Quality improvement Randomised controlled trial
Effect of communication training on patient, family and healthcare provider outcomes: missing links 10.1136/eb-2014-101720 Kelly M Trevino,1 Holly G Prigerson2 1
Department of Psychiatry, Rowan University, Glassboro, New Jersey, USA; 2Department of Medicine, Weill Cornell Medical College, New York, New York, USA Correspondence to: Professor Holly G Prigerson, Department of Psychiatry, Weill Cornell Medical College, 525 East 68th Street, Box 39, New York, NY 10065, USA; [email protected]
Commentary on: Curtis JR, Back AL, Ford DW, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomised trial. JAMA 2013;310:2271–81.
Context Significant energy and resources have been devoted to the development of end-of-life (EOL) communication skills training programmes for healthcare providers. Development of these programmes is supported by evidence that patients who communicate with their providers about EOL care receive less aggressive care, early hospice enrollment and experience better quality of life at EOL.1 However, while palliative care communication skills training programmes improve providers’ communication skills,2 preliminary studies indicate that training does not affect patient-reported outcomes.3 This randomised trial examined the relationship between provider participation in a palliative care communication skills training programme, and patient-reported, family-reported and healthcare provider-reported outcomes.
mental status ( p=0.82) or family member depression ( p=0.33) in adjusted analyses. However, the intervention was associated with a significant increase in patient depressive symptom severity from preintervention to postintervention ( p=0.006).
Commentary These results are consistent with previous findings that communication skills training programmes are not associated with patient outcomes. Why do communication skills training programmes fail to impact patient well-being and perceptions of clinical care? We noted that the methodological characteristics may account for these results. However, we would like to propose two alternative explanations. The first is the potential role of the patient-provider therapeutic alliance (TA). TA is the collaborative bond between a healthcare provider and patient, characterised by mutual trust and respect. A strong TA is associated with patient mental and physical health, engagement in advance care planning, receipt of less aggressive EOL care and better quality of death.4 TA may mediate the relationship between provider communication skills and patient care and well-being. Provider communication skills training has been shown to be associated with increased patient trust in the provider, but not an increased TA.5 Communication skills training that improves the therapeutic bond may result in better EOL care of the patient and well-being. The second possible explanation for the failure of communication skills training to impact on well-being and perceptions of care is that current interventions focus primarily on the provider and the patient, often failing to consider the potential role of family caregivers in EOL decision-making.6 Most communication skills training programmes require multiple hours across multiple days—a commitment that is impractical and self-selected for a highly motivated group of clinicians. In addition, expecting weak and debilitated patients approaching EOL to modify their communication strategies seems unreasonable. Informal caregivers may be a potential resource for improving patient-provider communication. Training informal caregivers in effective communication and improving their self-efficacy to communicate with providers may provide a more feasible and effective method for using communication to improve patient EOL care and distress. Competing interests None.
Methods Internal medicine residents, subspecialty fellows, and nurse practitioners were randomly assigned to a simulation-based, communication skills intervention (n=232) or usual education (n=240). The intervention consisted of eight 4 h sessions that included didactics, skills practice (using simulated patient encounters) and reflective discussions. The primary outcome was the quality of communication (QOC); secondary outcomes included the quality of EOL care (QEOLC), patient and family member depression, and patient functional status. Measures were completed by patients and family members who had encounters with participants and clinicians who observed care provided by participants in 6 months before or 10 months after the intervention.
Findings Intervention participation was not significantly associated with QOC after covariate adjustment across evaluators ( p=0.15–0.94). In post hoc subgroup analyses, the intervention was not associated with QOC in outpatients (b=0.041, 95% CI −1.36 to 1.44), but was associated with QOC improvement for patients with ‘poor’ self-reported health status (b=1.43, 95% CI 0.28 to 2.58). Similarly, the intervention was not associated with QEOLC across evaluators ( p=0.20–0.88), patient physical status ( p=0.32),
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References 1. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665–73. 2. Goelz T, Wuensch A, Stubenrauch S, et al. Specific training program improves oncologists’ palliative care communication skills in a randomized controlled trial. J Clin Oncol 2011;29:3402–7. 3. Johnson LA, Gorman C, Morse R, et al. Does communication skills training make a difference to patients’ experiences of consultations in oncology and palliative care services? Eur J Cancer Care (Engl) 2013;22:202–9. 4. Mack JW, Block SD, Nilsson M, et al. Measuring therapeutic alliance between oncologists and patients with advanced cancer: the Human Connection Scale. Cancer 2009;115:3302–11. 5. Tulsky JA, Arnold RM, Alexander SC, et al. Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Ann Intern Med 2011;155:593–601. 6. Prigerson HG. Socialization to dying: social determinants of death acknowledgement and treatment among terminally ill geriatric patients. J Health Soc Behav 1992;33:378–95.
