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VERBAL COMMUNICATION SKILLS
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VERBAL COMMUNICATION
SKILLS
Medical Research in Biblical Times

from the Viewpoint of Contemporary
Perspective
Liubov Ben-Nun
The present book deals with communication which is an
important human characteristic. In order to maintain relationships
effectively humans must communicate with each other. In everyday
life, there are many types of communication including with work
colleagues, family, neighbors, and friends, some efficient and some
inefficient.
How do health care providers interact with each other? How do
they interact with their patients? How do they deliver difficult issues
to their patients? To their families? How do they handle
conversations related to difficult medical situations? Should medical
students, interns and health care providers be taught how to conduct
effective conversations? How to deliver difficult messages to the
patients?
In order to answer these questions biblical verses related to
communications skills are studied.
About the Author

Dr. Liubov Ben-Nun, the Author of dozens Books and Articles that have
been published in scientific journals worldwide.
Professor Emeritus at Ben Gurion University of the Negev, Faculty of
Health Sciences, Beer-Sheva, Israel. She has established the "LAHAV"
International Forum for research into medicine in the Bible from the
viewpoint of contemporary medicine.
NOT FOR SALE

VERBAL COMMUNICATION SKILLS
Liubov Ben-Nun
Professor Emeritus
Ben-Gurion University of the Negev,

Faculty of Health Sciences, Dept. of Family Medicine
Beer-Sheva, Israel
rd
43 Book.
Published By B. N. Publication House, Israel. 2015.
Fax: +(972) 8 6883376 Mobile 050 5971592

E-Mail: L-bennun@smile.net.il
Distributed Worldwide
Technical Assistance: Carmela Ben-Nun-Moshe.
© All rights reserved
NOT FOR SALE `

CONTENTS
MY VIEW 1
PREFACE 2
FOREWORD 3
INTRODUCTION 6
THE BIBLICAL VERSES 9
LISTENING AND UNDERSTANDING 10
PEOPLE WITH COMPLEX COMMUNICATION NEEDS 13
PHYSICIAN-PATIENT COMMUNICATION 16
COMMUNICATION WITH WORK COLLEAGUES 18
PHYSICIAN NON-ENGLISH LANGUAGE PROFICIENCY 24
E-MAIL FOR CLINICAL COMMUNICATION 25
GENDER DIFFERENCES IN MEDICAL ENCOUNTER 28
COMMUNICATION WITH YOUNG ADULTS 30
STRESSFUL/DIFFICULT CONVERSATIONS 31
CUES TO PERCEPTION OF REDUCED FLAPS 35
LOW HEALTH LITERACY 35
CULTURALLY COMPETENT COMMUNICATION 37
EFFECTIVE COMMUNICATION PREVENTS LITIGATION 39
HEALTH CARE PROFESSIONALS 41
NURSES' QUALIFICATION QUALITIES 53
PATIENTS WITH ACUTE/CHRONIC DISEASES 56
CARDIOVASCULAR DISEASES
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
AIDS PATIENTS
DEMENTIA
MENTAL HEALTH NURSING
PEDIATRICS 82
PALLIATIVE CARE 90
ONCOLOGY
TEACHING COMMUNICATION SKILLS 105
SUMMARY 118
ABBREVIATIONS 126
1
L. Ben-Nun Communication skills
MY VIEW
MEDICINE IN THE BIBLE AS A RESEARCH
CHALLENGE
This is a voyage along the well-trodden routes of contemporary
medicine to the paths of the Bible, from the time of the first man to
the period of the People of Israel. It covers the connection between
body and soul, and the unbroken link between our earliest ancestors,
accompanied by spiritual yearning and ourselves. Through the verses
of the Bible flows a powerful stream of ideas for medical research
combined with study of our roots and the Ancient texts.
It would not be too adventurous to state that if there is one book
in the world that all Jews are proud of, that is the Book of Books, the
greatest classic among all literary works, whose original language is
not Greek or Latin, but the Hebrew that I and other Israelis speak
every day, our mother tongue, the language of Eliezer Ben Yehuda.
The Bible exists as evidence in the Book of Books, open to all
humankind. For thousands of years it has been placed before us, still
as fresh as before, the history of peoples who have disappeared and
of the Jewish people, which has survived with its Holy Text that has
been translated into hundreds of languages and dialects, and remains
our eternal taboo.
Many people ask me about the connection between the Bible and
medical science. My reply is simple: the roots of science are buried
deep in the biblical period and I am just the archeologist and medical
researcher. This scientific medical journey to the earliest roots of the
nation in the Bible has been and remains moving, exciting and
enjoyable. It has created a kind of meeting in my mind between the
present and those Ancient times, through examining events frozen in
time.
Sometimes it is important to stop, to look back a little. In real
time, it is hard to study every detail, because time is passing as they
appear. However, when we look back we can freeze the picture and
examine every detail, see many events that we missed during that
fraction of a second when they occurred.
The Book of Books, the Bible, is not just the identity card of the
Jewish, but an essential source for the whole world.
2
PREFACE
The purpose of this research is to analyze the medical situations
and conditions referred to in the Bible, as we are dealing with a
contemporary medical record.
These are scientific medical studies incorporating verses from the

Bible, without no interpretation or historical descriptions of places.
Fundamentally, this Research is constructed purely from an

examination of passages from the Bible, exactly as written.
The research is part of a long series of published studies on the

subject of biblical medicine from a modern medical perspective.
This is not a laboratory research. The Research is built entirely on

a secular foundation. With due to respects to people faith, this
Research takes a modern look at medical practices. Each to his own
beliefs.
3
FOREWORD
Communication is an important component of patient care.
Traditionally, communication in medical school curricula was
incorporated informally as part of rounds and faculty feedback, but
without a specific or intense focus on skills of communicating per se.
The reliability and consistency of this teaching method left gaps,
which are currently getting increased attention from medical schools
and accreditation organizations. There is also increased interest in
researching patient-doctor communication and recognizing the need
to teach and measure this specific clinical skill. In 1999, the ACGME
implemented a requirement for accreditation for residency programs
that focuses on "interpersonal and communications skills that result
in effective information exchange and teaming with patients, their
families, and other health professionals." The National Board of
Medical Examiners, Federation of State Medical Boards and the
Educational Commission for Foreign Medical Graduates have
proposed an examination between the third and fourth year of
medical school that "requires students to demonstrate they can
gather information from patients, perform a physical examination,
and communicate their findings to patients and colleagues" using
SPs. One's efficiency and effectiveness in communication can be
improved through training, but it is unlikely that any future advances
will negate the need and value of compassionate and empathetic
two-way communication between clinician and patient. The
published literature also expresses belief in the essential role of
communication. "It has long been recognized that difficulties in the
effective delivery of health care can arise from problems in
communication between patient and provider rather than from any
failing in the technical aspects of medical care. Improvements in
provider-patient communication can have beneficial effects on health
outcomes". A systematic review of randomized clinical trials and
analytic studies of physician-patient communication confirmed a
positive influence of quality communication on health outcomes.
Continuing research in this arena is important. For a successful and
humanistic encounter at an office visit, one needs to be sure that the
patient's key concerns have been directly and specifically solicited
and addressed. To be effective, the clinician must gain an
understanding of the patient's perspective on his or her illness.
4
Patient concerns can be wide ranging, including fear of death,

mutilation, disability; ominous attribution to pain symptoms; distrust
of the medical profession; concern about loss of wholeness, role,
status, or independence; denial of reality of medical problems; grief;
fear of leaving home; and other uniquely personal issues. Patient
values, cultures, and preferences need to be explored. Gender is
another element that needs to be taken into consideration. Ensuring
key issues are verbalized openly is fundamental to effective patient-
doctor communication. The clinician should be careful not to be
judgmental or scolding because this may rapidly close down
communication. Sometimes the patient gains therapeutic benefit just
from venting concerns in a safe environment with a caring clinician.
Appropriate reassurance or pragmatic suggestions to help with
problem solving and setting up a structured plan of action may be an
important part of the patient care that is required. Counseling
around unhealthy or risky behaviors is an important communication
skill that should be part of health care visits. Understanding the
psychology of behavioral change and establishing a systematic
framework for such interventions, which includes the 5 As of patient
counseling (assess, advise, agree, assist, and arrange) are steps
toward ensuring effective patient-doctor communication. Historically
in medicine, there was a paternalistic approach to deciding what
should be done for a patient: the physician knew best and the patient
accepted the recommendation without question. This era is ending,
being replaced with consumerism and the movement toward shared
decision-making. Patients are advising each other to "educate
yourself and ask questions". Patient satisfaction with their care rests
heavily on how successfully this transition is accomplished. Ready
access to quality information and thoughtful patient-doctor
discussions is at the fulcrum of this revolution (1).
Effective communication is an essential skill in general practice
consultations. The art of communication is the development of
effective skills and finding a style of communication that suits the
clinician and produces benefits for both patient and doctor. The
essential skills are required for effective communication with a
patient and clinicians consider this communication as an art that can
be developed throughout a medical career. Good communication
can improve outcomes for patients and doctors, and deserves equal
importance to develop clinical knowledge and procedural skill. A
5
therapeutic patient-doctor relationship uses the clinician as a

therapeutic intervention and is part of the art of communication.
Despite all the technological advances of recent caring,
compassionate, healing doctors remain the best therapeutic tool in
medicine. The ability of a doctor to provide comfort through their
presence and their words is a fundamental component of good
medical care (2).
Because communication is something that is often taken for
granted, many people do not consciously think about communication
habits and behaviors. When patients are questioned concerning
important attributes of a doctor, they say they want someone who
respects and listens to them. In a time of increasing malpractice
litigation, physicians need to examine their communication skills. In
an increasingly more diverse world, social and cultural beliefs,
attitudes, and behaviors have a considerable effect on the health of
communities. Patient safety, satisfaction, and successful outcomes
rely on understanding the patient's medical and cultural needs. The
concept of becoming a "cultural anthropologist" is improbable, but
becoming aware of the demographics of the community in which the
physician serves will improve communication and lead to improved
patient and physician satisfaction, better patient compliance, and
improved health outcomes (3).
Interpersonal communication and cooperation do not happen
exclusively face to face. In work contexts, as in private life, there are
more and more situations of mediated communication and
cooperation in which new online tools are used. However,
understanding how to use the Internet to support collaborative
interaction presents a substantial challenge for the designers and
users of this emerging technology. Collaborative Internet
environments are designed to serve a purpose, so must be designed
with intended users' tasks and goals explicitly considered. In
cooperative activities, the key content of communication is the
interpretation of the situations in which actors are involved.
Therefore, the most effective way of clarifying the meaning of
messages is to connect them to a shared context of meaning.
However, this is more difficult in the Internet than in other
computer-based activities. This paper tries to understand the
characteristics of cooperative activities in networked environments -
shared 3D virtual worlds - through 2 different studies. The first used
6
the analysis of conversations to explore the characteristics of the

interaction during the cooperative task; the second analyzed whether
and how the level of immersion in the networked environments
influenced the performance and the interactional process (4).
References
1. Teutsch C. Patient-doctor communication. Med Clin North Am. 2003;
87(5):1115-45.
2. Warnecke E. The art of communication. Aust Fam Physician. 2014;
43(3):156-8.
3. Lewis VO, McLaurin T, Spencer HT, et al. Communication for all your
patients. Instr Course Lect. 2012;61:569-80.
4. Galimberti C, Ignazi S, Vercesi P, Riva G. Communication and
cooperation in networked environments: an experimental analysis.
Cyberpsychol Behav. 2001;4(1):131-46.
INTRODUCTION
A successful reciprocal evaluation of social signals serves as a
prerequisite for social coherence and empathy. In a previous fMRI
imaging study, naturalistic communication situations by presenting
video clips to participants and recording their behavioral responses
regarding empathy and its components were studied. In 2 conditions,
all 3 channels transported congruent emotional or neutral
information, respectively. Three conditions selectively presented 2
emotional channels and 1 neutral channel and were thus bimodally
emotional. Channel-specific emotional contributions in modality-
related areas, elicited by dynamic video clips with varying
combinations of emotionality in facial expressions, prosody, and
speech content were reported. However, to better understand the
underlying mechanisms accompanying a naturalistically displayed
human social interaction in some key regions that presumably serve
as specific processing hubs for facial expressions, prosody, and
speech content, a reanalysis of the data were pursued. Two different
descriptions of temporal characteristics within these 3 modality-
related regions including right FFG, left AC, left AG and left dmPFC
were examined. By means of a FIR analysis within each of the 3
7
regions, the post-stimulus time-courses as a description of the

temporal characteristics of the BOLD response during the video clips
were examined. Second, effective connectivity between these areas
and the left dmPFC was analyzed using DCM in order to describe
condition-related modulatory influences on the coupling between
these regions. The FIR analysis showed initially diminished activation
in bimodally emotional conditions but stronger activation than that
observed in neutral videos toward the end of the stimuli, possibly by
bottom-up processes in order to compensate for a lack of emotional
information. The DCM analysis instead showed a pronounced top-
down control. Remarkably, all connections from the dmPFC to the 3
other regions were modulated by the experimental conditions. This
observation is in line with the presumed role of the dmPFC in the
allocation of attention. In contrary, all incoming connections to the
AG were modulated, indicating its key role in integrating multimodal
information and supporting comprehension. Notably, the input from
the FFG to the AG was enhanced when facial expressions conveyed
emotional information. These findings serve as preliminary results in
understanding network dynamics in human emotional
communication and empathy (1).
A patient may become a "problem" owing to 3 groups of causes
acting either independently or together. Group 1 is characteristic
features of the patient including psychological problems and
borderline psychiatric disorders. Group 2 is related to the physician's
activity (overfatigue, poor communicative skills, etc.). Group 3 is
comprised by the causes related to the peculiarities of the healthcare
system structure and organization (overworked physicians,
insufficient time that they can spend in direct care to an individual
patient, and inadequate information the patients acquire from non-
medical sources). Poor organization of work in an outpatient facility
inevitably deteriorates the quality of the provided care. The patients
attending it begin making complaints against the personnel, which
leads to conflicts even in the absence of serious medical errors.
Practical recommendations are proposed designed to help the
"problem patients" to obtain quality medical aid and avoid conflict
situations (2).
As pastoral care personnel are compassionate companions of the
sick, we should cultivate a number of personal characteristics and
communication skills that will make our ministry most effective.
8
Similarly, certain common characteristics and communication styles

should be eschewed because they make our ministry ineffective.
Being comfortable with feelings, our own as well as others', helps
patients feel free to share their emotions and troubles. Similarly,
being aware of and accepting our personal identity is requisite to
accepting and affirming others. Such negative personal traits as a
poor self-image and a high need for control, on the other hand, can
keep interactions with patients superficial. Communication styles,
positive and negative, flow from personality traits, and it is important
to work on both communication and personality at the same time.
The pastoral care person should develop skills in attending, "door-
opening," and responding, even as he or she strives to eliminate such
detrimental practices as "sending solutions," evaluating the other
person, and reassuring the person prematurely (3).
Effective communication is essential to practice and can result in
improved interpersonal relationships at the workplace. Effective
communication is shaped by basic techniques such as open-ended
questions, listening, empathy, and assertiveness. However, the
relationship between effective communication and successful
interpersonal relationships is affected by intervening variables. The
variables of gender, generation, context, collegiality, cooperation,
self-disclosure, and reciprocity can impede or enhance the outcome
of quality communication (4).
As we see, communication is an important human characteristic.
In order to maintain relationships effectively humans must
communicate with each other. In everyday life, there are many types
of communication including with work colleagues, family, neighbors,
and friends, some efficient and some inefficient.
This research deals principally with human communication. How
do HCPs interact with each other? How do they interact with their
patients? How do they deliver difficult issues to their patients? To
their families? How do they handle conversations related to difficult
medical situations? Should medical students, interns and HCPs be
taught how to conduct effective conversations? How to deliver
difficult messages to the patients?
9
References
1. Regenbogen C, Habel U, Kellermann T. Connecting multimodality in
human communication. Front Hum Neurosci. 2013;7:754.
2. No authors listed. How to help a "problem" patient. Klin Med (Mosk).
2011;89(6):63-5.
3. Niklas GR. Personal traits, communication skills for effective pastoral
care. Health Prog. 1985;66(6):64-6, 72.
4. Grover SM. Shaping effective communication skills and therapeutic
relationships at work: the foundation of collaboration. AAOHN J.
2005;53(4):177-82; quiz 186-7.
THE BIBLICAL VERSES

Communication between humans is a vital interaction in our lives.
This research deals with two biblical verses "Death and life are in the
power of the tongue" (Proverbs 18:21) and "A soft tongue breaks the
bone" (Proverbs 25:15). These verses indicate that verbal
communication is an essential part of human existence. How can we
deal with these verses in our everyday life?
Communication is defined as the exchange information, or the use
of common system of symbols, signs, behavior for this; a verbal or
written message; a system of routes; techniques for the effective
transmission of information, ideas, etc. (1). Communication also
transfers information from one person to another (2).
The main message of verses, cited above, is to show the people
that their ability to communicate with each other is of vital
importance for their existence. The verses have a wide range of
implications for our everyday life, dealing with communication with
the family, with friends, in society, at work, and with patients. Since
the author of this research is a medical doctor, studying Medicine in
the Bible, it is natural that this study concentrates mainly on
communication in a variety of medical situations.
References
ND
1. The Penguin English Dictionary. 2 ED. Penguin Books. Robert Allen
Consultant ed. 2003. England.
10
2. Examples of Non Verbal Communication. Available 15 May 2014 at

yourdictionary.com/examples-of-non-verbal-communication.
LISTENING AND UNDERSTANDING
The activities involved in mediating reinforcement for a speaker's

behavior constitute only one phase of a listener's reaction to verbal
stimulation. Other phases include listening and understanding what a
speaker has said. It is argued that the relative subtlety of these
activities is reason for their careful scrutiny, not their complete
neglect. Listening is conceptualized as a functional relation obtaining
between the responding of an organism and the stimulating of an
object. A current instance of listening is regarded as a point in the
evolution of similar instances, whereby one's history of perceptual
activity may be regarded as existing in one's current interbehavior.
Understanding reactions are similarly analyzed; however, they are
considerably more complex than listening reactions due to the
preponderance of implicit responding involved in reactions of this
type. Implicit responding occurs by way of substitute stimulation, and
an analysis of the serviceability of verbal stimuli in this regard is
made. Understanding is conceptualized as seeing, hearing, or
otherwise reacting to actual things in the presence of their "names"
alone. The value of an inferential analysis of listening and
understanding is also discussed, with the conclusion that unless some
attempt is made to elaborate on the nature and operation of these
activities, the more apparent reinforcement mediational activities of
a listener are merely asserted without an explanation for their
occurrence (1).
As we celebrate the 50th anniversary of the publication of B. F.
Skinner's Verbal Behavior, it is important to reconsider the role of the
listener in the verbal episode. Although by Skinner's own admission,
Verbal Behavior was primarily about the behavior of the speaker, his
definition of verbal behavior as "behavior reinforced through the
mediation of other persons" focused on the behavior of the listener
(2). However, because many of the behaviors of the listener are
11
fundamentally no different than other discriminated operants, they

may not appropriately be termed listening. Even Skinner noted that
the behavior of the listener often goes beyond simply mediating
consequences for the speaker's behavior, implying that the listener
engages in a repertoire of behaviors that is itself verbal. It has been
suggested that listening involves subvocal verbal behavior; there are
some of the forms and functions of the listener's verbal behavior
(including echoic and intraverbal behavior). In conclusion, there may
be no functional distinction between speaking and listening (3).
As part of the epistemological transition from positivistic to
relativistic science that had begun earlier in the twentieth century,
the researchers attempted to update psychoanalytic thinking in
formulating the empathic mode of observation (4-7). The purpose of
this paper is to reassess, through a conceptual and historical lens, the
considerable controversy generated by the empathic perspective.
The author specifically addresses constructivist philosophical
underpinnings, the use and impact of the analyst's subjectivity, the
inclusion of unconscious processes, the need for additional listening
perspectives, and the influence of theoretical models in the
organization of empathically acquired data (8).
A rhetorical form designs to clarify and sharpen the focus of the
very special stance required - which must be painstakingly learned
under careful supervision - in order to effectively tune in to
communications coming from the unconscious of the patient. This is
the hardest task that must be mastered to become truly empathic
and sensitive in dyadic relationships, a unique expertise that marks
the psychiatrist as a genuine specialist in medical practice. Regardless
of theoretical orientation, neither the form nor content of any
therapeutic intervention can be appropriate unless it is empathically
based. Clinical vignettes illustrate that the lack of such empathy, and
readings enhance our approach to learning this skill, borrowing
especially from Kohut and Bion. The great importance of the often
ignored "background" of the patient's communication is emphasized,
and is illustrated from the field of music in the work of John Cage and
Anton Webern. The congruence between this clinical psychiatric
problem and the main thrust of Continental philosophy, which
attempts to put man back in touch with himself, is described.
Suggestions are offered to supervisors how to develop these skills in
the novice. Finally, a discussion is presented of the effect on the
12
professional and personal life of the therapist who has not developed
these skills, emphasizing the dangers of "burn-out" in therapists and
the implicit philosophy of life in a money-oriented practice of
psychotherapy. The dangers of not attending to such matters even
during residency training are pointed out in an attempt to raise the
consciousness level of the therapist to the extreme importance of
background practices both in the patient and in the therapist (9).
In the HCPs, the results of miscommunication and
misunderstanding can be costly. Stress-related ailments and burnout
frequently occur. Managers therefore should examine organizational
communication strategies and offer ways of dealing with stress, if
necessary. One stress-reduction measure that can be undertaken at
little cost is bridge building. The bridge-building process involves
making a connection or link between people by careful listening and
attention to their interactions with another. Bridge building may
include persons from all organizational levels; the only limits are
participants' willingness to risk and their desire to improve the work
environment. One strategy for bridge building is the story meeting.
Because stories are a representative way of addressing complex
issues, they can provide a framework for handling sensitive
situations. Creating a story about a department or work team allows
persons to deal with inner frustrations in a nonthreatening way and
to consider creative outcomes to their shared problem (10).
This paper reviews empirical research which has been directly
influenced by Skinner's Verbal Behavior. Despite the importance of
this subject matter, the book has generated relatively little empirical
research. Most studies have focused on Skinner's mind and tact
relations while research that focused on the other elementary verbal
operands has been limited. However, the results of empirical
research that exist support Skinner's analysis of the distinction
between elementary verbal operands and his distinction between the
speaker and listener's repertoires. Research suggests that language
training programs may not be successful if they do not provide
explicit training of each elementary verbal operant and independent
training of speaker's and listener's repertoires (11).
13
References
1. Parrott LJ. Listening and understanding. Behav Anal. 1984;7(1):29-39.
2. Chomsky N. A Review of B.F. Skinner's Verbal Behavior. In Leon A.
Jakobovits and Murray S. Miron (eds.) Readings in the Psychology of
Language, Prentice-Hall. 1967, pp. 142-3.
3. Schlinger HD. Listening is behaving verbally. Behav Anal. 2008;
31(2):145-61.
4. Kohut H. Introspection, empathy and psychoanalysis. J Americ
Psychoanalysis Assn. 1959;7:459-83.
5. Kohut H. The restoration of the self. New York International Press.
1977.
6. Kohut H. Introspection, empathy and the semicircle of mental health.
Intern J Psycho-Anal. 1982;63:359-407.
7. Kohut H. How does analysis cure? Goldberg A, Stepansky P (eds.).
Chicago: The University of Chicago Press. 1984.
8. Fosshage JL. The use and impact of the analyst's subjectivity with
empathic and other listening/experiencing perspectives. Psychoanal Q.
2011;80(1):139-60.
9. Chessick RD. Psychoanalytic listening II. Am J Psychother. 1985;
39(1):30-48.
10. Ward JR. Communications bridges raise productivity, reduce stress.
Health Prog. 1987;68(2):71-2.
11. Oah SZ, Dickinson AM. A review of empirical studies of verbal
behavior. Anal Verbal Behav. 1989;7:53-68.
PEOPLE WITH COMPLEX COMMUNICATION NEEDS

A series of PA and single-word reading tasks, which did not
require spoken responses, was developed for administration to
people with complex communication needs. The aims of the study
were to 1] determine the construct validity of the PA tasks and 2]
investigate the relationship between PA and single-word reading in
adults with complex communication needs. Forty adults with physical
and/or intellectual disability were administered these tasks and a
standardized measure of receptive spoken vocabulary. In assessing
construct validity, data from all participants, including those who
used speech, were included in a factor analysis, which indicated that
the PA tasks loaded onto a single factor. This factor was interpreted
to be PA. The relationship between PA and single-word reading in
14
adults with complex communication needs was determined using

correlational and multiple regression analyses of data from 34 of the
original participants who did not have functional speech skills. These
analyses indicated that receptive spoken vocabulary accounted for a
significant amount of variance on most tasks. Additional significant
variance in performance on the single-word reading tasks was
accounted for by performance on the PA tasks, in particular,
Nonword Blending and Phoneme Analysis. These results indicate that
the tasks developed provide a valid means of assessing PA and single-
word reading skills. In addition, the results indicate that adults with
complex communication needs demonstrate the same positive
association between PA and reading as has been found in other
groups of individuals with and without disability (1).
The morphological awareness skills of fourth-grade African
American children and the association between degree of AAE use
and performance on written measures of morphological awareness
were examined. Additional purposes were to determine whether
performance on the morphological awareness tasks 1] was affected
by the transparency of morphologically related words and the type of
task administered, 2] was associated with other literacy and literacy-
related skills, and 3] explained unique variance on these latter
abilities. Thirty fourth-grade African American children from low-
income backgrounds were administered 2 morphological awareness
tasks and completed norm-referenced measures of word-level
reading, reading comprehension, spelling, phonemic awareness, and
receptive vocabulary. The degree of AAE use was not associated with
students' performance on the morphological awareness tasks. On
these tasks, significantly higher scores were obtained on items that
represented a transparent relationship between a base word and its
derived form. The students' performance on the morphological
awareness tasks was significantly and moderately related to their
performance on the word-level reading, spelling, and receptive
vocabulary measures. Morphological awareness scores explained
significant unique variance on measures of word-level reading and
spelling, above that predicted by performance on measures of
phonemic awareness and vocabulary. In conclusion, fourth-grade
African American students' morphological awareness abilities are
associated with select language and literacy skills. Professionals
should capitalize on students' intact capabilities in morphological
15
awareness during literacy instruction in an effort to maximize

language and literacy performance for African American students (2).
In this study, the contribution made by dialect shifting to reading
achievement test scores of AAE-speaking students when controlling
for the effects of SES, general oral language abilities, and writing skills
were evaluated. Participants included 165 typically developing
African American 1st through 5th graders. Half were male and half
were female, one third was from low-SES homes, and two-thirds
were from middle-SES homes. Dialect shifting away from AAE toward
SAE was determined by comparing AAE production rates during oral
and written narratives. Structural equation modeling evaluated the
relative contributions of AAE rates, SES, and general oral language
and writing skills on standardized reading achievement scores. AAE
production rates were inversely related to reading achievement
scores and decreased significantly between the oral and written
narratives. Lower rates in writing predicted a substantial amount of
the variance in reading scores, showing a significant direct effect and
a significant indirect effect mediated by measures of oral language
comprehension. In conclusion, the findings support a dialect shifting-
reading achievement hypothesis, which proposes that AAE-speaking
students who learn to use SAE in literacy tasks will outperform their
peers who do not make this linguistic adaptation (3).
References
1. Iacono T, Cupples L. Assessment of phonemic awareness and word
reading skills of people with complex communication needs. J Speech Lang
Hear Res. 2004;47(2):437-49.
2. Apel K, Thomas-Tate S. Morphological awareness skills of fourth-grade
African American students. Lang Speech Hear Serv Sch. 2009;40(3):312-24.
3. Craig HK, Zhang L, Hensel SL, Quinn EJ. African American English-
speaking students: an examination of the relationship between dialect
shifting and reading outcomes. J Speech Lang Hear Res. 2009; 52(4):839-55.
16
PHYSICIAN-PATIENT COMMUNICATION
An understanding of means to improve patient adherence to the
therapeutic regimen is a subject of increasing concern in medical
care. This study examined the effects of physician interpersonal skills
and teaching on patient satisfaction, recall, and adherence to the
regimen. The ambulatory visits of 63 patients to 5 medical residents
at a teaching hospital in Baltimore were studied. Quality of
interpersonal skills influenced patient outcomes more than quantity
of teaching and instruction. All the effects of physician
communication skills on patient adherence were mediated by patient
satisfaction and recall. These findings indicate that the physician
might pay particular attention to these 2 variables in trying to
improve patient adherence, and enhancing patient satisfaction is
pivotal to the care of patients with chronic illness (1).
The physician-patient interview is the key component of all health
care, particularly of primary medical care. This review sought to
evaluate existing primary-care-based research studies to determine
which verbal and non-verbal behaviors on the part of the physician
during the medical encounter have been linked in empirical studies
with favorable patient outcomes. The literature from 1975 to 2000
for studies of office interactions between primary care physicians and
patients that evaluated these interactions empirically using neutral
observers who coded observed encounters, videotapes, or
audiotapes were reviewed. Each study was reviewed for the quality
of the methods and to find statistically significant relations between
specific physician behaviors and patient outcomes. In examining non-
verbal behaviors, because of a paucity of clinical outcome studies,
outcomes were expanded to include associations with patient
characteristics or subjective ratings of the interaction by observers.
Fourteen studies of verbal communication and 8 studies of non-
verbal communication met inclusion criteria. Verbal behaviors
positively associated with health outcomes including empathy,
reassurance and support, various patient-centered questioning
techniques, encounter length, history taking, explanations, both
dominant and passive physician styles, positive reinforcement,
humor, psychosocial talk, time in health education and information
sharing, friendliness, courtesy, orienting the patient during
examination, and summarization and clarification. Non-verbal
17
behaviors positively associated with outcomes included head

nodding, forward lean, direct body orientation, uncrossed legs and
arms, arm symmetry, and less mutual gaze. In conclusion, existing
research is limited because of lack of consensus of what to measure,
conflicting findings, and relative lack of empirical studies (especially
of non-verbal behavior). Nonetheless, medical educators should
focus on teaching and reinforcing behaviors known to be facilitative,
and to continue to understand how physician behavior can enhance
favorable patient outcomes, such as understanding and adherence to
medical regimens and overall satisfaction (2).
Medical educators and researchers recommend a patient-
centered interviewing style, but little empirical data exists regarding
what aspects of physician communication patients like and why.
Patient responses to videotaped doctor-patient vignettes were
investigated to ascertain what they liked about patient-centered and
biomedical communication. Semi-structured interviews with 230
adult medicine patients who viewed videotapes depicting both
patient-centered and biomedical physician communication styles
were conducted. A mixed methods approach to derive a "ground-up"
framework of patient communication preferences was used.
Respondents who preferred different communication styles
articulated different sets of values, important physician behaviors,
and physician-patient role expectations. Participants who preferred
the patient-centered physician (69%) liked that the physician worked
with and respected patients and explored what the patient wanted.
Participants who preferred the biomedical physician (31%) liked that
the physician prevented harm, demonstrated medical authority, and
delivered information clearly. In conclusion, patients like (and
dislike) patient-centered communication for thoughtful, considered
reasons that appear grounded in their values and expectations about
physicians, patients, and the clinical encounter. Better
understanding the diversity of patient communication preferences
may lead to more effective and individualized care (3).
The motivation for developing patient-centered communication
stems from a desire to enhance the quality of patient care, fulfill
professional competency requirements, reduce medical errors, and
improve health outcomes and patient satisfaction. Patient-centered
communication skills can optimize the physician-patient relationship
without significantly prolonging office visits. A series of practical and
18
generally effective techniques for verbal and non-verbal

communication is proposed. A targeted approach for specific difficult
conversations that may occur frequently in the practice of
dermatology is suggested (4).
References
1. Bartlett EE, Grayson M, Barker R, et al. The effects of physician
communications skills on patient satisfaction; recall, and adherence. J
Chronic Dis. 1984;37(9-10):755-64.
2. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication
in the primary care office: a systematic review. J Am Board Fam Pract. 2002;
15(1):25-38.
3. Swenson SL, Zettler P, Lo B. 'She gave it her best shot right away':
patient experiences of biomedical and patient-centered communication.
Patient Educ Couns. 2006;61(2):200-11.
4. Nguyen TV, Hong J, Prose NS. Compassionate care: enhancing
physician-patient communication and education in dermatology: Part I:
Patient-centered communication. J Am Dermatol. 2013;68(3):353.e1-8.
COMMUNICATION WITH WORK COLLEAGUES

