Medical students' experiences when empathizing with patients' emotional issues during a medical interview - a qualitative study.

BACKGROUND: There is evidence that empathy decreases as medical students go through clinical training. However, there are few in-depth studies investigating the students' own experiences when trying to empathize in concrete clinical encounters. We therefore wanted to explore medical students' perceptions, experiences, and reflections when empathizing with patients expressing emotional issues. METHODS: A qualitative content analysis of semi-structured interviews with third year medical students (N = 11) was conducted using video-stimulated recall from their own medical interview with a simulated chronically ill patient. Students were led to believe that the patient was real. RESULTS: Five themes which may influence student empathy during history-taking were identified through analysis of interview data: (1) Giving priority to medical history taking, (2) Interpreting the patient's worry as lack of medical information, (3) Conflict between perspectives, (4) Technical communication skill rather than authentic and heart-felt and (5) The distant professional role. CONCLUSIONS: The participating students described conflicts between a medical agenda, rules and norms for professional conduct and the students' own judgments when trying to empathize with the patient. To our knowledge, this is the first study ever to document the students' own perspective in concrete situations as well as how these reported experiences and reflections affect their empathy towards patients. Since we now know more about what is likely to hinder medical students' empathy, educators should actively encourage group reflection and discussion in order to avoid these negative effects of history taking both inside and outside of the clinical setting.

Caught between ideals and reality: Phenomenological-hermeneutic study of healthcare providers' experiences while interacting with mechanically ventilated patients.

This study aimed to explore healthcare providers' experiences of their communication and interaction with conscious patients on mechanical ventilation in intensive care. Nurses, physicians, and physiotherapists were interviewed after they had been video recorded in naturally occurring interactions with patients. The interviews were analyzed using a phenomenological-hermeneutical approach. Three themes were identified: The willingness to engage and understand the mechanically ventilated patient, the potential risk of neglecting the patient in the encounters, and provider interdependence as the core of intensive care. The themes elicited how providers handled the dissonance between their own personal ideals of care and their real-world encounters with patients and other professionals. The healthcare providers were aware of how easily patients could be neglected while being non-vocal, and therefore invested time and effort communicating with the patients. Based on their personal ideals of patient participation and autonomy, it was difficult to perform procedures, such as weaning off the ventilator or mobilization, to which the patient was opposed. Interprofessional collaboration was valued by the providers in such situations. The study revealed that providers need to consider the communication barriers that exist on the individual and team levels when interacting with patients on mechanical ventilation.

Social attainment in physically well-functioning long-term survivors of pediatric brain tumour; the role of executive dysfunction, fatigue, and psychological and emotional symptoms.

The purpose of this cross-sectional study was to investigate long-term social attainment in physically well-functioning adult survivors of pediatric brain tumour (PBT) and identify demographic, medical, and psychological factors related to poor social outcomes, with a special focus on the significance of executive dysfunction. One hundred and fourteen PBT survivors and a healthy control group provided personal data on social outcomes, i.e., education, work, and government benefits, and completed questionnaires on executive function (EF), psychological and emotional difficulties, and fatigue. A significantly higher number of survivors compared to healthy controls reported having received educational adjustments and substantial government benefits, and significantly more survivors than controls were currently not engaged in regular employment/training. PBT survivors and healthy controls did not differ on educational level or living situation. The factors most strongly associated with poor social outcomes were self-reported executive dysfunction, difficulties with adaptive functioning, and fatigue. The findings show that physically well-functioning PBT survivors are at risk of poorer social outcomes and financial dependence in adulthood compared to their healthy peers, and underline the importance of investigating EF in short- and long-term follow-ups. Future rehabilitation efforts should focus more on compensatory strategies for executive dysfunction and improving EF skills.

Attention-seeking actions by patients on mechanical ventilation in intensive care units: A phenomenological-hermeneutical study.

