Search

Background: Complementary medicine such as yoga, massage and art therapy has become increasingly popular among patients with cancer. However, the topic remains under-discussed during oncology consultations: patients seem hesitant to disclose complementary medicine use, and healthcare providers lack resources to discuss complementary medicine. This study aims to gain an understanding of how to improve communication and information provision in oncological settings about complementary medicine by assessing the experiences and needs of patients and healthcare providers., Materials and Methods: Semi-structured interviews were conducted with 17 patients with cancer and 13 oncology healthcare providers recruited from two general hospitals and one breast cancer center in the Netherlands. Nine (former) patients with breast cancer collaborated with the research team as 'co-researchers'. Reflexive thematic analysis was used., Results: The main themes identified were barriers to patient-provider communication about complementary medicine (e.g. lack of time and knowledge among healthcare providers, negative attitudes toward complementary medicine), facilitators of communication (e.g. openness of healthcare providers, complementary medicine as a routine topic) and information provision needs (e.g. easy access to information, the hospital being involved in providing information)., Conclusion: Patients with cancer and healthcare providers report issues with the current approach to discussing complementary medicine and are of the opinion that complementary medicine should be a routine topic in oncology consultations. Future studies should focus on effective methods for standardizing complementary medicine discussions into oncology care and making reliable information available for patients and healthcare providers., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Contemporary healthcare is characterized by multidisciplinary teamwork across a vast array of primary, secondary and tertiary services, augmented by progressively more technology and data. While these developments aim to improve care, they have also created obstacles and new challenges for both patients and health professionals. Indeed, the increasingly fragmented and transactional nature of clinical encounters can dehumanize the care experience across disciplines and specialties. Effective communication plays a pivotal role in reinforcing the humanity of healthcare through the delivery of person-centered care - compassionate, collaborative care that focuses on the needs of each patient as a whole person. After convening at the International Conference on Communication in Healthcare (Glasgow, 2022), an interdisciplinary group of researchers, educators and health professionals worked together to develop a framework for effective communication that both acknowledges critical challenges in contemporary health services and reinforces the humanity of healthcare. The Glasgow Consensus Statement is intended to function as a useful international touchstone for the training and practice of health professionals, fully recognizing and respecting that different countries are at different stages when it comes to teaching, assessment and policy. It also provides a vocabulary for monitoring the impact of system-level challenges. While effective communication may not change the structure of healthcare, it can improve the process if health professionals are supported in infusing the system with their own innate humanity and applying the framework offered within this consensus statement to reinforce the humanity in everyday practice., Competing Interests: Declaration of Competing Interest The authors declare that the work reported in this paper is the product of consensus and that they have no known competing financial interests or personal relationships that could have appeared to influence it., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Aim: To explore how the expression of positive emotions during the interaction between patients and providers can cultivate the patient-provider relationship., Design: We conducted a realist review guided by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards., Methods: We systematically searched CINAHL, MEDLINE, PsychINFO and Scopus from inception to March 2019. Study selection and data extraction were performed blinded in pairs. From 3146 abstracts blinded in pairs, 15 papers were included and analysed. From each included paper, we extracted contexts, mechanisms and outcomes that were relevant to answer our research questions, creating a configuration between these elements (CMO configuration)., Results: Our findings suggest that in the contexts of person orientation and positive outlook, patient-provider relationships improve by communication conveying and eliciting positive emotions. We found six underlying mechanisms for this that form either direct or indirect pathways between the context and the outcome., (© 2023 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Objective: Gender can be a valuable resource in communication but also a problem, perpetuating gender stereotypes. So far, there has been little attention for how healthcare professionals and patients make gender relevant in medical interactions. The approach of Membership Categorization Analysis (MCA) is particularly pertinent to meticulously analyze gender in medical communication. Applying MCA, this study analyzes how activity descriptions implicitly associated with gender stereotypes, e.g., "carrying a laundry basket up the stairs", feature in the course of GPs' explanations of a question or diagnosis. The aim is to provide a new perspective on the relationship between gender and medical interaction, and to increase our understanding of how gender stereotypes are reproduced in the medical setting., Method: Two cases of GPs using gendered explanations in Dutch general practice interactions are analyzed turn-by-turn using MCA., Results: The findings show how GPs' descriptions of gendered activities serve the exemplification of technical terms, designed for the specific patient, while also casting the patient in a traditional gender role., Conclusion: Invoking gender in medical interaction may serve a communicative goal while also perpetuating stereotypes., Practice Implications: Insight in the subtleties of gender construction in medical interactions could enhance gender awareness and sensitivity in healthcare., Competing Interests: Declarations of interest None., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The quality of communication between healthcare professionals (HCPs) and patients affects health outcomes. Different coding systems have been developed to unravel the interaction. Most schemes consist of predefined categories that quantify the content of communication (the what). Though the form (the how) of the interaction is equally important, protocols that systematically code variations in form are lacking. Patterns of form and how they may differ between groups therefore remain unnoticed. To fill this gap, we present CLECI, Coding Linguistic Elements in Clinical Interactions, a protocol for the development of a quantitative codebook analyzing communication form in medical interactions., Methods: Analyzing with a CLECI codebook is a four-step process, i.e. preparation, codebook development, (double-)coding, and analysis and report. Core activities within these phases are research question formulation, data collection, selection of utterances, iterative deductive and inductive category refinement, reliability testing, coding, analysis, and reporting., Results and Conclusion: We present step-by-step instructions for a CLECI analysis and illustrate this process in a case study. We highlight theoretical and practical issues as well as the iterative codebook development which combines theory-based and data-driven coding. Theory-based codes assess how relevant linguistic elements occur in natural interactions, whereas codes derived from the data accommodate linguistic elements to real-life interactions and contribute to theory-building. This combined approach increases research validity, enhances theory, and adjusts to fit naturally occurring data. CLECI will facilitate the study of communication form in clinical interactions and other institutional settings., (© 2022. The Author(s).)

Objectives: Affective communication in outpatient care is important, especially in the palliative phase. Appropriate responses by healthcare providers to emotional cues or concerns let patients express their feelings and enhance information recall and patient satisfaction. Patients with limited health literacy experience more barriers in health-related communication and information, which makes recognizing their cues and concerns even more relevant. This study explores emotional cues/concerns expressed by patients with limited health literacy and evaluates healthcare providers' responses to these utterances., Methods: Verona Coding Definitions of Emotional Sequences (VR-CoDES), a consensus-based system for coding patients' expression of emotional distress in medical consultations, was used in this exploratory observational study to analyse affective communication in video-recorded outpatient consultations. Consultations of 18 (10 female, 8 male) COPD or lung cancer patients (aged 70.3±6.8) with limited health literacy were recorded and analysed. Eight healthcare providers in four hospitals participated in the study., Results: 101 cues and 11 concerns were observed, making 6.2 (SD = 4.2) cues or concerns per consultation. Healthcare provider responses were explicit in 56% and left scope for further disclosures in 58% of the cases. Patients with limited health literacy seem to express more cues or concerns than other patient populations. Healthcare providers responded roughly equally often in five different ways, but they shied away from further exploring the emotion disclosed in the cue/concern. Future research should elaborate on these exploratory observations, especially regarding why HCPs often only leave limited space for further disclosure of emotions in palliative care., Competing Interests: The authors have declared that no competing interests exist.

