Papers by Sandra van Dulmen
Patient Education and Counseling, Aug 1, 2017
• Communication can influence analogue patient outcomes using a RCT videovignette design. • Posit... more • Communication can influence analogue patient outcomes using a RCT videovignette design. • Positive affect communication can influence outcomes such as anxiety, mood and satisfaction. • Positive expectations can influence outcomes such as self-efficacy and outcome expectancy. • The most positive effects were found when positive affect-oriented communication was combined with positive expectations. • Continued medical training and research are needed to harness the placeboeffects of medical communication into practice.
Women & Health, Sep 1, 2015
The shift of tasks from primary care physicians to practice nurses and the continuing incease in ... more The shift of tasks from primary care physicians to practice nurses and the continuing incease in the numbers of women involved in medical care may have consequences for the provision of health care and communication. The aim of the present study was to examine potential differences in female practice nurses' application of communication skills, practice guidelines, and motivational interviewing skills during consultations with female and male patients. Nineteen female practice nurses and their patients (n = 181) agreed to have their consultations videotaped (during 2010-2011). The videotaped consultations were rated using two validated instruments: the Maas-Global (to assess generic communication skills and practice guidelines) and the Behaviour Change Counselling Index (to assess motivational interviewing skills). Multilevel linear and logistic regression analyses were performed. Female practice nurses provided significantly more comprehensive information during consultations with female patients (p = .03) and talked more about management with male patients (p = .04). Furthermore, nurses applied motivational interviewing skills more clearly during consultations with female than with male patients (p < .01). The shift in tasks from primary care physicians toward practice nurses may have implications for clinical and patient outcomes as patients will no longer be counseled by male professionals. Conceivably, female patients are motivated more by nurses to change their behavior, while male patients receive more concrete management information or advice.
Social Science & Medicine, Jun 1, 2013
Combining the Stages of Change (SOC) model with Motivational Interviewing (MI) is seen as a helpf... more Combining the Stages of Change (SOC) model with Motivational Interviewing (MI) is seen as a helpful strategy for health care providers to guide patients in changing unhealthy lifestyle behaviour. SOC suggests that people are at different stages of motivational readiness for engaging in health behaviours and that intervention methods are most useful when tailored to a person's stage of change. However, it is unknown whether practice nurses (PNs) actually adapt their MI and more generic communication skills to a particular stage during real-life face-to-face consultations with their patients. The aim of this study was to explore whether and how PNs apply MI and general communication skills to the different SOC of patients, targeting behaviour change about smoking, alcohol use, dietary habits and/or physical activity. Real-life consultations between nineteen Dutch PNs and 103 patients were recorded on video between June 2010 and March 2011. All consultations focused on a discussion of patients' lifestyle behaviour. The Behaviour Change Counselling Index (BECCI) was used to code PNs' MI skills. Generic communication skills were rated with the MAAS-global. Patients' SOC was assessed for each consultation by observing the communication between patient and PN regarding the patient's current lifestyle behaviour.
Patient Education and Counseling, Sep 1, 2004
The aim of this review is to identify assessment instruments that can be used for analyzing seque... more The aim of this review is to identify assessment instruments that can be used for analyzing sequences and can be applied to research into nurse-patient communication in cancer care. A systematic search of the literature revealed a variety of methods and instruments applicable to studies recording nurse-patient interaction. The studies that were qualitative in nature offered valuable information on observational research in general, on procedures relating to informed consent and observational arrangements in nursing practice. The quantitative studies provided an insight into the content and structure of the interaction by describing communication concepts or by frequency counts of previously determined behaviours. Systematic research into interaction sequences was not found. However, some of the quantitative instruments identified could be adapted for this purpose. The complexity and time-consuming nature of observational research highlight the need for efficiency. For instance a combination of quantitative and qualitative instruments could be considered.
