Effective Communication on Patient safety at Healthcare Centers Essay assignments and case studies
Effective Communication on Patient safety at Healthcare Centers Essay assignments and case studies
Effective Communication on Patient safety at Healthcare Centers Essay assignments and case studies
Abstract
The main aim of this work is to investigate the impact of effective communication on patient safety on the Primary Healthcare Centers (PHC) in Jeddah province. To achieve this objective study adopted the descriptive analytical approach. The data needed to achieve this objective is obtained by distribution a survey questionnaire to the sample of the study represented by healthcare providers working in these centers. After survey questionnaire returned, the researcher was able to collect a round (150) valid questionnaire form. The data collected is entered and treated by using (SPSS). The results of analysis of data concluded with number of findings, the most important ones are: The study established there was a statistically significant positive relationship between the core elements of effective communication and patient safety. In particularly the study revealed that patient safety had a significant high positive correlation with the two-core element of effective communication (cultural difference, and sharing decision making) at the significant level (0.01), whereas, the other result proved that there is a significant association between patient safety and empathy and establish relationship at the significant level (0.05). Based on the findings of this study, the recommendation made from those results are the following: In order to the required patient safety in Primary Healthcare centers in Jeddah province, effective communication practicing should be given valued importance, to make more improvement in patient safety in Primary Healthcare Centers in Jeddah province, the PHC management should sustain and give more importance to cultural difference and sharing decision making, It was very important for PHC, management to improve the practicing empathy and establish relations as ones of the most important elements of effective communication. That can be reached through planning for comprehensive training programs in work for all staff, and finally it was very important of PHC, management to study the status of information gathering as one of the core elements of effective communication as the analysis of multiple regression confirmed that gathering of information has no significant effect on patient safety. Effective Communication on Patient safety at Healthcare Centers Essay assignments and case studies
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تأثير التواصل الفعال على سلامة المرضى في مراكز الرعاية الصحية
بمحافظة جدة في المملكة العربية السعودية دراسة تحليلية
امال الصومالي
المستخلص
الهدف الرئيسي من هذه الدراسة هو دراسة تأثير التواصل الفعال على سلامة المرضى في مراكز الرعاية الصحية الأولية في محافظة جدة. ولتحقيق هذه الدراسة الموضوعية اعتمدنا المنهج الوصفي التحليلي. ويتم الحصول على البيانات اللازمة لتحقيق هذا الهدف من خلال توزيع استبيان وعينة الدراسة ممثلة من قبل مقدمي الرعاية الصحية العاملين في هذه المراكز. وبعد الانتهاء من الاستبيان، تمكن الباحث من جمع (150) استبانة صالحة. وتم إدخال البيانات ومعالجتها باستخدام (SPSS). وعند تحليل نتائج البيانات توصلت الدراسة إلى: وجود ارتباط إحصائي هام وإيجابي بين العناصر الأساسية للاتصال الفعال وسلامة المرضى. وقد أظهرت الدراسة بشكل خاص وجود علاقة ارتباط معنوي وإيجابي للغاية بين سلامة المرضى والعنصرين الأساسيين في التواصل الفعال (الاختلاف الثقافي وتقاسم اتخاذ القرار) عند مستوى معنوي (0.01)، في حين أثبتت النتيجة الأخرى أن هناك ارتباط كبير بين سلامة المرضى والتعاطف وإقامة علاقة عند مستوى معنوي (0.05). وبناء على النتائج التي توصلت إليها هذه الدراسة، نجد أن التوصيات على النحو التالي: من أجل ضمان سلامة المرضى المطلوبة في مراكز الرعاية الصحية الأولية في محافظة جدة، ينبغي إعطاء أهمية فعالة لممارسة التواصل، من أجل زيادة تحسين سلامة المرضى في مراكز الرعاية الصحية الأولية في محافظة جدة، يجب على إدارة الرعاية الصحية الأولية الحفاظ على الاختلاف الثقافي ومشاركة القرار وتمكين أهمية كبيرة لهما، ومن المهم ايضاَ على إدارة الرعاية الصحية الأولية تحسين الممارسة في التعاطف مع المرضى والعلاقات بين المرضى والكادر الصحي باعتبارهما من أهم عناصر الاتصال الفعال. ويمكن الوصول إلى ذلك من خلال التخطيط لبرامج التدريب الشاملة في العمل لجميع الموظفين، وأخيرا كان على إدارة الرعاية الصحية الأولية، دراسة حالة جمع المعلومات باعتبارها واحدة من العناصر الأساسية للاتصال الفعال كما أكد تحليل الانحدار المتعدد أن جمع المعلومات ليس له تأثير كبير على سلامة المرضى.
