Wendy G. Anderson, MD, MS

Admission to a hospital can be a stressful event,^1,2 and patients report having many concerns at the time of hospital admission.³ Over the last 20 years, the United States has widely adopted the hospitalist model of inpatient care. Although this model has clear benefits, it also has the potential to contribute to patient stress, as hospitalized patients generally lack preexisting relationships with their inpatient physicians.^4,5 In this changing hospital environment, defining and promoting effective medical communication has become an essential goal of both individual practitioners and medical centers.

Successful communication and strong therapeutic relationships with physicians support patients’ coping with illness-associated stress^6,7 as well as promote adherence to medical treatment plans.⁸ Empathy serves as an important building block of patient-centered communication and encourages a strong therapeutic alliance.⁹ Studies from primary care, oncology, and intensive care unit (ICU) settings indicate that physician empathy is associated with decreased emotional distress,^10,11 improved ratings of communication,¹² and even better medical outcomes.¹³

Prior work has shown that hospitalists, like other clinicians, underutilize empathy as a tool in their daily interactions with patients.^14-16 Our prior qualitative analysis of audio-recorded hospitalist-patient admission encounters indicated that how hospitalists respond to patient expressions of negative emotion influences relationships with patients and alignment around care plans.¹⁷ To determine whether empathic communication is associated with patient-reported outcomes in the hospitalist model, we quantitatively analyzed coded admission encounters and survey data to examine the association between hospitalists’ responses to patient expressions of negative emotion (anxiety, sadness, and anger) and patient anxiety and ratings of communication. Given the often-limited time hospitalists have to complete admission encounters, we also examined the association between response to emotion and encounter length.

METHODS

We analyzed data collected as part of an observational study of hospitalist-patient communication during hospital admission encounters¹⁴ to assess the association between the way physicians responded to patient expressions of negative emotion and patient anxiety, ratings of communication in the encounter, and encounter length. We collected data between August 2008 and March 2009 on the general medical service at 2 urban hospitals that are part of an academic medical center. Participants were attending hospitalists (not physician trainees), and patients admitted under participating hospitalists’ care who were able to communicate verbally in English and provide informed consent for the study. The institutional review board at the University of California, San Francisco approved the study; physician and patient participants provided written informed consent.

Enrollment and data collection has been described previously.¹⁷ Our cohort for this analysis included 76 patients of 27 physicians who completed encounter audio recordings and pre- and postencounter surveys. Following enrollment, patients completed a preencounter survey to collect demographic information and to measure their baseline anxiety via the State Anxiety Scale (STAI-S), which assesses transient anxious mood using 20 items answered on a 4-point scale for a final score range of 20 to 80.^10,18,19 We timed and audio-recorded admission encounters. Encounter recordings were obtained solely from patient interactions with attending hospitalists and did not take into account the time patients may have spent with other physicians, including trainees. After the encounter, patients completed postencounter surveys, which included the STAI-S and patients’ ratings of communication during the encounter. To rate communication, patients responded to 7 items on a 0- to 10-point scale that were derived from previous work (Table 1)^12,20,21; the anchors were “not at all” and “completely.” To identify patients with serious illness, which we used as a covariate in regression models, we asked physicians on a postencounter survey whether or not they “would be surprised by this patient’s death or admission to the ICU in the next year.”²²

As previously described, we professionally transcribed and coded the audio recordings.¹⁷ Following past work,^15,16,23-25 we identified patient expressions of negative emotion and categorized the initial hospitalist response to each expression. Table 2 shows examples to illustrate the coding scheme. We considered an empathic response to be one that directed further discussion toward a patient’s expressed negative emotion. A neutral response was one that directed discussion neither towards nor away from the expressed emotion, while a nonempathic physician response directed further discussion away from the patient’s emotion.¹⁵ To assess reliability, 2 coders independently coded a randomly selected 20% of encounters (n = 15); kappa statistics were 0.76 for patient expressions of emotion and 0.85 for physician responses, indicating substantial to almost perfect agreement.²⁶

We used regression models to assess the association between the number of each type of physician response (empathic, neutral, nonempathic) in an encounter and the following variables: (1) the change in the patient’s anxiety level, defined as the difference between the post- and preencounter STAI-S score (using linear regression); (2) patient ratings of the physician and encounter (using Poisson regression); and (3) encounter length (using linear regression). To assess each patient rating item, we utilized a single model that included frequencies for each type of physician response. For ratings of their encounters, most patients gave high ratings, resulting in a preponderance of 10/10 scores for several items. Thus, we focused on trying to understand “negativity,” meaning the minority of less than completely positive reactions. To do this, we analyzed reflected outcomes (defined as 10 minus the patient’s response) using zero-inflated Poisson regression models. This approach allowed us to distinguish between degrees of dissatisfaction and to determine whether additional change in ratings resulted from additional physician responses. Encounter length also demonstrated right skewness, which we addressed through log transformation; results for this are reported as percent change in the encounter length per physician response.

We considered physician as a clustering variable in the calculation of robust standard errors for all models. In addition, we included in each model covariates that were associated with the outcome at P ≤ 0.10, including patient gender, patient age, serious illness,²² preencounter anxiety, encounter length, and hospital. We considered P values < 0.05 to be statistically significant. We used Stata SE 13 (StataCorp LLC, College Station, TX) for all statistical analyses.

 

RESULTS

We analyzed data from admission encounters with 76 patients (consent rate 63%) and 27 hospitalists (consent rate 91%). Their characteristics are shown in Table 3. Median encounter length was 19 minutes (mean 21 minutes, range 3-68). Patients expressed negative emotion in 190 instances across all encounters; median number of expressions per encounter was 1 (range 0-14). Hospitalists responded empathically to 32% (n = 61) of the patient expressions, neutrally to 43% (n = 81), and nonempathically to 25% (n = 48).

The STAI-S was normally distributed. The mean preencounter STAI-S score was 39 (standard deviation [SD] 8.9). Mean postencounter STAI-S score was 38 (SD 10.7). Mean change in anxiety over the course of the encounter, calculated as the postencounter minus preencounter mean was −1.2 (SD 7.6). Table 1 shows summary statistics for the patient ratings of communication items. All items were rated highly. Across the items, between 51% and 78% of patients rated the highest score of 10.

Across the range of frequencies of emotional expressions per encounter in our data set (0-14 expressions), each additional empathic hospitalist response was associated with a 1.65-point decrease in the STAI-S (95% confidence interval [CI], 0.48-2.82). We did not find significant associations between changes in the STAI-S and the number of neutral hospitalist responses (−0.65 per response; 95% CI, −1.67-0.37) or nonempathic hospitalist responses (0.61 per response; 95% CI, −0.88-2.10).

The Figure shows the adjusted relative effects (aREs) and 95% CIs from zero-inflated multivariate Poisson regression models of the association between physician response to patient expressions of negative emotion and reflected patient ratings of the encounters, defined as 10 minus the patient’s response. Empathic hospitalist responses to patient expressions of emotion were associated with less negative patient ratings of communication in the encounter for 4 of 7 items: covering points of interest, the doctor listening, the doctor caring, and trusting the doctor. For example, for the item “I felt this doctor cared about me,” each empathic hospitalist response was associated with an approximate 77% reduction in negative patient ratings (aRE: 0.23; 95% CI, 0.06-0.85).

In addition, nonempathic responses were associated with more negative ratings of communication for 5 of the 7 items: ease of understanding information, covering points of interest, the doctor listening, the doctor caring, and trusting the doctor. For example, for the item “I felt this doctor cared about me,” each nonempathic hospitalist response was associated with a more than doubling of negative patient ratings (aRE: 2.3; 95% CI, 1.32-4.16). Neutral physician responses to patient expressions of negative emotion were associated with less negative patient ratings for 2 of the items: covering points of interest (aRE 0.68; 95% CI, 0.51-0.90) and trusting the doctor (aRE: 0.86; 95% CI, 0.75-0.99).

We did not find a statistical association between encounter length and the number of empathic hospitalist responses in the encounter (percent change in encounter length per response [PC]: 1%; 95% CI, −8%-10%) or the number of nonempathic responses (PC: 18%; 95% CI, −2%-42%). We did find a statistically significant association between the number of neutral responses and encounter length (PC: 13%; 95% CI, 3%-24%), corresponding to 2.5 minutes of additional encounter time per neutral response for the median encounter length of 19 minutes.

DISCUSSION

Our study set out to measure how hospitalists responded to expressions of negative emotion during admission encounters with patients and how those responses correlated with patient anxiety, ratings of communication, and encounter length. We found that empathic responses were associated with diminishing patient anxiety after the visit, as well as with better ratings of several domains of hospitalist communication. Moreover, nonempathic responses to negative emotion were associated with more strongly negative ratings of hospitalist communication. Finally, while clinicians may worry that encouraging patients to speak further about emotion will result in excessive visit lengths, we did not find a statistical association between empathic responses and encounter duration. To our knowledge, this is the first study to indicate an association between empathy and patient anxiety and communication ratings within the hospitalist model, which is rapidly becoming the predominant model for providing inpatient care in the United States.^4,5

As in oncologic care, anxiety is an emotion commonly confronted by clinicians meeting admitted medical patients for the first time. Studies show that not only do patient anxiety levels remain high throughout a hospital course, patients who experience higher levels of anxiety tend to stay longer in the hospital.^1,2,27-30 But unlike oncologic care or other therapy provided in an outpatient setting, the hospitalist model does not facilitate “continuity” of care, or the ability to care for the same patients over a long period of time. This reality of inpatient care makes rapid, effective rapport-building critical to establishing strong physician-patient relationships. In this setting, a simple communication tool that is potentially able to reduce inpatients’ anxiety could have a meaningful impact on hospitalist-provided care and patient outcomes.

In terms of the magnitude of the effect of empathic responses, the clinical significance of a 1.65-point decrease in the STAI-S anxiety score is not precisely clear. A prior study that examined the effect of music therapy on anxiety levels in patients with cancer found an average anxiety reduction of approximately 9.5 units on the STAIS-S scale after sensitivity analysis, suggesting a rather large meaningful effect size.³¹ Given we found a reduction of 1.65 points for each empathic response, however, with a range of 0-14 negative emotions expressed over a median 19-minute encounter, there is opportunity for hospitalists to achieve a clinically significant decrease in patient anxiety during an admission encounter. The potential to reduce anxiety is extended further when we consider that the impact of an empathic response may apply not just to the admission encounter alone but also to numerous other patient-clinician interactions over the course of a hospitalization.

A healthy body of communication research supports the associations we found in our study between empathy and patient ratings of communication and physicians. Families in ICU conferences rate communication more positively when physicians express empathy,¹² and a number of studies indicate an association between empathy and patient satisfaction in outpatient settings.⁸ Given the associations we found with negative ratings on the items in our study, promoting empathic responses to expressions of emotion and, more importantly, stressing avoidance of nonempathic responses may be relevant efforts in working to improve patient satisfaction scores on surveys reporting “top box” percentages, such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). More notably, evidence indicates that empathy has positive impacts beyond satisfaction surveys, such as adherence, better diagnostic and clinical outcomes, and strengthening of patient enablement.⁸Not all hospitalist responses to emotion were associated with patient ratings across the 7 communication items we assessed. For example, we did not find an association between how physicians responded to patient expressions of negative emotion and patient perception that enough time was spent in the visit or the degree to which talking with the doctor met a patient’s overall needs. It follows logically, and other research supports, that empathy would influence patient ratings of physician caring and trust,³² whereas other communication factors we were unable to measure (eg, physician body language, tone, and use of jargon and patient health literacy and primary language) may have a more significant association with patient ratings of the other items we assessed.

