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

Nursing activities for health promotion in palliative home care: an integrative review

Palliative care in community contexts is undergoing significant change as a result of public policy and new models of care, which link health promotion principles with palliative care practices. These models support the creation of partnerships between formal care structures and the communities in which care is provided. Given the central role of nurses in the institutional delivery of palliative care, particularly in the home, it is important to provide a systematic description of the activities of nurses that fall within the principles of health promotion. The objective was to describe the diverse range of nursing activities for health promotion that are provided in the palliative home care setting. This is an integrative review. Fifty-five studies listed in the MEDLINE, CINAHL and EMBASE databases, and published between 1999 and December 2022, were identified. Data analysis and presentation of the results were guided by Kellehear's Health-Promoting Palliative Care (HPPC) model. Six themes were identified to describe nursing activities for health promotion in the context of palliative home care: creating a meaningful relationship, supplying medical information, promoting self-care throughout the trajectory, providing emotional support, involving professional or community services and supporting change. The findings point to nurses focusing more on the individual context and on direct care. The relationship with communities in which they work remains unidirectional. However, some HPPC principles are relevant to nursing activities through the contextualization of nurses' actions and their moral responsibility to work towards the respect of patient's values. Being poorly described, how nurses can truly engage their practice towards health-promoting principles, such as the enhancement of support and control over their lives for people living with serious illness, still requires further empirical research.

Self-driven solutions and resilience adapted by people with drug-resistant tuberculosis and their caregivers in Bengaluru and Hyderabad, India: a qualitative study

Background

One-fifth of people with drug-resistance tuberculosis (DR-TB) who were initiated on newer shorter treatment regimen (with injection) had unfavourable treatment outcomes in India as on 2020. Evidence on self-driven solutions and resilience adapted by people with DR-TB (PwDR-TB) towards their multi-dimensional disease and treatment challenges are scarce globally, which we aimed to understand.

Methods

In this qualitative study using positive deviance framework, we conducted semi-structured in-depth interviews among consenting adult PwDR-TB (7 women, 13 men) who completed shorter treatment regimen (including injections) with maximum treatment adherence. The study was conducted in the southern districts of Bengaluru and Hyderabad, India between June 2020 and December 2022. Caregivers (14 women, 6 men) and health providers (8 men, 2 women) of PwDR-TB were also interviewed. Interviews were conducted in local language (Kannada, Tamil, Telugu, Urdu and Hindi) and inquired about practices, behaviours, experiences, perceptions and attributes which enabled maximum adherence and resilience of PwDR-TB. Interviews were audio recorded, transcribed, and translated to English and coded for thematic analysis using inductive approach.

Findings

Distinctive themes explanatory of the self-driven solutions and resilience exhibited by PwDR-TB and their caregivers were identified: (i) Self-adaptation towards the biological consequences of drugs, by personalised nutritional and adjuvant practices, which helped to improve drug ingestion and therapeutic effects. Also home remedies and self-plans for ameliorating injection pain. (ii) Perceptual adaptation towards drugs aversion and fatigue, by their mind diversion practices, routinisation and normalisation of drug intake process. and constant reinforcement and re-interpretation of bodily signs of disease recovery (iii) Family caregivers intense and participatory care for PwDR-TB, by aiding their essential life activities and ensuring survival, learning and fulfilling special nutritional needs and goal oriented actions to aid drug intake (iv) Health care providers care, marked by swift and timely risk mitigation of side-effects and crisis response (v) Acquired self-efficacy of PwDR-TB, by their decisive family concerns resulting in attitudinal change. Also being sensitised on the detrimental consequences of disease and being motivated through positive examples.

Interpretation

Synthesised findings on self-driven solutions and resilience towards the multi-dimensional DR-TB challenges provides opportunity for developing and testing new interventions for its effectiveness in DR-TB care settings globally. Designing and testing personalised cognitive interventions for PwDR-TB: to inculcate attitudinal change and self-efficacy towards medication, developing cognitive reinforcements to address the perception burden of treatment, skill building and mainstreaming the role of family caregivers as therapeutic partners of PwDR-TB, curating self-adaptive behaviours and practices of PwDR-TB to normalise their drug consumptions experiences could be the way forward in building resilience towards DR-TB.