Effect of communication training on patient, family and healthcare provider outcomes: missing links 10.1136/eb-2014-101720 Kelly M Trevino,1 Holly G Prigerson2 1
Department of Psychiatry, Rowan University, Glassboro, New Jersey, USA; 2Department of Medicine, Weill Cornell Medical College, New York, New York, USA Correspondence to: Professor Holly G Prigerson, Department of Psychiatry, Weill Cornell Medical College, 525 East 68th Street, Box 39, New York, NY 10065, USA; [email protected]
Commentary on: Curtis JR, Back AL, Ford DW, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomised trial. JAMA 2013;310:2271–81.
Context Significant energy and resources have been devoted to the development of end-of-life (EOL) communication skills training programmes for healthcare providers. Development of these programmes is supported by evidence that patients who communicate with their providers about EOL care receive less aggressive care, early hospice enrollment and experience better quality of life at EOL.1 However, while palliative care communication skills training programmes improve providers’ communication skills,2 preliminary studies indicate that training does not affect patient-reported outcomes.3 This randomised trial examined the relationship between provider participation in a palliative care communication skills training programme, and patient-reported, family-reported and healthcare provider-reported outcomes.
mental status ( p=0.82) or family member depression ( p=0.33) in adjusted analyses. However, the intervention was associated with a significant increase in patient depressive symptom severity from preintervention to postintervention ( p=0.006).
Commentary These results are consistent with previous findings that communication skills training programmes are not associated with patient outcomes. Why do communication skills training programmes fail to impact patient well-being and perceptions of clinical care? We noted that the methodological characteristics may account for these results. However, we would like to propose two alternative explanations. The first is the potential role of the patient-provider therapeutic alliance (TA). TA is the collaborative bond between a healthcare provider and patient, characterised by mutual trust and respect. A strong TA is associated with patient mental and physical health, engagement in advance care planning, receipt of less aggressive EOL care and better quality of death.4 TA may mediate the relationship between provider communication skills and patient care and well-being. Provider communication skills training has been shown to be associated with increased patient trust in the provider, but not an increased TA.5 Communication skills training that improves the therapeutic bond may result in better EOL care of the patient and well-being. The second possible explanation for the failure of communication skills training to impact on well-being and perceptions of care is that current interventions focus primarily on the provider and the patient, often failing to consider the potential role of family caregivers in EOL decision-making.6 Most communication skills training programmes require multiple hours across multiple days—a commitment that is impractical and self-selected for a highly motivated group of clinicians. In addition, expecting weak and debilitated patients approaching EOL to modify their communication strategies seems unreasonable. Informal caregivers may be a potential resource for improving patient-provider communication. Training informal caregivers in effective communication and improving their self-efficacy to communicate with providers may provide a more feasible and effective method for using communication to improve patient EOL care and distress. Competing interests None.
Methods Internal medicine residents, subspecialty fellows, and nurse practitioners were randomly assigned to a simulation-based, communication skills intervention (n=232) or usual education (n=240). The intervention consisted of eight 4 h sessions that included didactics, skills practice (using simulated patient encounters) and reflective discussions. The primary outcome was the quality of communication (QOC); secondary outcomes included the quality of EOL care (QEOLC), patient and family member depression, and patient functional status. Measures were completed by patients and family members who had encounters with participants and clinicians who observed care provided by participants in 6 months before or 10 months after the intervention.
Findings Intervention participation was not significantly associated with QOC after covariate adjustment across evaluators ( p=0.15–0.94). In post hoc subgroup analyses, the intervention was not associated with QOC in outpatients (b=0.041, 95% CI −1.36 to 1.44), but was associated with QOC improvement for patients with ‘poor’ self-reported health status (b=1.43, 95% CI 0.28 to 2.58). Similarly, the intervention was not associated with QEOLC across evaluators ( p=0.20–0.88), patient physical status ( p=0.32),
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References 1. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665–73. 2. Goelz T, Wuensch A, Stubenrauch S, et al. Specific training program improves oncologists’ palliative care communication skills in a randomized controlled trial. J Clin Oncol 2011;29:3402–7. 3. Johnson LA, Gorman C, Morse R, et al. Does communication skills training make a difference to patients’ experiences of consultations in oncology and palliative care services? Eur J Cancer Care (Engl) 2013;22:202–9. 4. Mack JW, Block SD, Nilsson M, et al. Measuring therapeutic alliance between oncologists and patients with advanced cancer: the Human Connection Scale. Cancer 2009;115:3302–11. 5. Tulsky JA, Arnold RM, Alexander SC, et al. Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Ann Intern Med 2011;155:593–601. 6. Prigerson HG. Socialization to dying: social determinants of death acknowledgement and treatment among terminally ill geriatric patients. J Health Soc Behav 1992;33:378–95.
