Communication in Nursing, 4th Edition

BackgroundThe aim of this study was to assess nurses’ self-reported confidence in their professional skills before and after an extensive Emergency Department (ED) reform in Kanta-Häme Central Hospital.MethodsEmergency nurses participated in transitional training commencing two years before the establishment of the new organization in 2007. Training was followed by weekly practical educational sessions in the new ED. During this process nurses improved their transition skills, defined house rules for the new clinic and improved their knowledge of new technology and instruments. The main processes involving critically ill ED patients were described and modelled with an electronic flow chart software.During the transitional training nurses compiled lists of practical skills and measures needed in the ED. These were updated after feedback from physicians in primary and secondary care and head physicians in Kanta-Häme Central Hospital. The final 189-item list comprised 15 different categories, each containing from 4 to 35 items. Based on the work described above, a questionnaire was developed to reflect ED nurses’ skills in clinical measures but also to estimate the need for professional education and practical training. Nurses working in the ED were asked to fill the questionnaire in January 2007 (response rate 97%) and in January 2011 (response rate 98%).ResultsNurses’ self-reported confidence in their professional skills improved significally in eight classes out of fifteen. These classes were cannulations, urinary catheterizations, patient monitoring, cardiac patients, equipment, triage and nurse practising, psychiatric patients as well as infection risk. Best results were noted in urinary catheterizations, patient monitoring and infection risk. When studying the group of nurses participating in both surveys in 2007 and 2011, improvements were observed in all fifteen categories. All but two of these changes were significant (p<0.05).ConclusionsDuring an extensive reform of emergency services, we noted a significant improvement in the professional skills of nurses. This improvement was especially consistent among nurses working in the ED during the whole transition process. Nurses’ education and training program in the ED may be successfully put into practice when based on co-operation between nurses and physicians dedicated to emergency services.

BackgroundPerforming microsurgery requires a breadth and depth of experience that has arguably been reduced as result of diminishing operating exposure. Fresh frozen cadavers provide similar tissue handling to real-time operating; however, the bloodless condition restricts the realism of the simulation. We describe a model to enhance flap surgery simulation, in conjunction with qualitative assessment.MethodsThe fresh frozen cadaveric limbs used in this study were acquired by the University. A perfused fresh cadaveric model was created using a gelatin and dye mixture in a specific injection protocol in order to increase the visibility and realism of perforating vessels, as well as major vessels. A questionnaire was distributed amongst 50 trainees in order to assess benefit of the model. Specifically, confidence, operative skills, and transferable procedural-based learning were assessed.ResultsTraining with this cadaveric model resulted in a statistically significant improvement in self-reported confidence (p < 0.005) and prepared trainees for unsupervised bench work (p < 0.005). Respondents felt that the injected model allowed easier identification of vessels and ultimately increased the similarity to real-time operating. Our analysis showed it cost £10.78 and took 30 min.ConclusionsPerfusion of cadaveric limbs is both cost- and time-effective, with significant improvement in training potential. The model is easily reproducible and could be a valuable resource in surgical training for several disciplines.Level of Evidence: Not ratable.

ABSTRACTCommunication skills are a competency highlighted by the Accreditation Council on Graduate Medical Education; yet, little is known about the frequency with which trainees receive formal training or what programs are willing to invest. We sought to answer this question and designed a program to address identified barriers. We surveyed pediatric fellowship program directors from all disciplines and, separately, pediatric hematology/oncology fellowship program directors to determine current use of formal communication skills training. At our institution, we piloted a standardized patient (SP)-based communication skills training program for pediatric hematology/oncology fellows. Twenty-seven pediatric hematology/oncology program directors and 44 pediatric program directors participated in the survey, of which 56% and 48%, respectively, reported having an established, formal communication skills training course. Multiple barriers to implementation of a communication skills course were identified, most notably time and cost. In the pilot program, 13 pediatric hematology/oncology fellows have participated, and 9 have completed all 3 years of training. Precourse assessment demonstrated fellows had limited comfort in various areas of communication. Following course completion, there was a significant increase in self-reported comfort and/or skill level in such areas of communication, including discussing a new diagnosis (p =.0004), telling a patient they are going to die (p =.005), discussing recurrent disease (p <.001), communicating a poor prognosis (p =.002), or responding to anger (p ≤.001). We have designed a concise communication skills training program, which addresses identified barriers and can feasibly be implemented in pediatric hematology/oncology fellowship.

