Communication Skills Improvement: End-of-Life Patient Care in Nursing

This essay critically examines the importance of effective communication skills for nurses providing end-of-life care. It begins by identifying the author's personal learning need: to improve communication and confidence when delivering news to patients at the end of life. The essay then critically analyzes two research papers. The first paper, a randomized controlled trial, explores barriers to communication experienced by nursing and medical students, such as extrinsic factors like the inability to make sense of the experience and intrinsic factors, like dealing with emotional responses. The second paper, using convenience sampling, investigates how carers are supported during patient discharge at the end of life and the potential value of using The Carer Support Needs Assessment Tool (CSNAT) Approach. The essay uses Gibbs' reflective model to analyze these studies and the author's personal experiences, highlighting the challenges of communicating with patients and families, addressing issues like gatekeeping, uncommunicative patients, and language barriers. The essay emphasizes the importance of empathy, formal discussions, and the use of technology in improving communication, while also considering the needs of carers. The essay concludes with a reflection on how the author will attempt to change or improve their practice based on the analysis.

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Introduction
When the patients are at the end of their life, they deserve a palliative based approach
to take care of their specific needs (Wachterman et al., 2016). This care plan helps the nurse
understand the needs of the patient and provides them with the best care for which they have
been admitted (Kisorio & Langley, 2016). Improvisation of communication between nurses
and patients is crucial for the best outcome of personalized medical care of every patient
(Bello, 2017). In the following essay, the specific learning need that will be discussed is
improving my communication skills when providing care for end-of- life patients. The paper
will also include a critical analysis of two research papers which specifically addresses this
learning need. The model that will be used to critically reflect in the essay will be Gibb’s
reflection model. There is improvement in the quality of care when the doctors derive the
meaning out of the situation and try to comprehend the situation efficiently with the proper
implementation in their practice (Riley, 2015). This implementation will increase the
satisfaction of the patient (Kirca & Bademli, 2019). At the end of the essay it is critically
reflect how you will attempt to change or improve your practice as a result of this learning
Identify ONE specific learning need which you feel you need to develop
your nursing practice
I am now a third-year nursing student. I was facing many problems relating to poor
communication skills such as the inadequate communication with the patient and the nurses.
During my training last year, I was working in a hospital where I was caring for an 80-year-
old patient suffering from the final stages of Parkinson’s disease. He was in the critical care
unit and I was told to provide him with palliative treatment (Kelley & Morrison, 2015). He
was so restless and fidgety that I was not able to communicate with him. I failed to make him
comfortable as I was rarely talking to him. I could not talk to him because I was very
frightened and nervous on seeing his condition. His condition deteriorated gradually, and I

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just stood there like a puppet doing nothing (Kirsebom et al., 2013). That day, I felt very
disturbed and asked myself as to why I chose to nurse as a career. It was after this that my
senior staff nurse made me understand that it was time to gear up and make this my strength.
It was my senior who told me to enrol myself on a training programme for improving my
verbal and non-verbal communication skills. This specific learning need has limited my
practice by not enabling me to provide patients with the best care.
Step one: (150 words suggested per article): analysing the specific article.
The randomized controlled trial conducted by Gillet, O’Neill & Bloomfield (2016) is
a well-researched paper where extrinsic and intrinsic barriers were identified by the nurses
which demonstrated the communication gap in them. These barriers were extrinsic factors
such as the inability to make sense of the experience and intrinsic factors, for example; the
inability to deal with emotional responses. To prevent this, certain facilitators, such as good
role models, have been found to decrease the issue of the communication gap between
patients and nurses. The study was conducted on participants who are second and fourth-year
undergraduate nursing students in UK. The study used randomized control trial because of its
proven advantage in eliminating any sort of bias in the study (Gillet, O’Neill & Bloomfield
2016). Knowledge of the factors that have been identified in this paper that act as barriers
will help to improve the communication of nurses with patients dealing with their end of life
as they help in overcoming the discomfort and lack of confidence among the nurses.
