Effective communication skills are the key to good cancer care

What surgeons tell patients and what patients want to know before major cancer surgery: a qualitative study

BACKGROUND

The information surgeons impart to patients and information patients want about surgery for cancer is important but rarely examined. This study explored information provided by surgeons and patient preferences for information in consultations in which surgery for oesophageal cancer surgery was discussed.

METHODS

Pre-operation consultations in which oesophagectomy was discussed were studied in three United Kingdom hospitals and patients were subsequently interviewed. Consultations and interviews were audio-recorded, transcribed in full and anonymized. Interviews elicited views about the information provided by surgeons and patients' preferences for information. Thematic analysis of consultation-interview pairs was used to investigate similarities and differences in the information provided by surgeons and desired by patients.

RESULTS

Fifty two audio-recordings from 31 patients and 7 surgeons were obtained (25 consultations and 27 patient interviews). Six consultations were not recorded because of equipment failure and four patients declined an interview. Surgeons all provided consistent, extensive information on technical operative details and in-hospital surgical risks. Consultations rarely included discussion of the longer-term outcomes of surgery. Whilst patients accepted that information about surgery and risks was necessary, they really wanted details about long-term issues including recovery, impact on quality of life and survival.

CONCLUSIONS

This study demonstrated a need for surgeons to provide information of importance to patients concerning the longer term outcomes of surgery. It is proposed that "core information sets" are developed, based on surgeons' and patients' views, to use as a minimum in consultations to initiate discussion and meet information needs prior to cancer surgery.

Masculinity in the doctor's office: Masculinity, gendered doctor preference and doctor-patient communication

OBJECTIVE

Mortality and morbidity data suggest that men have shorter life expectancies than women and outrank women on several leading causes of death. These gendered disparities may be influenced by psychosocial factors like masculinity.

METHODS

Three studies (Total N=546) examined the role of masculinity in men's doctor choices and doctor-patient interactions. In Studies 1 and 2, men completed measures of masculinity, gender bias, and doctor preference. Using structural equation modeling, we tested the direct relationship between masculinity and male doctor preference and the indirect relationship of masculinity on male doctor preference through an association with gendered competence stereotypes. Participants in Study 3 disclosed symptoms in private followed by disclosure to a male or female interviewer in a clinical setting. Using repeated measures analysis of variance (ANOVA), we examined the interaction among symptom reporting, masculinity and doctor gender, controlling for participant comfort.

RESULTS

In Study 1, results suggested that masculinity encouraged choice of a male doctor directly and indirectly via beliefs that men make more competent doctors than women; Study 2 directly replicated the results of Study 1. In Study 3, independent of participant comfort, an interaction between interviewer gender and masculinity emerged such that men scoring higher on masculinity reported symptoms less consistently to male interviewers (relative to higher scoring men reporting to female interviewers); the reverse was found for men scoring low on masculinity.

CONCLUSIONS

Taken together these studies suggest that masculinity may affect men's health by encouraging choice of a male doctor with whom doctor-patient communication may be impaired.

Assessing the quality of written information provision for surgical procedures: a case study in oesophagectomy

OBJECTIVE

To examine the content and quality of written information provided by surgical centres for patients undergoing oesophagectomy for cancer.

DESIGN

Cross-sectional study of the content of National Health Service (NHS) patient information leaflets (PILs) about oesophageal cancer surgery, using a modified framework approach.

DATA SOURCES

Written information leaflets from 41 of 43 cancer centres undertaking surgery for oesophageal cancer in England and Wales (response rate 95.3%).

ELIGIBILITY CRITERIA

All English language versions of PILs about oesophagectomy.

RESULTS

32 different PILs were identified, of which 2 were generic tools (Macmillan 'understanding cancer of the gullet' and EIDO 'oesophagectomy'). Although most PILs focused on describing in-hospital adverse events, information varied widely and was often misleading. Just 1 leaflet described survival benefits of surgery and 2 mentioned the possibility of disease recurrence.

CONCLUSIONS

Written information provided for patients by NHS cancer centres undertaking oesophagectomy is inconsistent and incomplete. It is recommended that surgeons work together with patients to agree on standards of information provision of relevance to all stakeholders' needs.

Oncology health workers' views and experiences on caring for ethnic minority patients: A mixed method systematic review

OBJECTIVES

To investigate what published research reveals about the views and experiences of oncology health workers when caring for ethnic minority patients.

DESIGN

Systematic review of qualitative and quantitative studies.

DATA SOURCES

The following databases were systematically screened: PubMed, CINAHL, Web of Science, and AnthroSource. Reference lists were checked for additional articles.

REVIEW METHODS

Empirical studies or systematic reviews (1/2000 to 12/2013) were included if they concerned the oncology setting and the views or experiences of healthcare workers and care users belonging to an ethnic or cultural minority group. The methodological quality of each individual study was assessed using the Critical Appraisal Skills Programme for Qualitative Studies and the Quality Assessment Tool for Quantitative Studies.

RESULTS

Eighteen publications met the inclusion criteria. Thirteen articles had a qualitative, four a quantitative, and one a mixed methods design. The results in the individual studies were heterogeneous. Most studies reported challenges or barriers when caring for ethnic minority patients, whereas fewer than half of the articles discussed facilitating factors and opportunities. Oncology health workers participating in the included studies sought to provide professional standards of care and tried to adapt care to the needs of ethnic minority patients. However, they experienced formidable communication barriers and they feared doing things that might be considered culturally insensitive. The organizational aspects of care for the oncology patient appeared to have a significant influence on how healthcare providers view and experience oncology care for ethnic minority patients.

