Poor Communication in Cancer Care

Patient Perspectives on What It Is and What to Do About It

Sally Thorne, PhD, RN, FAAN, FCAHS; John L. Oliffe, PhD, RN; Kelli I. Stajduhar, PhD, RN; Valerie Oglov, BSW, MA; Charmaine Kim-Sing, MD, FRCPC; T. Gregory Hislop, MDCM, MSc

Disclosures

Cancer Nurs. 2013;36(6):445-453. 

In This Article

Discussion

Although the problem of poor communication has been the focus of considerable research attention,[4,5] methodological limitations have precluded useful evidence-based conclusions as to appropriate resolutions. The approaches that might seem self-evident using conventional studies, such as expanding communication training at the basic and continuing professional development levels, have produced incremental improvements at best.[46,47] This is largely because they have focused almost exclusively on the clinician perspective rather than that of patients.[48] What we learn from patient perspectives is that lasting improvements will require that we move beyond the level of individual clinical responsibility to pay serious attention to such factors as professional attitudinal norms[49] and practice routines,[50] as well as organizational obstacles that may compromise care quality deriving from such factors as leadership styles, budgetary conditions, and operational vision.[51]

An advantage of constant comparative techniques within our larger qualitative research program is the capacity for thematic examination across a diversity of patient contexts, allowing for increasingly nuanced understandings that place the situation in its complexity and take an array of factors into consideration.[39,40] Each patient example reveals a generally appropriate and responsible communication approach that may turn out to be powerfully problematic for some patients. Thus, this kind of inquiry offers a way of surfacing new knowledge with which we can continue to identify what patients interpret as perceptual errors within our care delivery approaches. The insights that arise from an in-depth study of human experience help us move beyond standardized options and closer to generating the kind of clinical intelligence that enables increasingly informed action. Because we know that skilled communication requires an iterative and interactive approach in which interpreting the behavioral cues and communication responses of the patient shapes subsequent communicative approaches to that patient,[20,52,53] we see this kind of research as unpacking these complexities into a form that can be taken up and applied by clinicians in their everyday work.[43]

The Complex Nature of the Communication Challenge

Having been immersed in the patient-reported effects of care communication across contexts and through the cancer trajectory, we have come to appreciate that truly effective communication in cancer care is among those human qualities that defy truly meaningful categorization and measurement. What distinguishes one human encounter from another in the sense of transmitting courage or confidence is essentially ineffable and for the most part inarticulable.[54] Capturing the essence of brilliant clinical communication may more properly lie in the domain of poets and philosophers than in the realm of conventional science. We know that it cannot be standardized—and paradoxically where we attempt to capture and standardize communication, we inherently defeat it, because a standardized response is so often interpreted as one in which individuality is being disregarded.[52] Thus, although we can be inspired by the fact that brilliant communication exists—and patient-perspective data certainly confirm that to be the case—the direction forward will not lie in dissecting its essence and encouraging others to mimic it. Rather, we must recognize that clinicians are, for the most part, "ordinary" people, with the same kinds of flaws that we attribute to the normal state of being human.

The Relevance of a Focus on Poor Communication

In conceptualizing poor communication in terms of these 3 distinct categories, we have brought new clarity to why it is that directing our emphasis toward capturing, and promoting, and trying to measure the essence of good communication may be insufficient to create meaningful improvements. Redirecting our focus toward the kind of patient-perspective knowledge that expands our understanding of the intricate dimensions of poor communication on an experiential level contributes significantly to the selection of targeted intervention approaches and our capacity to evaluate relevant outcomes. The typology of poor communication that has surfaced from the accounts of these patients helps us understand why multiple and layered approaches are needed to address the distinct dimensions that comprise the spectrum of problematic cancer care communication.

Practically speaking, occasional misses will never be eliminated. However, we can reasonably assume that they can normally be reduced through the kinds of basic and continuing education, professional socialization, and access to communication mentorship that all of the health disciplines would consider the hallmark of an appropriately maturing clinical practice.[55] Indeed, the fact that good communication exists as often as it does is a testament to the integrity and effectiveness of these processes.[56]

Systemic misunderstandings will require a more research-oriented approach. At this point in the development of our knowledge, it seems most appropriate to advocate for the deconstructive and illuminating potential of qualitative patient-perspective research rather than simply suggesting that better measurement and more systematic reviews will address the gaps in our understanding. In particular, we might purposefully aim our qualitative investigations toward the aspects of cancer care communication where we are most likely to assume the appropriateness of standardized approaches so that we can identify which patients might be suboptimally served. Toward this end, we would be wise to carefully consider the kinds of junctures where patients report dissatisfaction or clinicians sense potential vulnerabilities. Because their discipline's proximity to patient-professional interactions affords opportunities to observe communication in action and because they are optimally positioned to support patients when communication doers not go well, nurses seem ideally placed to take a leading role in this kind of research agenda.

Opportunities for Care System Solutions

The management and buffering of repeat offenders clearly require more complex and strategic intervention strategies. Voluntary continuing education or expectations of professional insight are clearly inadequate for correcting insensitive or disrespectful communication patterns,[57] and it seems morally reprehensible to simply assume that nothing can be done until there is tangible evidence of malpractice or demonstrable harm.[55] Rather, we need proactive approaches that heighten our collective sense of responsibility within care settings so as to ensure that our ideals of patient safety extend to their communication experience.[58] Beyond compassionate, patient- and family-centered organizational cultures in which communication is deeply valued as a component of professional competence,[59] we might envision engaged interprofessional healthcare teams within which problematic communication patterns are not tolerated. Furthermore, we might aspire to models of care delivery in which, if certain clinicians cannot overcome their communication disabilities, patients are skillfully protected through the strategic buffering mechanisms afforded by effective interprofessional care models. For example, it may well be that certain oncologists should never dispense bad news to a patient outside the presence of a skilled nurse.

On the basis of this research, it seems apparent that as meaningful solutions to protect patients and increase the likelihood of their receiving the best possible communication across all encounters throughout their entire cancer journey, we must strategically target multiple points within the system. Our analysis reveals 3 key components of the path forward: (a) an ongoing clinician learning environment in which lifelong development of communication expertise is valued and mentored, (b) a strategic knowledge generation approach in which useful patterns in interpreting the complexities of cancer communication from the patient perspective are brought to light to inform our systemic understandings, and (c) an engaged interprofessional team approach to cancer care delivery in which the important work of supporting and enhancing the patient experience is intimately embedded within the work of diagnosing disease, deciding on a course of action, and delivering treatment.

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