The paper by Ewing et al. (2018) which used convenience sampling employed 40
hospital and community-based practitioners who interviewed 22 care providers about their
experiences in providing care to the patient during hospital discharge. The Carer Support
Needs Assessment Tool (CSNAT) was used by the researchers and was found to address the
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difficulties faced by caregivers in communicating end-of-life care to patients. It was found
that organisational focus on the needs of the patient was more than the needs of the carer that
means that the organisation focuses more on the patient and creates a misbalance between the
carer and the patient. In addition, it was identified that there was a lack of awareness on the
carers’ part about the end of life care situation. The study applied convenience sampling to
select the participants, which has proven to be effective in reducing the time and cost in
conducting the research (Ewing et al., 2018).
Both of the initiatives were proven successful but had some limitations. Both the
research papers included in the critical analysis are taken from trustworthy sources which
meet all the ethical parameters.
Step two:
The paper which used a randomized-controlled trial found that medical students and
nursing students experience difficulty in communicating end-of-life care to patients. Other
researchers previously found this information. The first barrier which was identified in this
research paper was gatekeeping. It was conveyed by the medical students that registered
nurses are the primary reason for blocking access to dying patients by their family. This study
also suggested that nurses get frustrated when they are assigned a non-reciprocating patient,
where the patient is unable to understand their illness and fails to reciprocate their feelings to
the nurses as well as the physician. It was a common emotion of not understanding what to
say, by nurses and medical students, when a dying patient approached them. The nurses were
mostly clueless as to what would have been an appropriate answer in the above situation.
There have been instances where the patient is unaware of their critical situation because the
nursing professional is scared or anxious to share the news with the family and the patient.
According to Norouzinia et al. (2016) nurse-patient communication is what makes the patient
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satisfied with the care that they have received. This study have suggested that training has
been provided to the nurses to utilise the communication skills, however they have not and
the patient has been left unsatisfied. In accordance with this study, other studies have found
that the nursing professionals have not been putting effort into making the patient feel like
home in the hospitals, which has decreased the satisfaction levels in the patient.
In this paper, an extrinsic barrier, uncommunicative patients, have been considered to
create frustration in nurses which increases the communication gap between patients and
nurses. There are patients who cannot reciprocate their feelings to the nurse which makes it
difficult for the nurse to interpret their actual feelings and deduce an action plan for their
care. Previous studies have been conducted which suggested that nurses need to be more
empathetic towards the patient so that the patient feels familiar with the hospital environment
and shares their concerns. If the nurse faces an angry patient, empathy decreases the
frustration in the patient and makes them soften towards the nurse and share their pain. An
instance was recorded in the paper of a nurse handling a dementia patient. The dementia
patient had been unable to communicate his feelings to create a bond with the nurse. Due to
the inability of the nurse to communicate effectively with the patient, it was felt that they
blamed themselves for their inefficiency. Patients with dementia have been popularly
observed to be in their own world regardless of who is present in front of them and what they
are trying to communicate. This gives rise to negative emotional consequences in the nurse
which makes them unable to function properly with the next patient.
There was another instance presented in the paper which was shared by another
nursing student. The student was dealing with a patient who was unable to understand the
English language and thus made it difficult for the nurse to convey the news of their death.
There was no interpreter available to break the news to the patient despite the patient
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understanding what was coming. It was observed that the patient felt more relaxed when
relatives were present with them. Meuter et al. (2015) noted in their research findings that
communication in the first language of the patient is important in conveying the information
of treatment and diagnosis. The likelihood of associated risk factors should be informed to
the patients in a language that is understandable by them. The nurse felt it to provide
company to the patient, but it would have been difficult to challenge the rules of the hospital.
