A Mixed-Methods Pilot Study of Symptom Communication in Advanced Cancer: Patterns and Associating Factors
Conditions: Communication, Cancer, Symptom, Behavioral
Sponsor: National Taiwan University Hospital

201807052RINC, Sep, 2018 
CM03 
 
 
 
A MIXED-METHODS PILOT STUDY OF SYMPTOM COMMUNICATION 
IN ADVANCED CANCER: PATTERNS AND ASSOCIATING FACTORS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chia-Chun Tang, PhD, RN 
School of Nursing,  
National Taiwan University College of Medicine 
Approved by the National Taiwan University Hospital Human Subjects Office Institutional Review Board 
201807052RINC, Sep, 2018 
 
 

2 
 
CM03 
 
Table of Contents 
Abstract ............................................................................................................................................................. 3 
Background ....................................................................................................................................................... 4 
Purpose and Specific Aims .............................................................................................................................. 4 
Conceptual Underpinnings .............................................................................................................................. 5 
Research Design, Methods, and Procedures ................................................................................................10 
Research Design ...........................................................................................................................................10 
Methods and Procedures .............................................................................................................................12 
Trustworthiness ..............................................................................................................................................17 
Innovations and Challenges ...........................................................................................................................17 
Expecting Results ............................................................................................................................................18 
Conclusion .......................................................................................................................................................19 
References .......................................................................................................................................................22 
 
 
 

3 
 
CM03 
Abstract 
Background 
Improving patient-provider communication is a fundamental and cost-effective method to 
advance patient outcomes, including symptom management which is often the primary goal of care 
for patients with advanced cancer. Unfortunately, some studies revealed the poor quality of symptom 
communication among cancer patients and healthcare providers. While these evidences suggest 
important gaps in communication about symptoms with some of our most vulnerable patients, we 
know little about the patterns and associating factors of symptom communication.  
Purpose and Specific Aims 
The proposed 3-year pilot project aims to provide an enrich and systematic description of 
symptom communication by validating a newly developed typology of interaction patterns of 
symptom communication (TIPSC) between patients with advanced cancer, their caregivers, and 
healthcare providers and explore factors related to each interaction pattern. The specific aims are to: 
(1) validate TIPSC in Taiwanese advanced cancer population, (2) explore patients’ /caregivers’ 
experience and thoughts of symptom discussion in regard to their interaction patterns and symptom 
management, and (3) examine relationships between interaction patterns and (a) demographic factors, 
(b) symptom severity, (c) congruence in symptom assessment between patients/caregivers and 
providers, (d) patients’/caregivers’ perceived ability to communicate with providers, and (e) 
patient/caregiver satisfaction.           
Sampling 
This pilot study plans to recruit about 50 patient/caregiver — oncologist dyads. The recruitment 
process contains three stages. First, medical oncologists who are currently in clinical practice at 
participating institutions and care for patients with solid tumors will be approached. Second, 
participating oncologists’ patients will be recruited if they are: (1) currently a patient of a participating 
oncologist, (2) diagnosed with stage III or IV solid cancer, (3) aged 20 years or older, (4) able to 
tolerate an interview that will last approximately 30 minus, and (5) able to speak Chinese or 
Taiwanese. Finally, if applicable, adult caregivers who intent to join selected out-patient-department 
(OPD) visit with the patients will also be recruited.  
Research Design 
This is a mixed-methods study with a two-phase exploratory sequential design. The first phase 
is a qualitative descriptive study in which we will record patient/caregiver—oncologist OPD visits 
and conduct patient/caregiver interviews to address aim 1 and 2. Discourse and conversation analysis 
will be used to analyze the recorded visits and content analysis will be used to analyze the interviews.  
The second phase is a correlational study in which we use questionnaires to measure variables and 
examine their relationship with interaction patterns (aim 3). Descriptive statistics, binomial logistic 
regression, and linear regression will be used to analyze quantitative data. 
Expecting Results 
This is a pioneering study addressing the patterns and associating factors of symptom 
communication in Taiwanese patients with advanced cancer. Our findings will systematically map 
out the patient/caregiver─provider symptom communication and identify relationships between 
communication patterns and meaningful indicators. This proposed study is a critical step to 
understand patient/caregiver—provider communication regarding symptoms in order to pinpoint 
symptom management and communication barriers and design proper interventions in Taiwan. 
 
Key words: Health communication, Symptom management, Mixed-methods design, Cancer 
Care, Advanced cancer   

4 
 
CM03 
Background 
Questionable quality of patient—provider communication is a worldwide issue which can 
negatively affect patient outcomes, satisfaction, quality of decision making, patient—provider 
relationship, and healthcare resource utilization and expenditures (1-4). Poor quality of 
communication also contributes to increasing medical error, adverse events, and patient aggression 
or violence behavior (5-8). While health communication has gained increasing attention in developed 
countries, more studies done in Taiwan are needed because of the culture-specific 
communication needs and special communication challenges that Taiwanese healthcare 
providers have encountered. For example, evidence shows that Taiwanese patients have lower 
health literacy compared to some developed countries which may affect their communication ability 
or efficacy (9-11). In addition, Taiwanese healthcare providers perceived lower communication 
openness compared to their counterpart in the U.S. (12). The escalating patient violence behavior 
toward healthcare providers also suggests ineffective patient-provider communication in Taiwan (9).   
Among the multiple aspects of healthcare that can be affected by communication, symptom 
management is one of the critical outcomes of patient—provider communication (13-15). 
Indeed, symptom, perceived indicators of change in normal functioning as experienced by patients 
(16),  is often the major topics of cancer patient—provider communication (17). In Taiwan, cancer 
remains the leading cause of death since 1982. It was estimated that there were more than 103 
thousand newly diagnosed cancer patients in 2014 with considerable portion of them diagnosed with 
advanced stages (i.e., stage III or IV)(18).  While symptom management is one of the primary 
care goal for these advanced cancer patients, the quality of symptom communication is beyond 
satisfactory. Cancer patients had either no chance to talk about or low motivation to discuss their 
severe symptoms (19-21). A study done in Taiwan have further revealed that the “fear of distracting 
the doctor” was a main barrier for cancer patients to report the symptom of fatigue (22). The 
ineffective symptom communication may prevent healthcare providers (HCP) from conducting 
accurate symptom evaluation and effective management. For example, HCP tended to underestimate 
patients’ symptoms which shows the incongruence of symptom evaluation between patients and HCP 
(23). Despite the poor quality of symptom communication, there is a lack of systematic and 
comprehensive understanding regarding patient—provider symptom communication. Specifically, 
few studies have considered (1) the theoretical underpinnings, (2) naturally occurring medical 
encounters, and (3) both patients’ and providers’ communication behavior. In fact, to date, no 
published study exploring advanced cancer patient—provider symptom communication in Asia 
countries. Studies which explore symptom communication thoroughly is thus much-needed in 
order to fully map out and facilitate symptom communication in Taiwan.  
Purpose and Specific Aims 
The purpose of this mixed methods study is to provide an enrich and systematic description 
of symptom communication by validating a typology of interaction patterns regarding 
symptom communication (TIPSC) between patients with advanced cancer and their 
healthcare providers (HCP) and exploring factors related to each interaction pattern. The 
specific aims are to:  
1. Validate TIPSC in Taiwanese advanced cancer population in terms of how patients, 
caregivers, and HCP discuss symptoms during out-patient-department (OPD) visits.  
2. Explore patients’/caregivers’ experience and thoughts of symptom discussion in regard to 
their interaction patterns and symptom experience. 
3. Examine relationships between interaction patterns and (a) demographic variables: age and 
educational level, (b) symptom severity, (c) congruence in symptom assessment between 
patients/caregivers and HCP, (4) patients’/caregivers’ perceived ability to communicate with 

