Integrating palliative care into intensive care requires active involvement of bedside nurses in discussions of patients’ prognosis and goals of care.
To improve critical care nurses’ skills and confidence to engage in discussions with patients’ families and physicians about prognosis and goals of care by using a focused educational intervention.
An 8-hour-long workshop was developed for critical care nurses. Key roles and skills of nurses in communication about prognosis and goals of care were defined. Participants practiced skills during facilitated role-plays. A reflection session addressed burnout, distress, and self-care. Participants completed surveys before, immediately after, and 3 months after their workshop, rating their confidence and skill in performing key tasks. Use of a participant focus group and open-response items in the surveys further elucidated the impact of the workshop.
Between March 2011 and April 2013, a total of 82 critical care nurses completed a workshop. Compared with before the workshop, after the workshop, nurses reported greater skill and confidence for 14 survey items (P < .001), including assessing families’ understanding of prognosis and goals of care, addressing families’ emotional needs, and contributing to family meetings. Increases were sustained 3 months after the workshop.
Defining roles and providing opportunities for skills practice and reflection can enhance nurses’ confidence to engage in discussions about prognosis and goals of care.
One-fifth of patients in the United States die during or shortly after receiving care in an intensive care unit (ICU),1 and many patients who survive prolonged ICU stays have poor functional outcomes and quality of life.2 Yet, a patient’s family members are not well informed about the patient’s prognosis, and goals of care are often not discussed.2,3 These findings have raised concerns that many patients receive invasive treatments that are not in accord with the patients’ wishes. Furthermore, patients’ families experience psychological distress during and after patients’ ICU stay.4,5
Palliative care interventions in the ICU provide emotional support to patients’ families and communication about prognosis and goals of care; this improved communication is associated with shorter ICU length of stay and lower costs.6,7 A key step in translating proven interventions into practice is multidisciplinary collaboration that includes the active involvement of nurses.8,9 Nurses’ training and roles uniquely position them to ensure that communication about prognosis and goals of care occurs, to interpret and clarify information presented by physicians, to support patients’ families emotionally, and to provide continuing support at the bedside after family meetings.10,11 However, nurses often are not involved in discussions of prognosis and goals of care.12 For seriously ill patients, the omission of nurses’ involvement deprives physicians, patients, and patients’ families of nurses’ input and results in uncoordinated care, job strain, and moral distress.13
Despite the wide success to date of educational programs for nurses on palliative care,14,15 a need still exists for training in communication skills for critical care nurses so that they can actively engage in discussions of prognosis and goals of care with patients’ families and physicians.16,17 To address this gap at the University of California San Francisco Medical Center, we built on previous work10,18,19 to design a training workshop on communication skills for critical care nurses.
Design and Setting
An educational workshop was developed for critical care nurses at the University of California San Francisco Medical Center. All critical care nurses who provided care for adult patients in the medical-surgical, cardiac, and neurological ICUs, as well as nurses on the rapid response teams and in the emergency department, were eligible to participate. The workshop was free to nurses, and participants received continuing education credit. The hospital’s institutional review board determined that as quality improvement the project did not require review.
Workshop on Communication Skills
The communication workshop was developed at the request of the critical care bedside nurses, who expressed interest in taking an active role in communicating with patients’ families and physicians about prognosis and goals of care. An interdisciplinary working group within the hospital’s ICU-Palliative Care Committee, a special interest group focused on improving palliative care in the ICU, was created to design and implement the workshop. The working group was composed of ICU bedside nurses (K.T., N.P., R.R., C.S., H.W.), a critical care nurse researcher and educator (K.P.), a palliative care physician (W.G.A.), a critical care and palliative care physician (M.M.), and a palliative care chaplain and psychologist (D.J.). During the needs assessment, nurses identified numerous challenges in communicating about prognosis and goals of care, including bridging gaps between patients’ families and clinicians across multiple specialties and disciplines, lack of adequate skills to support and comfort patients’ family members, and poorly defined roles of bedside nurses in this communication.
One-fifth of Americans die during or shortly after receiving care in an intensive care unit.
