiple regression model included all variables except education. Reported amount of information shared was the only independently significant factor associated with knowledge (β = 0.28, p = 0.01). Participants who reported higher levels of information shared by a family member about information learned during a genetic counseling session also demonstrated increased knowledge about breast cancer genetics.

Hospice nurse identification of comfortable and difficult discussion topics: Associations among self-perceived communication effectiveness, nursing stress, life events, and burnout

OBJECTIVE

To assess hospice nurses' self-perceived communication effectiveness, identify comfortable and difficult discussion topics, and explore associations between self-perceived communication effectiveness, burnout, nursing stress, and life events.

METHODS

181 nurses completed self-report measures, then listed comfortable and/or difficult patient and caregiver discussion topics.

RESULTS

Nurses were generally experienced (median 9 years, range <1-46 as a registered nurse; median 3 years, range <1-23 as a hospice nurse), reporting overall Effective/Very Effective communication skills (85.6%); 70% desired more communication training. As nursing stress increased perceived overall communication effectiveness decreased (rs = -0.198; p 0.012). As burnout increased overall effectiveness (rs = -0.233; p 0.002) and effectiveness with difficult topics (rs = -0.225; p 0.003) decreased. Content analysis revealed 9 categories considered both comfortable and difficult to discuss; contextual comments provided fuller explanation (e.g. providing general information on the Dying Process was comfortable, discussing Dying process during patient death was difficult). Seven additional categories (e.g. Denial) were deemed uniquely difficult.

CONCLUSION

Hospice nurses perceive themselves as effective communicators, yet want additional training. Perceived communication effectiveness is associated with burnout and stress.

PRACTICE IMPLICATIONS

Communication training that focuses on contextually grounded topics identified by participants may optimize communication between hospice nurses, patients and caregivers.

Female family members lack understanding of indeterminate negative BRCA1/2 test results shared by probands

Genetic test results have important implications for close family members. Indeterminate negative results are the most common outcome of BRCA1/2 mutation testing. Little is known about family members' understanding of indeterminate negative BRCA1/2 test results. The purpose of this mixed-methods study was to investigate how daughters and sisters received and understood genetic test results as shared by their mothers or sisters. Participants included 81 women aged 40-74 with mothers or sisters previously diagnosed with breast cancer and who received indeterminate negative BRCA1/2 test results. Participants had never been diagnosed with breast cancer nor received their own genetic testing or counseling. This Institutional Review Board-approved study utilized semi-structured interviews and surveys. Descriptive coding with theme development was used during qualitative analysis. Participants reported low amounts of information shared with them. Most women described test results as negative and incorrectly interpreted the test to mean there was no genetic component to the pattern of cancer in their families. Only seven of 81 women accurately described test results consistent with the meaning of an indeterminate negative. Our findings demonstrate that indeterminate negative genetic test results are not well understood by family members. Lack of understanding may lead to an inability to effectively communicate results to primary care providers and missed opportunities for prevention, screening, and further genetic testing. Future research should evaluate acceptability and feasibility of providing family members letters they can share with their own primary care providers.

Communication of emotion in home hospice cancer care: Implications for spouse caregiver depression into bereavement

OBJECTIVE

Family caregivers of cancer hospice patients likely benefit from clinician provision of verbal support and from expression of positive emotions. Our aim was to identify the effects of hospice nurse supportive communication as well as caregiver-nurse exchange of positive emotions on family caregiver depression during bereavement.

METHODS

This prospective, observational longitudinal study included hospice nurses (N = 58) and family caregivers of cancer patients (N = 101) recruited from 10 hospice agencies in the United States. Digitally recorded nurse home visit conversations were coded using Roter interaction analysis system to capture emotion-focused caregiver-nurse communication and supportive nurse responses. Caregivers completed the Hospital Anxiety and Depression Scale Anxiety Subscale and Geriatric Depression Scale-Short Form at study enrollment and at 2, 6, and 12 months after patient death.

RESULTS

Caregivers had moderate levels of depression at study enrollment and throughout bereavement. Multilevel modeling revealed that caregiver positive emotion communication and nurse emotional response communication are associated with caregiver depression in bereavement. There was no significant association between caregiver distress communication and depression in bereavement.

CONCLUSIONS

This is the first study to demonstrate that communication demonstrating emotional expression between cancer spouse caregivers and nurses during home hospice may have implications for caregiver depression up to a year after patient death. Our findings may help identify caregivers who may be coping well in the short term but may struggle more over time.

Rigor and Reproducibility: A Systematic Review of Salivary Cortisol Sampling and Reporting Parameters Used in Cancer Survivorship Research

Salivary cortisol is a commonly used biomarker in cancer survivorship research; however, variations in sampling protocols and parameter reporting limit comparisons across studies. Standardized practices to provide rigor and reproducibility of diurnal salivary cortisol sampling and reporting are not well established. Previous systematic reviews examining relationships between diurnal salivary cortisol and clinical outcomes have resulted in mixed findings. It remains unclear which sampling protocols and reporting parameters offer the greatest utility for clinical research. This review examines diurnal salivary cortisol sampling protocols and reporting parameters to evaluate whether a standardized approach is recommended. A comprehensive search of intervention studies among adult cancer survivors including diurnal salivary cortisol resulted in 30 articles for review. Sampling protocols ranged from 1 to 4 days with the majority of studies sampling cortisol for 2 days. Sampling instances ranged from 2 to 7 times per day, with the majority collecting at 4 time points per day. Diurnal cortisol slope and cortisol awakening response (CAR) were the most commonly reported parameters associated with clinical outcomes. Flattened cortisol slopes, blunted CARs, and elevated evening cortisol concentrations were associated with poorer psychosocial and physiological outcomes. Based on our review, we propose that a rigorous, standardized diurnal salivary cortisol sampling protocol should include sampling at key diurnal times across ≥3 consecutive days to report diurnal cortisol parameters (i.e., CAR and slope) and objective measures of participant protocol adherence. Diminishing budgetary resources and efforts to minimize participant burden dictate the importance of standardized cortisol sampling protocols and reporting parameters.

