Abstract and Keywords
This chapter examines the problems health professionals involved in cancer and palliative care report in communicating with patients, families, and colleagues. It proposes a three-step guide for improving communication in a palliative care setting. These steps include looking at how good communication skills can be acquired and considering the difficulties of transferring training into clinical practice, identifying the skills necessary for effective interviewing, and understanding how communication goes wrong and investigating why this happens.
This chapter reviews the problems health professionals involved in cancer and palliative care report in communicating with patients, families and colleagues. A three-step guide to improving practice is presented.
1. To understand how communication goes wrong and consider why this happens.
2. To identify the key skills necessary for effective interviewing.
3. To look at how good communication skills can be acquired and consider the difficulties of transferring training into clinical practice.
The need to improve communication skills within palliative care
Communication underpins every aspect of the care we offer to our patients their families, and is the key to effective team work. It is estimated that on average in a 40-year professional career the average doctor will conduct between 160 000 and 200 000 consultations (Lipkin et al. 1995), making communication the most used clinical skill any palliative care professional possesses.
Recent changes in UK and other government policies have meant that providing compassionate care, which assesses need, provides accurate information and gives people the choices in treatment and care, is a requirement (NICE 2004). These requirements are based on research showing not only the need to improve skills but also the value of those improvements to physical and emotional well-being of patients families and staff. They are also a response to analysis of hospital complaints, which, certainly in the UK, show that 90% of complaints dealt with by official bodies concern poor communication (Royal College of Physicians, London 1997) and that communication and insufficient information is the second most common cause for complain (Healthcare Commission 2007), despite that fact that it is known that 30–40% of patients who have begun litigation will not proceed if they receive an apology (Vincent 1994).
Poor communication is linked to poor assessment of patients concerns (Heaven and Maguire 1996; Farrell et al. 2005) and this in turn is known to be associate with the development of anxiety and depression, in both newly diagnosed and palliative care patients (Parle et al. 1996; Heaven and Maguire 1998) and in relatives or carers of cancer patients (Pitceathly and Maguire 2000). A relationship has also been established between the types of concerns commonly found in palliative care, such pain (Derogatis et al. 1983), fatigue (Worden and Weisman 1977), breathlessness (Bredin et al. 1999), and psychiatric morbidity.
Given that one in three cancer patients suffer from an episode of anxiety or depression regardless of stage (Barraclough 1994; Ibbotson et al. 1994; Fulton 1998), and between 30 and 33% of relatives also suffer an episode of such morbidity (Kissane et al. 1994; Pitceathly and Maguire 2000), it is vital that healthcare professionals are able to identify concerns and recognize the associated distress. However, in practice, many concerns are not elicited, and psychological morbidity is missed (Heaven and Maguire 1997; Sharpe et al. 2004; Farrell et al. 2005). This failure to elicit problems is not restricted to the psychological domain, but also applies to physical concerns, for example, pain and fatigue (Glajchen et al. 1995; Heaven and Maguire 1997). Consequently, many patients are not given the appropriate help or support to resolve or come to terms with their difficulties.
It has been found that patients cope better with their predicament if they perceive they are given adequate information (Butow et al. 1996; Schofield 2003). Yet, only a small proportion receive the information they require (Hinds et al. 1995). Some patients are given too much or too little, and this increases the risk of anxiety and depression (Fallowfield et al. 1990). The challenge for the health professional is to quickly establish what information individual patients need. However, many healthcare professionals do not have the strategies to do this (Butow et al. 1996; Ford et al. 1996). So, they tend to use routinized ways of giving the information, which take no account of individual needs or preferences (Maguire 1998).
Non-involvement or overinvolvement in decision-making can lead to dissatisfaction and non-compliance (Dowsett et al. 2000) and affect patient outcomes adversely (Coulter 1999). There is some debate as to whether all seriously ill cancer patients want involvement in decision making (Cox 2002). Rothenbacher et al. (1997) established that the majority of patients with (p.23) advanced cancer want a collaborative or active role in decisions, but a substantial minority (28%) desire a passive role. Thus, healthcare professionals need to identify those who wish to take part in decisions and respect those who wish the clinician to take decisions for them. Clinicians do not know how to assess patients' wish for involvement (Rothenbacher et al. 1997), and fear patients will blame themselves or lose confidence in the doctor, if treatment does not work (Richards et al. 1995). Doctors take refuge in a paternalistic approach, in which less disclosure and less patient participation are favoured (Fallowfield et al. 1990; de Valch et al. 2001) but this increases both anxiety and depression (Ashcroft et al. 1985; Morris and Royle 1987).
Many health professionals report frustration in communicating with colleagues (Maguire and Faulkner 1988; Fallowfield et al. 1998; Madge and Khair 2000), but little research has been conducted in this area. A study of 48 nurses showed that much of the written interprofessional reporting was task orientated, focused on medical treatments, and failed to cover psychological and social aspects of care (Dowding 2001). The study also showed that during shift reports nurses recorded less than half the information given or discussed, and recalled less than 27%. There was a clear bias in recall towards medical information, treatment, and history. Professionals appear to only report and record a small amount of the information they have elicited from the patient (Heaven and Maguire 1997). The rules that govern which information is valued and passed on between healthcare professionals and which is not are complex and need further investigation, but it is clear that each person's professional training and background will mean that they attend to and value different cues, and that these will influence how they report a patient's situation to colleagues within the team (Crow et al. 1995).
