This report describes a new training program to enhance nurses' skills for interdisciplinary communication with ICU physicians and families of patients in the ICU. Using evidence-based pedagogical methods, we implemented a 1-day educational intervention focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. We sought to equip these nurses to realize their full potential as members of the interdisciplinary team, working together with physicians and other health professionals to communicate effectively and sensitively in ICU family meetings. The participants' ratings of the program and its impact on their skills indicate that this intervention can form a valuable part of the education of critical care nurses.
Communication skills are both teachable and learnable. As with training of other skills, communication skills are optimally taught by active participation of trainees. We employed a “learner centered” approach to skills training,20,21
which has several integral components. Among these are: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered.20
Eighty-five percent of the program was devoted to role-playing exercises in which nurses practiced and refined their skills with close supervision and constructive feedback from experienced faculty and from peers.
The value of interactive training programs has been demonstrated among nurses and physicians at various levels of training and experience.12–15,22
In a randomized controlled trial of communication skills training for oncology physicians, Fallowfield and colleagues found that an intervention combining didactic instruction and role-play led to lasting improvements in the use of open-ended questions, appropriate responses to patients' cues, and the expression of empathy.12
Negative communication behaviors, such as interrupting, were shown to decrease. These skills were sustained for one year after the initial training.23
To date, there are limited opportunities for bedside intensive care nurses to participate in rigorous communication training. An intervention to enhance communication skills among nurse leaders and physicians in two ICUs led to improvements in demonstrated and perceived skills.10
These outcomes correlated with a decrease in stress among staff nurses, but the staff nurses themselves did not participate in the intervention.10
The End-of-Life Nursing Education Consortium (ELNEC)-Critical Care represents the first comprehensive palliative care curriculum for ICU nurses.9
ELNEC-Critical Care encompasses several universal themes, one of which is that an interdisciplinary approach is essential for quality care. Although communication is part of the ELNEC-Critical Care curriculum, other topics are also covered, most material is presented in lecture format, and small-group training with intensive communication skills practice is not feasible in the program. Shannon et al.24
recently reported on a 90-minute session including interactive exercises that they presented on tools to “Manage End-of-Life Conversations” at an annual conference of a critical care nursing association in Europe. Some participants provided written comments indicating that the tools were relevant to their practice.
Our program focused specifically on enhancing skills for active participation by nurses in interdisciplinary communication with ICU families. With a faculty including both nurse and physician representation, we provided a comprehensive workshop in a relatively short time frame (6 hours including a lunch break) in a clinical environment. We framed this program to address not only end-of-life care but a broader range of skills needed for effective and compassionate communication by the interdisciplinary team with all patients and families receiving treatment in the ICU, as well as within the team. At the same time, we addressed specific roles for critical care nurses in interdisciplinary family meetings. Finally, we conducted a detailed assessment of participants' self-rated communication skills before and after the program and of the techniques and materials we used. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.
Communication by an interdisciplinary team is identified by patients and families as a key element of high-quality ICU palliative care.25
Performance of an interdisciplinary family meeting has been accepted and validated as a core indicator of quality care for critically ill patients and their families.26,27
In order to implement this standard in clinical practice and to encourage nurses to participate and contribute actively to these meetings, nurses need training in communication skills. An “intensive communication” strategy within one ICU,7
where multidisciplinary patient/family meetings were mandated within 72 hours of ICU admission, had a significant and lasting impact on length of stay in the ICU and resulted in earlier transition to palliative care where appropriate.8
Effective introduction of a multidisciplinary family meeting has also been shown to decrease health care costs in the ICU at the end of life and enhance family satisfaction.5,6
Spending more time at the bedside than any other member of the interdisciplinary team, nurses serve an important and unique role that includes participation in communication and decision making.28
As a member of the ICU team, “the nurse is in a more privileged position for fostering…communal decisions” regarding patient care.16,29
Nurses are often first to become aware of distressing symptoms and other concerns, and to gain knowledge of the patient as a person. Their intimate role at the bedside also gives them insights into the family that may not be evident to other members of the team.30,31
Information and education provided by nurses can have a significant impact on decision making for critically ill patients.32,33
Moreover, professional nursing societies include communicating about goals of care among the responsibilities of the ICU nurse,11,34
and many nurses are comfortable embracing this role.35
Time constraints and continuity of care are known barriers for timely and effective communication by physicians with patients and families in the ICU.36,37
Although time constraints exist for busy ICU nurses as well, nurses can help to overcome these barriers to communication and contribute in important ways to effective communication.
The role of the nurse in “shuttle diplomacy”38
(i.e., acting as interpreters between various groups in the ICU) presents an opportunity for nurses to meet their fullest potential as members of the ICU multidisciplinary team. Unless nursing involvement is accompanied by active and effective participation in communication about goals of care, the role of interpreter can also contribute to nursing moral distress and job burnout.29,39
Several studies demonstrate that nurses experience distress when they perceive the plan of care for their patient to be excessively burdensome in relation to potential benefits, or to be inconsistent with the patient's values and preferences.31,40
The problem may be magnified when input from the nurse is not obtained or not valued in decision making. Including nurses as essential participants in family meetings as well as multidisciplinary rounds, and training them to communicate effectively as part of the interdisciplinary team, may help to mitigate nursing distress and burnout.41
There were several limitations to this pilot study. First, all participants were nurses in ICUs in Department of Veterans Affairs hospitals in the same geographic region (northeastern United States). However, the techniques we used have been used successfully in many different settings to train health care professionals in communication skills; thus, we believe they are broadly applicable to nurses in any ICU setting. Second, we were not able to observe or evaluate a direct impact on the clinical practice of nurses involved or on patient care, nor did we objectively measure the nurses' skills; this was beyond the breadth of the present study, but will be an important area of further investigation. Third, we did not obtain completed responses to our questionnaires from all nurses who participated; thus, some nonresponding participants might have answered differently. Fourth, the strict requirement of anonymity precluded matching individual nurses' pre- and post- questionnaires. Fifth, our faculty members were experienced in ICU communication skills training. This expertise may not be locally available at all institutions, but trainer programs are increasingly available. Finally, we did not have the opportunity to compare the effectiveness of training nurses separately versus training them together with physicians. We plan future training in interdisciplinary sessions to foster an educated team approach to ICU clinician-patient-family communication.