Introduction
An understanding of patients’ goals, values, and preferences is integral in the delivery of high-quality medical care, particularly for patients with serious illnesses facing challenging treatment choices Back et al. (Reference Back, Fromme and Meier2019). For clinicians to gain an understanding of patients’ goals, high-quality conversations between patients, their families, and clinicians must occur (Lin et al. Reference Lin, Smith and Feder2018). These conversations rely on highly effective communication skills by clinicians to communicate complex information about prognoses and treatments, elicit patient values and goals, provide support, and ensure care plans and outcomes align with patient preferences (Bernacki et al. Reference Bernacki, Paladino and Neville2019). These discussions, known as Goals of Patient Care (GoPC) conversations, have been shown to improve patient experience and quality of care, reduce costs, and improve the job satisfaction of clinicians (Back et al. Reference Back, Fromme and Meier2019; Hayashi et al. Reference Hayashi, Sato and Ogawa2022; Stephens et al. Reference Stephens, William and Lim2021).
GoPC conversations establish “the overarching aims of medical care for a patient that are informed by patients’ underlying values and priorities, established within the existing clinical context, and used to guide decisions about the use of or limitation(s) on specific medical interventions” (Secunda et al. Reference Secunda, Wirpsa and Neely2020). This is integral to patient-centered care, where full information is provided and patients are involved in decision making, which is the standard for quality care (Jeffrey Reference Jeffrey2018). In contrast, multidisciplinary case conferences discuss patient or patients details and coordinate care among healthcare providers from across a variety of professions (Government of Western Australia, n.d.). Patients who have discussed their wishes for end-of-life care with a physician are more likely to receive care that aligns with their preferences (Clark et al. Reference Clark, Person and Gosline2018; Mack et al. Reference Mack, Weeks and Wright2010; Wright et al. Reference Wright, Zhang and Ray2008), and when these conversations are discussed in a clear, empathetic way that is patient-centered, patients report greater satisfaction and rate experiences as positive (Bischoff et al. Reference Bischoff, O’Riordan and Marks2018; O’Connor et al. Reference O’Connor, Watts and Kilburn2020). GoPC conversations are alsoassociated with less aggressive medical care near death, earlier hospice referrals, higher quality of life ratings for patients and improved bereavement outcomes for families (Bernacki and Block Reference Bernacki and Block2014; Tang et al. Reference Tang, Liu and Liu2014; Wright et al. Reference Wright, Keating and Ayanian2016).
Only 14.5–40% of patients with serious illness have a conversation about their goals with their clinician (Gieniusz et al. Reference Gieniusz, Nunes and Saha2018; Mack et al. Reference Mack, Weeks and Wright2010), with even fewer conversations documented in the patient medical record (Bischoff et al. Reference Bischoff, O’Riordan and Marks2018). When GoPC conversations do occur, they often take place relatively late in the course of illness and neglect psychosocial, emotional, and cultural needs, with clinicians often missing opportunities to listen and respond to family members, acknowledge and address emotions, and explain treatment options (Curtis et al. Reference Curtis, Engelberg and Wenrich2005; Mack et al. Reference Mack, Cronin and Taback2012). People living with serious illnesses and their caregivers report experiencing high levels of suffering and are at risk of receiving care that is not aligned with their preferences (Committee on Approaching Death: Addressing Key End of Life Issues 2015). When GoPC conversations do not occur, physicians often misunderstand patients’ end-of-life treatment preferences (Winkler et al. Reference Winkler, Reiter-Theil and Lange-Riess2009), and patients overestimate the benefits of life-sustaining treatments (Weeks et al. Reference Weeks, Cook and O’Day1998). Although studies have found that patients and/or their decision makers typically prefer less aggressive care at the end of life, a concerning number of patients still receive care that does not align with their goals to minimize suffering (Gieniusz et al. Reference Gieniusz, Nunes and Saha2018; Mack et al. Reference Mack, Weeks and Wright2010).
Clinicians often feel uncomfortable or ill-equipped to discuss end-of-life care with patients (Fulmer et al. Reference Fulmer, Escobedo and Berman2018), and report high levels of moral stress when limiting life-prolonging treatment (Mehlis et al. Reference Mehlis, Bierwirth and Laryionava2018). Clinicians’ reluctance to engage in end-of-life communication has been attributed to lack of training, insufficient time, competing needs, and discomfort in communicating difficult information, responding to emotional reactions, and discussing palliative care (Committee on Approaching Death: Addressing Key End of Life Issues 2015; Granek et al. Reference Granek, Krzyzanowska and Tozer2013; Lin et al. Reference Lin, Smith and Feder2018; Waldron et al. Reference Waldron, Johnson and Saul2016). Studies have reported relatively limited communication skills in clinicians when discussing GoPC conversations, with inappropriate use of medical jargon during, which can compromise patient understanding (O’Connor et al. Reference O’Connor, Watts and Kilburn2020). Even physicians who report high confidence in being able to address patients’ concerns rarely respond empathetically when patients’ express emotions (Committee on Approaching Death: Addressing Key End of Life Issues 2015; Pollak et al. Reference Pollak, Arnold and Jeffreys2007). When GoPC conversations are discussed in a rushed manner or the physician is dismissive, patients report feeling fearful and invisible, and rate the experience as negative (O’Connor et al. Reference O’Connor, Watts and Kilburn2020). The lack of clinician confidence and skills about palliative care and communication skills necessary to lead these conversations with patients and families is likely influenced by the absence of training in both undergraduate and graduate education (Committee on Approaching Death: Addressing Key End of Life Issues 2015; Horowitz et al. Reference Horowitz, Gramling and Quill2014; Kamal et al. Reference Kamal, Maguire and Meier2015). These skills can be acquired through explicit training at any point in clinicians’ educational careers, and when implemented, formal teaching of palliative care and communication skills in medical school curricula and post-graduate education, including didactic and clinical learning experiences, has been shown to improve competency of clinicians (Bickel-Swenson Reference Bickel-Swenson2007; Clayton et al. Reference Clayton, Butow and Waters2012; Rodenbach et al. Reference Rodenbach, Kavalieratos and Tamber2020; Walczak et al. Reference Walczak, Butow and Bu2016).
