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Communication and Empathy in the Patient-Centered Care Model—Why Simulation-Based Training Is Not Optional

      Patient-centered care (PCC) is increasingly being highlighted as an important model to improve quality of health care having been linked to improved patient satisfaction, better health outcomes, and cost-effective care (
      • Cosgrove D.M.
      • Fisher M.
      • Gabow P.
      • Gottlieb G.
      • Halvorson G.C.
      • James B.C.
      • Toussaint J.S.
      Ten strategies to lower costs, improve quality, and engage patients: The view from leading health system CEOs.
      ,
      Committee on Quality of Health Care in America IOM
      Crossing the quality chasm: A new health system for the 21st century.
      ,
      • Griffin S.J.
      • Kinmonth A.-L.
      • Veltman M.W.M.
      • Gillard S.
      • Grant J.
      • Stewart M.
      Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: A systematic review of trials.
      ,
      • Stewart M.
      • Brown J.B.
      • Donner A.
      • McWhinney I.R.
      • Oates J.
      • Weston W.W.
      • Jordan J.
      The impact of patient-centered care on outcomes.
      ,
      • Weiner S.J.
      • Schwartz A.
      • Sharma G.
      • Binns-Calvey A.
      • Ashley N.
      • Kelly B.
      • Harris I.
      Patient-centered decision making and health care outcomes: An observational study.
      ). The traditional clinical learning environment is, in fact, not teaching nursing students or physician trainees' vital communication skills essential to PCC. Our challenge is to find an effective means of training nontechnical skills, such as empathy, to promote a patient-centric model of care. Empathy is arguably an important cornerstone to effective PCC. The answer to improving patient satisfaction, better health outcomes, and cost-effectiveness may surprise hospital administration because it may lie in simulation training.
      The Picker Institute (
      • Frampton S.B.
      • Guastello S.
      Honoring the life of a pioneer in patient-centered care: Harvey Picker, PhD (1915-2008).
      ,
      • Frampton S.
      • Guastello S.
      • Brady C.
      • Hale M.
      • Horowitz S.
      • Bennett Smith S.
      • Stone S.
      Patient-centered care improvement guide.
      ) coined the term patient-centered care (PCC) and eloquently stated “Patient-centered care does not replace excellent medicine (… high quality and safe care …)—it both complements clinical excellence and contributes to it through effective partnerships and communication.” It is through these partnerships and communication with patients that the literature abounds with how the licensed provider-patient relationship can lead to better patient health outcomes, such as: disease understanding, medication compliance, symptoms, quality of life, reduced emotional distress, and shorter hospital stays (
      • Epstein R.M.
      • Street R.L.
      Patient-centered communication in cancer care-promoting healing and reducing suffering.
      ,
      • Kelley J.M.
      • Kraft-Todd G.
      • Schapira L.
      • Kossowsky J.
      • Riess H.
      The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials.
      ,
      • Kim S.S.
      • Kaplowitz S.
      • Johnston M.V.
      The effects of physician empathy on patient satisfaction and compliance.
      ,
      • Neumann M.
      • Wirtz M.
      • Bollschweiler E.
      • Mercer S.W.
      • Warm M.
      • Wolf J.
      • Pfaff H.
      Determinants and patient-reported long-term outcomes of physician empathy in oncology: A structural equation modelling approach.
      ,
      • Price S.
      • Mercer S.W.
      • MacPherson H.
      Practitioner empathy, patient enablement and health outcomes: A prospective study of acupuncture patients.
      ). Alternatively, poor communication, including with patients and family, has been well documented as one of the top three contributors to sentinel events by the Joint Commission (
      The Joint Commission
      Office of Quality and Safety. Sentinel event data root causes by event type 2004-2015.
      ). The importance of the “patient/caregiver experience” in improving health is being increasingly recognized by the Center for Medicare and Medicaid Services through requirements for hospitals to report quality metrics in this domain for payment (Department of Human and Health Services, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/HospitalQualityInits/HospitalHCAHPS.html; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures.html). The importance of education in PCC is recognized by the medical community (Accreditation Counsel for Graduate Medical Education) and by national nursing organizations such as the American Association of Colleges of Nursing and the National League for Nursing. These organizations (
      • Philibert I.
      • Patow C.
      • Cichon J.
      Incorporating patient- and family-centered care into resident education: Approaches, benefits, and challenges.
      ,

      The Evolution of the Quality and Safety Education for Nurses (QSEN) Initiative. (2014). Retrieved from http://qsen.org/about-qsen/project-overview/.