To illustrate how sequence analysis may be applied to the medical interview to: 1. explore how physicians without formal training in communication skills elicit and respond to patient cues and expression of expectations and opinions; and 2. test the hypothesis that physicians' closed ended questions determine the use of subsequent closed ended questions. 238 consultations in primary care, coded with the Verona Medical Interview Classification System, were analysed. Lag 1 analysis was applied to study which physician behaviour precedes and follows patient cues. Pattern recognition analysis for five lag sequences was performed to test the occurrence of predefined specific code chains, where a closed and an open ended question were followed either by two closed-ended questions or by two patient facilitating interventions Patients' cue offers were most likely after facilitative interventions, but not after open-ended questions; physicians were most likely to respond to these expressions with facilitation. Physicians' tendency to use closed ended questions increased after previous closed questions and decreased after an open-ended question. Lag sequential analysis and pattern recognition analysis are useful methods to study exploratory and theory driven hypotheses and allow an initial approach to validate the supposed appropriateness of specific physician interventions.

The pediatric videofluoroscopic swallow study (VFSS) is a specialized procedure, with speech pathologists (SPs) requiring additional training prior to independent clinical practice. Given the limited available research examining pediatric VFSS training methods, this study aimed to investigate self-reported learner outcomes of a virtual multicomponent education program (facilitator-led peer learning groups and eLearning package). Using a prospective pre-post evaluation design, SPs in Queensland (Australia) were recruited to participate in the program over a 12-month period. The eLearning package consisted of seven modules, which provided information about preparing for, conducting, and interpreting pediatric VFSS. Twelve 60-minute online facilitator-led peer learning groups were offered, incorporating didactic presentations, professional discussions, and inter-rater reliability activities. Participants completed questionnaires regarding demographics, self-reported confidence, case management, overall and individual session satisfaction. Overall, 30 speech pathologists participated in this project. A significant increase in self-reported confidence was reported on 20/21 parameters, and 95% of participants attributed this to the virtual learning program. No significant changes were observed on the case management questionnaire. Participants reported high levels of overall satisfaction with the virtual education program (mean rating 4.3/5), with the use of interactive learning (e.g., videos, case studies) and peer-discussion reported to be highly beneficial. Overall, results highlighted that interactive, peer-based online training methods were well-accepted and resulted in improvements in self-reported confidence. Future research should investigate the impacts of virtual training on clinician performance and patient outcomes.

Objective To explore the problems present in the training program for vocational nursing students and explore the corresponding solutions. Methods A questionnaire was conducted among preceptors in teaching hospitals. Results Thc majority prcceptors confirmed the necessity of inter-curriculum practice, but they also point out such difficulties as being unable to access typical cases, insufficient practice time,interference with hospital schedule because of too many nursing students, and the distance between hospitals and the campus. The college has to realize the problems in nursing skill training and evaluation system, e. g. ,insufficient training of the abilities about clinical thinking and comprehensive analysis, unavailable of simulation ward, and inadequate recognition of nursing training and evaluation. Conclusions The college leaders should establish a curriculum and a simulation ward to facilitate nursing skill practice and train nursing students the abilities to think clinically and solve real problems, and highlight the importance of clinical thinking, and the training and evaluation of nursing skills. The abilities of nursing students of clinical thinking, observation and decision-making should be enhanced, and the training of inter-personal communication, self-protection,jurisprudence and nursing documentation should be implemented too. Key words: Pre-internship period; Nursing students; Nursing skill training; Simulation training