CONCLUSIONS

Views and experiences of participating oncology health workers were characterized by a willingness to provide proper care for ethnic minority patients, but this was hampered by a tangle of interrelated issues such as linguistic barriers, fear and uncertainty, and assumptions about cultural matters. Organizational aspects were shown to be a strong influence on healthcare workers caring for ethnic minority patients. Due to methodological limitations of the included studies, conclusions should be viewed with caution.

Communication between family carers and health professionals about end-of-life care for older people in the acute hospital setting: a qualitative study

BACKGROUND

This paper focuses on communication between hospital staff and family carers of patients dying on acute hospital wards, with an emphasis on the family carers' perspective. The age at which people in the UK die is increasing and many continue to die in the acute hospital setting. Concerns have been expressed about poor quality end of life care in hospitals, in particular regarding communication between staff and relatives. This research aimed to understand the factors and processes which affect the quality of care provided to frail older people who are dying in hospital and their family carers.

METHODS

The study used mixed qualitative methods, involving non-participant observation, semi-structured interviews and a review of case notes. Four acute wards in an English University teaching hospital formed the setting: an admissions unit, two health care of older people wards and a specialist medical and mental health unit for older people. Thirty-two members of staff took part in interviews, five members of the palliative care team participated in a focus group and 13 bereaved family carers were interviewed. In all, 245 hours of observation were carried out including all days of the week and all hours of the day. Forty-two individual patient cases were constructed where the patient had died on the wards during the course of the study. Thirty three cases included direct observations of patient care. Interviews were completed with 12 bereaved family carers of ten patient cases.

RESULTS

Carers' experience of the end of life care of their relative was enhanced when mutual understanding was achieved with healthcare professionals. However, some carers reported communication to be ineffective. They felt unsure about what was happening with their relative and were distressed by the experience of their relative's end of life care.

CONCLUSIONS

Establishing a concordant relationship, based on negotiated understanding of shared perspectives, can help to improve communication between healthcare professionals and family carers of their patients.

A Qualitative Investigation of Health Care Professionals', Patients' and Partners' Views on Psychosocial Issues and Related Interventions for Couples Coping with Cancer

INTRODUCTION

There is growing evidence that cancer affects couples as an interdependent system and that couple-based psychosocial interventions are efficacious in reducing distress and improving coping skills. However, adoption of a couples-focused approach into cancer care is limited. Previous research has shown that patients and partners hold differing views from health care professionals (HCPs) regarding their psychosocial needs, and HCPs from different disciplines also hold divergent views regarding couples' psychosocial needs. This study aimed to explore the perspectives of HCPs and couples on the provision of couple-focused psychosocial care in routine cancer services.

METHODS

A qualitative study using semi-structured interviews was undertaken with 20 HCPs (medical oncologists, nurses, psycho-oncology professionals) and 20 couples where one member had been diagnosed with cancer (breast, prostate, head/neck, bowel, multiple myeloma). Interviews were analysed using the framework approach.

RESULTS

Three core themes were identified: "How Do Couples Cope with Cancer?" emphasised the positive and negative coping strategies used by couples, and highlighted that partners perceived a lack of engagement by HCPs. "What Is Couple-focused Psychosocial Care for People with Cancer?" described varying perspectives regarding the value of couple-focused psychosocial care and variation in the types of support couples need among HCPs and couples. Whereas most couples did not perceive a need for specialist couple-focused support and interventions, most HCPs felt couple-focused psychosocial care was necessary. "How Can Couple-Focused Psychosocial Care be Improved?" described couples' view of a need for better provision of information, and the importance of their relationship with oncology clinicians. HCPs identified a lack of confidence in responding to the emotional needs of couples, and barriers to providing psychosocial care, including challenges identifying distress (through screening) and referring distressed individuals/couples for specialist assessment.

CONCLUSIONS

The three core themes revealed discrepancies about couple-focused psychosocial care between HCPs and couples, and HCPs from different professional backgrounds, and several barriers to the provision of psychosocial care for couples. Despite HCPs and couples acknowledging that a couple-focused approach to psycho-social support was potentially beneficial, the majority of couples did not feel they needed specific couple-focused interventions. These issues and recommendations for future research are discussed.

ComOn Coaching: Study protocol of a randomized controlled trial to assess the effect of a varied number of coaching sessions on transfer into clinical practice following communication skills training

BACKGROUND

Communication skills training has proven to be an effective means to enhance communication of health care professionals in oncology. These effects are well studied in standardized settings. The question of transferring these skills into clinical consultations remains open. We build up on a previous developed training concept consisting of a workshop and coaching. This training achieved a medium effect size in two studies with standardized patients. In the current study, we expanded and manualized the coaching concept, and we will evaluate effects of a varied number of coaching sessions on real clinical consultations. Our aim is to determine how much coaching oncologists need to transfer communication skills into clinical practice.

METHODS/DESIGN

Physicians of two German medical centers will participate in a workshop for communication skills and will be randomized to either a group with one coaching session or a group with four coaching sessions following the workshop. The participation is voluntary and the physicians will receive medical education points. Consultations held by the participating physicians with actual patients who gave their informed consent will be filmed at three time points. These consultations will be evaluated by blinded raters using a checklist based on the training content (primary outcome). Secondary outcomes will be the self-evaluated communication competence by physicians and an evaluation of the consultations by both physicians and patients.

DISCUSSION

We will evaluate our communication training concept on three levels - rater, physician and patient - and concentrate on the transfer of communication skills into real life situations. As we emphasize the external validity in this study design, limitations will be expected due to heterogeneity of data. With this study we aim to gain data on how to improve communication skills training that will result in better patient outcomes.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00004385 .