Funding

United States Agency for International Development (USAID) through Karnataka Health Promotion Trust (KHPT), Bengaluru, India.

Close but Not Close Enough: How Distance Caregiving is Associated with Hospice Family Caregiver Hospice Communication Experiences

Half of hospice family caregivers report having unmet information needs, which can contribute to poor pain and symptom management, emergency department use, and hospice disenrollment for care-recipients and to caregiver strain and stress. Effective communication between hospice teams and family caregivers is critical yet communication inadequacies persist. Despite the growing prevalence of distance caregiving, including in hospice care, and the relationship between caregiver proximity and communication effectiveness, little is known about how caregiver proximity is associated with caregiver perceptions of hospice communication. In this secondary analysis of quantitative data from two multisite randomized clinical trials (NCT03712410 and NCT02929108) for hospice family caregivers (N = 525), multivariate linear models with demographic and contextual controls were used to analyze caregivers' perceptions of caregiver-centered communication with hospice providers based on caregiver proximity to the hospice care-recipient. In multivariate models, "local" hospice family caregivers who lived within 1 hour of the hospice care-recipient reported less effective communication with the hospice team than co-residing caregivers; and older caregivers rated communication more favorably than younger caregivers. To improve communication and collaboration between hospice teams and caregivers, regardless of proximity, distance communication training for hospice teams and interventions such as telehealth communication and virtual tools that enable triadic collaboration are recommended. Research is needed to understand why local caregivers, specifically, perceive communication quality less favorably and how hospice teams can better meet local and distance caregiver communication needs.

Comparing situational influences on differential healthcare utilization trajectories in patients on home palliative care: A qualitative study

OBJECTIVES

Patients with terminal cancer receiving home palliative care present differential healthcare utilization trajectories before death. It remains unclear which situational elements influence these trajectories among disparate patient groups. The aim of this study was to compare situational influences on "persistently high" and "low stable" trajectories of healthcare utilization in patients who received palliative care support at home.

METHODS

Bereaved family caregivers were recruited from our prior quantitative study investigating healthcare utilization trajectories in oncology patients on home-based palliative care. In-depth interviews were conducted with 30 family caregivers. Data were analyzed using thematic analysis.

RESULTS

Analysis of data uncovered how the 2 utilization trajectories were influenced by the interplay of 1 or more of 4 situational elements. Perceived symptom control in patients, influenced by their determination to die at home, shapes the susceptibility to situational contingencies, resulting in differential utilization trajectories. Caregivers' mental readiness in dealing with unexpected circumstances has a significant impact on the overall manageability of care, ultimately affecting decisions related to healthcare utilization. The concordance between symptom needs and scope of homecare services in a given situation proves to be an important determinant. Lastly, perceived accessibility to informal support in times of need acts as a contextual reinforcement, either preventing or precipitating decisions regarding healthcare utilizations.

SIGNIFICANCE OF RESULTS

Our findings hold important implications for the provision of homecare services, in particular, the need for comprehensive assessment of end-of-life wishes during homecare enrolment and strengthening psychological preparedness of caregivers. Expansion of home-based clinical interventions tailored to high utilizers, and funding for temporary in-home respite should be considered to optimally manage potentially preventable acute healthcare utilization.

Cancer caregivers at the end-of-life: How much me vs. how much we?

OBJECTIVE

This study explored cancer caregivers' individual and communal coping through their use of personal and communal pronouns during naturally occurring conversations.

METHODS

Nurse-home hospice visits involving cancer patients and their partner caregivers were audio recorded and then transcribed. Pronoun use was analyzed using Linguistic Inquiry Word Count (LIWC) software and descriptive statistics compared patient and partner caregivers' pronoun use. Personal and communal pronoun use was examined within six identified topics of caregiver speech: patient medical care, daily life, emotion, criticism/disagreement, relationships with family/friends, and asserting needs.

