27CHAPTER 4
Teaching and Evaluating Therapeutic Communication in Simulated Scenarios
Communication is the foundation for all interpersonal relationships and involves an authentic presence and facilitative style that indicates one’s interest in and care for another. In health care, an interaction between health care professionals and patients is called therapeutic communication and is operationally defined as “aims to enhance the patient’s comfort, safety, trust, or health and well-being” (“Therapeutic communication,” 2017). When therapeutic communication is done well, patients are comforted, feel safe, and develop a sense of trust in health care professionals. This contributes to improved health or sense of well-being and a safe environment with improved quality of care. Communication is necessary to build trustworthy and therapeutic relationships.
In looking for frameworks that resonate with the importance of communication, the language within the American Academy Colleges of Nursing BSN and MSN Essentials refers to communication within leadership, advocacy, telehealth, and interprofessional areas (American Association of Colleges of Nursing [AACN], 2008, 2011) and there is an acknowledgment of the importance of communication as a critical skill to be practiced and learned as part of professional nursing. However, the Canadian Code of Ethics for Registered Nurses holds references to communication in both ethical responsibilities 2 and 3 under A. Providing Safe, Compassionate, Competent, and Ethical Care:
2. Nurses engage in compassionate care through their speech and body language and through their efforts to understand and care about others’ health-care needs.
3. Nurses build trustworthy relationships as the foundation of meaningful communication, recognizing that building these relationships involves a conscious effort. Such relationships are critical to understanding people’s needs and concerns. (CNA, 2008, p. 8)
One of the main competencies health professionals are expected to master is therapeutic communication; regulators look for it in ethical codes of conduct and accrediting bodies evaluate curriculum and education looking for evidence of students’ mastery of communication, both with patients and interprofessionally. Competency in communication is an expectation of all health professionals.
Studies have suggested that communication may have direct and/or indirect effects on patients’ health, such that when patients receive clinicians’ support and clear explanations about treatment, they establish trust and better understand the next steps. This open communication facilitates the follow-up process and positively affects the health outcomes. Through effective communication, health teams work together with the patient to recognize patients’ needs and devise a suitable plan to meet those needs (Leonard, Graham, & Bonacum, 2004). Misconceptions can be identified and clarified, accommodating patients’ varying health literacy needs, leading to 28power sharing in decision making and improving self-maintenance of patient health (Siminoff et al., 2011; Street, Makoul, Arora, & Epstein, 2013).
The World Health Organization (WHO) has outlined a framework for action on interprofessional education (Interprofessional Education Collaboration [IPEC], 2011; WHO, 2010) and encourages practitioners coming together in team-training exercises. The simulation environment provides an opportunity to bring together health professionals from varying backgrounds to allow for the development of leaders and promotion of ethical behaviors as they gain a perspective on each other’s roles and scopes of practice, and an opportunity to foster professional attitudes. In addition, these simulated scenarios provide a practice arena for both technical and nontechnical skills, such as communication strategies, and research demonstrates that this method of teaching can affect the quality and safety of patient care (Commission, 2010; Cooper et al., 2012; Institute of Medicine [IOM], 2001).
Other researchers have identified a connection between miscommunication and adverse events or errors in clinical practice, which affects the quality of care (Fay-Hillier, Regan, & Gallagher Gordon, 2012). In order to minimize miscommunication, a variety of strategies and tools have been used from other disciplines with good outcomes. Nevertheless, these strategies are often limited to communication among health professionals rather than communication between health professionals and their patients. One example is the SBAR acronym purported to improve communication in urgent situations by incorporating the following aspects in the report or handover: situation, background, assessment, and recommendation (Clancy, 2008; Institute for Healthcare Improvement [IHI], 2016; Thomas, Bertram, & Johnson, 2009). Another tool for communication among health professionals is iDRAW, which aims to define a pattern of information to be exchanged between health professionals in nonurgent handover situations by incorporating an interactive component and its acronym; iDRAW, stands for: i = identify patient and most responsible practitioner (MRP), D = diagnosis/current problems, R = recent changes (e.g., up to date vitals), A = anticipated changes (in next few hours), and W = what to watch for (Hill, 2013; Hill & Marcellus, 2015). Finally, TeamSTEPPS® has been used for interdisciplinary team-based communication (Weaver et al., 2010; Zhang, Miller, Volkman, Meza, & Jones, 2015).
