The Effect of a Complementary Therapy Education Seminar on Support Persons of Individuals with Cancer.

Objectives: Complementary therapy (CT) use is prevalent among individuals living with cancer, who often consult family and friends (i.e., support persons) in making decisions about CT. This study examines the effect of an education seminar for adult cancer patients and support persons on the support persons' use, knowledge, and decision-making processes related to CT. Design: A patient education seminar that included support persons was developed and evaluated as part of a CT decision support research program. Survey data were collected before and after the education seminar to examine its impact on support persons' knowledge and use of CT, as well as their engagement in the CT decision-making process. Setting: The study was conducted in Western Canada. Subjects: 62 adult support persons. Interventions: Participants attended a 4-h CT education seminar at one in four provincial cancer centers. The seminar provided recommendations regarding how to make informed decisions about CT, where to find credible information, and key issues to consider to avoid potential risks of CT use. The evidence related to popular CT was also reviewed. Outcome Measures: The primary outcome was support persons' CT knowledge. Secondary outcomes included CT use, information-seeking behavior, decision self-efficacy, decision conflict, and distress. Results: A significant increase in support persons' CT knowledge was observed, as well as improved confidence in CT decision making. There was no significant difference in participants' CT use following the education seminar. Most indicated they would continue to locate information about CT using the Internet. A significant decrease in support persons' decisional conflict was reported; however, there were no significant change in distress related to CT decision making. Conclusions: This study demonstrates the importance of including support persons in patient education related to CT and the positive impact on their knowledge and treatment decision-making processes. No significant change in CT use, information seeking behavior and distress related to CT decisions, however, was observed in the study.

Observations of the communication practices between nurses and patients in an oncology outpatient clinic.

PURPOSE: Effective communication in cancer care and treatment is linked to better health outcomes, improved treatment adherence, and improved quality of life for cancer patients. While the characteristics of effective communication have been identified, there is sparse knowledge about the current conditions for providing effective communication especially within the outpatient clinical context, where the majority of cancer patients are currently being treated. This study aimed to explore communication practices between nurses and patients undergoing chemotherapy in an outpatient clinic to gain insight into how patients are supported in this setting. METHODS: Data were collected through 70 h of participant observations of nurse-patient interactions supplemented with ad hoc interviews with nurses in an oncology outpatient clinic. The methodology and data analysis are guided by interpretive description, thematic analysis and symbolic interactionism. RESULTS: Three themes were generated that characterised communication in the outpatient clinic: Treatment-centred communication, efficient communication and spatially-bound communication. While there was good opportunity for patients to learn about treatment and side effects during cancer treatment, psychosocial concerns were rarely addressed. CONCLUSIONS: The outpatient setting influences the type and quality of communication between nurses and patients. Improvement of communication should include not only verbal and written information, but focus on the importance of nonverbal communication in the oncology outpatient clinic. Furthermore, there is a need to make environmental adjustments that can facilitate the opportunity for patients to express their needs and for nurses to respond to them.

Can nursing epistemology embrace p-values?

The use of correlational probability values (p-values) as a means of evaluating evidence in nursing and health care has largely been accepted uncritically. There are reasons to be concerned about an uncritical adherence to the use of significance testing, which has been located in the natural science paradigm. p-values have served in hypothesis and statistical testing, such as in randomized controlled trials and meta-analyses to support what has been portrayed as the highest levels of evidence in the framework of evidence-based practice. Nursing has been minimally involved in the rich debate about the controversies of treating significance testing as evidentiary in the health and social sciences. In this paper, we join the dialogue by examining how and why this statistical mechanism has become entrenched as the gold standard for determining what constitutes legitimate scientific knowledge in the postpositivistic paradigm. We argue that nursing needs to critically reflect on the limitations associated with this tool of the evidence-based movement, given the complexities and contextual factors that are inherent to nursing epistemology. Such reflection will inform our thinking about what constitutes substantive knowledge for the nursing discipline.

Communication challenges for chronic metastatic cancer in an era of novel therapeutics.

