Communication Skills Training for Nurses and Social Workers: An Initiative to Promote Interdisciplinary Advance Care Planning and Palliative Care in Patients on Dialysis

Abstract

Palliative care initiatives are needed in nephrology, yet implementation is lacking. We created a 6-hour workshop to teach the skills of active listening, responding to emotion, and exploring goals and values to nurses and social workers working in dialysis units. The workshop consisted of interactive didactics and structured role play with trained simulated patients. We assessed preparedness using a Likert scale and utilized paired t tests to measure the impact using a self-assessment survey following the training. Ten nurses and two social workers from six dialysis units completed the training. Mean scores improved in all domains: demonstrating empathic behaviors, responding to emotion and end-of-life concerns, eliciting family’s concerns at end-of-life and patient’s goals, and discussing spiritual concerns. Further testing in larger samples may help to confirm these results.

There is now increasing recognition of the need for advance care planning (ACP) in nephrology. The Medicare End Stage Kidney Disease (ESKD) program cost in excess of $49 billion in 2018, yet evidence indicates mortality is high and quality of life is low (Davison & Jhangri, 2010; United States Renal Data System [USRDS], 2020). As many as 21% to 61% of patients on maintenance dialysis report regretting the decision to start dialysis, and almost a quarter of patients discontinue dialysis (Davison, 2010; Saeed, 2020; USRDS, 2020). The symptom burden in patients receiving maintenance dialysis is high and includes fatigue, pain, and insomnia, and these symptoms correlate with negative mental and physical quality-of-life scores (Davison & Jhangri, 2010). Patients rely on nephrology nurses and social workers to address symptom burden, psychosocial and spiritual needs, and advance care planning (ACP). Yet dialysis nurses and social workers report a lack of education and systemic implementation to meet these palliative care needs (Culp et al., 2016; Davison, 2010).

Lack of communication skills training is a potential barrier to integration palliative care in nephrology. Recent efforts to improve communication skills have focused on nephrologists and fellows. NephroTalk and a program at Harvard are successful communication skills training programs that have used didactics and role play to train nephrology fellows since 2011 (Cohen et al., 2016; Schell et al., 2013; Schell et al., 2018). Dialysis staff, including nurses, technicians, social workers, and dieticians, often spend an order magnitude greater time with the patients receiving maintenance hemodialysis than nephrologists and have the potential to respond to palliative care concerns and participate in ACP.

Data demonstrate nephrology registered nurses and social workers feel unprepared to address ACP and palliative care (Rabetoy & Bair, 2007; Yee et al., 2011). Haras and colleagues (2015) explored reasons for low participation in ACP and found that knowledge, support, attitudes, and comfort were necessary for nephrology nurses to participate in ACP. A qualitative study by O’Hare and colleagues (2016) reported that the locus of responsibility and authority for ACP was unclear, with some nurses considering ACP to be the domain of the social worker or nephrologist, and that they did not feel qualified to enter into ACP conversations (O’Hare et al, 2016). Resources do exist, such as a PowerPoint module produced by the American Nephrology Nurses Association (ANNA, 2017) describing end-of-life decision-making, but to our knowledge, there are no practical skills training simulations designed specifically for nephrology nurses and social workers. There are models outside of nephrology, for example in the critical care setting, in which communication skills training of nursing personnel exist to enhance the delivery of palliative care (Anderson et al., 2016; Milic et al., 2015). One solution to address the lack preparedness is the use of hands-on training in communication skills.

Our goal was to develop and pilot a two-part curriculum consisting of palliative care didactics and communication skills training for nurses and social workers in both inpatient and outpatient dialysis units to promote ACP and palliative care in an interdisciplinary setting. We aimed to test whether the training would improve self-reported preparedness in ACP discussions.

Materials and Methods

Dialysis nurses and social workers were invited to participate from within the University of Vermont Medical Center inpatient and outpatient dialysis units via email, direct contact, flyers, and announcements at quarterly dialysis staff meetings. Key stakeholders included dialysis nursing leadership and the nurse educator, who helped shape the initiative and encouraged participation. National leaders in communication skills training within nephrology provided expertise in planning and implementation. Local expertise in teaching communication skills and the use of trained actors, who served as simulated patients, also helped shape the training. This study was considered quality improvement by the Institutional Review Board (IRB) at the University of Vermont.

The curriculum included two parts. First, we developed brief didactics on a core set of kidney palliative care topics that were administered via online, interactive learning modules in the week preceding the workshop. The online module platform was familiar to staff because it was used for required annual training on a variety of clinical care topics. These modules consisted of video-recorded didactics with local palliative care providers on key kidney palliative care topics, including advance care planning versus advanced directives, symptoms related to ESKD, and frequent reasons for consulting palliative care in ESKD. The palliative care providers selected from the topics and created a script of the didactic. The script was revised with input from the author (K.L.C.), and they had the opportunity to revise it further during video-recording. Knowledge acquisition of the participants was tested using multiple choice questions immediately after watching the videos as part of the eLearn module The goal of the didactics was to provide key knowledge content on palliative care and ACP as it relates to patients on dialysis and to promote active learning prior to the skills workshop.

