Translation and cultural adaptation of the Greek integrated palliative care outcome scale (IPOS): challenges in a six-phase process.

AIM: To translate and culturally adapt IPOS to the Greek population. METHODS: A four phases- sequential study, which included verification of conceptual equivalence, double forward- backward translations and conceptual cognitive debriefing. Focus group interviews used 'think aloud' and 'verbal probing' techniques. Interviews were audio-recorded, transcribed verbatim and thematically analyzed using predefined categories. Purposely sampled from two oncology and palliative care units in Athens. RESULTS: The Integrated Palliative Care Outcome Scale was well accepted by both patients and health professionals. Overall comprehension and acceptability of the scale were good. The comprehension and judgement challenges identified in the pre-final version were successfully resolved in the cognitive interviewing phase. Five out of the seventeen translated items of the scale were modified after cognitive debriefing. Comprehension difficulties were identified with specific terms (e.g., energy/feeling depressed) and with some answer options. Severity of symptoms and not their impact was a common difficulty. A judgement challenge was reported in relation to 7-days recall and fluctuation of symptoms. Layout concerns in relation to length of questions were also stated. All questions were considered important and none as inappropriate. CONCLUSION: This study demonstrated face and content validity and acceptability of the Integrated Palliative Care Outcome Scale in the Greek context. Cognitive Interviewing proved valuable in refining concepts within the specific cultural context. CLINICAL IMPLICATIONS: The IPOS outcome measure tool is now being used routinely in a palliative care service in Athens and is currently used to evaluate service outcomes.

Cancer patients' perceptions of quality-of-care attributes-Associations with age, perceived health status, gender and education.

AIMS AND OBJECTIVES: The aim of this study was to explore the associations between patients' gender, education, health status in relation to assessments of patient-centred quality and individuality in care and trust in nurses for those <65 (working age) and ≥65 years (older people). BACKGROUND: Patients' assessments of the quality of care they receive are essential for the development of the provision of patient care and services. Previous studies have revealed age of the patient is associated with their assessment of care quality attributes. DESIGN: The study employed a cross-sectional, multicultural comparative survey design. METHODS: The data were collected using questionnaires among hospitalised cancer patients (N = 876, n = 599, 68%) in four European countries: Greece, Cyprus, Sweden and Finland. The data were divided into two subgroups based on age (cut point 65 years) and were analysed statistically. RESULTS: Cancer patients' age, gender and level of education were not related to their assessments of care quality attributes: person-centred care quality, individuality in care and trust in nurses. Subgroup analysis of the older adults and those of working age showed clear associations with patients' assessments of quality-of-care attributes and perceived health status. The lower the perceived health status, the lower the assessment of care quality attributes. DISCUSSION: The results suggest that the cancer itself is the strongest determinant of the care delivered, rather than any patient characteristics, such as age, education or gender. Perceived health status, in association with cancer patient assessments of care quality attributes, may be useful in the development of patient-centred, individualised care strategies alongside a stronger focus on people instead of cancer-care-related processes and duties. CONCLUSIONS: Health status was the only factor associated with cancer patients' assessments of care quality attributes. Cancer itself may be the strongest determinant of the care quality perceptions, rather than any patient characteristics. RELEVANCE TO CLINICAL PRACTICE: The findings of this study have implications for cancer care professionals in terms of patient assessment and care planning. The measures may be useful in assessing quality of cancer nursing care.

Recognizing European cancer nursing: Protocol for a systematic review and meta-analysis of the evidence of effectiveness and value of cancer nursing.

AIM: To identify, appraise and synthesize the available evidence relating to the value and impact of cancer nursing on patient experience and outcomes. BACKGROUND: There is a growing body of literature that recognizes the importance and contribution of cancer nurses, however, a comprehensive review examining how cancer nurses have an impact on care quality, patient outcomes and overall experience of cancer, as well as cost of services across the entire cancer spectrum is lacking. DESIGN: A systematic review and meta-analysis using Cochrane methods. METHODS: We will systematically search 10 electronic databases from 2000, with pre-determined search terms. No language restrictions will be applied. We will include all randomized and controlled before-and-after studies that compare cancer nursing interventions to a standard care or no intervention. Two reviewers will independently assess the eligibility of the studies and appraise methodological quality using the Cochrane Risk of Bias tool. Disagreements will be resolved by discussion and may involve a third reviewer if necessary. Data from included studies will be extracted in accordance with the Template for intervention Description and Replication reporting guidelines. Missing data will be actively sought from all trialists. Data will be synthesized in evidence tables and narrative to answer three key questions. If sufficient data are available, we will perform meta-analyses. DISCUSSION: This review will allow us to systematically assess the impact of cancer nursing on patient care and experience. This evidence will be used to determine implications for clinical practice and used to inform future programme and policy decisions in Europe.

