"For Me, This Has Been Transforming": A Qualitative Analysis of Interprofessional Relationship-Centered Communication Skills Training.

In 2018, Yale Medicine (YM)-an academic multispecialty practice-and Yale New Haven Health System (YNHH), partnered with the Academy of Communication in Healthcare to develop a one-day interprofessional workshop to introduce relationship-centered communication skills to all of their nurses and physicians. Relationship-centered communication skills include showing positive regard, listening actively and expressing empathy and have been demonstrated to improve patient outcomes. A professionally diverse group of 12 nurses and physicians, committed to improving patient experiences, were purposefully selected for training to teach the workshop. Individual interviews with trainers 3 months post training revealed themes reflecting the intrapersonal, interpersonal, and organizational impact of participation in the Train-the-Trainer program. At the intrapersonal level, training contributed to personal growth, skillfulness, and confidence. At the interpersonal level, it expanded and strengthened professional networks. As an organizational catalyst, training transformed the work experience among nurse and physician trainers, thereby supporting YM/YNHH's vision to provide interprofessional relationship-centered care. Results suggest that trainer training had additional benefits beyond learning to deliver the workshop, including improving the quality of trainers' personal and professional relationships, and enhancing organizational efficiency and interprofessionalism.

Introduction

Relationship-centeredness is a systems approach that recognizes an organization as a network of relationships, through which all work gets done. The stronger that relationships are throughout the system, the more effectively work is accomplished. One way to strengthen relational ties and improve organizational effectiveness is by introducing relationship-centered communication (RCC) skills, which include encountering people with positive regard, displaying curiosity, listening actively, and expressing empathy (1); these skills ideally generate shared meaning between people. Previous research suggests that the introduction of RCC to a health care system benefits patients, as well as teams and organizational outcomes. (2) This article focuses on the reported impact of introducing RCC skills to a cohort of physicians, advance practice providers, and nurses.

Method

In 2018, the leadership of Yale Medicine (YM)—a large academic multispecialty practice—and the Yale New Haven Health System (YNHH)—sought to strengthen their organizational commitments to exceptional care by introducing a RCC skills workshop in partnership with the Academy of Communication in Healthcare (ACH). The ACH has developed a one-day RCC workshop that highlights skills training in small groups. The goals of YM/YNHH’s workshop, branded “Enhancing Relationship-Centered Communication” (ERCC), were to improve the patient experience and the quality of patient care (1,2).

YM and YNHH leadership deliberately chose to deliver the ERCC workshop interprofessionally to nurses, advanced-practice providers (APPs), and physicians. The goal of this design was to simultaneously improve the patient experience while creating shared paradigms among teams (3 –6). To deliver the workshop, 12 staff (6 nurses, 5 physicians, and 1 APP) who were identified as good communicators and committed to improving patient experience were recruited from various service lines throughout the institution to become trainers. The 12 trainers first participated in the one-day ERCC workshop taught by ACH faculty (A.H.F. and K.H.). A month later they began the Train-the-Trainer (TTT) program—5 days of training over 6 weeks—to prepare them to teach the workshop. This training focused on didactic presentation skills, small group facilitation, role-play, feedback skills, and working with learners they find challenging. Following the classroom training, the trainers, in interprofessional pairs, delivered the workshop to interprofessional audiences of their colleagues with the support of an ACH faculty member (A.H.F. or K.H.). After demonstrating workshop facilitation competency (including mastery of content and giving effective feedback to workshop attendees), trainers were certified to deliver the workshops at YM/YNHH.

On the first day of the TTT program, the 2 ACH faculty (A.H.F. and K.H.) recognized the impact on the trainer cohort of the skills they had learned a month before in the one-day ERCC workshop. Trainers spontaneously shared multiple stories, not only of their improved interactions with patients but also of their enhanced work and home relationships. As the TTT program progressed, the ACH faculty also heard many trainers’ statements of respect for each other’s diverse professional roles. Although the interprofessional TTT program was intended to be a means to an end—train nurses and clinicians to train other nurses and clinicians in order to improve the patient experience—we were drawn to the following question: How had the initial one-day workshop and the subsequent RCC training, impacted the trainers?

In order to investigate this question, one of us (G.R.) carried out semistructured interviews (see interview guide Appendix A) both in-person and remotely with 11 of the 12 trainers (one trainer could not be scheduled due to extensive clinical and administrative responsibilities). The interviews were recorded and transcribed. All 3 authors independently reviewed the verbatim transcripts in conjunction with the audio recordings for accuracy and additional conversational context.

