E ECTIVE COMMUNICATION SKILLS IN NURSING PRACTICE

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Effective communication skills in nursing practice NS772 Bramhall E (2014) Effective communication skills in nursing practice. Nursing Standard. 29, 14, 53-59. Date of submission: July 18 2014; date of acceptance: September 1 2014.

Abstract This article highlights the importance of effective communication skills for nurses. It focuses on core communication skills, their definitions and the positive outcomes that result when applied to practice. Effective communication is central to the provision of compassionate, high-quality nursing care. The article aims to refresh and develop existing knowledge and understanding of effective communication skills. Nurses reading this article will be encouraged to develop a more conscious style of communicating with patients and carers, with the aim of improving health outcomes and patient satisfaction.

Author Elaine Bramhall Managing director, consultant and trainer, Effective Communication Matters, Manchester, England. Correspondence: [email protected]

Keywords Active listening, communication skills, communication skills training, compassionate care, effective communication, empathy, interpersonal skills, nursing care, patient cues, patient safety

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines

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Aim and intended learning outcomes The aim of this article is to increase readers’ awareness and understanding of the role of effective communication in compassionate nursing care. The article can be used to help readers develop a more conscious style of communication, while enhancing their confidence and ability to notice and respond to patient cues. After reading this article and completing the time out activities you should be able to: Outline the role of effective communication in the provision of compassionate nursing care. Discuss barriers to effective communication. Describe the core communication skills required in healthcare settings. Integrate effective communication skills into clinical practice. Identify individual learning requirements and recognise the need for support and/or additional communication skills training.

Introduction Communication can be defined as a process during which information is shared through the exchange of verbal and non-verbal messages (Brooks and Heath 1985), and where people create a relationship by interacting with each other (Groogan 1999). Communication is integral to the nurse-patient relationship and is one of the six fundamental values of nursing identified in the government’s strategy to deliver high-quality, compassionate care for patients (Department of Health (DH) 2012). The policy document Compassion in Practice states that ‘communication is central to successful caring relationships and to effective team working’ december 3 :: vol 29 no 14 :: 2014 53

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1 Reflect on one or two of your recent interactions or consultations with patients where there were communication challenges. List the challenges and emotions involved, and write down how you managed these challenges. Reflect on how you think the other person felt at the end of the consultation. How did you feel?

(DH 2012). The Nursing and Midwifery Council (2008) highlights the importance of communication in its code of conduct, stating that nurses must meet people’s language and communication needs and ‘share with people, in a way they can understand, the information they want or need to know about their health’. Effective communication helps vulnerable patients to cope with and make better decisions about their care and treatment (Donnelly and Neville 2008). However, maintaining effective communication in busy healthcare environments where patients are vulnerable and staff are frequently stressed requires advanced interpersonal skills, as well as an awareness of self and others. A growing body of evidence demonstrates that it is possible to improve and develop effective communication skills with training (Maguire et al 1996, Fallowfield et al 2002, Wilkinson et al 2008, Connolly et al 2014). However, in recent years there has been a surge in complaints about care and significant failings in communication and attitudes of staff (Francis 2010, DH 2013a, 2013b, Royal College of Nursing 2013). The need to provide compassionate care is emphasised, but it is difficult to clarify exactly what it is and how it can be demonstrated in practice. One definition of compassion is a ‘deep awareness of the suffering of another coupled with the wish to relieve it’ (The Free Dictionary 2014). The Oxford English Dictionary (2014) refers to the Latin origins of compassion, ‘compati’, meaning ‘suffer with’. Peters (2006) defines compassion as ‘…a deep feeling of connectedness with the experience of human suffering that requires personal knowing of the suffering of others’ and results in caring that comforts the sufferer. Compassionate care is also defined as ‘a relational activity that is concerned with the way in which we relate to other human beings when they are vulnerable’ (Dewar et al 2011). The varied definitions and understanding of what compassion is highlights the challenges of demonstrating this complex connection with another person in nursing practice. If nurses had a deep awareness of the suffering of every individual they cared for, they could easily become overwhelmed and find it almost impossible to function within a professional role.