End of life care often involves multiple, sudden and complex problems that require many healthcare professionals to be involved (Committee on Approaching Death: Addressing Key End of Life Issues 2015). This can present challenges for effective communication amongst healthcare providers, patients and their family, to effectively coordinate care to align with the patient’s preferences (Jeffrey Reference Jeffrey2018). Collaborative interdisciplinary healthcare teams can increase adoption of GoPC conversations, with Ma et al. (Reference Ma, Haverfield and Lorenz2021) finding that an interdisciplinary team approach improved provider perception of goals of care uptake. When provided training that encouraged nurses and social workers to initiate conversations to educate patients on goals of care discussions, physicians and advanced practice providers would follow up their conversations, confirm patients’ wishes, and sign-related orders (Ma et al. Reference Ma, Haverfield and Lorenz2021). Similarly, Stephens et al. (Reference Stephens, William and Lim2021) found that interdisciplinary educational environments improved training experiences and identified diversity of participants’ perspectives to be a key learning point, reporting improvements in communication skills with patients and also interprofessional team members.
Goal-concordant care also relies on systems to ensure information can be documented and accessed when needed. Benton (Reference Benton2017) found that GoPC conversations were more likely to occur when a formal system was in place for assessing patients’ end-of-life wishes and goals of care, suggesting that systematic interventions are also necessary in facilitating effective communication between clinicians and their patients. This requires a significant shift in the organization of healthcare systems, leadership recognition and involvement, training for providers, and support to manage systems and roles across disciplines (Ma et al. Reference Ma, Haverfield and Lorenz2021). When patients’ preferences are poorly or not documented, they are at greater risk of receiving care that does not align to their wishes (Heyland et al. Reference Heyland, Barwich and Pichora2013). Heyland et al. (Reference Heyland, Barwich and Pichora2013) found that nearly 70% of documented orders were discordant with patients’ expressed preferences for end-of-life, despite documentation occurring shortly after conversations. System-level barriers, such as lack of accessible documentation, lack of training to navigate systems, and storing and updating patient information across time and locations may contribute to difficulties providing goal-concordant care (Heyland et al. Reference Heyland, Barwich and Pichora2013; Lakin et al. Reference Lakin, Isaacs and Sullivan2016; Turley et al. Reference Turley, Wang and Meng2016). Lakin et al. (Reference Lakin, Isaacs and Sullivan2016) found that physicians reported low confidence in finding or using documentation in the Electronic Medical Records to care for patients, suggesting clear guidelines for GoPC conversations need to be embedded within hospital policies and into communication skills training (O’Connor et al. Reference O’Connor, Watts and Kilburn2020).
To improve communication skills training about end-of-life care, several postgraduate education programs have been developed. These typically have been designed for physicians or residents, with relatively few non-physician professionals participating (Bays et al. Reference Bays, Engelberg and Back2014). Training programs have increasingly utilized experiential learning and skills practice through simulation, where clinicians role play communication with simulated patients (Cannone et al. Reference Cannone, Atlas and Fornari2019). Practicing communication skills in a high fidelity but low risk simulated environment aims to prepare clinicians for real life encounters while decreasing learner stress and fostering a safe learning environment (Back et al. Reference Back, Fromme and Meier2019). As part of skills practice, training programs typically also include a feedback element to encourage clinicians’ development of self-awareness and perceptions of their own or others’ emotions, attitudes, and underlying beliefs that may impact communication (Back et al. Reference Back, Fromme and Meier2019; Thomas et al. Reference Thomas, Zubair and Hayes2014). Delivery of communication skills training is primarily through in-person workshops, though recently virtual training programs have been developed to increase reach and observe social distancing requirements (Crossman et al. Reference Crossman, Stobart-Gallagher and Siegel2021; Uemura et al. Reference Uemura, Ito and Yuasa2024). Back et al. (Reference Back, Fromme and Meier2019) outline a number of established communication training workshops that vary greatly in curriculum, format, and target populations. These focus on using a scripted conversation guide (Ariadne Labs 2024), advanced care planning (Choices R 2024), foundational communication skills (Center to Advance Palliative Care 2024), flexible use of communication skills (VITALtalk 2024), interprofessional skills (American Association of Colleges of Nursing 2024), and providing an overview of communication skills (Back et al. Reference Back, Fromme and Meier2019; Northwestern University 2024).
Despite recommendations for mandatory communication skills training at undergraduate and postgraduate levels (references), almost none of the established programs or models have been widely disseminated in health professional accreditation requirements or training curricula (Back et al. Reference Back, Fromme and Meier2019; Gilligan et al. Reference Gilligan, Coyle and Frankel2017). Although there has been an increase in palliative care training programs in the last 20 years, teaching methods vary greatly between programs, with trainees and leaders often rating current education as inadequate (Albert et al. Reference Albert, Collins and Bauman2023). Overall, there has been a lack of widely adopted interdisciplinary pedagogical models based on clear theoretical frameworks that can be tailored to teach a broad spectrum of difficult conversations. As such, this review explores research that has investigated interventions to train health professionals to effectively communicate with patients in acute settings who are establishing their goals of care.