Let’s chat: Piloting an approach to patient-caregiver goal discussions in a neuro-oncology clinic

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Background: Communication is important to fostering joint coping in patients with advanced cancer and their family caregivers. Joint goal setting has been shown to enhance relationship quality for dyads and increase interpersonal ease and connection. Often patients and caregivers indicate they wish to discuss issues together but have difficulty doing so, which can inhibit dyadic coping and achievement of treatment goals and interpersonal plans. The aim of this study was to determine the feasibility and describe the methods of a short, one-time goal communication intervention for neuro-oncology patients and their primary family caregivers. Methods: Participants were recruited from a neuro-oncology clinic at an NCI-Designated Comprehensive Cancer Center. After informed consent from both patient and caregiver, the dyad was taken to a private room to complete a demographic questionnaire, eight-minute self-directed dyadic discussion of goals, and post-discussion questionnaire. For the discussion, dyads were asked to create and discuss three goals they had for themselves, and three goals they thought their partner would list, with at least one non-cancer related goal. Results: 10 dyads (n=20) were recruited for this study. Participants were mostly white, non-Hispanic, and married spouses. Only one patient participant was unable to list three goals. Dyads reported that the discussion was not stressful and they found high levels of benefit. Analysis of questionnaire and open-ended feedback overwhelmingly indicated the discussion task was useful to participants and that the study environment encouraged open, non-confrontational communication. Conclusions: Our brief prompted dyadic discussion intervention was feasible to implement and participants reported it was useful. Communication between advanced cancer patients and caregivers is vitally important to facilitate dyadic coping and ensure dyads are better able to achieve their goals. This pilot could be easily adapted to facilitate dyadic communication longitudinally to help facilitate communication between patients and caregivers along the cancer care continuum.

Using Social Network Analysis to Investigate Positive EOL Communication

CONTEXT

End-of-life (EOL) communication is a complex process involving the whole family and multiple care providers. Applications of analysis techniques that account for communication beyond the patient and patient/provider will improve clinical understanding of EOL communication.

OBJECTIVES

The objectives of the study were to introduce the use of social network analysis to EOL communication data and to provide an example of applying social network analysis to home hospice interactions.

METHODS

We provide a description of social network analysis to model communication patterns during home hospice nursing visits. We describe three social network attributes (i.e., magnitude, directionality, and reciprocity) in the expression of positive emotion among hospice nurses, family caregivers, and hospice cancer patients. Differences in communication structure by primary family caregiver across gender and time were also examined.

RESULTS

Magnitude (frequency) in the expression of positive emotion occurred most often between nurses and caregivers or between nurses and patients. Female caregivers directed more positive emotion to nurses, and nurses directed more positive emotion to other family caregivers when the primary family caregiver was male. Reciprocity (mutuality) in positive emotion declined toward day of death but increased on day of actual patient death. There was a variation in reciprocity by the type of positive emotion expressed.

CONCLUSION

Our example demonstrates that social network analysis can be used to better understand the process of EOL communication. Social network analysis can be expanded to other areas of EOL research, such as EOL decision making and health care teamwork.

Distress and Supportive Care Needs of Ethnically Diverse Older Adults With Advanced or Recurrent Cancer

OBJECTIVES

To assess the prevalence of supportive care needs (SCNs) and distress and to describe relationships among these and patient characteristics for ethnically diverse older adults with advanced or recurrent cancer.

SAMPLE & SETTING

Cross-sectional survey in five outpatient oncology clinics in an urban academic medical center involving 100 participants receiving cancer care in an economically challenged community.

METHODS & VARIABLES

The supportive care framework for cancer care guided this study, and participants completed the SCN Survey Short Form 34 and the Distress Thermometer. Study variables are cancer diagnosis, gender, helping to raise children, number of comorbid diseases, race or ethnicity, treatment status, and zip code.

RESULTS

Clinically meaningful distress was found in about a third of patients. Distress was not affected by race or ethnicity. Many ethnically diverse older patients with advanced or recurrent cancer report distress and SCNs; those with high distress are more likely to report multiple SCNs.

IMPLICATIONS FOR NURSING

Nursing assessment of patient SCNs and distress is integral to establishing individualized patient-centered care plans and to delivering optimal care.

Communicating Caregivers' Challenges With Cancer Pain Management: An Analysis of Home Hospice Visits

CONTEXT

Family caregivers (FCGs) of hospice cancer patients face significant challenges related to pain management. Addressing many of these challenges requires effective communication between FCGs and hospice nurses, yet little empirical evidence exists on the nature of communication about pain management between hospice nurses and FCGs.

OBJECTIVES

We identified ways in which FCGs of hospice cancer patients communicated their pain management challenges to nurses during home visits and explored nurses' responses when pain management concerns were raised.

METHODS

Using secondary data from audio recordings of hospice nurses' home visits, a deductive content analysis was conducted. We coded caregivers' pain management challenges and immediate nurses' responses to these challenges.