RESULTS

Dyads (N = 76) had an average of 35.8 years in their relationship. Caregivers used proportionately more first-person singular (I-talk) than first-person plural (we-talk). However, they used significantly less I-talk than patients and less I-talk than LIWC measures in naturally occurring speech. Caregivers were most likely to discuss patient medical care (41.9%) and least likely to discuss their own needs (3.8%).

CONCLUSION

Partner caregivers may find it easier to express emotions related to communal stressors, rather than their individual ability to cope with end-of-life caregiving.

INNOVATION

Examining personal and communal pronoun use by partner caregivers during nurse-home hospice visits may provide a more objective measure of caregiver coping than standard self-report measures.

Family Members' Perceptions of Caregiver-Centered Communication with Hospice Interdisciplinary Teams: Relationship to Caregiver Wellbeing

OBJECTIVE

Investigators sought to determine how family caregivers' psychological and physical wellbeing influenced their perceptions of communication with hospice providers.

METHODS

Researchers conducted a secondary analysis of quantitative data generated during two multisite randomized clinical trials of supportive interventions for hospice family caregivers. Caregivers' (N = 525) self-reported anxious symptoms, depressive symptoms, physical quality of life, and perceptions of communication with hospice providers were analyzed via a series of linear models that included demographic and contextual controls.

RESULTS

Caregivers' anxious symptoms, depressive symptoms, and physical quality of life were largely unrelated to caregivers' perceptions of their communication with hospice providers when adjusted for demographic and contextual factors.

CONCLUSIONS

Variation in caregivers' perceptions of their communication with hospice providers was not well explained by caregiver wellbeing. Additional research is needed to understand if and how caregivers' perceptions of communication with hospice providers are related to factors not included in this secondary analysis. Provider-related variables may be particularly important to consider.

Treatment decision conversations, symptoms, and functional status in older adults with advanced cancer: An exploratory study utilizing mixed methods

INTRODUCTION

Adults 65 years of age or older with metastatic cancer face complicated treatment decisions. Few studies have explored the process with oncology clinicians during clinic encounters. Our exploratory study evaluated whether symptom burden or functional status impacted treatment decision conversations between older adults, caregivers, and oncology clinicians in a single National Cancer Institute within the Mountain West region.

MATERIALS AND METHODS

We conducted an observational, convergent mixed methods longitudinal study between November 2019 and January 2021; participants were followed for six months. The MD Anderson Symptom Inventory (MDASI) and Katz Index of Independence in Activities of Daily Living (ADL) were administered prior to clinical encounter. Ambulatory clinic encounters were audio recorded, transcribed, and analyzed. Nineteen older adults with a metastatic cancer diagnosis or a relapsed refractory hematologic malignancy were approached to achieve a sample of fifteen participants. The main outcome of interest was the number and quality of treatment decision making conversations, defined broadly and encompassing any interaction between the participant and oncology provider that involved (a) an issue or concern (e.g., symptoms, quality of life) brought up by anyone in the room during the clinical encounter, (b) a clinician addressing the concern, or (c) the patient or caregiver making a decision that involved a discussion of their goals or treatment preferences.

RESULTS

Nine men and six women with a mean age of 71.3 years (6.6; standard deviation [SD]) were enrolled, and four died while on study. Participants were followed from one to ten visits (mean 4.5; SD 2.8) over one to six months. Of the 67 analyzed encounters, seven encounter conversations (10%) were identified as involving any type of treatment decision discussion. The seven treatment decision conversations occurred with five participants, all male (although female participants made up 40% of the sample), and 63% of participants who reported severe symptoms on the MDASI were female. Severe symptoms or functional status did not impact treatment conversations.

DISCUSSION

Our results suggest that older adults with incurable cancer and their oncology clinicians do not spontaneously engage in an assessment of costs and benefits to the patient, even in the setting of palliative treatment and significant symptom burden.

Registered nurse-patient communication research: An integrative review for future directions in nursing research

AIM

To explore communication research in nursing by investigating the theoretical approaches, methods, content and perspectives in research on real-time registered nurse (RN)-patient communication.

DESIGN

An integrative review of real-time communication between RNs and patients.

