Abstract
Purpose:
Effective symptom management and provider-patient communication are critical components of quality palliative cancer care. Studies suggest nurse-telephone-interventions are feasible, acceptable and may improve the provision and satisfaction with care. However, little is known about what specific elements of nurse-telephone-interventions are most beneficial. The study’s purpose was to describe the nature and key elements of therapeutic calls made by nurses to advanced cancer patients to understand what may have previously contributed to improvement in patients who received the intervention.
Methods:
As part of a larger study on methylphenidate and/or a nurse-telephone-intervention for fatigue in advanced cancer patients from a tertiary hospital, nurse calls were made to 95 patients. This qualitative descriptive study used thematic analysis of transcribed telephone calls between nurses and advanced cancer patients.
Results:
The overarching theme of these calls was supporting patients with empathy. Empathy in these conversations included nurses’ efforts to understand patients’ experiences, nurses communicating their understanding back to patients and nurses taking action in response to their understanding of patients’ experiences. While humor and validation were used to communicate empathy, problem solving and providing support constituted the content of empathic communication.
Conclusions:
This study illustrates a nurse-telephone-interventions that embraced multiple components of clinical empathy. Nurse-telephone-interventions are feasible and acceptable with diverse, advanced cancer patients. The growing evidence base underscoring the numerous benefits of medical empathy may serve as a basis for adopting simple, feasible and accessible approaches such as empathic nurse-telephone-interventions in both research and clinical practice.
Keywords: Empathy, nurse telephone interventions, palliative care, advanced cancer, diverse patients
Introduction
Effective symptom management and provider-patient communication are critical components of quality palliative cancer care. Telephone calls have increasingly been used in a variety of settings in clinical cancer practice to provide education and psychosocial support and in research to obtain patient data. Indeed, nurses and others in clinical settings are increasingly using calls during the COVID-19 pandemic. Research has shown that cancer patients and their families welcome nurse-telephone-interventions, specifically as a means of communicating with healthcare professionals. Studies also suggest that nurse-telephone-interventions are feasible, acceptable and may improve the provision of and satisfaction with care. These elements include improvements in management and coordination of care, health service utilization, patients’ physical and psychosocial symptoms, knowledge, empowerment, problem solving skills, and encouragement (Suh and Lee, 2017; Liptrott et al., 2018).
A recent systematic review of adult cancer patients’ perceptions of telephone-based interventions during or posttreatment concluded that patients perceive that telephone interventions are convenient and enhance access to care. However, findings regarding patients’ positive perceptions of the quality of support and impact of the care on patient-professional relationships were not consistent (Liptrott et al., 2018). A recent pilot test of a nurse-led telephone-based palliative care intervention for persons newly diagnosed with lung cancer found the intervention was feasible in terms of recruitment and retention rates, and acceptable to participants and providers (Reinke et al., 2018). Studies with persons with ovarian cancer have determined that patients perceived the nurse-led interventions as convenient and more relaxed in terms of time constraints (Cox et al., 2008; Cox and Faithfull, 2015). However, a pilot study of a nurse-led posttreatment support intervention for bowel cancer survivors emphasized potential difficulties in dealing with emotions by telephone (Jefford et al., 2011).
