Clinical communication: A core clinical skill that underpins quality cancer care

Abstract

How we communicate with our patients, families, and colleagues underpins everything we do in cancer care. Despite a huge body of literature over the last 40–50 years outlining the impact of suboptimal cancer care, there continues to be a very significant theory-practice gap. Suboptimal communication impacts the patient, their carers, the workforce, and our health systems. We know patients want to be more involved in decisions about their care, yet multinational studies demonstrate almost half of them were not involved in these key decisions as much as they would like. 1 The literature about shared decision-making have described how we could improve this. 2 How we communicate with our patients has an impact on diagnostic accuracy, 3 , 4 aiding recall 5 , 6 of information provided and treatment adherence. 7 These skills have been shown to have strong links to the psychological adjustment to cancer many months after a cancer diagnosis, including the prevalence of severe anxiety and depression. 8 , 9 Despite decades of focus on increasing safety a significant proportion of major adverse events are found to be primarily due to poor communication. 10 Our cancer workforce reports that the complex conversations that occur daily in cancer care can be difficult to master and can be stressful. 11 Many feel they are not adequately trained to have such conversations. 12 Examples include communicating risk for complex surgery, 13 breaking bad news 14 and dealing with prognostic discordance. Prognostic discordance is remarkably common even in the setting of advanced cancer. 15 Much of this literature is based on the medical workforce, but recent studies show that nurses report similar challenges. 16 , 17 Increasingly, there has been a focus on the importance of team communication, and the negative impacts of incivility on clinical performance, as well as clinician well-being. 18 , 19 Most health care systems show that communication continues to be one, if not the most, important areas that result in a complaint being made. 20 While all health systems are under enormous pressure, there is clear evidence that many people are receiving nonbeneficial care that can be very burdensome and have a significant impact on their quality of life. 21 This is particularly well quantified in the last few months of life in cancer care. 22 This is exacerbated when patients and families have a poor understanding of their prognosis and when we have not understood what is important to them during this time. 23 The potential for advanced care planning discussions to improve care has been articulated for many chronic illnesses, including cancer yet the reality of how often these discussions result in a meaningful formal document remains very disappointing. 24 When goals of care conversations occur early in hospital admissions they have a dramatic impact on clinical outcomes. 24 , 25 Nurses have a critical role in these conversations. 26 Some in the nursing profession have expressed concern that patient-centered care may be eroded as the focus moves to more technical or task orientated approaches. 16 , 17 There is a significant variation in how communication skills are taught in undergraduate nursing degrees and an even wider variation in how this is embedded in professional development. 16 Despite this clearly being described in the key competencies of advanced practice roles there is very little written about how they acquire these skills. 16 Knowing the wider psychosocial context of people experiencing cancer can fundamentally change the care they receive, yet clinicians often miss these critical cues about people’s concerns. 27 In addition to increasingly evolving workforce roles, how we deliver healthcare is changing, and the deployment of Telehealth during the COVID pandemic is a striking example. 28 In addition, many developed health care systems are based on the use of diverse electronic health records and using them changes how we communicate with patients. 29 Understanding how to most effectively communicate while interacting with these complex systems will be critical for future quality care. As a nurse, like all health professionals, comes under more time pressure never has it become more critical for us to be not only as effective as possible but also efficient with our time, which is such a precious resource. Acquiring communication skills that allow us to be efficient yet person-centered will increasingly be a marker of quality cancer nursing. Despite the nursing profession representing the largest number of health care professionals, there is a relatively sparse literature 30 on which communication skills they require and how best they should be taught at scale in the postgraduate oncology setting. 16 There is encouraging work to show that we can and should teach these skills to nurses at the organization scale if we truly want to achieve a cultural tipping point. 31 , 32 The emerging literature would suggest that to do this at scale will require a blending learning approach that incorporates knowledge of frameworks and microskills, the ability to embed reflective practice about our communication, experiential opportunities to actually refine these skills, and last, a way to consolidate them in our busy clinical practice. A sophisticated blended program could drive the consistency of quality communication that our community is so keen to experience. 32 Demonstrating the return on investment will be critical if we are to compete with other demands on the limited health funds, and further work should be prioritized to demonstrate the return on professional development in this area. 33 , 34 The increasing weight given to patient-rated outcomes and experiences in health care may mean communication skills training finally gets the attention that it so clearly deserves. Declaration of competing interest None declared.