Good intercollegial communication is a relatively unstudied topic,
although it is important for both health professionals and patients,
contributing to enhanced well-being, self-awareness and integrity for
HCPs, and positively affecting patient outcome and satisfaction. The
main objective of this study was to investigate whether a
communication skills training course would improve intercollegial
communication in an orthopedic department, Kolding Hospital,
Odense, Denmark. The study was designed as an intervention study
investigating the effectiveness of an in-house training course,
evaluated by means of questionnaires. A total of 177/181 (97.8%)
participants answered the questionnaire before (T1), 165/169
(97.6%) immediately after (T2) and 150/153 (98%) 6 months after the
course (T3). Of 6 questions about intraprofessional communication, 1
and 2 questions were significantly higher at T2 and T3, respectively.
Of the 6 questions about interprofessional communication, the
increase was statistically significant for 4 questions in T2 and for 5
19
questions in T3, respectively. In conclusion, a communication skills

training course improved health care professionals' assessment of
intercollegial communication, and this was more pronounced in
interprofessional rather than in intraprofessional communication,
and was more pronounced 6 months after the training course than
immediately after the training course. Communication skills training
for HCPs is recommended, and should also include all health care
professions that have patient contact (1).
A systematic review of published literature was conducted to gain
a better understanding of ITC in hospital setting in the field of
surgical and anesthetic care. Communication breakdowns are a
common cause of surgical errors and adverse events. Data sources
included Medline, Embase, PsycINFO, Cochrane Database of
Systematic Reviews, and hand search of articles bibliography. Of the
4,027 citations identified through the initial electronic search and
screened for possible inclusion, 110 articles were retained following
title and abstract reviews. Of these, 38 were accepted for this review.
Data were extracted from the studies about objectives, clinical
domain, and methodology including study design, sample population,
tools for assessing communication, results, and limitations.
Information transfer failures are common in surgical care and are
distributed across the continuum of care. They not only lead to errors
in care provision but also lead to patient harm. Most of the articles
have focused on ITC process in different phases especially in
operating room. None of the studies has looked at whole of the
surgical care process. No standard tool has been developed to
capture the ITC process in different teams and to evaluate the effect
of various communication interventions. Uses of standardized
communication through checklist, proformas, and technology
innovations have improved the ITC process, with an effect on clinical
and patient outcomes. In conclusion, ITC deficits adversely affect
patient care. There is a need for standard measures to evaluate this
process. Effective and standardized communication among HCPs
during the perioperative process facilitates surgical safety (2).
The aim of this systematic review was to assess the impact of
surgical safety checklists on the quality of teamwork and
communication in the operating room. Safety checklists have been
shown to impact positively on patient morbidity and mortality
following surgery, but it is unclear whether this clinical improvement
20
is related to an improvement in operating room teamwork and

communication. A systematic search strategy of MEDLINE, EMBASE,
PsycINFO, Google Scholar, and the Cochrane Database for Systematic
Reviews was undertaken to obtain relevant articles. After de-
duplication and the addition of limits, 315 articles were screened for
inclusion by 2 researchers and all articles meeting a set of
prespecified inclusion criteria were retained. Information regarding
the type of checklist, study design, assessment tools used, outcomes,
and study limitations was extracted. Twenty articles formed the basis
of this systematic review. All articles described an empirical study
relating to a case-specific safety checklist for surgery as the primary
intervention, with some measure of change/improvement in
teamwork and/or communication relating to its use. The methods for
assessing teamwork and communication varied greatly, including
surveys, observations, interviews, and 360° assessments. The
evidence suggests that safety checklists improve the perceived
quality of operating room teamwork and communication and reduce
observable errors relating to poor team skills. This is likely to function
through establishing an open platform for communication at the start
of a procedure: encouraging the sharing of critical case-related
information, promoting team coordination and decision-making,
flagging knowledge gaps, and enhancing team cohesion. However,
the evidence would also suggest that when used suboptimally or
when individuals have not bought in to the process, checklists may
conversely have a negative impact on the function of the team. In
conclusion, safety checklists are beneficial for operating room
teamwork and communication and this may be one mechanism
through which patient outcomes are improved. Future research
should aim to elucidate the relationship between how safety
checklists are used and team skills in the operating room using more
consistent methodological approaches and utilizing validated
measures of teamwork such that best practice guidelines can be
established (3).
Many hospitals are unable to successfully implement evidence-
based practices. For example, implementation of the CLB, proven to
prevent CRBSIs, is often challenging. This problem is broadly
characterized as a "change implementation failure." A prospective
study was conducted it 2 ICUs, a MICU and a PICU, within an
academic health center. Both units had low baseline adherence to
21
CLB and higher-than-expected CRBSIs. This study sought to promote

CLB implementation in both units through periodic QI interventions
over a 52-week period. Simultaneously, it examined 1] the content
and frequency of communication related to CLB through weekly
"communication logs" completed by physicians, nurses, and
managers, and 2] outcomes, that is, CLB adherence rates through
weekly medical record reviews. The aim of the study was 2-fold: 1] to
examine associations between QI interventions and communication
content and frequency at the unit level, and 2] to examine
associations between communication content and frequency and
outcomes at the unit level. The periodic QI interventions were
expected to increase CLB adherence and reduce CRBSIs through their
influence on communication content and frequency. A total of 2,638
instances of communication were analyzed. Both units demonstrated
an increase in "proactive" communications-that is, communication
intended to reduce infection risk between physicians and nurses over
time. Proactive communications increased by 68% in the MICU
(p<0.05) and 61% in the PICU (p<0.05). During the same timeframe,
both units increased CLB adherence to 100% while demonstrating
significant declines in 1] catheter days: 34% decline in the MICU
(p<0.05) and 30% in the PICU (p<0.05); and 2] CRBSI rates: 63%
decline in the MICU (p<0.05) and 100% in the PICU (p<0.10). Direct
costs savings from reduced CRBSIs in 1 year were estimated to be at
least $840 000. Periodic QI interventions were effective in reframing
interprofessional communication dynamics and enabling practice
change. This prospective design provides insights into communication
content and frequency associated with collective learning and culture
change. The study identifies evidence-based management strategies
for positive practice change at the unit level (4).
Although patient-centered communication has provided a focus
point in health care for many years, patient surveys continuously
reveal serious communication problems as experienced by patients
due to poor communication. Likewise, poor inter-collegial
communication can cause problems for both health care staff and
patients. Therefore, knowing that patient-centered communication
and good inter-collegial communication is for the benefit of both
HCPs and patients, the relevance of improving HCPs' communication
skills and investigating the effect on both professionals and patients
is beyond doubt. The aim of this study was to investigate whether a
22
training course in communication skills for HCPs could improve: 1]

HCPs' self-efficacy in communication with patients and colleagues 2]
HCPs' evaluation of inter-collegial communication 3] Patients'
experience of quality of care, and to investigate HCPs' experience: a)
participation in a communication skills training course b) the
influence of the course on their ability to communicate with patients
and colleagues. The study was carried out in the Department of
Orthopaedic Surgery, Kolding Hospital, a part of Lillebaelt Hospital, as
an intervention study with baseline measurements and
measurements after the intervention. The intervention was an in-
house communication skills training course for all HCPs at the
department. The effect was measured partly on the HCPs' self-
efficacy and evaluation of inter-collegial communication, partly on
patients' evaluation of quality of information, continuity and care.
Data were collected by means of questionnaires and further explored
by focus group interviews with HCPs. A total of 181 HCPs were
included in the study. The questionnaire was completed by 177
(97.8%) before; 165/169 (97.6%) immediately after and 150/153
(98%) 6 months after the course. The HCPs' self-efficacy was
significantly increased, both for communication with patients and
colleagues. The effect was still present 6 months after the training
course. The HCPs' evaluation of inter-collegial communication
showed significant improvements after the course; the effect was
more pronounced for inter-professional than for intra-professional
communication and more pronounced 6 months after than
immediately after the course. A total of 32 HCPs' participated in the
focus group interviews, which showed that nurses, nursing assistants,
medical secretaries and managers principally experienced better
control over the patient interview, increased confidence in
communication, improved inter-collegial understanding and
increased focus on patient-centered communication after the
training course. The doctors had an overall negative experience of
their participation in the training course, but experienced positive
changes in their communication after the course. In the patient
survey, 3,660 patients answered the questionnaire. The eligible
response rates were 67.75% for the baseline measurement and
77.63% for the after measurement. There was a significant increase
in patients responding "To a considerable extent" for 15/19
questions; an insignificant increase for 3/19 questions, and a
23
significant decrease for 1/19 question after the training course. In

conclusion, a communication skills training course can improve HCPs'
self-efficacy in communication with both patients and colleagues and
improve inter-collegial communication. The focus group interviews
showed that the most essential experiences of change were more
confident communication with patients and colleagues and an
increased patient-centeredness, and a significant increase in patient
satisfaction concerning information, continuity and care after the
training course for HCPs (5).
Communication failure is a risk factor for mishaps and complaints,
which can be reduced by effective communication between
operating room team members and patients. The aim of this study
was to conduct a survey among anesthesiologists regarding
communications skills and related issues like stress in case of
communication failure, need for training, music in operation theater,
and language barrier at their work place. A survey among
anesthesiologists coming for a neuroanesthesia conference in India
(n=110) in February 2011 was conducted by questionnaire sent by e-
mail. The response rate was 61.8% (68/110). Majority (95.5%) of the
respondents agreed that good verbal communication leads to better
patient outcome, better handling of crisis and is important between
surgeons and anesthesiologists (98.5%). Of the anesthesiologists,
86% felt that failure of communication caused stress to them. The
idea of communication by e-mail or phone text messages instead of
verbal communications was discouraged by 65.2%. Of respondents,
82% felt that training of communication skills should be mandatory
for all medical personnel and 77.6% were interested in participating
in such course. Language barrier at work place was seen as hurdle by
62.7% of the respondents. A total of 80% of respondents felt that
playing music in operating theater is appropriate. In conclusion,
results of the survey highlight the need for effective communication
in the operating room between team members and need for formal
training to improve it (6).
24
References
1. Nørgaard B, Ammentorp J, Kofoed PE, Kyvik KO. Training improves
inter-collegial communication. Clin Teach. 2012;9(3):173-7.
2. Nagpal K, Vats A, Lamb B, et al. Information transfer and
communication in surgery: a systematic review. Ann Surg. 2010;252(2):225-
39.
3. Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve
teamwork and communication in the operating room? A systematic review.
Ann Surg. 2013;258(6):856-71.
4. Rangachari P, Madaio M, Rethemeyer RK, et al. Role of
communication content and frequency in enabling evidence-based
practices. Qual Manag Health Care. 2014;23(1):43-58.
5. Nørgaard B. Communication with patients and colleagues. Dan Med
Bull. 2011;58(12):B4359.
6. Kumar M, Dash HH, Chawla R. Communication skills of
anesthesiologists: An Indian perspective. J Anaesthesiol Clin Pharmacol.
2013;29(3):372-6.
PHYSICIAN NON-ENGLISH LANGUAGE

PROFICIENCY
The main aim of this study was describe the initial impact of an
organizational policy change on measurement of physician non-
English language proficiency. Study setting included multispecialty
health care organization in the San Francisco Bay Area. In response to
preliminary findings suggesting that the organization's non-validated
and undefined 3-category tool for physician self-report of non-English
language proficiency levels was likely inadequate, the organization
asked physicians to rate their non-English language proficiency levels
using an adapted ILR scale, a validated measure with 5 rating levels
and descriptors. The self-reported language proficiency on the
original scale and the ILR for those physicians who completed both
were then compared and regression analysis to investigate physician
characteristics potentially associated with a change in score on the
old versus ILR scales was used. Six months after the ILR scale was
implemented throughout the organization, 75 percent (258/342) of
physicians had updated their language proficiency ratings. Among
clinicians who had previously rated themselves in the
25
"Medical/Conversational" category, there were substantial variations

in scores using the ILR scale. Physicians who spoke 2 or more non-
English languages were significantly more likely to lower their self-
reported proficiency when updating from the old scale to the ILR
scale. In conclusion, the organization was willing to adopt a relatively
straightforward change in how data were collected and presented to
patients based on the face validity of initial findings. This
organizational policy change appeared to improve how self-reported
physician language proficiency was characterized (1).
Reference
1. Diamond LC, Luft HS, Chung S, Jacobs EA. Does this doctor speak my
language? Improving the characterization of physician non-English language
skills. Health Serv Res. 2012;47(1 Pt 2):556-69.
E-MAIL FOR CLINICAL COMMUNICATION

E-mail is a popular and commonly used method of
communication, but its use in health care is not routine. Its
application in health care has included the provision of information
on disease prevention and health promotion, but the effects of using
email in this way are not known. This review assesses the use of
email for the provision of information on disease prevention and
health promotion. The main objective of this study was to assess the
effects of e-mail for the provision of information on disease
prevention and health promotion, compared to standard mail or
usual care, on outcomes for HCPs, patients and caregivers, and health
services, including harms. The Cochrane Consumers and
Communication Review Group Specialized Register (January 2010),
the Cochrane Central Register of Controlled Trials (CENTRAL, The
Cochrane Library, Issue 1 2010), MEDLINE (1950 to January 2010),
EMBASE (1980 to January 2010), CINAHL (1982 to February 2010),
ERIC (1965 to January 2010) and PsycINFO (1967 to January 2010)
were searched. Grey literature: theses/dissertation repositories, trials
registers and Google Scholar (searched July 2010) were also
searched. Additional search methods: examining reference lists, and
26
contacting authors were used. RCTs, quasi-randomized trials,

controlled before and after studies and interrupted time series
studies examining interventions where e-mail is used by HCPs to
provide information to patients on disease prevention and health
promotion, and taking the form of 1] unsecured email 2] secure email
or 3] web messaging. HCPs or associated administrative staff as
participants originating the e-mail communication, and patients and
caregivers as participants receiving the e-mail communication, in all
settings were considered. E-mail communication was 1-way from
HCPs or associated administrative staff originating the e-mail
communication, to patients or caregivers receiving the e-mail
communication. Two authors independently assessed the risk of bias
of included studies and extracted data. Study authors were contacted
for additional information. Risk of bias according to the Cochrane
Handbook for Systematic Reviews of Interventions was assessed. Six
RCTs involving 8,372 people were included. Four trials compared e-
mail communication to standard mail and 2 compared e-mail
communication to usual care. For the primary health service outcome
of uptake of preventive screening, there was no difference between
e-mail and standard mail (OR 0.93, 95% CI 0.69-1.24). For both
comparisons (email vs. standard mail and e-mail vs. usual care) there
was no difference between the groups for patient or caregiver
understanding and support. Results were inconclusive for patient or
caregiver behaviors and actions. For e-mail vs. usual care only, there
was insignificant difference between groups for the primary outcome
of patient health status and well-being. No data were reported
relating to HCPs or harms. The evidence on the use of e-mail for the
provision of information on disease prevention and health promotion
was weak, and therefore inadequate to inform clinical practice. The
available trials mostly provide inconclusive, or no evidence for the
outcomes of interest in this review. Future research needs to use
high-quality study designs that take advantage of the most recent
developments in information technology, with consideration of the
complexity of e-mail as an intervention (1).
E-mail is a popular and commonly used method of
communication, but its use in health care is not routine. Where e-
mail communication has been demonstrated in health care this has
included its use for communication between patients/caregivers and
HCPs for clinical purposes, but the effects of using e-mail in this way
27
is unknown. This review addresses the use of e-mail for 2-way clinical
communication between patients/caregivers and HCPs. The main
objective of this study was to assess the effects of HCPs and patients
using e-mail to communicate with each other, on patient outcomes,
health service performance, service efficiency and acceptability. The
Cochrane Consumers and Communication Review Group Specialized
Register, Cochrane Central Register of Controlled Trials (CENTRAL,
The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to
January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO
(OvidSP) (1967 to January 2010), CINAHL (EbscoHOST) (1982 to
February 2010) and ERIC (CSA) (1965 to January 2010) were
searched. Grey literature: theses/dissertation repositories, trials
registers and Google Scholar (searched July 2010) was also searched.
Additional search methods: examining reference lists, contacting
authors were used. RCTs, quasi-randomized trials, controlled before
and after studies and interrupted time series studies examining
interventions using e-mail to allow patients to communicate clinical
concerns to a HCPs and receive a reply, and taking the form of 1]
unsecured e-mail 2] secure e-mail or 3] web messaging. All HCPs,
patients and caregivers in all settings were considered. Two authors
independently assessed the risk of bias of included studies and
extracted data. Study authors for additional information were
contacted. Risk of bias according to the Cochrane Handbook for
Systematic Reviews of Interventions was assessed. Nine trials
enrolled 1,733 patients; all trials were judged to be at risk of bias.
Seven were RCTs; 2 were cluster-randomized controlled designs.
Eight examined e-mail as compared to standard methods of
communication. One compared email with telephone for the delivery
of counseling. When e-mail was compared to standard methods, for
the majority of patient/caregiver outcomes it was impossible to
adequately assess whether email had any effect. For health service
use outcomes, it was not possible to adequately assess whether e-
mail has any effect on resource use, but some results indicated that
an e-mail intervention leads to an increased number of e-mails and
telephone calls being received by HCPs. Three studies reported some
type of adverse event but it was not clear if the adverse event had
any impact on the health of the patient or the quality of health care.
When e-mail counseling was compared to telephone counseling only
patient outcomes were measured, and for the majority of measures
28
there was no difference between groups. Where there were

differences these showed that telephone counseling leads to greater
change in lifestyle modification factors than e-mail counseling. There
was 1 outcome relating to harm, which showed no difference
between the e-mail and the telephone counseling groups. There
were no primary outcomes relating to HCPs for either comparison.
The evidence base was limited with variable results and missing data,
and therefore it was not possible to assess the effect of e-mail for
clinical communication between patients/caregivers and HCPs.
Recommendations for clinical practice could not be made (2).
References
1. Sawmynaden P, Atherton H, Majeed A, Car J. Email for the provision of
information on disease prevention and health promotion. Cochrane
Database Syst Rev. 2012 Nov 14;11:CD007982.
2. Atherton H, Sawmynaden P, Sheikh A, et al. Email for clinical
communication between patients/caregivers and healthcare professionals.
Cochrane Database Syst Rev. 2012 Nov 14;11:CD007978.
GENDER DIFFERENCES IN MEDICAL ENCOUNTER

This article examines gender differences in HCP-patient
communication within the framework of an ecological model of
communication in the medical encounter. The ecological perspective
posits that although HCP-patient interactions are situated within a
number of contexts (e.g. organizational, political, and cultural), the
interpersonal domain is the primary context within which these
interactions unfold. Hence, gender may influence provider-patient
interaction to the extent that it can be linked to the interactants'
goals, skills, perceptions, emotions, and the way the participants
adapt to their partner's communication. The evidence indicates that
gender differences in medical encounters may come from several
sources including differences in men and women's communicative
styles, perceptions of their partners, and in the way they
accommodate their partner's behavior during the interaction.
However, because gender is one of many personal and partner
variables (e.g. age, ethnicity, and personal experiences) that can
29
influence these processes, gender differences are often quite modest

(if apparent at all) when examined across a population of HCPs and
patients (1).
The main objective of this study was to review systematically
evidence about the impact of gender dyads on clinician-patient
communication. Search of Medline, CINAHL and PsychINFO (1960-
2007) and the British Library of grey literature, and hand searching of
Patient Education and Counseling and Social Science and Medicine
(2005-2007), returning 648 articles. Ten studies met all inclusion
criteria. Gender dyads influenced the patient agendas elicited, talk
content, communication style, non-verbal communication, the
exhibition of power, and consultation length. Consultation length was
studied and affected by gender dyads more frequently than other
phenomenon. Distinctive differences between the dyads were
identified, largely as expected, but with some surprises. For example,
female/female dyads were the most patient-centered, and had
longer consultations containing the most talk. However, they
contained the most bio-medical talk. The evidence base is small, and
a more rigorous approach to reporting quality indicators is needed.
However, observed dyad differences may provide different
opportunities for effective communication and clinical outcomes for
patients. Findings have implications for policy, healthcare
organizations, and individual doctors alike, raising awareness about
workforce issues and communication skills training needs in
particular (2).
References
1. Street RL Jr. Gender differences in health care provider-patient
communication: are they due to style, stereotypes, or accommodation?
Patient Educ Couns. 2002;48(3):201-6.
2. Sandhu H, Adams A, Singleton L, et al. The impact of gender dyads on
doctor-patient communication: a systematic review. Patient Educ Couns.
2009;76(3):348-55.
30
COMMUNICATION WITH YOUNG ADULTS

Young adulthood is an important transitional period during which
there is a higher risk of individuals engaging in behaviors which could
have a lasting impact on their health. Research has shown that young
adults are the lowest responders to surveys about healthcare
experiences and are the least satisfied with the care they receive.
However, the factors contributing to this reduced satisfaction are not
clear. The focus of this research was to explore the needs and
experiences of young adults around healthcare services with an aim
of finding out possible reasons for lower satisfaction. Twenty young
adults were interviewed at GP surgeries and at a local young adult
advice agency, exploring their experiences and use of primary care
services. Interviews were analyzed using thematic analysis. The use
of primary care services varied amongst the young adult
interviewees. Many interviewees reported positive experiences;
those who did not linked their negative experiences to difficulties in
negotiating their care with the health care system, and reported
issues with trust, and communication difficulties. Most of the
interviewees were unaware of the use of patient surveys to inform
healthcare planning and delivery and were not inclined to take part,
mainly because of the length of surveys and lack of interest in the
topic area. In order to effectively address the health needs of young
adults, young adults need to be educated about their rights as
patients, and how to most efficiently use primary care services. GPs
should be alert to effective means of approaching and handling the
healthcare needs of young adults. A flexible, varied approach is
needed to gathering high quality data from this group in order to
provide services with information on the changes necessary for
making primary care services more accessible for young adults (1).
Reference
1. Davey A, Asprey A, Carter M, Campbell JL. Trust, negotiation, and
communication: young adults' experiences of primary care services. BMC
Fam Pract. 2013 Dec 30;14:202.
31
STRESSFUL/DIFFICULT CONVERSATIONS
Stressful conversations are unavoidable in life. In business, they
can run the gamut from firing a subordinate to, curiously enough,
receiving praise. However, whatever the context, stressful
conversations carry a heavy emotional load. Indeed, stressful
conversations cause such anxiety that most people simply avoid
them. Yet it can be extremely costly to dodge issues, appease difficult
people, and smooth over antagonisms; avoidance usually only
worsens a problem or a relationship. Using vivid examples of the 3
basic stressful conversations that people bump up against most often
in the workplace, the author explains how managers can improve
those interactions unilaterally. To begin with, they should approach
the situations with greater self-awareness. Awareness of building is
not about endless self-analysis; much of it simply involves making
tacit knowledge about oneself more explicit. It is important for those
who are vulnerable to hostility, for example, to know how they react
to it. Do they clam up or do they retaliate? Knowing how you react in
a stressful situation will teach you a lot about your trouble areas and
can help you master stressful situations. Rehearsing difficult
conversations in advance is recommended to fine-tune phrasing and
tone. The best way to keep from being thrown off balance by difficult
conversations that crop up unexpectedly is to develop a few hip-
pocket phrases that you can pull out on the spot. We know from
experience what kinds of conversations and people we handle badly.
The trick is to have prepared conversational tactics to address those
situations (1).
The main objective of this study was to explore clinicians'
experiential knowledge when conducting difficult conversations; and
to verify if experiential knowledge is culturally based. Data were
collected in Italy and the US during the PERCS workshops. At the
beginning of each workshop, during a whiteboard exercise, clinicians
shared the strategies they had found helpful in difficult
conversations. The strategies were analyzed in each country through
content analysis. Upon completion of this primary analysis, the
themes identified within each country were synthesized into second-
order themes by means of aggregated concept analysis. Fourteen
Italian and 12 American PERCS-workshops enrolled 304 clinicians.
The suggestions that were similar across both countries were related
32
to organizational aspects and setting preparation; communication

and relational skillfulness; clinician mindfulness; interpersonal
qualities and sensibilities; and teamwork and care coordination.
Additionally, US participants identified attention to cultural
differences as a helpful strategy. In conclusion, clinicians can access
relational strategies, tied to their experience, that are typically
unrecognized in medical education. The whiteboard exercise is an
effective teaching tool to uncover and validate already-existing
relational knowledge. Communication training programs can foster
clinicians' sense of preparation by building upon their already-
existing knowledge (2).
This article describes the adaptation and implementation of the
PERCS in Italy. PERCS was originally developed at Boston Children's
Hospital and aimed to enhance clinicians' preparedness to engage in
difficult conversations with patients/families. After a period of
collaboration by the first author with the Children's Boston Hospital,
PERCS was launched at San Paolo Hospital, Milan, in 2008. Over 80
participants have voluntarily attended the program. The program
featured monthly 4-hour workshops geared around the enactment of
a case scenario by trained actors and participants. Each workshop
enrolled 10-13 interdisciplinary participants. After each enactment,
participants received feedback by actors, other participants and
facilitators on the challenging junctures of the conversation.
Pedagogical principles included creating safety for learning;
emphasizing moral and relational dimensions of care; suspending
hierarchy among participants; valuing self-reflection; honoring
multiple perspectives; and offering continuity of the educational
offering. In conclusion, implementing PERCS in Italy has
demonstrated that it is possible to culturally adapt learning
opportunities that embrace the relational and ethical experience of
learners. The positive response of participants affirms that relational
learning is meaningful and needed (3).
The aim of this study was to assess the effect of communication
skills training on radiology trainees': [1] comfort with communicating
directly with patients and family members about unexpected or
difficult diagnoses ("bad news"), radiologic errors, and radiation risks
and [2] attitudes about disclosing radiologic errors directly to patients
and their families. From 16 US programs, 109 radiology trainees were
asked to complete questionnaires immediately before and after
33
attending an institutional review board-exempted and full-day

communication workshop. Questionnaires assessed [1] comfort
communicating with patients and their families generally and about
bad news, radiologic errors, and radiation risks specifically; [2]
attitudes and behavioral intent regarding a hypothetical vignette
involving a radiologic error; and [3] desire for additional
communication training. After completing the questionnaires, more
trainees reported comfort communicating with patients about bad
news, errors, and radiation risks (pre vs. post, 44% vs. 73%, 25% vs.
44%, and 34% vs. 58%, respectively, p<0.001 for all). More agreed
that the radiologist in the error vignette should discuss the error with
the patient (pre vs. post, 84% vs. 95%, p=0.002) and apologize (pre
vs. post, 78% vs. 94%; p<0.001). After participation, fewer trainees
reported unwillingness to disclose the error despite medicolegal
concerns (pre vs. post, 39 vs. 15%, p<0.001). Despite high baseline
comfort (92%) and low stress (14%), after talking with patients in
general, most respondents after participation desired additional
communication training on error disclosure (83%), general
communication (56%), and radiation risks (80%). In conclusion, this
program provides effective communication training for radiology
trainees. Many trainees desire more such programs (4).
The high incidence of fatal diseases, inequitable access to health
care, and socioeconomic disparities in India generate plentiful clinical
bad news including diagnosis of a life-limiting disease, poor
prognosis, treatment failure, and impending death. These contexts
compel HCPs to become the messengers of bad news to patients and
their families. The purpose of this article is to identify the issues for
future research that would contribute to the volume,
comprehensiveness, and quality of empirical literature on breaking
bad news in clinical settings across India. Towards this end, the
studies done across the globe on breaking bad news were
synthesized under 4 themes: 1] deciding the amount of bad news to
deliver; 2] attending to cultural and ethical issues; 3] managing
psychological distress; and 4] producing competent messengers of
bad news. Robust research is inevitable to build an indigenous
knowledge base, enhance communicative competence among health
care professionals, and thereby to improve the quality of clinical
interactions in India (5).
34
A strong interest and need exist in the workplace today to master

the skills of conducting difficult conversations. Theories and
strategies abound, yet none seems to have found the magic formula
with universal appeal and success. If it is such an uncomfortable skill
to master is it better to avoid or initiate such conversations with
employees? Best practices and evidence-based management guide
us to the decision that quality improvement dictates effective
communication, even when difficult. Mastering the skills of
conducting difficult conversations is clearly important to keeping
lines of communication open and productive. Successful
communication skills may actually help to avert confrontation
through employee engagement, commitment and appropriate
corresponding behavior (6).
References
1. Weeks H. Taking the stress out of stressful conversations. Harv Bus
Rev. 2001;79(7):112-9, 146.
2. Lamiani G, Barello S, Browning DM, et al. Uncovering and validating
clinicians' experiential knowledge when facing difficult conversations: a
cross-cultural perspective. Patient Educ Couns. 2012;87(3):307-12.
3. Lamiani G, Meyer EC, Browning DM, Moja EA. Between science and
suffering: difficult conversations in healthcare. Recenti Prog Med. 2009;
100(5):239-46.
4. Brown SD, Callahan MJ, Browning DM, et al. Radiology trainees'
comfort with difficult conversations and attitudes about error disclosure:
effect of a communication skills workshop. J Am Coll Radiol. 2014 Mar 27.
pii: S1546-1440(14)00025-8.
5. Martis L, Westhues A. A synthesis of the literature on breaking bad
news or truth telling: potential for research in India. Indian J Palliat Care.
2013;19(1):2-11
6. Polito JM. Effective communication during difficult conversations.
Neurodiagn J. 2013;53(2):142-52.
35
CUES TO PERCEPTION OF REDUCED FLAPS

