Resources
Bibiliography and Abstracts of RIAS Studies through 2014

Following are abstracts of RIAS studies, listed in alphabetical order by first author. Just click on a letter below to view the abstracts by the author's last name. Monographs and doctoral theses have their own page.

A     B     C     D     E     F     G     H     I     J     K     L     M     N     O     P     Q     R     S

T     U     V     W     X     Y     Z     Monographs & Theses

V

Vail L, Sandhu H, Fisher J, Cooke H, Dale J, Barnett M. Hospital consultants breaking bad news with simulated patients: an analysis of communication using the Roter Interaction Analysis System. Patient Educ Couns. 2011 May;83(2):185-94.
(Bad News Delivery, Standardized Patients, United Kingdom)
OBJECTIVE: To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness. METHODS: Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System. RESULTS: Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness. CONCLUSION: Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations.PRACTICE IMPLICATIONS: It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.

van den Brink-Muinen A, Bensing JM, Kerssens JJ. Gender and communication style in general practice. Differences between women's health care and regular health care. Med Care. 1998 Jan;36(1):100-6.
(Primary Care, Netherlands)
OBJECTIVES: Differences were investigated between general practitioners providing women's health care (4 women) and general practitioners providing regular health care (8 women and 8 men). Expectations were formulated on the basis of the principles of women's health care and literature about gender differences. METHODS: Data were used from 405 videotaped consultations of female patients (over 15 years). Roter's Interaction Analysis System (RIAS) was used to measure the verbal affective and instrumental behavior of the doctors and their patients. These data were supplemented by various nonverbal measures. The data were analyzed by means of multilevel analysis. RESULTS: Doctors in the women's health care practice (called Aletta) look at their patients and talk with them more than other doctors. The general practitioners have approximately the same affective behavior, but the Aletta doctors show more verbal attentiveness and warmth. They also give more medical information and advice. Most of the characteristics of Aletta doctors fit female doctors providing regular health care too. Male doctors show a less communicative behavior in most respects. The differences between general practitioners are reflected in their patients' communication style. CONCLUSIONS: The integration into regular care of some aspects of doctor-patient communication that were found in women's health care might be desirable in the light of the further improvement of the quality of care for women and men.

van den Brink-Muinen A, Caris-Verhallen W. Doctors' responses to patients' concerns: testing the use of sequential analysis. Epidemiol Psichiatr Soc. 2003 Apr-Jun;12(2):92-7.
(Primary Care, Interaction Analysis, Netherlands)
AIMS: The aim of this small scale study was to explore interaction sequences during the medical consultation. Specific attention was paid to how doctors responded to patient's concerns and worries. Empathic behaviours (e.g. concern, partnership, legitimizing) and facilitating behaviours (e.g. paraphrasing, agreement) were considered as an adequate response to a patient's concern. METHODS: Nine consultations of nine different GPs were randomly selected from a sample of 1600 videotaped doctor-patient consultations, that were all rated with the Roter Interaction Analysis System. Each consultation contained at least 9 utterances of patient's concern. It was investigated how doctors respond within five lags of utterances after a patient's concern. RESULTS: The results showed that doctors more often responded to a patient's concern in a facilitative way than in an empathic way. When an empathic response was given, it appeared mostly during the first utterance after the patient expressed a concern. CONCLUSIONS: The findings indicate that sequential analysis is appropriate to investigate a health care provider's specific style of responding. Based on the problems emerged during the sequential analysis, further exploration of the method is recommended.

van den Brink-Muinen A, van Dulmen SM, de Haes HC, Visser AP, Schellevis FG, Bensing JM. Has patients' involvement in the decision-making process changed over time? Health Expect. 2006 Dec;9(4):333-42.
(Decision-Making, Netherlands)
OBJECTIVE: To get insight into the changes over time of patients' involvement in the decision-making process, and into the factors contributing to patients' involvement and general practitioners' (GPs) communication related to the Medical Treatment Act (MTA) issues: information about treatment, other available treatments and side-effects; informed decision making; asking consent for treatment. BACKGROUND: Societal developments have changed the doctor-patient relationship recently. Informed decision making has become a central topic. Patients' informed consent was legalized by the MTA (1995). DESIGN: Data of two cross-sectional studies, the First (1987) and Second (2001) Dutch National Survey of General Practice, were compared. SETTING AND PARTICIPANTS: General practice consultations; 16 GPs and 442 patients in 1987; 142 GPs and 2784 patients in 2001. METHODS: Consultations were videotaped and rated using Roter's Interaction Analysis System and observer questionnaires; pre- and post-consultation patient questionnaires; and GP questionnaires. Descriptive analyses and multivariate, multilevel analysis were applied. MAIN RESULTS: Most patients reported to have received the information they had considered as important prior to the consultation. There were discrepancies in involvement in treatment decisions and in giving information about other available treatments, side-effects and risks. GPs who were more affective and gave more information, more often involved their patients, especially younger patients, in decision making. In 2001, more informed decision making was observed and the GPs asked consent for a treatment more often, but they less often asked for the patients' understanding. CONCLUSION: Patients' involvement in decision making has increased over time, but not in every respect. However, this does not apply for all patients, especially the older ones. It should be questioned whether they are willing or capable to be involved and if so, how they could be encouraged.