Table of Contents
Dedication………………………………………………………………………………………………………………………. II
Acknowledgement………………………………………………………………………………………………………….. III
Abstract………………………………………………………………………………………………………………………… IV
Chapter one: Introduction………………………………………………………………………………………………….. 2
1.1 Background of the study…………………………………………………………………………………….. 2
1.2 Research Problem……………………………………………………………………………………………… 4
1.3 Research Gap…………………………………………………………………………………………………… 4
1.4 Rationale of the Research………………………………………………………………………………….. 4
1.5 Research Objectives………………………………………………………………………………………….. 5
1.6 Research Model and Dimensions…………………………………………………………………………. 5
1.7 Research Hypothesis…………………………………………………………………………………………. 5
1.8 Research Methodology………………………………………………………………………………………. 6
1.9 Research Scope…………………………………………………………………………………………………. 6
1.10 Research Structure………………………………………………………………………………………….. 6
Chapter Two: Literature Review and Previous Studies…………………………………………………………… 8
2.1 Introduction……………………………………………………………………………………………………… 8
2.2 Literature Review……………………………………………………………………………………………… 8
2.2.1 Communication and patient safety…………………………………………………………… 8
2.2.2 Establish relationship……………………………………………………………………………. 11
2.2.3 Empathy……………………………………………………………………………………………… 12
2.2.4 Gathering information………………………………………………………………………….. 12
2.2.5 Shared decision making…………………………………………………………………………. 13
2.2.6 Cultural differences………………………………………………………………………………. 14
2.2.7 Patient safety management……………………………………………………………………. 15
2.2.8 Management of patient safety in Saudi Arabia………………………………………… 16
2.2.9 Essential safety standards requirements…………………………………………………. 16
2.3 Previous studies………………………………………………………………………………………. 17
3.1 Introduction……………………………………………………………………………………………………. 28
3.2 The Research Methodology:…………………………………………………………………………….. 28
3.3 The Research Approach and Design………………………………………………………………….. 28
3.4 Population and Sampling Techniques:………………………………………………………………… 28
3.5 Data Collection Tool………………………………………………………………………………………… 30
3.6 Survey Questionnaire Reliability………………………………………………………………………. 30
3.7 Survey Questionnaire Validity………………………………………………………………………….. 31
3.8 Statistical Techniques for Data Analysis…………………………………………………………….. 32
Chapter Four: Data Analysis and Interpretations………………………………………………………………….. 35
4.1 Introduction……………………………………………………………………………………………………. 35
4.2 Section One…………………………………………………………………………………………………….. 35
4.3 Section Two: The Descriptive Analysis of the Sample Response.…………………………… 37
4.4 Section Three: Examining Significant Differences Related to Demographic Characteristics. 52
4.5 Summary of Results…………………………………………………………………………………………. 55
Chapter Five: Summary, Conclusion and Recommendation………………………………………………….. 59
5.1 Summary of Results…………………………………………………………………………………………. 59
References…………………………………………………………………………………………………………………….. 63
Appendix………………………………………………………………………………………………………………………. 69
Chapter One:
Introduction
Chapter one: Introduction
1.1 Background of the study
Patients safety is at the core of health services provision and is considered as one of crucial issues in health research, having ranked as one of the significant global public health concern (Vincent, 2011; p2). The World Health Organization (WHO) has identified patient safety as one of the challenges in healthcare provision and has went ahead to set up guidelines to improve patient safety. Patient safety issues affect all countries irrespective of their economic development. The WHO (2007) has set six international safety goals to achieve patient safety. The safety goals to attain patient safety include reducing the risk of reducing nosocomial infections, improving patients identification, effective communication, improving the safety of high-alert medications, safe surgery and reducing patients falls.
Patient safety encompasses avoiding and preventing harm to the patients or injuries or any adverse resulting from the health care delivery process (Patient Safety Group, 2012). According to WHO, patient safety is described as an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. It includes harmful incidents (formerly adverse or sentinel), no harm incidents (that reach the patient but did not cause harm), and near miss (also known as close calls).
