The impact of the SAGE & THYME foundation level workshop on factors influencing communication skills in health care professionals.

INTRODUCTION: The "SAGE & THYME Foundation Level Workshop" delivers evidence-based communication skills training to 30 health care workers in 3 hours. It teaches a structured approach (the SAGE & THYME model) to discuss patient/carer concerns. The aim of this study was to determine whether the workshop had a positive outcome on factors that influence communication skills. METHODS: The study had a pragmatic, mixed methods design. Workshops were run in an acute hospital. One hundred seventy health care workers completed questionnaires pre- and post-workshop; 141 were sent follow-up questionnaires at 2 weeks and 2 months; and 9 were filmed talking to a simulated patient pre- and post-workshop. RESULTS: From pre- to post-workshop, there was a significant increase in knowledge (p < 0.001), self-efficacy (p < 0.001), and outcome expectancy (p < 0.001). An expert's rating of behavior with the simulated patient also significantly increased after the training (p = 0.011). Motivation to use the training, and the perceived usefulness of the SAGE & THYME model, were high post-workshop. There was a poor response rate in the follow-up period; hence, the quantitative data are not reported. The qualitative data are described, however, as they give an insight into the impact of the training on staff and their patients. DISCUSSION: The SAGE & THYME Foundation Level Workshop significantly increases communication skills knowledge, self-efficacy, and outcome expectancy of hospital health care workers who are predominantly white, female, nursing, or nonclinical staff. This suggests that the workshop may have a positive impact on some factors influencing communication skills in this group.

Exploring the scope of oncology specialist nurses' practice in the UK.

PURPOSE: Revolutionary changes have taken place to nurses' roles and clinical responsibilities over the past decade, leading to new ways of working and higher levels of nursing practice. However, despite the development of nurse-led clinics and services within oncology there has been little formal evaluation. METHODS: A survey of 103 UK oncology specialist nurses was undertaken to explore their scope of practice, with emphasis on nurse-led services. RESULTS: The survey highlighted significant developments within nurses' roles and nurse-led services, although there was a distinct lack of clarity between nurses' titles and their roles/responsibilities. Most nurses had extended their role. However there were significant differences in the nature of clinical practice, such as clinical examination and nurse prescribing. Overall, new roles were greatly valued by the multidisciplinary team, reducing waiting times and providing benefits for patients. However other nurses felt frustrated by deficiencies in infrastructure and support, which often overshadowed potential benefits. CONCLUSIONS: There is a great diversity in oncology specialist nurses' roles; however lack of clarity in titles, training, competencies and responsibilities is creating confusion. Role developments and nurse-led clinics have been ad hoc and poorly evaluated. The introduction of a competency framework, national standards and a system of clinical appraisals seems key to providing increased transparency and vital safeguards for both nurses and patients. Without further exploration and evaluation of nurse-led initiatives it is difficult to fully appreciate their impact on patients, staff and service delivery.

Coding patient emotional cues and concerns in medical consultations: the Verona coding definitions of emotional sequences (VR-CoDES).

OBJECTIVE: To present the Verona Coding Definitions of Emotional Sequences (VR-CoDES CC), a consensus based system for coding patient expressions of emotional distress in medical consultations, defined as Cues or Concerns. METHODS: The system was developed by an international group of communication researchers. First, consensus was reached in different steps. Second, a reliability study was conducted on 20 psychiatric consultations. RESULTS: A Cue is defined as a verbal or non-verbal hint which suggests an underlying unpleasant emotion that lacks clarity. A Concern is defined as a clear and unambiguous expression of an unpleasant current or recent emotion that is explicitly verbalized with or without a stated issue of importance. The conceptual framework sets precise criteria for cues and concerns and for whom (health provider or patient) elicits the cue/concern. Inter-rater reliability proved satisfactory (agreement 81.5%, Cohen's Kappa 0.70). CONCLUSION: The VR-CoDES CC will facilitate comparative research on provider-patient communication sequences in which patients express emotional distress. PRACTICE IMPLICATIONS: The VR-CoDES CC may be used to help clinicians in recognizing or facilitating cues and concerns, thereby improving the recognition of patients' emotional distress, the therapeutic alliance and quality of care for these patients.

