Relationship between Teach-back and patient-centered communication in primary care pediatric encounters

ObjectiveWe proposed and tested a theoretical framework for how use of Teach-back could influence communication during the pediatric clinical encounter.MethodsAudio-taped pediatric primary care encounters with 44 children with asthma were coded using the Roter Interaction Analysis System to measure patient-centered communication and affective engagement of the parent. A newly created Teach-back Loop Score measured the extent to which Teach-back occurred during the clinical encounter; parental health literacy was measured by Newest Vital Sign. Logistic regression was used to test the relationship between Teach-back and features of communication. Focus groups held separately with clinicians and parents elicited perceptions of Teach-back usefulness.ResultsTeach-back was used in 39% of encounters. Visits with Teach-back had more patient centered communication (p = 0.01). Adjusting for parent health literacy, parent age, and child age, Teach-back increased the odds of both patient centered communication [proportional AOR (95% CI) = 4.97 (4.47–5.53)]and negative affect [AOR (95% CI) = 5.39 (1.68–17.31)]. Focus group themes common to clinicians and parents included: Teach-back is effective, could cause discomfort, should be used with children, and nurses should use it.ConclusionsTeach-back was associated with more patient-centered communication and increased affective engagement of parents.Practice implicationsStandardizing Teach-back use may strengthen patient-centered communication.     

Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children

ObjectiveTo investigate the relationship between parents’ health literacy and decision-making regarding child vaccinations.MethodsA cross-sectional survey was conducted among 731 parents of children aged 3–4 years. Functional, communicative, and critical health literacy (HL), knowledge, beliefs, reliability of the vaccine’s information resources, and vaccine's attitudes were measured. Attitudes included three types: pro-vaccine attitudes, anti-vaccine attitudes, and attitudes regarding mandatory vaccination. Path analysis was conducted to explore direct and indirect associations of compliance with childhood vaccinations and HL.ResultsCommunicative HL has a significant negative direct association with compliance with vaccinations (ß = − 0.06, p < 0.05). High functional and critical HL have significant negative indirect associations with vaccinations through parents’ attitudes regarding vaccines. Higher levels of perception of reliability of informal information resources are associated with non-compliance.ConclusionsThe results indicate that parents with high functional, communicative, and critical HL are more at risk of not vaccinating their children. The results are contrary to expectations in which people with high HL adopt more positive health behaviors.Practical implicationsPublic health professionals may need more sophisticated communication methods to transfer messages regarding vaccines to parents in order to prevent decline in vaccine coverage rates, taking into account levels of trust and health literacy.     

Perceptions of care coordination in a population-based sample of diverse breast cancer patients

ObjectiveTo identify factors associated with perceptions of care coordination in a diverse sample of breast cancer patients.MethodsBreast cancer patients reported to the metropolitan SEER registries of Detroit or Los Angeles from 6/05 to 2/07 were surveyed after diagnosis (N = 2268, RR = 72.4%). Outcomes were two dichotomous measures reflecting patient appraisal of care coordination during their treatment experience. Primary independent variables were race/ethnicity (white, African American, Latina-high acculturated, Latina-low acculturated) and health literacy (low, moderate, high). Logistic regression was used to evaluate factors associated with both measures of care coordination.Results2148 subjects were included in the analytic dataset. 16.4% of women perceived low care coordination and 12.5% reported low satisfaction. Race/ethnicity was not significantly associated with care coordination. Women with low subjective health literacy were 3–4 times as likely as those with high health literacy to perceive low care coordination and low satisfaction with care coordination (OR = 3.88; 95% CI: 2.78–5.41; OR = 3.19 95% CI: 2.25–4.52, respectively).ConclusionsMany breast cancer patients positively appraised their care coordination, but patients with low health literacy perceived low care coordination.Practice implicationsProviders should be aware of the health literacy deficits that may contribute to their patients’ attitudes towards their breast cancer care coordination.     

