Introduction
It is now established that all patients with serious illness, including those with cancer, should have early access to high-quality palliative care and that patients can benefit from specialist palliative care consultation (Bakitas et al., Reference Bakitas, Lyons and Hegel2009; Temel et al., Reference Temel, Greer and Muzikansky2010; Greer et al., Reference Greer, Pirl and Jackson2012; El-Jawahri et al., Reference El-Jawahri, LeBlanc and VanDusen2016; Walling et al., Reference Walling, Tisnado and Ettner2016). While specialty teams are growing in number and size, the increasing demand for palliative care in oncology is unlikely to be met by specialists alone (Spetz et al., Reference Spetz, Dudley and Trupin2016). One way to address this need is by elevating “primary” — i.e., non-specialist palliative care (PPC) — practice. The movement to strengthen PPC has widespread support among leading oncology, palliative care, and nursing organizations. They recommend that all oncology clinicians be educated in palliative care to support the creation of a culture that normalizes interprofessional palliative care as part of comprehensive cancer care (Hui and Bruera, Reference Hui and Bruera2015; Bickel et al., Reference Bickel, McNiff and Buss2016; Oncology Nursing Society, 2019). The oncology nurse is identified as vital to the promotion of widespread palliative care, an issue that has become increasingly important during the COVID-19 pandemic (Rosa et al., Reference Rosa, Dahlin and Battista2021).
Evidence demonstrates the importance of skillful, empathic communication in the care of seriously ill patients (Curtis et al., Reference Curtis, Downey and Back2018). Empathic responses to emotion help promote communication and enhance coping among patients and caregivers (Pollak et al., Reference Pollak, Arnold and Jeffreys2007; Pehrson et al., Reference Pehrson, Banerjee and Manna2016). Education of medical professionals in communication skills improves the expression of empathy and addresses emotions (Wittenberg et al., Reference Wittenberg, Ferrell and Goldsmith2016; Selman et al., Reference Selman, Brighton and Hawkins2017; Ferrell et al., Reference Ferrell, Buller and Paice2019; Paladino et al., Reference Paladino, Kilpatrick and O'Connor2019). However, oncology nurses have reported feeling unprepared in responding to emotion (Chen and Raingruber, Reference Chen and Raingruber2014; Hill et al., Reference Hill, Evans and Forbat2015). Nurses recognize the special challenges involved in addressing patients’ emotional needs yet describe inadequate access to communication training programs with this focus (Rask et al., Reference Rask, Jensen and Andersen2009; Banerjee et al., Reference Banerjee, Manna and Coyle2016; Bumb et al., Reference Bumb, Keefe and Miller2018). This article describes the development and dissemination of a novel tool to enhance empathic communication skills among nurses within an institutional PPC quality improvement initiative.
The End-of-Life Nursing Education Consortium (ELNEC), a curriculum that was first developed almost 20 years ago, has educated tens of thousands of nurses in best practices for end-of-life communication (Ferrell et al., Reference Ferrell, Malloy and Virani2015). Subsequent communication skills training programs for nurses have incorporated core ELNEC methods, including the use of didactic modules and participatory educational sessions (Coyle et al., Reference Coyle, Manna and Shen2015; Bishop et al., Reference Bishop, Mazanec and Bullington2019). Communication training programs created for physicians, such as VitalTalk, emphasize the importance of interactive sessions including supervised practice and structured feedback (Jackson and Back, Reference Jackson and Back2011) to complement didactic pedagogy. Research has demonstrated the value of combining didactic and interactive models, including role play (Pulsford et al., Reference Pulsford, Jackson and O'Brien2013; Wittenberg-Lyles et al., Reference Wittenberg-Lyles, Goldsmith and Ferrell2014). This approach usually consists of multi-day training sessions for small groups of clinicians. For example, the COMSKIL program, an interdisciplinary communication skills training initiative developed at our institution in 2005, consists of lectures and practice sections with simulated patients over the course of a two-day workshop (Kissane et al., Reference Kissane, Bylund and Banerjee2012). Palliative care communication training programs, including COMSKIL, that incorporate these components have been successful in improving nurses’ communication skills and confidence (Krimshtein et al., Reference Krimshtein, Luhrs and Puntillo2011; Wittenberg-Lyles et al., Reference Wittenberg-Lyles, Goldsmith and Ferrell2014; Coyle et al., Reference Coyle, Manna and Shen2015; Buller et al., Reference Buller, Virani and Malloy2019; Fuoto and Turner, Reference Fuoto and Turner2019).
