TABLE 4.

Operationalizations of Communication Functions

Communication Function	Operationalization of Function
Building relationships
	Demonstrating clinical competence and reliability: “She knows everything. You can say we’re doing this, this, and this. This is our symptoms. She’s like, ‘All right. Well, I’m gonna run this test, this test, and this test. Let me get blood.’ She just knows everything. [Nurse] is amazing” (mother, treatment).
	Demonstrating care and concern: “Well, the family feel, it really makes you feel like an individual, not a number, not just a patient, which I think it’s easy to get lost, but I think the family feel makes you just feel safe, secure, and just loved, I guess, I don’t know” (mother, survivorship).
	Advocating: “I think the [palliative care] team was probably who was with us during those meetings. It was nice to have somebody that I had known from previous experiences was gonna be on my side, no matter what I was thinking. They were going to be that person who was my advocate. I really appreciated that. Being in those meetings is terrifying. You’re not entirely sure of what’s going on, and you have that person who does know what’s going on, and they know how you feel about it. They can be that bridge between the parents and the doctors not quite understanding each other” (mother, bereavement).
	Engendering solidarity: “I think one of the best things is they brought us to [clinic] to have our meetings and to sit down with our team so that even though at the time it seems super overwhelming. We could at least see that we weren’t alone. We could see dozens and dozens of other kids and their families there with cancer. That made my husband feel a lot better. He actually felt like we weren’t alone anymore and he told me that. That was something that they did really well on the diagnosis” (mother, treatment).
	Using an open and reassuring tone and nonverbal communication: “Nonverbal communication plays a large role in that too. If you look disinterested or perturbed, or as if it’s above you to have to answer such questions, that’s all poor communication” (mother, treatment).
Exchanging information
	Offering consistent, accurate, and timely information: “Well, I mean, they always communicated well—it seemed—after MRIs. Although, sometimes I had to wait too long—I thought—for results” (mother, bereavement).
	Engaging in bidirectional information exchange: “They would always come in and just ask how she was doing, how her appetite was, always get a weight, how her activity level was, if she was having any new pains or anything. They would always discuss the lab values, always make sure she wasn’t having any signs of infection, latent signs, where they couldn't really pick up on it right away, something like that” (father, bereavement).
	Explaining rationale for medical care: “No. The biggest thing really is communication, just letting me know where their thinking is heading or what’s important that needs to be done. That’s really always been the most important thing. I like to be kept in the loop” (mother, treatment).
	Meeting individual’s unique information needs: “Anything and everything. They were really good about—they always gave us information, as far as scan results and things like that. They were always very straight and to the point because they—and they asked us at the beginning, how do you want us to approach this? Do you want [patient] to know everything? Do you just want to know, and then you tell her?” (mother, bereavement).
	Providing understandable information and checking for understanding: “They always call us after procedures. They call us to make sure he's doing okay. They come in and do our paperwork, one on one with us. It's not just you get handed discharge papers. They sit down, they talk to you about it. They make sure you understand” (mother, treatment).
	Offering transparent disclosure of difficult news: “Well, things you didn’t want the answer to. Right? It was a tough situation. It was a very hard situation. I feel like they were always very easy to talk to even about the tough decisions that we had to make. There were two bad situations. The initial diagnosis was awful. Right? In the first couple appointments as we found out what was going on were really, really hard” (father, survivorship).
Enabling family self-management
	Providing anticipatory guidance and planning in advance: “Just their overall plan of getting her better. They were looking at long-term and spreading out the goal instead of just today. They would tell us today we’re gonna do this, tomorrow we’re gonna do this and the next day we’ll do this, so we kinda knew what to look forward to” (mother, treatment).
	Training in technical skills: “They were very good at explaining to us what we needed to monitor, and I think we’re also pretty good at making sure we knew everything. We knew what we had to monitor ‘cause we didn’t know what we were dealing with” (mother, survivorship).
	Identifying needs and directing toward resources: “To just listen to the family and offer support, offer ways that they can get some respite or help with this, either psychological—‘cause it’s very stressful—or respite care, like somebody to help out—give a hand when the work is hard. Luckily, I have a husband, but some families don’t. It’s just a mom or a dad. They don’t have a spouse to rely on. That’s what I would say is just tell them ways that they can get help. Make things easier for them” (mother, bereavement).