These communication difficulties create problems for patients and relatives, and also affect healthcare professionals. Lack of confidence in their ability to communicate with patients and relatives contributes to high levels of burnout in cancer professionals (Delvaux et al. 1988; Ramirez et al. 1996; Taylor et al. 2005). Within palliative care and oncology nursing, communication problems have been identified as contributory factors to stress, burnout, illness, and staff turnover (Payne 2001; Wiseman 2002).
The key to improving communication is to understand how and why it breaks down.
How communication breaks down
Healthcare professionals often ‘distance’ from what the patients is saying. While this is often a conscious process (Booth et al. 1996) it may also happen unconsciously (Maguire 1999). From analysis of many consultation behaviours that have the function of distancing have been identified (Maguire et al. 1996a,b; Zimmerman et al. 2003; Eide et al. 2004; Heaven et al. 2006).
A behaviour reported in both nurse and doctors (Crow et al. 1995; Bornstein and Emler 2001), which happens when the interviewer controls the content of the conversation, by picking up only certain areas, commonly those which are factual or which contain no feeling. In doing this, the interviewer limits the agenda to those topics they feel comfortable discussing or helping with. For example,
I was in pain, weak and tired, and was absolutely terrified that the treatment wasn't working'
‘Tell me about your pain. How bad was it?’
This is the term used when the interviewer changes the focus of what is being said, so controlling the content, emotional depth, or focus of the conversation. Switching can happen in several ways.
1. Switching the time focus. This is when the interviewer changes the ‘time-frame’ of the interview, so preventing the patient from talking further about the concern they have offered. For example, responding to talk about initial fears, by encouraging a person to focus on current thoughts. In doing this the interviewer inhibits patients from expressing their emotions about past events, by focusing them on different events.
2. Switching the topic. This is when the interviewer, often unconsciously, changes the topic or content of the conversation completely.
3. Switching the person focus. This happens when the interviewer changes the focus of the interview from the interviewee, or person being spoken to, to a third party, either present at the interview or not. So inhibiting the interviewee from talking about how he or she feels.
Offering advice or reassurance
One of the most common responses to expression of emotion is for the health profession to give reassurance or offer advice. However, Maguire et al. (1996a,b) in their investigation of facilitative and (p.25) inhibitory interviewing behaviours found that giving advice prematurely, before patients concerns have been fully explored, significantly decreased patient disclosure. This early finding has been confirmed using a more robust system of sequence analysis (Zimmerman et al. 2003), which show that disclosure falls after advice or reassurance has been given. These findings create a difficulty for many healthcare professionals who struggle to resist the pressure to problem solve when a concern is heard and find allowing space for ventilation of feelings hard, when they feel that something can be done to help.
‘I was really very upset when she first mentioned the word hospice’
‘Well, it's only natural that you should feel that way at first, all patients do’
In the example above moving immediately into advice has the function of inhibiting the patient from saying more about their distress, and means that the health professional's advice or reassurance may not actually address the patients' real concern.
Passing the buck
This is a particular form of advice giving in which the interviewer, in direct response to the patient's cue or concerns, advises the patient to talk to a third party. While this may be appropriate at the end of an interview, using it immediately a patient mentions a problem indicates that the interviewer does not want to hear the patients concerns.
‘I was so upset, I just didn't know what he meant’
‘Clearly you need to talk to the surgeon about that, to get things clear’
Using medical jargon in communication can create an obstacle between the patient or relative and the healthcare professional. It is interesting to note that the use of medical terminology is not confined solely to the health professional. As information is now widely available from the internet there is increasing evidence that patients and relatives are using medical terms, which may or may not be fully understood. Health professionals need to be alert not only about their own use of language, but also to medical terms used by the patient, which may seem appropriate, but which may be a source of misunderstanding as the word may simply be being repeated without having been understood.
Why communication breaks down
Communication is a complex process that is dependent not just on skills, but also on a number of other factors that relate to both the professional and to the recipient of the communication, i.e. the patient, relative, or colleague. The healthcare professional's ability to use their skills, or the patient's willingness (p.26) to come clean about concerns is dependent on many factors, including attitudes, beliefs, and fears. For communication to be effective these influences must be understood (Bandura 1977).
A number of very specific studies have been conducted in this area, and have focused on asking both staff (Booth et al. 1996; Heaven et al. 2006) and patients (Heaven and Maguire 1997) about specific distancing behaviours and disclosure of concerns and worries. These studies build on a large literature, which has reported communication problems and the potential reasons for these difficulties. Interestingly, in these specific studies for the majority of cases both nurses and patients were conscious of their non-disclosure and distancing behaviours, and gave clear explanations as to why they had withheld information of changed the focus or switched topic at the identified points (Booth et al. 1996; Heaven and Maguire 1997; Wiseman 2002; Heaven et al. 2006).