Methods
Aim
This integrative review evaluates and synthesises research that investigated interventions to train registered health professionals to effectively communicate with patients in acute settings who are establishing their goals of care. This review describes current uni- and multidisciplinary training interventions and their clinician, patient, and system outcomes.
Design
This review used the Whittemore and Knafl (Reference Whittemore and Knafl2005) Integrative Review methodology and followed the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist (Page et al. Reference Page, McKenzie and Bossuyt2021) (Fig. 1). This approach allowed the analysis and synthesis of both empirical (qualitative and quantitative) and theoretical literature related to GoPC conversations. Following this approach, problem identification, literature search, data evaluation, data analysis and presentation were completed. Problem identification involved identifying the aim of the review, target population, intervention, outcome. A literature search was undertaken, and inclusion criteria was formulated. Relevant reports were critically appraised using the Joanna Briggs Institute Methodological Appraisal tools (Aromataris et al. Reference Aromataris, Lockwood and Porritt2024), and data relevant to the aim of the review were extracted and is presented in table format. Themes and subthemes were identified and are presented in a table format with an accompanying narrative discussion. Finally, conclusions to inform practice, policy and education and further research are presented (Whittemore and Knafl Reference Whittemore and Knafl2005).
The + indicates updated search conducted in November–December 2023, in addition to original search in February 2023. From: Page MJ, Mckenzie JE, Bossuyt PM, et al. (2021) The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 372, n71. https://doi.org/10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/.
Search methods
A search strategy was developed with the assistance of the Faculty of Health librarian. A concept grid was used to determine the likely subject headings and keywords. Appropriate combining search terms were explored.
The search terms include variations of the following keywords and phrases; doctor* or physician* or clinician* or nurse* or hospitalist* or “health* professional*” or “allied health*” or physiotherapist* or “occupational therapist*” or fellow* or “speech pathologist*” or “social work*” or oncologist*, intervention* or program* or training* or VitalTalk* or workshop* or course*, Communication* or conversation*, goal* ADJ3 care or goc* or gopc* or “treatment* goal*” or “treatment* choice*” or “end-of-life conversation*” or “serious illness conversation*” or “difficult conversation*,” and hospital* or “acute setting*” or “emergency* department*” or “intensive care unit*” or center* or outpatient*
The following databases were searched; CINAHL, Embase, PsycINFO, Medline (Ovid), Scopus, and ProQuest.
Inclusion criteria captured qualitative, quantitative and mixed methods, and text and opinion studies, explicitly investigating communication skills training for registered health professionals conducting GoPC conversations, published in peer-review journals. Exclusion criteria were studies that included undergraduate students, non-registered health professionals (for example, ENs or AINs), or outpatient settings.
Search outcomes
The initial literature search was conducted in February 2023, with an updated search conducted in December 2023. The initial search identified 2,133 records; 223 were duplicates identified using EndNote (The EndNote Team 2013) and Rayyan (Ouzzani et al. Reference Ouzzani, Hammady and Fedorowicz2016) leaving 1,910 for possible inclusion (Fig. 1). Titles and abstracts of the remaining records were reviewed (author initials to be included after peer review) and 1,786 were excluded. This left 124 records for full-text review (author initials to be included after peer review), after which a further 81 records were excluded leaving 43 reports for quality appraisal (author initials to be included after peer review). The second search identified 520 new records published between February 2023 and December 2023; 185 were duplicates EndNote (The EndNote Team 2013) and Rayyan (Ouzzani et al. Reference Ouzzani, Hammady and Fedorowicz2016) leaving 335 for possible inclusion. Titles and abstracts of the remaining records were reviewed (author initials to be included after peer review) and 326 were excluded. This left 9 records for full-text review (author initials to be included after peer review), after which a further 5 records were excluded leaving 4 reports for quality appraisal (author initials to be included after peer review). Records were input into Retraction Watch (The Center for Scientific Integrity 2018) on 14/05/2024 to ensure no records had been retracted.
Quality appraisal
The data evaluation stage was completed using the Joanna Briggs Institute (JBI) Quality Appraisal Framework (2017). Studies which met the inclusion criteria based on title and abstract review were read independently in full by two authors to confirm eligibility and to conduct quality appraisal for methodological quality using the appropriate The JBI (2017) quality appraisal tools. Six tools were used; the checklists for analytical cross-sectional studies, for qualitative research, for quasi-experimental studies (non-randomized experimental studies), systematic reviews, text and opinion, and for randomized controlled trials (RCTs; The Joanna Briggs Institute, 2017). There is no specific tool to evaluate descriptive studies, so the checklist for analytical cross-sectional studies was adapted to review descriptive studies. Mixed methods studies were appraised in two parts using an appropriate quantitative checklist and the checklist for qualitative research. Quality appraisal criteria were discussed, and consensus was reached upon which criteria were essential and any modifications and considerations in the assessment of criteria for each tool. To be included in the review, studies had to meet all essential criteria and be in two points of the total achievable score (Tables 1–8). Where criterion was not applicable to a particular study, the total achievable score was reduced. Following quality appraisal, a further 25 from the initial search, and three publications from the second search did not meet the required level of quality, leaving a total of 19 for review.