In considering the clinical application of our results, it is important to note that communication skills, including responding empathically to patient expressions of negative emotion, can be imparted through training in the same way as abdominal examination or electrocardiogram interpretation skills.^33-35 However, training of hospitalists in communication skills requires time and some financial investment on the part of the physician, their hospital or group, or, ideally, both. Effective training methods, like those for other skill acquisition, involve learner-centered teaching and practicing skills with role-play and feedback.³⁶ Given the importance of a learner-centered approach, learning would likely be better received and more effective if it was tailored to the specific needs and patient scenarios commonly encountered by hospitalist physicians. As these programs are developed, it will be important to assess the impact of any training on the patient-reported outcomes we assessed in this observational study, along with clinical outcomes.

Our study has several limitations. First, we were only able to evaluate whether hospitalists verbally responded to patient emotion and were thus not able to account for nonverbal empathy such as facial expressions, body language, or voice tone. Second, given our patient consent rate of 63%, patients who agreed to participate in the study may have had different opinions than those who declined to participate. Also, hospitalists and patients may have behaved differently as a result of being audio recorded. We only included patients who spoke English, and our patient population was predominately non-Hispanic white. Patients who spoke other languages or came from other cultural backgrounds may have had different responses. Third, we did not use a single validated scale for patient ratings of communication, and multiple analyses increase our risk of finding statistically significant associations by chance. The skewing of the communication rating items toward high scores may also have led to our results being driven by outliers, although the model we chose for analysis does penalize for this. Furthermore, our sample size was small, leading to wide CIs and potential for lack of statistical associations due to insufficient power. Our findings warrant replication in larger studies. Fourth, the setting of our study in an academic center may affect generalizability. Finally, the age of our data (collected between 2008 and 2009) is also a limitation. Given a recent focus on communication and patient experience since the initiation of HCAHPS feedback, a similar analysis of empathy and communication methods now may result in different outcomes.

In conclusion, our results suggest that enhancing hospitalists’ empathic responses to patient expressions of negative emotion could decrease patient anxiety and improve patients’ perceptions of (and thus possibly their relationships with) hospitalists, without sacrificing efficiency. Future work should focus on tailoring and implementing communication skills training programs for hospitalists and evaluating the impact of training on patient outcomes.

 

Acknowledgments

The authors extend their sincere thanks to the patients and physicians who participated in this study. Dr. Anderson was funded by the National Palliative Care Research Center and the University of California, San Francisco Clinical and Translational Science Institute Career Development Program, National Institutes of Health (NIH) grant number 5 KL2 RR024130-04. Project costs were funded by a grant from the University of California, San Francisco Academic Senate.

Disclosure

 All coauthors have seen and agree with the contents of this manuscript. This submission is not under review by any other publication. Wendy Anderson received funding for this project from the National Palliative Care Research Center, University of California San Francisco Clinical and Translational Science Institute (NIH grant number 5KL2RR024130-04), and the University of San Francisco Academic Senate [From Section 2 of Author Disclosure Form]. Andy Auerbach has a Patient-Centered Outcomes Research Institute research grant in development [From Section 3 of the Author Disclosure Form].

Admission to a hospital can be a stressful event,^1,2 and patients report having many concerns at the time of hospital admission.³ Over the last 20 years, the United States has widely adopted the hospitalist model of inpatient care. Although this model has clear benefits, it also has the potential to contribute to patient stress, as hospitalized patients generally lack preexisting relationships with their inpatient physicians.^4,5 In this changing hospital environment, defining and promoting effective medical communication has become an essential goal of both individual practitioners and medical centers.

Successful communication and strong therapeutic relationships with physicians support patients’ coping with illness-associated stress^6,7 as well as promote adherence to medical treatment plans.⁸ Empathy serves as an important building block of patient-centered communication and encourages a strong therapeutic alliance.⁹ Studies from primary care, oncology, and intensive care unit (ICU) settings indicate that physician empathy is associated with decreased emotional distress,^10,11 improved ratings of communication,¹² and even better medical outcomes.¹³

Prior work has shown that hospitalists, like other clinicians, underutilize empathy as a tool in their daily interactions with patients.^14-16 Our prior qualitative analysis of audio-recorded hospitalist-patient admission encounters indicated that how hospitalists respond to patient expressions of negative emotion influences relationships with patients and alignment around care plans.¹⁷ To determine whether empathic communication is associated with patient-reported outcomes in the hospitalist model, we quantitatively analyzed coded admission encounters and survey data to examine the association between hospitalists’ responses to patient expressions of negative emotion (anxiety, sadness, and anger) and patient anxiety and ratings of communication. Given the often-limited time hospitalists have to complete admission encounters, we also examined the association between response to emotion and encounter length.

METHODS

We analyzed data collected as part of an observational study of hospitalist-patient communication during hospital admission encounters¹⁴ to assess the association between the way physicians responded to patient expressions of negative emotion and patient anxiety, ratings of communication in the encounter, and encounter length. We collected data between August 2008 and March 2009 on the general medical service at 2 urban hospitals that are part of an academic medical center. Participants were attending hospitalists (not physician trainees), and patients admitted under participating hospitalists’ care who were able to communicate verbally in English and provide informed consent for the study. The institutional review board at the University of California, San Francisco approved the study; physician and patient participants provided written informed consent.

Enrollment and data collection has been described previously.¹⁷ Our cohort for this analysis included 76 patients of 27 physicians who completed encounter audio recordings and pre- and postencounter surveys. Following enrollment, patients completed a preencounter survey to collect demographic information and to measure their baseline anxiety via the State Anxiety Scale (STAI-S), which assesses transient anxious mood using 20 items answered on a 4-point scale for a final score range of 20 to 80.^10,18,19 We timed and audio-recorded admission encounters. Encounter recordings were obtained solely from patient interactions with attending hospitalists and did not take into account the time patients may have spent with other physicians, including trainees. After the encounter, patients completed postencounter surveys, which included the STAI-S and patients’ ratings of communication during the encounter. To rate communication, patients responded to 7 items on a 0- to 10-point scale that were derived from previous work (Table 1)^12,20,21; the anchors were “not at all” and “completely.” To identify patients with serious illness, which we used as a covariate in regression models, we asked physicians on a postencounter survey whether or not they “would be surprised by this patient’s death or admission to the ICU in the next year.”²²

As previously described, we professionally transcribed and coded the audio recordings.¹⁷ Following past work,^15,16,23-25 we identified patient expressions of negative emotion and categorized the initial hospitalist response to each expression. Table 2 shows examples to illustrate the coding scheme. We considered an empathic response to be one that directed further discussion toward a patient’s expressed negative emotion. A neutral response was one that directed discussion neither towards nor away from the expressed emotion, while a nonempathic physician response directed further discussion away from the patient’s emotion.¹⁵ To assess reliability, 2 coders independently coded a randomly selected 20% of encounters (n = 15); kappa statistics were 0.76 for patient expressions of emotion and 0.85 for physician responses, indicating substantial to almost perfect agreement.²⁶

We used regression models to assess the association between the number of each type of physician response (empathic, neutral, nonempathic) in an encounter and the following variables: (1) the change in the patient’s anxiety level, defined as the difference between the post- and preencounter STAI-S score (using linear regression); (2) patient ratings of the physician and encounter (using Poisson regression); and (3) encounter length (using linear regression). To assess each patient rating item, we utilized a single model that included frequencies for each type of physician response. For ratings of their encounters, most patients gave high ratings, resulting in a preponderance of 10/10 scores for several items. Thus, we focused on trying to understand “negativity,” meaning the minority of less than completely positive reactions. To do this, we analyzed reflected outcomes (defined as 10 minus the patient’s response) using zero-inflated Poisson regression models. This approach allowed us to distinguish between degrees of dissatisfaction and to determine whether additional change in ratings resulted from additional physician responses. Encounter length also demonstrated right skewness, which we addressed through log transformation; results for this are reported as percent change in the encounter length per physician response.

We considered physician as a clustering variable in the calculation of robust standard errors for all models. In addition, we included in each model covariates that were associated with the outcome at P ≤ 0.10, including patient gender, patient age, serious illness,²² preencounter anxiety, encounter length, and hospital. We considered P values < 0.05 to be statistically significant. We used Stata SE 13 (StataCorp LLC, College Station, TX) for all statistical analyses.

 

RESULTS

We analyzed data from admission encounters with 76 patients (consent rate 63%) and 27 hospitalists (consent rate 91%). Their characteristics are shown in Table 3. Median encounter length was 19 minutes (mean 21 minutes, range 3-68). Patients expressed negative emotion in 190 instances across all encounters; median number of expressions per encounter was 1 (range 0-14). Hospitalists responded empathically to 32% (n = 61) of the patient expressions, neutrally to 43% (n = 81), and nonempathically to 25% (n = 48).

The STAI-S was normally distributed. The mean preencounter STAI-S score was 39 (standard deviation [SD] 8.9). Mean postencounter STAI-S score was 38 (SD 10.7). Mean change in anxiety over the course of the encounter, calculated as the postencounter minus preencounter mean was −1.2 (SD 7.6). Table 1 shows summary statistics for the patient ratings of communication items. All items were rated highly. Across the items, between 51% and 78% of patients rated the highest score of 10.

Across the range of frequencies of emotional expressions per encounter in our data set (0-14 expressions), each additional empathic hospitalist response was associated with a 1.65-point decrease in the STAI-S (95% confidence interval [CI], 0.48-2.82). We did not find significant associations between changes in the STAI-S and the number of neutral hospitalist responses (−0.65 per response; 95% CI, −1.67-0.37) or nonempathic hospitalist responses (0.61 per response; 95% CI, −0.88-2.10).

The Figure shows the adjusted relative effects (aREs) and 95% CIs from zero-inflated multivariate Poisson regression models of the association between physician response to patient expressions of negative emotion and reflected patient ratings of the encounters, defined as 10 minus the patient’s response. Empathic hospitalist responses to patient expressions of emotion were associated with less negative patient ratings of communication in the encounter for 4 of 7 items: covering points of interest, the doctor listening, the doctor caring, and trusting the doctor. For example, for the item “I felt this doctor cared about me,” each empathic hospitalist response was associated with an approximate 77% reduction in negative patient ratings (aRE: 0.23; 95% CI, 0.06-0.85).

In addition, nonempathic responses were associated with more negative ratings of communication for 5 of the 7 items: ease of understanding information, covering points of interest, the doctor listening, the doctor caring, and trusting the doctor. For example, for the item “I felt this doctor cared about me,” each nonempathic hospitalist response was associated with a more than doubling of negative patient ratings (aRE: 2.3; 95% CI, 1.32-4.16). Neutral physician responses to patient expressions of negative emotion were associated with less negative patient ratings for 2 of the items: covering points of interest (aRE 0.68; 95% CI, 0.51-0.90) and trusting the doctor (aRE: 0.86; 95% CI, 0.75-0.99).

We did not find a statistical association between encounter length and the number of empathic hospitalist responses in the encounter (percent change in encounter length per response [PC]: 1%; 95% CI, −8%-10%) or the number of nonempathic responses (PC: 18%; 95% CI, −2%-42%). We did find a statistically significant association between the number of neutral responses and encounter length (PC: 13%; 95% CI, 3%-24%), corresponding to 2.5 minutes of additional encounter time per neutral response for the median encounter length of 19 minutes.