Studies suggest that nurse-telephone-interventions may improve various cancer patient outcomes. A recent meta-analysis of 13 randomized controlled trials and 3 non-randomized controlled trials found that nurse-telephone-interventions reduced cancer symptoms with a moderate effect size, emotional distress with a small effect size, improved self-care with a large effect size and health-related quality of life with a small effect size (Suh and Lee, 2017). A recent quasi-experimental study concluded that their nurse-telephone-intervention significantly reduced chemotherapy-related symptoms for lung cancer patients and improved participants’ social functioning (Hintistan et al., 2017). Other findings suggest that telephone counseling by nurses may improve fatigue, depression, and quality of life in persons with cancer (Cusack and Taylor, 2010; Ream et al., 2015). Yet findings regarding the effectiveness of nurse-telephone-interventions with cancer patients have been equivocal. A nurse-led telephone supportive care program for patients following esophageal cancer surgery resulted in greater satisfaction with information received but not improved quality of life ratings (Malmström et al, 2016). Women with endometrial cancer receiving nurse-led telephone follow up care reported similar quality of life and satisfaction with care as women receiving standard follow-ups (Smits et al., 2015). A recent randomized controlled trial of a nurse-led intervention for bowel cancer survivors found that patients in the intervention arm were more satisfied with care received but did not have improved distress, unmet needs or quality of life outcomes (Jefford et al., 2016). The evidence also suggests that nurse-telephone-interventions may improve the continuity of care for cancer patients transitioning from hospital to home (Zheng et al., 2013; Hand and Cunningham, 2014).
While nurse-telephone-interventions may be feasible, acceptable and influence several patient outcomes, little is known about what specific elements of nurse-telephone-interventions are most beneficial. Nurse-telephone-interventions by their very nature influence communication between providers and patients – a critical component for providing quality care. One qualitative study identified four crucial elements when communicating with advanced cancer patients: respecting the importance of time; demonstrating caring; acknowledging fear; and balancing hope and honesty when providing information (Stajduhar et al., 2010).
Cancer researchers have also posited that empathy is particularly important for effective patient-centered communication (Pehrson et al., 2016). Indeed, a systematic review of the influence of provider empathy on patient outcomes in cancer care found that clinicians’ empathy was related to higher patient satisfaction and lower distress, yet not necessarily to patient empowerment (e.g., medical knowledge, coping) (Lelorain et al., 2012). Clinical empathy has been described as “a learned intellectual process that requires (provider) understanding of (patient) feelings” and the adoption of cognitive empathy versus affective empathy which involves the understanding of a person’s feelings (Platt and Keller, 1994; Pehrson et al., 2016). However, others emphasize emotional feeling as central to defining empathy and describe it as an effective response to the emotions of others (Robieux et al., 2018; Eisenberg, 2000). Also, the question of whether to add a behavioral component to the definition of empathy has been disputed (Robieux et al., 2018; Eisenberg, 2000). Finally, a more recent qualitative study of cancer care physicians organized clinical empathy into six dimensions: 1) patient-physician encounter, 2) standing in another person’s shoes, 3) adjustment to patient, 4) communication skills, 5) building interpersonal relationship and giving information and 6) teaching skills (Robieux et al., 2018).
Our group published the quantitative results from a study examining the influence of methylphenidate and/or a nursing telephone intervention on fatigue in advanced cancer patients. Cancer-related fatigue is the most common symptom experienced by advanced cancer patients. The randomized controlled, double-masked, parallel study investigating the interaction between methylphenidate and nurse phone calls in reducing fatigue and associated symptoms in patients with metastatic, incurable cancer produced mixed results. Details on the methodology and findings from the randomized controlled trial (RCT) can be found in Bruera et al., (2013). However, briefly, patients were randomized into one of four treatment groups: 1) methylphenidate with the addition of nurse-telephone-intervention; 2) methylphenidate with the addition of a control telephone intervention (CTI); 3) Placebo with nurse-telephone-intervention; 4) Placebo with CTI. While improvement in median FACIT-F fatigue scores were not found between any of the four groups (P = .16), the nurse-telephone-intervention groups showed significant improvements in HADS anxiety scores (P = .02) but not in HADS depression scored (P = .1). In addition, fatigue (P < .001), nausea (P = .01), depression (P = .02), anxiety (P = .01), drowsiness (P < .001), appetite (P = .009), sleep (P < .001), and feeling of well-being (P < .001), as measured by the ESAS, significantly improved in patients who received the nurse-telephone-intervention (Bruera et al., 2013).