In the past two editions of this text, this chapter has outlined the usefulness of simulation for the teaching, assessment, and evaluation of health communication for practitioner–patient, practitioner–practitioner, and team communication (O’Shea, Pagano, Campbell, & Caso, 2013; Pagano & Greiner, 2013). This new chapter provides an overview of methods to assess and evaluate therapeutic communication by health care professionals with patients. The focus of this chapter is on the education, assessment, and evaluation of health communication skills to improve health outcomes (Bhui et al., 2015) through patient-centered care (Epstein & Street, 2007) with the use of simulation. It provides a brief introduction of the development of a new Global Interprofessional Therapeutic Communication Scale (GITCS©) and subsequent development of train-the-trainer videos for health professions educators. Many researchers and health professions educators have invested their time and resources into enhancing therapeutic communication through the use of innovative teaching and learning models, such as simulation. Their goal is to prepare health professionals in their ongoing development of therapeutic communication or relationship techniques that will create a high-quality and safe health care system that truly serves the populations in need. Ultimately, these techniques can improve patients’ experiences within the health care system—increasing patients’ understanding to maintain well-being, providing a more satisfactory interaction so patients are partners in determining their treatment and plan of care, and removing accessibility barriers, such as cultural and health literacy factors, that may create a less-than-optimal experience.
Communication skills are widely recognized as a desirable “nontechnical” skill for nurses (Lai, 2016). Mental health nurses have provided leadership in studying therapeutic communication with standardized patients (SPs; Doolen, Giddings, Johnson, de Nathan, & Badia, 2014), yet communication is a core competency for all nursing disciplines as well as all health professionals: physicians, nurses, nutritionists, physiotherapists, psychologists, social workers, and so on. Health care providers are in direct contact with patients and their families and communicate in 29team-based situations continuously, such that communication in the health care context is a main issue reflecting on quality and safety, especially in areas such as the emergency room or operating room (Shapiro et al., 2004; Theilen et al., 2013; Weaver et al., 2010). Therefore, enhancing our ability to educate prelicensure and practicing clinicians by developing methods, education tools, and evaluation or assessment capabilities is crucial.
REVIEW OF LITERATURE: INSTRUMENTS TO SUPPORT TEACHING AND EVALUATION OF HEALTH PROFESSIONAL STUDENTS’ HEALTH COMMUNICATION
In order to provide effective education in communication skills for health care professionals, it is necessary to move beyond conceptualization to feasible methods of implementation and measurement. Table 4.1 provides a review of the literature representing instruments that have been developed and validated to support teaching or evaluation in health communication. This recognizes the scarce resources presently available, similar to findings from a previous study (Caron et al., 2013). In addition, the International Nursing Association for Clinical Simulation and Learning (INACSL) has identified the gap in reliable and valid instruments or scales for testing, research, and evaluation in simulation, and has created a Repository of Instruments Used in Simulation Research (INACSL, 2015; Kardong-Edgren, Adamson, & Fitzgerald, 2010).
These instruments have been used to teach and evaluate therapeutic communication skills in health professionals, mostly physicians and nurses. The instruments identify important elements of therapeutic communication and include both positive and negative behaviors that influence the interaction, as well as concepts related to relationship building. Each instrument examined is attempting to systematize and measure the concept of therapeutic communication and in so doing brings to the forefront consistent themes and behaviors. These instruments all have strengths for the context in which they were used, but a global scale, adapted for different cultural contexts and translated into different languages specific to health care professional and patient communication, does not yet exist.
