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Social Science & Medicine 54 (2002) 10111023

Communicative competence in the delivery of bad news

Cathy Gillottia, Teresa Thompsonb,*, Kelly McNeilisc

aDepartment of Communication, Purdue University Calumet, USAbDepartment of Communication, University of Dayton, Dayton, OH 45460-1410, USA

cDepartment of Communication, Southwest Missouri State University, USA

Abstract

Grounded in the Cegala and Waldron (Communication Studies 43 (1992) 105) model of communicative competence,the present study applied the McNeilis (Health Communication 13 (2001) 5) provider-patient coding scheme to video

tapes of 3rd year medical students delivering bad news to a standardized patient. The goal of the study was to

understand the specific communicative moves that are associated with perceptions of competence during bad news

delivery. The coding scheme assesses Content, Acknowledgment Tokens, Interruptions, Alignment, and Function of the

message. Na.ve observers also evaluated the tapes on several items, assessing empathy and communicative effectiveness.

Nonmedical talk was the most common type of content, followed by discussion of the current health problem. Neither

acknowledgment tokens nor interruptions were frequent. The most common function of a message was a closed

question, followed by explanations, assertions, and open questions. Summing across the functions indicated that

information giving was the most common behavior. The perceivers data showed fairly neutral assessments of the

medical students}they were generally not evaluated very positively, although they were not disliked. Regression

analyses indicated numerous specific communicative behaviors that were associated with judgments of competence.

Statements falling into the Nonspecific Content category were associated with more positive perceptions, whilerelational statements, moderately closed questions, solicited answers, expansions, restatements, assertions, explana-

tions, open questions, bracketing, and small talk as well as information verifying, seeking, and giving (summed

functions) led to more negative perceptions. The results indicate that the delivery of bad news requires communicative

moves that differ from other kinds of medical communication. Depending on the results of future analyses of this topic,

health care providers may be well advised to focus little of their communication on information seeking, giving, or

verifying during the initial bad news delivery consultation, but rather to save most communication of information for a

follow-up scheduled shortly afterwards. # 2002 Elsevier Science Ltd. All rights reserved.

Keywords: USA; Doctorpatient communication; Competence

Communicative competence in the delivery of bad news

Research on the interaction between patients and

their health care providers has grown tremendously over

the last 20 years (see reviews by Thompson, 1994, 1998,

2000). One theme that pervades this literature is the need

for an understanding of the communicative behaviors

that are more vs. less competent within such interac-

tions. The research on the outcomes of health care

interaction indicates that how patients and care provi-

ders interact matters}it impacts such outcomes as

patient compliance with treatment regimens (DiMatteo,

Reiter, & Gambone, 1994), the filing of malpractice suits

(Vincent, Young, & Phillips, 1994), patient recovery

(Anderson, 1987), numerous physiological and medical

outcomes (Kaplan, Greenfield, & Ware, 1989; Van

Veldhuizen-Scott, Widmer, Stacey, & Popovich, 1995),

medical costs (Lieberman, 1992), pain (King, 1991),

mortality (Lieberman, 1992), and patient understanding

*Corresponding author. Tel.: +1-937-229-2379.

E-mail address: [email protected] (T. Thompson).

0277-9536/02/$ - see front matter # 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 0 7 3 - 9


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of the diagnosis, prognosis, and treatment plan (Thomp-

son, 2000). How competently providerpatient interac-

tion occurs, then, is worthy of study.

One framework that has been suggested for the study

of providerpatient interaction is the concept of com-

munication competence (Kasch, 1984; Kasch, Kasch, &

Lisnek, 1998; Kreps & Query, 1990; Morse & Piland,1981). Research on communicative competence argues

that some communicative behaviors are more effective in

terms of meeting goals than are other behaviors, and

that context determines the behaviors that are most

appropriate and effective.

A context that is particularly troubling for both

patients and health care providers is the delivery of bad

news (Gillotti & Applegate, 2000). This is, of course, a

context with which care providers are frequently faced,

but at which they are not always successful. Care

providers experience great discomfort in such situations

(Bowers, 1999; Maynard, 1991) and do not typicallydeliver the bad news very effectively (Franks, 1997;

Girgis, Sanson-Fisher, & Schofield, 1999; Parathian &

Taylor, 1993; Roth & Nelson, 1997; Salander, Bergen-

heim, Bergstroem, & Henriksson, 1998; Vetto, 1999).

This, then, is a context in which the notion of

communicative competence has particular applicability.

The goal of the present study is to apply the commu-

nicative competence framework to the bad news delivery

context in an attempt to ascertain those communicative

behaviors that are associated with more vs. less

competent bad news delivery.

Communicative competence

The notion of communicative competence requires a

dyadic perspective. Competence in communication is

determined by both conversational partners, involves

knowledge of how to communicate, references actual

communicative behavior, and reflects the communica-

tors success at achieving goals (Parks, 1994). The

particular competence framework selected for the

present study was the model developed by Cegala and

Waldron (1992). This model was selected because it

privileges participants language-in-use and is context

bound. These characteristics of the model make itespecially relevant to the providerpatient context.

Although, as mentioned above, much research has been

conducted on the providerpatient relationship, little of

this research has been theoretically grounded. This has

limited the applicability and usefulness of the findings.