Health Communication, Mar 3, 2016
The aim of this study was to examine cue-responding behavior at the pharmacy while counseling abo... more The aim of this study was to examine cue-responding behavior at the pharmacy while counseling about inhaled corticosteroids (ICS) in relation to medication adherence and medication beliefs. Patients with asthma aged ≥18 years using ICS were recruited from 12 pharmacies. Counseling sessions were videorecorded. Patients' emotional and informational cues and pharmacists' and pharmacy technicians' cueresponding behaviors were coded using an expanded version of the Medical Interview Aural Rating Scale. The Beliefs about Medicines Questionnaire assessed patients' ICS concern and necessity beliefs. Self-reported ICS adherence was measured by four questions. During the 86 sessions, patients expressed on average 2.3, mostly informational, cues (70.8%). In 26.7% of the sessions, no cues were expressed. Pharmacists' and technicians' responses to emotional cues (59.3%) were mostly inadequate, and to informational cues mostly appropriate (63.6%). Providing inappropriate information (20.3%) was related to higher concerns post session (p < .05), and cue exploration to higher self-reported adherence at 3 months (p < .05). Apparently, providers' responses to patients' cues might have therapeutic value. In addition, patients might need to be encouraged to ask questions and express their concerns. Driesenaar, J.A., Smet, P.A.G.M. de, Hulten, R. van, Noordman, J., Dulmen, A.M. van. Cueresponding behaviors during pharmacy counseling sessions with patients with asthma about inhaled corticosteroids: Potential relations with medication beliefs and self-reported adherence.
Patient Education and Counseling, 2015
Objective: Pre-counseling education helps counselees to prepare for breast cancer genetic counsel... more Objective: Pre-counseling education helps counselees to prepare for breast cancer genetic counseling and might subsequently result in more positive experiences, improved cognitive outcomes and more experienced control. This study assessed the effects of a website with tailored information and a blank sheet to fill in questions (question prompt; QP), at 1 week and 1 year postcounseling. Methods: Consecutive counselees were randomized to the usual care group (UC) or the intervention group (UC + website + QP). Counselees completed questionnaires pre-and post-counseling and 1 year follow-up. We conducted multilevel regression analyses corrected for time. Results: Intervention group counselees (n = 103) were more satisfied about their final visit (β = .35; CI: .06-.65; P = .02; n = 156) than UC group counselees (n = 94). Intervention group counselees also reported more positive experiences with the counseling (β = .32; CI: .
Social Science & Medicine, Sep 1, 2014
The purpose of the study was to assess the counselee participation in the followup visits, compar... more The purpose of the study was to assess the counselee participation in the followup visits, compared to the first visits, for breast cancer genetic counselling and to explore associations with counselees' achievement of their preferred role in decision making, information recall, knowledge, risk perception alignment and perceived personal control. First and follow-up visits for breast cancer genetic counselling of 96 counselees of a Dutch genetics center were videotaped (2008)(2009)(2010). Counselees completed questionnaires before counselling (T1), after the follow-up visit (T2) and one year after the follow-up visit (T3). Consultations were rated with the Roter Interaction Analysis System (RIAS). Counselee participation was measured as the percentage of counselee utterances, the percentage of counselee questions and the interactivity (number of turns per minute). Follow-up visits had higher levels of counselee participation than first visits as assessed by the percentage of counselee talk, the interactivity and counselee questions. More counselee talk in the follow-up visit was related to higher achievement of the preferred role (T2) and higher perceived personal control (T3). Higher interactivity in the follow-up visit was related to lower achievement of the preferred role in decision making and lower information recall (T2). There were no significant associations with the percentage of Albada, A., Ausems, M.G.E.M., Dulmen, S. van. Counselee participation in follow-up breast cancer genetic counselling visits and associations with achievement of the preferred role, cognitive outcomes, risk perception alignment and perceived personal control. Social Science & Medicine: 2014, 116(sept), 178-186 This is a NIVEL certified Post Print, more info at questions asked and none of the participation measures was related to knowledge, risk perception alignment and perceived personal control (T2). In line with the interviewing admonishment 'talk less and listen more', the only assessment of counselee participation associated to better outcomes is the percentage of counselee talk. High interactivity might be associated with lower recall in breast cancer genetic counselees who are generally highly educated. However, this study was limited by a small sample size and a heterogeneous group of counselees. Research is needed on the interactions causing interactivity and its relationships with involvement in decision making and recall. Albada, A., Ausems, M.G.E.M., Dulmen, S. van. Counselee participation in follow-up breast cancer genetic counselling visits and associations with achievement of the preferred role, cognitive outcomes, risk perception alignment and perceived personal control. Social Science & Medicine: 2014, 116(sept), 178-186 This is a NIVEL certified Post Print, more info at Albada, A., Ausems, M.G.E.M., Dulmen, S. van. Counselee participation in follow-up breast cancer genetic counselling visits and associations with achievement of the preferred role, cognitive outcomes, risk perception alignment and perceived personal control. Social Science & Medicine: 2014, 116(sept), 178-186