Background: Patients have a 'need to know' (instrumental need) and a 'need to feel known' (affective need). During consultations with patients with limited health literacy (LHL) in the palliative phase of their disease, both the instrumental and the affective communication skills of healthcare providers are important. The study aims to explore instrumental and affective communication between care providers and LHL patients in the palliative phase of COPD or cancer., Methods: In 2018, consultations between LHL patients in the palliative phase of cancer or COPD and their healthcare providers were video-recorded in four hospitals in the Netherlands. As there was no observation algorithm available for this setting, several items were created to parameterize healthcare providers' instrumental communication (seven items: understanding, patient priorities, medical status, treatment options, treatment consequences, prognosis, and information about emotional distress) and affective communication (six items: hope, support, reassurance, empathy, appreciation, and emotional coping). The degree of each item was recorded for each consultation, with relevant segments of the observation selected and transcribed to support the items., Results: Consultations between 17 care providers and 39 patients were video-recorded and analyzed. Care providers primarily used instrumental communication, most often by giving information about treatment options and assessing patients' care priorities. Care providers assessed patients' understanding of their disease less often. The patients' prognosis was not mentioned in half the consultations. Within the affective domain, the care providers did provide support for their patients; providing hope, reassurance, empathy, and appreciation and discussing emotional coping were observed less often., Conclusions: Care providers used mostly instrumental communication, especially treatment information, in consultations with LHL patients in the palliative phase of cancer or COPD. Most care providers did not check if the patient understood the information, which is rather crucial, especially given patients' limited level of health literacy. Healthcare providers did provide support for patients, but other expressions of affective communication by care providers were less common. To adapt the communication to LHL patients in palliative care, care providers could be less wordy and reduce the amount of information, use 'teach-back' techniques and pay more attention to affective communication.

There is a disproportionate underuse of genetic testing in breast cancer patients from lower education or migrant background. Within these groups, communication about referral to genetic counseling appears challenging due to limited health literacy and cultural barriers. Our aim was to develop and evaluate a training program for healthcare professionals (breast surgeons and specialized nurses), to increase effective communication. We systematically developed a blended training program based on patients' and healthcare professionals' needs and preferences. Prior to the training, we assessed awareness, knowledge and self-efficacy of healthcare professionals. Acceptability and usefulness of the training program were assessed directly after the training. Healthcare professionals (n = 65) from 17 hospitals showed moderate to high awareness and knowledge about the prevalence and impact of limited health literacy. They were aware of cultural factors that influence communication. However, they did not feel confident in recognizing limited health literacy and their self-efficacy to communicate effectively with these patients was low. The training program was rated as acceptable and useful. Healthcare professionals lack confidence to effectively communicate with patients with limited health literacy or migrant background. The training program offers opportunities to improve communication about referral to breast cancer genetic counseling.

Objective: Given the free movement of workers across countries, knowledge regarding communication differences between countries is imperative. In this study, we explored and compared the supportive responses of nursing staff to older persons' emotions in home care in Norway and Sweden., Methods: The study had an observational, cross-sectional, comparative design, which included 383 audio-recorded home-care visits. Communication was coded using Verona Coding Definitions of Emotional Sequences. Worries and responses were categorised with regard to reference, communicative function and level of person-centredness. Standard statistical tests were used to analyse the data., Results: The Swedish nursing staff provided space for further disclosure of worry more frequently than the Norwegian nursing staff (75.0 % versus 60.2 %, χ2 = 20.758, p < 0.01). In all, 65 % of the responses were supportive. Multiple logistic regression analyses showed that highly person-centred responses were independently associated with worries phrasing an emotion, OR (95 % CI) 3.282 (1.524-7.067)., Conclusion: The level of person-centredness was associated with the way in which older persons expressed their distress. The Swedish nursing staff provided opportunities for further disclosure of worries more frequently than the Norwegian nursing staff., Practice Implications: Findings of intercultural differences should be incorporated into the training of nursing staff., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To gain insight into patient participation in general practice by examining if and how patients' question-asking behaviour has changed over the years (2007-2016)., Methods: A random set of real-life video-recorded consultations collected in 2015-2016 (n = 437) was observed and compared with that of a former study in 2007-2008 (n = 533). Patients' question-asking behaviour was coded using an adapted RIAS protocol containing six categories: medical condition/therapeutic regimen; psychosocial; social context; lifestyle; ask for opinion doctor; practical. GPs and patients completed questionnaires about their background characteristics. Data were analysed using multi-level analysis., Results: Patients asked fewer questions in 2016 than in 2007. The type of question-asking behaviour changed significantly: in particular medical questions decreased while practical questions increased. Less educated patients asked significantly more practical questions than higher educated patients., Conclusion: Contrary to our expectations, patients' question-asking has decreased in 2016 compared to 2007, while the average consultation length has increased. The type of questions shifted from medical to practical, especially in less educated patients. It seems that GPs' professional role has expanded over time, since patients nowadays ask their GP more non-medical questions., Practice Implications: GPs probably could continue facilitating patient involvement by more frequently using partnership-building and supportive communication., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: Tailoring medical information to cancer patients' needs is recommended, but there is little guidance on how to tailor, and limited research exists about its effects. Tailoring to the amount of preferred information may be easily implementable in clinic and is tested here., Methods: A video-vignette experiment was used to systematically vary video patients' information preferences (limited/extensive) and amount of provided information (additional/no additional). N = 253 cancer patients/survivors evaluated these video-recorded consultations, serving as analogue patients (APs), and completed outcome measures., Results: Tailoring information to video patients' preferences had no effect on APs' evaluation of the consultation (satisfaction, trust). Yet, there was a main effect of APs' own information preferences: Those preferring extensive information recalled (MΔ = 5.8%) and recognized (MΔ = 3.5%) more information than those preferring limited information. Moreover, information provision mattered among APs who preferred limited information: They recognized even less if provided with extensive information., Conclusions: Tailoring to the amount of video patient's information preferences did not affect APs' evaluation of the consultation (satisfaction, trust), while APs' personal information preferences determined their recall and recognition of medical information., Practice Implications: Information preferences should be assessed and tailored to in clinical practice. Overwhelming patients/survivors, who prefer limited information, should be prevented., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The online tool PatientVOICE has been developed to enhance older patients' participation during educational nursing encounters preceding chemotherapy and to increase their information recall., Objective: The aim of this study was to evaluate perceived usefulness, usability, satisfaction with emotional support, language use, attractiveness, and visit intention of PatientVOICE by older (ex-)patients with cancer., Methods: Older (ex-)patients with cancer were invited to evaluate the website via an online questionnaire. Perceived usefulness, usability, and satisfaction with emotional support were measured using evaluation statements, the System Usability Scale, and an adapted subscale of the Website Satisfaction Scale, respectively. Questions were also included about language use and attractiveness of the website and patients' intention to visit the website., Results: A total of 44 questionnaires were analyzed. Many patients evaluated the provided information and other integrated techniques (such as the question prompt sheet, video fragments, and the audio facility) positively on aspects as usefulness and helpfulness. The usability was considered good (mean scale score, 74.3). Most patients (84.9%) considered the language use on the website clear, and 63.6% of the patients found the website attractive. Many patients (71.9%) would visit the website if they would like to gather information on the encounter preceding chemotherapy, and 62.5% of the patients would do this for information about chemotherapy., Conclusions: PatientVOICE is evaluated as a useful and user-friendly tool, enabling patients to prepare themselves for the nursing encounter preceding chemotherapy and to gather information about chemotherapy., Implications for Practice: Preparatory online tools, such as PatientVOICE, can be implemented in hospitals to offer patients extra support.