Fears, Uncertainties, and Hopes: Patient-Initiated Actions and Doctors' Responses During Oncology Interviews

New cancer patients frequently raise concerns about fears, uncertainties, and hopes during oncology interviews. This study sought to understand when and how patients raise their concerns, how doctors responded to these patient-initiated actions, and implications for communication satisfaction. A subsampling of video recorded and transcribed encounters was investigated involving 44 new patients and 14 oncologists. Patients completed pre/post self-report measures about fears, uncertainties, and hopes as well as postevaluations of interview satisfaction. Conversation analysis was used to initially identify pairs of patient-initiated and doctor-responsive actions. A coding scheme was subsequently developed, and two independent coding teams, comprised of two coders each, reliably identified patient-initiated and doctor-responsive social actions. Interactional findings reveal that new cancer patients initiate actions much more frequently than previous research had identified, concerns are usually raised indirectly, and with minimal emotion. Doctors tend to respond to these concerns immediately, but with even less affect, and rarely partner with patients. From pre/post results, it was determined that the higher patients' reported fears, the higher their postvisit fears and lower their satisfaction. Patients with high uncertainty were highly proactive (e.g., asked more questions), yet reported even greater uncertainties after encounters. Hopeful patients also exited interviews with high hopes. Overall, new patients were very satisfied: oncology interviews significantly decreased patients' fears and uncertainties, while increasing hopes. Discussion raises key issues for improving communication and managing quality cancer care.

Reliability and validity of OSCE checklists used to assess the communication skills of undergraduate medical students: A systematic review

OBJECTIVES

To explore inter-rater agreement between reviewers comparing reliability and validity of checklist forms that claim to assess the communication skills of undergraduate medical students in Objective Structured Clinical Examinations (OSCEs).

METHODS

Papers explaining rubrics of OSCE checklist forms were identified from Pubmed, Embase, PsycINFO, and the ProQuest Education Databases up to 2013. Included were those studies that report empirical validity or reliability values for the communication skills assessment checklists used. Excluded were those papers that did not report reliability or validity.

RESULTS

Papers focusing on generic communication skills, history taking, physician-patient communication, interviewing, negotiating treatment, information giving, empathy and 18 other domains (ICC -0.12-1) were identified. Regarding the validity and reliability of the communication skills checklists, agreement between reviewers was 0.45.

CONCLUSIONS

Heterogeneity in the rubrics used in the assessment of communication skills and a lack of agreement between reviewers makes comparison of student competences within and across institutions difficult.

PRACTICE IMPLICATIONS

Consideration should be afforded to the adoption of a standardized measurement instrument to assess communication skills in undergraduate medical education. Future research will focus upon evaluating the potential impact of adoption of a standardized measurement instrument.

The lasting impact of the therapeutic alliance: Patient-oncologist alliance as a predictor of caregiver bereavement adjustment

BACKGROUND

Caregivers of patients with advanced cancer provide extensive care and experience high levels of psychosocial distress. The patient-oncologist therapeutic alliance may be a modifiable factor that can prevent or reduce negative caregiver outcomes.

METHODS

Coping with Cancer (CwC) was a prospective, longitudinal, multisite cohort study of terminally ill cancer patients (life expectancy ≤6 months) and their informal caregivers, who were followed into bereavement (n = 68). Trained raters interviewed patients and caregivers upon study entry and also interviewed caregivers 6 months after the patient's death. Patients answered quantitative questions assessing their perception of the patient-oncologist therapeutic alliance (The Human Connection scale), and caregivers completed a measure of health-related quality of life (Medical Outcomes Study Short Form-36). Interviewers rated caregivers' level of emotional well being. Associations between therapeutic alliance and caregiver outcomes were analyzed using univariate analysis of variance and logistic regression analyses, controlling for baseline caregiver measures and confounding sample characteristics.

RESULTS

A strong patient-oncologist therapeutic alliance was bivariately associated with caregiver self-report of less role limitation because of emotional problems, better social function and mental and general health-related quality of life, and better interviewer-rated emotional well being after the patient's death. After controlling for baseline measures and confounding sample characteristics, the correlation between patient-perceived therapeutic alliance and bereaved caregivers' mental health and interviewer ratings of bereaved caregivers' emotional well being remained significant.

CONCLUSIONS

The influence of the patient-oncologist alliance may generalize beyond the patient to positively impact the caregiver. By developing a strong relationship with the patient, the oncologist may benefit the caregiver and the patient. This caregiver benefit may extend into bereavement.

'Abandoned by medicine'? A qualitative study of women's experiences with lymphoedema secondary to cancer, and the implications for care

BACKGROUND

Lymphoedema secondary to cancer is a relatively neglected and under-researched condition. Few studies report people's experiences of care and treatment provision when living with the condition. Current practice focuses on the physical treatment yet psychosocial needs often remain unmet. A previous study examining the patient perspective identified the theme of being 'abandoned by medicine'. Perceived lack of support may result in a delayed adaptation and acceptance of this long-term condition and can significantly impact on psychological well-being. We explore this emerging theme alongside others in order to provide a guide to action for improvements for patient benefit.

AIM

The central aim was to explore women's views of their care and treatment following a diagnosis with lymphoedema secondary to cancer. This forms part of a larger study aimed at assessing appropriate screening tools to measure psychosocial distress.

METHODS

A mixed-methods approach was used for the main study. Here we report the qualitative component, derived from in-depth semi-structured interviews conducted in the homes of the participants (n = 14) and focus group discussions (n = 15). In addition, qualitative comments from questionnaire data from a large-scale postal survey are included (n = 104).