Familial Cancer, Aug 11, 2013
To optimally inform counselees about their and their relatives' risks, information about lifestyl... more To optimally inform counselees about their and their relatives' risks, information about lifestyle risk factors, e.g. physical activity and alcohol consumption, might be discussed in breast cancer genetic counselling. This study explored whether lifestyle was discussed, on whose initiative, whether information and/or advice was given, and whether discussion of lifestyle was related to counselees' characteristics and their causal attributions. First and follow-up consultations with 192 consecutive counselees for breast cancer genetic counselling were videotaped and coded for discussion of lifestyle topics. Counselees completed web-based questionnaires before the initial and after the final consultation. With 52 (27 %) counselees lifestyle was discussed, either in the first, or the final consultation, or both. Counselees mostly raised the topic (60 %). Counsellors provided information about lifestyle risk factors to 19 % and lifestyle advice to 6 % of the counselees. Discussion of lifestyle was not associated with counselees' characteristics or causal attributions. Postcounselling, more affected counselees considered lifestyle as a cause of their breast cancer (29 %) compared to pre-counselling (15 %; p = 0.003). Information and advice about lifestyle risk factors was infrequently provided, both with breast cancer unaffected and affected counselees and with those who did and did not consider their lifestyle as a cause of their breast cancer. Modifiable lifestyle factors could be discussed more frequently to optimally inform counselees about possible ways to reduce their risk. Counsellors should be educated about effects of lifestyle and research should be conducted on how to best integrate lifestyle information in breast cancer genetic counselling.
European Journal of Clinical Nutrition, Oct 30, 2013
BACKGROUND/OBJECTIVE: To examine the content of Dutch practice nurses' (PNs') advices about weigh... more BACKGROUND/OBJECTIVE: To examine the content of Dutch practice nurses' (PNs') advices about weight, nutrition and physical activity to overweight and obese patients. SUBJECTS/METHODS: A 100 videotaped real-life PN consultations (The Netherlands, 2010/2011) with overweight or obese patients were selected. An observational checklist was developed to assess frequency and content. Personalization of advices was scored, as also the guidelines on which PNs based their advices. Content analysis was used to identify different categories of advices. RESULTS: About one quarter of advices concerned weight, over two-thirds nutrition and one-third physical activity. Lose weight, eat less fat and be more physically active in general were the main categories for each type of advice. Despite high clarity of advices, lower scores were found for specificity and personalization. Very few nutrition advices were provided in combination with physical activity advices. CONCLUSIONS: Weight advices often related to the patient's complaint. PNs seldom set a concrete weight goal. Although benefits of physical activity were discussed, often no practical advices were provided about how to achieve this. Integrated lifestyle advice was not common: advices about nutrition and physical activity were fragmented throughout the consultation. Obesity prevention needs more emphasis in PNs' educational programs.
Patient Education and Counseling, Sep 1, 2013
Objective: To evaluate what information and communication aspects older cancer patients ( ≤ 65) c... more Objective: To evaluate what information and communication aspects older cancer patients ( ≤ 65) consider important in preparing for chemotherapy treatment (CT), the extent to which this corresponds with what oncology nurses consider important, and the extent to which nurses attend to these aspects during real-life educational visits in oncology. Methods: The QUOTE chemo was used to have patients (n = 116) and nurses (n = 123) rate the importance of 66 aspects of patient education. Subsequently, the implementation of these 66 aspects during videotaped nursing visits (n = 155) with older cancer patients receiving CT for the first time was examined. Results: Older cancer patients attached most importance to 'treatment-related information', 'rehabilitation information', 'affective communication' and discussing 'realistic expectations'. Nurses placed great importance to almost all aspects except to discussing 'realistic expectations'. Discrepancies were found between expressed importance and the actual performance during the videotaped consultations, particularly in discussing realistic expectations, coping information, interpersonal communication, and tailored communication. Conclusion: Results pointed to aspects that need improvement to ensure high quality patient education tailored to the patients' needs. Practice implications: To make sure older cancer patients' needs are met, more attention should be paid to the development of interventions supporting both needs assessment and fulfillment.