RESULTS

From 63 hospice nurse visits, 101 statements describing caregivers' pain management challenges were identified. Thirty percent of these statements pertained to communication and teamwork issues. Twenty-seven percent concerned caregivers' medication skills and knowledge. In 52% of the cases, nurses responded to caregivers' pain management challenges with a validating statement. They provided information in 42% of the cases. Nurses did not address 14% of the statements made by caregivers reflecting pain management challenges.

CONCLUSION

To optimize hospice patients' comfort and reduce caregivers' anxiety and burden related to pain management, hospice nurses need to assess and address caregivers' pain management challenges during home visits. Communication and educational tools designed to reduce caregivers' barriers to pain management would likely improve clinical practice and both patient- and caregiver-related outcomes.

Nursing Support of Home Hospice Caregivers on the Day of Patient Death

PURPOSE/OBJECTIVES

To describe nurse-caregiver communication on the day of patient death.
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DESIGN

A descriptive secondary analysis of 44 audio-recorded home hospice nursing visits on day of death.
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SETTING

Nine hospices in Utah, Oregon, and Massachusetts.
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SAMPLE

42 caregiver-patient dyads, 27 hospice nurses.
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METHODS

Transcripts of audio recordings were coded for supportive nursing communication and relative time spent in physical, psychosocial, and spiritual discussion.
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MAIN RESEARCH VARIABLES

Tangible, emotional, informational, esteem, and networking supportive communication; nurses' self-reported communication effectiveness; caregiver religious affiliation.
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FINDINGS

Nurses reported that their communication skills were less effective when discussing difficult topics as compared to their overall communication effectiveness. Eleven patients died before the nursing visit, 3 died during the visit, and 30 died post-visit. Nurses primarily engaged in discussions facilitating caregiver emotional, tangible, and informational support. More informational support was observed when patient death occurred during the nursing visit. Time spent in general conversation showed that physical care conversations predominated (80% of the average overall amount of conversation time), compared to lifestyle/psychosocial discussions (14%) and spiritual discussions (6%). Spiritual discussions were observed in only 7 of 44 hospice visits. Spiritual discussions, although short and infrequent, were significantly longer, on average, for caregivers without a religious affiliation.
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CONCLUSIONS

Nurses support caregivers on the day of patient death using multiple supportive communication strategies. Spiritual discussions are minimal.
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IMPLICATIONS FOR NURSING

Communication skills programs can potentially increase self-reported communication effectiveness. Emerging acute spiritual concerns, particularly for caregivers without a previous religious affiliation, should be anticipated. Spiritual support is included in the hospice model of holistic care.

Supporting home hospice family caregivers: Insights from different perspectives

ABSTRACTObjective:Our intention was to describe and compare the perspectives of national hospice thought leaders, hospice nurses, and former family caregivers on factors that promote or threaten family caregiver perceptions of support.

METHOD

Nationally recognized hospice thought leaders (n = 11), hospice nurses (n = 13), and former family caregivers (n = 14) participated. Interviews and focus groups were audiotaped and transcribed. Data were coded inductively, and codes were hierarchically grouped by topic. Emergent categories were summarized descriptively and compared across groups.

RESULTS

Four categories linked responses from the three participant groups (95%, 366/384 codes): (1) essentials of skilled communication (30.6%), (2) importance of building authentic relationships (28%), (3) value of expert teaching (22.4%), and (4) critical role of teamwork (18.3%). The thought leaders emphasized communication (44.6%), caregivers stressed expert teaching (51%), and nurses highlighted teamwork (35.8%). Nurses discussed teamwork significantly more than caregivers (z = 2.2786), thought leaders discussed communication more than caregivers (z = 2.8551), and caregivers discussed expert teaching more than thought leaders (z = 2.1693) and nurses (z = 2.4718; all values of p < 0.05).

SIGNIFICANCE OF RESULTS

Our findings suggest differences in priorities for caregiver support across family caregivers, hospice nurses, and thought leaders. Hospice teams may benefit from further education and training to help cross the schism of family-centered hospice care as a clinical ideal to one where hospice team members can fully support and empower family caregivers as a hospice team member.

Positive emotion communication: Fostering well-being at end of life

OBJECTIVE

Little is known about positive emotion communication (PEC) in end-of-life care. This study aims to identify types and patterns of PEC among hospice nurses, caregivers, and patients.

METHODS

A coding system based on positive psychology theory was applied as a secondary analysis to audio recordings of hospice nurse home visits with cancer patients and family caregivers, collected as part of a prospective longitudinal study. Eighty recordings (4 visits from 20 triads) were coded for humor, connection, praise, positive focus, gratitude, taking joy/savoring, and perfunctory statements.

RESULTS

Descriptive statistics revealed the greatest proportion of PEC was made by nurses. Humor was most frequently used across all speakers. Cluster analysis revealed four PEC visit types: Savor/Take Joy; Humor; Perfunctory; and Other-focused Expressions of Positive Emotions. Linear mixed effect regression was used to estimate the trajectory of PEC over time, but no significant change was found.

CONCLUSION

We found that positive emotions are common in nurse, caregiver and patient communication at end-of-life and do not decline closer to death.

PRACTICE IMPLICATION

This study is among the first to explore PEC at end-of-life, and offers a way to bring strengths-based approaches into end of life communication research.

Shared Decision Making in Home Hospice Nursing Visits: A Qualitative Study

CONTEXT

Shared decisions between health care providers and patients and families are replacing the traditional physician-driven plans of care. Hospice philosophy recognizes the patient and family as a unit of care and embraces their role in decision making.

