A comparison of two educational interventions for the cognitive empowerment of ambulatory orthopaedic surgery patients

Objective

The aim of this study was to compare the cognitive empowerment of ambulatory orthopaedic surgery patients when using Internet-based education (experiment) in contrast to face to face education conducted by a nurse (control).

Methods

Elective ambulatory orthopaedic surgery patients were randomized to either an experiment group (n = 72) receiving Internet-based education, or to a control group (n = 75) receiving face-to-face education with a nurse. The data were collected at three different time points: before the preoperative education session, after preoperative education and 2 weeks after the operation. Three structured instruments were used: the Knowledge Test, the Sufficiency of Knowledge and the Orthopaedic Patient Knowledge Instrument.

Results

Patients in both groups showed improvement in their knowledge. However, patients who received Internet-based education improved their knowledge level significantly more in the ethical (p = 0.005) and functional (p = 0.023) dimensions and also in total (p = 0.033) than those patients who underwent face-to-face education with a nurse. In addition, patients in the experiment group had higher scores in sufficiency of knowledge in the experiential (p = 0.050) and financial (p = 0.048) dimensions and, moreover, their scores in sufficiency of knowledge in the ethical dimension improved significantly more (p = 0.008) during the study period than patients in the control group.

Conclusion

Improvements in the patients’ level and sufficiency of knowledge within both groups indicates an increase in patients’ cognitive empowerment.

Practice implications

Internet-based education can be used in ambulatory orthopaedic surgery patient education for increasing patients’ cognitive empowerment.     

Improving informed consent to chemotherapy: a randomized controlled trial of written information versus an interactive multimedia CD-ROM

Objective

This randomized controlled trial aimed to determine whether an interactive CD-ROM improved cancer patients’ recall of chemotherapy treatment information over standard written information, and whether demographic, cognitive, and psychological factors better predicted recall than this format of delivery.

Methods

One-hundred-and-one new patients about to commence chemotherapy were randomized to receive written information or a CD-ROM containing treatment information before giving informed consent. Patients’ recall, concentration, short-term memory, reading comprehension, anxiety, depression, and coping styles were assessed with standardized measures pre-treatment. Seventy-seven patients completed tests for recall of treatment information before their second chemotherapy session.

Results

Intention-to-treat analyses indicated no significant differences between the written information and CD-ROM groups across recall questions about number of drugs received (p = .43), treatment length (p = .23), and treatment goal (p = .69). Binary logistic regressions indicated that for groups combined different variables predicted each of the recall questions.

Conclusion

An interactive CD-ROM did not improve cancer patients’ recall of treatment information enough to warrant changes in consent procedures.

Practice implications

Different variables predicted recall of different treatment aspects highlighting the complex nature of attempting to improve patient recall. Attending to the effect of depression on patient knowledge and understanding appears paramount.     

Association between nonverbal communication during clinical interactions and outcomes: a systematic review and meta-analysis

Objective

To conduct a systematic review and meta-analysis of studies reporting associations between patients’ and clinicians’ nonverbal communication during real clinical interactions and clinically relevant outcomes.

Methods

We searched 10 electronic databases, reference lists, and expert contacts for English-language studies examining associations between nonverbal communication measured through direct observation and either clinician or patient outcomes in adults. Data were systematically extracted and random effects meta-analyses were performed.

Results

26 observational studies met inclusion criteria. Meta-analysis was performed for patient satisfaction, which was assessed in 65% of studies. Mental and physical health status were evaluated in 23% and 19% of included studies, respectively. Both clinician warmth and clinician listening were associated with greater patient satisfaction (p < 0.001 both). Physician negativity was not related to patient satisfaction (p = 0.505), but greater nurse negativity was associated with less patient satisfaction (p < 0.001). Substantial differences in study design and nonverbal measures existed across studies.

Conclusion

Greater clinician warmth, less nurse negativity, and greater clinician listening were associated with greater patient satisfaction. Additional studies are needed to evaluate the impact of nonverbal communication on patients’ mental and physical health.

