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Effective communication skills are the key to good cancer care.

Communication within oncology is a core clinical skill but one in which few oncologists or specialist cancer nurses have received much formal training. Inadequate communication may cause much distress for patients and their families, who often want considerably more information than is usually provided. Many patients leave consultations unsure about the diagnosis and prognosis, confused about the meaning of--and need for--further diagnostic tests, unclear about the management plan and uncertain about the true therapeutic intent of treatment. Additionally, communication difficulties may impede the recruitment of patients to clinical trials, delaying the introduction of efficacious new treatments into clinics. Lack of effective communication between specialists and departments can also cause confusion and a loss of confidence amongst the team. Oncologists themselves acknowledge that insufficient training in communication and management skills is a major factor contributing to their own stress, lack of job satisfaction and emotional burnout. Consequently, over the past few years there have been several initiatives aimed at improving basic communication skills training for healthcare professionals in the cancer field. In this paper, some of the issues that influence communication within an oncology setting, and ultimately affect patient care, are discussed.

Clinical Competence↗

Relationship between adolescent-parental communication and initiation of first intercourse by adolescents.

OBJECTIVE: To examine the level of communication between parents and adolescents and correlate the findings with onset of sexual intercourse. METHODS: This was a 10-year longitudinal study. Subjects filled out questionnaires at the time of each health supervision visit. The data in this article were harvested at enrollment and at the 5-year point. Comparisons of adolescent-parental communication were first compared between the virginal and nonvirginal groups at the initiation of the study. The results were then confirmed by adding data from patients in the virginal group who converted over the first 5 years of the study to the nonvirginal group. Two hundred and three patients, aged 12-21 years, were studied from a pediatrician's practice panel in Middleton, Wisconsin. The questionnaires inquired about grades and activities school, relationship with siblings and parents at home, and risk-taking behaviors involving alcohol, drugs, and sex with peers. Statistical analysis included the Student's t-test to determine the mean difference between groups. Fisher's exact test was used to evaluate the association of variables to the status of patients' sexual activity at enrollment. Multiple logistic regression was conducted on the initial enrollment data to examine the association between the initial covariates and patients' sexual status. RESULTS: During the initial survey, 172 enrolled patients were in the virginal group and 31 in the nonvirginal group. The virginal group had a higher rating of communication with their parents after adjusting for age (p <.001). To verify these findings, we examined an additional 29 patients in the virginal group who converted to nonvirginal status during the first 5 years of the study. We then compared the level of adolescent-parental communication between the subgroup who converted to nonvirginal status with the level of communication of the subgroup who remained virgins. Even after correcting for age, communication with the mother was significantly better in patients who maintained their virginal status (p <.01). CONCLUSIONS: Teenagers who perceive that they have a better level of communication with their parents are less likely to engage in sexual intercourse.

Adolescent↗

Utilization of electronic communication (E-mail) with patients at university and college health centers.

PURPOSE: To examine the utilization and potential uses and problems of electronic communication with patients. METHODS: University and college health centers were surveyed about the type of utilization and policies of electronic communication with patients. The survey group consisted of 99 health centers predominantly serving students representing small-, medium-, and large-sized public and private colleges and universities. Eighty-nine health centers completed the survey. RESULTS: Of the responding health centers, 63.6% use some form of electronic communication with patients. Twenty-seven percent of the health centers give out some form of medical advice via E-mail or the Internet; 14.7% give out some laboratory results via E-mail; 3.4% make appointments via E-mail; and 63.6% give out administrative advice by E-mail. While there was consistent concern expressed about confidentiality and security, only five health centers had a policy about electronic communication. Uses were most common in nonclinical areas but did include health education, Web sites, medical advice, laboratory results, appointment-making or confirmation, and contacting hard-to-reach patients including those studying abroad. CONCLUSIONS: While electronic communication with patients was common, provision of direct medical advice was less common. Issues receiving little attention include determining the types of electronic communication that is acceptable to staff and students, determining the level of security of their current information system, educating staff about confidentiality and security issues, and establishing a comprehensive policy regarding electronic communication with patients.

Adolescent↗

Health communications: nursing education for increased visibility and effectiveness.