5 
 
CM03 
HCP, and (5) patient/caregiver satisfaction. 
Conceptual Underpinnings 
The specific aims and research design of this proposed study are informed by two conceptual 
frameworks. Aim one and two which seek to deductively explore interaction patterns of 
symptom communication are informed by a typology, TIPSC, developed by the applicant. The 
applicant used qualitative methods to explore naturally occurring symptom discussions to establish 
this typology that describes eight interaction patterns of advanced cancer patient—provider symptom 
communication. These eight interaction patterns which reflects unique style of symptom 
communication are collaborative, explanatory, agentic, checklist, cross-purpose, empathic, 
admonishing, and diverging interactions (24). The definitions and exemplars of each interaction 
pattern are presented in table 1. Building on this typology developed in the U.S., the proposed study 
seeks to explore and categorize symptom communication in Taiwanese cancer population and, at the 
same time, verify or even expand the TIPSC. Once the qualitative verification of the TIPSC is 
established, we are able to quantitatively examine the relationship between interaction patterns and 
meaningful variables or outcomes which lead to our specific aim three.  
While the proposed study does not intend to test the whole theory, specific aim three was 
informed by the Dual Process Theory of Supportive Message (DPT). DPT was firstly published 
by Burleson in 2008 with the main purpose of providing a systematic explanation about factors 
affecting communication and its outcomes (25). One of the important assumptions proposed by the 
DPT is: communicators’ ability to handle the massage (A) and their motivation (M) to discuss the 
topics mediates the relationship between quality of communication (Q) and communication outcomes 
(O). In the proposed study, we conceptualize the ‘ability to handle the message’ as patients’ perceived 
ability to communicate with providers and ‘motivation’ as symptom severity. That is, we propose to 
explore the relationship between TIPSC (Q), patients’ perceived ability to communicate with 
providers (A), symptom severity (M), congruence in symptom assessment between patients and 
providers (O), and patient satisfaction (O).  Figure 1 shows the modified conceptual framework.    
Quality of 
Communication 
(Q): Interaction 
Patterns (TIPSC)  
Motivation 
(M): 
Symptom 
severity 
Ability to 
handle the 
massage 
(A): 
Perceived 
ability to 
communicate 
with 
providers 
Communication 
Outcomes (O): 
Congruence in 
symptom 
assessment and 
Patient satisfaction 
Figure 1. Modified Conceptual Framework of Dual Process Theory of Supportive Message 

201807052RINC, Sep, 2018 
CM03 
 
Table 1. Interaction Patterns, Defining Characteristics, and Exemplars 
Interaction 
pattern  
Defining characteristics 
Exemplars 
[O] Oncologist, [P] Patient, [C] Caregiver 
Collaborative 
Patients/ caregivers and 
providers worked together to 
figure out the nature of a 
symptom or a course of 
action. 
O: But with the pain changing this much I am worried that the cancer might be growing, Mr. [Patient]. 
P: Well, that’s what I said to my wife, is I don't know this chemo’s working. 
O: Right. 
P: It just seems to be growing. 
O: Right. I. . . I think so, too.  You know, and I feel that - 
P: Can we. . . can we prove that through tests somehow? 
O: We can.  It’s not . . . if you think that it will help you decide that let’s put this final chemo, you know, put to rest and 
know that it’s not working then we’ll do the scan.  I. . . I don't know if we need the scan, Mr. [Patient], because, you 
know, everyone at home and we here who know you see the change.  Right?  You have never required a pain pill in 
clinic, right? 
P: Yeah. 
O: And so I think whether the scan shows growth that can be measured, you know, I don't know if. . . we need that. I think 
that I have enough evidence here for me to say that this chemo is not working. 
P: Oh, okay.  Unless. . .  
O: Yeah, I think so. 
P: I’ll go with the Lord…I have a lot of good faith for the Lord and I carry him with me everywhere I go.  Along with my. . . 
along with my navy anchor. [Laughter]  
O: They go together, right? 
P: Yeah, why don’t we just stop it. 
O: Yeah, because if I felt that it was just the tiredness or if you were having some side effects we would come up with some 
way to get through.  But I think that, you know, and we’ll have blood work, we’ll have some tests there. 
P: Are you okay with that [to his wife]? 
C: Hmm? 
P: Are you okay with that? 
C: It’s your decision.  Your decision.  I would say he was more tired this week than before. 
Explanatory 
Providers gave factual 
information to patients and 
caregivers 
O: They [lymph nodes] are all less than 5 millimeters but they are new and they are increasing, which means that the cancer 
is spreading.   
P: [takes a breath, possibly a gasp] 
O: But none of them is more than 5 millimeters.  What’s going on in the liver.  So, in the liver also there is the same thing.  
There is an increase in size and number of the [lymph nodes in the] liver.  There is some fluid around your liver.  Also in 
some area between -- the liver is covered by a capsule and there is some bleeding underneath the capsule from the old 
tumor dying.  So there is some collection of fluid there.  So, remember when you had that one instance where you had a 
tumor and you had a lot of pain in that area? 
P: Yes. 
O: That could have triggered the tumor dying and bleeding and stretching the capsule could have triggered your pain.  And 
since then you haven’t had any pain? 
P: No. 

7 
 
CM03 
O: So that probably is what happened that time when … I first saw you and you ended up in the hospital afterwards.  Now 
this is more pronounced so we can go back and say this is why you had the pain at the time.  So, clearly the disease is 
growing and I don't want to go over each lesion because the. . . each lesion does not matter.  The fact that the disease has 
increased in size and number tells me that we need to change course.  You know, just the Gemcitabine alone might not be 
enough… 
Agentic 
Patients and/or caregivers 
were particularly vocal 
during discussions with 
providers and/or very 
involved in making treatment 
decisions. 
P: …My appetite, I want to eat.  The problem I have doctor is. . . when I eat everything tastes bitter. 
O: I see. 
P: And it’s hard to eat. It’s hard - even when you want to eat it’s hard to sustain yourself when you’re trying to eat 
something and the food doesn’t taste like food or you get that initial something sweet. And then, and on the back end as 
you swallow it or whatever, it’s bitter.  So I'm constantly getting this food don’t taste like food, it’s this bitterness that’s 
going on. 
O: Are there any foods that you still enjoy or is this something that’s everything? 
P: It’s a lot of foods that I enjoy and those are the ones I go after. 
O: I see. 
P: But I still get this, like last night I had a little, I wanted to have a little piece of pizza, you know, just a taste of tomato 
sauce. 
O: Yeah. [keyboarding]  
P: And that kind of thing. And I couldn’t eat it. It was just bitter.  Um. . . that’s a problem for me, one issue right now I don't 
know how to deal with. 
O: Okay. 
P: Because it’s like I know to eat, my family is constantly on me about eating. And I know what you told me what I should 
be trying to do is the small meals. Okay.  So those -- it’s just the problem is when I do try to eat something it’s. . . it’s the 
taste.  I don't have the taste that I would normally associate with those foods that I like.  And so this is an issue. 
O: And that’s probably the chemo. 
P: Yeah.  This is an issue.  I don't really know how to get around it. My wife says eat anyway. And I said -  
C: Well, it’s so bitter it’s disgusting. 
P: And I said, baby, it’s hard to eat when. . . what you’re eating is either doesn’t have a taste that you normally associate it 
with so it’s not as desirable as before. 
Checklist 
Providers asked a series of 
questions in rote fashion, as 
if they were “going down” a 
list. 
O: Do you have an appetite? 
P: No. I’m not hungry. I… 
O: Stick out your tongue for me.  Deep breaths. You were having regular bowel movements. 
P: Yeah, like every other day, too. 
O: Solid or loose? 
P: I’d say . . .  solid.  Yeah, solid.   
O: Pain here as I press? 
P: [Non verbal reply.] 
O: Fevers at all? 
P: None. 
O: Shaking, chills? 
P: None.  I think for the most… 
C: So, he’s not on [Emend]…Is he?  It seems like… 

