Communication in Cancer Care: Can Research Make a Difference?


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Communication in Cancer Care: Can Research Make a Difference?

  1. 1. 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 Nursing PUTTING SCHOLARSHIP INTO PRACTICE
  2. 2. 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
  3. 3. 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
  4. 4. Health Care Relationships Trajectory Naïve Trust Disenchantment Guarded Alliance (Thorne & Robinson, 1988)
  5. 5. Two Intersecting Dimensions: Trust and Confidence High Confidence High Trust Low Trust Low Confidence
  6. 6. Guarded Alliance Model High Confidence High Trust Low Trust Low Confidence Team Playing Consumerism Hero Worship Resignation
  7. 7. Dominant Ideology Health Care Politics POLITICS •Bureaucratic Issues •Territorial Battles •Economic Implications IDEOLOGY •Superiority of Conventional Medicine •Limitations of Scientific Logic Health Care Communication
  8. 8. 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
  9. 9. 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
  10. 10. • 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
  11. 11. • 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
  12. 12. 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
  13. 13. 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
  14. 14. 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)
  15. 15. 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)
  16. 16.     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?
  17. 17. Sue Harris, UBC Rehabilitation Sciences Greg Hislop, BCCA Cancer Research Centre
  18. 18. 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.”
  19. 19. 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.”
  20. 20. 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.”
  21. 21. 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)
  22. 22. Translation into Practice • “Thoughtful clinician” test • Grounding clinical initiatives • Supporting best practice • Exposing problematic practice
  23. 23. 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
  24. 24. • Nursing leadership • Confidence in nursing competence • Policies and processes to enact organizational values • Scientific “scaffolding” to support systems of care
  25. 25. “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.”
  26. 26. 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!