Let's Talk Critical. Development and Evaluation of a Communication Skills Training Program for Critical Care Fellows

Abstract

Rationale: Although expert communication between intensive care unit clinicians with patients or surrogates improves patient- and family-centered outcomes, fellows in critical care medicine do not feel adequately trained to conduct family meetings.

Objectives: We aimed to develop, implement, and evaluate a communication skills program that could be easily integrated into a U.S. critical care fellowship.

Methods: We developed four simulation cases that provided communication challenges that critical care fellows commonly face. For each case, we developed a list of directly observable tasks that could be used by faculty to evaluate fellows during each simulation. We developed a didactic curriculum of lectures/case discussions on topics related to palliative care, end-of-life care, communication skills, and bioethics; this month-long curriculum began and ended with the fellows leading family meetings in up to two simulated cases with direct observation by faculty who were not blinded to the timing of the simulation. Our primary measures of effectiveness were the fellows' self-reported change in comfort with leading family meetings after the program was completed and the quality of the communication as measured by the faculty evaluators during the family meeting simulations at the end of the month.

Measurements and main results: Over 3 years, 31 critical care fellows participated in the program, 28 of whom participated in 101 family meeting simulations with direct feedback by faculty facilitators. Our trainees showed high rates of information disclosure during the simulated family meetings. During the simulations done at the end of the month compared with those done at the beginning, our fellows showed significantly improved rates in: (1) verbalizing an agenda for the meeting (64 vs. 41%; Chi-square, 5.27; P = 0.02), (2) summarizing what will be done for the patient (64 vs. 39%; Chi-square, 6.21; P = 0.01), and (3) providing a follow-up plan (60 vs. 37%; Chi-square, 5.2; P = 0.02). More than 95% of our participants (n = 27) reported feeling "slightly" or "much" more comfortable with discussing foregoing life-sustaining treatment and leading family discussions after the month-long curriculum.

Conclusions: A communication skills program can be feasibly integrated into a critical care training program and is associated with improvements in fellows' skills and comfort with leading family meetings.

Keywords: communication skills; critical illness; medical education.

Figure 1.

Structure and flow of the communication skills program. Fellows started the month with an opportunity for up to two simulated family meetings with directed feedback and then attended lectures and case-based discussions around palliative care, bioethics, and end-of-life care in the intensive care unit (ICU). At the end of the month, the fellows were given another opportunity to participate in up to two family meeting simulations with directed feedback.

Figure 2.

Fellows’ performance of communication tasks during family meeting simulations. Shows the performance rates for nine communication tasks that faculty facilitators were asked to document in all family meeting simulations. Explicitly attending to emotions refers to any of five strategies used to acknowledge emotions during a communication encounter (reflected in the mnemonic “NURSE” for Naming, Understanding, Respect, Supportive Statement, and Explore). First Simulations refers to family meeting simulations done at the beginning of the month-long curriculum, and Second Simulations refers to those done at the end of the month. Consensus was reached regarding the skill level of each task: level 1 skills were considered necessary for effective communication; level 2 skills were considered intermediate communication skills that could be used to enhance communication and rapport building; level 3 skills were advanced skills that were unlikely to accrue with experience alone. *Comparisons between the first and second simulations were not statistically significant except for the three that are highlighted in the figure.

Figure 3.

Faculty ratings of simulations across four quality domains. Shows the faculty quality ratings for the family meeting simulations across four quality domains. First Simulations refers to family meeting simulations done at the beginning of the month-long curriculum, and Second Simulations refers to those done at the end of the month. *Does not add up to 100% because of missing data. ^†Does not add up to 100% because of the many simulations where no follow-up plan was provided. ^‡Comparisons between the first and second simulations were not statistically significant except for the two that are highlighted in the figure.

Figure 4.

Fellows’ self-assessment at the end of the month-long curriculum. Shows the percent of program participants who felt that they were slightly more comfortable or much more comfortable performing the four communication challenges after the month-long curriculum.