8 
 
CM03 
P: I think they give me that on at the… 
O: You’re getting … a steroid.  But you’re not getting Emend. 
Cross-purpose 
Patients and/or caregivers 
and providers seemed to have 
differing agendas and failed 
to acknowledge the remarks 
of the other. 
P: Because if I was to poke right in here…It’s not a pain but it aches really hard. 
O: Hard.  So have you been able to eat much? 
P: I don’t eat at all. 
C: Well, he’s. . . he eats very little.  For a while he was hardly eating.  Luckily he will drink the Glucerna. 
O: Okay. 
C: He’ll drink that.  And something like maybe oatmeal. 
O: Um hmm, okay. 
P: Cup of tea. 
O: Right.  And you just don’t have the appetite for it? 
C: Definitely. 
P: Don’t have any taste there. 
O: We can control the pain because. . . 
Empathic 
Providers showed, or 
attempted to show, that they 
understood and cared about 
the emotions or experiences 
of the patients and/or 
caregivers. 
P: And. . . um. . . I just discovered, what, about 3 days ago, my hair. 
O: This chemo started making your hair fall out? 
C: Um hmm.  
P: And I was very depressed. 
O: I'm sorry. 
P: I know it happens. It didn’t happen the first time, the first time I had chemo. 
O: I know.  
P: So, I figured, you know, well okay, I'm one of the ones that it’s not gonna happen to.  But well, you know, this is a wig 
that I have on. My hair, starting from back here up to about right here is all gone. 
O: I'm sorry, [Patient]. 
P: Yeah. 
O: It’s hard to tell because you always look good and this wig is so much like your real hair that it’s very hard to tell. You 
know?  And a lot of people, I know especially African Americans sometimes have all kinds of braids and they change 
their style so much that it’s hard to, for people that don’t know, to tell that this is all happening. 
P: Yeah. 
O: But I know you can tell and that must be upsetting and I'm sorry. So what to do, some of these chemos, the newer ones, 
they’re stronger, they’re better in some ways but then their side effects are also a little bit, you know, more.  And as long 
as the other things that affect quality of life like, you know, eating and energy, you’re not too badly affected, most 
patients say okay, I can wear a wig for a while. 
P: Right. 
Admonishing 
Providers cautioned patients 
and caregivers against 
behaviors thought not to be 
in the patients’ best interest 
or gently scolded them for 
taking certain actions or 
voicing certain opinions. 
O: . . . are you careful about when you take your pain medicine and driving? 
P: Well, . . . I find myself weaving sometimes. . . I don't like to drive with a lot of people because they tend to weave. Do 
you know what I mean? 
O: Well, you’re not filling me with a lot of confidence here. 
C: But it’s not a frequent occurrence when you’re driving. 
P: Oh, no, it was happening on Easter…when I was going to [name of relative].  So… I got off on the wrong place, and I 
wound up on those 3 roundabouts…Have you ever been on roundabouts…? 

9 
 
CM03 
O: I know what you mean, yeah…Well, that is a little scary…So how much driving are you doing since then? 
P: Oh, I drive, like to mah jong a couple of days a week and. . .  
O: Is that like a few blocks or is that halfway across the city?...What do you do that for? 
P: [Makes a fun noise]: Pow!  [Chuckles] Slots. 
O: Do you have a friend that can go with you? 
P: Why?  I have to take my car. 
O: I don't like this, what you’re telling me about your driving, that’s why. 
P: Oh.  Well, basically I don’t drive on the days that I’m really feeling blech.  I know when to drive…And the people that 
want to pick me up, like my sister, believe me, I’m better off driving.  [Chuckles] She’s 85 years old and I think she’s 
beginning to get a little flaky. 
O: Yeah, but she’s not on pain medicine.  That’s what I’m concerned about. 
P: I never feel tired from it…I mean I go to bed at 2 o’clock in the morning. 
O: Well, I understand but it’s like alcohol.  You don’t have to be falling down drunk to have decreased reflexes and maybe 
that’s why you were weaving a little bit. 
P: … I said my driving days are numbered if I feel like I did today…I’m not dumb. 
O: You’ve heard me and I know you’re not dumb.  So. 
Diverging 
Providers and patients and/or 
caregivers expressed a 
disagreement. 
O: That could have been a different virus that led to your decreased immunity that led to your pneumonia, actually.  That’s 
probably the most likely thing. 
C: But generally that kind of stuff starts getting better after 3 or 4 days. 
O: Yes. 
C: If it’s a virus. 
O: Right. 
C: And this wasn’t getting better. 
O: I'll bet you anything it was a virus.  You didn’t think it was getting better because you got a subsequent pneumonia after 
the virus happened. And that’s called a secondary super infection.  That actually happens a lot.  I. . . I personally think it 
came about because of an initial virus more than anything and I, personally myself don’t think this has anything to do 
with the Everolimus.  But prove me wrong -- I hope you don’t because I don't want you to have anymore infections. 
C: We don’t want to prove you wrong. 
O: I really do think you are tolerating very well.  I see no reason to lower the dose. It’s doing what we asked it to do…I'm not 
pushing surgery by any means but if it’s something that you guys want to talk about then you guys should get together 
and talk about it. 
P: Thank you. We’ve been bothered all along about the. . . we saw Dr. [Name] first and then you…And we’ve seen you a 
couple of times since.  And it just didn’t seem like there was, you know, we came into this thing thinking you guys were a 
team. And we didn’t feel that this team thing was a reality.  That you had one. . . set. You know, you were definite on 
keeping me on this for ten years if it continued to work - 
O: oncologist, P: patient, C: caregiver  

201807052RINC, Sep, 2018 
CM03 
 
Research Design, Methods, and Procedures 
Research Design 
This is a mixed-methods research project with exploratory sequential design (Fig. 2). Mixed-
methods study is an emerging type of research design which has gained increasing popularity in social 
science and medical research (26). It allows us to study and comprehend the phenomenon from 
multiple aspects. Because we are seeking to explore and describe the interested phenomenon in-depth 
and comprehensively, mixed-methods best address our research purpose. Exploratory sequential 
design is one of the major types of mixed-methods designs. It fits the specific aims which explore the 
unknown phenomenon first and then validate and test the exploratory findings in the following phases 
in order to generalize to larger population and make concrete suggestions. The following paragraph 
describes the exploratory sequential design according to the six key characteristics which are used to 
categorize and understand different mixed-methods designs (27). 
1. Number of study phases, type of implementation process, and stage of integration of 
approaches: The proposed study include two study phases which are conducted sequentially. 
Primary qualitative data is collected and analyzed first (phase 1) to inform the following 
quantitative research (phase 2). The integration of qualitative and quantitative findings 
happens in the second phase as the analysis of the second phase will be conducted based on 
the findings from phase one.  
2. Theoretical perspective: The exploratory sequential design includes dealing with both 
qualitative data and quantitative data and is supported by the pragmatism worldview. The 
pragmatism perspective appreciates both singular and multiple realities and emphasizes 
practicality. Pragmatism embraces abduative logic and is research question centered (26).  
3. Function of the research study: The primary goal of the exploratory sequential design is to 
first explore the little-known area qualitatively and then enhance and generalize qualitative 
findings.  
4. Priority of methodological approach: Qualitative method is the primary part of this study 
because the qualitative data collection and analysis builds to quantitative phase.