Second, we developed a 6-hour, two-part communication skills workshop aimed at improving preparedness and skill in handling palliative care communication challenges in the dialysis setting (see Table 1). We employed a model of learning grounded in experiential learning and deliberate practice as described by Fryer-Edwards and colleagues (2006). The workshop began with interactive didactics, followed by a faculty role-play demonstration that reinforced skills taught. In small groups, participants role-played scenarios with a simulated patient to practice the skills modeled earlier by faculty. We repeated these cycles of brief interactive didactics, facilitator demonstration of skills via role play, and small group, structured role play with simulated patients for each skill (see Figure 1). The first part of the workshop focused on active listening by teaching non-verbal listening skills (SOLER) and how to respond verbally to emotion using the NURSE acronym (see Table 2) (Smith & Hoppe, 1991). The second part of the workshop was dedicated to teaching skills of how to respond to ‘big’ questions (see Table 3). This included a road map (AEIOU) and ways of exploring values that might underlie the ‘big’ questions.

Table 1.

Overview of Workshop

Session	Didactic	Demonstration by Faculty	Role Play Scenarios with Simulated Patient	Goals for Participants
Active listening	• Non-verbal communication ‘SOLER’ (Table 2). • Responding to emotion ‘NURSE’ (Table 2).	• 80-year-old man with cardiovascular disease and acute kidney injury about to start dialysis.	• 74-year-old woman receiving maintenance hemodialysis who has developed painful calciphylaxis lesions that are recalcitrant to treatment. • Her son is worried and has come to the dialysis unit looking for answers.	• Identify active listening skills used by faculty. • Practice non-verbal communication ‘SOLER.’ • Practice responding to emotion using ‘NURSE.’
Exploring big questions	• Responding to ‘big questions’ ‘AEIOU’ (Table 3). • Exploring values.	• 80-year-old man with end stage kidney disease, prolonged hospital course for infections, recent rehab course, significant functional decline.	• 57-year-old man with amyloidosis on maintenance hemodialysis who is experiencing recent functional decline and is withdrawn. • Patient asks to speak with you on dialysis.	• Identify road map used to respond to big questions and how values were explored by faculty. • Practice responding to big questions. • Practice exploring values with patient.

Figure 1. Adult Learning Strategy Included Cycles of Didactics, Demonstrations by Facilitators and Role Play by Participants With a Simulated Patient.

Table 2.

Communication Tools to Promote Active Listening

Active Listening Skills
Non-verbal communication “SOLER”	Sit squarely facing the patient Open posture Lean forward Eye contact Relax
Responding to emotions “NURSE”	Naming Understanding Respecting Supporting Exploring

Table 3.

Communication Tools to Respond to ‘Big Questions’

Responding to Big Questions
Road map “AEIOU”	A – Ask permission to discuss. E – Expect emotion, respond with empathy. I – Interests: Be interested in VALUES of the patient. O – Overall: Provide summary statement and check for understanding. U – Unite: Connect with other team members.
Exploring “VALUES”	V – Values: What is important to you? A – Activities: What brings you joy? L – Living: What does living mean to you? U – Uncertainty: What worries you? What concerns you? E – Experience: What was the last hospitalization like for you? S – Strength: What brings you strength? What gives you hope?

In the small group practice, participants were asked to name a skill they wished to practice in order to personalize the feedback received from the faculty and other participants immediately after a practice encounter. Following the role play faculty asked the participant to name what went well in the scenario to encourage reflection on their strengths (Fryer-Edwards et al., 2006).

We measured short-term impact of communication skills training workshop using pre-/post-workshop self-assessment surveys. We assessed preparedness using a Likert scale (1 = not prepared, 5 = very prepared) in six domains and utilized paired t tests to measure the impact of the workshop using pre- and post-retrospective self-assessment surveys. We also assessed attitudes towards communication and prior communication skills training in the pre-assessment and the usefulness of the workshop in the post-assessment survey. Statistical analyses were performed in Stata v.14.0.

Results

There were 10 RNs and 2 social work participants out of a total eligible 49 RNs and 7 social workers, with a mean age of 57 years. Participants were all female, 92% non-Hispanic white, and 8% Hispanic.

Six participants completed the online modules, including two who were not able to attend the workshop. Participants answered most questions correctly (mean score 83%, range 70% to 90%). Prior communication skills training was common (75%), but only one-third had skills training on how to respond to emotion or end-of-life concerns. On a Likert scale (0 = not important, 5 = extremely important), participants rated communication skills as extremely important to their profession (mean score 4.83 ± 0.39).