Critical appraisal of eligible systematic review and research synthesis – search one only
1 Did not meet an essential criterion.
Critical appraisal of eligible randomized controlled trials – search one only
1 Did not meet the threshold and an essential criterion.
Critical appraisal of eligible quasi-experimental studies – searches one and two
1 Did not meet an essential criterion and the threshold.
2 Did not meet the threshold.
Critical appraisal of eligible analytical cross-sectional study – search two only
1 Did not meet an essential criterion.
Critical appraisal of eligible qualitative research – searches one and two
1 Did not meet an essential criterion.
Critical appraisal of eligible text and opinion studies – searches one and two
1 Did not meet an essential criterion.
Critical appraisal of eligible mixed methods studies (qualitative and RCT) – search one only
Critical appraisal of eligible mixed methods studies (qualitative and quasi-experimental) – search one only
Data extraction and synthesis
Data about the text and studies’ sample sizes, interventions, and measures were extracted (see Supplementary file 1). Results data from each study and one text were also extracted (see Supplementary file 1). As data were extracted (see Supplementary file 1), consistent patterns and themes across the sources, for example, similar statistical outcomes, words, phrases or concepts that were reported in the studies’ results or key findings were tabulated. Subthemes were identified and then collapsed into themes (data analysis stage) according to the review aim.
Results
Included studies
The 19 included studies (Table 9) were published over a 7-year period, from 2016 to 2023. Four were qualitative (Day et al. Reference Day, Saunders and Steinberg2022; Doherty et al. Reference Doherty, Gujral and Frenette2023; Geerse et al. Reference Geerse, Lamas and Sanders2019; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021), nine were quasi-experimental (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017; Casey et al. Reference Casey, Price and Markwalter2022; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Fettig et al. Reference Fettig, Tang and Newton2022; Haley et al. Reference Haley, Meisel and Gitelman2017; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020; Ouchi et al. Reference Ouchi, Lee and Block2023; Smith Reference Smith2017), two were randomized controlled trials (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Epstein et al. Reference Epstein, Duberstein and Fenton2017), three were mixed methods (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Kruser et al. Reference Kruser, Taylor and Campbell2017; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020), and one was a text article (Wolfe et al. Reference Wolfe, Denniston and Baker2016). Studies originated in the United States of America (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Annadurai et al. Reference Annadurai, Smith and Bickell2021; Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017; Casey et al. Reference Casey, Price and Markwalter2022; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Epstein et al. Reference Epstein, Duberstein and Fenton2017; Fettig et al. Reference Fettig, Tang and Newton2022; Geerse et al. Reference Geerse, Lamas and Sanders2019; Haley et al. Reference Haley, Meisel and Gitelman2017; Kruser et al. Reference Kruser, Taylor and Campbell2017; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020; Ouchi et al. Reference Ouchi, Lee and Block2023; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Smith Reference Smith2017; Wolfe et al. Reference Wolfe, Denniston and Baker2016) and Canada (Day et al. Reference Day, Saunders and Steinberg2022; Doherty et al. Reference Doherty, Gujral and Frenette2023; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021). Sample sizes ranged from 3 to 342 participants (qualitative studies 3–25 and quantitative studies 6–342).
Summary of included studies
Themes
Four themes emerged from the data, Delivery of training programs, Clinician outcomes, Patient outcomes, and System outcomes. Subthemes were identified within each theme (see Supplementary File 1).
Theme one, Delivery of training programs, highlights a shift from didactic learning to simulated learning, to align with evidence of increased effectiveness of learning for participants, with Subtheme 1, Simulated learning, highlighting the use of simulated learning in the teaching of communication skills, Subtheme 2 describing Virtual training, Subtheme 3 exploring the Challenges and barriers to training and GOPC, while Subtheme 4 describes the role of training in Filling the gaps.
Simulated learning (Subtheme 1) was commonly reported across included studies. Sixteen studies utilized roleplaying between clinicians and simulated patients to teach and practice communication skills (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Annadurai et al. Reference Annadurai, Smith and Bickell2021; Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Doherty et al. Reference Doherty, Gujral and Frenette2023; Epstein et al. Reference Epstein, Duberstein and Fenton2017; Fettig et al. Reference Fettig, Tang and Newton2022; Geerse et al. Reference Geerse, Lamas and Sanders2019; Kruser et al. Reference Kruser, Taylor and Campbell2017; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020; Ouchi et al. Reference Ouchi, Lee and Block2023b; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Smith Reference Smith2017; Wolfe et al. Reference Wolfe, Denniston and Baker2016). Authors of the included studies advocated for utilization of simulated learning as it provides a realistic and safe environment to practice (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Smith Reference Smith2017; Wolfe et al. Reference Wolfe, Denniston and Baker2016), more opportunities to practice skills (Doherty et al. Reference Doherty, Gujral and Frenette2023), increases clinicians’ confidence (Doherty et al. Reference Doherty, Gujral and Frenette2023), encourages self-reflection (Berns et al. Reference Berns, Camargo and Meier2017; Doherty et al. Reference Doherty, Gujral and Frenette2023; Fettig et al. Reference Fettig, Tang and Newton2022), increased clinician’s understanding of patients’ perspectives (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Doherty et al. Reference Doherty, Gujral and Frenette2023), and could result in greater learning and acquisition of communication skills (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017; Doherty et al. Reference Doherty, Gujral and Frenette2023; Smith Reference Smith2017; Wolfe et al. Reference Wolfe, Denniston and Baker2016). Roleplay scenarios were beneficial as they could be adapted to clinicians’ settings (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Fettig et al. Reference Fettig, Tang and Newton2022) and any areas of difficulty identified in prior to participants attending the workshops (Wolfe et al. Reference Wolfe, Denniston and Baker2016).