During this independent review, the authors used qualitative methods of coding to identify patterns of experience and recurring themes of discourse across interviews. Each reviewer initially identified between 7 and 15 themes. A second independent review of the data revealed additional subsets of these preliminary themes. After 2 rounds of independent coding, the reviewers exchanged findings to synthesize analysis. This grounded theory approach of repeated review, constant comparison, and interpretation continued until all reviewers achieved interrater reliability, reducing the initial variance among individual coders, and identified a set of 7 unique, but complementary themes (7).

Results

Discourse analysis of interview transcripts with the 11 participants revealed responses reflective of participants’ experiences as a result of receiving interprofessional ERCC TTT training. Seven discrete themes were identified, the impact of which could be grouped according to their place of emergence within the relational system: (A) intrapersonal, (B) interpersonal, and (C) organizational. Specifically, 3 subthemes reflected intrapersonal impact—defined as an impact happening within the individual—and contributing factors. Those included: (A1) Personal Growth and Transformation, (A2) Uniqueness of Opportunity, and (A3) Best in Class. The second grouping of themes reflected interpersonal impact—defined as an impact occurring between 2 or more people—and included: (B1) Interprofessional Relationships and (B2) Transferability of RCC Skills. Finally, the last 2 themes reflected current or potential impact on the organization’s functioning including (C1) Commitment to Sustainability & Eliminating Gaps and (C2) Systems Impact. The consistency and quality of responses within these areas contributed to recognizing a theme as important.

The following section presents, interprets, and offers verbatim examples for each of these themes, showing their singular importance, as well as their unifying contribution toward the impact on intrapersonal, interpersonal, and organizational experiences described by participants. Respondents’ professional roles are noted after each example: PHY = physician, N = nurse, PA = physician assistant.

A. Themes Reflecting Intrapersonal Impact

The first category of themes highlights transformation at the intrapersonal or individual level due to personal application of learned RCC skills, reflection, or experience. It captures the overall personal paradigm shift many participants experienced due to their ERCC training (see Table 1).

Table 1.

Interview Themes Reflecting Intrapersonal Impact.

A. Intrapersonal impact	Examples
A1. Personal growth and transformation	“In terms of interacting with the nurses with the hierarchical way of communicating in the ED, it was transformative for me. It’s been very helpful. I always thought I was a good communicator, but now I’m taking it to the next level in ways I didn’t experience.” (PHY1)
	“I think that this is truly transformational. I can see that in my own practice.” (N1)
	“I still have a long way to go. I call it a transformation” (N2)
	“So what I learned about myself is that I didn’t listen.” (N1)
	“My oldest came home from college recently and we were having a dialogue. Afterwards she came to me and said, ‘I’m not sure I get what’s changed here, but I really appreciate it because I feel like you’re hearing us. I feel like you’re listening to us instead of directing us.’ For me, this has been transforming.” (N2)
A2. Uniqueness of opportunity	“There’s nothing else in my career that I’ve done that’s really anything like this.” (PHY2)
	“Interdisciplinary mix makes this different” (N3)
	“Different backgrounds of the trainers add to the uniqueness of this course.” (PA1)
	“Skills are taught and it’s something to ‘work on’ that makes this different,” (N5)
	“…communication skills that many healthcare providers don’t inherently get either in their training or on the job at a lot of hospitals” (PA1)
	“I’ve attended different seminars on patient experience…But I have to say that this is different because with this it gives you the tools that you need to actually improve your interactions with patients, which is key.” (N1)
	“…time investment is bigger than other professional development.” (N3)
A3. Best of class	“I thought the feedback that they gave us as a group and individually was some of the best feedback I’ve ever gotten.” (PA1)
	“I would say that this is probably one of the more rich opportunities that I’ve had.” (N4)
	“I would say that compared to anything /else I’ve done, I would say it was probably one of the better experiences I’ve had over the years.” (N6).
	“With this being interactive with the role playing and being able to practice communicating is a lot more effective than other ways we have been taught.” (N5)
	“This is by far the best.” (PHY1)
	“I’ve been in healthcare for 17 years…for 17 years I was just winging it…But I realize that there’s a lot I didn’t know, regarding interaction, relating to patients and interact in the most relationship-centered way. So, this has really changed me. It’s remarkable. Compared to everything else I’ve done, this is amazing.” (N1)

“In terms of interacting with the nurses with the hierarchical way of communicating in the ED, it was transformative for me. It’s been very helpful. I always thought I was a good communicator, but now I’m taking it to the next level in ways I didn’t experience.” (PHY1)

A1. Personal growth & transformation

One of the most striking themes to arise was the experience of personal growth through transformative experiences. Participants frequently used “transformative” to describe the personal change they experienced. Although some saw themselves as a work in progress, others specifically noted the impact of the transformation on their performance as well as their personal awareness. Others focused on the relational transformations that occurred from their improved skillfulness.