OBJECTIVE

The goal of this study was to evaluate the shared decisions between hospice nurses and patients and family members.

METHODS

A secondary analysis of audio recordings of 65 home hospice nurse visits from 65 home hospice nurse visits in 11 different U.S. hospice programs.

RESULTS

To varying degrees, hospice nurses used all the recommended elements of shared decision making during home visits with patients and families; however, not all elements were used in every visit. The most commonly used element was defining a problem, and the least used element was the assessment of patient and family understanding.

CONCLUSIONS

Hospice staff can benefit from a more purposeful shared decision-making process and a greater focus on assessment of patient and family understanding and ability to implement plans of care.

Communication among cancer patients, caregivers, and hospice nurses: Content, process and change over time

OBJECTIVE

First, to describe communication of home hospice nurse visits to cancer patient-caregiver dyads. Second, to assess change in communication related to domains of care over the course of visits.

METHODS

Multi-site prospective observational longitudinal study of audio-recorded home hospice visits (N=537 visits; 101 patient-caregiver dyads; 58 nurses). Communication was coded using the Roter Interaction Analysis System to describe content and process. Conversation representing three care domains (physical, psychosocial/daily life, and emotional) was calculated from RIAS categories across speakers and analyzed to assess change in communication over time.

RESULTS

On average, nurses spoke 54% of total utterances, caregivers 29%, and patients 17%. For all participants, the predominant conversational focus was on physical care. Linear mixed effects models indicated that combined participant emotional talk showed a small systematic decrease over time; however, the results for all domains indicated variability unexplained by time or speaker effects.

CONCLUSIONS

Home hospice conversations are predominantly focused on physical care. Systematic change in communication versus responsiveness to the dynamic effects of patient death and family response over time are discussed.

PRACTICE IMPLICATIONS

Communication strategies already in use by hospice nurses could be leveraged and expanded upon to better facilitate family competence and confidence.

Caregiver, patient, and nurse visit communication patterns in cancer home hospice

OBJECTIVE

Few studies have examined the triadic communication between patients, spouse caregivers, and nurses in the home hospice setting. Thus, little is known about the types of communication patterns that unfold. The goals of the study were to, first, identify common patterns of communication in nurse-patient-caregiver home hospice visits and, second, to identify nurse, caregiver-patient dyad, and visit characteristics that predict visit communication patterns.

METHOD

Nurses (N = 58) and hospice cancer patient and spouse caregiver dyads (N = 101; 202 individuals) were recruited from 10 hospice agencies. Nurses audio recorded visits to patient/caregiver homes from study enrollment until patient death. All patient, caregiver, and nurse utterances from the audio recordings were coded using an adapted Roter interaction analysis system. Using identified codes, cluster analysis was conducted to identify communication patterns within hospice visits. Logistic regression was used with demographic variables to predict visit communication patterns.

RESULTS

Six visit communication patterns were identified and were defined largely by 2 dimensions: (1) either the patient, the caregiver, or the patient and caregiver dyad interacting with the nurse and (2) the relatively high or low expression of distress during the visit. Time until death significantly predicted several clusters.

CONCLUSION

This study leads the way in outlining triadic communication patterns in cancer home hospice visits. Our findings have implications for nursing education, letting future nurses know what to expect, and lays the foundation for future research to determine effectiveness and interventions to improve health care communication.

Shared understanding: Predicting home hospice nurse-cancer family caregiver communication similarity

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Background: In cancer home hospice, families provide 24/7 care with support from a nurse-led hospice team. Effective patient-caregiver-nurse communication can facilitate a “shared understanding,” resulting in better patient caregiver outcomes. Shared understanding may be evidenced by high similarity in language usage/meaning. Objective: Describe communication caregiver-nurse similarity (relatedness in word usage/meaning) in cancer home hospice using latent semantic analysis (LSA) and to identify nurse communication processes, confidence, and preferences that predict communication similarity. Methods: As part of a larger study, nurse home hospice visits to spouse cancer caregivers were audio recorded. Interaction analysis was used to quantify caregiver and nurse emotion talk, nurse partnering, and nurse dominance (ratio of total nurse/caregiver talk). Nurses completed questionnaires to capture preference for patient oriented care and confidence in their communication. Verbatim transcripts were analyzed using LSA, a tool that assesses the similarity of communication (range 0-1 where higher scores indicate greater similarity). Descriptive statistics and bivariate correlations were calculated. Results: 31 nurse-caregiver home hospice interactions were analyzed. Nurses were female, average age 44.03 (SD = 9.8), with an average 14.6 years experience. Spouse caregivers were 77% female, average age 64.7 (SD = 10.9). The average LSA score was .83 (range = .66-.89). Higher LSA values were significantly associated with more nurse partnering (r = .36, p = .05) and lower nurse dominance (r = -.39, p = .03), but not caregiver or nurse emotion talk (ps > .05). Higher LSA values also predicted more nurse-reported preference for patient-oriented care (r = -.75, p < .01) and lower nurse communication confidence (r = -.46, p = .01). Conclusions: Our findings suggest that hospice nurses who are more patient-oriented, listen to and encourage caregivers’ concerns are more likely to use concordant meaning and language usage in their home hospice visits. Further research should examine if a nurse’s use of language similarity strategies improve caregiver understanding, competency and satisfaction with care.