AIMS AND OBJECTIVES: The aim of this study was to explore the interaction between mechanically ventilated patients and healthcare personnel in intensive care units (ICUs), with a special emphasis on patients' initiative to communicate. BACKGROUND: Patients on mechanical ventilation in ICUs tend to be less sedated today compared to standard care in the past. Their experiences of being voiceless may cause emotional distress, and for many patients, communication is difficult. Healthcare personnel are reported to be the main initiators of the communication exchanges that occur. DESIGN: An observational study with a phenomenological-hermeneutical approach. METHODS: Video recording was used to collect data on the naturally occurring communication and interaction. Ten conscious and alert patients from two Norwegian ICUs were recruited. Two relatives and a total of sixty healthcare personnel participated. Content analysis was conducted, with focus on both the manifest and latent content meaning. RESULTS: We found a total of 66 situations in which patients attempted to attract the attention of others on their own initiative in order to express themselves. Attention-seeking actions, defined as the act of seeking attention and understanding without a voice, became an essential theme. Four patterns of interaction were identified: immediately responded to, delayed response or understanding, intensified attempts or giving up. Patients had a variety of reasons for seeking attention, which were classified into four domains: psychological expressions, physical expressions, social expressions and medical treatment. CONCLUSIONS: Patients' attention-seeking actions varied in content, form and the types of responses they elicited. The patients had to fight to first gain joint attention and then joint understanding. This was both energy-draining and time-consuming. RELEVANCE TO CLINICAL PRACTICE: Healthcare personnel need to spend more time for communication purposes, giving attention and being more alert to bodily or symbolic gestures to understand the patient's needs.

Experiences with late effects-related care and preferences for long-term follow-up care among adult survivors of childhood lymphoma.

PURPOSE: Given childhood cancer survivors' risk of treatment-induced late effects, long-term follow-up care is recommended. We explored experiences with late effects-related care and preferences for long-term follow-up care among adult survivors of childhood malignant lymphoma in Norway. METHODS: We conducted five focus group interviews with 34 survivors (19 females; 21 Hodgkin/13 non-Hodgkin lymphoma survivors; mean age 39 years; mean time from diagnosis 26 years). Data was analyzed using principles of thematic analysis. RESULTS: Two main themes were identified: (1) the survivors' experiences with late effects-related care and (2) their preferences for long-term follow-up care. Most of the survivors were dissatisfied with their late effects-related care due to perceptions of poor coordination of healthcare needs in a fragmented system, combined with a perceived lack of knowledge of late effects among themselves and general practitioners (GPs). All survivors valued long-term follow-up care. Oncologists were the preferred care providers, but GPs were considered acceptable providers if they had sufficient knowledge of late effects and routine examinations, short waiting times, and improved GP-oncologist collaboration. CONCLUSIONS: Our results suggest that a shared care model of long-term follow-up care involving specialists, GPs, and the survivors themselves is likely to fulfill several of the currently unmet needs among adult survivors of childhood cancers. Improved patient education about late effects and follow-up care would aid self-management. The survivors' concerns regarding lack of sufficient knowledge of late effects among GPs suggest a need for improving access to, and dissemination of, information of late effects.

Do medical students and young physicians assess reliably their self-efficacy regarding communication skills? A prospective study from end of medical school until end of internship.

BACKGROUND: This prospective study from end of medical school through internship investigates the course and possible change of self- reported self-efficacy in communication skills compared with observers' ratings of such skills in consultations with simulated patients. METHODS: Sixty-two medical students (43 females) from four Norwegian universities performed a videotaped consultation with a simulated patient immediately before medical school graduation (T1) and after internship (internal medicine, surgery and family medicine, half a year each - T2). Before each consultation, the participants assessed their general self-efficacy in communication skills. Trained observers scored the videos and applied a well-validated instrument to rate the communication behaviour. Results from the two assessment methods were correlated at both time points and possible differences from T1 to T2 were explored. RESULTS: A close to zero correlation between self-efficacy and observed communication skills were found at T1. At T2, participants' self-efficacy scores were inversely correlated with levels of observed skills, demonstrating a lack of concordance between young physicians' own assessment of self-efficacy and observers' assessment. When dividing the sample in three groups based on the observers' scores (low <1/3-, medium 1/3 to 2/3-, high competence >2/3), the group of male physicians showed higher levels of self-efficacy than females in all the three performance groups at T1. At T2, those having a high performance score yielded a low self-efficacy, regardless of gender. CONCLUSIONS: The lack of positive correlations between self-efficacy assessment and expert ratings points to limitations in the applicability of self-assessment measures of communication skills. Due to gender differences, groups of female and male physicians should be investigated separately. Those obtaining high-performance ratings from observers, through the period of internship, may become more conscious of how demanding clinical communication with patients may be. This insight may represent a potential for growth, but could in some physicians represent too much of a self-critical attitude. Active supervision of young physicians throughout internship is important in order to help physicians to be more aware of their strengths and weaknesses, in order to gain increased mastery in the art of doctoring.