DISCUSSION

Our study set out to measure how hospitalists responded to expressions of negative emotion during admission encounters with patients and how those responses correlated with patient anxiety, ratings of communication, and encounter length. We found that empathic responses were associated with diminishing patient anxiety after the visit, as well as with better ratings of several domains of hospitalist communication. Moreover, nonempathic responses to negative emotion were associated with more strongly negative ratings of hospitalist communication. Finally, while clinicians may worry that encouraging patients to speak further about emotion will result in excessive visit lengths, we did not find a statistical association between empathic responses and encounter duration. To our knowledge, this is the first study to indicate an association between empathy and patient anxiety and communication ratings within the hospitalist model, which is rapidly becoming the predominant model for providing inpatient care in the United States.^4,5

As in oncologic care, anxiety is an emotion commonly confronted by clinicians meeting admitted medical patients for the first time. Studies show that not only do patient anxiety levels remain high throughout a hospital course, patients who experience higher levels of anxiety tend to stay longer in the hospital.^1,2,27-30 But unlike oncologic care or other therapy provided in an outpatient setting, the hospitalist model does not facilitate “continuity” of care, or the ability to care for the same patients over a long period of time. This reality of inpatient care makes rapid, effective rapport-building critical to establishing strong physician-patient relationships. In this setting, a simple communication tool that is potentially able to reduce inpatients’ anxiety could have a meaningful impact on hospitalist-provided care and patient outcomes.

In terms of the magnitude of the effect of empathic responses, the clinical significance of a 1.65-point decrease in the STAI-S anxiety score is not precisely clear. A prior study that examined the effect of music therapy on anxiety levels in patients with cancer found an average anxiety reduction of approximately 9.5 units on the STAIS-S scale after sensitivity analysis, suggesting a rather large meaningful effect size.³¹ Given we found a reduction of 1.65 points for each empathic response, however, with a range of 0-14 negative emotions expressed over a median 19-minute encounter, there is opportunity for hospitalists to achieve a clinically significant decrease in patient anxiety during an admission encounter. The potential to reduce anxiety is extended further when we consider that the impact of an empathic response may apply not just to the admission encounter alone but also to numerous other patient-clinician interactions over the course of a hospitalization.

A healthy body of communication research supports the associations we found in our study between empathy and patient ratings of communication and physicians. Families in ICU conferences rate communication more positively when physicians express empathy,¹² and a number of studies indicate an association between empathy and patient satisfaction in outpatient settings.⁸ Given the associations we found with negative ratings on the items in our study, promoting empathic responses to expressions of emotion and, more importantly, stressing avoidance of nonempathic responses may be relevant efforts in working to improve patient satisfaction scores on surveys reporting “top box” percentages, such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). More notably, evidence indicates that empathy has positive impacts beyond satisfaction surveys, such as adherence, better diagnostic and clinical outcomes, and strengthening of patient enablement.⁸Not all hospitalist responses to emotion were associated with patient ratings across the 7 communication items we assessed. For example, we did not find an association between how physicians responded to patient expressions of negative emotion and patient perception that enough time was spent in the visit or the degree to which talking with the doctor met a patient’s overall needs. It follows logically, and other research supports, that empathy would influence patient ratings of physician caring and trust,³² whereas other communication factors we were unable to measure (eg, physician body language, tone, and use of jargon and patient health literacy and primary language) may have a more significant association with patient ratings of the other items we assessed.

In considering the clinical application of our results, it is important to note that communication skills, including responding empathically to patient expressions of negative emotion, can be imparted through training in the same way as abdominal examination or electrocardiogram interpretation skills.^33-35 However, training of hospitalists in communication skills requires time and some financial investment on the part of the physician, their hospital or group, or, ideally, both. Effective training methods, like those for other skill acquisition, involve learner-centered teaching and practicing skills with role-play and feedback.³⁶ Given the importance of a learner-centered approach, learning would likely be better received and more effective if it was tailored to the specific needs and patient scenarios commonly encountered by hospitalist physicians. As these programs are developed, it will be important to assess the impact of any training on the patient-reported outcomes we assessed in this observational study, along with clinical outcomes.

Our study has several limitations. First, we were only able to evaluate whether hospitalists verbally responded to patient emotion and were thus not able to account for nonverbal empathy such as facial expressions, body language, or voice tone. Second, given our patient consent rate of 63%, patients who agreed to participate in the study may have had different opinions than those who declined to participate. Also, hospitalists and patients may have behaved differently as a result of being audio recorded. We only included patients who spoke English, and our patient population was predominately non-Hispanic white. Patients who spoke other languages or came from other cultural backgrounds may have had different responses. Third, we did not use a single validated scale for patient ratings of communication, and multiple analyses increase our risk of finding statistically significant associations by chance. The skewing of the communication rating items toward high scores may also have led to our results being driven by outliers, although the model we chose for analysis does penalize for this. Furthermore, our sample size was small, leading to wide CIs and potential for lack of statistical associations due to insufficient power. Our findings warrant replication in larger studies. Fourth, the setting of our study in an academic center may affect generalizability. Finally, the age of our data (collected between 2008 and 2009) is also a limitation. Given a recent focus on communication and patient experience since the initiation of HCAHPS feedback, a similar analysis of empathy and communication methods now may result in different outcomes.

In conclusion, our results suggest that enhancing hospitalists’ empathic responses to patient expressions of negative emotion could decrease patient anxiety and improve patients’ perceptions of (and thus possibly their relationships with) hospitalists, without sacrificing efficiency. Future work should focus on tailoring and implementing communication skills training programs for hospitalists and evaluating the impact of training on patient outcomes.

 

Acknowledgments

The authors extend their sincere thanks to the patients and physicians who participated in this study. Dr. Anderson was funded by the National Palliative Care Research Center and the University of California, San Francisco Clinical and Translational Science Institute Career Development Program, National Institutes of Health (NIH) grant number 5 KL2 RR024130-04. Project costs were funded by a grant from the University of California, San Francisco Academic Senate.

Disclosure

 All coauthors have seen and agree with the contents of this manuscript. This submission is not under review by any other publication. Wendy Anderson received funding for this project from the National Palliative Care Research Center, University of California San Francisco Clinical and Translational Science Institute (NIH grant number 5KL2RR024130-04), and the University of San Francisco Academic Senate [From Section 2 of Author Disclosure Form]. Andy Auerbach has a Patient-Centered Outcomes Research Institute research grant in development [From Section 3 of the Author Disclosure Form].

Admission to a hospital can be a stressful event,^1,2 and patients report having many concerns at the time of hospital admission.³ Over the last 20 years, the United States has widely adopted the hospitalist model of inpatient care. Although this model has clear benefits, it also has the potential to contribute to patient stress, as hospitalized patients generally lack preexisting relationships with their inpatient physicians.^4,5 In this changing hospital environment, defining and promoting effective medical communication has become an essential goal of both individual practitioners and medical centers.

Successful communication and strong therapeutic relationships with physicians support patients’ coping with illness-associated stress^6,7 as well as promote adherence to medical treatment plans.⁸ Empathy serves as an important building block of patient-centered communication and encourages a strong therapeutic alliance.⁹ Studies from primary care, oncology, and intensive care unit (ICU) settings indicate that physician empathy is associated with decreased emotional distress,^10,11 improved ratings of communication,¹² and even better medical outcomes.¹³

Prior work has shown that hospitalists, like other clinicians, underutilize empathy as a tool in their daily interactions with patients.^14-16 Our prior qualitative analysis of audio-recorded hospitalist-patient admission encounters indicated that how hospitalists respond to patient expressions of negative emotion influences relationships with patients and alignment around care plans.¹⁷ To determine whether empathic communication is associated with patient-reported outcomes in the hospitalist model, we quantitatively analyzed coded admission encounters and survey data to examine the association between hospitalists’ responses to patient expressions of negative emotion (anxiety, sadness, and anger) and patient anxiety and ratings of communication. Given the often-limited time hospitalists have to complete admission encounters, we also examined the association between response to emotion and encounter length.

METHODS

We analyzed data collected as part of an observational study of hospitalist-patient communication during hospital admission encounters¹⁴ to assess the association between the way physicians responded to patient expressions of negative emotion and patient anxiety, ratings of communication in the encounter, and encounter length. We collected data between August 2008 and March 2009 on the general medical service at 2 urban hospitals that are part of an academic medical center. Participants were attending hospitalists (not physician trainees), and patients admitted under participating hospitalists’ care who were able to communicate verbally in English and provide informed consent for the study. The institutional review board at the University of California, San Francisco approved the study; physician and patient participants provided written informed consent.

Enrollment and data collection has been described previously.¹⁷ Our cohort for this analysis included 76 patients of 27 physicians who completed encounter audio recordings and pre- and postencounter surveys. Following enrollment, patients completed a preencounter survey to collect demographic information and to measure their baseline anxiety via the State Anxiety Scale (STAI-S), which assesses transient anxious mood using 20 items answered on a 4-point scale for a final score range of 20 to 80.^10,18,19 We timed and audio-recorded admission encounters. Encounter recordings were obtained solely from patient interactions with attending hospitalists and did not take into account the time patients may have spent with other physicians, including trainees. After the encounter, patients completed postencounter surveys, which included the STAI-S and patients’ ratings of communication during the encounter. To rate communication, patients responded to 7 items on a 0- to 10-point scale that were derived from previous work (Table 1)^12,20,21; the anchors were “not at all” and “completely.” To identify patients with serious illness, which we used as a covariate in regression models, we asked physicians on a postencounter survey whether or not they “would be surprised by this patient’s death or admission to the ICU in the next year.”²²

As previously described, we professionally transcribed and coded the audio recordings.¹⁷ Following past work,^15,16,23-25 we identified patient expressions of negative emotion and categorized the initial hospitalist response to each expression. Table 2 shows examples to illustrate the coding scheme. We considered an empathic response to be one that directed further discussion toward a patient’s expressed negative emotion. A neutral response was one that directed discussion neither towards nor away from the expressed emotion, while a nonempathic physician response directed further discussion away from the patient’s emotion.¹⁵ To assess reliability, 2 coders independently coded a randomly selected 20% of encounters (n = 15); kappa statistics were 0.76 for patient expressions of emotion and 0.85 for physician responses, indicating substantial to almost perfect agreement.²⁶

We used regression models to assess the association between the number of each type of physician response (empathic, neutral, nonempathic) in an encounter and the following variables: (1) the change in the patient’s anxiety level, defined as the difference between the post- and preencounter STAI-S score (using linear regression); (2) patient ratings of the physician and encounter (using Poisson regression); and (3) encounter length (using linear regression). To assess each patient rating item, we utilized a single model that included frequencies for each type of physician response. For ratings of their encounters, most patients gave high ratings, resulting in a preponderance of 10/10 scores for several items. Thus, we focused on trying to understand “negativity,” meaning the minority of less than completely positive reactions. To do this, we analyzed reflected outcomes (defined as 10 minus the patient’s response) using zero-inflated Poisson regression models. This approach allowed us to distinguish between degrees of dissatisfaction and to determine whether additional change in ratings resulted from additional physician responses. Encounter length also demonstrated right skewness, which we addressed through log transformation; results for this are reported as percent change in the encounter length per physician response.

We considered physician as a clustering variable in the calculation of robust standard errors for all models. In addition, we included in each model covariates that were associated with the outcome at P ≤ 0.10, including patient gender, patient age, serious illness,²² preencounter anxiety, encounter length, and hospital. We considered P values < 0.05 to be statistically significant. We used Stata SE 13 (StataCorp LLC, College Station, TX) for all statistical analyses.

 

RESULTS

We analyzed data from admission encounters with 76 patients (consent rate 63%) and 27 hospitalists (consent rate 91%). Their characteristics are shown in Table 3. Median encounter length was 19 minutes (mean 21 minutes, range 3-68). Patients expressed negative emotion in 190 instances across all encounters; median number of expressions per encounter was 1 (range 0-14). Hospitalists responded empathically to 32% (n = 61) of the patient expressions, neutrally to 43% (n = 81), and nonempathically to 25% (n = 48).