DATA SOURCES

Empirical research papers were searched in PubMed, CINAHL Plus and Medline. The results from the database searches were supplemented with results from manual searches in reference lists.

REVIEW METHODS

A total of 1369 articles published between January 1996 and December 2021 were screened, which resulted in the inclusion of 52 articles.

RESULTS

The integration of various theories, such as nursing or communication theories, is weak in most of the included studies. RN-patient communication appears to influence relationship building. Even when nurses strive to meet patients' needs, they often focus primarily on nursing routines and physical care. The topic of the communication varies depending on the situation and different communication styles are used. When a patient-centred approach is adopted, the interpersonal communication becomes quite symmetrical, with complementary roles of nurses and patients. Within a more asymmetric communication context, nurses dominate communication, choose topics and function as instructors. How the nurses communicated subsequently influenced the patients' communication styles and strategies.

CONCLUSION

Communication is multifaceted, contains different strategies and is important for building trust and facilitating patient-centred care. The importance of RNs' communication for interaction and relationship-building seems to be well established within research, but few studies focused on patients' communication with RNs.

IMPACT

This integrative review gives an overview of the width and depth of observational studies on RN-patient communication research. The variety of studies indicates that this area is a less well-grounded field of research. Future research is warranted to support nurses in their communication, especially regarding the exploration of patients' communication and desired communication skills in nurse-patient interactions.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was included in this integrative review.

Exploring the Impact of Language Concordance on Cancer Communication

PURPOSE

Patients with cancer who have limited English proficiency are more likely to experience inequities in cancer knowledge, timely care, and access to clinical trials. Matching patients with language-concordant clinicians and working with professional interpreters can effectively reduce language-related disparities, but little data are available regarding the impact of language-concordant interactions in oncology care. This study aimed to assess the use of the Roter Interaction Analysis System (RIAS) in language-concordant and -discordant interactions for patients with non-English language preference presenting for an initial oncology visit at four New York City hospitals.

METHODS

We used the RIAS, a validated tool for qualitative coding and quantitative analysis, to evaluate interactions between 34 patients and 16 clinicians. The pairings were stratified into dyads: English language-concordant (n = 12); professionally interpreted (n = 11); partially language-concordant (n = 4, partially bilingual clinicians who communicated in Spanish and/or used ad hoc interpreters); and Spanish language-concordant (n = 7). A trained Spanish-speaking coder analyzed the recordings using established RIAS codes.

RESULTS

Spanish language-concordant clinicians had almost two-fold greater number of statements about biomedical information than English language-concordant clinicians. Spanish language-concordant patients had a higher tendency to engage in positive talk such as expressing agreement. The number of partnership/facilitation-related statements was equivalent for English and Spanish language-concordant groups but lower in professionally interpreted and partially language-concordant dyads.

CONCLUSION

Language concordance may facilitate more effective biomedical counseling and therapeutic relationships between oncology clinicians and patients. Future research should further explore the impact of language concordance on cancer-specific health outcomes.

Identification of psychological stressors in cancer patients based on a computer decision support nursing system

OBJECTIVE

We aim to improve the decision-making process of nursing evaluation, and the purpose of this paper was to introduce nursing outcome classifications based on standardized nursing language, as well as build a comprehensive nursing evaluation decision-making system model based on an artificial neural network and fuzzy comprehensive evaluations.

METHODS

Based on the principle and method of the decision support system (DSS), this paper proposed a framework of DSS and developed an intelligent nursing decision support system which integrates expert systems, data, models and knowledge.

RESULTS

Taking cancer patients as examples, based on the analysis and comparison of cancer stressors and their frequency of occurrence, this paper found that the 5 major factors for cancer patients' stress events were lack of privacy, attitude of the medical workers, unfamiliar medical workers and uncomfortable temperature in wards. In addition, through the single factor analysis of the stressors, it was found that "the impact of hospitalization on individuals and their families", "the professional level and service attitude of medical workers", and "partial loss of free social contact in the hospital" were all positively correlated with stress level. The degree of cancer patients' participation in treatment decision-making was lower than the expectation of the patients. There was a statistically significant difference between the actual participation and the anticipated participation of cancer patients in nursing decision-making (P < 0.0001). In addition, the system helped patients adapt to the hospital environment as quickly as possible, so that they could feel comfortable in the hospital environment, as well as a relaxed and pleasant with the humanistic environment.