Quality of nursing care as perceived by cancer patients: A cross-sectional survey in four European countries.

PURPOSE: To explore and compare cancer patients' perceptions on the quality of nursing care in four European countries. METHODS: Data were collected in Cyprus, Finland, Greece and Sweden. The sample comprised 596 hospitalized cancer patients. The quality of nursing care was measured using the "Oncology Patients' Perceptions of the Quality of Nursing Care Scale" (OPPQNCS). Patient characteristics were also collected. Analysis of variance was used to examine the effects of country on the perceptions of the quality of nursing care. RESULTS: Patients' age ranged from 18 to 86 years, and 58% were male. The comparison of cancer patients' perceptions regarding the quality of nursing care between the four countries showed a statistically significant difference in the total OPPQNCS scores (p<0.001) as well as in the subscales responsiveness (p<0.001), individualization (p<0.001), coordination (p<0.001) and proficiency (p<0.001). The Cronbach's alpha coefficient for the OPPQNCS ranged between 0.89 and 0.95. A multivariate analysis of variance for the OPPQNCS controlled by respondents' demographic characteristics revealed that only the patient's country was significantly related with the patients' perceptions of quality care. CONCLUSION: Quality of nursing care as perceived by cancer patients was high, but differed between the four countries. The impact of the clinical status of cancer patients on the quality of nursing care and managerial factors such as staffing/nursing care delivery models that influence the ability of nurses to offer high quality care should also be explored by more focused studies.

Patients' decisional control over care: a cross-national comparison from both the patients' and nurses' points of view.

BACKGROUND: Patients' decisional control over care is the ability or power for patients to decide what their involvement will be in healthcare decisions. There is evidence of limited agreement between the perceptions of patients and the perceptions of nurses and/or caregivers with regard to the degree of patient involvement in the planning and performance of their care. AIM: To analyse and compare patients' and nurses' perceptions of patients' decisional control over their own care. METHOD: A multisite cross-sectional comparative survey design was employed. Data were collected from hospitalised surgical inpatients (n = 1315) and their caregivers (n = 960 nurses) in five European countries. The Individualised Care Scale part B was used for collecting data from both the patients and nurses. Ethical standards were followed throughout the study. RESULTS: Significant between-country differences were found between patients and nurses. In all countries, both patients and nurses regarded that decisional control over care had been actualised (ICS-B: M = 3.75-4.47 and 3.48-4.33, respectively), but there were significant differences in their perceptions regarding four of the six items of the decisional control factor of the ICS-B. CONCLUSIONS: The results show that there are disparities between patients' and nurses' perceptions of patient involvement in care, probably due to cultural issues that need further exploration. CLINICAL RELEVANCE: The disparities between patients' and nurses' perceptions on patients' decisional control over their care should be taken into consideration as a potential cause of patient dissatisfaction with nursing care.

Anxiety symptoms and quality of interaction among oncology nurses: a correlational, cross-sectional study.

OBJECTIVE: To explore the severity of Anxiety Symptoms (AS) among Greek oncology nursing personnel, the degree of satisfaction from professional relationships, and potential association between them. METHOD: A descriptive cross-sectional correlational study was performed in 2 Greek Oncology Hospitals, in 72 members of nursing personnel. Hamilton Anxiety Scale was used for the assessment of AS severity and the Index of Work Satisfaction subscale "Satisfaction from Interaction" for the degree of satisfaction from professional relationships among nursing personnel (NN) and between nursing personnel and physicians (NP). RESULTS: 11% of the sample reported clinical AS [≥26, scale range (SR): 0-52]. Satisfaction from NN [5.10 (SD: 1.04), SR: 1-7], and NP [4.21 (SD: 0.77), SR: 1-7] professional interaction were both moderate. Statistically significantly associations were observed between clinical AS and satisfaction from NN (p=0.014) and NP (p=0.013) professional interaction. CONCLUSIONS: Anxiety reduction interventions and improvement of professional relationships are essentials in order to reduce oncology nurses' psychological distress.