201807052RINC, Sep, 2018 
CM03 
 
 
Figure 2. Research Schema: Conceptual Underpinnings, Study Phases, and Corresponding Specific Aims and Procedures 
Phase 1 
(2018-2020) 
Qualitative Data Collection and 
Analysis: Qualitative descriptive 
design 
Phase 2 
(2020-2021) 
Quantitative Data Collection and 
Analysis: Correlational research 
d
i
Final Research Reports 
(2021) 
Typology 
of 
Interaction 
Patterns Regarding Symptom 
Communication (TIPSC) 
Typology 
of 
Interaction 
Patterns Regarding Symptom 
Communication (TIPSC)  
Dual 
Process 
Theory 
of 
Supportive Message (DPT) 
Aim 1. Validating a newly established 
typology regarding interaction patterns 
of unstructured symptom discussion in 
Taiwanese advanced cancer population.  
Aim 2: Exploring patients’ experience 
and thoughts of symptom discussion in 
regard to their interaction patterns and 
symptom experience. 
Aim 3: Examine relationships between 
interaction patterns and (a) demographic 
variables, (b) symptom severity, (c) 
congruence in symptom assessment 
between 
patients/caregivers 
and 
providers, 
(d) 
patients’/caregivers’ 
perceived ability to communicate with 
providers, 
and 
(e) 
patient/caregiver 
satisfaction. 
Conceptual Underpinnings  
Specific Aims 
Procedures 
Recruiting oncologists, patients, and caregivers 
(collecting demographic information and 
scheduling an out-patient-department (OPD) 
visit to be recorded)  
Record 1 OPD visit 
Collect quantitative data: questionnaire 
measurements 
Schedule an 30-40 minutes interview 
Interview (Incentive will be provided after the 
interview) 
Analyze the recorded office visit using discourse 
and conversational analysis: determining 
interaction patterns  
Analyze the interview using content analysis: 
exploring patients’ experience regarding the 
recorded symptom communication 
Analyze quantitative data: the relationship 
between identified interaction patterns and 
questionnaire measurements 
Triangulation: compare the results from 
qualitative interview with the quantitative data 
to see how the data support or disagree with 
each other 
Drafting preliminary research report 
 
Builds to 
Interpretation 

201807052RINC, Sep, 2018 
CM03 
 
Methods and Procedures 
The method section describes sampling process and study methods of each phase.  
Sampling.  Because a qualitative study typically requires about 30-50 participants (28), the sample 
size of this pilot study is set to be 50. The two samples of phase one and two will include the 
exactly same individuals and same sample size which is about 50 patient/caregiver—physician 
dyads, including about 50 patients, 10 physicians, and 50 caregivers, if applicable. 
There are three steps of recruitment processes. First, physicians who are currently in clinical 
practice at National Taiwan University Hospital and care for patients with solid tumors will be 
recruited through study presentations at grand rounds, meetings, or personal contacts. A research 
assistant then meets with interested physicians for explaining the details of the study, consenting, and 
setting up following schedules for recruiting patients at OPD visits. Second, research assistants 
identify potential eligible patients by working closely with participating physicians and their clinic 
nurses. These potential eligible patients will be approached by their physicians, nurses, or research 
assistants. We include patients who are: (1) currently a patient of a participating physician, (2) 
diagnosed with advanced solid cancer (TNM stage III or IV), (3) aged 20 years or older, (4) able to 
tolerate an interview that will last approximately 30 minus, and (5) able to speak Chinese or 
Taiwanese. Patients who (1) do not experience any symptoms, or (2) are hospitalized at recruitment 
are excluded. Finally, caregivers who will participate in the OPD visits with participating patient will 
be approached. Caregivers who are younger than 20 years old or cannot speak Chinese or Taiwanese 
will be excluded.   
Recruitment process. Interested patients and their caregivers will receive a pamphlet regarding 
study information when research assistants explain study process, confirm participation, and arrange 
schedules. Signed written consents will be obtained from physicians, patients, and caregivers before 
data collection. Participated patients and caregivers are required to (1) provide an audio-recorded, 
unstructured OPD visit with their physicians, (2) complete 3 survey measurements (European 
Organization for Research and Treatment of Cancer, Perceived Efficacy in Patient-Physician 
Interactions scale, and The Chinese Patients’ Satisfaction Scale), and (3) participate in a 30-40 
minutes interview at home or a private room. On the other hand, participated physicians will complete 
European Organization for Research and Treatment of Cancer immediately after the recorded OPD 
visit. Figure 3 represents the recruitment and data collection process.

201807052RINC, Sep, 2018 
CM03 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2. Example Interview Guide (Patient version) 
 
*[]中文字會視每位病人在診間與醫師的對話內容而更動 
 
今天的會談主要想了解您對於上次在診間、被錄音的那次會診的想法或感受。我們的重點
尤其會放在當時您在診間溝通症狀時的一些內容；等一下我所問的問題都沒有所謂的正確
答案，主要是以您的感覺為主。在開始之前，我很樂意回答您的任何問題。 
 
1. 請回憶上次的會診，您在開始與醫師談話前是否有特別想討論的重點或問題? 
2. 告訴我您對這次與醫師談話的任何感受、感想或印象最深刻的事情。 
3. 您與醫師曾討論[所有在診間討論提及的症狀]，請以你的話描述一下當時討論這些
症狀的情形。 
4. 在討論這些症狀的當下，您的感受是…?  
5. 請問您當時還有任何症狀或問題是沒有被提及的嗎? 為什麼? 請多跟我描述這個[症
狀或問題]。 
6. 我們發現，您和醫師常以[以簡易方式說明某種互動模式]討論症狀，對於這種互動
模式，您的想法或感受是…? 
7. 依您的看法，這次的診間談話與平常的診間談話比較起來…? 
8. 您覺得這次的談話有什麼優點或是可以改進的地方? 
 
 
Fig 3. Recruitment and Data Collection Process 
Locations
Clinical meetings, via phone, or at 
waiting area of out-patient-
department (OPD)
OPD examinaion 
room
Waiting area 
of out-patient-
department
(OPD)
Private 
room at 
home or 
office

201807052RINC, Sep, 2018 
CM03 
 
Phase 1: qualitative data collection and analysis. The qualitative phase is a qualitative 
descriptive study because we want to provide a fundamental and straightforward description 
regarding the validation of TIPSC (aim 1) and how patients experience and think about the interaction 
(aim 2).  
On the day of the scheduled, audio-recorded office visit, a research assistant will first meet with 
the patient and caregiver for completing the survey measurements and then accompany them to the 
office, set up the recording device, and leave. The research assistant will collect the device and 
recordings after the visit and schedule a follow-up interview between 2 days to a week after the 
recorded visit. This 30-40 minutes follow-up interview will be conducted by the PI who is a certified 
oncology nurse with expertise in qualitative study, symptom management, and psycho-oncology. The 
PI will listen to the recorded visit before interviewing each patient in order to design individual-
specific interview questions. Table 2 demonstrates example interview guide. All recorded visits and 
interviews will be transcribed verbatim. 
Conversation analysis (CA) and discourse analysis (DA) will be used to analyze the 
transcripts of audio-recorded, naturally occurring OPD conversations as we want to understand 
patterns of symptom communication and verify the TIPSC (aim 1). CA and DA are selected because 
they allow us to focus on naturally occurring conversation and what is being accomplished in 
conversations (29-31). Particularly, CA considers talk-in-interaction as a co-constructive and 
collaborative process, which fits more with patient-centered and relationship-centered approaches to 
medical communication (32). CA and DA share similar assumptions and are firstly developed in 
sociology and linguistics before rapidly evolving in a wide range of disciplines including psychology 
and social medicine (31). While CA will provide analytic tools to (1) examine the talk turn by turn 
and (2) look for the related features of patient-provider symptom communication which is a unique 
sub-type of medical communication (33-36), Goodman’s (2017) eight steps of conducting DA will 
guide the analysis steps of the current study. 
Step 1: Deciding Appropriate Research Question. The researchers will focus on aim one 
which is appropriate for CA/DA because of its action-orientation. 
Step 2: Picking Appropriated Data Source. The researchers will analyze naturally occurring 
OPD conversations which are idea for CA/DA as they are interaction-based. 
Step 3: Generating a Corpus. ‘Corpus’ means ‘the collection of all the appropriate data that 
will be analyzed.’ While the researchers plan to record one OPD visit for 50 patient/caregiver
─physician dyads, only conversations which contain discussions of symptoms will be included 
and analyzed. 
Step 4: Transcribing Data. The data are primarily transcribed according to the conventions 
developed by Jefferson (37, 38), with slight modifications to those inapplicable to Mandarin 
Chinese characters. Jefferson’s transcription conventions make it possible to capture the 
details of the talk─ not only what was said, but also the way it is said. Pauses, rising/lower 
volume, or the change of intonation will be noted. Remarks on other verbal sounds—such as 
coughing and clearing throat—will be provided in italics inside double parentheses. The 
following software will be used to assist data transcription: Speechnotes, ELAN, and 
InqScribe. 
Step 5: Preliminary Reading of the Data. The researchers will immerse themselves in the data 
and begin the first round of analysis including writing down initial thoughts about the data and 
categorize interactions into different patterns based on TIPSC. NVivo qualitative data analysis 