On the basis of the needs assessment and previous scholarly work,8,10–12 a model was developed for beside nurses to facilitate communication about prognosis and goals of care among patients’ families and other clinicians (Figure 1). The objectives of the workshop are to assess understanding of prognosis and goals of care by patients’ families; communicate the needs of patients’ families to physicians; advocate for family members’ informational and emotional needs in a family meeting; and develop skills for coping with stress, moral distress, and compassion fatigue. These objectives are met by using evidence-based methods to help learners acquire new skills: a small-group format, a learner-centered approach, and facilitated role-play.18–20 The resulting curriculum is an 8-hour workshop with 15 nurse learners.
A communication workshop was conducted at the request of critical care bedside nurses.
At the beginning of the workshop, each learner states the challenges that he or she faces in communicating with patients’ families and other clinicians about prognosis and goals of care and the learner’s main goal to accomplish in the workshop. Next, a brief didactic session and discussion are presented by nurse leaders on the roles and responsibilities of bedside nurses to patients and patients’ families and within the health care team. On the basis of previous research,10 the role of a bedside nurse is outlined as The Four Cs: convening and identifying the needs of each patient’s family members for communication and bringing the team together to discuss concerns at a family meeting, checking and assessing the informational needs of the patient’s family and clarifying information exchanged between the team and the family, caring and assessing the emotional needs of the family and responding with empathy, and continuing and following up with the family after the meeting to address questions and provide support.
The next part of the workshop includes 3 role-play discussions, modeling a bedside nurse’s discussions with a patient’s family member, a physician, and in a family meeting (Figure 1). Table 1 presents the skills that participants practice during role-play sessions, also modeled after previous research.21 A case of a patient with worsening respiratory failure is used for all of the role-play sessions, in which participants play the bedside nurse, a patient’s family member, and a physician. Before beginning the role-play, learners are provided an overview of its rationale and the ground rules to keep the role-play sessions nonthreatening and productive. A safe, positive environment is created for the learners, and time-outs are allowed if a learner is uncomfortable and would like to ask the faculty or colleagues for suggestions. In addition, faculty members give a learner time-out after he or she has mastered a skill or if he or she is struggling. Observers are encouraged to write down specific phrases, descriptions of nonverbal body language, and the effect of the skills used in the discussion. Each learner works toward his or her personal “learning edge” and is encouraged to practice a new skill or work on an area the learner finds challenging. The discussion after a time-out focuses on the positive: “What went well?” Each learner troubleshoots with the facilitator and observers on what the learner would like to do differently and reenters the role-play.
Each of the 3 role-play sessions is 60 to 70 minutes long and begins with a review of the goals of the discussion and the specific skills that will be practiced. Before the learners engage in role-play for each session, faculty members present a 2-minute model role-play to illustrate the use of these skills in each conversation. In the first role-play, the bedside nurse meets with the wife of a critically ill patient and practices using open-ended questions and providing emotional support. The second role-play focuses on communication with physicians to address the needs of patients’ family members. The learner is encouraged to elicit the physician’s understanding of prognosis and goals of care, share the information gleaned from the earlier discussion with the patient’s family, and collaborate with the physician to make a plan for further discussions or a family meeting. The purpose of the third role-play session is for the learner to advocate for a family’s informational and emotional needs within a family meeting.
The final session of the day is a reflection session led by the palliative care chaplain. This interactive session addresses coping with the daily stressors that affect ICU bedside nurses. Faculty members facilitate a discussion about compassion fatigue, burnout, and personal practices of self-care to combat these effects. Then a narrative reflection practice is used in which each learner reflects on an experience involving communication with a patient or a patient’s family in which the learner was moved, surprised, or distressed. After approximately 10 minutes of writing about this encounter, volunteers are sought to share their reflection with the group. Note cards are handed out so each learner can write an encouraging message to himself or herself and identify a plan to use a new skill. This card is mailed 1 month later as a reminder of this session and the learner’s commitment to incorporating new techniques into practice.
The workshop closes with a discussion of lessons learned, and participants share their take-home points from the session. An open question-and-answer session is used to address any issues that were inadequately addressed during the day.
The workshop was evaluated by using surveys of the participants and discussions with a focus group. Participants completed 14- to 22-item surveys, modeled after previous research,10 before, immediately after, and 3 months after the workshop. Each survey assessed participants’ confidence (rated on a 4-point Likert-type scale, from not very confident to very confident) and skill (rated on a 5-point Likert-type scale, from poor to excellent) to engage in specific tasks in communication with patients’ families and physicians about prognosis and goals of care (Figures 2 and 3). Additional items in the evaluations completed immediately after the workshop and 3 months later included rating the overall impact of the workshop, the awareness of the nurses’ role in communication, and the frequency with which the nurses use the skills in the tool kit. The focus group was led by 1 of the workshop faculty (K.P.) and included 11 nurses who had completed the workshop. The purpose of the discussion was to elicit participants’ perspectives on the impact of the workshop on their practice. The discussion was collected via a sound recording and was transcribed for analysis.