Determinants of quality of life in children and adolescents with CHD: a systematic review.

PURPOSE: This review aims to outline a systematic approach for the assessment of quality of life in children and adolescents with CHD and to cite its main determinants. METHODS: A systematic critical literature search in PubMed, Scopus, and Cinahl databases resulted in 954 papers published after 2000. After the quality assessment, 32 original articles met the inclusion criteria. RESULTS: Methodological quality of the included studies varied greatly, showing a moderate quality. Impaired quality of life was associated with more severe cardiac lesions. Children with CHD, after cardiac surgery, reported diminished quality of life concerning physical, psycho-social, emotional, and school functioning. The majority of clinical studies showed significant differences among children and their parents' responses regarding their quality of life, with a tendency of children to report greater quality of life scores than their parents. According to our analysis, concerning children with CHD, the most cited determinants of their quality of life were as follows: (a) parental support; (b) lower socio-economic status; (c) limitations due to physical impairment; (d) sense of coherence; as well as (e) the level of child's everyday anxiety and depression. These findings suggest that differences in quality of life issues may exist across lesion severities. CONCLUSION: Quality of life in children with CHD should be assessed according to age; severity; therapeutic approach; acceptance of the disease; and personality features. Effective management and early recognition of significant impairments in quality of life could impact clinical outcomes in children with CHD.

Validation of the revised Bakas Caregiving Outcomes Scale in Greek caregivers of patients with advanced cancer receiving palliative radiotherapy.

PURPOSE: Caregiver burden considerably affects the lives of families providing care to people with advanced cancer. The aim of this study was to validate the Greek translation of the revised Bakas Caregiving Outcomes Scale (BCOS) with a sample of informal caregivers of people with advanced cancer receiving outpatient palliative radiotherapy. METHODS: Following a formal "forward-backward" method to translate the original BCOS into Greek, the scale was administered to 100 consecutive family caregivers. Participants also completed the Greek Hospital Anxiety and Depression Scale (G-HADS) and five quality-of-life related linear analogue scale assessment (LASA) scales. Validity and reliability analyses were performed. RESULTS: The Cronbach's α coefficient for the total BCOS score was 0.83. Test-retest reliability analysis in a subgroup of caregivers (n = 40) revealed good short-term stability over a 2-week interval. Exploratory factor analysis generated a one-factor structure for the Greek translation, which was further confirmed through confirmatory factor analysis. Construct validity was supported through the scale's high correlations with G-HADS anxiety (-0.524; p < 0.001) and depression (-0.533; p < 0.001) scores, and LASA quality of life scores (0.696; p < 0.001). The BCOS discriminated well between groups of caregivers with different levels of quality of life. A total score of 52.5 offered high sensitivity (91 %) and specificity (86 %) in detecting highly burdened caregivers. CONCLUSIONS: The Greek version of the BCOS is a psychometrically sound instrument that can be usefully implemented into clinical practice to identify family caregivers in need for support, and stimulate relevant research in our country.

A cross-cultural study of the concept of caring through behaviours: patients' and nurses' perspectives in six different EU countries.

AIM: This paper is a report of an international study of patients' and nurses' perceptions of nurse caring behaviours. BACKGROUND: Current economic constraints on healthcare systems, demand to increase the quality of care and the incorporation of the consumers' perspective into care, have created a need to develop a clear understanding of nursing behaviours which convey caring. Patients in different areas of the world report different expectations of nurses' caring actions when compared to nurses' views. METHOD: A descriptive comparative survey design was used to analyse a sample of surgical patients (n = 1659) and their nurses (n = 1195) in 88 wards of 34 hospitals in Cyprus, the Czech Republic, Finland, Greece, Hungary and Italy. Data were collected in autumn 2009 using the Caring Behaviours Inventory-24. Nurses' and patients' responses were compared using both inferential and descriptive statistics. RESULTS: Independent samples t-tests showed important differences between nurses' and patients' views. Although both groups perceived knowledge and skill as being the most important sub-scale, the nurses' responses were higher compared to patients (P < 0·05) with important differences in the 'assurance of human presence' (P < 0·001) and the 'respectful deference to others' (P < 0·001) sub-scales. Cross-country comparisons showed important differences between the nurses' (F = 24·199, P < 0·001) and patients' views on caring (F = 26·945, P < 0·001). CONCLUSIONS: Important differences were observed between patient-nurse perceptions in the participating countries. The results form a foundation for future research into the development of a common international perspective about caring behaviours between patients and their nurses.