eHealth literacy in chronic disease patients: An item response theory analysis of the eHealth literacy scale (eHEALS)

BackgroundChronic disease patients are affected by low computer and health literacy, which negatively affects their ability to benefit from access to online health information.ObjectiveTo estimate reliability and confirm model specifications for eHealth Literacy Scale (eHEALS) scores among chronic disease patients using Classical Test (CTT) and Item Response Theory techniques.MethodsA stratified sample of Black/African American (N = 341) and Caucasian (N = 343) adults with chronic disease completed an online survey including the eHEALS. Item discrimination was explored using bi-variate correlations and Cronbach’s alpha for internal consistency. A categorical confirmatory factor analysis tested a one-factor structure of eHEALS scores. Item characteristic curves, in-fit/outfit statistics, omega coefficient, and item reliability and separation estimates were computed.ResultsA 1-factor structure of eHEALS was confirmed by statistically significant standardized item loadings, acceptable model fit indices (CFI/TLI > 0.90), and 70% variance explained by the model. Item response categories increased with higher theta levels, and there was evidence of acceptable reliability (ω = 0.94; item reliability = 89; item separation = 8.54).ConclusioneHEALS scores are a valid and reliable measure of self-reported eHealth literacy among Internet-using chronic disease patients.Practice implicationsProviders can use eHEALS to help identify patients’ eHealth literacy skills.     

The association of health literacy and blood pressure reduction in a cohort of patients with hypertension: The heart healthy lenoir trial

ObjectiveLower health literacy is associated with poorer health outcomes. Few interventions poised to mitigate the impact of health literacy in hypertensive patients have been published. We tested if a multi-level quality improvement intervention could differentially improve Systolic Blood Pressure (SBP) more so in patients with low vs. higher health literacy.MethodsWe conducted a non-randomized prospective cohort trial of 525 patients referred with uncontrolled hypertension. Stakeholder informed and health literacy sensitive strategies were implemented at the practice and patient level. Outcomes were assessed at 0, 6, 12, 18 and 24 months.ResultsAt 12 months, the low and higher health literacy groups had statistically significant decreases in mean SBP (6.6 and 5.3 mmHg, respectively), but the between group difference was not significant (Δ 1.3 mmHg, P = 0.067). At 24 months, the low and higher health literacy groups reductions were 8.1 and 4.6 mmHg, respectively, again the between group difference was not significant (Δ 3.5 mmHg, p = 0.25).Conclusions/practice implicationsA health literacy sensitive multi-level intervention may equally lower SBP in patients with low and higher health literacy. Practical health literacy appropriate tools and methods can be implemented in primary care settings using a quality improvement approach.     

Low health literacy and healthcare utilization among immigrants and non-immigrants in Switzerland

ObjectiveThis study aimed at investigating the association between functional health literacy and knowledge on when to seek medical help for potentially harmless (overutilization) or serious (underutilization) situations among immigrants and non-immigrants in Switzerland.MethodsData was collected among three immigrant groups and the native population (N = 1146) in the German- and Italian-speaking part of Switzerland. Health literacy was assessed with the Short Test of Functional Health Literacy (S-TOFHLA) and three Brief Health Literacy Screeners. Over- and underutilization of healthcare services was assessed with items asking participants about when to seek medical help for minor, respectively major, physical symptoms.ResultsImmigrants were more likely to seek medical help when unwarranted (overutilization). Health literacy, when assessed with the S-TOFHLA, was significantly associated with over- and underutilization. Yet, once controlled for covariates, the association between health literacy and overutilization was negative. Immigration background and micro-cultural differences emerged as important predictors of utilization.ConclusionsResults suggest that functional health literacy is directly related to healthcare utilization. The effects might be amplified by (micro-)cultural differences.Practice implicationsHealthcare providers should be aware of differences in health literacy and utilization patterns among different population groups. Communication between patients and providers should be literacy and culturally sensitive.     