We identified the need for a compact tool that can be quickly learned, easily remembered, and used efficiently in a fast-paced clinic environment. The Acknowledge–Normalize–Partner (ANP) Framework is a practical and evidence-based educational tool that was created to address the specific priorities and needs of oncology nurses for communicating with patients and designed to enhance empathic communication skills in a variety of situations. The goal of creating this tool was to enhance nurses’ communication skills through an approach that could be easily and efficiently learned and effectively implemented even in busy clinics. We also sought to explore the impact of this nurse training on patient perceptions of the quality and frequency of nurses’ discussions of patient values in outpatient oncology care. The development and the subsequent broad dissemination of the ANP Framework beyond The 1-2-3 Project to nursing professionals (both outpatient and inpatient) across the institution are described below.
Methods
Development of the ANP Framework: Initial discovery phase
Communication skill needs of oncology nurses were first assessed through focus groups that were audio-recorded with participants’ consent. Specialist palliative care advanced practice nurses (APRNs) utilized a written guide to conduct 1-h focus groups including both inpatient and outpatient oncology nurses as participants. Discussion domains included: (1) the most rewarding/challenging aspects of the nurses’ current role; (2) perceptions of the communication needs of patients; (3) how the nurses respond to a patient in emotional distress; and (4) the nurses’ role in PPC. Before each session, the participating nurses were asked to complete a short, 14-item questionnaire adapted from prior communication research (Krimshtein et al., Reference Krimshtein, Luhrs and Puntillo2011) to assess their comfort in a variety of challenging communication scenarios. An interprofessional/interdisciplinary team of physicians, nurses, and APRNs analyzed transcripts of the focus group sessions individually to identify themes. The team later met and refined those themes in order to create the final codebook.
The ANP Framework guide
Based on the focus group discussions and guided by clinical expertise, a list was compiled of patient statements reflecting emotional distress commonly heard by oncology nurses (e.g., “What's going to happen to me?”, “I'm scared”, and “Am I dying?”). These were categorized into themes, including fear, worry, sadness, uncertainty, isolation, avoidance, and anger. For each theme, specialist palliative care APRNs developed explicit empathic responses, which were then categorized into a three-step framework guiding nurses to: Acknowledge emotions, Normalize the experience, and Partner with patients and caregivers to provide emotional support – named the ANP Framework (Figure 1).
Fig. 1. The ANP Framework.
Educational pilot
Session 1
The ANP Framework was first piloted in four outpatient oncology clinics as part of The 1-2-3 Project (Desai et al., Reference Desai, Klimek and Chow2018; Epstein et al., Reference Epstein, Desai and Bernal2019), a quality improvement initiative that aims to normalize and systematize palliative care in the outpatient setting and elevate PPC practice, with a focus on the role of the oncology nurse. The project employed a small group teaching format (two Palliative Care APRN facilitators and two to three nurse trainees) combining didactic and role-play techniques in two sessions lasting approximately 45 min each, 1 month apart. A printed guide listed patient emotions, provided examples of empathic responses, and offered follow-up questions, considerations, and additional resources (Figure 2). Patient scenarios were created in advance and scripts were utilized to ensure uniform content delivery. In Session 1, the two facilitators demonstrated the use of ANP in a simulated patient–nurse discussion in which the patient expressed emotional distress. Nurse trainees then practiced in a role play with facilitators as patients and could refer to the printed guide throughout the session. Facilitators provided direct feedback and encouraged trainees to provide feedback to one another. Sessions were completed during regular shifts and did not require supplementary conference funding nor staffing. Nurses who completed this training were formally debriefed about session content, usability, and feasibility. They were asked to practice the ANP skills they learned prior to the second session.