Listening behind closed doors: Shared decision making between hospice nurses and cancer patients and caregivers

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Background: The philosophy behind hospice care recognizes the patient and family as a unit of care and embraces their role in decision making. Research has primarily focused on physician and patient decision making yet, most decisions made at the end of life are between nurses, patients, and family members. The majority of hospice care is delivered in patient homes and little is known about these interactions. The goal of this study was to evaluate the shared decisions within the home environment between hospice nurses and patients/family. Methods: A secondary qualitative analysis of audio recordings of visits by 65 home hospice nurses to cancer patients in 11 hospice programs was conducted. Recordings were transcribed and coded by two team members using a pre-established nine element model of shared decision making. Elements of the model included: Defining a problem and options, discussing risks and benefits, focusing on how the options relate to patient values, the patient’s or family member’s ability to follow through, the provider’s recommendation, clarification of the understanding of options, and a follow-up plan. Results: Hospice nurses worked with families on an average of four problems in a mean visit time of 30 minutes. The hospice nurses used all the 9 recommended elements of shared decision making during home visits with patients and families however, not all elements were used in every visit. The most commonly used element was defining a problem, and the least used element was the assessment of patient and family understanding of options. Conclusions: Decision making for those enrolled in hospice occurs between nurses and patients/families. While ultimately responsible for the decisions that are made, physicians have limited interaction with the patient and family in their natural setting. Hospice nurses on the other hand, experience the impact of decisions in the environment in which they are implemented. Hospice nurses are the physician’s eyes and ears behind the closed doors of the home and can be valuable partners as they work with families on critical decisions several times each week.

Managing conflict during home hospice nursing visits: Communication between nurses, cancer patients, and spouse caregivers

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Background: Many hospice cancer patients and their spouse caregivers experience conflict as roles change and patients decline. Nurses can be asked to mediate conflicts during home visits. Our objective is to describe patient-caregiver conflict and nurse responses in home hospice communication. Methods: A secondary, qualitative analysis was conducted on transcripts of nurse visits to home hospice cancer patients and their spouse caregivers. Transcripts were selected based on high caregiver and patient emotion, identified by interaction analysis coding in primary analysis. Using an iterative process of constant comparison, coders inductively categorized nurse and dyad communication behavior during conflict into overarching themes. Results: 19 visits were identified for analysis. Nurses (from 7 hospice agencies) were all female and averaged 13 years nursing experience (SD = 11). Patient-caregiver dyads were all white, heterosexual, married an average 36 years (SD = 20). 84% of patients were male and average age was 72 years (SD = 9). Caregiver average age was 68 years (SD = 11). Patient-caregiver conflict fell under two major content themes 1) negotiating transitions in patient level of independence and 2) navigating patient/caregiver emotions (e.g. frustration, sadness). When not explicitly asked for input during conflict, nurses occasionally did not engage. Nurse response to transition conflict included problem-solving, mediating, or facilitating dyadic discussion about conflicts/concerns raised with her independently. Nurse response to emotional conflict included validation and reassurance. Conclusions: Little research has been conducted on couples’ conflict resolution in cancer home hospice. However, unresolved conflict can impact the quality of care and has been linked to poor bereavement adjustment. Nurses are sometimes asked to take on the role of mediator, often with little training. Our findings provide insight into home hospice patient and caregiver conflict communication with hospice nurses and could be used during nursing education. Further research could address specific patient and caregiver outcomes associated with nurse communication strategies.

Spiritual Care Communication in Cancer Patients

OBJECTIVES

To provide a definition of spirituality, define the scope and nature of spiritual care communication, describe how to initiate communication about, and elicit, a spiritual history, and introduce the AMEN protocol to support patient/family hopes for a miracle.

DATA SOURCES

Literature review.

CONCLUSION

Spiritual communication is important throughout cancer care. Nurses can assess and integrate patient and family caregivers' spiritual needs in clinical care by practicing self-awareness and engaging in spiritual care communication strategies.

IMPLICATIONS FOR NURSING PRACTICE

Spirituality is recognized as an essential component of quality care. Spiritual conversations can increase patients' satisfaction with care and improve well-being.

A Research Agenda for Communication Scholars in the Precision Medicine Era

The 2015 announcement of the Precision Medicine Initiative (PMI) galvanized and energized efforts to reconsider medical practice through tailoring of prevention and treatment recommendations based on genetics, environment, and lifestyle. Numerous disciplines contributed white papers identifying challenges associated with PMI and calling for discipline-specific research that might provide solutions to such challenges. Throughout these white papers, the prominence of communication in achieving the PMI's goals is obviously apparent. In this article, we highlight opportunities for communication scholars' contributions to the PMI based on challenges identified in white papers from other disciplines and work already conducted by research teams in the field of communication.

Patient and family communication during consultation visits: The effects of a decision aid for treatment decision-making for localized prostate cancer

OBJECTIVE

To analyze the effects of a decision aid on improving patients' and family members' information giving and question asking during consultations for prostate cancer treatment decision-making.

METHODS

This study is a secondary analysis of archived audio-recorded real-time consultation visits with participants from a randomized clinical trial. Participants were randomly assigned into three groups: TD-intervention targeted patient-only; TS-intervention targeted patients and family members; and control-a handout on staying healthy during treatment. We conducted content analysis using a researcher-developed communication coding system. Using SAS 9.3, we conducted Chi-square/Fisher's exact test to examine whether information giving and question asking among patients and family members varied by groups when discussing different content/topics.