Patient Education and Counseling, May 1, 2017
To systematically review the literature on the effectiveness of a patient coach intervention on p... more To systematically review the literature on the effectiveness of a patient coach intervention on patient -physician communication in specialists consultations. Methods PubMed, Cochrane, PsycInfo, Cinahl and Embase were searched until November 2015. Included were papers describing interventions directed at adult outpatients in secondary care with a variety of somatic diseases. Outcomes had to be measured in communication effectivity from a patient's perspective. Seventeen publications met the inclusion criteria (involving 3787 patients), describing 13 unique interventions. Most interventions were single one-on-one sessions taking between 20 and 40 min before consultation. Research quality in ten studies was high. These studies showed significant improvement on immediate, intermediate and long term patient -physician communication. We found limited evidence suggesting an improvement of patient -physician communication by having multiple patient coaching encounters during which questions are prepared and rehearsed and consultations are evaluated and reflected upon, sometimes supported by audio recording the consultation. The results of this review contribute to the (re-)design of an effective model for patient coaching, a profile and training approach of patient coaches. Future
European Journal of Clinical Nutrition, Jul 2, 2014
Background/objective: To assess the quality of weight-loss counseling provided by Dutch primary c... more Background/objective: To assess the quality of weight-loss counseling provided by Dutch primary care practice nurses (PNs) to overweight and obese patients including both PNs' compliance with the Five A's Model for behavioral counseling in primary care, and the use of different communication styles. In addition, relationships between PN/patient characteristics (including Five A's) and communication styles will be examined. Subjects/methods: In this observational study, 100 videotaped real-life consultations, collected in 2010/2011, were viewed using an observational checklist. Selection of consultations was based on PNs' registration of patient's complaint. The quality of weight-loss counseling was assessed by the Five A's Model (sequence of evidence-based practice behaviors that are effective for helping patients to change health behaviors) and by PNs' communication styles. Moreover, several PN and patient characteristics were registered. Descriptive statistics and logistic regression analysis were conducted with significance set at P<0.05. Results: PNs most frequently arranged follow-up, assessed the risk and current behavior and advised. However, they rarely assisted in addressing barriers and securing support. For weight or physical activity, most PNs used a motivational communication style. In discussions of nutrition, they mostly used an informational communication style. Moreover, PNs used a combination of communication styles. PN characteristics, including their behavior concerning
Patient Education and Counseling, Nov 1, 2012
To systematically review the literature on the relative effectiveness of face-to-face communicati... more To systematically review the literature on the relative effectiveness of face-to-face communication-related behavior change techniques (BCTs) provided in primary care by either physicians or nurses to intervene on patients' lifestyle behavior. Methods: PubMed, EMBASE, PsychINFO, CINAHL and The Cochrane Library were searched for studies published before October 2010. Fifty studies were included and assessed on methodological quality. Results: Twenty-eight studies reported significantly favorable health outcomes following communica-tionrelated BCTs. In these studies, 'behavioral counseling' was most frequently used (15 times), followed by motivational interviewing (eight times), education and advice (both seven times). Physicians and nurses seem equally capable of providing face-to-face communication-related BCTs in primary care. Conclusion: Behavioral counseling, motivational interviewing, education and advice all seem effective communication-related BCTs. However, BCTs were also found in less successful studies. Furthermore, based on existing literature, one primary care profession does not seem better equipped than the other to provide face-to-face communication-related BCTs. Practice implications: There is evidence that behavioral counseling, motivational interviewing, education and advice can be used as effective communication-related BCTs by physicians and nurses. However, further research is needed to examine the underlying working mechanisms of Noordman, J., Weijden, T. van der, Dulmen, S. van. Communication-related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Education and Counseling: 2012, 89(2), 227-244 This is a NIVEL certified Post Print, more info at communication-related BCTs, and whether they meet the requirements of patients and primary care providers. Noordman, J., Weijden, T. van der, Dulmen, S. van. Communication-related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Education and Counseling: 2012, 89(2), 227-244 Noordman, J., Weijden, T. van der, Dulmen, S. van. Communication-related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Education and Counseling: 2012, 89(2), 227-244