Development of family and dietary habits questionnaires: the assessment of family processes, dietary habits and adolescents' impulsiveness in Norwegian adolescents and their parents.

BACKGROUND: There is a need for valid and comprehensive measures of parental influence on children's energy balance-related behaviours (EBRB). Such measures should be based on a theoretical framework, acknowledging the dynamic and complex nature of interactions occurring within a family. The aim of the Family & Dietary habits (F&D) project was to develop a conceptual framework identifying important and changeable family processes influencing dietary behaviours of 13-15 year olds. A second aim was to develop valid and reliable questionnaires for adolescents and their parents (both mothers and fathers) measuring these processes. METHODS: A stepwise approach was used; (1) preparation of scope and structure, (2) development of the F&D questionnaires, (3) the conducting of pilot studies and (4) the conducting of validation studies (assessing internal reliability, test-retest reliability and confirmatory factor analysis) using data from a cross-sectional study. RESULTS: The conceptual framework includes psychosocial concepts such as family functioning, cohesion, conflicts, communication, work-family stress, parental practices and parental style. The physical characteristics of the home environment include accessibility and availability of different food items, while family meals are the sociocultural setting included. Individual characteristics measured are dietary intake (vegetables and sugar-sweetened beverages) and adolescents' impulsivity. The F&D questionnaires developed were tested in a test-retest (54 adolescents and 44 of their parents) and in a cross-sectional survey including 440 adolescents (13-15 year olds), 242 mothers and 155 fathers. The samples appear to be relatively representative for Norwegian adolescents and parents. For adolescents, mothers and fathers, the test-retest reliability of the dietary intake, frequencies of (family) meals, work-family stress and communication variables was satisfactory (ICC: 0.53-0.99). Barratt Impulsiveness Scale-Brief (BIS-Brief) was included, assessing adolescent's impulsivity. The internal reliability (Cronbach's alphas: 0.77/0.82) and test-retest reliability values (ICC: 0.74/0.77) of BIS-Brief were good. CONCLUSIONS: The conceptual framework developed may be a useful tool in guiding measurement and assessment of the home food environment and family processes related to adolescents' dietary habits, in particular and for EBRBs more generally. The results support the use of the F&D questionnaires as psychometrically sound tools to assess family characteristics and adolescent's impulsivity.

Subjective sleep quality in relation to objective sleep estimates: comparison, gender differences and changes between the acute phase and the six-month follow-up after stroke.

AIMS: To describe sleep experiences after stroke using subjective and objective indicators and identify possible gender differences in sleep in the acute phase and at 6-month follow-up. BACKGROUND: Sleep disturbances after stoke are recognized, but poorly described. Gender differences in sleep exist in other populations, but have not been reported after stroke. DESIGN: A longitudinal cohort study. METHOD: Subjective sleep quality was measured with the Pittsburgh Sleep Quality Index and objective sleep was estimated with actigraphy in 100 patients in the acute phase and six months after stroke, from April 2007-March 2009. FINDINGS: Subjective sleep quality was better and objective wake percentage was lower at follow-up than in the acute phase after stroke. Actigraphy estimated low sleep efficiency and many awakenings at both time points. Subjective and objective measures were correlated at the 6-month follow-up, but not in the acute phase. Women's subjective sleep efficiency and total score on the Pittsburgh Sleep Quality Index were worse than men's in the acute phase, but actigraphy estimated that women slept more than men in the course of a day. Women's subjective sleep quality was better at follow-up than in the acute phase. Men reported worse subjective sleep quality, but better subjective sleep efficiency at follow-up than in the acute phase, and also had lower objective wake percentage at follow-up. CONCLUSIONS: Subjective sleep quality was poor and actigraphy indicated disturbed sleep-wake patterns in the acute phase and at 6-month follow-up. Gender differences existed in subjective and objective sleep in the acute phase, but not at follow-up.

The physician's role and empathy - a qualitative study of third year medical students.