The participants had expressed their viewpoints of no formal discussions being conducted to
share their experiences of dealing with a dying patient. According to Coyle et al. (2015)
formal discussions are to be conducted for the nurses who are deployed to provide quality
care to the patients undergoing end-of-life treatment. Discussion of death, dying and
acceptability among the nurses reduces the probability of stress among nurses and overdrive
of emotions among them. The participants that were included in this study have voluntarily
expressed interest in developing the necessary skills of communication for end-of-life
patients. As per the guidelines released by the National Institute of Health and Clinical
Excellence in 2019, implementation of technology in communicating with patients has been
improved recently. It is a guideline that must be followed by the developers of the technology
to create a framework such that it is patient-friendly (Evidence Standards Framework for
Digital Health Technologies, 2019).
The second paper which also used convenience sampling and deploys the CSNAT
approach to provide the carers with the necessary support during discharge of the patient
from the hospital. The results that have been obtained from the research have been divided
into three sections. The first section deals with the barriers that have been observed on the
part of the carers by the healthcare professionals. Unrealistic expectations have been found to
be the most prevalent barrier in the carers. It is often seen that the caregivers have little or no
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idea of their work or care that they are supposed to provide to the patient after they have been
discharged from the hospital. Making the carers aware of their duty and acknowledging their
responsibility while providing care is an integral part of communication that needs to be
discussed. The carers will undergo emotional and physical demands while providing 24-hour
care to the patient. The relatives of the patient must always keep in mind the duties of the
carer and not let them do any other task than what they have employed for.
Another barrier that was identified in this particular study was the lack of knowledge
in the carers about end-of-life situations. The lack of awareness among the carers had caused
problems in helping patients prepare for it. The patient does not acquire the required
knowledge about the present situation of their health which leads to dissatisfaction and
carelessness in the treatment or care that was being provided to them. According to Caswell
et al., (2015), communication between the healthcare professionals and the patient needs to
be strong enough, with relevant knowledge being provided, to satisfy them about the care.
Effective communication by the professionals needs to be ensured to establish a concordant
relationship and improve the quality of communication. Inability to communicate and transfer
necessary information from the physician to the patient, as well as the relatives of the patient,
can result in the relatives being confused about the situation and cause unnecessary stress in
the mind of the relative as well as the patient.
CSNAT is an assessment tool which is used by practitioners to determine the
requirement of support among carers. The family of the patient and the carer answer some
questions to understand what kind of support is required. This helps the carer reach a
common point with the family of the patient in developing the best action plan for the patient
to be provided with quality end-of-life care. The questions that have been incorporated in the
questionnaire help the carer understand the requirements from the point of view of the patient
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as well as their family members. This enables drawing up a patient-centric action plan and the
caregivers get an idea as to what care they are supposed to deliver. There were instances
where the carers did not have enough knowledge to answer the queries of the relatives of the
patient relating to the home-care that will be provided to them once they are discharged from
the hospital (Baille, 2016). In this study, it is mentioned to incorporate discussions with
carers who will be providing care to the patient at their home should be conducted to
facilitate a common point among them. The third section of the results deals with the
implementation of the CSNAT approach within a hospital. For the findings to be valid, the
practitioners and the carers had to consider the issues in an organization for incorporating this
approach. Specific departmental training needs to be provided for the carers to be able to take
care of patients who are at the end-of-life. Skills need to be developed by the caregivers to
make the patient feel that their concerns are being heard and comprehended by them. It was
also observed in this study to initiate the process of CSNAT form filling in the initial stages
of hospital admission (Aoun et al., 2018) because the patients feel stressed and frustrated by a
long stay at the hospital which makes them irritated to fill out forms while being discharged.
The starting of the form filling should be initiated early to make the assigned carer used to the
medical case of the patient. This will enable better patient handling and a better quality of
care to be offered to the patient with maximum satisfaction of the relatives of the patient as
well as patient. In order to address the issues faced by the organizations or its employers, Sir
Robert Francis QC from the NHS Foundation Trust wrote ‘The Francis Report’ which
outlined the failures by individuals and by different levels of people in the management. This
report helps the organizations to understand where their lack is and where immense effort
must be contributed to better the service that will be provided to the patients (Francis report,
2015).
