“Seinfeld” often was dismissed as a TV show about nothing. But there was something in the middle of all that nothingness that made the 1990s sitcom so groundbreaking. And University of Utah College of Nursing faculty members are mining that unusual substance for opportunities to teach their students about how to talk to patients.
Remember Kramer’s “low-talking” girlfriend, who no one could hear, let alone understand? Or the “close talker” who invaded everyone’s personal space? Nursing instructors show videos of those bits to young nursing students (who were toddlers when the characters first appeared on television) to illustrate the potential miscommunication minefields ahead. Mastering the delicate art of communicating in healthcare settings is life-long work that defines nursing education and scientific research. And the YouTube clips are just the beginning of a campaign that starts when a nursing student enters their first class at the college.
“Nurses are a hub for communication and information because they function as coordinators of care,” says Mollie Cummins, associate dean for research. “They’re constantly managing communication and interpreting information — whether phone calls, diagnostic reports, treatment information, or logistics of care – and they facilitate communication across patients, family members, physicians and other members of the team. Communication is foundational to everything a nurse does.”
With that focus, college instructors and researchers, many of whom have worked in interdisciplinary healthcare teams for years, are acutely aware of what works and doesn’t in a hospital room, or when a patient or grieving family member is sent home. Healthcare providers struggle with gaps between poison control center and emergency department records. They know what stops awkward end-of-life conversations from happening. They’re painfully aware of the miserable chemotherapy symptoms suffered at home that rarely get reported. And they know how talking to others can head off complicated grief and other health problems in bereaved caregivers.
Communication is the thread through it all. And it starts on Day One at the College of Nursing.
Teaching More than Just How to Talk
Students entering college these days are a distinct generation—leaps and bounds ahead of their instructors and even the U.S. healthcare system when it comes to using technology to communicate, but also lagging when face-to-face conversations are required. To some traditional educators, the Twitter and Instagram generation can seem disconnected, bored even. But to Connie Madden, assistant dean of the college’s baccalaureate program, breaking through takes a matter of minutes. And the strengths the students’ intrinsic knowledge of technology brings are equal to the nuts-and-bolts communication skills they can be taught.
“They are thoughtful and reflective,” Madden says. “You’ve just got to dig.
“They come to us as good thinkers. They have a lot more questions. They’re curious and inquisitive,” she adds. “They’ve had to start thinking in much different ways than I did. Technology helps them understand the possibility of things.”
In early classes, students role play, pretending not to listen, getting face-to-face encounters wrong. They talk about how that makes them feel, how that might make a patient feel. In the college’s SIM Center, students practice communicating in a healthcare “crisis” — with the patient and each other. An instructor in the control room plays the patient. The interactions are recorded and broken down in a confidential group debriefing session afterward.
“My first mistake was on a real person. We want them to learn from their mistakes here so they don’t make mistakes on real patients,” says Maddie Lassche, the college’s executive director of simulation. “We talk about it. They all learn from it. And then they’re better prepared to go out and manage situations with real live people.”
But while this training in eye contact and active listening and caring for diverse populations are among the most critical skills a new nurse can learn, the communication tools they will use day-in and day-out in hospitals and clinics and nursing homes have changed. Pagers have been replaced by Vocera wearable microphones. Paper patient files have gone digital, supplanted by electronic health records (EHRs).
As in all things, there’s a flip side to these innovations. Technology has transformed patient care, making communication between healthcare team members a matter of seconds. Sharing records with patients takes the click of a button. Diagnostics that took days or weeks now can transmit in hours or minutes.
But technology, with all its gadgets and gizmos and cutting out of the middle man, also has opened some gaping holes in healthcare. The personal touch can be lost. Many patients still want and need a face-to-face consultation. And a smart phone app can’t tell you if a caregiver’s health is declining, or a patient is bumping up against a language barrier. That takes a human being.
Bridging the Gaps
Over years of working in teams with doctors and social workers and physical therapists, nursing researchers have become acutely aware of the places and times when healthcare communication breaks down. They also can identify the best prospects for new technology — social media including Facebook and Twitter, gaming platforms, iPads and smart phones and smart watches — that might be able to bridge those gaps.
Which explains why so many College of Nursing researchers’ projects are dedicated to taking the next steps in communication: making connections between patients and their doctors, innovating and tweaking technology, helping caregivers think about what happens to them. Their research builds on the old school communication that still forms the backbone of patient care.
