Parental views on communication between children and clinicians in pediatric oncology: a qualitative study

Parents' Experiences of Palliative Care Decision Making for Children With Terminal Cancer: A Qualitative Study

The objective of this study was to describe the experiences and perceptions of parents making palliative care decisions for children with end-stage malignancies. This qualitative study was conducted with 13 parents from 9 families of children with end-stage malignant tumors. Data were analyzed using thematic content analysis. Three interrelated themes were identified: (1) parental knowledge of the child's condition influences palliative care decision making, (2) the establishment of a mutually trusting relationship between parents and health care professionals is key to implementing palliative care decision making, and (3) the influence of family background and traditional culture on parental palliative care decision making. This study adds to the evidence related to parents' experiences of end-of-life care decision making and provides findings of international significance, particularly concerning the place of care and the introduction of end-of-life care discussions. Parents' expert knowledge of their child's condition is important and should be recognized. End-of-life care decision making is a complex and delicate process; each family's information needs and preferences are individualized and need to be understood by the professionals involved in care.

Successful Development and Implementation of Communication Skills Simulation Training Within Pediatric Hematology-oncology Fellowship Education

Difficult discussions with patients and families are a primary component of pediatric oncology care. We report our experience in the development and implementation of a longitudinal simulation-based Communication Skills Curriculum within a pediatric hematology-oncology fellowship training program. A 6-session simulation curriculum was created for fellows to practice difficult oncology related discussions with a standardized patient (SP). This program was implemented in 2017 and continues presently. Throughout fellowship training the scenarios progress in content and scope. Each simulation was observed and recorded, and written and verbal feedback was provided. The Gap-Kalamazoo Communication Skills Assessment Form was used to assess communication skills in each session. A total of 15 fellows (100% of possible participants) have participated in this curriculum to date. Across all domains of communication skills assessed, the ratings given by the physician evaluators and self-evaluations improved over the course of the scenarios completed throughout fellowship training. This type of simulation-based communication skills curriculum within a pediatric hematology-oncology fellowship training program is feasible to implement. This training is useful to fellows beyond training in improving communication skills, which has the potential to directly benefit the future patients they care for.

An exploratory qualitative study on factors influencing the level of agreement in symptom reports in child-caregiver dyads

OBJECTIVES

Clinicians often rely on caregiver proxy symptom reports to treat cancer-related symptoms in children. Research has described disagreement between children's and caregivers' symptom reports. Factors influencing the level of agreement is an understudied area. Thus, this study aimed to examine potential factors contributing to the level of agreement between symptom reports provided by children and their caregivers.

METHODS

Sixteen child-caregiver dyads participated separately in semi-structured interviews after completing a brief symptom measure independently using an electronic device. Child and caregiver quantitative symptom responses were reviewed in real-time and incorporated into the semi-structured interview. Sample characteristics and the level of agreement between symptom reports were calculated using descriptive statistics. Transcribed participant interviews were analyzed using content analysis.

RESULTS

Nearly half of child-caregiver dyads exhibited a moderate (37.5%, n = 6) or low (18.75%, n = 3) level of agreement on the abbreviated symptom measure. Qualitative analysis identified 5 themes: recognizing symptoms, experiencing symptoms, communicating symptoms, re-assessing and treating symptoms, and influencing individual and relationship factors. Influencing individual, including a child's tendencies or personality traits, and relationship factors intersected the other themes, partially explained their symptom perceptions, and served to facilitate or hinder symptom communication.

SIGNIFICANCE OF RESULTS

Symptom communication is an important part of the symptom cycle, comprised of symptom recognition, experience, and management. Individual and relational factors may influence discrepancies in symptom perceptions between the child and caregiver. Clinicians and researchers should consider developing interventions to enhance symptom communication and promote collaboration between children and their caregivers to address symptom suffering during cancer treatment.

Providing Adolescents with Access to Online Patient Portals: Interviews with Parent-Adolescent Dyads

OBJECTIVE

To identify perceived benefits, problems, facilitators, and barriers to adolescent online patient portal use.

STUDY DESIGN

Qualitative, semi-structured interviews with dyads of parents and adolescents with or without chronic illness. The study team purposively sampled for racial and ethnic minorities and fathers. Three team members then performed thematic analysis of the transcripts, with subsequent dyadic analysis of themes represented by related parents and adolescents.