van den Brink-Muinen A, van Dulmen S, Messerli-Rohrbach V, Bensing J. Do gender-dyads have different communication patterns? A comparative study in Western-European general practices. Patient Educ Couns. 2002 Dec;48(3):253-64.
(Primary Care, Gender, Netherlands)
From the viewpoint of quality of care, doctor-patient communication has become more and more important. Gender is an important factor in communication. Besides, cultural norms and values are likely to influence doctor-patient communication as well. This study examined (1). whether or not communication patterns of gender-dyads in general practice consultations differ across and between Western-European countries, and (2). if so, whether these differences continue to exist when controlling for patient, GP and consultation characteristics. Doctor-patient communication was assessed in six Western-European countries by coding video taped consultations of 190 GPs and 2812 patients. Cluster analysis revealed three communication patterns: a biomedical, a biopsychosocial and a psychosocial pattern. Across countries, communication patterns of the female/female dyad differed from that of the other gender-dyads. Differences in communication patterns between countries could especially be explained by differences in consultations of male doctors, irrespective of the patients' gender. It is important to take into consideration differences between gender-dyads and between countries when studying gender effects on communication across countries or when comparing studies performed in different countries.

van den Brink-Muinen A, Verhaak PF, Bensing JM, Bahrs O, Deveugele M, Gask L, Leiva F, Mead N, Messerli V, Oppizzi L, Peltenburg M, Perez A. Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective. Patient Educ Couns. 2000 Jan;39(1):115-27.
(Patient Recall or Satisfaction, Netherlands)
Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

van den Brink-Muinen A, Verhaak PF, Bensing JM, Bahrs O, Deveugele M, Gask L, Mead N, Leiva-Fernandez F, Perez A, Messerli V, Oppizzi L, Peltenburg M. Communication in general practice: differences between European countries. Fam Pract. 2003 Aug;20(4):478-85.
(Primary Care, Netherlands)
BACKGROUND: Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies. OBJECTIVES: Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice. METHODS: Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis. RESULTS: Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication. CONCLUSION: The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.

van der Pasch M, Verhaak PF. Communication in general practice: recognition and treatment of mental illness. Patient Educ Couns 1998 Feb;33(2):97-112.
(Primary Care, Patient Emotional Distress, Netherlands)
From previous studies there is a lot of evidence that in primary care settings, many patients tend to express their mental problems in terms of physical symptoms. Therefore, the general practitioner (GP) needs to recognize mental problems at an early stage. Early recognition allows for adequate treatment that might speed up recovery. The present article reports on a study exploring the GP's ability to recognize mental illness, the communication style that is supposed to support this ability, the subsequent treatment of mental problems, and the patient's recovery. Two databases were used. First, an observation study, involving 351 videotaped consultations held by 15 GPs, yielded information on communication style and recognition abilities. Patients in this study were selected randomly. The second database obtained treatment data and measures of patient recovery from a 1-year follow-up study dealing with the treatment and course of mental illness. Patients in this study were selected because their GPs considered their problems "mainly psychosocial by nature". Half of them were categorized within psychological and social diagnostic categories of the International Classification for Primary Care (ICPC), the other half were categorized within physical disease categories, with an assessment by the GP that the complaints were mainly psychosocial. Results showed no significant relationships between the recognition of mental illness and nine communication features supposed to induce these abilities. There was a tendency however, for a positive association between recommended communicative behaviour of the GP and his or her tendency to give frequently psychosocial evaluations of the patient's complaints. Also, there was a negative tendency between this recommended behaviour and the degree of agreement between the GP's evaluation and the score on a psychiatric screening questionnaire. This agreement is called "accuracy". Frequent psychosocial evaluations were related to exploring behaviour and mental health referral in case of psychosocial complaints. Further, relationships between the GPs' recognition ability and various measures of patients' recovery did not prove univocal. Both positive, negative and absent relationships were found.