Fig. 2. Excerpt from the ANP Framework training guide.
Session 2
Session 2 served as a “booster” to reinforce learning from the previous session. Trainees were asked in advance to think of scenarios involving patient emotion that they found challenging in their own clinic. They shared these experiences and practiced responses using the ANP Framework in role-playing exercises. Facilitators provided feedback to help trainees further refine communication skills. A final debriefing session was conducted to determine whether content was complementary to the first session and allowed nurse participants to build on their skills.
Quality of communication
The Institutional Review Board granted approval to evaluate the impact of ANP Framework education on the impact of the intervention and on patient outcomes. Patients from six solid tumor gastrointestinal oncology clinics were asked to describe and rate the quality of nurse communication about their values using the validated Quality of Communication questionnaire (Engelberg et al., Reference Engelberg, Downey and Curtis2006). Three clinics in the pilot intervention group implementing The 1-2-3 Project included nurses who had undergone communication skills training practicing values discussions using the ANP Framework, while nurses in three other clinics provided usual care without this training (Epstein et al., Reference Epstein, Desai and Bernal2019).
Broad dissemination
Champion training
Based on the positive feedback and experiences of nurses participating in The 1-2-3 Project, eligibility for participation was expanded to include both inpatient and outpatient nurses to allow for broad dissemination throughout the institution. A network of palliative care champions (Lindley et al., Reference Lindley, Herr and Norton2017), representing care settings throughout the center, was created to disseminate the educational framework more broadly. Nurses with interest and/or demonstrated skill in PPC either self-identified or were nominated by their managers to participate as future champions. They then participated in a one-day educational program, developed in collaboration with the Department of Nursing, which consisted of didactic sessions and communication skills training and for which the nurses received continuing education credits. The first half of the program included didactic presentations on foundational palliative care principles, the role of the champion in culture change, and an introduction to The 1-2-3 Project. Champions discussed their experiences in oncology, their perceptions of palliative care, and the factors affecting palliative care integration into their clinical practices.
Trainees were then divided into groups of up to eight, with two facilitators per group; facilitators were specialist palliative care RNs including nurses from The 1-2-3 Project, palliative care APRNs, and palliative care physicians. These groups participated for about 3 h in intensive communication skills practice adapted from the initial model, using the same printed guide with an expanded list of patient scenarios. Activities included exercises on recognizing emotions, practicing empathic responses in the ANP Framework, and multiple rounds of role play with structured feedback. At the end of the day, learners demonstrated their ANP skills through a simulated discussion eliciting patients’ core health-related values (e.g., “What does living well mean to you at this time?”; Epstein et al., Reference Epstein, Desai and Bernal2019). Pre- and post-education day evaluation surveys were completed by course participants.
Champion dissemination
Champions who had completed this training went on to participate in monthly meetings in which they shared practice-level progress and received supplemental palliative care education to further develop their knowledge and expertise. Each champion was assigned a mentor to support and encourage growth, provide ongoing feedback, and guide the development of unit-based projects to help establish the champion role and integrate PPC into the culture of units throughout the institution (Figure 3).
Fig. 3. ANP dissemination.
Follow-up interviews
Several follow-up interviews were conducted with champions who had completed the educational day. The interviews were facilitated by one specialist palliative care APRN who used a semi-structured interview guide. Interviews were audio-recorded. The champions were asked open-ended questions about their satisfaction with the educational day, the usefulness of the ANP Framework, and examples of how the ANP Framework influenced their clinical practice. Transcripts were created from the audio recording and reviewed by the APRN and a physician collaborator. Common themes were identified, and the coding was agreed upon by both parties.