The Cegala and Waldron (1992) competence model is

based upon four assumptions, each of which reflects a

synthesis of current theorizing on competence. First,

competence is best defined by how interactants align

their utterances as they coordinate goals (Delia &

OKeefe, 1982; Pearce & Cronen, 1980). Next, defini-

tions of competence must be context-specific and

acknowledge that competence evaluations are situa-

tional (Fisher, 1982; Watzlwawick, Beavin, & Jackson,

1967). Third, competence is dyadic and must be

measured by looking at patterns of interaction (Watzla-

wick et al., 1967). Finally, individual differences in

competence are partially determined by cognitive/

affective processes involving the interpretation andproduction of messages during interactions (Applegate,

1990; Burleson, 1984; Delia & OKeefe, 1982). Thus,

competence requires participants to align their goals and

necessitates an ability to grasp the meaning and intent of

the other. These assumptions are also consistent with a

constructivist, person-centered perspective on compe-

tence (Applegate, 1990; Burleson, 1984; Delia &

OKeefe, 1982), which will serve as the basis for the

measurement of competence perceptions in the present

study. The CegalaWaldron model, while building upon

the same assumptions as a constructivist perspective,

allows for more precise measurement of speech variablesand the sequential nature of language.

The application of this model to medical interaction

requires an understanding of the objectives of talk in this

context. This necessitates a task analysis that reveals

participants likely goals in the situation and the

communicative moves that will likely allow the accom-

plishment of goals (McFall, 1982). Meta-analytic re-

views of research on providerpatient interaction (Hall,

Roter, & Katz, 1988; Roter, Hall, & Katz, 1988) and

research by Cegala and colleagues (Cegala, McNeilis,

McGee, & Jonas, 1995; Cegala, McGee, & McNeilis,

1996) reveal that the primary communicative tasks in the

medical context are information exchange and relational

development.

The importance of information exchange in the health

care context has been discussed by numerous researchers

(e.g., Beisecker, 1990; Beisecker & Beisecker, 1990;

Guttman, 1993; Katz, Gurevitch, Peled, & Danet,

1969; Pendleton & Bochner, 1980; Roter, 1989; Roter

& Frankel, 1992; Street, 1991a; Waitzkin, 1984, 1985),

although little research has actually focused on the

specifics of how such information exchange takes place.

Additionally, physicians and patients also communicate

with each other to build a relationship (Ben-Sira, 1980;

Smith & Hoppe, 1991), which then impacts trust,respect, loyalty, and satisfaction with health care

(Cegala et al., 1996). We know little about the relation-

ship between the information exchange and relationship

development functions of medical communication (for

exceptions see Buller & Street, 1991; Cegala et al., 1996;

Roter, 1989; Street, 1991b). The coding scheme used in

the present study}the Communication and Compe-

tence System (CACS, McNeilis, 2001)}addresses both

of these components of medical exchange and over-

comes many of the limitations of other commonly used

methods. Past methods have focused upon rating scales,

coding systems that are not theoretically grounded, and

C. Gillotti et al. / Social Science & Medicine 54 (2002) 101110231012


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conversation analysis, which, while interesting, are not

useful for quantitative assessments relating communica-

tion patterns to outcome variables.

Grounded in Cegala and Waldrons competence

model, the CACS coding scheme can be used to look

at communicative competence within the medical con-

text more microscopically than past coding schemeswhile still allowing the quantitative comparisons neces-

sary to study outcomes. For a more complete descrip-

tion of the development of this coding scheme, see

McNeilis (2001). The coding scheme is a multidimen-

sional system that tracks participants responsiveness to

previous utterances on global, topical levels, and to the

intent and meaning of the interactional partner. The

scheme assesses communicative functions such as

information giving, information seeking, information

verifying, and socio-emotional communication using 31

different categories; it also addresses communicative

content issues (9 categories) and conversational align-ment (9 categories, including acknowledgement tokens

and interruptions). No other coding scheme offers

such a detailed assessment of competence in commu-

nication, while still being theoretically grounded

(Thompson, 2001). The particular medical context to

which the coding scheme was applied was the delivery of

bad news.

Bad news delivery

The study of bad news delivery may seem insignificant

among the many communicative tasks clinicians must

undertake. However, while the interactions are routine

in some respects, they are particularly challenging in

others (Maynard, 1991). Bad news is typically defined as

information that negatively alters (Buckman, 1992,

p. 15) the patients perspective of his or her future. The

interaction still involves information giving and seeking,

as do most medical consultations, but the emotional

component and subsequent patient retention are differ-

ent than other medical interactions (Buckman, 1992).