Background: General practice is the centre of care for patients with medically unexplained symptoms (MUS). Providing explanations for MUS, i.e. making sense of symptoms, is considered to be an important part of care for MUS patients. However, little is known how general practitioners (GPs) do this in daily practice., Objective: This study aimed to explore how GPs explain MUS to their patients during daily general practice consultations., Methods: A thematic content analysis was performed of how GPs explained MUS to their patients based on 39 general practice consultations involving patients with MUS., Results: GP provided explanations in nearly all consultations with MUS patients. Seven categories of explanation components emerged from the data: defining symptoms, stating causality, mentioning contributing factors, describing mechanisms, excluding explanations, discussing the severity of symptoms and normalizing symptoms. No pattern of how GPs constructed explanations with the various categories was observed. In general, explanations were communicated as a possibility and in a patient-specific way; however, they were not very detailed., Conclusion: Although explanations for MUS are provided in most MUS consultations, there seems room for improving the explanations given in these consultations. Further studies on the effectiveness of explanations and on the interaction between patients and GP in constructing these explanations are required in order to make MUS explanations more suitable in daily primary care practice., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved.)

Objective: General practitioners (GPs) disclose more uncertainty (e.g. "I don't know") in consultations with patients presenting medically unexplained symptoms (MUS) versus medically explained symptoms (MES), which could negatively affect patient outcomes. This study assessed if this pattern also holds for more subtle, implicit uncertainty expressions (e.g. "maybe", "might") during different consultation phases, and assessed their relation to patient pre-post consultation anxiety., Methods: We quantified implicit markers of uncertainty of 18 GPs in 82 consultations about MUS or MES during different consultation phases. Relative frequencies of implicit uncertainty per consultation were regressed on differences in momentary anxiety pre and post consultation., Results: We coded 2590  GP utterances. Uncertainty expressions were more frequent in MUS versus MES consultations (OR = 1.54, p = .004), especially during diagnosis and treatment recommendations compared to physical examinations (OR =0 .45, p = .001). Implicit uncertainty was not related to patients' changes in anxiety (b = -0.11, p = .817)., Conclusions: GPs express more uncertainty during MUS (versus MES) consultations, especially during the diagnostic phase and treatment recommendations. This does not necessarily affect patient anxiety., Practice Implications: Implicit uncertainty expressions reflect the mere complexity of communicating a medically unexplained diagnosis, which does not affect patient anxiety., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The aim of this study was to explore the influence of characteristics of nurses and older people on emotional communication in home care settings. A generalized, linear, mixed model was used to analyze 188 audio-recorded home care visits coded with Verona Coding Definitions of Emotional Sequences. The results showed that most emotional distress was expressed by older females or with female nurses. The elicitation of an expression of emotional distress was influenced by the nurses' native language and profession. Older women aged 65-84 years were given the most space for emotional expression. We found that emotional communication was primarily influenced by sex for nurses and older people, with an impact on the frequency of expressions of and responses to emotional distress. Expressions of emotional distress by older males were less common and could risk being missed in communication. The results have implications for students' and health professionals' education in increasing their knowledge of and attentiveness to the impacts of their and others' characteristics and stereotypes on emotional communication with older people., (© 2019 John Wiley & Sons Australia, Ltd.)

Background: It is unknown whether patients with medically unexplained symptoms (MUS) differ from patients with medically explained symptoms (MES) regarding their expectations and experiences on task-oriented communication (ie, communication in which the primary focus is on exchanging medical content), affect-oriented communication (ie, communication in which the primary focus is on the emotional aspects of the interaction) and therapy-oriented communication (ie, communication in which the primary focus is on therapeutic aspects) of the consultation and the extent to which GPs meet their expectations., Objective: This study aims to explore (a) differences in patients' expectations and experiences in consultations with MUS patients and patients with MES and (b) the influence of patients' experiences in these consultations on their post-visit anxiety level., Study Design: Prospective cohort., Setting: Eleven Dutch general practices., Measurements: Patients completed the QUOTE-COMM (Quality Of communication Through the patients' Eyes) questionnaire before and after the consultation to assess their expectations and experiences and these were related to changes in patients' state anxiety (abbreviated State-Trait Anxiety Inventory; STAI)., Results: Expectations did not differ between patients with MUS and MES. Patients presenting with either MUS or MES rated their experiences for task-related and affect-oriented communication of their GP higher than their expectations. GPs met patients' expectations less often on task-oriented communication in MUS patients compared to MES patients (70.2% vs 80.9%; P = ˂0.001). Affect-oriented communication seems to be most important in reducing the anxiety level of MUS patients (β -0.63, 95% Cl = -1.07 to -0.19)., Discussion: Although the expectations of MUS patients are less often met compared to those of MES patients, GPs often communicate according to patients' expectations. Experiencing affect-oriented communication is associated with a stronger reduction in anxiety in patients with MUS than in those with MES., Conclusion: GPs communicate according to patients' expectations. However, GPs met patients' expectations on task-oriented communication less often in patients with MUS compared to patients with MES. Experiencing affect-oriented communication had a stronger association with the post-consultation anxiety for patients with MUS than MES., (© 2018 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Background: Shared decision-making (SDM) is, largely, espoused as the preferred model for making decisions in everyday health care. Studies exploring the application of SDM in primary care practice are still lacking., Objectives: This study explores how GPs involve their patients in decision-making, if application of SDM has increased over time (2007-15), and what factors are associated with it., Methods: We investigated the application of SDM by Dutch GPs by analysing a random set of real-life video-recorded consultations collected in 2007 (n = 50) and 2015 (n = 50). SDM was assessed by observing patient involvement in decision making (OPTION), a reliable and valid instrument measuring the extent to which clinicians involve patients in decision-making by coding 12 behavioural items. In addition, GPs and patients completed questionnaires about their background characteristics. The potential determinants for application of SDM by Dutch GPs (including year of measurement, sex and age of patients and GPs, the nature of complaints, consultation duration and the type of decision discussed) were analysed using multilevel analysis [with patients (Level 1) nested within GPs (Level 2)]., Results: In 2015, GPs applied SDM more often compared with 2007 according to OPTION. In consultations with older patients, there is less application of SDM by GPs., Conclusions: Although application of SDM by Dutch GPs has increased, low overall SDM scores still leave room for improvement. GPs should elicit the patient's preferred role in the decision-making process at any time, in particular in consultations with older patients., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Adequate information-provision forms a crucial component of optimal cancer care. However, information-provision is particularly challenging in an oncology setting. It is therefore imperative to help oncological health care practitioners (HCP) optimise their information-giving skills. New forms of online education, i.e. e-learning, enable safe and time and location independent ways of learning, enhancing access to continuous learning for HCP. As part of a user-centred approach to developing an e-learning to improve information-giving skills, this study aims to: 1) uncover the learning needs of oncological healthcare providers related to information- provision, and 2) explore their training preferences in the context of clinical practice., Methods: Focus groups and interviews were organised with oncological HCP (medical specialists and clinical nurse specialists) addressing participants' learning needs concerning information- provision and their training preferences with respect to a new digital training tool on this issue. All sessions were audiorecorded and transcribed verbatim. Using an inductive approach, transcripts were independently coded by three researchers and discussed to reach consensus. Main themes were summarised and discussed., Results: Four focus group sessions (total n = 13) and three interviews were conducted. The first theme concerned the patient outcomes HCP try to achieve with their information. We found HCP to mainly strive to promote patients' understanding of information. The second theme concerned HCP reported strategies and challenges when trying to inform their patients. These entailed tailoring of information to patient characteristics, structuring of information, and dealing with patients' emotions. Regarding HCP training preferences, an e-learning should be neatly connected to clinical practice. Moreover, participants desired a digital training to allow for feedback on their own (videotaped) information-giving skills from peers, communication experts, and/or patients; to monitor their progress and to tailored the training to individual learning needs., Conclusions: An e-learning for improvement of information-giving skills of oncological HCP should be aimed at the transfer of skills to clinical practice, rather than at enhancing knowledge. Moreover, an e-learning is probably most effective when the facilitates individual learning needs, supports feedback on competence level and improvement, and allows input from significant others (experts, peers, or patients).

