Communication in Cancer Care: Can Research Make a Difference?

BCCA Annual Cancer Conference Provincial Oncology Nurses Meetings

November 28, 2003

Sally Thorne, RN, PhD,

Professor & Director

School of NursingPUTTING SCHOLARSHIP INTO PRACTICE

Context of the Times

• The world of nursing practice• The world of research• The self-evident nature of communication• The pressure of an evidence-based

accountability system in health care

An Inquiry Trajectory

• Clinical practice• Cancer & chronic illness experience• Health care relationships • Social context of health care• Communications in chronic illness• Communications in cancer care

Health Care Relationships Trajectory

Naïve Trust

Disenchantment

Guarded Alliance

(Thorne & Robinson, 1988)

Two Intersecting Dimensions:

Trust and Confidence

High Confidence

High Trust

Low Trust

Low Confidence

Guarded Alliance Model

High Confidence

High Trust

Low Trust

Low Confidence

Team Playing

Consumerism

Hero Worship

Resignation

Dominant Ideology

Health Care

Politics POLITICS

•Bureaucratic Issues

•Territorial Battles

•Economic Implications

IDEOLOGY

•Superiority of Conventional Medicine

•Limitations of Scientific Logic

Health Care Communication

Domain Effective Communication

Problematic Communication

Courtesy Office practices, listening, acknowledgement, sincerity

Rudeness, patronizing

Respect Recognition of expertise, recognition of social context, empathy, offering information

Insulting intelligence, withholding info, discounting, failure to appreciate limits of western science

Engagement Coaching, teamwork, shared decision-making

Dismissing, blocking access, distancing

Current Research: “Blind Spots”(Mostly) untested but entrenched assumptions

• Patients hate you when you give them bad news

• If you show interest in patients, you can’t control time with them

• All patients are concerned about is whether or not you can cure them

• Western biomedical science is the only rational approach to cancer

• Lay persons can’t understand medical science

• People can’t hold two mutually exclusive

truths in their minds at the same time• Non-compliance is a result of irrational

thinking, stupidity, or psychological problems

• Providing options creates anxiety for patients

• Professional uncertainty creates anxiety for patients

• Unrealistic hope is dangerous• All other professionals are as caring as I am

• NCIC Funded 3 year project• Largest qualitative consumer data base in cancer

communications research• Province-wide (range of geographic, tumour site,

demographic, stage of disease contexts)• Individual interviews and focus groups

http://www.school.nursing.ubc.ca/Scholarship/cancercare/index.html

Cancer Communication Field

• Emerging field of study• Key consumer concern• Increasing recognition of the

multiple impacts of of communication breakdown( psychosocial, legal, economic)

• Implications for all aspects of the care process

What Does the Research Tell Us?

• Studies that tell us communication is important

• Studies that describe certain communication dynamics

• Studies that link communication to outcomes

• Studies the evaluate specific communication interventions

Cochrane Review: Effect of Communication Skills Training

• 4238 studies retrieved• 1417 considered duplicates • 2508 not quite on target• of 48 remaining, 46 excluded (measured change

in attitude rather than skills; no control groups; subjective evaluation)

Conclusions

• In standardized videotaped role playing, trained oncology nurses more ‘in control” of the interview

• In clinical consultations, trained oncologists used more “emotion focused” words

(Fallowfield, 2002; Razavi et al, 1993; 2002)

  What we Still Don’t Know and Why? • The problem of evidence• What assumptions are we operating from? • What are the implications of human

variation> (are there any universals?)• How can ethical principles and moral

convictions compete with evidence claims?

Sue Harris, UBC Rehabilitation Sciences

Greg Hislop, BCCA Cancer Research Centre

Being “Known”

“They would walk out to meet you like “Oh, oh, come on in.” And I guess everybody with cancer is frightened, and they would walk out and relieve your fear right off the bat like they understood your fear and were going to answer all your questions and relieve you. Maybe they understood that mums and women are caregivers but don’t know how to care for themselves. So when someone else picks up on that, it’s a very secure, wonderful feeling.”

Hope and Probability

“He basically gave me some ultimatums and gave me some statistics regarding death, right away He was abrupt and didn’t seem to relate to my fears and what I was going through. He told me my chances of surviving if I didn’t take chemo and what my chances were if I did take chemo. I didn’t ask those questions. It was like he was trying to rush me through a decision when I was very emotional and very scared and had a million questions.”

Why it Matters

“The doctor should not tell patients you have how many months to live because every individual is different, our immune systems are different. Once they’ve told the patient, then they start thinking about dying and then, mind over matter, they die.”

Next Steps?

• What is the nature of human variation in cancer communication ?  

• How do trajectory issues influence patterns? 

• What can reasonably constitute principles?• Which are the communication issues about

which we can create guidelines?•  What can we learn from revisiting the

evidence?

(with Charmaine Kim-Sing, John Oliffe, Kelli Stajduhar as additional Co-Investigators)

Translation into Practice

• “Thoughtful clinician” test

• Grounding clinical initiatives

• Supporting best practice

• Exposing problematic

practice

Creating an Informed Evidence Culture

• Recognizing diverse expressions of evidence• Decisions about interpretation and application of

evidence claims• Resisting the hierarchical model• Critical interpretive approach to application• Emphasis on integrative review and knowledge

synthesis skills

• Nursing leadership

• Confidence in nursing competence

• Policies and processes to enact organizational values

• Scientific “scaffolding” to support systems of care

“And then I went to the cancer clinic.

Now I’ve never been to anything nicer in my life. I loved everything! Everyone was so nice and explained every step of the way and made sure you were secure and not scared. The care was like a big, beautiful family.”

Can Communication Research Make a Difference?• Clinical community can force the research

community toward relevance (including complexity and context)

• Research community can strengthen claims in support of best practice.

• We need each other!