Virtual training (Subtheme 2) and online formats are emerging across GoPC communications skills training, with two studies utilizing completely virtual training formats (Casey et al. Reference Casey, Price and Markwalter2022; Day et al. Reference Day, Saunders and Steinberg2022), and two (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Ouchi et al. Reference Ouchi, Lee and Block2023) using a combination of in-person and virtual methods. Virtual training included didactics (Casey et al. Reference Casey, Price and Markwalter2022; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Ouchi et al. Reference Ouchi, Lee and Block2023), demonstrations (Casey et al. Reference Casey, Price and Markwalter2022; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Ouchi et al. Reference Ouchi, Lee and Block2023), roleplay conversations (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Ouchi et al. Reference Ouchi, Lee and Block2023), and virtual assessment of communication skills (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022). Virtual delivery increased the feasibility of training programs and increased the reach of training programs (Ouchi et al. Reference Ouchi, Lee and Block2023) by providing workarounds for policies that restricted in person contact (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Ouchi et al. Reference Ouchi, Lee and Block2023), and provided participants flexibility, allowing them to participate around busy schedules, or not be restricted by distance (Ouchi et al. Reference Ouchi, Lee and Block2023). All studies that used virtual training methods found that virtual learning was effective in supporting clinicians to approach GoPC conversations (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Day et al. Reference Day, Saunders and Steinberg2022; Ouchi et al. Reference Ouchi, Lee and Block2023).
Many Challenges and barriers (Subtheme 3) that impact training were identified by clinicians. Studies highlighted clinician’s competing priorities (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Epstein et al. Reference Epstein, Duberstein and Fenton2017), time constraints (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Day et al. Reference Day, Saunders and Steinberg2022; Doherty et al. Reference Doherty, Gujral and Frenette2023; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Wolfe et al. Reference Wolfe, Denniston and Baker2016), as barriers to attending GoPC training. Studies also discuss challenges and barriers to implementing communication training or tools. These include training being resource intensive (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Kruser et al. Reference Kruser, Taylor and Campbell2017), unfeasible training structures (Berns et al. Reference Berns, Camargo and Meier2017), having to prioritize clinical duties (Kruser et al. Reference Kruser, Taylor and Campbell2017), and difficulty adapting conversation guides into real conversations with patients (Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021).
GoPC communication training has the potential for Filling the gaps (Subtheme 4) in clinicians’ knowledge and skills. Studies report improvement in the uptake of the communication skills in areas where clinicians have traditionally received limited training, such as outpatient settings (Berns et al. Reference Berns, Camargo and Meier2017). Similarly on-the-job communication training for nursing staff (Doherty et al. Reference Doherty, Gujral and Frenette2023) and residents (Berns et al. Reference Berns, Camargo and Meier2017) who reportedly received less instruction and practice on communication as part of undergraduate and postgraduate training, prepares them to engage in GoPC conversations. Studies also highlighted how GoPC communication can improve serious illness conversations (Doherty et al. Reference Doherty, Gujral and Frenette2023), responding to difficult situations and questions (Doherty et al. Reference Doherty, Gujral and Frenette2023), and empathy skills (Banerjee et al. Reference Banerjee, Manna and Coyle2017).
Theme two, Clinician outcomes, explores how training programs impacted Confidence with GoPC conversations (Subtheme 1), Skills regarding GoPC conversations (Subtheme 2), Clinician wellbeing (Subtheme 3), and Communication and collaboration (Subtheme 4).
Clinician’s Confidence with GoPC conversations (Subtheme 1) changes after receiving communication skills training. Eight studies have reported increases in clinicians’ confidence, or reductions in anxiety about having GoPC conversations (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017; Doherty et al. Reference Doherty, Gujral and Frenette2023; Fettig et al. Reference Fettig, Tang and Newton2022; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Smith Reference Smith2017). This has included improved confidence in initiating conversations (Smith Reference Smith2017), discussing prognosis (Annadurai et al. Reference Annadurai, Smith and Bickell2021), discussing treatment options (Berns et al. Reference Berns, Camargo and Meier2017; Fettig et al. Reference Fettig, Tang and Newton2022), expressing empathy (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Fettig et al. Reference Fettig, Tang and Newton2022), discussing spiritual issues (Fettig et al. Reference Fettig, Tang and Newton2022), eliciting patient values, concerns and preferences (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017; Fettig et al. Reference Fettig, Tang and Newton2022), and having difficult discussions(Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017).
Similarly to confidence, Skills regarding GoPC conversations (Subtheme 2), change in clinician’s skills after receiving communication skills training. Nine studies report an increase in utilization of communication skills (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Annadurai et al. Reference Annadurai, Smith and Bickell2021; Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Doherty et al. Reference Doherty, Gujral and Frenette2023; Geerse et al. Reference Geerse, Lamas and Sanders2019; Kruser et al. Reference Kruser, Taylor and Campbell2017; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020), such as initiating conversations and engaging patients (Doherty et al. Reference Doherty, Gujral and Frenette2023; Geerse et al. Reference Geerse, Lamas and Sanders2019), exploring and clarifying patients’ understandings (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017), exploring patient feelings, values, concerns and preferences (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Annadurai et al. Reference Annadurai, Smith and Bickell2021; Geerse et al. Reference Geerse, Lamas and Sanders2019), disclosing concerns (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023), responding empathetically (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Berns et al. Reference Berns, Camargo and Meier2017), responding to emotions (Epstein et al. Reference Epstein, Duberstein and Fenton2017), active listening (Doherty et al. Reference Doherty, Gujral and Frenette2023), engaged in reflective practice (Doherty et al. Reference Doherty, Gujral and Frenette2023), making engaging statements (Epstein et al. Reference Epstein, Duberstein and Fenton2017), and discussing prognosis and treatment options(Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Epstein et al. Reference Epstein, Duberstein and Fenton2017; Kruser et al. Reference Kruser, Taylor and Campbell2017). Five studies (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Banerjee et al. Reference Banerjee, Manna and Coyle2017; Epstein et al. Reference Epstein, Duberstein and Fenton2017; Geerse et al. Reference Geerse, Lamas and Sanders2019; Kruser et al. Reference Kruser, Taylor and Campbell2017) found no significant difference in some clinical skills before and after training, such as assessing patient/family understanding (Annadurai et al. Reference Annadurai, Smith and Bickell2021), discussing prognosis, particularly with specific timelines (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Geerse et al. Reference Geerse, Lamas and Sanders2019), avoiding use of medical jargon (Annadurai et al. Reference Annadurai, Smith and Bickell2021), checking for understanding (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Banerjee et al. Reference Banerjee, Manna and Coyle2017), providing a summary (Annadurai et al. Reference Annadurai, Smith and Bickell2021), empathy skills, such as acknowledging and validating patients’ feelings (Banerjee et al. Reference Banerjee, Manna and Coyle2017), and responding to emotions (Annadurai et al. Reference Annadurai, Smith and Bickell2021), questioning skills, such as asking open-ended questions, or encouraging questions (Banerjee et al. Reference Banerjee, Manna and Coyle2017), and agenda setting, such as information organization skills, or checking skills (Banerjee et al. Reference Banerjee, Manna and Coyle2017). One study found that utilization of skills depended on the physician, suggesting that underlying physician attributes and institutional norms may also impact skill utilization after training (Epstein et al. Reference Epstein, Duberstein and Fenton2017).