The impact of expert- and peer feedback on communication skills of undergraduate dental students – a single-blinded,randomized, controlled clinical trial

ObjectiveTo evaluate the effect of peer- and expert feedback on communication skills of undergraduate dental students.MethodsAll students of the first clinical treatment course (n = 46) were randomly assigned into two groups. For three times a medical-dental interview/consultation of each student with a real patient was videotaped. After every consultation the videos were assessed either by a person experienced in communication (expert group) or by a fellow student (peer group), giving the students feedback regarding their chairside performed communication skills. Before and after the feedback-interventions all students conducted an interview with simulated patients, which was rated using a validated global rating and analyzed statistically.ResultsGlobal ratings mean scores after feedback-intervention were significantly improved (p < 0.05). Thereby, no significant differences in the overall assessment could be observed between expert and peer feedback (p > 0.05).ConclusionDuring this study students improved their communication skills in dentist-patient interactions. The communication experience of the feedback provider seems not to have any impact on the communication skills in undergraduate dental students.Practice implicationsThe clinical courses in dentistry offer the opportunity to implement peer-feedback interventions in real treatment situation as part of communication training to longitudinally improve communication skills.     

Designing,delivering and evaluating a distance learning nursing course responsive to students needs

Background and purposeThe majority of available studies in distance learning in nursing and health lack the sufficient details of course design and delivery processes which greatly affect the learning outcomes. Also, little is available about the fairness of this method of education to students with limited access to course resources. We describe the design and delivery processes and experience, in terms of satisfaction and achievement, of undergraduate nursing students in a distance course. The difference in achievement between the distance students and a comparable cohort of hybrid students is also examined. We also demonstrate the possibility of providing accessible education to students with limited technological resources.MethodsParticipants included all undergraduate nursing students who were enrolled in a distance and a hybrid section of a communication skills course offered at a School of Nursing in Jordan. The distance course was created using Blackboard and Tegrity learning management systems. The design and delivery processes of the distance course incorporated three pedagogical principles that enhance: (a) course access and navigation; (b) communication and interaction; and (c) active and collaborative learning experiences. After course completion, distance students completed a 27-item satisfaction questionnaire. Achievement in the course and correlates of satisfaction were measured.ResultsThe final sample included 25 students in the distance section and 35 in the hybrid section (N = 60). The mean score of overall satisfaction in the distance section was 4.14 (0.32) out of a 5-point scale, indicating a high satisfaction. Results revealed significant associations between total satisfaction score and achievement in the distance course, grade expected in the course, and frequency of accessing the course materials (p < .05). All distance students, including students with limited technological resources available at home, managed to successfully complete the course. Major concerns reported by distance students were related to lack of time management skills and negative attitudes toward group assignments. The mean final course grade of the distance section (80 ± 8.2) was significantly higher than the hybrid section (72.2 ± 9.5), (t = 3.5, p < .05).ConclusionsThe use of effective instructional strategies resulted in delivering successful distance learning, even for students with limited resources. Institutions have to make strategic decisions on how to optimize the use of technology to fit their individualized learning environments. Instructors need to become familiar with the characteristics of students cohort served by the course and design the course accordingly. In addition, students should be guided on how to manage their time in distance learning environments and work effectively in group assignments.     

Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial

ObjectivesTo assess advanced communication skills among second-year medical students exposed either to a computer simulation (MPathic-VR) featuring virtual humans, or to a multimedia computer-based learning module, and to understand each group’s experiences and learning preferences.MethodsA single-blinded, mixed methods, randomized, multisite trial compared MPathic-VR (N = 210) to computer-based learning (N = 211). Primary outcomes: communication scores during repeat interactions with MPathic-VR’s intercultural and interprofessional communication scenarios and scores on a subsequent advanced communication skills objective structured clinical examination (OSCE). Multivariate analysis of variance was used to compare outcomes. Secondary outcomes: student attitude surveys and qualitative assessments of their experiences with MPathic-VR or computer-based learning.ResultsMPathic-VR-trained students improved their intercultural and interprofessional communication performance between their first and second interactions with each scenario. They also achieved significantly higher composite scores on the OSCE than computer-based learning-trained students. Attitudes and experiences were more positive among students trained with MPathic-VR, who valued its providing immediate feedback, teaching nonverbal communication skills, and preparing them for emotion-charged patient encounters.ConclusionsMPathic-VR was effective in training advanced communication skills and in enabling knowledge transfer into a more realistic clinical situation.Practice implicationsMPathic-VR’s virtual human simulation offers an effective and engaging means of advanced communication training.     

Knowledge about asthma and COPD: associations with sick leave, health complaints, functional limitations, adaptation, and perceived control

We sought to investigate associations between knowledge about the disease and sick leave, health complaints, functional limitations, adaptation and perceived control. Patients with asthma (n = 101) and COPD (n = 64) underwent lung function tests and completed questionnaires. In addition, all were asked the question: ‘what is the diagnosis of your disease?’, with the response categories: ‘asthma’ and ‘COPD (chronic bronchitis or emphysema)’. Thirty-five percent of the asthma patients and 30% of the COPD patients did not know their correct diagnosis. Sick leave was not associated with knowledge about the disease in asthma and COPD. In asthma, much knowledge about management of the disease was associated with better adaptation (P = 0.01) and less perceived control over health by external factors (P = 0.02). Knowing the correct diagnosis was associated with less control over health by powerful others (P = 0.02). For COPD, more knowledge about management of the disease was associated with better adaptation (P = 0.02) and less control over health by internal factors (P = 0.01). Knowing the correct diagnosis was associated with less control over dyspnea at work (P = 0.01).     

Existing instruments for assessing physician communication skills: Are they valid in a computerized setting?

ObjectivesThis study aims to highlight the differences in physicians’ scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it.MethodsWe use the Wilcoxon Signed Ranks Test to compare physicians’ scores on each of the tools during 16 simulated medical encounters that were rated by two different raters.ResultsResults show a significant difference between physicians’ scores on each tool (z = −3.519, p < 0.05 for the first rater, and z = −3.521, p < 0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower.ConclusionThese results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results.Practice implicationsWe therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated.     

Voices emerging from the shadows: Radiologic practitioners’ experiences of challenging conversations

ObjectiveTraditionally, radiologists have practiced their profession behind the scenes. Today, radiologic practitioners face mounting expectations to communicate more directly with patients. However, their experiences with patient communication are not well understood. The aim of this study was to describe the challenges of radiologic practitioners when communicating with patients.MethodsTwelve day-long interprofessional communication skills workshops for radiologic clinicians were held at Boston Children’s Hospital. Prior to each workshop, participants were asked to write narratives describing experiences with difficult radiologic conversations that they found particularly challenging or satisfying. The narratives were transcribed and analyzed through thematic content analysis by two researchers.ResultsRadiologists, radiology trainees, technologists, nurses, and medical interpreters completed 92 narratives. The most challenging aspects of healthcare conversations included: Conveying Serious News (n = 44/92; 48%); Expanded Scope of Radiologic Practice (n = 37/92; 40%); Inexperience and Gaps in Education (n = 15/92; 16%); Clinical Uncertainty (n = 14/92; 15%); and Interprofessional Teamwork (n = 9/92; 10%).ConclusionRadiologic clinicians face substantial communicative challenges focused on conveying serious, unexpected and uncertain diagnoses amid practical challenges and limited educational opportunities.Practice implicationsInnovative educational curricula that address these challenges may enhance radiologic practitioners’ success in adopting patient-centered communication.     