Not much is known about the actual training of

health care professionals in this area (Sharp, Strauss, &

Lorch, 1992). Some clinicians have argued that what

training does take place is inadequate (Davis, 1991;Fallowfield, 1993; McLauchlan, 1990; Miranda &

Brody, 1992; Quill & Townsend, 1991; Speck, 1991). It

has also been argued that even though appropriate

theoretical frameworks exist which could assist health

care providers to accomplish their interactional goals

more successfully in this situation, professionals gen-

erally do not frame their presentation of bad news

according to any theoretical underpinning (Gillotti &

Applegate, 2000). Additionally, these pieces are pre-

dominantly authored by clinicians and while they may

serve as sound advice for interpersonal communication,

little empirical research has been completed that would

provide systematic insight on improving communication

competencies of clinicians who unfortunately must

engage in the task of delivering bad news. What is

suggested are practical strategies and behaviors focusing

on when, where, with whom and how the news should be

delivered (Brewin, 1991; Charlton, 1992; Davis, 1991;

Fallowfield, 1993; Graham, 1991; McLauchlan, 1990;Miranda & Brody, 1992; Ptacek & Eberhardt, 1996;

Quill & Townsend, 1991; Speck, 1991; Statham &

Dimavicius, 1992). This literature is summarized by

Ptacek and Eberhardt (1996) and Ellis and Tattersall

(1999).

Many factors affect care providers abilities to deliver

bad news successfully and competently. First, care

providers must face the issue of medical disclosure

(Waitzkin, 1985), which includes attention to patient

autonomy and patient rights (Sell, Devlin, & Bourke,

1993). Other concerns include the uncertainty of medical

prognosis (Miranda & Brody, 1992); feelings of failureand attention to face needs in the interaction (Goffman,

1959; Miranda & Brody, 1992); expressions of emotion

(DiMatteo, 1979; Fallowfield, 1993; Kaiser, 1993;

Krahn, Hallum, & Kime, 1993; Maynard, 1989;

Maynard, 1991; Ptacek & Eberhardt, 1996; Sharp

et al., 1992; Swanson, 1993; Wesley, 1996); and lack of

training and socialization to a detached style of

interaction (Flynn & Hekelman, 1993; Hafferty, 1991;

McWhinney, 1989; Mizrahi, 1991; Novack, Volk,

Drossman, & Lipkin, 1993; Rappaport & Witzke,

1993). Physician expressions of compassion, however,

do reduce patient anxiety (Fogarty, Curbow, Wingard,

McDonnell, & Somerfield, 1999). An examination of the

research suggests that much is left to be uncovered in the

study of communication competence in this context. A

more complete review of literature on bad news delivery

can be found in Gillotti and Applegate (2000).

Research question

The delivery of bad news is a problematic task for

health care providers. The present study attempted to

examine the bad news delivery process within a

competence framework. Applying the theoretical model

of communication competence should illuminate parti-cular features of bad news delivery and health care

provider competence in terms of specific communicative

utterances. The goal of the present study is not to look

at the effectiveness of bad news delivery in the target

population per se, but to look at the relationships

between the very specific communicative categories

identified in the coding scheme as they relate to

perceptions of competence. We examine not the ques-

tion of how effectively the medical students in the

present study delivered bad news, but what commu-

nicative behaviors were associated with perceptions of

competence. Thus, the following research question was

C. Gillotti et al. / Social Science & Medicine 54 (2002) 10111023 1013


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addressed: What communicative moves are associated

with perceptions of competence during a bad news

delivery context?

Method

There were three phases to the procedure. In the first

phase, 3rd year medical students delivering bad news to

a simulated patient were videotaped. The tapes were

then coded using the McNeilis (2001) providerpatient

interaction coding scheme}the Coordination and

Competence System (CACS). The competence of the

medical students was then rated by outside observers in

an attempt to determine those communicative behaviors

that best predict perceptions of competence. Thus, data

collection and coding involved several phases.

Phase I}taping medical students bad news delivery

Participants for Phase I were recruited from a class of

third year medical students at a large Southern

university. Fifty-four out of 90 medical students agreed

to participate in the study. Thirty-nine of the 54 were

male, and 15 were female. The participants ranged in age

from 23 to 51. The training received by the medical

students had already included discussion of bad news

delivery.

The medical students were videotaped in an 11 min

roleplay interaction during the students clinical

performance examination for their internal medicine

clerkship. This 6-h examination tests students clinical

and interpersonal skills. The medical students move

from station to station completing different tasks. Many

of the stations require the students to interact with

actors playing patients. The actors were hired by the

medical school to play the various standardized patients.

The actors for this role play were trained by the senior

investigator and the clinicians in charge of the clerkship.

There were a total of three actresses who participated in

this bad news role play over the course of a 14-month

data collection period. Videotaping took place on three

separate occasions, as the medical students do therotations for their clerkships in groups of 30.

Each medical student was given 11 min to inform the

standardized patient that she was HIV positive. The

clinicians in charge of the course and the senior

investigator created the character to be played by the

actress. The patient, Mrs. Murphy, was 36 years old

with two children, ages eight and ten. After 15 years of

marriage she discovered that her husband had been

repeatedly unfaithful throughout the course of their

marriage. After being separated from her husband for

six months, she decided to have an HIV test. She has

returned to the physicians office to find out her results.

This role play was one of many in which the medical

students participated during the course of their 6-h

examination. All 90 students were required to partici-

pate in the role play even though only 54 consented to

have their videotaped interactions used in the analyses.

The senior investigator was located outside the room

designated for the bad news role play station. During thevideotaped sessions, the medical students approached

the consultation room and were given 2 min to read the

instructions for that testing station posted on the door.

