In the highly charged ICU environment, the bedside nurse is on the front line for communicating information about patients’ conditions. Yet many nurses are unclear about their role in fostering that communication and lack confidence to address families’ questions. That has significant implications, particularly in light of a Robert Wood Johnson Foundation study indicating that approximately one in five patients who are treated in an ICU dies while receiving care or soon after.
Now, a separate study by researchers in California and Washington has found that critical care nurses who underwent a recently developed training regimen had enhanced ability and confidence with regard to tasks such as evaluating families’ comprehension of loved ones’ prognoses and care goals and meeting families’ emotional needs.
Wendy Anderson, MD, MS, Associate Professor in the Division of Hospital Medicine and Palliative Care Program and the Department of Physiological Nursing at the University of California San Francisco (UCSF), helped create the eight-hour workshop, which focuses on communication among patients, families and physicians. Adequate training is key, Dr. Anderson notes, because of the centrality of nurses in the critical-care setting.
“A lot of nurses … see themselves as diplomat[s] — going back and forth between the physicians and the families and even between different physician teams,” Dr. Anderson says. “The nurse is at the bedside all the time. They are the continuity.”
Eighty-two nurses completed six workshops between March 2011 and April 2013. Directly after the workshop, 78 reported it had “increased” or “greatly increased” their awareness of their role in communicating prognoses and goals of care to patients’ families. Three months later, 22 of the 41 participants who responded to a follow-up survey reported using the skills presented in the workshop during all or most shifts. Thirty-three of 36 responding participants “agreed” or “strongly agreed” the training enhanced their ability to ensure patients’ families and providers communicated about prognoses and goals of care.
The workshops relied heavily on roughly hour-long role-playing sessions. In the first session, the bedside nurse meets with the wife of an ICU patient and asks open-ended questions to provide emotional support. The second role-play focuses on communication with physicians: understanding physicians’ opinions, in terms of prognoses and goals of care, before talking to the families, as well as explaining families’ concerns to physicians and, if necessary, planning additional family meetings. The final role-play is geared toward encouraging family members to express their needs in the family meeting.
At the end of the workshop, the chaplain from the palliative team encourages nurses to reflect on the stresses of working in an ICU environment.
“In critical care nursing, you have to be pretty tough …,” Dr. Anderson says. “[Nurses] don’t feel they can show their colleagues they’re vulnerable. This workshop has raised the awareness that everybody needs support.”
Meeting a Need
Dr. Anderson cites the End-of-Life Nursing Education Consortium (ELNEC) project as an inspiration for the UCSF program. One architect of ELNEC, Betty Ferrell, PhD, RN, at City of Hope, a comprehensive cancer center in California, emphasizes the value of such training in helping individuals deal with an especially painful time in their lives:
“[E]ven with the best of treatments, many patients die in this setting,” Ferrell says. “Most patients and families face very difficult treatment decisions in intensive care.”