Development of the Verona coding definitions of emotional sequences to code health providers' responses (VR-CoDES-P) to patient cues and concerns.

OBJECTIVE: To present a method to classify health provider responses to patient cues and concerns according to the VR-CoDES-CC (Del Piccolo et al. (2009) [2] and Zimmermann et al. (submitted for publication) [3]). The system permits sequence analysis and a detailed description of how providers handle patient's expressions of emotion. METHODS: The Verona-CoDES-P system has been developed based on consensus views within the "Verona Network of Sequence Analysis". The different phases of the creation process are described in detail. A reliability study has been conducted on 20 interviews from a convenience sample of 104 psychiatric consultations. RESULTS: The VR-CoDES-P has two main classes of provider responses, corresponding to the degree of explicitness (yes/no) and space (yes/no) that is given by the health provider to each cue/concern expressed by the patient. The system can be further subdivided into 17 individual categories. Statistical analyses showed that the VR-CoDES-P is reliable (agreement 92.86%, Cohen's kappa 0.90 (±0.04) p<0.0001). CONCLUSION: Once validity and reliability are tested in different settings, the system should be applied to investigate the relationship between provider responses to patients' expression of emotions and outcome variables. PRACTICE IMPLICATIONS: Research employing the VR-CoDES-P should be applied to develop research-based approaches to maximize appropriate responses to patients' indirect and overt expressions of emotional needs.

Effects of a computer-supported interactive tailored patient assessment tool on patient care, symptom distress, and patients' need for symptom management support: a randomized clinical trial.

OBJECTIVE: To examine the effects of a computer-assisted, interactive tailored patient assessment (ITPA) tool in oncology practice on: documented patient care, symptom distress, and patients' need for symptom management support during treatment and rehabilitation. DESIGN AND METHODS: For this repeated measures clinical trial at a university hospital in Norway, 145 patients starting treatment for leukemia or lymphoma were randomly assigned to either an intervention (n=75) or control group (n=70). Both groups used the ITPA for symptom assessments prior to inpatient and outpatient visits for up to one year. The assessment summary, which displayed patients' self-reported symptoms, problems, and distress in rank-order of the patient's need for support, was provided to physicians and nurses in the intervention group only but not in the control group. RESULTS: Significantly more symptoms were addressed in the intervention group patient charts versus those of the control group. Symptom distress in the intervention group decreased significantly over time in 11 (58%) of 19 symptom/problem categories versus 2 (10%) for the control group. Need for symptom management support over time also decreased significantly more for the intervention group than the control group in 13 (68%) symptom categories. CONCLUSION: This is the first study to show that an ITPA used in an interdisciplinary oncology practice can significantly improve patient-centered care and patient outcomes, including reduced symptom distress and reduced need for symptom management support.

Cue-responding behaviours of oncology nurses in video-simulated interviews.

AIM: This paper is a report of a study to describe nurse-patient interactions, i.e. nurses' cue-responding behaviour in encounters with actors playing the role of patients. BACKGROUND: Patients with cancer seldom express their concerns directly but express cues instead. Few studies empirically investigated nurses' cue-responding behaviour and the subsequent influence of disclosure of cues and concerns. METHODS: In this descriptive observational study, conducted from April to June 2004, five oncology nurses interviewed an actor playing the role of a patient with cancer. Each nurse performed seven different interviews (n = 35); these were videotaped and subsequently rated for cue-responding using the Medical Interview Aural Rating Scale. Mixed model analysis was used to investigate the relation between cues and cue-responding. FINDINGS: Half of the patients' cues were responded to with distancing behaviours. The other half of the cues were either explored (33%) or acknowledged (17%). In 16% of these responses, nurses used open directive questions. One out of four open directive questions were used as a distancing response, suggesting that open directive questions are not used to explore or acknowledge cues of patients. Cue-responding influenced subsequent expression of concerns and emotions, i.e. disclosure of a concern is two times higher after exploration or acknowledging of a preceding cue than after a distancing response. CONCLUSION: Cue-responding is a valuable concept which can contribute to our understanding of optimal ways of communicating. Cue-responding behaviour facilitates the disclosure of worries and concerns of patients. Further research is needed to assess the clinical relevancy of cue-responding.

