Development of a tool to assess the impact of a brief counseling curriculum: Validation of the Attitudes to Psychological Interventions and Counseling in Primary Care (APIC-PC) survey

Objective

To develop and validate an instrument to assess knowledge and attitudes regarding the use of psychological interventions in primary care.

Methods

A 13-item questionnaire was developed based on literature review and expert panel discussion. Exploratory and confirmatory factor analyses were carried out to test the construct validity of the subscales. Item-scale correlations were used to test the construct validity of the items. Internal reliability was tested by Cronbach's alpha. Responsiveness of the instrument was evaluated by using independent t-test of pre and post program scores.

Results

Exploratory factor analysis extracted four factors: skills and knowledge, confidence to provide counseling, willingness to provide counseling, and curriculum needs. Confirmatory factor analysis demonstrated excellent goodness-of-fit. Item scale correlations confirmed convergent and discriminant validity. Good responsiveness was shown on independent t-test of the pre and post responses.

Conclusions

The Attitudes to Psychological Interventions and Counseling in Primary Care (APIC-PC) survey is a valid and responsive instrument for assessing knowledge and attitudes regarding psychological approaches in patient management (mental health care).

Practice implications

Psycho-social counseling skills training is increasingly being recognised as a valuable component of undergraduate primary care medical education. The APIC-PC is a useful tool for evaluating the impact of such programs.     

Exploring the community pharmacist's role in palliative care: focusing on the person not just the prescription

Objective

Changes in health care provision have led to an emphasis on providing end of life care within the home. community pharmacists are well positioned to provide services to community-based palliative care patients and carers.

Methods

A multiple qualitative case study design was adopted. A total of 16 focus groups and 19 interviews with pharmacists, nurses, general practitioners and carers were undertaken across metropolitan and regional settings in Western Australia, New South Wales, Queensland and Victoria. Data were analysed thematically using a framework that allowed similarities and differences across stakeholder groups and locations to be examined and compared.

Results

Three main themes emerged: effective communication; challenges to effective communication; and: towards best practice, which comprised two themes: community pharmacists’ skills and community pharmacists’ needs.

Discussion

A key component of the provision of palliative care was having effective communication skills. Although community pharmacists saw an opportunity to provide interpersonal support, they suggested that they would need to develop more effective communication skills to fulfil this role.

Conclusion

There is clear need for continuing professional development in this area - particularly in communicating effectively and managing strong emotions.

Practice implications

Community pharmacists are willing to support palliative care patients and carers but need education, support and resources.     

Computer-based execution of clinical guidelines: a review

Purpose

Clinical guidelines are useful tools to standardize and improve health care. The automation of the guideline execution process is a basic step towards its widespread use in medical centres. This paper presents an analysis and a comparison of eight systems that allow the enactment of clinical guidelines in a (semi) automatic fashion.

Methods

This paper presents a review of the literature (2000-2007) collected from medical databases as well as international conferences in the medical informatics area.

Results

Eight systems containing a guideline execution engine were selected. The language used to represent the guidelines as well as the architecture of these systems were compared. Different aspects have been assessed for each system, such as the integration with external elements or the coordination mechanisms used in the execution of clinical guidelines. Security and terminology issues complement the above study.

Conclusions

Although these systems could be beneficial for clinicians and patients, it is an ongoing research area, and they are not yet fully implemented and integrated into existing careflow management systems and hence used in daily practice in health care institutions.     

Medical and psychology students' self-assessed communication skills: A pilot study

Objective

The purpose of this study was to describe how psychology and medical students assess their own competency and skills before and after training, in which role-play was used to teach interpersonal and communication skills.

Method

Interpersonal and communication skills were assessed with a semi-structured questionnaire before and after the training.

Results

The students of both medicine and psychology estimated their skill levels to be higher after the course. The psychology students estimated their skills for communication, motivating interviewing, empathy and reflection, and change orientation to be better at the end of the course. Medical students estimated their communication skills, motivating interviewing skills, and change orientation skills to be better at the end of the course.

Conclusion

Even a short period of training in interpersonal and communication skills can positively affect the self-assessed skills of the medical students.

Practice implications

In the future, it would be worthwhile to pay attention to reflective teaching practices in the training of both medical and psychology students. The cognitive and emotional components of these practices help students to develop their own communication skills.     

Initial evaluation of EPSCALE, a rating scale that assesses the process of explanation and planning in the medical interview

Objective

To evaluate the content validity, internal consistency and generalisability of EPSCALE, a new rating scale to measure communication skills in explanation and planning.