Patients' and nurses' perceptions of individualised care: an international comparative study.

AIM: The aim of this study was to compare patients' and nurses' perceptions of individualised care in five European countries, the Czech Republic, Cyprus, Finland, Greece and Hungary. BACKGROUND: Individualised nursing care has been studied from both patients' and nurses' perspectives, but to date, there are no studies comparing these perspectives internationally. METHODS: A cross-sectional comparative survey design was used. Data were collected from nurses (n = 960; response rate, 79%) and patients (n = 1315; response rate, 78%) in 71 surgical units from 26 acute hospitals in 2009. Data were collected using two Individualised Care Scales (ICS-Nurse and ICS-Patient) and analysed statistically using descriptive and inferential statistics. RESULTS: Differences in patients' and nurses' assessments of individualised nursing care were found between each country. Nurses, compared with patients, assessed that they supported patient individuality more often. The Mean(nurses) ranged from 3·61 (SD 0·90, Greece)-4·31 (SD 0·53, Hungary), and the Mean(patients) ranged from 3·05 (SD 1·09, Greece)-3·79 (SD 1·00, Cyprus). To a large extent, the care provided was individualised as defined by the Mean(nurses) 3·75 (SD 0·92, Greece)-4·36 (SD 0·49, Hungary) and the Mean(patients) 3·41 (SD 0·95, Greece)-4·18 (SD 0·79, Cyprus). In Cyprus and Finland, patients' assessments of the individuality in their care corresponded well with nurses' assessments. Clear between-country differences in both patients' and nurses' assessments were found in both subscales of the ICS. CONCLUSIONS: An in-depth analysis of the European between-country differences is required to define the causes of differences that may be due to the differing content of education, the organisation of nursing work, ideology and values assigned to individualised care and health care systems and processes in each country. RELEVANCE TO CLINICAL PRACTICE: Obtaining both patients' and nurses' assessments of individualised care may facilitate the further development of individualised nursing care and be used to help to harmonise European health care processes and nursing care.

Patient satisfaction as an outcome of individualised nursing care.

BACKGROUND: The association between individualised nursing care and patient satisfaction has been previously found. However, there is a lack of studies examining this association between individualised care and patient satisfaction in a cross-cultural study. AIMS: This study examines the association between individualised care and patient satisfaction in a sample of general surgical patients from five European countries. METHODS: A cross-sectional design and survey method were used to collect data from general surgical patients (N = 1315, response rate 78%) in 72 inpatient wards in 26 general acute hospitals' in 2009 using self-completed questionnaires the Individualised Care Scale and the Patient Satisfaction Scale. Data were analysed using descriptive statistics, Pearson correlation coefficients and multiple stepwise regression analyses. RESULTS: Surgical patients reported that the care they received was only moderately individualised overall, but individuality was taken into account well in patients' clinical situation and decisional control over care. Patients were satisfied with their care, mostly with the technical aspects of care and least with the information given. There were between-country differences in patients' perceptions of individuality in care and patient satisfaction. A positive correlation between the level of individualised care received and patient satisfaction was found, confirming that individualised nursing care delivery influences patients' satisfaction with care and demonstrating that this quality of care indicator might be able to be used as a predictor of patient satisfaction, one outcome of care. CONCLUSION: The findings of this study strengthen previous results and further reporting the existence of a relationship and the positive correlation between individualised care and patient satisfaction. The results can inform administrative decisions and policy on introducing nursing approaches to care that would increase patient satisfaction.

Patients' and nurses' perceptions of respect and human presence through caring behaviours: a comparative study.

Although respect and human presence are frequently reported in nursing literature, these are poorly defined within a nursing context. The aim of this study was to examine the differences, if any, in the perceived frequency of respect and human presence in the clinical care, between nurses and patients. A convenience sample of 1537 patients and 1148 nurses from six European countries (Cyprus, Czech Republic, Finland, Greece, Hungary and Italy) participated in this study during autumn 2009. The six-point Likert-type Caring Behaviours Inventory-24 questionnaire was used for gathering appropriate data. The findings showed statistically significant differences of nurses' and patients' perception of frequency on respect and human presence. These findings provide a better understanding of caring behaviours that convey respect and assurance of human presence to persons behind the patients and may contribute to close gaps in knowledge regarding patients' expectations.