RESULTS

Compared with those in the TS and control groups, significantly higher percentages of participants in the TD group demonstrated information giving in discussing topics about diagnosis, treatment options, risks and benefits, and preferences; and engaged in question asking when discussing diagnosis, watchful waiting/active surveillance, risks and benefits, and preferences for treatment impacts.

CONCLUSION

Information support and communication skills training for patients were effective in improving communication during treatment decision-making consultations.

PRACTICE IMPLICATIONS

Providing information about prostate cancer and communication skills training empower patients and their family members.

NEXus: Making Efficient Use of Limited Resources

Faculty to teach and mentor doctoral nursing students are and will continue to be in short supply. Coupled with ever-increasing resource-constricted educational environments, doctoral programs are challenged to provide high-quality education with limited resources. The Nursing Education Exchange (NEXus) is a viable solution to help meet that challenge. This article presents an overview of the origins and evolution of NEXus, financial considerations, and basic steps for joining NEXus, along with 4 exemplars. NEXus has continued to grow since its inception in 2007. In 2015, the number of NEXus schools reached 20, with 11 schools offering both doctor of philosophy and doctor of nursing practice courses. Currently, NEXus offers over 160 courses, organized into 14 clusters such as gerontology and chronic illness. Recently, a collaboration between the National Hartford Centers of Gerontological Nursing Excellence and NEXus was formalized. This collaboration prepares faculty to address an aging population. In summary, in an era of increased demand for doctoral prepared nurses, a lack of qualified doctoral nursing faculty, and limited financial resources, the NEXus collaborative provides a model for optimal resource sharing.

Addressing Methodological Challenges in Large Communication Data Sets: Collecting and Coding Longitudinal Interactions in Home Hospice Cancer Care

In this article, we present strategies for collecting and coding a large longitudinal communication data set collected across multiple sites, consisting of more than 2000 hours of digital audio recordings from approximately 300 families. We describe our methods within the context of implementing a large-scale study of communication during cancer home hospice nurse visits, but this procedure could be adapted to communication data sets across a wide variety of settings. This research is the first study designed to capture home hospice nurse-caregiver communication, a highly understudied location and type of communication event. We present a detailed example protocol encompassing data collection in the home environment, large-scale, multisite secure data management, the development of theoretically-based communication coding, and strategies for preventing coder drift and ensuring reliability of analyses. Although each of these challenges has the potential to undermine the utility of the data, reliability between coders is often the only issue consistently reported and addressed in the literature. Overall, our approach demonstrates rigor and provides a "how-to" example for managing large, digitally recorded data sets from collection through analysis. These strategies can inform other large-scale health communication research.

Interdisciplinary Team Care and Hospice Team Provider Visit Patterns during the Last Week of Life

BACKGROUND

Hospice provides intensive end-of-life care to patients and their families delivered by an interdisciplinary team of nurses, aides, chaplains, social workers, and physicians. Significant gaps remain about how team members respond to diverse needs of patients and families, especially in the last week of life.

OBJECTIVE

The study objective was to describe the frequency of hospice team provider visits in the last week of life, to examine changes in frequency over time, and to identify patient characteristics that were associated with an increase in visit frequency.

DESIGN

This was a retrospective cohort study using electronic medical record data.

SETTING/SUBJECTS

From U.S. not-for-profit hospices, 92,250 records were used of patients who died at home or in a nursing home, with a length of stay of at least seven days.

MEASUREMENTS

Data included basic demographic variables, diagnoses, clinical markers of illness severity, patient functioning, and number of hospice team member visits in the last seven days of life.

RESULTS

On average the total number of hospice team member visits in the last week of life was 1.36 visits/day. Most were nurse visits, followed by aides, social workers, and chaplains. Visits increased over each day on average across the last week of life. Greater increase in visits was associated with patients who were younger, male, Caucasian, had a spouse caregiver, and shorter lengths of stay.

CONCLUSIONS

This study provides important information to help hospices align the interdisciplinary team configuration with the timing of team member visits, to better meet the needs of the patients and families they serve.

Breast Cancer Risk Perceptions among Relatives of Women with Uninformative Negative BRCA1/2 Test Results: The Moderating Effect of the Amount of Shared Information

The most common result of BRCA1/2 mutation testing when performed in a family without a previously identified mutation is an uninformative negative test result. Women in these families may have an increased risk for breast cancer because of mutations in non-BRCA breast cancer predisposition genes, including moderate- or low-risk genes, or shared environmental factors. Genetic counselors often encourage counselees to share information with family members, however it is unclear how much information counselees share and the impact that shared information may have on accuracy of risk perception in family members. We evaluated 85 sisters and daughters of women who received uninformative negative BRCA1/2 results. We measured accuracy of risk perception using a latent variable model where accuracy was represented as the correlation between perceived risk (indicators = verbal and quantitative measures) and calculated risk (indicators = Claus and BRCAPRO). Participants who reported more information was shared with them by their sister or mother about her genetic counseling session had greater accuracy of risk perception (0.707, p = 0.000) than those who reported little information was shared (0.326, p = 0.003). However, counselees shared very little information; nearly 20 % of family members reported their sister or mother shared nothing with them about her genetic counseling. Family members were generally not aware of the existence of a genetic counseling summary letter. Our findings underscore the need for effective strategies that facilitate counselees to share information about their genetic counseling sessions. Such communication may help their relatives better understand their cancer risks and enhance risk appropriate cancer prevention.