Methods

Content validity: consensus exercise and expert review. Internal consistency and generalisability: 124 clinical students undertaking 4 OSCE stations with simulated patients, with one observer (hospital specialist, GP or communication specialist) per station, during finals examinations. Internal consistency estimated by coefficient alpha, generalisability estimated by generalisability coefficient and variance components using EPSCALE.

Results

Content validity was supported by consensus exercise and expert review. Internal consistency was high with a coefficient alpha of greater than 0.8 for all four explanation and planning stations in the finals exam. Generalisability coefficient for 4 OSCE stations was 0.50.

Conclusions

This paper provides initial evidence that EPSCALE has content validity and high internal consistency when used to assess explanation and planning skills in the consultation. It defines the generalisability of this new rating scale. Further work is needed to explore the scale's validity by a range of other measures.     

Attitudes and anxiety levels of medical students towards the acquisition of competencies in communication skills

Objective

Results of third year medical students’ attitudes and stress levels towards the acquisition of communication skills before and after a Communication and Clinical Skills Course (CCSC) at the Faculty of Medicine of the University of Porto (FMUP), Portugal, are presented.

Methods

115 students attending third-year CCSC completed a demographic questionnaire, State-Trait Anxiety Inventory, Communication Skills Attitudes Scale and Interpersonal Behavior Survey.

Results

Significant negative correlation was found between anxiety levels and attitudes towards learning communication skills in general as well as the teaching and learning process. At the end of the Course students reported that when compared to the start, their communication skills are less sufficient.

Conclusion

At the end of this CCSC at FMUP, students recognized its major importance and how they need to invest and improve communication skills. However, it seems important to monitor the attitudes and anxiety levels of students towards patient care and communication during the medical course and to identify ways of overcoming barriers towards learning communication skills.

Practice implications

It is recommended that there should be a complete (transversal and vertical) integration of communication skills, including effective teaching methods, assessments, and examinations in order to be valued by the students. This would necessitate curricular changes.     

Author Index

Objective

To operationally define cancer literacy, understanding which aspects of cancer are important to be known by a layperson to be considered cancer literate.

Methods

A Delphi study in three consecutive rounds was conducted among a panel of Swiss cancer experts (oncologists, GPs, nurses from oncology wards, social workers, public health experts).

Results

The result of the Delphi process is a first operational definition of the concept of cancer literacy, a list of the aspects of cancer that, in the expert's view, laypeople should know to be considered cancer literate.

Conclusions

We have now an idea of what should be known about cancer. The study also provides us with some useful hints about what should be communicated about cancer, e.g. via public communication campaigns, school education, or media.

Practice implications

The operational definition of the concept can be used for the development and the validation of a measure of cancer literacy, not anymore limited to basic literacy and numeracy skills.     

Development and validation of a patient measure of doctor-patient caring

Objective

Conceptualising the doctor-patient relationship as a ‘window mirror’ exposes care delivery from doctor to self, doctor to patient, patient to self, and patient to doctor. These directions have not been measured concurrently. We aimed to develop and validate a patient questionnaire informed by this model.

Methods

A modified-Delphi exercise was conducted to develop, and face and content validate, the questionnaire. Stage 2 surveyed 495 patients in general practice to assess the internal consistency and construct validity of the questionnaire.

Results

The questionnaire is face and content valid. Its internal reliability and construct validity appear good. Patients who care more about their doctor also care more about themselves. A patient or doctor who cares about the other person is associated with increased self-care by that person.

Conclusions

Further development and testing of the patient questionnaire is warranted to validate measurement of how patients perceive the caring they and their doctor give, and receive from, each other.

Practice implications

From the patient perspective the questionnaire may increase awareness of the importance of family doctors and patients caring about each other and themselves. It may inform and evaluate medical students, educational programmes and caring in doctor-patient relationships.     

Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques

Objective

Health literacy is a growing concern as its relationship with health outcomes becomes clearer. Efforts to enhance awareness of patient health literacy in health professional education have focused on physicians, and the objective of this research was to provide an initial assessment of a training session designed for healthcare workers of all kinds.

Methods

Pre- and post-surveys were completed by 166 participants (N = 166) in training sessions designed to improve knowledge of health literacy and instruction in clear communication techniques. Participants provided baseline and post-training assessments of perceived knowledge of health literacy and use of strategies to improve communication with low health literate audiences.

Results

Participants, initially overestimating their own knowledge of health literacy, improved on outcome measures regarding perceived health literacy knowledge. Participants also indicated strong intentions to use clear communication techniques covered in the training.

Conclusion

Results suggest there is an opportunity and need to improve health literacy training for healthcare workers of all kinds. Widespread adoption of health literacy training programs would improve the delivery of healthcare to low health literate patients.

