The Open Nursing Journal




ISSN: 1874-4346 ― Volume 14, 2020
OPINION ARTICLE

Promoting Effective Nurse-Patient Communication in Palliative Care Using the SAGE and THYME Model: Can it be Implemented Cross-Culturally?



Seng H. M. Ang1, *
1 School of Health and Social Science, Nanyang Polytechnic, Ang Mo Kio, Singapore

Abstract

Effective communication in palliative care is essential in making optimal health care decisions that align with the interests of the patients and empowering them to be involved in their care planning. However, many Asian nurses lacked the prerequisite communication skills required to assess and address the informational needs of advanced cancer patients. These nurses often adopt a routinized approach of giving information to patients to overcome their inadequacies in eliciting patients’ concerns. Thus, this opinion paper seeks to understand whether the SAGE and THYME model can be utilised widely by nurses across different cultural contexts to facilitate more effective communication and to develop therapeutic relationships with advanced cancer patients who are receiving palliative care.

Keywords: Information, Relationship, Cancer, Palliative, SAGE, THYME.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 153
Last Page: 155
Publisher Id: TONURSJ-13-153
DOI: 10.2174/1874434601913010153

Article History:

Received Date: 18/06/2019
Revision Received Date: 10/07/2019
Acceptance Date: 30/07/2019
Electronic publication date: 25/09/2019
Collection year: 2019

© 2019 Seng Hock Martin Ang.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the School of Health and Social Science, Nanyang Polytechnic, Ang Mo Kio, Singapore; Tel: +6592213363;
E-mail shangmartin@gmail.com






1. INTRODUCTION

Effective communication in palliative care is a powerful therapeutic tool which, when used appropriately, can lead to inculcate a sense of empowerment in patients, encourage them to make good decisions and make them feel to be a part of care planning [1Schofield NG, Green C, Creed F. Communication skills of health-care professionals working in oncology can they be improved? Eur J Oncol Nurs 2008; 12(1): 4-13.
[http://dx.doi.org/10.1016/j.ejon.2007.09.005] [PMID: 18446927]
]. Studies have found that patients living with life-limiting illness often experience emotional distress and require informational support to improve their psychosocial adjustment, as well as to cope with their physical concerns [2Kvåle K. Do cancer patients always want to talk about difficult emotions? A qualitative study of cancer inpatients communication needs. Eur J Oncol Nurs 2007; 11(4): 320-7.
[http://dx.doi.org/10.1016/j.ejon.2007.01.002] [PMID: 17446134]
-4Marcusen C. Information and communication needs of individuals living with advanced cancer. Semin Oncol Nurs 2010; 26(3): 151-6.
[http://dx.doi.org/10.1016/j.soncn.2010.05.006] [PMID: 20656138]
].

As many as one in three adult late-stage cancer patients suffer from either anxiety or depression [5Chong PH, Poon WH. The lived experience of palliative homecare nurses in Singapore. Singapore Med J 2011; 52(3): 151-7.
[PMID: 21451922]
]. Effective communication can help provide much-needed safety and comfort through transmitting open, honest and accurate information and by eliciting the concerns of patients [3Lloyd-Williams M. Psychosocial issues in palliative care 2nd ed. 2008.
[http://dx.doi.org/10.1093/acprof:oso/9780199216420.001.0001]
]. The communicative behaviors of nurses can assist these patients to resolve their problems and integrate the illness into their daily lives by offering additional information that addresses their concerns [6Stajduhar KI, Thorne SE, McGuinness L, Kim-Sing C. Patient perceptions of helpful communication in the context of advanced cancer. J Clin Nurs 2010; 19(13-14): 2039-47.
[http://dx.doi.org/10.1111/j.1365-2702.2009.03158.x] [PMID: 2092 0030]
].

The SAGE and THYME model is a robust, structured and accessible form of communication model that has the function of facilitating the nurses in interacting effectively and developing therapeutic relationships with patients living with advanced cancer who are receiving palliative care. Thus, this opinion paper aims to identify whether the SAGE and THYME framework can be utilized widely by nurses across different cultural contexts given that studies on this communication model were conducted entirely in a Western context.

2.1. The SAGE and THYME Communication Model

The SAGE and THYME model helps to guide the nurses through the active cycle of empathetic listening to identify and address the key concerns of patients living with advanced cancer [7Griffiths J, Wilson C, Ewing G, Connolly M, Grande G. Improving communication with palliative care cancer patients at home: A pilot study of SAGE & THYME communication skills model. Eur J Oncol Nurs 2015; 19(5): 465-72.
[http://dx.doi.org/10.1016/j.ejon.2015.02.005] [PMID: 25782722]
]. Table 1 shows the SAGE and THYME model.