Compassionate nursing care Empathy is perhaps a more realistic way of showing we appreciate and care about the

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experiences of patients as they cope with difficult diagnoses, treatments, symptoms of ill health and life-limiting illness. Empathy verbalised by one person to another can offer support and comfort at times of vulnerability, anxiety and distress. Empathy can be described as the ability to set aside your own thoughts and feelings. This may sound easy, but in practice nurses often have an overpowering desire to offer a solution, information or reassurance to patients and relatives. The desire to help or alleviate distress can dominate the thoughts and feelings of any healthcare professional. The act of setting aside personal thoughts and feelings enables active listening to take place. In addition, empathy means being willing to try to perceive the world as it is for the other person. Being willing to view the world of someone who is experiencing a high level of distress takes courage and bravery. Finally, empathy is conveyed by expressing appreciation of the other person’s situation and feelings (Mearns and Thorne 2007). Complete time out activity 1

Communication skills training A report from the Royal College of Physicians (2014) on end of life care in hospitals in England found that the majority of discussions with families and friends took place less than two days before death. This finding may indicate some degree of reluctance to engage in these sensitive discussions earlier in the patient’s illness, not only by nursing staff but also by all members of the multiprofessional team across health and social care, hospital and community settings. The report recommends that training in communication skills should be mandatory for all staff involved in caring for dying people. If healthcare professionals felt more confident and competent to engage in these sensitive discussions, more discussions would take place at a time when people who are dying and those close to them are better able to prepare and adjust to the situation. This is not a new recommendation. Improving Supportive and Palliative Care for Adults with Cancer (National Institute for Health and Care Excellence (NICE) 2004) described a four-level model for providing psychological support to patients. The guidance stated that psychological distress is common and these signs of distress are not readily recognised, with the result that

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people fail to receive the support they require. All healthcare professionals, regardless of grade, role or specialty, were noted as having a role in identifying and responding to the distress of patients and their relatives (NICE 2004). The core responsibility to be able to recognise distress and respond in a helpful and supportive way continues to be highlighted in the literature. However, healthcare professionals are failing in this core responsibility to recognise and respond to the needs of patients in distress (Francis 2013). These failings may in part be the result of inadequate formal, structured or consistent communication skills training in pre and post-registration nursing courses. Nurses learn much about communication in clinical practice from peers, senior staff and others, who may themselves have received little or no communication skills training. This informal approach can be effective for some, but it may offer little constancy or opportunity for feedback and development. Promoting effective communication in health care is demanding, complex and challenging because of the nature of the work environment, which is often stressful and pressurised, providing little time for communication. If nurses are to meet these challenges in the future they need to be supported by high-quality, evidence-based training. Nurses should receive regular communication skills training if they are to feel confident and competent in their role. The benefits for patients, carers and healthcare professionals are clear – good communication influences patients’ emotional health, symptom resolution, function and physiological measures such as blood pressure, and it decreases reported pain and drug use (Stewart 1995). Most nurses should be able to remember a patient who had reduced pain as a result of feeling less anxious and frightened. Fear has the potential to increase pain, and in the labour ward it can impede the birthing progress (Otley 2011). Healthcare professionals themselves experience benefit if they feel confident about managing communication situations such as breaking bad news, handling difficult questions and responding helpfully to strong emotions. Ramirez et al (1996) and Taylor et al (2005) found that healthcare professionals experience adverse psychological effects if they have not had sufficient training in effective communication skills to match the demands of their role.