The STAI-S was normally distributed. The mean preencounter STAI-S score was 39 (standard deviation [SD] 8.9). Mean postencounter STAI-S score was 38 (SD 10.7). Mean change in anxiety over the course of the encounter, calculated as the postencounter minus preencounter mean was −1.2 (SD 7.6). Table 1 shows summary statistics for the patient ratings of communication items. All items were rated highly. Across the items, between 51% and 78% of patients rated the highest score of 10.

Across the range of frequencies of emotional expressions per encounter in our data set (0-14 expressions), each additional empathic hospitalist response was associated with a 1.65-point decrease in the STAI-S (95% confidence interval [CI], 0.48-2.82). We did not find significant associations between changes in the STAI-S and the number of neutral hospitalist responses (−0.65 per response; 95% CI, −1.67-0.37) or nonempathic hospitalist responses (0.61 per response; 95% CI, −0.88-2.10).

The Figure shows the adjusted relative effects (aREs) and 95% CIs from zero-inflated multivariate Poisson regression models of the association between physician response to patient expressions of negative emotion and reflected patient ratings of the encounters, defined as 10 minus the patient’s response. Empathic hospitalist responses to patient expressions of emotion were associated with less negative patient ratings of communication in the encounter for 4 of 7 items: covering points of interest, the doctor listening, the doctor caring, and trusting the doctor. For example, for the item “I felt this doctor cared about me,” each empathic hospitalist response was associated with an approximate 77% reduction in negative patient ratings (aRE: 0.23; 95% CI, 0.06-0.85).

In addition, nonempathic responses were associated with more negative ratings of communication for 5 of the 7 items: ease of understanding information, covering points of interest, the doctor listening, the doctor caring, and trusting the doctor. For example, for the item “I felt this doctor cared about me,” each nonempathic hospitalist response was associated with a more than doubling of negative patient ratings (aRE: 2.3; 95% CI, 1.32-4.16). Neutral physician responses to patient expressions of negative emotion were associated with less negative patient ratings for 2 of the items: covering points of interest (aRE 0.68; 95% CI, 0.51-0.90) and trusting the doctor (aRE: 0.86; 95% CI, 0.75-0.99).

We did not find a statistical association between encounter length and the number of empathic hospitalist responses in the encounter (percent change in encounter length per response [PC]: 1%; 95% CI, −8%-10%) or the number of nonempathic responses (PC: 18%; 95% CI, −2%-42%). We did find a statistically significant association between the number of neutral responses and encounter length (PC: 13%; 95% CI, 3%-24%), corresponding to 2.5 minutes of additional encounter time per neutral response for the median encounter length of 19 minutes.

DISCUSSION

Our study set out to measure how hospitalists responded to expressions of negative emotion during admission encounters with patients and how those responses correlated with patient anxiety, ratings of communication, and encounter length. We found that empathic responses were associated with diminishing patient anxiety after the visit, as well as with better ratings of several domains of hospitalist communication. Moreover, nonempathic responses to negative emotion were associated with more strongly negative ratings of hospitalist communication. Finally, while clinicians may worry that encouraging patients to speak further about emotion will result in excessive visit lengths, we did not find a statistical association between empathic responses and encounter duration. To our knowledge, this is the first study to indicate an association between empathy and patient anxiety and communication ratings within the hospitalist model, which is rapidly becoming the predominant model for providing inpatient care in the United States.^4,5

As in oncologic care, anxiety is an emotion commonly confronted by clinicians meeting admitted medical patients for the first time. Studies show that not only do patient anxiety levels remain high throughout a hospital course, patients who experience higher levels of anxiety tend to stay longer in the hospital.^1,2,27-30 But unlike oncologic care or other therapy provided in an outpatient setting, the hospitalist model does not facilitate “continuity” of care, or the ability to care for the same patients over a long period of time. This reality of inpatient care makes rapid, effective rapport-building critical to establishing strong physician-patient relationships. In this setting, a simple communication tool that is potentially able to reduce inpatients’ anxiety could have a meaningful impact on hospitalist-provided care and patient outcomes.

In terms of the magnitude of the effect of empathic responses, the clinical significance of a 1.65-point decrease in the STAI-S anxiety score is not precisely clear. A prior study that examined the effect of music therapy on anxiety levels in patients with cancer found an average anxiety reduction of approximately 9.5 units on the STAIS-S scale after sensitivity analysis, suggesting a rather large meaningful effect size.³¹ Given we found a reduction of 1.65 points for each empathic response, however, with a range of 0-14 negative emotions expressed over a median 19-minute encounter, there is opportunity for hospitalists to achieve a clinically significant decrease in patient anxiety during an admission encounter. The potential to reduce anxiety is extended further when we consider that the impact of an empathic response may apply not just to the admission encounter alone but also to numerous other patient-clinician interactions over the course of a hospitalization.

A healthy body of communication research supports the associations we found in our study between empathy and patient ratings of communication and physicians. Families in ICU conferences rate communication more positively when physicians express empathy,¹² and a number of studies indicate an association between empathy and patient satisfaction in outpatient settings.⁸ Given the associations we found with negative ratings on the items in our study, promoting empathic responses to expressions of emotion and, more importantly, stressing avoidance of nonempathic responses may be relevant efforts in working to improve patient satisfaction scores on surveys reporting “top box” percentages, such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). More notably, evidence indicates that empathy has positive impacts beyond satisfaction surveys, such as adherence, better diagnostic and clinical outcomes, and strengthening of patient enablement.⁸Not all hospitalist responses to emotion were associated with patient ratings across the 7 communication items we assessed. For example, we did not find an association between how physicians responded to patient expressions of negative emotion and patient perception that enough time was spent in the visit or the degree to which talking with the doctor met a patient’s overall needs. It follows logically, and other research supports, that empathy would influence patient ratings of physician caring and trust,³² whereas other communication factors we were unable to measure (eg, physician body language, tone, and use of jargon and patient health literacy and primary language) may have a more significant association with patient ratings of the other items we assessed.

In considering the clinical application of our results, it is important to note that communication skills, including responding empathically to patient expressions of negative emotion, can be imparted through training in the same way as abdominal examination or electrocardiogram interpretation skills.^33-35 However, training of hospitalists in communication skills requires time and some financial investment on the part of the physician, their hospital or group, or, ideally, both. Effective training methods, like those for other skill acquisition, involve learner-centered teaching and practicing skills with role-play and feedback.³⁶ Given the importance of a learner-centered approach, learning would likely be better received and more effective if it was tailored to the specific needs and patient scenarios commonly encountered by hospitalist physicians. As these programs are developed, it will be important to assess the impact of any training on the patient-reported outcomes we assessed in this observational study, along with clinical outcomes.

Our study has several limitations. First, we were only able to evaluate whether hospitalists verbally responded to patient emotion and were thus not able to account for nonverbal empathy such as facial expressions, body language, or voice tone. Second, given our patient consent rate of 63%, patients who agreed to participate in the study may have had different opinions than those who declined to participate. Also, hospitalists and patients may have behaved differently as a result of being audio recorded. We only included patients who spoke English, and our patient population was predominately non-Hispanic white. Patients who spoke other languages or came from other cultural backgrounds may have had different responses. Third, we did not use a single validated scale for patient ratings of communication, and multiple analyses increase our risk of finding statistically significant associations by chance. The skewing of the communication rating items toward high scores may also have led to our results being driven by outliers, although the model we chose for analysis does penalize for this. Furthermore, our sample size was small, leading to wide CIs and potential for lack of statistical associations due to insufficient power. Our findings warrant replication in larger studies. Fourth, the setting of our study in an academic center may affect generalizability. Finally, the age of our data (collected between 2008 and 2009) is also a limitation. Given a recent focus on communication and patient experience since the initiation of HCAHPS feedback, a similar analysis of empathy and communication methods now may result in different outcomes.

In conclusion, our results suggest that enhancing hospitalists’ empathic responses to patient expressions of negative emotion could decrease patient anxiety and improve patients’ perceptions of (and thus possibly their relationships with) hospitalists, without sacrificing efficiency. Future work should focus on tailoring and implementing communication skills training programs for hospitalists and evaluating the impact of training on patient outcomes.

 

Acknowledgments

The authors extend their sincere thanks to the patients and physicians who participated in this study. Dr. Anderson was funded by the National Palliative Care Research Center and the University of California, San Francisco Clinical and Translational Science Institute Career Development Program, National Institutes of Health (NIH) grant number 5 KL2 RR024130-04. Project costs were funded by a grant from the University of California, San Francisco Academic Senate.

Disclosure

 All coauthors have seen and agree with the contents of this manuscript. This submission is not under review by any other publication. Wendy Anderson received funding for this project from the National Palliative Care Research Center, University of California San Francisco Clinical and Translational Science Institute (NIH grant number 5KL2RR024130-04), and the University of San Francisco Academic Senate [From Section 2 of Author Disclosure Form]. Andy Auerbach has a Patient-Centered Outcomes Research Institute research grant in development [From Section 3 of the Author Disclosure Form].

 

Most Americans diagnosed with serious illness will be hospitalized in their last months. During these hospitalizations, hospitalists direct their care.

For seriously ill patients, consultation with palliative care specialists has been shown to promote patient- and family-centered care, ensuring that care is consistent with patients’ goals, values, and preferences. Yet, many hospitalized patients lack access to palliative care consultation, and specialists have identified key domains of primary palliative care that can be delivered by nonspecialists.

There is now an important opportunity for hospitalists to lead prognosis and goals of care communication for their patients. To succeed in this role, hospitalists need training and structural support that may not yet be available to them.

To fill this gap, SHM’s Center for Quality Improvement partnered with The Hastings Center, a world-renowned bioethics research institution, to develop a resource room focused on hospitalists’ role in providing high-quality communication about prognosis and goals of care. The resource room presents a Prognosis and Goals of Care Communication Pathway, which highlights key processes and maps them onto the daily workflows of hospitalist physicians.

The care pathway is grounded in palliative care communication research and the consensus guidance of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. It was informed by a national stakeholder meeting of hospitalists, other hospital clinicians, patient and family advocates, bioethicists, social scientists, and other experts, who identified professional values of hospital medicine aligned with communication as part of good care for seriously ill patients.

A collaborative interdisciplinary work group convened by SHM and including hospitalists, palliative medicine physicians, a bioethicist, and a palliative nursing specialist constructed the care pathway in terms of key processes occurring at admission, during hospitalization, and in discharge planning to support primary palliative care integration into normal workflow. The resource room also includes skills-building tools and resources for individual hospitals, teams, and institutions.

The work group will present a workshop on the care pathway at Hospital Medicine 2017: “Demystifying Difficult Decisions: Strategies and Skills to Equip Hospitalists for High-Quality Goals of Care Conversations with Seriously Ill Patients and Their Families.” For more information on the resource room, visit www.hospitalmedicine.org/EOL.
 

Dr. Anderson is associate professor in residence in the division of hospital medicine at the University of California, San Francisco. She also serves as attending physician in the Palliative Care Program and codirector of the School of Nursing Interprofessional Palliative Care Training Program at UCSF.

 

Most Americans diagnosed with serious illness will be hospitalized in their last months. During these hospitalizations, hospitalists direct their care.

For seriously ill patients, consultation with palliative care specialists has been shown to promote patient- and family-centered care, ensuring that care is consistent with patients’ goals, values, and preferences. Yet, many hospitalized patients lack access to palliative care consultation, and specialists have identified key domains of primary palliative care that can be delivered by nonspecialists.

There is now an important opportunity for hospitalists to lead prognosis and goals of care communication for their patients. To succeed in this role, hospitalists need training and structural support that may not yet be available to them.