15 
 
CM03 
software (version 11.4.1; QSR International Pty Ltd, 2017) and Microsoft Word will be used to 
aid the analysis 
Step 6: Generating Results. The researchers use specific strategies or ‘discursive devices’ to 
enhance the analysis. Specifically, the researchers explore the following characteristics of each 
interaction type of TIPSC: turn-taking organization, sequence organization, and turn design (34, 
35, 39, 40). These interrelated characteristics reflect different dimensions of patient-provider 
communication. First, we will examine how participants take turns and whether the interaction 
uses a special turn-taking organization. Looking at turn-taking, we will by default locally deal 
with pauses, overlaps, and interruptions. We will also, on overall level, explore whether the 
turns are equally distributed throughout the OPD visits by considering turn length and turn 
composition. For example, the interaction pattern identified as ‘agentic’ refers to the interaction 
in which patients and/or caregivers are particularly vocal during discussions, taking longer and 
complex turns; the pattern ‘checklist’ is organized by question-answer turn-taking organization 
with providers asking a series of questions in rote fashion. Second, with a focus on sequence 
organization, we will look at how particular courses of action are initiated and negotiated in 
sequences. Then, we will look at the turn design: how a turn is designed to perform certain 
action and how the turn is composed. That is, what the turns are doing and what linguistic 
elements, both syntactically and lexically, are selected to embody the actions. Lexical choice 
particularly draws researchers’ attention in prior research (41). Here we provide a data set from 
Heritage et al. (2007) to demonstrate the three dimensions turn by turn analysis. 
 
01 DOC: –> And do you have any other medical problems? 
02 PAT:      Uh No  
03  
   (7 s of silence)  
04 DOC: –> No heart disease?  
05 PAT:     ((cough)) No. 
06 
   (1 s of silence)  
07 DOC: –> Any lung disease as far as you know? 
08 PAT:       No.  
(Heritage et al., 2007: 1430) 
This spate of talk constitutes a prototypical turn-taking organization of doctor-patient 
communication—doctors posing questions and patients answering. The doctor’s turns are 
compositionally complex than the patient’s but relatively straightforward; the patient provides 
(negative) minimal responses. The turn organization represents a course of checklist symptom 
inquiry with patient indicating no problem. The doctor’s questions are all designed as yes-no 
questions in different syntactic formats with different lexical choices. All the questions 
communicate an expectation in favor of ‘no’ responses. The preference for ‘no’ answers is 
enforced by the use of the lexical item ‘any’ (instead of ‘some’) and ‘no’. Through an 
intervention study, it is shown that such question designs may lead to unmet concerns in office 
visits. 
Step 7: Building a Case to Support the Findings. Similar to table one which was established 
in the preliminary study, the researchers refine definitions and pick best exemplars to describe 
each interaction patterns.  
Step 8: Report Writing. Final research report and manuscripts will be established in this stage. 
The standard content analysis will be used to analysis the follow-up interview because we 
want to provide a fundamental and low-interpretive description of how patients experience the 

16 
 
CM03 
symptom discussions (42).  
   Phase 2: Quantitative data collection and analysis. The quantitative phase employs a 
correlational design because the aim of this phase is to examine the relationships between interaction 
patterns and variables including demographic variables, symptom severity, congruence in symptom 
assessment between patients/caregivers and physicians, patients’ perceived ability to communicate 
with physicians, and patient/caregiver satisfaction (aim 3). 
In addition to demographic information, three questionnaire measurements: European 
Organization for Research and Treatment of Cancer (EORCT-QLQ C30), Perceived Efficacy 
in Patient-Physician Interactions scale (PEPPI), and The Chinese Patients’ Satisfaction Scale 
(C-PSS) will be used to collect data regarding symptom severity, perceived ability to process the 
information, and overall satisfaction, respectively. The oncologists are required to provide their own 
demographic information and EORCT-QLQ ratings after seeing each participated patient. Patients 
are required to provide information of demographic data, EORCT-QLQ C30, PEPPI, and Satisfaction 
scale. The demographic information will be collected at the time of recruitment while other 
questionnaires will be collected after the recorded office visits. More information regarding each 
questionnaire measurements are described below.  
Symptom severity will be measured by European Organization for Research and Treatment 
of Cancer (EORCT-QLQ C30, Taiwan Chinese version). The EORTC QLQ-C30 is a 30-item 
questionnaire developed by a group of scientists to evaluate functions, symptoms, and overall health-
related quality of life of cancer patients. EORTC QLQ-C30 has been verified and widely applied in 
health-related research. Evaluators rate patients’ functions, symptoms, and quality of life using 4-
point Likert scales. The Taiwan Chinese version of the EORTC QLQ-C30 has been tested and shows 
good reliability and validity (43, 44). The reported Cronbach’s alpha coefficient of most items was 
above 0.70 across studies. A 5-10─points difference of EORTC QLQ-C30 rating is considered a 
significant difference (45). That is, if the difference of EORTC QLQ-C30 rating between a 
patient/caregiver and a physician is greater than 5, it is defined as an incongruence symptom report.   
Patients’ perceived ability to communicate with providers will be measured by Perceived 
Efficacy in Patient-Physician Interactions Scales (PEPPI-10, Chinese version). PEPPI-10 is a 
self-evaluated, 10-item instrument measuring patients’ self-efficacy in “obtaining medical 
information and attention to their medical concerns from physicians (46).” Patients rate their 
confidence of interacting with physicians (e.g., get a doctor to pay attention to what you have to say) 
from “no confident (0)” to “extremely confident (10)”. The Chinese version of PEPPI-10 shows good 
validity and reliability with the reported Cronbach’s α coefficient of 0.907 (47). 
Patients’ overall satisfaction will be measured by the Chinese Patients’ Satisfaction Scale (C-
PSS). C-PSS is a 27-item instrument which was developed to measure Chinese patients’ satisfaction 
using a 5-point Likert scale.  Patients rate their satisfaction from strongly disagree (1) to strongly 
agree (5) with higher scores represent better satisfaction. It is a reliable and valid tool with the reported 
Cronbach’s alpha coefficient of all dimensions above 0.90 (48).  
The major interaction patterns or combination of interaction patterns will be determined and 
dummy coded. Binomial Logistic Regression will be used to examine the relationship between 
interaction patterns and dichotomous variables (i.e., the congruence of symptom reports) while Linear 
Regression will be applied to examine the relationship between the interaction patterns and other 
variables, such as age, level of symptom severity, perceived communication ability, and satisfaction. 
The SPSS software will be used to organize the data and facilitate data analysis. Finally, combining 
and comparing the findings from the interviews and the results from the quantitative measurements 
enable us to do triangulation to fully map up the interaction behavior pertinent to symptom discussion.  

