As we all know, the communication skill is one of the most important professional skills in doctors daily work. When doctors use communication skills effectively, the benefit is bidirectional for both doctor and patients (Maguire & Pitceathly, 2002). Not only could patients problems be understood more fully and precisely, but also they will be more satisfied with the consultation and understand their problems and treatment better. It has been demonstrated repeatedly that patients are more likely to adhere to treatment and follow advices, even have better outcomes, when communication is successful (Street,1991; Hall et al., 2002;Tates & Meeuwesen, 2000; Hall et al., 1988; Roter, 1989; Van Dulmen, 1998; Aronsson& Rundstrom,1988; Pantell et al.,1982; Meeuwesen et al., 1996; Korsch et al., 1968; Korsch &Gozzi, 1968; Winter et al., 1999;Tates et al., 2002; Roter et al., 1987, as cited in Howells et al., 2006). Studies have also reported that patients and doctors both showed reduction in emotional distress when used better communication skills (Roter et al., 1995; Ramirez et al.1996). For health professionals in a paediatric department, communication is even more essential, because they are usually confronted with more complex doctor-patient relationships, which comprise both children and their parents. Evidence had been presented that children over the age of 5 years should be presumed competent to be involved in their own healthcare choices (Alderson ,& Montgomery,1996, as cited in Cahill & Papageorgiou, 2007). So this essay will primarily talk about children over 5 years old. Needless to say, children should be invited in to consultations by using appropriate communication skills. And doctors need to use proper communication skill to set up good relations with both children and their parent. In addition, in some special situations such as when breaking bad news to patients and their families, health professionals should communicate with children and parents in a more sensitive way. Furthermore, communication skills could be improved by appropriate training, so adequate training should be introduced to all health professionals in a paediatric department.
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Children, namely patients, as the core part of the communication, deserve most of the attention. On the contrary, although the doctor Cpatient relationship has been evolved from an autocratic and paternalistic dyad one into a more equal one (Ong LML et al., 1995). The role of children in the medical conversation has usually been ignored (Pantell et al., 1982; Tannen & Wallat, 1983; Aronsson & Rundstro, 1988, as cited in Tates K, Meeuwesen L., 2001). Sometimes, the parents rather than the children are considered to be the patients ( Korsch et al. ,1985, p. 865, as cited in Tates K, Meeuwesen L., 2001). And research has been focused mainly on dyadic interactions between adults. Studies suggested that children had little involvement in consultations (Wassmer et al., 2004; Cahill, & Papageorgiou, 2007). There are various reasons: firstly, young children s language ability is poor, they can not express their feelings and requirements effectively, so the parents usually speak for them (Tates et al., 2002). Study showed that children s switching pause is longer than adult (Garvey & Berninger, 1981, as cited in Cahill, & Papageorgiou, 2007). Thus, parents answer questions for them when they take too long time in conversations. Particularly, outdoor patients usually do not have much time communicate with doctors. Secondly, young children s cognitive ability and mental status usually are defined incompetent to understand the illness or to take responsibility for themselves by both doctors and their parents. And health professionals are more inclined to involve older children in medical interactions (Tates & Meeuwasen, 2000; Deatrick 1984; Alderson 1993, as cited in Coyne, 2006). Therefore, sometimes the doctors would rather talk to the parents when the children were too young. Moreover, parents frequently interrupt the children-doctors conversations just to voice their own concerns (Cahill, & Papageorgiou, 2007). Fourthly, not all the children want to participate in the consultations. Some children reluctant to talk to doctors, especially when they are sick, being sensitive and vulnerable.