Practice implications

Communication-based interventions that target clinician warmth and listening and nurse negativity may lead to greater patient satisfaction.     

Quality of decision making is related to decision outcome for patients with cardiac arrhythmia

Objective

Clinical consultations with patients should be informed by the evidence-based and involve shared decision making (SDM). We aimed to determine the delivery of SDM by clinicians with patients referred for invasive treatment of cardiac electrical disease and to establish whether decisions made corresponded with patient and referring physician expectations.

Methods

Forty-nine outpatient consultations with two consultant cardiologists in one large tertiary centre were audio-recorded. Demographic data, diagnosis, reasons for referral and decision reached were compared directly with patient and referring physician expectations. The OPTION instrument was used to measure SDM. Patient expectations and satisfaction were elicited.

Results

Quality of SDM was good (mean OPTION score 49%) and there was broad patient satisfaction. While all patients were suitable for invasive treatment, and the majority (80%, n = 39) had been explicitly referred for it, only 59% (n = 29) opted to proceed. Consultation quality with respect to SDM was significantly greater for patients choosing a less invasive option.

Conclusion

These consultations often change expected management. Where decision making in the consultation is of higher quality, patients were more likely to change to a less invasive option.

Practice implications

Clinicians performing invasive cardiac treatment should be able to demonstrate high quality decision making.     

When the safety net of treatment has been removed: Patients’ unmet needs at the completion of treatment for haematological malignancies

Objective

To determine patients’ information, emotional and support needs at the completion of treatment for a haematological malignancy.

Methods

A self-report questionnaire was mailed to 113 adult patients.

Results

Sixty-six questionnaires were returned. The most frequently endorsed patient needs related to care co-ordination and help to manage the fear of recurrence. The most frequently endorsed unmet needs included managing the fear of recurrence, the need for a case-manager and the need for communication between treating doctors. Predictors of unmet needs included younger patients (p = 0.01), marital status (p = 0.03) and employment (p = 0.03). Almost two-thirds of patients (59%) reported they would have found it helpful to talk with a health care professional about their experience of diagnosis and treatment at the completion of treatment and endorsed significantly more need in the arenas of Quality of Life (p = 0.03) and Emotional and Relationships (p = 0.04).

Conclusion

This study provides valuable data on haematological cancer patients’ needs in the first 12 months of finishing treatment. It appears that many needs emerge or remain unresolved at this time.

Practice implications

An opportunity for patients to talk with a health professional about making the transition from active treatment to extended survivorship may be helpful.     

Physicians’ attitudes towards disclosure of prognostic information: A survey among a representative cross-section of 1605 Norwegian physicians

Objective

To investigate if attitudes towards disclosure of prognostic information vary by speciality, previous experience and demographic factors in a general physician population.

Methods

A postal survey among a representative sample of Norwegian physicians across all specialities (N = 1605), using a translated questionnaire previously used to study attitudes towards disclosing prognostic information among US internists.

Results

A response rate of 70% was obtained after one reminder. 85% of the responders agreed to the helpfulness of an optimistic attitude. A factor analysis revealed three meaningful factors: ‘Prognostic communication is stressful’, ‘Fearing loss of reputation’ and ‘Reinforcement of positive prospects’. In multivariable models significantly more female than male physicians found aspects of prognostication straining (β = 0.143, p < 0.001). Those more experienced in communication of prognostic information towards end of life were less likely to support using reinforcement of positive prospects (β = 0.067, p = 0.001).

Conclusion

After years of focusing on patient autonomy and open communication between patient and physician many Norwegian physicians display attitudes that might hide the true content of prognostic information from the patients.

Practice implications

Many physicians think they are inadequately trained in prognostication and communication of prognostic information, suggesting that increased education and training are needed if patients’ wishes for information on prognosis are to be met in an individualised manner.     