Table 1
The SAGE and THYME Model.


Within this model, ‘SAGE’ reminds the nurses to arrange the Setting to provide some privacy, Ask their patients about their major concerns, Gather all their concerns, and show Empathy by being sensitive to their feelings [8Connolly M, Thomas JM, Orford JA, et al. The impact of the SAGE & THYME foundation level workshop on factors influencing communication skills in health care professionals. J Contin Educ Health Prof 2014; 34(1): 37-46.
[http://dx.doi.org/10.1002/chp.21214] [PMID: 24648362]
]. As for ‘THYME’, it prompts the nurses to ask the patients whether is there anyone they have Talk to regarding their concerns?, does it Help after talking to them?, is there any solutions that the patients (You) believe would help?, and is there anything that they would like the nurses (Me) to help? followed by summarizing their concerns to End the conversation [7Griffiths J, Wilson C, Ewing G, Connolly M, Grande G. Improving communication with palliative care cancer patients at home: A pilot study of SAGE & THYME communication skills model. Eur J Oncol Nurs 2015; 19(5): 465-72.
[http://dx.doi.org/10.1016/j.ejon.2015.02.005] [PMID: 25782722]
].

2.2. Cross-Cultural Communication in Palliative Care

As compared to the nurses in the Western contexts, most Asian nurses often adopt a routinized approach of giving information to patients given that they are not sufficiently equipped with the required prerequisite communication skills and are not capable of interacting effectively with advanced cancer patients to identify and explore their information needs [2Kvåle K. Do cancer patients always want to talk about difficult emotions? A qualitative study of cancer inpatients communication needs. Eur J Oncol Nurs 2007; 11(4): 320-7.
[http://dx.doi.org/10.1016/j.ejon.2007.01.002] [PMID: 17446134]
]. As a result, they have the tendency to quickly make an advice before their patients have had a chance to fully express their needs to overcome their inadequacies in eliciting their concerns [3Lloyd-Williams M. Psychosocial issues in palliative care 2nd ed. 2008.
[http://dx.doi.org/10.1093/acprof:oso/9780199216420.001.0001]
, 8Connolly M, Thomas JM, Orford JA, et al. The impact of the SAGE & THYME foundation level workshop on factors influencing communication skills in health care professionals. J Contin Educ Health Prof 2014; 34(1): 37-46.
[http://dx.doi.org/10.1002/chp.21214] [PMID: 24648362]
, 9Lau LK, Mok E, Lai T, Chung B. Quality-of-life concerns of Chinese patients with advanced cancer. Soc Work Health Care 2013; 52(1): 59-77.
[http://dx.doi.org/10.1080/00981389.2012.728560] [PMID: 23301935]
].

Besides, cross-culturally, nurses in both Western and Asian contexts find it challenging to withstand the desire to resolve patients’ problem whenever a concern is raised, which is one of the most common blocking behaviors [10Lobb EA, Lacey J, Kearsley J, Liauw W, White L, Hosie A. Living with advanced cancer and an uncertain disease trajectory: An emerging patient population in palliative care? BMJ Support Palliat Care 2015; 5(4): 352-7.
[http://dx.doi.org/10.1136/bmjspcare-2012-000381] [PMID: 2464 4173]
-12Tay LH, Hegney D, Ang E. Factors affecting effective communication between registered nurses and adult cancer patients in an inpatient setting: A systematic review. Int J Evid Based Healthc 2011; 9(2): 151-64.
[http://dx.doi.org/10.1111/j.1744-1609.2011.00212.x] [PMID: 2159 9844]
]. Studies found that these nurses offer advice prematurely to end-of-life cancer patients, which may significantly constrain them from disclosing more about their anxiety and distress, and that the information given may not actually focus on their key concerns [6Stajduhar KI, Thorne SE, McGuinness L, Kim-Sing C. Patient perceptions of helpful communication in the context of advanced cancer. J Clin Nurs 2010; 19(13-14): 2039-47.
[http://dx.doi.org/10.1111/j.1365-2702.2009.03158.x] [PMID: 2092 0030]
, 9Lau LK, Mok E, Lai T, Chung B. Quality-of-life concerns of Chinese patients with advanced cancer. Soc Work Health Care 2013; 52(1): 59-77.
[http://dx.doi.org/10.1080/00981389.2012.728560] [PMID: 23301935]
, 13Costello J. Nursing the dying patient 2004.
[http://dx.doi.org/10.1007/978-1-137-26647-7]
, 14Tay LH, Ang E, Hegney D. Nurses’ perceptions of the barriers in effective communication with inpatient cancer adults in Singapore. J Clin Nurs 2012; 21(17-18): 2647-58.
[http://dx.doi.org/10.1111/j.1365-2702.2011.03977.x] [PMID: 2233 2954]
].

