The healthcare team was also surveyed prior to the “moving” portion of the intervention, so their DBN education and support needs could be identified and addressed.
As part of moving towards the desired new communication and documentation behaviors for DBN, group and individual educational sessions were provided over a 3-month period, with case studies provided so DBN skills could be reviewed as a team, following the CPM for DBN.
The next phase of the “moving” process, which reinforced skill-building in DBN, was called “Picking Up the Pieces.” It involved four didactic sessions and small-group discussions offered over a 2-month period, plus four additional sessions offered for new staff or team members who missed earlier sessions. The educational sessions reviewed the collaborative practice model for DBN as well as two communication models that can be effective tools for DBN: “SPIKES” and “NURSE.” (Very good summaries of SPIKES and NURSE, as well as strategies to optimize difficult conversations with patients, are presented in a 2008 article in ASCO’s Journal of Oncology Practice.)
SPIKES, a model for physician-patient communication developed at MD Anderson Cancer Center, follows a six-step protocol:
S = Plan the setting of the interview (with patient privacy/comfort; family involvement, if the patient desires it; and no interruptions).
P = Assess the patient’s perception of the medical situation, by asking open-ended questions.
I = Invite the patient to tell you how much information s/he wants regarding diagnosis/prognosis.
K = Give the patient knowledge using small amounts of information in a manner that is easy to process (eg, using plain English and avoiding medical jargon).
E = Provide empathetic responses that address and acknowledge the patient’s emotional response to information/bad news.
S = Provide a clear care strategy for treatment/palliative care options, to lessen patient anxiety.
NURSE, developed by James Tulsky, MD, director of the center for palliative care at Duke University, and colleagues, can be used by any healthcare member. It teaches how to express empathy using continuer statements that allow patients to both feel heard and continue expressing emotions.
N = Name the patient’s emotion. (This provides support and lets the patient know it’s okay to discuss feelings.)
U = Understand the emotion being expressed.
R = Respect what the patient is communicating and feeling.
S = Show support.
E = Explore what emotions s/he is experiencing.
In the DBN project reported by Ms. Allen, a medical actor played the role of a patient with progressive symptoms receiving bad news, while the healthcare team engaged in role-playing and analysis/group discussion of positive (eg, attentive listening, ask-tell-ask) and negative DBN strategies.
Physician and nursing/allied healthcare staff completed pre- and post-intervention Likert-like surveys, in which participants used a 1-to-5 (“never” to “always”) scale to rank statements about skills, support, and communication related to DBN. Post-implementation surveys were completed by 75% of healthcare team members. The results showed significant improvements in early notification and involvement of nurses regarding DBN; colleague support of nurses for care coverage, enabling nurses to participate in DBN; better communication between healthcare team members regarding DBN; and successful incorporation of DBN as a formal action item in daily practice.
In discussing the “refreezing” phase of this DBN improvement project, Ms. Allen and her colleagues noted nurse inclusion in DBN can be further enhanced by holding team members accountable for incorporating the CPM into daily practice; identifying missed opportunities; and continuing the “Picking Up the Pieces” training program for new hires, twice a year.