Accessibility of standardized information of a national colorectal cancer screening program for low health literate screening invitees: A mixed method study

ObjectiveTo explore the accessibility of standardized printed information materials of the national Dutch colorectal cancer screening program among low health literate screening invitees and to assess the effect of the information on their knowledge about colorectal cancer and the screening program.MethodsLinguistic tools were used to analyze the text and design characteristics. The accessibility, comprehensibility and relevance of the information materials were explored in interviews and in observations (n = 25). The effect of the information on knowledge was assessed in an online survey (n = 127).ResultsThe materials employed a simple text and design. However, respondents expressed problems with the amount of information, and the difference between screening and diagnostic follow-up. Knowledge significantly increased in 10 out of 16 items after reading the information but remained low for colorectal cancer risk, sensitivity of testing, and the voluntariness of colorectal cancer screening.ConclusionDespite intelligible linguistic and design characteristics, screening invitees with low health literacy had problems in accessing, comprehending and applying standard information materials on colorectal cancer screening, and lacked essential knowledge for informed decision-making about participation.Practice implicationsTo enable equal access to informed decision-making, information strategies need to be adjusted to the skills of low health literate screening invitees.     

Mind the gap: Disclosure of dietary supplement use to hospital and family physicians

ObjectiveWe aim to compare patients’ perspectives on communication with their hospital physicians (HPs) and primary care physicians (PCPs) on patients' dietary and herbal supplements (DHS) use.MethodsWe conducted a cross-sectional prospective study among in-patients using structured questionnaires on DHS use. Multivariate logistic regression models assessed variables influencing doctor-related reasons for patients' nondisclosure of supplement use.ResultsOf 452 DHS users identified, 133 (29.4%) used herbs and 319 (70.6%) used non-herbal supplements. DHS users reported that PCPs were more aware of DHS consumption than HPs (70.1% vs. 34.1%, P < 0.0001). PCPs initiative to detect supplement use was higher compared with HPs (P < 0.0001). Doctor-related reasons for non-disclosure of DHS use were more prominent in a hospital setting. Multivariate logistic regression model suggested association between older patient age and doctor-related non-disclosure (p = 0.03). DHS use was recorded in only 33 patients medical files.ConclusionsDoctor-patient communication concerning DHS use is significantly poorer during hospitalization compared with primary-care settings. A significant barrier for in-hospital disclosure is doctor-related.Practice implicationsContinuity of care between community and hospital physicians regarding patients' DHS use should be improved due to the safety implications of such use. Educating physicians on DHS and improving communication could bridge this gap.     

Breaking bad news to patients with cancer: A randomized control trial of a brief communication skills training module incorporating the stories and preferences of actual patients

ObjectiveThis study tested the effectiveness of a brief, learner-centered, breaking bad news (BBN) communication skills training module using objective evaluation measures.MethodsThis randomized control study (N = 66) compared intervention and control groups of students (n = 28) and residents’ (n = 38) objective structured clinical examination (OSCE) performance of communication skills using Common Ground Assessment and Breaking Bad News measures.ResultsFollow-up performance scores of intervention group students improved significantly regarding BBN (colon cancer (CC), p = 0.007, r = −0.47; breast cancer (BC), p = 0.003, r = −0.53), attention to patient responses after BBN (CC, p < 0.001, r = −0.74; BC, p = 0.001, r = −0.65), and addressing feelings (BC, p = 0.006, r = −0.48). At CC follow-up assessment, performance scores of intervention group residents improved significantly regarding BBN (p=0.004, r = −0.43), communication related to emotions (p = 0.034, r = −0.30), determining patient’s readiness to proceed after BBN and communication preferences (p = 0.041, r = −0.28), active listening (p = 0.011, r = −0.37), addressing feelings (p < 0.001, r = −0.65), and global interview performance (p = 0.001, r = −0.51).ConclusionThis brief BBN training module is an effective method of improving BBN communication skills among medical students and residents.Practice implicationsImplementation of this brief individualized training module within health education programs could lead to improved communication skills and patient care.     