Nadzam (2009) underlines the significance of effective communication in the countless interactions that between healthcare workers in the workplace. This suggests that staff must communicate effective and enhance collaboration in healthcare teams to ensure accurate and timely delivery of information. A dearth of effective communication in health care teams may compromise patients safety and negate the health outcomes.
Public health care requires establishing and/or building community relationship in public health as a significant aspect in healthcare practice. Community relationships are important in ensuring public participation in healthcare provision. Partnering with community in the provision of healthcare enables the identification of health problems accurately as well as developing more holistic and effective solutions (Minnesota Department of health office of performance improvement, 2014).
Empathy, a constituent of cognitive, emotional and executive syndrome is an emotional reaction in social communication that perceives meaningful cues from the surrounding by which it aligns the abilities of correctly interpreting the meaning of stimuli to human emotions. It is the ability to accept another individual’s perspective. Getting insight on empathy as a dimension of social communication will assist in understanding emotions; improve social abilities and communication with significant greater sensitivity to patient’s feelings and the consequences of an individual behavior (Jemczura, 2004).
According to WHO (2012), individual health information must accompany the patient when receiving care from healthcare providers. This calls for data interoperability as a prerequisite to effective utilisation of health information. Information and communication technology (ICT) has enormous potential in delivering improvement in healthcare systems in both the developed and the developing countries through enhancement of access to patients’ health information, in essence making healthcare delivery not only effective, but efficient. ICT also improves the quality of health services while ensuring it is relatively cost-effective. For instance, tracking specific health problems and their management over time, may assist in developing optimal diagnosis and therapy that can lead to improved health outcomes.
According to Margot (2006), data gathering is a crucial nursing role that is fundamental in provision of optimum patient care. Data collected from patients can be used in the evaluation of the patient condition and planning the optimal treatment. Data collection is a first step in clinical care that enables the nurse to accurately identify symptoms and diagnosis for appropriate interventions.
Effective physician-patient communication helps in the decision-making process and is the single most significant enabler of delivery of quality care in the physician-patient dyad. It is therefore to have clear, empathetic and respectful communication that supports information exchange in the shared decision-making as well in patients’ self-management (Huy & Kristiana, 2014, p.7). According to Tereza and Fleury (1999, p.110), cultural difference is an aspect that arises from the mixture of people of different group identities within the social system. On the other hand, Mannix and Neals (2005) and Jackson, Joshi, and Erhardt (2003) have argued that cultural difference is just one of the aspect that a person uses to uncover personal differences. Cultural differences include variations in the population such as gender, age, race, culture, and physical adequacies. Other definitions of cultural differences include ethnic and nationality, social class as well as religion and ways of communication and learning.
1.2 Research Problem
The research problem revolves around investigating the impact of effective communication in healthcare clinical centers on patient safety. The current research is significant since it seeks the positive impact of effective communication on patient safety which has a direct role on collect the needed information to attend the patient professionally.
1.3 Research Gap
The need for reducing patients harm resulting from lack of patient safety in the clinical settings motivates the need for this study. There is a dearth of research on the impact of effective communication in improving patient safety in the context of Saudi Arabia. The study is relevant for various stakeholders in the healthcare sectors including health practitioners and patients. The outcome of the study seeks to contribute to the current body of knowledge on the impact of effective communication in the healthcare settings in the context of Saudi Arabia. From the recommendations of this study, suggestions will be availed on a suitable framework for improving the quality of care through effective communication.
1.4 Rationale of the Research
This research has a valuable significance to the patients, the healthcare providers and the community at large. For the community it raises the community awareness about the issue of patient safety, and the importance of effective communication between patients and healthcare providers. For healthcare providers, this research will seek to increase awareness on the importance of healthcare information as an ethical attribute of protecting patients from preventable harm in the healthcare setting. For the patient safety, this research will contribute in proposing workable recommendations that can contribute to the achievement of patient safety through provision of high-quality care.
1.5 Research Objectives
This research attempts to achieve the following objectives:
To assess the role of effective communication on patients’ safety.
To examine how the healthcare staff give high rate for the effectiveness of communication on patient safety.