Advances in the production of novel therapies for cancer management are creating new challenges for the support of increasing numbers of persons surviving for extended periods with advanced disease. Despite incurable and life-limiting metastatic conditions, these patients are living longer with serious disease, pushing the boundaries of what science explains and clinicians can confidently interpret using available evidence. Here we report findings from an early subset of such individuals within a longitudinal qualitative cancer cohort study on clinician-patient communication across the cancer trajectory. In these findings, we contextualize experiential accounts of communication in a changing environment of the costs and uncertainties of personalized medicine, and examine the complex psychosocial circumstances of this rapidly growing patient population. Interpretation of these findings illustrates how emerging issues in cancer treatment influence the experience of these patients, their social and support networks, their cancer care specialists, and the multidisciplinary teams charged with coordinating their care.

Patient perceptions of communications on the threshold of cancer survivorship: implications for provider responses.

INTRODUCTION: Although high quality professional-patient communication is recognized as fundamental to effective cancer care, less attention has been paid to developing an evidence basis for communications surrounding the stage of the cancer journey when primary cancer treatment concludes, management responsibilities shift from oncology specialist services into the generalist care domain, and the patient transitions beyond patienthood and into survivorship. METHODS: Using applied qualitative methodology, we analyzed a database of multiple interviews with 14 Canadian cancer patients from a larger study of changing communication needs and preferences across the cancer trajectory. Through constant comparative analysis, we generated a thematic summary of interpretive understandings from the patient perspective of communication patterns across the transition from active treatment to survivorship. RESULTS: The accounts illuminate the complexities of the communication environment in which the transition to survivorship occurs. Communication gaps and misinterpretations by clinicians contributed to the confusion, insecurity, vulnerability, loss, and abandonment associated with this transition when they failed to accurately and sensitively respond to individual conditions. DISCUSSION/CONCLUSIONS: Despite increasing recognition of the importance of this transition, communication gaps occur in relation to attending to cues, giving prior warning, avoiding avoidance, sensitivity to context, managing relationships, surfacing anxieties, and clarifying roles and responsibilities. These findings expand upon previous reports to explain mechanisms whereby interactions between clinicians and patients may significantly shape the transitional experience and set the stage for survivorship. IMPLICATIONS FOR CANCER SURVIVORS: From the perspective of cancer survivors, the transition beyond initial treatment warrants well-informed anticipatory and supportive healthcare communications.

Patient perceptions of helpful communication in the context of advanced cancer.

AIMS AND OBJECTIVES: Based on a secondary analysis of data from a large qualitative study on cancer care communication, we address the question: what do patients with advanced cancer identify as helpful in their communication encounters with health care providers? BACKGROUND: Communication is of critical importance to the care of patients with advanced cancer. A better understanding of what such patients identify as helpful in their communication encounters with nurses and other health care providers seems critical to creating evidence-informed recommendations for best practices. DESIGN: Secondary analysis of qualitative interview data. METHODS: Data from 18 participants interviewed individually and 16 focus group participants, with advanced cancer in the palliative phase of care. Interpretive description methodology informed data collection and analysis. RESULTS: Findings suggest four key elements are critically important to consider in communications with patients in an advanced or palliative phase - respecting the importance of time, demonstrating caring, acknowledging fear and balancing hope and honesty in the provision of information. CONCLUSIONS: Communication is an important element in the provision of advanced cancer care. RELEVANCE TO CLINICAL PRACTICE: Findings emphasise the complex meanings inherent in cancer care communication and identify central themes that are fundamental to effective cancer care communication.

Time-related communication skills from the cancer patient perspective.