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The availability and quality of communication skills training is variable, but some workshops provide evidence that attendance and participation can have a positive effect on clinical practice. Two such workshops are Connected – National Advanced Communication Skills Training, previously part of the National Cancer Action Team Programme (The Royal Marsden 2014), and the foundation-level half-day SAGE & THYME course (Connolly et al 2010, 2014). Evidence-based communication skills training workshops have similar core elements. These include theory and an evidence base; the participants decide the content of the workshop and receive supporting handouts and references. A presentation and/or demonstration is given of effective communication skills in practice and participants have the opportunity to practise skills and receive feedback in a structured format. The insight they gain leads to a greater awareness of the way people communicate with others, and their confidence and competence increases. Complete time out activity 2

Barriers to effective communication The following tasks are aimed at raising awareness of the barriers to effective communication and developing a common language and understanding of communication skills (Box 1). This knowledge has the potential to improve effectiveness and focus the consultation on the needs of the patient. By having a conscious awareness of the potential barriers to effective

2 Working with a colleague, discuss and list the barriers to effective communication. One person could consider the barriers from the healthcare professional’s point of view and one from the patient and/or carer’s point of view.

BOX 1 Barriers to effective communication Patient and carer barriers:  Environment – noise, lack of privacy, no control over who is present or not present (staff or relatives).  Fear and anxiety – related to being judged, being weak, or breaking down and crying.  Other barriers – difficulty explaining feelings (no emotional language to explain feelings), being strong for someone else, or communication cues being blocked by healthcare professionals. Healthcare professional barriers:  Environment – high workload, lack of time, lack of support, staff conflict, lack of privacy or lack of referral pathway.  Fear and anxiety – related to making the patient more distressed by talking and/or asking difficult questions.  Other barriers – not having the skills or strategies to cope with difficult reactions, questions and/or emotions. Thinking ‘it is not my role’, and ‘the patient is bound to be upset’. (Wilkinson 1991, Booth et al 1996, Heaven and Maguire 1998, Maguire 1999)

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CPD communication skills communication, it is possible to manage and minimise the effect of these barriers in the clinical environment. Complete time out activity 3

Effective communication skills It is essential that nurses have skills that keep the focus of communication on the patient, that demonstrate active listening and assist with information giving (Box 2). Examples of communication skills that are integral to nursing are provided in Box 3. It is important that these skills are developed in pre-registration training and further developed during preceptorship, clinical supervision and mentorship throughout a nursing career to promote confidence and competence in this area.

Cues Cues can be anything you see or hear when you are interacting with another. Cues are sometimes obvious, for example, crying, or subtle, for example, if a patient looks away

every time treatment or results are talked about. While cues assist any interaction to be patient-centred, there are other benefits. Zimmermann et al (2003) reported using facilitative questions linked to cues to increase the probability of more cues. The following is an example of an interaction in which a facilitative question linked to a cue (selected cues are written in bold) is used: Patient: ‘I thought, after the surgery, I would bounce back, but that hasn’t happened.’ Nurse: ‘Bounce back…?’ Nurse uses sensitive reflection to pick up the cue ‘bounce back’ and waits for the patient to say more. Patient: ‘…well, I suppose, I hoped I would be like I was before I got ill… I know it’s daft really… I need to be patient with myself.’ Fletcher (2006) explored the effect of facilitating the first patient cue, which appears to be important. If this is missed, patient cues can drop off as the consultation progresses, whereas open questions linked to a cue are notably more likely to lead to further disclosures than unlinked open questions.

BOX 2 Effective communication skills

3 Make a list of all the effective communication skills you can think of and categorise these into skills that: Assist in keeping the focus on the patient and/or carer. Demonstrate listening. Assist with information giving. It may help you to think about an interaction you had recently or the challenges you reflected on in time out activity 1.

Skills that assist in keeping the focus on the patient and/or carer:  Looking and listening for cues.  Asking open questions. For example: ‘How are you?’  Asking open directive questions. For example: ‘How are you since I last saw you?’  Asking open questions about feelings.  Exploring cues. For example: ‘You said you are not with it, can you tell me more about that?’  Using pauses and silence.  Using minimal prompts.  Screening. For example: asking the question ‘Is there something else?’ before continuing with the discussion.  Clarifying. For example: asking the question ‘You said you are not with it, from what you say, it sounds like it is hard to concentrate?’ Skills that demonstrate listening:  Reflecting.  Acknowledging.  Summarising.  Empathising.  Making educated guesses.  Paraphrasing.  Checking. Skills that assist with information giving:  Checking what information the person knows already.  Giving small amounts of information at a time, using clear terms and avoiding jargon.  Avoiding detail unless it is requested – do not assume people want to know.  Checking understanding using an open question. For example: ‘I’ve gone through some difficult information, what sense have you made of it?’  Pausing and waiting for a response to what you have said before moving on.  Checking, with sensitivity, the effect of the information you have given on the patient or carer. For example: ‘There has been a lot of information to take in today, how are you feeling?’