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In addition to these two papers, there has been substantial evidence presented which
suggests the implementation of the COMFORT curriculum to increase the communication
skills of the nurses towards the patient. COMFORT is an associate signifier that stands for
seven themes or principles that frame a framework for teaching communication skills to
nurses. The COMFORT signifier stands for (a) Communication, (b) Orientation and chance,
(c) Attentiveness, (d) Family, (e) Oversight, (f) Unvaried and radically adaptational
Messages, and (g) Team (Lima, 2016). The communication module is the initial of the seven
principles custom-made for the COMFORT program (Pelaez & Hall, 2017). The
communication module intends to satisfy the requirement of teaching the basic concepts of
two, adaptive, verbal, and nonverbal communication messages for BBN (Bible Broadcasting
Network). Understanding the importance of narrative communication may be the main
intention of this communication system. The COMFORT program may be a tool that was
created to fill a void in communication skills coaching for nurses. The COMFORT program
provides instructors of nursing programs a singular chance to develop effective
communication skills in their students. The COMFORT program need not be restricted to
nursing students (Cronin & Finn, 2017). This program might not be able to teach active
nurses within the sort of skill development workshops. Finally, communication skills
coaching can possibly still be a crucial part of coaching for nursing students. Domain has to
still develop and implement the employment of effective communication skills to nursing
students to exemplify the requirement for these essential skills and the importance within the
nursing curricula.
After critically analysing the research papers, it proved that the introduction of
communication skills, as a learning need, is very important and that has helped patients in
their recovery as well (McCabe & Timmins, 2013). Enrolling myself in a communication
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development programme will enable me to care for a patient who is dying and due to be
discharged home. There will be times when patients can become delirious but I have to be
patient. My action plan for dealing with my future patients is to first make them feel
comfortable (Smith, O'Sullivan, Lo & Chen, 2013). If I am able to make them comfortable by
speaking with them about other affairs and not about their health, then only they will be able
to trust me and will help me in doing my duty in caring for them as well. My main aim is to
treat my patient as prescribed by the doctor and to see that my patient’s health does not
deteriorate because of my omissions (Moir et al., 2015).
I learned about therapeutic communication recently, where the nurse needs to
prioritize their patients for their physical and mental well-being so that they can recover from
the illness as soon as possible. I need to provide my patient with support and information and
treat them with a lot more ease. I also learned how to be an active listener. Nurses should
listen to their patient with care and should respond to their every question asked, however
difficult the question is. I have to treat my patient with more respect because being in the
hospital can sometimes be very scary (Radtke, 2013). Patients may feel frightened and
helpless. Therefore, it is the duty of nurses to comfort them and help them understand and
give them hope for their well-being. My learning does not stop here, it is a continuous
process. It is my responsibility as a nurse to regularly enhance my nursing skills by enrolling
myself in Personal and Professional Skill Development. This will refresh my nursing skills
with better patient health outcomes and greater satisfaction of the patient towards the
treatment and care that has been provided. It will also enable me to be culturally competent
with diverse patients that arrive at the hospital for treatment. The essential task of the nurse is
to provide the patient with relevant information regarding the treatment and care that is being
provided to them. The implementation these aspects, will help me to overcome the
communication problem that is faced by me.
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In conclusion, the learning need that was identified is the communication gap in
delivering news to patients who are at the end of their life. The two research papers that have
been critically analysed, compared and contrasted with other available supporting evidence
are in line with the specific learning need. The findings that have been obtained by the two
research articles concerning the communication gap among nurses and nursing students have
suggested the use of open discussion with clinical placements, and interventions which
improve the discharge planning by carefully integrating assessment of the carers and
subsequently reducing the readmission rates of the patient. Gibb’s reflective model was used
to help in critical reflection of the evidence that had been gathered to improve communication
skills once they are a Registered Nurse. In order to meet this learning need, engaging in
personal and professional skill development is necessary to deliver holistic and evidence-
based care to the patient.
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