Challenges for nurses when communicating with people who have life-limiting illness and their families: A focus group study

A conceptual model of the nurse's role as primary palliative care provider in goals of care communication

Objective

Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses.

Methods

An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria.

Results

Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training.

Conclusion

This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care.

Innovation

The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.

An online intervention to improve oncology health professional self-efficacy in communicating with carers: Hybrid effectiveness-implementation evaluation of the eTRIO program

OBJECTIVES

Many oncology health professionals (HPs) report communicating with carers as complex; and receive limited carer-relevant training. We developed an online HP education program for supporting and managing carer involvement (eTRIO). We aimed to assess whether HPs' self-efficacy in carer communication, knowledge, and decision-making preferences improve following eTRIO. Satisfaction and implementation potential were assessed.

METHODS

This type 1 hybrid effectiveness-implementation study used a pre-post single arm intervention design. HPs completed baseline measures, the eTRIO online module, and measures at 1- and 12-weeks post-intervention. Measures included: self-efficacy in carer communication (13-items), applied knowledge (7-items), preference for carer involvement in decisions (1-item). Fifteen of participants completed feedback interviews which underwent thematic analysis. User analytics were collected and analysed.

RESULTS

Fifty-six HPs completed baseline measures, 42 completed post- and follow-up measures. At baseline mean self-efficacy score was 88. HPs showed a statistically significant increase in self-efficacy post-intervention (mean = 105.8, CI [12.99, 20.47]), maintained at 12-weeks (mean = 101.1, CI [8.00, 15.72]). There were no changes in knowledge or decision-making preferences. Program engagement and satisfaction were high, 86.7% participants rated eTRIO as very/extremely helpful.

CONCLUSIONS AND PRACTICE IMPLICATIONS

eTRIO provided HPs with confidence to effectively engage with carers and manage complex situations such as family dominance. These gains are noteworthy, as conflict with families/carers contributes to HP burnout.

Communication strategies for expressing empathy during family-clinician conversations in the intensive care unit: A mixed methods study

OBJECTIVES

To explore communication strategies intensive care clinicians and patients' family members prefer for expressing empathy during family-clinician conversations.

RESEARCH METHODOLOGY/DESIGN

Mixed-methods survey study.

SETTING

Two medical ICUs of a German academic tertiary care hospital.

MAIN OUTCOME MEASURES

Using a self-developed online survey with closed and open-ended questions with free-text options, the participants' preferences of communication strategies for expressing empathy were investigated. Quantifiable similarities and differences were determined by statistical analysis. Qualitative themes were derived at by directed content analysis.

FINDINGS

The responses of 94 family members, 42 nurses, and 28 physicians were analysed (response rate: 45.3 %). Four communication strategies were deduced: (1) reassuring the families that the intensive care unit team will not abandon neither them nor the patient, (2) acknowledging emotions and offering support, (3) saying that the families are welcome and cared for in the intensive care unit, (4) providing understandable information. In comparison, the families considered an expression of nonabandonment as more empathic than the physicians did (p =.031,r = 0.240), and those expressions focussing solely on the family members' well-being (p =.012,r = 0.228) or comprising evaluative wording ("good", "normal") (p =.017,r = 0.242) as less empathic than the nurses did. Unanimously advocated nonverbal communication strategies included to listen attentively and to avoid interrupting as well as being approachable and honest.

CONCLUSION

The participants' preferences supported expert recommendations and highlighted that it is not only important what the clinicians say but also how they say it. Further research is needed to elucidate ways of successfully expressing empathy during family-clinician conversations in the intensive care unit.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care unit clinicians are encouraged to practice active listening and to express their caring and nonabandonment. It is further suggested to reflect on and adjust pertinent nonverbal behaviours and relational aspects of their communication, as applicable.

Fundamentals of end-of-life communication as part of advance care planning from the perspective of nursing staff, older people, and family caregivers: a scoping review

BACKGROUND

Nursing staff is ideally positioned to play a central role in end-of-life communication as part of advance care planning for older people. However, this requires specific skills and competences. Only fragmented knowledge is available concerning important fundamentals in end-of-life communication performed by nursing staff.

OBJECTIVE

This review aimed to explore the fundamentals of end-of-life communication as part of advance care planning in the hospital, nursing home and home care setting, from the perspective of the nursing staff, the older person, and the family caregiver.

DESIGN

Scoping review.

METHODS

A literature search in PubMed, PsycINFO, CINAHL and Google (Scholar) was conducted on August 20, 2022. The search strategy followed the sequential steps as described in the Joanna Briggs Institute Manual. Peer-reviewed articles of empirical research and gray literature written in English or Dutch and published from 2010 containing fundamentals of end-of-life communication as part of advance care planning from the perspective of nursing staff, older people, and family caregivers in the hospital nursing home or home care setting were considered eligible for review.