Practice implications

Participants initially overestimated their knowledge of health literacy, suggesting a need to improve initial training and continuing medical education regarding health literacy.     

Hospital consultants breaking bad news with simulated patients: an analysis of communication using the Roter Interaction Analysis System

Objective

To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness.

Methods

Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System.

Results

Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness.

Conclusion

Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations.

Practice implications

It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.     

Web-enabled video-feedback: a method to reflect on the communication skills of experienced physicians

Objective

To describe our web-enabled video-feedback method designed to reflect on the communication skills of experienced physicians.

Methods

Participating physicians (n = 28) received a ‘personal web link’ to two of their video-recorded consultations. After watching the consultations physicians received feedback by telephone or in a face-to-face meeting, structured around an individualized feedback report. This report contained scores on the communication behavior of the physician in comparison with colleagues and their own communication behavior observed in a previous study, as well as patients’ opinions about their physician's communication behavior. The physicians were asked to reflect on their communication skills and to comment on the usefulness and efficiency of the feedback method.

Results

Almost all physicians were satisfied with the feedback method and in particular valued the web-enabled link to the video-recorded consultations and the structured written report. Feedback by telephone or face-to-face feedback was considered equally appropriate.

Conclusion

This web-enabled video-feedback method is a useful and structured design to reflect on the communication skills of physicians.

Practice implications

As part of continuing medical education, feedback on communication skills should become a recurrent activity for experienced physicians. This method can also be used to reflect on the communication skills of medical students.     

Determinants of Internet use as a preferred source of information on personal health

Objective

To understand the personal, social and cultural factors likely to explain recourse to the Internet as a preferred source of personal health information.

Design

A cross-sectional survey was conducted among a population of 2923 Internet users visiting a firmly established website that offers information on personal health. Multiple regression analysis was performed to identify the determinants of site use.

Measurement

The analysis template comprised four classes of determinants likely to explain Internet use: beliefs, intentions, user satisfaction and socio-demographic characteristics. Seven-point Likert scales were used. An analysis of the psychometric qualities of the variables provided compelling evidence of the construct's validity and reliability. A confirmatory factor analysis confirmed the correspondence with the factors predicted by the theoretical model.

Findings

The regression analysis explained 35% of the variance in Internet use. Use was directly associated with five factors: perceived usefulness, importance given to written media in searches for health information, concern for personal health, importance given to the opinions of physicians and other health professionals, and the trust placed in the information available on the site itself.

Conclusion

This study confirms the importance of the credibility of information on the frequency of Internet use as a preferred source of information on personal health. It also shows the potentially influential role of the Internet in the development of personal knowledge of health issues.     

The feasibility of a multi-format Web-based assessment of physicians' communication skills

Objective

Little is known about the best approaches and format for measuring physicians’ communication skills in an online environment. This study examines the reliability and validity of scores from two Web-based communication skill assessment formats.

Methods

We created two online communication skill assessment formats: (a) MCQ (multiple-choice questions) consisting of video-based multiple-choice questions; (b) multi-format including video-based multiple-choice questions with rationales, Likert-type scales, and free text responses of what physicians would say to a patient. We randomized 100 general internists to each test format. Peer and patient ratings collected via the American Board of Internal Medicine (ABIM) served as validity sources.

Results

Seventy-seven internists completed the tests (MCQ: 38; multi-format: 39). The adjusted reliability was 0.74 for both formats. Excellent communicators, as based on their peer and patient ratings, performed slightly better on both tests than adequate communicators, though this difference was not statistically significant. Physicians in both groups rated test format innovative (4.2 out of 5.0).

Conclusion

The acceptable reliability and participants’ overall positive experiences point to the value of ongoing research into rigorous Web-based communication skills assessment.

Practice implications

With efficient and reliable scoring, the Web offers an important way to measure and potentially enhance physicians’ communication skills.     

Assessment of a motivational interviewing curriculum for year 3 medical students using a standardized patient case

Objective

We sought to evaluate a year 3 motivational interviewing (MI) curriculum using a standardized patient case.

Methods

The 2-h small group MI curriculum included a didactic presentation followed by interactive role plays. During a clinical skills assessment at the end of year 3 the MI skills of 80 students who had participated in the curriculum were compared with those of 19 students who had not participated.

Results

The standardized patient reliably rated the students on their performance of 8 items. Students who had participated in the MI curriculum were significantly more proficient than nonparticipating students in the performance of 2 strategic MI skills, importance and confidence rulers (ps < .006). The groups did not differ in their use of patient-centered counseling skills or collaborative change planning commonly used in MI.

Conclusions

Third year medical students can learn to use MI skills that specifically aim to enhance patients’ motivations for change.

