Evaluating a training intervention for improving alignment between emergency medical telephone operators and callers: a pilot study of communication behaviours.

BACKGROUND: Calls to emergency medical lines are an essential component in the chain of survival. Operators make critical decisions based on information they elicit from callers. Although smooth cooperation is necessary, the field lacks evidence-based guidelines for how to achieve it while adhering to strict parameters of index-driven questioning. We aimed to evaluate the effect of a training intervention for emergency medical operators at a call centre in Tønsberg, Norway. The course was designed to enhance operators' communication skills for smoothing cooperation with callers. METHODS: Calls were analyzed using inductively developed coding based on the course rationale and content. To evaluate whether the course generated consolidated behavioral change in everyday practice, the independent analyst evaluated 32 calls, selected randomly from eight operators, two calls before and two after course completion. To measure whether skill attainment delayed decision making, we compared the time to the first decision logged by intervention operators to eight control operators. Analysis included 3034 calls: 1375 to intervention operators (T1 = 815; T2 = 560) and 1659 to control operators (T1 = 683; T2 = 976). RESULTS: Operators demonstrated improved behaviours on how they greeted the caller (p < .001), acknowledged the caller (p < .001), and displayed empathy (p = 0.015). No change was found in the use of open-ended questions and agreeing with the caller. Contrary to expectations, operators who took the course logged first decisions more quickly than the control group (p < .001). CONCLUSIONS: This pilot study demonstrated that the training intervention generated behavioural change in these operators, providing justification for scaling up the intervention.

Improving communication in general practice when mental health issues appear: piloting a set of six evidence-based skills.

OBJECTIVE: To test a communication skills training program teaching general practitioners (GPs) a set of six evidence-based mental health related skills. METHODS: A training program was developed and tested in a pilot test-retest study with 21 GPs. Consultations were videotaped and actors used as patients. A coding scheme was created to assess the effect of training on GP behavior. Relevant utterances were categorized as examples of each of the six specified skills. The GPs' self-perceived learning needs and self-efficacy were measured with questionnaires. RESULTS: The mean number of GP utterances related to the six skills increased from 13.3 (SD 6.2) utterances before to 23.6 (SD 7.2) utterances after training; an increase of 77.4% (P<0.001). Effect sizes varied from 0.23 to 1.37. Skills exploring emotions, cognitions and resources, and the skill Promote coping, increased significantly. Self-perceived learning needs and self-efficacy did not change significantly. CONCLUSION: The results from this pilot test are encouraging. GPs enhanced their use on four out of six mental health related communication skills significantly, and the effects were medium to large. PRACTICE IMPLICATIONS: This training approach appears to be an efficacious approach to mental health related communication skills training in general practice.

Communication and mental health in general practice: physicians' self-perceived learning needs and self-efficacy.

Background General practitioners (GPs) often see patients presenting with mental health problems, but their training regarding mental health treatment varies. GPs' communication skills are of particular importance in these consultations, and communication skills training of GPs has been found to improve patients' mental health. To tailor a communication skills training by basing it on GPs' learning needs and self-efficacy, thereby maximising learning, we conducted a questionnaire study. Objective To measure GPs' self-perceived needs regarding communication with and treatment of mental health patients. Methods GPs in training for specialist general practice were given a questionnaire on communication and mental health in general practice. The questionnaire measured prevalence, referring practices, self-efficacy and self-perceived learning need regarding mental health treatment and communication skills, as well as interest in attending training. Results A majority of GPs in our sample was interested in training on communication skills and mental health treatment. However, they reported moderate learning needs and high confidence on the different measures. GPs reported highest learning needs regarding specific communication skills and treatment of the most common mental health problems. At the same time, they reported highest self-efficacy in treating the same disorders. They also reported high confidence in communication skills. Conclusion Despite being confident, GPs in this sample recognise the need for specific skills in consultations with patients with mental health problems, but may underestimate the importance of general communication skills. These results are informative when designing training for GPs in communication and mental health.

Physicians' responses to patients' expressions of negative emotions in hospital consultations: a video-based observational study.

OBJECTIVE: Patients express their negative emotions in medical consultations either implicitly as cue to an underlying unpleasant emotion or explicitly as a clear, unambiguous concern. The health provider's response to such cues and concerns is important for the outcome of consultations. Yet, physicians often neglect patient's negative emotions. Most studies of this subject are from primary health care. We aimed to describe how physicians in a hospital respond to negative emotions in an outpatient setting. METHODS: Ninety six consultations were videotaped in a general teaching hospital. The Verona Coding Definitions of Emotional Sequences was used to identify patients' expression of negative emotions in terms of cue and concern and to code physicians' subsequent responses. Cohen's kappa was used as interrater reliability measure. Acceptable kappa level was set to .60. RESULTS: We observed 163 expressions of negative emotions. In general, the physician responses to patients' cues and concerns did not include follow up or exploration. Concerns more often than cues led to lack of emotional exploration. CONCLUSIONS: When patients expressed negative emotions or cues to such, hospital physicians tended to move away from emotional communication, particularly if the emotion was expressed as an explicit concern. PRACTICE IMPLICATIONS: Medical training should enable physicians' to explore the patients' emotions in situations where it will improve the medical treatment.