1.6 Research Model and Dimensions
The research model is illustrated in the following diagram:
Independent Variable Dependent Variables
Independent Variable: effective communication includes the following:
Establish relationship
Empathy
Gathering information
Share decision making
Cultural differences
Dependent Variables: patient safety
1.7 Research Hypothesis
H1: A significant relationship exists between establish relationship and patient safety.
H2: There is a positive and significant relationship between empathy and patient safety.
H3: There is a significant relationship between gathering information and patient safety.
H4: There is a significant relationship between share decision making and patient safety.
H5: There is a significant relationship between cultural differences and patient safety.
1.8 Research Methodology
Research methodology embodies a systematical organization and completion of research to unravel a research problem. The method applied in this study is a descriptive analytical approach. The researcher defines the type of method applied, the methods of data collection, target population and an appropriate sample for the study. In addition, the methods for data collection and the research strategy as well as data analysis approach are determined. This study will include all professionals’ health care (physicians-nurses and other healthcare providers) and managerial employees working in the healthcare field. Therefore, the total population in the four healthcare centers will be 150 subjects. The research will take all number of healthcare providers in the selected four healthcare centers due to their small population.
1.9 Research Scope
Place: This study will be applied in primary health care centers in Alhamra, Bryman, Almahjar and Khalid alnamodagi healthcare centers, Jeddah province – MOH.
Time: January –February –March 2018
Subject: The Impact of Effective communication on Patient safety
1.10 Research Structure
Chapter One: Introduction
Chapter Two: Literature Review and Previous Studies
Chapter Three: Research Methodology
Chapter Four: Data Analysis and Interpretation
Chapter Five: Summary, Conclusion and Recommendation
Chapter Two:
Literature Review and Previous Studies
2
Chapter Two: Literature Review and Previous Studies
2.1 Introduction
Responsibility of ensuring patient safety in healthcare institutions in any given society is connected with the roles and responsibilities of various parties including nurses, physicians, and the management of the healthcare institutions, in addition to the patient family. In this regard, the accessibility and provision of flexible communication tools, is considered to have much importance, and an essential element which can effectively contribute to achievement of high-quality care for the patient.
In this chapter, patient safety, and effective communication are the major issues of the subject of the study which will be discussed in detail. The literature reviewed will cover the two concepts, patient safety, and effective communication within the frame of this chapter. Patient safety would be defined by the principles of management of patient safety, and how to assess patient safety as well as the role of nurses in patient safety. Formal aspect of communication, strategies for effective communication, in addition to barriers to effective communication.
2.2 Literature Review
The following sections present Communication and patient safety, Establish relationship, Empathy, Gathering information, Share decision making, Cultural differences, Patient safety management, Management of patient safety in Saudi Arabia and Essential safety standards requirements.
2.2.1 Communication and patient safety
Effective communication is an essential life skill that requires continuous development and improvement. Individuals with good communication skills develop empathy and trust from other easily. Good communicators are able to align their communication to align with the audience situation. Communication is a complex two-way process that is characterized by much iteration that focuses on developing mutual understanding between parties to the communication. Communication encompasses different aspects including words, facial expression, voice, pictures, tones, body languages as well as clothing and graphics (Team FME, 2013, p.4).
Communication is defined by two approaches namely the social construction approach and the information engineering approach. Social construction approach underlies the creation of a dynamic context in team communication while information engineering approach entails the linear transmission of messages via a conduit which guarantee effective communication through an accurate and unbroken transmission. In essence, information engineering results in the receiver understanding the message by decoding the messages. The information engineering framework is hindered by psychological and physical noise in the system. On the other hand, social construction framework of communication does not have a neutral conduit; rather it considers communication as a social process where meaningful common environment is constructed. The social construction approach is limited in the sense that it does not address how communication patterns generate and sustain team communication. In team communication, there is both social construction of reality and transmission that include implicit and explicit frameworks that a team develops in order to fit certain roles, goals and behavior (MPH, 2011; p2).
According to the WHO report (2009; p18) regarding the human factors in patient safety, efficiency and high-quality output in the workplace relies on effective communication. It is through good communication in the workplace that knowledge is transferred, predictable behavior patterns and relationships established as well as establishment of effective team coordination and leadership. According to the report, the standard model of communication entails the sender encoding an idea into a message, which is then transformed to one or more receivers who then decode it back to the original idea.