The bad news station instructions informed the student

to tell the patient she was HIV positive and that the

results had been confirmed by a Western-blot test. The

medical students were also informed that the probable

contraction point for the HIV virus was Mrs. Murphys

husband.

Neither the students nor the actress were given a

script. However, the actresses were instructed by the

investigator to play the interaction with two dominantemotions, distress and anger, in order to create a

challenging context within which the medical students

were to deliver the bad news. According to Platt and

Keller (1994), one of the most difficult situations faced

by physicians involves strong emotional displays from

patients.

Great consistency was noted in the behavior of the

actresses for all medical students by the raters of the

tapes (described below), the investigators, and the

physician in charge of the testing situation. All three

actresses went through similar training sessions with the

physician in charge of the test and the senior investi-

gator. The actresses for the 2nd and 3rd rounds were

given a copy of the tape of the 1st actress so that they

could model their behavior on her behavior.

For the purposes of the present study, the context of

bad news delivery was defined as encompassing the

entire interaction, not just the sentence or two in which

the diagnosis of HIV was actually stated. The rationale

for this was based upon the observation that past

research on bad news has typically focused on attempts

at providing additional information or comforting

patients about the diagnosis. Those aspects of bad news

delivery have been deemed important in past research,

and appeared relevant in the present videotapes. Theactual statement of prognosis}frequently requiring

only a sentence or two}is more straightforward and

of less apparent research interest.

Phase II}coding communicative behaviors

Each medical students tape was coded using the

CACS providerpatient coding scheme developed by

McNeilis (2001). Based upon the Cegala and Waldron

(1992) context-bound model of communicative compe-

tence, the CACS focuses upon alignment of utterances

as communicators coordinate goals on a turn by turn



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basis. Alignment implies the interpretation and produc-

tion of messages that facilitate individual and mutual

goals and entails participants attention to the intent and

meaning of each others messages. The coding system

centers on message content, alignment (two levels) and

function of messages. Global message content is assessed

with nine categories that range from medical concernssuch as diagnosis and treatment to nonmedical concerns.

Judgments of goal-matching and contextual appropri-

ateness are inherent in the categorizations.

While competent communication cannot occur if

interactants are talking about two different topics,

effective interaction management (Wiemann, 1977) also

requires local topic synchronization or uptake.

Acknowledgment tokens and interruptions are coded

as part of the message content. Matters such as topic

change and issue versus event extensions are also coded,

allowing for assessment of the extent to which

participants address central, peripheral, or differentsubstantive matters relative to the previous utterance.

This is assessed in the alignment portion of the coding

scheme.

Finally, the coding scheme assesses how utterances

mesh functionally, for example, looking at whether an

answer follows a question. Functional meshing con-

tributes to conversational coherence, and the attainment

of information and relational goals. Content categories

include history taking, current problems, diagnosis,

treatment, procedure, prognosis, nonmedical, behavior-

al, and nonspecific. Alignment has two levels. One

involves simple acknowledgement tokens and overlap-

ping talk (interruptions). The second involves more

topic assessments of alignment, including issue exten-

sions, event extensions, continuers, pop extensions, topic

changes, first utterances, and immediate pops. Pop

extensions and immediate pops refer to statements that

return to a previously discussed topic, but vary in how

long ago that topic was mentioned. Finally, the 31

functional categories involve tasks relating to informa-

tion giving, seeking, and verifying, and socioemotional

statements. The complete list of categories will be

presented in Table 1 in Results section.

Each utterance is given five different codes: Content (9

categories), acknowledgement token (absent or present),interruption (absent or present), alignment (7 cate-

gories), and function (31 categories). The unit of analysis

was the utterance, defined as a word or series of words

spoken by an individual constituting a thought or partial

thought that may or may not be interrupted by or

overlap with other talk by the partner. If there is

overlap, the first unit ends there and the next unit begins

with the overlapped talk by the partner. Multiple

utterances can occur within one speaking turn. During

development of the coding scheme, McNeilis (1996)

reported unitizing reliability of 0.96 using Holstis (1969)

formula.

Table 1

Frequencies of language categories

Lang. category Freq. M SD

Content

History 45 0.83 1.22

Current Problem 382 7.07 7.78Treatment 110 2.04 2.85

Procedure 125 2.31 2.42

Prognosis 143 2.65 3.00

Diagnosis 90 1.67 1.44

Nonmedical 1046 19.37 10.47

Behavioral 146 2.76 4.51

Nonspecific 186 3.51 3.87

Acknow. Token 240 4.53 4.85

Interruption 105 1.98 2.90

Alignment:

Continuer 147 2.77 3.45

Event Extension 578 10.91 6.63

Issue Extension 785 14.81 11.09

Pop Extension 96 1.81 1.85

Topic Change 430 8.11 5.66

First Utterance 73 1.38 2.11

Immediate Pop 65 1.23 1.64

Function

Information-seeking

Closed question 321 6.06 5.13

Mod. closed question 120 2.26 2.56

Open question 234 4.23 3.20

Embedded question 35 0.66 0.96

Information-giving

Solicited answer 61 1.15 1.55Elaboration 74 1.40 2.49

Unsolicited info. 64 1.21 1.62

Expansion 87 1.64 2.02

Assertion 300 5.66 9.28

Agreement 96 1.81 2.88

Disagreement 3 0.06 0.23

Correction 2 0.04 0.19

Justification 36 0.68 1.21

Explanation 318 6.00 5.91

Bracketing 7 0.13 0.34

Verifying

Cond. relevant ques. 15 0.28 0.57

Formulation 17 0.32 0.78

Restatement 66 1.25 1.83Socio-emotional

Legitimizing Affect 86 1.63 1.73

Naming 12 0.23 0.51

Apology 32 0.61 0.88

Relational 80 1.51 1.80

Reinforcement 18 0.35 0.79

Small Talk 14 0.26 0.56

Humor 1 0.02 0.14

Miscellaneousa

Polite Directive 27 0.51 1.03

Directive 53 1.00 1.86

Qualified Directive 5 0.09 0.41

Compliance 8 0.15 0.41



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McNeilis also reported reliability with two different

coders on the various components of the coding scheme:

Content=0.83 and 0.80; Acknowledgement To-kens=0.68 and 0.72; Interruptions=1.00 and 1.00;

Alignment=0.80 and 0.76, Function=0.70 and 0.70.

In the present study, 18 undergraduate coders were

trained by one primary coder who had past experience in

the use of the coding scheme. Each coder worked on

some practice data to establish reliability with the

primary coder. The coders were allowed to code the

data tapes when practice reliability exceeded 0.80 on

unitizing and each individual category. Each coder then

coded four of the medical student interactions. Thus,

some, but not all, interactions were coded by more than

one rater. In such cases, the data from the coder with thehighest reliability score were used for analysis.

Although both the communication of the medical

student and the simulated patient were coded, only the

data from the medical students were analyzed for this

paper since it was only the competence of the medical

students that was under investigation. The sequential

nature of the data is still taken into account by the

coding scheme, however, in that judgements of each

statement made by a medical student were assessed for

competence in the context of the utterances preceding

and following it.

Phase III}assessment of communicative competence

The final phase of the project involved seeking the

opinions of lay evaluators of the medical students

performances in terms of communication competence.

The sample of evaluators consisted of 527 (246 male and

281 female) undergraduate students enrolled in 20 lower

division communication courses at the same university.

The undergraduate student sample ranged in age from

20 to 53. The lay evaluators represented all academic

majors, as the courses in which the data were evaluated

fulfilled a university-wide requirement.

Each undergraduate lay evaluator viewed three

videotaped interactions and rated the three medical

students on a global communication competence scale.

The interviews shown to each class of undergraduates

were determined by the order in which the medical

students went through the role play. Therefore, the first

three videotaped interactions were shown to the firstclass of undergraduate students and so on until all the

medical students were evaluated. The undergraduate

students were offered an alternative exercise if they did

not wish to participate in the evaluation of the medical

students.

Instrumentation. The general communication compe-

tence scale used by the undergraduate, lay evaluators

was a 14-item Likert scale modified from Woods (1993).

The original items of the scale were derived from

competence scales developed by Hosman (1987) and

Planalp and Tracy (1980). In Woods (1993) research the

items reflected three constructs, including general com-munication competence, social attractiveness, and per-

suasiveness. The persuasion items were removed and

replaced with dimensions that reflected person-centered

communication behavior, such as autonomy granting

and empathic behaviors. This perspective, derived from

a constructivist view, is consistent with the assumptions

of the CegalaWaldron model. Items ranged from 1 to 5,

with a higher score indicating more of the variable.

A factor analysis using an oblique rotation was

conducted to illuminate the factors of the modified

scale. The oblique rotation was chosen due to the

probable relationship between the items of the scale

(Ferguson & Takane, 1989). For instance, social

attractiveness was correlated to communication compe-

tence, and empathy to social attractiveness. All the items

of the scale were positively correlated with one another

to some degree. The factor analysis yielded two factors.

The first factor contained 11 items and addressed those

items previously regarded as empathy, social attractive-

ness, global likability, and four new items related to

person-centered communication. Thus, the empathy

factor, included questions one, three, four, five, six,

eight, and 1014 (Cronbachs alpha=0.94). Three items

cleanly loaded on factor two, the general communica-

tion skills factor. Questions two, seven and nine reflectedspeech skills, such as being understandable, easy to

follow, and communicating effectively (alpha=0.82). A

copy of the questionnaire is available from the senior

investigator. Table 2 in Results section presents these

items grouped within factors.

Data analysis

Linear multiple regressions were used to examine

communicative behaviors that best predicted ratings of

competence. The frequencies of the various coded

competence scores were used to predict competence

Table 1 (continued)

Lang. category Freq. M SD

Hedging 10 0.19 0.59

Incomplete 76 1.43 2.71

Composite function scoresInformation-seeking 700 13.21 6.65

Information-giving 940 17.74 11.77

Verifying 105 1.98 2.41

Socio-emotional 571 10.77 7.44

Total 2353

aMiscellaneous categories were not included within the

composites.



