Morasso, G., Caruso, A., Belbusti, V., Carucci, T., Chiorri, C., Clavarezza, V., . . . Di Leo, S. (2015). Improving physicians' communication skills and reducing cancer patients' anxiety: A quasi-experimental study. Tumori, 101, 131–137. 

DOI Link

Study Purpose

To determine the effectiveness of a physician-centered communication skills training program on anxiety levels in patients with cancer. A three-phrase, multicenter, quasi-experimental study was used.

Intervention Characteristics/Basic Study Process

The intervention phase of the study invited physician participants in the treatment group to attend a skills program to improve communications knowledge and strategies. The intent of the communications training was to improve communication with patients with cancer and families. The training sessions, taught by psycho-oncologists, were held at each study center and were scheduled in three-hour sessions for three weeks to total nine hours of training. Each physician participant was emailed relevant scientific papers (two published, one unpublished) five days in advance of each three-hour session. The treatment group physician participants were asked to read the materials in preparation for sharing during the training. Each session included didactic, experiential learning, and group discussion including clinical cases and role play. There was no communications training for physician participants from the control group.

Sample Characteristics

  • N = 36 physicians (17 in the treatment group and 19 in the control group) and 339 patients (174 in the control group and 165 in the treatment group)    
  • MEAN AGE = physician: 46.64 years (SD = 7.9), range = 38.74–53.64; patient: 61.2 years (SD = 13.61), range = 47.59–74.81
  • MALES: physicians, 47%; patients, 45%; FEMALES: physicians, 53%; patients, 55%
  • KEY DISEASE CHARACTERISTICS: None, intervention was focused on physicians. Patients seen by control and intervention physicians varied widely in age, cancer type and cancer stage/prognosis.
  • OTHER KEY SAMPLE CHARACTERISTICS: Physicians were oncologists, hematologists, with a median of 15 years of professional experience, from northern, central and southern Italy, equally. Nineteen had no prescribed training in physician-centered communication; 17 attended training. There was no difference in pre-consultation anxiety scores between the 339 patients enrolled in the two groups. 

Setting

  • SITE: Multi-site    
  • SETTING TYPE: Multiple settings  
  • LOCATION: Italian oncology practices

Phase of Care and Clinical Applications

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Pediatrics, elder care, palliative care 

Study Design

Multi-center, quasi-experimental, three-phase study. Of note, the phases of the study, as described, are not phases as used in North American scientific study. Rather, they are components of the methodology. Specifically, the authors describe phase 1 as recruitment, phase 2 as intervention, and phase 3 is evaluation.

Measurement Instruments/Methods

  • Physician demographics and professional training
  • Patient demographics and communication documentation (physician self-report)
  • Anxiety in patients was measured by the Psychological Distress Inventory (PDI) and completed before the consultation.
  • STAI-S (State-Trait Anxiety Inventory-State) was completed before and after the consultation.

Results

A significant decrease in anxiety scores was noted; however, it was difficult to ascertain if this is a treatment effect. Evaluation of the two groups indicated by adjusted standardized residuals (ASRs) that physicians more heavily represented some wards than others. Otherwise, there were no differences between the two physician groups. There were significant differences in patient groups based on gender, primary tumor type, and disease stage; interestingly, communication of a cancer diagnosis took place more in the treatment group than in the control group. However, the effect size indicated little evidence for bias of effect estimation. Outpatients who were in consultation with physicians who attended the communications training showed a greater decrease (though not a significant change) in anxiety scores than patients in consultation with physicians in the control group. Higher anxiety at baseline was shown in women, had lower educational levels, and who were in more distress. A lower probability of high anxiety scores was associated with longer time since diagnosis and longer consultation periods. 

Conclusions

Suggestion of effectiveness of a communication skills training program with reference to patient anxiety levels.  Further research needed.

Limitations

  • Small sample (less than 100)
  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)
  • Measurement validity/reliability questionable
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: Needing to train physicians, expensive, time constraints. Patients were blinded to physician group allocation. Physician communication performance may be skewed (possible Hawthorne effect) because of tendency to improve on each subsequent patient communication encounter when the evaluation form was completed.
 
 

Nursing Implications

Implications were difficult to ascertain because the intervention was physician-based. The authors indicated a need to explore if nurse training in communication would be beneficial.  Also discussed was the difference in communication styles between oncologists and oncology nurses and the effect on anxiety.