Patients' negative emotional cues and concerns in hospital consultations: a video-based observational study.

OBJECTIVE: Little is known about the frequency and occurrence of patients' negative emotional cues and concerns (NECC) across specialties in hospital departments. METHODS: Ninety-six consultations were videotaped in a general hospital. The VR-CoDES (Verona Coding Definitions of Emotional Sequences) were used to code the patients' NECC. Cohen's kappa was used to establish reliability between coders. RESULTS: Cohen's kappa was above 0.60. NECC were observed in more than half of the consultations. The number of NECC in the consultations was 163, with 109 negative emotional cues and 54 concerns. The mean number of NECC in the consultations was 1.69, with a median of 1. The first NECC in consultations were stated after a median duration of 5min 21s. We could not find significant differences related to the gender and age of the patient or the physician, or the specialty of the physician. CONCLUSIONS: More than half of the concerns were not preceded by a negative emotional cue. Few consultations contained more than 3 NECC, and NECC tended to be expressed relatively early. PRACTICE IMPLICATIONS: Patients' expressions of emotional issues are few, and most of them are subtle. Physicians should be thoroughly trained to identify and respond to them.

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.

Frequency of GP communication addressing the patient's resources and coping strategies in medical interviews: a video-based observational study.

BACKGROUND: There is increasing focus on patient-centred communicative approaches in medical consultations, but few studies have shown the extent to which patients' positive coping strategies and psychological assets are addressed by general practitioners (GPs) on a regular day at the office. This study measures the frequency of GPs' use of questions and comments addressing their patients' coping strategies or resources. METHODS: Twenty-four GPs were video-recorded in 145 consultations. The consultations were coded using a modified version of the Roter Interaction Analysis System. In this study, we also developed four additional coding categories based on cognitive therapy and solution-focused therapy: attribution, resources, coping, and solution-focused techniques.The reliability between coders was established, a factor analysis was applied to test the relationship between the communication categories, and a tentative validating exercise was performed by reversed coding. RESULTS: Cohen's kappa was 0.52 between coders. Only 2% of the utterances could be categorized as resource or coping oriented. Six GPs contributed 59% of these utterances. The factor analysis identified two factors, one task oriented and one patient oriented. CONCLUSION: The frequency of communication about coping and resources was very low. Communication skills training for GPs in this field is required. Further validating studies of this kind of measurement tool are warranted.

Communication skills training for general practitioners to promote patient coping: the GRIP approach.

OBJECTIVE: To develop, perform and test the effects of a communication skills training program for general practitioners (GPs). The program specifically addresses the patients' coping and resources despite more or less severe psychological or physical illness. METHODS: A training model was developed, based on cognitive therapy and solution-focused therapy. The training was given the acronym GRIP after its main content: Get a measure of the patient's subjective complaints and illness attributions. Respond to the patient's understanding of the complaints. Identify resources and solutions. Promote positive coping. The study involved a quasi-experimental design in which 266 consultations with 25 GPs were video recorded. Forty hours of communication skills training were given to the intervention group. RESULTS: Consultation duration, patient age and distress determined the frequency of the GRIP communication. There was a significant effect of training on four particular subcategories of the GRIP techniques. The effect of the training was most evident in a subgroup of GPs who used little or no resource-oriented communication before training. CONCLUSION: This pilot training model may help change the GPs' communicative pattern with patients in some situations. PRACTICE IMPLICATION: Communication skills training programmes that emphasize patient attributions and personal resources should be developed further and tested in general practice settings with an aim to promote patient coping.

The medical consultation viewed as a value chain: a neurobehavioral approach to emotion regulation in doctor-patient interaction.

OBJECTIVE: To present a model of the medical consultation as a value chain, and to apply a neurobehavioral perspective to analyze each element in the chain with relevance for emotion regulation. METHODS: Current knowledge on four elements in medical consultations and neuroscientific evidence on corresponding basic processes are selectively reviewed. RESULTS: The four elements of communication behaviours presented as steps in a value chain model are: (1) establishing rapport, (2) patient disclosure of emotional cues and concerns, (3) the doctor's expression of empathy, and (4) positive reappraisal of concerns. CONCLUSION: The metaphor of the value chain, with emphasis on goal orientation, helps to understand the impact of each communicative element on the outcome of the consultation. Added value at each step is proposed in terms of effects on outcome indicators; in this case patients affect regulation. Neurobehavioral mechanisms are suggested to explain the association between communication behaviour and affect regulation outcome. PRACTICE IMPLICATIONS: The value chain metaphor and the emphasis on behaviour-outcome-mechanisms associations may be of interest as conceptualizations for communications skills training.