Leaving the nurturing surroundings of a college classroom or practice laboratory for the pediatric clinical inpatient setting can be a difficult experience for nursing students and aspiring medical professionals. Caring for a critically ill child, where monitoring machines and vigilance are the highest priorities, is daunting. Add family dynamics, unpredictably played out in the pediatric intensive care unit (PICU), to the mix, and nursing students may find themselves pushed to their limits. Communicating with parents can be one of the most challenging aspects of pediatric care (Bidmead & Cowley, 2005; Fisher & Broome, 2011; Lee, 2007; Reid, Bramwell, Booth, & Weindling, 2007). Learning about patient–nurse communication is typically a part of nursing education (Gilbert, 2004; Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009; Rosenzweig et al., 2008). Education addressing parent–nurse communication in critical care environments, specifically in the areas of recognizing and addressing a new nurse’s apprehension and empathy, are less evident. Alligood (1992) showed that trained empathy (professionally engaging in a relationship-centered dynamic), is a vital component of nursing education. Identifying and practicing family-centered care is integral in a nurse’s ability to sustain relationships. This article describes an educational project detailing the sequence and significance of practicing parent–nursing student communication using scenarios and emphasizing professional empathy.
Communication is a therapeutic tool comprising an essential set of skills integral in quality nursing. Yet, development of these skills is often lacking in nursing education (Fallowfield, Saul, & Gilligan, 2001; Ustun, 2006). Effective communication between parents and nurses plays a vital role in health care, particularly when parents’ perspectives and knowledge are part of the care process (Young et al., 2006). Vigilant care is an expectation for both parents and health care providers. Yet poor communication between the two frequently occurs, creating conflict and distrust. In a study involving 108 pediatric patients in an intensive care unit, poor parent–provider communication led to 48% of all conflicts (Studdert et al., 2003). Exchange of information is a useful purpose of communication; however, good relationships and rapport rely also on effective communication (Astedt-Kurki, Paavilainen, Tammentie, & Paunonen-Ilmonen, 2001; Espezel & Canam, 2003). Nurses who engage in active listening with parents and children assist in validating families’ perspectives, and those who express empathy help parents feel supported (Buford, 2005). Parents who feel they have a more proactive relationship with their child’s health care providers make better care choices for their child (Shepard & Rose, 1995).
Empathy and empathic communication are teachable skills (Platt & Keller, 1994) that are helpful in developing caring relationships between parents and nurses (Bidmead & Cowley, 2005; Schwerin, 2004). Furthermore, empathy is an expectation parents have of health care providers. Empathy is expressed through proactive communication, relying on an individuals’ willingness to understand perspectives and interpretations of another (LaFerney, 2009). Empathy, support, and reciprocity are essential parts of trusting relationships (Bidmead & Cowley, 2005). If health care providers are expected to apply family-centered principles through their actions and behaviors, empathy must be a fundamental part of their education.
As a pedagogical method, role-playing has been commonly used since the 1960s and is ideally suited for health care providers. It amplifies the experiential element of learning for students by involving them in a real-world experience (Gaba, 2004, p. i2). Role-playing can be used to hone effective communication among the patient, family members, and health care providers. Role-playing is an emotive-centered practice requiring an individual’s expressions of empathy to achieve family-centered care outcomes. Emotions, notably fears, affect how parents process and disclose information, requiring nurses to practice emotional intelligence; that is, learning how to recognize, manage, and harness their own feelings and empathize and manage feelings that emerge from parent–nurse relationships (Goleman, 1997, p. 191). Difficult clinical conversations involving several emotions have been successfully used in simulated health care provider communication training and education (Gough, Frydenberg, Donath, & Marks, 2009; Gough, Johnson, Waldron, Tyler, & Donath, 2009; McGrath, 2005; Rosenzweig et al., 2008; VandeKieft, 2001). By developing and implementing brief communication training programs and methods involving empathy and emotions, the authors envision the integration of family-centered care principles into practice.