17 
 
CM03 
Trustworthiness 
To ensure the quality of study results and conclusions, five standards outlined by Miles and 
colleagues (2013) will serve as an evaluative framework. The standards are confirmability, 
reliability, credibility, transferability, and utilization. 
Confirmability is the extent to which the findings are neutral, that is free of researcher bias, and 
thus can be confirmed by others. The strategies that will be used to ensure confirmability for the 
current study include the following: (1) The study processes, especially the analysis plan, will be 
explicitly described and documented, and (2) The research team will meet regularly to monitor the 
analytic processes and confirm study findings.  
Reliability is whether the study processes remains consistent and stable over time and across 
researchers. Reliability is based on whether the researcher has taken care to ensure the quality and 
integrity of the research process. The strategies that will be used to ensure reliability are as follows: 
(1) Clear study aims have been established and the study design is explicit and consistent with the 
aims, and (2) The research team will meet regularly to ensure that all study procedures as outlined in 
this proposal are closely followed.  
Credibility is the “truth value” of the findings – that is whether the study findings are authentic 
and thus make sense to people we study and to readers. The strategies that will be used to ensure 
credibility are as follows: (1) the researcher will obtain feedback on all codes and categories as they 
emerge from peer and qualitative research interest group, if available, and (2) asking for selected 
participants’ feedback regarding study findings. Specifically, researchers will mail preliminary 
findings to 3-5 participants who agreed to provide their feedback and then conduct phone interviews 
to examine if their experience is similar to or different than the study findings. The research group 
will meet to discuss patients’ feedback and modify the study findings accordingly.  
Transferability is whether the study results can be generalized or transferred to other contexts, 
populations, or settings (49). Although it is similar to external validity or generalization in quantitative 
studies, they are different in that transferability invites the readers of the study to determine if the 
findings can apply or inform their understanding of the phenomenon by describing the participants 
and the study context fully.  The strategy that will be used to ensure transferability is to clearly 
describe the study context, population and settings 
Utilization describes the pragmatic value of the study. It is determined based on whether the 
study results can be applied to real world and advance the knowledge (50). The strategy that will be 
used to ensure utilization is asking for national and international health experts’ feedback regarding 
the usefulness of study findings by conducting expert panels. Specifically, we have established 
collaboration relationship with Dr. Prigerson and her research team at Cornell Center for 
Research on End of Life Care and will invite Dr. Prigerson for online discussions and onsite 
visits. Dr. Prigerson’s extensive knowledge and experience in cross-culture cancer care, decision 
making, and communication will not only help ensure the quality and utilization of the proposed study 
but also identify cultural differences which can inform future studies.  
Innovations and Challenges 
This is an innovative study because of its pioneering focus and unique design. First, this is 
one of the few studies focused on conceptualizing interactions patterns related to symptom 
communication. It is also the first study examining the possible factors related to interaction 
patterns of symptom communication. Such information can be used to conduct larger scale research 
and facilitate patient—provider communication and symptom management. Second, part of the 

18 
 
CM03 
study design was informed by a communication theory. It is not common to see a healthcare study 
considering theories developed in communication field. Integrating knowledge established in 
different fields allow us to decipher researcher questions more efficiently and comprehensively. 
Third, this proposed study address national issues based on international and interdisciplinary 
evidence and perspectives by (1) test a typology developed with U.S. population in Taiwan, (2) 
considering expert opinions from heterogeneous recourses, such as healthcare providers from 
Taiwan and other countries, patients, and caregivers when interpreting results. Results will 
provide useful information regarding communicating symptoms with patients with diverse 
background.  
Our study faces several possible challenges including the difficulties of recruiting physicians and 
advanced cancer patients because of physicians’ limited time and the critical condition of patients 
with advanced cancer. Strategies designed to tackle these challenges including closely working with 
clinical experts, allowing reasonable recruitment duration, providing incentives, and interviewing 
patients/caregivers at a place of their choice.   
Expecting Results 
This will be a three-year study project starting from September, 2018. Table 3 shows study 
procedure and timeline.  The expecting results of the research projects can be discussed in two 
categories: direct research results and indirect process results (table 4). The major direct research 
results are: (1) the verified TIPSC and (2) a comprehensive map describing symptom 
communication including interaction patterns and associating factors. The major indirect 
process results which are the byproducts of the proposed research include (1) parameters 
establishment for larger scale quantitative studies, (2) establishment of a health communication 
lab, (3) international and interdisplinary collaboration, and (4) international/national/ local 
conference presentations and journal publications (i.e. practical results). The next paragraph 
describes the corresponding resources and strategies of achieving these indirect process results. 
Parameters establishment for larger scale quantitative studies. As this pilot study is among 
the first to describe the relationship between interaction patterns and clinical outcomes, our findings 
can be used to calculate power and determine adequate sample sizes for future, larger scale 
quantitative studies.  
Establishment of a health communication lab. The specific plan is to (1) conduct 
informational interviews in the campus with colleagues and students about suggestions and resources 
of beginning a lab, (2) recruit research team members and create training plans, (3) establish the lab 
culture and routines, such as missions, equipment and space, website, lab management systems, and 
regular meetings, (4) identify and securing collaboration opportunities by promoting the lab and 
research at research meetings and conferences, (5) networking other similar labs in Taiwan (e.g., 
language and communication lab at National Cheng Kung University) and other countries.  
International and interdisplinary collaboration. The strategy of working with diverse partners 
builds on the applicant’s abundant global experience, including being members of professional 
organizations (e.g., Oncology Nursing Society, Communication, Medicine, and Ethics International 
Society), serving as a reviewer of a Cancer Nursing, and international collaboration experiences with 
Johns Hopkins University and Hospital, Indiana University and Cancer Center, Purdue University, 
and University of Rochester Medical Center. To achieve this goal, we first will continuously work 
with international experts and institutions by meeting online or onsite to brainstorm research ideas, 
refine study procedures, and generate joint recommendations. Specifically, as we mentioned earlier, 
the research team of Cornell Center for Research on End of Life Care have expressed their interest in 
collaborating on this and future projects. Other possible international collaboration institutions 

19 
 
CM03 
include Behavioral Cooperative Oncology Group (BCOG) and Center for Symptom Management at 
Indiana University, Brian Lamb School of Communication at Purdue University, and Center for 
Health Communication at the University of Texas at Austin. Second, in addition to continuing the 
membership of professional organizations and reviewer service, the PI also plans to participate in 
more professional services, such as serving as a moderator in conferences or doing editorial service 
for journals.  
International/national/ local conference presentations and journal publications. Research 
findings will be published in journals and presented in conferences, such as Oncology Nursing 
Society congress, European Society for Medical Oncology-Asia conference, and Asia Clinical 
Oncology Society conference. Table 5 demonstrates aforementioned practical results, including the 
number of conference presentations, and journal publications.   
Conclusion 
This study proposal focusing on patient-provider symptom communication in advanced cancer 
population is a groundbreaking study which addresses not only an underexplored area in Taiwan 
but also two global research priorities in Cancer and Palliative Care: symptom management 
and communication (51-56). For instance, the 2014–2018 Oncology Nursing Society (ONS) 
Research Agenda Project Team identified eight high-priority cancer research areas including 
symptoms. Since 2001, managing physical and psychological symptoms in patients with cancer has 
consistently topped the ONS Research Agenda. The ONS Research Agenda Project Team also 
pointed out that studies enhancing communication in palliative care are a priority area for research 
(51, 52). Likewise, research focusing on using symptom management to improve HRQOL for patients 
with cancer has been a focus for National Institute for Nursing Research (NINR) for over 25 years. 
NINR has also stressed the importance of establishing effective patient—provider communication in 
order to promote health and decision-making regarding complex treatment and care options, 
especially in end-of-life care (54).In a European survey which obtained researchers’ opinions from 
36 countries found that symptom management, especially pain, was rated as the most active and most 
important research area in cancer end-of-life care (56). On the other hand, the quality of patient—
provider communication is questionable and may link to several health issues, including patient 
outcomes, in Taiwan. Grounding on international evidence, this proposed study is a critical step to 
close knowledge gaps of symptom communication and management and identify local problems. 
Findings will inform relevant research, education, and clinical practice in Taiwan.  Moreover, our 
findings will serve as a basis to transform healthcare in Taiwan by raising public awareness and 
facilitating expert discussions of issues related to patient—provider communication.  
Conflict of Interest 
The researchers declare that they have no conflict of interest. The research and development 
results ownership belongs to National Taiwan University. 
Privacy and Confidentiality 
All data will be de-identified by using heuristic methods. Electronic data will only be send using 
NTU or NTUH email system and be stored in the secure space at the network-attached storage system 
which can only be accessed with assigned username and password. Written information will be locked 
in PI’s office at National Taiwan University.    
 