FINDINGS

Participants identified considerable deficiencies in health care workers' knowledge and awareness of lymphoedema, which subsequently impacted on the patients' needs for information, support and understanding. Access to appropriate treatment was patchy and problems were identified with the process of obtaining compression garments, massage and other sources of help. Although lymphoedema is a long-term disfiguring condition, and much is known about how this impacts on patients' emotional well-being, little attention was paid by health professionals to potential psychosocial consequences. In essence women had to become experts of their own condition and cope as best as they could. We provide recommendations to improve service delivery and address these unmet needs.

How do surgeons think they learn about communication? A qualitative study

CONTEXT

Communication education has become integral to pre- and post-qualification clinical curricula, but it is not informed by research into how practitioners think that good communication arises.

OBJECTIVES

This study was conducted to explore how surgeons conceptualise their communication with patients with breast cancer in order to inform the design and delivery of communication curricula.

METHODS

We carried out 19 interviews with eight breast surgeons. Each interview centred on a specific consultation with a different patient. We analysed the transcripts of the surgeons' interviews qualitatively using a constant comparative approach.

RESULTS

All of the surgeons described communication as central to their role. Communication could be learned to some extent, not from formal training, but by selectively incorporating practices they observed in other practitioners and by being mindful in consultations. Surgeons explained that their own values and character shaped how they communicated and what they wanted to achieve, and constrained what could be learned.

CONCLUSIONS

These surgeons' understanding of communication is consistent with recent suggestions that communication education: (i) should place practitioners' goals at its centre, and (ii) might be enhanced by approaches that support 'mindful' practice. By contrast, surgeons' understanding diverged markedly from the current emphasis on 'communication skills'. Research that explores practitioners' perspectives might help educators to design communication curricula that engage practitioners by seeking to enhance their own ways of learning about communication.

Exploring the role of communications in quality improvement: A case study of the 1000 Lives Campaign in NHS Wales

INTRODUCTION

Effective communication is critical to successful large-scale change. Yet, in our experience, communications strategies are not formally incorporated into quality improvement (QI) frameworks. The 1000 Lives Campaign ('Campaign') was a large-scale national QI collaborative that aimed to save an additional 1000 lives and prevent 50 000 episodes of harm in Welsh health care over a 2-year period. We use the Campaign as a case study to describe the development, application, and impact of a communications strategy embedded in a large-scale QI initiative.

METHODS

A comprehensive communications strategy guided communications work during the Campaign. The main aims of the communications strategy were to engage the hearts and minds of frontline National Health Service (NHS) staff in the Campaign and promote their awareness and understanding of specific QI interventions and the wider patient safety agenda. We used qualitative and quantitative measures to monitor communications outputs and assess how the communications strategy influenced awareness and knowledge of frontline NHS staff.

RESULTS

The communications strategy facilitated clear and consistent framing of Campaign messages and allowed dissemination of information related to the range of QI interventions. It reaffirmed the aim and value of the Campaign to frontline staff, thereby promoting sustained engagement with Campaign activities. The communications strategy also built the profile of the Campaign both internally with NHS organizations across Wales and externally with the media, and played a pivotal role in improving awareness and understanding of the patient safety agenda. Ultimately, outcomes from the communications strategy could not be separated from overall Campaign outcomes.

CONCLUSION AND RECOMMENDATIONS

Systematic and structured communications can support and enhance QI initiatives. From our experience, we developed a 'communications bundle' consisting of six core components. We recommend that communications bundles be incorporated into existing QI methodology, though details should be tailored to the specific context and available resource.

Incentivised case finding for depression in patients with chronic heart disease and diabetes in primary care: an ethnographic study

OBJECTIVE

To examine the process of case finding for depression in people with diabetes and coronary heart disease within the context of a pay-for-performance scheme.

DESIGN

Ethnographic study drawing on observations of practice routines and consultations, debriefing interviews with staff and patients and review of patient records.

SETTING

General practices in Leeds, UK.

PARTICIPANTS

12 purposively sampled practices with a total of 119 staff; 63 consultation observations and 57 patient interviews.

MAIN OUTCOME MEASURE

Audio recorded consultations and interviews with patients and healthcare professionals along with observation field notes were thematically analysed. We assessed outcomes of case finding from patient records.

RESULTS

Case finding exacerbated the discordance between patient and professional agendas, the latter already dominated by the tightly structured and time-limited nature of chronic illness reviews. Professional beliefs and abilities affected how case finding was undertaken; there was uncertainty about how to ask the questions, particularly among nursing staff. Professionals were often wary of opening an emotional 'can of worms'. Subsequently, patient responses potentially suggesting emotional problems could be prematurely shut down by professionals. Patients did not understand why they were asked questions about depression. This sometimes led to defensive or even defiant answers to case finding. Follow-up of patients highlighted inconsistent systems and lines of communication for dealing with positive results on case finding.

CONCLUSIONS

Case finding does not fit naturally within consultations; both professional and patient reactions somewhat subverted the process recommended by national guidance. Quality improvement strategies will need to take account of our results in two ways. First, despite their apparent simplicity, the case finding questions are not consultation-friendly and acceptable alternative ways to raise the issue of depression need to be supported. Second, case finding needs to operate within structured pathways which can be accommodated within available systems and resources.