Practice implications

Medical schools should consider providing students with MI training and MI skill assessments using standardized patient cases to help students prepare to counsel patients for behavior change.     

Correlating reading comprehension and health numeracy among adults with low literacy

Objective

Using the Test of Functional Health Literacy for Adults (TOFHLA), a pilot study was conducted to assess whether reading comprehension and numeracy scores sufficiently correlate in health contexts among adults with low literacy skills.

Methods

The TOFHLA was administered to 144 adults with low literacy enrolled in a health literacy program prior to the start of coursework. Raw scores for reading and numeracy were calculated. Weighted numeracy scores were calculated and compared to raw reading comprehension scores.

Results

Among 143 participants, 20% (n = 28) had a higher numeracy score than reading comprehension score, while an additional 20% scored lower in numeracy than in reading comprehension.

Conclusion

This study found that reading comprehension and numeracy skill in the context of understanding health information do not necessarily correlate for specific disadvantaged groups. This finding calls attention to the need to further examine numeracy as a construct which is conceptually separate from reading comprehension, and highlights the importance of including a numerate component in health literacy evaluations.

Practice implications

The results of this study have important implications for medical decision-makers, health educators, and health promoters working with traditional methods of assessing health literacy.     

Measuring providers' verbal and nonverbal emotion recognition ability: reliability and validity of the Patient Emotion Cue Test (PECT)

Objective

To describe the development and validation of the Patient Emotion Cue Test (PECT) as a tool to measure providers’ emotion cue recognition ability.

Methods

The PECT consists of 47 video clips depicting emotion cues that systematically vary in intensity of both verbal and nonverbal contents. The PECT assesses the provider's ability to detect and identify patients’ emotion cues accurately. A multi-stage development process produced the PECT. Reliability and validity were assessed in three studies.

Results

Scores on the PECT are normally distributed with significantly above chance responding. Across three studies, the PECT demonstrates convergent validity through significant correlations with standardized tests representing multiple channels of emotion recognition, including the face, body, and voice. The PECT shows adequate inter-item and split-half reliability.

Conclusion

The PECT is an easily administered, reliable, and valid test of emotion cue recognition.

Practice implications

The PECT can be used in future research on providers’ emotion recognition ability, for evaluating self-assessment of ability, and as a teaching tool in medical schools.     

Opinions of patients with type 2 diabetes about responsibility, setting targets and willingness to take medication. A cross-sectional survey

Objective

To assess opinions and their determinants of patients with type 2 diabetes about responsibility for managing their diabetes, setting treatment targets and willingness taking medication.

Methods

Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands. Outcomes: opinions about responsibility, targets and medication. Multinomial logistic regression analysis.

Results

Data of 994 consecutive persons were analysed (mean age 65 years; 54% males). Of these 62% agreed to take responsibility for their diabetes. In the opinion of 89% the setting of targets should be by or in cooperation with their physician or nurse and 40% were willing to take tablets until all targets were attained. Patients who perceived dysfunction by barriers to activity did not agree to take responsibility (OR 3.68; 1.65-8.19). Patients with complications preferred to set targets in cooperation with their physician or nurse (OR 1.98; 1.03-3.80). Males were more willing to take tablets until all targets were attained (OR 1.62; 1.17-2.25).

Conclusion

Not all patients want to take responsibility for their diabetes or taking all necessary tablets, especially those with barriers to activity or complications.

Practice implications

Doctors and nurses should ask for patients’ opinions about responsibility and treatment goals before starting education.     

Evaluating verbal and non-verbal communication skills, in an ethnogeriatric OSCE

Objective

Communication during medical interviews plays a large role in patient adherence, satisfaction with care, and health outcomes. Both verbal and non-verbal communication (NVC) skills are central to the development of rapport between patients and healthcare professionals. The purpose of this study was to assess the role of non-verbal and verbal communication skills on evaluations by standardized patients during an ethnogeriatric Objective Structured Clinical Examination (OSCE).

Methods

Interviews from 19 medical students, residents, and fellows in an ethnogeriatric OSCE were analyzed. Each interview was videotaped and evaluated on a 14 item verbal and an 8 item non-verbal communication checklist. The relationship between verbal and non-verbal communication skills on interview evaluations by standardized patients were examined using correlational analyses.

Results

Maintaining adequate facial expression (FE), using affirmative gestures (AG), and limiting both unpurposive movements (UM) and hand gestures (HG) had a significant positive effect on perception of interview quality during this OSCE. Non-verbal communication skills played a role in perception of overall interview quality as well as perception of culturally competent communication.

Conclusion

Incorporating formative and summative evaluation of both verbal and non-verbal communication skills may be a critical component of curricular innovations in ethnogeriatrics, such as the OSCE.