Managing Medications During Home Hospice Cancer Care: The Needs of Family Caregivers

CONTEXT

Family caregivers (FCGs) are often at the frontline of symptom management for patients with advanced illness in home hospice. FCGs' cognitive, social, and technical skills in complex medication management have been well studied in the literature; however, few studies have tested existing frameworks in clinical cases in home hospice.

OBJECTIVES

This study sought to assess the applicability of caregiver medication management skills framework by Lau et al. in the context of family caregiving in home hospice to further the understanding of FCGs' essential medication management skills.

METHODS

This was a secondary data analysis of 18 audio recorded home hospice visits transcribed verbatim; deductive content analysis of caregiver-nurse interactions was conducted. The target sample included FCGs of hospice patients who had cancer diagnoses in hospices located in the greater urban area of the Rocky Mountain West. Caregiver medication management skills were identified and categorized into the five domains of caregiver expertise. Exemplars of each domain were identified.

RESULTS

An average of four medications (SD = 3.5) was discussed at each home hospice visit. Medication knowledge skills were observed in most home hospice visits (15 of 18). Teamwork skills were observed in 11 of 18 cases, followed by organizational and personhood skills (10 of 18). Symptom management skills occurred in 12 of 18 cases. An additional two subconstructs of the personhood domain-1) advocacy for the caregiver and 2) skills in discontinuing medications-were proposed.

CONCLUSION

These findings support framework by Lau et al. for caregiver medication management skills and expands on the existing domains proposed. Future interventions to assess FCGs' skills are recommended.

Predicting Nurses' Turnover: The Aversive Effects of Decreased Identity, Poor Interpersonal Communication, and Learned Helplessness

Through a social identity theoretical lens, this study examines how nurses' identification with their working small group, unit, or floor, nursing role (e.g., staff ER nurse, nurse practitioner), and nursing profession relate to nurses' interaction involvement, willingness to confront conflict, feelings of learned helplessness, and tenure (employment turnover) intentions. A cross-sectional survey (N = 466) was conducted at a large, quaternary care hospital system. Structural equation modeling uncovered direct and indirect effects between the five primary variables. Findings demonstrate direct relationships between nurse identity (as a latent variable) and interaction involvement, willingness to confront conflict, and tenure intentions. Feelings of learned helplessness are attenuated by increased nurse identity through interaction involvement and willingness to confront conflict. In addition, willingness to confront conflict and learned helplessness mediate the relationship between interaction involvement and nurses' tenure intentions. Theoretical extensions include indirect links between nurse identity and learned helplessness via interaction involvement and willingness to confront conflict. Implications for interpersonal communication theory development, health communication, and the nursing profession are discussed.

Social support needs: discordance between home hospice nurses and former family caregivers

OBJECTIVE

The two goals of our study were to (1) identify which of five types of social support (Informational, Esteem, Emotional, Tangible, Belonging) are most cited by hospice nurses and family caregivers and (2) determine the match in perception of support needs.

METHOD

As part of a larger multiphase project, focus groups were conducted with former family caregivers and hospice nurses to discuss their experiences of home hospice care and to gather their opinions on the important issues involved in that care. Transcripts of focus group discussions were coded for support type (Informational, Esteem, Emotional, Tangible, Belonging) based on definitions from the literature. Nurse and caregiver data were compared to assess for potential match.

RESULTS

Analysis of coded data suggested that nurses see different types of support to be needed in equal measure across their caseloads, while caregivers expressed priorities for some types of support. Illustrative examples of each type of support are provided and discussed.

SIGNIFICANCE OF RESULTS

Because matching support provided with the type of support desired has been linked to improved physical and psychological outcomes, it is important to focus on this match in healthcare populations particularly vulnerable to psychological stress, including family caregivers of home hospice patients. This research has implications for interventions to match support provision to caregiver needs, or for education for home hospice providers to ensure that they are not only sensitive to the possibility of a broad range of needs but also to the necessity to tailor care to those needs.

The Religion of “I Don’t Know”

The goal of this pilot study was to identify naturally occurring, spiritually relevant conversations and elucidate challenges for nurses in home hospice. We examined naturalistic communication data collected during nurse hospice visits with cancer patients and their family caregivers. Using deductive content analysis, guided by Consensus Conference spiritual categories and definition, categorical themes were identified. Thirty-three visits to seven families were recorded by five nurses. Although most spiritual dialogue was brief, analysis revealed five themes: Spiritual Beliefs and Rituals, Connection, Spiritual Comfort, Closure and Acceptance, and Spiritual Distress. Findings demonstrate the range of spiritual issues raised in hospice and challenges nurses face in maintaining boundaries while remaining genuine and family-centered in providing care. This work serves as a foundation for future research and education to help clinicians to engage in more intentional spiritual conversations in the support of families at end of life.

Strategies to Support Spirituality in Health Care Communication

Background: Although there is growing recognition of the importance of integrating spirituality within health care, there is little evidence to guide clinicians in how to best communicate with patients and family about their spiritual or existential concerns. Methods: Using an audio-recorded home hospice nurse visit immediately following the death of a patient as a case-study, we identify spiritually-sensitive communication strategies. Results: The nurse incorporates spirituality in her support of the family by 1) creating space to allow for the expression of emotions and spiritual beliefs and 2) encouraging meaning-based coping, including emphasizing the caregivers’ strengths and reframing negative experiences. Discussion: Hospice provides an excellent venue for modeling successful examples of spiritual communication. Health care professionals can learn these techniques to support patients and families in their own holistic practice. Implications for Practice: All health care professionals benefit from proficiency in spiritual communication skills. Attention to spiritual concerns ultimately improves care.

