Enhancing the Communication Skills of Critical Care Nurses: Focus on Prognosis and Goals of Care Discussions

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.