RESULTS

We performed 102 interviews with 51 dyads of parents and adolescents (26 with chronic illness, 25 without chronic illness). Nearly all participants believed that adolescents should be permitted portal access. We identified 4 themes related to portal benefits: improves adolescent's knowledge of health; supports medical self-management and autonomy; strengthens communication and relationships; and supports parental influence. We identified 4 themes related to portal problems: misunderstanding or confusion; emotional distress; strain on relationships; and irresponsible use of portal. Facilitators of portal use included severity of illness, adolescent's curiosity, and ease of technology use. Barriers included lack of awareness or interest, complexity of information, and access difficulties. Twenty adolescents (39%) did not know they could access the portal, and 23 (45%) lacked interest in portals. Parents and adolescents seldom used the portal as a collaborative tool, and instead were engaging with the portal independently.

CONCLUSION

Parents and adolescents perceive several benefits and problems with portal use, but many adolescents lack interest in using portals. Adolescent portals represent an underutilized resource to engage adolescents in their care.

Parental agency in pediatric palliative care

The study discusses a new approach to parental agency in pediatric palliative care based on an active form of caregiving. It also explores the possibility of a positive conceptualization of parental agency in its relational context. The paper begins with an illustrative case study based on a clinical situation. This is followed by an analysis of various aspects of parental agency based on empirical studies that disclose the insufficiencies of the traditional approach to parental agency. In the next step, parental agency is analyzed from a reality-based perspective as an activity focused on relationships and the cognitive capacity of parents vis-a-vis their seriously ill children. The paper also considers the importance of the cultural and social contexts in which parental agency and decision-making take place. This agency is addressed not as individualistic in form, and nor is it exercised in terms of fixed choices. Rather, the focus is on its dynamic and future-oriented aspects. Consequently, parental agency should be comprehended not only as a form of proxy agency representing the child's best interests but also as a complex decision-making process in which the parents learn from their child how to become good, compassionate caregivers and at the same time good parents.

Children's interaction with a dog when having Animal Assisted Activity in paediatric hospital care

The aim of the study was to investigate the interaction process between child and dog and how it possibly affects children's wellbeing during Animal Assisted Activity. Children have reported negative feelings such as fear and anxiety when being cared for in hospital and various kinds of complementary treatment can alleviate this. Different complementary treatments, including interaction with a dog, can create positive emotions and the treatment has been reported to have both physiological and psychological beneficial effects. However, there is a lack of studies describing children's interaction with a dog. This is an observational study, analysed from field notes with qualitative content analysis using a deductive approach. Children (n = 49) aged 3-18 years of age at a paediatric hospital voluntarily participated in the study. The results are reported on a six-level scale that describes the child-dog interaction: 1. Passive interaction, 2. One-way non-spoken communication, 3. Facilitating the interaction, 4. Interaction by activity encouragement, 5. Interaction initiated by the child, and 6. Interaction through deepened interplay. All children attained level five. Eighty-nine per cent attained level six and these children interacted fully, having a two-way deepened interplay with the dog. Further, when the interaction proceeded to a deepened interplay this affected the children positively both physically and emotionally. Structured Animal Assisted Activity with a dog that includes an introduction, an active part and a relaxing part is a suitable model to offer children in paediatric hospital care since the children attained a child-initiated interaction or interaction through deepened interplay.

Oncology Clinicians' Perspectives on Online Patient Portal Use in Pediatric and Adolescent Cancer

PURPOSE

Online patient portals represent widely available communication tools in pediatric oncology. Previous studies have not evaluated clinicians' perspectives on portal use, including issues related to access to adolescents' portals.

METHODS

We performed semistructured interviews with physicians and advanced practice providers (APPs) who care for children or adolescents with cancer. We performed thematic analysis of benefits, problems, and accommodations related to portal use in oncology.

RESULTS

We interviewed 29 physicians and 24 APPs representing 26 institutions. Participants described five themes of benefits provided by portals: (1) empowering adolescents, (2) improving efficiency and accuracy of communication, (3) promoting open and adaptive communication, (4) supporting parents in managing care, and (5) bolstering clinical relationships. Participants described eight themes of problems caused by portal access: (1) creating emotional distress and confusion, (2) increasing workload and changing workflows, (3) threatening adolescent confidentiality, (4) adolescents lacking interest to engage, (5) diminishing clinical relationship, (6) misusing portal messages, (7) diminishing quality of sensitive documentation, and (8) parents losing access to adolescents' records. Participants described three themes related to accommodations they made as a result of portal access: (1) modifying note writing, (2) providing anticipatory guidance about viewing results, and (3) adapting workflows. Some portal functions created either benefits or problems depending on the clinical context.

