Use of Collaborative Reflective Teams for Practice Discussing Sexual Issues With Patients

Nursing education programs typically teach therapeutic communication skills across the nursing curriculum. However, there are few forums in which nursing students can receive feedback regarding the helpfulness and appropriateness of their interactions with patients around sensitive issues such as spirituality, sexuality, or end of life concerns. Many nurses learn these skills through listening to more experienced coworkers hold such conversations with patients. These conversations tend to be anxiety producing and create a sense of vulnerability within the nurse. Simulation provides an excellent venue for practicing these conversations. However, typical simulation debriefing practices tend to focus on adherence to an algorithm for completion of tasks or the incorporation of specific elements communication, limiting the development of personal communication styles or awareness of the variety of ways that patients may experience their interactions. In this poster/presentation, we describe an innovative use of an interdisciplinary reflecting team to provide coaching, feedback, and multiple perspectives to nursing students and other healthcare providers who engage in sensitive conversations in patient care.

The reflecting team approach is an adaptation from the field of family therapy in which a team of therapists views a therapy session through a one-way mirror. At a predetermined point in the session, the therapist and family listen in as the reflecting team muses about the therapist, the patient, and the circumstances that brought caused the family or individual to seek therapy. After a 10 minute reflective discussion between the viewing therapists that is not directed toward the family, the family is again engaged by the treating therapist. The reflections of the observing therapists are incorporated into the ensuing conversation. This allows multiple perspectives to be raised regarding motivation and causation, etc., that the patients may not have considered.

The reflecting team approach has been used in family therapy for over 30 years and has only recently been adapted for use in healthcare education and practice. For example, an Australian nursing program uses reflecting teams composed of family members of patients to encourage a more holistic perspective of mentally ill patients and individuals (Morrison, 2009). A Swedish hospital has used reflecting teams to generate greater willingness to engage in empathic dialog, respond to difficult patient cases, and to improve patient care (Jonasson, Carlsson & Nyström, 2014). Formalized reflection through Balint groups are used in approximately half of all U.S. family medicine residency programs (Johnson, Brock, Hamadeh & Stock, 2001). Reflective practice groups for nurses are well described in the literature (Dawber, 2013; Mankiewicz, 2014) and have similar functions as reflection teams, namely the development of multiple perspectives and variant interpretations of meaning that assist nurses with collaboration and improved patient care.

The authors have adapted family therapy reflecting teams as an alternative to conventional debriefing after medical simulation. This is accomplished by utilizing mental health practitioners in training to offer their reflections and feedback regarding student learner’s interactions with simulated patients and family members. This method helps increase self-reflexivity by offering learners the opportunity to listen without having to respond, while pondering the reflections of psychotherapists whose observations raise questions and provide thought provoking reflections. The impact of hearing the feedback of these clinicians creates a sense of competence and motivation in nursing learners. This is particularly true as their skills and motives are affirmed, appreciated and sometimes challenged by such feedback.

A typical collaborative reflecting team training proceeds in the following manner:

1. A team of four to six mental health and medical practitioners are briefed regarding the reflective team methodology. Expectations and guidelines are provided regarding the reflection categories that they are to note during simulation.
2. A simulation is conducted that requires learners to engage in communication with patients and their family members regarding a sensitive issue: discussing a medical prognosis that severely limits sexual function; responding to family members’ insistence that their dying loved one will be miraculously healed; or assisting in telling a family that their loved one is dying. During the simulation the reflecting team records their speculations, ideas, and observations.
3. At the end of the simulation the reflection team shares their reflections about the simulation while remaining behind a one-way mirror. Learners listen in a “protected listening space” on the other side of the mirror. This space allows privacy and depth of thought as they do not respond to what is said.
4. The learners then reflect on the reflections provided by the reflection team. They discuss the emotional impact of participating in the sensitive conversation as well as their responses to the comments made by other learners and the reflection team. Feedback is shared among the learner group.
5. The content expert and a reflection team member (nurse and physician) then reflect in the presence of all learners and reflecting team members regarding their experience as they learned how to have these sensitive conversations. Attendees listen in and passively learn what has worked well for the more experienced providers.
6. A summative reflection is conducted that includes all present regarding the impact of the simulation and reflection process. Each member describes the most memorable feature of the experience and how they believe this will influence the manner in which they interact with patients in the future.

Couples and families who have participated in therapy with reflecting teams have reported positive gains, citing the helpfulness of viewing their issues in a new way and seeing their presenting issues as normative (Fischel, Ablon, McSheffrey & Buchs, 2005; Hoger, Tomme, Reiner & Steiner, 1994). However, outcomes research is only now being conducted on the adaptation of the reflection team model for healthcare education.

The authors offer the findings from the utilization of collaborative reflective training in interdisciplinary simulations that involved 24 participants, including nurses, nursing students, family therapy interns, medical residents, and fellows from NICU, PICU, OB-GYN, and Emergency medicine staff. Qualitative program evaluation measures were used to capture the usefulness of this approach.

The majority of learners indicated that this was a positive process that would impact their clinical practice in specific ways: “I’m going to make sure that I tell family members that their child didn’t die alone.” “No one really tells us how to manage ourselves in these kinds of situations, even though people think that [nurses] learn this.” “It’s a privilege to share these intimate moments with my patients, and I’m always thinking, how do I make it better? What can I say to help them?” Significant feedback was provided by a participant who stayed after the group to tearfully tell us, “Thank you for noticing how hard this is. No one is talking about that and it means so much that you can see the struggle and express appreciation. We don't hear that very often.”

Ongoing data collection is being conducted in quarterly trainings in our medical simulation center. Two external validation sites are expected to begin collecting data within the next year which will contribute to a more accurate description of the process and more reliable quantitative outcome measures. More specific application to nursing communication regarding sexual implications of illness will be highlighted in future investigation.

Dawber, C. (2013). Reflective practice groups for nurses: A consultation liaison psychiatry nursing initiative: Part 1—the model. International Journal of Mental Health Nursing, 22(2), 135 – 144.

Fishel, A.K., Ablon, S., McSheffrey, C. & Buchs, T. (2005). What do couples find most helpful about the reflecting team? Journal of couple & Relationship Therapy, 4, 23 – 37.

Hoger, C., Tomme, M., Reiner, L., & Steiner, E., (1994). The reflecting approach: Convergent results of two exploratory studies. Journal of Family Therapy, 16, 427 – 437.

Johnson, A.H., Brock, C.D., Hamadeh, G., & Stock, R., (2001). The current status of Balint groups in US family practice residencies: A 10-year follow-up study, 1990 – 2000. Family Medicine, 33(9), 672 – 677.

Jonasson, L.L., Carlsson, G., & Nyström, M., (2014). Prerequesites for sustainable care improvement using the reflective team as a work model. International Journal of qualitative studies on health and well-being. Retrieved from: http://www.ijqhw.net/index.php/qhw/  article/view/23934/36413

Mankiewicz, P.D. (2014). Reflective practice on inpatient mental health wards (2/2): Evaluation of CBT-integrated reflective learning process. British Journal of Healthcare Assistants, 8(7), 347 – 351.

Morrison, P.A., (2009). Using an adapted reflecting team approach to learn about mental health and illness with general nursing students: An Australian example. International Journal of Mental Health Nursing, 18, 18 – 25.