van Dulmen AM. Children's contribution to pediatric outpatient encounters. Pediatrics 1998 Sept;102:563-568.
(Pediatrics, Netherlands)
OBJECTIVE: Generally, increasing attention is being paid to the quality of doctor-patient communication. However, children's contributions have been, until now, primarily ignored in communication research, although there are indications that considering their views increases satisfaction and compliance. In the present study, we examined how children contributed to communication during outpatient pediatric encounters and what factors were associated with children's contributions. PATIENTS: Twenty-one consulting pediatricians videotaped a total of 302 consecutive outpatient encounters. DESIGN: Multilevel analysis was used to take into account the similarity among encounters with the same pediatrician. RESULTS: Children's contributions to the outpatient encounters were limited to 4%. Pediatricians directed one out of every four statements to the child. Although pediatricians asked children a lot of medical questions (26%), only a small part of the medical information (13%) was directed at the children. Apart from social talk and laughter, the amount of pediatrician-child communication increased with children's age. Communication with children suffering from disorders of the nervous system seemed to differ from that with children suffering from other diseases. Allowing children more room in the medical visit did not seem to increase the duration of the visit. CONCLUSIONS: Although recent legislation requires children to be adequately informed, in pediatric outpatient encounters information still tends to be directed primarily at the parents. Children do get the oppotunity to talk about social and psychosocial issues. Pediatricians may need to acquire similar communication skills to discuss medical-technical issues with the children.

van Dulmen AM. Communication during gynecological outpatient consultations. J.Psychosom Obstet Gynecol 1999;20:119-126.
(Primary Care, Netherlands)
The intimate nature of women's health problems presented during gynecological encounters places great demands on gynecologists' communicative behavior. The present study examined what patients expect from their gynecologist, how gynecologists and patients actually communicate during out-patient encounters, and what factors shape the structure and process of the encounter. Twenty-one gynecologists (13 consultants and eight residents) videotaped 303 consecutive out-patient encounters. Multilevel analysis was used to take into account the similarity among encounters with the same gynecologist. The results showed that gynecological patients expected foremost to receive clear and understandable information. One-third of the patients expected support and understanding. Psychosocial issues were hardly ever the topic of conversation. The length of the out-patient visits increased in the presence of patients' partner, with the type of problem presented, and with the frequency with which the patient disagreed with the gynecologist. The visit was also longer when gynecologists provided more medical information and asked more psychosocial questions. Although gynecological encounters focus almost exclusively on medical issues, talking about non-somatic aspects does not seem to prolong the visit as much as the presence of the patient's partner or whether or not the gynecologist and patient had met before. In view of patients' affecive needs, it would be worthwhile to examine whether gynecologists can be taught to handle patients' psychosocial needs as well.

van Dulmen AM. Physician reimbursement and the medical encounter: an observational study in Dutch pediatrics. Clinical Pediatrics 2000;39:591-601.
(Pediatrics, Netherlands)
Pediatrician reimbrusement is shifting from fee-for-service to a fixed salary. In the Netherlands, as physicians working on a fee-for-service basis have a financial interest in talking less and in carrying out more diagnostic tests and investigations, it may be questioned whether this will influence the structure and content of medical visits. With use of 302 videotaped outpatient encounters with either salaried or fee-for-service pediatricians, differences were examined in visit length, number of requests for diagnostic tests and investigations (laboratory test, endoscopy, and radiography), pediatrician-parent communication behaviors, and patient satisfaction. This investigation was carried out by means of bivariate and multilevel analysis. The results showed that the visits with salaried pediatricians lasted almost 4 minutes longer. This surplus time was not spent on social talk or on a more elaborate history taking but was used to provide more information and advice. In addition, salaried pediatricians engaged in more empathic behavior toward the patient, thereby faciliating a therapeutic relationship. No differences were found in the number of diagnostic tests and investigations or in patient satisfaction. It may be concluded that history taking and social talk took place in a fixed part of the visit. Salaried pediatricians spent more time on exchanging information with their patients and paid more attention to patient concerns and emotions. As the reimbursement shift is not likely to diminish the number of diagnostic tests and investigations and will increase the length of the medical visits, overall financial benefits may be limited.