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ratings. The competence ratings were averaged across

evaluators of each medical student to yield a mean score

for each item per student. The mean competence ratings

were then summed to create scores for empathic

behavior (alpha on this averaged scale=0.99) and skills

(alpha=0.93), consistent with the factor structure

mentioned above. In addition to the composites,

individual competence ratings were used as dependent

measures in follow-up analyses in order to examine the

data in more detail. The CACS coding data were also

used both as individual categories and as composites.

These variables were converted to ratios based upon the

total number of utterances per student, as there was

great variability amongst the medical students in the

number of utterances.

Results

Frequencies of communicative behaviors

The frequencies with which each of the CACS coded

behaviors were noted are reported in Table 1. As the

table indicates, the most commonly occurring type of

Content was Nonmedical talk. This includes small talk

and other topics not directly relevant to the health

problem. This topic far exceeded any of the other

categories. Within the coded interactions, the medical

student and the simulated patient frequently discussed

the patients personal situation}her husbands infide-

lity, their current separation, and her children. Because

of the nature of the context, very little time was spent on

history-taking. The next largest category was the

discussion of the current problem.

Neither acknowledgement tokens, which would in-

dicate explicit recognition of the partners previous

statement, nor interruptions were very frequent in the

present data. Acknowledgement tokens, however, oc-

curred more frequently than interruptions did. Align-ment behaviors also showed some variability, with issue

extensions being most frequent, followed by event

extensions (a continuation of the previous topic, but

with some shifting) and topic change.

The most frequent function of a message was as a

closed question. Second most common was an explana-

tion. The medical students frequently explained the

nature of HIV, the type of testing, and so forth, to the

patient. The number of explanations was closely

followed, however, by assertions. It is likely that the

assertions accompanied the explanations. Open ques-

tions were also relatively common. All of the remainingfunctions occurred fewer than 100 times in the 54

interactions.

For each medical student, the frequencies of various

functions were then summed to represent four basic

types of communicative behaviors. Information seeking

included closed questions, moderately closed questions,

open questions, and embedded questions. Information

giving was composed of solicited answers, elaborations,

unsolicited information, expansions, assertions, agree-

ment, disagreement, corrections, justifications, explana-

tions, and bracketing (mentioning that a topic will be

discussed later). Socio-emotional statements were legit-

imizing affect, naming (commenting on an emotion),

apologies, relational statements, reinforcement, small

talk, humor and three types of directives. Information

verifying was represented by conditionally relevant

questions, formulations summarizing the gist of what

someone has said, and restatements. These groupings

were determined a priori and were based on the

theoretical model and past literature.

The most common of these function types was

information giving, followed by information seeking,

and socio-emotional statements. Information verifying

statements were much less frequent, accounting for only

105 out of the 2253 coded statements. Note that somecomponents may not sum to 2253 because of missing

data.

Assessment of communicative competence

The means and standard deviations of the competence

ratings are reported in Table 2. A higher score indicates

more of the variable being measured. The highest score

was for politeness. The medical students were generally

seen as polite. Attentiveness and niceness scored slightly

less than politeness. The lowest score was for liking}the

respondents were generally only neutral in their feelings

Table 2

Means and standard deviations of perceived competence

Variable Mean SD

Empathy 2.47 1.34

Caring 2.57 0.58

Sensitivity 2.49 0.63Treated patient as an individual 2.68 0.47

Nice 2.88 0.45

Polite 2.97 0.45

Attentive 2.88 0.39

Friendly 2.69 0.48

Pleasant 2.55 0.50

Courteous 2.80 0.51

I liked the medical student 2.40 0.59

I. Overall empathy (averaged) 2.67 0.49

Effectiveness 2.51 0.57

Understandable 2.74 0.43

Easy to follow 2.62 0.48

II. Overall skills (averaged) 2.62 0.47



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toward the medical students. Liking was followed

closely by empathy}the students were not seen as very

empathic. It is interesting to note that this item,

however, also demonstrated much greater variability

than did the other items. Fairly low scores (relative to

the other items) were also noted on effectiveness, caring,

and pleasantness. On the summed Empathic/PersonCenteredness (items 1, 36, 8, and 1014) and Skills

(items 2, 7, 9) measures, means also indicated fairly

neutral scores.

Relations between communication and competence

A series of multiple regression analyses was conducted

to determine the relationships between the communica-

tion frequency data from the CACS and the assessments

of competence. Ratios were created for each medical

student because of the great variability in the numbers of

utterances coded for individual students. The frequen-cies were divided by the total number of coded

utterances. Regressions were first conducted on the

summed Function scores (information giving, seeking,

and verifying and socio-emotional statements) as pre-

dictors of the Empathic and Skills scores, then as

predictors of the individual competence ratings. To

examine the impact of the specific communicative

behaviors more directly, the next set of analyses used

the individual CACS categories (as ratios) as they

predicted overall Empathy and Skills. While this

approach resulted in a large number of regression tests,

with an increased possibility of Type 1 error, the

exploratory nature of the research dictated a need for

in-depth examination. Predictor variables were not

highly correlated within each regression analysis, so

multicollinearity was not a problem. Significant stan-

dardized beta weights and probability estimates are

reported in Tables 3 and 4.