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Patient: ‘…well, I suppose, I hoped I would be like I was before I got ill… I know it’s daft really… I need to be patient with myself.’ Nurse: ‘So you hoped you would be like you were before you were ill, and you are finding it hard to be patient with yourself as you recover… how are you feeling about that?’ The nurse uses reflection of what the patient has said to show it has been heard, and acknowledgement to pick up the cue relating to being patient, then a pause and tentative open directive question to find out more. By recognising and acting on cues, the nurse is able to gain insight about the effect of the illness on the patient in this example. Patient: ‘Well, not very happy. I’m not a patient person, or one that sits about. I don’t get looked after, I do the looking after... I feel like everyone is managing without me now, that I’m not really needed anymore.’

There are few healthcare professionals who do not feel they work under considerable time pressure, and nurses experience it daily. Counterintuitively, recognising and responding to cues improves time management. In studies that explored cue-based consultations specifically, consultations were consistently shorter by 10-12% (Levinson et al 2000, Butow et al 2002). If the consultation is led by the patient and/or carer, the healthcare professional’s conversation can be tailored to elements that have been identified as important for the patient, omitting non-relevant detail, and therefore less time is needed. Complete time out activities 4 and 5 Various cues can be ascertained from the quotes in time out activity 4. However, the quotes cannot also portray whether the

BOX 3 Definitions and examples of core communication skills Skills to keep the consultation patient-focused: Empathising Saying something to show you appreciate (not understand or sympathise) how the other person seems to be feeling. For example: ‘Everything has happened so fast, no wonder you are finding it difficult to take in.’ Making educated guesses Seeing or hearing something (cues) that gives you a hint about how the person is feeling. For example: ‘You are telling me you know what is going to happen, but you look a little confused.’ Looking and listening for cues Cues are hints and can be words, gestures or body language. Noticing verbal and non-verbal cues is important to understanding the patient’s needs. Psychological focus Recognising and responding to emotions, feelings and concerns. Patients appreciate healthcare professionals asking about their feelings. Using pauses and silence Pauses and silence provide a slower pace and will help the person to engage in the conversation and give them time to think what they want to say. Using minimal prompts Small, encouraging words and gestures, for example, nodding or saying ‘go on’. Negotiating Negotiating and asking permission. For example: ‘Would it be okay to talk about what is worrying you?’ Active listening: acknowledging Showing a response to what you are noticing or hearing. For example: ‘I can see you are very upset about this.’ Active listening: summarising A clear way to prove you have heard all the cues, concerns or questions. For example: ‘So what you told me you are concerned about is the treatment, your husband and how long you may need to be off work.’ Reflecting Reflecting is a helpful way to pick up a cue. Reflection can also function like a question, but is easier for the person to respond to. Reflect back to the patient or relative their own words, or use your own words to check that you understand. For example: ‘You have been thinking, what will happen… [pause].’

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4 Identify cues in the three quotes from patients and carers in Box 4, and explain how you noticed these cues. Discuss which cue you noticed first, which are physical and symptom cues, and which may lead you to psychological concerns or a deeper understanding of feelings. 5 Look at the photograph in Figure 1. What non-verbal cues can you identify? Describe what could be going on for this person. How many ideas can you generate

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6 Reflect on the skills discussed, and identify one or two you intend to use consciously in practice as a result of working through these time out activities. Think about how these skills will affect the interactions you have with patients and carers. After several patient and carer interactions, reflect on your communication skills and check if you identified accurately the cues and the insights to be gained from these using effective communication skills.