Psychometric evaluation and feasibility of the Greek Pittsburgh Sleep Quality Index (GR-PSQI) in patients with cancer receiving chemotherapy.

PURPOSE: Quality of sleep in patients with cancer is regarded as of utmost importance. The aim of the present study was to assess psychometric properties and feasibility of the Greek version of the Pittsburgh Sleep Quality Index (GR-PSQI). METHODS: Following a "forward-backward" procedure, the scale was translated into Greek. The GR-PSQI was administered as a self-report instrument to 209 consecutive patients with cancer during active-phase chemotherapy treatment. For stability analysis purposes, a subgroup of 60 patients completed the GR-PSQI on two occasions, 14-21 days apart. All participants also completed the Insomnia Severity Index, the Epworth Sleepiness Scale-Greek version, a Sleep Quality-Visual Analogue Scale and the Hospital Anxiety and Depression Scale-Greek version. Validity and reliability analyses were performed for GR-PSQI data. RESULTS: The Chronbach's alpha for the global GR-PSQI score was 0.76. Test-retest reliability analysis for the global GR-PSQI score yielded a high intra-class correlation coefficient of 0.82 (p < 0.001). Exploratory factor analysis generated a two-factor structure for the GR-PSQI, [quality of nocturnal sleep] and [daily disturbances and management of sleep problems]. This construct was further supported by its high correlations with similar content instruments, as well as by the instrument's ability to discriminate well between contrasting groups of patients with different levels of anxiety, depression and performance status. CONCLUSIONS: The present findings support the GR-PSQI as a reliable, stable over time and valid sleep quality instrument when administered to patients with cancer during chemotherapy treatment; however, it is suggested that the use of a two-factor scoring method (instead of the traditional unidimensional) could improve its sensitivity in this patient group.

'The patient is my space': hermeneutic investigation of the nurse-patient relationship in critical care.

BACKGROUND: The nurse-patient relationship has been postulated to lie at the core of nursing care. However, it is unclear how this concept applies in critical care, as a great majority of critically ill patients are unable to communicate. AIMS: Through a phenomenological hermeneutical perspective, we aimed to explore intensive care nurses' perceptions and meanings regarding their interpersonal relationship with critically ill individuals. METHODS: A Heideggerian hermeneutical approach was used to design the study and analyse the data, which were collected through repetitive interviews with 12 intensive care nurses. RESULTS: Critical care nurses report to experience deep relationships with patients, which seem to be mediated by the ongoing contact with patients' bodies. These relationships evoke intense feelings of love, empathy and care and affect how nurses perceive and make sense of their role and their world. The identified core theme of their experience is entitled 'syncytium', which describes a network of closely connected cells. According to participants' perceptions, nurse and patient affect each other reciprocally and are mutually dependent upon each other. In Heideggerian terms patients provide nurses with opportunities to experience 'authentic care' and they participate in their 'being-in-the-world', thus they are central in nurses' meanings about their role and existence. Other elicited themes that account for the perceived nurse-patient relationship include the spatiality/temporality of the relationship, nurses' perceptions and meanings attributed to their role and nurses' perceptions of death. CONCLUSIONS: Critical care nurses appear to experience their relationships with patients intensely. These relationships are invested with meanings and elicit powerful feelings over a shared course with patients. Patients are central in nurses' meaning-making process and role perception. RELEVANCE TO CLINICAL PRACTICE: These findings have implications for the educational preparation of critical care nurses and their psychological support.

Real time remote symptom monitoring during chemotherapy for cancer: European multicentre randomised controlled trial (eSMART).

