The COMFORT Model: Moving the Initiative Outside of the Academy.

Reflexive and prospective in nature, the creators of the COMFORT model describe experiences of moving this research outside of the academy. The COMFORT model represents the seven basic principles of healthcare provider communication: C - Connect, O - Options, M - Making Meaning, F - Family Caregivers, O - Openings, R - Relating, T - Team. The COMFORT initiative began as a call for change in healthcare communication education. Originally published as a final chapter in a volume on family and palliative care communication, it was the start of an extensive translational program of trainings and tools addressing healthcare provider communication.

A conceptual model of the nurse's role as primary palliative care provider in goals of care communication.

Objective: Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses. Methods: An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria. Results: Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training. Conclusion: This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care. Innovation: The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.

Validating the Communicating Care Needs Tool for HIV (CCNT-HIV).

Health literacy has been identified as an influential factor affecting the HIV care continuum and HIV epidemic, but recent systematic reviews found mixed relationships between health literacy and HIV medication adherence. This may be partially due to discrepancies between health literacy conceptualizations, health literacy measures, and the lifeworld, day-to-day challenges that persons with HIV (PWH) face as they seek and receive care. To address these challenges, a new health literacy tool, Communicating Care Needs Tool for HIV (CCNT-HIV), was developed. With survey responses from 118 PWH, the current study compares CCNT-HIV with the Brief Health Literacy Screening Tool (BRIEF) and the All Aspects of Health Literacy Scale (AAHLS) by conducting a principal component analysis. Six principal components were identified for CCNT-HIV; one principal component was identified for BRIEF; and three principal components were identified for AAHLS. With a correlation analysis, relevance among principal components across the three tools validated CCNT-HIV. This study extended the scope of health literacy measures by emphasizing the relational, multi-variable, collaborative impacts stakeholders make on patients' health management. Practical implications for how health literacy tools, like the CCNT-HIV, can be used to directly benefit patients and their health management are also discussed.

Exploring Differences in Caregiver Communication in Serious Illness.

Background: Demographic factors, such as disease context and family relationships, are communication mediators and moderators; however, little is known about how understanding these factors can improve caregiver communication with providers. Recognition of communication differences among caregivers may aid the development of approaches to improve serious illness communication. Objective: To explore whether caregiver communication differs by disease context (cancer vs. dementia) and caregiver communication type (Manager, Carrier, Partner, and Lone). Caregiver communication type is based on communication patterns between the care recipient and caregiver. Design and Measurements: Caregivers of persons with cancer and/or dementia were surveyed from a U.S. national research registry website. Measures of caregiver communication included information needs, communication confidence, perception of provider understanding of the caregiver, perceived frequency of caregiver assessment, and caregiver stress. Analysis of variance (ANOVA) determined significant differences between caregiver communication (p < 0.05) based on disease context and caregiver communication type. Results: Cancer caregivers reported higher unrecognized-demanded information states (i.e., not recognizing information was needed), more communication confidence, and more frequent caregiver assessment compared to dementia caregivers. Among caregiver communication types, Manager caregiver types were more confident communicating than other caregiver types and perceived greater understanding by providers than the Lone caregiver type. Manager caregivers reported significantly less stress than other caregiver communication types. Conclusions: Understanding disease context and caregiver communication type may help improve caregiver communication with health care providers.

Assessing Family Caregiver Communication in Chronic Illness: Validation of the FCCT-CI.

Background: Chronic illness care demands attention to the unique needs of family caregivers who support care at home, yet few tools exist for family caregiver assessment in the social domain of practice. Objectives: The Family Caregiver Communication Tool (FCCT) assesses caregiver communication as part of the family system and was originally developed for cancer caregivers. The aim of this study was to develop and psychometrically-validate a version of the FCCT for Chronic Illness (FCCT-CI). Methods: We revised the FCCT, including the generation of new items, and psychometrically tested it in 303 family caregivers recruited through Amazon Prime Panels. Item reduction through exploratory factor analysis was conducted, internal consistency was assessed using Cronbach's alpha, and concurrent validity was conducted to demonstrate correlation of the new scale with previously validated instruments. Results: A principal axis analysis with promax rotation initially revealed a five-factor structure of the 27 items initially tested, but, after statistical and theoretical reduction and refinement, a 10 item FCCT-CI emerged. Cronbach's alpha ranged from .74 to .86 for the FCCT-CI instrument. Concurrent validity was supported by bivariate correlation tests. Conclusions: The FCCT-CI is the first psychometrically tested scale designed to assess caregiver communication with chronically ill patients, family members, and palliative care providers about caregiving. The FCCT-CI scale includes but is not limited to cancer caregiving and palliative care contexts and has good reliability and validity. Palliative care providers can use this tool to assess, design, and test interventions to support family caregivers.

