Margaret F. Clayton

Delay in diagnostic testing after abnormal mammography in low-income women

PURPOSE/OBJECTIVES To identify factors associated with diagnostic delay after an incomplete or abnormal mammogram among women participating in a state mammography screening program. RESEARCH APPROACH Retrospective case-control design using bivariate and multivariate logistic regression analyses to explore the associations between age, race, ethnicity, marital status, breast cancer history, and self-reported breast symptoms and delay. SETTING A statewide program of free screening mammography for women who are under- or uninsured. PARTICIPANTS 11,460 women enrolled in a free, statewide screening program from 2002-2006. METHODOLOGIC APPROACH Using the Tennessee Breast and Cervical Cancer Screening Program database, further analyses were conducted. MAIN RESEARCH VARIABLES The outcome measure was delay in completion of all diagnostic tests and was defined as women who did not complete testing within 60 days. FINDINGS Thirty-seven percent of women required follow-up, and of a subset used in the analysis, 30% experienced delay of more than 60 days. Controlling for marital status, age, and breast cancer history, women who experienced delay were more likely to be African American versus Caucasian (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.13, 1.85) or Hispanic (OR = 0.72, 95% CI = 0.55, 0.93) and to have self-reported breast symptoms (OR = 1.50, 95% CI = 1.27, 1.77). CONCLUSIONS In a sample of women with low income needing mammography follow-up, delay was associated with three intrapersonal variables, potentially reducing the effectiveness of mammography screening for women who were African American, or Hispanic, or had self-reported breast symptoms. INTERPRETATION Nurses providing cancer screening examinations are uniquely positioned to assess the knowledge, beliefs, and resources of women using the program and to navigate women through barriers to completion. Knowledge of factors associated with delay is valuable for planning interventions and allocating program resources.

Hospice Nurse Communication with Patients with Cancer and their Family Caregivers

BACKGROUND Effective communication by hospice nurses enhances symptom management for the patient, reduces family caregiver burden and distress, and potentially improves bereavement adjustment. However, research has not kept pace with the rising use of hospice by patients with cancer and thus we know little about how hospice nurses communicate. METHODS The overriding objective of this pilot study was to provide insight into these in-home visits. Hospice nurses audiorecorded their interactions over time with family caregivers and patients with cancer. The communication within these tapes was coded using Roter Interaction Analysis System (RIAS) and analyzed. RESULTS We found that tape recording home hospice nurse visits was feasible. RIAS was suited to capture the general content and process of the home hospice encounter and the coded interactions show the range of topics and emotions that are evident in the dialogue. Implications and future directions for research are discussed.

Nurse responsiveness to cancer patient expressions of emotion

OBJECTIVE This theoretically based study examined nurse responses to cancer patient expressions of emotion using a videotaped, simulated cancer patient. METHODS This study used an experimental crossover design with a videotaped patient expressing anger, sadness, and neutral emotion to elicit nurse responses. Seventy-four nurses from eight sites participated. Responses were coded using Roter interaction analysis system. Correlations explored relationships between variables that impact communication (age, gender, work experience, trait anxiety, work stress, self-efficacy). Regression models explored the effect of variables on nurse affective responsiveness. RESULTS Patient expressions of sadness elicited more affective responses than anger. Expressions of anger or neutral emotion elicited more instrumental behaviors than sadness. Variables such as age, work stress and work experience were significantly correlated. No variables predicted affective responsiveness to patient expressions of anger or sadness. CONCLUSION Nurse communication showed significant variation in response to patient emotional expressions. Understanding the relationships between demographic, personality, and work variables, and identification of new variables that influence nurse-patient communication, has implications for interventional studies. PRACTICE IMPLICATIONS Over 90% of the participants indicated that the videotape simulation would be a useful method for teaching and practicing communication skills with patients expressing emotions.