The limited scientific evidence describing what aspects of nurse-telephone-interventions may be beneficial, coupled with our findings specific to symptom improvements in the nurse-telephone-intervention groups (Bruera et al., 2013) prompted our interest to explore the content of calls made by nurses to advanced cancer patients enrolled in our randomized controlled study. The purpose of this study was to describe the nature and key elements of the therapeutic calls made by nurses to better understand what may have contributed to the improvements observed in the prior RCT among patients who received the intervention.
2. Methods
2.1. Ethical considerations
The Institutional Review Board (IRB) of The University of Texas MD Anderson Cancer Center and the Committee for the University of Texas Health Science Center at Houston approved the study and all participants provided written informed consent.
2.2. Data collection
As part of a larger study, research nurses trained and supervised by Ph.D. nurse researcher (MZC) called 190 cancer patients in the study of methylphenidate and/or nursing telephone interventions. Of these, 95 patients received calls from nurses and 95 were called by a non-nurse research assistant. Calls were made to patients’ homes 1 to 6 times over 2 weeks. Verbatim transcripts were made of the 491 calls, 269 of which were nurse-telephone-intervention and 222 were control telephone intervention, from the research assistant.
2.3. Study population
Of the 95 patients who received calls from a nurse, 45 received methylphenidate and 50 had the placebo. Participants ranged in age from 29 to 84 years with a median age of 59. Of these 95 cancer patients, 65% were female and 35% were male. White (non-Hispanic) accounted for 74% of participants with 7% black (non-Hispanic), and 19% Hispanic. Cancer diagnoses included lung, GI, breast, genitourinary, melanoma, hematologic and other (see detail in Bruera et al., 2013).
2.4. Data analysis
Thematic analysis guidelines from Braun and Clark (2006) were used to analyze verbatim transcripts. Each call was analyzed inductively line by line and topic areas were labeled in the margins. These labels and the text associated with them were separated and three researchers independently reviewed results for consistency and overlap. Analysis moved between the data and the emerging analysis. We organized the data into meaningful groups. Analysis results were discussed until consensus was reached by the three researchers conducting the analysis. All coauthors then reviewed the results and further refinements were made. Final themes and subthemes are described below.
3. Results
Analysis revealed that the overarching and central aspect of these calls was supporting patients with empathy. Three major themes regarding empathy were identified (see Table 1). The first theme was “understanding patients’ experiences”. The second theme, “Communicating the understanding of patients’ experiences”, included the subthemes of humor and validation. The third and final theme, “Acting on the understanding of patients’ experiences”, included the subtheme of problem solving and providing support. We used quotes from many of the patients and did not repeat exemplars from the same patient.
Table 1.
Supporting patients with Empathy
| Theme 1. | Understanding patients’ experiences |
| Theme 2. | Communicating the understanding of patients’ experiences |
| Humor | |
| Validation | |
| Theme 3. | Acting on Understanding of patients’ experiences |
| Problem solving and providing support |
The overarching themes that emerged under the overarching theme “Supporting patients with Empathy” illustrate how nurses supported their patients with empathy. Ways nurses supported patients with empathy included their building relationships by listening and expressing understanding of patients’ thoughts and feelings. In some calls, nurses used examples of experiences to assist patients to put a symptom, emotion, or experience into context.
3.1. Theme 1. Understanding patients’ experiences
The first theme within empathy was understanding patients’ experiences. Nurses used a variety of skills to obtain an understanding of patients’ experiences while displaying empathy. The protocol for the calls for the RCT of reducing fatigue included symptom assessment. Nurses’ assessments were guided by the patients’ responses to the questions. Some assessments sought to obtain further information while others were to determine if further follow-up was needed, and in some instances to provide interventions or recommendations based on the assessment. Symptoms were usually assessed at the beginning of the calls and often served as an “ice-breaker” to other exchanges that facilitated nurses’ understanding of patients’ circumstances and feelings. This involved much more than just asking patients to rate their symptoms on a numerical scale.
Descriptions of fatigue were particularly prevalent.
Patient: The past 24 hours? Terrible! I’ve had awful fatigue today. So today I would say my fatigue is probably a 7.