Reflective research: supporting researchers engaged in analyzing end-of-life communication

OBJECTIVES

The objectives of this commentary are to: (1) identify unique aspects of communication at end-of-life as compared to more commonly studied healthcare encounters; (2) outline challenges and opportunities research team members may encounter in coding and analyzing end-of-life communication; and (3) offer recommendations for quantitative communication research teams. This commentary is based on ours and others' experiences in studying the communication among patients with terminal illnesses, their families and their providers. Provider-patient/caregiver communication at end-of-life has some differences as compared to other forms of healthcare communication and, thus, has implications for researcher response. Challenges and opportunities for research team members include gaining new knowledge, developing feelings of attachment to study participants, burn-out, and emotional and existential impact on personal life. Practical and psychological considerations for conducting end-of-life communication research are discussed.

CONCLUSIONS

Researchers engaged in the study of end-of-life interactions may experience unique challenges, potentially compromising the validity of the research results and interpretation of communication processes. A balance between likely coder emotions and objectivity must be achieved.

IMPLICATIONS

Anticipating and facilitating the research teams' reactions to end-of-life interactions while still maintaining scientific standards may be achieved by using a reflective, mindful approach.

Hospice nurse communication with patients with cancer and their family caregivers

BACKGROUND

Effective communication by hospice nurses enhances symptom management for the patient, reduces family caregiver burden and distress, and potentially improves bereavement adjustment. However, research has not kept pace with the rising use of hospice by patients with cancer and thus we know little about how hospice nurses communicate.

METHODS

The overriding objective of this pilot study was to provide insight into these in-home visits. Hospice nurses audiorecorded their interactions over time with family caregivers and patients with cancer. The communication within these tapes was coded using Roter Interaction Analysis System (RIAS) and analyzed.

RESULTS

We found that tape recording home hospice nurse visits was feasible. RIAS was suited to capture the general content and process of the home hospice encounter and the coded interactions show the range of topics and emotions that are evident in the dialogue. Implications and future directions for research are discussed.

Validity of the Patient Generated Index as a quality-of-life measure in radiation oncology

PURPOSE/OBJECTIVES

To evaluate psychometric properties of an instrument designed to measure individualized health-related quality of life (HRQOL).

DESIGN

Repeated measures of self-reported quality of life.

SETTING

An outpatient radiation therapy department in the western part of the United States.

SAMPLE

86 adults with cancer receiving their first course of radiation therapy.

METHODS

The Patient Generated Index (PGI), the National Comprehensive Cancer Network's Distress Thermometer (DT), and the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core-30 (QLQ-C30).

MAIN RESEARCH VARIABLES

Convergent validity, responsiveness, sensitivity, and response shift.

FINDINGS

PGI scores were inversely correlated with scores on the DT (r = -0.49, -0.55, -0.44; p < 0.001), as well as the role (r = 0.31, 0.4, 0.38; p < 0.01), emotional (r = 0.33, 0.41, 0.33; p < 0.01), social functioning (r = 0.27, 0.49, 0.42; p < 0.05), pain (r = -0.29, -0.39, -0.39; p < 0.01), and fatigue (r = -0.35, -0.25, -0.47; p < 0.05) QLQ-C30 subscales at all measurement times. The PGI was responsive to those reporting high or low DT scores (t = 4.42, 3.32, 2.9; p < 0.05). A small-to-moderate effect size was detected in those who had an increase (effect size = 0.51) or decrease (effect size = 0.38) in HRQOL over time. Participants reconceptualized HRQOL over time.

CONCLUSIONS

Data supported the PGI as a valid measure of individualized HRQOL.

IMPLICATIONS FOR NURSING

The PGI potentially provides a more patient-centered measure of HRQOL in patients with cancer. Additional testing is needed in larger, more diverse groups.

Assessing patient-centered communication in a family practice setting: how do we measure it, and whose opinion matters?

OBJECTIVE

This study evaluated variables thought to influence patient's perceptions of patient-centeredness. We also compared results from two coding schemes that purport to evaluate patient-centeredness, the Measure of Patient-Centered Communication (MPCC) and the 4 Habits Coding Scheme (4HCS).

METHODS

174 videotaped family practice office visits, and patient self-report measures were analyzed.

RESULTS

Patient factors contributing to positive perceptions of patient-centeredness were successful negotiation of decision-making roles and lower post-visit uncertainty. MPCC coding found visits were on average 59% patient-centered (range 12-85%). 4HCS coding showed an average of 83 points (maximum possible 115). However, patients felt their visits were highly patient-centered (mean 3.7, range 1.9-4; maximum possible 4). There was a weak correlation between coding schemes, but no association between coding results and patient variables (number of pre-visit concerns, attainment of desired decision-making role, post-visit uncertainty, patients' perception of patient-centeredness).

CONCLUSIONS

Coder inter-rater reliability was lower than expected; convergent and divergent validity were not supported. The 4HCS and MPCC operationalize patient-centeredness differently, illustrating a lack of conceptual clarity.

PRACTICE IMPLICATIONS

The patient's perspective is important. Family practice providers can facilitate a more positive patient perception of patient-centeredness by addressing patient concerns to help reduce patient uncertainty, and by negotiating decision-making roles.

Modeling relationships in clinical research using path analysis part I: an overview of the process

Scientific Inquiry provides a forum to facilitate the ongoing process of questioning and evaluating practice, presents informed practice based on available data, and innovates new practices through research and experimental learning.