van Dulmen AM, Bensing JM. Gender differences in gynecologist communication. Women Health. 2000;30(3):49-61.
(Gender, Netherlands)
The intimate nature of gynecological health problems requires the physician's specific attention. On the basis of previous findings in primary care, female gynecologists are expected to communicate more affectively than men. This study addressed gender differences in gynecologist communication behavior by comparing videotapes of real-life outpatient encounters with female (N = 107) and male (N = 196) gynecologists by means of bivariate and multilevel analysis. Only a few gender differences were found: female gynecologists performed longer physical examinations, showed more global attentiveness, and asked fewer medical questions. Either the duration of the medical education or the type of statistical analysis may account for this lack of gender differences.

van Dulmen AM, Holl RA. Effects of continuing pediatric education in interpersonal communication skills. Eur J Pediatr 2000;159:489-495.
(Pediatrics, Netherlands)
Paediatric care places great demands on interpersonal communication skills, especially as regards the handling of psychosocial issues. Recent shifts in paediatric morbidity and increases in patient empowerment furthermore emphasize the need for continuing paediatric education in communication skills. It is, however, debatable, whether after residency paediatric education can influence paediatrician performance. This study evaluated the effects of a 5-day experimental communication training by means of a pretest/post-test control group design. A total of 21 consulting paediatricians (10 experimental, 11 control group paediatricians) videotaped two series of consecutive outpatient encounters. Compared with the untrained control group, trained paediatricians asked more psychosocial questions and looked at the patients and their parents more often. In addition, they gave patients and parents more room to talk. No difference was found in the length of the outpatient visits. CONCLUSION: Paediatric educaton after residency influences paediatricians' verbal and nonverbal communication skills positively, especially as regards handling psychosocal issues. On the basis of these findings, it appears worthwhile to encourage continuing paediatric education in interpersonal communication skills.

van Dulmen AM, Verhaak PF, Bilo HJ. Shifts in doctor-patient communication during a series of outpatient consultations in non-insulin-dependent diabetes mellitus. Patient Educ Couns 1997 Mar;30(3):227-37.
(Primary Care, Netherlands)
As the treatment of non-insulin-dependent diabetes mellitus (NIDDM) largely depends on self-management, patient compliance and satisfaction, diabetes-specific beliefs and fears need special consideration during medical consultations by means of effective communication. Communication patterns are likely to change through time. For that reason, the first three consultations between 18 newly referred patients with poorly controlled NIDDM and their medical specialist were videotaped. Subsequently, changes in doctor's and patients' verbal and nonverbal communication behaviours during these 54 consultations were anlyzed. Furthermore, an investigation was carried out to distinguish those communication behaviours most strongly related to patient satisfaction. Findings suggest that the first consultation is most important for building an effective doctor-patient relationship, the second for discussing treatment matters, and the third for addressing psychosocial issues. Further research incorporating clinical outcome measures is recommended to determine which were the behaviours with the greatest influence on patient health outcome.

van Dulmen AM, aan Weert JC. Effects of gynaecological education on interpersonal communication skills. Br J Obstet Gynaecol 2001;108:485-491.
(Primary Care, Netherlands)
OBJECTIVE: To investigate the effects of an experimental communication course on how gynaecologists handle psychosocial issues in gynaecological consultation. DESIGN: Pre-post testing. Multilevel analysis was used to take into account the similarity among encounters with the same gynaecologist. SAMPLE: Eighteen gynaecologists (13 consultatns and 5 junior doctors) from five different hospitals participated. All gynaecologists videotaped consecutive outpatient encounters before and after attending an intensive training course. MAIN OUTCOME MEASURES: The communicative performance of the gynaecologists at pre-and post measurment. RESULTS: The gynaecologists recorded a total of 526 outpatient encounters, 272 before and 254 after the training. As a result of the training, gynaecologists' sensitivity to psychosocial aspects of their patients increased. At post measurement, the gynaecologists gave more signs of agreement, became less directive, asked fewer medical questions and more psychosocial questions. No difference was found in the duration of the outpatient visits. With the trained gynaecologists, patients asked more questions and provided more psychosocial information. CONCLUSIONS: Junior doctors and clinically experienced gynaecologists can be taught to handle psychosocial issues without lengthening the visit.