When considering something as simple as introductions, differences among cultures abound. For example, in certain cultures, patients may not make direct eye contact while communicating with a health care provider, which can sometimes be perceived as the patient being disinterested or disengaged; however, the patient may be quietly reflecting or might not be comfortable holding the gaze of someone of another gender. In the health care setting, a smile with eye contact is the most common and socially acceptable greeting during an introduction between health care professionals and patients. In North America, a handshake is perceived, for the majority, as a respectful and appropriate introductory greeting. Individuals from South Asian cultures would perceive a nod with no touching at all to be more respectful. In Brazil, although a handshake may be an appropriate greeting, it is perceived to be very formal and generally associated with a business environment. Apart from introductions, the health care planning process also presents a plethora of cultural differences. For example, in some cultures, it is the family who helps to devise the plan especially if the patient is living in an extended family household or the patient relies on family members to help interpret and navigate the health care system. Simulation provides a risk-free opportunity for students to learn about therapeutic communication in a culturally safe manner.
Because of globalization, nurses find themselves caring for diverse people from a variety of countries with social, cultural, and religious differences and whose interaction and expectation of health care professionals may vary widely as well. Navigating care requires advanced communication skills and a solid foundation in health care professional curriculum with an opportunity to practice, receive feedback, and reflect on best practices. Simulation is well suited for this type of experiential learning.
Therefore, after an attempt to translate one of the instruments in Table 4.1, a decision was made to start from scratch with an international team and create an instrument that would be 30globally adaptable, reflective of a broad range of interprofessional health care professionals, and useful in academic and clinical environments. For this reason, the GITCS was developed (Campbell & Aredes, 2017).
31GITCS DEVELOPMENT
Attempting to use one of the other communication scales proved to be very ineffective because of poor interrater reliability and difficulty translating the scales in an international environment. This led to the authors going back to examine theory and skills from mental health on “therapeutic communication.” Based on empirical knowledge from years of practicing and teaching nursing and with input from interprofessional and international colleagues from many disciplines, a 45-item scale was developed and was used in a pilot study with nine nursing faculty from seven schools in a province in Canada to evaluate student nurse communication during a simulated scenario with either a human patient simulator (HPS) or an SP. Two expert panels reviewed the items and identified constructs for each of these items (Campbell & Aredes, 2017).
This scale developed items categorized according to active listening, empathy, empowerment, verbal and nonverbal communication, rapport and trust building, barriers, and cultural boundaries, among others. The goal was to create an instrument capable of supporting faculty, students, and health professionals in learning and assessing appropriate actions to establish and maintain therapeutic communication in an international environment. The hope is that the use of GITCS will allow teachers and facilitators to identify individuals’ strengths and weaknesses easily during active learning experiences, such as simulations or interactions with patients in clinical practicums (students) or work activities (health professionals).
A recent study (Lum, Dowedoff, & Englander, 2016) stated the importance of training immigrant nurses in therapeutic communication, considering the differences in the process of nursing education and work in practice amid various countries, in addition to changes in the cultural context and, sometimes, language. Although the study arose in Canada, we believe that, given globalization, this discussion is relevant in many countries and the researchers’ findings for a need to strengthen therapeutic communication in nursing courses and strengthen self-assessment among nurses about their knowledge in communication resonates with what we have experienced.
GITCS was developed and is being validated in Canada. Validity and reliability will be tested using an international and interprofessional sample of health care professional educators who use simulation for education. A multicenter research project in a province in Canada will also test its reliability and validity across sites, level of students, and varied simulation and clinical experiences. In addition, it will be translated into French, Portuguese, Spanish, Mandarin, and Punjabi, in collaboration with colleagues in Quebec, Brazil, Chile, Hong Kong, and India, respectively. Other validation in countries where English is the main language will be possible, including the United Kingdom, Ireland, Australia, United States, and other areas with interested participants. The scale will be appropriate for use in simulated and clinical environments, with prelicensure or seasoned clinicians.