Careful planning and purposeful coordination of post-clinical activities connected with course objectives help students relate their clinical experiences to textbook learning (Oermann, 2008). Three characteristics of effective clinical postconferences (i.e., instructor-led conversation with nursing students following a clinical experience) are that they are group events, they contribute to achieving course objectives, and they provide a setting where students can explore personal feelings and attitudes (Wink, 1995). Knowledge application gained in the process of providing nursing care develops professional values and enhances problem-solving skills (Hsu, 2007). Effective clinical postconferences assist students in making valuable connections between didactic information and clinical practice and increase the opportunity for students to hone their critical thinking and clinical reasoning skills.
Development and Structure of Parent-Led Sessions
The authors initiated the planning process for the parent-led nursing sessions 6 months before the first postconference through their involvement in a developing hospital-based family advisory council (Landis, 2007; MCG Health System, 2010) and an emerging network of working relationships. Early on, the instructor (M.J.F.) made clear that his role was to assist in developing the postconference structure and logistics, and that the parents (E.A.T., P.L.H.) were to lead the sessions. Both parents have considerable experience caring for their children in PICUs, and they actively seek opportunities to provide nursing and medical students with a parent’s perspective, which is often overlooked in the training of pediatric health care providers. Deeply rooted in their experience with critical care, the parents wanted students to be intellectually and emotionally challenged, to develop awareness that nurses are care educators and “system navigators,” to understand that nurses have the ability to empower parents, and to realize that empathy is a professional expectation. In addition, the parents believed that providing students with specific speaking and soothing strategies would be helpful in facilitating high-quality parent–nurse interactions. Finally, the parents were interested in helping students cue into nonverbal expression and the significance of parents’ repeated questions and fears, demonstrating how parent–nurse communication could quickly deteriorate.
Open and respectful dialogue among the authors and an exploration of students’ concerns guided the development of the structure for the parent–nurse postconferences. Learning objectives were collaboratively identified, negotiated, and determined using clinical course objectives and parents’ experiences. The parents were intentional in determining the content, overall design, and their interest in serving not as presenters but as facilitators. Precise medical diagnoses or health care trajectories for the children were not the focus of these sessions. Instead, personal narratives served as the gateway for nursing students to practice their communication skills and confront their apprehension in speaking with parents.
Each postconference session involved a pediatric critical care clinical group composed of 10 to 12 nursing students and their clinical instructor. The students were informed that they would attend a parent-led postconference. A week before their session, students were given a research article about maternal involvement in decision making, a parent-authored article, and a participating parent’s personal journal entries in an attempt to provide the context for the learning experience. Before initiating the sessions, student expectations were obtained through written preevaluations. The instructor provided the context for the 1-hour conference, including a brief introduction of the two participating parents. After being introduced, the parents led the three-part postconference involving introductions, role-play scenarios, and debriefing. The parents introduced themselves and provided an abbreviated overview of their children’s diagnoses and PICU history. Although the students were familiar with seeing children through the lens of clinical observation, sharing family photographs provided an emotive context to the postconference, highlighting how parents perceived their child’s numerous hospitalizations, as well as their lives in happier times. The parents described what they expected from the nurses caring for their child in the critical care setting, as well as what nurses could expect from parents at their child’s bedside (i.e., parents experiencing physical and mental exhaustion, challenges and forgetfulness of comprehending vast amounts of information, and tense moments between parents and providers).
Based on their experience, the parent presenters created two scenarios intended to address difficult clinical conversations that nurses might face in the PICU. Two students were asked to serve as nurses in the PICU role-playing activity and interacted with the presenters, who assumed the role of the PICU parent. The remaining nursing students observed the interactions. Occasionally, the parents would step out of the simulation role to assist the students in understanding a parent’s perspective, communication needs, and expectations.