van Dulmen S. Pediatrician-parent-child communication: problem-related or not? Patient Educ Couns. 2004 Jan;52(1):61-8.
(Pediatrics, Netherlands)
Pediatricians are generally confronted with a variety of health problems. Each of these problems may benefit from another pattern of healthcare communication. It is unknown whether the communication process during pediatric visits actually differs by the nature of the child's problem. This study first examined whether three formerly identified communication patterns could be distinguished within real-life pediatric outpatient encounters (N=846). Then, communication patterns during encounters with children with respiratory (n=269) or behavioral problems (n=77) were compared. Videotaped visits were observed using the Roter Interaction Analysis System. Two-level multivariate logistic regression analysis examined what factors contributed to the communication patterns. A biopsychosocial communication pattern was observed in 45%, a psychosocial in 15% and a biomedical pattern in 40% of the visits. Child's age and pediatrician's experience were related to the communication pattern. Different patterns did indeed prevail in respiratory and behavioral problems. As less experienced pediatricians attend to psychosocial issues less, they may have to be specifically encouraged to do so.

van Dulmen S, Nubling M, Langewitz W. Doctor's responses to patients' concerns; an exploration of communication sequences in gynaecology. Epidemiol Psichiatr Soc. 2003 Apr-Jun;12(2):98-102.
(Primary Care, Interaction Analysis, Netherlands)
AIMS: Like other medical doctors, gynaecologists have difficulty attending to psychosocial issues and concerns. Communication training has proven to be effective in teaching them to spend more time on discussing these factors. However, whether or not they do this in response to patients' utterances remains unclear. The question is how gynaecologists respond to patients' concerns, whether or not they do this adequately and what the effects of a communication training are on the use of these communication sequences. METHODS: Nineteen gynaecologists participated in a study which examined the effects of a three-day residential communication training. Before and after the training the gynaecologists videotaped series of consecutive outpatient visits. The communication during these visits was rated using the Roter Interaction Analysis System. Gynaecologists' responses to patients' concerns were examined at lag one, i.e. immediately following the patient's concern. RESULTS: The most prevalent responses made by the gynaecologists were showing agreement and understanding and giving medical information. Affective responses were observed less. At postmeasurement, the gynaecologists responded neither more adequately nor inadequately to patients' concerns. CONCLUSIONS: The gynaecologists did not respond in a very affective way to patients' concerns. However, the patients did not express many concerns. Future studies should focus on more prevalent communication behaviours and incorporate more lags.

van Dulmen S, Tromp F, Grosfeld F, Ten Cate O, Bensing J. The impact of assessing simulated bad news consultations on medical students' stress response and communication performance. Psychoneuroendocrinology. 2007 Sep-Nov;32(8-10):943-50.
(Primary Care, Netherlands)
Seventy second-year medical students volunteered to participate in a study with the aim of evaluating the impact of the assessment of simulated bad news consultations on their physiological and psychological stress and communication performance. Measurements were taken of salivary cortisol, systolic and diastolic blood pressure, heart rate, state anxiety and global stress using a Visual Analogue Scale. The subjects were asked to take three salivary cortisol samples on the assessment day as well as on a quiet control day, and to take all other measures 5min before and 10min after conducting the bad news consultation. Consultations were videotaped and analyzed using the information-giving subscale of the Amsterdam Attitude and Communication Scale (AACS), the Roter Interaction Analysis System (RIAS), and the additional non-verbal measures, smiling, nodding and patient-directed gaze. MANOVA repeated measurements were used to test the difference between the cortisol measurements taken on the assessment and the control day. Linear regression analysis was used to determine the association between physiological and psychological stress measures and the students' communication performance. The analyses were restricted to the sample of 57 students who had complete data records. In anticipation of the communication assessment, cortisol levels remained elevated, indicating a heightened anticipatory stress response. After the assessment, the students' systolic blood pressure, heart rate, globally assessed stress level and state anxiety diminished. Pre-consultation stress did not appear to be related to the quality of the students' communication performance. Non-verbal communication could be predicted by pre-consultation physiological stress levels in the sense that patient-directed gaze occurred more often the higher the students' systolic blood pressure and heart rate. Post-consultation heart rate remained higher the more often the students had looked at the patient and the more information they had provided. However, the heart rate appeared to diminish the more often the students had reassured the patient. These findings suggest that in evaluating students' communication performance there is a need to take their stress levels into account.