“Communication is everything. And ineffective communication contributes to a lot of unnecessary healthcare costs,” says Cummins. “When there’s a breakdown, patients get the wrong medication, are readmitted or suffer in silence at home. All the outcomes we want to achieve as healthcare providers are best facilitated through quality communication.”
Some researchers are using devices — and the unique tools, online platforms and languages developed for them — to take communication one step further. College researchers are helping develop smart watches that will track false clinic alarms, mobile-adapted apps to walk parents through the process of signing off on genetic testing of a baby’s bloodspot, and internet-based platforms that will allow parents of kids with asthma to report and track their symptoms. They’re using Facebook and Twitter to engage diabetic patients in their care, and developing animated emoji-like icons to aid those with intellectual disabilities in identifying depression symptoms.
Other nursing scientists are using technology to track traditional strands of communication around cancer care — adapting iPads to help adolescents report their symptoms, for example, or creating an automated, phone-based system to check on chemotherapy patients after they leave the oncology clinic.
“Patients experience a lot of uncomfortable symptoms at home. And until very recently, our health records didn’t capture the patient experience at all,” says Distinguished Professor Kathi Mooney, whose research project drew the notice of former Vice President Joe Biden during his 2016 listening tour stop at Huntsman Cancer Institute. “We have been missing our biggest partner — the patients — and understanding their symptoms and how their quality of life is affected.”
With the Symptom Care at Home (SCH) system Mooney developed with Professor Susan Beck, patients who report severe nausea are prompted with ways to treat their feelings of sickness — from avoiding certain foods to which fluids to drink. The system also notifies each patient’s nurse or doctor so they can follow up. For patients who reported severe nausea, the automated coaching system helped diminish bad symptom days by two-thirds. “We have very strong evidence that if they are routinely monitored and use the guidelines to improve poorly controlled symptoms, they will significantly benefit,” Mooney says.
Still other researchers are studying the ways caregivers are impacted by the grueling, unpaid work of taking care of a dying family member by documenting what is said around them, what the caregivers say themselves. The health effects of caregiving range from depression and isolation to debilitating complicated grief once that patient dies. And many times, caregivers sacrifice their own health to take care of a family member.
Over the next few years, Associate Professor Lee Ellington will track communication between 120 family caregivers and the healthcare workers who visit their care recipients at four hospices around the country — everyone from chaplains to social workers, if they’re willing, will be recorded. At the same time, the caregivers will report their care recipients’ symptoms through Mooney’s phone-based system. The two streams of information will be analyzed to determine if the caregivers themselves need medical intervention. The study’s design is meant to monitor and help a sometimes-forgotten population of healthcare providers, Ellington says.
“When the nurse walks into the home, the tape recorder is turned on and is kept on. We capture everything — talking to the patient, talking to the caregiver, washing hands.” The recordings are not just practical, she adds. Researchers will glean stress, humor, joy and resilience from the conversations. “There’s really a lot of beauty in those conversations at the end of life. In the clinic, there’s some chitchat, but it’s business,” Ellington explains. Whereas in the home, the dog is there, the family is reflecting. It’s equal parts beauty and distress.”
And finally, several college researchers are delving into the pain of the end of life.
Associate Professor Kathie Supiano is preparing a group therapy model for those caring for family members with end-stage dementia. When their care recipient dies, they are at greater risk for debilitating complicated grief. Supiano’s community-based research, which is funded by the Alzheimer’s Association, will rely on staff at three Salt Lake City long-term care facilities — the William E. Christofferson Salt Lake Veterans Home, Silverado Aspen Park, Mission at Hillside Rehabilitation Center — help identify family members who need intervention.
“We want to help dementia family caregivers navigate the last months of life with their family member to optimize their relationship in such a way that when the death happens, their grief is actually satisfying and brings the sense of accomplishment that we hope long-term dementia caregivers can realize,” Supiano says. “Part of that is gaining support from each other and group facilitators, gaining skills, and translating that to their own interactions with the person with dementia.”
In the end, the communication work of the college’s scientists and educators traverses the lifespan of both nurses and their patients. At the same time, the College of Nursing is pushing the bounds of the technological tools of healthcare.
It’s much more than talk.