However, in recent years, as parents becoming less repressive and authoritarian (De Swaan, 1988, as cited in Tates,& Meeuwesen, 2001) , attention has been paid on children s right increasingly, and more and more people become to realize that children have right to be involved and actively participate in consultations (Wassmer et al., 2004; Mayall 1994, 1995,1996; Roche 1999, as cited in Coyne, 2006). And
it has been increasingly recognized that children should be involved in decision making of their own health care (Alderson & Montgomery, 1996; Rylance, 1996; Hart & Chesson, 1998, as cited in Tates K, Meeuwesen L. 2001).Studies indicated some parents thought taking part in consultations could help children to improve self-esteem and self-concept(Angst, & Deatrick, 1996; Coyne, 2006). And it is a good opportunity to develop their skills and experience of participating in medical consultations, which is also one of the goals of the medical interaction. At the same time, there also research reported that children wanted to have information and to participate in decision-making processes since they were in primary school age (Rylance et al., 1995). Actually, children appear to be more competent to provide information than generally has been assumed. A lot of studies suggested that direct communication between doctors and children contributes to an development in satisfaction with care and adherence to treatment, and would produce better health outcomes (Pantell et al., 1982; Colland, 1990; Holtzhei- mer et al., 1998, as cited in Tates, & Meeuwesen , 2001). Hence, with no doubt, children should be invited into consultations, but how?
As a matter of fact, children can participate in the consultations when communication skills are used appropriately by health professionals. Cahill & Papagergiou (2007a) analyzed the video recordings of real consultations in paediatric department. They found that both verbal and nonverbal methods could help inviting children to join the communication. First of all, when the child and the doctor sat next to each other without parent between them, the child was more likely to participate in the consultation. In order to communicate better with children and their parents at the same time, many doctors used a triangular seat arrangement, by which doctors could switch the objects of conversations more easily. It was indicated that children participated more than when in a liner seat arrangement, so it might provide valuable guidance to clinicians. Moreover, eye contact also played an important role. When the doctor gaze was directed at the child and addressed child s name, the patient was more inclined to respond to the doctor, and the parent was more likely not to answer for the child. An effective method to encourage children to participate in consultations is to let both children and the parents know that doctors want children rather than parents to answer questions. In addition, Children have their own special communication styles, which considerably different from adults. It was found that children should be given more time to answer questions, and they preferred to answer closed questions rather than open ones. Doctors are trained to use open questions as a communication skill in the consultations, which would encourage patients to talk about their problems without limitations or thinking formulary. However, in paediatric department, doctors should use different wordings between adults and children to make sure children could be more involved in consultations. There was also study reported that doctors often talk to children using different type of speech which has been called as motherese (Tannen, & Wallat, 1983, as cited in Cahill & Papagergiou, 2007). By using a simplified and repetitive type of speech and exaggerated intonation and rhythm, doctors tried to be more understandable and invited the children to join in the consultations. Furthermore, when children fail to express themselves by utterance, doctor need to appeal to nonverbal clues, such as facial expressions and body language. Studies supported that perceiving facial expression accurately would help health professionals to interpreting the pain patients were experiencing and to evaluate patients emotional state (Mentes et al., 2004; Achinard, 2000, as cited in Endres, & Laidlaw, 2009). So in paediatric department, by decoding children s nonverbal behaviour, health professionals would obtain more information. In a pilot study, METT (Micro Expression Training Tool) has been used to improve medical students ability of recognizing facial micro-expression, after training the students recognized as good communicators significantly improved in the recognition of micro-expressions (Endres,& Laidlaw, 2009).That indicated METT could be an important tool to improve doctors communication skills.
However, there were considerable evidences supporting that in the medical communications, children s contribution was still small (Nova et al.,2005; Tates et al., 2002; Tates, & Meeuwasen,2000; Cahill, & Papageorgiou, 2007a; Cahill, & Papageorgiou, 2007b ; Wassmer et al., 2004). Although recent legislation required children to be adequately informed, in pediatric consultations information still tended to be directed primarily at the parents. Children do get the opportunity to talk, but most of them were about social and psychosocial issues rather than the medical-technical ones (Van Dulmen, 1998). And they participated in information gathering but were unlikely to take part in the treatment planning(Cahill& Papageorgiou,2007b ). Some studies argued that children should be involved into consultations integrated with their particular needs, cognitive ability and mental state (Coyne, 2006).Sometimes children may not desire to involve in decision making of their care, because they feel sick and vulnerable. They may just want to be informed and have their view heard. Thus, to what extent children should be involved in consultations still need to be investigated by further research and it may be different from individuals.