individuals concerned made eye contact or averted their eyes while speaking, whether the individual’s speech was loud, a whisper, slow or fast, and other non-verbal cues are not known. In quote (A): ‘Hello again, I’m really feeling much better and not sure that I need to be here taking up your time, I hardly notice the pain now’, picking up the three cues in bold would enable the nurse to gain more insight into how this person is feeling and coping with the current situation. Once the nurse has used skills such as reflection to recognise and explore the cues that may indicate the patient is attempting to minimise the symptoms or worry, the nurse could then ask ‘is there something else on

BOX 4 Patient and carer quotes A. ‘Hello again, I’m really feeling much better and not sure that I need to be here taking up your time, I hardly notice the pain now.’ B. ‘I’m not sleeping well at all, I keep going over what’s happened, I can’t take it in, the pain is a bit worse but I’m sure that it’s me thinking about it all the time. My husband keeps telling me to relax and not think about it.’ C. ‘I am so angry, I should have been here last week but the appointment card didn’t arrive until the day after I was due to be here. More time wasted before I get this thing sorted and I can get back to normal.’

your mind?’ to ensure there is the opportunity to express additional thoughts, feelings or concerns before moving on with the discussion. The final part of the conversation can explore any physical symptoms and future appointments. In quote (B): ‘I’m not sleeping well at all, I keep going over what’s happened, I can’t take it in, the pain is a bit worse but I’m sure that it’s me thinking about it all the time. My husband keeps telling me to relax and not think about it’, the listener hears about not sleeping and pain, but the more significant cues for the nurse to recognise and respond to are those highlighted. Using effective communication skills to show you have heard that this person is trying to assimilate and adjust to the news or situation has the potential to reduce anxiety and improve coping. In quote (C): ‘I am so angry, I should have been here last week but the appointment card didn’t arrive until the day after I was due to be here. More time wasted before I get this thing sorted and I can get back to normal’, the important cues relate to the angry emotion, time and the future, which this person hopes will be a time when he or she will have regained health. Anger can often mask other difficult feelings such as fear. These cues provide insight into how an individual is experiencing what is happening to him or her and also how the individual is

References Booth K, Maguire PM, Butterworth T, Hillier VF (1996) Perceived professional support and the use of blocking behaviours by hospice nurses. Journal of Advanced Nursing. 24, 3, 522-527. Brooks W, Heath R (1985) Speech Communication. Seventh edition. Madison, Oxford. Butow PN, Brown RF, Cogar S, Tattersall MH, Dunn SM (2002) Oncologists’ reactions to cancer patients’ verbal cues. Psychooncology. 11, 1, 47-58. Connolly M, Perryman J, McKenna Y et al (2010) SAGE & THYME: a model for training health and social care professionals in patient-focussed support. Patient Education and Counselling. 79, 1, 87-93. Connolly M, Thomas JM, Orford JA et al (2014) The impact of the SAGE & THYME foundation level

workshop on factors influencing communication skills in health care professionals. Journal of Continuing Education in the Health Professions. 34, 1, 37-46. Department of Health (2012) Compassion in Practice. Nursing, Midwifery and Care Staff. Our Vision and Strategy. The Stationery Office, London. Department of Health (2013a) The Cavendish Review. An Independent Review into Healthcare Assistants and Support Workers in the NHS and Social Care Settings. The Stationery Office, London. Department of Health (2013b) More Care, Less Pathway. A Review of the Liverpool Care Pathway. The Stationery Office, London. Dewar B, Pullin S, Tocheris R (2011) Valuing compassion

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through definition and measurement. Nursing Management. 17, 9, 32-37. Donnelly E, Neville L (2008) Communication and Interpersonal Skills. Reflect Press, Exeter. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R (2002) Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. The Lancet. 359, 9307, 650-656. Fletcher I (2006) Patterns of verbal interaction between health professionals and cancer patients. Unpublished PhD thesis, University of Manchester, Manchester. Francis R (2010) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust. January 2005-March

2009. Volume 1. The Stationery Office, London. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office, London. Groogan S (1999) Setting the scene. In Long A (Ed) Interaction for Practice in Community Nursing. Macmillan, London, 9-23. Heaven CM, Maguire P (1998) The relationship between patients’ concerns and psychological distress in a hospice setting. Psychooncology. 7, 6, 502-507. Levinson W, Gorawara-Bhat R, Lamb J (2000) A study of patient clues and physician responses in primary care and surgical settings. Journal of the American Medical Association. 284, 8, 1021-1028.