Natural, spontaneous speech (and even quite careful speech)
often shows extreme reduction in many speech segments, even
resulting in apparent deletion of consonants. Where the flap
([inverted J]) allophone of /t/ and /d/ is expected in American
English, one frequently sees an approximant-like or even vocalic
pattern, rather than a clear flap. Still, the /t/ or /d/ is usually
perceived, suggesting the acoustic characteristics of a reduced flap
are sufficient for perception of a consonant. This paper identifies
several acoustic characteristics of reduced flaps based on previous
acoustic research (size of intensity dip, consonant duration, and F4
valley) and presents phonetic identification data for continua that
manipulate these acoustic characteristics of reduction. The most
obvious types of acoustic variability seen in natural flaps do affect
listeners' percept of a consonant, but not sufficiently to completely
account for the percept. Listeners are affected by the acoustic
characteristics of consonant reduction, and they are skilled at
evaluating variability along the acoustic dimensions that realize
reduction (1).
Reference
1. Warner N, Fountain A, Tucker BV. Cues to perception of reduced
flaps. J Acoust Soc Am. 2009;125(5):3317-27.
LOW HEALTH LITERACY

Health literacy is defined in the US Department of Health and
Human Services initiative Healthy People 2010 as "the degree to
which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make
appropriate health decisions." It is estimated that 48.8 million
Americans are functionally illiterate, making health literacy a major
obstacle for providing health care. Although communicating with
physicians is a small component of the tasks that are incorporated in
a definition of health literacy, it remains the most important aspect
36
of this concept contributing to personal health. Primary care clinics

within the Sioux Falls area were provided with both English and
Spanish patient education brochures on communicating with
physicians. A survey was then distributed to determine how low
health literacy was affecting physician practices and what they were
doing to remove the obstacles that health literacy presented.
Physicians were asked to evaluate the multiple skills and
competencies required by patients to access health care services and
resources they use to assist patients. Of 77 surveys distributed, 22
(28.6 percent) were returned. Of the physicians who returned the
survey, the majority (77 percent) thought that low health literacy is a
moderate obstacle in their practices. Several physicians stated that
their offices had at least 1 method in place to assist those with low
health literacy, but none of them was using a formal test of health
literacy. Only 6 physicians could name a community resource to assist
patients with low health literacy. In conclusion, low health literacy is
an unavoidable barrier to effective patient care for physicians across
the country. If the full spectrum definition of health literacy is
understood by physicians and carefully considered in the context of
their own practices, it is likely they would come to the realization
that health literacy is a greater obstacle to providing health care than
they previously considered. In order to communicate more
effectively and better serve our patients, we need to resist
stereotyping patients when estimating (e.g., over estimating or under
estimating) their health literacy, to identify educational resources
and methods of communication that will ease the burden of health
illiteracy. With nearly half of patients having low health literacy
nationwide, it is essential to understand health literacy and
acknowledge this problem in all of our practices (1).
Reference
1. Seurer AC, Vogt HB. Low health literacy: a barrier to effective patient
care. D Med. 2013;66(2):51, 53-7.
37
CULTURALLY COMPETENT COMMUNICATION
Western cultural practices and values have largely shaped ACP

policies across the world. In most Western countries utilization of
ACP is typically lower among minority cultural groups (1). Cultural
factors may influence attitudes towards ACP (2). The main aim of this
study was to explore perceptions of ACP among older, non-
hospitalized first-generation Dutch-Australian and Italian-Australian
migrants. Twenty-nine people participated in individual interviews
(n=16) and focus groups (n=13). Average time residing in Australia
was 52 years. Most participants were proficient in English; some
Italian participants preferred to speak Italian and utilized
interpreters. Interviews were recorded, transcribed verbatim and
thematically analyzed. Pre-migration experiences, reliance on ethnic
community support networks and continued contact with the native
country contributed to migrant identity, which influenced attitudes
towards ACP. Dutch participants typically adopted an individualist
approach to medical decision-making, whereas Italian participants
associated more with a familial style. Mistrust towards institutions
was often associated with less support for ACP. Discussions about
ACP elicited unprompted views on euthanasia, particularly among
Dutch participants. Participants with poorer English language skills
showed similar openness to considering ACP when supported with
appropriate language assistance. An individualistic decision making
style was associated with openness to ACP. Familial decision making
styles and the presence of ethnic community support networks were
associated with a view that ACP was redundant. In conclusion,
ensuring informed access to ACP for migrant Australians will require
appropriate language assistance, understanding the patient's social
history and framing benefits of ACP within the broader context of
decision-making styles and reliance on ethnic community support
networks (3).
The main aim of this study was to examine the existing situation,
barriers and consequences of the intercultural communication in
health institutions and to offer training models for strengthening and
improving communication skills of health professionals in the
Republic of Macedonia. A cross-sectional survey was conducted to
assess the relationship between patients and health professionals.
HCPs (n=813, 302 physicians and 511 other medical staff) from
38
different healthcare institutions, and 1,016 patients participated in

cross-sectional survey performed in autumn 2010. The research has
showed that each third examined patient thought that his/her
physician or the other medical personnel had no understanding for
his/her emotions and gave no answer to all of his/her questions. On
the other side, 60% of the physicians declare that they have a good
communication with patients speaking other language than their
mother tongue. Only 60% of physicians said that they know well the
culture of their patient and 52% of the other medical staff noted that
they adjusted the treatment to the patient culture (religion,
attitudes, language, and life style). In conclusion, there are some gaps
in current provision of health care practice in an aspect of effective
interactions and communication skills of HCPs to meet patient needs
in a multicultural and multilingual setting. A training model is
proposed for strengthening communication skills of HCPs (4).
Ninety percent of the aboriginal communities of Argentina are
located in areas of endemic vectorial transmission of Chagas disease.
Control activities in these communities have not been effective. The
goal of this research was to explore the role played by beliefs, habits,
and practices of Pilaga and Wichi indigenous communities in their
interaction with the local health system in the province of Formosa.
This article contributes to the understanding of the cultural barriers
that affect the communication process between indigenous peoples
and their HCPs. Twenty-nine open ended interviews were carried out
with members of 4 indigenous communities (Pilaga and Wichi)
located in central Formosa. These interviews were used to describe
and compare these communities' approach to health and disease as
they pertain to Chagas as well as their perceptions of Western
medicine and its incarnation in local health practice. Five key findings
included: 1] members of these communities tend to see disease as
caused by other people or by the person's violation of taboos instead
of as a biological process; 2] while the Pilaga are more inclined to
accept Western medicine, the Wichi often favor the indigenous
approach to health care over the Western approach; 3] members of
these communities do not associate the vector with the transmission
of the disease and they have little awareness of the need for vector
control activities; 4] indigenous individuals who undergo diagnostic
tests and accept treatment often do so without full information and
knowledge; 5] the clinical encounter is rife with conflict between the
39
expectations of HCPs and those of members of these communities.

This analysis suggests that there is a need to consider the role of the
cultural patterning of health and disease when developing
interventions to prevent and control Chagas disease among
indigenous communities in Northern Argentina. This is especially
important when communicating with these communities about
prevention and control. These research findings might also be of
value to national and provincial agencies in charge of decreasing the
rates of Chagas disease among indigenous populations (5).
References
1. Searight HR, Gafford J. "It's like playing with your destiny": Bosnian
immigrants' views of advance directives and end-of-life decision-making. J
Immigr Health. 2005;7(3):195-203.
2. Searight HR, Gafford J. Cultural diversity at the end of life: issues and
guidelines for family physicians. Am Fam Physician. 2005;71(3):515-22.
3. Smith J, Sinclair C, Touissant Y, Auret K. More than just language: older
Dutch and Italian migrants' views on advance care planning. BMJ Support
Palliat Care. 2013;3(2):249-50.
4. Pollozhani A, Kosevska E, Petkovski K, et al. Some Aspects of Culturally
Competent Communication in Health Care in the Republic of Macedonia.
Mater Sociomed. 2013;25(4):250-254.
4. Dell'Arciprete A, Braunstein J, Touris C, et al. Cultural barriers to
effective communication between Indigenous communities and health care
providers in Northern Argentina: an anthropological contribution to Chagas
disease prevention and control. Int J Equity Health. 2014;13(1):6.
EFFECTIVE COMMUNICATION PREVENTS

LITIGATION
Good communication in all aspects of medical practice is essential.
Effective communication with patient not only enables to take an
accurate history but also helps the patient to understand their illness
and assists the healing process. Communication with other HCPs
allows the team approach to healthcare to succeed. It reduces the
chances of a breakdown in continuity of care, builds relationships and
understanding between different disciplines and specialties and helps
professionals to learn from each other. In the medico-legal field,
40
poor communication is the underlying problem in the most of cases

that MPS deals with. The majority of negligence cases are not related
to the clinical quality of care but are triggered by inadequate
communication. A breakdown in the doctor-patient often occurs
before the incident that leads to a claim. It is as if the patient is just
waiting for their moment to sue. In a busy clinic or GP surgery, it is
often easy to forget the human needs of the patient and concentrate
on their medical needs. First impressions are vital not just with the
doctor but also with other staff and even the clinic or hospital itself.
During the consultation careful listening, giving sincere empathy early
in the consultation and an expression of understanding of their
concerns will go a long way to instill confidence in the patient and
reduce the likelihood of a complaint should things go wrong (1).
Communication is the most powerful tool in clinical practice.
Repeatedly, research has shown that good communication skills
result in better clinical outcomes, a greater propensity to follow
clinical recommendations and reduced risk of clinical negligence and
complaints. In using a proactive approach to communication, HCPs
must become increasingly sensitized to the stresses associated with
illness and hospitalization and must learn the importance of good
listening and effective communication to ensure high quality patient
care. A study by Lester and Smith (2) demonstrated that time-limited,
negative communications by doctors is associated with increased
litigious intentions among patients, even when outcomes were
neither adverse nor negligent. The qualities of caring and concern
exhibited by doctors make a difference in healthcare outcome (3).
Many malpractice suits are brought neither because of
malpractice nor even because of complaints about the quality of
medical care but as an expression of anger about some aspect of
patient-doctor relationships and communications. The theory
presented is that under the stress of anxiety and physical illness,
some patients regress to childhood needs; physicians are not
generally trained to fill such needs. These patients, angry because of
this, express their anger in malpractice suits. This theory has been
taught to physicians and medical students as part of a physician CME
seminar on Loss Prevention/Risk Management through
demonstration of active-listening techniques to seminar participants.
Physicians who understand and can respond appropriately to the
emotional needs of their patients are less likely to be sued. This may
41
translate into a more fulfilled practice of medicine by those

physicians who are most aware of the importance of a positive
relationship (4).
References
1. Hegan T. The importance of effective communication in preventing
litigation. Med J Malaysia. 2003;58 Suppl A:78-82.
2. Lester GW, Smith SG. Listening and talking to patients: a remedy for
malpractice suits? West J Med. 1993;158(3):268-72.
3. Wilson J. Proactive risk management: effective communication. Br J
Nurs. 1998;7(15):918-9.
4. Virshup BB, Oppenberg AA, Coleman MM. Strategic risk management:
reducing malpractice claims through more effective patient-doctor
communication. Am J Med Qual. 1999;14(4):153-9.
HEALTH CARE PROFESSIONALS

The rapid proliferation of catheter-mediated treatments for CHDs
has brought with it a critical need for cooperation and
communication among the numerous physicians supporting these
new and complex procedures. New interdependencies between
physicians in specialties including cardiac imaging, interventional
cardiology, pediatric cardiology, anesthesia, cardiothoracic surgery,
and radiology have become apparent, as centers have strived to
develop the best systems to foster success. Best practices for CHD
interventions mandate confident and timely input from an individual
with excellent adjunctive imaging skills and a thorough understanding
of the devices and procedures being used. The imager and
interventionalist must share an understanding of what each offers for
the procedure, use a common terminology and spatial orientation
system, and convey concise and accurate information about what is
needed, what is seen, and what cannot be seen (1).
The rapid proliferation of catheter-mediated treatments for CHDs
has brought with it a critical need for cooperation and
communication among the numerous physicians supporting these
new and complex procedures. New interdependencies between
physicians in specialties including cardiac imaging, interventional
42
cardiology, pediatric cardiology, anesthesia, cardiothoracic surgery,

and radiology have become apparent, as centers have strived to
develop the best systems to foster success. Best practices for CHD
interventions mandate confident and timely input from an individual
with excellent adjunctive imaging skills and a thorough understanding
of the devices and procedures being used. The imager and
interventionalist must share an understanding of what each offers for
the procedure, use a common terminology and spatial orientation
system, and convey concise and accurate information about what is
needed, what is seen, and what cannot be seen. The goal of this
article is to review how the cardiovascular imaging specialists and
interventionalists can work together effectively to plan and execute
catheter interventions for CHD (2).
Despite the fact that communication has become a core topic in
health care, patients still experience the information provided as
insufficient or incorrect and a lack of involvement. The main objective
of this study was to investigate whether adult orthopedic patients'
evaluation of the quality of care had improved after a communication
skills training course for HCPs. The study was designed as an
intervention study offering professionals training in communicating
with patients and colleagues. The outcome was measured by
assessing patients' experience of quality of care. Data were collected
by means of a questionnaire and analyzed using a linear regression
model. Approval was obtained from the Danish Data Protection
Agency. A total of 3,133 patients answered the questionnaire, 1,279
before staff had attended courses and 1,854 in the postcourse
period, with response rates of 67.8% and 77.8%, respectively. After
the course period, significant increases in responses indicating
'considerable' improvement were recorded for 15/19 questions,
insignificant increases were registered for 3/19 questions and a
significant decrease for 1 question. In conclusion, patients show
increased satisfaction with the quality of health care after
professionals have attended a communication skills training course,
even when implemented in an entire department. HCPs should be
trained in patient-centered communication and training is extended
to the entire organization (3).
Focused dialogue, as good communication between practitioners,
offers a condition of possibility for development of high levels of
situation awareness in surgical teams. This has been termed
43
"achieving ensemble". Situation awareness grasps happening in time

and space with regard to one's own unfolding work in relation to that
of colleagues is necessary to maintain patient safety throughout a
surgical list. A typology was refined, initially developed for use in
studying the dynamics of teams in aviation safety, of 10 kinds of
communication within 2 broad areas: 'Reports', or authoritative acts
of communication setting up a monological or authoritative climate;
and 'Requests', or facilitative acts of communication setting up a
dialogical or participatory climate. How orthopedic surgical teams use
verbal communication through analysis of videotaped operations
using the typology was mapped. 'Do orthopedic surgical teams set up
the conditions of possibility for the emergence of situation
awareness through effective communication?' were asked.
Orthopedic surgical teams tend to produce monological rather than
dialogical climates. Dialogue increases with more complex cases, but
in routine work, communication levels are depressed and 1-way
influenced by surgeons working within a traditionally hierarchical and
authoritative culture. Such a monological climate inhibits
development of situation awareness and compromises patient's
safety. The same teams, however, generate potentially rich
educational climates through exchange of profession-specific
knowledge and skills, and where technical skill exchange is good,
non-technical or interpersonal communication skill levels can follow
(4).
Communication skills play a key role in many aspects of both
medical education and clinical patient care. The objectives of this
study were to identify the key components of communication skills
from the perspectives of both orthopedic residents and their
program directors and to understand how these skills are currently
taught. This study utilized a mixed methods design. Quantitative
data were collected with use of a thirty-item questionnaire
distributed to all Canadian orthopedic residents. Qualitative data
were collected through focus groups with orthopedic residents and
semistructured interviews with orthopedic program directors. Of 325
questionnaires, 119 (37%) were completed, 12 residents participated
in 2 focus groups, and 9 of 16 program directors from across the
country were interviewed. Both program directors and residents
identified communication skills as being the accurate and appropriate
use of language (i.e., content skills), not how the communication was
44
presented (i.e., process skills). Perceived barriers to effective

communication included time constraints and the need to adapt to
the many personalities and types of people encountered daily in the
hospital. Residents rarely have explicit training in communication
skills. They rely on communication training implicitly taught through
observation of their preceptors and clinical experience interacting
with patients, peers, and other HCPs. In conclusion, orthopedic
residents and program directors focus on content and flexibility
within communication skills as well as on the importance of being
concise. They value the development of communication skills in the
clinical environment through experiential learning and role modeling.
Education should focus on developing residents' process skills in
communication. Care should be taken to avoid large-group didactic
teaching sessions, which are perceived as ineffective (5).
The main aim of this study was to examine patients' perceptions
on communication surrounding the cancellation of orthopedic
operations and to identify areas for improvement in communication.
A prospective survey was undertaken at a university teaching hospital
within the department of Trauma and Orthopedics. Patients
admitted to an acute orthopedic unit, whose operations were
cancelled, were surveyed to assess patient satisfaction and
preferences for notification of cancellation of their operations.
Patients with an abbreviated mental test score of <9, patients unable
to complete the survey independently, those under 16 years of age,
and any patient notified of the cancellation by any of the authors
were excluded from this study. Patients were surveyed the morning
after their operation had been cancelled thus ensuring that every
opportunity was given for the medical staff to discuss the
cancellation with the patient. The survey included questions on
whether or not patients were notified of the cancellation of their
surgery, the qualifications of the person discussing the cancellation,
and patient preferences on the process. Satisfaction was assessed via
5-point Likert scale questions. Sixty-five consecutive patients had
their operations cancelled on 75 occasions. Of the patients, 54.7%
who had cancellations were notified by a nurse and 32% by a doctor.
No formal communication occurred for 13.3% cancellations and no
explanation was provided for a further 16%. Patients reported that
they were dissatisfied with the explanation provided for 36 of the 75
(48%) cancellations. Of those patients who were dissatisfied, 25
45
(69.4%) were notified by a nurse. Twenty-three of the 24 (96%)

patients notified by a doctor were satisfied with the explanation and
that communication. Of those patients who were notified by a nurse,
83% patients reported that they would have preferred it if a doctor
had discussed the cancellation with them. There was a significant
difference in satisfaction between those counseled by a nurse and
those notified by a doctor (p<0.0001). In conclusion, communication
surrounding cancellations does not meet patient expectations.
Patients prefer to be notified by a doctor, illustrating the importance
of communication in the doctor-patient relations (6).
Delay in surgical treatment is a source of distress to patients and
an important reason for poor outcome. The delay before carrying out
scheduled operative orthopedic procedures and the factors
responsible for it were studied. This prospective study was carried
out between March 2011 and December 2012. Temporal details of
the surgical procedures at this hospital were recorded including the
patients' perception of the causes of the delay to surgery. Based on
the urgency of the need for surgery, patients were classified into 3
groups using a modification of the method (7).
Two hundred and forty-nine patients with a mean age 36.2 ± 19.2
years and M:F ratio 1.3 were recruited; 34.1% were modified
Lankester group A, 45.4% group B and 20.5% group C; 47 patients
(18.9%) had comorbidities, hypertension being the commonest (22
patients; 8.8%). Median delay to surgery was 4 days (mean = 17.6
days). Fifty percent of emergency room admissions were operated on
within 3 days, the figure was 13% for other admissions. Lack of
theatre slot was the commonest cause of delay. There was full
concordance between doctors and patients in only 70.7% regarding
the causes of the delay. In 15.7%, there was complete discordance.
Logistic regression analysis confirmed modified Lankester groups B
and C (p=0.003) and weekend admission (p=0.016) as significant
predictors of delay to surgery of >3 days. In conclusion, promptness
to operative surgical care falls short of the ideal. Theatre inefficiency
is a major cause of delay in treating surgical patients in the
environment. Theatre facilities should be expanded and made more
efficient. There is a need for better communication between
surgeons and patients about delays in surgical treatment (8).
46
Communication skills are an important component of the

neurosurgery residency training program. A simulation-based training
module was developed for neurosurgery residents in which medical,
communication and ethical dilemmas are presented by role-playing
actors at the Department of Neurosurgery, Sheba Medical Center, Tel
Hashomer. The main aim of this study was to assess the first national
simulation-based communication skills training for neurosurgical
residents. Eight scenarios covering different aspects of neurosurgery
were developed by the team: 1] obtaining informed consent for an
elective surgery, 2] discharge of a patient following elective surgery,
3] dealing with an unsatisfied patient, 4] delivering news of
intraoperative complications, 5] delivering news of a brain tumor to
parents of a 5-year-old boy, 6] delivering news of brain death to a
family member, 7] obtaining informed consent for urgent surgery
from the grandfather of a 7-year-old boy with an epidural hematoma,
and 8] dealing with a case of child abuse. Fifteen neurosurgery
residents from all major medical centers in Israel participated in the
training. The session was recorded on video and was followed by
videotaped debriefing by a senior neurosurgeon and communication
expert and by feedback questionnaires. All trainees participated in 2
scenarios and observed another 2. Participants largely agreed that
the actors simulating patients represented real patients and family
members and that the videotaped debriefing contributed to the
teaching of professional skills. In conclusion, simulation-based
communication skill training is effective, and together with thorough
debriefing is an excellent learning and practical method for imparting
communication skills to neurosurgery residents. Such simulation-
based training will ultimately be part of the national residency
program (9).
This research sought to describe and compare perceptions of
consent-related health communication between surgical patients
undergoing procedures at facilities that did and did not adopt a new
health literacy-based consent form and process. A self-administered,
mail survey was used to collect information about demographic
characteristics, health locus of control, and perceptions of surgical
consent-related health communication from patients aged 18 years
or older, approximately 2 to 4 months after undergoing laparascopic
cholecystectomy, total hip replacement, or TNR surgery within a 10-
hospital integrated health system in Iowa. A static group comparison
47
design with multivariable logistic regression analyses was used to

compare perceptions about 12 aspects of surgical consent-related
health communication between the adopting and non-adopting
facilities while controlling for observed differences in respondent
background characteristics using a threshold of p<0.05 for model
inclusion. Respondents from facilities, implementing the new
consent form and process, had significantly higher odds of strongly
agreeing that the nurses asked them to restate the type of surgery
being performed in their own words (AOR 1.92, 95% CI 1.30-2.82)
and they were comfortable asking questions about their surgery
(AOR 1.53, 95% CI 1.04-2.26). In conclusion, the consent process can
be refined to stimulate communication and comfort with asking
questions, and promote use of health literacy-based techniques (i.e.,
teach-back) in the perioperative care setting. Adopting a health
literacy-based informed consent process promotes patient safety and
supports health providers' obligations to communicate in simple,
clear, and plain language (10).
Evaluation of long-term patient-perceived functional outcomes
and QOL related to communication and eating with an emphasis on
voice, speech production, and swallowing after CPA surgery. In this
prospective cross-sectional study, the MD Anderson Dysphagia
Inventory (MDADI), Voice Handicap Index (VHI), and Facial Clinimetric
Evaluation (FaCE) surveys were distributed to patients who
underwent CPA surgery between January 2008 and December 2010.
Immediate postoperative cranial nerve function extracted from
medical records was compared to long-term patient-perceived
function and associated QOL. There was a 61% response rate with a
mean postoperative period of 31.6 months (range 15-49). The
presence of facial palsy in the postoperative period and the
corresponding House-Brackmann score were the strongest predictors
of patient-perceived long-term function and QOL in all 3 domains
(p <0 .005). Postoperative vagal palsy by comparison was not
associated with long-term disturbance of voice or speech function.
Postoperative dysphagia had a particularly large association with
perceived long-term facial function and related QOL (p <0 .0005),
with a smaller but significant impact on perceived swallow outcome
(p <0 .05). After adjusting for other variables, the postoperative
House-Brackmann score remained a significant predictor of perceived
long-term facial and voice function and related QOL. In conclusion,
48
patients with severe facial dysfunction following surgery to the CPA

are at increased risk for long-term self-reported difficulties with
communication and eating, even with improvement of vagal
function. Speech and swallow therapy should therefore be provided
to these patients whether or not they also have pharyngeal
dysphagia or voice disturbance (11).
Effective teamwork is important for patient safety, and verbal
communication underpins many dimensions of teamwork. The
validity of the simulated environment would be supported if it
elicited similar verbal communications to the real setting. The
authors hypothesized that anesthesiologists would exhibit similar
verbal communication patterns in routine operating room cases and
routine simulated cases, and anesthesiologists would exhibit
different communication patterns in routine cases (real or simulated)
and simulated cases involving a crisis. Key communications relevant
to teamwork were coded from video recordings of anesthesiologists
in the operating room, routine simulation and crisis simulation.
Comparable videos of 20 anesthesiologists in the 2 simulations were
recorded, 17 of these anesthesiologists in the operating room
generated 400 coded events, 683 in the routine simulation, and
1,419 in the crisis simulation. Insignificant differences were found in
communication patterns in the operating room and the routine
simulations and communication patterns between the crisis
simulation and both the operating room and the routine simulations.
Participants rated team communication as realistic and considered
their communications occurred with a similar frequency in the
simulations as in comparable cases in the operating room. In
conclusion, the similarity of teamwork-related communications
elicited from anesthesiologists in simulated cases and the real setting
supports for the ecological validity of the simulation environment
and its value in teamwork training. Different communication patterns
and frequencies under the challenge of a crisis support the use of
simulation to assess crisis management skills (12).
This paper reports a project evaluating the efficacy and impact of
a pilot communication skills and cultural awareness course for HCPs
who care for patients with sickle cell disease. Poor communication
between patients with sickle cell disease and HCPs causes suspicion
and mistrust. Many patients feel that they are negatively labeled by
the healthcare system and are skeptical of opening themselves to an
49
unsympathetic system. They may therefore appear hostile and