RESULTS

Nine studies were included, and four themes were composed, reflecting 11 categories. Nursing staff attunes end-of-life communication to the values and needs of older people to approach the process in a person-centered manner. This approach requires additional fundamentals: building a relationship, assessing readiness, timing and methods to start the conversation, communication based on information needs, attention to family relationships, a professional attitude, improving communication skills, listening and non-verbal observation skills, and verbal communication skills.

CONCLUSIONS

This review is the first to compile an overview of the fundamentals of end-of-life communication performed by nursing staff. Building a nursing staff-older-person relationship is the most important foundation for engaging in a person-centered end-of-life communication process. Knowing each other enables nursing staff to have a sense of older people's readiness, determine the right timing to initiate an end-of-life conversation, identify specific needs, and accurately apply (non-)verbal observation skills. end-of-life communication is not a one-time conversation, but a complex process that takes time, effort, and genuine interest in each other.

Facilitators and Barriers to a Hospital-Based Communication Skills Training Programme: An Interview Study

This study aimed to investigate the facilitators and barriers experienced by the department management (DMs) and communication skills trainers (trainers) during the implementation of a 3-day communication skills training (CST) programme for healthcare professionals (HCPs). Thus, we conducted semi-structured interviews with 23 DMs and 10 trainers from 11 departments concurrently implementing the CST programme. Thematic analysis was undertaken to elucidate the themes across the interviews. Five themes were developed: resource consumption; obstacles; management support; efforts and outcomes; and a lack of systematic follow-up. Although the DMs and trainers were largely in agreement, the theme of a lack of systematic follow-up was derived exclusively from the trainers, as were two of the subthemes within obstacles: (b) seniority, profession, and cultural differences, and (c) the trainers' competencies. The greatest perceived barrier was resource consumption. In addition, DMs found planning and staff resistance to be a challenge. However, the HCPs' resistance diminished or even changed to satisfaction after participating. The mandatory approach served as both a facilitator and a barrier; DMs' support was an essential facilitator. Explicit communication related to resource demands, planning, and participation is crucial, as is management support and the allocation of resources.

Healthcare practitioners' experiences of breaking bad news: A critical interpretative meta synthesis

OBJECTIVE

To provide an overview of healthcare practitioners' experiences of breaking bad news.

METHOD

Interpretative meta synthesis of 14 qualitative papers identified through a systematic search. Data were extracted and constructs elicited via reciprocal translational analysis.

RESULTS

Findings comprised four inter-connected themes: (1) Discomfort, particularly difficult emotional and physical responses to breaking bad news; (2) Relational distress, connected to attachment and identification with patients; (3) Inadequate clinician, indicating the fear and rumination about the possibility of getting it wrong and the subsequent self-blame; and (4) Only human, highlighting a culture of invulnerability where practitioner self-care is deprioritised.

CONCLUSIONS

Breaking bad news provokes significant distress for practitioners, particularly where they experience strong attachment to or identification with a patient. Breaking bad news was understood as an isolating experience and staff's non-disclosure of difficulties appeared to sustain a culture of invulnerability in which admission of distress was not encouraged.

PRACTICE IMPLICATIONS

Given the adverse impacts and potential for practitioner burnout, organisations should acknowledge ramifications and offer time for staff to process the delivery of bad news, promote a culture of collective care and provide space for reflective practice.

Responding to nurses' communication challenges: Evaluating a blended learning program for communication knowledge and skills for nurses

OBJECTIVES

To evaluate the effectiveness of the Blended Communication Skills Training Program for Nurses (CSTN). The program aims to improve nurses' knowledge about communication skills and structure for interactions with individuals who a have life limiting illness.

METHODS

This was a quasi-experimental study using a pre- and post-test quiz and self-efficacy questionnaire undertaken in Victoria, Australia. Nurses employed across three wards participated. The Blended CSTN comprised two major components: Asynchronous Web-Based Education Program and Experiential Workshop. The program focused on specific communication challenges: Gathering Information, Dealing with Difficult Questions, and Articulating Empathy. The primary outcome was improvement in knowledge of communication skills and structure. Self-efficacy and perceived importance of communication skills were assessed as secondary outcomes.

RESULTS

Eighteen nurses completed both Web-Based and Workshop components. Statistically significant increases in knowledge regarding communication skills and structure were found, with a large effect size for Gathering Information (r = 0.80) and moderate effect for Articulating Empathy (r = 0.62), and Responding to Difficult Questions (r = 0.532). Self-efficacy significantly increased for all measured communication skills.

CONCLUSIONS

Knowledge improvements and perceived self-efficacy in communication were observed after nurses participated in a blended education program PRACTICE IMPLICATIONS: A blended CSTN may improve nurse-patient communication in the clinical setting, worthy of further study.