Results
Initial discovery phase
A total of four focus groups involving 12 oncology nurses were conducted. Participants were all female, many worked in an outpatient practice (8/12, 67%), most had greater than 5 years of clinical experience (10/12, 83%) and were between the ages of 30 and 50 (7/12, 58%). The 12 nurses completed a questionnaire before the focus group session and reported varying levels of comfort in responding to patients across common palliative care communication scenarios. Most of the nurses reported feeling comfortable responding to family conflict (10/12, 83%), determining support systems (11/12, 92%), and assessing coping mechanisms (12/12, 100%). However, the nurses reported feeling less comfortable discussing topics such as hospice (8/12, 66%), prognosis (4/12, 33%), and end of life (6/12, 50%).
During the focus group discussions, several themes emerged. Many of the participants reported that they felt comfortable responding empathically to patient emotions but expressed a desire for more tools and training to enhance their skills, improve their confidence, and enable them to be more efficient with these conversations so that they could be completed during their busy oncology clinics. Overall, the nurses described a desire to play a central role in discussions of health-related values and in the palliative care of their patients.
Educational pilot
Eleven nurses participated in the initial, small-scale training pilot using the ANP Framework when practicing patient values discussions in role play. These nurses went on to employ these skills in over 200 documented values discussions per The 1-2-3 Project protocol with patients in their oncology clinics. They have also educated other nurses in the ANP Framework through co-facilitation of the education days and monthly champion meetings (Figure 3).
Quality of communication
In the pilot clinics, all patients (201/201) participated in nurse-led values discussions supported by the ANP Framework. Most patients (85%) chose to discuss their end-of-life preferences with the nurse during these values discussions. 97% of patients found the discussions to be helpful and comfortable and would recommend them to other cancer patients. Patients cared for in clinics with nurses trained in the ANP Framework (n = 63), compared to those receiving usual care (n = 45) from nurses without this training, reported both increased occurrence (97% vs. 58%, p < 0.0001) and higher quality of clinician communication about values (mean [SD] from 0 = very worst to 10 = very best: 7.18 [2.3] vs. 5.04 [2.9], p = 0.001).
Patient comments regarding values discussions:
• “Thanks so much [nurse] … for the highly professional interview. You are an excellent listener who shows such a level of respect. I felt very comfortable during the interview, and hope that the information I provided, that you so accurately documented, will be used in a positive way to enhance the level of my care.”
• “You have captured all my feelings in response to the questions regarding my cancer concerns and thoughts. As always it was a pleasure talking with you. Your feedback and assurance of care and support was very helpful.”
• “Nice to be heard.”
Broad dissemination
A total of 128 nurse champions have participated in three education days (Session 1: 36 nurses, Session 2: 48 nurses, Session 3: 44 nurses) focusing on the ANP Framework. These champions represent 11 outpatient sites (NYC and metropolitan areas including greater NY and NJ) and 14 inpatient units in a dedicated cancer center. They include nurses from every medical and surgical oncology service as well as chemotherapy infusion units, interventional radiology units, and nursing education staff. The nurse champions have further disseminated the ANP Framework education to their nurse colleagues at over 30 sites throughout the institution. At this time, over 350 nurses have been educated through the champion network in the use of this framework for empathic response to patient emotions (Figure 3). This process is ongoing.
The nurse champions were given pre- and post-course evaluations to complete. The pre-course evaluations were sent out electronically the day before the educational session and 72% (92/128) of the participants completed the survey. Before the educational day, 73% (67/92) of the nurses reported feeling comfortable responding to empathic conversations with their patients and 63% (58/92) reported feeling comfortable discussing patient's health-related values. A post-course evaluation was distributed on paper at the end of the educational session and 61% (78/128) of the participants completed the survey (Table 1). The vast majority of nurses (75/78, 96%) now reported feeling comfortable discussing patients’ health-related values and using the ANP Framework (74/78, 95%) in their clinical practice, capable of teaching the framework to others (73/78, 94%), and comfortable facilitating small group role play (71/78, 91%).