Family Communication in Autism Spectrum Disorder: Applying the Family Caregiver Communication Typology to Parent Caregivers.

Parents of children with Autism Spectrum Disorder (ASD) experience greater stress and caregiver burden than parents of children with other disabilities. To cope with the stress of long-term caregiving, they rely on professionals for support and guidance. However, parents continue to report unmet communication and support needs. To inform tailored communication for parents of a child with ASD, this study used the existing Family Caregiver Communication Typology framework which identifies four caregiver communication types (manager, carrier, partner, and lone) and their unique communication and support needs. In-depth, structured interviews were conducted with parents (n = 22) and ASD professionals (n = 28) to explore communication characteristics of ASD parent caregivers. A thematic analysis revealed communication behaviors among four ASD parent caregiver types, further validating the typology. Future research is needed to develop targeted interventions for improving family-centered care based on ASD parent caregiver types.

Sharing COMFORT Communication Training With Healthcare Professionals in Nairobi, Kenya: A Pilot Webinar Series.

BACKGROUND: Communication training for healthcare providers is evident in the context of the COVID-19 global pandemic, however training opportunities are not available in countries with limited resources. OBJECTIVES: To investigate perceived comfort in communication about end-of-life and palliative care among healthcare providers in Nairobi, Kenya and to evaluate a pilot webinar-based communication training series. METHODS: Through a partnership with a research hospital in Nairobi, healthcare providers engaged an online survey to assess perceived comfort in communication and prior educational training in communication. The COMFORT communication model was used to develop and pilot a webinar-based communication training series to meet training needs. Pre-post measures of comfort in communication and post-curriculum evaluation were used to evaluate the webinars. RESULTS: Survey findings from 94 healthcare providers demonstrated that communication training is most needed when patient/family culture is different from provider. Physicians reported less comfort in communication than nurses and other professionals, especially in communication with family about spiritual or religious concerns. Nurses reported more overall training in palliative care communication topics than physicians and other disciplines. The 3-part webinar series increased communication comfort for physicians and nurses, was highly rated, and participants reported that they would recommend COMFORT webinar training to colleagues. CONCLUSION: Webinar-based platforms for communication training show promise for meeting communication training needs of healthcare providers.

Collective caregivers: A novel examination of health literacy management approaches.

OBJECTIVE: Health literacy and communication skills are necessary for family caregivers who often work in pairs, known as collective caregiving. Health literacy management is a relational process where communication between caregivers can be a barrier or pathway to improving or co-creating health literacy. The purpose of this study was to examine how collective caregivers manage health literacy. METHODS: Semi-structured interviews were conducted separately for 42 caregiving pairs (n = 84). The interview guide was developed using a cancer caregiver health literacy framework. Caregiving pairs were placed into one of three collective caregiving communication patterns (absolute concordant, semi-concordant, absolute discordant). Interviews were audio-recorded, transcribed, and a thematic analysis was performed by independent coders. RESULTS: The analysis revealed three different health literacy management approaches: a defined approach where caregiver roles were clearly designated (absolute concordant pairs); a contrasting approach where one caregiver was the health literacy expert (semi-concordant pairs); an independent approach characterized by individual information seeking, processing, and patient/provider engagement (absolute discordant pairs). CONCLUSIONS: Health literacy support should address aspects of the family system such as caregiver-caregiver communication which influence variance in health literacy management. Practice implications Our study can inform provider communication and healthcare interventions aimed at supporting health literacy for caregivers.

Communication and Competencies Across Undergraduate BSN Programs and Curricula.