aggressive when interacting with HCPs, which in turn leads to
distortions and misunderstandings between both groups. The use of
good communication skills by HCPs is therefore vital for good
healthcare practice. Forty-seven HCPs took part in a series of 3 pilot
courses each lasting 3 days. HCPs were taught a repertoire of
communication skills and cultural awareness strategies to use in
challenging situations that arise in their care of sickle cell patients.
Expert facilitators used a variety of teaching techniques, such as
professionally made videos, role-play, and group exercises.
Participants' confidence in dealing with challenging situations was
assessed at baseline, immediately after the intervention, and at 3-
and 6-month postintervention. A repeated measures anova revealed
a significant increase in confidence from pre- to postcourse scores.
Confidence scores further increased from immediately postcourse
and 3 months postcourse follow-up. These were then maintained at 6
months postcourse. In conclusion, this type of communication skills
and cultural awareness training had a positive and enduring impact
on professionals' perceived ability and confidence in communicating
with patients with sickle cell disease. Participants attributed this to
the learner-centered approach of the course that provided them with
the opportunity to transfer and apply the taught skills in their daily
practice. This type of training might be helpful in reducing mistrust
and increasing empathetic responses in HCPs (13).
Optimizing communication between radiotherapy team members
and patients and between colleagues requires training. This study
applies a randomized controlled design to assess the efficacy of a 38-
hours communication skills training program. Four radiotherapy
teams were randomly assigned either to a training program or to a
waiting list. Team members' communication skills and their self-
efficacy to communicate in the context of an encounter with a
simulated patient were the primary endpoints. These encounters
were scheduled at the baseline and after training for the training
group, and at the baseline and 4 months later for the waiting list
group. Encounters were audiotaped and transcribed. Transcripts
were analyzed with content analysis software (LaComm) and by an
independent rater. Eighty team members were included in the study.
Compared to untrained team members, trained team members used
more turns of speech with content oriented toward available
50
resources in the team (RR=1.38, p=0.023), more assessment

utterances (RR=1.69, p<0.001), more empathy (RR=4.05, p=0.037),
more negotiation (RR=2.34, p=0.021) and more emotional words
(RR=1.32, p=0.030), and their self-efficacy to communicate increased
(p=0.024 and p=0.008, respectively). In conclusion, the training
program was effective in improving team members' communication
skills and their self-efficacy to communicate in the context of an
encounter with a simulated patient (14).
The aim of this study was to describe current practices in
assessing patient communication skills in US colleges and schools of
pharmacy. Syllabi and behavioral assessment forms were solicited
and key faculty members were interviewed. Forms were analyzed to
determine skills most commonly assessed in communication with
simulated or role-playing patients. Fifty schools submitted behavioral
assessment forms for patient communication skills. Individuals from
47 schools were interviewed. Colleges were found to vary in the way
communication skills were assessed. Assessment forms focused more
on dispensing a new prescription than monitoring ongoing therapy.
Providing information was emphasized more than promoting
adherence. Common faculty concerns were lack of continuity and
congruence of assessment across the curriculum. In conclusion, a
common understanding of the standards and procedures for
determining competence is needed. Experience and assessment
activities should be sequenced throughout a program to build
competence (15).
The objective of this study was to evaluate the non-intentional
prescription discrepancies between home medication and hospital
medication for in-patients, their potential clinical impact and the
impact of pharmaceutical communication between community
pharmacists and hospital clinical pharmacists to prevent them. This
prospective study included 278 in-patient's files hospitalized in
orthopedic surgery + units. After reconciliation by the hospital clinical
pharmacists including patient interviews, GP prescription reviews and
community pharmacists drug delivery analyses, patient files
(prescription and patient chart) were analyzed and the administered
drugs (home medication) to those that the patient should have
received were compared. The pharmaceutical intervention was
tracked, the physician acceptance and the identified and avoided
errors. The clinical impact of each discrepancy was evaluated by a
51
team composed of a physician and a clinical pharmacist. Frequency of

intentional and NID, evaluation of NID clinical impact and rate of NID
identified and corrected by the reconciliation procedure. In this
study, 278 consecutive patients were included; 1,532 prescription
lines were analyzed and 471 discrepancies were observed (95% CI,
28.43-33.00). NID affected 9.2% of prescription lines (95% CI, 7.7-
10.6) and 34.2% of patients (95% CI, 31.3-37.1). Fifty-one patients
(18.3%) had at least 1 NID classified as potentially harmful. Sixty-nine
percent of errors at admission were identified by the reconciliation
procedure including data exchanges with community pharmacists. In
conclusion, this study demonstrates the importance of drug
reconciliation at patient's admission by the hospital clinical
pharmacists supported by communication with the community
pharmacists (16).
The objective of this study was to review the literature relating to
the use of simulated patient methods to enhance communication
skills of pharmacists. Embase, Lilacs, Medline, Scielo, and Scopus
databases between 1980 and 2008, using "communication skills",
"patient counseling" and "pharmacist" as keywords were searched.
This search was then refined by using "simulated patients", "pseudo-
customer", "standardized patients", and "mystery shoppers" as
additional keywords. The initial search identified 241 published
studies. Once further refined, 15 studies met inclusion criteria. In
conclusion, the majority of studies had an assessment focus aimed at
documenting counseling behavior of practicing pharmacists, rather
than an educational focus aimed at equipping pharmacists with
effective communication skills. In instances where simulated patient
methods were used for educational purposes, little regard was given
to the role of performance and corrective feedback in shaping
communication behavior of pharmacists. The majority of studies
failed to describe the competencies and skills being investigated in
relation to communication in the practice of pharmacy. Simulated
patient methods provide pharmacy educators with a tool for
implementing communication skills in the practice of pharmacy and
will serve as a basis for implementing communication skills
development programs at the College of Pharmacy of the Federal
University of Sergipe in Brazil (17).
52
References
1. Kutty S, Delaney JW, Latson LA, Danford DA. Can we talk? Reflections
on effective communication between imager and interventionalist in
congenital heart disease. J Am Soc Echocardiogr. 2013;26(8):813-27.
2. Huang YH, Hsieh SI, Hsu LL. The effect of a scenario-based simulation
communication course on improving the communication skills of nurses. Hu
Li Za Zhi. 2014;61(2):33-43.
3. Nørgaard B, Kofoed PE, Ohm Kyvik K, Ammentorp J. Communication
skills training for health care professionals improves the adult orthopaedic
patient's experience of quality of care. Scand J Caring Sci. 2012;26(4):698-
704.
4. Bleakley A, Allard J, Hobbs A. 'Achieving ensemble': communication in
orthopaedic surgical teams and the development of situation awareness - an
observational study using live videotaped examples. Adv Health Sci Educ
Theory Pract. 2013;18(1):33-56.
5. Lundine K, Buckley R, Hutchison C, Lockyer J. Communication skills
training in orthopaedics. J Bone Joint Surg Am. 2008;90(6):1393-400.
6. Mehta SS, Bryson DJ, Mangwani J, Cutler L. Communication after
cancellations in orthopaedics: The patient perspective. World J Orthop.
2014;5(1):45-50.
7. Lankaster T, Hart R, Gardner S. Literature and medicine: evaluating a
special study module using the nominal group technique. Med Educ. 2002;
36:1071-6.
8. Ifesanya AO, Ogundele OJ, Ifesanya JU. Orthopaedic surgical treatment
delays at a tertiary hospital in sub Saharan Africa: Communication gaps and
implications for clinical outcomes. Niger Med J. 2013;54(6):420-5.
9. Harnof S, Hadani M, Ziv A, Berkenstdt H. Simulation-based
interpersonal communication skills training for neurosurgical residents. Isr
Med Assoc J. 2013;15(9):489-92.
10. Miller MJ, Abrams MA, Earles B, et al. Improving patient-provider
communication for patients having surgery: patient perceptions of a revised
health literacy-based consent process. J Patient Saf. 2011; 7(1):30-8.
11. Starmer HM, Ward BK, Best SR, et al. Patient-perceived long-term
communication and swallow function following cerebellopontine angle
surgery. Laryngoscope. 2014;124(2):476-80.
12. Weller J, Henderson R, Webster CS, et al. Building the evidence on
simulation validity: comparison of anesthesiologists' communication
patterns in real and simulated cases. Anesthesiology. 2014;120(1):142-8.
13. Thomas VJ, Cohn T. Communication skills and cultural awareness
courses for healthcare professionals who care for patients with sickle cell
disease. J Adv Nurs. 2006;53(4):480-8.
14. Gibon AS, Merckaert I, Liénard A, et al. Is it possible to improve
radiiotherapy team members' communication skills? A randomized study
53
assessing the efficacy of a 38-h communication skills training program.

Radiother Oncol. 2013;109(1):170-7.
15. Kimberlin CL. Communicating with patients: skills assessment in US
colleges of pharmacy. Am J Pharm Educ. 2006;70(3):67.
16. Pourrat X, Corneau H, Floch S, et al. Communication between
community and hospital pharmacists: impact on medication reconciliation at
admission. Int J Clin Pharm. 2013;35(4):656-63.
17. Mesquita AR, Lyra DP Jr, Brito GC, et al. Developing communication
skills in pharmacy: a systematic review of the use of simulated patient
methods. Patient Educ Couns. 2010;78(2):143-8.
NURSES' COMMUNICATION QUALITIES

The aim of this study was to establish the best available evidence
regarding the factors affecting effective communication between
registered nurses and inpatient cancer adults. Electronic databases
(CINAHL, Ovid, PubMed, ScienceDirect, Scopus and Wiley
InterScience) were searched using a 3-step search strategy to identify
the relevant quantitative and qualitative studies published in English.
The grey literature was not included in the review. The identified
studies were evaluated using the guidelines from the Joanna Briggs
Institute System for the Unified Management, Assessment and
Review of Information. Three studies were included in the
quantitative component of the review, and the data were presented
in a narrative summary. Five studies were included in the qualitative
component of the review, and the findings were categorized in a
meta-synthesis which generated 4 synthesized findings. The factors
that influenced effective communication were identified in the
characteristics of nurses, patients and the environment. The
promoting factors in nurses included genuineness, competency and
effective communication skills. The role of post-basic training in
improving nurse-patient communication remained inconclusive.
Conversely, nurses who were task-orientated, who feared death and
who had low self-awareness of their own verbal behaviors inhibited
communication. Nurses communicated less effectively when
delivering psychosocial aspects of care and in emotionally charged
situations. On the other hand, patients who participated actively in
their own care and exhibited information-seeking behavior promoted
54
communication with the nurses. However, patients' unwillingness to

discuss their disease/feelings, their preference to seek emotional
support from their family/friends and their use of implicit cues were
some of the factors that were found to inhibit communication. A
supportive ward environment increased facilitative behavior in
nurses, whereas conflict among the staff led to increased use of
blocking behaviors. Cultural norms within the Chinese society were
found to inhibit nurse-patient communication. In conclusion,
personal characteristics of patients and nurses are the key factors
that influence effective nurse-patient communication within the
oncology setting. Little evidence exists to explain the role of
environment in effective nurse-patient communication, particularly
within an Asian setting. Training can be implemented to inform
nurses about the communication challenges, to equip them with
effective communication skills and improve their receptivity to
patient cues. Information sharing can be used as a non-threatening
approach to initiate rapport-building and open communication.
Nurses should consider patients' psychological readiness to
communicate and respect their preference as to whom they wish to
share their thoughts/emotions with. Hospitals/institutions need to
ensure a supportive ward culture and appropriate workload that will
enable nurses to provide holistic care to patients (1).
The aim of this study was to examine the effects of individual
video-feedback on the generic communication skills, clinical
competence (i.e. adherence to practice guidelines) and motivational
interviewing skills of experienced practice nurses working in primary
care. Continuing professional education may be necessary to refresh
and reflect on the communication and motivational interviewing
skills of experienced primary care practice nurses. A video-feedback
method was designed to improve these skills. Pre-test/posttest
control group design included 17 Dutch practice nurses and 325
patients participated between June 2010-June 2011. Nurse-patient
consultations were videotaped at 2 moments (T0 and T1), with an
interval of 3-6 months. The videotaped consultations were rated
using 2 protocols: the Maastrichtse Anamnese en Advies Scorelijst
met globale items (MAAS-global) and the Behavior Change
Counseling Index. Before the recordings, nurses were allocated to a
control or video-feedback group. Nurses allocated to the video-
feedback group received video-feedback between T0 and T1. Nurses
55
who received video-feedback appeared to pay significantly more

attention to patients' request for help, their physical examination and
gave significantly more understandable information. With respect to
motivational interviewing, nurses who received video-feedback
appeared to pay more attention to 'agenda setting and permission
seeking' during their consultations. In conclusion, video-feedback is a
potentially effective method to improve practice nurses' generic
communication skills. Although a single video-feedback session does
not seem sufficient to increase all motivational interviewing skills,
significant improvement in some specific skills was found. Nurses'
clinical competences were not altered after feedback due to already
high standards (2).
The aim of the present study was to analyze nurses' perceptions
of the communication qualities that are essential for nurse managers
to carry out their jobs effectively. An examination of effective
communication may help to identify nurse manager behaviors that
promote dignity and respect. A paper-and-pencil survey collected
open-ended data from 1,526 nursing professionals representing 22
hospitals in Oman. Qualitative content analysis was conducted first,
followed by a quantitative descriptive analysis. The participants
reported frustration with nurse managers who seemed overly
focused on mistakes. Many participants felt there was little to no
appreciation for tasks that were well done. Nurses disliked being
disciplined openly in front of colleagues or patients. In conclusion,
the participants stressed that nurse manager feedback should be
shared privately and framed in a positive and constructive tone.
Active listening, team collaboration and the avoidance of
discrimination/favouritism were also emphasized. A supportive and
communicative work environment promotes nurses' dignity and
respect. Embarrassing nurses in front of other HCPs may be
counterproductive. Instead, privately discussing concerns in a
positive, constructive tone is more likely to foster nurse trust and
dignity (3).
References
1. Tay LH, Hegney D, Ang E. Factors affecting effective communication
between registered nurses and adult cancer patients in an inpatient setting:
a systematic review. Int J Evid Based Health. 2011;9(2):151-64.
2. Noordman J, van der Weijden T, van Dulmen S. Effects of video-
feedback on the communication, clinical competence and motivational
56
interviewing skills of practice nurses: a pre-test posttest control group study.

J Adv Nurs. 2014 Mar 3. doi: 10.1111/jan.12376.
3. Rouse RA, Al-Maqbali M. Identifying nurse managers' essential
communication skills: an analysis of nurses' perceptions in Oman. J Nurs
Manag. 2014;22(2):192-200.
PATIENTS WITH ACUTE/CHRONIC DISEASES

Communication between patient and providers is extremely
important, especially for the treatment of chronically ill patients,
characterized by a biopsychosocial disease model. This article
presents an overview of the current status of research on patient-
provider communication in 3 selected areas: the communication
preferences of chronically ill persons, the correlation between
communication and relevant endpoints, and interventions to improve
patient-provider communication. One major result of the research is
that patients display a rather high degree of inter- and intra-
individual variability with respect to the preference of certain
communication styles (e.g. patient participation); there are
differences among them, and they develop varying preferences in the
course of their illness. However, communicative behavior of the
provider that is generally perceived by many patients to be positive
can also be identified: affective behavior (for example, asking the
patient about his/her feelings, being sensitive to these feelings and
responding to them), providing information in an understandable,
proactive manner, and attempting to understand the patient's
perceptions, expectations, and cognitive concepts. Successful
communication requires certain congruence between the patient's
communication preferences and the provider's behavior. Successful
communication leads to greater adherence. The correlation with
patient satisfaction is not documented quite as clearly but has often
been shown. The findings vary with respect to the improvement in
the patient's health status. The effectiveness of communication
training for providers has been documented quite well regarding the
immediate endpoints in patient-provider interaction (e.g., patient-
oriented behavior); the evidence with respect to medium-term
57
endpoints such as patient satisfaction varies, also due to the number

of possible operationalizations of the endpoints. Supplementing
provider training with communication-related training for patients
appears to be an important and useful method showing that the
behavior of providers can be influenced by using relatively simple
measures that start with the patient. There is a need for further
development of research on patient-provider communication, in
particular with respect to a more solid theoretical basis, integration
of methods including qualitative and quantitative methods, self-
evaluations and interaction analyses, and concerning conducting
more longitudinal studies (1).
The objective of this exploratory study was to identify patient-
related predictors of communication preferences in patients with
chronic LBP for various dimensions of patient-physician
communication (patient participation and orientation, effective and
open communication, emotionally supportive communication, and
communication about personal circumstances). Eleven rehabilitation
centers from various parts of Germany participated in collection of
data between 2009 and 2011. A total of 701 patients with chronic
LBP were surveyed at the start of rehabilitation. The patient
questionnaire captured communication preferences, pain impact,
pain intensity, and psychological variables (fear avoidance beliefs,
illness coherence, control beliefs, communication self-efficacy, and
personality characteristics). The rehabilitation physicians filled out a
documentation sheet containing information on diagnosis, inability
to work, duration of the illness, and comorbidity at the beginning and
end of rehabilitation. On average, effective, open, and patient-
centered communication was very important for patients with back
pain, emotionally supportive communication was important, and
communication about personal circumstances was somewhat
important. The variance in communication preferences explained by
the predictors studied here was 8-19%. Older patients showed a
lower preference for patient-centered and open communication, but
a higher preference for communication about personal
circumstances. Patients with psychological risk factors (e.g., fear of
avoidance beliefs), extroverted patients, and patients with high self-
efficacy in patient-physician interaction generally had higher
expectations of the physician's communicative behavior. In
conclusion, providers should take into consideration the fact that
58
patients with back pain have a strong need for effective, open, and
patient-centered communication. A flexible approach to
communication is important for communication about emotional and
personal circumstances, because the patients differ in this respect.
Personal characteristics provided only initial clues to possible
preferences; for more precision, an individual assessment (by means
of questionnaires or discussion) is needed (2).
Effective reassurance of patients suffering from complaints for
which no clear etiological origin is available, is one of the most
important challenges in the early phases of non-specific back pain.
However, there is a lack of empirical studies on the effects of
reassurance and, effects were small. Improvements are needed with
respect to the process of physician-patient interaction and to the
methods used by the physician. A short narrative review of the
literature with special reference to affective and cognitive
communication, based on a systematic review of 16 studies is
provided. Recent evidence in the prognosis of LBP, the role of
physical activity and sub-groups-based individual differences in pain
coping, questioning the information basis of reassurance is
considered. A 2-process model of affective and cognitive
reassurance, was supported. Recovery improved in a combination of
communication of empathy with cognitive reassurance, giving
concrete information and instructions. In terms of information,
recent research indicate that a substantial rate of patients do not
recover within the first year after onset of back pain. Very low and
high levels of physical activity are associated with pain and disability,
associated with cognitive/behavioral pain coping. In conclusion,
reassurance of patients in early phases of persistent back pain might
improve from affective and cognitive parts of communication and
individually tailored information. Subgroup differences with respect
to different prognosis, associated patterns of adaptive or
maladaptive pain coping and levels of health promoting versus
harmful physical activity should be considered more carefully (3).
Chronic LBP is a common chronic condition whose treatment
success can be improved by active involvement of patients. Patient
involvement can be fostered by web-based applications combining
health information with decision support or behavior change
support. These so-called IHCAs can reach great numbers of patients
at low financial cost and provide information and support at the time,
59
place and learning speed patients prefer. However, high attrition

often seems to decrease the effects of web-based interventions.
Tailoring content and tone of IHCAs to the individual patient ́s needs
might improve usage and therefore effectiveness. This study aims to
evaluate a tailored IHCA for people with chronic LBP combining
health information with decision support and behavior change
support. The tailored IHCA will be tested regarding effectiveness and
usage against a standard website with identical content in a single-
blinded randomized trial with a parallel design. The IHCA contains
information on chronic LBP and its treatment options including
health behavior change recommendations. In the intervention group,
the content is delivered in dialogue form, tailored to relevant patient
characteristics (health literacy, and coping style). In the control group
there is no tailoring, a standard web page is used for presenting the
content. Participants are unaware of group assignment. Eligibility
criteria are age ≥ 18 years, self- reported chronic LBP, and Internet
access. To detect the expected small effect (Cohen's d = 0.2), the
sample aims to include 414 patients, with assessments at baseline,
directly after the first on-page visit, and at 3-month follow-up using
online self-report questionnaires. It is expected that the tailored IHCA
has larger effects on knowledge and patient empowerment (primary
outcomes) compared to a standard website. Secondary outcomes are
website usage, preparation for decision making, and decisional
conflict. In conclusion, IHCAs can be a suitable way to promote
knowledge about chronic LBP and self-management competencies.
Results of the study can increase the knowledge on how to develop
IHCAs which are more useful and effective for people suffering from
chronic LBP (4).
The objective of this study was to examine whether
communication factors affect HCP and patient agreement on the
need for, risks of, and benefits of joint replacement, and whether
degree of agreement predicts patient satisfaction and intent to
follow treatment recommendations. HCPs (n=27) and patients
(n=74) with severe OA were recruited from clinics in Houston, Texas.
Patients completed a baseline survey prior to the consultation. After
the visit, patients and providers completed measures of the severity
of the patient's OA, the expected benefits of TKR, and concern about
surgical complications. Patients also completed satisfaction and
intent to adhere measures. Provider communication and patient
60
participation were measured by patient self-report and by observers'

coding of audio recordings of the consultations. Provider-patient
agreement was modest to poor regarding severity of the patient's OA
and the expected benefits and risks of TKR. Providers and patients
were more aligned on the patient's OA severity when providers used
more partnership building but spent less time simply giving
information. Differences between providers' and patients' concerns
about surgery were greater when patients were less participatory,
African American, or expressed lower trust in their doctors. Patient
satisfaction and intent to adhere were predicted by provider-patient
agreement on the benefits of TKR. In conclusion, patients and
providers often differ in their beliefs about the need for, risks of, and
benefits of TKR and these differences can affect patient satisfaction
and commitment to treatment. Facilitating active patient
participation might contribute to greater physician-patient
agreement on the patient's concerns about OA and surgical
interventions (5).
Communication with patients with FMS is often considered
difficult. The primary objective of this explorative study was to
describe the communication preferences of FMS patients in
comparison with other chronic diseases, and the secondary objective
was to identify patient-related predictors of those communication
preferences. A total of 256 FMS, Medical Centre, Freiburg, patients
were asked to fill out the KOPRA, communication preferences of
patients with chronic illness, questionnaire at the beginning of their
rehabilitation, answering questions about their communication
preferences. The KOPRA's descriptive parameters were calculated
and compared with other diagnosis groups. In order to include as
many influencing factors as possible, data on patient-related
sociodemographic, medical, pain impact and psychological variables
were gathered. FMS patients consider an open and patient-centered
communication style to be especially important. Emotionally
supportive communication and communication about personal
circumstances are important for FMS patients, but the preferences of
individual patients vary widely. FMS patients reveal higher values in
all the subdimensions of communication preferences compared with
patients with LBP or CIHD. Only a few variables appear to predict
patient communication preferences. The explained variance ranged
from 3.1% to 9.7%. Psychological variables have been identified as
61
predictors in conjunction with all communication preferences. In

conclusion, HCP who communicate with FMS patients should employ
an open and patient-centered communication style, and affective
communication components should be accepted to accommodate
each patient (6).
The objectives of the current study were to describe fibromyalgia
patient-spouse incongruence regarding patient pain, fatigue, and
physical function; and to examine the associations of individual and
interpersonal factors with patient-spouse incongruence. Of FMS
patients core siding partners, 204 rated the patient's symptoms and
function. Multilevel modeling revealed that spouses, on average,
rated patient fatigue significantly lower than patients. Couple
incongruence was not significantly different from zero, on average,
for pain severity, interference, or physical function. However, there
was significant variability across couples in how they rated the
severity of symptoms and function, and how much incongruence
existed within couples. Controlling for individual factors, patient and
spouse reports of communication problems were significantly
associated with levels of couple incongruence regarding patient
fatigue and physical function, albeit in opposing directions. Across
couples, incongruence was high when patients rated communication
problems as high; incongruence was low when spouses rated
communication problems as high. An important within-couple
interaction was found for pain interference, suggesting that couples
who are similar on level of communication problems experience low
incongruence; those with disparate ratings of communication
problems experience high incongruence. Findings suggest the
important roles of spouse response and the patient's perception of
how well the couple is communicating. Couple-level interventions
targeting communication or other interpersonal factors may help to
decrease incongruence and lead to better patient outcomes (7).
Despite a high prevalence of pain and ongoing effort to
understand and reduce pain, studies show that there remains a
considerable unmet need for pain relief and management. In part,
this may be due to patient's not adhering to treatment
recommendations. Models such the health belief model, self-
regulation theory, and the theory of planned behavior suggest 2 key
factors in promoting adherence: 1] good HCP-patient communication
and 2] interventions that are tailored to individuals' reasons for non-
62
adherence. Hence, communication skills that express a non-

judgmental approach, allow open exploration of patient beliefs and
concerns, and use a negotiating approach that fosters shared
decision making are crucial. RCTs of brief communication skills
training have shown improved outcomes in primary care settings for
patients with fibromyalgia and acute pain. Thus, although treatment
of chronic pain is challenging, good communication between HCPs
and patients can promote adherence and improve outcomes (8).
The majority of throat infections is of viral origin and resolve
without antibiotic treatment. Despite this, antibiotic use for sore
throat infections remains high, partly because it is difficult to
determine when antibiotics may be useful, based on physical findings
alone. Antibiotics may be beneficial in bacterial throat infections
under certain clinical and epidemiological circumstances; however,
even many of those infections in which bacteria play a role do resolve
just as quickly without antibiotics. Non-medical factors such as
patient expectations and patient pressure are also important drivers
of antibiotic use. To address these issues, a behavioral change is
required that can be facilitated by improved communication between
primary HCPs and patients. In this article, doctors, nurses and
pharmacy staff, working in primary care or in the community, with a
structured approach to sore throat management, and the aim of
educating empowered patients to self-manage their condition. The
first component of this approach involves identifying and addressing
patients' expectations and concerns with regard to their sore throat
and eliciting their opinion on antibiotics. The second part is dedicated
to a pragmatic assessment of the severity of the condition, with
attention to red-flag symptoms and risk factors for serious
complications. Rather than just focusing on the cause (bacterial or
viral) of the upper respiratory tract infections as a rationale for
antibiotic use, HCPs should instead consider the severity of the
patient's condition and whether they are at high risk of
complications. The third part involves counseling patients on
effective self-management options and providing information on the
expected clinical course. Such a structured approach to sore throat
management, using empathetic, non-paternalistic language,
combined with written patient information, will help to drive patient
confidence in self-care and encourage them to accept the self-
63
limiting character of the illness - important steps towards improving

antibiotic stewardship in acute throat infections (9).
Small changes in the wording of health related recommendations
about STDs can significantly influence their impact. In this paper,
advances in research investigating the content and structure of these
framed messages were review. The results of a recent longitudinal
study examining the effects of a brief risk awareness intervention
(i.e., a brochure) targeting young adults-the population at highest risk
of contracting STDs were summarized. Building on a leading theory
and emerging data, key aspects of the psychological processes that
underlie the impact of framed messages on prevention and detection
of STDs were reviewed, how these messages can be made more
influential when accompanied by visual aids and were detailed. This
review converges with other research indicating that well
constructed visual aids are often among the most highly effective,
transparent, and ethically desirable means of health risk
communication. Larger scale implementation of these and other
theory-based, custom-tailored methods holds the promise of
relatively inexpensive yet highly effective systems for promoting
prevention and detection of STDs (10).
Many hospitals are unable to successfully implement "evidence-
based practices" at the unit level. For example, consistent
implementation of the CLB, proven to prevent CRBSIs is often
difficult. This problem has been broadly characterized as "change
implementation failure" in health care organizations. Several studies
have used retrospective designs to examine the problem; however,
there are few prospective studies examining communication
dynamics underlying successful implementation of change (e.g.,
evidence-based practices). This prospective study will be set in 2 ICUs
at an academic medical center. At baseline, both units have low
compliance with CLB and higher-than-expected CRBSIs. Periodic QI
interventions will be conducted over a 52-week period to promote
implementation of CLB in both units. Simultaneously, the following
parameters will be examined: 1] Structure and content of
communication related to CLB in both units through "communication
logs" completed weekly by nurses, physicians, and managers; and 2]
outcomes, that is, CLB adherence in both units through weekly chart
review. Catheter utilization and CRBSI (infection) rates will serve as
additional unit-level outcome measures. The aim is 2-fold: 1] to
64
examine associations between QI interventions and structure and