CONCLUSION

Cancer patients have a variety of stressors, and the pressure is high. Our computer decision support nursing system assisted nurses to help patients to take positive coping measures to relieve pressure as soon as possible, so as to improve their quality of life.

Analyzing Factors Associated with the Behavior-Change Stage of Colorectal Cancer Screening

This study attempted to identify the stages of colorectal cancer screening (CRCS) behavior change by applying the precaution adoption process model (PAPM) and to examine the factors affecting each stage. A quantitative, descriptive, cross-sectional design was used. A total of 305 workers at one of the largest industrial complexes in South Korea were allocated using convenience sampling. Data were analyzed using independent t-test, one way ANOVA and multi-nominal logistic regression using SPSS 25.0 (SPSS Inc., Chicago, IL, USA). Most of the subjects were in the undecided-to-act stage. The factors affecting each stage were gender, marital status, family history, private insurance subscription, perceived barrier, and self-efficacy. It is critical to select a target group considering the behavioral change stage to establish a strategy for improving the CRCS rate. Developing and implementing a CRCS education program in consideration of the behavioral change stage will be a strategy to increase the examination of effectiveness of CRCS.

Toward a basic science of communication in serious illness

High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.

The Influence of Patient-Provider Language Concordance in Cancer Care: Results of the Hispanic Outcomes by Language Approach (HOLA) Randomized Trial

PURPOSE

Delivering linguistically competent care is critical to serving patients who have limited English proficiency (LEP) and represents a key national strategy to help reduce health disparities. Current acceptable standards of communication with patients who have LEP include providers communicating through professional interpretive services or bilingual providers speaking the patients' preferred language directly. This randomized clinical trial tests the effect of patient-provider language concordance on patient satisfaction.

METHODS AND MATERIALS

Eighty-three adult Spanish-speaking patients with cancer were randomly assigned to receive care from either (1) 1 of 2 bilingual physicians speaking to the patient directly in Spanish or (2) the same physicians speaking English and using a professional interpreter service. Validated questionnaires were administered to assess patient-reported satisfaction with both provider communication and overall care. Transcripts of initial consultations were analyzed for content variations.

RESULTS

Compared with patients receiving care through professional interpretive services, patients cared for in direct Spanish reported significantly improved general satisfaction, technical quality of care (mean composite score [MCS], 4.41 vs 4.06; P = .005), care team interpersonal manner (MCS, 4.37 vs 3.88; P = .004), communication (MCS, 4.50 vs 4.25; P = .018), and time spent with patient,(MCS, 4.30 vs 3.92; P = .028). Specific to physician communication, patients rated direct-Spanish care more highly in perceived opportunity to disclose concerns (MCS 4.91 vs 4.62; P = .001), physician empathy (MCS, 4.94 vs 4.59; P <.001), confidence in physician abilities (MCS, 4.84 vs 4.51; P = .001), and general satisfaction with their physician (MCS, 4.88 vs 4.59; P <.001). Analyzing the content of consultation encounters revealed differences between study arms, with the direct-Spanish arm having more physician speech related to patient history verification (mean number of utterances, 13 vs 9; P = .01) and partnering activities (mean utterances, 16 vs 5; P <.001). Additionally, patients in the direct-Spanish arm were more likely to initiate unprompted speech (mean utterances, 11 vs 3; P <.001) and asked their providers more questions (mean utterances, 11 vs 4; P = .007).

CONCLUSIONS

This study shows improved patient-reported satisfaction among patients with cancer who had LEP and were cared for in direct Spanish compared with interpreter-based communication. Further research into interventions to mitigate the patient-provider language barrier is necessary to optimize care for this population.