BACKGROUND: An investigation was conducted to assess for and describe health communication instruction in entry-level baccalaureate (BSN) programs. METHOD: This cross-sectional descriptive study examined entry-level baccalaureate degree nursing programs in the United States. A three-step process was used: (1) online survey of directors of BSN programs, (2) online survey of simulation directors, and (3) analysis of course titles and descriptions. RESULTS: Communication instruction remains primarily knowledge-based rather than skills-based. The findings of this study confirm there is ambiguity in defining the scope of communication instruction across curricula, as well as radical differences in the inclusion of communication in course descriptions and content. CONCLUSION: There is a need for clear definition of the scope of health communication skill development across BSN programs for communication behaviors to be measured and competency to be determined. A knowledge-building approach to communication instruction does not align with new plans for competency-based nursing education. [J Nurs Educ. 2021;60(11):618-624.].

COVID 19-transformed nursing education and communication competency: Testing COMFORT educational resources.

BACKGROUND: The COVID-19 pandemic brought a disruption to nurse education for both nursing faculty and students as all non-clinical nurse education courses worldwide moved to distance or online learning. The sudden shift to online education meant the loss of traditional activities for students to learn communication skills creating a critical demand for open educational resources for students and nursing faculty. Tools to support nursing faculty development for teaching communication are nearly non-existent and pedagogical content knowledge is needed. OBJECTIVES: The purpose of this study was to test two COMFORT COVID-19 Communication Modules (PPE and Video/Phone) for undergraduate nursing students and evaluate student communication competency post-intervention. DESIGN: This pre-post study includes qualitative and quantitative data collected to evaluate student communication competency post-intervention. SETTINGS: Undergraduate Bachelor of Science in Nursing (BSN) students at four university campuses in the Pacific and MidSouth regions of the United States. PARTICIPANTS: BSN nursing students (n = 197) predominantly in the third year of study (n = 138, 70%). METHODS: Students completed online modules as part of a nursing course. Faculty provided information and a link to access online learning modules. A pre-post assessment was completed for each module. RESULTS: Significant statistical differences were found across variables of communication attitude, knowledge, and skill across both modules. CONCLUSIONS: As nursing education in the United States shifts to competency-based education which emphasizes skill development across the BSN program, it is imperative to establish communication learning objectives that are measurable and ensure communication theory and evidence-based practice is part of curriculum content.

Opportunities to improve COVID-19 provider communication resources: A systematic review.

OBJECTIVE: Communication related to COVID-19 between provider and the patient/family is impacted by isolation requirements, time limitations, and lack of family/partner access. Our goal was to determine the content of provider communication resources and peer-reviewed articles on COVID-19 communication in order to identify opportunities for developing future COVID-19 communication curricula and support tools. METHODS: A systematic review was conducted using the UpToDate clinical decision support resource database, CINAHL, PubMed, PsycInfo, and Web of Science. The grey literature review was conducted in September 2020 and articles published between January-September 2020 written in English were included. RESULTS: A total of 89 sources were included in the review, (n = 36 provider communication resources, n = 53 peer-reviewed articles). Resources were available for all providers, mainly physicians, and consisted of general approaches to COVID-19 communication with care planning as the most common topic. Only four resources met best practices for patient-centered communication. All but three articles described physician communication where a general emphasis on patient communication was the most prevalent topic. Reduced communication channels, absence of family, time, burnout, telemedicine, and reduced patient-centered care were identified as communication barriers. Communication facilitators were team communication, time, patient-centered and family communication, and available training resources. CONCLUSIONS: Overall, resources lack content that address non-physician providers, communication with family, and strategies for telehealth communication to promote family engagement. The gaps identified in this review reveal a need to develop more materials on the following topics: provider moral distress, prevention communication, empathy and compassion, and grief and bereavement. An evidence-base and theoretical grounding in communication theory is also needed. PRACTICE IMPLICATIONS: Future development of COVID-19 communication resources for providers should address members of the interdisciplinary team, communication with family, engagement strategies for culturally-sensitive telehealth interactions, and support for provider moral distress.

Access to Broadband Internet and its Utilization for Health Information Seeking and Health Communication among Informal Caregivers in the United States.