BACKGROUND: Empathy is important in ensuring the quality of the patient-physician relationship. Several studies have concluded that empathy declines during medical training, especially during the third year. However, there is little empirical research on what may influence a medical student's empathy. In addition, studies of empathy in medicine have generally been dominated by quantitative approaches, primarily self-assessment questionnaires. This is a paradox given the complexity and importance of empathy. In this paper we explore medical students' opinions of what may foster or inhibit empathy during medical school, with a particular emphasis on how empathy is influenced by the initiation into the physician's role. METHODS: We performed semi-structured qualitative interviews with 11 third year medical students. Content analysis was used to analyse the transcribed interviews. RESULTS: Five aspects of the the physician's role and the students' role acquisition emerged when the students were asked to describe what may influence their empathy: 1) Becoming and being a professional, 2) Rules concerning emotions and care, 3) Emotional control, 4) The primary importance of biomedical knowledge, and 5) Cynicism as a coping strategy. CONCLUSION: This study suggest that the described inhibitors of empathy may originate in the hidden curriculum and reinforce each other, creating a greater distance between the physician and the patient, and possibly resulting in decreased empathy. Mastering biomedical knowledge is an important part of the students' ideals of the physician's role, and sometimes objective and distanced ideals may suppress empathy and the students' own emotions.

Talk-in-interaction and neuropsychological processes.

Talk-in-interaction is characterized by a pattern of turn-taking between conversational partners and rapid shifts from turn to turn without pauses between turns. During talk-in-interaction speakers constantly adjust to one another's terminology, repeat expressions from turn to turn and imitate each other's verbal as well as nonverbal behavior, a phenomenon characterized by automatic processing referred to as interactive alignment. Recent studies have shown how interactive alignment is subserved by neural coupling of brain activity of speakers and listeners, integrating comprehension and language production across many brain areas. Verbal behavior during talk-in-interaction is also dependent on the ability to draw inferences from verbally ambiguous expressions, to a large extent subserved by right hemisphere (RH) functioning, but the nature of the RH contribution to the activation and selection of inferences is under discussion in the research literature. There is emerging evidence of synchrony in neural activity and psychophysiological processing reflecting the interactive alignment observed on the behavioral level during talk-in-interaction. An understanding of neuropsychological aspects of talk-in-interaction may have potential implications for our understanding of doctor-patient dialogue.

Effects of an interactive tailored patient assessment on patient-clinician communication in cancer care.

BACKGROUND: To test the effect of Choice, an interactive tailored patient assessment (ITPA) tool on the number and types of symptoms addressed during consultations with cancer patients, cancer patients' active participation during consultation with clinicians, and clinicians' responses. METHOD: A total of 193 consultations were audio taped and coded with the task-oriented part of Roter Interactive Assessment System. In addition, we recorded the initiator of each coded utterance (clinician or patient) as defined by Verona Coding Definitions of Emotional Sequences and indicated the symptoms addressed in a list of all symptoms within the Choice ITPA. Of the 193 consultations, 99 were standard consultations that served as a control group. In the 94 intervention group consultations, patients utilized the Choice ITPA prior to the consultation, and the assessment summary was available to both patients and clinicians. We compared the two groups in both multilevel and multivariate analyses. RESULTS: We found significantly more symptoms addressed in the intervention group as compared with the control group. We also found that the patients asked more questions in the intervention group, indicating that they were more active participants when utilizing Choice. The clinicians also provided more information in the intervention group. CONCLUSION: The Choice ITPA was successful in making cancer patients more active participants in the consultation with their clinician.

A smartphone-based intervention with diaries and therapist feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain. part 2: 11-month follow-up results of a randomized trial.

