Research in communication skills training translated into practice in a large organization: a proactive use of the RE-AIM framework

Applying the RE-AIM framework to evaluate an educational model to "close the gap" and improve health equity in uncontrolled hypertension

OBJECTIVES

To use the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to evaluate an educational model addressing self-management of uncontrolled hypertension.

METHODS

We used a pre-post single cohort design to identify minoritized patients with uncontrolled hypertension (systolic > 160 mmHg and/or diastolic > 100 mmHg). Trained Ambassadors provided telephone outreach, skill-based blood pressure (BP) monitoring, and goal-setting for 4 months. Follow-up occurred at 7 months. We evaluated the initiative using the RE-AIM framework and quantitative analysis for process and outcome measures post-intervention.

RESULTS

Among Black patients (n = 345), the average age was 55.4 years (8.7), half identified as male (n = 173, 50.1 %); many were uninsured (n = 159, 46.1 %). Engagement in calls occurred for 67.8 % (n = 234) of the cohort; monitor distribution was 22.9 % (n = 79); and goal setting occurred for 64 patients. BP improved for 40 % of the cohort (mean pre: 168/98 mmHg, mean post: 150/89 mmHg; p < 0.0001) and 40 % of patients' last known BP was < 140/90.

CONCLUSIONS

RE-AIM evaluation of the Closing the Gap initiative suggests that the model is associated with BP reduction in high-risk Black patients.

PRACTICE IMPLICATIONS

An educational model for patient-centered hypertension management in low-income populations is feasible and addresses self-monitoring barriers.

Communication, Cognition and Competency Development in Healthcare: A Model for Integrating Cognitive Ethnography and Communication Skills Training in Clinical Interventions

OBJECTIVES

The aim of this study was to conduct and evaluate the Blended Learning communication skills training program. The key objective was to investigate (i) how clinical intervention studies can be designed to include cognitive, organizational, and interactive processes, and (ii) how researchers and practitioners could work with integrated methods to support the desired change.

METHODS

The method combined design and implementation of a 12-week Blended Learning communication skills training program based on the Calgary-Cambridge Guide. The training was implemented in a patient clinic at a Danish university hospital and targeted all healthcare professionals at the clinic. Cognitive ethnography was used to document and evaluate healthcare professionals' implementation and individual competency development, and support the design of in-situ simulation training scenarios.

RESULTS

Thirteen participants completed the program. The synergy within the teams, as well as the opportunities for participants to coordinate, share, discuss, and reflect on the received knowledge with a colleague or on-site researcher, affected learning positively. The knowledge transfer process was affected by negative feedback loops, such as time shortages, issues with concept development and transfer, disjuncture between the expectations of participants and instructors of the overall course structure, as well as participant insecurity and a gradual loss of motivation and compliance.

CONCLUSION

We propose a novel 3-step model for clinical interventions based on our findings and literature review. This model will effectively support the implementation of educational interventions in health care by narrowing the theory-practice gap. It will also stimulate desired change in individual behavior and organizational culture over time. Furthermore, it will work for the benefit of the clinic and may be more suitable for the implementation of communication projects than, for example, randomized setups.

Health literacy education programmes developed for qualified health professionals: a scoping review

OBJECTIVES

Both literature and policy have identified the need for health literacy education for qualified health professionals. This study aimed to identify and map health literacy competencies and health literacy related communication skills educational interventions for qualified health professionals. The research questions included: Of the qualified health professional education interventions identified, which are focused on diabetes care? What health literacy competencies and health literacy related communication skills are integrated into each programme? What are the characteristics of each education programme? What were the barriers and facilitators to implementation? What methods are used to evaluate intervention effectiveness, if any?

DESIGN

Scoping review, informed by the Joanna Briggs Institute guidelines.

DATA SOURCES

The following databases: OVID; CINAHL; Cochrane; EMBASE; ERIC: PsycInfo; RIAN; Pro-Quest; UpToDate were searched.

ELIGIBILITY CRITERIA

Articles were included if the education programme focused on qualified health professionals, in all clinical settings, treating adult patient populations, of all study types.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened titles, abstracts and full text articles that met the inclusion criteria. The third author mediated any discrepancies. The data were extracted and charted in table format.

RESULTS

In total, 53 articles were identified. One article referred to diabetes care. Twenty-six addressed health literacy education, and 27 addressed health literacy related communication. Thirty-five reported using didactic and experiential methods. The majority of studies did not report barriers (N=45) or facilitators (N=52) to implementation of knowledge and skills into practice. Forty-nine studies evaluated the reported education programmes using outcome measures.