Transfer of communication skills training from workshop to workplace: the impact of clinical supervision.

OBJECTIVE: Recent studies have recognised that the communication skills learned in the training environment are not always transferred back into the clinical setting. This paper reports a study which investigated the potential of clinical supervision in enhancing the transfer process. METHODS: A randomised controlled trial was conducted involving 61 clinical nurse specialists. All attended a 3-day communication skills training workshop. Twenty-nine were then randomised to 4 weeks of clinical supervision, aimed at facilitating transfer of newly acquired skills into practice. Assessments, using real and simulated patients, were carried out before the course, immediately after the supervision period and 3 months later. Interviews were rated objectively using the Medical Interview Aural Rating Scale (MIARS) to assess nurses' ability to use key skills, respond to patient cues and identify patient concerns. RESULTS: Assessments with simulated patients showed that the training programme was extremely effective in changing competence in all three key areas. However, only those who experienced supervision showed any evidence of transfer. Improvements were found in the supervised groups' use of open questions, negotiation and psychological exploration. Whilst neither group facilitated more disclosure of cues or concerns, those in the experimental group responded more effectively to the cues disclosed, reduced their distancing behaviour and increasing their exploration of cues. CONCLUSIONS: The study has shown that whilst training enhances skills, without intervention, it may have little effect on clinical practice. The potential role of clinical supervision as one way of enhancing the clinical effectiveness of communication skills training programmes has been demonstrated. PRACTISE IMPLICATIONS: This study raises questions about the effectiveness of training programmes which do not incorporate a transfer element, and provides evidence to support the need for clinical supervision for clinical nurse specialist.

Identifying the concerns of women undergoing chemotherapy.

This cross-sectional study aimed to identify key concerns of cancer patients receiving in-patient chemotherapy, determine the prevalence of anxiety and depression, and assess whether ward nurses could identify patients' concerns. Thirty-three women on a chemotherapy ward in the northwest of England who had breast, ovarian, cervical or uterine cancer were interviewed using a Concerns Checklist and the Hospital Anxiety and Depression Scale. Patients expressed an average of 10.3 concerns (range: 2-27). Eighty percent of these were not identified by the nurses, who showed a clear bias towards physical symptoms and treatment-related concerns. The nurses were unable to identify the three main concerns in 70% of patients. Twenty-four percent of patients were found to be probable cases of anxiety and/or depression; there was a moderate correlation between the number of concerns and levels of anxiety and depression. Given the body of evidence that lack of identification of concerns leads to unmet needs, increased psychological distress, dissatisfaction with care and possible complaints, this study has provided clear evidence for the need to address this key area of care, and has highlighted the potential of the Concerns Checklist in busy clinical environments.

A patient-centred approach to defining and assessing interviewing competency.

The inclusion of communication skills as a core competency in health care curricula, has led to the need to define adequacy in this area. Developments in the field of interview analysis have meant that robust and objective ways of assessing interview behaviours are now available; however, these systems in themselves do not provide a model for assessing competency. As adequacy in interviewing is contextually driven, this paper discusses the potential of using patient centeredness to address the issue. It suggests two ways in which patient centeredness may be operationally defined, permitting data available from current rating systems, and from a new system shortly to be available, to be used to assess interviewing competency.