BACKGROUND: Internet-based interventions are increasingly used to support self-management of individuals with chronic illnesses. Web-based interventions may also be effective in enhancing self-management for individuals with chronic pain, but little is known about long-term effects. Research on Web-based interventions to support self-management following participation in pain management programs is limited. OBJECTIVE: The aim is to examine the long-term effects of a 4-week smartphone-intervention with diaries and therapist-written feedback following an inpatient chronic pain rehabilitation program, previously found to be effective at short-term and 5-month follow-ups. METHODS: 140 women with chronic widespread pain, participating in a 4-week inpatient rehabilitation program, were randomized into two groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of one face-to-face individual session and 4 weeks of written communication via a smartphone, consisting of three diaries daily to elicit pain-related thoughts, feelings, and activities, as well as daily personalized written feedback based on cognitive behavioral principles from a therapist. Both groups were given access to an informational website to promote constructive self-management. Outcomes were measured with self-reported paper-and-pencil format questionnaires with catastrophizing as the primary outcome measure. Secondary outcomes included daily functioning and symptom levels, acceptance of pain, and emotional distress. RESULTS: By the 11-month follow-up, the favorable between-group differences previously reported post-intervention and at 5-month follow-up on catastrophizing, acceptance, functioning, and symptom level were no longer evident (P>.10). However, there was more improvement in catastrophizing scores during the follow-up period in the intervention group (M=-2.36, SD 8.41) compared to the control group (M=.40, SD 7.20), P=.045. Also, per protocol within-group analysis showed a small positive effect (Cohen's d=.33) on catastrophizing in the intervention group (P=.04) and no change in the control group from the smartphone intervention baseline to 11-month follow-up. A positive effect (Cohen's d=.73) on acceptance was found within the intervention group (P<.001) but not in the control group. Small to large negative effects were found within the control group on functioning and symptom levels, emotional distress, and fatigue (P=.05) from the intervention baseline to the 11-month follow-up. CONCLUSION: The long-term results of this randomized trial are ambiguous. No significant between-group effect was found on the study variables at 11-month follow-up. However, the within-group analyses, comparing the baseline for the smartphone intervention to the 11-month data, indicated changes in the desired direction in catastrophizing and acceptance in the intervention group but not within the control group. This study provides modest evidence supporting the long-term effect of the intervention. TRIAL REGISTRATION: Clinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6FF7KUXo0).

A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial.

BACKGROUND: Internet-based interventions using cognitive behavioral approaches can be effective in promoting self-management of chronic pain conditions. Web-based programs delivered via smartphones are increasingly used to support the self-management of various health disorders, but research on smartphone interventions for persons with chronic pain is limited. OBJECTIVE: The aim of this trial was to study the efficacy of a 4-week smartphone-delivered intervention with written diaries and therapist feedback following an inpatient chronic pain rehabilitation program. METHODS: A total of 140 women with chronic widespread pain who participated in a 4-week inpatient rehabilitation program were randomized into 2 groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of 1 face-to-face session and 4 weeks of written communication via a smartphone. Participants received 3 smartphone diary entries daily to support their awareness of and reflection on pain-related thoughts, feelings, and activities. The registered diaries were immediately available to a therapist who submitted personalized written feedback daily based on cognitive behavioral principles. Both groups were given access to a noninteractive website after discharge to promote constructive self-management. Outcomes were measured with self-reported questionnaires. The primary outcome measure of catastrophizing was determined using the pain catastrophizing scale (score range 0-52). Secondary outcomes included acceptance of pain, emotional distress, functioning, and symptom levels. RESULTS: Of the 140 participants, 112 completed the study: 48 in the intervention group and 64 in the control group. Immediately after the intervention period, the intervention group reported less catastrophizing (mean 9.20, SD 5.85) than the control group (mean 15.71, SD 9.11, P<.001), yielding a large effect size (Cohen's d=0.87) for study completers. At 5-month follow-up, the between-group effect sizes remained moderate for catastrophizing (Cohen's d=0.74, P=.003), acceptance of pain (Cohen's d=0.54, P=.02), and functioning and symptom levels (Cohen's d=0.75, P=.001). CONCLUSIONS: The results suggest that a smartphone-delivered intervention with diaries and personalized feedback can reduce catastrophizing and prevent increases in functional impairment and symptom levels in women with chronic widespread pain following inpatient rehabilitation. TRIAL REGISTRATION: Clinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6DUejLpPY).

A complex communication skills training program for physicians providing advanced cancer care - content development and barriers and solutions for implementation.

Background: Early integration of oncology and patient-centered palliative care is the recommended clinical practice model for patients with advanced cancer. General and specific communication skills are necessary to achieve integrated patient-centered care, but require organized training to be adequately mastered. Challenges and barriers on several levels, i.e. organizational, professional and individual may, however, hamper implementation. The development, implementation, and evaluation of such an educational program focusing on communication skills contain many steps, considerations and lessons learned, which are described in this article.Methods: A multi-professional faculty developed, implemented, and evaluated an educational program through a 5-step approach. The program was part of a Norwegian cluster-randomized controlled trial aiming to test the effect of early integration of oncology and palliative care for patients with advanced cancer.Results: The result is the PALLiON educational program; a multi-faceted, evidence-based, and learner-centered program with a specific focus on physicians' communication skills. Four modules were developed: lectures, discussion groups, skills training, and coaching. These were implemented at the six intervention hospitals using different teaching strategies. Evaluation in a subgroup of participants showed a positive appraisal of the group discussions and skills training.Conclusion:We present our experiences and reflections regarding implementation and lessons learned, which should be considered in future developments and implementations; (1) Include experienced faculty with various backgrounds, (2) Be both evidence-based and learner-centered, (3) Choose teaching strategies wisely, (4) Expect resistance and skepticism, (5) Team up with management and gatekeepers, (6) Expect time to fly, and (7) Plan thorough assessment of the evaluation and effect.Trial registration: ClinicalTrials.gov identifier: NCT03088202.