Professionals' lack of skills
One of the reasons given by the nurses in Booth et al's study was their perception that they lacked skills. Studies of communication in medicine and nursing have shown repeatedly that doctors and nurses lack the skills necessary to elicit and explore patients' concerns, identify and respond to patients' information needs and decision making preferences (Maguire et al. 1996a,b; Heaven and Maguire 1996; Wilkinson et al. 1998; Razavi et al. 2000; Fallowfield 2002).
Healthcare professionals experience other difficulties when interviewing, including: integrating factual, physical, emotional, social and spiritual modes of enquiry, and avoiding a purely bio-medical approach to the interview (Maguire et al. 1996; Ford et al. 1996; Butow et al. 2002); assessing less familiar aspects (for example, body image or anxious preoccupation), and knowing how to close an
The literature points to a large number of fears that affect health professionals' use of communication skills. These include fear of upsetting the patient, fear of unleashing strong emotions such as anger or uncontrollable distress (Heaven and Maguire 1997). Many health professionals are aware of the depth and strength of patients and relatives emotions, and so fear encouraging the expression of them; for example, asking how a man feels when he has just been told he is dying could easily provoke extreme distress, or even anger. If the professional giving the bad news is fearful of handling such emotions, then the likelihood of giving the patient the chance to ventilate his or her feelings is remote.
Another fear is that of opening up a ‘can of worms’, and in doing so giving patients false expectations about the professionals' ability to alleviate concerns. Health professionals may fear that they could get out of their depth, or be unable to cope with the list of worries. They may fear that they might respond in a way that would make the situation worse for the patient worse or even damage the patient (Maguire 1985; Booth et al. 1996; Heaven et al. 2006).
Fear of taking up too much time is reported as a deterrent to exploring feelings by many nurses and doctors, who they envisage that once patients are encouraged to talk about emotions they will be difficult to stop, or they may somehow lose control (Maguire 1985; Fielding and Llewelyn 1987; Sellick 1991). Even in palliative care, where time is often less of an issue, the fear of getting stuck with a patient, or of not being able to complete our allocated workload, can be a powerful deterrent to exploring the concerns expressed (Booth et al. 1996).
In a study of in-depth interviews with general practitioners, Rosser and Maguire (1982) noted that the fear of having to face one's own sense of failure in not being able to help also influences health professionals' willingness to talk openly with their patients (Rosser and Maguire 1982). This is echoed by Baider and Porath (1981) in discussing nurses' difficulties in facing patients who are having difficult death experiences. One's own death anxieties have been identified as a factor mediating communication with patients by a (p.28) number of authors (Field and Kitson 1986; Wilkinson 1991), and have therefore been part of a number of training schemes aimed at altering communication behaviours (Razavi et al.1993).
It is easy to see how such strong fears about what might happen inhibit and change the course of an interview. If these issues are not explored and addressed, they will inevitably result in professionals exhibiting ‘blocking’ behaviours to protect both the patient and themselves from what they perceive might be negative consequences (Parle et al. 1997; Razavi et al. 2000; Heaven et al. 2006).
Professionals' attitudes and beliefs
A broad number of attitudes have been associated with distancing. Beliefs about emotional problems being an inevitable consequence of a palliative situation encourages professionals to either ignore concerns, or normalize them, i.e. accept everyone feels like that (Peterson 1988; Booth et al. 1996). This, coupled with the belief that nothing can be done about certain types of concerns, for example, anxiety while waiting for results, can mean some worries get overlooked or minimized (Fallowfield et al. 2001; Sharpe et al. 2004). There is evidence that nurses and doctors believe there is no point in talking about things that cannot be changed. Opening up irresolvable issues will upset the patient unnecessarily (Booth et al. 1996). In a palliative situation this might be shown by reluctance to discuss issues such as ‘what might happen when the cancer becomes worse’. While the professional does this to protect the patient, the patient who is experiencing such fears, realizes the health professional is reluctant to talk about them and so remains isolated with their concerns.
The belief that people from different cultures experience different problems or interpret things differently can be a powerful deterrent to open communication. This may explain why cultural differences were put at the top of the list of patient characteristics which oncologists found most difficult to handle (Fallowfield et al. 1998). An awareness of cultural differences will enhance professional communication and has been the focus of a recent training and resource handbook (Kai 2005). Evidence suggests that patients in different cultures experience similar worries and problems (Cheturvedi et al. 1996), experience the same range of emotional difficulties (Kai-hoi Sze et al. 2000), and that constructs such as quality of life are stable across several cultural boundaries (Lo et al. 2001). However, they are known to access services less and appear to receive less information about their cancer (Chattoo et al. 2002; Fazil and Kai 2004).
Beliefs that if patients have concerns they will volunteer them spontaneously can also hinder communication (Maguire 1985; Hardman et al. 1989), (p.29) as can the notion that healthcare professionals should not intrude on patients' private feelings by asking directly about their fears and concerns (Booth et al. 1996).