The media play an influential role in American society. The challenge for health professionals, including nurses, is to translate and transmit complex health information for the public through many channels. Although nurses are trained to be effective communicators in practice, a recent study demonstrates that nurses are virtually invisible in the media. This lack of visibility limits nursing's ability to communicate important health information, impedes nursing's ability to define its role and contributions in the health care delivery system, and restricts nursing's ability to advocate for health policy. One option to improve nurses' ability to communicate effectively in all media venues is to integrate health communications content into nursing programs, which would provide nurses with the opportunity to develop advanced communication skills, media expertise, and new strategies for educating the public. Health communications programs exist in several colleges and universities, but not within nursing programs. Because nursing curricula are in a period of transition as changes in the health care environment are accommodated, health communications courses could be integrated into nursing programs as elective courses, graduate certificate programs, or a field of graduate study. Without creative educational strategies, nursing will remain invisible to the public and ineffective in its ability to influence the health care environment.

Communications Media↗

Communication, conflict, and psychological distance in nondistressed, clinic, and divorcing couples.

This study compared communication patterns and conflicts over psychological distance in 25 nondistressed couples, 15 clinic couples, and 22 divorcing couples. Data consisted of questionnaire reports completed independently by husbands and wives. The two distressed groups, compared with nondistressed couples, had less mutual constructive communication, more avoidance of communication, more demand/withdraw communication, and more conflict over psychological distance in their relationships. In addition, the divorcing group had less mutual constructive communication than the clinic group and evidenced a trend for more conflict over psychological distance than the clinic group. Consistent with past research, wife demand/husband withdraw communication was more likely across all groups than husband demand/wife withdraw communication. Results are discussed in terms of skills deficits and incompatability models of marital discord.

Adult↗

Stability and transitions in mother-infant face-to-face communication during the first 6 months: a microhistorical approach.

In this study the authors attempted to unravel the relational, dynamical, and historical nature of mother-infant communication during the first 6 months. Thirteen mothers and their infants were videotaped weekly from 4 to 24 weeks during face-to-face interactions. Three distinct patterns of mother-infant communication were identified: symmetrical, asymmetrical, and unilateral. Guided by a dynamic systems perspective, the authors explored the stability of and transitions between these communication patterns. Findings from event history analysis showed that (a) there are regularly recurring dyadic communication patterns in early infancy, (b) these recurring patterns show differential stabilities and likelihoods of transitions, (c) dynamic stability in dyadic communication is shaped not only by individual characteristics (e.g., infant sex and maternal parity) but also by the dyad's communication history, and (d) depending on their recency, communication histories varying in temporal proximity exert differential effects on the self-organization processes of a dyadic system.

Child Behavior↗

The interactive effect of leader-member exchange and communication frequency on performance ratings.

The authors tested the hypothesis that communication frequency moderates the relationship between leader-member exchange (LMX) and job-performance ratings. In a study of 188 private sector workers, they found that LMX was more strongly related to job-performance ratings among individuals reporting frequent communication with the supervisor than among those reporting infrequent communication. At high levels of LMX, workers reporting frequent communication with the supervisor received more favorable job-performance ratings than did workers reporting infrequent communication. In contrast, at low levels of LMX, workers reporting frequent communication with the supervisor received less favorable job-performance ratings than workers reporting infrequent communication. The authors conducted a 2nd study of 153 public sector workers to provide a constructive replication and found similar results.

Adult↗

Overview: For crying out loud--dangers and opportunities of communicating in the public domain.

Communication often extends into the public domain, inviting "eavesdropping" and other forms of exploitation by other species. Conflict is frequently the result, although interspecific communication can be mutually beneficial even when interests conflict fundamentally, such as between predator and prey. However, the most complex communication systems are likely to involve species with mutual rather than with conflicting interests. When interests do conflict, exploitation of the communication systems of others may impose high costs on signalers and select for signals that are less exploitable. Other costs of communication in the public domain arise from "mistakes" (e.g., mating with the wrong species) and select for more species-specific signal structure. The articles in this section illustrate the complexity of interspecific communication and yield important insights into the dynamic nature of communication systems.

Agonistic Behavior↗

Effect of communication disability on satisfaction with health care: a survey of medicare beneficiaries.