Informal caregivers provide unpaid care to their physically or mentally ill loved ones and play a critical role in the healthcare delivery. eHealth tools, including the broadband internet, can facilitate care processes and impact the caregiving burden through seeking health information and health communication. This study examines the predictors of access to broadband internet and the factors associated with health information seeking and health communication among informal caregivers with broadband internet. We used data from cycles 1 and 2 of the Health Information National Trends Survey (HINTS 5) and employed generalized linear regression models with the maximum likelihood estimation. Specifically, we performed a two-part model: (1) a logistic regression model of broadband internet access among all caregivers (n = 929) and (2) a logistic regression model of health information seeking and health communication among caregivers with broadband internet access (n = 404). We found that caregivers who were younger (18-34 years versus 45+ years), female (versus male), and those who were divorced/widowed/separated (versus singles) were less likely to have broadband internet access. While those who were married/living as married (versus singles), with higher incomes (≥$100,000 versus <$35,000), and those living in metropolitan areas were more likely to have broadband internet access. Among caregivers with broadband internet access, younger, female, non-Hispanic white caregivers, and those with higher levels of education and income, as well as those who cared for cancer patients, were more likely to seek health information for someone else. Additionally, caregivers aged 35-39 years and those with more education were more likely to look for health information for themselves than their counterparts. Furthermore, caregivers who were aged 40-44 years, females, divorced/widowed/separated, those with higher incomes, and those who cared for patients with Alzheimer's, confusion, and dementia were more likely to communicate electronically with a provider. The results suggest disparities in broadband internet access and indicate variations in factors associated with health information seeking and health communication. The findings underscore the need to address barriers attributed to the digital divide among informal caregiving groups.

A student-driven HIV/PrEP communication intervention using a modified social network strategy.

OBJECTIVE: The authors examined college students' experiences of providing peer-education, using the modified Social Network Strategy (SNS). PARTICIPANTS: Ninety-six college students participated this project during the 2018 academic year, drawn from a large, Mid-Southern urban university. METHODS: Students who administered the HIV-PrEP health intervention completed a cross-sectional assessment about their experiences in the project. A series of open-ended prompts garnered written narrative responses. We utilized a qualitative content analysis to identify SNS codes and their frequencies. RESULTS: Student responses were overwhelmingly supportive of the community engagement project. Student narratives featured the health communication intervention with peers most often (44.4%: counseling, testing, and referral communication), followed by influences on themselves (28.7%; what he/she learned, influences on student health and choices). CONCLUSIONS: A modified SNS demonstrated in this project reveals its utility in supporting undergraduates in the delivery of HIV/PrEP training in the 7th highest HIV transmission area in the nation.

Family caregivers' perceived communication self-efficacy with physicians.

OBJECTIVE: Family-centered health care requires successful communication between patient, family caregivers, and healthcare providers. Among all providers, physicians are most likely to interact with caregivers. Using the Family Caregiver Communication Typology, this study examined perceived communication self-efficacy with physicians among four types of caregivers: Manager, Partner, Carrier, and Lone. METHOD: A cross-sectional online survey included the Family Communication Typology Tool, Communication Perceived Self-Efficacy Scale, the Caregiver Quality of Life-Revised Index, and the Generalized Anxiety Disorder (GAD-2) questionnaire. RESULTS: An online survey of 220 family caregivers currently caring for an adult family member revealed significant differences in communication self-efficacy among family caregiver communication types, revealing that Partner caregivers have the highest perceived communication self-efficacy, and that for some caregiver types, higher perceived communication self-efficacy is associated with certain quality of life dimensions. SIGNIFICANCE OF RESULTS: Differences in communication self-efficacy with physicians among the four caregiver communication types (Manager, Partner, Carrier, and Lone) provide further evidence that the typology represents variance in caregiver communication abilities. Development of future medical curricula targeting communication skill training should include an overview of the typology and communication strategies as these may increase effective communication between physicians and caregivers.

Exploring Family Caregiver Communication Difficulties and Caregiver Quality of Life and Anxiety.