Management of total cancer pain: a case of young adult

Pain due to cancer is one of the most distressing symptoms experienced by the patients at some or the other time during the course of treatment or disease progression. The multidimensional nature of cancer pain is characterized by various dimensions including physical, social, psychological, and spiritual; which together constitute the term "total pain". Young cancer patients illustrate their unique psychological and developmental needs. This case report highlights the concept of "total cancer pain" in a young adult and demonstrates his distinctive social, spiritual, and psychological sufferings. The report emphasizes that addressing all these concerns is considerably significant in order to provide optimal pain relief to the patient. In the present scenario, it has been done by a skillful multiprofessional team communicating effectively with both the patient and the carer.

Provider perspectives on presenting risk information and managing worry about recurrence among breast cancer survivors

BACKGROUND

Although worry about recurrence is a persistent concern among breast cancer survivors, little is known about physicians' confidence about presenting recurrence risk information, identifying women with considerable worry, and helping women manage worry.

METHODS

Between January and June 2012, we surveyed 750 surgeons and 750 medical oncologists randomly sampled from the American Medical Association Physician Masterfile. We tested differences between surgeons and medical oncologists on confidence of presenting risk, identifying and managing worry using chi-square statistic and Student's t-tests and developed multiple variable logistic regression models to explain odds regarding confidence and use of different strategies for managing worry.

RESULTS

The analytic sample included 403 surgeons and 363 medical oncologists (n = 766; response rate = 60%). Compared with surgeons, medical oncologists were significantly more likely to report confidence in: presenting risk information (87.5% vs 73.2%), identifying women who are worried (74.1% vs 63.9%), and managing worry (66.9% vs 52.4%). Confidence in managing worry was associated with more regular inquiry about worry (p = 0.009). Models of the likelihood of using different management strategies varied by provider type (e.g., surgeons more likely than medical oncologists to recommend support group or online resources, oncologists more likely to refer to psychologist or use medications, all p < 0.05).

CONCLUSION

Cancer providers, particularly surgeons, may benefit from educational training to raise confidence in identifying women with high levels of worry and managing women with considerable worry. Communication between specialties and primary care physicians on efforts to manage worry is necessary for coordinated, quality care for women with breast cancer.

Talking about sex with health professionals: the experience of people with cancer and their partners

Changes to sexuality can be one of the most difficult aspects of life following cancer. This study examines the experience of discussing sexuality post cancer with health care professionals (HCPs), from the perspective of women and men with cancer (PWC), and their partners (PPWC), across a range of cancer types. A total of 657 PWC (535 women, 122 men) and 148 PPWC (87 women, 61 men) completed a survey containing closed and open-ended items, analysed by analysis of variance and thematic analysis. Discussions about sexuality with a HCP were more likely to be reported by men (68%) compared to women PWC (43%), and by women (47%) compared to men PPWC (28%), as well as by those with a sexual or reproductive cancer. Men PWC and women PPWC were most likely to want to discuss sexuality with a HCP, with men PWC and PPWC reporting highest levels of satisfaction with such discussions. Open-ended responses revealed dissatisfaction with the unwillingness of HCPs to discuss sexuality, unhappiness with the nature of such discussion, and positive accounts of discussions about sexuality with HCPs. These findings lend support to the notion that people with cancer and their partners may have unmet sexual information and support needs.

The role of helplines in cancer care: intertwining emotional support with information or advice-seeking needs

Helplines are core feature of the contemporary U.K. health care system, however little is known about callers' experiences of seeking cancer-related telephone help. Qualitative interviews were conducted with 32 cancer helpline callers. The findings suggest cancer helplines offer callers (1) time to discuss their issues, (2) anonymity, (3) convenience, and (4) an open outlet for anyone affected by cancer including family/friends. Further, the findings highlighted that callers' help-seeking behavior was multifaceted, with their psychosocial needs being intrinsically intertwined with their information or advice-seeking needs. The implications are discussed in relation to the role of cancer helplines in the healthcare system.

Satisfaction following immediate breast reconstruction: Experiences in the early post-operative stage

OBJECTIVES

This qualitative study aimed to achieve an understanding of women's experiences of immediate breast reconstruction following mastectomy, to better understand the factors influencing patient satisfaction.

DESIGN

Nine women were recruited from a breast unit in the North West of England. Participants were 3-9 months post-reconstruction, had received either an implant-based or Latissimus Dorsi-based immediate reconstruction and were not receiving any adjuvant therapies. An inductive qualitative and phenomenological approach was adopted to data collection and analysis.

METHODS

Women took part in semi-structured interviews. All interviews were transcribed and analysed using thematic analysis.

RESULTS

Four themes were generated: Seeking and receiving information; coping with the outcome of reconstruction; the need for on-going support and a new life after surgery.

CONCLUSION

The study highlights difficulties surrounding receiving information and decision-making, how women make sense of recovery, how they solicit and receive support, and the process by which they begin to make sense of their futures. More focus on these areas in service provision may aid positive psychological outcomes in the recovery process following immediate breast reconstruction.

Information perception, wishes, and satisfaction in ambulatory cancer patients under active treatment: patient-reported outcomes with QLQ-INFO25

Background

Information is vital to cancer patients. Physician–patient communication in oncology presents specific challenges. The aim of this study was to evaluate self-reported information of cancer patients in ambulatory care at a comprehensive cancer centre and examine its possible association with patients’ demographic and clinical characteristics.

Patients and methods

This study included adult patients with solid tumours undergoing chemotherapy at the Institute Jules Bordet’s Day Hospital over a ten-day period. EORTC QLQ-C30 and QLQ-INFO25 questionnaires were administered. Demographic and clinical data were collected. Descriptive and inferential statistics were used.