On the other hand, parent plays another important role in the triadic interaction. First of all, when children get ill, parents usually unavoidably feel stressed, anxious and depressed, which may have a strong effect on children s mood. Doctors need to be patient listeners, letting parents express their emotions. A study illustrated that when parents had expressed their concerns early in the consultations they would less interrupt into doctor-child conversations, so children could participated more in the consultations. And it was also found that children were more likely to be involved in consultations when both the adults, doctors and parents, are supportive to their participation (Tates et al., 2002). On the contrary, if the parent does not support of involving child in consultations and keep interrupting into the doctor-child conversation, it is possible to become a doctor Cadult dyad, having the child being excluded out of the conversation (Cahill, & Papageorgiou, 2007a). In such a situation, the doctors who tend to direct the interview and have the power to invite participants to the consultation, need to keep a balance between children and parents. On one hand they have to give signals to children, encouraging them to participate in the conversations. On the other hand, they have to respect the parental authority. Doctors should allocate turns in conversations properly. Secondly, patients often demonstrate a need of great varieties of information which includes diagnosis, treatment plan, and prognosis. They usually feel unsatisfied with the amount, quality and consistency of information provided by professionals (Hummelinck, & Pollock, 2005). However, some parents seek for information actively, but at the same time, they are afraid to hear the bad news. One study has found that superabundant information also have negative influence. When information provision and shared decision-making exceed the patient s needs, mental strain and anxiety will increase and their confidence will reduce (Fisher, 2001). Therefore, doctors need to provide information which meet parents requirements but not unnecessarily increase their stress or insecurity (Hummelinck, & Pollock, 2005).
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Breaking bad news is one of the most difficult tasks for health professionals. In a paediatric department, for most of the time, doctors need to disclose bad news to the parents rather than the children themselves. And the way it is done may have a profound effect on the relationship between doctors, parents and their children. A study reported that when bad news was communicated badly, it could lead to confusion, disbelief, recrimination, long lasting distress, anger or even litigation. But when it communicated in an appropriate way, it could improve understanding, acceptance, and adjustment (Fallowfield, & Jenkins, 2004). Delivering bad news could be particularly stressful for physicians, especially in the early stages of their careers. Doctors had been reported to be low in confidence in this skill, particularly in the paediatric setting (Charlton, 2000, as cited in Horwitz, & Ellis, 2007). Study showed that parents never felt adequately prepared for their child’s death, even when there had been a period of severe illness (Finlay I, Dallimore D.1991). And sometimes parents could not distinguish between their personal reactions to the bad news itself and their reactions to the way doctors had informed them. That makes breaking bad news more difficult. A questionnaire survey has been conducted to investigate parents who had experienced death of their child. Many parents criticized the poor communication with the health professionals (Finlay, & Dallimore, 1991). The study also elaborated the most appreciated way in which the bad news was broken. The parents felt more satisfied if the interviews were unhurried and conducted in private. The parents appreciated informants who were confident had showed an understanding and caring attitude. They reported that it made them feel more supported when being aware that the informant was also upset. Parents needed sufficient time to talk and ask questions, with the interviewers checking that they had understood the news, which made them feel being respected. Moreover, parents also needed health professionals to provide subsequent information and help. How to break bad news have been discussed and described in many papers. In the year 2000, a 6 step protocol for breaking bad news was set up by Baile and his colleagues. The protocol SPIKEST has been implemented by oncologists, oncology trainees, and medical students. Almost all of them were satisfied with the improvements and reported increased confidence in their ability to reveal bad medical information to patients. It not only facilitated the clinician to gather information but also helped providing intelligible information meet the patient s needs. In addition, it also assisted doctors to develop treatment plans for the patients in the future (Baile et al., 2000). So SPIKEST may be an applicable tool to improve the communication skill of breaking bad news in paediatric department. On the other hand, health professionals also need to communicate with the patients in a bad health situation. A study suggested that nurses could use play therapy in paediatric palliative care to help both children and their parents (Camara van Breemen, 2009). It pointed that play is the language of children (Axline, 1969, as cited in Camara van Breemen, 2009). And through play expression, health professionals could set up a safe and permissive relationship which let the children to feel free to explore and express self completely. They could communicate with children about their fears, hopes. (Sourkes, 1995; Worden, 2000, as cited in Camara van Breemen, 2009). Play also could make a discussion of death a normal part of a child s experience (Worden, 2000). So it could be used as a special communication method in communicating with dying children.