LIGHTS, CAMERA, AND ACTION
To set up a train-the-trainer opportunity for health care professions faculty and in order to validate the GITCS, videos were developed demonstrating interactions between an RN and a patient during a home care visit. Therefore, it was possible to test the items’ application over the same interaction presented in three different ways: overall therapeutic communication with good behaviors, overall nontherapeutic communication with poor behaviors, and mixed communication combining both good and poor behaviors.
32Because of the complexity of clinical settings, we chose to film the videos in a structured environment using a trained actor and public health nurse faculty with decades of experience. The scenario involved a visit by a public health RN to an older adult at her home and was roughly scripted based on Chapter 24 in the second edition of this text (Mager, 2012).
The videos provided a level of consistency for train-the-trainer education and validation of the instruments’ reliability. In addition, the videos match teaching needs by allowing for pausing, rewinding, forwarding, and replaying anytime depending on the students’ needs. Other studies have shown positive results using videos of simulation for teaching and evaluating therapeutic communication in health care (Hammer, Fox, & Hampton, 2014).
FILMING: THE CHALLENGES OF PRODUCING AN EDUCATIONAL VIDEO
In preparation for the production of videos for train-the-trainer education, the authors used a scenario from the second edition of this text (Mager, 2012), home care of a patient with elevated blood sugars, to create a script with three modules that became three separate videos. As mentioned previously, the goal was to create modules demonstrating good, bad, and mixed therapeutic communication. The intention in creating the videos was to be able to portray sufficiently different interactions that would demonstrate good and poor therapeutic communication behaviors.
Lessons learned in creating these videos included that it would have been helpful for more of a rehearsal process before filming the videos. Scheduling conflicts meant that the faculty member was unable to meet the crew or the actress before the filming process began. In hindsight, it is important to have time allotted for the actors to meet and practice with the director’s guidance. A suggestion would be to consider including the actors in the development of the script, the production meetings, allowing ample time for discussion and questions so that they have a clear understanding of the video and its purpose. This would enhance the development of such tools and create a more beneficial learning process for all involved. When the faculty member and actress finally met, they became comfortable with each other and briefly practiced the scenarios before the filming began.
As a faculty member acting the RN role, the scenario of overall therapeutic communication with good behavior was easy to memorize and act out during production. However, it was challenging and difficult to act out the patient scenario with overall nontherapeutic communication with bad behaviors. It had become second nature to always conduct communication with patients using excellent therapeutic communication skills so that when prompted to act out scenes with bad behavior, it was challenging to speak. This made it difficult to follow the script, which was incumbent to demonstrating bad communication and meeting the goal of the video. In future, recognizing that a seasoned and expert nurse may face more challenges with the poor behavior video, we would have scheduled more time for filming that portion. We also recommend that it would have been better to film this more difficult scenario first.
These videos provided nurse educators concrete examples of good and poor behaviors and allowed for an opportunity to reflect on therapeutic communication. This opportunity for reflection allowed discussion of strategies for improved communication and methods to develop trust and rapport while being respectful and actively listening to the client’s needs. Finally, videotaped examples allowed for moving at the individual’s own pace of learning and helped to connect effective communication techniques to actual clinical practice, which can encourage students to think of examples of when communication with a patient went particularly well or particularly poorly.
In the area of instrument development, video recording can also be used as a strategy to educate faculty about the instrument’s features and uses, and can allow for beginning interrater reliability testing and enhancement.
33EVALUATING THERAPEUTIC COMMUNICATION THROUGH SIMULATION
Creative and experimental strategies for learning and the adoption of more participative learning theories, in the student’s point of view, have increased alongside technology and innovation (Hammer et al., 2014). The use of simulation in teaching therapeutic health communication is successful when students are able to project themselves into a “real situation,” experiment with different approaches, debrief with a group, and know they are in a controlled environment that allows for error without life-threatening adverse events. Many studies have reported simulation use as a strategy to teach communication in the health arena and have identified favorable results (Caron et al., 2013; Fay-Hillier et al., 2012; Fejzic & Barker, 2015; Kameg, Howard, Clochesy, Mitchell, & Suresky, 2010; Strada, Vegni, & Lamiani, 2016); and as such, simulation is a valuable ally of health communication skills improvement.