Familial Cancer, Sep 7, 2011
Counselees who are the first in their family to request breast cancer genetic counselling often d... more Counselees who are the first in their family to request breast cancer genetic counselling often don't know what to expect or have unrealistic expectations of genetic counselling. Receiving tailored information might help them to prepare for their first visit. We conducted a study of the effects of a pre-visit website providing computer-tailored information (E-info gene ca ), on counselees' expectations, knowledge about breast cancer and heredity and information needs. Counselees were randomized to receive usual care (UC) or UC plus website. All counselees completed a baseline questionnaire and those randomized to the intervention group also completed a questionnaire after having viewed the website. After having accessed E-info gene ca counselees (n = 101) better knew what to expect of their first visit (χ 2 = 4.43; P = .04) and less often showed unrealistic expectations about possibilities for DNA-testing (χ 2 = 4.84; P = .03) than counselees in the UC group (n = 89). In addition, the website increased counselees' knowledge of breast cancer and heredity (B = .23; P = .003) and lowered their information needs (B = -.16; P = .000) compared to the UC group. Especially, information concerning procedural aspects and emotional consequences of genetic counselling was considered less important. This study showed that counselees know more and need less when they are provided with extended pre-visit information through a tailored website and counselees enter the visit with more realistic expectations of genetic counselling. This might facilitate and focus communication within the subsequent consultation.
Patient Education and Counseling, May 1, 2010
Objective: To investigate older cancer patients' informational and emotional cues, how nurses res... more Objective: To investigate older cancer patients' informational and emotional cues, how nurses respond to these cues and the effect of cues and responses on patients' information recall. Methods: 105 cancer patients (aged ≥65 years) completed a recall questionnaire after an educational session preceding chemotherapy treatment. Recall was checked against the actual communication in videorecordings of the consultations. Patients' emotional and informational cues and subsequent responses by the nurse were rated using an adaptation of the Medical Interview Aural Rating Scale (MIARS). Results: Patients gave more informational than emotional cues. The most frequent response to emotional cues was distancing followed by acknowledgement. Nurses gave appropriate information in response to the majority of informational cues. Patients' expression of emotional or informational cues did not influence recall; neither did nurses' responses to informational cues. Responses to emotional cues did affect recall. The more nurses responded by giving 'minimal' encouragements (e.g. 'Hmmm'), the more patients recalled, while distancing responses (e.g. switching focus) were associated with lower recall scores. Conclusion: Responding to patients' emotions is likely to impact information recall. Practice implications These results highlight the importance of addressing patients' expressions of emotions in the context of patient education, as it enhances information recall.
Patient Education and Counseling, Nov 1, 2009
To study interventions that provide people with information about cancer risk and about screening... more To study interventions that provide people with information about cancer risk and about screening that is tailored to their personal characteristics. We assess the tailoring characteristics, theory base and effects on risk perception, knowledge and screening behavior of these interventions. A systematic literature review in this field was performed. PubMed, EMBASE, PsychINFO, CINAHL and Cochrane databases were searched. Forty studies fulfilled all inclusion criteria. Methodological quality was assessed and a best evidence synthesis conducted for the 28 randomized controlled trials without co-intervention or with similar cointervention in intervention and control group. Most included studies evaluated an intervention aiming to promote cancer screening. The majority of articles (30) evaluated information that was tailored based on variables related to behavior change, sometimes combined with cancer risk factors. Ten other articles described an intervention that tailored information based on risk factors only. Information that was tailored based on behavior change variables increased realistic perception of cancer risks and knowledge of cancer compared to generic information. Also, information tailored to individuals' risk factors increased realistic risk perception compared to generic information. To improve cancer risk perception and knowledge health providers could better give patients information about cancer risk and screening that is tailored to their personal characteristics than generic information.