The report categorized communication problems as system failures, message and reception failures. Common communication failures include:
Organizational system failures where channels of communication are non-existent, rarely used or in some cases are malfunctioning.
Transmission failures, where communication channels exist, but information is not transmitted.
Reception failures occurs when communication channels exists and the information is sent, but it is misinterpreted by the recipient or there are delays such that communication is not effective. Reception failures are mostly caused by equipment failures or physiological problems.
Lastly, there is failure occasioned by interference between rational and emotional context such as communication failures due to an argument.
According to the National Health Service (NHS, 2010; p8) in the UK, national benchmarks for communication require communication needs to be assessed and appropriate methods applied to enable effective communication between the patients and carers. These national benchmarks patient to the accessibility of information, acceptable and accurate information which should be actively and consistently shared to meet the needs of the patients. Effective communication among the staff in the healthcare settings ensures that staff are able to maintain safety and quality of patient and continuity in their service for all.
Several studies have demonstrated that ineffective communication among healthcare practitioners as a leading factor in medical errors occurrence and patients harm (Woolf, 2004; Lingard, 2004, P.330; Leonard, 2004, P.68). A review of reports from the joint commission also corroborates the findings from these studies where it reveals that failures in communication being implicated in over 60 percent of sentinel events. In another study by Zwarenstein and Reeves (2002; p243), ineffective communication in medical teams is linked to adverse patients outcome associated with low safety standards and compromised error prevention mechanism. Moreover, in the acute healthcare settings failures in communication result in lengthy hospital stays and patients harm as well as increased cost of healthcare , caregiver low satisfaction that leads to high turnover in healthcare facilities.
Patient safety research developed as intellectual history of patient safety accumulated (Linda, 2008, p6). Initially there were debates on whether patients safety can be considered as a risk in healthcare delivery, a philosophy that encompasses explanatory frameworks, ethical principles as well as methods or as a discipline or an attribute with its own goals.
There are several definition of patient safety including the Institute of Medicine in the USA which defines patient safety as freedom from accidental injury, while the National Patient Safety Foundation defined patient safety as a key aspect emerging from the appropriate interaction of components of the healthcare system with a for patient safety.
According to Linda (2008; p1), patient safety is a health care discipline that utilises safety science approaches towards achieving a trustworthy system of health care delivery. Patient safety seeks to reduce the incidence of adverse events or their impacts and maximise recovery from such events. It has also been defined as the prevention, avoidance and improvement from recovery adverse events in occurring in healthcare settings (Vincent, 2011, p1). Patient safety calls for rapid intervention in case patient safety is infringed and supporting staff in erecting measures to guarantee patient safety in the healthcare settings.
2.2.2 Establish relationship
The quality of care for the patient depends on effective communication that seeks a patient-centered care based on a sound therapeutic relationship between the physician and the patient. Effective communication is a vehicle towards which healthcare is optimized through the facilitation of a therapeutic relationship. For instance, the cornerstone of the nursing practice rests on the registered nurses’ ability to build therapeutic relationships with the patients. A successful doctor-patient relationship develops under an environment of shared perceptions and knowledge regarding the disease as well as the nature of the treatment and the underlying treatment goals (Razzaghi & Afshar, 2016). Through shared knowledge settings, the patient can effectively participate in the decision-making process regarding his or her health. The importance of establishing a relationship between the patient and the physician is underpinned by the need to understand patients’ experiences and interpret the negative impact on patients’ health outcomes (Razzaghi & Afshar, 2016). In most cases, patients are not in a position to make informed decisions without having relevant information regarding the disease and therapeutic management. Effective communication enables the physician to develop a sound and effective relationship with the patient such that the patients can receive quality care and understand the goal of the care.
Effective communication in the physician-patient interaction is a core element of patient-centered care since it facilitates the provision of quality care and influences patient outcome. It leads to the development of the shared perception of the patient condition and helps in effective participation of the patients in the decision-making process regarding their health. Insight into the patient’s experiences ensures the patient can make relevant and informed decisions towards the improvement of the therapeutic care (Begum, 2015).