Meeting the Challenges of COVID-19: Evaluation of Nurse-Led Changes to Telephonic Assessment

The early months of the COVID-19 pandemic caused suspension of physician home visits at our NYC home-based primary care practice as well as disruptions in community-based services homebound patients rely on. This produced gaps in care for a vulnerable patient population that is considered underserved and medically and socially complex. Telephone triage nurses at Mount Sinai Visiting Doctors Program responded to these gaps in care with targeted enhancements to telephonic patient assessment: creating an encrypted email address to receive photographs, the use of two Epic dot phrases to screen and educate regarding COVID-19, assessment of patients' ability to complete a video visit, the reassessment of goals of care, and the assessment of changes in home care services. We surveyed 15 attending physicians in our practice to evaluate primary care providers' opinions regarding changes in nurse telephone triage and how helpful they were in managing patients at home during the early pandemic. We found enhancements to nurse telephone triage were viewed by physicians as beneficial, valuable, and improved patient care. Physicians found changes improved timeliness of care, could improve self-management, helped avoid transfer to emergency department, and helped manage patient care at home. As the pandemic continues and telehealth becomes more widely used, nurse telephone triage may be adaptable to help care for a variety of patient populations during future public health emergencies.

Conditions Influencing Effective Nurse Nonverbal Communication With Hospitalized Older Adults in Cameroon

Effective communication between nurses and patients is an important factor to quality nursing care but ineffective nonverbal communication could take a toll on health care. Therefore, understanding the factors that influence nonverbal communication between nurses and hospitalized older adults could help solve communication problems, thus improve nursing care. A sample of 13 nurses and 4 student nurses from two hospitals in Cameroon participated in the study. Data were collected using participant observations and semi-structured interviews, and analyzed using open coding and constant comparative analysis. Three categories were identified as influencing factors: nurse views of hospitalized older adults, hospitalized older adult-related factors, and nurse intrinsic factors. Effective nurses’ nonverbal communication with hospitalized older adults relies mostly on nurses’ intrinsic factors. Identification and nurturing of the positive nurse intrinsic factors are important to develop effective nonverbal communication skills among nurses.

Transition to comfort-focused care: Moral agency of acute care nurses

BACKGROUND

Moving into the last phase of life comprises a developmental transition with specific needs and risks. Facilitating transitions is an important component of the work of nurses. When curative interventions are no longer helpful, nurses enact key roles in caring for patients and families.

AIM

The aim of this study was to examine the experiences of registered nurses in acute care settings as they worked with patients and families to facilitate transition to comfort-focused care.

RESEARCH DESIGN

Sampling, data collection, and data analysis were guided by constructivist grounded theory, chosen because of its strength in identifying and explicating social processes.

PARTICIPANTS AND CONTEXT

A purposeful sample of 26 registered nurses working in acute care hospitals in one community in the northeastern United States participated in this study through semi-structured interviews.

ETHICAL CONSIDERATIONS

The study received approval from the university's Institutional Review Board for the Protection of Human Subjects. Participants provided informed consent.

FINDINGS

Nurses facilitated transition to comfort-focused care by enacting their moral commitments to patients and families. They focused on building relationships, honoring patient self-determination, and maintaining respect for personhood. In this context, they discerned a need for transition, opened a discussion, and used diverse strategies to facilitate achieving consensus on the part of patients, family members, and care providers. Regardless of how the process unfolded, nurses offered support throughout.

DISCUSSION

Achievement of consensus by all stakeholders is critical in the transition to comfort-focused care. This study deepens our understanding of how nurses as moral agents utilize specific strategies to assist progress toward consensus. It also offers an example of recognizing the moral agency of nurses through listening to their voices.

CONCLUSION

Increased understanding of effective nursing strategies for facilitating transition to comfort-focused care is essential for developing needed evidence for excellent care and strengthening end-of-life nursing education.

The effectiveness of training interventions on nurses' communication skills: A systematic review

OBJECTIVES

The objective of this systematic review was to identify, critically appraise and synthesise evidence for the effectiveness of communication skills training interventions in nursing practice.

DESIGN

A systematic review of literature.

DATA SOURCES

Randomised controlled trials published in English from 1998 to 2018, identified in five computerised databases (Medline, Cinahl, Embase, Psychinfo and Cochrane Database). Studies were included if they reported an educational intervention to enhance nurses' communication with patients and contained an objective measure of communication skills and/or patient outcome measures.

REVIEW METHODS

The Preferred reporting Items for Systematic reviews and Meta-Analyses guided the review. Data were extracted regarding study design and effectiveness on nurses' communication skills. Trial quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The heterogeneity of the included studies prohibited meta-analysis.

RESULTS

Of the 7811 papers identified, seven trials met the eligibility criteria. The quality was modest. Training programs varied significantly in duration, structure, location and use of outcome measurement tools. Five trials focused on communication with cancer patients using simulated patients. All trials found at least one statistically significant improvement for nurses' communication skills.

CONCLUSIONS

Educational interventions to enhance nurses' capacity to communicate with patients show promise. The paper reports the first systematic review of randomised controlled trials concerning the effect of communication skills training on nurses' abilities to communicate with patients, inclusive of non-cancer settings. The direct impact of educational interventions on nurses' communication skills is difficult to measure arising from non-standardised outcome measurement tools. Further research is particularly needed in acute, chronic illness, aged care and community settings.