Health Psychology, 2014
Objective: Patients' recall of provided information during bad news consultations is poor. Accord... more Objective: Patients' recall of provided information during bad news consultations is poor. According to the attentional narrowing hypothesis, the emotional arousal caused by the bad news might be responsible for this hampered information processing. Because affective communication has proven to be effective in tempering patients' emotional reactions, the current study aims to explore in an experimental design whether physician's affective communication in bad news consultations decreases patients' anxiety and uncertainty and improves information recall. Methods: Two scripted video-vignettes of a bad news consultation were used in which physician's verbal communication was manipulated (standard vs. affective condition). Fifty healthy women (i.e. analogue patients) randomly watched one of the two videos. The effect of communication on participants' anxiety, uncertainty, and recall was assessed by self-report questionnaires. Additionally, a moderator analysis was performed. Results: Affective communication reduced anxiety (p = .01) and uncertainty (p = .04), and improved recall (p = .05), especially for information about prognosis (p = .04) and to some extent for treatment options (p = .07). The moderating effect of (reduced) anxiety and uncertainty on recall could not be confirmed and showed a trend for uncertainty. Conclusions: Physicians' affective communication can temper patients' anxiety and uncertainty during bad news consultations, and enhance their ability to
Patient Education and Counseling, Nov 1, 2007
Objective:Active listening is a prerequisite for a successful healthcare encounter, bearing poten... more Objective:Active listening is a prerequisite for a successful healthcare encounter, bearing potential therapeutic value especially in clinical situations that require no specific medical intervention. Although generally acknowledged as such, active listening has not been studied in depth. This paper describes the development of the Active Listening Observation Scale (ALOS-global), an observation instrument measuring active listening and its validation in a sample of general practice consultations for minor ailments. Method : Five hundred and twenty-four videotaped general practice consultations involving minor ailments were observed with the ALOS-global. Hypotheses were tested to determine validity, incorporating patients' perception of GPs' affective performance, GPs' verbal attention, patients' self-reported anxiety level and gender differences. Results:The final 7-item ALOS-global had acceptable inter-and intra-observer agreement. Factor analysis revealed one homogeneous dimension. The scalescore was positively related to verbal attention measured by RIAS, to patients' perception of GPs' performance and to their pre-visit anxiety level. Female GPs received higher active listening scores. The results of this study are promising concerning the psychometric properties of the ALOS-global. More research is needed to confirm these preliminary findings. Practice implications: After establishing how active listening differentiates between health professionals, the ALOS-global may become a valuable tool in feedback and training aimed at increasing listening skills.
Patient Education and Counseling, 2017
Objective: Listening is at the very heart of communication in healthcare, but largely ignored in ... more Objective: Listening is at the very heart of communication in healthcare, but largely ignored in research and teaching. This paper presents different perspectives on listening within the context of healthcare and its implications for goal-directed communication. Methods: The assets of listening are examined from several angles (the listening patient, the listening health professional, and the listening self) and illustrated by the results of relevant research. Results: Listening is a multidimensional concept and serves different purposes in healthcare. To benefit fully from it's potentials, the listening attitude and skills of patients and health professionals need to be enhanced through interventions at the level of policy, practice and research. Results from research evaluating creative and innovative ways of strenghtening persons' listening skills are encouraging. Conclusion: Listening has underused potential which can be boosted by interventions directed at the level of healthcare policy, practice and research. Practice implications For healthcare practice, it is helpful to keep in mind that listening involves more than hearing what the other person says; one also needs eyes, a heart, and undivided attention.
Journal of Psychiatric and Mental Health Nursing, 2015
• A core skill of practice nurses' mental health is to recognize and explore patients' unpleasant... more • A core skill of practice nurses' mental health is to recognize and explore patients' unpleasant emotions. • Patients rarely express their unpleasant emotions directly and spontaneously, but instead give indirect signs that something is worrying them. • Patients with mild psychosocial and psychological problems provide signs of worrying or express a clear unpleasant emotion in 94% of consultations with a practice nurse mental health. • Nurses' responses to patients' signs of worrying or clear unpleasant emotions were mostly characterized by providing space for patients to talk about these emotions, by using minimal responses. • Practice nurses' mental health have passive listening skills, and to a lesser extent, use active listening techniques. • Accurate emotion detection and the ability to pick out emotional signs during consultations must also be considered as an important skill for health providers • to improve patient-centred communication.
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Papers by Sandra van Dulmen