Objective: Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety., Methods: Language use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient's state anxiety (abbreviated State Trait Anxiety Inventory; STAI)., Results: In total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42-2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages (b = 0.67, 95% CI 0.07-1.27) CONCLUSIONS: GPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety., Practice Implications: GPs could manage patient's state anxiety by expressing negative messages in an indirect rather than direct manner., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To enhance patient participation during (oncological) encounters, this study aims to gain insight into communication barriers and supportive interventions experienced by elderly patients with cancer., Method: A mixed method design, including both quantitative (secondary survey data analysis) and qualitative (interviews) methods Survey data were used to identify communication barriers and need for supportive interventions of elderly cancer patients, compared to younger patients. Next, interviews provided in-depth insight into elderly patients' experiences and underlying mechanisms., Results: A majority of the 70 participating elderly cancer patients (53%) felt confident in communicating and participating during medical encounters. However, 47% of patients experienced barriers to effectively communicate with their healthcare provider and felt the need for supportive interventions. The 14 interviewed patients mentioned barriers and facilitators related to attributes of themselves (e.g. feeling sick, self-efficacy), the provider (e.g. taking patient seriously) and the healthcare system (e.g. time constraints)., Conclusions: Although many elderly cancer patients feel confident, offering support to patients who feel less confident in communicating with their provider is recommended., Practice Implications: The outcomes of this study can be used as a first step for developing interventions for elderly cancer patients to overcome communication barriers, and help providers to facilitate this process., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: Placebo effects (true biopsychological effects not attributable to the active ingredients of medical technical interventions) can be attributed to several mechanisms, such as expectancy manipulation and empathy manipulation elicited by a provider's communication. So far, effects have primarily been shown in laboratory settings. The aim of this study is to determine the separate and combined effects of expectancy manipulation and empathy manipulation during preoperative and postoperative tonsillectomy analgesia care on clinical adult patients' outcomes., Methods and Analysis: Using a two-by-two randomised controlled trial, 128 adult tonsillectomy patients will be randomly assigned to one out of four conditions differing in the level of expectancy manipulation (standard vs enhanced) and empathy manipulation (standard vs enhanced). Day care ward nurses are trained to deliver the intervention, while patients are treated via the standard analgesia protocol and hospital routines. The primary outcome, perceived pain, is measured via hospital routine by a Numeric Rating Scale, and additional prehospitalisation, perihospitalisation and posthospitalisation questionnaires are completed (until day 3, ie, 2 days after the operation). The manipulation is checked using audio recordings of nurse-patient interactions., Ethics and Dissemination: Although communication is manipulated, the manipulations do not cross norms or values of acceptable behaviour. Standard medical care is provided. The ethical committee of the UMC Utrecht and the local OLVG hospital committee approved the study. Results will be published via (inter)national peer-reviewed journals and a lay publication., Trial Registration Number: NTR5994; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To explore in what way emotional communication can enhance the memory of people with (different types of) dementia., Methods: Relevant studies published after 2000 were searched using the terms: dementia, positive, words, communication, recall, and memory. Papers were included that reported results of studies with people with dementia that investigated memory effects of communication with either an emotionally valent content or context., Results: Twelve papers grouped under four prevailing themes (pictures, facial emotions, stories and words) are described. The studies provide mixed results: in some studies negative emotional information enhances memory in older people with dementia, in other studies positive emotional information is helpful or hardly any effect is found., Conclusion: Emotional communication seems to enhance memory in people with dementia. None of the studies described focused on the association between personally relevant, emotionally valent information and memory, so further research is needed., Practice Implications: Caregivers in dementia care should realize that 1) the information they provide might carry an emotional valence, and 2) this valence might influence the extent to which people with dementia remember information., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Listening is at the very heart of communication in healthcare, but largely ignored in research and teaching. This paper presents different perspectives on listening within the context of healthcare and its implications for goal-directed communication., Methods: The assets of listening are examined from several angles (the listening patient, the listening health professional, and the listening self) and illustrated by the results of relevant research., Results: Listening is a multidimensional concept and serves different purposes in healthcare. To benefit fully from it's potentials, the listening attitude and skills of patients and health professionals need to be enhanced through interventions at the level of policy, practice and research. Results from research evaluating creative and innovative ways of strenghtening persons' listening skills are encouraging., Conclusion: Listening has underused potential which can be boosted by interventions directed at the level of healthcare policy, practice and research., Practice Implications: For healthcare practice, it is helpful to keep in mind that listening involves more than hearing what the other person says; one also needs eyes, a heart, and undivided attention., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Many GPs find the care of patients with medically unexplained symptoms (MUS) challenging. Patients themselves are often not satisfied with the care they receive., Aim: To explore the problems patients with MUS experience in communication during consultations, with the aim of improving such consultations DESIGN AND SETTING: A qualitative analysis of semi-structured interviews., Method: GP consultations were videorecorded and the GPs were asked immediately afterwards whether MUS were presented. Patients in these MUS consultations were asked to reflect on the consultation in a semi-structured interview while watching a recording of their own consultation., Results: Of the 393 videorecorded consultations, 43 contained MUS. Patients who did identified six categories of problems. First, they reported a mismatch between the GP's and their own agenda. Second, patients indicated that the GP evoked an uncomfortable feeling in them during the consultation. Third, they found that GPs did not provide a specific management plan for their symptoms. Fourth, patients indicated that the GP was not well prepared for the consultation. Fifth, they perceived prejudices in the GP during the consultation. Finally, one patient found that the GP did not acknowledge a limited understanding of the origin of the symptoms., Conclusion: According to patients, GPs can improve their consultations on MUS by making genuine contact with their patients, by paying more attention to the patient's agenda, and by avoiding evoking uncomfortable feelings and displaying prejudices. They should prepare their consultations and focus on the issues that matter to patients, for example, symptom management. GPs should be honest to patients when they do not understand the origin of symptoms., (© British Journal of General Practice 2017.)

Taking a history is a key diagnostic instrument in paediatric consultations. Numerous issues potentially reduce the history's reliability. Therefore, paediatricians have always expressed ambivalence regarding history taking from parents, both valuing and distrusting it. In this review, we describe how parents build and present a description of their child's health issues in the conceptual framework of self-regulation theory. We performed a systematic review on the literature on the reliability of history taking. No studies examined the reliability of history taking from parents, but there is a considerable body of evidence on the issue of mutual trust in relationships between health care professionals and patients. Because trust is a dynamic relational phenomenon, taking a patient centred approach in consultations is likely to increase the patients' and parents' trust in the health care professional, and their willingness to follow the health care professional's treatment proposals. We provide evidence based recommendations on how to build and maintain trust in paediatric consultations by taking a patient centred approach in such consultations., (Copyright © 2017. Published by Elsevier Ltd.)

