Cultivating Relationship-Centered Care: Patient, Caregiver, and Provider Communication Preferences for and Experiences with Prognostic Conversations

Prognostic conversations present many challenges for patients, caregivers, and providers alike. Most research examining the context of prognostic conversations have used a more siloed approach to gather the range of perspectives of those involved, typically through the lens of patient-centered care. However, the mutual influence evident in prognostic conversations suggests a relationship-centered care model may be useful in cancer communication research. Similarities and differences in preferences for and experiences with prognostic conversations among oncology patients, caregivers, and providers (N = 32) were explored. Identified themes were then mapped to the principles of the relationship-centered care framework to extend our understanding of prognostic conversations and contribute to a new direction in the application of relationship-centered care. Findings suggest fewer similarities than differences, point to important discrepancies among participant perspectives, and reinforce the utility of relationship-centered care in identifying communication practices that enhance the prognostic conversation experience.

Evaluating the Implementation of a Relationship-Centered Communication Training for Connecting With Patients in Virtual Visits

The use of telehealth, specifically virtual visits, has increased and adoption continues. Providers need effective training for how to communicate with patients to develop a connection during virtual visits. This article describes the implementation and evaluation of a course called Mastering Presence in Virtual Visits. Results show that although providers perceive lack of time, technology issues, and lacking experiential knowledge as barriers to enacting course behaviors, the course was feasible and acceptable. Following the course, providers rated key course behaviors as helpful for practice, and 80.7% of providers were likely to recommend the course to a colleague. The course shifted provider perceptions of the purpose, patient experience, and procedures in virtual visits. Prior to the course, providers perceived virtual visits as fundamentally different than in-person visits. However, after the course, they recognized the importance of connection in virtual visits and how to foster that connection. Providers continue to require support in conducting high-quality virtual visits. Online, asynchronous courses, developed in partnership with providers, are feasible and effective for encouraging behavior change. Key findings: When asked on a needs assessment in 2020, communication strategies to connect with patients in virtual visits were a top provider need. Partnering with providers to create online, communication training content is effective for increasing the acceptability of courses about virtual visits. Asynchronous, online courses can meet provider needs for communication strategies to connect with patients in virtual visits.

Qualitatively exploring the impact of a relationship-centered communication skills training program in improving patient perceptions of care

Objective

To explore qualitative patient experience comments before and after a relationship-centered communication skills training to understand patient experience, program impact, and opportunities for improvement.

Methods

Qualitative patient experience evaluation data was captured from January 2016 to December 2018 for 483 health care clinicians who participated in the skills training. A random sampling of available open-ended patient comments (N = 33,223) were selected pre-training (n = 668) and post-training (n = 566). Comments were coded for valence (negative/neutral/positive), generality versus specificity, and based on 12 communication behaviors reflective of training objectives.

Results

No significant difference was found in the valence of comments, or generality versus specificity of comments before and after the training. A significant decrease was present in perceived clinician concern. "Confidence in care provider" was the communication skill most frequently identified in comments both pre- and post-training.

Conclusion

Perceptions of interactions largely remained the same following training. Key relationship-centered communication skills require further attention in future training efforts. Measurements of patient satisfaction and engagement may not adequately represent patient experience.

Innovation

This study identified areas for improvement in the training program and offers a model for utilizing patient experience qualitative data in understanding communication training impact.

Goals of Care Documentation: Insights from A Pilot Implementation Study

CONTEXT

The Life Sustaining Treatment Decision Initiative is a national effort by the Veterans Health Administration to ensure goals of care documentation occurs among all patients at high risk of life-threatening events.

OBJECTIVES

Examine likelihood to receive goals of care documentation and explore associations between documentation and perceived patient care experience at the individual and site level.

METHODS

Retrospective, quality improvement analysis of initiative pilot data from four geographically diverse Veterans Affairs (VA) sites (Fall 2014-Winter 2016) before national roll-out. Goals of care documentation according to gender, marital status, urban/rural status, race/ethnicity, age, serious health condition, and Care Assessment Needs scores. Association between goals of care documentation and perceived patient care experience analyzed based on Bereaved Family Survey outcomes of overall care, communication, and support.

RESULTS

Veterans were more likely to have goals of care documentation if widowed, urban residents, and of white race. Patients older than 65-years and those with a higher Care Assessment Needs score were twice as likely as a frail patient to have goals of care documented. One pilot site demonstrated a positive association between documentation and perceived support. Pilot site was a statistically significant predictor of the occurrence of goals of care documentation and Bereaved Family Survey scores.

CONCLUSION

Older and seriously ill patients were most likely to have goals of care documented. Association between a documented goals of care conversation and perceived patient care experience were largely unsupported. Site-level largely contributed to understanding the likelihood of documentation and care experience.