Patient knowledge of blood pressure target is associated with improved blood pressure control in chronic kidney disease

Objective

To describe patient hypertension knowledge and associations with blood pressure measurements.

Methods

Patients with chronic kidney disease (CKD) were asked about the impact of high blood pressure on kidneys and their target blood pressure goal. Systolic blood pressure was measured using automated sphygmomanometers.

Results

In 338 adults with hypertension and pre-dialysis CKD, the median [IQR] age was 59 [47,68] years, 45% [n = 152] were women, and 18% [n = 62] were non-white. Lower systolic blood pressure (SBP) was associated with female sex (SBP mmHg median [IQR] 132 [117,149] women vs. 137 [124,152] men; p = 0.04), less advanced CKD (SBP 134 [122,147] stages 1–2 vs. 132 [118,148] stage 3 vs. 140 [125,156] stages 4–5; p = 0.01), and patient ability to correctly identify SBP goal (SBP 134 [119,150] correct vs. 141 [125,154] incorrect; p = 0.05). In adjusted analysis, knowledge of blood pressure goal remained independently associated with lower SBP (−9.96 mmHg [−19.97, −1.95] in correct respondents vs. incorrect; p < 0.001).

Conclusion

Patient knowledge of goal blood pressure is independently associated with improved blood pressure control.

Practice implications

Interventions to improve patient knowledge of specific blood pressure targets may have an important role in optimizing blood pressure management.     

Subjective dimensions of patient competence: relationships with selected healthcare usage behaviors and general features of self-rated competence

Objective

To introduce the concept of patient competence and provide additional information on the concurrent validity of a new self-rating measure of patient competence in the context of cancer employing healthcare usage behaviors and more general self-rated features of patient competence as criteria.

Methods

Based on a multi-center sample of n = 536 patients with cancer, bivariate correlations and multiple regressions were computed.

Results

The competence subscale of striving for autonomous decisions emerged as significant, albeit weak predictor of having used professional psycho-social support (r = .31, β = .28) and employing other complementary medicines (r = .28; B = .65) in relation to one's cancer. Problem-focused and emotion-focused competencies relate differently to different general features of self-rated competence like feeling informed and assertive or adapting well.

Conclusion

Additional support for the concurrent validity of the new self-rating measure of patient competence in the context of cancer has been found. Viewed in perspective, this measure may therefore provide a methodological basis to examine determinants and health effects of patient competence empirically. Nevertheless, further research on the conceptualization and measurement of patient competence appears necessary.

Practice implications

Having available measures of patients’ specific competencies in the context of cancer will help identify their strength and weaknesses in dealing with life-threatening disease and enhance their coping resources.     

Degree and correlates of cardiac knowledge and awareness among cardiac inpatients

Objective

To investigate the degree of CHD awareness as well as symptom, risk factor, and treatment knowledge in a broad sample of cardiac inpatients, and to examine its sociodemographic, clinical and psychosocial correlates.

Methods

1308 CHD inpatients (351 [27.0%] female), recruited from 11 acute care sites in Ontario, participated in this cross-sectional study. Participants were provided with a survey which included a knowledge questionnaire among other measures, and clinical data were extracted from medical charts.

Results

855 (68.8%) respondents cited heart disease as the leading cause of death in men, versus only 458 (37.0%) in women. Participants with less than high school education (p < .001), an annual family income less than $50,000CAD (p = .022), low functional capacity (p = .042), who were currently smoking (p = .022), who had no family history of heart disease (p < .001), and who had a perception of low personal control (p = .033) had significantly lower CHD knowledge.

Conclusions

Awareness of CHD is not optimal, especially among women, South Asians, and those of low socioeconomic status. CHD patients have a moderate level of disease knowledge overall, but greater education is needed.

Practice implications

Tailored educational approaches may be necessary for those of low socioeconomic status, particularly with regard to the nature of CHD, tests and treatments.     