Together, these communicative behaviors can potentially cause advanced cancer patients to make incorrect assumptions about nurses for being unwilling to interact and connect with them, which subsequently can lead to dissatisfaction and impede the nurse-patient relationships [11Tan JXJ. The use of effective therapeutic communication skills in nursing practice. Spore Nur J 2009; 36: 35-8.]. Furthermore, failure to provide patients with appropriate information that addresses their psychosocial needs and physical concerns can significantly affect their quality of life and ability to make informed decisions about their own care, leading to unnecessary emotional distress [15Thorne SE, Bultz BD, Baile WF. Is there a cost to poor communication in cancer care?: A critical review of the literature. Psychooncology 2005; 14(10): 875-84.
[http://dx.doi.org/10.1002/pon.947] [PMID: 16200515]
].

2.3. Effectiveness of the SAGE and THYME Model

To enhance the Asian nurses’ communication skills and minimize their blocking behaviors, the SAGE and THYME model is an ideal framework that guides the nurses to utilize evidence-based communication skills such as active listening, empathy and empowerment to support them in withholding their advice before the patients have fully disclosed their needs and concerns [16Maskor NA, Krauss SE, Muhamad M, Nik Mahmood NH. Communication competencies of oncology nurses in Malaysia. Asian Pac J Cancer Prev 2013; 14(1): 153-8.
[http://dx.doi.org/10.7314/APJCP.2013.14.1.153] [PMID: 23534716]
]. Such communication behaviors are considered to be universal, which can be implemented cross-culturally, and are useful in minimizing the nurses’ use of blocking behaviors which can inhibit the patients from revealing more about their distress [11Tan JXJ. The use of effective therapeutic communication skills in nursing practice. Spore Nur J 2009; 36: 35-8.]. In this way, the nurses are able to gain a deeper understanding of the patients’ cancer-related concerns before giving them the appropriate advice to help them maximize their psychological adjustments and improve their quality of life [6Stajduhar KI, Thorne SE, McGuinness L, Kim-Sing C. Patient perceptions of helpful communication in the context of advanced cancer. J Clin Nurs 2010; 19(13-14): 2039-47.
[http://dx.doi.org/10.1111/j.1365-2702.2009.03158.x] [PMID: 2092 0030]
].

The SAGE and THYME model is structured in a way that it facilitates the Asian nurses through patient-centered assessment and simple problem-solving to evaluate patients’ level of informational needs and to empower them to utilize their existing coping methods to resolve their concerns [13Costello J. Nursing the dying patient 2004.
[http://dx.doi.org/10.1007/978-1-137-26647-7]
]. Giving too little or too much information may increase patients’ likelihood of experiencing anxiety and emotional distress, which may affect their overall well-being [7Griffiths J, Wilson C, Ewing G, Connolly M, Grande G. Improving communication with palliative care cancer patients at home: A pilot study of SAGE & THYME communication skills model. Eur J Oncol Nurs 2015; 19(5): 465-72.
[http://dx.doi.org/10.1016/j.ejon.2015.02.005] [PMID: 25782722]
, 14Tay LH, Ang E, Hegney D. Nurses’ perceptions of the barriers in effective communication with inpatient cancer adults in Singapore. J Clin Nurs 2012; 21(17-18): 2647-58.
[http://dx.doi.org/10.1111/j.1365-2702.2011.03977.x] [PMID: 2233 2954]
, 17Rainbird K, Perkins J, Sanson-Fisher R, Rolfe I, Anseline P. The needs of patients with advanced, incurable cancer. Br J Cancer 2009; 101(5): 759-64.
[http://dx.doi.org/10.1038/sj.bjc.6605235] [PMID: 19654579]
].