Communication training can support, Clinician wellbeing (Subtheme 3). Three studies (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Day et al. Reference Day, Saunders and Steinberg2022; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021) discuss how communication training can reduce moral distress (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Day et al. Reference Day, Saunders and Steinberg2022; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021), bring meaning to work (Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021), improve clinicians’ satisfaction (Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021). Day et al. (Reference Day, Saunders and Steinberg2022) describe how after training, residents felt greater alignment with their ethical standards, and increased tolerance of uncertainty and complexity involved in GoPC decisions, which reduced emotional and moral distress, and alleviated the impact of perceived pressures around GoPC conversations.
Improved Communication and collaboration (Subtheme 4) are direct benefits of team-focused and interdisciplinary communication training. Six studies provided training to interprofessional teams, which included nurses, physicians, social workers, chaplains, medical doctors, and advanced care providers (Doherty et al. Reference Doherty, Gujral and Frenette2023; Fettig et al. Reference Fettig, Tang and Newton2022; Geerse et al. Reference Geerse, Lamas and Sanders2019; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Wolfe et al. Reference Wolfe, Denniston and Baker2016). Training with a multidisciplinary focus fostered close partnerships between disciplines (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Doherty et al. Reference Doherty, Gujral and Frenette2023; Fettig et al. Reference Fettig, Tang and Newton2022), which resulted in an increase in palliative care consultations (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022), task integration across teams (Fettig et al. Reference Fettig, Tang and Newton2022), and improved communication between teams (Doherty et al. Reference Doherty, Gujral and Frenette2023). Collaboration within teams was facilitated by senior team members coaching junior staff (Banerjee et al. Reference Banerjee, Manna and Coyle2017), or by having experienced clinicians provide mentorship to teams in a champion role (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021; Ouchi et al. Reference Ouchi, Lee and Block2023).
Theme three, Patient outcomes, explores how training programs Reduced uncertainty (Subtheme 1), Increased readiness for conversations (Subtheme 2), facilitated Communication between patient and practitioners (Subtheme 3), and Surrogate decision makers (Subtheme 4), and promoted Patient-centered care (Subtheme 5).
Communication training for clinicians and/or patients, families and carers Reduced uncertainty (Subtheme 1) regarding patients’ prognoses and treatment options. Communication training facilitated reducing uncertainty without reducing hope (Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020), and increased patients’ understandings of what might happen in the future (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023), with patients reporting that felt they were able to ask important questions (Epstein et al. Reference Epstein, Duberstein and Fenton2017).
Communication training for patients and families Increased readiness for conversations (Subtheme 2), and their preparation to engage in goals of care conversations. Epstein et al. (Reference Epstein, Duberstein and Fenton2017) reported that patients who received communication training were more active partners in care, demonstrating greater assertiveness, asking questions, requesting clarification, expressing opinions and preferences to a greater degree more control patients. Communication training also increased participants’ self-reported readiness to talk to their clinicians about their goals for end-of-life care (Ouchi et al. Reference Ouchi, Lee and Block2023).
Similarly, communication training facilitates more effective Communication between patient and practitioners (Subtheme 3), and families. Communication training promoted improved communication between clinicians and patient/families (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Day et al. Reference Day, Saunders and Steinberg2022; Epstein et al. Reference Epstein, Duberstein and Fenton2017; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Wolfe et al. Reference Wolfe, Denniston and Baker2016), greater involvement of family members and other members of a patient’s healthcare team in goals of care discussions (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Epstein et al. Reference Epstein, Duberstein and Fenton2017; Kruser et al. Reference Kruser, Taylor and Campbell2017; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020), closer relationships between clinicians and patients/caregivers (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Day et al. Reference Day, Saunders and Steinberg2022; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020), greater understanding of families’ emotions (Doherty et al. Reference Doherty, Gujral and Frenette2023). The training also provides effective structure to conversations (Doherty et al. Reference Doherty, Gujral and Frenette2023), to gather information (Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020) and greater alignment between patient, caregiver, and clinician expectations (Epstein et al. Reference Epstein, Duberstein and Fenton2017; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020).
Subtheme 4, addresses the importance of training emphasizing the role of Surrogate decision makers, in GoPC conversations (Berns et al. Reference Berns, Camargo and Meier2017). Involvement of surrogate decision makers after communication training (also referred to as Health Care Decision Makers) increases advanced care planning activities that are aligned with the patients’ values (Casey et al. Reference Casey, Price and Markwalter2022). Even when the patient died during hospitalization, surrogates reported that the conversation was worthwhile, as it increased their understanding of the patient’s condition and they felt a greater sense of control, aligned with a strong relationship with the patient’s care team (Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020).