The professional's environment and support
The final factor known to affect health professionals' use of their communication is the environment in which they work and how supportive it is. Direct links have been made between support and communication behaviour; demonstrating that lack of support for both senior and junior cancer professionals is likely to lead to blocking of patient cues, and that blocking is more evident when there is team conflict (Wilkinson 1991; Booth et al. 1996; Heaven et al. 2006).
Authors for many decades have discussed the role of stress and support in determining communication behaviour (Delvaux et al. 1988; Ramirez et al. 1996; Payne 2001; Taylor et al. 2005). In 1982 McElroy wrote that: ‘Today the professional nurse realises the importance of giving emotional support and compassionate care to each patient and family. As a result of this involvement, the nurse is more vulnerable, and this adds to the stress already present in her job. The nurse who does not receive emotional support is not able to give emotional support.’ There is continuing evidence to show that this statement is still true today (Payne 2001; Heaven et al. 2006).
Other influences created by the ward environment include a feeling of there being lack of time. However, the evidence, from early and more recent work, of the relationship of workload to communication behaviour shows that workload impacts on nurses' feelings of stress, but that reducing workload is not associated with increased communication with the patients (Huckaby and Neal 1979).
Relatively few studies have looked at the role of patients in breakdown of communication. A comparison of a patient-generated list of concerns with a list generated from ratings of the audio-taped interviews with nursing carers, revealed that the patients withheld up to 60% of the concerns they were experiencing. Patients experiencing most distress, as assessed by the Hospital Anxiety and Depression Scale, withheld most concerns (Heaven and Maguire 1997). Further analysis demonstrated that patients only revealed certain types of concerns to their nursing carers, the physical concerns, and withheld other types, e.g. emotional concerns and those relating to impact on life. This was despite the fact that the nurses considered themselves to be providing holistic care, and had undertaken basic skills training. Withholding of key information (p.30) was also found in a more recent study of clinical nurse specialists assessments of patients (Heaven et al. 2006) and in a study of patient disclosure of pain to both nurses and doctors (Glajchen et al. 1995), showing little has changed since these early studies. However, Anderson et al. (2001) reported that patients disclosed over 90% of troublesome concerns, although some differences were found between disclosure of physical, psychological, and social areas.
Patients fears, which reduce the likelihood of them being open about their concerns, include fear of the stigma of cancer, especially the elderly for whom cancer equates to death (Maguire 1985), those whose lifestyles could have contributed to the illness, e.g. smokers (Heaven and Maguire 1997), or those who come from a culture where cancer is less openly accepted (Parker and Hopwood 2000). Patients also fear that being troubled by concerns may make them less liked or less popular among staff, they fear allowing staff to see that they are not coping, or talking about difficulties with side-effects may make them seem ungrateful, or may lead to treatment being stopped.
An interesting finding from the Heaven and Maguire (1997) study was that patients worry about burdening the staff caring from them. It is well documented that patients withhold concerns from relatives in order to protection them (Pistrang and Barker 1992) but this protection is less often discussed in relation to professional carers. Insights into this phenomena were gained in the study (Heaven and Maguire 1997), when a patient who told two nurses completely different concerns on the same day, reported that she did this because: ‘The first nurse was so sweet and nice, I did not want to hurt her by telling her all about that. Nurse ‘X’ on the other hand seemed stronger, less fragile, I felt I could tell her all my troubles.’ (Hospice Patient, Heaven and Maguire 1997).
This response raises important issues for palliative care. The line between being a personal and professional friend should always be kept clear, least the patient starts to protect the professional and closes off to themselves a line of support.
Patients' attitudes and beliefs
Patients hold inaccurate beliefs or assumptions which get in the way of open communication. For example many patients believe that certain problems are an inevitable part of having cancer and thus they suppose that health professionals would automatically recognize the presence of such difficulties and would offer help is it was available. They assume, that the lack of help being offered must mean that the problem cannot be alleviated, and as they do not (p.31) want to embarrass nurses and doctors, by asking for the impossible, they withhold the concern (Rosser and Maguire 1982; Maguire 1985; Heaven and Maguire 1997).
Patients also believe that there is not enough time to go into all their worries. They, therefore, prioritize worries on the basis of what they think the professional will need or want to hear about, quite wrongly believing that certain types of professionals are only interested in certain types of problems or concerns (Glajchen et al. 1995; Heaven and Maguire 1997). A palliative care doctor may thus be told about physical symptoms, treatments, etc., while a nurse may be told about deficits in self-care and the family situation, etc.
Other patient factors
Other factors that inhibit open communication include a lack of privacy from people overhearing what is being said, especially in a ward environment, or a lack of space away from key individuals in front of whom that patient or relative may not wish to discuss certain fears, e.g. spouses, children, etc. Many health professionals do not consider the impact of the presence of a family member on an interview. Indeed in palliative care, professionals positively encourage the carer to be present when interviewing the patient (Heaven et al. 2006); however, this may lead to many concerns being withheld, as patients actively seek to protect their relatives (Pistrang and Barker 1992).