To fill this gap, SHM’s Center for Quality Improvement partnered with The Hastings Center, a world-renowned bioethics research institution, to develop a resource room focused on hospitalists’ role in providing high-quality communication about prognosis and goals of care. The resource room presents a Prognosis and Goals of Care Communication Pathway, which highlights key processes and maps them onto the daily workflows of hospitalist physicians.

The care pathway is grounded in palliative care communication research and the consensus guidance of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. It was informed by a national stakeholder meeting of hospitalists, other hospital clinicians, patient and family advocates, bioethicists, social scientists, and other experts, who identified professional values of hospital medicine aligned with communication as part of good care for seriously ill patients.

A collaborative interdisciplinary work group convened by SHM and including hospitalists, palliative medicine physicians, a bioethicist, and a palliative nursing specialist constructed the care pathway in terms of key processes occurring at admission, during hospitalization, and in discharge planning to support primary palliative care integration into normal workflow. The resource room also includes skills-building tools and resources for individual hospitals, teams, and institutions.

The work group will present a workshop on the care pathway at Hospital Medicine 2017: “Demystifying Difficult Decisions: Strategies and Skills to Equip Hospitalists for High-Quality Goals of Care Conversations with Seriously Ill Patients and Their Families.” For more information on the resource room, visit www.hospitalmedicine.org/EOL.
 

Dr. Anderson is associate professor in residence in the division of hospital medicine at the University of California, San Francisco. She also serves as attending physician in the Palliative Care Program and codirector of the School of Nursing Interprofessional Palliative Care Training Program at UCSF.

 

Most Americans diagnosed with serious illness will be hospitalized in their last months. During these hospitalizations, hospitalists direct their care.

For seriously ill patients, consultation with palliative care specialists has been shown to promote patient- and family-centered care, ensuring that care is consistent with patients’ goals, values, and preferences. Yet, many hospitalized patients lack access to palliative care consultation, and specialists have identified key domains of primary palliative care that can be delivered by nonspecialists.

There is now an important opportunity for hospitalists to lead prognosis and goals of care communication for their patients. To succeed in this role, hospitalists need training and structural support that may not yet be available to them.

To fill this gap, SHM’s Center for Quality Improvement partnered with The Hastings Center, a world-renowned bioethics research institution, to develop a resource room focused on hospitalists’ role in providing high-quality communication about prognosis and goals of care. The resource room presents a Prognosis and Goals of Care Communication Pathway, which highlights key processes and maps them onto the daily workflows of hospitalist physicians.

The care pathway is grounded in palliative care communication research and the consensus guidance of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. It was informed by a national stakeholder meeting of hospitalists, other hospital clinicians, patient and family advocates, bioethicists, social scientists, and other experts, who identified professional values of hospital medicine aligned with communication as part of good care for seriously ill patients.

A collaborative interdisciplinary work group convened by SHM and including hospitalists, palliative medicine physicians, a bioethicist, and a palliative nursing specialist constructed the care pathway in terms of key processes occurring at admission, during hospitalization, and in discharge planning to support primary palliative care integration into normal workflow. The resource room also includes skills-building tools and resources for individual hospitals, teams, and institutions.

The work group will present a workshop on the care pathway at Hospital Medicine 2017: “Demystifying Difficult Decisions: Strategies and Skills to Equip Hospitalists for High-Quality Goals of Care Conversations with Seriously Ill Patients and Their Families.” For more information on the resource room, visit www.hospitalmedicine.org/EOL.
 

Dr. Anderson is associate professor in residence in the division of hospital medicine at the University of California, San Francisco. She also serves as attending physician in the Palliative Care Program and codirector of the School of Nursing Interprofessional Palliative Care Training Program at UCSF.

From the University of California Irvine Health/Chao Family Comprehensive Cancer Center Orange, CA (Ms. Boyle) and the University of California San Francisco Medical Center, San Francisco, CA (Dr. Anderson).

 

Abstract

• Objective: To describe components of a unique interactive workshop focusing on the enhancement of critical care nurses’ communication skills within the realm of prognosis and goals of care discussions with family members and physicians.
• Methods: A series of one-day workshops were offered to critical care nurses practicing in the 5 University of California hospital settings. After workshop attendance, nurse participants were followed by workshop facilitators in their units to ensure new communication skills were being integrated into practice and to problem solve if barriers were met.
• Results: Improvement in nurses’ self-confidence in engaging in these discussions was seen. This confidence was sustained months following workshop participation.
• Conclusion: The combination of critical care nurse workshop participation that involved skill enhancement through role-playing, in combination with clinical follow-up with attendees, resulted in positive affirmation of nurse communication skills specific to prognosis and goals of care discussions with family members and physicians.

 

There is increasing evidence that in the absence of quality communication between professional caregivers and those they care for, negative outcomes may prevail, such as reduced patient/family satisfaction, lower health status awareness, and a decreased sense of being cared about and cared for [1–5]. Communication skill competency is a critical corollary of nursing practice. In the intensive care unit (ICU) setting, patients and families have cited skilled communication as a core element of high-quality care [3,6]. Proficiency in this realm enhances nurses’ understanding of the patient and family’s encounter with health care and provides a vehicle to gather information, inform, teach, and offer emotional support. Additionally, it identifies values, goals, health care preferences, worries and concerns, and facilitates the nurses’ coordination of care [7]. Despite this skill’s importance, however, it is generally not taught in basic education and until recently has been overlooked as a key competency [8,9].

Skilled communication in palliative and end-of-life care is pivotal for discussing prognosis and care planning. In the acute care setting this is particularly relevant as the majority of Americans die in hospitals versus their preferred site of home [10]. Additionally, 1 in 5 Americans die during or shortly after receiving care in an ICU [11]. Hence, while the ICU is a setting in which intensive effort to save lives is employed, it is also a setting where death frequently occurs. The complexity and highly emotive nature of critical care often results in family needs for information and support not being met [12]. A number of reasons for this occurrence have been proposed. In this paper, we will delineate barriers to critical care nurses’ involvement in prognosis and goals of care discussions, identify why nurse involvement in this communication is needed, describe a unique workshop exemplar with a sample role play that characterizes the workshop, and offer recommendations for colleagues interested in replicating similar education offerings.

 

Barriers to Communication

In the ICU, the sheer number of professionals families interact with may cause confusion. In particular, numerous medical consultants commonly offer opposing opinions. Additionally, each specialist may provide information that focuses on their area of expertise such that the “big picture” is not relayed to the patient and family. Emotional discomfort on the part of the health professional around discussions of poor prognosis, goals of care, and code status may prompt limiting discussion time with patients and families and even the avoidance of interpersonal exchanges [13–15]. Health professionals have also reported concern that end-of-life discussions will increase patient distress [16]. Among health care professionals, the subject of mortality may prompt personal anxiety, trigger unresolved grief, or fear that they will “become emotional” in front of the patient/family [7]. Lack of knowledge about cultural and religious norms has been cited as a barrier, as has time constraints [17,18]. Most frequently, inadequate or absent communication skill training is noted as a significant barrier [19,20]. Many ICU nurses also report feeling marginalized due their exclusion from goals of care and decision-making discussions with patients and families they know well [21,22].

Nurses As Key Palliative Care Communicators

Education efforts that foster communication proficiency during serious illness have traditionally focused on training physicians. Recently, nursing has become a focus of communication skill enhancement in recognition of nurses’ intense and protracted interactions with patients and families in the acute care setting. Nurses are the ‘constant’ in the patient and family’s journey through the fragmented health care system [21,23]. They often have the best knowledge of, and strongest relationship with, the family and often have had extensive discussions with them about their loved one’s status [24]. Nurses are aware of the patients’ symptom experiences and are privy to valuable information about the concerns and priorities of patients and families [12]. Additionally, having the most continuous presence, nurses have seen and heard interactions with clinicians from numerous disciplines. Nurses are the most visible, constant resource for patient and family education, information and support, and thus they perceive one of their most important roles to be that of advocate for the patient and family [20,21].

Communication Training Programs for Critical Care Nurses

Education is critical to enhance communication skills within palliative care [7,15,17,20,21,24]. The preferred teaching style within this realm is role play, where skills can be practiced and the affective component of engaging in sensitive discussions can be addressed [25–27]. Role play also demonstrates firsthand the importance of nonverbal communication (eg, body language, proximity, use of gestures, tone of voice) [7,20] and facilitates nurses’ gaining a sense of comfort with wordless communication [18].

Communication skills training programs have been designed to provide bedside critical care nurses with the tools they need to be active participants in discussions of prognosis, goals of care, and palliative care with families and physicians [27,28]. These programs have demonstrated improvement in nurses’ confidence to engage in key palliative care-related discussions. Essential elements of these programs include (1) delineation of the role of the bedside nurse in palliative care communication; (2) presentation and learner-centered practice of communication skills using role play; and (3) a reflection session focused on self-care and sustainability.

Across the 5 academic University of California medical centers (San Francisco, Davis, Los Angeles, Irvine, and San Diego), a communication training program based on this work has been implemented [29]. The one-day workshop, entitled IMPACT-ICU (Integrating Multidisciplinary Palliative Care into the ICU), has taught a total of 527 critical care nurses across the 5 centers. In addition to classroom training, the IMPACT-ICU program also includes proactive specialty palliative nursing support for bedside nurses by facilitating the availability of palliative care advanced practice nurses and nurse educators resources. This support helps nurses to apply the skills learned in the workshop in their practice. During rounds at the bedside, the nurse resources coach the bedside staff on the “how” and “when” of addressing palliative care needs. Education and support on a range of topics are offered, including clarifying goals and interventions provided by palliative care teams, the specifics of how to provide family emotional support and delivery of understandable information, the assessment and management of symptoms distress, and the nurses’ role in organizing and participating in family meetings. Case-specific consultations are also offered that address how to interface with resistant medical staff. The importance of nurse documentation of these varied exchanges is also emphasized.

 

IMPACT-ICU Workshop

A maximum of 15 nurses participate in each 8-hour workshop. The session begins with introductions and small group discussions about what the participants perceive to be the greatest barriers to goals of care discussions and fostering patient/family decision-making in the ICU. Participants are also asked to reflect on what they want to learn as a result of their workshop attendance.

A short didactic session then reviews the definition of palliative care and its core components, addresses the nurses’ role in communication within palliative care, a social worker’s perspective of what it is like to be a family member in the ICU, and the outline of the day. This includes delineation of expectations for involvement within the role plays and the various roles to be enacted. An emphasis is placed on the workshop being a safe place to explore and trial skills with the support of colleagues, and that practice is the optimum way to integrate communication expertise into the nurses’ skill set.

The “4 Cs” serves as the instructional basis for nurse communication skill enhancement [27]. This model outlines 4 key nursing roles in optimizing communication within palliative care:

Convening: Making sure multidisciplinary patient/family/clinician communication occurs.

Checking: Identifying the patient and family needs for information; ensuring that patients and families clearly receive desired information; ensuring that clinicians understand patient and family perspectives.

Caring: Naming emotions and responding to feeling.

Continuing: Following up after discussions to clarify and reinforce information and provide support.

 

The roles of bedside ICU nurses in discussions with families and physicians are delineated within the context of 3 scenarios: nurse-family conversations, nurse-physician conversations, and family meetings (Figure) [28]. For each scenario, there are 3 role-play sessions in which participants practice core communication skills. These skills with example verbiage are shown in the Table. Prior to engaging in the role play, nurses are asked to identify a conversation goal and skill they want to practice. Course leaders present a model role play to illustrate the use of the communication skills prior to the role play.