The regressions indicated that increased utilization of

the information-verifying ratio was associated with less

perceived Skill (composite), less empathy, effectiveness,

understandability, politeness, ease in following, and

niceness. The information-seeking and information-

giving ratios were both associated with lower levels of

friendliness (see Table 3).The second set of regression analyses looked at how

ratios of the individual coding categories predicted the

overall Empathy and Skills scores. More Empathy was

associated with fewer moderately closed questions,

solicited answers, expansions, restatements, assertions,

relational statements, explanations, and small talk.

Higher levels of perceived Skills were associated with

fewer open questions, solicited answers, expansions,

formulations, assertions, relational statements, bracket-

ing, and nonspecific content (see Table 4).

To explore the data further, all of the variables were

examined for gender differences. This included looking

for gender differences (1) in the behaviors of the medical

students, (2) based upon the gender of the coder, and (3)based upon the gender of the 3rd party evaluators.

Although a few small differences were noted, the number

was small enough that it could have been due to

experiment-wise error.

Discussion

These results indicate some potentially interesting

patterns for our examination of communicative

competence within the bad news delivery context. As

we interpret these results, it is important to note that the

Table 3

Beta weights and probabilities. Analyses with composite

behavior ratios as predictors

Behavioral

variable

Evaluative

variable

Beta Probability Partial

r

Verifying Composite skills

0.36 0.02

0.35Verifying Individual empathy

item

0.33 0.02 0.32

Verifying Effectiveness 0.33 0.03 0.32

Verifying Niceness 0.32 0.03 0.31

Verifying Understandability 0.29 0.05 0.27

Verifying Politeness 0.30 0.04 0.29

Verifying Easy to follow 0.41 0.005 0.39

Info-seeking Friendliness 0.43 0.03 0.31

Info-giving Friendliness 0.47 0.03 0.31

Table 4

Beta weights and probabilities. Analyses with individual ratiosas predictors

Behavioral

predictor

variable

Composite

criterion

variable

Beta Probability

Nonspecific content Skills 0.31 0.05

Restatement Empathic 0.40 0.05

Moderately closed

question

Empathic 0.72 0.003

Solicited answer Empathic 0.42 0.05

Expansion Empathic 0.75 0.008

Assertion Empathic 0.79 0.03

Relational Empathic

0.54 0.007Explanation Empathic 0.73 0.03

Small talk Empathic 0.38 0.04

Open question Skills 0.50 0.03

Solicited answer Skills 0.43 0.05

Expansion Skills 0.70 0.02

Formulation Skills 0.47 0.03

Assertion Skills 0.75 0.05

Relational Skills 0.53 0.01

Bracketing Skills 0.68 0.01



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communicative tasks involved in the delivery of bad

news may well differ from the requirements of other

medical communication.

The competence ratings indicate that the medical

students were generally not very well liked, although

they were not disliked. Most respondents were rather

neutral in their feelings toward the medical students.Perhaps this was because the students were not seen as

very empathic. In a bad news delivery context, empathy

would likely be seen as more important than it might

otherwise be. The scores also indicated relatively little

amounts of caring, effectiveness, and pleasantness.

Pleasantness, of course, might not be a very appropriate

behavior for a bad news delivery context, but caring

and effectiveness would be appropriate. The students,

however, did not do a bad job of delivering the bad

news.

Perceived competence of communicative behaviors

The analyses of the composite communicative func-

tions, as ratios, indicated that information verifying was

perhaps the most interesting behavior. More informa-

tion verifying statements led to perceptions of less skill,

effectiveness, understandability, and ease in following. It

may be that the information-verifying statements made

the interaction appear more awkward. Other analyses

indicated that use of verifying statements also had less

than positive relational consequences, in that it was

associated with less empathy, politeness, and niceness.

When a patient has just been told that she is HIV+,

raters may well assume that she should not be forced to

verify information at that point. Too much information

seeking and giving were associated with less friendliness

and negative outcomes. It is likely that raters were aware

that the bad news delivery context is different from other

medical contexts, and that care providers should not

focus upon information giving or seeking when deliver-

ing bad news. When patients are receiving bad news,

they may need time to absorb the diagnosis before being

overwhelmed with additional information.

While it appears that socio-emotional behaviors

would be seen as appropriate in bad news delivery, the

category of socio-emotional functions included suchinappropriate behaviors as small talk, directives, and

humor as well as more appropriate ones that might

comfort or legitimate affect. Perhaps this is why the

composite socio-emotional function was not a signifi-

cant predictor of perceived competence, though indivi-

dual items, such as small talk, were significant although

negatively related.

The overall Empathy and Skills behaviors were also

associated with several variables. Communicators were

seen as more empathic when they relied on fewer

moderately closed questions, solicited answers, expan-

sions, restatements, assertions, relational statements,

explanations, and small talk. All of these except

relational statements and small talk are communicative

moves that could be seen as overkill or information

overload in the bad news delivery process. As noted

above, small talk, too, could be seen as inappropriate

when a patient is being informed that she is HIV+.