Unfortunately, the traditional apprenticeship methods usually failed to equipped medical students with sufficient communication skills. Study also reported that many doctors of paediatric department were using inadequate communication skills ( Ejaz et al., 2010), so various studies have been focused on finding effective method to improve communication skills of health professionals. In one study, it was found that medical students who got feed back training with television and audiotape replay would have a significant improvement in communication skills, and only the television group recorded significantly more information on their written histories (Maguire et al., 1978). Another study supported that the medical students who had video feedback training got significantly better score of communication skills than those who had conventional training. And their superiority was long-lasting (Maguire et al., 1986). That indicated video feedback should be an effective method to improve communication skills. It is worth mentioning that although being video recorded can increase the anxiety of the participants, video or audio playback has greater impact on communication behaviour than individual feedback alone (Maguire et al., 1978). Recordings of consultations enable participants to see or hear exactly the nonverbal and verbal behaviour and the effect it has on the patients. Therefore feedback plus video recorded interviews result in greater changes to communication behaviours. Moreover, actors have been recruited as simulated patients in the training to create a safe environment for rehearsing communication skills, which is widely used in medical curricula. And doctors could not distinguish the simulated patients from the real patients (Maguire et al., 1986). In addition, another study suggested that doctor should simulate patients they had known well, by which they could get the insight into how the patients feel about different communication skills (Maguire and Pitceathly, 2002). These training methods could also be used in paediatric departments. There was a study elaborated that there was no relationship between age and communication skills, and doctors became fixed in their style of interviewing soon after qualifying, which indicated that effective training should to be conducted in the early professional years (Byrne, & Long, 1976, as cited in Maguire et al., 1986). However, another study showed that communication training after residency still could improve paediatricians’ communication skills. This 5-day communication training contained: a) education on the significance of communication, b) theoretical and practical homework and application of what was learned between sessions, c) role-playing exercises, d) trainers’ and colleagues’ feedback of videotaped and role-play interaction style, and e) discussion of their own experiences (Alexandra et al.,2000). Compared with the control group, trained health professionals not only asked more psychosocial questions but also have more direct gaze on the patients and their parents. Although they gave patients and parents more room to talk, the length of the interviews was not longer than control group. On the basis of these findings, it is worthwhile to conduct continuing education in communication skills in the paediatric department. And this training method also has instructive function for practice in paediatric department. But it is still not sure how long the effects of this training will last, so further research still need to examine the performance of the trained doctors in a long period. Furthermore, communication training should not only involve doctors but also should include nurses and any other relevant health professionals in the paediatric department. That will enable health professionals of different group to look at problems from various angles, which will facilitate them best communicate with patients and their parents. There was a study recruited both nurses and doctors. It aimed to evaluate a training program which designed to improve the communication skills of breaking bad news in paediatric setting (Farrell et al., 2001). In the workshop both facilitators and participants were from varied backgrounds, which reflected meaningful collaboration and demonstrated a shared learning approach. It also promoted the cooperation of the health professionals in paediatric department. Although considerable research has been done in communication skills training for doctors and other health professionals, there is little to test the actual result of such training on patients and parents satisfaction. However, that may be one of the most important standards to evaluate the communication skills. Thus, further research about communication training should consider more about the feedback from the patients and parents.
In conclusions, communication in paediatric department is a complicated prosess. Not like the traditional dyadic doctor-patient relationship, there is a triadic doctor-parent-child interaction in paediatric consultation. So it is a little hard for doctors to keep a balance between children and their parents. Although in substantial studies, children’s role in medical conversation is frequently ignored, they should be invited into consultations. Children and their parents are both important in consultations. But to what extent children should be involved still need to be investigated. Health professionals need to use appropriate communication skill to break bad news, because it will exert a lasting impact on patients and their parents. However, many health professionals of paediatric department are still using inadequate communication skills. Accordingly, communication skills could be improved by appropriate training. Further investigation is required of a more feasible and effective training method which could be introduced to both medical schools and hospitals.
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