Each scenario integrates numerous roles that require enactment. The facilitator is one of the course leaders who provides oversight to the process of the role play. They guide the vignette and have the option to “time out” and stop the role play if the learner is struggling or when the learner’s goal is achieved. Facilitators then solicit feedback from the observers, those participants not engaging in the role play but watching it unfold. Observers are asked to record what they heard and saw that demonstrated the learner’s achievement of their goal. The observers’ input is solicited at the end of the role play to question if and how the learner met their conversation goal. The learner is the nurse engaging in the role play in each of the 3 vignettes. The learner is encouraged to refer to the list of skills in the Table and use them during the actual interpersonal exchange. The room is set-up in a “U-shape” style such that learners’ chairs are placed at the front of the configuration and the facilitator stands to the side of where the conversation takes place.

Sample Role Play

Facilitator: So our first role play is focused on eliciting patient and family perspectives and needs. I need a learner and someone to play the role of the family member.

Learner: I’ll give it a try.

Facilitator: Lisa, you’re going to do great. Who wants to play the family member?

Workshop Participant: I’ll do it.

Facilitator: So Mary (who has agreed to play the role of the wife), why don’t you read us the scenario. (She reads it out loud to the group).

Facilitator: Lisa, as the nurse, I want you to look at your guide and tell me what your goal is for this conversation with Mrs. Ames and then which skill you want to practice.

Learner: I think I want to try eliciting the patient and family’s needs for information and I’ll try “Tell Me More” statements.

Facilitator: Alright. So remember Lisa, if you feel the conversation isn’t going well, you can call a “time out.” I can do this as well if I feel you need to start over. I’ll also call a time out when I feel you have met your goal. Sound OK? Mary, do you have any questions playing the part of Mrs. Ames?

Wife Role: Well, how hard should I make this for her? Should I be one of those “difficult” family members?

Facilitator: Our goal here is not to “stump” you or make it particularly difficult. We want you to try out these skills and get a sense of your “comfort zone.” So let’s start with some basic communication skills, OK?

Wife Role: Alright.

Facilitator: Why don’t we set the stage, such that Lisa, you are Mr. Ames’ nurse assessing him at the start of your shift, when Mrs. Ames enters. This is the first time you have taken care of him. The night nurse has told you that he has been requiring increasing ventilator support and his renal function is declining. Per Mrs. Ames’ request, the night nurse called her to let her know how he was doing and Mrs. Ames told her she would be in shortly.

Wife Role: (nervously enters the room and grasps her husband’s hand and looks at the nurse). How’s he doing? Is he better? The night nurse called me and I was so worried I rushed over here.

Learner: (Turns to Mrs. Ames and extends her hand). Are you Mrs. Ames? I’m Lisa and I am going to be taking care of Mr. Ames today. Let me just finish my assessment and how about we talk then? Will that be OK? It will be just a few minutes.

Wife Role: Alright, I’ll be in the waiting area but please come get me as soon as you can.

Learner: I will. (Nurse then shortly comes into the waiting area and asks Mrs. Ames to come back into the ICU where she invites her to sit just outside Mr. Ames’ room). Mrs. Ames, how are you doing? This must be so stressful for you, having your husband in the ICU.

Wife Role: It’s awful. He’s never been in the hospital before this and look at him, all hooked up to machines. I’m so worried. He seems to be getting worse instead of better.

 

Learner: What’s your understanding of what is going on?

Wife Role: I really don’t know. One doctor comes in and says one thing and then another comes in and tells me the opposite. I’m so confused I don’t know what to think.

Learner: Would having a better idea of his condition from the doctors who are treating him help you have a better understanding?

Wife Role: Oh, yes, but they always seem in such a hurry.

Learner: What exactly would you like to know?

Wife: Well, I want to know when he can get off that breathing machine because we have been planning to go to our son’s house for Thanksgiving.

Facilitator: Time out. Lisa, did you meet your conversation goal?

Learner: Um, I’m not sure, I guess so.

Facilitator: (Turns to Observers). What do you think, did she meet her goal?

Observer: Yes, she determined Mrs. Ames’ need for more information and she asked her what she wanted to know exactly.

Facilitator: What else did we see Lisa do to enhance communication with Mrs. Ames?

Observer: Well, when Mrs. Ames rushed into the room and asked her for information, Lisa didn’t just jump in and spout out values for the ventilator and his output. She took the time to introduce herself and de-escalate Mrs. Ames’ anxiety and she followed up on her promise to come get her in the waiting room as soon as she could.

Facilitator: Why do you think was important?

Observer: It helps establish trust.

Facilitator: Did Lisa use the skill she wanted to try out?

Observer: Yes.

Facilitator: How do you know? What did you hear her say?

Observer: She said, “What’s your understanding of what is going on with Mr. Ames?”

Facilitator: Absolutely. Great job, Lisa. And who wants to take a guess at how long Lisa’s exchange with Mrs. Ames took?

Observer: Less than two minutes?

Facilitator: That’s right. So just as you consider how long it takes, and how proficient you are, in starting an IV or inserting a Foley catheter, when you have a goal in mind and have practiced the skills to do it well, any skill can be mastered.

Feedback

Participants in the workshops uniformly report an enhanced sense of self-confidence in their palliative care communication skills as a result of their participation [29]. Key to the success of the workshop is the ongoing contact by the workshop facilitators with participants. Rounding is routinely planned such that each participant is visited weekly by a workshop facilitator in their clinical area to determine if the bedside nurse has practiced the new skills and if so, how the interaction transpired. Positive feedback is given for attempts to engage in new behaviors and participants are reminded that with any new skill, repetitive trials are necessary to foster success.

Lessons Learned and Next Steps

One of our major lessons learned was recognizing that it was difficult for many critical care nurses to practice the new communication skills. Nurses are trained to fix problems and perform medico-technical tasks; “listening” has not always been recognized as real work [18]. We needed to reinforce that skills like eliciting another’s perspective or making reflection statements are equally important to those associated with behavioral/technical proficiency.

While our program has been successful, we recognize that the next step in fostering ideal palliative care communication is to provide education within an interdisciplinary context. We recommend that colleagues interested in replicating this or a similar education intervention, survey nurse participants prior to and following workshop participation to measure attitudes, self confidence and perceived barriers over time [30]. We hope to translate our positive experience into a program that engages multiple professionals in the enhancement of optimum palliative care communication proficiency.

 

Corresponding author: Deborah A. Boyle MSN, RN, AOCNS, Department of Nursing Quality, Research and Education, University of California, Irvine Health, 101 The City Drive, Bldg 22A, Room 3104, Orange, CA 92868.

From the University of California Irvine Health/Chao Family Comprehensive Cancer Center Orange, CA (Ms. Boyle) and the University of California San Francisco Medical Center, San Francisco, CA (Dr. Anderson).

 

Abstract

• Objective: To describe components of a unique interactive workshop focusing on the enhancement of critical care nurses’ communication skills within the realm of prognosis and goals of care discussions with family members and physicians.
• Methods: A series of one-day workshops were offered to critical care nurses practicing in the 5 University of California hospital settings. After workshop attendance, nurse participants were followed by workshop facilitators in their units to ensure new communication skills were being integrated into practice and to problem solve if barriers were met.
• Results: Improvement in nurses’ self-confidence in engaging in these discussions was seen. This confidence was sustained months following workshop participation.
• Conclusion: The combination of critical care nurse workshop participation that involved skill enhancement through role-playing, in combination with clinical follow-up with attendees, resulted in positive affirmation of nurse communication skills specific to prognosis and goals of care discussions with family members and physicians.

 

There is increasing evidence that in the absence of quality communication between professional caregivers and those they care for, negative outcomes may prevail, such as reduced patient/family satisfaction, lower health status awareness, and a decreased sense of being cared about and cared for [1–5]. Communication skill competency is a critical corollary of nursing practice. In the intensive care unit (ICU) setting, patients and families have cited skilled communication as a core element of high-quality care [3,6]. Proficiency in this realm enhances nurses’ understanding of the patient and family’s encounter with health care and provides a vehicle to gather information, inform, teach, and offer emotional support. Additionally, it identifies values, goals, health care preferences, worries and concerns, and facilitates the nurses’ coordination of care [7]. Despite this skill’s importance, however, it is generally not taught in basic education and until recently has been overlooked as a key competency [8,9].

Skilled communication in palliative and end-of-life care is pivotal for discussing prognosis and care planning. In the acute care setting this is particularly relevant as the majority of Americans die in hospitals versus their preferred site of home [10]. Additionally, 1 in 5 Americans die during or shortly after receiving care in an ICU [11]. Hence, while the ICU is a setting in which intensive effort to save lives is employed, it is also a setting where death frequently occurs. The complexity and highly emotive nature of critical care often results in family needs for information and support not being met [12]. A number of reasons for this occurrence have been proposed. In this paper, we will delineate barriers to critical care nurses’ involvement in prognosis and goals of care discussions, identify why nurse involvement in this communication is needed, describe a unique workshop exemplar with a sample role play that characterizes the workshop, and offer recommendations for colleagues interested in replicating similar education offerings.

 

Barriers to Communication

In the ICU, the sheer number of professionals families interact with may cause confusion. In particular, numerous medical consultants commonly offer opposing opinions. Additionally, each specialist may provide information that focuses on their area of expertise such that the “big picture” is not relayed to the patient and family. Emotional discomfort on the part of the health professional around discussions of poor prognosis, goals of care, and code status may prompt limiting discussion time with patients and families and even the avoidance of interpersonal exchanges [13–15]. Health professionals have also reported concern that end-of-life discussions will increase patient distress [16]. Among health care professionals, the subject of mortality may prompt personal anxiety, trigger unresolved grief, or fear that they will “become emotional” in front of the patient/family [7]. Lack of knowledge about cultural and religious norms has been cited as a barrier, as has time constraints [17,18]. Most frequently, inadequate or absent communication skill training is noted as a significant barrier [19,20]. Many ICU nurses also report feeling marginalized due their exclusion from goals of care and decision-making discussions with patients and families they know well [21,22].

Nurses As Key Palliative Care Communicators

Education efforts that foster communication proficiency during serious illness have traditionally focused on training physicians. Recently, nursing has become a focus of communication skill enhancement in recognition of nurses’ intense and protracted interactions with patients and families in the acute care setting. Nurses are the ‘constant’ in the patient and family’s journey through the fragmented health care system [21,23]. They often have the best knowledge of, and strongest relationship with, the family and often have had extensive discussions with them about their loved one’s status [24]. Nurses are aware of the patients’ symptom experiences and are privy to valuable information about the concerns and priorities of patients and families [12]. Additionally, having the most continuous presence, nurses have seen and heard interactions with clinicians from numerous disciplines. Nurses are the most visible, constant resource for patient and family education, information and support, and thus they perceive one of their most important roles to be that of advocate for the patient and family [20,21].

Communication Training Programs for Critical Care Nurses

Education is critical to enhance communication skills within palliative care [7,15,17,20,21,24]. The preferred teaching style within this realm is role play, where skills can be practiced and the affective component of engaging in sensitive discussions can be addressed [25–27]. Role play also demonstrates firsthand the importance of nonverbal communication (eg, body language, proximity, use of gestures, tone of voice) [7,20] and facilitates nurses’ gaining a sense of comfort with wordless communication [18].

Communication skills training programs have been designed to provide bedside critical care nurses with the tools they need to be active participants in discussions of prognosis, goals of care, and palliative care with families and physicians [27,28]. These programs have demonstrated improvement in nurses’ confidence to engage in key palliative care-related discussions. Essential elements of these programs include (1) delineation of the role of the bedside nurse in palliative care communication; (2) presentation and learner-centered practice of communication skills using role play; and (3) a reflection session focused on self-care and sustainability.

