Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication With Patients With Serious Illness A Randomized Trial
Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication With Patients With Serious Illness A Randomized Trial
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DOI：
10.1001/jama.2013.282081
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发表时间：
2013-12-04
影响因子：
120.7
通讯作者：
Engelberg, Ruth A.
中科院分区：
文献类型：
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作者：
Curtis, J. Randall;Back, Anthony L.;Engelberg, Ruth A.
临终关怀的重要性沟通是一项核心的临床技能。目的评估内科沟通技能干预对患者和家庭报告结果的影响。设计、设置和参与者2007年至2013年在华盛顿大学和南卡罗来纳医科大学对391名内科医生和81名实习护士进行了随机试验。干预参与者被随机分为8个疗程，基于模拟的沟通技能干预(N=232)或常规教育(N=240)。主要结果和测量主要结果是患者报告的沟通质量(QOC；17个项目的平均评分从0到10，0=差，10=完美)。次要结果是患者报告的临终关怀质量(QEOLC；26个项目的平均评分从0到10)和抑郁症状(使用8项个人健康问卷[PHQ-8]进行评估；范围0-24，得分越高越差)，以及家庭报告的QOC和QEOLC。结果患者评分1866分(有效率44%)，家庭评分936分(有效率68%)。干预与QOC或QEOLC的显著变化无关。干预后患者QOC和QEOLC的平均值分别为6.5(95%CI，6.2~6.8)和8.3(95%CI，8.1~8.5)，而对照组分别为6.3(95%CI，6.2~6.5)和8.3(95%CI，8.1~8.4)。调整后，干预组与对照组的QOC评分差异无统计学意义(差异0.4分[95%CI，-0.1~0.9]；P=0.15)或家庭差异(0.1分[95%CI，-0.8~1.0]；P=.81)。患者的QEOLC评分差异无统计学意义(差异0.3分[95%CI，-0.3~0.8]；P=0.34)，家庭差异无统计学意义(差异0.1[95%CI，-0.7~0.8]；P=0.88)。干预与干预后受训患者的抑郁评分显著增加相关(平均得分10.0[95%CI，9.1至10.8]，而对照组为8.8[95%CI，8.4至9.2])；调整模型显示干预效果为2.2(95%CI，0.6至3.8；结论：与常规教育相比，模拟沟通培训并不能改善临终关怀或临终关怀的沟通质量，但与患者抑郁症状的增加有关。这些发现提出了从模拟训练到实际患者护理的技能转移以及沟通技能评估的充分性的问题。
IMPORTANCE Communication about end-of-life care is a core clinical skill. Simulation-based training improves skill acquisition, but effects on patient-reported outcomes are unknown.OBJECTIVE To assess the effects of a communication skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes.DESIGN, SETTING, AND PARTICIPANTS Randomized trial conducted with 391 internal medicine and 81 nurse practitioner trainees between 2007 and 2013 at the University of Washington and Medical University of South Carolina.INTERVENTION Participants were randomized to an 8-session, simulation-based, communication skills intervention (N = 232) or usual education (N = 240).MAIN OUTCOMES AND MEASURES Primary outcome was patient- reported quality of communication (QOC; mean rating of 17 items rated from 0-10, with 0 = poor and 10 = perfect). Secondary outcomes were patient- reported quality of end-of-life care (QEOLC; mean rating of 26 items rated from 0-10) and depressive symptoms (assessed using the 8-item Personal Health Questionnaire [PHQ-8]; range, 0-24, higher scores worse) and family-reported QOC and QEOLC. Analyses were clustered by trainee.RESULTS There were 1866 patient ratings (44% response) and 936 family ratings (68% response). The intervention was not associated with significant changes in QOC or QEOLC. Mean values for postintervention patient QOC and QEOLC were 6.5 (95% CI, 6.2 to 6.8) and 8.3 (95% CI, 8.1 to 8.5) respectively, compared with 6.3 (95% CI, 6.2 to 6.5) and 8.3 (95% CI, 8.1 to 8.4) for control conditions. After adjustment, comparing intervention with control, there was no significant difference in the QOC score for patients (difference, 0.4 points [95% CI, -0.1 to 0.9]; P = .15) or families (difference, 0.1 [95% CI, -0.8 to 1.0]; P = .81). There was no significant difference in QEOLC score for patients (difference, 0.3 points [95% CI, -0.3 to 0.8]; P = .34) or families (difference, 0.1 [95% CI, -0.7 to 0.8]; P = .88). The intervention was associated with significantly increased depression scores among patients of postintervention trainees (mean score, 10.0 [95% CI, 9.1 to 10.8], compared with 8.8 [95% CI, 8.4 to 9.2]) for control conditions; adjusted model showed an intervention effect of 2.2 (95% CI, 0.6 to 3.8; P = .006).CONCLUSIONS AND RELEVANCE Among internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients' depressive symptoms. These findings raise questions about skills transfer from simulation training to actual patient care and the adequacy of communication skills assessment.