Purpose: There is little consensus on the role of training in bedside ultrasound skills for medical students or junior doctors early in their careers.Methods: We trained 20 Foundation Year 1 doctors in the use of ultrasound as an adjunct to peripheral venous cannulation and following an assessment of competence gave them access to an ultrasound machine to assist with difficult cannulations in their clinical practice. Self-reported confidence and competence were assessed using pre- and post-training questionnaires, with competence objectively assessed immediately post-training and at one and three months follow up. Clinical use of ultrasound was studied over three months.Results: Improvements in self-reported confidence and competence were observed post-training and retained at three months. 85% (17/20) of participants were objectively assessed as competent immediately post-training, with retention of competence demonstrated in 80% (16/20) and 75% (15/20) at one and three months, respectively. There were 33 separate uses of ultrasound during the three month study period with a 73% (24/33) success rate and no adverse incidents.Conclusions: We suggest that doctors in their first post-graduate year can be trained in the use of ultrasound as an adjunct to peripheral venous cannulation, retain the skill over time and use it safely in their clinical practice.

Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted. We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience. This was an observational study. The study was conducted at a large, multispecialty academic medical center. Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014. An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction. Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p < 0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p = 0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p = 0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4 ± 12.7 vs. 124 ± 11.9, p < 0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3months. System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.

ES 06.01 Advanced Directives — Are They Useful?

IntroductionSupported self-management is an important aspect of managing pain, however widely held beliefs about the biomedical nature of pain and limited time availability can make it a tricky concept to introduce to patients. Social prescribers are in an ideal position to support self-management of pain if appropriate training is available to support them. This study aimed to evaluate training for social prescribers and to explore their opinions and experiences about providing self-management support.MethodsThis was a mixed methods study. Repeated measures t-tests were used to compare the reported confidence of attendees in supporting different facets of self-management before and after the training. Thematic analysis of interviews was used to develop a deeper understanding of how participants related the training to their work with patients.ResultsAverage confidence improved in all aspects of supporting self-management, and particularly with regard to supporting understanding pain, acceptance, pacing, setting goals, sleep and managing setbacks. Challenges were identified around explaining pain in an accurate and accessible way in order to provide a meaningful rationale for self-management.ConclusionTraining for social prescribers in self-management support is feasible and leads to improvements in self-reported confidence. Further research is needed to determine the impact on patients and over a longer period of time.

We aimed to identify and categorise advanced communication skills used by experienced consultant paediatric anaesthetists to facilitate the induction of paediatric anaesthesia. The communication techniques were both verbal and non-verbal. Communications with potentially negative effects were also noted. Eighty-three inductions were observed over a three-month period. The 12 anaesthetists observed were all senior consultants at a tertiary referral paediatric centre. The mean age of patients was 6.1 years SD+/-4.8. There were 53 males (63.9%) and 30 females (36.1%). A first anaesthetic was administered to 43 patients (56%) and sedative premedication to six (8%). Inhalational inductions were observed in 59 patients (71%). The remainder received an intravenous induction. Anaesthesia was induced in the operating room on 68 occasions (82%), in the induction room on 11 (13%) and in the radiology department on 4(5%). The most common communication techniques used were: voice change in 60 (72%); distraction in 49 (59%); direct commands in 39 (47%); repetition in 34 (41%); imagery in 21 (25%) and focused attention 21 (25%). Other techniques used were seeding of ideas, utilisation, non-verbal cues, double-binds, story-telling, indirect suggestion, dissociation and reversed effect. Sabotage by parents or staff such as inadvertent negative suggestions, was observed on 14 occasions (17%). Paediatric anaesthetists utilise a wide range of communication techniques in a highly flexible manner when inducing anaesthesia in children. Many of these communications can be characterised as hypnotherapeutic. Our observations suggest that formal structured training in communication skills and further research is warranted.