Across the 5 academic University of California medical centers (San Francisco, Davis, Los Angeles, Irvine, and San Diego), a communication training program based on this work has been implemented [29]. The one-day workshop, entitled IMPACT-ICU (Integrating Multidisciplinary Palliative Care into the ICU), has taught a total of 527 critical care nurses across the 5 centers. In addition to classroom training, the IMPACT-ICU program also includes proactive specialty palliative nursing support for bedside nurses by facilitating the availability of palliative care advanced practice nurses and nurse educators resources. This support helps nurses to apply the skills learned in the workshop in their practice. During rounds at the bedside, the nurse resources coach the bedside staff on the “how” and “when” of addressing palliative care needs. Education and support on a range of topics are offered, including clarifying goals and interventions provided by palliative care teams, the specifics of how to provide family emotional support and delivery of understandable information, the assessment and management of symptoms distress, and the nurses’ role in organizing and participating in family meetings. Case-specific consultations are also offered that address how to interface with resistant medical staff. The importance of nurse documentation of these varied exchanges is also emphasized.

 

IMPACT-ICU Workshop

A maximum of 15 nurses participate in each 8-hour workshop. The session begins with introductions and small group discussions about what the participants perceive to be the greatest barriers to goals of care discussions and fostering patient/family decision-making in the ICU. Participants are also asked to reflect on what they want to learn as a result of their workshop attendance.

A short didactic session then reviews the definition of palliative care and its core components, addresses the nurses’ role in communication within palliative care, a social worker’s perspective of what it is like to be a family member in the ICU, and the outline of the day. This includes delineation of expectations for involvement within the role plays and the various roles to be enacted. An emphasis is placed on the workshop being a safe place to explore and trial skills with the support of colleagues, and that practice is the optimum way to integrate communication expertise into the nurses’ skill set.

The “4 Cs” serves as the instructional basis for nurse communication skill enhancement [27]. This model outlines 4 key nursing roles in optimizing communication within palliative care:

Convening: Making sure multidisciplinary patient/family/clinician communication occurs.

Checking: Identifying the patient and family needs for information; ensuring that patients and families clearly receive desired information; ensuring that clinicians understand patient and family perspectives.

Caring: Naming emotions and responding to feeling.

Continuing: Following up after discussions to clarify and reinforce information and provide support.

 

The roles of bedside ICU nurses in discussions with families and physicians are delineated within the context of 3 scenarios: nurse-family conversations, nurse-physician conversations, and family meetings (Figure) [28]. For each scenario, there are 3 role-play sessions in which participants practice core communication skills. These skills with example verbiage are shown in the Table. Prior to engaging in the role play, nurses are asked to identify a conversation goal and skill they want to practice. Course leaders present a model role play to illustrate the use of the communication skills prior to the role play.

Each scenario integrates numerous roles that require enactment. The facilitator is one of the course leaders who provides oversight to the process of the role play. They guide the vignette and have the option to “time out” and stop the role play if the learner is struggling or when the learner’s goal is achieved. Facilitators then solicit feedback from the observers, those participants not engaging in the role play but watching it unfold. Observers are asked to record what they heard and saw that demonstrated the learner’s achievement of their goal. The observers’ input is solicited at the end of the role play to question if and how the learner met their conversation goal. The learner is the nurse engaging in the role play in each of the 3 vignettes. The learner is encouraged to refer to the list of skills in the Table and use them during the actual interpersonal exchange. The room is set-up in a “U-shape” style such that learners’ chairs are placed at the front of the configuration and the facilitator stands to the side of where the conversation takes place.

Sample Role Play

Facilitator: So our first role play is focused on eliciting patient and family perspectives and needs. I need a learner and someone to play the role of the family member.

Learner: I’ll give it a try.

Facilitator: Lisa, you’re going to do great. Who wants to play the family member?

Workshop Participant: I’ll do it.

Facilitator: So Mary (who has agreed to play the role of the wife), why don’t you read us the scenario. (She reads it out loud to the group).

Facilitator: Lisa, as the nurse, I want you to look at your guide and tell me what your goal is for this conversation with Mrs. Ames and then which skill you want to practice.

Learner: I think I want to try eliciting the patient and family’s needs for information and I’ll try “Tell Me More” statements.

Facilitator: Alright. So remember Lisa, if you feel the conversation isn’t going well, you can call a “time out.” I can do this as well if I feel you need to start over. I’ll also call a time out when I feel you have met your goal. Sound OK? Mary, do you have any questions playing the part of Mrs. Ames?

Wife Role: Well, how hard should I make this for her? Should I be one of those “difficult” family members?

Facilitator: Our goal here is not to “stump” you or make it particularly difficult. We want you to try out these skills and get a sense of your “comfort zone.” So let’s start with some basic communication skills, OK?

Wife Role: Alright.

Facilitator: Why don’t we set the stage, such that Lisa, you are Mr. Ames’ nurse assessing him at the start of your shift, when Mrs. Ames enters. This is the first time you have taken care of him. The night nurse has told you that he has been requiring increasing ventilator support and his renal function is declining. Per Mrs. Ames’ request, the night nurse called her to let her know how he was doing and Mrs. Ames told her she would be in shortly.

Wife Role: (nervously enters the room and grasps her husband’s hand and looks at the nurse). How’s he doing? Is he better? The night nurse called me and I was so worried I rushed over here.

Learner: (Turns to Mrs. Ames and extends her hand). Are you Mrs. Ames? I’m Lisa and I am going to be taking care of Mr. Ames today. Let me just finish my assessment and how about we talk then? Will that be OK? It will be just a few minutes.

Wife Role: Alright, I’ll be in the waiting area but please come get me as soon as you can.

Learner: I will. (Nurse then shortly comes into the waiting area and asks Mrs. Ames to come back into the ICU where she invites her to sit just outside Mr. Ames’ room). Mrs. Ames, how are you doing? This must be so stressful for you, having your husband in the ICU.

Wife Role: It’s awful. He’s never been in the hospital before this and look at him, all hooked up to machines. I’m so worried. He seems to be getting worse instead of better.

 

Learner: What’s your understanding of what is going on?

Wife Role: I really don’t know. One doctor comes in and says one thing and then another comes in and tells me the opposite. I’m so confused I don’t know what to think.

Learner: Would having a better idea of his condition from the doctors who are treating him help you have a better understanding?

Wife Role: Oh, yes, but they always seem in such a hurry.

Learner: What exactly would you like to know?

Wife: Well, I want to know when he can get off that breathing machine because we have been planning to go to our son’s house for Thanksgiving.

Facilitator: Time out. Lisa, did you meet your conversation goal?

Learner: Um, I’m not sure, I guess so.

Facilitator: (Turns to Observers). What do you think, did she meet her goal?

Observer: Yes, she determined Mrs. Ames’ need for more information and she asked her what she wanted to know exactly.

Facilitator: What else did we see Lisa do to enhance communication with Mrs. Ames?

Observer: Well, when Mrs. Ames rushed into the room and asked her for information, Lisa didn’t just jump in and spout out values for the ventilator and his output. She took the time to introduce herself and de-escalate Mrs. Ames’ anxiety and she followed up on her promise to come get her in the waiting room as soon as she could.

Facilitator: Why do you think was important?

Observer: It helps establish trust.

Facilitator: Did Lisa use the skill she wanted to try out?

Observer: Yes.

Facilitator: How do you know? What did you hear her say?

Observer: She said, “What’s your understanding of what is going on with Mr. Ames?”

Facilitator: Absolutely. Great job, Lisa. And who wants to take a guess at how long Lisa’s exchange with Mrs. Ames took?

Observer: Less than two minutes?

Facilitator: That’s right. So just as you consider how long it takes, and how proficient you are, in starting an IV or inserting a Foley catheter, when you have a goal in mind and have practiced the skills to do it well, any skill can be mastered.

Feedback

Participants in the workshops uniformly report an enhanced sense of self-confidence in their palliative care communication skills as a result of their participation [29]. Key to the success of the workshop is the ongoing contact by the workshop facilitators with participants. Rounding is routinely planned such that each participant is visited weekly by a workshop facilitator in their clinical area to determine if the bedside nurse has practiced the new skills and if so, how the interaction transpired. Positive feedback is given for attempts to engage in new behaviors and participants are reminded that with any new skill, repetitive trials are necessary to foster success.

Lessons Learned and Next Steps

One of our major lessons learned was recognizing that it was difficult for many critical care nurses to practice the new communication skills. Nurses are trained to fix problems and perform medico-technical tasks; “listening” has not always been recognized as real work [18]. We needed to reinforce that skills like eliciting another’s perspective or making reflection statements are equally important to those associated with behavioral/technical proficiency.

While our program has been successful, we recognize that the next step in fostering ideal palliative care communication is to provide education within an interdisciplinary context. We recommend that colleagues interested in replicating this or a similar education intervention, survey nurse participants prior to and following workshop participation to measure attitudes, self confidence and perceived barriers over time [30]. We hope to translate our positive experience into a program that engages multiple professionals in the enhancement of optimum palliative care communication proficiency.

 

Corresponding author: Deborah A. Boyle MSN, RN, AOCNS, Department of Nursing Quality, Research and Education, University of California, Irvine Health, 101 The City Drive, Bldg 22A, Room 3104, Orange, CA 92868.

From the University of California Irvine Health/Chao Family Comprehensive Cancer Center Orange, CA (Ms. Boyle) and the University of California San Francisco Medical Center, San Francisco, CA (Dr. Anderson).

 

Abstract

• Objective: To describe components of a unique interactive workshop focusing on the enhancement of critical care nurses’ communication skills within the realm of prognosis and goals of care discussions with family members and physicians.
• Methods: A series of one-day workshops were offered to critical care nurses practicing in the 5 University of California hospital settings. After workshop attendance, nurse participants were followed by workshop facilitators in their units to ensure new communication skills were being integrated into practice and to problem solve if barriers were met.
• Results: Improvement in nurses’ self-confidence in engaging in these discussions was seen. This confidence was sustained months following workshop participation.
• Conclusion: The combination of critical care nurse workshop participation that involved skill enhancement through role-playing, in combination with clinical follow-up with attendees, resulted in positive affirmation of nurse communication skills specific to prognosis and goals of care discussions with family members and physicians.

 

There is increasing evidence that in the absence of quality communication between professional caregivers and those they care for, negative outcomes may prevail, such as reduced patient/family satisfaction, lower health status awareness, and a decreased sense of being cared about and cared for [1–5]. Communication skill competency is a critical corollary of nursing practice. In the intensive care unit (ICU) setting, patients and families have cited skilled communication as a core element of high-quality care [3,6]. Proficiency in this realm enhances nurses’ understanding of the patient and family’s encounter with health care and provides a vehicle to gather information, inform, teach, and offer emotional support. Additionally, it identifies values, goals, health care preferences, worries and concerns, and facilitates the nurses’ coordination of care [7]. Despite this skill’s importance, however, it is generally not taught in basic education and until recently has been overlooked as a key competency [8,9].

Skilled communication in palliative and end-of-life care is pivotal for discussing prognosis and care planning. In the acute care setting this is particularly relevant as the majority of Americans die in hospitals versus their preferred site of home [10]. Additionally, 1 in 5 Americans die during or shortly after receiving care in an ICU [11]. Hence, while the ICU is a setting in which intensive effort to save lives is employed, it is also a setting where death frequently occurs. The complexity and highly emotive nature of critical care often results in family needs for information and support not being met [12]. A number of reasons for this occurrence have been proposed. In this paper, we will delineate barriers to critical care nurses’ involvement in prognosis and goals of care discussions, identify why nurse involvement in this communication is needed, describe a unique workshop exemplar with a sample role play that characterizes the workshop, and offer recommendations for colleagues interested in replicating similar education offerings.