content of communication at the unit level; and 2] to examine
associations between structure and content of communication and
outcomes at the unit level. The periodic QI interventions are
expected to increase CLB adherence and reduce CRBSIs through their
influence on structure and content of communication. The
prospective design would help examine dynamics in unit-level
communication structure and content related to CLB, as well as unit-
level outcomes. The study has potential to make significant
contributions to theory and practice, particularly if interventions are
effective in enabling successful practice change at the unit level. To
this effect, the study has potential to provide insights into
communication structure and content associated with collective
learning and culture change at the unit level. Results and insights are
expected to lay a foundation for generating context-sensitive
"evidence-based management" strategies for successful practice
change at the unit level. An ultimate expected deliverable is the
development of an "action-learning framework" for successful
implementation of evidence-based practices in health care
organizations (11).
In the HIV context, risky sexual behaviors can be reduced through
effective parent-adolescent communication. This study used the
Parent Adolescent Communication Scale to determine parent-
adolescent communication by ethnicity and identify predictors of
high parent-adolescent communication amongst South African
adolescents post-apartheid. A cross-sectional interviewer-
administered survey was administered to 822 adolescents from
Johannesburg, South Africa. The sample was predominantly Black
African (62%, n=506) and female (57%, n=469). Of the participants,
57% (n=471) reported high parent-adolescent communication.
Multivariate regression showed that gender was a significant
predictor of high parent-adolescent communication (Black African OR
1.47, CI 1.0-2.17, Indian OR 2.67, CI 1.05-6.77, and White OR 2.96, CI
1.21-7.18). Female-headed households were predictors of high
parent-adolescent communication amongst Black Africans (OR 1.49,
CI 1.01-2.20), but of low parent-adolescent communication amongst
Whites (OR 0.36, CI 0.15-0.89). Overall levels of parent-adolescent
communication in South Africa are low. HIV prevention programs for
65
South African adolescents should include information and skills

regarding effective parent-adolescent communication (12).
Patient retention in HIV care may be influenced by patient-
provider interactions. In an urban, academic HIV clinic, 1,363 patients
rated the quality of communication and relationships with their
providers on 5 domains. In multivariate analysis, patients kept more
appointments if providers treated them with dignity and respect,
listened carefully to them, explained in ways they could understand,
and knew them as persons. Being involved in decisions was
insignificantly associated with appointment adherence. Enhancing
providers' skills in effective communication and relationship building
may improve patient retention in HIV care (13).
Patient-centered care, including the domains of access and
communication, is an important determinant of positive clinical
outcomes. The objective of this study was to explore associations
between race and HIV-infected patients' experiences of access and
communication. This cross-sectional survey included 915 HIV-
infected adults receiving care at 14 US HIV clinics. Dependent
variables included patients' reports of travel time to their HIV care
site and waiting time to see their HIV provider (access) and ratings of
their HIV providers on always listening, explaining, showing respect,
and spending enough time with them (communication). Patients
traveled a median 30 minutes (range 1-180) and waited a median 20
minutes (range 0-210) to see their provider. On average, blacks and
Hispanics reported longer travel and wait times compared with
whites. Adjusting for HIV care site attenuated this association. HIV
care sites that provided services to a greater proportion of blacks and
Hispanics were more difficult to access for all patients. The majority
of patients rated provider communication favorably. Compared to
whites, blacks reported more positive experiences with provider
communication. In conclusion, racial disparities in patients'
experience of access to care but not in patient-provider
communication were observed. Disparities were explained by poor
access at minority-serving clinics. Efforts to make care more patient-
centered for minority HIV-infected patients should focus more on
improving access to HIV care in minority communities than on
improving cross-cultural patient-provider interactions (14).
66
References
1. Farin E. Patient-provider communication in chronic illness: current
state of research in selected areas. Rehabilitation (Stuttg). 2010;49(5):277-
91.
2. Farin E, Gramm L, Schmidt E. Predictors of communication preferences
in patients with chronic low back pain. Patient Prefer Adherence. 2013;
7:1117-27.
3. Hasenbring MI, Pincus T. Effective reassurance in primary care of low
back pain: what messages from clinicians are most beneficial at early stages
of LBP? Clin J Pain. 2014 Mar 21. [Epub of print].
4. Dirmaier J, Härter M, Weymann N. A tailored, dialogue-based health
communication application for patients with chronic low back pain: study
protocol of a randomised controlled trial. BMC Med Inform Decis Mak.
2013;13:66.
5. Street RL Jr, Richardson MN, Cox V, Suarez-Almazor ME.
(Mis)understanding in patient-health care provider communication about
total knee replacement. Arthritis Rheum. 2009;61(1):100-7.
6. Ullrich A, Hauer J, Farin E. Communication preferences in patients
with fibromyalgia syndrome: descriptive results and patient characteristics
as predictors. Patient Prefer Adherence. 2014;8:135-45.
7. Lyons KS, Jones KD, Bennett RM, et al. Couple perceptions of
fibromyalgia symptoms: the role of communication. Pain. 2013;154(11):
2417-26.
8. Butow P, Sharpe L. The impact of communication on adherence in pain
management. Pain. 2013;154 Suppl 1:S101-7.
9. van der Velden AW, Bell J, Sessa A, et al. Sore throat: effective
communication delivers improved diagnosis, enhanced self-care and more
rational use of antibiotics. Int J Clin Pract Suppl. 2013;180:10-6.
10. Garcia-Retamero R, Cokely ET. Advances in efficient health
communication: promoting prevention and detection of STDs. Curr HIV Res.
2012;10(3):262-70.
11. Rangachari P. Effective communication network structures for
hospital infection prevention: a study protocol. Qual Manag Health Care.
2013;22(1):16-24.
12. Coetzee J, Dietrich J, Otwombe K, et al. Predictors of parent-
adolescent communication in post-apartheid South Africa: a protective
factor in adolescent sexual and reproductive health. J Alzheimer's disease.
2014;37(3):313-24.
13. Flickinger TE, Saha S, Moore RD, Beach MC. Higher quality
communication and relationships are associated with improved patient
engagement in HIV care. J Acquir Immune Defic Syndr. 2013;63(3):362-6.
67
14. Korthuis PT, Saha S, Fleishman JA, et al. Impact of patient race on
patient experiences of access and communication in HIV care. J Gen Intern
Med. 2008;23(12):2046-52.
CARDIOVASCULAR DISEASES
Effective communication is critical for palliative and supportive
care in patients with heart failure. This article contains a review of
available information to assist clinicians in undertaking discussions
regarding prognosis, treatment decisions and advance care planning.
Emerging from a range of studies at the end of life is that patients
and their families appreciate honesty and do not want to be
abandoned by HCPs. The receptivity of patients and their careers to
information is highly variable, underscoring the importance of an
individualized approach. When having these difficult conversations,
clinicians need to assess the individual's need and wishes for
information as well as their social and cultural background. They also
need to consider the setting, timing and content of the discussion, as
well as strategies to promote coping and adjustment. Most
importantly, patients need a treatment plan to address palliative and
supportive care needs to be implemented at the time of breaking this
bad news, so that they and their families do not feel abandoned.
Learning effective communication skills, implementing strategies for
debriefing and the fostering of a team approach, may minimize
burden on HCPs and improve palliative and supportive care for
people with heart failure (1).
The purpose of this study was to examine the communication
preferences of patients with CIHD and matching between the
preferences and physician communication behavior. Prior to this,
psychometric testing was performed on a questionnaire on the
perceived communication behavior of the physician (KOVA
Questionnaire). Patients with CIHD undergoing rehabilitation
(n=342) in Germany were questioned. At the beginning of
rehabilitation, patients answered questions about their
communication preferences (KOPRA Questionnaire), and at the end
of rehabilitation, they answered questions regarding the perceived
communication behavior of the physician. Preference-matching
68
values were determined by combining the KOPRA and KOVA items.

The KOVA Questionnaire psychometric properties are proved to be
good. Patients with CIHD indicated clear and open communication
and patient participation were especially important. This was
followed by emotionally supportive communication and, finally,
communication about personal things. Overall, the behavior of
physicians corresponded quite closely with the patients'
communication preferences. However, preference matching was low
(the physicians demonstrated too little of the desired behavior)
regarding the open communication of bad news and explanation of
treatments. There was relatively high fulfillment of expectations on
the part of patients in terms of seeking information from the
physician, the physician's explanation of the diagnosis, and regarding
aspects of shared decision-making. Gender differences were not
observed, although age-group differences were identified. In
conclusion, the instruments developed (KOPRA and KOVA
questionnaires) can be used for communication studies of patients
with chronic conditions. However, some patient communication
needs seem to require greater consideration from physicians (2).
Many heart failure patients have palliative care needs, but
communication about prognosis and end-of-life care is lacking. Heart
failure nurses can play an important role in such communication. This
study aims to describe heart failure nurses' perspectives on, and daily
practice regarding, discussing prognosis and end-of-life care with
heart failure patients in outpatient care. It further aims to explore
barriers, facilitators and related factors for discussing these issues. A
national survey including nurses from outpatient clinics and primary
health care centers was performed. Data was collected using a
questionnaire on communication with heart failure patients about
prognosis and end-of-life care. In total, 111 (82%) of the heart failure
nurses completed the questionnaire. Most of them reported that
physicians should have the main responsibility for discussing
prognosis (69%) and end-of-life care (67%). Most nurses felt
knowledgeable to have these discussions, but 91% reported a need
for further training in at least one of the areas. Barriers for
communication about prognosis and end-of-life care included the
unpredictable trajectory of heart failure, patients' comorbidities and
the opinion that patients in NYHA class II-III are not in the end-of-life.
In conclusion: although heart failure nurses feel competent
69
discussing prognosis and end-of-life care with the heart failure

patient, they are hesitant to have these conversations. This might be
partly explained by the fact that they consider the physician to be
responsible for such conversations, and by perceived barriers to
communication. This implies a need for clinical policy and education
for heart failure nurses to expand their knowledge and awareness of
the patients' possible needs for palliative care (3).
Communication with heart failure patients about their condition
and wishes for end-of-life care is recommended in all heart failure
guidelines. The aims of this study were to: 1] identify whether
hospitalized heart failure patients want to communicate regarding
disease management, prognosis and resuscitation wishes, and 2] to
identify the relationship of communication with clinical variables and
QOL. Hospitalized heart failure patients (n=47) were asked: 1) Did
they want more information about their heart failure 2) Did they
want to discuss their prognosis? 3) Did they discuss their
resuscitation wishes since being hospitalized? Patients' mean age
was 62.8 ± 17.0, mean QOL score was 29.4 (0-100) and approximately
half (n=22, 47%) were re-hospitalized within 3 months. Twenty-eight
(62%) wanted more information regarding disease self-management
while 20 (44%) wanted more communication regarding their
prognosis. Twenty-four (51%) did not recall a conversation about
resuscitation during their hospitalization. Multivariate analysis
showed patients who wanted more heart failure information were
4.4 times more likely to have better NYHA class (p=0.02). Patients
wanting more communication about their prognosis were more than
4 times more likely to experience future rehospitalizations (p=0.03).
In conclusion, the majority of patients desired more information
about heart failure. A minority had not discussed issues around
prognosis, despite their desire to do so. HCPs are encouraged to
communicate with heart failure patients about self-management
when patients are less symptomatic (4).
End-of-life communication is lacking despite patients with heart
failure and their caregivers desiring it. The aim of this study was to
review the existing literature to identify barriers that inhibit end-of-
life communication in the heart failure population. An integrative
literature review method was chosen and began by searching
CINAHL, Medline, PsychInfo, Web of Science, Health Source Nursing
Academic, EBMR, dissertations and theses searches through the
70
University of Victoria and through Proquest from 1995 to 2011. End-

of-life communication regarding wishes, prognosis and options for
care rarely happen. Patients who lacked understanding of heart
failure, feared engaging HCP, did not wish to talk about end-of-life, or
waited for HCPs to initiate the conversation. HCPs lacked
communication skills, focused on curative therapies and found
diagnosing and prognosticating heart failure difficult. Limited time
and space for conversations played a role. In conclusion, the
challenge of diagnosing and prognosticating heart failure, its
unpredictable trajectory, HCP inexperience in recognizing nearing
end-of-life and lack of communication skills lead to HCPs avoiding
end of life conversations. Four categories of barriers to
communication were identified: patient/caregiver, HCP, disease-
specific and organizational challenges (5).
The aim of this study was to review the literature concerning
conversations about end-of-life care between patients with heart
failure and HCPs, with respect to the prevalence of conversations;
patients' and practitioners' preferences for their timing and content;
and the facilitators and blockers to conversations. This systematic
literature review and narrative synthesis includes searches of
Medline, PsycINFO and CINAHL databases from January 1987 to April
2010, with citation and journal hand searches. Studies of adult
patients with heart failure and/or their HCPs concerning discussions
of end-of-life care were included: discussion and opinion pieces were
excluded. Extracted data were analyzed using NVivo, with a narrative
synthesis of emergent themes. Conversations focus largely on
disease management; end-of-life care is rarely discussed. Some
patients would welcome such conversations, but many do not realize
the seriousness of their condition or do not wish to discuss end-of-
life issues. Clinicians are unsure how to discuss the uncertain
prognosis and risk of sudden death; fearing causing premature alarm
and destroying hope, they wait for cues from patients before raising
end-of-life care issues. Consequently, the conversations rarely take
place. In conclusion, prognostic uncertainty and high risk of sudden
death lead to end-of-life-care conversations being commonly
avoided. The implications for policy and practice are discussed: such
conversations can be supportive if expressed as 'hoping for the best
but preparing for the worst' (6).
71
Physicians are frequently unaware of patient preferences for end-

of-life care. Identifying and exploring barriers to patient-physician
communication about end-of-life issues may help guide physicians
and their patients toward more effective discussions. The objective of
this study was to examine correlates and associated outcomes of
patient communication and patient preferences for communication
with physicians about CPR and prolonged mechanical ventilation.
This prospective cohort study was conducted at 5 tertiary care
hospitals. Of 2,162 eligible patients, 1,832 (85%) completed
interviews. Surveys of patient characteristics and preferences for
end-of-life care; perceptions of prognosis, decision-making, and QOL;
and patient preferences for communication with physicians about
end-of-life decisions were studied. Less than one-fourth (23%) of
seriously ill patients had discussed preferences for CPR with their
physicians. Of patients who had not discussed their preferences for
resuscitation, 58% were not interested in doing so. Of patients who
had not discussed and did not want to discuss their preferences, 25%
did not want resuscitation. In multivariable analyses, patient factors
independently associated with not wanting to discuss preferences for
CPR included being of an ethnicity other than black (AOR 1.48, 95% CI
1.10-1.99), not having an advance directive (OR 1.35, 95% CI 1.04-
1.76), estimating an excellent prognosis (OR 1.72, 95% CI 1.32-2.59),
reporting fair to excellent QOL (OR 1.36, 95% CI 1.05-1.76), and not
desiring active involvement in medical decisions (OR 1.33, 95% CI
1.07-1.65). Factors independently associated with wanting to discuss
preferences for CPR but not doing so included being black (OR 1.53,
95% CI 1.11-2.11), and being younger (OR 1.14 per 10-year interval
younger, 95% CI 1.04-1.25). In conclusion, among seriously ill-
hospitalized adults, communication about preferences for CPR is
rare. A majority of patients who have not discussed preferences for
end-of-life care do not want to do so. For patients who do not want
to discuss their preferences, as well as patients with an unmet need
for such discussions, failure to discuss preferences for CPR and
mechanical ventilation may result in unwanted interventions (7).
72
References
1. Davidson PM. Difficult conversations and chronic heart failure: do you
talk the talk or walk the walk? Curr Opin Support Palliat Care. 2007;1(4):274-
8.
2. Farin E, Gramm L, Schmidt E. The congruence of patient
communication preferences and physician communication behavior in
cardiac patients. J Cardiopulm Rehabil Prev. 2011;31(6):349-57.
3. Hjelmfors L, Strömberg A, Friedrichsen M, et al. Communicating
prognosis and end-of-life care to heart failure patients: A survey of heart
failure nurses' perspectives. Eur J Cardiovasc Nurs. 2014;13(2):152-61.
4. Howie-Esquivel J, Dracup K. Communication with hospitalized heart
failure patients. Eur J Cardiovasc Nurs. 2012;11(2):216-22.
5. Garland EL, Bruce A, Stajduhar K. Exposing barriers to end-of-life
communication in heart failure: an integrative review. Can J Cardiovasc
Nurs. 2013;23(1):12-8.
6. Barclay S, Momen N, Case-Upton S, et al. End-of-life care
conversations with heart failure patients: a systematic literature review and
narrative synthesis. Br J Gen Pract. 2011;61(582):e49-62.
7. Hofmann JC, Wenger NS, Davis RB, et al. Patient preferences for
communication with physicians about end-of-life decisions. SUPPORT
Investigators. Study to understand prognoses and preference for outcomes
and risks of treatment. Ann Intern Med. 1997;127(1):1-12.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

COPD is a leading cause of mortality and disability worldwide. For
many patients, maximal therapy for COPD produces only modest
relief of disabling symptoms and these symptoms result in a
significantly reduced QOL. Despite the high morbidity and mortality,
patients with COPD do not receive adequate palliative care. One
reason these patients may receive poor quality palliative care is that
patient-physician communication about palliative and end-of-life care
is unlikely to occur. The purpose of this review is to summarize recent
research regarding patient-physician communication about palliative
care for patients with COPD. Understanding the barriers to this
communication may be an important step to improving
communication about end-of-life care and improving patient-
centered outcomes. Two areas that may influence the quality of care
received by patients with COPD are highlighted: 1] the role of
73
depression, a common problem in patients with COPD, in physician-

patient communication; and 2] the role of advance care planning in
this communication (1).
Patients with COPD frequently do not discuss end-of-life care with
physicians; therefore, the aim of this study was to identify the
barriers and facilitators to this communication as a first step to
overcoming barriers and capitalizing on facilitators. Fifteen barriers
and 11 facilitators to patient-physician communication about end-of-
life care were generated from focus groups of patients with COPD. A
cross-sectional study of 115 patients with oxygen-dependent COPD
and their physicians was conducted to identify the common barriers
and facilitators and examine the association of these barriers and
facilitators with communication about end-of-life care. Patients with
oxygen-dependent COPD were recruited from clinics at a university,
county, and Veterans Affairs teaching hospital, and an oxygen
delivery company. The physician was identified by each patient as
primarily responsible for their lung disease. Patients were
interviewed by trained research interviewers. Physician data
collection was completed by mail survey. Participation rates were
40% for patients and 86% for physicians. Only 32% of patients
reported discussing end-of-life care with their physician. Two of 15
barriers and 8 of 11 facilitators were endorsed by >50% of patients.
The most commonly endorsed barriers were "I'd rather concentrate
on staying alive," and "I'm not sure which doctor will be taking care
of me." Two barriers were significantly associated with lack of
communication, as follows: "I don't know what kind of care I want,"
and "I'm not sure which doctor will be taking care of me." The greater
the number of barriers endorsed by patients, the less likely they were
to have discussed end-of-life care with physicians (p<0.01),
suggesting the validity of these barriers. Conversely, the more
facilitators, the more likely patients were to report having had end-
of-life discussions with their physicians (p<0.001). In conclusion,
although patients endorsed many barriers and facilitators, few
barriers were endorsed by most patients. Barriers and facilitators
associated with communication are targets for interventions to
improve end-of-life care, but such interventions will need to address
the specific barriers relevant to individual patient-physician pairs (2).
74
References
1. Curtis JR, Engelberg RA, Wenrich MD, Au DH. Communication about
palliative care for patients with chronic obstructive pulmonary disease. J
Palliat Care. 2005;21(3):157-64.
2. Knauft E, Nielsen EL, Engelberg RA, et al. Barriers and facilitators to
end-of-life care communication for patients with COPD. Chest. 2005;
127(6):2188-96.
AIDS PATIENTS
The objective of this study was to perform a qualitative study
using focus groups to identify barriers and facilitators to
communication about end-of-life medical care for patients with AIDS
and their physicians. Patients with AIDS and physicians with
moderate or extensive HIV experience were recruited from clinics
and community-based settings using network sampling. A total of 47
patients participated in 6 focus groups and 19 physicians participated
in 3 groups. Patients or physicians identified 29 barriers and
facilitators to communication about end-of-life care. Many patients
and physicians expressed discomfort talking about death and dying,
and some felt that discussing end-of-life care could cause harm or
even hasten death. Several patients expressed the view that a living
will obviated the need for discussion with their physician. Previous
experience of discrimination from the health care system was a
strong barrier to end-of-life communication for some patients with
AIDS. Some patients hesitate to bring up end-of-life issues because
they want to protect their physicians from uncomfortable
discussions. Many patients identified the quality of communication as
an important facilitator to these difficult discussions. In conclusion,
improving the quality of patient-physician communication about end-
of-life care will require that physicians identify and overcome the
barriers to this communication. To improve the quality of medical
care at the end of life, we must address the quality of communication
about end-of-life care (1).
Patients with chronic and terminal disease frequently do not talk
to their physicians about end-of-life care. Interventions to improve
this communication have generally been unsuccessful, suggesting
75
that important barriers to this communication must exist. The

objective of this study was to determine the barriers to and
facilitators of patient-clinician communication about end-of-life care
and to identify barriers and facilitators that are more common among
those patients who are least likely to discuss end-of-life care:
minorities and injection drug users. A prospective study of 57
patients with advanced AIDS and their primary care clinicians who
were recruited from university and private clinics was conducted.
Barriers to and facilitators of end-of-life communication were
identified from a prior qualitative study and assessed for frequency
and importance and for an association with the occurrence and
quality of end-of-life communication. Clinicians identified more
barriers than patients did. Barriers identified by patients and
clinicians fell into 3 categories of potential interventions: education
about end-of-life care, counseling to help address end-of-life
concerns, and health care system changes to facilitate patient-
clinician communication. Although none of the patient-identified
barriers was associated with the occurrence of communication, 2
clinician-identified barriers were associated with less communication:
"the patient has not been very sick yet" and "the patient isn't ready
to talk about end-of-life care." Nonwhite patients were more likely to
identify the following 2 barriers than white patients: "I feel that if I
talk about death, it could bring death closer" and "I don't like to talk
about the care I want if I get very sick." In conclusion, the diversity of
barriers and facilitators relevant to patients with AIDS and their
clinicians suggests that interventions to improve communication
about end-of-life care must be focused on individual needs and must
involve counseling interventions and health system changes in
addition to education. Clinician barriers are more common and more
strongly associated with the occurrence of end-of-life communication
than patient barriers, suggesting that clinicians are an important
target group for improving this communication (2).
Reference
1. Curtis JR, Patrick DL. Barriers to communication about end-of-life care
in AIDS patients. J Gen Intern Med. 1997;12(12):736-41.
2. Curtis JR, Patrick DL, Caldwell ES, Collier AC. Why don't patients and
physicians talk about end-of-life care? Barriers to communication for
patients with acquired immunodeficiency syndrome and their primary care
clinicians. Arch Intern Med. 2000;160(11):1690-6.
76
DEMENTIA
Empathic curiosity is a standpoint that we adopt when we focus
our attention on the perceptual experiences of people with
dementia, as they are experiencing them in the here and now.
Adopting an empathic and curious stance may help to establish the
common ground for meaningful communication and help to cultivate
relationships that are based upon equality and common
understanding, rather than power and dependency. Four key sets of
communication skills can support this approach: 1] asking short open
questions in the present tense; 2] picking up on emotional cues; 3]
giving time and space for the person with dementia to find their
words and share responsibility for steering the course of a
conversation; and 4] exploring the use of metaphors. Providing
access to training and supervision that supports these
communication skills may be an essential element of building an
informed and effective dementia care workforce (1).
Over the past two decades the advocates of person-centered
approaches to dementia care have consistently argued that some of
the negative impacts of dementia can be ameliorated in supportive
social environments and they have given lie to the common but
unfounded, nihilistic belief that meaningful engagement with people
with dementia is impossible. This discussion paper contributes to this
welcome trend by exploring how careers can use empathic curiosity
to establish the common ground that is necessary to sustain
meaningful engagement with people who have mild to moderate
dementia. The first section of the paper gives a brief theoretical
introduction to the concept of empathic curiosity, which is informed
by perceptual control theory and applied linguistics. Three case
examples taken from the literature on dementia care are then used
to illustrate what empathic curiosity may look like in practice and to
explore the potential impact that adopting an empathic and curious
approach may have (1).
Caring for and caring about people with dementia require specific
communication skills. HCPs and family caregivers usually receive little
training to enable them to meet the communicative needs of people
with dementia. This review identifies existent interventions to
enhance communication in dementia care in various care settings.
MEDLINE, AMED, EMBASE, PsychINFO, CINAHL, The Cochrane
77
Library, Gerolit, and Web of Science for scientific articles reporting

interventions in both English and German were searched. An
intervention was defined as communication skills training by means
of face-to-face interaction with the aim of improving basic
communicative skills. Both professional and family caregivers were
included. The effectiveness of such training was analyzed. Different
types of training were defined. Didactic methods, training content,
and additional organizational features were qualitatively examined.
This review included 12 trials totaling 831 persons with dementia,
519 professional caregivers, and 162 family caregivers. Most studies
were carried out in the USA, the UK, and Germany. Eight studies took
place in nursing homes; 4 studies were located in a home-care
setting. No studies could be found in an acute-care setting. A list of
basic communicative principles for good communication in dementia
care is provided. Didactic methods included lectures, hands-on
training, group discussions, and role-play. In conclusion, this review
shows that communication skills training in dementia care
significantly improves the QOL and wellbeing of people with
dementia and increases positive interactions in various care settings.
Communication skills training shows significant influence on
professional and family caregivers' communication skills,
competencies, and knowledge. Additional organizational features
improve the sustainability of communication interventions (2).
Alzheimer's disease is a progressive degenerative neurogenic
disease that is more prevalent among the old than the young. The
primary symptoms are forgetfulness, repetitiousness, losing one's
way, and the loss of ability to perform complex tasks on the job.
Diagnostic confirmation of Alzheimer's disease is determined by
autopsy. As of this writing, there is no specific drug that can stop or
reverse the disease. Medical management is focused on treating
behavioral symptoms and managing the individual's general well-
being. The communication needs of the Alzheimer's client depend on
the individual's level of cognition, degree of independence,
circumstance, and communicative abilities. Due to their poor
rehabilitation potential, the majority of persons with Alzheimer's
disease are not suitable candidates for traditional therapy programs.
An alternative to traditional therapies is the Tri-Model system. The
Tri-Model philosophy of rehabilitation and service delivery systems
lends itself readily to the needs of the dementia client because the
78
model is designed to maintain the continuum of rehabilitation care

for individuals with "red flag" diagnoses such as dementia.
Establishing a treatment protocol based on the Tri-Model philosophy
of rehabilitation not only assures the individual treatment based on
his or her level of functional ability and rehabilitation need, it
provides a framework for the rehabilitation specialist to use as
reference for the various stages of disability and change during
rehabilitation. The Tri-Model System is a decision tree which allows
movement in any direction according to the client's needs. Clients,
staff, and families are encouraged to set realistic goals at the outset
of the rehabilitation program. By delineating 3 overlapping phases in
the recovery process a base is established which allows the
rehabilitation professional to appropriately follow the client after
discharge and maintain the continuum of care. Since each restorative
phase in the system requires the design of restorative programs
which address that particular phase of the rehabilitation process and
cooperation of an interdisciplinary team, addressing all 3 phases of
rehabilitation at the time of the initial evaluation maintains the
continuity of the client's treatment protocol throughout the course of
the disease. Inclusion of Restorative III (functional maintenance)
assures the continuum of care. The strength of the Tri-Model
philosophy and system of rehabilitation is the inclusion of the
definition and delineation of functional maintenance, the most
neglected and for many clients the most important part of a
complete rehabilitation program. When an incomplete definition of
rehabilitation is used, questions regarding the efficacy of treatment is
common (3,4).
Communication problems stemming from Alzheimer's disease
often result in misunderstandings that can be linked with problem
behaviors and increased caregiver stress. These communication
breakdowns can result either from caregivers' use of ineffective
communication strategies, which paradoxically are perceived as
helpful, or can occur because of not using effective communication
strategies that are perceived as unhelpful. The two primary aims
were to determine the effectiveness of strategies used to resolve
communication breakdowns and to examine whether caregivers'
ratings of strategy effectiveness were consistent with evidence from
video-recorded conversations and with effective communication
strategies documented in the literature. Twenty-eight mealtime
79
conversations were recorded using a sample of 15 dyads consisting of

individuals with early, middle and late clinical-stage Alzheimer's
disease and their family caregivers. Conversations were analyzed
using the trouble-source repair paradigm to identify the
communication strategies used by caregivers to resolve breakdowns.
Family caregivers rated the helpfulness of communication strategies
used to resolve breakdowns. Analyses were conducted to assess the
overlap or match between the use and appraisals of the helpfulness
of communication strategies. Matched and mismatched appraisals of
communication strategies varied across stages of Alzheimer's
disease. Matched appraisals by caregivers of persons with early-stage
Alzheimer's disease were observed for 68% of 22 communication
strategies, whereas caregivers of persons with middle- and late-stage
Alzheimer's disease had matched appraisals for 45% and 55% of the
strategies, respectively. Moreover, caregivers of persons with early-
stage Alzheimer's disease had matched appraisals over and above
making matched appraisals by chance alone, compared with
caregivers of persons in middle- and late-stage Alzheimer's disease.
Mismatches illustrate the need for communication education and
training, particularly to establish empirically derived evidence-based
communication strategies over the clinical course of Alzheimer's
disease (5).
Communication difficulties between individuals with Alzheimer's
disease and their caregivers are commonly reported. Caregivers carry
the burden of managing breakdowns in communication because
people with Alzheimer's disease are often unable to modify their
communicative behavior. To assist caregivers in this endeavor,
clinicians and care giving professionals have offered a variety of
strategies aimed at accommodating the individual's declining
abilities. Many of these strategies are intuitively appealing, but they
lack empirical support. This study investigated the effectiveness of 10
frequently recommended communication strategies when employed
by family caregivers of persons with Alzheimer's disease. In
particular, 1] which strategies family caregivers report using and with
what degree of success, 2] which of these strategies are used by
caregivers in actual interactions with their spouses, and 3] which
strategies contribute to improved communication were assessed. The
study included a self-report questionnaire and wireless audio-
recorded interactions between 18 persons with Alzheimer's disease
80
and their spousal caregivers during activities of daily living. The

findings validate the effectiveness of certain communication
strategies (e.g., simple sentences) but not others (e.g., slow speech).
The results should be of interest to both family members and
professionals who want to enhance communication and the quality
of their interactions with persons with Alzheimer's disease (6).
References
1. McEvoy P, Plant R. Dementia care: using empathic curiosity to
establish the common ground that is necessary for meaningful
communication. J Psychiatr Ment Health Nurs. 2014 Mar 21. doi:
10.1111/jpm.12148. [Epub ahead of print]
2. Eggenberger E, Heimerl K, Bennett MI. Communication skills training
in dementia care: a systematic review of effectiveness, training content, and
didactic methods in different care settings. Int Psychogeriatr. 2013;25(3):
345-58.
3. Glickstein JK, Neustadt. In: Essentials of Speech, Language, and
Hearing Disorders. Franklin H. Silverman (ed.). Atomic Dog Publishing,
Incorporated, Dec 1, 2003.
4. Glickstein JK, Neustadt GK. Speech-language interventions in
Alzheimer's disease. A functional communication approach. Clin Commun
Disord. 1993;3(1):15-30.
5. Savundranayagam MY, Orange JB. Matched and mismatched
appraisals of the effectiveness of communication strategies by family
caregivers of persons with Alzheimer's disease. Int J Lang Commun Disord.
2014;49(1):49-59.
6. Small JA, Gutman G, Makela S, Hillhouse B. Effectiveness of
communication strategies used by caregivers of persons with Alzheimer's
disease during activities of daily living. J Speech Lang Hear Res. 2003;46(2):
353-67.
81
MENTAL HEALTH NURSING