OBJECTIVE: Although it is well recognized that skilled communication is an essential element of effective cancer care, lack of time to communicate is often cited as an explanation for the ongoing cancer care communications problems patients report. In this study, we sought to answer the question: How do cancer patients describe and explain the effects of health care communication upon their experience of time? METHODS: We conducted a qualitative secondary analysis, using interpretive description methodology, on a large data set that comprised transcribed interview data from two studies of cancer communication from the patient perspective. One primary study represented a cross-sectional study of helpful and unhelpful communications (n=200) and the other a longitudinal study of changes in communication needs and preferences over the illness trajectory (n=60). RESULTS: We found time a meaningful and symbolic construct for cancer patients. They describe clinician time-related attitudes and behaviors as significant factors in shaping the impact of clinical encounters on their overall psychosocial cancer experiences. They report a number of ways in which clinician communications have been particularly effective in buffering and manipulating the impact of time pressures and describe a capacity within exceptionally skilled clinicians to manufacture a perception of available time even in the context of such pressures. CONCLUSIONS: We believe that the patient perspective on cancer care communication provides an important angle of vision from which to discern strategies that may assist clinicians to buffer the untoward effects of the time pressure under which most care systems currently operate.

Cancer care communication: the power to harm and the power to heal?

OBJECTIVE: This study was designed to examine the belief held by many cancer patients that communication with their care providers has a meaningful part to play in shaping their disease outcomes. METHODS: From a large qualitative interview data set in which cancer patients described their perceptions of helpful and unhelpful heath care communication; we extracted the accounts of 69 patients and 13 focus group participants who specifically articulated a perceived relationship between communication and cancer outcomes. Through secondary analysis of that subset, we generated an interpretive description of patterns and themes within their accounts of a relationship between communication and cancer survivorship. RESULTS: Our findings document patient perceptions of the mechanisms involved in indirect and, some instances, direct relationships between communication encounters and cancer outcomes. CONCLUSION: Some cancer patients believe that, by virtue of its influence upon comfort, inclusion, clarity and hope, communication can influence cancer outcomes. PRACTICE IMPLICATIONS: While competing discourses exist within the patient population with regard to such associations, the perception that communication may influence clinical outcomes seems sufficiently pervasive and persistent that it warrants serious attention within care systems and by the psychosocial cancer research community.

Nursing education: key issues for the 21st century.

In this paper, I reflect on what can be learned by engaging in future thinking within our discipline, and what implications the results of that thinking may have for the development of nursing education. Recognizing the marvelous diversity of perspective within our discipline with regard to what will and ought to be our future mandate, it seems reasonable to search for some grounding in what might ensure that we enter that future wisely. We all know that change is a fundamental characteristic of all future projections, and yet that insight seems a weak justification for failure to plan. Nurse educators hold a particular obligation to ensure that they are preparing the professionals who will take that future forward. Although we have always recognized that they must nurse for today with an eye on tomorrow, it is inordinately difficult to come to some agreement on how we can best bridge that gap within our educational programs and strategies. Toward this end, I draw on lessons that can be drawn from our professional history as a rich and vibrant context to propose some key issues for that future theorizing.

Nursing education: Key issues for the 21st century.

In this paper, I reflect on what can be learned by engaging in future thinking within our discipline, and what implications the results of that thinking may have for the development of nursing education. Recognizing the marvelous diversity of perspective within our discipline with regard to what will and ought to be our future mandate, it seems reasonable to search for some grounding in what might ensure that we enter that future wisely. We all know that change is a fundamental characteristic of all future projections, and yet that insight seems a weak justification for failure to plan. Nurse educators hold a particular obligation to ensure that they are preparing the professionals who will take that future forward. Although we have always recognized that they must nurse for today with an eye on tomorrow, it is inordinately difficult to come to some agreement on how we can best bridge that gap within our educational programs and strategies. Toward this end, I draw on lessons that can be drawn from our professional history as a rich and vibrant context to propose some key issues for that future theorizing.

Is there a cost to poor communication in cancer care?: a critical review of the literature.

In this paper, the authors engage in a critical analysis of the existing empirical literature which addresses the impact of ineffective communication between cancer patients and clinicians. It is increasingly accepted that communication plays a significant role in many aspects of the care experience, and that poor communication can have a significantly negative influence on the patient's psychosocial experience, symptom management, treatment decisions, and quality of life. However, scant attention has been given to the idea that poor communication may also have an economic impact worthy of attention. This area has not been the focus of systematic inquiry or substantive critical consideration. On the basis of critical analysis of the limited empirical evidence that exists across a wide range of studies in related areas, the authors propose that the existential and material costs associated with poor communication in cancer care may well be considerable, and conclude with a call to mobilize a heightened enthusiasm for addressing the research challenges in this field.