The importance of effective communication skills to sustain the cancer patient quality of life (QOL) and their satisfaction with healthcare professionals is well documented. This study aims to assess the effectiveness of communication skills training (CST) of nurses for patient QOL and their satisfaction with healthcare professionals just after being diagnosed with cancer. This is a secondary analysis of a randomized controlled trial. Eight nurses, who mainly provide psychological and informational support for patients soon after they were informed of their cancer diagnosis by physicians at a cancer screening center, were randomly assigned to an experimental group attending a CST program (four nurses) or to a control group (four nurses). Eighty-nine patients with gastric, colorectal, or breast cancer were supported and assessed by either group of nurses during the study period. The effectiveness for patient QOL and their satisfaction with healthcare professionals was assessed by administering the Short Form-8 Health Survey (SF-8) and a single-item VAS three times (1 week after diagnosis: T1; 1 month after diagnosis: T2; and 3 months after diagnosis: T3). Repeated measures analysis of variance showed a group-by-time significant increase of the mental aspects of SF-8 (F=3.48; P=0.03) and satisfaction with the nurse (F=3.18; p=0.04). Our findings underscore the importance of CST for healthcare professionals to improve the QOL of patients as well as their satisfaction with these professionals.

The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians...

This is a report of a study investigating processes used by final-year nursing students to recognize and act on clinical cues of deterioration in a simulated environment. Initial decisions about patients who are deteriorating in medical and surgical wards are often made by newly qualified nurses and doctors, increasing the risk of clinical error. There has been an emphasis on the use of teams in simulation; however, signs of deterioration are missed by individual clinicians. During July 2008, final-year undergraduate nursing students in Australia attended a simulation laboratory for 1·5 hours and completed a knowledge questionnaire and two (mannequin-based) scenarios simulating deteriorating patients with hypovolaemic and septic shock. Scenarios were video-recorded and reflective interviews conducted. Additionally, scenarios were stopped around the midpoint to ascertain students' level of Situation Awareness. Fifty-one students participated in the study, providing a total of 102 videoed scenarios and 51 interviews. Thematic analysis of video data and reflective interviews identified considerable differences in processes used by students to identify cues. Four aspects of cue recognition were evident: initial response, differential recognition of cues, accumulation of signs and diversionary activity. Nursing skills training should emphasize the importance of trends in identifying and acting on deterioration and the need for systematic assessment in stressful situations. Nursing curricula should focus on enhancing the ability to piece information together, including linking pathophysiology with patient assessment, and identify trends, rather than seeing observations as parallel to each other.

Most lung cancer patients report perceiving stigma surrounding their diagnosis, and routine clinical interactions with their health care providers (HCPs) are reported as a common source. The adverse effects of lung cancer stigma are associated with several adverse psychosocial and behavioral outcomes. One potential clinician-level intervention target is empathic communication because of its association with higher rates of patients' satisfaction, treatment adherence, and lower levels of psychological distress. This study describes the conceptual model and evaluation of clinician-targeted empathic communication skills training to reduce lung cancer patients' experience of stigma. The goal of the training module is to enhance clinician recognition and responsiveness to lung cancer patients' empathic opportunities by communicating understanding, reducing stigma and distress, and providing support. Thirty multidisciplinary HCPs working in thoracic oncology, thoracic surgery, or pulmonary medicine participated in 2.25 hr of didactic and experiential training on responding empathically to patients with lung cancer. Overall, participants reported highly favorable evaluations of the training, with at least 90% of participants agreeing or strongly agreeing to 11 of the 12 items assessing clinical relevance, novelty, clarity, and facilitator effectiveness. Participants' self-efficacy to communicate empathically with lung cancer patients increased significantly from pretraining to posttraining, t(29) = -4.58, p < .001. The empathic communication skills training module was feasible and well received by thoracic and pulmonary medicine HCPs and demonstrated improvements in self-efficacy in empathic communication from pretraining to posttraining. The examination of patient outcomes is warranted.