Differences between participating nurses’ skills and confidence before, immediately after, and 3 months after the workshop were compared by using ordered logistic regression in Stata 12.1 (StataCorp LP) software. This approach allowed use of a single model to assess trends for the 3 time points for each participant. Results are reported as dichotomized ratings of skill and confidence as the percentage of participants reporting a certain level of skill or confidence before, immediately after, and 3 months after the workshop. Confidence was dichotomized as not very confident or somewhat confident vs confident or very confident; skill, as poor, fair, or good vs very good or excellent.
Participants’ written comments on the evaluations obtained immediately after the workshop and 3 months later and the focus group transcript were analyzed qualitatively by using a thematic approach.22,23 A total of 4 investigators independently assessed these data sources and then collaboratively developed a list of 5 themes to categorize the impact of the workshop on participants (Table 2).
A total of 6 workshops with 12 to 15 participants each were conducted between March 2011 and April 2013. During this period, 82 critical care nurses completed the workshop, all 82 completed the survey done before the workshop, 80 (98%) completed the survey done immediately after the workshop, and 43 (52%) completed the 3-month follow-up survey. Demand for this workshop was high; each session filled up within days of its announcement, and a waiting list of nurses requesting participation in the next workshop was established. For all 9 skill survey items, the percentage of nurses who reported very good or excellent levels of skill after the workshop was higher than the percentage who did before the workshop (P < .001 for all items; Figure 2). Participants who completed the 3-month follow-up survey also rated their skill in all items higher than they did before the workshop (P < .001). Similar increases were noted in participants’ reports of their confidence to engage in 5 tasks related to communication about prognosis and goals of care; confidence was higher for all items immediately after the workshop and 3 months later than it was before the workshop (P < .001; Figure 3).
In the survey immediately after the workshop, 78 participants rated the degree to which the workshop increased their awareness of their role and responsibilities in ICU communication with patients’ families about prognosis and goals of care; all 78 reported that the workshop had either increased or greatly increased their awareness. In the 3-month follow-up survey, 22 of the 41 responding participants (54%) reported that they used the skills presented in the workshop on either every shift or most shifts. Also, in the 3-month follow-up survey, 33 of 36 responding participants (92%) agreed or strongly agreed that the skills presented in the workshop enhanced their ability to ensure that patients’ families and providers communicated about prognosis and goals of care.
Table 2 is a summary of the themes from qualitative analysis of open-response items in the surveys done immediately after the workshop and 3 months later and from the focus group. The themes included clarification and reinforcement of nurses’ role in discussions, empowerment, increased empathy and feeling more connected to patients’ families and to colleagues, and fostering a culture in which nurses are centrally involved in communication about prognosis and goals of care.
We designed, implemented, and evaluated an educational intervention to enhance bedside nurses’ communication skills in addressing goals of care of patients and patients’ family members, communicating with physicians about the needs of patients’ family members, and participating in a family meeting. The participants reported an increase in awareness of their roles and responsibilities and increases in skill and confidence to engage in discussions of prognosis and goals of care with patients’ families and physicians that were sustained 3 months after the workshop. Qualitative analysis indicated that the workshop helped empower nurses and created a culture of support in the ICU.
For all skill items, nurses reported greater skills after the workshop.
This workshop encourages bedside nurses to be stronger patient advocates and to avoid the potential harm of providing care that is inconsistent with the goals and values of a patient and the patient’s family. We highlighted the unique contributions of the bedside nurse because he or she spends the most time with patients and patients’ families, liaises with multiple consulting services, and often has the most insight into the concerns of a patient’s family. By means of the tool kit, evidence-based methods are used to practice skills and focus on clear clinical applications of skills in nurses’ daily practice. This curriculum builds community around shared educational experiences and personal reflections. Setting up a safe environment for role-play, providing positive feedback, and observing colleagues successfully use the skills bolsters the group dynamic and confidence of the participants. As others24 have found, use of an interdisciplinary faculty enhanced the educational experience and reinforced the team-based nature of palliative and critical care. This workshop continues to strengthen our ICU culture as the network of participants grows and new nurse champions expand this program into their units.