For many patients finding the right words is another difficulty that inhibits their ability to disclose concerns (Maguire 1985). Some individuals have a broad and extensive vocabulary for describing emotions, but some will have never talked about their emotions. They may simply not have the words to describe how they feel or what they are experiencing. This is particularly relevant for certain groups, for example, those who are conducting the interview in a language that is not their first or native tongue (Firth 2001; Chattoo et al. 2002); those who are mentally impaired due to illness (Morita et al. 2001) or learning difficulties, and those who are very young. The danger for health professionals is that they may jump to the wrong conclusion, by filling in too many gaps or not providing sufficient time and space.
The literature reveals a great number of reasons why communication difficulties occur. To date no study has compared the relative impact of the different influences identified, and therefore there is no way of knowing which represents the greatest influence on behaviour. Indeed it is probable that the influence is different for each individual. There are many valid reasons why healthcare professionals may be ill at ease in talking openly and frankly to (p.32) patients, and why patients or relatives may withhold so much information about their fears and concerns.
Step 2: developing effective interviewing
What are effective interviewing behaviours?
The evidence for what constitutes an effective interview behaviour has been developed over a number of years. This review will draw on literature that has researched the effectiveness of medical student, GP, nursing, psychotherapy, and psychiatry interviews. Effective interviewing is about not only using facilitative micro-skills but also adopting a style that is patient centred and enables optimal disclosure.
Effective interviewing micro-skills
In the late 1970s and early 1980s studies were conducted with GPs that showed that a number of key skills were associated with better interview outcomes (Marks et al. 1979; Goldberg et al. 1980). Key skills were:
◆ using more eye contact at the outset of an interview
◆ clarifying more about the presenting complaint
◆ responding to verbal cues about possible distress
◆ asking directly about feelings
◆ asking about the home situation
◆ handling interruptions well
◆ making supportive comments
◆ using directive questions about specific problems and using open questions more generally
◆ coping with talkativeness
◆ responding to verbal and non-verbal cues
◆ showing empathy.
The studies also showed that reading notes as the patient talks was inhibitory and suggested that changes in question style seem appropriate when seeking specific information about a specific issue, or when establishing what the issues and events had been. Taking this evidence into the field of cancer and palliative care Maguire and colleagues (1980) showed that that nurses trained to ask open questions about feelings and respond to cues empathetically were more effective in establishing patients' emotional concerns and concerns about side-effects.
In 1996 a study was published that looked at the validity of certain interviewing behaviours in relation to cancer patient disclosure (Maguire et al. 1996a,b). (p.33) It involved assessment interviews conducted by 206 healthcare professionals, from different professionals disciplines. Result showed that disclosure of key information, emotions, and concerns was significantly enhanced by certain key skills and significantly inhibited by others. These key skills are shown and defined in Figure 2.2. Interestingly a ratio of 1 inhibitory to 1 facilitative behaviours was noted by the authors prior to training, regardless of interviewer's age, experience, or professional grouping.
Recent developments in both interviewer rating systems and also in conversation analysis tools have enabled researchers to look in more detail at the impact of individual behaviours within interviews. Evidence has been published, which confirms these early findings, showing that open questions are more likely to elicit cues than closed (Zimmerman et al. 2003), that giving information during an interview reduces the likelihood of further disclosure (Langowitz et al. 2006), and that pauses, or short silences are the most likely things to immediately precede patient disclosure (Eide et al. 2004). There is also new evidence generated from the field of linguistics that suggests that certain words have a positive or negative polarity or inference; i.e. they generate expectations and influence how somebody might respond. Testing out this hypothesis, Heritage et al. (2006) found that asking patients visiting a GPs whether they had ‘something else’ they would like to discuss was more than
The most recent work done in this area has looked at the context in which skills are used, and has shown that it is not just what skills are used, but the context in which they are used which is important (Fletcher et al. 2006, pers. comm.). For example, open questions can be used to block if they chance the subject or switch the conversation, but they can also be used very effectively to explore key disclosure (Heaven et al. 2006). This is discussed more in the next section.
Effective interviewing style
Using effective micro-skills is not sufficient in creating an effective interview. An efficient interviewer needs to adopt a style that will facilitate optimal disclosure and leave the patient feeling both listened to and understood.
The early studies (Marks et al. 1979; Goldberg et al. 1980) supported a probing, enquiring style of interviewing in which the doctor was encouraged to ask questions. However, there is much support for a less probing interviewer dominated approach within the field of psycho—oncology (Mead and Bower 2000). Testing out the benefits of a more passive approach to medical interviewing a Dutch group (Bensing and Sluijs 1985), evaluated the training of general practitioners to be more empathic, take more time and give the lead to the patient more. Interestingly, the outcome showed that this more passive approach led to patients giving a more confused and less sequenced history of events and that overall they said significantly less about their key problems. These results are backed up by an American study (Putnam et al. 1988), which confirmed that teaching medical residents a more passive interview style showed no improvement in clinical outcomes.