 

201807052RINC, Sep, 2018 
CM03 
 
 
Table 3. Study Process and Timeline  
Year 2018 
2019 
2020 
2021 
Months 9 
10-12 1-3 
4-6 
7-9 
10-12 1-3 
4-6 
7-9 
10-12 1-3 
4-7 
Phase 0. Obtain IRB approval  
x 
 
 
 
 
 
 
 
 
 
 
 
Phase 0. Obtain questionnaire measurements 
x 
 
 
 
 
 
 
 
 
 
 
 
Phase 0. Establish research team 
x 
 
 
 
 
 
 
 
 
 
 
 
Phase 0. Recruit oncologists & patients 
 
x 
x 
x 
 
 
 
 
 
 
 
 
Phase 1. Record 1 OPD visit & collect questionnaire measurements 
 
x 
x 
x 
 
 
 
 
 
 
 
 
Phase 1. Interview  
 
 
x 
x 
x 
 
 
 
 
 
 
 
Phase 1. Analyze recorded office visits  
 
 
 
x 
x 
x 
x 
x 
 
 
 
 
Phase 1. Analyze interviews 
 
 
 
x 
x 
x 
x 
x 
 
 
 
 
Phase 1. Check study trustworthiness: request selected participants’ 
feedback on qualitative results 
 
 
 
 
 
 
 
x 
x 
 
 
 
Phase 2.  Analyze quantitative data based on qualitative findings of 
recorded OPD visit  
 
 
 
 
 
 
 
x 
x 
x 
 
 
Phase 2.  Compare the qualitative findings of interview with the 
quantitative data (triangulation) 
 
 
 
 
 
 
 
 
x 
x 
x 
 
Phase 2.  Check study trustworthiness: request international experts’ 
feedback on final results 
 
 
 
 
 
 
 
 
 
 
x 
 
Phase 2. Report and Manuscript writing  
 
 
 
 
 
 
 
 
 
 
x 
x 
*Abbreviation: Out-patient-department (OPD) 
 
Table 4. Expecting Direct and Indirect Results of the Proposed Study 
 
Expecting direct research results  
Expecting indirect process results  
YEAR 1  
(2018, 9—2019, 7) 
 Obtaining IRB approval  
 Obtaining questionnaire measurements  
 Finishing the recruitment of oncologists and 
patients  
 Establishing research team: recruit members and establish regular 
meetings 
 Training: recruitment strategies and research methodology (mixed-
methods), interview skills 
 Presenting methodology at local/national/international conferences 
 Online international collaboration: study design  
YEAR 2  
 Finishing collection of qualitative data: recorded 
 Identifying and securing international collaboration opportunities  

21 
 
CM03 
(2019, 8—2020, 7) 
office visits & interviews  
 Finishing collection of quantitative data: 
questionnaire measurements  
 Training: data collection (qualitative and quantitative) and data 
analysis (discourse analysis method, content analysis method, usage of 
Nvivo) 
 Presenting recruitment process and results at 
local/national/international conferences 
 Online international collaboration: ensure study trustworthiness  
YEAR 3  
(2020, 8—2021, 7) 
 Completing the analysis of qualitative data: 
recorded office visits & interviews  
 Completing the analysis of quantitative data: 
questionnaire measurements  
 Triangulation  
 Continuing international collaboration through on-site visits and email 
or online discussions 
 Identifying conferences and journals for results dissemination 
 Presenting preliminary results at local/national/international 
conferences 
 Training: data analysis (descriptive and correlational statistics, 
triangulation, usage of SPSS) 
 Onsite international collaboration: ensure study trustworthiness 
 
Table 5. Practical Results  
 
 
9, 2018—7,2019 
8, 2019—7,2020 
8, 2020—7,2021 
Manuscripts 
Journal  
1 (methodology) 
2 (discourse analysis results, content 
analysis results for patient) 
3 (content analysis results for caregiver, 
quantitative results for patient and caregiver) 
Conference  
1 
2 
3 
Research Reports 
 
1 
1 
1 

201807052RINC, Sep, 2018 
CM03 
 
References 
1. 
van Osch M, van Dulmen S, van Vliet L, Bensing J. Specifying the effects of physician's 
communication on patients’ outcomes: A randomised controlled trial. Patient education and 
counseling. 2017. 
2. 
Kee JW, Khoo HS, Lim I, Koh MY. Communication Skills in Patient-Doctor Interactions: 
Learning from Patient Complaints. Health Professions Education. 2017. 
3. 
Leslie JL, Lonneman W. Promoting Trust in the Registered Nurse-Patient Relationship. 
Home healthcare now. 2016;34(1):38-42. 
4. 
Okunrintemi V, Spatz E, Salami J, Warraich H, Virani S, Blaha M, et al. Patient Provider 
Communication and Patient-centered Outcomes Among Patients With Atherosclerotic 
Cardiovascular Disease in United States: Medical Expenditure Panel Survey 2010-2013. Am Heart 
Assoc; 2017. 
5. 
Angland S, Dowling M, Casey D. Nurses’ perceptions of the factors which cause violence 
and aggression in the emergency department: a qualitative study. International emergency nursing. 
2014;22(3):134-9. 
6. 
Hahn S, Müller M, Hantikainen V, Kok G, Dassen T, Halfens RJ. Risk factors associated 
with patient and visitor violence in general hospitals: Results of a multiple regression analysis. 
International journal of nursing studies. 2013;50(3):374-85. 
7. 
Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, et al. Rates 
of medical errors and preventable adverse events among hospitalized children following 
implementation of a resident handoff bundle. JAMA : the journal of the American Medical 
Association. 2013;310(21):2262-70. 
8. 
Cornett JA. Identifying communication precursors to medical error in an in-patient clinical 
environment—A palliative sedation therapy case study: University of Ottawa (Canada); 2013. 
9. 
劉玠暘, 賴其萬. 台灣醫療暴力應對方案芻議. 臺灣醫界. 2016;59(12):43-8. 
10. 
Duong VT, Lin I-F, Sorensen K, Pelikan JM, Van Den Broucke S, Lin Y-C, et al. Health 
literacy in Taiwan: a population-based study. Asia Pacific Journal of Public Health. 
2015;27(8):871-80. 
11. 
Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, et al. Health literacy in 
Europe: comparative results of the European health literacy survey (HLS-EU). European journal of 
public health. 2015;25(6):1053-8. 
12. 
Leonard S, O'Donovan A. Measuring safety culture: Application of the Hospital Survey on 
Patient Safety Culture to radiation therapy departments worldwide. Practical Radiation Oncology. 
2017. 
13. 
Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing 
and reducing suffering. 2007. 
14. 
Scheunemann LP, McDevitt M, Carson SS, Hanson LC. Randomized, controlled trials of 
interventions to improve communication in intensive care: A systematic review. CHEST Journal. 
2011;139(3):543-54. 
15. 
Thorne SE, Bultz BD, Baile WF. Is there a cost to poor communication in cancer care?: a 
critical review of the literature. Psycho‐Oncology. 2005;14(10):875-84. 
16. 
Lenz ER, Gift AG, Pugh LC, Milligan RA. Unpleasant symptoms. In: Peterson SI, Bredow 
TS, editors. Middle range theories: Application to nursing research. 3 ed. Philadelphia, PA: Wolters 
Kluwer: Lippincott Williams and Wilkins; 2013. p. 68-81. 
17. 
Grant MS, Wiegand DL. Conversations With Strangers: The Needs of Those Accessing a 
Palliative Care Nurse Practitioner on a Pancreatic Cancer Web Site. Journal of Hospice & Palliative 
Nursing. 2013;15(5):278-85. 
18. 
Cancer registry annual report 2014 Taiwan. In: Taiwan HPAMoHaW, editor.: Health 
Promotion Adminstration Ministry of Health and Welfare Taiwan; 2016. 
19. 
Donovan HS, Hartenbach EM, Method MW. Patient–provider communication and 
perceived control for women experiencing multiple symptoms associated with ovarian cancer. 
Gynecologic oncology. 2005;99(2):404-11. 