Using ethnographic methods to classify the human experience in medicine: a case study of the presence ontology

OBJECTIVE

Although social and environmental factors are central to provider-patient interactions, the data that reflect these factors can be incomplete, vague, and subjective. We sought to create a conceptual framework to describe and classify data about presence, the domain of interpersonal connection in medicine.

METHODS

Our top-down approach for ontology development based on the concept of "relationality" included the following: 1) a broad survey of the social sciences literature and a systematic literature review of >20 000 articles around interpersonal connection in medicine, 2) relational ethnography of clinical encounters (n = 5 pilot, 27 full), and 3) interviews about relational work with 40 medical and nonmedical professionals. We formalized the model using the Web Ontology Language in the Protégé ontology editor. We iteratively evaluated and refined the Presence Ontology through manual expert review and automated annotation of literature.

RESULTS AND DISCUSSION

The Presence Ontology facilitates the naming and classification of concepts that would otherwise be vague. Our model categorizes contributors to healthcare encounters and factors such as communication, emotions, tools, and environment. Ontology evaluation indicated that cognitive models (both patients' explanatory models and providers' caregiving approaches) influenced encounters and were subsequently incorporated. We show how ethnographic methods based in relationality can aid the representation of experiential concepts (eg, empathy, trust). Our ontology could support investigative methods to improve healthcare processes for both patients and healthcare providers, including annotation of videotaped encounters, development of clinical instruments to measure presence, or implementation of electronic health record-based reminders for providers.

CONCLUSION

The Presence Ontology provides a model for using ethnographic approaches to classify interpersonal data.

Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) for Health Care Interventions: a Proposed Framework

Human-centered design (HCD), an empathy-driven approach to innovation that focuses on user needs, offers promise for the rapid design of health care interventions that are acceptable to patients, clinicians, and other stakeholders. Reviews of HCD in healthcare, however, note a need for greater rigor, suggesting an opportunity for integration of elements from traditional research and HCD. A strategy that combines HCD principles with evidence-grounded health services research (HSR) methods has the potential to strengthen the innovation process and outcomes. In this paper, we review the strengths and limitations of HCD and HSR methods for intervention design, and propose a novel Approach to Human-centered, Evidence-driven Adaptive Design (AHEAD) framework. AHEAD offers a practical guide for the design of creative, evidence-based, pragmatic solutions to modern healthcare challenges.

Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative

CONTEXT

The Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.

OBJECTIVES

Our goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls.

METHODS

We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation.

RESULTS

Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.

CONCLUSION

Learning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.

"Asking Is Never Bad, I Would Venture on That": Patients' Perspectives on Routine Pain Screening in VA Primary Care

OBJECTIVE

Screening for pain in routine care is one of the efforts that the Veterans Health Administration has adopted in its national pain management strategy. We aimed to understand patients' perspectives and preferences about the experience of being screened for pain in primary care.

DESIGN

Semistructured interviews captured patient perceptions and preferences of pain screening, assessment, and management.

SUBJECTS

We completed interviews with 36 patients: 29 males and seven females ranging in age from 28 to 94 years from three geographically distinct VA health care systems.

METHODS

We evaluated transcripts using constant comparison and identified emergent themes.

RESULTS

Theme 1: Pain screening can "determine the tone of the examination"; Theme 2: Screening can initiate communication about pain; Theme 3: Screening can facilitate patient recall and reflection; Theme 4: Screening for pain may help identify under-reported psychological pain, mental distress, and suicidality; Theme 5: Patient recommendations about how to improve screening for pain.

CONCLUSION

Our results indicate that patients perceive meaningful, positive impacts of routine pain screening that as yet have not been considered in the literature. Specifically, screening for pain may help capture mental health concerns that may otherwise not emerge.

Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review

BACKGROUND

Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).

METHODS

We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.

RESULTS

Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.

DISCUSSION

Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

Advancing Evidence Synthesis from Effectiveness to Implementation: Integration of Implementation Measures into Evidence Reviews

BACKGROUND

In order to close the gap between discoveries that could improve health, and widespread impact on routine health care practice, there is a need for greater attention to the factors that influence dissemination and implementation of evidence-based practices. Evidence synthesis projects (e.g., systematic reviews) could contribute to this effort by collecting and synthesizing data relevant to dissemination and implementation. Such an advance would facilitate the spread of high-value, effective, and sustainable interventions.

OBJECTIVE

The objective of this paper is to evaluate the feasibility of extracting factors related to implementation during evidence synthesis in order to enhance the replicability of successes of studies of interventions in health care settings.