Nurse: Okay. Now, is there a particular reason you’re feeling more fatigued today or tell me what’s going on?
Patient: I have no idea, I just, I woke up today, I didn’t wake up, I mean I slept a long time last night, like I had a hard time sleeping, and then, I didn’t get out of bed today until like, 11:30 and I just didn’t feel well, I just haven’t felt well at all today.
Nurse: Okay, and are you having any other symptoms other than the fatigue?
Patient: Um, just nausea today.
Nurse: Okay.
Patient: I didn’t feel, I just haven’t felt good at all today, I don’t know if I’m just worn out or what from the holiday?
Patients also discussed other symptoms. An example was discussion of sleep and a holistic assessment of sleep.
Nurse: Disturbed sleep?
Patient: I have had disturbed sleep, yes, I have not slept well, that would be about a 6.
Nurse: Gosh.
Patient: Yeah, I have not slept well for the last 2 nights.
Nurse: Do you think it’s something physical happening or are you worried about something?
Patient: I, you know, I’m really thinking it may be work.
Nurse: Uh-huh?
Patient: Cause I hate to say that I am getting back into the full swing of work and that’s just kind of part of what I do with work sometimes.
Nurse: Yeah, you just sort of go over it in your head.
Patient: Yeah, yeah.
Nurse: Did you review the day and review what you said [laugh]?
Patient: Yeah, that’s what I do. I’ve had to hire new employees, I’m looking for more employees, and all of that sort of thing…It’s all part of it.
The process of assessing symptoms sometimes led to very profound exchanges.
Nurse: How about sadness?
Patient: That’s a wide range thing, you know…. 4 or 5 I guess…. That’s because I’m going to die. You do understand that?
Nurse: I do understand that, yes.
Patient: I want to live to be 100.
Nurse: Yeah, I know you have a great family, and you want to be with them.
Nurses also learned more about the patient’s life, including their professions and their sense of loss due to their cancer.
Nurse: Okay. How about, how is it affecting your mood?
Patient: Most cancer patients can work, can’t they?
Nurse: It all depends, everybody is very different.
Patient: I don’t understand why I feel like, why I can’t work.
Nurse: Well, I’m pretty sure you can work depending on what kind of work you’re talking about. And some of them can handle the light duty stuff. I don’t know if you ever tried that. Not physical work. Hello.
Patient: Yeah, I’m still here, it just makes me sad.
Nurse: Why is that?
Patient: Because, I’m not gonna be the same anymore, and I hate it.
Nurse: Yeah, you know, it is very true, you have to adjust your lifestyle.
Patient: I don’t wanna be just sitting around the house all day. I wanna be productive.
Nurse: I know, but have you, I’m pretty sure you can do something, and see, you still have the mind to do things that … I’m pretty sure that you are able to do something that doesn’t take a whole lot of physical work. Have you thought about those things?
Patient: No, I’ve only thought about the one job that I know how to do and that’s work in a bakery.
Nurse: Oh, that’s what you used to do?
Patient: I wanna go back to my old job.
Nurse: Yeah, a lot of times you have to modify what you were doing before.
Things change.
Nurses were receptive to hearing patient’s experiences and encouraged them to talk about their feelings.
Patient: So that’s the only thing. I cried a lot yesterday, cause I just don’t know how I’m gonna work, but I know I’m gonna work. See [husband] doesn’t have a job and I’m the only one. I thought, the funny thing is, cause he came back from Saudi, he interviewed for two jobs down there, he was in the top three – (expletive) he didn’t get either one of them.
Nurse: Oh, I’m sorry.
Patient: I know it. This is just like so ironic. The only person that’s bringing in any money is the one that’s got cancer. You know, it’s just like, you gotta be kidding me.
Nurse: Yeah, that stinks.
Patient: (coughing) but, so and, you didn’t want to hear all that.
Nurse: Well, tell me. I do. I mean that has to do with how you’re feeling.