OBJECTIVE: To evaluate effects of remote monitoring of adjuvant chemotherapy related side effects via the Advanced Symptom Management System (ASyMS) on symptom burden, quality of life, supportive care needs, anxiety, self-efficacy, and work limitations. DESIGN: Multicentre, repeated measures, parallel group, evaluator masked, stratified randomised controlled trial. SETTING: Twelve cancer centres in Austria, Greece, Norway, Republic of Ireland, and UK. PARTICIPANTS: 829 patients with non-metastatic breast cancer, colorectal cancer, Hodgkin's disease, or non-Hodgkin's lymphoma receiving first line adjuvant chemotherapy or chemotherapy for the first time in five years. INTERVENTION: Patients were randomised to ASyMS (intervention; n=415) or standard care (control; n=414) over six cycles of chemotherapy. MAIN OUTCOME MEASURES: The primary outcome was symptom burden (Memorial Symptom Assessment Scale; MSAS). Secondary outcomes were health related quality of life (Functional Assessment of Cancer Therapy-General; FACT-G), Supportive Care Needs Survey Short-Form (SCNS-SF34), State-Trait Anxiety Inventory-Revised (STAI-R), Communication and Attitudinal Self-Efficacy scale for cancer (CASE-Cancer), and work limitations questionnaire (WLQ). RESULTS: For the intervention group, symptom burden remained at pre-chemotherapy treatment levels, whereas controls reported an increase from cycle 1 onwards (least squares absolute mean difference -0.15, 95% confidence interval -0.19 to -0.12; P<0.001; Cohen's D effect size=0.5). Analysis of MSAS sub-domains indicated significant reductions in favour of ASyMS for global distress index (-0.21, -0.27 to -0.16; P<0.001), psychological symptoms (-0.16, -0.23 to -0.10; P<0.001), and physical symptoms (-0.21, -0.26 to -0.17; P<0.001). FACT-G scores were higher in the intervention group across all cycles (mean difference 4.06, 95% confidence interval 2.65 to 5.46; P<0.001), whereas mean scores for STAI-R trait (-1.15, -1.90 to -0.41; P=0.003) and STAI-R state anxiety (-1.13, -2.06 to -0.20; P=0.02) were lower. CASE-Cancer scores were higher in the intervention group (mean difference 0.81, 0.19 to 1.43; P=0.01), and most SCNS-SF34 domains were lower, including sexuality needs (-1.56, -3.11 to -0.01; P<0.05), patient care and support needs (-1.74, -3.31 to -0.16; P=0.03), and physical and daily living needs (-2.8, -5.0 to -0.6; P=0.01). Other SCNS-SF34 domains and WLQ were not significantly different. Safety of ASyMS was satisfactory. Neutropenic events were higher in the intervention group. CONCLUSIONS: Significant reduction in symptom burden supports the use of ASyMS for remote symptom monitoring in cancer care. A "medium" Cohen's effect size of 0.5 showed a sizable, positive clinical effect of ASyMS on patients' symptom experiences. Remote monitoring systems will be vital for future services, particularly with blended models of care delivery arising from the covid-19 pandemic. TRIAL REGISTRATION: Clinicaltrials.gov NCT02356081.

A critical review of the evidence for nurses as information providers to cancer patients.

AIMS: To review evidence on the role of oncology nurses in the provision of information to cancer patients and to delineate evidence-based implications for clinical practice and research. BACKGROUND: Provision of information is central for the empowerment of patients to participate in their care. There is not enough evidence regarding the nursing role in the information delivery process in cancer patients. DESIGN: Descriptive literature review. METHODS: From January 1990-2008, databases searched included Medline, CINAHL, PubMed, CancerLit and the Cochrane Library. Original research articles addressing the role of nurses in information delivery were included. We explored evidence on: (1) the effectiveness of nurses as information providers, (2) the way patients evaluate nurses' input to information delivery, (3) the extent to which nurses contribute to information delivery to cancer patients and (4) the types of information provided by nurses. RESULTS: The most important findings were: (1) nurses' role as information providers for cancer patients is prominent, especially after the initiation of treatment, (2) specialist nurses are very effective in providing information, (3) no clear evidence exists on how nurses compare with other health-care professionals as information providers and (4) some evidence exists that patients may prefer nurses as information providers at specific times in their treatment and especially in regards to symptom management. CONCLUSION: Well-designed studies provide some evidence that nurses are effective as information providers to cancer patients. Specifically, oncology nurses are able to provide information of both high quality and of appropriate quantity and to assist individuals to interpret information provided by others. RELEVANCE TO CLINICAL PRACTICE: Oncology nurses should be specifically educated and prepared to offer explicit, practical and timely information and they should be trained in interpersonal communication skills, which will increase their ability to comprehend patient information needs.