Family communication as strategy in diabetes prevention: an observational study in families with Dutch and Surinamese South-Asian ancestry

Objective

To explore the possibility of utilizing family communication as a diabetes prevention strategy, specifically targeting high-risk families with South-Asian ancestry in the Netherlands.

Methods

In a cross-sectional study, type 2 diabetes patients from Dutch (n = 311) and Surinamese South-Asian (n = 157) origin filled in a questionnaire assessing socio-demographic characteristics, beliefs and concerns about familial diabetes risk, primary prevention, and diabetes-related family communication.

Results

Discussing diabetes is regarded acceptable in most families. Especially Surinamese South-Asian patients (68%) seemed motivated to convey risk messages to their relatives; they reported a higher risk perception and expressed more concern than Dutch patients. While 40% in both groups thought relatives are able to prevent developing diabetes, 46% in Dutch and 33% in Surinamese South-Asian patients were unsure.

Conclusion

Promoting family communication appears a feasible strategy in diabetes prevention in high-risk (Surinamese South-Asian) families. Health care providers should address patients’ concern and emphasize opportunities for prevention.

Practice implications

Findings favor training of clinicians in utilizing a family approach as prevention strategy. Patients (particularly Surinamese South-Asians) are in need of professional help in the process of family risk disclosure. (Online) Educational tools should be made available at which patients can refer their relatives.     

Optimising anticoagulant education in the paediatric setting using a validated model of education

Objective

Providing education to patients requiring anticoagulant therapy may be associated with improved outcomes. This study investigated the knowledge outcomes of a validated educational intervention.

Methods

Parents of children with congenital heart disease requiring warfarin therapy took part in an educational intervention. Warfarin knowledge was assessed prior to commencing the program, immediately following its completion and 6 months following completion.

Results

Parents demonstrated a statistically significant improvement in their warfarin knowledge immediately following completion of the program (p < 0.0001), with this improvement being sustained over time.

Conclusion

Current approaches to educating parents of children requiring warfarin therapy are likely suboptimal. Using a validated model of education may be associated with improved knowledge outcomes for patients.

Practice implications

Consideration to the processes used in delivering patient education may result in improved patient knowledge outcomes.     

Patients feeling severely affected by multiple sclerosis: How do patients want to communicate about end-of-life issues?

Objective

Investigate multiple sclerosis patients’ desire to communicate with their physicians about their disease progression and end-of-life issues.

Methods

Persons meeting the inclusion criteria of feeling severely affected by MS were invited via the German MS society to complete a needs questionnaire. Replies to questions on physician empathy and wishes about communication regarding disease progression and death and dying were quantitatively analyzed. Endpoints (point 1 + 2/4 + 5) of 5-point-likert scales are summarized under results.

Results

573 of 867 questionnaires meeting our criteria were analyzed. In response to a general question 64% (n = 358) indicated a wish for disease progression and death and dying to be addressed by their doctor. A majority (76%, n = 427) considered it important that progression of their disease be discussed, while 44% (n = 246) regard addressing death and dying as unimportant. No objective disease criteria could be identified to explain the wish for communicating end-of-life issues. Doctors who were retrospectively viewed as avoiding raising critical aspects of the illness were perceived as less empathetic (p < 0.001).

Conclusion

People with MS have a desire to talk about progression of their disease with their doctors.

Practice implications

Physicians should be empathetic in raising critical aspects of the patients’ illness individually.     

Expert consensus on gender criteria for assessment in medical communication education

Objective

The aim of this study is to develop gender criteria that can be included in communication skills assessment in medical education.

Methods

A three-round Delphi study was conducted. The invited 59 participants were experts in the field of gender medicine education (n = 28) and doctor–patient communication (n = 31). Each Delphi round comprised a questionnaire, an analysis, and a feedback report. In the first round, gender experts explored gender themes in doctor–patient communication from which initial gender criteria were defined. The second and third rounds were used to validate the importance and feasibility of gender criteria. Consensus was defined as a 75% panel agreement and a mean of 4 or higher on a 5-point Likert scale.