Patient: Yeah.
3.2. Theme 2: Communicating the understanding of patients’ experiences
Empathy was shown as nurses did a variety of things to communicate that they understood patients’ experiences. They introduced themselves, asked how other family members were doing, how a planned activity went, or how the drive home from the clinic was. Small talk included asking about patient’s plan for the weekend or the weather. Nurses and patients also used shared experiences and information about themselves. The communication skills used included engaging patients with humor and validation.
3.2.1. Humor
The first subtheme of communicating understanding of patients’ experiences was engaging patients with the use of humor. Both patients and nurses engaged in humorous moments, which facilitated communication. The following exemplars reflect a safe and relaxed environment that allowed for nurses and patients to engage in humorous moments.
Patient: [Discussing his diarrhea] you don’t pass gas other than in the bathroom cause you never know whether that’s the only thing you’re going to pass…
Nurse: Wow…
Patient: Uh huh, I’ve learned to live with that.
Nurse: You learn to live with that?
Patient: Mm hmm, panty liners are my best friends.
Nurse: (Laughs)…
Patient: (Laughs)… it’s just a fact of life now.
Patient: (Laugh)…I ate some chocolate and I couldn’t sleep last night.
Nurse: (Laugh), did you enjoy the chocolate?
Patient: Well I thought I did at the time but then, no.
Nurse: I know, I know! I do that with a late night cup of coffee and then I just lay in bed, (Laugh)!
Patient: I have no problem with remembering things.
Nurse: Oh, my gosh, I have a terrible problem remembering things! (Laugh)
Patient: Would you like me to give you the apple, uh, penny and cake (Laugh)…(referring to the memory test used with patients)
Nurse: Oh, no!!!!! You are amazing.
Nurse: How are those things affecting your enjoyment of life?
Patient: (Laughs) the whole thing sucks.
Nurse: Whole thing sucks, huh?
Patient: let’s go with a four (Laughs) - sorry to be so blunt.
Nurse: I see… you have lot of distress you know.
Patient: No, I got lung cancer… (Laughs) that sucks… (Laughs)
Nurse: It sure does.
Nurse: You know it’s a pretty serious disease…. But you know affecting your life.
Patient: Oh yeah… No … I’m not dealing with it too bad.
Nurses were sometimes self-effacing in a humorous way as they connected with the patients.
Patient: I went out and picked me a handful of dewberries a while ago.
Nurse: Oh, ok you didn’t have to increase your pain medicine?
Patient: No uh, huh.
Nurse: Really?
Patient: No … In fact I cut back on that … what do you call quick relief I didn’t take but two yesterday.
Nurse: Uh huh…
Patient: So.
Nurse: Sometimes good not to listen to your nurse huh?
Patient: Yeah… (Laughs)
3.2.2. Validation
Validation was a second subtheme of communicating understanding of patients’ experiences. This involved active listening, which is attentive listening, carefully reflecting back what patients express so they feel heard and supported. Sometimes it included expanding patients’ perspective to help them see strengths or possibilities that they have not fully seen.
Patient: I’m pitiful, aren’t I?
Nurse: No, you’re struggling with something that just jumped out at you that you weren’t prepared for, and you’ve just got to figure out, how to live with it, or get somebody to help you control the symptoms that can be controlled, so you can live with it.
Patient: I just have a lot of symptoms.
Nurse: Yes, you have a whole lot of symptoms, so no, you’re not pitiful, not one little bit!
Nurses also validated and supported patient’s outlook regarding their response to their cancer as illustrated by the following quote:
Patient: I refuse to let this damn disease get the best of me, excuse my language.
Nurse: That’s very true. You know it’s the best way to deal with it. The thing is you don’t have control.
Patient: And I don’t like not having control - that frustrates me.
Nurse: And then… and for the things you have control of… you’re doing…you have a good attitude.
Patient: Well, you get up and I’m at work every day and that’s important.
Nurse: mm hmm, you don’t let the sadness or things, negative feelings, stay too long.