While we can conclude from this that a structured probing style is required, there is a great deal of evidence to show that taking a patient-centred rather that a disease-centred or medically focused approach to interviewing has benefits. The patient-centred approach has been shown to be both effective and acceptable to patients and their families (Bensing 2000; Mead and Bower 2000), and has been associated with increased satisfaction, reduced anxiety, more accurate recall of information, compliance with treatment, better management, and recovery (Laine and Davidoff 1996; Bensing 2000; Mead and Bower 2000).
One way of combining proactive interviewing skills and a patient-centred approach is to be ‘cue focused’ (Heaven et al. 2006). A cue is ‘A verbal or non verbal hint which suggests an underlying unpleasant emotion and would need clarification from the health provider’ (Butow et al. 2002). A European group (p.35) set up to look at measuring good interviewing practice have identified seven categories of cue (Del Piccolo et al. 2006):
◆ Verbal cues
• word of phrases suggesting vague undefined emotions (e.g. ‘it felt odd’)
• verbal hints to hidden concerns (e.g. ‘I cope with it’)
• words or phrases that describe psychological correlates or unpleasant emotional states (e.g. sleep disturbance, agitation, panic, irritability).
• unusual or affect loaded emphasis or repeated mentions of issues of potential importance (e.g. ‘hell of a day’, ‘left like I'd been hit by a car’, use of profanity as emphasis)
• communication of life-threatening events (e.g. ‘doctor said I had cancer’, ‘I know I am dying’)
◆ Non verbal cues
• non-verbal expressions of emotion (e.g. crying)
• non-verbal hints of emotion (e.g. signing, frowning, silence, looking away, looking uncomfortable).
The number of cues per interview has been shown to vary, Some studies show it to be as little as 1–2 per 15-minute interview while others consider it to be approximately 10–11 (Heaven et al. 2006). These differences can be accounted for in terms of definition. What is clear it that both emotional distress and the interviewers responsiveness to cues will increase the level of cue emission (Davenport et al. 1987; Del Piccolo et al. 2000; Fletcher et al. 2006, pers. comm.). The importance of picking up cues has been shown by a number of authors; most recently the importance of the first cue has been highlighted (Fletcher et al. 2006, pers. comm.). The group showed, using interviewed conducted by clinical nurse specialists in cancer care, that if the first cue in an interview is missed there is a 20% drop in the number of cues given by the patient over the course of the interview, irrespective of whether the second cue was picked up or missed. Linking effective interviewing skills to cues has been the focus of some of the most recent work in this area. Fletcher et al. (2006, pers. comm.) have shown that when open questions are used in an interview they have only a 50:50 chance of leading to disclosure; however, if they are linked to a cue they are 4.5 times more likely to facilitate more information.
Despite the fact that there is a great deal of evidence to support cue-based interviewing (Butow et al. 2002; Fletcher et al. 2006, pers. comm.) studies of interviewer behaviour continue to report difficulties in following patient cues (Ford et al. 1996; Levinson et al. 2000; Butow et al. 2002; Heaven et al. 2006). (p.36) A common concern is that allowing the patient or relative to dictate the course of an interview will increase its length; however, the evidence is to the contrary. Working with GPs, Levenson et al. (2000) showed that cue-based consultations were on average 15% shorter than those in which cues were missed, while Butow et al. (2002) showed that in oncology consultations, addressing cues reduced consultation times by 10–12%.
To be effective an interviewer needs to be proactive and use open and directive questions to elicit cues about patient experiences (for example, ‘how is chemotherapy going’) and then acknowledge and clarify those cues to obtain further disclosure about their impact on the patient both physically and emotionally. The use of empathy and educated questions is likely to encourage patients to disclose associated feelings. Repeated summarizing of what the interviewer has heard lets patients know that they have been understood correctly or allows them to correct the interviewer. The establishment and maintenance of good eye contact is key. The integration of enquiry about physical symptoms, the psychological impact, social impact, and effect of spirituality is particularly important.
What are effective information giving skills?
So far effective interviewing has only been considered in terms of assessment. The process of giving information, specifically bad news is now considered. The importance of the bad news interview on patient adjustment has been shown (Butow et al. 1996); however, very little research has been conducted that identifies how aspects of the process affect patients outcomes.
Mager and Andrykowski (2002) established long-term distress was related to the ‘caring skills’, i.e. the empathy and responsiveness, and not the doctor's technical competence. Fallowfield et al. (1990) showed that adjustment was related to meeting patients' information needs appropriately. Too much or too little information can be detrimental to a patient's mental health (Fallowfield et al. 1990), indicating that the amount of information given should be tailored to need, that the pace of delivery should be dictated by the recipient (Maguire 1998). There is also evidence that using audio-recordings can assist patients in taking on board complex information (Hogbin et al. 1992), but that they may be detrimental if the news received is of a poor prognosis. (McHugh et al. 1995). Cultural background has not been found to affect a patient's desire to know about their diagnosis (Fielding and Hunt 1996; Seo et al. 2000), although relatives clearly have a greater influence in some cultures than in others (Mosoiu et al. 2000; Di Mola and Crisci 2001).