BACKGROUND: When family caregivers are involved in patient care, both patients and caregivers experience better clinical outcomes. However, caregivers experience communication difficulties as they navigate a complex health care system and interact with health care providers. Research indicates that caregivers experience a communication burden that can result in topic avoidance and distress; however, little is known about how burden stemming from communication difficulties with health care providers relates to caregiving outcomes. OBJECTIVES: To investigate how family caregiver communication difficulties with health care providers influence caregiver quality of life and anxiety. METHODS: Data were collected in a cross-sectional online survey of 220 caregivers with communication difficulties resulting from caregiver avoidance of caregiving-related topics, inadequate reading and question-asking health literacy, and low communication self-efficacy. RESULTS: Caregiver outcomes were not affected by reading health literacy level but did differ based on question-asking health literacy level. Adequate question-asking health literacy was associated with lower anxiety and a higher quality of life. Caregivers who avoided discussing caregiving topics reported higher anxiety and lower quality of life and caregivers with increased communication self-efficacy reported a higher quality of life. CONCLUSION: Involvement of family caregivers in care is likely to require tailored approaches that address caregiver communication and health literacy skills. Findings from this study suggest that hospice and palliative care providers should identify and provide support for caregiver communication difficulties in order to positively influence caregiver quality of life and anxiety.

The COMFORT Communication Model: A Nursing Resource to Advance Health Literacy in Organizations.

The COMFORT Model has recently been revised based on feedback from bedside nurses working in palliative care and oncology and includes the following components: Connect, Options, Making Meaning, Family Caregiver, Openings, Relating, and Team. Based on clinical and nonclinical research in hospital, hospice, palliative care, and interdisciplinary education settings, the authors present the updated COMFORT Model. Originally introduced in 2012 to support the work of the nurse, the model is not a linear guide, an algorithm, a protocol, or a rubric for sequential implementation by nurses, but rather a set of communication principles that are practiced concurrently and reflectively during patient/family care. In its restructuring, we focus on the role of health literacy throughout the COMFORT components in relationship to the health literacy attributes of a health care organization. A brief summary of COMFORT components is provided and includes strategies and competencies contributing to a health-literate care organization. Both health literacy and COMFORT are explored using specific communication challenges that underscore the role of the nurse in accomplishing person-centered and culturally responsive care, especially in chronic and terminal illness. The integration of the COMFORT Model into nursing education is proposed.

Promoting Transformative Community Change for Equitable Health: Peer Education and Intervention for Pre-Exposure HIV Prophylaxis.

Many new HIV infections occur through individuals who are unaware of their HIV status. HIV disparities are more prevalent among underserved populations, and the number of new cases in the U.S. is highest in the Southern region. Using the Social Network Intervention, 63 undergraduate students delivered a face-to-face, communication-centered, peer education to 333 peers in the underserved communities; of those, 220 verified cases were analyzed. A baseline assessment was followed by the intervention and the second assessment, with the third assessment 2 weeks later. Assessments measured intervention impacts on health information sharing, knowledge about HIV/AIDS, and the dimensions of vested interest theory. The peer education was effective in making changes in participants' vestedness, knowledge regarding HIV/AIDS, and trust and expectation toward informational sources. Communication and tailored messages through established relationship channels were proven crucial for promoting positive behaviors about HIV sexual health, with strong evidence of change in stigma and the culture of silence.

Development of a communication and health literacy curriculum: Optimizing the informal cancer caregiver role.

OBJECTIVE: The aim of this study was to develop learning objectives and identify content for a core communication and health literacy curriculum designed to optimize the role of informal cancer caregivers (family or friends). METHODS: A three-step process was conducted: (a) two-round online Delphi method process with experts (n = 9) in cancer caregiving to gain consensus on curriculum learning objectives; (b) online survey of oncology providers (n = 32) to generate potential content and rate importance of domains; and (c) focus group of cancer caregivers (n = 6) to explore caregiving experiences and curriculum content topics. RESULTS: Overall, 17 learning objectives and 53 topics were identified for a cancer caregiver communication and health literacy curriculum. Feedback from cancer caregivers did not produce any new topics yet confirmed topics generated by experts and providers. The curriculum identified as essential has been organized under the following headings: finding cancer information; assessing and integrating information; working with health care providers; getting help; talking with the care recipient; recognizing the care recipient's needs; and planning for caregiver self-care. CONCLUSIONS: This theoretically grounded study systematically identified seven curriculum topic areas and content unique to caregivers and included input from key stakeholders. The next step is to develop the program for dissemination and to test its impact on caregiver and patient outcomes.