DESIGN

Drawing on the implementation science literature, we suggest 10 established implementation measures that should be considered when conducting evidence synthesis projects. We describe opportunities to assess these constructs in current literature and illustrate these methods through an example of a systematic review.

SUBJECTS

Twenty-nine studies of interventions aimed at improving clinician-patient communication in clinical settings.

KEY RESULTS

We identified acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, intervention complexity, penetration, reach, and sustainability as factors that are feasible and appropriate to extract during an evidence synthesis project.

CONCLUSIONS

To fully understand the potential value of a health care innovation, it is important to consider not only its effectiveness, but also the process, demands, and resource requirements involved in downstream implementation. While there is variation in the degree to which intervention studies currently report implementation factors, there is a growing demand for this information. Abstracting information about these factors may enhance the value of systematic reviews and other evidence synthesis efforts, improving the dissemination and adoption of interventions that are effective, feasible, and sustainable across different contexts.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

IMPORTANCE

Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

OBJECTIVE

To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

EVIDENCE REVIEW

Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

FINDINGS

The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).

CONCLUSIONS AND RELEVANCE

This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection

OBJECTIVE

We sought to investigate the concept and practices of 'clinician presence', exploring how physicians and professionals create connection, engage in interpersonal interaction, and build trust with individuals across different circumstances and contexts.

DESIGN

In 2017-2018, we conducted qualitative semistructured interviews with 10 physicians and 30 non-medical professionals from the fields of protective services, business, management, education, art/design/entertainment, social services, and legal/personal services.

SETTING

Physicians were recruited from primary care clinics in an academic medical centre, a Veterans Affairs clinic, and a federally qualified health centre.

PARTICIPANTS

Participants were 55% men and 45% women; 40% were non-white.

RESULTS

Qualitative analyses yielded a definition of presence as a purposeful practice of awareness, focus, and attention with the intent to understand and connect with individuals/patients. For both medical and non-medical professionals, creating presence requires managing and considering time and environmental factors; for physicians in particular, this includes managing and integrating technology. Listening was described as central to creating the state of being present. Within a clinic, presence might manifest as a physician listening without interrupting, focusing intentionally on the patient, taking brief re-centering breaks throughout a clinic day, and informing patients when attention must be redirected to administrative or technological demands.

CONCLUSIONS

Clinician presence involves learning to step back, pause, and be prepared to receive a patient's story. Building on strategies from physicians and non-medical professionals, clinician presence is best enacted through purposeful intention to connect, conscious navigation of time, and proactive management of technology and the environment to focus attention on the patient. Everyday practice or ritual supporting these strategies could support physician self-care as well as physician-patient connection.

Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields

BACKGROUND

While barriers to physician wellness have been well detailed, concrete solutions are lacking.

OBJECTIVE

We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.

DESIGN

We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.

PARTICIPANTS

Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).

APPROACH

Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.

KEY RESULTS

Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.

LIMITATIONS

In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.

CONCLUSION

Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.

Patient-Centered Pain Management Communication from the Patient Perspective

BACKGROUND

Pain management discussions between patient and provider can be stressful to navigate and greatly impact the care received. Because of the complexity, emotional color, and sensitivity of pain management, such discussions require a high degree of skill.

OBJECTIVE

To identify patients' perspectives of patient-centered care communication within the context of pain management discussions.

DESIGN

We conducted semi-structured interviews (25-65 min) with patients regarding their experiences with pain assessment and management.

PARTICIPANTS

36 patients (29 males, 7 females), from 3 Veteran Affairs healthcare locations. Participant age ranged from 28 to 94 with pain intensity ranging from 0 to 10, based on the "pain now" numeric rating scale report gathered at the time of the interview.

APPROACH

Interview transcript analysis was conducted using the constant comparison method to produce mutually agreed upon themes.

KEY RESULTS

Elements of patient-centered care communication described by participants include judgment, openness, listening, trust, preferences, solution-oriented, customization, and longevity. Patients perceive provider reciprocation in openness and trust as drivers of the patient-provider relationship, thereby enhancing positive, associated themes.

CONCLUSIONS

Findings highlight the importance of the patient-provider relationship in patient-centered care and offer patient-centered care communication tools for practitioners to utilize, such as solution-oriented messages and communicating trust, especially when interacting with patients about pain.

Social Support Strategies in Online Forums Among Adult Offspring of Parents with Harmful Alcohol Use

The authors categorized communication strategies employed to exchange social support (type and person centeredness) in three online forums about parents with harmful drinking. Data included discussion postreplies over 2 months; N = 1,644 units of analysis. Support type categories were identification, emotional, informational, network, and esteem. For person centeredness, most messages were moderate (expressed sympathy, provided distraction), followed by high (helped with feelings), and then low (minimized feelings). Adult offspring of parents with harmful drinking predominantly communicate self-interested forms of support in online forums. Based on principles of supportive communication, esteem support and high person centeredness may enhance social support in these settings.