PURPOSE: To examine the prevalence and characteristics of community-dwelling Medicare beneficiaries reporting a communication disability and the relationship between that disability and dissatisfaction with medical care. METHOD: A total of 12,769 Medicare Current Beneficiary Survey respondents age 65 and older in 2001 were categorized by level of communication disability. Sampling weights were used to make inferences about the entire Medicare population. RESULTS: Over 16 million beneficiaries reported a communication disability. Hearing problems were most commonly reported (41.99%). The association between dissatisfaction and communication disability was statistically significant (p <or= .05) for 8 of 10 items. CONCLUSIONS: Prevalence of dissatisfaction among those with a communication disability varied, ranging from 3.43% to 19.34%. Respondents with a communication disability reported much more dissatisfaction when compared with those respondents without a communication disability.

Aged↗

Effectiveness of communication strategies used by caregivers of persons with Alzheimer's disease during activities of daily living.

Communication difficulties between individuals with Alzheimer's disease (AD) and their caregivers are commonly reported. Caregivers carry the burden of managing breakdowns in communication because people with AD are often unable to modify their communicative behavior. To assist caregivers in this endeavor, clinicians and caregiving professionals have offered a variety of strategies aimed at accommodating the individual's declining abilities. Many of these strategies are intuitively appealing, but they lack empirical support. This study investigated the effectiveness of 10 frequently recommended communication strategies when employed by family caregivers of persons with AD. In particular, we assessed (a) which strategies family caregivers report using and with what degree of success, (b) which of these strategies are used by caregivers in actual interactions with their spouses, and (c) which strategies contribute to improved communication. The study included a self-report questionnaire and wireless audio-recorded interactions between 18 persons with AD and their spousal caregivers during activities of daily living. The findings validate the effectiveness of certain communication strategies (e.g., simple sentences) but not others (e.g., slow speech). The results should be of interest to both family members and professionals who want to enhance communication and the quality of their interactions with persons with Alzheimer's disease.

Activities of Daily Living↗

The meaning of communication to a group of deaf college students: a multidimensional perspective.

The purpose of this study was to investigate the meaning of communication to deaf college students and to explore with them the range of skills and conditions that they consider important for communication. Ethnographic interviews with 23 first-year students at the National Technical Institute for the Deaf at Rochester Institute of Technology (NTID at RIT) were used to gather information about communication. Analysis of the interviews led to the organization of informants' comments into four dimensions of communication, including language-modality, affective, situational, and sociopolitical. These dimensions were then used to develop a multidimensional perspective on communication. The paper concludes with a discussion of the implications of a multidimensional perspective on communication for the development of comprehensive communication training programs for deaf people.

Communication↗

Communicating about pupils in mainstream school with special health needs: the NHS perspective.

AIM: To add to previous research carried out with young people, parents and teachers, by investigating health staff's perspectives on the difficulties, and possibilities for, achieving good communication with school staff with regard to children in mainstream school with a chronic illness or physical disability. RESEARCH DESIGN AND METHODS: A qualitative research study was carried out in one NHS Trust. Twenty semi-structured interviews were carried out with a purposive sample of health staff to cover the spectrum of professionals who have responsibility for meeting the needs of children with a chronic illness or physical disability in mainstream schools (paediatricians, school doctors, school nurses, specialist nurses, health visitors, GPs, speech and language therapists, paediatric occupational therapists, paediatric physiotherapists, clinical psychologists and psychiatrists). RESULTS: The extent to which health professionals communicated with school staff, and the way in which they went about it, varied widely. Communication was facilitated by joint meetings, shared documentation, and local policy development. Sources of difficulty in communication between health and education staff were: the parent as a conduit of information; the practical difficulties of arranging meetings; and lack of knowledge about other professionals' roles. The ethos of the school with regard to health matters, and the flow of information within health services, also had an impact on the communication process. Participants' recommendations focused on two key issues: clarification of the roles of health and education staff with regard to this group of pupils; and how information should flow from health to school staff. DISCUSSION: Many of the findings parallel the previous research with teachers, indicating agreement between professionals from different agencies about aspects of the communication process which are problematic and require attention. The findings suggest that improving communication requires both joint work between health and education staff, and improvements to practice within each agency.