2.2.3 Empathy
Effective communication is shaped by basic techniques such as assertiveness, listening, and empathy (Begum, 2015). In the context of health care, one of the most important social factors a physician should possess is professional empathy. Physician’s empathy is a critical component of effective communication in doctor-patient communication (Jani, Blane, & Mercer, 2012). The physician should possess professional empathy involving three attributes that include (1) understanding the experiences and concerns of the patients, and (2) emotional awareness. These help in contextualizing patient’s own feelings and (3) being able to communicate the understanding of the patient with the intention of assisting (Cánovas et al., 2017). The level of physician professional empathy has a far-reaching impact on the therapeutic outcome. Jani, Blane, and Mercer (2012) have recognized the role of physician’s professional empathy in determining the patient’s clinical outcome. Empathy is important in the healthcare in promoting meaning and reducing stress and compassion fatigue. Fostering physician professional empathy has the effect of reducing patients’ stigmatization. Empathy, for instance, can reduce stigmatization since it prevents the adoption of common culturally negative stereotypes towards the patient’s conditions. Empathy also helps in earning patients’ trust and satisfaction, helping to eliminate ambiguity and uncertainties about the nature of the symptoms the patients are presenting (Cánovas et al., 2017). Empathy leads to the generation of dispositional optimism which can improve the patient outcome though it is not a coping strategy. Dispositional optimism precedes motivational aspects and the adoption of an active and adaptive approach towards one health. This optimism contributes to the psychosocial factors that are important in determining the positive outcome of the patients in improving the quality of life for the patients (Cánovas et al., 2017). Empathy promotes meaning to the therapy and mitigates against compassion fatigue and stress.
2.2.4 Gathering information
A core skill enshrined in medical practice is the physician’s ability to effectively communicate with the patients by developing good interpersonal skills in gathering information from the patients. The ability to obtain information from the patient through effective communications promotes precise diagnosis of the patients and also allows the physician to give therapeutic instructions to the patients. Ultimately, information gathering is a critical component of medical practice that helps in achieving therapeutic goals (Giroldi et al., 2015). Gathering information as an aspect of effective communication in the physician-patient relationship leads to reduction of iatrogenic harm in health care delivery (Kelley et al., 2014). The fundamental principle in gathering information from patients helps in the mitigation of systemic errors and when objectively utilized they assist in incident reporting. In gathering information from patients, physicians’ communication strategies are key, such as the empathic interruption so as to furnish the physician with the necessary information while meeting the patient’s need for social closeness (Giroldi et al., 2015). Gathering information helps in proper diagnosis of the patients and improves the efficiency of a patient-centered approach to healthcare, which ultimately improves patient satisfaction. Gathering information as a strategy for effective communication is linked to the traditional paternalistic model that acknowledges the significance of the patient’s story in the course of the provision of healthcare (Kelley et al., 2014). Gathering information can be viewed as part of cognitive and emotional care offered to the patient which enhances physician-patient relationship. In gathering information from patients, physicians are argued to ask open-ended questions and resist the urge to interrupt patients such that they are able to identify and respond to patients’ concerns and expectations, and appropriately diagnose the patient and offer appropriate therapy (Giroldi et al., 2015). These techniques serve as factors that improve the quality of information exchange and produce a richer interpersonal interaction in the healthcare settings.
2.2.5 Shared decision making
The pinnacle of patient-centered care rests in a shared decision-making process that involves physicians and patients jointly participating in making health care decisions (Barry & Edgman-Levitan, 2012). Effective communication between physicians and patients as well as the shared decision-making process takes into consideration the patient’s circumstances, informed preferences, and the associated uncertainties related to the intervention. Shared decision making goes beyond identifying the risk and benefits of the intervention strategy to provide informed consent. In the framework of effective physician-patient communication shared decision making takes into consideration the patient circumstances, informed preferences and the associated uncertainties related to the intervention (Elwyn, 2014). Traditional, the decision-making process rested on the clinicians making decisions for the patients. However, in a patient-centered care, shared decision making recognizes the difference between the patient and the physicians and puts the consideration of the expertise such that the decision made resonates along a continuum of two extremes, a patient-driven and a physician-driven decision-making process (Guyatt et al., 2014).
Shared decision making is only attainable in an environment of effective physician-patient communication. The quality of communication within the physician-patient dyad is the most significant determining factor of the quality of care delivered to the patients. Shared decision making as an aspect of effective communication between the physician and the patient supports and enhances patient empowerment, better management of emotions, and improves the social support offered to the patient. Moreover, shared decision making contributes to
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