Oncology providers, patients, and caregivers reflect: Applying "big data" for better supportive outcomes

59

Background: The development of “big data” methods offers an opportunity to more precisely predict patient outcomes. We explored physicians, patients, and caregivers’ perspectives about the use of predictive models in oncology practice. Methods: We conducted 12 patient, 12 provider, and 12 caregiver interviews (N = 36) from Stanford University outpatient oncology clinics. We queried participants about patient and family-centered applications of predictive models for prognosis, cost, and novel patient and family-centered outcomes. Two trained coders iteratively examined transcripts for consistent topics and used the constant comparative methods to establish themes and sub-themes. Results: Several overlapping themes emerged: 1) Outcomes of Interest, [provider] “Predictive information about side effects or adverse effects of treatment would be helpful”: 2) Barriers to Using Predictions, [patient] “If it seems too sort of set in stone, without…you know, everything has grey areas”; 3) Benefits to Using Predictions, [provider] “Some people…their cancer may be cured, but they live with these really horrible chronic illnesses and some people would say, ‘I would have rather have just died from my disease than be in this shape’; and 4) Communication Strategy, [provider] “I’m not even sure if I would bring up the models…I would kind of fall back on what I normally discuss with patients”. A theme specific to the provider group was 5) Accuracy of Model Information, [provider] “It’s hard to know whether to use in the clinical setting just the results of the model or whether you would really want to go down to the root level and actually access the raw data”. A theme specific to the patient and caregiver groups was 6) Privacy, [caregiver] “I would want to be able to have the patient authorize that”. Conclusions: There is consistency between provider strategies to communicate prognostic information and patients’ perceptions of how they would like prognostic information to be communicated to them. While providers are concerned with accuracy of predictive models, patients and caregivers are more concerned with privacy.

Parent's alcoholism severity and family topic avoidance about alcohol as predictors of perceived stigma among adult children of alcoholics: Implications for emotional and psychological resilience

Alcoholism is a highly stigmatized condition, with both alcohol-dependent individuals and family members of the afflicted experiencing stigmatization. This study examined the severity of a parent's alcoholism and family topic avoidance about alcohol as two factors that are associated with family members' perceptions of stigma. Three dimensions of stigma were considered: discrimination stigma, disclosure stigma, and positive aspect stigma. In addition, this study assessed associations between perceived stigmatization and individuals' experiences of depressive symptoms, self-esteem, and resilience. Adult children of alcoholics (N = 622) were surveyed about family conditions, perceived stigma, and their emotional and psychological well-being. Regression analyses revealed that the severity of a parent's alcoholism predicted all three types of stigma for females, but not for males. In addition, family topic avoidance about alcohol predicted all types of stigma for males and discrimination stigma and positive aspect stigma for females. With few exceptions, the three types of stigma predicted depressive symptoms, self-esteem, and resilience for both male and female adult children of alcoholics. The results are discussed in terms of their implications for promoting a family environment that mitigates stigma and encourages emotional and psychological well-being. In 2012, approximately 3.3 million deaths worldwide were due to the harmful use of alcohol (World Health Organization [WHO], 2014). Individuals who abuse alcohol are susceptible to a variety of negative health outcomes (Rehm et al., 2009) and display inappropriate social behaviors (Klingemann, 2001; Schomerus et al., 2011a). General societal perceptions tend to characterize alcohol-dependent individuals as irresponsible and lacking in self-control (Schomerus et al., 2011b). Research in the United Kingdom found that 54% of the population believes alcohol-dependent individuals are personally to blame for their own problems (Crisp, Gelder, Goddard, & Meltzer, 2005). In the United States, a person's own bad character or the way they were raised are more likely to be identified as reasons for alcoholism than they are for other types of mental illness (Schnittker, 2008). In addition, people prefer greater social distance between themselves and alcoholics than between themselves and people with mental illness (Crisp et al., 2005). The negative social perceptions of alcoholics likely contribute to feelings of stigma (Room, 2005). Not only does stigma affect the afflicted individual, but also members of his or her family (WHO, 2014). Children of parents with an alcohol dependency may be reluctant to discuss a parent's alcoholism with others if they feel pressured to keep it a secret or to avoid negative stereotypes (Afifi & Olson, 2005; Burk & Sher, 1990; Caughlin & Petronio, 2004; Lam & O'Farrell, 2011). Thus, the stigma of a parent's alcoholism may prevent children from addressing concerns and coping with their surroundings.