Table 1. Post-course evaluations
Participants were also asked to evaluate the overall success of the one-day educational session. Almost all (76/78, 97%) agreed that they were able to understand and describe foundational principles of palliative care. All also agreed that the educational session helped them recognize emotional responses from their patients and understand how to use the ANP Framework to respond empathically. All felt the course was successful in applying the framework to clinical scenarios through role play. Overall, nurses who participated in the training reported high satisfaction with the content and the mixed training methods (didactic presentations and role play).
Follow-up interviews
Five nurse champions participated in the follow-up interviews; three (60%) were done in person and two (40%) were conducted over the phone. All the nurses were female and worked in the outpatient setting, and they had a range of 2–30 years of clinical experience. The nurses described the education and ANP Framework in enthusiastic terms as helpful and easy to use, and they reported that they felt comfortable teaching it to others. They also shared numerous examples of successfully applying the ANP Framework in their own clinical practice (Table 2).
Table 2. Follow-up qualitative interviews
Case study: The ANP Framework in practice
Mr. P presented to the leukemia clinic in 2018 for management of newly diagnosed myelodysplastic syndrome (MDS) after previous treatment for multiple myeloma. He expressed anger that his MDS was likely caused by prior cancer treatment. He stated he felt “lied to,” that he may have chosen a different path had he known about this potential outcome. He also demanded an allogeneic stem cell transplant, the only curative treatment for MDS. The nurse recognized the need to establish a relationship of trust and mutual respect and she recognized that this patient's management would likely be complex with an uncertain prognosis. From the first visit, she began utilizing the ANP Framework that she had been introduced to as part of her involvement in The 1-2-3 Project. Acknowledging the patient's anger and distrust, normalizing and contextualizing those emotions, and partnering with the patient and family allowed the nurse to establish a trusting, therapeutic relationship with them.
Several months later, during a structured discussion of his values, the patient shared how dramatically his quality of life was compromised by the treatment and his inability to do many things that gave his life meaning. The nurse acknowledged the patient's suffering and the increasing challenge of his treatments, normalized the feelings of confusion and fear, and partnered with the patient and family, which led to a goals of care discussion with the full team (oncologist and nurse) and family. During that discussion, Mr. P articulated his goal of more time at home with family.
As the patient's goals changed, the team adjusted the chemotherapy regimen, selecting a less toxic agent to ease the burden of travel for treatment and transfusions and allowing family time at home. His self-reported symptom assessment scores of distress, insomnia, worry about the future, and spiritual distress decreased from severe to mild or absent. When his disease progressed, the patient remained firm in his goal of maximal time with family and chose to pursue home hospice. The oncology nurse continued to use the strategies from the ANP Framework and used acknowledging, normalizing, and partnering statements when communicating with the patient. The patient was able to spend the end of his life at home, well supported by the hospice provider and surrounded by family.
The nurse credits her education in the ANP Framework with helping her feel confident discussing patient values. By responding to emotion effectively, she was able to foster a trusting relationship with open communication. This facilitated an exchange of information critical to understanding and advocating for Mr. P, allowing for earlier discussions about treatment decisions in order to optimize goal-concordant care.
Discussion
This article has provided a summary of the development, dissemination, and impact on both nurses and patients of the ANP framework, a novel communication skills training tool for oncology nurses. The framework was designed to enhance the empathic communication skills of nurses to enable them to provide PPC. The skills training program was easily adopted, efficiently learned, and enthusiastically received. As evaluated quantitatively and qualitatively, including by nurses and patients themselves, this program was shown to be helpful in improving nurses’ communication in outpatient clinic and hospital settings within a tertiary cancer center. The ANP Framework can be taught in a single session, which allows for institution-wide dissemination.