Objective: To experimentally test the effects of physician's affect-oriented communication and inducing expectations on outcomes in patients with menstrual pain., Methods: Using a 2×2 RCT design, four videotaped simulated medical consultations were used, depicting a physician and a patient with menstrual pain. In the videos, two elements of physician's communication were manipulated: (1) affect-oriented communication (positive: warm, emphatic; versus negative: cold, formal), and (2) outcome expectation induction (positive versus uncertain). Participants (293 women with menstrual pain), acting as analogue patients, viewed one of the four videos. Pre- and post video participants' outcomes (anxiety, mood, self-efficacy, outcome expectations, and satisfaction) were assessed., Results: Positive affect-oriented communication reduced anxiety (p<0.001), negative mood (p=0.001), and increased satisfaction (p<0.001) compared to negative affect-oriented communication. Positive expectations increased feelings of self-efficacy (p<0.001) and outcome expectancies (p<0.001), compared to uncertain expectations, but did not reduce anxiety. The combination of positive affect-oriented communication and a positive expectation reduced anxiety (p=0.02), increased outcome expectancies (p=0.01) and satisfaction (p=0.001)., Conclusion: Being empathic and inducing positive expectations have distinct and combined effects, demonstrating that both are needed to influence patients' outcomes for the best., Practice Implications: Continued medical training is needed to harness placebo-effects of medical communication into practice., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: To explore patients' preferences and experiences regarding intercultural communication which could influence the development of intercultural patient-centred communication training., Methods: This qualitative study is based on interviews with non-native patients. Thirty non-native patients were interviewed between September and December 2015 about their preferences and experiences regarding communication with a native Dutch doctor. Fourteen interviews were established with an interpreter. The semi-structured interviews took place in Amsterdam. They were focused on generic and intercultural communication skills of doctors. Relevant fragments were coded by two researchers and analysed by the research team by means of thematic network analysis. Informed consent and ethical approval was obtained beforehand., Results: All patients preferred a doctor with a professional patient-centred attitude regardless of the doctor's background. Patients mentioned mainly generic communication aspects, such as listening, as important skills and seemed to be aware of their own responsibility in participating in a consultation. Being treated as a unique person and not as a disease was also frequently mentioned. Unfamiliarity with the Dutch healthcare system influenced the experienced communication negatively. However, a language barrier was considered the most important problem, which would become less pressing once a doctor-patient relation was established., Conclusions: Remarkably, patients in this study had no preference regarding the ethnic background of the doctor. Generic communication was experienced as important as specific intercultural communication, which underlines the marginal distinction between these two. A close link between intercultural communication and patient-centred communication was reflected in the expressed preference 'to be treated as a person'.

Objective: To systematically review the literature on the effectiveness of a patient coach intervention on patient - physician communication in specialists consultations., Methods: PubMed, Cochrane, PsycInfo, Cinahl and Embase were searched until November 2015. Included were papers describing interventions directed at adult outpatients in secondary care with a variety of somatic diseases. Outcomes had to be measured in communication effectivity from a patient's perspective., Results: Seventeen publications met the inclusion criteria (involving 3787 patients), describing 13 unique interventions. Most interventions were single one-on-one sessions taking between 20 and 40min before consultation. Research quality in ten studies was high. These studies showed significant improvement on immediate, intermediate and long term patient - physician communication., Conclusion: We found limited evidence suggesting an improvement of patient - physician communication by having multiple patient coaching encounters during which questions are prepared and rehearsed and consultations are evaluated and reflected upon, sometimes supported by audio recording the consultation., Practice Implications: The results of this review contribute to the (re-)design of an effective model for patient coaching, a profile and training approach of patient coaches. Future research should aim at determining which patients will benefit most from coaching interventions., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging. The patients themselves are often not satisfied with the care they receive., Objectives: The aim of this study is to explore what patients with MUS expect from their GP by looking at relevant communication elements in consultations as identified by patients., Methods: We video-recorded everyday consultations with GPs and asked the GPs immediately after the consultation whether MUS were presented. The patients in these MUS consultations were asked to reflect on the consultation during a semi-structured interview while watching a recording of their own MUS consultation. The interviews were analysed qualitatively according to the principles of constant comparative analysis., Results: Of the 393 video-recorded consultations, 43 concerned MUS. All MUS patients said that they wanted to be taken seriously. According to the patients, their feeling of being taken seriously is enhanced when the GP: (i) pays empathic attention to them as individuals, meaning that the GP knows their personal circumstances and has an open and empathic approach, (ii) ensures a good conversation by treating the patient as an equal partner and (iii) is attentive to their symptoms by exploring these symptoms in depth and by acting on them., Conclusion: Like chronic patients, patients with MUS value a personalised approach in which GPs pay attention to patients' personal circumstances, to proper somatic management of their symptoms and to a proper conversation in which they are treated as equal partners. Use of these basic consultation skills may greatly improve care of MUS patients., (© The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Little is known about how older persons in home care express their concerns. Emotional cues and concerns can be identified by the Verona coding definitions of emotional sequences (VR-CoDES), but the method gives no insight into what causes the distress and the emotions involved. The aims of this study are to explore (1) older persons' worries and (2) the content of these expressions., Methods: An observational exploratory two-step approach was used to investigate audiotaped recordings from 38 Norwegian home care visits with older persons and nurse assistants. First, 206 cues and concerns were identified using VR-CoDES. Second, the content and context of these expressions were analysed inductively., Results: Four main categories emerged: worries about relationships with others, worries about health care-related issues, worries about aging and bodily impairment, and life narratives and value issues, with several subcategories showing the causes of worry and emotions involved., Conclusion: The two-step approach provides an in-depth knowledge of older persons' worries, causes of worries, and their related emotions., Practice Implications: The subcategories described in a language close to the experience can be useful in practice development and communication training for students and health care providers., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Aim: To explore communicative challenges in encounters between nurse assistants and older persons during home care visits., Background: The older population is increasing worldwide. Currently, there is a shift in care for older people from institutional care to home care. Providing home care in a person's home involves several challenges, including the complexity of communication., Design: A descriptive observational design with a qualitative approach was used., Methods: The data consisted of audio recordings of real-life encounters during home care visits between nurse assistants and older persons, collected in 2014. A hermeneutic phenomenological analysis was conducted., Results: Communicative challenges were identified: (a) in situations where the older persons had a different view than the nurse assistants on the care task and its content; and (b) when unexpected actions or turns occurred in the communication. Challenges included older person's existential issues, fragility and worries and concerns, which often appeared to be only vaguely expressed and difficult to verbally detect and tackle. This engendered a risk of misinterpretation or ignorance of these challenges., Conclusion: The findings point to the importance of communication as the key to facilitate person-centred home care. Communication training should focus more on addressing needs and existential issues in older persons. Person-centred home care for older persons needs to be addressed at both an individual and an organizational level., (© 2016 John Wiley & Sons Ltd.)

Background: The complex nature of the medical dialogue and the often emotional context in cancer care present challenges to health care professionals (HCPs) and patients. Patients are increasingly expected to be informed participants and to be able to make conscious decisions, which they often find very difficult. In an attempt to support patients with malignant lymphoma in clinical communication, we developed a stand-alone, Web-based intervention called "PatientTIME." The development of PatientTIME was based on a participatory intervention mapping framework. Its primary aim is to boost patients' self-efficacy in patient-professional communication (ie, their confidence when interacting with their HCP). Patients can use this intervention before their hospital visit to prepare for their clinical consultation. PatientTIME is fully automated and use is patient-initiated., Objective: The aim of this study was to evaluate if and in what way patients benefit from PatientTIME and if it enhances their confidence in clinical communication., Methods: The intervention was evaluated in a closed randomized controlled trial with continuous recruitment (using online and offline methods to reach potential participants) and data collection. In accordance with the Medical Research Council guidance, we started with a process evaluation. Subsequently, an outcome evaluation was performed focusing on the patients' perceived confidence in communication with their HCP, measured with the validated PEPPI questionnaire at baseline and at 3 months after participation. Process and outcome data were obtained through Web-based questionnaires, log files (automatically generated files mapping the interactions between program and users), and a logbook (comprising a record of actions and interactions kept by the researchers). Participants were not blinded. A total of 146 patients registered online, of whom 97 gave their informed consent and were assigned at random to the control group (N=34) or 1 of the 2 intervention groups (N=63). Ultimately 87/97 (90%) of these patients actually participated in the study, producing 87 datasets for analysis., Results: More than half of the intervention group patients reported that the intervention helped them prepare for a clinical consultation; it created awareness about the importance of communication and reinforced their existing communication skills. In the postvisit test, the control group showed a small, nonsignificant improvement in perceived communication efficacy. The intervention group showed a significant improvement in perceived efficacy. However, the interaction effect was not significant, indicating that the improvement solely as a result of the intervention may not be significant., Conclusions: A considerable number of patients reported that PatientTIME did provide support. We found a trend indicating that in the long run, patients with access to PatientTIME scored better on the perceived efficacy scale than patients without access. However, at this stage we cannot conclude that PatientTIME improves patients' confidence when interacting with HCPs., Clinicaltrial: Netherlands National Trial Register (NTR): 3779; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3779 (archived by WebCite at http://www.webcitation.org/6iztxJ5Nt).