A mindfulness-based group intervention to reduce psychological distress and fatigue in patients with inflammatory rheumatic joint diseases: a randomised controlled trial.

OBJECTIVE: To evaluate the effects of a mindfulness-based group intervention, the Vitality Training Programme (VTP), in adults with inflammatory rheumatic joint diseases. METHODS: In a randomised controlled trial, the VTP-a 10-session mindfulness-based group intervention including a booster session after 6 months-was compared with a control group that received routine care plus a CD for voluntary use with mindfulness-based home exercises. The primary outcome was psychological distress measured by the General Health Questionnaire-20. Self-efficacy (pain and symptoms) and emotion-focused coping (emotional processing and expression) were used as co-primary outcomes. Secondary outcomes included pain, fatigue, patient global disease activity, self-care ability and well-being. Effects were estimated by mixed models repeated measures post-intervention and at 12-month follow-up. RESULTS: Of 73 participants randomised, 68 completed assessments post-intervention and 67 at 12 months. Significant treatment effects in favour of the VTP group were found post-treatment and maintained at 12 months in psychological distress (adjusted mean between-group difference -3.7, 95% CI -6.3 to -1.1), self-efficacy pain (9.1, 95% CI 3.4 to 14.8) and symptoms (13.1, 95% CI 6.7 to 19.3), emotional processing (0.3, 95% CI 0.02 to 0.5), fatigue (-1.1, 95% CI -1.8 to -0.4), self-care ability (1.0, 95% CI 0.5 to 1.6) and overall well-being (0.6, 95% CI 0.1 to 1.2). No significant group differences were found in emotional expression, pain or disease activity. CONCLUSION: The VTP improved most primary and secondary outcomes compared with individual use of CD exercises. Improvements were maintained at 12 months, suggesting that the VTP is a beneficial complement to existing treatments for patients with inflammatory rheumatic joint diseases.

Specialist physicians' sensitivity to patient affect and satisfaction.

BACKGROUND: Studies indicate that physicians do not respond adequately to patients' emotional issues. Physician sensitivity to patient affect has not been much explored. OBJECTIVES: To describe specialist physicians' sensitivity to patient affect and satisfaction. RESEARCH DESIGN: Cross-sectional study of physicians' and patients' postvisit questionnaire statements about patient affective states and satisfaction. SUBJECTS: A representative sample of 71 physicians covering nonpsychiatric clinical specialties in a general teaching hospital were observed during 497 encounters with patients (outpatient, inpatient on rounds, emergency room, maximum 8 encounters per physician). MEASURES: Standardized correlations between physician and patient statements. RESULTS: Physician statements about patient negative affect were moderately correlated with patient self-report of negative affect [r=0.379 (0.301; 0.452)]. Physician statements about patient positive affect and patient satisfaction were weakly correlated with patient self-report of positive affect [r=0.238 (0.153; 0.319)] and satisfaction [r=0.219 (0.134; 0.301)]. Internists [r=0.300 (0.161; 0.428)] were significantly less sensitive to negative affect than surgeons [r=0.500 (0.360; 0.618), P=0.038] and neurologists [r=0.621 (0.432; 0.758), P=0.007]. Physicians previously known by the patient were significantly more sensitive to negative affect than those who were not known [r=0.509 (0.391; 0.611) vs. 0.293 (0.189; 0.390), P=0.006]. We could not find differences in affective sensitivity between male and female physicians. CONCLUSIONS: Specialist physicians have moderate ability to identify patient negative affect and poor ability to identify patient positive affect and patient satisfaction.

Children's expressions of negative emotions and adults' responses during routine cardiac consultations.