CONCLUSION

Oncologists identified benefits and problems created by portal use, which were sometimes in tension, depending on the clinical context. To make portals useful, we must take steps to mitigate risks while preserving functionality for parents and adolescent patients.

Child-centered communication interventions in pediatric oncology: A scoping review and proposed new communication model

Child-centered communication in pediatric oncology can be challenging. We aimed to review communication interventions with children about cancer treatment and prognosis to identify potentially effective child-centered communication models and approaches. We updated a previous review on communication interventions in oncology and searched MEDLINE, Scopus, and PsychINFO for studies indexed between October 2019 up to October 2022. We further searched for ongoing studies on ClinicalTrials.gov. Communication interventions targeting pediatric oncology patients (below 18 years), with outcomes of communication, psychological symptoms or satisfaction in the target population were eligible. We identified 685 titles/abstracts, screened the full text of 34 studies and included only one published study and two ongoing studies. The published study tested a communication tool to help clinicians inform adolescents about treatment options and facilitate shared decision-making. No communication models were identified. We drew on knowledge from existing studies and guidelines to develop a new child-centered communication model.

[The announcement of treatment resistance in pediatric oncology: Understanding parents' experiences and influencing factors with a mixed methodology]

OBJECTIVE

The announcement of a resistance to treatment in pediatric oncology occurs within the framework of an established parent-pediatrician relationship. The aim of this study was to understand the parents' experience of this announcement and the relational and communicational factors likely to impact it.

METHOD

A mixed-methods study was conducted in a pediatric oncology department with 15 parents of a child with treatment-resistant cancer, with an average age of 40.8years. The parents completed three questionnaires to assess their anxiety and depression (HADS) and their information needs (EORTC - QLQ Info 25 and PTPQ). Semi-structured interviews were conducted and a content analysis was performed.

RESULTS

The majority of parents have "suspected" or "proven" anxiety and/or depressive disorders. The experience of this announcement was influenced by the quality of the parent-pediatrician relationship, the perceived quality of the management, the anticipation of the announcement, the context of the announcement, and the experience of previous announcements. The parents interviewed were very satisfied with the informational exchanges. This satisfaction was underpinned by honest communication and by the responsiveness and availability of the pediatricians.

DISCUSSION

The establishment of a relationship of trust between the family and the pediatrician throughout the course of care plays a major role in the parents' experience of the announcement of resistance to treatment.

Concept Analysis of Family-Centered Care in Childhood Cancer: An Evolutionary Approach

The purpose of this article is to further develop the concept of family-centered care (FCC) in childhood cancer using Rodgers' evolutionary method of concept analysis. A search of the existing literature related to the overarching concept of FCC revealed several concept analyses specific to hospitalized children and children with chronic illness; however, none of these were specific to children with cancer. Five defining attributes of FCC in childhood cancer were identified through this concept analysis: ripple effect, customized care, family functioning, collaboration, and communication. A definition of FCC in childhood cancer is offered based on identified characteristics of the concept. Findings of this concept analysis provide a starting point for on-going development of the concept of FCC in childhood cancer and may facilitate more rigorous nursing studies involving FCC in childhood cancer.

Long-term care, care needs and wellbeing of individuals after cancer in childhood or adolescence (VersKiK): study protocol of a large scale multi-methods non-interventional study

BACKGROUND

It has been shown previously that a relevant proportion of childhood cancer survivors suffers from late effects, which are often directly related to the cancer itself or its therapy, resulting in particular follow-up needs, additionally burdening healthcare systems. Being diagnosed with cancer at a vulnerable stage of development, this group of cancer survivors is at comparatively higher risk of relapse or subsequent cancer. Although national and international follow-up guidelines based on treatment modalities have been developed, their implementation seems to leave room for improvement. Additionally, they lack a sufficient consideration of the survivors' psychosocial needs, affecting their adherence to them. The aim of the VersKiK study is to provide representative information on late effects in childhood and adolescence cancer survivors in Germany. The main research objectives are: (1) to describe the state of follow-up care among survivors after a cancer diagnosis in childhood or adolescence; (2) to quantify the occurrence of late effects among this group of survivors; (3) to examine the adherence to selected audiological and cardiological follow-up guidelines and to identify factors affecting it; (4) to explore actual follow-up needs of paediatric cancer survivors; (5) to review selected follow-up guidelines with the aim to improve and expand them.