When running a simulation, faculty are encouraged to observe the dynamic interaction critically by using a tool to assess various areas of therapeutic communication and positive or negative interactions. After the scenario is complete there is time to use debriefing questions to discuss with students their perception of their performance and identify what they felt good about and areas where they believe they can do better.
Learning about health communication is an important activity even for experienced professionals. One research study used simulation to train health professionals from diverse backgrounds to communicate with their patients around the topic of sexuality. Even with a mean of 11 years of experience in the clinical practice field, the participants, physicians, nurses, and psychosocial professionals consistently reported acquiring new strategies of communication to not only approach the sexuality subject, but also to explore patients’ health concerns related to sexuality. The researchers emphasized the importance of communication and relational skills, and appreciated the interactivity allowed through simulation as a pedagogical approach (Strada et al., 2016).
Simulation promotes engaging experiences of learning for adults (students, health professionals, and even professors, in the perspective of continuous learning). It naturally arouses curiosity and inquiry, providing a rich environment to develop critical thinking, clinical reasoning, and self-reflection (Hammer et al., 2014). Faculty and students observe that they like this form of “hands-on” activity and found, even if they were the observer and member of the debriefing group, they felt they had better knowledge about the team and experienced greater satisfaction in the method of learning (Fay-Hillier et al., 2012; Fejzic & Barker, 2015; Strada et al., 2016).
Studies that combined health communication skills training and simulation did have differences in preference related to the use of actors—SPs over HPSs, even with high-fidelity HPSs. Researchers stated that sometimes it is hard to interact properly with an HPS because it does not manifest nonverbal signs (Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009), which are considered important in communication. In this regard, it is important to consider what is being accomplished and how you will teach and evaluate health communication skills through simulation whether the “patient” is an HPS or an SP.
Debriefing is the core of simulation as it is the moment for reflection, concept rebuilding based on simulated actions, and exchange of information with colleagues and teachers or facilitators (Decker et al., 2013). After the simulation scenario, it is crucial to discuss the effectiveness of communication with students identifying what went well and what might be improved to enhance the relationship between the health professional and the patient and their families to provide patient-centered care. Considering that most clinical experiences do not allow for clinical faculty to observe every interaction or provide feedback for students about their communication skills, simulation provides a feasible venue to build skills to mastering therapeutic communication.
34FUTURE OF THERAPEUTIC COMMUNICATION
Based on our academic and clinical practice in Canada, the United States of America, and Brazil, we conclude that checklists or instruments support the debriefing process to provide useful feedback to students or health professionals, to identify completed performance, and facilitate the follow-up of skills improvement throughout the course. However, we are still lacking a robust, valid, and reliable tool to measure outcomes in health communication between professionals and patients and families, in both global and interprofessional scenarios. The researchers who used simulation to teach communication did not have this type of instrument, because they usually developed their own to conduct research or approached self-efficacy techniques to present data. Still, all of them stated that this lack of a standard measurement tool is a limitation and suggested one should be developed for future research and that it would be best to use validated instruments (Fay-Hillier et al., 2012; Fejzic & Barker, 2015; Hammer et al., 2014; Kameg et al., 2010; Kawamura, Mylopoulos, Orsino, Jimenez, & McNaughton, 2016).
Given the complexity of a faculty’s role, it is important to establish a way to evaluate health communication globally. Faculty members are responsible for complex evaluations during a simulation, including clinical reasoning, critical thinking, as well as cognitive and procedural knowledge. Therefore, a valid, reliable, and simple instrument to measure student performance would be a valuable asset.
Broadly, the flexibility simulation provided is an incentive for teachers to offer engaging learning in therapeutic communication skills training that is aligned with learning objectives and patient-centered care. This chapter describes some of the instruments and scales available today as well as an innovative new method for validating an instrument that will also be used in a train-the-trainer fashion globally.
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