The initial group of 33 students did not receive written information detailing the patient’s case beforehand. Based on student feedback, the second group of 31 students was provided with a one-page description of the fictional patient’s history. A second scenario was conducted with a new pair of students serving as nurses at the child’s PICU bedside. Following the role-playing scenarios, the parents led a debriefing discussion where students asked questions and received feedback about technique. A postevaluation survey was disseminated to the students, parent presenters, and faculty. The parents expressed their appreciation for the nursing students’ time and answered any last-minute questions, and the students were then dismissed.
Student Feedback and Implications
Students provided written expectations before and feedback immediately after the parent-led postconference, as well as several weeks later, using an adapted version of Fisher’s (2006) “One-Minute Paper.” Expectations before the postconferences addressed students’ interest in understanding parents’ perspectives and identified specific skills they hoped to master:
- To learn how to be a better nurse (empathy and awareness) so I can prepare and support them in the areas that they need.
- To be able to understand the parents’ view of the hospitalization. I do not have any kids of my own so it’s very hard to truly understand.
- To learn about parents’ feelings and expectations when they have a hospitalized child. I also expect to learn things that I can do as a nurse to help with family centered care.
Survey responses following the postconferences demonstrated preconference learning expectations were either exceeded (54%) or met (24%) for the majority of the students. The survey also demonstrated that students wanted more information using additional scenarios, appreciated having the learning opportunity, and suggested all nursing students would benefit from the information provided:
- This presentation far exceeded my expectation. I felt like I learned so much about what to say and what not to say in a safe environment.
- I would like more information (surveys maybe?) about parent’s reactions to nurses and their thoughts concerning empathy, medical jargon, or even is hugging appropriate. I would personally like more training.
- The scenarios were the best practice as far as family interaction we have ever had.
- As much as the role play situation freaked me out, it really made a lasting impression. Moms are great to learn from and these two moms really know their stuff.
Some challenges or negative feedback students shared related to the content and process of the role-playing activities:
- It showed me how easy it is to get flustered when a parent is frantic and asking you questions about their child’s care status. I completely got hot and shaky and lost my own mind which didn’t help any. Very good at making me very nervous.
- I’m terrified now but I really enjoyed it. I didn’t like the role playing.
- I’ll say that I’m glad I wasn’t the person in the scenario.
Overall, the students innately understood that parental involvement is critical to patient care outcomes. However, the students believed they were ill prepared to engage parents as valued members of the health care team. Students wanted to know what parents thought of the PICU and nursing staff, as well as the nursing care their children received. Specifically, nursing students wanted to know which forms of communication were distinctly helpful or nonhelpful to parents.
Ten (15.6%) of 64 students provided feedback 6 weeks and up to 12 weeks after the sessions, reporting usefulness in practice:
- We were given the opportunity to speak with them as if it were a real life situation. I found this hard to do because all you want to do is speak logic and scientific with them, but you need to keep in mind that they are having to deal with a lot. They need the nurse to be empathetic.
- I learned so many new things that I have already used in the clinical setting. When talking to parents, I am very careful and tactful about the things I say.
- Before the post conference I was timid when entering a room where there were parents sitting in, after the post conference I feel at ease explaining who I am and my role in their child’s care.
The parents and nursing faculty also provided feedback after the sessions. The parents’ expectations were either exceeded or met, and appreciation for the event typified the responses. Future sessions would benefit from additional scenarios and a review of the reading assignment. Parents and faculty provided the following suggestions: creating opportunities for informal conversations between parents and nursing students, implementing long-term formal tracking methods to follow the students after graduating, and providing students in future sessions the opportunity to interact with parents with different backgrounds and additional health care experiences. Postconferences facilitated nursing students’ learning about actions and behaviors that may be helpful in parent–nurse relationships centered on empathy and family-centered care (Table).
Table: Parent–Nursing Student Communication Practice: Role Play
The parent presenters believe there is value to this PICU postconference because, as adults, the nursing students are more likely to identify with the parents’ point of view than that of the minor child and there was a lesser gap for the students to imagine themselves witnessing their acutely ill child than themselves as the patient. This helped diminish students’ fears that they would use inappropriate language when engaging with parents. Repeatedly, the parent presenters encouraged students to practice professional empathy and compassion-centered care. Parents do not expect nurses to develop personal relationships with all parents, but they do expect that nurses recognize the family’s struggle is fraught with uncertainty.