Communication has been identified as an important attribute of
clinical leadership in nursing. This article presents the findings of a
grounded theory informed study exploring the attributes and
characteristics required for effective clinical leadership in mental
health nursing, specifically the views of nurses working in mental
health about the importance of effective communication in day-to-
day clinical leadership. In-depth interviews were conducted to gain
insight into the participants' experiences and views on clinical
leadership in mental health nursing. The data that emerged from
these interviews were constantly compared and reviewed, ensuring
that any themes that emerged were based on the participants' own
experiences and views. Participants recognized that effective
communication was one of the attributes of effective clinical
leadership and they considered communication as essential for
successful working relationships and improved learning experiences
for junior staff and students in mental health nursing. Four main
themes emerged: choice of language; relationships; non-verbal
communication, and listening and relevance. Participants identified
that clinical leadership in mental health nursing requires effective
communication skills, which enables the development of effective
working relationships with others that allows them to contribute to
the retention of staff, improved outcomes for clients, and the
development of the profession (1).
Communication is an integral component of nursing education
that improves health outcomes, patient compliance, and patient
satisfaction. Psychiatric nursing emphasizes knowledge and
utilization of communication skills. Nursing students often express
anxiety and lack of confidence regarding communicating with
patients diagnosed with psychiatric illnesses. Human patient
simulation is one method that may be used for students to practice
and become proficient with communication skills in a simulated
environment (2).
The aim of this research was to explore mental health clinicians'
experiences and perceptions of discussing a diagnosis of
schizophrenia with their patients. The results of this research will
inform a communication skills training program for psychiatry
trainees. Semistructured interviews were conducted with 16 mental
82
health clinicians from public mental health services in New South

Wales, Australia. Interviews were recorded and transcribed for
qualitative analysis. Although most clinicians supported the need to
give patients a named diagnosis of schizophrenia, most gave multiple
reasons for not doing so in practice. The reasons given centered on
concerns for the patient; they included fear of making an incorrect
diagnosis, fear of the patient's distress, and harm from stigma.
Mental health clinicians need to reflect on their own feelings,
examine personal identification with their patients, and recognize the
subtle interplay of hope and pessimism in their communication of a
schizophrenia diagnosis (3).
References
1. Ennis G, Happell B, Broadbent M, Reid-Searl K. The importance of
communication for clinical leaders in mental health nursing: the perspective
of nurses working in mental health. Issues Ment Health Nurs. 2013;34(11):
814-9.
2. Kameg K, Mitchell AM, Clochesy J, et al. Communication and human
patient simulation in psychiatric nursing. Issues Ment Health Nurs. 2009;
30(8):503-8.
3. Outram S, Harris G, Kelly B, et al. Communicating a schizophrenia
diagnosis to patients and families: a qualitative study of mental health
clinicians. Psychiatr Serv. 2014;65(4):551-4.
PEDIATRICS
Pediatricians spend a considerable proportion of their time
performing follow-up visits for children with chronic conditions, but
they rarely receive specific training on how best to perform such
consultations. The traditional method of running a follow-up
consultation is based on the doctor's agenda, and is problem-
oriented. Patients and parents, however, prefer a patient-centered
and solution-focused approach. Although many physicians recognize
the importance of addressing the patient's perspective in a follow-up
consultation, a number of barriers hamper its implementation in
practice, including time constraints, lack of appropriate training, and
a strong tradition of the biomedical, doctor-centered approach.
Addressing the patient's perspective successfully can be achieved
83
through shared decision-making, clinicians and patients making

decisions together based on the best clinical evidence. Research
shows that shared decision making not only increases patient,
parent, and physician satisfaction with the consultation, but also may
improve health outcomes. Shared decision-making involves building a
physician-patient-parent partnership, agreeing on the problem at
hand, laying out the available options with their benefits and risks,
eliciting the patient's views and preferences on these options, and
agreeing on a course of action. Shared decision-making requires
specific communication skills, which can be learned, and should be
mastered through deliberate practice (1).
Physician behavior is an important but understudied influence on
child and parental adherence to medical treatment. To address this
need, this research reviewed the following topic areas: child and
adolescent perceptions of physicians' behavior in pediatric chronic
illness management, parental perceptions of physicians' behavior in
pediatric chronic illness management; physicians' adherence to
guidelines for pediatric chronic illness management; physicians'
communication of information concerning pediatric chronic illness
treatment; the relationship of physician behavior to treatment
adherence; and interventions to enhance physicians' management of
pediatric chronic illness. Findings underscore discrepancies between
the needs of parents and adolescents and physician behavior as well
as inconsistencies in physician behavior, including adherence to
practice guidelines, which may limit children's adherence to medical
treatment. However, results of interventions designed to enhance
physicians' management of pediatric asthma have been promising. In
conclusion, future research should be guided by a comprehensive
model of physician behavior in chronic illness management that
considers contextual determinants (e.g., culture and socioeconomic
status), identifies clinically relevant targets for intervention, and
documents the impact on health outcomes. Approaches to chronic
illness management that involve physicians in active communication,
support, and decision making with children with chronic illness and
their parents should be developed and evaluated (2).
Over 8% of children have a chronic disease and many are unable
to adhere to treatment. Satisfaction with chronic disease care can
impact adherence. How visit satisfaction is associated with physician
communication style and ongoing physician-family relationships was
84
examined. Surveys and visit videos for 75 children ages 9-16 years
visiting for asthma, diabetes, or sickle cell disease management were
collected. Raters assessed physician communication style
(friendliness, interest, responsiveness, and dominance) from visit
videos. Quality of the ongoing relationship was measured with 4
survey items (parent-physician relationship, child-physician
relationship, comfort asking questions, and trust in the physician),
while a single item assessed satisfaction. Satisfaction was positively
associated with physician and parent friendliness (p<0.05), the
quality of the ongoing parent-physician (p<0.001) and child-physician
relationships (p<0.05), comfort asking questions (p<0.001), and trust
(p<0.01). Both the communication style and the quality of the
ongoing relationship contribute to pediatric chronic disease visit
satisfaction (3).
Communication skills and relational abilities are essential core
competencies that are associated with improved health outcomes,
better patient adherence, fewer malpractice claims, and enhanced
satisfaction with care. Yet, corresponding educational opportunities
are sorely underrepresented and undervalued. The main objective of
this study was to evaluate the impact of an interdisciplinary
experiential learning paradigm to improve communication skills and
relational abilities of pediatric critical care practitioners. This Prepost
design, including baseline, immediate follow-up and 5-month self-
report questionnaires was conducted at Tertiary care pediatric
hospital, Boston Children's Hospital. Participants included 106
interdisciplinary clinicians with a range of experience levels and
clinical specialties. Participants rated their sense of preparation,
communication and relational skills, confidence, and anxiety. Open-
ended questions asked participants about lessons learned, aspects of
the training they found most helpful, and suggestions to improve the
training. When questions were posed in a yes/no format,
participants were nearly unanimous (93% to 98%) that the training
had improved their sense of preparation, communication skills, and
confidence immediately after and 5 months posttraining. Ninety
percent of participants reported improvements in establishing
relationships immediately after the training and 84% reported
improvements 5 months posttraining. Eighty-two percent reported
reduced anxiety immediately after training and 74% experienced
reduced anxiety 5 months posttraining. On Likert items, 70%
85
estimated their preparation had improved; 40% to 70% reported

improvements in communication skills, confidence and anxiety, and
15% in relationship skills. Four qualitative themes emerged:
identifying one's existing competence; integrating new
communication skills and relational abilities; appreciating
interdisciplinary collaboration; and valuing the learning itself. In
conclusion, a 1-day experiential learning paradigm focused on
communication skills and relational abilities was highly valued,
clinically useful, and logistically feasible. Participants reported better
preparation, improved communication and relational skills, greater
confidence, and reduced anxiety. Participants deepened their
understanding of family perspectives, recognized valuable existing
competencies, and strengthened their commitment to
interdisciplinary teamwork (4).
Pediatric patients with health conditions requiring follow-up
typically depend on a caregiver to mediate at least part of the
necessary 2-way communication with HCPs on their behalf. HIT and
its subset, ICT, are increasingly being applied to facilitate
communication between HCP and caregiver in these situations.
Awareness of the extent and nature of published research involving
HIT interventions used in this way is currently lacking. This scoping
review was designed to map the health literature about HIT used to
facilitate communication involving HCPs and caregivers (who are
usually family members) of pediatric patients with health conditions
requiring follow-up. Terms relating to care delivery, information
technology, and pediatrics were combined to search MEDLINE,
EMBASE, and CINAHL for the years 1996 to 2008. Eligible studies
were selected after 3 rounds of duplicate screening in which all
authors participated. Data regarding patient, caregiver, health care
provider, HIT intervention, outcomes studied, and study design were
extracted and maintained in a Microsoft Access database. Stage of
research was categorized using the UK's MRC framework for
developing and evaluating complex interventions. Quantitative and
qualitative descriptive summaries are presented. Of 104 eligible
studies (112 articles) conducted in 17 different countries, 30 different
health conditions were included. The most common conditions were
asthma, type 1 diabetes, special needs, and psychiatric disorder.
Most studies (88, 85%) included children 2 to 12 years of age, and 73
(71%) involved home care settings. HCP operated in hospital settings
86
in 96 (92%) of the studies. Interventions featured 12 modes of

communication (e.g., Internet, intranets, telephone, video
conferencing, e-mail, short message service [SMS], and manual
downloading of information) used to facilitate 15 categories of
functions (e.g., support, medication management, education, and
monitoring). Numerous patient, caregiver, and health care relevant
outcomes have been measured. Most outcomes concerned
satisfaction, use, usability, feasibility, and resource use, although
behavior changes and QOL were reported. Most studies (57 studies,
55%) were pilot phase, with a lesser proportion of development
phase (24 studies, 23%) and evaluation phase (11 studies, 11%)
studies. HIT interventions addressed several recurring themes in this
review: establishing continuity of care, addressing time constraints,
and bridging geographical barriers. In conclusion, HIT used in
pediatric care, involving caregivers, has been implemented
differently in a range of disease settings, with varying needs
influencing the function, form and synchronicity of information
transfer. Although some authors have followed a phased approach to
development, evaluation and implementation, a greater emphasis on
methodological standards such as the MRC guidance for complex
interventions would produce more fruitful programs of development
and more useful evaluations in the future (5).
This study investigated physician-parent communication styles
and the effects of concordance between parent's desired
communication styles and the communication style exhibited by
physicians. Subjects were 107 parents of children scheduled for an
appointment with a pediatrician at a general medical clinic. Parents
and physicians completed rating forms indicating the degree to which
parents desired each of 4 communication styles (information giving,
interpersonal sensitivity, partnership, and directing one's own
treatment). Parents and physicians also rated the degree to which
they believed the physician exhibited each of these 4 styles. Follow-
up interviews with parents assessed the level of satisfaction with the
visit, perception that parent's concerns had been addressed, and
subsequent telephone calls to the physician. Results indicated that
physicians underestimated the degree of interaction desired by the
parents. Parent desires for particular communication styles were not
predicted by characteristics of the parents. Interaction variables
87
predicted parent perceptions and subsequent need for contact with

the physician (6).
In addition to their physical challenges, children and adolescents
with IBD living in the United States face a number of administrative
and regulatory hurdles that affect their QOL. This article, written by a
physician, attorney/patient advocate, and social worker, discusses a
number of these challenges and describes how the provider can help
his or her patient overcome them. Specifically, the article discusses 4
areas in detail: appeals of denials of coverage from insurance
companies and third party payers; assisting children with IBD with
classroom and school accommodations; assisting uninsured children
in obtaining Social Security benefits; and aiding a parent to care for
their child using the Family and Medical Leave Act. Although this
article has a pediatric focus, results have similar advocacy needs.
Case examples and sample letters to third-party payers, schools, and
employers are included in this article (7).
Medical non-adherence has been termed the "Achilles' heel of
modern healthcare." In considering the need to improve medical
adherence among chronically ill children, it is necessary to
understand parent non-adherence. Parents have been acknowledged
the primary socialization agents in children's development across the
various domains of functioning. Through communication of their
beliefs, the behavior they model, and direct training, parents exert a
powerful influence on the development of children's beliefs and
behavior. Non-adherence may be similarly conceptualized as a
socialization process, in which parents influence the development of
children's beliefs and behavior regarding their eventual disease self-
management. Given this perspective, it is important for clinicians to
emphasize the need for parental adherence to a child's treatment
regimen (8).
The main objective of this study was to investigate the association
between autistic traits and emotion recognition in a large community
sample of children using facial and social motion cues, additionally
stratifying by gender. A general population sample of 3,666 children
from the Avon Longitudinal Study of Parents and Children (ALSPAC)
were assessed on their ability to correctly recognize emotions using
the faces subtest of the Diagnostic Analysis of Non-Verbal Accuracy,
and the Emotional Triangles Task, a novel test assessing recognition
of emotion from social motion cues. Children with autistic-like social
88
communication difficulties, as assessed by the Social Communication

Disorders Checklist, were compared with children without such
difficulties. Autistic-like social communication difficulties were
associated with poorer recognition of emotion from social motion
cues in both genders, but were associated with poorer facial emotion
recognition in boys only (OR 1.9, 95% CI 1.4-2.6, p=0.0001). This
finding must be considered in light of lower power to detect
differences in girls. In conclusion, in this community sample of
children, greater deficits in social communication skills are associated
with poorer discrimination of emotions, implying there may be an
underlying continuum of liability to the association between these
characteristics. As a similar degree of association was observed in
both genders on a novel test of social motion cues, the relatively
good performance of girls on the more familiar task of facial emotion
discrimination may be due to compensatory mechanisms. This study
might indicate the existence of a cognitive process by which girls with
underlying autistic traits can compensate for their covert deficits in
emotion recognition, although this would require further
investigation (9).
Vaccination is a cost-effective public health measure and is central
to the Millennium Development Goal of reducing child mortality.
However, childhood vaccination coverage remains sub-optimal in
many settings. While communication is a key feature of vaccination
programs, we are not aware of any comprehensive approach to
organizing the broad range of communication interventions that can
be delivered to parents and communities to improve vaccination
coverage. Developing a classification system (taxonomy) organized
into conceptually similar categories will aid in understanding the
relationships between different types of communication
interventions; facilitating conceptual mapping of these interventions;
clarifying the key purposes and features of interventions to aid
implementation and evaluation; and identifying areas where
evidence is strong and where there are gaps. This paper reports on
the development of the 'Communicate to vaccinate' taxonomy. The
taxonomy was developed in 2 stages. Stage 1 included: 1] forming an
advisory group; 2] searching for descriptions of interventions in trials
(CENTRAL database) and general health literature (Medline); 3]
developing a sampling strategy; 4] screening the search results; 5]
developing a data extraction form; and 6] extracting intervention
89
data. Stage 2 included: 1] grouping the interventions according to

purpose; 2] holding deliberative forums in English and French with
key vaccination stakeholders to gather feedback; 3] conducting a
targeted search of grey literature to supplement the taxonomy; 4]
finalizing the taxonomy based on the input provided. The taxonomy
includes 7 main categories of communication interventions: inform
or educate, remind or recall, teach skills, provide support, facilitate
decision-making, enable communication and enhance community
ownership. These categories were broken down into 43 intervention
types across 3 target groups: parents or soon-to-be-parents;
communities, community members or volunteers; and HCPs. In
conclusion, this taxonomy illuminates and organizes this field and
identifies the range of available communication interventions to
increase routine childhood vaccination uptake. A variety of data
sources were utilized, capturing information from rigorous
evaluations such as randomized trials as well as experiences and
knowledge of practitioners and vaccination stakeholders. The
taxonomy reflects current public health practice and can guide the
future development of vaccination programs (10).
References
1. Brand PL, Stiggelbout AM. Effective follow-up consultations: the
importance of patient-centered communication and shared decision
making. Paediatr Respir Rev. 2013;14(4):224-8.
2. Drotar D. Physician behavior in the care of pediatric chronic illness:
association with health outcomes and treatment adherence J Dev Behav
Pediatr. 2009;30(3):246-54.
3. Swedlund MP, Schumacher JB, Young HN, Cox ED. Effect of
communication style and physician-family relationships on satisfaction with
pediatric chronic disease care. Health Commun. 2012;27(5):498-505.
4. Meyer EC, Sellers DE, Browning DM, et al. Difficult conversations:
improving communication skills and relational abilities in health care.
Pediatr Crit Care Med. 2009;10(3):352-9.
5. Gentles SJ, Lokker C, McKibbon KA. Health information technology to
facilitate communication involving health care providers, caregivers, and
pediatric patients: a scoping review. J Med Internet Res. 2010;12(2):e22.
6. Worchel FF, Prevatt BC, Miner J, et al. Pediatrician's communication
style: relationship to parent's perceptions and behaviors. J Pediatr Psychol.
1995;20(5):633-44.
7. Jaff JC, Arnold J, Bousvaros A. Effective advocacy for patients with
inflammatory bowel disease: communication with insurance companies,
90
school administrators, employers, and other health care overseers. Inflamm

Bowel Dis. 2006;12(8):814-23.
8. Orrell-Valente JK, Cabana MD. 'The apple doesn't fall far from the
tree': the role of parents in chronic disease self-management. Curr Opin
Pediatr. 2008;20(6):703-4.
9. Kothari R, Skuse D, Wakefield J, Micali N. Gender differences in the
relationship between social communication and emotion recognition. J Am
Acad Child Adolesc Psychiatry. 2013;52(11):1148-1157.e2.
10. Willis N, Hill S, Kaufman J, et al. "Communicate to vaccinate": the
development of a taxonomy of communication interventions to improve
routine childhood vaccination. BMC Int Health Hum Rights. 2013 May
11;13:23. Erratum in BMC Int Health Hum Rights. 2013;13:37.
PALLIATIVE CARE
Effective communication is a core skill for professionals. Skilled
communication is also regarded as one of the key domains of
leadership that doctors should develop. Postgraduate training in
communication skills is not embedded within training programs other
than GPs. This pilot study examines the feasibility and outcomes of
communications skills training for doctors in their Core Medical
Training. Doctors completed a pre and post training questionnaire at
3 months to rank, knowledge and understanding of palliative care
issues and their confidence in the 'talking and supporting' aspects of
end of life care. Dealing with anger and confrontation was the
training need identified most. Although some identified the general
need to develop skills in 'breaking bad news' or 'discuss sensitive
topics', many cited needs in specific scenarios: "Dealing with patients
who don't understand the prognosis/or who don't want to know",
"Increase in confidence discussing death with patients", "Discussing
sensitive topics like Do not resuscitate (sic) terminally ill patients", and
"How to discuss end of life issues without being bogged down by
clichés". There was an increase in confidence and knowledge in all
areas evaluated in the questionnaire and 86% evaluated the course
as very useful and 14% as useful. Trainees valued the way the
simulation exercises broke down difficult aspects of communication
and the ability to try diverse communication strategies. Rehearsal of
a listening approach rather than a defensive approach with 'difficult'
91
patients allowed trainees to feel they had new ideas to utilize within
their practice. In conclusion, this blended method course was useful
and increased confidence in a range of end of life care
communication tasks. It may also have promoted an increase in
knowledge in other areas of end of life care (1).
Existing literature evidences the centrality of interpersonal
communication during end-of-life care, but several barriers currently
compromise its effectiveness. One of them is a common lack of
communication skills among physicians in this challenging context.
Several strategies have been suggested to enhance end-of-life
interactions; however, a solid theoretical framework is needed for
the development of effective systematic guidelines and interventions
that can facilitate this goal. The present research study addresses this
gap, choosing to focus particularly on the physician's perspective. It
relies on Baxter and Montgomery's Relational Dialectics Theory (2) to
illuminate the complexity of reality doctors commonly face in
interactions with their patients during end-of-life care.
Semistructured interviews were conducted with 11 physicians in a
southern canton of Switzerland who had experienced at least 1 end-
of-life encounter with a patient. The interviews probed whether and
under what conditions Baxter and Montgomery's theoretical
contradictions translate to physicians' end-of-life communication
with their patients and the patients' family members. The results
replicated and extended the original theoretical contradictions,
evidencing that Relational Dialectics Theory is very applicable to end-
of-life conversations. This study adds a theoretically framed,
empirically grounded contribution to the current literature on the
communicative challenges physicians commonly face during end-of-
life interactions with their patients and their patients' family
members (3).
A novel individualized training program regarding end-of-life
communication was designed to be time effective for busy junior-
doctors working in hospital settings. The main aim was to pilot this
brief individualized training program with junior-doctors to explore
its acceptability, feasibility and effect on the doctors' confidence,
communication skills, attitudes towards psychosocial care and
burnout. The content of the training intervention was informed by a
systematic literature review and evidence-based clinical practice
guidelines regarding end-of-life communication. The intervention
92
was based on sound educational principles and involved 3 1-hour

teaching sessions over a 3-week period, including 2 individual
sessions with an expert facilitator and simulated patient/caregiver. In
addition, participants received written and audiovisual take-home
learning materials. Participants were videotaped consulting with a
simulated patient/caregiver pre/post training to assess the impact of
the course on their communication behaviors. Participants
completed de-identified questionnaires pre/post training, including
self-assessed confidence, attitudes to psychosocial care, and the
Maslach Burnout inventory. Participants included 22 junior-doctors
from a large teaching hospital in Sydney, Australia. All participants
reported that the training was useful, had been helpful for their
communication with patients and that they would recommend the
training to others. Significant improvements were found in
participants' communication skills (in 7 out of 21 specific and all 3
global communication behaviors assessed, range p=0.02 to <0.001),
confidence in communicating about relevant topics (p<0.001),
attitudes towards psychosocial care (p=0.03) and sense of personal
accomplishment (p=0.043). There were no overall differences in
participants' burnout levels. In conclusion, this intervention shows
promise and warrants further formal evaluation (4).
The main objective of this study was to provide a clinical update
on practical strategies to enhance the quality of communication in
the palliative and end-of-life medical care settings. Data sources
included published articles, textbooks, reports, and clinical
experience. The components of effective and compassionate care
throughout the advanced illness trajectory require thoughtful and
strategic communication with patients, families, and members of the
health care team. Unfortunately, few HCPs are formally trained in
communication skills. Implications for nursing practice: nurses who
possess self-awareness and are skilled in effective communication
practices are integral to the provision of high-quality palliative care
for patients and families coping with advanced malignancies (5).
Effective communication is considered essential for the delivery of
high-quality care. Communication in palliative care is particularly
difficult, and there is still no accepted set of communication skills for
GPs in providing palliative care. The main aim of this study was to
obtain detailed information on facilitators and barriers for GP-patient
communication in palliative care, with the aim to develop training
93
programs that enable GPs to improve their palliative care

communication skills. This was a qualitative study with focus groups,
interviews, and questionnaires conducted in GPs with patients
receiving palliative care at home, and end-of-life consultants in the
Netherlands. GP (n=20) focus groups discussing facilitators and
barriers, palliative care patient (n=6) interviews regarding facilitators,
and end-of-life consultant (n=22) questionnaires concerning barriers.
Facilitators reported by both GPs and patients were accessibility,
taking time, commitment, and listening carefully. GPs emphasize
respect, while patients want GPs to behave in a friendly way, and to
take the initiative to discuss end-of-life issues. Barriers reported by
both GPs and end-of-life consultants were difficulty in dealing with
former doctors' delay and strong demands from patients' relatives.
GPs report difficulty in dealing with strong emotions and
troublesome doctor-patient relationships, while consultants report
insufficient clarification of patients' problems, promises that could
not be kept, helplessness, too close involvement, and insufficient
anticipation of various scenarios. In conclusion, the quality of GP-
patient communication in palliative care in the Netherlands can be
improved. It is recommended that specific communication training
programs for GPs should be developed and evaluated (6).
The main aim of this study was to identify barriers and facilitators
for GP-patient communication in palliative care. In a systematic
review, 7 computerized databases were searched to find empirical
studies on GP-patient communication in palliative care. Fifteen
qualitative studies and 7 quantitative questionnaire studies were
included. The main perceived barriers were GPs' lack of availability,
and patients' and GPs' ambivalence to discuss prognosis. Main
perceived facilitators were GPs being available, initiating discussion
about several end-of-life issues and anticipating various scenarios.
Lack of availability and failure to discuss former mistakes appear to
be blind spots of GPs. GPs should be more forthcoming to initiate
discussions with palliative care patients about prognosis and end-of-
life issues (7).
There are major challenges confronting clinicians, researchers,
and policy-makers regarding improving communication about
palliative and end-of-life care with patients and families. There is
mounting evidence that the intensity of care at the end-of-life is
increasing, despite the fact that most patients report they would
94
prefer not to die in high-intensity medical settings. Recent research

suggests that improved communication about palliative and end-of-
life care is associated with reduced intensity of care at the end of life,
improved QOL for patients and families, improved quality of dying for
patients, and reduced psychological symptoms for families. Yet, the
most effective and cost-effective ways to achieve improved
communication are not clear. One important step to improving
communication is being able to reliably measure the quality of this
communication (8).
Even though good communication among clinicians, patients, and
family members is identified as the most important factor in end-of-
life care in ICUs, it is the least accomplished. According to
accumulated evidence, communication about end-of-life decisions in
ICUs is difficult and flawed. Poor communication leaves clinicians and
family members stressed and dissatisfied, as well as patients' wishes
were neglected. Conflict and anger both among clinicians and
between clinicians and family members also result. Physicians and
nurses lack communication skills, an essential element to achieve
better outcomes at end of life. There is an emerging evidence base
that proactive, multidisciplinary strategies such as formal and
informal family meetings, daily team consensus procedures, palliative
care team case finding, and ethics consultation improve
communication about end-of-life decisions. Improving end-of-life
communication in ICUs can improve the quality of care by resulting in
earlier transition to palliative care for patients who ultimately do not
survive and by increasing family and clinician satisfaction (9).
References
1. Feathers L, Decaestecker S, Norrie P, et al. Developing skills in
communication in end of life care: evaluation of a 3 day pilot course for core
medical training. BMJ Support Palliat Care. 2014;4 Suppl 1:A38.
2. Baxter LA, Montgomery BM. Language Arts & Disciplines. Guilford
Press. 1996.
3. Amati R, Hannawa AF. Relational dialectics theory: disentangling
physician-perceived tensions of end-of-life communication. Health
Commun. 2014;29(10):962-73.
4. Clayton JM, Butow PN, Waters A, et al. Evaluation of a novel
ndividualized communication-skills training intervention to improve doctors'
confidence and skills in end-of-life communication. Palliat Med.
2013;27(3):236-43.
95
5. Moore CD, Reynolds AM. Clinical update: communication issues and