Communication with Breast Cancer Survivors

Breast cancer survivors must manage chronic side effects of original treatment. To manage these symptoms, communication must include both biomedical and contextual lifestyle factors. Sixty breast cancer survivors and 6 providers were recruited to test a conceptual model developed from uncertainty in illness theory and the dimensions of a patient-centered relationship. Visits were audio-taped, then coded using the Measure of Patient-Centered Communication (Brown, Stewart, & Ryan, 2001). Consultations were found to be 52% patient-centered. Chi-square Automatic Interaction Detection (CHAID) analysis showed that survivor self-reported fatigue level and conversation about symptoms were associated with survivor uncertainty, mood state, and survivor perception of patient-centered communication. Survivors may want to discuss persistent symptom concerns with providers, due to concerns about recurrence, and discuss lifestyle contextual concerns with others.

Patient-centered communication during oncology follow-up visits for breast cancer survivors: content and temporal structure

Purpose/Objectives: To understand the content and temporal structure of survivor-provider communication during breast cancer survivor follow-up visits. Design: Descriptive correlational. Setting: Private outpatient oncology practice. Sample: 55 breast cancer survivors; 6 oncology providers. Methods: A secondary analysis of audio recordings of survivor follow-up visits. Main Research Variables: Survivors: demographics, uncertainty, mood, length of survival, years receiving care from providers, survivor expectations. Providers: demographics, medical uncertainty, specialty (physician, nurse practitioner, or physician assistant). Outcomes: time spent in patient-centered communication, perception of patient-centeredness. Findings: Most visit time (55%) was spent waiting. Of the remaining 45%, silence represented the most time spent with providers, followed by symptom conversations. More specific survivor discussion plans predicted more time spent discussing symptoms and in reassurance interactions. More specificity of visit purpose predicted survivor perceptions of less patient-centeredness; however, more time in contextual conversations predicted a greater perception of patient-centeredness. Provider factors were not associated with time spent in patient-centered communication or survivor perceptions of patient-centeredness. All dimensions of patient-centered communication occurred during each visit section (before, during, and after the physical examination). Conclusions: Discussing symptoms and concerns with providers offers reassurance about cancer recurrence. When visit expectations are very high, achieving a survivor perception of patient-centered communication may be difficult. However, time spent understanding a survivor within the context of her life can enhance survivor perceptions of patient-centeredness. Implications for Nursing: Providers must be sensitive to concerns that are presented throughout a visit. When visit time is short, a second appointment may be necessary to address survivor concerns.

AMOS versus LISREL: one data set, two analyses.

Background: Path analysis is used commonly to evaluate direct and indirect associations among observed variables. Although there are sufficient user guides for commonly referenced structural equation modeling (SEM) software programs, there is little information to help the researcher compare usability and outcomes of these programs. Therefore, deciding which SEM software program to use often presents a challenge for both novice and experienced researchers. Objective: To evaluate path analysis results from one data set using two commonly referenced SEM programs, AMOS (Analysis of Moment Structures) Version 6.0 and LISREL (Linear Structural Relations) Version 8.80. Approach: Using one data set, each researcher worked solely within one SEM program and was blinded to the solution obtained by the other until analyses were complete. Subsequently, each researcher replicated the others solution in the opposite program. Finally, a reduced model using modification indices was obtained by each researcher and then compared across SEM programs for similarity. Results: Results showed extremely similar but not totally identical solutions. Modification indices suggested one additional variable and two extra paths in both AMOS and LISREL. Discussion: An examination of the solutions obtained in the two SEM programs suggested small discrepancies in the critical ratios due to rounding, which may have produced subtle alterations in the order of path deletion during model reduction. Despite minor differences, the final solutions could be replicated accurately in each program. Researchers should select an SEM program based on their programming knowledge and the research questions being addressed. Regardless of the program selected, the researcher can have confidence in the comparability of results.