Subtheme 5, Patient-centered care, explores how communication training affected patient care and outcomes. Studies reported greater understandings of patients’ goals, values and preferences after communication training, which allowed patients’ care to be better aligned with their wishes (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Day et al. Reference Day, Saunders and Steinberg2022; Doherty et al. Reference Doherty, Gujral and Frenette2023; Geerse et al. Reference Geerse, Lamas and Sanders2019; Ouchi et al. Reference Ouchi, Lee and Block2023; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020), and greater provision and discussion of treatment choices (Kruser et al. Reference Kruser, Taylor and Campbell2017). Studies noted a shift from an emphasis on code status to patient-centered approaches to care that focused on patient values and shared decision making (Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Day et al. Reference Day, Saunders and Steinberg2022; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021). One study found that children of parents involved in a communication program had significantly higher rates of hospice enrolment and lower rates of high-intensity medical interventions at end of life (Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020). In contrast, Epstein et al. (Reference Epstein, Duberstein and Fenton2017) found that communication training had no effect on quality of life or aggressive treatments and hospice use in the last 30 days of life. Another study noted that surrogates described their conversations as mostly or extremely worthwhile, even when patients died during hospitalization (Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020).
Theme four, System outcomes, explores how training programs impacted Documentation of GoPC conversations (Subtheme 1), and Occurrence of GoPC conversations (Subtheme 2).
Communication training positively influenced, Documentation of GoPC conversations (Subtheme 1). Studies reported increases in documentation of GOPC conversations (Casey et al. Reference Casey, Price and Markwalter2022; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Haley et al. Reference Haley, Meisel and Gitelman2017; Ouchi et al. Reference Ouchi, Lee and Block2023), which were supported by formalization of documentation procedures (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021), changes to electronic medical records to allow documentation and retrieval (Berns et al. Reference Berns, Camargo and Meier2017; Casey et al. Reference Casey, Price and Markwalter2022), and having a documentation template in the electronic medical record (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Casey et al. Reference Casey, Price and Markwalter2022; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020).
Finally, communication training also influenced the Occurrence of GoPC conversations (Subtheme 2). Studies reported increases in rates of GOPC conversations (Ouchi et al. Reference Ouchi, Lee and Block2023), and documentation (Casey et al. Reference Casey, Price and Markwalter2022; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Haley et al. Reference Haley, Meisel and Gitelman2017; Ouchi et al. Reference Ouchi, Lee and Block2023), which was reportedly supported by implementation of electronic identification of patients that would benefit from GOPC discussion (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023), and electronic reminders or cues from supporting clinicians (Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021) to ensure all patients received opportunities to have GOPC conversations when appropriate (Haley et al. Reference Haley, Meisel and Gitelman2017).
Discussion
The aim of this integrative review of the literature was to evaluate and synthesize research that has investigated interventions to train registered health professionals to effectively communicate with patients in acute settings who are establishing their goals of care, to develop an understanding of current practices and their effectiveness. Effective communication in healthcare is essential for building trust, ensuring mutual understanding and shared decision-making (Simon et al. Reference Simon, Danner and Saavedra2021).
Like literature review by Bakke et al. (Reference Bakke, Miranda and Castillo-Angeles2018) regarding communication training for health professionals, the studies included in this review highlight a growing trend towards interventions that utilize role-play to both teach and evaluate communication skills. Although the literature suggests many benefits to simulated learning, virtual training and other face-to-face pedagogies, it is evident that there are some persistent challenges and barriers to their widespread and consistent use and adoption. Clinicians report the difficulties they encounter when attempting to balance the demands of their clinical responsibilities with their desire and the patients’ need for thorough and empathetic communication (Kruser et al. Reference Kruser, Taylor and Campbell2017). Further complicating the barriers to accessing communication training, healthcare provides infrequently prioritize or fund this training to the extent that is required (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023). As a result, patient care can be negatively impacted, their goals and values may not be adequately understood, documented or addressed, and patient and clinician satisfaction is compromised (Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021). Blended to approaches to communication training may overcome some of these barriers by providing accessible, high-fidelity learning opportunities for clinicians (Cappi et al. Reference Cappi, Artioli and Ninfa2019).
The shift from didactic learning to simulated learning highlighted in the review aligns with the broader trends evident in the healthcare communication literature (Voogt et al. Reference Voogt, Pratt and Rollet2022) where there has been a consistent shift towards experiential and interactive approaches. The use of simulation and roleplaying across the included studies, also reflects the value of experiential learning in healthcare education (Martin et al. Reference Martin, Cross and Attoe2020), and its ability to bridge the gap between the theory and application of communication (Elendu et al. Reference Elendu, Amaechi and Okatta2024). The included studies explored communication training for professionals working in a variety of settings, such as ED, ICU, outpatient settings etc., across a range of specialties (for example pediatrics, oncology).
Effective communication is complex, but communication training can improve clinician confidence and skill, and fill knowledge and skills gaps. Communication is a core clinical competency and integral to the delivery of patient-centered care (Sharkiya Reference Sharkiya2023). The finding that clinicians require the skills and knowledge to build relationships and facilitate complex decision making, in order support patients to plan their goals of care is consistent across disciplines (Bornman and Louw Reference Bornman and Louw2023). Communication training that adopts contemporary approaches to delivery, opportunities for practice and is contextually specific, can support clinician readiness for GoPC (Doherty et al. Reference Doherty, Gujral and Frenette2023), decrease their hesitancy (Smith Reference Smith2017) and improve communication with their patients (Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Wolfe et al. Reference Wolfe, Denniston and Baker2016) and surrogates (Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Wolfe et al. Reference Wolfe, Denniston and Baker2016). Where clinicians have the skills to communicate effectively, patient’s wishes, goals and values are more likely to be addressed and met (Sharkiya Reference Sharkiya2023). An emphasis on clear and compassionate communication ensures that the emotional complexity is sensitively managed (Malenfant et al. Reference Malenfant, Jaggi and Hayden2022). A thorough approach to care that includes a comprehensive and documented GoPC can improve patient, carer and clinician satisfaction (Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021), especially where there is systemwide support and infrastructure in place (Berns et al. Reference Berns, Camargo and Meier2017; Casey et al. Reference Casey, Price and Markwalter2022).