	Providing guidance during acute illness: “I would call about small concerns like that. Here, recently, I’ve had to start calling the [clinic], ‘Hey, we have a fever of this,’ and they would give us instructions to ‘Check it 30 minutes later,’ or ‘Go ahead and head this way; we’re waiting on you’” (mother, treatment).
Providing validation
	Empowering parents as partner and advocate: “I would say that it was very clear from the beginning as well, especially with my wife, that it was acceptable to be an active part of the team. In fact, it was potentially going to be very necessary that we be strong advocates. That was great to hear. I think if all parents hopefully hear something like that, it’s true. I think that that’s a great thing” (father, survivorship).
	Reinforcing good parenting beliefs: “They said it previously as well, but, in those moments, that meant a lot to hear because, yes, my daughter is dying, but the communication said, ‘But as her mom, as her caregiver, from your point of view, you've done a really good job’” (mother, bereavement).
	Validating concerns: “Just understanding, listening to things, and being listened to in that way, even if they were going to do the same thing, no matter what, knowing that they did hear what you had to say and your concerns and address them” (mother, bereavement).
Managing uncertainty
	Exploring unknowns and/or developing contingency plans: “So, to me, ‘being comforting’ is part of that being reassuring of the information you’re delivering, the experience that that team has with this particular condition…and then understanding and acknowledging that fact that we’re in unchartered territory and it’s okay that we don’t understand things” (mother, treatment).
	Making educated guesses based on evidence: “I would wanna know like, hey, in these particular types of cancer, in this particular situation where there was a similar thing that happened where the margins weren't cleaned, and this is what we did. Like what, what does that actually end up? How did that end up working out? Getting that kind of information, maybe. But what I’m always told is, ‘Every case is different. We could tell you a bunch of statistics, but what really matters is your daughter's case’” (mother, treatment).
	Reassuring with presence, close follow-up, tests, or procedures: “In terms of doing a blood test, see if any of her markers have changed, they’ve just responded immediately. It’s given me kind of a peace of mind throughout this whole process. If the results are good, then I know that probably it’s okay and I shouldn’t worry as much as I worry. It’s made the whole thing a little bit easier” (mother, treatment).
Responding to emotions
	Anticipating emotional needs: “They always came in and checked up on us just to make sure we were okay. One of the nurses, “Hey, do you need to go take a shower? Go take a break for a minute.” She didn’t have to do that on her lunch break, but she gave me a minute to go and do that. It was beyond grateful for what they did. They did above and beyond to help me and my family” (mother, survivorship).
	Recognizing and adapting to emotions: “Some of ‘em maybe kinda cried with us a little bit. They would actually sit there and talk to us. Even after the fact, we would get calls from ‘em just regularly just to check up on her and calls from random people at the hospital to see how we were doing as well and stuff like that” (father, bereavement).
Supporting hope
	Emphasizing the positives: “Then you put your child through those things, but you’re hopeful. They were very good at assuring us that ‘Everybody’s bodies are slightly different. This could be that one-in-a-million chance’” (mother, bereavement).
	Demonstrating intent to treat and/or cure: “Just kind of, I guess, not necessarily relax, but just feel like she was well taken care of and that we’re just gonna figure out what to do next. It made me feel like they were trying, they were actually trying to put her care and her future—make it the best as possible, from what they can do” (mother, treatment).
	Avoiding false hopes: “Yeah. Don’t sugarcoat it. Don't make — I mean, don’t — obviously, don't just tell something bad, but we need to know what to be prepared for. We need to know what to watch for on the bad parts” (mother, treatment).
	Redirecting toward hopes in addition to survival: “[The doctor] said, ‘The tumors are all over the ventricles. It’s down here. It’s in the brainstem.’ I said, ‘You have to give me something like [other doctor] does, something hopeful.’ He said, ‘Well, look at him. He’s walking around. He’s going to school. That’s what you need to hold onto.’ I said, ‘Okay.’ Live every day” (mother, bereavement).
Making decisions
	Involving parents in the decision-making process: “They always made it clear that it was totally our choice, whatever we chose to do. It was very reassuring. Just the way that they spoke to us, it was—we felt really secure in putting him or placing him in the trial and just, overall, in general, felt really good about how hard everyone was going to work on his treatment” (father, treatment).
	Offering opinions: “If this was your child, I think I asked her that once. If this was yours, what would you do? She was, well, I would pick this one. Yeah” (mother, bereavement).
	Providing strong recommendations: “It didn’t seem like I had much choice in what was going on. It was, ‘Well, this seems to have worked or helped, and we’re gonna go with this.’ It didn’t seem like we really had much choice. It was important that they explain all that” (mother, bereavement).

We define operationalization as the ways in which each function manifests in clinical encounters.