Results

101 (99%) fully completed the questionnaires. They were mostly Belgian (74.3%), female (78.2%), with a mean age of 56.9 ± 12.8 years. The most frequent tumour was breast cancer (58.4%). Patients were well-informed about the disease and treatments, but presented unmet information domains. The Jules Bordet patients desired more information on treatment side effects, long-term outcome, nutrition, and recurrence symptoms. Patients on clinical trials reported having received less information about their disease and less written information than patients outside clinical trials. Higher information levels were associated with higher quality of life (QoL) scores and higher patient satisfaction.

Conclusion

Patients were satisfied with the information they received and this correlated with higher QoL, but they still expressed unmet information wishes. Additional studies are required to investigate the quality of the information received by patients enrolled in clinical trials.

Physician and Patient and Caregiver Health Attitudes and Their Effect on Medicare Resource Allocation for Patients With Advanced Cancer

IMPORTANCE

Physicians must participate in end-of-life discussions, but they understand poorly their patients' end-of-life values and preferences. A better understanding of these preferences and the effect of baseline attitudes will improve end-of-life discussions.

OBJECTIVE

To determine how baseline attitudes toward quality vs quantity of life affect end-of-life resource allocation.

DESIGN, SETTING, AND PARTICIPANTS

Otolaryngology-head and neck surgery (OHNS) physicians were recruited to use a validated online tool to create a Medicare health plan for advanced cancer patients. During the exercise, participants allocated a limited pool of resources among 15 benefit categories. These data were compared with preliminary data from patients with cancer and their caregivers obtained from a separate study using the same tool. Attitudes toward quality vs quantity of life were assessed for both physicians and patients and caregivers.

INTERVENTIONS

Participation in online assessment exercise.

MAIN OUTCOMES AND MEASURES

Medicare resource allocation.

RESULTS

Of 9120 OHNS physicians e-mailed, 767 participated. Data collected from this group were compared with data collected from 146 patients and 114 caregivers. Compared with patients and caregivers, OHNS physician allocations differed significantly in all 15 benefit categories except home care. When stratified by answers to 3 questions about baseline attitudes toward quality vs quantity of life, there were 3 categories in which allocations of patients and caregivers differed significantly from the group with the opposite attitude for at least 2 questions: other medical care (question 1, P < .001; question 2, P = .005), palliative care (question 1, P = .008; question 2, P = .006; question 3, P = .009), and treatment for cancer (questions 1 and 2, P < .001). In contrast, physician preferences showed significant differences in only 1, nonmatching category for each attitude question: cash (question 1, P = .02), drugs (question 2, P = .03), and home care (question 3, P = .048).

CONCLUSIONS AND RELEVANCE

Patients with cancer and their caregivers have different preferences from physicians. These preferences are, for these patients and their caregivers, affected by their baseline health attitudes, but physician preferences are not. Understanding the effect of baseline attitudes is important for effective end-of-life discussions.

The development and piloting of the REnal specific Advanced Communication Training (REACT) programme to improve Advance Care Planning for renal patients

BACKGROUND

In recent years, the End-Stage Kidney Disease population has increased and is ever more frail, elderly and co-morbid. A care-focused approach needs to be incorporated alongside the disease focus, to identify those who are deteriorating and improve communication about preferences and future care. Yet many renal professionals feel unprepared for such discussions.

AIM

To develop and pilot a REnal specific Advanced Communication Training (REACT) programme to address the needs of End-Stage Kidney Disease patients and renal professionals.

DESIGN

Two-part study: (1) development of the REnal specific Advanced Communication Training programme informed by multi-professional focus group and patient survey and (2) piloting of the programme.

SETTING/PARTICIPANTS

The REnal specific Advanced Communication Training programme was piloted with 16 participants (9 renal nurses/health-care assistants and 7 renal consultants) in two UK teaching hospitals.

RESULTS

The focus group identified the need for better information about end-of-life phase, improved awareness of patient perspectives, skills to manage challenging discussions, 'hands on' practice in a safe environment and follow-up to discuss experiences. The patient survey demonstrated a need to improve communication about concerns, treatment plans and decisions. The developed REnal specific Advanced Communication Training programme was acceptable and feasible and was associated with a non-significant increase in confidence in communicating about end-of-life issues (pre-training: 6.6/10, 95% confidence interval: 5.7-7.4; post-training: 6.9/10, 95% confidence interval: 6.1-7.7, unpaired t-test - p = 0.56), maintained at 3 months.

CONCLUSION

There is a need to improve end-of-life care for End-Stage Kidney Disease patients, to enable them to make informed decisions about future care. Challenges include prioritising communication training among service providers.

Breaking bad news-what patients want and what they get: evaluating the SPIKES protocol in Germany

BACKGROUND

Evaluation of the SPIKES protocol, a recommended guideline for breaking bad news, is sparse, and information about patients' preferences for bad-news delivery in Germany is lacking. Being the first actual-theoretical comparison of a 'breaking bad news' guideline, the present study evaluates the recommended steps of the SPIKES protocol. Moreover, emotional consequences and quality of bad-news delivery are investigated.

PATIENTS AND METHODS

A total of 350 cancer patients answered the MABBAN (Marburg Breaking Bad News Scale), a questionnaire representing the six SPIKES subscales, asking for the procedure, perception and satisfaction of the first cancer disclosure and patient's assign to these items.

RESULTS

Only 46.2% of the asked cancer patients are completely satisfied with how bad news had been broken to them. The overall quality is significantly related to the emotional state after receiving bad news (r = -0.261, P < 0.001). Patients' preferences differ highly significantly from the way bad news were delivered, and the resulting rang list of patients' preferences indicates that the SPIKES protocol do not fully meet the priorities of cancer patients in Germany.