(p.37) In 1995, Girghis and Sanson-Fisher created guidelines on breaking bad news that were drawn up on the basis of a comprehensive literature review, and recommendations of a panel of doctors and cancer patients. The guidelines covered: practical issues, privacy and adequate time; and strategy of approach, assess the patient's current understanding, provide information simply and honestly, being realistic concerning time frames and prognosis, avoiding euphemisms, encouraging patients to express feelings and being empathic. Miller and Maguire (2000, pers comm) drew similar conclusions from a systematic review of the literature; however, they found some evidence that using euphemisms to deliver bad news in a step-wise fashion was beneficial for patients who are totally unaware of diagnoses.
The longitudinal study conducted by Parle et al. (1996) suggested that a key element in bad news consultation was to acknowledge the distress the bad news had created and then invite the patient proactively to explain how they were feeling and the concerns that were contributing to that distress. The patient should then be invited to prioritize their concerns so each concern could be taken in order. Only then should further information be given based on what information patients wanted at that point.
This approach has been the subject of a randomized trial. The data suggest that this model not only increases the chances that patients will disclose their concerns, but also reduces their distress. Moreover, it helps the doctors feel better about the way they are breaking bad news and gives them validation that they are helping rather than upsetting patients (Green et al. 2007, pers comm).
While it is clear that the process of giving bad news is crucial to long-term adjustment little evidence exists as to what constitutes effective practice. It is clear that information must be tailored to individual needs no matter what culture the individual comes from, and that it should be given in ‘bite-sized chunks' and delivered at a pace that is controlled by the patient. Empathy and understanding of the potential impact of the news on the patient appears is crucial.
Step 3: acquiring and transferring skills to the work-place and maintaining them over time
Acquiring effective interviewing skills
There are a large number of communication skills training studies published, some show admirable results; however few have been evaluated formally to assess their effectiveness in achieving desired outcomes. Those that can (p.38) provide evidence of effectiveness are clearly most desirable. Within the UK, these types of course are now available to all senior healthcare professionals in cancer care, through the National Advanced Communication Skills Training Programme (Cancer Action Team 2007), although such courses are not as yet available to all within palliative care. This section, therefore, considers the key elements of effective communication skills training, so individual can assess the value of potential courses.
Early studies, conducted with medical students measured outcomes in terms of changes in interviewing behaviour, and ability to identify diagnoses and problems. These experimental studies showed the value in a didactic introduction to a model of interviewing behaviour, together with some kind of demonstration of that model working in practice (Rutter and Maguire 1976; Maguire et al. 1977). Subsequent evidence confirmed the value of feedback on individual performance as being essential, with video and audio feedback conferring equal benefit (Maguire et al. 1978). An alternative training approach developed in America, but shown to be effective in nurse and doctor training, is micro-counselling training (Daniels et al. 1988; Crute et al. 1989). This again uses the same core elements of training, but focuses on one micro-skill per session, rather than one strategy or task, as described in the studies already mentioned.
Studies of the problems of open and honest communication highlighted the important role of attitudes and beliefs (Wilkinson 1991; Booth et al. 1996). This led to training that focused on attitudes, but a comparison study showed that attitude training alone was not sufficient to change communication behaviour, and that training had to encompass a skills focus if skills were to be changed (Rickert 1982). The role of attitudes, however, must not be overlooked, as was shown by Razavi and colleagues (1988) and by a major evaluation of their workshop training programme by Maguire et al. (1996a,b). The 1996 UK-based evaluation showed that the training conferred many positive skill changes in communication skills, but did not confer changes in the key skills of empathy and educated guesses. Furthermore, it was found that while training which addresses skills alone leads to more significant and emotional disclosure from the patient, it also led to significantly more blocking on the part of the professional.
To overcome these difficulties changes were implemented so that workshops provided more time to practise skills and feedback on performance, and greater safety to address attitudes and beliefs and fears about possible consequences of the communication process (Parle et al. 1997). At the same time the structural issues of interviewing, for example, learning about how long to remain with one particular topic, when and how to move on, as well as how to (p.39) integrate the factual, physical and emotional modes of interviewing was explored. The experimental evaluation showed that the optimal training method was one that addressed not only skills, but also interview structure, and professionals attitudes and feelings. This multidimensional focus in training has now been shown to be highly effective in different contexts (Wilkinson et al. 1998; Razavi et al. 2000; Fallowfield et al. 2002; Heaven et al. 2006).
For communication skills training to be effective there appear to be key elements that need to be in place. These include: presentation of a clear, evidence-based model of communication; demonstration of that model; opportunity for trainees to practise skills in a safe environment; and explicit but constructive feedback on performance. Furthermore, to be effective training needs to take account not only of skills, but to challenge beliefs and overcome fears, and needs to teach integration of factual, physical, emotional, spiritual, and social domains.