Child↗

Training programme in techniques of self-control and communication skills to improve nurses' relationships with relatives of seriously ill patients: a randomized controlled study.

The interpersonal relationships with relatives of seriously ill patients may cause anxiety on the part of nurses and the need for adequate communication and self-control skills. To assess the efficacy of training nurses in self-control techniques and communication skills when they interact with relatives of seriously ill patients we planned a randomized, controlled trial in two parallel groups: an experimental group, with immediate training, and a control group, with training delayed for 6 months. We recruited 61 nurses from the nursing staff of a university hospital of 500 beds. The intervention consisted of training in relaxation, cognitive restructuring and some communication skills. The outcome variables were communication skills measured under simulated conditions using an observation instrument of our own, administered by observers masked with respect to the study groups, and the levels of state-anxiety measured with the self-assessment questionnaire the State-Trait Anxiety Inventory, under imaginary conditions. The two groups initially had similar scores in the scales of communication skills, and state and trait-anxiety. After intervention, compared with the control group, the experimental group showed significant improvements in the skills of listening, emphasizing, interrupting and coping with emotions (P < 0.05). State-anxiety levels did not show any changes. In conclusion, the joint training in self-control and communication improves some communication skills in nurses when they interact with relatives of seriously ill patients under simulated conditions.

Adaptation, Psychological↗

Assessing the development of communication skills in undergraduate medical students.

CONTEXT: The teaching of clinical communication skills' teaching has become an important part of medical school curricula. Many undergraduate medical courses include communication skills training at various points in their curriculum. Very few reports have been published on the development of communication skills over the duration of a medical undergraduate training. AIMS: To determine the change in communication skills between early and mid-stages of the students' 5-year curriculum, and to investigate the predictive and theoretical significance of knowledge and understanding of communication skills in relation to observed performance. PARTICIPANTS: Students entering as the first cohort to the new medical curriculum at Liverpool Medical School (n=207). Nine students withdrew leaving 198 students who completed two summative assessments in June 1997 (level 1) and November 1998 (level 2). STATISTICAL ANALYSIS: Repeated measures multivariate ANOVAS were applied to the main study data to detect any change in performance between levels 1 and 2. RESULTS AND CONCLUSIONS: An improvement in communication skills was found in medical students over 17 months of their undergraduate teaching: that is from the level 1 to the level 2 assessment. Knowledge and understanding of communication skills at initial assessment did not show the predicted association with performance at level 2.

Analysis of Variance↗

Predicting communication skills with a paper-and-pencil test.

AIM: This study was conducted to investigate the value of a written knowledge test of communication skills for predicting scores on a performance test of communication skills. METHOD: A paper-and-pencil test of knowledge about communication skills and a performance test of communication skills, consisting of four stations with standardised patients, were administered to students of two classes of the medical schools of Maastricht and Leiden, the Netherlands. The results on these tests were compared. RESULTS: From the results of both instruments, the classes of the participating students could be recognised equally well: 60% correct qualifications of the classes by the knowledge test and 64% by the multiple station examination. Between the two tests an overall, disattenuated correlation of 0.60 was found (N=133, P < 0.01), suggesting moderate predictive value of the knowledge test for the performance test of communication skills. The correlation is stronger for students from Maastricht medical school than for their colleagues in Leiden. Correlation between the knowledge of communication skills test and other available test results of the participating Maastricht students is close to zero, suggesting that the test measures a distinct quality of students' competence. DISCUSSION: The paper-and-pencil test of knowledge of communication skills has predictive value for the performance of these skills, but this value seems to be less pronounced than similar findings for clinical procedural skills. The stronger relationship between 'knowing how' and 'showing' in the Maastricht student group might be indicative of an effect of the training format.

Clinical Competence↗

Barriers to communication about end-of-life care in AIDS patients.