Exercising empathy is a competency expected by patients and families of their nurses. Parents of children in the PICU are overwhelmed with uncertainty and grief, and nurses are expected to practice emotional intelligence (Goleman, 1997) in conjunction with their technical skills. Because nurses must amass a great deal of technical skill and be able to deal with incoming data objectively, empathy can seem somewhat irrelevant to acute patient care. However, the ability to relate to a patient’s (or parent’s) mental and emotional states has the potential to improve health outcomes.
Although nursing lectures and textbooks may discuss professional standards of empathy, these are insufficient training tools (Evans, Wilt, Alligood, & O’Neil, 1998). Medicine and health care, provided by both nurses and doctors, is an interactive practice not merely a cognitive process. Simply reading about how to place an nasogastric tube or how to give an injection is not enough; eventually, individuals must attempt and practice the procedures. Nurse educators do little service to nursing students when they ask them to absorb information on how to communicate effectively but do not give them the opportunity to practice the skills. Effective nurse–patient–family role-playing provides nurturing challenges for students to reconsider their communication skills. Students involved in this postconference routinely discovered they were responding to parents’ questions with rapid-fire technical information, which often deteriorated the quality of the interaction. The parent presenters and instructors encouraged students to first respond empathetically, acknowledging the challenges of the situation, and then disseminate appropriate medical and care protocol information.
Nursing students repeatedly asked whether it was appropriate to show emotion. PICU parents stressed that empathy—a voiced recognition that their situation was incredibly difficult—soundly conveyed professional standards. Students wanted specific terms to use when dialoguing with PICU families, as the terms helped to allay their fears about these interactions. However, students must let go of preconceived notions that are there ideal phrases to use in an environment where little occurs that is ideal. Instead, students were asked to listen more actively, often “below” the level of a parent’s actual words, and hone in on unspoken fears. Participating students expected they would have a complete family background for each PICU case (e.g., parents’ marital status, language skills, primary caretaker). As any seasoned PICU nurse could attest to, this information is often not readily known. Navigating the family dynamic while caring for the patient is an expectation. For instance, a vast difference exists between a mother of a child who is in the PICU for the first time and one whose child has required repeated or extended critical care. Therefore, the parent presenters stressed the importance of nurses uncovering the information needed to communicate with the families. This is often accomplished by simply having a friendly conversation with family members. In addition, the parent presenters conveyed the appropriateness of nurses asking parents questions, such as “Did Rose struggle with extubation last time?” or “Do you understand why the doctors ordered a CT scan?”
The authors strongly believe in the value of parent presentations and scenario work during pediatric nursing clinical rotations. Based on student, parent, and faculty feedback, additional sessions using a more structured setting (i.e., workshop instead of postconference) were planned for the next academic year. Students attending the postconferences, through the survey evaluations, provided supportive qualitative and quantitative evidence. Although the content design intentionally generates moments of anxiety and uncertainty in the students, we, nonetheless, find this to be ultimately transformative and empowering learning for nursing students and aspiring professionals.
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Parent–Nursing Student Communication Practice: Role Play
|One-minute paper (Fisher, 2006): Expectation evaluation before presentation|
|Introductions: Parents or speakers by instructor(s)|
Purpose of the session
Personal experiences, impressions, and perspectives—what presenting parents wish every nurse knew
Role-playing: Scenario #1: Child fails extubation, is reintubated while parent is briefly away; failure to extubate has already happened twice before; followed by Scenario #2: Parents informed child is brain dead; one parent wants to call the organ harvest team and the other parent does not believe their child is at the end of life.
|Debrief; feedback on scenario role-play; more questions and observations (parents and instructor[s])|
|Thank participants for their time and acknowledge the challenges (parents and instructor[s])|
|One-minute paper (Fisher, 2006): Postpresentation evaluation|