Transfer of skills from training environment to the work-place
The final step to changing communication behaviour is to ensure the transfer of learning to the workplace and then maintain the improvement in skills over time. Those who have looked at the learning of skills in the training situation and then compared it with skills used with real patients have found discrepancies (Mumford et al. 1987; Pieters et al. 1994; Heaven et al. 2006). There appears to be a difference between competence (what a health professional can do in interviewing simulated patients, and what they actually do when faced with real patients or relatives). Parle et al. (1997) suggested that this difference could be accounted for by Bandura's learning theory. They highlighted the importance of considering self-efficacy, a persons confidence in their ability to perform a communication task successfully, and outcome expectancy, a personal belief that the outcome of using a specific skill or strategy would benefit both themselves and their patient.
Within the communication skills training literature ‘drop off’ in skills has been noted (Maguire et al. 1996a,b; Wilkinson et al. 1998), as has the inability of trainees to apply skills in a clinically meaningful way (Putman et al. 1988; Razavi et al. 1993; Heaven and Maguire 1996). A much greater understanding of the problem of transfer can be gained from other applied psychology literature, where the phenomena has been researched in great depth (Gist et al. 1990). In a major literature review Baldwin and Ford (1988) point to a number of key factors in facilitating transfer. First, that before training there needs to be real commitment not only to learning but also behaviour change. Secondly, that the training has to be effective and, finally, that the environment (p.40) into which the trainee is returning must be supportive. There is strong evidence to support the notion that for skills to be effectively transferred back into the workplace, both general support and more specifically facilitated integration of skills appears crucial (Gist et al. 1990; Bandura 1992).
These factors have been the focus of the authors' most recent work, in which the role of clinical supervision in affecting transfer of communication skills training from workshop to workplace was investigated. Sixty-one clinical nurse specialists 42 of whom were palliative care nurses, participated in a randomized controlled trial of workshop training alone versus workshop training plus a 4-week integration programme using clinical supervision (Heaven et al. 2006). Those nurses who had received supervision used significantly more facilitative communication skills with patients and relatives, responded to cues in a more facilitative fashion, and were more able to identify concerns of an emotional nature, than those who did not.
If the key to transfer is facilitating the integration of skills into practice then it is logical to assume that programmes of training that extend over a period of time, will be more effective. Wilkinson et al. (1998) published a study of nurses who had undergone a programme of communication skills training as part of a palliative care course. The results show significant improvements in the nurses' interviewing behaviours with real patients over the course of the training programme suggesting that this method of training may overcome the transfer problem. Wilkinson et al. (2001), however, compared workshop training with an integrated programme of training. They found both conferred equal learning and transfer, suggesting that the apparent transfer effect could be due to other factors. The use of intensive workshop training, following a similar format to that previously discussed, has been shown to have a clinically measurable effect, which was transferred back into the workplace by the senior doctors undergoing the training (Fallowfield et al. 2002). This training was highly intensive (one facilitator/four participants) and provided written feedback on performance for a randomized sample of participants. Written feedback was not found to confer greater learning or use of skills.
The conclusion of the studies is that transfer of skills to the workplace must not be assumed. To ensure integration of skills and facilitate maintenance over time support within the workplace and help during the integration process is key. Extended or highly intensive training may overcome some of these problems, as may workplace structures, such as clinical supervision (Heaven et al. 2006).
The key aim of any intervention aimed at facilitating transfer should be to provide a forum in which self-efficacy can be boosted, negative outcome expectancies challenged, and emotional and practical support provided (p.41) (Gist et al. 1990; Bandura 1992; Heaven et al. 2006). Other methods include informal peer supervision, in which two or three individuals meet together with the purpose of discussing specific difficulties. Alternatively individual reflection, a personal debriefing of an event or encounter (Newell 1992) or alternatively debriefing or critical event analysis can provide a forum in which the individual can challenge their assumptions, attribution, purpose, and outcomes; and gain confidence in their abilities and outcomes.
On a more informal level support for skills can be elicited during the course of a normal day through feedback from the patient, which it is noted may be positive or negative influence; ‘chats' with colleagues about specific events and team meetings at which views can be validated, and ideas endorsed. There is evidence that many people leave courses with good intentions about using skills but often these are not put into practice. Goal setting may help avoid this, as may reviewing courses after a period of time to appraise how much trainees feel they have used the skills learned (Baile et al. 1997; Fallowfield et al. 1998). Another method of self-appraisal is audio recording of an interview, with the patients' full consent, and then to review it. It is important to remember that to boost self-efficacy positive reinforcement is very important; therefore, a balanced appraisal is critical. The final method available to maintain learning is to regularly reappraise learning needs and further training courses that offer the chance to re-look at skills or learn new skills (Razavi et al. 1993). Initiatives in Scandinavia have shown that initial training followed by shorter booster workshops have been very effective in changing practice, when evaluated subjectively (Aspegren et al. 1996).
The key to transfer appears to be recognizing that intentions and actions are not the same, and that without specific action and support, changes in competence are not necessarily translated into changes in performance.
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