METHODS

VersKiK is designed as a mixed-methods non-interventional study. We will use claims data from statutory health insurance companies in combination with individually linked population-based registry data from the German Childhood Cancer Registry (GCCR). This data base will permit us to quantify diagnoses and procedures in comparison to the general population as well as the adherence to existing follow-up guidelines. Additional information will be obtained through interviews with childhood and adolescence cancer survivors and their informal caregivers, as well as in focus groups with healthcare professionals.

DISCUSSION

The present study aims to research the actual needs of individuals after cancer diagnosis and treatment in childhood or adolescence - physical, psychological and organisational - in order to improve existing follow-up guidelines. These improvements might further positively affect not only actual care provided to paediatric cancer survivors, but also benefit healthcare systems in general while decreasing consequent medical visits in this group of patients.

TRIAL REGISTRATION

Registered at German Clinical Trial Register (ID: DRKS00025960 and DRKS00026092).

The Perceptions of Children and Adolescents with Cancer Regarding Nurses' Communication Behaviors during Needle Procedures

Background: Communicating with children and adolescents with cancer during a needle procedure can prove challenging for healthcare professionals. Objective: Our aim was to explore the perceptions of children and adolescents with cancer regarding communication with nurses during needle procedures. Method: Thus was a qualitative phenomenological study. Data were gathered through seven in-depth interviews with a convenience sample of children and adolescents with cancer. Data were analyzed using a grounded theory approach to identify themes in the participants' narratives. Results: The analysis revealed three themes describing participants' experience: (1) nurses need to explain clearly what they are going to do while also allowing children to express their emotions without feeling coerced; (2) nurses need to be honest and approachable and relate to children as active participants in the treatment process; and (3) it is distressing to hear other children who are undergoing a needle procedure cry out in pain. Further application of the constant comparison method yielded a core theme: (4) the pressures faced by oncology nurses lead them to focus on the technical side of procedures at the expense of their young patients' communication needs. Conclusions: We suggest that hospital managers need to ensure that oncology nurses have sufficient training in communication skills and are confident in their ability to respect and respond to the communication preferences and needs of patients.

Interdependent functions of communication with adolescents and young adults in oncology

BACKGROUND

Communication is central to patient-centered care in adolescent and young adult (AYA) cancer. Previously, we developed a functional communication model from perspectives of parents whose children had cancer. No prior studies have established a framework for the breadth of communication functions in AYA oncology. We aimed to identify these communication functions from AYAs' perspectives.

METHODS

Semistructured interviews with 37 AYAs with cancer aged 12-24 years at diagnosis from two pediatric centers during treatment or survivorship. We performed thematic analysis, using a functional communication model as an a priori framework, but remaining open to novel themes.

RESULTS

We identified eight interdependent functions of communication in AYA oncology that were consistent with those previously identified among parents: building relationships, exchanging information, enabling family self-management, making decisions, managing uncertainty, responding to emotions, providing validation, and supporting hope. AYAs held varying preferences for engagement in different communication functions. While some AYAs preferred very passive or active roles, most AYAs described an interdependent process of communication involving them, their parents, and their clinicians. Parents often served as a conduit and buffer of communication between the AYA and clinician.

CONCLUSIONS

Interviews with AYAs provided evidence for eight interdependent communication functions in AYA oncology. Many AYAs described the integral role of parents in communication regardless of their age. Clinicians can use this framework to better understand and fulfill the communication needs of AYA patients. Future work should aim to measure and intervene upon these functions to improve communication experiences for AYAs with cancer.

A proposed global framework for pediatric cancer communication research

The authors introduce a functional communication framework that can be used for global pediatric cancer research.

Cancer-Related Decision-Making Among Adolescents, Young Adults, Caregivers, and Oncology Providers

Decision-making among adolescents and young adults with cancer (AYA) is often complex, ongoing, and multifaceted, involving caregiver and oncology provider perspectives. Engagement in decision-making against the backdrop of normative developmental processes of acquiring autonomy and gaining independence contributes to the complexity of decision-making. Semi-structured qualitative interviews from 11 AYA and caregiver dyads and eight oncology providers examined decision-making processes with specific attention to the role of shared decision-making, cognitive and emotional processes, and coping with the decision-making experience. Five decision-making patterns were identified, with collaborative decision-making and AYA-driven decisions most commonly described. Utilizing hypothesis coding, AYA and caregivers explained how cognitive (i.e., pros/cons) and emotional (i.e., shock and fear of missing out) processes influenced cancer-related decisions. Coping strategies provided clarity and respite when engaged in decision-making. Our findings illuminate important implications for how to best support decision-making among AYA and caregivers, including the role oncology providers can play during decision-making.