Patient: No, cause you’re around people and you have to be upbeat. I deal with people all day long and … you know you just have to be upbeat.
Nurse: Mm hmm, that’s really (true)
Patient: Otherwise you crawl into a hole.
Nurse: That’s right, yeah.
Patient: I’m not gonna do that.
Nurse: Very good, just keep it up that way.
Patient: I’m trying.
Nurse: You are doing your best, yeah.
Nurses sometimes showed their understanding by sharing personal experiences that related to the patient’s situation.
Patient: See if I could get a little bit more activities and, well I’ve been… of course I’m still sitting down but at least I’m up doing something.
Nurse: Right, rather than the bed. I know that to me, that feels better too, I had some surgery this past winter and was at home for two months and it hurt to get up but I know what you mean, it feels better to get up.
3.3. Theme 3: Acting on Understanding of patients’ experiences
The third and final subtheme of empathy was acting on understanding of patients’ experiences. While humor and validation show the process of communicating empathy, problem solving and providing support are the content of communicating with empathy.
3.3.1. Problem solving and providing support
Problem solving and providing support is the subtheme under acting on the understanding of patients’ experiences. Nurses often provided information to help patients deal with problems. Nurses advised patients about what to do or made suggestions that might include an intervention. Patients also talked about their feelings and families.
Patient symptom assessments frequently led nurses to educate patients about symptoms, including explaining possible causes of symptoms and ways to manage them.
Nurse: Ok, and your appetite?
Patient: Uh… four.
Nurse: You’re not eating that well huh?
Patient: Well it’s more difficulty of preparing the food so it’s that… probably has me down to two meals a day. I would be hungry but it’s just, you know, fixing things with the neuropathy makes it more and more difficult.
Nurse: I’m so sad to hear that.
Patient: It’s ok… don’t worry about that.
Nurse: You never should starve.
Patient: Oh, I’m not starving.
Nurse: Ok, yeah, but you know nutrition is very important at this time.
Patient: Oh, I agree, I agree.
Nurse: Yeah…so, I don’t know if you’re trying to like [use a] blender and make things easier for you. I’m pretty sure you’re pretty good at figuring things out.
Patient: Yeah I’m just … I’m shifting more to frozen food which of course aren’t fresh. That’s what bothers me.
Nurse: It is true… if you need a dietician, if you need help in that aspect, you know we have dieticians here to help with those things, to figure out what would be easier for you.
Patient: That’s probably a good idea… I’ve got the dietician’s name and number. I’ll get in touch her.
Nurses often encouraged patients to engage in healthy activities to manage their symptoms.
Nurse: You’re doing ok huh… hang in there… I know it’s not easy…
Patient: Yeah
Nurse: Nausea and diarrhea and all that
Patient: Yeah… yeah
Nurse: Alright ok… you… you continue with your exercise a little bit?
Patient: Not yet
Nurse: ok but you just when you can, huh
Patient: yeah when I get better in a couple of days
Nurse: Ok, try to do a little bit of exercise even though you don’t feel like to… ok… uh… even 5 minutes if you can do it that would be wonderful
Nurses also provided patients with support to keep going or commending them for having a good attitude.
Patient: Yes, sometimes it’s difficult to enjoy life, when you …
Nurse: It can very well do that. I’m sorry to hear that, is there anything we think that we can do to make it a little bit better for you?
Patient: …So I feel like, and then too I do have some optimism that I am going to get better.
Nurse: That’s a very good outlook.
Patient: Yeah.
Nurse: I think that would help with your enjoyment of life too. Sometimes our outlook on things can affect how we feel too.
Patient: I have to get better, I still have things to do.
Another example of support was nurses telling patients that they agreed with their decision or conclusion about a symptom or solution.
Patient: I mean I don’t have the most interesting life, but I do twiddle around and do a little of this and a little of that. I’ve gotta stay active, or I’ll get blood clots in my legs.