Prior to completing the training, participant preparedness was self-rated in six domains: demonstrating empathic behavior, responding to emotion, eliciting family concerns, eliciting patient goals and values, responding to existential concerns, and discussing religious concerns. The mean scores ranged from 2.58/5 for discussing religious concerns and 2.83/5 for responding to existential concerns to 4/5 for demonstrating empathic behavior. Mean scores improved after the training in each domain, p < 0.01 for all domains (see Figure 2). Half of the individual participants reported improved preparedness for each domain, one participant reported no improvement in any domain, and the remainder of participants improved in 1 to 5 domains.

Figure 2. Self-rated Preparedness Before and After the Communication Skills Training.

Notes: Mean pre- and post-scores are reported. Paired t test values less than 0.01 for each domain.

The skills training workshop was rated highly in terms of relevance of content (4.9/5), importance of topic (5/5), effectiveness of facilitators (4.9/5), opportunity for interaction (5/5), and overall quality (5/5). Data were missing from one participant in answering two questions from the post-assessment survey, and from 11 of 12 participants in answering one question due to formatting issues. Participants were eager to utilize active learning in the future and felt they had gained confidence in engaging in conversations. Qualitative data were collected in the form of free text responses on the post-assessment survey (see Table 4).

Table 4.

Qualitative Comments from Participants After the Workshop

Most important thing I learned:

“The importance of genuine communication.” “Not to be afraid to have difficult ‘big question’ discussions with my patients.” “That I can have difficult conversations.” “How to better deal with patient emotions and end-of-life issues.” “Taking the risk to talk with the patient.”

One thing you want to work on:

“Continue to explore avenues of conversation with the patient.” “Being quiet and allowing for silence.” “Listening with my whole focus.”

Discussion

Nurses and social workers rated the communication skills workshop highly and reported improved self-reported preparedness in ACP and palliative care. This interactive workshop utilized iterative cycles of didactics, demonstration, and role play with simulated patients, and incorporated established and novel teaching tools. In a small group of participants, we demonstrated that self-rated preparedness in communication skills improved across several domains.

Kidney palliative care (KPC) is gaining acceptance in the nephrology community, and multidisciplinary involvement in advance care planning is critical to the implementation of primary palliative care in dialysis units. Schell and colleagues (2013) and Cohen and colleagues (2016) demonstrated that nephrology fellows can gain communication skills in kidney palliative care through workshops that involved demonstration and role play (Cohen et al., 2016; Schell & Arnold, 2012; Schell et al., 2013). We have extended this work by demonstrating a similar workshop is feasible for nephrology nurses and social workers, and perceived preparedness improves as a result. To our knowledge, there are no previous reports of communication skills training in kidney palliative issues for dialysis nurses and social workers. This workshop differed from fellowship training programs in some important ways. We did not seek to place participants in the role of delivering ‘difficult’ news or prognostication, which could be considered outside of their scope of practice. We emphasized skills of responding to emotion, active listening, and responding to ‘big’ questions that arose from a qualitative study of dialysis nurses (Cheung et al., 2017). We also highlighted interdisciplinary communication by encouraging connection with other team members.

Previous work identified low comfort level as a reason dialysis nurses were not participating in ACP and KPC (Grbich et al., 2006). Our study indicates that a surrogate of comfort level, degree of preparedness, can be improved by a structured one-day communication skills workshop. This has advantages beyond the currently available resources to nephrology nurses in that our training focuses on skills rather than knowledge and utilizes real-time, participant-centered feedback. Although most participants had prior training in communication skills, only one-third had training specifically on how to respond to emotion and end-of-life concerns. It is likely that these skills would be valuable in ACP and KPC in patients on dialysis.

There are several strengths to this communication skills intervention. First, our intervention focused on members of the dialysis team who could play a key role in KPC but have not yet received dedicated communication skills training in this area. Second, the content of the intervention was informed by qualitative studies on the same population, which may have improved concordance with skills desired by learners and skills delivered/practiced in the workshop. Third, we relied on active learning principles, including tasks that called upon learners’ experiences and utilized cycles of brief didactic, demonstration, and role play to practice new skills. Feedback from participants indicated they benefited from this structure because they wanted a longer workshop, with even greater time for role play. Finally, we adapted our teaching methods from those already demonstrated to work in similar populations.

There are limitations to our work that deserve note. We trialed this workshop in a single institution, and although we had representation from across the state, the population was homogenous. It is conceivable that interest or preparedness may be different in our not-for-profit dialysis practice or influenced by the degree of rurality of the state. Generalizability may also have been influenced by the high proportion of experienced dialysis nurses in our group. Greater nursing experience may correlate with greater comfort level in discussing topics in KPC, and thus, greater propensity to take up the new skills and sense of preparedness, which was our main outcome. Barriers to future implementation include having trained simulated patients and faculty, as well as dedicated time for nurses and social workers to receive training.

Conclusion

To provide high-quality care, all members of the interdisciplinary dialysis team require excellent communication skills. Our communication skills workshop focused on the needs of dialysis nurses and social workers. We addressed key communication domains necessary for ACP and palliative care, which resulted in perceived improvement in preparedness across each domain. Future work may include interdisciplinary team communication involving nephrologists and fellows in the same workshop, and testing in larger, more diverse populations.