Many patients with haematological malignancies experience barriers in clinical communication. Reaching effective communication is of great importance as it has been linked to a range of improved patient outcomes such as satisfaction, compliance to treatment, perceived quality of life and physical and mental health. To get a better understanding how communication in haematological consultations can be improved, the current study focussed on patients' preferences and perceived performances regarding the communicative behaviour of their health care professional. Secondly, the mediation of an online communication tool for patients was analysed. Within a controlled pre- post-test design, 78 datasets of clinical consultations could be analysed. Patients considered both affective and instrumental communication aspects important. The affective communication behaviour of the health care professional met the patients' pre-visit preferences well. In the information exchange, more variability and discrepancies were found. Overall, the online intervention did not seem to influence the patients' perceived communication performance of their health care professional much. To further improve the communication during clinical consultations, health care professionals should inquire about patients' expectations, especially during the exchange of information and advices. At the same time, patients should be supported to express their preferences at the start of the consultation. The study was registered in the Netherlands Trial Register, number 3779.

Objectives: This study focuses on facilitation of clients' psychosocial communication during prenatal counseling for fetal anomaly screening. We assessed how psychosocial communication by clients is related to midwives' psychosocial and affective communication, client-directed gaze and counseling duration., Methods: During 184 videotaped prenatal counseling consultations with 20 Dutch midwives, verbal psychosocial and affective behavior was measured by the Roter Interaction Analysis System (RIAS). We rated the duration of client-directed gaze. We performed multilevel analyses to assess the relation between clients' psychosocial communication and midwives' psychosocial and affective communication, client-directed gaze and counseling duration., Results: Clients' psychosocial communication was higher if midwives' asked more psychosocial questions and showed more affective behavior (β=0.90; CI: 0.45-1.35; p<0.00 and β=1.32; CI: 0.18-2.47; p=0.025, respectively). Clients "psychosocial communication was not related to midwives" client-directed gaze. Additionally, psychosocial communication by clients was directly, positively related to the counseling duration (β=0.59; CI: 0.20-099; p=0.004)., Conclusions: In contrast with our expectations, midwives' client-directed gaze was not related with psychosocial communication of clients., Practice Implications: In addition to asking psychosocial questions, our study shows that midwives' affective behavior and counseling duration is likely to encourage client's psychosocial communication, known to be especially important for facilitating decision-making., (Copyright © 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

The shift of tasks from primary care physicians to practice nurses and the continuing incease in the numbers of women involved in medical care may have consequences for the provision of health care and communication. The aim of the present study was to examine potential differences in female practice nurses' application of communication skills, practice guidelines, and motivational interviewing skills during consultations with female and male patients. Nineteen female practice nurses and their patients (n = 181) agreed to have their consultations videotaped (during 2010-2011). The videotaped consultations were rated using two validated instruments: the Maas-Global (to assess generic communication skills and practice guidelines) and the Behaviour Change Counselling Index (to assess motivational interviewing skills). Multilevel linear and logistic regression analyses were performed. Female practice nurses provided significantly more comprehensive information during consultations with female patients (p = .03) and talked more about management with male patients (p = .04). Furthermore, nurses applied motivational interviewing skills more clearly during consultations with female than with male patients (p < .01). The shift in tasks from primary care physicians toward practice nurses may have implications for clinical and patient outcomes as patients will no longer be counseled by male professionals. Conceivably, female patients are motivated more by nurses to change their behavior, while male patients receive more concrete management information or advice.

Background: Patients with medically unexplained physical symptoms (MUPS) are prevalent 25-50% in general and specialist care. Medical specialists and residents often find patients without underlying pathology difficult to deal with, whereas patients sometimes don't feel understood. We developed an evidence-based communication training, aimed to improve specialists' interviewing, information-giving and planning skills in MUPS consultations, and tested its effectiveness., Methods: The intervention group in this multi-center randomized controlled trial received a 14-hour training program to which experiential learning and feedback were essential. Using techniques from Cognitive Behavioral Therapy, they were stimulated to seek interrelating factors (symptoms, cognitions, emotions, behavior, and social environment) that reinforced a patient's symptoms. They were taught to explain MUPS understandably, reassure patients effectively and avoid unnecessary diagnostic testing. Before and after the intervention training, specialists videotaped a total of six consultations with different MUPS patients. These were evaluated to assess doctors' MUPS-focused communicating skills using an adapted version of the Four Habit Coding Scheme on five-point Likert scales. Participants evaluated the training by self-report on three-point Likert scales. Doctors in the control group received training after completion of the study., Results: 123 doctors (40% specialists, 60% residents) and 478 MUPS patients from 11 specialties were included; 98 doctors completed the study (80%) and 449 videotaped consultations were assessed. Trained doctors interviewed patients more effectively than untrained ones (p < 0.001), summarized information in a more patient-centered way (p = 0.001), and better explained MUPS and the role of perpetuating factors (p < 0.05). No effects on planning skills were found. On a 3-point scale the training was evaluated with 2.79., Conclusion: MUPS-focused communication training increases the interviewing and information-giving skills of medical specialists. We recommend that the training is incorporated in postgraduate education for medical specialists and residents who frequently encounter patients with MUPS., Trial Registration: Dutch Trial Registration NTR2612.

Context: Competency-based education is a resurgent paradigm in professional medical education. However, more specific knowledge is needed about the learning process of such competencies, since they consist of complex skills. We chose to focus on the competency of skilled communication and want to further explore its learning process, since it is regarded as a main competency in medical education., Objective: This study aims to explore in more detail the learning process that residents in general practice go through during workplace-based learning in order to become skilled communicators., Methods: A qualitative study was conducted in which twelve GP residents were observed during their regular consultations, and were interviewed in-depth afterwards., Results: Analysis of the data resulted in the construction of five phases and two overall conditions to describe the development towards becoming a skilled communicator: Confrontation with (un)desired behaviour or clinical outcomes was the first phase. Becoming conscious of one's own behaviour and changing the underlying frame of reference formed the second phase. The third phase consisted of the search for alternative behaviour. In the fourth phase, personalization of the alternative behaviour had to occur, this was perceived as difficult and required much time. Finally, the fifth phase concerned full internalization of the new behaviour, which by then had become an integrated part of the residents' clinical repertoire. Safety and cognitive & emotional space were labelled as overall conditions influencing this learning process., Conclusions: Knowledge and awareness of these five phases can be used to adjust medical working and learning environments in such a way that development of skilled medical communication can come to full fruition and its benefits are more fully reaped.

