Four Habits Model prepares pediatric nurses for emotionally difficult discussions

A child's illness and hospitalization are extremely stressful for both the child and the parents. A new study reports that the Four Habits Model of Highly Effective Clinicians, a core set of communication skills developed to help physicians communicate with patients, can successfully prepare inexperienced nurses for emotionally difficult conversations with parents of pediatric patients.

The evidence-based Four Habits Model was co-developed 20 years ago by Regenstrief Institute investigator Richard Frankel, Ph.D., a sociologist and medical educator whose current research focuses on facilitating and improving clinician-patient communication in the context of advanced cancer. This is the first time the Four Habits Model's effectiveness has been tested with nurses.

The new study, published in the July 2014 issue of Patient Education and Counseling, found that when taught the Four Habits Model, newly licensed nurses reported significant improvements in emotion-focused conversations with parents in four of the five areas measured: preparation, communication skills, relationships and confidence.

"Newly minted nurses, like other newly trained professionals, tend to concentrate on getting the work done," Dr. Frankel said. "Getting the work done is obviously important to patient care, but so is being thoughtful and reflecting on what one is doing, not simply operating in the moment. We don't do a lot of real-world training of nurses, doctors or any type of health professional; we put them in classrooms and provide simulations exercises but don't really give them on-the-job coaching or opportunities to practice important communication and other skills. With exposure to the Four Habits, inexperienced nurses can improve how they interact with both young patients and their parents."

Newly licensed nurses involved in the study did not demonstrate a decrease in their anxiety level, which Dr. Frankel said is not necessarily bad for their relationship with young patients or families.

"All people with responsibility for others experience anxiety," he said. "In lower doses, anxiety can propel you to be vigilant. Vigilance is one of the major ways to prevent accidents and errors. So it is not surprising and actually might be a good thing that people just embarking on a professional career remain somewhat anxious but are able to convert that anxiety into vigilance."

Previous studies by Dr. Frankel and other researchers have shown that the Four Habits Model has a positive long-term effect on both clinician and patient satisfaction. The model is used extensively in the United States and other countries to train physicians. The Four Habits are:

1. Invest in the beginning.

2. Elicit the patient's perspective.

3. Demonstrate empathy.

4. Invest in the end.

Twenty-three skills make up the Four Habits.

Each of the Four Habits contributes to good . For example, eliciting the patient's perspective allows a better understanding of the disease and the person's psychological and social response(s), both of which contribute to improved outcomes, according to Dr. Frankel.

In addition to his Regenstrief appointment, Dr. Frankel is an Indiana University School of Medicine professor of medicine and the inaugural director of the Mary Margaret Walther Palliative Care Research and Education Program at the Indiana University Melvin and Bren Simon Cancer Center.

Additional authors of "The effectiveness of a brief intervention for emotion-focused nurse-parent communication" are first author Mark J. Fisher, Ph.D., of the College of Nursing, University of Oklahoma Health Sciences Center; Marion E. Broome, Ph.D., R.N.; Barbara M. Friesth, Ph.D., R.N. and Tracy Magee, Ph.D., R.N., all faculty of the Indiana University School of Nursing.

The researchers note that their findings suggest the use of effective , such as eliciting parents' perspectives and empathy, may result in increased parent satisfaction. They conclude "teaching nurses how to use a few new habits for nurse-parent during an emotionally charged situation is an effective way to shed light on an invaluable relationship in health care, the nurse-parent relationship."

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