Relational statements are intended to establish arelationship of some sort. While patients who are

receiving bad news may want to be comforted, they

may not be quite ready to establish much of a

relationship with the care provider. Certainly a patient

who is being told that she is HIV+ would have other

things on her mind beyond building a relationship with

the care provider, although relationship building might

well be a concern at a later point. Within the context of

an established providerpatient relationship, relation-

ship building may be more relevant than in the present

context. The lack of an established relationship is one of

the limitations of the present study.Similarly, communicators were seen as more skilled

when they relied on fewer open questions, solicited

answers, expansions, formulations, assertions, relational

statements, bracketing, and nonspecific statements.

Bracketing statements indicate that a topic will be

discussed later in a visit. While putting off a patients

concerns might be acceptable in some contexts, it is

likely not seen as acceptable in the bad news delivery

process. Expansions, formulations, and assertions are all

information exchange types of statements, which would

also be seen as inappropriate when the patient is

preoccupied with the bad news she has received.

Implications

It is interesting that alignment codes, conceptually an

important portion of the competence model, did not

predict communicative skills in the medical students.

Alignment has not, however, been a very predictive

category in other research applying this model to

medical communication (McNeilis, 1995, 1996, 2001).

However, when alignment codes are combined with

function categories, they tend to become more pre-

dictive. The code system is multidimensional and

sequential and may require that categories be combinedfor better comparisons. Such future analyses are in

process.

It is important to note that the results of this study do

provide some evidence that the criteria for commu-

nicative competence in the bad news delivery context

differ from the traditional medical interview (McNeilis,

2001). In the traditional medical interview, information

exchange utterances are more likely to relate to

perceptions of skill and relational competence. This is

especially true of information verifying and following up

on patient initiated topics. Some qualitative research

has shown that highly competent care providers com-



10/13

municate more information about diagnosis, prognosis,

and treatment options (McNeilis, 1995). Additional

research has also determined that consultation inter-

views may be characterized by more relationally

oriented statements, humor, and legitimizing affect than

was found in the bad news context (see also Cegala,

1997). Such communication occurs primarily duringnonmedical discussion.

Research into providerpatient interaction in other

contexts typically indicates that patients desire more

information than they usually receive from physicians,

especially about prognoses (Thompson, 2000). However,

with regard to the delivery of bad news, the question is

one of timing. A patient receiving bad news may not be

able to absorb much additional information at that

point. An astute care provider may plan to keep the

initial bad news consultation shorter and schedule a

follow-up visit at which additional information is

provided fairly shortly thereafter.

Limitations

The care providers within the present study were 3rd

year medical students, not practicing physicians. This

limits the generalizability of the study. Although it might

be assumed that in a testing situation such as this,

students would attempt to communicate as effectively as

possible, an examination of the tapes did not indicate

very skillful approaches. The neutral scores they

received are consistent with this assessment. The low

level of skills is cause for concern if the students

were indeed trying to be as effective as possible. It

is, of course, just as important to provide evidence for

poor skills to be eliminated as for good skills to be

learned.

Those who have more experience in medical commu-

nication in general and in bad news delivery, in

particular, would most likely have developed their own

variations on how to deliver bad news based upon their

experiences, thus leading to more variability in the data

and perhaps more interesting and realistic results. The

relationship between perceived competence and com-

municative behaviors may be different in a more

experienced sample.A second limitation was the use of non-patient judges

of communicative competence whose perceptions may

differ from patients. The third-party observers in the

present study were likely focusing on the giver of bad

news rather than on their own internal anxieties and

needs, as would be the case with real patients. The

judges in this study may also have been more demanding

because they were in an academic setting and may

be better educated than the general population. Within

the present study the actresses were asked to rate the

competence of the medical students, but their ratings

showed very little variance and were of little use for data

analysis. Real patients may show more variance. Using

actual bad news delivery would, of course, also greatly

increase the validity of the findings in many other ways,

too. It should be kept in mind, however, that the goal of

the study was not to determine how care providers

deliver bad news, but to determine some rather specific

relationships between certain communicative behaviorsand perceived competence.

The large number of coders used in the present study

made maintaining reliability more difficult than it might

otherwise have been. Although all of the coders

established reliability with one primary coder at the

outset, and then only coded four interactions, there was

variability amongst coders. The results generated by

some coders included more utterances than those

generated by others. There were also differences

amongst the coders in terms of unitizing, with some

coders recording longer utterances than others. This

variability was the rationale for dividing the variables bythe number of utterances from each interaction for some

of the analyses, but was also a limitation to the present

study and should be overcome in future research.

Future research should also investigate alternative

methods of assessing competence. The measure used in

the present study was derived from a constructivist,

person-centered communication perspective. While this

perspective is consistent with the assumptions of the

CegalaWaldron model, it is not the only one that could

be used to assess competence (see Cegala, Coleman, &

Turner, 1998, for a discussion of this topic).

Conclusion

The present findings offer some tentative conclusions

regarding the relations between specific communicative

behaviors and perceptions of competence during the

process of delivering bad news. It is important for care

providers who will be delivering bad news to know that

the requirements of delivering bad news differ from

those of other medical interactions. These findings

indicate that when delivering bad news, it may be less

important to communicate large amounts of informa-

tion or attempt to verify information than wouldnormally be the case in health care interaction. The

validity of such a conclusion, however, depends on the

replication of the present findings in other bad news

delivery contexts, varied by gender, health problems,

and life circumstances.

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