      ) agree that PCC needs to be learned and competency needs to be attained by health care professionals.
      The traditional methods of teaching PCC, through clinical care and rudimentary role modeling, are inadequate. Traditional teaching values medical knowledge and the clinical setting emphasizes task completion and in fact, exposes students to complex interpersonal interactions with patients that they are unable to interpret and unprepared to negotiate effectively in the absence of faculty members (
      • McNelis A.
      • Ironside P.
      • Ebright P.
      • Dreifuerst K.
      • Zvonas S.
      • Conner S.
      Learning nursing practice: A multisite, multimethod investigation of clinical education.
      ). Not surprising, communication skills and empathy decline throughout clinical training leading to poor communication patterns in practicing nurses and physicians (
      • Bry K.
      • Bry M.
      • Hentz E.
      • Karlsson H.L.
      • Kyllönen H.
      • Lundkvist M.
      • Wigert H.
      Communication skills training enhances nurses' ability to respond with empathy to parents' emotions in a neonatal intensive care unit.
      ,
      • Levinson W.
      • Gorawara-Bhat R.
      • Lamb J.
      A study of patient clues and physician responses in primary care and surgical settings.
      ;
      • Neumann M.
      • Edelhäuser F.
      • Tauschel D.
      • Fischer M.R.
      • Wirtz M.
      • Woopen C.
      • Scheffer C.
      Empathy decline and its reasons: A systematic review of studies with medical students and residents.
      ,
      • Nightingale S.D.
      • Yarnold P.R.
      • Greenberg M.S.
      Sympathy, empathy, and physician resource utilization.
      ,
      • Roter D.L.
      • Stewart M.
      • Putnam S.M.
      • Lipkin M.
      • Stiles W.
      • Inui T.S.
      Communication patterns of primary care physicians.
      ;). Barriers to strong patient-caregiver communication and patient and family-centered care are partly attributed to the lack of training in communication skills (
      • Visser M.
      • Deliens L.
      • Houttekier D.
      Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: A systematic review.
      ), although studies demonstrate that these skills can be learned by nurses and physicians (

      Bauchat, J. R., Anderson, L. M., Santos, J. P., & Park, C. S. (2016). Simulation curriculum for anesthesiology residents improves empathy as measured by the Jefferson scale of physician empathy, Presented at the International Meeting for Simulation in Healthcare, San Diego, CA.