OBJECTIVE: Patients and physicians do not adequately discuss patients' preferences for medical care at the end of life. Our objective was to perform a qualitative study using focus groups to identify barriers and facilitators to communication about end-of-life medical care for patients with AIDS and their physicians. PARTICIPANTS: Patients with AIDS and physicians with moderate or extensive HIV experience were recruited from clinics and community-based settings using network sampling. A total of 47 patients participated in six focus groups and 19 physicians participated in three groups. MEASUREMENTS AND MAIN RESULTS: Patients or physicians identified 29 barriers and facilitators to communication about end-of-life care. Many patients and physicians expressed discomfort talking about death and dying, and some felt that discussing end-of-life care could cause harm or even hasten death. Several patients expressed the view that a living will obviated the need for discussion with their physician. Previous experience of discrimination from the health care system was a strong barrier to end-of-life communication for some patients with AIDS. Some patients hesitate to bring up end-of-life issues because they want to protect their physicians from uncomfortable discussions. Many patients identified the quality of communication as an important facilitator to these difficult discussions. CONCLUSIONS: Improving the quality of patient-physician communication about end-of-life care will require that physicians identify and overcome the barriers to this communication. To improve the quality of medical care at the end of life, we must address the quality of communication about end-of-life care.

Acquired Immunodeficiency Syndrome↗

House staff nonverbal communication skills and standardized patient satisfaction.

OBJECTIVE: To examine the association of physician nonverbal communication with standardized patient (SP) satisfaction in the context of the "quality" of the interview (i.e., information provided and collected, communication skills). DESIGN: Observational. SETTING: One university-based internal medicine residency program. PARTICIPANTS: Fifty-nine internal medicine residents. INTERVIEWING: The 59 residents were recruited to participate in 3 SP encounters. The scenarios included: 1) a straightforward, primarily "medical" problem (chest pain); 2) a patient with more psychosocial overlay (a depressed patient with a history of sexual abuse); and 3) a counseling encounter (HIV risk factor reduction counseling). Trained SPs rated physician nonverbal behaviors (body lean, open versus closed body posture, eye contact, smiling, tone of voice, nod, facial expressivity) in the 3 encounters. Multiple regression approaches were used to investigate the association of physician nonverbal behavior with patient satisfaction in the context of the "quality" of the interview (SP checklist performance, measures of verbal communication skills), controlling for physician characteristics (gender, postgraduate year). RESULTS: Nonverbal communication skills was an independent predictor of standardized patient satisfaction for all 3 patient stations. The effect sizes were substantial, with nonverbal communication predicting 32% of the variance in patient satisfaction for the chest pain station, 23% of the variance for the depression-sexual abuse station, and 19% of the variance for the HIV counseling station. CONCLUSION: Better nonverbal communication skills are associated with significantly greater patient satisfaction in a variety of different types of clinical encounters with standardized patients. Formal instruction in nonverbal communication may be an important addition to residency.

Female↗

Intercellular communication via gap junctions in activated rat hepatic stellate cells.

BACKGROUND AND AIMS: Gap junctional communication was studied in quiescent and activated hepatic stellate cells. METHODS: Connexin expression and intercellular dye transfer were studied in rat hepatic stellate cells in culture and in vivo. RESULTS: Protein expression of connexin 43 was up-regulated in activated hepatic stellate cells in vivo and in vitro and was mainly localized on the cell surface, whereas connexin 26 was found intracellularly. In contrast to hepatocytes, hepatic stellate cells do not express connexin 32. Confluent hepatic stellate cells in culture communicate via gap junctions, resulting in lucifer yellow transfer and propagation of intracellular calcium signals. Phorbol ester induces a protein kinase C-dependent hyperphosphorylation and degradation of connexin 43 and inhibits intercellular communication on a short-term time scale. At the long-term level, vitamin D(3) , lipopolysaccharide, thyroid hormone T(3), dexamethasone, platelet-derived growth factor, endothelin 1, and interleukin 1beta up-regulate connexin 43 protein and messenger RNA expression and enhance intercellular communication. Slight down-regulation of connexin 43 is observed in response to vitamin A. Connexin 43 induction by endothelin 1 is inhibited by both endothelin A and endothelin B receptor antagonists. In coculture systems, hepatic stellate cells communicate with each other, which is suggestive of a syncytial organization, but no communication was found between hepatic stellate cells and other liver cell types. As shown by immunohistochemistry and electron microscopy, gap junctions are formed between activated hepatic stellate cells in vivo. CONCLUSIONS: Gap junctional communication occurs between hepatic stellate cells, is enhanced after activation, and underlies complex regulation by cytokines, hormones, and vitamins.

Animals↗