Evaluación de la efectividad de la versión en español de un curso de comunicación de malas noticias

IntroductionGood communication by health professionals is associated with better patient outcomes. The Program to Enhance Relational and Communication Skills (PERCS) has been adapted to other cultures. The objective of this study is to describe the effectiveness of the Spanish version of the PERCS program, from the perspective of the participants, at the end of the course and 6 months after the course.MethodsA process of cultural and epidemiological adaptation of the PERCS program to the reality of Peru was carried out. A qualitative and quantitative approach was used to evaluate the educational impact of the program.ResultsThirty-nine professionals participated voluntarily. Participants found it more difficult to communicate ominous diagnoses (48.15%). Anxiety is the most frequent emotion when faced with difficult communications (77.78%). Almost all (92%) stated that the course improved their preparation, and 88.9% that it reduced their anxiety. At 6 months, participants recognised the importance of honesty and empathy, as well as some steps in conducting the patient-centred interview.DiscussionAn intensive training program in difficult communication can be adapted to Spanish, and positively impact the skills, self-confidence, and self-perception of learning in Peruvian professionals, in relation to promoting communication focused on the needs of the patient and family.     

Exploring the effects of patients taking a vigilant role in collaborating on their e-medication administration record

ObjectiveErrors in the electronic medication administration record (eMAR) occur in 25.6% of cases, mainly due to communication errors. The aim of this study is to investigate whether the quality of the eMAR improves when patients play a vigilant role by checking their medication using a patient communication tool linked to their eMAR (eMAR-PCT) to communicate asynchronously with the pharmacist about errors. Effects on health outcomes and self-care are also explored.MethodsIn this quasi-experimental study, polypharmacy patients using five or more medications were randomly selected and invited to use their eMAR-PCTs. Participants also received two digital questionnaires assessing health and self-care (week 0 and 26). Statistical analyses were performed on two subgroups: eMAR-PCT users and non-users.ResultsAn inclusion rate of 43.5% (n = 152) was achieved. Women were more prevalent than men among the users group (56.4% vs. 43.6%). Among the eMAR-PCT users, 75% logged in more than once, and 17.9% communicated asynchronously with the pharmacist. The content of the e-mails shows that eMAR-PCT was used as intended. No improvement in the quality of the eMAR was found. The self-care variables self-efficacy (p = .006) and collaboration with the pharmacist (p = .021) showed significant improvement in the users group.Conclusion and discussionThe results showed no effect on eMAR quality and a modest improvement in self-care. Active digital patient participation to improve the quality of eMAR merits further investigation as, in line with other research, tentatively positive results are shown on self-care. Possibilities for implementation are promising as half of the patients who pledged to use eMAR-PCT actually did, and used it as intended.     

Take the HEAT: A pilot study on improving communication with angry families

ObjectiveOur objective was to evaluate the utility of an educational program consisting of a workshop based on the Take the HEAT communication strategy, designed specifically for addressing patients who are angry, using a novel tool to evaluate residents’ skills in employing this method.Methods33 first-year pediatric and internal medicine-pediatrics residents participated in the study. The workshop presented the Take the HEAT (Hear, Empathize, Apologize, Take action) strategy of communication. Communication skills were assessed through standardized patient encounters at baseline and post-workshop. Encounters were scored using a novel assessment tool.ResultsAfter the workshop, residents’ Take the HEAT communication improved from baseline total average score 23.15 to total average score 25.36 (Z = −3.428, p < 0.001). At baseline, empathy skills were the lowest. Intraclass Correlation Coefficient demonstrated substantial agreement (0.60 and 0.61) among raters using the tool.ConclusionFirst-year pediatric trainees’ communication with angry families improved with education focused on the Take the HEAT strategy. Poor performance by residents in demonstrating empathy should be explored further.Practice implicationsThis study demonstrates the utility of a brief communications curriculum aimed at improving pediatric residents' ability to communicate with angry families.