CONCLUSIONS

It could be postulated that the low satisfaction of patients observed in this study reflects the highly significant difference between patients' preferences and bad-news delivery. Therefore, some adjunctions to the SPIKES protocol should be considered, including a frequent reassurance of listeners' understanding, the perpetual possibility to ask question, respect for prearrangement needs and the conception of bad-news delivery in a two-step procedure.

The effect of patient involvement in surgical decision making for carpal tunnel release on patient-reported outcome

PURPOSE

To investigate whether patient-reported outcomes are different according to patients' preference or experience in surgical decision making for carpal tunnel release.

METHODS

We preoperatively surveyed 85 patients who underwent carpal tunnel release regarding their preferred role in the process of surgical decision making and assessed their experienced role in the actual decision making 6 months after surgery using a Control Preference Scale. For patient-reported surgical outcomes, we used the Disabilities of the Arm, Shoulder, and Hand questionnaire. We compared these outcomes with those of patients having different preferences or experiences in surgical decision making and also compared the outcomes according to whether the preferred roles match the experienced roles.

RESULTS

The Disabilities of the Arm, Shoulder, and Hand scores were not significantly different between patients with different preferences for involvement in decision making for surgery or between those with different experiences in the actual decision making. However, those who experienced the same level of involvement as they had preferred were found to have better Disabilities of the Arm, Shoulder, and Hand scores than those who experienced a more active role or a more passive role than they had preferred.

CONCLUSIONS

This study demonstrates that patient-reported outcomes were not different between those with different preferences or experiences in surgical decision making for carpal tunnel release. However, this study suggests that patients whose experience in decision making matched with their preference may have better subjective outcomes after carpal tunnel release. This suggests that patients with carpal tunnel syndrome may benefit from physicians' efforts of identifying patients' preferences for involvement in decision making and matching the identified preferences to the decision-making process.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Patients understanding of depression associated with chronic physical illness: a qualitative study

Background

Detection of depression can be difficult in primary care, particularly when associated with chronic illness. Patient beliefs may affect detection and subsequent engagement with management. We explored patient beliefs about the nature of depression associated with physical illness.

Methods

A qualitative interview study of patients registered with general practices in Leeds, UK. We invited patients with coronary heart disease or diabetes from primary care to participate in semi-structured interviews exploring their beliefs and experiences. We analysed transcripts using a thematic approach, extended to consider narratives as important contextual elements.

Results

We interviewed 26 patients, including 17 with personal experience of depression. We developed six themes: recognising a problem, complex causality, the role of the primary care, responsibility, resilience, and the role of their life story. Participants did not consistently talk about depression as an illness-like disorder. They described a change in their sense of self against the background of their life stories. Participants were unsure about seeking help from general practitioners (GPs) and felt a personal responsibility to overcome depression themselves. Chronic illness, as opposed to other life pressures, was seen as a justifiable cause of depression.

Conclusions

People with chronic illness do not necessarily regard depression as an easily defined illness, especially outside of the context of their life stories. Efforts to engage patients with chronic illness in the detection and management of depression may need further tailoring to accommodate beliefs about how people view themselves, responsibility and negative views of treatment.

"Not a nice experience, not at all": Underprivileged women's experiences of being confronted with cervical cancer

OBJECTIVE

Research on women's experiences of cervical cancer as a health problem focuses primarily on cervical screening, while their experiences of cervical cancer as a disease seem to be underresearched. This study addresses this understudied area and aims to yield insight into the experiences of underprivileged women confronted with this disease.

METHOD

Our study was qualitative, exploratory, and contextual with descriptive and interpretive elements. The context of the study was a radiation oncology department at an academic hospital in the Gauteng Province of South Africa. The target population was all patients diagnosed with cervical cancer referred for treatment at the specific hospital. Convenience sampling selected participants typical of the population. Nineteen open-ended unstructured interviews were conducted after demographic data were collected. One question was posed: "Please tell me what made you think there was something wrong with you?" Thematic analyses were used to analyze the data.

RESULTS

The average age of participants was 47.2 years, with a youngest participant of 29 and oldest of 70. Three themes arose from the data: experiencing the symptoms of cervical cancer, hearing the bad news, and what remained unsaid.

SIGNIFICANCE OF RESULTS

Being confronted with cervical cancer is a traumatic experience. Women suffer unexplained, severe, humiliating vaginal bleeding and unrelieved pain. They have to face a dual healthcare system: on the one hand, unaffordable effective private healthcare and, on the other, the free-of-cost public healthcare that failed them. The bad news of their cervical cancer is most commonly broken in a kind and sympathetic manner, yet misunderstandings and a need for additional information prevail after the bad news conversation. Having to inform their families of their cancer adds to their suffering.

Effect of physician perspective on allocation of Medicare resources for patients with advanced cancer

OBJECTIVES

To assess how physician perspective (perspective of patient vs perspective of physician) affects Medicare resource allocation for patients with advanced cancer and compare physician allocations with actual cancer patient and caregiver allocations.

STUDY DESIGN

Cross-sectional assessment.

SETTING

National assessment.

SUBJECTS

Otolaryngologists.

METHODS

Physicians used a validated tool to create a Medicare plan for patients with advanced cancer. Participants took the perspective of an advanced cancer patient and made resource allocations between 15 benefit categories (assessment 2, November/December 2012). Results were compared with data from a prior assessment made from a physician's perspective (assessment 1, February/March 2012) and with data from a separate study with patients with cancer and caregivers.