Results

Four gender criteria achieved consensus after the third round. The importance of including the gender criteria in communication skills assessment was rated consistently higher than its feasibility. Gender criteria relating to the patients’ perspective, to gathering information and to gender and power were considered the most important.

Conclusion

Using a Delphi study, we have developed gender criteria for inclusion in communication skills assessment to promote good communication between doctors and patients.

Practice implications

Gender influences medical communication. Incorporating gender in communication skills assessment may be useful to improve the teaching and learning of communication skills.     

Validating the Medical Data Interpretation Test in a Dutch population

Objective

To validate the Dutch translation of the Medical Data Interpretation Test.

Methods

A test–retest design with a 2-week interval was used.

Results

The intraclass correlation coefficient (ICC = .82), the limits-of-agreement interval (LOA = −8.96 to 2.48) and the test–retest reliability (Pearson's r = 86) suggest that the Dutch translation has good reproducibility. Construct validity was tested by two hypotheses, both of which were confirmed. University participants had higher test scores than non-university participants (p = .02), and males did not score differently than females (p = .61).

Conclusion

The results suggest that the Dutch version of the Medical Data Interpretation Test is an adequate scale to assess ability to interpret medical data.

Practice implications

Assessing patients’ numeracy skills before a counseling session will enable the counselor to adjust subsequent communication accordingly and, as such, improve the session's effectiveness.     

Patients’ evaluation of quality of care in general practice: What are the cultural and linguistic barriers?

Objective

Increased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients’ satisfaction and perceived quality of care.

Methods

Patients (n = 663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the ‘Quote-mi’ scale (quality of care through the patient's eyes—for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed.

Results

In general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients’ Dutch language proficiency, the more negative they were about the communication process.

Conclusion

It is concluded that next to communication aspects, especially when the patient's proficiency in Dutch is poor, physician awareness about the patient's cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated.

Practice implications

Medical students and physicians should be trained to become aware of the relevance of patients’ different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.     

The effect of using standardized patients or peer role play on ratings of undergraduate communication training: a randomized controlled trial

Objectives

Considering the expense of standardized patients (SP) for training communication skills and the convenience of peer role playing (RP) there is a surprising lack of studies directly comparing the two methods.

Methods

Fifth year medical students (N = 103) were assigned to three groups receiving a training in counseling parents of sick children with RP (N = 34) or SP (N = 35) or to a control group (CG, N = 34). We assessed self-efficacy, as well as objective performance in parent–physician communication using questionnaires and the Calgary-Cambridge-Observation-Guide Checklist in a six-station OSCE, respectively.

Results

The training led to an increase in self-efficacy ratings and in the post-intervention OSCE score after RP (p < .021 and p < .001 respectively) and SP-training (p < .007 and p < .006 respectively) compared to controls. Surprisingly, this benefit was higher after RP than after SP-training (p < .021) due to significantly higher performance in the domain understanding of parents’ perspective (p < .001).

Conclusion

Both RP and SP are valuable tools for training specific communication skills. RP offer a methodological advantage in fostering empathy for patient perspectives.

Practice implications

Both peer-role-play and standardized patients hold specific benefits for communication training. Peer-role-play seems to foster a more empathic approach towards patients’ concerns justifying its prominent role in medical curricula.     

A linguistic study of patient-centered interviewing: Emergent interactional effects

Objectives

To evaluate interactional effects of patient-centered interviewing (PCI) compared to isolated clinician-centered interviewing (CCI).

Methods

We conducted a pilot study comparing PCI (N = 4) to CCI (N = 4) for simulated new-patient visits. We rated interviews independently and measured patient satisfaction with the interaction via a validated questionnaire. We conducted interactional sociolinguistic analysis on the interviews and compared across three levels of analysis: turn, topic, and interaction.