'Being known': patients' perspectives of the dynamics of human connection in cancer care.

In the context of a large study of effective and ineffective cancer care communications from the perspective of patients with cancer, the authors documented the pervasiveness of the desire for human connection. Analyzing accounts from 200 patients with diverse cancer experiences, they concluded that, while anonymity is generally antithetical to a comfortable cancer care encounter, there are wide variations in what it means to 'be known' in a meaningful way. In this discussion, a description of the dynamics of being known and not being known within the cancer care encounter is presented, and a range of variations considered. By illuminating the manner in which communication influences human connection within the cancer care context, the findings of this study challenge some current research directions and propose alternative conceptualizations that might better orient future inquiry to enhance practice.

The problematic allure of the binary in nursing theoretical discourse.

Recent ideological positioning on the world stage has borne a startling resemblance to a form of positioning within nursing theory--that of taking complex ideas, reducing them to a simplistic binary form, and uncritically adopting one half of that form. In some cases, this adoption of a binary position has led to a passionately held form of "othering" that prohibits a healthy and critical engagement with ideas. As alluring as settling for the binary form may be--we argue for holding binaries in tension as a catalyst for stimulating dialogue--reasoning and exploration of new ways of wrestling with the social and moral complexity of nursing.

The context of health care communication in chronic illness.

Patient-professional communication is a critically important element of effective chronic illness care. However, the dynamics of health care communication in supporting self-care management and effective coping with various chronic diseases is not well understood. The present study examined health care communication from the perspective of 38 patients with four distinct chronic conditions: end-stage renal disease (ESRD), non-insulin dependent diabetes mellitus (NIDDM), multiple sclerosis (MS), and fibromyalgia (FM). Analysis revealed the dimensions of courtesy, respect, and engagement to be inherent in communication priorities across conditions. However, distinct "disease worlds" among and between these chronic conditions illuminated salient differences within these dimensions, thereby illustrating the way in which relevant variables such as legitimacy, the availability of conventional treatments, and lifestyle implications shape the meaning of health care communication. The findings enlarge upon patient-centered approaches to health care communication and inform further analysis of the interactional dynamics associated with chronic conditions.

Satisfaction and anxiety for women during investigation of an abnormal screening mammogram.

Five community-designed pilot projects were undertaken to reduce the time to diagnosis following an abnormal mammogram. One thousand five hundred and seventy-eight women with abnormal mammograms completed a self-administered questionnaire (71% response) which inquired about experiences and satisfaction with time delay from screening to diagnosis, the information received and support given by health professionals, and measures of anxiety and stress during this time interval. Four of the five pilot project initiatives shortened the time interval from screening to diagnosis, the greatest improvement occurring with facilitated referral from screening to diagnostic breast imaging. There was little difference among the pilot projects and control for most measures of client satisfaction and anxiety. Differences were found between biopsied and nonbiopsied women for several of these measures. Shortening the time to diagnosis positively influenced the client's perception of unnecessary delay.

The Experience of Waiting for Diagnosis After an Abnormal Mammogram.

In order to better understand the experience of women following abnormal screening mammogram and before definitive diagnosis, we undertook a series of focus group interviews in six geographic areas in the province of British Columbia, Canada. While all 33 participants had experienced abnormal mammograms within the previous year, each group included women with a range of ages and diagnostic outcomes. Verbatim transcripts of all focus groups were subjected to qualitative secondary analysis using interpretive descriptive methods. Through a process of grounded inductive analysis, conceptual themes within the data were identified and tested. The findings of this study provide an experiential account of common patterns within the structure and process of waiting for diagnosis. The accounts depict the way the women experienced time, their individual and common responses to waiting, and the impact of health system factors, including provider communication. These findings confirm that, regardless of its outcome, waiting for definitive diagnosis after an abnormal screening mammogram is an intense and often agonizing experience for the women involved and for their families. Furthermore, our results highlight the relevance of such issues as information systems, support, coordination of services, and health care communication, and underscore the important role that service delivery factors can play in making such experiences bearable.