van Weert J, van Dulmen S, Bar P, Venus E. Interdisciplinary preoperative patient education in cardiac surgery. Patient Educ Couns. 2003 Feb;49(2):105-14.
(Cardiac Surgery, Patient Education, Netherlands)
Patient education in cardiac surgery is complicated by the fact that cardiac surgery patients meet a lot of different health care providers. Little is known about education processes in terms of interdisciplinary tuning. In this study, complete series of consecutive preoperative consultations of 51 cardiac surgery patients with different health care providers (physicians, nurses and health educators) were videotaped. The information exchange between patients and providers was analyzed directly from the video recordings by using an adaptation of the Roter Interaction Analysis System (RIAS) and a checklist of relevant informational topics. Results pointed to overlaps and gaps as well as to a lack of a patient-centered approach. The physicians were mostly overlapped by the nurses, who spent almost 30% of the time on talking about medical issues. Gaps were found in giving psycho-educational information and emotional support, needed to establish effective patient education. The findings provided a sound basis for developing guidelines and changes in the organization of the education process.

van Weert JC, van Dulmen AM, Spreeuwenberg PM, Ribbe MW, Bensing JM. Effects of snoezelen, integrated in 24h dementia care, on nurse-patient communication during morning care. Patient Educ Couns. 2005 Sep;58(3):312-26.
(Nursing, Netherlands)
OBJECTIVE: To investigate the effectiveness of snoezelen, integrated in 24-hour care, on the communication of Certified Nursing Assistants (CNAs) and demented nursing home residents during morning care. METHODS: A quasi-experimental pre- and post-test design was conducted, comparing sic psychogeriatric wards, that implemented snoezelen, to six control wards, that continued in giving usual care. Measurements were performed at baseline and 18 months after a training 'snoezelen for caregivers'. Independent assessors analyzed 250 video-recordings directly from the computer, using an adapted version of the Roter Interaction Analysis System (RIAS) and non-verbal measurements. RESULTS: Trained CNAs showed a significant increase of resident-directed gaze, affective touch and smiling. The total number of verbal utterances also increased (more social conversation, agreement, talking about sensory stimuli, information and autonomy). Regarding residents, a significant treatment effect was found for smiling, CNA-directed gaze, negative verbal behaviors (less disapproval and anger) and verbal expressed autonomy. CONCLUSION: The implementation of snoezelen improved the actual communication during morning care. PRACTICE IMPLICATIONS: Teaching CNAs to provide snoezelen has added value for the quality of care. Morning care by trained CNAs appeared to take more time. This suggests that (some) time investment might be required to achieve positive effects on CNA- resident communication.

van Wieringen JC, Harmsen JA, Bruijnzeels MA. Intercultural communication in general practice. Eur J Public Health 2002 Mar;12(1):63-8.
(Primary Care, Intercultural Communication, Netherlands)
BACKGROUND: Little is known about the causes of problems in communication between health care professionals and ethnic-minority patients. Not only language difficulties, but also cultural differences may result in these problems. This study explores the influence of communication and patient beliefs about health (care) and disease on understanding and compliance of native-born and ethnic-minority patients. METHODS: In this descriptive study seven general practices located in a multi-ethnic neighbourhood in Rotterdam participated. Eighty-seven parents who visited their GP with a child for a new health problem took part: more than 50% of them belonged to ethnic-minorities. The consultation between GP and patient was recorded on video and a few days after the consultation patients were interviewed at home. GPs filled out a short questionnaire immediately after the consultation. Patient beliefs and previous experiences with health care were measured by different questionnaires in the home interview. Communication was analysed using the Roter Interaction Analysis System based on the videos. Mutual understanding between GP and patient and therapy compliance was assessed by comparing GP's questionnaires with the home interview with the parents. RESULTS: In 33% of the consultations with ethnic-minority patients (versus 13% with native-born patients) mutual understanding was poor. Different aspects of communication had no influence on mutual understanding. Problems in the relationship with the GP, as experienced by patients, showed a significant relation with mutual understanding. Consultations without mutual understanding more often ended in non-compliance with the prescribed therapy. CONCLUSION: Ethnic-minority parents more often report problems in their relationship with the GP and they have different beliefs about health and health care from native-born parents. Good relationships between GP and patients are necessary for mutual understanding. Mutual understanding has a strong correlation with compliance. Mutual understanding and consequently compliance is more often poor in consultations with ethnic-minority parents than with native-born parents.