Communication between Advanced Cancer Patients and Their Family Caregivers: Relationship with Caregiver Burden and Preparedness for Caregiving

Cancer impacts spouse caregivers, especially when couples engage in dyadic coping around the cancer. Communication is a key factor in this process. Our goals were to describe cancer-related communication between advanced cancer patients and their spouse caregivers, and to describe how dyadic communication patterns are related to caregivers' reported burden and preparedness for caregiving. Caregivers completed measures of caregiver burden and preparedness for caregiving. Then, the patient and caregiver were asked to interact with each other in two structured discussions: a neutral discussion and a problem discussion focused on cancer. Discussions were coded using the Rapid Marital Interaction Coding System (RMICS2). Caregivers reported moderate levels of preparation and burden. Greater caregiver hostility communication predicted higher levels of caregiver burden, whereas greater caregiver dysphoric affect communication predicted lower levels of caregiver burden. Whereas positivity was more common than hostility in couples' communication, patient hostility was a significant predictor of caregiver preparedness. Patient neutral constructive problem discussion was also associated with increased caregiver preparedness. Caregiver outcomes are an understudied component to dyadic cancer research. Our paper describes observational data on cancer-related communication between caregivers and advanced cancer patients and communication's influence on caregiver outcomes. This work provides the foundation for future evidence-based communication interventions that may influence both patient and caregiver outcomes.

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.

Taking care of dying patients through an 'interprofessional ecosystem': a grounded theory study on the experience of an interprofessional team in palliative care

BACKGROUND

The interprofessional approach is part of the philosophy in palliative care, and its benefits are already documented. However, there are no evidence regarding the process through which the interprofessional team faces the process of the patient's end-of-life and how this experience might be of value for the team's development itself. The aim of this study was to analyse and understand the psychosocial processes that occurs when an interprofessional team accompanies patients and their families to death in palliative care, with the ultimate aim to develop a substantive theory to describe this phenomenon.

METHODS

A Grounded Theory method, as theorized by Strauss and Corbin, was adopted for this study. Data were collected through semi-structured interviews and then independently analysed using constant comparison analysis. Fourteen healthcare professionals - belonging to different disciplines (doctor, nurse coordinator, nurse, nurse assistant, psychologist) - were interviewed in a Northern Italy palliative care facility.

FINDINGS

The core category of this study was identified to be the process of accompaniment of the dying patient as an interprofessional ecosystem. Moreover, the results showed four main factors determining the development of the core psychosocial process: from professionals' 'Hidden Amazement' to 'Onerous Happiness' where 'Weaving of Professional Resources' and 'Work Meaning' are the underlying conditions to catalyse the process itself.

CONCLUSION

Interprofessional care appears an essential value, which becomes the source of the team's strength when facing end-of-life experiences. Health policies and organisations should take the importance of the characteristics of the work environment more carefully. The meaning that professionals attribute to their work and to the team itself, indeed, it may have impact on the overall quality of care and contribute to sustain work engagement, even in stressful situations like end-of-life care.

Exploring patient-centered aspects of home care communication: a cross-sectional study

Background

Communication is a cornerstone in nursing and aims at both information exchange and relationship building. To date, little is known about the naturally occurring communication between older persons and nurses in home care. Communication might heal through different pathways and a patient- or person-centered communication could be important for health and well-being of older persons. However, the delivery of individualized home care is challenged by routines and organizational demands such as time constraints. Therefore, the aim of this study was to explore the patient-centered aspects of home care communication between older persons and registered nurses.

Methods

In total 37 older persons (aged 65 years or older) and eleven RNs participated in 50 audio-recorded home care visits. Roter Interaction Analysis System (RIAS) was used to code verbal communication. A ratio from these codes, establishing the degree of patient-centeredness, was analyzed using a Generalized Linear Mixed Model.

Results

The present home care communication contained more socio-emotional than task-oriented communication and the emotional tone was largely positive. The global affect ratings reflected an overall positive tone (m = 39.88, sd = 7.65), with higher ratings on dimensions of, for example, responsiveness/engagement and interactivity or interest were more frequent than those that may be considered as less-positive emotions (m = 15.56, sd = 3.91), e.g. hurried, dominance or anger. The ratio of the degree of patient-centered communication in the home care visits was an average of 1.53, revealing that the communication could be considered as patient-centered. The length of the visits was the only characteristic significantly associated with the degree of patient-centeredness in the communication, with a peak in patient-centeredness in visits 8–9 min long. Sex, age or procedural focus showed no significant effects on the degree of patient-centeredness.