      ,
      • Fellowes D.
      • Wilkinson S.
      • Moore P.
      Communication skills training for health care professionals working with cancer patients, their families and/or carers.
      ,
      • Parry R.
      Are interventions to enhance communication performance in allied health professionals effective, and how should they be delivered? Direct and indirect evidence.
      ). However, the lack of available clinical sites () and perhaps more significant, the lack of standardized education techniques remains a major contributor to poor training in PCC.
      Educational techniques that incorporate adult learning theory principles would be ideal to teach communication skills. Adult learners learn best when they are intrinsically motivated, have a high level of activation, and are involved in the learning process from initial knowledge acquisition, to self-assessment, setting goals, and mastery, via a cycle of reflection and future goal setting (
      • Fowler J.
      Experiential learning and its facilitation.
      ,
      • Kaufman D.M.
      Applying educational theory in practice.
      ). When assessing the traditional clinical environment against adult learning theory principles, it becomes clear why the clinical environment is not ideal for teaching nurses and physicians' critical communication and empathy skills. Although the clinical experience allows for knowledge acquisition and some emotional response critical to future clinical reasoning (
      • Langridge N.
      • Roberts L.
      • Pope C.
      The role of clinician emotion in clinical reasoning: Balancing the analytical process.
      ;
      • Marcum J.A.
      The role of emotions in clinical reasoning and decision making.
      ), the clinical experience does not allow time for the reflective process guided by the educators or instructors. A potential model, and there are many, for learning communication and empathy skills in a PCC model during clinical care would require time for skilled debriefers (instructors) to give patient feedback to trainees after their clinical interactions. This model would incorporate patients and would allow for immediate, emotionally impactful learning in the clinical environment guided by a role model. This model is not feasible in today's high production, efficient clinical environment where the demands for high quality, safe care, does not tolerate inexperienced “hands-on” training any longer.
      Skills can be broken down into three domains: (a) technical, (b) cognitive, and (c) behavioral. More traditional strategies such as lectures, screen-based tutorials, and limited workshops may assist in the cognitive domain with initial knowledge acquisition and self-assessment but have less effect in the behavioral domain. Behavioral skill acquisition, where communication and empathy generally fall, is complex and requires strategies that leverage engaging experiential and reflective learning strategies. Simulation using a variety of strategies including manikins, standardized patients, or hybrid models provides learners and educators alike, the opportunity to develop and explore these skills, particularly through the debriefing/guided reflection post-simulation activity (
      • Fox R.
      • Walker J.J.
      • Draycott T.J.
      Medical simulation for professional development-science and practice.
      ). The pathway to success and mastery is challenging to evaluate, although tools such as the behavioral assessment tool have been developed (
      • Kurosawa H.
      • Ikeyama T.
      • Achuff P.
      • Perkel M.
      • Watson C.
      • Monachino A.
      • Nishisaki A.
      A randomized, controlled trial of in situ pediatric advanced life support recertification (“pediatric advanced life support reconstructed”) compared with standard pediatric advanced life support recertification for ICU frontline providers*.
      ,
      • LeFlore J.L.
      • Anderson M.
      • Michael J.L.
      • Engle W.D.
      • Anderson J.
      Comparison of self-directed learning versus instructor-modeled learning during a simulated clinical experience.
      ) that show high levels of promise in assessing this domain. A recent editorial in the Journal for Advanced Nursing (
      • Dean S.
      • Williams C.
      • Balnaves M.
      Living dolls and nurses without empathy.
      ), sought to make the case that the simulation was failing to address the development of empathy in nursing students because of the authors' narrow definition of simulation (i.e., manikin-based education). The authors failed to recognize the multitude of educational strategies within simulation that can best address the desired behavioral objective. If the clinical environment is not adequate to teach these skills, then where? The reality is that the most effective strategies to improve communication are active, practice-based strategies (
      • Baile W.F.
      • Blatner A.
      Teaching communication skills: Using action methods to enhance role-play in problem-based learning.
      ). Simulation training emerges as an excellent tool for teaching communication and empathy skills. Simulation incorporates all the principles of adult learning theory (
      • Matics D.
      Implementing simulation in air medical training: Integration of adult learning theory.
      ,
      • Zigmont J.J.
      • Kappus L.J.
      • Sudikoff S.N.
      Theoretical foundations of learning through simulation.
      ) and has been used effectively to promote a holistic approach to patient care by incorporating communication and empathy skills training in addition to technical skills acquisition (
      • Berkhof M.
      • van Rijssen H.J.
      • Schellart A.J.M.
      • Anema J.R.
      • van der Beek A.J.
      Effective training strategies for teaching communication skills to physicians: An overview of systematic reviews.
      ,
      • Brydges R.
      • Mallette C.
      • Pollex H.
      • Carnahan H.
      • Dubrowski A.
      Evaluating the influence of goal setting on intravenous catheterization skill acquisition and transfer in a hybrid simulation training context.
      ,
      • Liaw S.Y.
      • Palham S.
      • Chan S.W.-C.
      • Wong L.F.
      • Lim F.P.
      Using simulation learning through academic-practice partnership to promote transition to clinical practice: A qualitative evaluation.
      ).
      The use of appropriate simulation modalities using a distributed educational approach allows the learner to effectively practice communication and empathy over a period of time (
      • Berragan L.
      Conceptualising learning through simulation: An expansive approach for professional and personal learning.
      ,
      • Morgan R.
      Using clinical skills laboratories to promote theory-practice integration during first practice placement: An Irish perspective.
      ). The distributed method allows skills to be learned in increments that are digestible, which in turn impacts retention. The simulated environment allows the educator to provide a controlled and intentional environment where learning becomes predictable, as opposed to opportunistic, as we see in the clinical environment. For example, the Interprofessional Education Collaborative (
      Interprofessional Education Collaborative Expert Panel
      Core competencies for interprofessional collaborative practice: Report of an expert panel.
      ) immerse medical, nursing, and chaplain students in a simulation with a difficult patient and family interaction (delivery of bad news) where communication, empathy, and teamwork are needed to get through the simulation successfully. The creation of an intentional interdisciplinary environment which allows practice of complex interpersonal communication skills, depicts a rich exemplar of the way in which simulation allows the educator to spiral and scaffold the learners educational experience, which are established educational strategies grounded in real theory. Simulation moves us from learning by chance to learning with intent. Realism can be accomplished with properly implemented evidence-based scenarios, matching the environmental and emotional experience of an actual clinical experience (
      • Keitel A.
      • Ringleb M.
      • Schwartges I.
      • Weik U.
      • Picker O.
      • Stockhorst U.
      • Deinzer R.
      Endocrine and psychological stress responses in a simulated emergency situation.
      ,
      • Schaumberg A.
      The matter of ‘fidelity’: Keep it simple or complex?.
      ,
      • Seropian M.A.
      General concepts in full scale simulation: Getting started.
      ). Not only is the realism matched, but now the educational process allows reflection and time to understand the complexities of communication and empathy.
      Simulation curriculum may be resource intensive, but it is one of the only tools that we have that incorporates effective adult learning theory for trainees while teaching effective communication for the patient-centered health care environment. Patient-centered outcomes such as patient satisfaction (
      • Boissy A.
      • Windover A.K.
      • Bokar D.
      • Karafa M.
      • Neuendorf K.
      • Frankel R.M.
      • Rothberg M.B.
      Communication skills training for physicians improves patient satisfaction.
      ) and the Hospital Consumer Assessment of Healthcare Providers and Systems scores and therefore, payment to hospitals, may be influenced by the degree of compassion and empathy nurses and doctors demonstrate toward their patients (
      • Brunett P.H.
      • Campbell T.L.
      • Cole-Kelly K.
      • Danoff D.
      • Frymier R.
      • Goldstein M.G.
      • Whelan G.P.
      Essential elements of communication in medical encounters: The Kalamazoo consensus statement.
      ). The effect of empathy and communication training can be monetized. Training in these nontechnical skills, through the use of simulation, will likely have a return and value on investment that few interventions can demonstrate, with trickle-down effects on patient satisfaction and health outcomes. It will take thought leaders to risk the upfront investment and realize the real downstream return. Behavioral skills are foreign and ambiguous to the health care industry, which may explain the reluctance to invest in them. Industry payers, patients, and ethicists are in fact prompting the medical industry to address these issues in measurable and systematic ways. The days of the cold scalpel blade are gone as we transition to a delivery model that sees the patient and providers as what they are—human.

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