Table 2.

Four components of the PARTNER intervention

1. Advanced communication skills training for 4–6 nurses from each ICU to deliver support to surrogates throughout the ICU stay
Duration	12 hours
Teaching methods	Didactic explanation of skills to be learnt Demonstration of the skill by an expert clinician Small group practice with simulated families Learners receive feedback from and observe each other interact with simulated families Structured-learner centred feedback provided by an expert communication skills educator
Core skills	Interacting with families: Establishing emotional supportive relationships† Daily check-ins with the families to elicit questions or concerns and provide update on the plans for the day. Preparing families for IDFM by explaining meeting goals, eliciting the patient’s values and helping them formulate their main question using a question prompt Attending family meetings to emotionally support the family and, if needed, use prompting skills to ensure that the families’ main questions are addressed. Interacting with providers: Conveying family questions and concerns to providers before IDFMS Verbal prompting and persuasion to ensure structured, regular clinician–family communication Ensuring care coordination when new clinicians come on service Documenting family meetings
Ongoing training	Quarterly ‘booster’ training sessions in which key skills are reviewed and practised
2. Deploying a structured family support pathway delivered by interprofessional ICU team
First meeting with family	Performs introduction Provides emotional support using NURSE behaviours Gets to know the family and the patient as individuals Orients the family to the ICU
Before interdisciplinary meeting with family	Provides emotional support Explains what to expect in the meeting Elicits main concerns and completes question prompt list
Interdisciplinary meeting with family	Provides emotional support Ensures that the family’s main questions are answered Brings the conversation back to the patient as an individual Ensures that the treatment options are discussed Ensures that there is a clear follow-up plan
After interdisciplinary meeting with the family	Attends to emotions raised during the meeting Elicits questions Corrects any misunderstandings of issues addressed during the meeting
Daily check-in	Check in daily to see how the family is doing Updates the family on the plan for the day Provides emotional support Elicits questions and concerns
3. Enacting strategies to increase collaboration between ICU and PC services
	Establishing a ‘PC champion’ Provision of recommended ‘triggers’* for PC consultation Twice weekly, in-person meetings between PC and ICU services to review the ICU census
4. Providing comprehensive implementation support to deploy the Intervention in each ICU
Engagement of hospital and ICU leadership	Prior to implementation, study investigators sought explicit endorsement of the PARTNER programme from hospital and ICU leadership at each site.
Recruitment of PARTNER physician and nurse champions	We will identify local nurse and critical care physician leaders at each site to act as a champion. These individuals commit to taking a leadership role for promoting the intervention and assisting with implementation challenges.
Orientation of all staff to the intervention	Study investigators will provide ICU physicians and bedside nurses with a structured orientation to the new care model and PARTNER nurses’ role responsibilities via email communications and in-person education sessions.
On-site implementation support	During the first 2 weeks of deployment, an implementation specialist is on-site to provide daily assistance. Thereafter, the implementation specialist makes weekly visits to directly observe the clinicians deploying the intervention, provide feedback and assist in overcoming implementation challenges.
Quarterly audit and feedback	Audit-generated feedback on site performance of key process measures: no of patients enrolled, proportion who received IDFMs per protocol, frequency and timing of IDFMs compared with control phase, and frequency and timing of PC consults compared with control phase

*Proposed by expert working group, as summarised by Weissman and Meier⁴⁰ and a suggested consensus-building strategy from the improving palliative care in the ICU (IPAL-ICU) working group.⁴¹

†Evidence-based strategies include the skills summarized in the NURSE mnemonic.⁶⁸

ICU, intensive care unit; IDFM, interdisciplinary family meeting; PARNTER, Pairing Re-engineered ICU Teams with Nurse-Driven Emotional Support and Relationship-Building; PC, palliative care.