advance care planning. Semin Oncol Nurs. 2013;29(4):e1-e12.
6. Slort W, Blankenstein AH, Deliens L, van der Horst HE. Facilitators and
barriers for GP-patient communication in palliative care: a qualitative study
among GPs, patients, and end-of-life consultants. Br J Gen Pract. 2011;61
(585):167-72.
7. Slort W, Schweitzer BP, Blankenstein AH, et al. Perceived barriers and
facilitators for general practitioner-patient communication in palliative care:
a systematic review. Palliat Med. 2011;25(6):613-29.
8. Curtis JR. Measuring and improving communication about palliative
and end-of-life care. BMJ Support Palliat Care. 2013; 3(2):225-6.
9. Boyle DK, Miller PA, Forbes-Thompson SA. Communication and end-
of-life care in the intensive care unit: patient, family, and clinician outcomes.
Crit Care Nurs Q. 2005;28(4):302-16.
ONCOLOGY
This is an updated version of a review that was originally
published in the Cochrane Database of Systematic Reviews in 2004,
Issue 2. People with cancer, their families and careers have a high
prevalence of psychological stress, which may be minimized by
effective communication, and support from their attending HCPs.
Research suggests communication skills do not reliably improve with
experience, therefore, considerable effort is dedicated to courses
that may improve communication skills for HCPs involved in cancer
care. Varieties of CST courses that are in practice have been
proposed. This review was conducted to determine whether CST
works and which types of CST, if any, are the most effective. The
objective of this study was to assess whether CST is effective in
improving the communication skills of HCPs involved in cancer care,
and in improving patient health status and satisfaction. The following
electronic databases: Cochrane Central Register of Controlled Trials
(CENTRAL) Issue 2, 2012, MEDLINE, EMBASE, PsycInfo and CINAHL to
February 2012 were searched. The original search was conducted in
November 2001. The reference lists of relevant articles and relevant
conference proceedings for additional studies were hand searched.
The original review was a narrative review that included RCTs and
controlled before-and-after studies. In this updated version, criteria
were limited to RCTs evaluating 'CST' compared with 'no CST' or
96
other CST in HCPs working in cancer care. Primary outcomes were

changes in HCP communication skills measured in interactions with
real and/or simulated patients with cancer, using objective scales.
Studies whose focus was communication skills in encounters related
to informed consent for research were excluded. Two review authors
independently assessed trials and extracted data to a pre-designed
data collection form. Fifteen RCTs (42 records), conducted mainly in
outpatient settings were included. Eleven studies compared CST with
no CST intervention, 3 studies compared the effect of a follow-up CST
intervention after initial CST training, and 1 study compared 2 types
of CST. The types of CST courses evaluated in these trials were
diverse. Study participants included oncologists (6 studies), residents
(1 study), other doctors (1 study), nurses (6 studies) and a mixed
team of HCPs (1 study). Overall, 1,147 HCPs participated (536
doctors, 522 nurses and 80 mixed HCPs). Ten studies contributed
data to the meta-analyses. HCPs in the CST group were significantly
more likely to use open questions in the post-intervention interviews
than the control group (5 studies, 679 participant interviews; p=0.04,
I² = 65%) and more likely to show empathy towards patients (6
studies, 727 participant interviews; p=0.004, I² = 0%); this evidence
was considered to be of moderate and high quality, respectively.
Doctors and nurses did not perform significantly differently for any
HCP outcomes. There were insignificant differences in the other HCP
communication skills except for the subgroup of participant
interviews with simulated patients, where the intervention group
was significantly less likely to present 'facts only' compared with the
control group (4 studies, 344 participant interviews; p=0.01, I² =
70%). There were insignificant differences between the groups with
regard to outcomes assessing HCP 'burnout', patient satisfaction or
patient perception of the HCPs communication skills. Patients in the
control group experienced a greater reduction in mean anxiety scores
in a meta-analyses of 2 studies (169 participant interviews; p=0.02; I²
= 8%); this evidence is considered to be of a very low quality. In
conclusion, various CST courses appear to be effective in improving
some types of HCP communication skills related to information
gathering and supportive skills. Whether the effects of CST are
sustained over time, whether consolidation sessions are necessary,
and which types of CST programs are most likely to work remained
unclear. Evidence was not found to support a beneficial effect of CST
97
on HCP 'burnout', patients' mental or physical health, and patient

satisfaction (1).
Interpersonal communication skills as part of the supportive care
in cancer won new dimensions by demonstrating the association with
enhanced ability of patients to cope with the disease, to enhance
trust in HCPs, compliance with treatment and to reduce emotional
distress and psychosocial burden. Besides empathy the effective
patient -centered communication is based upon perceptual and
behavioral skills of caregivers. Doctors, nurses, and oncology social
workers have to achieve skills to listen to patients complains and to
respond to his/ her support needs. The aim of the present paper was
to perform a meta analysis of published data dealing with principles
and methods of the assertive doctor patient communication within
the supportive care of patients suffering from emotional and social
dysfunctions. The data of interpersonal communication skills in
oncology presented in the current literature were collected using
electronic databases and were elaborated in form of Meta analysis of
24 selected publications. Active behavioral approach involved the
understanding of the non-verbal indications of patients' needs,
preferences, and expectations, the evaluation of patients' non-verbal
expression of fear, uncertainty, irritability, depression and apathy or
even the unwillingness to disclose his/ her concerns. Recognizing
these and other concerns (marital and sexual problems, physical and
cognitive functioning etc.), caregivers should respond these concerns
in verbal form of psychosocial support. Skills in the interpersonal
communication can be learned by clinical experience and theoretical
preparation. In conclusion, developing the communication skills
including the perception and behavioral style is particularly important
in clinicians' early medical teaching. The implementation of
communication skills into undergraduate and postgraduate study
programs in medicine, nursing, and other paramedical subjects is still
in infancy, although the professional communication with cancer
patient and its family members is associated with clear and important
outcomes of care approved by clinical research and recognized by
cancer professionals (2).
Contemporary oncology practice acknowledges the importance of
collaborating with the patient and family in dealing with the illness.
Patients also value their physicians as important sources of support
when they provide information about the illness, encouragement,
98
and hope, discuss treatment options, and address their concerns. For
this reason, outcomes associated with the quality of the physician-
patient relationship have received increasing recognition. This review
highlights relevant studies bearing on important outcomes of
communication with the cancer patient and discusses the implication
for training oncologists of the future. Evidence is mounting that
effective and empathic communication with the cancer patient and
family can influence desirable outcomes in cancer care, which affect
patient QOL, satisfaction with care, and medical outcomes.
Communication and interpersonal skills can be taught and learned.
Oncology training programs traditionally do not offer experience in
this aspect of care although communication skills have now been
defined as a core competency for oncology trainees. Finding
motivated faculty to teach and providing time and structure in the
curriculum are major obstacles to be overcome. In conclusion,
communication skills are the cornerstone of comprehensive cancer
care. Learning this aspect of patient care can expand the supportive
role of the oncologist especially at crucial times for the patient and
family such as diagnosis, disease recurrence, and transition to
palliative care (3).
Communicating about the end of life with patients has been
reported as one of the most difficult and stressful part of the work of
oncologists. Despite this fact, oncologists receive little training in this
area, and many do not communicate effectively with patients. The
purpose of this analysis, part of a larger study examining oncologists'
experiences of patient loss, was to explore oncologists'
communication strategies and communication barriers when
discussing end-of-life issues with patients. Twenty oncologists were
interviewed at 3 hospitals about their communication strategies on
end-of-life issues with patients. The strategies to effective
communication about the end of life included being open and
honest; having ongoing, early conversations; communicating about
modifying treatment goals; and balancing hope and reality. Barriers
to implementing these strategies fell into 3 domains, including
physician factors, patient factors, and institutional factors. Physician
factors included difficulty with treatment and palliation, personal
discomfort with death and dying, diffusion of responsibility among
colleagues, using the "death-defying mode," lack of experience, and
lack of mentorship. Patient factors included patients and/or families
99
being reluctant to talk about the end of life, language barriers, and
younger age. Institutional factors were stigma around palliative care,
lack of protocol about end-of-life issues; and lack of training for
oncologists on how to talk with patients about end-of-life issues. In
conclusion, further research and intervention are necessary to aid
oncologists in achieving effective communication about end-of-life
issues (4).
The quality of communication in medical care influences health
outcomes. Cancer patients, a highly diverse population, communicate
with their clinical care team in diverse ways over the course of their
care trajectory. Whether that communication happens and how
effective it is may relate to a variety of factors including the type of
cancer and the patient's position on the cancer care continuum. Yet,
many of the routine needs of cancer patients after initial cancer
treatment are often addressed inadequately. The aim of this study
was to identify areas of strength and areas for improvement in
cancer communication by investigating real-time cancer
consultations in a cross section of patient-clinician interactions at
diverse study sites. In this paper, the rationale and approach for an
ongoing observational study involving 3 institutions that will utilize
quantitative and qualitative methods and employ a short-term
longitudinal, prospective follow-up component to investigate
decision-making, key topics, and clinician-patient-companion
communication dynamics in clinical oncology were investigated.
Through a comprehensive, real-time approach, the fundamental
groundwork from which to promote improved patient-centered
communication in cancer care can be provided (5).
Communication within oncology is a core clinical skill but one in
which few oncologists or specialist cancer nurses have received much
formal training. Inadequate communication may cause much distress
for patients and their families, who often want considerably more
information than is usually provided. Many patients leave
consultations unsure about the diagnosis and prognosis, confused
about the meaning of - and need for - further diagnostic tests,
unclear about the management plan and uncertain about the true
therapeutic intent of treatment. Communication difficulties may
impede the recruitment of patients to clinical trials, delaying the
introduction of efficacious new treatments into clinics. Lack of
effective communication between specialists and departments can
100
also cause confusion and a loss of confidence amongst the team.

Oncologists themselves acknowledge that insufficient training in
communication and management skills is a major factor contributing
to their own stress, lack of job satisfaction and emotional burnout.
Consequently, over the past few years there have been several
initiatives aimed at improving basic communication skills training for
HCPs in the cancer field (6).
Effective communication is essential in developing any
relationship, this is particularly true between oncologists and their
patients. The patient-oncologist relationship is one of the most
delicate in medicine, and given the strong emotions associated with
cancer, successful communication plays a paramount role in the
wellbeing of patients and oncologists. Significant advances to close
the communication gap have occurred over the past several decades,
largely by addressing deficiencies in the various stages of an
oncologist's lengthy training: undergraduate medical education,
residency and fellowship, and continuing medical education.
Stemming from several milestones achieved by highly motivated
groups of individuals, including the creation of consensus statements
and guidelines by communication education experts, progress has
been made to improve patient-oncologist communication. This
progress is marked by the development of evidence-based
communication skills training programs, such as Oncotalk and
Comskil, in addition to the creation of distant-learning modalities,
such as the Studying Communication in Oncologist-Patient
Encounters trial (7).
Research suggests communication skills do not reliably improve
with experience. Considerable effort is dedicated to courses
improving communication skills for HCPs. Evaluation of such courses
is important to enable evidence-based teaching and practice. The
objective of this study was to assess whether communication skills
training is effective in changing health professionals' behavior in
cancer care with regard to communication/interaction with patients.
CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to
November 2001), EMBASE (1980 to November 2001), PsycInfo (1887
to November 2001), CINAHL (1982 to November 2001), AMED (1985 -
October 2001), Dissertation Abstracts International (1861 to March
2002) and EBMR (1991 to March/April 2001) were searched.
Reference lists of relevant articles were searched. Three further
101
studies were detected in November 2003. RCTs or controlled before

and after studies of CST in cancer HCPs, measuring changes in
behavior/skills using objective and validated scales were included.
Two reviewers independently assessed trials and extracted data. Of
2,824 references, 3 trials involving 347 HCPs were included. One
provided an intensive 3-day course then assessed oncology doctors
interacting with 640 patients; a second provided a modular course
then assessed role plays with oncology nurses; the third was modular
and assessed outcomes with clinical and simulated interviews and
patient questionnaires. In 1 trial, course attendees used more
focused questions (probability p<0.005), focused and open questions
(p=0.005), expressions of empathy (p<0.005), and appropriate cue
responses (p<0.05) at follow up than non-attendees. Insignificant
differences were found between attendees and non-attendees for
leading questions. From baseline to follow up, attendees had
significantly different changes in rates of leading questions (p<0.05),
focused questions (p<0.005), open questions (p<0.05), and empathy
(p=0.005). The only observed significant difference in the second trial
was that trained doctors controlled the follow-up interview more
than untrained doctors did (p<0.05). Neither study found differences
in summarizing, interrupting and checking. The third trial found
trained nurses used more emotional speech than untrained
counterparts, particularly regarding anxiety and distress. Patients
interviewed by trained nurses used more emotional terms, but no
differences emerged in questionnaires. In conclusion, training
programs assessed by these trials appear to be effective in improving
some areas of cancer care professionals communication skills. It is
unknown whether this training would be effective if taught by others,
nor the comparative efficacy of these programs (8).
CIM is becoming an increasingly popular and visible component of
oncology care. Many patients affected by cancer and their family
members are looking for informed advice and desire communication
with their physicians about CIM use. Patients affected by cancer
come to discuss CIM use with intense emotions and are experiencing
an existential crisis that cannot be ignored. Effective communication
is crucial in establishing trust with these patients and their families.
Communication is now recognized as a core clinical skill in medicine,
including cancer care, and is important to the delivery of high-quality
care. The quality of communication affects patient satisfaction,
102
decision-making, patient distress and well-being, compliance, and

even malpractice litigation. The communication process about CIM
use requires a very sensitive approach that depends on effective
communication skills, such as experience in listening, encouraging
hope, and ability to convey empathy and compassion. This process
can be divided into 2 parts: the "how" and the "what". The "how"
relates to the change in clinician attitude, the process of gathering
information, addressing patients' unmet needs and emotions, and
dealing with uncertainty. The "what" relates to the process of
information exchange while assisting patients in decisions about CIM
use by using reliable information sources, leading to informed
decision-making (9).
After testing the psychometric properties of a new questionnaire
that measures patient preferences for patient-physician
communication (KOPRA questionnaire), the communication
preferences of cancer patients were described. In order to do this,
the preferences were differentiated according to sociodemographic
subgroups and a comparison was made to the preferences of
patients with chronic back pain and CIHD. Patients (n=1,635) from 31
medical oncology practices were surveyed. For the KOPRA
questionnaire, reliability, unidimensionality, and fit to the Rasch
model were tested. Hierarchical models were used to conduct
subgroup analyses and comparisons with other diseases. The
psychometric properties of the KOPRA are satisfactory to good. For
patients, the 4 communication domains (patient participation and
patient orientation, effective and open communication, emotionally
supportive communication, and communication about personal
circumstances) measured by the KOPRA questionnaire are equally
important. Women generally have higher expectations of the
physician's communicative behavior. Affective communication is
considerably more important for cancer patients than for back pain
or cardiac patients. The KOPRA questionnaire is well suited for
examining the communication preferences of cancer patients. In
general, physician behavior associated with high scores in all 4
KOPRA dimensions is optimal. Especially in cases where the 4
communication aspects conflict with each other, the physician's
communication style should be individualized (10).
This paper reports on part of a large study to identify
competencies of oncology nurses in Malaysia. It focuses on oncology
103
nurses' communications-related competency. As an important cancer

care team member, oncology nurses need to communicate
effectively with cancer patients. Literature shows that poor
communication can make patients feel anxious, uncertain and
generally not satisfied with their nurses' care. This paper deliberates
on the importance of effective communication by oncology nurses in
the context of a public hospital. Four focus group discussions were
used in this study with 17 oncology/cancer care nurses from
Malaysian public hospitals. The main inclusion criterion was that the
nurses had to have undergone a post-basic course in oncology, or
have work experience as a cancer care nurse. The findings indicated
that nurses do communicate with their patients, patients' families
and doctors to provide information about the disease, cancer
treatment, disease recurrence and side effects. Nurses should have
good communication skills in order to build relationships as well as to
provide quality services to their patients (11).
The aim of this study was to review the literature on clinician
characteristics influencing patient-clinician communication or patient
outcome in oncology. Studies investigating the association of clinician
characteristics with quality of communication and with outcome for
adult cancer patients were systematically searched in MEDLINE,
PSYINFO, PUBMED, EMBASE, CINHAL, Web of Science and The
Cochrane Library up to November 2012. The preferred reporting
items for systematic reviews and meta-analyses statement to guide
this review were used. Articles were extracted independently by 2 of
the authors using predefined criteria. Twenty-seven articles met the
inclusion criteria. Clinician characteristics included a variety of
sociodemographic, relational, and personal characteristics. A positive
impact on quality of communication and/or patient outcome was
reported for communication skills training, an external locus of
control, empathy, a socioemotional approach, shared decision-
making style, higher anxiety, and defensiveness. A negative impact
was reported for increased level of fatigue and burnout and
expression of worry. Professional experience of clinicians was
unrelated to communication and/or to patient outcome, and
divergent results were reported for clinician gender, age, stress,
posture, and confidence or self-efficacy. Various clinician
characteristics have different effects on quality of communication
and/or patient outcome (12).
104
References
1. Moore PM, Rivera S, Grez Artigues M, Lawrie TA. Communication skills
training for healthcare professionals working with people who have cancer.
Cochrane Database Syst Rev. 2013 Mar 28;3:CD003751.
2. Bencová V. Communication as a part of the supportive treatment in
cancer care. Klin Onkol. 2013;26(3):195-200.
3. Baile WF, Aaron J. Patient-physician communication in oncology: past,
present, and future. Curr Opin Oncol. 2005;17(4):331-5.
4. Granek L, Krzyzanowska MK, Tozer R, Mazzotta P. Oncologists'
strategies and barriers to effective communication about the end of life. J
Oncol Pract. 2013;9(4):e129-35.
5. Kimball BC, James KM, Yost KJ, et al. Listening in on difficult
conversations: an observational, multi-center investigation of real-time
conversations in medical oncology. BMC Cancer. 2013;13(1):455.
6. Fallowfield L, Jenkins V. Effective communication skills are the key to
good cancer care. Eur J Cancer. 1999;35(11):1592-7.
7. Pham AK, Bauer MT, Balan S. Closing the patient-oncologist
communication gap: a review of historic and current efforts. J Cancer Educ.
2014;29(1):106-13.
8. Fellowes D, Wilkinson S, Moore P. Communication skills training for
health care professionals working with cancer patients, their families and/or
carers. Cochrane Database Syst Rev. 2004;(2):CD003751. Update in
Cochrane Database Syst Rev. 2013;3:CD003751.
9. Frenkel M, Cohen L. Effective communication about the use of
complementary and integrative medicine in cancer care. J Altern
Complement Med. 2014;20(1):12-8.
10. Farin E, Baumann W. Communication Preferences of Oncology
Patients. Gesundheitswesen. 2014 Jan 22. [Epub of print].
11. Maskor NA, Krauss SE, Muhamad M, Nik Mahmood NH.
Communication competencies of oncology nurses in Malaysia. Asian Pac J
Cancer Prev. 2013;14(1):153-8.
12. De Vries AM, de Roten Y, Meystre C, et al. Clinician
characteristics,.communication, and patient outcome in oncology: a
systematic review. Psychooncology. 2014;23(4):375-81
105
TEACHING COMMUNICATION SKILLS
The effective monitoring and prevention of complaints are

obligatory elements of management of medical institution. The
training of physicians to communicative skills has additional positive
potential in the process of prevention of occurrence of complaints.
The training of physicians to communicative skills following
procedure of patient-centered counseling makes it possible to
significantly decrease number of complaints about quality of medical
care in ambulatory medical institution. The training technology is to
be convenient for simultaneous training of large amount of
physicians (1).
The ACGME requires that "residents must be able to demonstrate
interpersonal and communication skills that result in effective
information exchange and teaming with patients, their patients'
families, and professional associates." The authors sought to assess
current methods of teaching and attitudes regarding communication
skills in their surgical residency. After obtaining Institutional Review
Board exemption, voluntary anonymous surveys were completed by
a sample of convenience at the Vanderbilt University Medical Center:
surgical residents at Grand Rounds and attending surgeons in a
faculty meeting. Data were evaluated from 49 respondents (33 of 75
total surgical residents, 16 representative attending surgeons). One
hundred percent of respondents rated the importance of
communication to the successful care of patients as "four" or "five"
of 5. Direct attending observation of residents communicating with
patients/families was confirmed by residents and faculty. Residents
reported varying levels of comfort with different types of
conversations. Residents were "comfortable" or "very comfortable"
as follows: obtaining informed consent, 91%; reporting operative
findings, 64%; delivering news, 61%; conducting a family conference,
40%; discussing do not resuscitate orders, 36%; and discussing
transition to comfort care, 24%. Resident receptiveness to
communication skills education varied with proposed venues: 84%
favored teaching in the course of routine clinical care, 52% via online
resources, and 46% in workshops. Residents were asked how
frequently they received feedback specific to their communication
skills during the past 6 months: most residents reported 0 (39%) or 1
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(21%) feedback episode. Only 30% of resident respondents reported

receiving feedback that they perceived helpful. Attending surgeons
reported that they did provide residents feedback specific to their
communication skills. When asked to estimate the number of
feedback episodes in the last 6 months, 16 faculty members reported
67 feedback episodes, whereas 33 residents reported only 24
episodes. Most faculty members rated their comfort with providing
feedback specific to communication skills as "very comfortable"
(56%) or "comfortable" (19%). "Time constraints" was the most
frequently cited barrier to teaching communication skills. In
conclusion, communication skills are valued as integral to patient
care by both residents and faculty in this study. Residents are most
receptive to teaching of communication skills in the clinical setting.
Faculty members report they are providing feedback to residents.
Although residents report direct observation by faculty, currently
only a minority (30%) are receiving feedback regarding
communication that they consider helpful. A need exists to facilitate
the feedback process to resolve this discrepancy. The authors
propose that an evaluation instrument regarding communication
skills may strengthen the feedback process (2).
As many as 90 million Americans lack basic skills needed to access,
understand, and use health information and services to make healthy
dietary choices. Effective teaching by physicians can bridge the
learning gap and arrest the epidemic of obesity. The Academy at
Harvard Medical School is developing best practices in teaching that
will equip future doctors to reduce health illiteracy and promote
positive changes in thinking and behavior in their patients. Models of
how people learn can help physicians select tasks, questions, and
prompts that advance teaching and learning. To keep and use new
information, adults need to integrate new ideas into existing
frameworks of understanding and participate in the learning process
by linking new information to what is already has been known. By
teaching patients how to read a single food label, starting with
calories, physicians can set the stage for future learning. The process
of change is challenging, particularly in adults. Best practices in
teaching and learning can help physicians be more effective agents of
change (3).
Accreditation of residency programs and certification of
physicians requires assessment of competence in communication and
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interpersonal skills. Residency and CME program directors seek ways

to teach and evaluate these competencies. This report summarizes
the methods and tools used by educators, evaluators, and
researchers in the field of physician-patient communication as
determined by the participants in the "Kalamazoo II" conference held
in April 2002. Communication and interpersonal skills form an
integrated competence with 2 distinct parts. Communication skills
are the performance of specific tasks and behaviors such as obtaining
a medical history, explaining a diagnosis and prognosis, giving
therapeutic instructions, and counseling. Interpersonal skills are
inherently relational and process oriented; they are the effect
communication has on another person such as relieving anxiety or
establishing a trusting relationship. This report reviews 3 methods for
assessment of communication and interpersonal skills: 1] checklists
of observed behaviors during interactions with real or simulated
patients; 2] surveys of patients' experience in clinical interactions;
and 3] examinations using oral, essay, or multiple-choice response
questions. These methods are incorporated into educational
programs to assess learning needs, create learning opportunities, or
guide feedback for learning. The same assessment tools, when
administered in a standardized way, rated by an evaluator other than
the teacher, and using a predetermined passing score, become a
summative evaluation. The report summarizes the experience of
using these methods in a variety of educational and evaluation
programs and presents an extensive bibliography of literature on the
topic. Professional conversation between patients and doctors
shapes diagnosis, initiates therapy, and establishes a caring
relationship. The degree to which these activities are successful
depends, in large part, on the communication and interpersonal skills
of the physician. This report focuses on how the physician's
competence in professional conversation with patients might be
measured. Valid, reliable, and practical measures can guide
professional formation, determine readiness for independent
practice, and deepen understanding of the communication itself (4).
Communication failures are a key cause of medical errors and are
particularly prevalent during handovers of patients between services.
To explore current perceptions of effectiveness in communicating
critical patient information during mission handovers between EM
residents and IM residents. Study design was a survey of IM and EM
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residents at a large urban hospital. Residents were surveyed about

whether critical information was communicated during patient
handovers. Measurements included comparisons between IM and
EM residents about their perceptions of effective communication of
key patient information and the quality of handovers. Ninety-three
percent of EM residents (50 of 54) and 80% of IM residents (74 of 93)
responded to the survey. The EM residents judged their handover
performance to be better than how their IM colleagues assessed
them on most questions. The IM residents reported that one-half of
the time, EM residents provided organized and clear information,
whereas EM residents self-reported that they did so most of the time
(80%-90%). The IM residents reported that 25% of handovers were
suboptimal and resulted in mission to an inappropriate level of care,
and 10% led to harm or delay in care. The EM residents reported
suboptimal communication was less common (5%). On the global
assessment of whether the mission handover provided the
information needed for good patient care, IM residents rated the
quality of the handover data lower than did responding EM residents.
In conclusion, there are gaps in communicating critical patient
information during mission handovers as perceived by EM and IM
residents. This information can form the basis for efforts to improve
these handovers (5).
Teaching advanced communication skills requires educators who
are not only excellent communicators themselves but have the ability
to deconstruct the components of the interaction and develop a
cognitive approach that can be used across a variety of learners,
diverse content, and under different time constraints while helping
the learner develop the skill of self-reflection in a 'safe' and effective
learning environment. The use of role-play in small groups is an
important method to help learners cultivate the skills required to
engage in nuanced, often difficult conversations with seriously ill
patients. To be effective, educators utilizing role-play must help
learners set realistic goals and know when and how to provide
feedback to the learners in a way that allows a deepening of skills
and a promotion of self-awareness. The challenge is to do this in a
manner that does not cause too much anxiety for the learner (6).
Good communication skills are essential for residents entering
postgraduate education programs. However, these skills vary widely
among medical school graduates. This pilot program was designed to
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create opportunities for 1] teaching essential interviewing and

communication skills to trainees at the beginning of residency, 2]
assessing resident skills and confidence with specific types of
interview situations, 3] developing faculty teaching and assessment
skills, 4] encouraging collegial interaction between faculty and new
trainees, and 5] guiding residency curricular development. During
residency orientation, all first-year internal medicine residents (n=26)
at the University of Minnesota participated in the CASE. CASE
consisted of 4 10-minute stations in which residents demonstrated
their communication skills in encounters with SPs while faculty
members observed for specific skills. Faculty and SPs were oriented
to the educational purposes and goals of their stations, and received
instructions on methods of providing feedback to residents. With
each station, residents were provided 1 and a half-minute of direct
feedback by the faculty observer and the SP. The residents were
asked to deal with an angry family member, to counsel smoking
cessation, to set a patient-encounter agenda, and to deliver bad
news. A resident's performance was analyzed for each station, and
individual profiles were created. All residents and faculty completed
evaluations of the exercise, assessing the benefits and areas for
improvement. Evaluations and feedback from residents and faculty
showed that most of the objectives were accomplished. Residents
reported learning important skills, receiving valuable feedback, and
increasing their confidence in dealing with certain types of stressful
communication situations in residency. The activity was also
perceived as an excellent way to meet and interact with faculty.
Evaluators found the experience rewarding, an effective method for
assessing and teaching clinical skills, a faculty development
experience for themselves in learning about structured practical skills
exercises, and a good way to meet new interns. The residency
program director found individual resident performance profiles
valuable for identifying learning issues and for guiding curricular
development. Time constraints were the most frequently cited area
for improvement. The exercise became feasible by collaborating with
the medical school Office of Education-Educational Development and
Research, whose mission is to collaborate with faculty across the
continuum of medical education to improve the quality of instruction
and evaluation. The residency program saved considerable time,
effort, and expense by using portions of the medical school's existing
110
student skills-assessment programs and by using chief residents and