Objective: This study aimed to provide insight into Dutch midwives' self-evaluation of prenatal counseling for anomaly screening in real life practice and, the degree of congruence of midwives' self-assessments with clients' perceptions and with observed performance., Methods: Counseling sessions were videotaped. We used the QUOTE(prenatal) questionnaire to have each midwife (N = 20) and her client (N = 240) rate the prenatal counseling that they had together. We used an adapted version of the RIAS video-coding system to assess actual counseling during videotaped prenatal counseling (N = 240)., Results: Midwives perceived the following functions of counseling performed well: 100% of Client-Counselor relation (CCR); 80% of Health Education (HE); and 17% Decision-Making Support (DMS). Congruence on HE of midwives with observers and with clients was ≥ 75%; congruence on DMS was higher between midwives and observers (80%) compared to midwives and clients (62%)., Conclusion: Midwives perceive that during prenatal counseling the CCR and HE functions of counseling were performed well, whereas DMS was not. Furthermore, this study shows incongruence between midwives and clients about the discussion during DMS, indicating DMS is more difficult to assess than HE., Practice Implications: The best way to measure prenatal counseling practice might be by using assessments of different sources within one study., (Copyright © 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Introduction: This paper presents an international cross-sectional study on person-centred communication with older people receiving healthcare (COMHOME). Person-centred care relies on effective communication, but few studies have explored this with a specific focus on older people. The main aim of the COMHOME study is to generate knowledge on person-centred communication with older people (>65 years) in home healthcare services, radiographic and optometric practice., Methods and Analysis: This study will explore the communication between care providers and older persons in home care services. Home healthcare visits will be audiorecorded (n=500) in Norway, the Netherlands and Sweden. Analyses will be performed with the Verona Coding Definitions for Emotional Sequences (VR-CoDES), the Roter Interaction Analysis System (RIAS) and qualitative methods. The content of the communication, communicative challenging situations as well as empathy, power distance, decision-making, preservation of dignity and respect will be explored. In Norway, an additional 100 encounters, 50 in optometric practice (video recorded) and 50 in radiographic practice (audiorecorded), will be analysed. Furthermore, healthcare providers' self-reported communication skills, empathy, mindfulness and emotional intelligence in relation to observed person-centred communication skills will be assessed using well-established standardised instruments., Ethics and Dissemination: Depending on national legislation, approval of either the central ethical committees (eg, nation or university), the national data protection officials or the local ethical committees (eg, units of home healthcare) was obtained. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. The research findings will add knowledge to improve services provided to this vulnerable group of patients. Additionally, the findings will underpin a training programme for healthcare students and care providers focusing on communication with older people., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Due to migration, doctors see patients from different ethnic backgrounds. This causes challenges for the communication. To develop training programs for doctors in intercultural communication (ICC), it is important to know which barriers and facilitators determine the quality of ICC. This study aimed to provide an overview of the literature and to explore how ICC works., Methods: A systematic search was performed to find literature published before October 2012. The search terms used were cultural, communication, healthcare worker. A realist synthesis allowed us to use an explanatory focus to understand the interplay of communication., Results: In total, 145 articles met the inclusion criteria. We found ICC challenges due to language, cultural and social differences, and doctors' assumptions. The mechanisms were described as factors influencing the process of ICC and divided into objectives, core skills and specific skills. The results were synthesized in a framework for the development of training., Conclusion: The quality of ICC is influenced by the context and by the mechanisms. These mechanisms translate into practical points for training, which seem to have similarities with patient-centered communication., Practice Implications: Training for improving ICC can be developed as an extension of the existing training for patient-centered communication., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Communication assessment in real-life consultations is a complex task. Generic assessment instruments help but may also have disadvantages. The generic nature of the skills being assessed does not provide indications for context-specific behaviour required in practice situations; context influences are mostly taken into account implicitly. Our research questions are: 1. What factors do trained raters observe when rating workplace communication? 2. How do they take context factors into account when rating communication performance with a generic rating instrument? Nineteen general practitioners (GPs), trained in communication assessment with a generic rating instrument (the MAAS-Global), participated in a think-aloud protocol reflecting concurrent thought processes while assessing videotaped real-life consultations. They were subsequently interviewed to answer questions explicitly asking them to comment on the influence of predefined contextual factors on the assessment process. Results from both data sources were analysed. We used a grounded theory approach to untangle the influence of context factors on GP communication and on communication assessment. Both from the think-aloud procedure and from the interviews we identified various context factors influencing communication, which were categorised into doctor-related (17), patient-related (13), consultation-related (18), and education-related factors (18). Participants had different views and practices on how to incorporate context factors into the GP(-trainee) communication assessment. Raters acknowledge that context factors may affect communication in GP consultations, but struggle with how to take contextual influences into account when assessing communication performance in an educational context. To assess practice situations, raters need extra guidance on how to handle specific contextual factors.

Objective: antenatal counselling for congenital anomaly tests is conceptualised as having both Health Education (HE) and Decision-Making Support (DMS) functions. Building and maintaining a client-midwife relation (CMR) is seen as a necessary condition for enabling these two counselling functions. However, little is known about how these functions are fulfilled in daily practice. This study aims to describe the relative expression of the antenatal counselling functions; to describe the ratio of client versus midwife conversational contribution and to get insight into clients' characteristics, which are associated with midwives' expressions of the functions of antenatal counselling., Design: exploratory video-observational study., Participants and Setting: 269 videotaped antenatal counselling sessions for congenital anomaly tests provided by 20 midwives within six Dutch practices., Measurements: we used an adapted version of the Roter Interaction Analysis System to code the client-midwife communication. Multilevel linear regression analyses were used to analyse associations between clients' characteristics and midwives' expressions of antenatal counselling in practice., Findings: most utterances made during counselling were coded as HE (41%); a quarter as DMS (23%) and 36% as CMR. Midwives contributed the most to the HE compared to clients or their partners (91% versus 9%) and less to the DMS function of counselling (61% versus 39%). Multilevel analyses showed an independent association between parity and shorter duration of antenatal counselling; (β=-3.01; p<0.001). The amount of utterances concerning HE and DMS during counselling of multipara was less compared to nulliparous., Key Conclusions: antenatal counselling for congenital anomaly tests by midwives is focused on giving HE compared to DMS. The relatively low contribution of clients during DMS might indicate poor DMS given by midwives. Counselling of multipara was significantly shorter than counselling of nulliparous; multiparae received less HE as well as DMS compared to nulliparous women., Implications for Practice: our findings should encourage midwives to reflect on the process of antenatal counselling they offer with regards to the way they address the three antenatal counselling functions during counselling of nulliparous women compared to multiparae., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: In a recent study comparing psychosocial consultations prior to and after the implementation of national clinical guidelines in the Netherlands, we found that general practitioners (GPs) showed less empathy in the more recent consultations. As a consequence, patients possibly have less scope to express their worries. The objective is to investigate whether patients have become more reluctant to open up about their concerns during psychosocial consultations and how GPs respond., Methods: Consultations from previous study samples videotaped between 1977 and 2008 and categorized by GPs as 'completely psychosocial' were selected for the present study. These consultations were observed using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to capture cues and concerns expressed by patients and GPs' immediate responses. We compared consultations prior to (N = 121) and after (N = 391) introduction of national clinical guidelines in the 1990s., Results: In 92% of the consultations, patients presented at least one worry. These were most often expressed implicitly. However, the proportion of consultations containing at least one explicit concern changed from 24% to 37% over time. The increased number of expressed cues and concerns was partly explained by a change in GP characteristics; the latter sample contained more female and more experienced GPs. Furthermore, cues and concerns were more often expressed during later phases of consultations in recent years., Conclusions: Our study shows that patients have become somewhat more explicit in expressing their worries. However, GPs need to be aware that, still, most worries are expressed implicitly and that new concerns may appear towards the end of consultations.