Although, much of the literature found that majority of the advanced cancer patients want to have information about their prognosis or disease progression to preserve hope by staying positive and to triumph over the forces of negative emotions and maintain a sense of control over their lives, the level of information needs differs between patients [6Stajduhar KI, Thorne SE, McGuinness L, Kim-Sing C. Patient perceptions of helpful communication in the context of advanced cancer. J Clin Nurs 2010; 19(13-14): 2039-47.
[http://dx.doi.org/10.1111/j.1365-2702.2009.03158.x] [PMID: 2092 0030]
, 10Lobb EA, Lacey J, Kearsley J, Liauw W, White L, Hosie A. Living with advanced cancer and an uncertain disease trajectory: An emerging patient population in palliative care? BMJ Support Palliat Care 2015; 5(4): 352-7.
[http://dx.doi.org/10.1136/bmjspcare-2012-000381] [PMID: 2464 4173]
]. Given that uncertainty allows patients to gain a sense of normalcy and independence in their daily lives instead of living with an overwhelming fear of impending death [9Lau LK, Mok E, Lai T, Chung B. Quality-of-life concerns of Chinese patients with advanced cancer. Soc Work Health Care 2013; 52(1): 59-77.
[http://dx.doi.org/10.1080/00981389.2012.728560] [PMID: 23301935]
]. In this way, they are able to acquire greater control over their lives by adopting an active role rather than the sick role [14Tay LH, Ang E, Hegney D. Nurses’ perceptions of the barriers in effective communication with inpatient cancer adults in Singapore. J Clin Nurs 2012; 21(17-18): 2647-58.
[http://dx.doi.org/10.1111/j.1365-2702.2011.03977.x] [PMID: 2233 2954]
].

Besides, employing the SAGE and THYME model allows Asian nurses to develop meaningful and sustained relationships with advanced cancer patients, which is the key towards showing the patients their willingness to connect with them and to establish a healing environment that optimizes their health outcomes [6Stajduhar KI, Thorne SE, McGuinness L, Kim-Sing C. Patient perceptions of helpful communication in the context of advanced cancer. J Clin Nurs 2010; 19(13-14): 2039-47.
[http://dx.doi.org/10.1111/j.1365-2702.2009.03158.x] [PMID: 2092 0030]
]. When a quality relationship is cultivated and developed, patients are more likely to reveal their distress and seek informational support from the nurses [13Costello J. Nursing the dying patient 2004.
[http://dx.doi.org/10.1007/978-1-137-26647-7]
]. This also allows them to feel cared for as an individual and reassures them by giving them a sense of hope that the nurses have a continuing responsibility of their care in spite of their poor prognosis [6Stajduhar KI, Thorne SE, McGuinness L, Kim-Sing C. Patient perceptions of helpful communication in the context of advanced cancer. J Clin Nurs 2010; 19(13-14): 2039-47.
[http://dx.doi.org/10.1111/j.1365-2702.2009.03158.x] [PMID: 2092 0030]
].

2.4. Limitation of the SAGE and THYME Model

The most substantial limitation of the SAGE and THYME model is that it is not suitable for delivering bad news to patients who are newly diagnosed with terminal cancer and dealing with patients who are in denial about their cancer conditions [3Lloyd-Williams M. Psychosocial issues in palliative care 2nd ed. 2008.
[http://dx.doi.org/10.1093/acprof:oso/9780199216420.001.0001]
, 18Connolly M, Perryman J, McKenna Y, et al. SAGE & THYME: A model for training health and social care professionals in patient-focussed support. Patient Educ Couns 2010; 79(1): 87-93.
[http://dx.doi.org/10.1016/j.pec.2009.06.004] [PMID: 19628353]
]. Given that, this framework is more appropriate for recognizing and addressing the key needs and concerns of patients living with end-stage cancer and are receiving palliative care treatment [19Gill F, Duffy A. Caring for cancer patients on non-specialist wards. Br J Nurs 2010; 19(12): 761-7.
[http://dx.doi.org/10.12968/bjon.2010.19.12.48654] [PMID: 20622 795]
].