Vegni E, Mauri E, D'Apice M, Moja EA. A quantitative approach to measure occupational therapist-client interactions: a pilot study. Scand J Occup Ther. 2010 Sep;17(3):217-24.
(Outside Primary Care, Italy)
AIMS: The purpose of this pilot study was to assess the feasibility of a quantitative approach to study occupational therapist-client interactions. Role plays were videotaped in which 10 therapists met three client-actors. A questionnaire assessed the occupational therapists' and the patient-actors' opinion of the role-play experience. A modified version of the Roter Interaction Analysis System (RIAS), OT-RIAS, was used to analyse data. MAJOR FINDINGS: Occupational therapists considered the role play experience to be "highly realistic" (mean score 5.4 on a 1-6 Likert scale). The actors' comfort role playing clients was also high (mean = 4.0; range 1-5). Inter-coder reliability for the OT-RIAS was highly significant (r = 0.919; p = 0.000). The modified version of this system fits well in an occupational therapy context. PRINCIPAL CONCLUSION: The quantitative approach used in this study to explore the therapist-client relationship appears to be effective. The role plays and RIAS may be useful in research exploring correlation between the OT communication style and outcome measures such as client satisfaction or comprehension, or in order to assess and offer feedback in teaching communication skills programmes.

Vegni E, Moja EA. Effects of a course on ophthalmologist communication skills: a pilot study. Educ. Health (Abingdon). 2004 Jul;17(2):163-71.
(Ophthalmology, Italy)
INTRODUCTION: Although the issue of communication skills is now considered crucial for ophthalmology, no previous research has discussed training in this field. This study aimed to discuss the effects of a 16 hour communication skills course for ophthalmologists. In particular the study assessed the interest of participants with respect to the topic and the efficacy on participants' communication skills, at least in a laboratory setting. MATERIALS AND METHODS: Eleven ophthalmologists participated in the course. Learner satisfaction was evaluated using a questionnaire with a six-point Likert scale. Course efficacy was assessed by a comparison between communicative behaviour of ophthalmologists in videoed role playing before and immediately after attending the course. Videoed consultations were coded using the Patient Centred Score Sheet (PCSS) and the Roter Interaction Analysis System (RIAS). The Wilcoxon signed rank test was used for statistical analysis. FINDINGS: The course obtained high satisfaction in participants (mean score 5.1). In the post test role playing, patient centredness increased significantly (p < 0.01). Furthermore, ophthalmologists improved their competence in using open ended questions (p < 0.02), process categories (e.g. orientation statement) (p < 0.05) and social communication categories (e.g. personal statement) (p < 0.01). DISCUSSION: According to our findings, ophthalmologists did show satisfaction for the course. Results also indicate that the course positively influenced ophthalmologist communication competence, at least in a laboratory setting. After the course, participants became more attentive to patients' psychosocial needs, both in terms of general quality of consultation (patient centredness) and in terms of using specific interpersonal skills. Present results are considered preliminary, and further research is needed with a larger sample and including an evaluation of the effects on ophthalmologists' communication skills in clinical practice.

Veiga P, Lapćo LV, Cavaco AM, Guerreiro MP. Quality supply of nonprescription medicines in Portuguese community pharmacy: An exploratory case study. Res Social Adm Pharm. 2015 Jan 8. pii: S1551-7411(15)00002-9.
(Portugal, Pharmacy, Standardized Patients)
BACKGROUND: Inappropriate use of non-prescription medicines (NPM) can increase morbidity, mortality and health care associated costs. Pharmacists have a well-established role in self-medication; however, the literature shows that pharmacies performance in the supply of NPM is often suboptimal. OBJECTIVE: To explore the interaction and dependability of pharmacy staff use of oral language, as well as staff's own assessment of reasons underlying their behavior during consultation regarding NPM. METHODS: In a case-study design, a high street urban community pharmacy was purposively selected as the setting. Covert patient simulation, using trained simulated patients (SPs), was used to ascertain staff's performance in dispensing NPM, via 4 symptom-based scenarios (SbS) and 3 product-based scenarios (PbS). Performance data were converted into 2 composite indexes: the Interpersonal Performance Index (IPI) and Technical Performance Index (TPI). Audiotaped interactions were transcribed verbatim and participants' utterances were identified, time stamped and coded employing the eight higher level categories of a framework inspired by the Roter interaction analysis system (RIAS). The transcripts of the in-depth interviews were analyzed using the Framework Approach. The tripartite model of attitudes was employed to develop the thematic framework. RESULTS: Ten SP visits were considered for analysis. Overall, the mean TPI score was 50% and the mean IPI score was 78%. TPI was higher for SbS (63%) than PbS (31%), whilst there was little difference IPI between SbS (79%) and PbS (76%). The mean number of questions in the evaluation section of technical performance was 4 for SbS and 1 for PbS. There was a clear predominance of closed questions (32%), when compared with open questions (5.5%). Providing advice was more frequent (23.5%) than giving information (12.5%). In line with the SPs data, comparison of information-gathering in SbS and PbS shows that more questions were asked in the former (44% versus 31%), which resulted in more information given by SPs (56% and 49%, respectively). Staff's reaction to their performance showed all the 3 dimensions of attitude: affective, cognitive and behavioral. Divergence between staff's views on what should be done in NPM consultations and performance data surfaced in the interviewees' accounts on direct product requests. While performance data shows that information gathering was scarce, its importance was overtly acknowledged. CONCLUSIONS: The supply of NPM appears to be influenced by both cognitive and emotional issues. This suggests that multimodal improvement interventions are needed, targeting not only technical and interpersonal communication skills but also the organizational context. Managerial tools such as the balanced scorecard, may prove valuable in addressing improvement in the quality supply of NPM.