CONCLUSIONS

This review mapped existing education programmes regarding health literacy and health literacy related communication skills, where programme characteristics were identified to inform future intervention development. An evident gap was identified regarding qualified health professional education in health literacy, specifically in diabetes care.

Facilitators and Barriers to a Hospital-Based Communication Skills Training Programme: An Interview Study

This study aimed to investigate the facilitators and barriers experienced by the department management (DMs) and communication skills trainers (trainers) during the implementation of a 3-day communication skills training (CST) programme for healthcare professionals (HCPs). Thus, we conducted semi-structured interviews with 23 DMs and 10 trainers from 11 departments concurrently implementing the CST programme. Thematic analysis was undertaken to elucidate the themes across the interviews. Five themes were developed: resource consumption; obstacles; management support; efforts and outcomes; and a lack of systematic follow-up. Although the DMs and trainers were largely in agreement, the theme of a lack of systematic follow-up was derived exclusively from the trainers, as were two of the subthemes within obstacles: (b) seniority, profession, and cultural differences, and (c) the trainers' competencies. The greatest perceived barrier was resource consumption. In addition, DMs found planning and staff resistance to be a challenge. However, the HCPs' resistance diminished or even changed to satisfaction after participating. The mandatory approach served as both a facilitator and a barrier; DMs' support was an essential facilitator. Explicit communication related to resource demands, planning, and participation is crucial, as is management support and the allocation of resources.

The effectiveness of a person-centred communication skills training programme for the health care professionals of a large hospital in Denmark

OBJECTIVE

As a part of an evaluation of a large-scale communication skills training (CST) programme, this study aimed to investigate the effect on health care professionals' (HCPs) self-efficacy (SE) and perceived importance (PI) of the skills taught.

METHODS

A pre-post intervention design was used, and 1647 HCPs responded to the SE-12 questionnaire. Changes in self-efficacy were examined at an item and scale level.

RESULTS

The responses of 74% of the HCPs who replied to at least two of the three questionnaires were analysed. A significant increase in the SE-12 scale scores by 12.45 points between Q1 (baseline) and Q2 (immediately after the intervention) across all professions was found. There was a small albeit statistically significant decrease in the SE-12 scale scores by 2.06 points between Q2 and Q3 (24 weeks after the intervention).

CONCLUSION

The implementation of the CST course significantly improved the self-efficacy of HCPs. The findings were supported by an increase in the number of HCPs who considered the skills that they had acquired to be very important.

PRACTICE IMPLICATIONS

The findings suggest that the large-scale implementation of evidence-based CST programmes can yield the same outcomes that have been observed in smaller and better controlled studies.

Healthcare professionals' experiences of using mindfulness training in a cardiology department - a qualitative study

OBJECTIVE AND AIM

Person-centred communication and healthcare professionals' ability to be attentively present in their encounter with patients are essential aspects of patients' experiences of well-being, ability to cope with illness-related challenges and feelings of being recognised. However, the ability to be attentive in relational encounters can be challenging for healthcare staff for many reasons, such as time constraints and a high work pace. Research suggests that mindfulness training could increase staff attentiveness and compassion, but only few qualitative studies have explored the subject. The aim of the current study was to explore doctors' and nurses' individual experiences of how attending an 8-week Mindfulness-Based Stress Reduction course (MBSR) influenced their clinical practice and encounters with colleagues and patients in a cardiology department.

METHOD

Qualitative interviews were held with six doctors and nurses who had completed the 8-week MBSR course. Interpretative phenomenological analysis was applied to explore and understand the meaning of the participants' accounts.

FINDINGS

The MBSR course appeared to have changed the healthcare professionals' thoughts and actions, especially regarding their ability to stay focused on the task at hand, to prioritise and to stay calm in an unpredictable and busy work environment. This was facilitated by using concrete techniques learned during the course, such as breathing and taking small breaks to clear their heads and help them be attentive in relation to themselves, colleagues and patients. Furthermore, they described an increased acceptance of their own limitations, better understanding of their colleagues and greater awareness of the unique patient.

CONCLUSION

These findings suggest that changing healthcare professionals' actions, mindset, awareness and understanding of others may result in a more compassionate work environment and more person-centred care.

Key components of knowledge transfer and exchange in health services research: Findings from a systematic scoping review

AIMS

To identify the key common components of knowledge transfer and exchange in existing models to facilitate practice developments in health services research.

BACKGROUND

There are over 60 models of knowledge transfer and exchange designed for various areas of health care. Many of them remain untested and lack guidelines for scaling-up of successful implementation of research findings and of proven models ensuring that patients have access to optimal health care, guided by current research.

DESIGN

A scoping review was conducted in line with PRISMA guidelines. Key components of knowledge transfer and exchange were identified using thematic analysis and frequency counts.