23 
 
CM03 
20. 
Coward DD, Wilkie DJ. Metastatic bone pain: meanings associated with self-report and 
self-management decision making. Cancer nursing. 2000;23(2):101-8. 
21. 
Passik SD, Kirsh KL, Donaghy K, Holtsclaw E, Theobald D, Cella D, et al. Patient-related 
barriers to fatigue communication: initial validation of the fatigue management barriers 
questionnaire. Journal of pain and symptom management. 2002;24(5):481-93. 
22. 
Shun S-C, Lai Y-H, Hsiao F-H. Patient-related barriers to fatigue communication in cancer 
patients receiving active treatment. The oncologist. 2009;14(9):936-43. 
23. 
Laugsand EA, Sprangers MA, Bjordal K, Skorpen F, Kaasa S, Klepstad P. Health care 
providers underestimate symptom intensities of cancer patients: a multicenter European study. 
Health and quality of life outcomes. 2010;8(1):104. 
24. 
Tang C. Symptom experience and communication in patients with advanced pancreatic 
cancer and their families. ProQuest: Indiana University Purdue University at Indianapolis 2017. 
25. 
Bodie GD, MacGeorge EL. Supportive communication theories: Dual-Process Theory of 
Supportive Message Outcomes and Advice Response Theory. In: Baxter LA, Braithwaite DO, 
editors. Engaging theories in interpersonal communication: Multiple perspectives. Los Angeles, 
CA: Sage; 2014. 
26. 
Creswell JW, Clark VLP. Designing and conducting mixed methods research. 2007. 
27. 
Teddlie C, Tashakkori A. A general typology of research designs featuring mixed methods. 
Research in the Schools. 2006;13(1):12-28. 
28. 
Morse JM. Determining sample size. Qualitative health research. 2000;10(1):3-5. 
29. 
Goodman S. How to conduct a psychological discourse analysis. Critical Approaches to 
Discourse Analysis across Disciplines. 2017;9(2):12. 
30. 
Wodak R, Meyer M. Methods for critical discourse analysis: Sage; 2009. 
31. 
Wooffitt R. Conversation analysis and discourse analysis: A comparative and critical 
introduction: Sage; 2005. 
32. 
Maynard DW, Heritage J. Conversation analysis, doctor–patient interaction and medical 
communication. Medical education. 2005;39(4):428-35. 
33. 
Antaki C. Applied conversation analysis: Intervention and change in institutional talk: 
Springer; 2011. 
34. 
Heritage J. Conversation analysis and institutional talk. Handbook of language and social 
interaction. 2005;103:47. 
35. 
Heritage J. Conversation analysis and institutional talk: Analyzing data. In: Silverman D, 
editor. Qualitative Research: Theory, Method and Practice. 2 ed. London: Sage; 2004. p. 222-45. 
36. 
Roter D, Hall JA. Doctors talking with patients/patients talking with doctors: improving 
communication in medical visits: Greenwood Publishing Group; 2006. 
37. 
Jefferson G. Glossary of transcript symbols with an introduction. In: Lerner G, editor. 
Conversation analysis: Studies from the first generation. Amsterdam: John Benjamins; 2004. p. 13-
31. 
38. 
Jefferson G. Transcript notation. In: Atkinson JM, Heritage J, editors. Structures of social 
action: studies in conversation analysis. Cambridge: Cambridge University Press 1984. p. ix-xvi. 
39. 
Drew P, Chatwin J, Collins S. Conversation analysis: a method for research into interactions 
between patients and health‐care professionals. Health Expectations. 2001;4(1):58-70. 
40. 
Heritage J, Maynard DW. Communication in medical care: Interaction between primary 
care physicians and patients: Cambridge University Press; 2006. 
41. 
Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients’ unmet 
concerns in primary care: the difference one word can make. Journal of general internal medicine. 
2007;22(10):1429-33. 
42. 
Krippendorff K. Content analysis: An introduction to its methodology: Sage; 2012. 
43. 
Huang CC, Lien HH, Sung YC, Liu HT, Chie WC. Quality of life of patients with gastric 
cancer in Taiwan: validation and clinical application of the Taiwan Chinese version of the EORTC 
QLQ‐C30 and EORTC QLQ‐STO22. Psycho‐Oncology. 2007;16(10):945-9. 

24 
 
CM03 
44. 
Chie W-C, Yang C-H, Hsu C, Yang P-C. Quality of life of lung cancer patients: validation 
of the Taiwan Chinese version of the EORTC QLQ-C30 and QLQ-LC13. Quality of Life Research. 
2004;13(1):257-62. 
45. 
Maringwa J, Quinten C, King M, Ringash J, Osoba D, Coens C, et al. Minimal clinically 
meaningful differences for the EORTC QLQ-C30 and EORTC QLQ-BN20 scales in brain cancer 
patients. Annals of Oncology. 2011;22(9):2107-12. 
46. 
Maly RC, Frank JC, Marshall GN, DiMatteo MR, Reuben DB. Perceived Efficacy in 
Patient‐Physician Interactions (PEPPI): Validation of an Instrument in Older Persons. Journal of the 
American Geriatrics Society. 1998;46(7):889-94. 
47. 
Zhao H, Luo W, Maly RC, Liu J, Lee J, Cui Y. Validation of the chinese version 10-item 
Perceived Efficacy in Patient–Physician Interactions scale in patients with osteoarthritis. Patient 
preference and adherence. 2016;10:2189. 
48. 
Stanworth JO, Hsu RS, Warden CA. Validation of a Measure of Chinese Outpatients’ 
Satisfaction in the Taiwan Setting. INQUIRY: The Journal of Health Care Organization, Provision, 
and Financing. 2017;54:0046958016688979. 
49. 
Trochim WM. The Research Methods Knowledge Base 2006. Available from: 
http://www.socialresearchmethods.net/kb/. 
50. 
Charmaz K. Constructing grounded theory: Sage; 2006. 
51. 
Knobf M, Cooley M, Duffy S, Doorenbos A, Eaton L, Given B, et al., editors. The 2014-
2018 Oncology Nursing Society Research Agenda. Oncology nursing forum; 2015. 
52. 
LoBiondo-Wood G, Brown CG, Knobf MT, Lyon P, D., Mallory G, Mitchell SA, et al., 
editors. Priorities for oncology nursing research: the 2013 national survey. Oncology nursing 
forum; 2014. 
53. 
Morrison RS. Research priorities in geriatric palliative care: an introduction to a new series. 
Journal of palliative medicine. 2013;16(7):726-9. 
54. 
NINR NIoNR. Bringing Science to Life: NINR Strategic Plan. 2011. 
55. 
Perkins P, Booth S, Vowler SL, Barclay S. What are patients' priorities for palliative care 
research?—a questionnaire study. Palliative medicine. 2008;22(1):7-12. 
56. 
Sigurdardottir KR, Haugen DF, Bausewein C, Higginson IJ, Harding R, Rosland H, et al. A 
pan-European survey of research in end-of-life cancer care. Supportive care in cancer : official 
journal of the Multinational Association of Supportive Care in Cancer. 2012;20(1):39-48. 

25 
 
CM03