Communication Behaviors and Patient and Caregiver Emotional Concerns: A Description of Home Hospice Communication

PURPOSE/OBJECTIVES To identify and describe communication behaviors used by hospice nurses when eliciting and addressing concerns of patients with cancer and their caregivers. DESIGN Secondary analysis. SETTING Home hospice in Salt Lake City, UT. SAMPLE Audio recordings from seven patient and caregiver dyads and five hospice nurses. METHODS Audio recordings were coded using the Roter Interaction Analysis System for patient and caregiver concern statements indicating negative affect and distress and the surrounding nurse communication behaviors. Concern content was categorized using domains developed by the National Consensus Project for Quality Palliative Care. MAIN RESEARCH VARIABLES Patient and caregiver concern statements and nurse communication behaviors. FINDINGS 180 patient and caregiver speaking turns containing concerns were identified across 31 hospice visits. Patients and caregivers expressed at least one concern in the vast majority of visits. The most prevalent distress areas reflected psychological and physical issues. Nurses used proportionally more positive emotion statements before patient and caregiver concerns, compared to the visit overall. Nurses asked proportionally more physical questions after concern statements. Nurses also used more emotional responses before and after patient and caregiver concerns, relative to the entire visit. CONCLUSIONS Patients with cancer and caregivers frequently talk about distressing issues. Hospice nurses use specific communication behaviors to elicit and address those issues. IMPLICATIONS FOR NURSING Home hospice provides a venue to examine nurse communication behaviors used to elicit and respond to patient and caregiver distress. These strategies could be taught to nurses who encounter patient distress less frequently or are less comfortable with emotional conversations.

Addressing Methodological Challenges in Large Communication Data Sets: Collecting and Coding Longitudinal Interactions in Home Hospice Cancer Care

ABSTRACT In this article, we present strategies for collecting and coding a large longitudinal communication data set collected across multiple sites, consisting of more than 2000 hours of digital audio recordings from approximately 300 families. We describe our methods within the context of implementing a large-scale study of communication during cancer home hospice nurse visits, but this procedure could be adapted to communication data sets across a wide variety of settings. This research is the first study designed to capture home hospice nurse–caregiver communication, a highly understudied location and type of communication event. We present a detailed example protocol encompassing data collection in the home environment, large-scale, multisite secure data management, the development of theoretically-based communication coding, and strategies for preventing coder drift and ensuring reliability of analyses. Although each of these challenges has the potential to undermine the utility of the data, reliability between coders is often the only issue consistently reported and addressed in the literature. Overall, our approach demonstrates rigor and provides a “how-to” example for managing large, digitally recorded data sets from collection through analysis. These strategies can inform other large-scale health communication research.

Validity of the Patient Generated Index as a Quality-of-Life Measure in Radiation Oncology

PURPOSE/OBJECTIVES To evaluate psychometric properties of an instrument designed to measure individualized health-related quality of life (HRQOL). DESIGN Repeated measures of self-reported quality of life. SETTING An outpatient radiation therapy department in the western part of the United States. SAMPLE 86 adults with cancer receiving their first course of radiation therapy. METHODS The Patient Generated Index (PGI), the National Comprehensive Cancer Networks Distress Thermometer (DT), and the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core-30 (QLQ-C30). MAIN RESEARCH VARIABLES Convergent validity, responsiveness, sensitivity, and response shift. FINDINGS PGI scores were inversely correlated with scores on the DT (r = -0.49, -0.55, -0.44; p < 0.001), as well as the role (r = 0.31, 0.4, 0.38; p < 0.01), emotional (r = 0.33, 0.41, 0.33; p < 0.01), social functioning (r = 0.27, 0.49, 0.42; p < 0.05), pain (r = -0.29, -0.39, -0.39; p < 0.01), and fatigue (r = -0.35, -0.25, -0.47; p < 0.05) QLQ-C30 subscales at all measurement times. The PGI was responsive to those reporting high or low DT scores (t = 4.42, 3.32, 2.9; p < 0.05). A small-to-moderate effect size was detected in those who had an increase (effect size = 0.51) or decrease (effect size = 0.38) in HRQOL over time. Participants reconceptualized HRQOL over time. CONCLUSIONS Data supported the PGI as a valid measure of individualized HRQOL. IMPLICATIONS FOR NURSING The PGI potentially provides a more patient-centered measure of HRQOL in patients with cancer. Additional testing is needed in larger, more diverse groups.

Modeling relationships in clinical research using path analysis Part II: evaluating the model

Column Editor: Lauren Clark Scientific Inquiry provides a forum to facilitate the ongoing process of questioning and evaluating practice, presents informed practice based on available data, and innovates new practices through research and experimental learning.