Conclusion

Overall, the degree of patient-centeredness and a positive emotional tone, which might have a positive outcome on older persons’ health, was high. Longer visits provided a higher degree of patient-centeredness, but no linear increase in patient-centeredness due to length of visit could be observed. The findings can be used for education and training of nurses, and for providing individualized care, e.g. patient- or person-centered care.

Addressing cancer patient and caregiver role transitions during home hospice nursing care

OBJECTIVE

Many family caregivers and hospice patients experience role changes resulting from advancing illness and the need for increased caregiver responsibility. Successful navigation of conflicts that arise because of these role transitions has been linked to higher quality of patient care and improved caregiver bereavement adjustment. Nursing communication with patients and their caregivers plays an important role in facilitating these transitions. Our objective is to describe patient-caregiver-nurse communication during transitions at end of life.

METHOD

A secondary, qualitative analysis was conducted on transcripts. Using an iterative process of constant comparison, coders inductively categorized nurse, caregiver, and patient communication behavior into overarching themes. Participants were home hospice nurses and cancer patient/spouse caregiver dyads; participants were >45 years of age, English speaking, and cognitively able to participate. Research took place in the home during nurse visits.

RESULT

Nineteen unique home hospice visits were analyzed. Patient-caregiver conflict occurred in two major content themes (1) negotiating transitions in patient independence and (2) navigating caregiver/patient emotions (e.g., frustration, sadness). Nurse responses to transition conflict included problem-solving, mediating, or facilitating discussions about conflicts. Nurse responses to emotional conflict included validation and reassurance.

SIGNIFICANCE OF RESULTS

Our findings provide insight into the topics and processes involved in patient and caregiver transitions in home hospice and the role hospice nursing communication plays in mediating potential conflict. Nurses are often asked to take on the role of mediator, often with little conflict resolution communication education; results can be used for nursing education.

The effectiveness of training interventions on nurses' communication skills: A systematic review

OBJECTIVES

The objective of this systematic review was to identify, critically appraise and synthesise evidence for the effectiveness of communication skills training interventions in nursing practice.

DESIGN

A systematic review of literature.

DATA SOURCES

Randomised controlled trials published in English from 1998 to 2018, identified in five computerised databases (Medline, Cinahl, Embase, Psychinfo and Cochrane Database). Studies were included if they reported an educational intervention to enhance nurses' communication with patients and contained an objective measure of communication skills and/or patient outcome measures.

REVIEW METHODS

The Preferred reporting Items for Systematic reviews and Meta-Analyses guided the review. Data were extracted regarding study design and effectiveness on nurses' communication skills. Trial quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The heterogeneity of the included studies prohibited meta-analysis.

RESULTS

Of the 7811 papers identified, seven trials met the eligibility criteria. The quality was modest. Training programs varied significantly in duration, structure, location and use of outcome measurement tools. Five trials focused on communication with cancer patients using simulated patients. All trials found at least one statistically significant improvement for nurses' communication skills.

CONCLUSIONS

Educational interventions to enhance nurses' capacity to communicate with patients show promise. The paper reports the first systematic review of randomised controlled trials concerning the effect of communication skills training on nurses' abilities to communicate with patients, inclusive of non-cancer settings. The direct impact of educational interventions on nurses' communication skills is difficult to measure arising from non-standardised outcome measurement tools. Further research is particularly needed in acute, chronic illness, aged care and community settings.

Challenges for nurses when communicating with people who have life-limiting illness and their families: A focus group study

AIMS AND OBJECTIVES

The proposed study aimed to answer the following question: What communication issues do nurses find challenging when caring for people with life-limiting illness?

BACKGROUND

Evidence suggests that attitudes, skills and knowledge about how nurses communicate effectively with patients and their families could be improved. However, the literature predominantly focuses on nurses working in oncology and the medical profession.