Our work highlights the importance of training interventions to enhance communication skills in palliative care for bedside nurses; previous investigators18,25,26 focused largely on physicians. Nurses play a central role in optimizing interdisciplinary communication in the ICU,8,11 yet many nurses have not received sufficient communication training to act in this role.17 Similar to the results of Krimshtein et al,10 our evaluation indicated that a key piece of our program’s ability to empower nurses is to clarify nurses’ scope of practice by using discussions of prognosis and goals of care. The role nurses take in these discussions may be different and complementary to the roles of members of other disciplines. Previous research11,12 indicated that although patients’ families look to physicians for information about prognosis, they seek interpretation and reinforcement of information as well as emotional support from nurses; the purpose of our curriculum was to empower nurses to serve these roles in individual discussions with patients’ families and physicians and in family meetings.
Our work also highlights the importance of self-care and reflection as components of training for ICU nurses. A full-day workshop separated from clinical duties, the open discussions of personal challenges and goals, the shared experiences of participants in a safe and nonthreatening learning environment set the stage for camaraderie and support. Gordon et al24 had similar success with an interactive, day-long session focused on communication and sources of moral distress. The reflection session embedded in our workshop is a powerful way to express the many emotions that accompany work as a critical care nurse, such as joy, sadness, and grief. The workshop has resulted in a culture change in our ICUs; nurses are more involved in conversations with patients’ families and physicians and in family meetings. Furthermore, the findings of the focus group indicate that nurses and coworkers support each other in their daily practice.
Our study has some limitations. First, our outcomes evaluation was limited to surveys of the participants and did not include observations of the participants’ communication or assessment of the impact of the program on the patients, patients’ families, and physicians with whom our participants worked. Second, our interventions consisted of an intensive yet single classroom session, a format that may limit the capability of the workshop to change participants’ practice. Third, although results of the 3-month follow-up evaluation indicated that increases in skill and confidence were sustained after the workshop, the response rate to this survey was low, a characteristic that limits interpretation of our data. Finally, we conducted our study at a single academic medical center. We are currently disseminating this program to other hospitals.
Our experience suggests several directions for future work. Future interventions may be more effective if they include longitudinal components. In order to support translation of these types of programs into practice, evaluation of future implementations should include the effect on the satisfaction of patients’ families and on resource utilization. On the basis of the local success and support of this program, we have expanded it to 4 additional hospital centers in our system throughout California. We have implemented a train-the-trainer program that is being conducted at each university medical center; our goal is to train 600 nurses during a 2-year period. This second phase of the program includes having an advanced practice nurse or a nurse educator do rounds in the ICUs where participants work to support incorporation of the skills learned in the workshop into the participants’ clinical practice. This second phase also includes more detailed assessment of the impact of the program, including its effect on patients’ outcomes and resource utilization. We learned from participants’ feedback that nurses would like to have additional training with physicians, so we are developing a curriculum in which nurse and physician graduates of communication training workshops will practice collaborative interprofessional communication skills within a simulated family meeting.
The workshop helped empower nurses and created a culture of support in the intensive care unit.
Communication is an essential part of quality care within all areas of health care and especially in the ICU. Bedside nurses provide not only physical care to their patients but also informational and emotional support to patients, patients’ family members, and colleagues. To be part of an interdisciplinary team and to have a strong voice that is respected, nurses require communication skills that will enable them to succeed in this more active role in discussions of prognosis and goals of care. This evidence-based educational workshop and reflection session provide those tools.
This research was performed and the University of California San Francisco. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or the University of California. We thank the critical care bedside nurses at the University of California San Francisco Medical Center and the critical care and medical center leaders for their support of this program. We are indebted to Eric Vittinghoff, phd, mph, Department of Epidemiology and Biostatistics, for assistance with statistical modeling.
Support for this research was provided by grant KL2 TR000143 from the National Center for Advancing Translational Sciences, National Institutes of Health, and by the University of California Center for Health Quality and Innovation (Dr Anderson).
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For more about patient and family communication, visit the Critical Care Nurse website, www.ccnonline.org, and read the article by McCullough and Schell-Chaple, “Maintaining Patients’ Privacy and Confidentiality With Family Communications in the Intensive Care Unit” (October 2013).
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