Other tools have been created to support and educate clinicians in palliative communication, often using open-ended prompts to encourage a larger discussion about values and goals (Baile et al., Reference Baile, Buckman and Lenzi2000; Nardi and Keefe-Cooperman, Reference Nardi and Keefe-Cooperman2006; Pollak et al., Reference Pollak, Arnold and Jeffreys2007; Coyle et al., Reference Coyle, Manna and Shen2015; Bumb et al., Reference Bumb, Keefe and Miller2018) and emphasizing empathic statements by clinicians in response to patients’ expressions of emotion (Baer and Weinstein, Reference Baer and Weinstein2013). Among these, the N-U-R-S-E mnemonic (Back et al., Reference Back, Arnold and Baile2005; Pollak et al., Reference Pollak, Arnold and Jeffreys2007) was developed to summarize types of empathic statements by physicians, but has been used more widely. The ANP Framework was specifically developed for nurses and focuses on communicating empathy with just three skills. While the ANP Framework shares fundamental concepts and approaches with some of the established tools, it also introduces innovation in that it was is created by, informed by, adapted for, targeted to, and preliminarily tested with nurses working in busy oncology clinics and hospital units in order to guide empathic communication in nurse–patient encounters. The framework is unique in that it can be effectively used by nurses with a busy workflow, limited resources, and time constraints, and that it is not restricted for use only in a formal family meeting or at end of life. The results demonstrate that the successful adoption of the ANP Framework by oncology nurses allows them to provide high-quality empathic communication, a key element of palliative care at primary and specialist levels. In addition, the framework was disseminated efficiently in a one-day training session using a train-the-trainer model with nurse champions. This process of dissemination is continually and broadly extending the reach of this framework across a large cancer center in which thousands of oncology nurses provide outpatient and inpatient care at hundreds of thousands of visits each year.
This work has several limitations. The institution includes clinical locations at multiple sites, spread across two states. The nursing educational days have been conducted only at the main hospital location during the day shift, and therefore many nurses have not the opportunity to complete the training program. Also, we did not collect specific, explicit, quantitative measures of the nurses’ perceived empathy and self-efficacy. Patient-level data has thus far been collected only in the outpatient setting as part of The 1-2-3 Project. In addition, the specialist palliative care mentors and most of the champions work at the main hospital during the day shift, and are therefore not available to provide real-time, in-person guidance and feedback to nurses who work at different clinical sites and those who work on night shifts. Additionally, the project has so far been conducted only in English and the ANP guide is only available in English. The Framework may need to be translated and transcreated before it can be more widely disseminated in non-English speaking populations. As this is an initial report of the development and preliminary dissemination of the ANP Framework, formal evaluations of caregiver satisfaction with nurse communication have yet to be conducted. These limitations should not limit the value of the Framework as a communication skills tool.
The early success of its introduction to oncology nurses continues to inform the program's development as ANP education is being adopted institution-wide. We have partnered with the Department of Nursing to facilitate institution-wide adoption of ANP education. The ANP Framework has already been incorporated into other educational training modules, including the nursing education program on screening for substance use disorder. There are also plans to include ANP training in the orientation curriculum for all newly hired nurses, advanced practice providers, and nursing assistants. In addition, this training is being used to prepare nurses for values discussions they conduct as part of an ongoing pilot trial supported by the National Institute of Nursing Research, which will include Spanish-speaking Latinx patients.
The ANP framework can be learned during a short training session and can be seamlessly integrated into practice by nurses who acquire not only the skills for their own use but for training their colleagues. This framework can also be disseminated widely using a champion program. While it was originally created for oncology nurses working in busy outpatient clinics, our experience demonstrates success in scaling and application across inpatient units within our dedicated cancer hospital. As such, this initiative complements existing communication skills programs while representing a further contribution to the field of primary palliative care.
Conflict of interest
There are no conflicts of interest.