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adjusting and coping. It is only by noticing, acknowledging and exploring cues like these that we can gain insight into the experience of the person and consequently discover how to support him or her. The cues in the photograph in Figure 1 relate to body language. The man’s seated position, looking down, his clasped hands and his gaze or

FIGURE 1 ISTOCK

Interpret the patient’s body language

Maguire P (1999) Improving communication with cancer patients. European Journal of Cancer. 35, 10, 1415-1422. Maguire P, Booth K, Elliot C, Jones B (1996) Helping health professionals involved in cancer care acquire key interviewing skills – the impact of workshops. European Journal of Cancer. 32A, 9, 1486-1489. Mearns D, Thorne B (2007) Person-Centred Counselling in Action. Third edition. Sage Publications, London. National Institute for Health and Care Excellence (2004) Improving Supportive and Palliative Care for Adults with Cancer. The Manual. NICE, London. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and

focus can be interpreted by nurses to gain more insight into how this patient is feeling. While a nurse may come up with a particular or several interpretations of what he may be feeling, the nurse would need to ask the patient to check what he is thinking or feeling. The nurse could communicate effectively with the patient by using open questions and empathising. Complete time out activity 6

Conclusion Effective communication is a core skill for all healthcare professionals and nursing staff in particular, since nurses spend more time with patients and relatives than any other healthcare professional. Developing rapport is integral to promoting good patient care. Supportive relationships with patients and carers grow from contact with warm, genuine and caring healthcare professionals. When nurses communicate effectively with interest, listen actively and demonstrate compassion, patients may be more likely to report their experiences as positive, even at times of distress and ill health. Nurses have an important role in the care of patients and their loved ones in a variety of healthcare settings. Therefore, every point of contact can be an opportunity to improve patient care and relationships using effective communication NS Complete time out activities 7 and 8

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Stewart MA (1995) Effective physician-patient communication and health outcomes: a review. Canadian Medical Association Journal. 152, 9, 1423-1433.

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Taylor C, Graham J, Potts HW, Richards MA, Ramirez AJ (2005) Changes in mental health of hospital consultants since the mid-1990s. The Lancet. 366, 9487, 742-744.

Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM (1996) Mental health of hospital consultants: the effects of stress and satisfaction at work. The Lancet. 347, 9003, 724-728.

The Free Dictionary (2014) Compassion. www.thefreedictionary. com/compassion (Last accessed: November 19 2014.)

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The Royal Marsden (2014) Connected: National Advanced Communication

7 Consider how confident you are in dealing effectively with communication challenges encountered regularly. Ask a colleague to give you some feedback about what you do well and where you could develop your communication skills. Explore options for attending courses or workshops to develop skills and improve patient care, experience and outcomes. 8 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.

Skills (ACST). www.royalmarsden. nhs.uk/education/school/courses/ pages/connected.aspx (Last accessed: November 10 2014.) Wilkinson S (1991) Factors which influence how nurses communicate with cancer patients. Journal of Advanced Nursing. 16, 6, 677-688. Wilkinson S, Perry R, Blanchard K, Linsell L (2008) Effectiveness of a three-day communication skills course in changing nurses’ communication skills with cancer/palliative care patients; a randomised controlled trial. Palliative Medicine. 22, 4, 365-375. Zimmermann C, del Piccolo L, Mazzi MA (2003) Patient cues and medical interviewing in general practice: examples of the application of sequential analysis. Epidemiologia e Psichiatria Sociale. 12, 2, 115-123.

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