Nurse: Exactly, exactly. And doing a little bit of work, is going to help you, like the other day, when you took a walk with us, you actually felt better right away.
Patient: Yes.
Nurse: So know that, that really helps. Exercise, you know, staying busy.
Patient: That’s why I don’t want to be staying asleep during the day.
Nurse: Yeah.
Patient: ‘Cause if I stay asleep during the day, I will never get any exercise.
Nurse: No, you don’t want to. But are you able to still just move around and just do some work, right?
Patient: Yeah.
Discussion and Conclusions
Findings from this qualitative study add to the cancer research literature on the importance of nurse telephone interventions and clinical empathy, which is increasingly important in this time of international use of physical distancing. The results complement past studies and may help inform future research. The objective of this qualitative study was to characterize the nature and key elements of the therapeutic calls made by nurses as part of our previous RCT to understand what may have contributed to the improvements found in the patients who received the intervention. The overarching theme that emerged from analysis of the telephone conversations between nurses and patients in this study was supporting patients with empathy. While empathy predominated the essence of most exchanges, further examination of the narrative revealed that empathy in these conversations could further be broken down into nurses’ efforts to understand their patients’ experiences, nurses’ efforts to communicate their understanding back to their patients, and finally nurses’ initiatives to take action in response to their understanding of their patients’ experiences. In this study, nurses used a variety of skills, particularly a holistic, interactive, iterative approach towards symptom assessment, to obtain an understanding of patients’ experiences while displaying empathy. While humor and validation illustrate the process of communicating empathy, problem solving and providing support constitute the content of communicating with empathy.
Worthy of noting is that this not a study of empathy, but rather of the content of nurses’ therapeutic calls to advanced cancer patients during their enrollment in a RCT. Transcripts of these calls were inductively analyzed, and emerging themes were labeled. After numerous iterations and until consensus was achieved, we decided that these themes fell under the larger theme of clinical empathy.
Empathy has been described as a two-stage process involving the understanding and appreciation of another person’s predicament or feelings and the communication of that understanding back to the patient in a supportive manner (Pehrson et al., 2016). Medical empathy thus necessitates the skills needed to both capture patient perspectives and communicate this understanding in a warm and compassionate manner to the patient (Platt and Keller, 1994; Lelorain et al., 2012). In our analyses of the nurse-telephone-intervention calls, both stages of this process emerged, with an additional action-oriented element that involved problem solving and support. In Robieux and colleagues’ study of cancer care physicians and empathy, the six dimensions of empathy that emerged reflect the sequences of the empathic process from the patient-physician encounter until patient-physician partnership. While, the cognitive and behavioral components of clinical empathy are strongly reflected in these dimensions, the affective component was present as well (Robieux et al., 2018). Our findings also suggest that the strongest components of empathy that emerged were cognitive and behavioral. Yet it is undeniable that the affective component of clinical empathy was also present in the calls between nurses and patients in this study.
The oncology scientific community largely agrees that clinical empathy is of critical importance in oncology at all stages of the illness and a systematic review of the role of empathy in patient outcomes in cancer care supports this belief (Lelorain et al., 2012). Persons with advanced cancer have also reported that contrary to sympathy, empathy is beneficial to them (Sinclair et al., 2017). Yet most studies on cancer and empathy do not clearly define or operationalize empathy (Lelorain et al., 2012; Sinclair et al., 2017). Furthermore, empathy is rarely linked to concrete outcome measures. Interestingly, patients in the larger RCT who received calls from nurses had better symptom outcomes compared to patients who did not receive the calls from nurses (Bruera et al., 2013). However, we are unable to determine if and how empathy may have influenced symptoms, nor can we infer causality from this study.