 

Barriers to Communication

In the ICU, the sheer number of professionals families interact with may cause confusion. In particular, numerous medical consultants commonly offer opposing opinions. Additionally, each specialist may provide information that focuses on their area of expertise such that the “big picture” is not relayed to the patient and family. Emotional discomfort on the part of the health professional around discussions of poor prognosis, goals of care, and code status may prompt limiting discussion time with patients and families and even the avoidance of interpersonal exchanges [13–15]. Health professionals have also reported concern that end-of-life discussions will increase patient distress [16]. Among health care professionals, the subject of mortality may prompt personal anxiety, trigger unresolved grief, or fear that they will “become emotional” in front of the patient/family [7]. Lack of knowledge about cultural and religious norms has been cited as a barrier, as has time constraints [17,18]. Most frequently, inadequate or absent communication skill training is noted as a significant barrier [19,20]. Many ICU nurses also report feeling marginalized due their exclusion from goals of care and decision-making discussions with patients and families they know well [21,22].

Nurses As Key Palliative Care Communicators

Education efforts that foster communication proficiency during serious illness have traditionally focused on training physicians. Recently, nursing has become a focus of communication skill enhancement in recognition of nurses’ intense and protracted interactions with patients and families in the acute care setting. Nurses are the ‘constant’ in the patient and family’s journey through the fragmented health care system [21,23]. They often have the best knowledge of, and strongest relationship with, the family and often have had extensive discussions with them about their loved one’s status [24]. Nurses are aware of the patients’ symptom experiences and are privy to valuable information about the concerns and priorities of patients and families [12]. Additionally, having the most continuous presence, nurses have seen and heard interactions with clinicians from numerous disciplines. Nurses are the most visible, constant resource for patient and family education, information and support, and thus they perceive one of their most important roles to be that of advocate for the patient and family [20,21].

Communication Training Programs for Critical Care Nurses

Education is critical to enhance communication skills within palliative care [7,15,17,20,21,24]. The preferred teaching style within this realm is role play, where skills can be practiced and the affective component of engaging in sensitive discussions can be addressed [25–27]. Role play also demonstrates firsthand the importance of nonverbal communication (eg, body language, proximity, use of gestures, tone of voice) [7,20] and facilitates nurses’ gaining a sense of comfort with wordless communication [18].

Communication skills training programs have been designed to provide bedside critical care nurses with the tools they need to be active participants in discussions of prognosis, goals of care, and palliative care with families and physicians [27,28]. These programs have demonstrated improvement in nurses’ confidence to engage in key palliative care-related discussions. Essential elements of these programs include (1) delineation of the role of the bedside nurse in palliative care communication; (2) presentation and learner-centered practice of communication skills using role play; and (3) a reflection session focused on self-care and sustainability.

Across the 5 academic University of California medical centers (San Francisco, Davis, Los Angeles, Irvine, and San Diego), a communication training program based on this work has been implemented [29]. The one-day workshop, entitled IMPACT-ICU (Integrating Multidisciplinary Palliative Care into the ICU), has taught a total of 527 critical care nurses across the 5 centers. In addition to classroom training, the IMPACT-ICU program also includes proactive specialty palliative nursing support for bedside nurses by facilitating the availability of palliative care advanced practice nurses and nurse educators resources. This support helps nurses to apply the skills learned in the workshop in their practice. During rounds at the bedside, the nurse resources coach the bedside staff on the “how” and “when” of addressing palliative care needs. Education and support on a range of topics are offered, including clarifying goals and interventions provided by palliative care teams, the specifics of how to provide family emotional support and delivery of understandable information, the assessment and management of symptoms distress, and the nurses’ role in organizing and participating in family meetings. Case-specific consultations are also offered that address how to interface with resistant medical staff. The importance of nurse documentation of these varied exchanges is also emphasized.

 

IMPACT-ICU Workshop

A maximum of 15 nurses participate in each 8-hour workshop. The session begins with introductions and small group discussions about what the participants perceive to be the greatest barriers to goals of care discussions and fostering patient/family decision-making in the ICU. Participants are also asked to reflect on what they want to learn as a result of their workshop attendance.

A short didactic session then reviews the definition of palliative care and its core components, addresses the nurses’ role in communication within palliative care, a social worker’s perspective of what it is like to be a family member in the ICU, and the outline of the day. This includes delineation of expectations for involvement within the role plays and the various roles to be enacted. An emphasis is placed on the workshop being a safe place to explore and trial skills with the support of colleagues, and that practice is the optimum way to integrate communication expertise into the nurses’ skill set.

The “4 Cs” serves as the instructional basis for nurse communication skill enhancement [27]. This model outlines 4 key nursing roles in optimizing communication within palliative care:

Convening: Making sure multidisciplinary patient/family/clinician communication occurs.

Checking: Identifying the patient and family needs for information; ensuring that patients and families clearly receive desired information; ensuring that clinicians understand patient and family perspectives.

Caring: Naming emotions and responding to feeling.

Continuing: Following up after discussions to clarify and reinforce information and provide support.

 

The roles of bedside ICU nurses in discussions with families and physicians are delineated within the context of 3 scenarios: nurse-family conversations, nurse-physician conversations, and family meetings (Figure) [28]. For each scenario, there are 3 role-play sessions in which participants practice core communication skills. These skills with example verbiage are shown in the Table. Prior to engaging in the role play, nurses are asked to identify a conversation goal and skill they want to practice. Course leaders present a model role play to illustrate the use of the communication skills prior to the role play.

Each scenario integrates numerous roles that require enactment. The facilitator is one of the course leaders who provides oversight to the process of the role play. They guide the vignette and have the option to “time out” and stop the role play if the learner is struggling or when the learner’s goal is achieved. Facilitators then solicit feedback from the observers, those participants not engaging in the role play but watching it unfold. Observers are asked to record what they heard and saw that demonstrated the learner’s achievement of their goal. The observers’ input is solicited at the end of the role play to question if and how the learner met their conversation goal. The learner is the nurse engaging in the role play in each of the 3 vignettes. The learner is encouraged to refer to the list of skills in the Table and use them during the actual interpersonal exchange. The room is set-up in a “U-shape” style such that learners’ chairs are placed at the front of the configuration and the facilitator stands to the side of where the conversation takes place.

Sample Role Play

Facilitator: So our first role play is focused on eliciting patient and family perspectives and needs. I need a learner and someone to play the role of the family member.

Learner: I’ll give it a try.

Facilitator: Lisa, you’re going to do great. Who wants to play the family member?

Workshop Participant: I’ll do it.

Facilitator: So Mary (who has agreed to play the role of the wife), why don’t you read us the scenario. (She reads it out loud to the group).

Facilitator: Lisa, as the nurse, I want you to look at your guide and tell me what your goal is for this conversation with Mrs. Ames and then which skill you want to practice.

Learner: I think I want to try eliciting the patient and family’s needs for information and I’ll try “Tell Me More” statements.

Facilitator: Alright. So remember Lisa, if you feel the conversation isn’t going well, you can call a “time out.” I can do this as well if I feel you need to start over. I’ll also call a time out when I feel you have met your goal. Sound OK? Mary, do you have any questions playing the part of Mrs. Ames?

Wife Role: Well, how hard should I make this for her? Should I be one of those “difficult” family members?

Facilitator: Our goal here is not to “stump” you or make it particularly difficult. We want you to try out these skills and get a sense of your “comfort zone.” So let’s start with some basic communication skills, OK?

Wife Role: Alright.

Facilitator: Why don’t we set the stage, such that Lisa, you are Mr. Ames’ nurse assessing him at the start of your shift, when Mrs. Ames enters. This is the first time you have taken care of him. The night nurse has told you that he has been requiring increasing ventilator support and his renal function is declining. Per Mrs. Ames’ request, the night nurse called her to let her know how he was doing and Mrs. Ames told her she would be in shortly.

Wife Role: (nervously enters the room and grasps her husband’s hand and looks at the nurse). How’s he doing? Is he better? The night nurse called me and I was so worried I rushed over here.

Learner: (Turns to Mrs. Ames and extends her hand). Are you Mrs. Ames? I’m Lisa and I am going to be taking care of Mr. Ames today. Let me just finish my assessment and how about we talk then? Will that be OK? It will be just a few minutes.

Wife Role: Alright, I’ll be in the waiting area but please come get me as soon as you can.

Learner: I will. (Nurse then shortly comes into the waiting area and asks Mrs. Ames to come back into the ICU where she invites her to sit just outside Mr. Ames’ room). Mrs. Ames, how are you doing? This must be so stressful for you, having your husband in the ICU.

Wife Role: It’s awful. He’s never been in the hospital before this and look at him, all hooked up to machines. I’m so worried. He seems to be getting worse instead of better.

 

Learner: What’s your understanding of what is going on?

Wife Role: I really don’t know. One doctor comes in and says one thing and then another comes in and tells me the opposite. I’m so confused I don’t know what to think.

Learner: Would having a better idea of his condition from the doctors who are treating him help you have a better understanding?

Wife Role: Oh, yes, but they always seem in such a hurry.

Learner: What exactly would you like to know?

Wife: Well, I want to know when he can get off that breathing machine because we have been planning to go to our son’s house for Thanksgiving.

Facilitator: Time out. Lisa, did you meet your conversation goal?

Learner: Um, I’m not sure, I guess so.

Facilitator: (Turns to Observers). What do you think, did she meet her goal?

Observer: Yes, she determined Mrs. Ames’ need for more information and she asked her what she wanted to know exactly.

Facilitator: What else did we see Lisa do to enhance communication with Mrs. Ames?

Observer: Well, when Mrs. Ames rushed into the room and asked her for information, Lisa didn’t just jump in and spout out values for the ventilator and his output. She took the time to introduce herself and de-escalate Mrs. Ames’ anxiety and she followed up on her promise to come get her in the waiting room as soon as she could.

Facilitator: Why do you think was important?

Observer: It helps establish trust.

Facilitator: Did Lisa use the skill she wanted to try out?

Observer: Yes.

Facilitator: How do you know? What did you hear her say?

Observer: She said, “What’s your understanding of what is going on with Mr. Ames?”

Facilitator: Absolutely. Great job, Lisa. And who wants to take a guess at how long Lisa’s exchange with Mrs. Ames took?

Observer: Less than two minutes?

Facilitator: That’s right. So just as you consider how long it takes, and how proficient you are, in starting an IV or inserting a Foley catheter, when you have a goal in mind and have practiced the skills to do it well, any skill can be mastered.

Feedback

Participants in the workshops uniformly report an enhanced sense of self-confidence in their palliative care communication skills as a result of their participation [29]. Key to the success of the workshop is the ongoing contact by the workshop facilitators with participants. Rounding is routinely planned such that each participant is visited weekly by a workshop facilitator in their clinical area to determine if the bedside nurse has practiced the new skills and if so, how the interaction transpired. Positive feedback is given for attempts to engage in new behaviors and participants are reminded that with any new skill, repetitive trials are necessary to foster success.

Lessons Learned and Next Steps

One of our major lessons learned was recognizing that it was difficult for many critical care nurses to practice the new communication skills. Nurses are trained to fix problems and perform medico-technical tasks; “listening” has not always been recognized as real work [18]. We needed to reinforce that skills like eliciting another’s perspective or making reflection statements are equally important to those associated with behavioral/technical proficiency.

While our program has been successful, we recognize that the next step in fostering ideal palliative care communication is to provide education within an interdisciplinary context. We recommend that colleagues interested in replicating this or a similar education intervention, survey nurse participants prior to and following workshop participation to measure attitudes, self confidence and perceived barriers over time [30]. We hope to translate our positive experience into a program that engages multiple professionals in the enhancement of optimum palliative care communication proficiency.

 

Corresponding author: Deborah A. Boyle MSN, RN, AOCNS, Department of Nursing Quality, Research and Education, University of California, Irvine Health, 101 The City Drive, Bldg 22A, Room 3104, Orange, CA 92868.