DESIGN

A qualitative descriptive design was used.

METHODS

Focus groups were conducted with 39 nurses from three wards within a regional healthcare organisation in Victoria, Australia. Data were analysed using thematic content analysis. The COREQ checklist was used to document reporting of the study.

RESULTS

In their view, nurses have the potential to develop a strong bond with patients and their families. Three key themes were identified: (a) feeling unskilled to have difficult conversations with patients who have life-limiting illness; (b) interacting with family members adds complexity to care of patients who have life-limiting illness; and (c) organisational factors impede nurses' capacity to have meaningful conversations with patients and their families.

CONCLUSIONS

Caring for individuals with life-limiting illness is complex and often occurs in an emotionally charged environment. However, nurses report being hampered by time restraints and lack of information about the patient's condition and goals of care. Limitations in conversation structure and a comprehensive range of core communication skills affect their ability to confidently engage in conversations, particularly when they are responding to prognostic questions.

RELEVANCE TO CLINICAL PRACTICE

Whilst nurses are responsible for performing technical skills, they can maximise care by developing a trusting relationship with patients and their relatives. Increased acuity limits the time nurses have to talk with patients. In addition, they lack confidence to deal with difficult questions. Specific training may increase nurses' confidence and efficiency when communicating with patients and their families.

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.

Impact of specialized pediatric palliative care programs on communication and decision-making

OBJECTIVE

To summarize and analyze the impact of specialized pediatric palliative care (SPPC) programs on communication and decision-making for children with life-threatening conditions.

METHODS

Our search strategy covered MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Scopus, and Embase through September 2018.

RESULTS

We reviewed 13 studies analyzing the impact of SPPC programs on communication and decision-making using a wide range of outcome indicators. Study quality was poor in 58% of included papers. SPPC programs improved communication and decision-making between families and healthcare professionals (HCPs), within and between families, and among HCPs.

CONCLUSION

SPPC programs generally support and improve communication and decision-making for children with life-threatening conditions, their families and associated HCPs. Families referred to an SPPC program had more discussions with HCPs on a broad variety of topics. However, data on communication with children, siblings, and other family members was scarce and of poor quality.

PRACTICE IMPLICATIONS

More research on SPPC program efficacy is needed from the perspective of the ill child, as well as about barriers to end-of-life discussions and the specific aspects of SPPC programs responsible for improving outcomes.

Measuring Communication Similarity Between Hospice Nurses and Cancer Caregivers Using Latent Semantic Analysis

BACKGROUND

Optimal end-of-life care requires effective communication between hospice nurses, caregivers, and patients, yet defining and evaluating effective communication are challenging. Latent semantic analysis (LSA) measures the degree of communication similarity (talking about the same topic) without relying on specific word choices or matching of communication behaviors (question-answer), thus more comprehensively evaluating communication interactions.

OBJECTIVE

Guided by the Communication Accommodation Theory, we evaluated communication similarity, indicating theoretical convergence, between hospice nurses and caregivers of cancer patients, identifying nurse attributes and communication skills that were associated with greater communication similarity.

METHODS

A descriptive secondary analysis of self-reported nurse data and 31 audio-recorded cancer patient home hospice nursing visits across 2 states and 7 hospices.

RESULTS

The average LSA score was 0.83 (possible range, 0-1). A nurse preference for greater patient-oriented visits, use of more Nurse Partnering statements, and less Conversation Dominance (ratio of total nurse to total caregiver talk) were associated with higher LSA scores.

CONCLUSIONS

Effective communication is essential to optimal end-of-life care. Latent semantic analysis is a feasible and promising approach for assessing communication similarity during home hospice care.

IMPLICATIONS FOR PRACTICE

Hospice nurses are at the forefront of family caregiver communication, playing a vital role in empowering caregivers to assume required patient care tasks. Communication strategies such as the use of partnering statements that increase LSA scores can be taught to hospice nurses and other members of the hospice interdisciplinary team as a way to enrich communication skills and improve communication confidence and can be translated into other oncology nursing contexts.

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.

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.

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.