OBJECTIVE: One function of expressing emotion is to receive support. The aim of this study was to assess how children with heart disease express negative emotions during routine consultations, and examine the interaction between children's expressions and adults' responses. METHODS: Seventy children, aged 7-13 years, completed measures of anxiety and were videotaped during cardiology visits. Adult-child interactions were analyzed using the Verona Definitions of Emotional Sequences. RESULTS: Children expressed negative emotion, mainly in subtle ways; however, adults rarely recognized and responded to these expressions. The frequency of children's expressions and adults' responses were related to the child's age, level of anxiety, and verbal participation. CONCLUSION: Children do not openly express negative emotions frequently during routine cardiac consultations; they are more likely to provide subtle cues of negative emotion. When expression of negative emotions does occur, adults may consider using the opportunity to explore the child's emotional experiences.

The trajectory of physical and mental health from injury to 5 years after multiple trauma: a prospective, longitudinal cohort study.

OBJECTIVES: To describe the trajectory of physical and mental health from injury to 5 years postinjury for patients with multiple trauma, and to examine predictors of recovery of physical and mental health. DESIGN: A prospective, longitudinal cohort study with data from injury (baseline), the return home (t1), and 1 (t2), 2 (t3), and 5 (t4) years. SETTING: Hospital and community setting. PARTICIPANTS: Patients (N=105; mean age ± SD, 35.3±14.0y; age range, 18-67y; 83% men) with multiple trauma and a New Injury Severity Score (NISS) ≥16 treated at a regional trauma referral center. Mean NISS ± SD was 34.6±12.6, and mean Glasgow Coma Scale (GCS) score ± SD was 12.2±3.9. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medical Outcomes Study 36-Item Short-Form Health Survey physical component summary (PCS) and mental component summary (MCS), injury severity parameters, and World Health Organization Disability Assessment Schedule II (WHODAS II) for activities and participation. RESULTS: The proportion with poor physical health (<40 points on the PCS) stabilized at 56% at t4 from 81% at t1. The proportion with poor mental health (<40 points on the MCS) stabilized at 31% at t4 from 43% at t1. Generalized estimating equations showed that predictors of PCS were time points of measurement (Wald, 85.50; P<.001), GCS (B=-.48, P=.004), time in hospital/rehabilitation (B=-.22, P=.001), and the rank-transformed WHODAS II subscales Getting around (B=.16, P<.001) and Participation in society (B=.06, P=.015). Predictors of MCS were time points of measurement (Wald 13.46, P=.004), sex (men/women) (B=-4.24, P=.003), education (low/high) (B=3.43, P=.019), and WHODAS II cognitive function (B=.18, P<.001) and Participation in society (B=.18, P≤.001). CONCLUSIONS: Physical and mental health over the 5 years improved with time, but was still significantly below population means. The physical and mental health status stabilized, but the recovery trajectories differed for physical and mental health. Predictors of health were personal and injury-related factors and function in a biopsychosocial perspective.

Stroke patients' functions in personal activities of daily living in relation to sleep and socio-demographic and clinical variables in the acute phase after first-time stroke and at six months of follow-up.

AIMS AND OBJECTIVES: To explore first-time stroke patients' degree of independence in activities of daily life in relation to sleep and other essential variables that might influence activities of daily life. BACKGROUND: Sleep has received little attention in rehabilitation of activities of daily life in stroke patients. DESIGN: This is a longitudinal survey and observational study design from the acute phase to six months poststroke. METHODS: First-time stroke patients (n = 90) were recruited from two hospitals in eastern Norway in 2007 and 2008. Data were collected by survey interview, medical records and wrist actigraphy in the first two weeks at the hospital and at six months of follow-up. Actigraph measures patient activity and estimates sleep during the day and night. RESULTS: Linear regression showed that high dependence in personal activities of daily living was directly related to low estimated sleep time at night and higher estimated sleep during the day in the acute phase, controlling for socio-demographic and clinical variables. Furthermore, high estimated numbers of awakenings in the acute phase were related to lower activities of daily life functioning at six months of follow-up after controlling for socio-demographic and clinical variables. Stronger pain and a lower physical functioning showed direct relationships with lower independency level of in activities of daily life both in the acute phase and after six months. CONCLUSIONS: Sleep patterns in the acute phase may influence the patients' activities of daily life functioning up to six months poststroke. Furthermore, pain in the acute phase may influence the level of activities of daily life functioning in stroke patients. RELEVANCE TO CLINICAL PRACTICE: Nurses should pay attention to stroke patients' sleep quality and pain in the rehabilitation period after a stroke. Facilitating good sleep conditions and screening for pain should be an integral part of the rehabilitation programme.