CONCLUSION

This paper has highlighted the value of using the SAGE and THYME model to guide Asian nurses to communicate effectively with advanced cancer patients undergoing palliative care. This structured framework improves the nurses’ communication skills and discourages their blocking behaviors by enabling them to explore and respond to patients’ needs and concerns using evidence based patient centered communication skills. Moreover, this communication model is effective in assisting the nurses to provide the appropriate advice that focuses on their true concerns by establishing trust with their patients so that they may feel involved and respected and are more willing to disclose openly their distress and seek informational support from them.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Schofield NG, Green C, Creed F. Communication skills of health-care professionals working in oncology can they be improved? Eur J Oncol Nurs 2008; 12(1): 4-13.
[http://dx.doi.org/10.1016/j.ejon.2007.09.005] [PMID: 18446927]
[2] Kvåle K. Do cancer patients always want to talk about difficult emotions? A qualitative study of cancer inpatients communication needs. Eur J Oncol Nurs 2007; 11(4): 320-7.
[http://dx.doi.org/10.1016/j.ejon.2007.01.002] [PMID: 17446134]
[3] Lloyd-Williams M. Psychosocial issues in palliative care 2nd ed. 2008.
[http://dx.doi.org/10.1093/acprof:oso/9780199216420.001.0001]
[4] Marcusen C. Information and communication needs of individuals living with advanced cancer. Semin Oncol Nurs 2010; 26(3): 151-6.
[http://dx.doi.org/10.1016/j.soncn.2010.05.006] [PMID: 20656138]
[5] Chong PH, Poon WH. The lived experience of palliative homecare nurses in Singapore. Singapore Med J 2011; 52(3): 151-7.
[PMID: 21451922]
[6] Stajduhar KI, Thorne SE, McGuinness L, Kim-Sing C. Patient perceptions of helpful communication in the context of advanced cancer. J Clin Nurs 2010; 19(13-14): 2039-47.
[http://dx.doi.org/10.1111/j.1365-2702.2009.03158.x] [PMID: 2092 0030]
[7] Griffiths J, Wilson C, Ewing G, Connolly M, Grande G. Improving communication with palliative care cancer patients at home: A pilot study of SAGE & THYME communication skills model. Eur J Oncol Nurs 2015; 19(5): 465-72.
[http://dx.doi.org/10.1016/j.ejon.2015.02.005] [PMID: 25782722]
[8] Connolly M, Thomas JM, Orford JA, et al. The impact of the SAGE & THYME foundation level workshop on factors influencing communication skills in health care professionals. J Contin Educ Health Prof 2014; 34(1): 37-46.
[http://dx.doi.org/10.1002/chp.21214] [PMID: 24648362]
[9] Lau LK, Mok E, Lai T, Chung B. Quality-of-life concerns of Chinese patients with advanced cancer. Soc Work Health Care 2013; 52(1): 59-77.
[http://dx.doi.org/10.1080/00981389.2012.728560] [PMID: 23301935]
[10] Lobb EA, Lacey J, Kearsley J, Liauw W, White L, Hosie A. Living with advanced cancer and an uncertain disease trajectory: An emerging patient population in palliative care? BMJ Support Palliat Care 2015; 5(4): 352-7.
[http://dx.doi.org/10.1136/bmjspcare-2012-000381] [PMID: 2464 4173]
[11] Tan JXJ. The use of effective therapeutic communication skills in nursing practice. Spore Nur J 2009; 36: 35-8.
[12] Tay LH, Hegney D, Ang E. Factors affecting effective communication between registered nurses and adult cancer patients in an inpatient setting: A systematic review. Int J Evid Based Healthc 2011; 9(2): 151-64.
[http://dx.doi.org/10.1111/j.1744-1609.2011.00212.x] [PMID: 2159 9844]
[13] Costello J. Nursing the dying patient 2004.
[http://dx.doi.org/10.1007/978-1-137-26647-7]
[14] Tay LH, Ang E, Hegney D. Nurses’ perceptions of the barriers in effective communication with inpatient cancer adults in Singapore. J Clin Nurs 2012; 21(17-18): 2647-58.
[http://dx.doi.org/10.1111/j.1365-2702.2011.03977.x] [PMID: 2233 2954]
[15] Thorne SE, Bultz BD, Baile WF. Is there a cost to poor communication in cancer care?: A critical review of the literature. Psychooncology 2005; 14(10): 875-84.
[http://dx.doi.org/10.1002/pon.947] [PMID: 16200515]
[16] Maskor NA, Krauss SE, Muhamad M, Nik Mahmood NH. Communication competencies of oncology nurses in Malaysia. Asian Pac J Cancer Prev 2013; 14(1): 153-8.
[http://dx.doi.org/10.7314/APJCP.2013.14.1.153] [PMID: 23534716]
[17] Rainbird K, Perkins J, Sanson-Fisher R, Rolfe I, Anseline P. The needs of patients with advanced, incurable cancer. Br J Cancer 2009; 101(5): 759-64.
[http://dx.doi.org/10.1038/sj.bjc.6605235] [PMID: 19654579]
[18] Connolly M, Perryman J, McKenna Y, et al. SAGE & THYME: A model for training health and social care professionals in patient-focussed support. Patient Educ Couns 2010; 79(1): 87-93.
[http://dx.doi.org/10.1016/j.pec.2009.06.004] [PMID: 19628353]
[19] Gill F, Duffy A. Caring for cancer patients on non-specialist wards. Br J Nurs 2010; 19(12): 761-7.
[http://dx.doi.org/10.12968/bjon.2010.19.12.48654] [PMID: 20622 795]

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