An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness

William C. Gautier, MSEd; Menna Abaye, MS; Shelly Dev, MD; Jennifer B. Seaman, PhD, RN; Rachel A. Butler, MHA, MPH; Marie K. Norman, PhD; Robert M. Arnold, MD; Holly O. Witteman, PhD; Tara E. Cook, MD, MS; Deepika Mohan, MD, MPH; Douglas B. White, MD, MAS

Disclosures

Am J Crit Care. 2022;31(3):189-201. 

In This Article

Abstract and Introduction

Abstract

Background:Large-scale efforts to train clinicians in serious- illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support.

Objective:To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness.

Methods:A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively.

Results:Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training.

Conclusions:Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.

Introduction

Critically ill patients often lack decision-making capacity, and thus surrogate decision makers make significant decisions about treatment options and end-of-life considerations on their behalf.[1,2] Surrogate decision makers frequently experience substantial emotional and psychological strain from this role,3 as well as prolonged psychological distress (eg, depression, anxiety, posttraumatic stress disorder).[4–8]

Some evidence suggests that treatment decisions in intensive care units (ICUs) may not align with patients' preferences.[9–11] Furthermore, numerous publications have documented common deficiencies in clinician–family communication, including a lack of timely family meetings, missed opportunities to provide emotional support to surrogates, and limited discussion of prognosis, patients' preferences, and the availability of comfort-focused care.[12–21] Responding to these concerns, the US National Academy of Medicine has identified improving clinicians' skills in communicating about serious illness as a priority area for national action.[22]

Strong evidence shows that in-person training programs can improve clinicians' communication skills[23–27] and that improving communication between clinicians and patients can improve patient-level outcomes.[23,28,29] However, 2 important gaps in knowledge remain. First, no training method currently exists that is both proven to be effective and that can be readily scaled to meet the need to train thousands of clinicians across the country. A recent expert consensus article concluded that developing training programs that are readily scalable and easy to access remains an important goal for improving communication about critical illness in clinical settings.[30] Second, although the value of interprofessional collaboration when supporting surrogates of incapacitated ICU patients is increasingly recognized,[31] few interventions exist to train ICU nurses in the communication skills needed to effectively collaborate with physicians in the coordinated delivery of interprofessional family support. Ultimately, the communication skills needed to deliver effective family support vary between medical professions and therefore new training interventions are required. Our training program diverges from many others in its target audience and the core skills that constitute the curriculum.

We recently reported the results of a randomized clinical trial of an in-person communication skills training program for ICU nurses called PARTNER (Pairing Reengineered ICU Teams With Nurse-Driven Emotional Support and Relationship-Building; Figure 1). We found that the intervention improved families' ratings of the patient-centeredness of care and the quality of communication between clinicians and family members and decreased health care utilization at the end of life.[23] However, the intervention required 16 hours of in-person training, which was expensive, was administratively burdensome to schedule, and required participants take time off work and travel to a central location.[23] Moreover, the in-person format of the training limits the potential scalability of the intervention and may be especially problematic for clinicians working in rural and underserved health care settings, who do not have access to local in-person training programs and may have economic and time-based barriers to attending geographically distant trainings.[32–35]

Figure 1.

Overview of the PARTNER (Pairing Reengineered ICU Teams With Nurse-Driven Emotional Support and Relationship-Building) intervention.
Abbreviation: ICU, intensive care unit.

Before we can effectively leverage technology to enable distance learning, we first must carefully adapt existing training programs and perform rigorous user testing before widescale dissemination. We therefore sought to develop and user-test a web- and videoconference-based training platform as a highly scalable alternative to in-person training in communication skills.

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