RESULTS

In total, 767 physicians completed assessment 1 and 237 completed assessment 2. Results were compared with 146 cancer patient and 114 caregiver assessments. Assessment 1 physician responses differed significantly from patients/caregivers in 14 categories (P < .05), while assessment 2 differed in 11. When comparing physician data, assessment 2 allocations differed significantly from assessment 1 in 7 categories. When these 7 categories were compared with patient/caregiver data, assessment 2 allocations in emotional care, drug coverage, and nursing facility categories were not significantly different. Assessment 1 allocations in cosmetic care, dental, home care, and primary care categories were more similar to patient/caregiver preferences, although all but home care were still significantly different.

CONCLUSIONS

Otolaryngology-head and neck surgery physician perspectives on end-of-life care differ significantly from cancer patient/caregiver perspectives, even when physicians take a patient's perspective when allocating resources. This demonstrates the challenges inherent in end-of-life discussions.

Effective doctor-patient communication: an updated examination

This article examines, in detail, the quality of doctor-patient interaction. Doctor-patient communication is such a powerful indicator of health care quality that it can determine patients' self-management behavior and health outcomes. The medical visit (i.e., the medical encounter) plays a pivotal role in the health care process. In fact, doctor-patient communication is one of the most essential dynamics in health care, affecting the course of patient care and patient compliance with recommendations for care. Unlike many other analyses (that often look at only one or two specific aspects of doctor-patient relationships), this analysis is more encompassing; it looks at doctor-patient communication from multiple perspectives.

Training the powerful: issues that emerged during the evaluation of a communication skills training programme for senior cancer care professionals

'Connected' is the name of the national advanced communication skills training programme developed in 2008 for cancer care professionals in the NHS. A 3-day training course combining didactic and experiential learning elements is run by two facilitators with course participants expected to engage fully in simulated consultations with trained actors. In 2011, and as a result of participant feedback on the length of the course and increasing pressures on budgets and clinical time, the Connected team developed and piloted an alternative 2-day training course. Before its roll-out in 2012, Birmingham City University was commissioned to evaluate the effectiveness and quality of the 2-day course vis-à-vis the 'traditional' 3-day one. This article is written by the two evaluators and it discusses some of the issues that emerged during the evaluation. We broadly grouped these issues into two overlapping categories: the mandatory nature of the course and the different professional background and seniority of participants. In our discussion we consider the implications these issues have for communication skills training policy and practice and put forward suggestions for further research.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Structure and content in consultations with patients undergoing surgery for colorectal cancer

PURPOSE

To explore the structure and content of pre-planned consultations as part of the care and treatment of patients undergoing surgery for colorectal cancer.

METHODS

The study was based on 50 transcripts of audio-recorded pre-planned consultations between seven patients and 36 healthcare professionals from the time of diagnosis, pre-operative consultation, discharge consultation and pathology report in a colorectal unit.

RESULTS

The spread of consultation time between professions was considerable. Total mean consultation time for patients during the care process (7 consultations/patient) was 111 min (range 83-191). The mean consultation time for surgeons was 18 min (7-40), anaesthesiologists 12 min (5-18) and nurses 14 min (5-49). Patients took up 40% of the word space, healthcare professionals used 59% and significant others 1%. Word space changed in such a way that the patient became more active towards the final consultation. Neither during the diagnosis consultation nor during the pre-operative consultation did the patients meet the operating surgeon. Six major subjects emerged: general health, diagnosis, surgical procedure, pre-operative preparations, recovery and treatment and follow-up.

CONCLUSIONS

There is a need for clearer structure in the consultations. Most consultations lacked a clear introduction to the subject of the conversation. The study makes it possible to develop methods and structure for supporting conversations in which the patient is given space to help with the difficult issues present after undergoing surgery for colorectal cancer. The study also contributes to providing knowledge of how to organise surgical consultations in order to optimise person-centeredness, teamwork and clinical efficiency.

Communicating advanced cancer patients' symptoms via the Internet: a pooled analysis of two randomized trials examining caregiver preparedness, physical burden, and negative mood

BACKGROUND

Using available communication technologies, clinicians may offer timely support to family caregivers in managing symptoms in patients with advanced cancer at home.

AIM

To assess the effects of an online symptom reporting system on caregiver preparedness, physical burden, and negative mood.

DESIGN

A pooled analysis of two randomized trials (NCT00214162 and NCT00365963) was conducted to compare caregiver outcomes at 6 and 12 months after intervention between two randomized, unblinded groups using General Linear Mixed Modeling. Caregivers in one group (Comprehensive Health Enhancement Support System-Only) were given access to an interactive cancer communication system, the Comprehensive Health Enhancement Support System. Those in the other group (Comprehensive Health Enhancement Support System + Clinician Report) received access to Comprehensive Health Enhancement Support System plus an online symptom reporting system called the Clinician Report. Clinicians of patients in the Comprehensive Health Enhancement Support System + Clinician Report group received e-mail alerts notifying them when a symptom distress was reported over a predetermined threshold.

SETTING/PARTICIPANTS

Dyads (n = 235) of advanced-stage lung, breast, and prostate cancer patients and their adult caregivers were recruited at five outpatient oncology clinics in the United States.

RESULTS

Caregivers in the Comprehensive Health Enhancement Support System + Clinician Report group reported less negative mood than those in the Comprehensive Health Enhancement Support System-Only group at both 6 months (p = 0.009) and 12 months (p = 0.004). Groups were not significantly different on caregiver preparedness or physical burden at either time point.

CONCLUSIONS

This study provides new evidence that by using an online symptom reporting system, caregivers may experience less emotional distress due to the Clinician Report's timely communication of caregiving needs in symptom management to clinicians.