Results

We found significant differences between PCI and CCI in physician responses to patients’ psychosocial cues and concerns. The number and type of physician questions also differed significantly across PCI and CCI sets. Qualitatively, we noted several indicators of physician–patient attunement in the PCI interviews that were not present in the CCI interviews. They spanned diverse aspects of physician and patient speech, suggesting interactional accommodation on the part of both participants.

Conclusions

This small pilot study highlights a variety of interactional variables that may underlie the effects associated with patient-centered interviewing (e.g., positive relationships, health outcomes). Question form, phonological accommodation processes, and use of stylistic markers are relatively unexplored in controlled studies of physician–patient interaction.

Practice implications

This study characterizes several interactional variables for larger scale studies and contributes to models of patient-centeredness in practice.     

Communication and self-management education at nurse-led COPD clinics in primary health care

Objective

The aim of the study was to explore the structure, content in communication and self-management education in patients’ first consultations at nurse-led chronic obstructive pulmonary disease (COPD) clinics in primary healthcare.

Method

Thirty consultations performed by seven registered nurses were videotaped; structure and content in the consultation was analyzed using Pendleton's Consultation Map. Nurses’ self-management education was assessed from the content of the conversation: whether important and relevant information and self-management education was given, and how investigations were performed.

Results

Each consultation lasted for a mean time of 37.53 min. Communication about reasons for consultations concerned mainly medical and physical problems and to a certain extent patients’ perceptions. Teaching about self-management and smoking cessation was of an informative nature. Two consultations ended with shared understanding, and none of the patients received an individual treatment-plan.

Conclusion

Nurses rarely planned the consultations on an individual basis and rarely used motivational dialogue in self-management education and in smoking cessation.

Practice implications

The findings could be used to help nurses to reflect on how to improve the structure of the visit, self-management education, smoking cessation and patient communication.     

Effectiveness of a discharge education program in reducing the severity of postpartum depression: A randomized controlled evaluation study

Objective

The effectiveness of a hospital discharge education program including information on postnatal depression was evaluated to reduce psychological morbidity after childbirth.

Methods

A randomized controlled trial (RCT) was conducted in a regional hospital in Taipei. Two hundred first-time mothers agreed to take part and were randomly allocated to an intervention group (n = 100) or control group (n = 100). The intervention group received discharge education on postnatal depression provided by postpartum ward nurses. The control group received general postpartum education. The main outcome measure was the Edinburgh Postnatal Depression Scale (EPDS) administered by postal questionnaire at six weeks and three months after delivery.

Results

Women who received discharge education intervention on postnatal depression were less likely to have high depression scores when compared to the control group at three months postpartum.

Conclusion

A discharge educational intervention including postnatal depression information given to women during the postpartum stay benefits psychological well-being.

Practice implications

A postpartum discharge education program including information on postnatal depression should be integrated into postpartum discharge care in general practice.     

Effectiveness of a computer tailored physical activity intervention in adolescents compared to a generic advice

Objective

To investigate the differences in effects of a computer tailored physical activity advice as compared to generic information in adolescents.

Methods

Students (mean age, 14.6 ± 1.2) out of 90 classes from six different Flemish schools were randomly assigned to the tailored intervention (n = 563) or the generic non-tailored intervention (n = 608) condition. Both interventions included information on public health recommendations and tips on becoming more active. Participants in both groups received their assessment and feedback at baseline, at 4 weeks and at 3 months during school hours. Physical activity levels were determined using an adolescent adaptation of the International Physical Activity Questionnaire (IPAQ).

Results

After 4 weeks, almost all physical activity scores increased over time in both the generic and the tailored intervention group. No differences between groups were found (all F ≤ 0.07). After 3 months, the generic intervention was more effective for increasing ‘walking in leisure time’ among students not complying with recommendations. For all other physical activity scores, no differences between groups were found (all F ≤ 2.3).

Conclusions

In contrast to the expectations, changes in physical activity scores did not differ between the tailored and the non-tailored intervention group. For most of the physical activity scores increases were found in both groups.