Elaine Wittenberg, PhD
Oncology nurses are known and respected to be the frontline of communication with their patients, but that does not mean that coordinating between families and palliative care clinicians or providing life-altering news always comes easy.
To strengthen communication, the National Cancer Institute granted City of Hope in Duarte, California, the funds to create the COMFORT curriculum, an evidence-based communication training course and the first train-the-trainer program for oncology nurses across the United States.
“Communication, empathy, and relationship-building are among the top three concerns reported by patients,” said Elaine Wittenberg, PhD, associate professor of Nursing Research and Education at City of Hope, and author on the results of the study. “Patients and families who report good healthcare experiences describe communication practices as timely, truthful, and compassionate.”
The curriculum, which emphasizes team communication, focuses on providing life-altering news, assessing patient/family health literacy needs, practicing mindful communication, acknowledging family caregivers, and addressing communication openings and goals. These issues are looked at across the cancer care continuum: diagnosis, treatment, survivorship, recurrence, and end of life.
After learning the curriculum, the 187 nurses then taught what they learned to additional healthcare providers, including primary nurses and physicians, ultimately educating an additional 2460 individuals, 1961 of them nurses.
“The goal of the course is to develop oncology nurses as experts who will return to their individual institutions, share information with others, and cultivate organizational change aimed at improving communication,” Wittenberg said.
COMFORT is currently 3 years into a 5-year grant, and researchers have captured 12-month follow up for the first course and post-course evaluation for courses 1 and 2.
“We are extremely pleased with the outcomes thus far,” Wittenberg said.
The modules most commonly taught included communication (25.5%), mindful communication (22.3%), team communication (18.5%), and family caregivers (11.4%).
“The train-the-trainer model for communication training appears to be a viable and promising strategy for broadly teaching communication across the cancer continuum,” the study says. “Train-the-trainer is less costly than traditional on-site training methods and allows instruction to be tailored to address the institution’s least effective communication practices across the cancer continuum.”
Many course participants said that their institution was least effective in communication between bereavement and time of death, and were most effective with communication during treatment.
Wittenberg said that this is because at diagnosis and throughout treatment, nurses are responsible for providing information about their diagnosis and treatments to patients and their families and caregivers. Nurses can explain the disease, the different treatment options, what kind of side effects can be expected and likely outcomes. During treatment, nurse communication takes place simultaneously with assessment and administration of treatment.
“In all of these instances, nurses have information to offer the patient and family. Communication at the end of life is challenging because patients and family members often avoid these topics, stress is high, and patients and families may lack of awareness that quality of life is as important as quantity of life,” Wittenberg said. “Overall, nurses are not clear what they should say or do for patients and families during this time. As a result, many nurses focus on physical care topics.”
But thanks to the COMFORT course, healthcare providers are improving their communication in many aspects, while also improving their scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a patient-reported survey which accounts for about 30% of value-based payments.
“Each module of the COMFORT curriculum matches items on the HCAHPS survey,” Wittenberg said. “We are seeing some great results ranging around a 5% and higher change in improvement.”
Nevertheless, Wittenberg said that the need for improvements in the field of patient-centered communication remain, such as discussing spirituality, which many healthcare providers say their patients bring up. Patients who are approaching end of life may want to review their life or gain forgiveness from self, others, or a higher power, Wittenberg said.
“Spiritual care is an intervention accomplished solely through communication, requiring nurses to engage in communication to facilitate spiritual meaning and explore forgiveness,” she explained, “Assessing spiritual and forgiveness concerns are important to ensuring quality end-of-life care and talking about spiritual concerns increases patient satisfaction.”
Wittenberg E, Ferrell BR, Hanson J, et al. Results from a train-the-trainer program for oncology nurses. J Clin Oncol
. 2016;34 (suppl 26S; abstr 26).