Objective: Patients' recall of provided information during bad news consultations is poor. According to the attentional narrowing hypothesis, the emotional arousal caused by the bad news might be responsible for this hampered information processing. Because affective communication has proven to be effective in tempering patients' emotional reactions, the current study used an experimental design to explore whether physician's affective communication in bad news consultations decreases patients' anxiety and uncertainty and improves information recall., Method: Two scripted video-vignettes of a bad news consultation were used in which the physician's verbal communication was manipulated (standard vs. affective condition). Fifty healthy women (i.e., analogue patients) randomly watched 1 of the 2 videos. The effect of communication on participants' anxiety, uncertainty, and recall was assessed by self-report questionnaires. Additionally, a moderator analysis was performed., Results: Affective communication reduced anxiety (p = .01) and uncertainty (p = .04), and improved recall (p = .05), especially for information about prognosis (p = .04) and, to some extent, for treatment options (p = .07). The moderating effect of (reduced) anxiety and uncertainty on recall could not be confirmed and showed a trend for uncertainty., Conclusion: Physicians' affective communication can temper patients' anxiety and uncertainty during bad news consultations, and enhance their ability to recall medical information. The reduction of anxiety and uncertainty could not explain patients' enhanced recall, which leaves the underlying mechanism unspecified. Our findings underline the importance of addressing patients' emotions and provide empirical support to incorporate this in clinical guidelines and recommendations., (PsycINFO Database Record (c) 2014 APA, all rights reserved.)

Objective: Contextual factors are known to influence the acquisition and application of communication skills in clinical settings. Little is known about residents' perceptions of these factors. This article aims to explore residents' perceptions of contextual factors affecting the acquisition and application of communication skills in the medical workplace., Method: We conducted an exploratory study comprising seven focus groups with residents in two different specialities: general practice (n=23) and surgery (n=18)., Results: Residents perceive the use of summative assessment checklists that reduce communication skills to behavioural components as impeding the learning of their communication skills. Residents perceive encouragement to deliberately practise in an environment in which the value of communication skills is recognised and support is institutionalised with appropriate feedback from role models as the most important enhancing factors in communication skills learning., Conclusion: To gradually realise a clinical working environment in which the above results are incorporated, we propose to use transformative learning theory to guide further studies., Practical Implications: Provided it is used continuously, an approach that combines self-directed learning with observation and discussion of resident-patient consultations seems an effective method for transformative learning of communication skills., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Today, in several north-western European countries, patients are encouraged to choose, actively, a healthcare provider. However, patients often visit the provider that is recommended by their general practitioner (GP). The introduction of patient choice requires GPs to support patients to be involved, actively, in the choice of a healthcare provider. We aim to investigate whether policy on patient choice is reflected in practice, i.e. what the role of the patient is in their choices of healthcare providers at the point of referral and to what extent GPs' and patients' healthcare paths influence the role that patients play in the referral decision., Methods: In 2007-2008, we videotaped Dutch GP-patient consultations. For this study, we selected, at random, 72 videotaped consultations between 72 patients and 39 GPs in which the patient was referred to a healthcare provider. These were analysed using an observation protocol developed by the researchers., Results: The majority of the patients had little or no input into the choice of a healthcare provider at the point of referral by their GP. Their GPs did not support them in actively choosing a provider and the patients often agreed with the provider that the GP proposed. Patients who were referred for diagnostic purposes seem to have had even less input into their choice of a provider than patients who were referred for treatment., Conclusions: We found that the GP chooses a healthcare provider on behalf of the patient in most consultations, even though policy on patient choice expects from patients that they choose, actively, a provider. On the one hand, this could indicate that the policy needs adjustments. On the other hand, adjustments may be needed to practice. For instance, GPs could help patients to make an active choice of provider. However, certain patients prefer to let their GP decide as their agent. Even then, GPs need to know patients' preferences, because in a principal-agent relationship, it is necessary that the agent is fully informed about the principal's preferences.

Objective: Acquiring adequate communication skills is an essential part of general practice (GP) specialty training. In assessing trainee proficiency, the context in which trainees communicate is usually not taken into account. The present paper aims to explore what context factors can be found in regular GP trainee consultations and how these influence their communication performance., Methods: In a randomly selected sample of 44 videotaped, real-life GP trainee consultations, we searched for context factors previously identified in GP consultations and explored how trainee ratings change if context factors are taken into account. Trainee performance was rated twice using the MAAS-Global, first without and then with incorporating context factors. Item score differences were calculated using a paired samples t-test and effect sizes were computed., Results: All previously identified context factors were again observed in GP trainee consultations. In communication assessment scores, we found a significant difference in 5 out of 13 MAAS-Global items, mostly in a positive direction. The effect size was moderate (0.57)., Conclusions: GP trainee communication is influenced by contextual factors; they seem to adapt to context in a professional way., Practice Implications: GP specialty training needs to focus on a context-specific application of communication skills. Communication raters need to be taught how to incorporate context factors into their assessments., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: This study aims to gain insight into patient-perceived communication barriers and facilitators at different stages after the diagnosis of malignant lymphoma. We have detected patterns to explain when these factors influence communication predominantly., Method: A qualitative approach was applied, derived from the context mapping framework. A total of 28 patients completed a set of assignments about their experiences with provider-patient communication during medical consultations. Subsequently, these patients and nine companions shared their experiences during a semistructured (group) interview, which was recorded on audiotape. The audiotapes and assignments were analysed with MAXQDA software., Results: From the patients' viewpoint, communicating effectively appears to depend on their own attributes (e.g. emotions), the health care professionals' attributes (e.g. attitude) and external factors (e.g. time pressure). Three patient communication states were identified: (i) overwhelmed, passive; (ii) pro-active, self-motivated; and (iii) proficient, empowered. Patients seem to behave differently in the three communication states., Conclusions: This study lists patient-perceived communication barriers and facilitators and identifies three different communication states, which indicate when certain barriers and facilitators are encountered., Practical Implications: These findings may support health care professionals to tailor the provision of support and information and remove communication barriers accordingly. Additionally, they provide input for interventions to support patients in effective communication., (Copyright © 2013 John Wiley & Sons, Ltd.)

Objective: To examine informational and emotional patient-provider and patient-patient communication sequences (i.e. cues and subsequent responses) during Shared Medical Appointments (SMAs) for children and adolescents with type 1 Diabetes Mellitus (T1DM) and their parents., Methods: 57 children/adolescents with T1DM and 36 healthcare providers participated in ten SMAs in seven Dutch hospitals. Parents were present in six SMAs. Video-recordings were made. Communication sequences, including informational and emotional cues and responses were rated using an adaptation of the Medical Interview Aural Rating Scale., Results: 143 patient-initiated cues were identified, followed by 140 provider responses and 30 patient responses. Patients gave more informational than emotional cues. Informational cues were mostly medical-related. Subsequent responses provided by providers and patients contained mostly appropriate information. We identified 17 patient and four parent cues with multiple responses., Conclusions: Almost all cues were identified by healthcare providers and responded to in an appropriate manner. Cues not followed by a provider's response were picked up by other patients. Providers acted as mediator between a patient cue and another patient's response, thereby stimulating the interaction during SMAs., Practice Implications: Professionals could more explicitly invite all participants to interact with each other, and enable them to have their share in the communication process., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)