DATA SOURCES

Six electronic databases were searched for papers published before January 2015 containing four key terms/variants: knowledge, transfer, framework, health care.

REVIEW METHODS

Double screening, extraction and coding of the data using thematic analysis were employed to ensure rigour. As further validation stakeholders' consultation of the findings was performed to ensure accessibility.

RESULTS

Of the 4,288 abstracts, 294 full-text articles were screened, with 79 articles analysed. Six key components emerged: knowledge transfer and exchange message, Stakeholders and Process components often appeared together, while from two contextual components Inner Context and the wider Social, Cultural and Economic Context, with the wider context less frequently considered. Finally, there was little consideration of the Evaluation of knowledge transfer and exchange activities. In addition, specific operational elements of each component were identified.

CONCLUSIONS

The six components offer the basis for knowledge transfer and exchange activities, enabling researchers to more effectively share their work. Further research exploring the potential contribution of the interactions of the components is recommended.

How participatory action research changed our view of the challenges of shared decision-making training

OBJECTIVE

This paper aims to demonstrate how the use of participatory action research (PAR) helped us identify ways to respond to communication challenges associated with shared decision-making (SDM) training.

METHODS

Patients, relatives, researchers, and health professionals were involved in a PAR process that included: (1) two theatre workshops, (2) a pilot study of an SDM training module involving questionnaires and evaluation meetings, and (3) three reflection workshops.

RESULTS

The PAR process revealed that health professionals often struggled with addressing existential issues such as concerns about life, relationships, meaning, and ability to lead responsive dialogue. Following the PAR process, a communication programme that included communication on existential issues and coaching was drafted.

CONCLUSION

By involving multiple stakeholders in a comprehensive PAR process, valuable communication skills addressing a broader understanding of SDM were identified. A communication programme aimed to enhance skills in a mindful and responsive clinical dialogue on the expectations, values, and hopes of patients and their relatives was drafted.

PRACTICAL IMPLICATIONS

Before integrating new communication concepts such as SDM in communication training, research methods such as PAR can be used to improve understanding and identify the needs and priorities of both patients and health professionals.

Design and implementation of electronic health record integrated clinical prediction rules (iCPR): a randomized trial in diverse primary care settings

Background

Clinical prediction rules (CPRs) represent a method of determining individual patient risk to help providers make more accurate decisions at the point of care. Well-validated CPRs are underutilized but may decrease antibiotic overuse for acute respiratory infections. The integrated clinical prediction rules (iCPR) study builds on a previous single clinic study to integrate two CPRs into the electronic health record and assess their impact on practice. This article discusses study design and implementation of a multicenter cluster randomized control trial of the iCPR clinical decision support system, including the tool adaptation, usability testing, staff training, and implementation study to disseminate iCPR at multiple clinical sites across two health care systems.

Methods

The iCPR tool is based on two well-validated CPRs, one for strep pharyngitis and one for pneumonia. The iCPR tool uses the reason for visit to trigger a risk calculator. Provider completion of the risk calculator provides a risk score, which is linked to an order set. Order sets guide evidence-based care and include progress note documentation, tests, prescription medications, and patient instructions. The iCPR tool was refined based on interviews with providers, medical assistants, and clinic managers, and two rounds of usability testing. “Near live” usability testing with simulated patients was used to ensure that iCPR fit into providers’ clinical workflows. Thirty-three Family Medicine and General Internal Medicine primary care clinics were recruited at two institutions. Clinics were randomized to academic detailing about strep pharyngitis and pneumonia diagnosis and treatment (control) or academic detailing plus use of the iCPR tool (intervention). The primary outcome is the difference in antibiotic prescribing rates between the intervention and control groups with secondary outcomes of difference in rapid strep and chest x-ray ordering. Use of the components of the iCPR will also be assessed.

Discussion

The iCPR study uses a strong user-centered design and builds on the previous initial study, to assess whether CPRs integrated in the electronic health record can change provider behavior and improve evidence-based care in a broad range of primary care clinics.

Trial registration

Clinicaltrials.gov (NCT02534987)

Mandatory communication training of all employees with patient contact

In 2010 a communication program that included mandatory communication skills training for all employees with patient contact was developed and launched at a large regional hospital in Denmark.

OBJECTIVE

We describe the communication program, the implementation process, and the initial assessment of the process to date.

METHOD

The cornerstone of the program is a communication course based on the Calgary Cambridge Guide and on the experiences of several efficacy and effectiveness studies conducted at the same hospital. The specific elements of the program are described in steps and a preliminary assessment based on feedback from the departments will be presented.