Verhaak CM, Kraaimaat FW, Staps AC, van Daal WA. Informed consent in palliative radiotherapy: participation of patients and proxies in treatment decisions. Patient Educ Couns 2000 Aug 1;41(1):63-71.
(Oncology, Netherlands)
Informed consent is regularly discussed, but little attention has been paid to the daily practice of the patient participation in treatment decisions regarding palliative care. Therefore, an exploratory study was conducted into shared decision making between radiation oncologists and patients and proxies in interviews where decisions regarding palliative radiotherapy have to be made. Interviews of 6 radiation oncologists with 26 outpatients were recorded on audiotape. Each verbal utterance was coded with the aid of the Roter Interaction Analysis System (RIAS). Results indicated that in over 75% of the interviews, patients and proxies were not asked for their opinion regarding treatment decisions. Other treatment options or the option of abstaining from treatment were discussed in 46% of the interviews. In conclusion, in this sample informed consent was not a natural part of the daily practice of palliative radiotherapy. The question remains to what extent informed consent in palliative radiotherapy is realistic.

Verhaak C, Staps A, Kraaimaat F, Van Daal W. Communication between patient and radiotherapist prior to palliative treatment. European Journal of Cancer 1997, 33(8): S59.
(Oncology, Netherlands)
In order to examine the content of the communication between patient and radiotherapist prior to palliative treatment and the participation of patients and proxies in decision-making. Twenty-five first interviews between patient and radiotherapist were audio- and videotaped. A few days later, the patients were invited by a psychologist to reflect on their experiences with this interview. Doctor patient interviews were analyzed by the Roter Interaction Analysis System (RIAS). The interviews with the psychology were analyzed qualitatively using methods of Grounded Theory. Results indicate that during the radiotherapist patient interview, about 60% of the utterances refer to biomedical topics such as diagnosis, side-effects and treatment protocol. Prognosis and alternative treatment options are only considered roughly. About 12% of the time was paid to psychosocial aspects and emotional support. The participation of patients and proxies in the decision-making is limited or lacking. However, patients do not show significant dissatisfaction with this procedure. Because of the stressful circumstances most patients and proxies feel unable to formulate relevant questions and make treatment decisions. The results rarely show any patient participation in decision-making with regard to palliative radiotherapy. Taking into account the psychological circumstances, actual patient participation would be hardly feasible in clinical practice.

Vigilante VA, Hossain J, Wysocki T, Sharif I. Correlates of type and quantity of child communication during pediatric subspecialty encounters. Patient Educ Couns. 2015 Nov;98(11):1352-9.
(Pediatrics, Interaction Analysis, United States)
OBJECTIVES: Understanding the factors associated with child communication during subspecialty encounters may inform interventions promoting shared decision-making in chronic disease management. Objectives were to (1) describe the quantity and quality of child communication during outpatient subspecialty encounters and (2) determine if and how the quantity and quality of child communication vary by demographic and visit characteristics. METHODS: We videotaped subspecialty clinic encounters involving 20 health care providers and 155 children with one of the following conditions: acute lymphoblastic leukemia (consolidation/maintenance), persistent asthma, cystic fibrosis, type 1 diabetes, and obesity. The Roter interaction analysis system was used to code child utterances into one of 10 discrete categories. RESULTS: Children exhibited a mean of 15% of all utterances made during clinical encounters. Children spoke more during obesity encounters. CONCLUSIONS: Similar to the findings of studies in primary care settings, children spoke infrequently during the subspecialty visits, and the most common utterances tended to be replies to questions from adults. PRACTICE IMPLICATIONS: In this study, there was relatively higher engagement of children during obesity clinic encounters in the area of lifestyle choices. Strategies used to engage children in conversation in obesity clinics may be useful for engaging children in other subspecialty clinics.

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