faculty as evaluators. Next year CASE is planned to be used with a
wider variety of physician-patient scenarios for interns, and to
expand the program to include beginning second- and third-year
residents. Since this type of exercise creates powerful feedback and
assessment opportunities for instructors and course directors, and
because feedback was so favorable from evaluators, we will
encourage participation in CASE as part of our faculty educational
development program (7).
VPs have the potential to augment existing medical school
curricula to teach history-taking and communication skills. A goal of
current efforts to study virtual characters in health professions
education is to develop a system that can be independently accessed
and thus user satisfaction is an important factor in how readily this
technology will be adopted. Twenty-three medical students
participated in a study in which they interviewed a VP and were
asked to rate the educational value of the experience. Despite some
of the limitations in this developing technology, students were
generally receptive to its use as an educational tool. Further
enhancements to the system, including increased fidelity of the
interaction and novel feedback mechanisms, should improve learner
satisfaction with and adoption of the virtual patient system (8).
At most institutions, medical students learn communication skills
through the use of SPs, but SPs are time and resource expensive. VPs
may offer several advantages over SPs, but little data exist regarding
the use of VPs in teaching communication skills. Therefore, initial
efforts to create an interactive virtual clinical scenario of a patient
with acute abdominal pain to teach medical students history-taking
and communication skills is reported. In the virtual scenario, a life-
sized VP is projected on the wall of an examination room. Before the
virtual encounter, the student reviews patient information on a
handheld tablet personal computer, and they are directed to take a
history and develop a differential diagnosis. The virtual system
includes 2 networked PCs, one data projector, 2 USB2 Web cameras
to track the user's head and hand movement, a tablet PC, and a
microphone. The VP is programmed with specific answers and
gestures in response to questions asked by students. The VP
responses to student questions were developed by reviewing
videotapes of students' performances with real SPs. After obtaining
111
informed consent, 20 students underwent voice recognition training

followed by a videotaped VP encounter. Immediately after the virtual
scenario, students completed a technology and SP questionnaire
(Maastricht Simulated Patient Assessment). All participants had prior
experience with real SPs. Initially, the VP correctly recognized
approximately 60% of the student's questions, and improving the
script depth and variability of the VP responses enhanced most
incorrect voice recognition. Student comments were favorable
particularly related to feedback provided by the virtual instructor.
The overall student rating of the virtual experience was 6.47 +/- 1.63
(1 = lowest, 10 = highest) for version 1.0 and 7.22 +/- 1.76 for version
2.0 (4 months later) reflecting enhanced voice recognition and other
technological improvements. These overall ratings compare favorably
to a 7.47 +/- 1.16 student rating for real SPs. In conclusion, despite
current technological limitations, virtual clinical scenarios could
provide students a controllable, secure, and safe learning
environment with the opportunity for extensive repetitive practice
with feedback without consequence to a real or SP (9).
Clear and adequate communication between physicians is
essential in modern medicine. Nevertheless, the medical curricula in
The Netherlands lack an identifiable part in their education
concerning inter-physician communication training. To train medical
students in inter-physician communication skills using the DPS, the
Academic Medical Center at the University of Amsterdam and the
Leiden University Medical Center joined in a 2-year project sponsored
by the Dutch government. DPS is an educational computer program
to create and simulate virtual patients with a wide variety of medical
conditions in different clinical settings and over different time
frames. To evaluate whether DPS is a suitable method for training
medical students in inter-physician communication, if medical
students felt that they had improved their inter-collegial
communication skills after the pilot with DPS were assessed. Students
on DPS' usability and their satisfaction with DPS were studied.
Twenty patient simulations were developed in DPS to be practiced
upon by 2 students asynchronously during a week. These students
were situated in different medical institutions, geographically spread
over The Netherlands and had to treat the virtual patient as a team
supported by DPS. The students had to report their findings and
treatment plan in the electronic referral form of DPS. A total of 134
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students participated in the pilot. To evaluate inter-physician

communication training using DPS we conducted a survey amongst
these students who were entering their internships. The evaluation
focused on self-assessment of their communication skills, usability of
the DPS program, and their satisfaction with DPS as educational
format, using multiple questionnaires. The outcome of the evaluation
showed significant progression in students' feeling of improvement
of their skills in different aspects concerning the referral of a patient
after participating in the pilot. Students evaluated the usability of
DPS positive and were highly satisfied with the education in inter-
physician communication training using DPS. Based on these
outcomes, nowadays this form of training is incorporated in the
curricula on a regular basis (10).
The Joint Commission and Institute for Healthcare Improvement
have mandated healthcare organizations to improve professional
communication. Nursing students lack experience in communicating
with physicians. As a result, recent graduates may not be prepared to
meet the demands of professional communication to ensure patient
safety. The authors discuss the SBAR communication technique
implemented during a 2-day simulation exercise that provided an
organized logical sequence and improved communication and
prepared graduates for transition to clinical practice (11).
This study reports on a pilot study of the effect of an inter-
professional course for medical and nursing students in how to
collaborate in the conduct of a ward round. A mixed group of 13
medical and 12 nursing students attended a 1-day course. They
worked together in small groups training in communication and
collaborative skills using a framework for ward rounds in a simulated
clinical ward environment. The course was evaluated on standard
evaluation forms and through focus group interviews. The program
was highly rated by both of the groups and considered most relevant,
well situated and efficient. Next term the training course will be
extended to include twice as many students (12).
Residents receive little information about how they interact with
patients. This pilot study assessed the feasibility and validity of a new
16-item tool developed to assess patients' perspectives of interns'
communication skills and professionalism and the team's
communication. Feasibility was determined by the percentage of
surveys completed, the average time for survey completion, the
113
percentage of target interns evaluated, and the mean number of

evaluations per intern. Generalizability was analyzed using an
(evaluator: evaluatee) × item model. Simulated D studies estimated
optimal numbers of items and evaluators. Factor analysis with
varimax rotation was used to examine the structure of the items.
Scores were correlated with other measures of communication and
professionalism for validation. Most patients (225 of 305 [74%])
completed the evaluation. Each survey took approximately 6.3
minutes to complete. In 43 days over 18 weeks, 45 of 50 interns
(90%) were evaluated an average of 4.6 times. Fifty evaluations
would be required to reach a minimally acceptable coefficient (0.57).
Two factor structures were identified. The evaluation did not
correlate with faculty evaluations of resident communication but did
correlate weakly (r =0.140, p =0 .04) with SPs evaluations. In
conclusion, a large number of patient evaluations are needed to
reliably assess intern and team communication skills. Evaluations by
patients add a perspective in assessing these skills that is different
from those of faculty evaluations. Future work will focus on whether
this new information adds to existing evaluation systems and
warrants the added effort (13).
Communication failures in healthcare teams are associated with
medical errors and negative health outcomes. These findings have
increased emphasis on training future health professionals to work
effectively within teams. The Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) communication
training model, widely employed to train healthcare teams, has been
less commonly used to train student interprofessional teams. The
present study reports the effectiveness of a simulation-based
interprofessional TeamSTEPPS training in impacting student
attitudes, knowledge and skills around interprofessional
communication. Three hundred and six fourth-year medical, third-
year nursing, second-year pharmacy and second-year physician
assistant students took part in 4-hour training - 1-hour TeamSTEPPS
didactic session and three 1-hour team simulation and feedback
sessions. Students worked in groups balanced by a professional
program in a self-selected focal area (adult acute, pediatric, and
obstetrics). Preassessments and postassessments were used for
examining attitudes, beliefs and reported opportunities to observe or
participate in team communication behaviors. One hundred and
114
forty-nine students (48.7%) completed the preassessments and

postassessments. Significant differences were found for attitudes
toward team communication (p<0.001), motivation (p<0.001), utility
of training (p<0.001) and self-efficacy (p=0.005). Significant
attitudinal shifts for TeamSTEPPS skills included, team structure
(p=0.002), situation monitoring (p<0.001), mutual support (p=0.003)
and communication (p=0.002). Significant shifts were reported for
knowledge of TeamSTEPPS (p<0.001), advocating for patients
(p<0.001) and communicating in interprofessional teams (p<0.001).
In conclusion, effective team communication is important in patient
safety. Positive attitudinal and knowledge effects in a large-scale
interprofessional TeamSTEPPS-based training involving 4 student
professions were demonstrated (14).
Communication is the essence of the process of psychotherapy.
Understanding the parameters of communication can form the
foundations for the development of psychotherapeutic skills in the
student therapist. Using learning objectives within the context of
teaching psychotherapy, the process of communication in individual
psychotherapy is explored in this paper. With the aim of offering a
practical framework to assist in the analysis of the communication
process involved in individual psychotherapy, the following concepts
are first examined. 1] channels of communication; 2] modes of
functioning; 3] interaction between channels of communication and
modes of functioning. Following this exploration, the learning
objectives in communication are discussed. Using clinical examples,
the relationship between the communication process and other
concepts of individual psychotherapy are illustrated. Finally, some
pedagogic reasons for teaching students the analysis of the
communication process early in their psychotherapy training are
presented (15).
Global migration of HCPs places responsibility on employers to
comply with legal employment rights whilst ensuring patient safety
remains the central goal. The pilot of a communication assessment
designed for doctors who trained and communicated with patients
and colleagues in a different language from that of the host country
is described. It is unique in assessing clinical communication without
assessing knowledge. A 14-station OSCE was developed using a
domain-based marking scheme, covering professional
communication and English language skills (speaking, listening,
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realizing and writing) in routine, acute and emotionally challenging

contexts, with patients, careers and healthcare teams. Candidates
(n=43), non-UK trained volunteers applying to the UK Foundation
Program, were provided with relevant station information prior to
the exam. The criteria for passing the test included achieving the
pass score and passing 10 or more of the 14 stations. Of the 43
candidates, 9 failed on the station criteria. Two failed the pass score
and also the station criteria. The Cronbach's alpha coefficient was
0.866. In conclusion, this pilot tested 'proof of concept' of a new
domain-based communication assessment for non-UK trained
doctors. The test would enable employers and regulators to verify
communication competence and safety in clinical contexts,
independent of clinical knowledge, for doctors who trained in a
language different from that of the host country (16).
There is a lack of data for the structured development and
evaluation of communication skills in radiation oncology residency
training programs. Effective communication skills are increasingly
emphasized by the ACGME and are critical for a successful clinical
practice. The design of a novel, pilot SP program and the evaluation
of communication skills among radiation oncology residents is
presented. Two case scenarios were developed to challenge
residents in the delivery of "bad news" to patients: 1 scenario
regarding treatment failure and the other regarding change in
treatment plan. Eleven radiation oncology residents paired with 6
faculty participated in this pilot program. Each encounter was scored
by the SPs, observing faculty, and residents themselves based on the
Kalamazoo guidelines. Overall, resident performance ratings were
"good" to "excellent," with faculty assigning significantly higher
scores and residents assigning lower scores. Inconsistent inter rater
agreement among faculty, residents, and SPs were found. SP
feedback was valuable in identifying areas of improvement, including
more collaborative decision making and less use of medical jargon. In
conclusion, the program was well received by residents and faculty
and regarded as a valuable educational experience that could be
used as an annual feedback tool. Poor inter rater agreement suggests
a need for residents and faculty physicians to better calibrate their
evaluations to true patient perceptions. High scores from faculty
members substantiate the concern that resident evaluations are
generally positive and non-discriminating. Faculty should be
116
encouraged to provide honest and critical feedback to hone

residents' interpersonal skills (17).
The JCAHO found that 65% of medical sentinel events or medical
errors are associated with communication breakdowns. In addition to
the JCAHO, The Institute of Medicine, in their Core Competencies for
health care professional education, recommend improvement in
professional communication, collaboration, and a patient-centered
approach to provide safety. Consistency of opportunities for students
to practice their communication and collaboration skills is limited
based on the variety of clinical experiences that are available.
Simulation would provide consistency in students' experiences.
Students can practice giving a structured report, providing and
receiving peer feedback, and obtaining patient feedback in a safe
setting through a simulation experience. A structured hand-off shift
report using a technique such as SBAR communication has been
found to improve patient safety in health care environments. This
paper examines the implementation of a simulation experience for
students taking a Mental Health course in a Bachelor of Science in
Nursing Program to support their practice of patient and professional
communication, as well as, collaboration skills with a patient-
centered approach using a standardized patient simulation (18).
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SUMMARY
Communication is an important human characteristic. In order to
maintain relationships effectively humans must communicate with
each other. In everyday life, there are many types of communication
including with work colleagues, family, neighbors, and friends, some
efficient and some inefficient.
This research deals principally with human communication. How
do HCPs interact with each other? How do they interact with their
patients? How do they deliver difficult issues to their patients? To
their families? How do they handle conversations related to difficult
medical situations? Should medical students, interns and HCPs be
taught how to conduct effective conversations? How to deliver
difficult messages to the patients?
Communication between humans is a vital interaction in our lives.
This research deals with two biblical verses "Death and life are in the
power of the tongue" (Proverbs 18:21) and "A soft tongue breaks the
bone" (Proverbs 25:15). These verses indicate that verbal
communication is an essential part of human existence. How can we
deal with these verses in our everyday life?
Communication is defined as the exchange information, or the use
of common system of symbols, signs, behavior for this; a verbal or
written message; a system of routes; techniques for the effective
transmission of information, ideas, etc. In addition, communication
transfers information from one person to another.
The main message of these verses is to show the people that their
ability to communicate with each other is of vital importance for their
existence. The verses have a wide range of implications for our
everyday life, dealing with communication with the family, with
friends, in society, at work, and with patients. Since the author of this
research is a medical doctor, studying Medicine in the Bible, it is
natural that this study concentrates mainly on communication in a
variety of medical situations.
Effective communication is essential to practice and can result in
improved interpersonal relationships at the workplace; it is shaped
by basic techniques such as open-ended questions, listening,
empathy, and assertiveness. The relationship between effective
119
communication and successful interpersonal relationships is affected

by intervening variables. The variables of gender, generation,
context, collegiality, cooperation, self-disclosure, and reciprocity can
impede or enhance the outcome of quality communication.
Quality of interpersonal skills influences patient outcomes more
than quantity of teaching and instruction. All the effects of physician
communication skills on patient adherence are mediated by patient
satisfaction and recall.
The physician-patient interview is the key component of all health
care, particularly of primary medical care. Verbal behaviors positively
associated with health outcomes include empathy, reassurance and
support, various patient-centered questioning techniques, encounter
length, history taking, explanations, both dominant and passive
physician styles, positive reinforcement, humor, psychosocial talk,
time in health education and information sharing, friendliness,
courtesy, orienting the patient during examination, summarization
and clarification.
Patients like (and dislike) patient-centered communication for
thoughtful, considered reasons that appear grounded in their values
and expectations about physicians, patients, and the clinical
encounter.
Good intercollegial communication is a relatively unstudied topic,
although it is important for both HCPs and patients, contributing to
enhanced well-being, self-awareness and integrity for HCPs, and thus
positively affecting patient outcome and satisfaction.
A communication skills training course improves HCPs' assessment
of intercollegial communication. Periodic QI interventions were
effective in reframing interprofessional communication dynamics and
enabling practice change.
The evidence on the use of e-mail for the provision of information
on disease prevention and health promotion is weak, and therefore
inadequate to inform clinical practice. The available trials mostly
provide inconclusive, or no evidence for the outcomes.
Gender may influence provider-patient interaction to the extent
that it can be linked to the interactants' goals, skills, perceptions,
emotions, and the way the participants adapt to their partner's
communication. However, gender differences are often quite modest
(if apparent at all) when examined across a population of HCPs and
patients.
120
In order to effectively address the health needs young adults need

to be educated about their rights as patients, and how to most
efficiently use primary care services. GPs should be alert to effective
means of approaching and handling the healthcare needs of young
adults.
Stressful conversations are unavoidable in life. The best way to
keep from being thrown off balance by difficult conversations that
crop up unexpectedly is to develop a few hip-pocket phrases that can
be pulled out on the spot. We know from experience what kinds of
conversations and people we handle badly. The trick is to have
prepared conversational tactics to address those situations.
The high incidence of fatal diseases, inequitable access to health
care, and socioeconomic disparities generate plentiful clinical bad
news including diagnosis of a life-limiting disease, poor prognosis,
treatment failure, and impending death. These contexts compel HCPs
to become the messengers of bad news to patients and their families.
Low health literacy is an unavoidable barrier to effective patient
care for physicians. If the full spectrum definition of health literacy is
understood by physicians and carefully considered in the context of
their own practices, it is likely they would come to the realization
that health literacy is a greater obstacle to providing health care. In
order to communicate more effectively and better serve our patients,
we need to resist stereotyping patients when estimating (e.g., over
estimating or under estimating) their health literacy.
Individuals with poorer English language skills show similar
openness to considering ACP when supported with appropriate
language assistance. An individualistic decision making style is
associated with openness to ACP.
There are some gaps in current provision of health care practice in
an aspect of effective interactions and communication skills of HCPs
to meet patient needs in a multicultural and multilingual setting.
Effective communication with patient not only enables to take an
accurate history but also helps the patient to understand their illness
and no doubt assists the healing process. Communication with other
HCPs allows the team approach to healthcare to succeed. It reduces
the chances of a breakdown in continuity of care, builds relationships
and understanding between different disciplines and specialties and
helps professionals to learn from each other. In the medico-legal
121
field, poor communication is the underlying problem in the most of

cases that MPS deals with.
Time-limited, negative communications by doctors is associated
with increased litigious intentions among patients, even when
outcomes were neither adverse nor negligent.
Good verbal communication leads to better patient outcome,
better handling of crisis and is important for surgeons, orthopedic
surgical teams, for patients with sickle cell disease, colleges of
pharmacy, anesthesiologists, and physicians of a variety specialties
including cardiac imaging, interventional cardiology, pediatric
cardiology, cardiothoracic surgery, and radiology.
A supportive and communicative work environment promotes
nurses' dignity and respect. Embarrassing nurses in front of other
HCPs may be counterproductive. The promoting factors in nurses
include genuineness, competency and effective communication skills.
Video-feedback is a potentially effective method to improve
practice nurses' generic communication skills. Although a single
video-feedback session is insufficient to increase all motivational
interviewing skills, significant improvement in some specific skills is
found.
Nurses communicate less effectively when delivering psychosocial
aspects of care and in emotionally charged situations. Patients'
unwillingness to discuss their disease/feelings, their preference to
seek emotional support from their family/friends and their use of
implicit cues are some of the factors that inhibit communication.
Personal characteristics of patients and nurses are the key factors
that influence effective nurse-patient communication within the
oncology setting.
Communication between patient and HCPs is important,
especially for the treatment of acute conditions such as sore throat,
STD including HIV, various infections in hospitals, and chronically ill
patients with LLB, heart failure, COPD, dementia including
Alzheimer's disease, as well as for psychiatric patients, nursing, and
palliative care such as end-of-life management, oncology, and
pediatrics.
Good communication between HCPs and patients can promote
adherence and improve outcomes.
When having difficult conversations with CIHD patients, clinicians
need to assess the individual's need and wishes for information, their
122
social and cultural background; to consider the setting, timing and

content of the discussion, as well as strategies to promote coping and
adjustment. Patients need a treatment plan to address palliative and
supportive care to be implemented at the time of breaking bad news,
so that they and their families do not feel abandoned.
Conversations focus largely on disease management; end-of-life
care is rarely discussed. Some patients would welcome such
conversations, but many do not realize the seriousness of their
condition or do not wish to discuss end-of-life issues. Clinicians are
unsure how to discuss the uncertain prognosis and risk of sudden
death; fearing causing premature alarm and destroying hope, they
wait for cues from patients before raising end-of-life care issues.
Consequently, the conversations rarely take place.
Identifying and exploring barriers to patient-physician
communication about end-of-life issues may help guide physicians
and their patients toward more effective discussions.
Among seriously ill-hospitalized adults, communication about
preferences for CPR is uncommon. A majority of patients who have
not discussed preferences for end-of-life care do not want to do so.
For patients who do not want to discuss their preferences, as well as
patients with an unmet need for such discussions, failure to discuss
preferences for CPR and mechanical ventilation may result in
unwanted interventions.
Empathic curiosity is a standpoint that we adopt when we focus
our attention on the perceptual experiences of people with
dementia. Adopting an empathic and curious stance may help to
establish the common ground for meaningful communication and
help to cultivate relationships that are based upon equality and
common understanding, rather than power and dependency. Four
key sets of communication skills can support this approach: asking
short open questions in the present tense; noticing emotional cues;
giving time and space for the person with dementia to find their
words and share responsibility for steering the course of a
conversation; and exploring the use of metaphors.
Pediatricians spend a considerable proportion of their time
performing follow-up visits for children with chronic conditions, but
they rarely receive specific training on how best to perform such
consultations. Physician behavior is an important but understudied
influence on child and parental adherence to medical treatment.
123
Satisfaction is associated with physician to parent friendliness, the

quality of the ongoing parent-physician and child-physician
relationships, comfort asking questions, and trust. Both the
communication style and the quality of the ongoing relationship
contribute to pediatric chronic disease visit satisfaction.
Improved communication about palliative and end-of-life care is
associated with reduced intensity of care at the end of life, improved
QOL for patients and families, improved quality of dying for patients,
and reduced psychological symptoms for families.
Even though good communication among clinicians, patients, and
family members is identified as the most important factor in end-of-
life care in ICUs, it is the least accomplished. Poor communication
leaves clinicians and family members stressed and dissatisfied, as
well as patients' wishes neglected. Conflict and anger both among
clinicians and between clinicians and family members also result.
Physicians and nurses lack communication skills, an essential element
to achieve better outcomes at end of life.
The patient-oncologist relationship is one of the most delicate in
medicine, and given the strong emotions associated with cancer,
successful communication plays a paramount role in the wellbeing of
patients and oncologists. Effective and empathic communication with
the cancer patient and family can influence desirable outcomes in
cancer care, which affect patient QOL, satisfaction with care, and
medical outcomes. Communication skills are the cornerstone of
comprehensive cancer care.
Cancer patients, a highly diverse population, communicate with
their clinical care team in diverse ways over the course of their care.
Whether that communication happens and how effective it relates to
a variety of factors including the type of cancer and the patient's
position on the cancer care continuum? Communication within
oncology is a core clinical skill but one in which few oncologists or
specialist cancer nurses have received much formal training.
Inadequate communication may cause much distress for patients and
their families, who often want considerably more information than is
usually provided. Many patients leave consultations unsure about the
diagnosis and prognosis, confused about the meaning of and need for
further diagnostic tests, unclear about the management plan and
uncertain about the true therapeutic intent of treatment.
124
Communicating about the end of life with patients is one of the

most difficult and stressful part of the work of oncologists. Despite
this fact, oncologists receive little training in this area, and many do
not communicate effectively with patients.
Many patients affected by cancer and their family members are
looking for informed advice and desire communication with their
physicians about CIM use. Patients affected by cancer come to
discuss CIM use with intense emotions and are experiencing an
existential crisis that cannot be ignored. Effective communication is
crucial in establishing trust with these patients and their families.
Communication is a core clinical skill in medicine, including cancer
care, and is important to the delivery of high-quality care.
Interpersonal communication skills as part of the supportive care
in cancer won new dimensions by demonstrating the association with
enhanced ability of patients to cope with the disease, to enhance
trust in HCPs, compliance with treatment and to reduce emotional
distress and psychosocial burden. Besides empathy, the effective
patient centered communication is based upon perceptual and
behavioral skills of caregivers. Doctors, nurses, and oncology social
workers have to achieve skills to listen to patients complains and to
respond to his/ her support needs.
Training programs are effective in improving some areas of cancer
care professionals communication skills.
Efforts have been implemented to teach communication skills
among a wide range of HCPs. Professional conversation between
patients and doctors shapes diagnosis, initiates therapy, and
establishes a caring relationship. The degree to which these activities
are successful depends, in large part, on the communication and
interpersonal skills of the physician.
Models of how people learn can help physicians select tasks,
questions, and prompts that advance teaching and learning. To keep
and use new information, adults need to integrate new ideas into
existing frameworks of understanding and participate in the learning
process by linking new information to what is known.
Our current efforts to study virtual characters in health
professions education is to develop a system that can be
independently accessed and thus user satisfaction is an important
factor in how readily this technology will be adopted. Communication
125
skills training improves the QOL and wellbeing of people and

increases positive interactions in various care settings.
We see that efficient communication covers a wide range of
issues. What we think of as a scientific discovery was already known
thousands of years ago. The wisdom of verses "Death and life are in
the power of the tongue" (Proverbs 18:21) and "A soft tongue beaks
the bone (Proverbs 25:15) should guide HCPs in their everyday life.
126
ABBREVIATIONS I
AAE African American English
AC Auditory cortex
ACGME Accreditation Council for Graduate Medical
Education
ACP Advance care planning
AD Alzheimer's disease
AG Angular gyrus
AIDS Acquired immunodeficiency syndrome
AOR Adjusted odds ratio
BOLD Blood oxygen level-dependent
CASE Communication assessment and skill-building
exercise
CHD Congenital heart disease
CI Confidence intervals
CIHD Chronic ischemic heart disease
CIM Complementary and integrative medicine
CLB Central line bundle
CME Continuing medical education
COPD Chronic obstructive pulmonary disease
CPA Cerebello-pontine angle
CPR Cardiopulmonary resuscitation
CRBSIs Catheter-related bloodstream infections
CST Communication skills training
DCM Dynamic causal modeling
DmPFC Dorsomedial prefrontal cortex
DNR Do not resuscitate
DPS Dynamic Patient Simulator
EBMR Evidence-Based Medicine Reviews
EM Emergency medicine
FFG Fusiform gyrus
FIR Finite impulse response
fMRI Functional magnetic resonance imaging
FMS Fibromyalgia syndrome
GP General practitioner
HCP Health care professional/provider
HIT Health information technology
HIV Human immunodeficiency virus
IBD Inflammatory bowel disease
ICT Information communication technology
127
ABBREVIATIONS II
ICU Intensive care unit

IHCAs Interactive Health Communication Applications
ILR Interagency Language Roundtable
IM Internal medicine
ITC Interprofessional information transfer and
communication
JCAHO Joint Commission on Accreditation of
Healthcare Organizations
KOPRA Kommunikationspraeferenzen
LBP Low back pain
MD Mean differences
MICU Medical intensive care unit
MRC Medical Research Council
NID Nonintentional discrepancies
OA Osteoarthritis
OR Odds ratio
OSCE Objective Structured Clinical Examination
PA Phonemic awareness
PCs Personal computers
PERCS Program to Enhance Relational and
Communication Skills
PICU Pediatric intensive care unit
QI Quality improvement
QOL Quality of life
RCTs Randomized controlled trials
RR Relative rate
SAE Standard American English
SBAR Situation, background, assessment, and
recommendations
SES Socioeconomic status
SMDs Standardized mean differences
SP Standardized patient
STDs Sexually transmitted diseases
TNR Total knee replacement
VP Virtual patient
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VERBAL COMMUNICATION SKILLS

Book · January 2015

Liubov Ben-Noun (Nun)

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L. Ben-Nun Communication skills

L. Ben-Nun Communication skills

These are scientific medical studies incorporating verses from the

Fundamentally, this Research is constructed purely from an

The research is part of a long series of published studies on the

This is not a laboratory research. The Research is built entirely on

L. Ben-Nun Communication skills

L. Ben-Nun Communication skills

Patient concerns can be wide ranging, including fear of death,

L. Ben-Nun Communication skills

therapeutic patient-doctor relationship uses the clinician as a

L. Ben-Nun Communication skills

the analysis of conversations to explore the characteristics of the

L. Ben-Nun Communication skills

regions, the post-stimulus time-courses as a description of the

L. Ben-Nun Communication skills

Similarly, certain common characteristics and communication styles

L. Ben-Nun Communication skills

THE BIBLICAL VERSES

L. Ben-Nun Communication skills

2. Examples of Non Verbal Communication. Available 15 May 2014 at

LISTENING AND UNDERSTANDING

The activities involved in mediating reinforcement for a speaker's

L. Ben-Nun Communication skills

fundamentally no different than other discriminated operants, they

L. Ben-Nun Communication skills

L. Ben-Nun Communication skills

PEOPLE WITH COMPLEX COMMUNICATION NEEDS

L. Ben-Nun Communication skills

adults with complex communication needs was determined using

L. Ben-Nun Communication skills

awareness during literacy instruction in an effort to maximize

L. Ben-Nun Communication skills

L. Ben-Nun Communication skills

behaviors positively associated with outcomes included head

L. Ben-Nun Communication skills

generally effective techniques for verbal and non-verbal

COMMUNICATION WITH WORK COLLEAGUES

L. Ben-Nun Communication skills

questions in T3, respectively. In conclusion, a communication skills

L. Ben-Nun Communication skills

is related to an improvement in operating room teamwork and

L. Ben-Nun Communication skills

CLB and higher-than-expected CRBSIs. This study sought to promote

L. Ben-Nun Communication skills

training course in communication skills for HCPs could improve: 1]

L. Ben-Nun Communication skills

significant decrease for 1/19 question after the training course. In

L. Ben-Nun Communication skills