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Program Teaches Nurses to Manage, Apply Emotions

 |  By Alexandra Wilson Pecci  
   July 08, 2014

The Four Habits model, used to improve patient-physician communication, can also prepare nurses to deliver relationship-centered care more effectively, study data shows.

When it comes to patient care, there's a technical side and an emotional side. The best nurses are masters of both, and according to a new study, a set of commonly used physician communication skills that aim to improve on the care provider's soft skills can be effectively applied to nursing training, too.

"I really believe relationship-centered care is really what it's about," the study's first author Mark J. Fisher, Ph.D., RN, an assistant professor in the College of Nursing at the University of Oklahoma Health Sciences Center, told me in an interview.

"Simply communicating using technical skills and focusing purely on information can provide a level of care, but I'm not sure it's the highest level or the most effective level."

The study found that a nurse training program based on the Four Habits Model "improves newly licensed nurses' self-perception of their preparation for emotion-focused conversations with parents" of pediatric patients.

The Four Habits are commonly used in physician training programs to help improve patient-physician communication, says Fisher, who tweaked the model slightly to study its effectiveness for pediatric nurses.

"My experience in the pediatric hospital setting and interactions with nursing students revealed many newly licensed nurses and most nursing students were quite anxious about talking with parents of children in the hospital setting," Fisher told me by email after our phone conversation.

The Four Habits are: 

  1. Invest in the beginning, which includes making introductions, asking questions about the patient/parent concerns, and planning visits
  2. Elicit the patient's perspective (adapted for pediatrics as "elicit parents' perspective,") which includes things such as asking the patient about how their health issue affects their lives and what their goals are for treatment
  3. Demonstrate empathy, which includes being open to the patient's emotions and conveying empathy, either with statements ("you seem worried") or with body language
  4. Invest in the end, which includes delivering and explaining diagnostic information and talking about the patient's understanding of and willingness to engage in follow-up care

The Four Habits model respects and integrates the patient's and family's perspective into the care in a real and meaningful way, "which I think it vital," Fisher said. "It's caring 'with' instead of caring 'for.'"

Caring "with" allows clinicians to have a richer knowledge base to apply to the patient. For instance, the parents of a 14-year old might not have any medical background, but they certainly know their child better than anyone.

"They have 14 years of experience that we need to incorporate into care," Fisher said. "If we don't elicit that information, that's 14 years of information that we're missing."

Eliciting and understanding such information requires empathy. Nurses are often simply assumed to be empathetic, but as an assistant professor of nursing, Fisher believes that real empathy training is lacking in much nursing training. Such training wouldn't teach nurses how to feel empathy, but how to manage it and apply it to patient care.

"We teach a lot of communication skills and technical skills," he said. "What can we do about these emotions?"

Because the Four Habits outline a way to manage and apply emotion, Fisher wanted to teach those techniques to nurses and find out whether such training was beneficial. The study's intervention group participated in a one-hour, three-part education simulation session that involved participating in role-playing scenarios, whereas the control group simply observed a one-hour video.

According to the published study results:

Compared with the controls, the intervention group improved significantly in four of five areas: preparation, communication skills, relationships, and confidence. [Fisher told me that the study's key outcome variables were preparation, communication skills, relationships, confidence, anxiety, and total preparation.] Experience level had minimal effect. Over half of the nurses in the intervention group reported using one or more of the Four Habits in clinical practice.

Fisher says nurse leaders who want to incorporate this type of training for their own nurses can accomplish it through similar role-playing workshops or in-service days, perhaps by recruiting parents of former patients to come in and work with nurses in simulated scenarios. It's something that his own nursing students appreciate and benefit from, he adds.

"It's not me teaching them. It's parents who have lived through the experience," he says. "It's real for them."

I asked Fisher whether being so in tune with patient and family emotions could exacerbate compassion fatigue.

"I think that's absolutely something that needs to be looked at and considered," he said. But he also pointed out that there's a difference between empathy and sympathy.

"We're more interested in the empathy," he added. "I think empathy is something we see in nursing a lot, but I don't know how much training there is around it."

Who knows? Perhaps a formal understanding and application of empathy through training could actually help alleviate compassion fatigue.

"I'm not talking about having the patients and the parents be our best friends," Fisher says. Instead, he believes nurses should simply slow down and take the time to hear and understand their perspective.

"We pause and take a moment to hear what is going on for that parent," he says. "It's not about us giving information, it's us receiving information."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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