RESULTS

The elements of the communication program are as follows: (1) education of trainers; (2) courses for health professionals employed in clinical departments; (3) education of new staff; (4) courses for health professionals in service departments; and (5) maintenance of communication skills. Thus far, 70 of 86 staff have become certified trainers and 17 of 18 departments have been included in the program.

CONCLUSION AND PRACTICE IMPLICATIONS

Even though the communication program is resource-intensive and competes with several other development projects in the clinical departments, the experiences of the staff and the managers are positive and the program continues as planned.

Healthy conversation skills: increasing competence and confidence in front-line staff

OBJECTIVE

(i) To assess change in confidence in having conversations that support parents with healthy eating and physical activity post-training. (ii) To assess change in staff competence in using 'open discovery' questions (those generally beginning with 'how' and 'what' that help individuals reflect and identify barriers and solutions) post-training. (iii) To examine the relationship between confidence and competence post-training.

DESIGN

A pre-post evaluation of 'Healthy Conversation Skills', a staff training intervention.

SETTING

Sure Start Children's Centres in Southampton, England.

SUBJECTS

A total of 145 staff working in Sure Start Children's Centres completed the training, including play workers (43%) and community development or family support workers (35%).

RESULTS

We observed an increase in median confidence rating for having conversations about healthy eating and physical activity (both P < 0·001), and in using 'open discovery' questions (P < 0·001), after staff attended the 'Healthy Conversation Skills' training. We also found a positive relationship between the use of 'open discovery' questions and confidence in having conversations about healthy eating post-training (r = 0·21, P = 0·01), but a non-significant trend was observed for having conversations about physical activity (r = 0·15, P = 0·06).

CONCLUSIONS

The 'Healthy Conversation Skills' training proved effective at increasing the confidence of staff working at Sure Start Children's Centres to have more productive conversations with parents about healthy eating. Wider implementation of these skills may be a useful public health nutrition capacity building strategy to help community workers support families with young children to eat more healthy foods.

Centering pregnancy in Missouri: a system level analysis

Background. Centering Pregnancy (CP) is an effective method of delivering prenatal care, yet providers have been slow to adopt the CP model. Our main hypothesis is that a site's adoption of CP is contingent upon knowledge of the CP, characteristics health care personnel, anticipated patient impact, and system readiness. Methods. Using a matched, pretest-posttest, observational design, 223 people completed pretest and posttest surveys. Our analysis included the effect of the seminar on the groups' knowledge of CP essential elements, barriers to prenatal care, and perceived value of CP to the patients and to the system of care. Results. Before the CP Seminar only 34% of respondents were aware of the model, while knowledge significantly after the Seminar. The three greatest improvements were in understanding that the group is conducted in a circle, the health assessment occurs in the group space, and a facilitative leadership style is used. Child care, transportation, and language issues were the top three barriers. The greatest improvements reported for patients included improvements in timeliness, patient-centeredness and efficiency, although readiness for adoption was influenced by costs, resources, and expertise. Discussion. Readiness to adopt CP will require support for the start-up and sustainability of this model.

Enhancement of decision rules to increase generalizability and performance of the rule-based system assessing risk for pressure ulcer

BACKGROUND

A rule-based system, the Braden Scale based Automated Risk Assessment Tool (BART), was developed to assess risk for pressure ulcer in a previous study. However, the BART illustrated two major areas in need of improvement, which were: 1) the enhancement of decision rules and 2) validation of generalizability to increase performance of BART.

OBJECTIVES

To enhance decision rules and validate generalizability of the enhanced BART.

METHOD

Two layers of decision rule enhancement were performed: 1) finding additional data items with the experts and 2) validating logics of decision rules utilizing a guideline modeling language. To refine the decision rules of the BART further, a survey study was conducted to ascertain the operational level of patient status description of the Braden Scale. The enhanced BART (BART2) was designed to assess levels of pressure ulcer risk of patients (N = 99) whose data were collected by the nurses. The patients' level of pressure ulcer risk was assessed by the nurses using a Braden Scale, by an expert using a Braden Scale, and by the automatic BART2 electronic risk assessment. SPSS statistical software version 20 (IBM, 2011) was used to test the agreement between the three different risk assessments performed on each patient.

RESULTS

The level of agreement between the BART2 and the expert pressure ulcer assessments was "very good (0.83)". The sensitivity and the specificity of the BART2 were 86.8% and 90.3% respectively.

CONCLUSION

This study illustrated successful enhancement of decision rules and increased generalizability and performance of the BART2. Although the BART2 showed a "very good" level of agreement (kappa = 0.83) with an expert, the data reveal a need to improve the moisture parameter of the Braden Scale. Once the moisture parameter has been improved, BART2 will improve the quality of care, while accurately identifying the patients at risk for pressure ulcers.