Researchers have suggested that empathic communication may improve patient outcomes directly and indirectly. Directly, it may lead to greater patient disclosure of symptoms and concerns, which in turn results in better information, diagnosis, understanding, response to patients’ individual needs and ultimately patient outcomes. Empathic communication can also lead to patients feeling listened to, valued as individuals, and understood and accepted, which can indirectly lead to improved patient outcomes (Neumann et al., 2009; Pehrson et al., 2016). Future research based on a conceptual framework and clearly defined and disentangled attendant measures is needed to determine the mechanism by which clinical empathy may improve symptoms in advanced cancer patients. This line of research may in turn inform empathy training interventions for oncology clinicians.
It is noteworthy that although patients in this study had advanced disease, they were open to receiving calls, in addition to other components of the research protocol. This finding is consistent with previous studies on nurse-telephone-intervention conducted with persons with cancer and advanced cancer (Liptrott et al., 2018; Reinke et al., 2018). Conducting nurse-telephone-interventions may also be useful for providing advanced cancer care to persons who have limited access to care or who are limited by physical distancing or isolation due to the pandemic. Nurses providing telephone interventions should be prepared to cover numerous issues and to have in-depth conversations as that is what patients often desire and need.
The data analyzed in this study were 8 years old. Findings from these data, however, are still relevant and important since nurse-telephone-interventions are increasingly being used internationally in both research and clinical practice (Jefford et al., 2016; Malmström et al., 2016; Suh and Lee, 2017; Liptrott et al., 2018; Reinke et al., 2018). Additionally, our finding related to the potential benefits of empathic provider communication should be timeless. This study was a descriptive qualitative study, aimed at characterizing the content of the calls made by nurses to patients enrolled in a larger RCT. Although important themes emerged regarding the role of empathy in clinical palliative cancer research, the study was not based on a conceptual framework and did not examine the potential mechanisms through which clinician empathy may influence patient outcomes. However, these findings may inform future studies on the role of clinician empathetic communication in both research and clinical practice.
Recent years have witnessed an increase of calls for expanded access to palliative care and its provision early in the illness trajectory. There is also a growing need for more research with advanced cancer patients, including studies to better understand the nature and components of newer interventions recently used with palliative care populations. As recommendations to extend palliative care are made, and more patients with cancer are treated in outpatient settings, the importance of telephone interventions increases as a means of providing convenient and accessible care. The repeated determination that nurse-telephone-interventions are feasible and acceptable by patients with advanced illness underscores the potential for adopting this approach with persons with reduced health care access, such as those living in rural communities. This study suggests that empathic nurse telephone calls are a simple, feasible and accessible approach, and based on the findings of the RCT, may improve outcomes for persons with advanced cancer. These approaches may be used in both research and clinical practice. Most studies to date have only reported on the association between nurse-telephone-interventions and numerous outcomes, but not on the actual content of the calls. This qualitative analysis resulted in the identification of the key elements of the calls and the overarching theme of empathy that may improve a series of patient outcomes. Recently, several studies on empathy in health care have revealed a disturbing shift away from empathy over the course of healthcare education and clinical practice (Sinclair et al., 2017). The growing evidence base underscoring the numerous benefits of medical empathy may very well serve as a basis for reversing this troubling trend and adopting simple, feasible and accessible approaches such as empathic nurse-telephone-interventions.
Highlights.
Empathic nurse telephone calls are feasible and acceptable with diverse, advanced cancer patients.
The main aspect of the nurse telephone calls was supporting patients with empathy.
Empathy included understanding patients, communicating that understanding and action.
Humor and validation communicate empathy; action was problem solving and support.
Acknowledgments
We gratefully acknowledge the research nurses who conducted the patient interviews as part of the larger study.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Institutes of Health National Institute of Nursing Research [Grant Number R01 NR010162-01A1]. I.T.V. was supported in part by a National Institutes of Health National Cancer Institute [Grant Number K01 CA151785-01].
Footnotes
Declarations
Research ethics and patient consent
The Institutional Review Board of The University of Texas MD Anderson Cancer Center and the Committee for the University of Texas Health Science Center at Houston approved the study and all participants provided written informed consent. The study was approved by the IRB on October 19, 2005.
Conflicts of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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