Patient-centered care relies on effective team-based communication and collaboration (Dahlke et al. Reference Dahlke, Hunter and Reshef Kalogirou2020), as well as effective clinician-patient communication (Santana et al. Reference Santana, Manalili and Jolley2018). While a number of studies (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023; Doherty et al. Reference Doherty, Gujral and Frenette2023; Fettig et al. Reference Fettig, Tang and Newton2022; Lagrotteria et al. Reference Lagrotteria, Swinton and Simon2021) provided training to a range of health professional roles, most studies tailored training towards nurses (Banerjee et al. Reference Banerjee, Manna and Coyle2017; Geerse et al. Reference Geerse, Lamas and Sanders2019; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020; Smith Reference Smith2017), or physicians (Annadurai et al. Reference Annadurai, Smith and Bickell2021; Berns et al. Reference Berns, Camargo and Meier2017; Casey et al. Reference Casey, Price and Markwalter2022; Chatterjee et al. Reference Chatterjee, Roberts and Ahluwalia2022; Day et al. Reference Day, Saunders and Steinberg2022; Epstein et al. Reference Epstein, Duberstein and Fenton2017; Geerse et al. Reference Geerse, Lamas and Sanders2019; Haley et al. Reference Haley, Meisel and Gitelman2017; Kruser et al. Reference Kruser, Taylor and Campbell2017; Moody et al. Reference Moody, Hendricks-Ferguson and Baker2020; Ouchi et al. Reference Ouchi, Lee and Block2023; Pasricha et al. Reference Pasricha, Gorman and Laothamatas2020; Wolfe et al. Reference Wolfe, Denniston and Baker2016)).
The included multidisciplinary studies reflect a recent increase in GoPC communication training for specialists and allied health professionals (i.e. not just generalist doctors and nurses), which mirrors prioritization of multi-disciplinary care and greater collaboration within teams. Clinician GoPC-focused training the has the potential to increase the occurrence of conversations, while positively influencing how patients understand and can express their goals to the treating team (Kruser et al. Reference Kruser, Taylor and Campbell2017), to ensure their care is appropriately aligned to their wishes (Geerse et al. Reference Geerse, Lamas and Sanders2019; Ouchi et al. Reference Ouchi, Lee and Block2023).
Importantly GoPC training for patients and their surrogate decision makers was able to improve their readiness for engagement in GOPC conversations (Epstein et al. Reference Epstein, Duberstein and Fenton2017; Ouchi et al. Reference Ouchi, Lee and Block2023). The widespread implementation of GoPC communication training is improved by healthcare and system processes, (Lakin et al. Reference Lakin, Isaacs and Sullivan2016), which improve the continuity of patient care, reduce errors and improve the overall quality of healthcare delivery (Haley et al. Reference Haley, Meisel and Gitelman2017). The implementation of systemwide initiatives such electronic medical records which prompt clinician action (Aaronson et al. Reference Aaronson, Kennedy and Gillis-Crouch2023) can improve the uptake of GoPC training program outcomes, resulting in higher quality patient care and improved system efficiency.
In summary, both individuals and organizations, should prioritize communication training. Training should be regularly provided, context specific and promote the use of conversation guides. Individuals should be encouraged to embed GoPC conversations into their practice to promote effective and patient-centered communication. Formalizing the integration of communication skills training into pre-registration education and providing regular post-graduate professional development for clinicians should be carefully considered. Additionally, policies that address the barriers of time and resources, through the adequate allocation of funding and support should be developed and implemented. The adoption of technologies that facilitate timely GoPC will promote standardized and consistently applied approaches to GoPC. As practice and policy change, further research is required to understand the sustained effects of GoPC training on clinicians and patients, across clinical contexts. Assessment of the impact of various approaches to training that address the barriers and challenges identified in this review are warranted. Further research should also explore the role of GoPC training in improving patient-centered care, patient satisfaction, adherence to treatment and overall patient outcomes. Finally, further research should adopt measures beyond self-assessment and explore translation of knowledge and simulation-demonstrated skill into clinical settings.
While there are a number of useful implications for practice and policy these should be interpreted with caution as there was a lack of homogeneity in the approaches used to explore the effectiveness of communication training to improve GOPC conversations in acute care. There were also a number of methodological weaknesses across the studies including a lack of control groups (in quantitative studies) and statements locating the researchers culturally or theoretically (in qualitative studies).
Conclusion
This review of the literature demonstrates that there is a shift from traditional didactic GoPC training towards experiential learning, supported by simulation and other practical opportunities. Approaches to training that adopt these strategies assist clinicians to develop communication skills that are nuanced to the complex environments in which they work. Despite the benefits of GoPC communication training, there are system barriers that preclude the effective and widespread implementation. Overcoming these barriers through strategies that resource and prioritize regular and timely training has the potential to ensure that clinicians can meet the GoPC needs of their patients. Effective, patient-centered communication builds trust, satisfaction and collaboration, constructs that are key to aligning patient care with their values and goals. In addition, there are clear benefits to the healthcare system through improvements in documentation and frequency of GoPC conversations, resulting in higher quality patient care.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951525000264.
Open access