“There’s nothing else in my career that I’ve done that’s really anything like this.” (PHY2)

A2. Uniqueness of opportunity

A second intrapersonal level theme for the participants was the comparison of this training experience to other opportunities for professional development that they had experienced. Some noted the interprofessional focus while others commented on the attention to skill development. One person noted the investment of time (60 hours of training in all). Collectively, these comments reflect the distinctiveness of the ERCC workshop and the TTT program. Their comments, however, do not end with noting the uniqueness of the training; in the next theme participants also spoke of its quality as well.

“I thought the feedback that they gave us as a group and individually was some of the best feedback I’ve ever gotten.” (PA1)

A3. Best of class

The theme Best of Class emerged consistently across the participants in describing both the ERCC workshop and the TTT program. Some of the assessments were general in nature; others identified specific processes that they found particularly effective, such as the focus on skills development. Trainers received and learned to provide behavior-based feedback, which emphasized specific, behavior-based reinforcing and corrective comments; they noted this opportunity as well as the overall quality of the program.

B. Themes Reflecting Interpersonal Impact

The 2 themes included in this section reflect transformation of personal relationships. The first theme, “Interprofessional Relationships” addresses the shift in dynamics among the trainers due to their shared experience in the TTT program. The second theme, “Transferability,” emphasizes the application of the skills beyond patient care (see Table 2).

Table 2.

Interview Themes Reflecting Interpersonal Impact.

B. Interpersonal impact		Examples
B1. Interprofessional relationships	General	“I feel like I can trust physicians and mid-level practitioners that I work with a little more and I can relate with them in a better way since the class…It’s different and it’s so much better.” (N1)
		“…us getting to know each other and build these relationships is just as important as these skills sets.” (PA1)
		“Part of burnout in general for any professional role you’re in is that you lack meaningful relationships…I feel like this training does…all of that.” (PHY1)
		“There’s definitely a better professional relationship across the organization.” (PHY4)
		“Training interprofessionally really helps us foster better relationships with one another.” (N1)
	Hierarchy	“It leveled us all and put us on the same page.” (N5)
		“Hierarchy went away and was replaced with collaboration.” (N6)
		“Nice to work with everybody together on the same level.” (N3)
	Perspective	“Sometimes you gain more insight and empathy when you can understand someone else’s perspective. I think it’s important to hear the challenges the other professions have.” (N3)
		“I like co-facilitating with the nurses because you get a different perspective on what their job is like, and they have a very good collegiality with each other.” (PHY4)
		“Disciplines have a better understanding of each other.” (N1)
	Unifying Identity	“We are partners.” (N2)
		“We are all YNHH employees.” (N5)
B2. Transferability of RCC skills	Family	“It’s been something that has gone far beyond just my professional life…It’s all stuff that has allowed me to approach conversations more empathetically, especially with my teenage daughter. Communicating with her now using some of these skills is amazing. It’s allowed me to not try to fix all her problems and just listen to her for a bit. It created a better relationship between us.” (N4)
	Work	“I had a staff member the other day who was extremely frustrated…I went through exactly the steps that we use. By the time she walked out of the meeting, she thanked us and verbalized appreciation for the meeting and thanked us for being heard. It actually changed our entire relationship. The assistant manager sat back and said, ‘What just happened?’” (N2)
	Everyone	“Professionally, it’s been amazing how usable these skills have been outside of patient interactions. This training has opened up more ways to connect with people.” (PA1)
		“We could instill that these communication tools can be used for everything. The message that these tools are tools to take with you everywhere, and not just when we’re dealing with patients is really a very powerful one.” (PHY3)
		“People who don’t really communicate with patients anymore can walk out of there feeling that they could communicate with anybody.” (N5)

Abbreviations: RCC, relationship-centered communication; YNHH, Yale New Haven Health system.

“I feel like I can trust physicians and mid-level practitioners that I work with a little more and I can relate with them in a better way since the class…It’s different and it’s so much better.” (N1)

B1. Interprofessional relationships

It came as no surprise that one of the most discussed themes of the 7 was that of interprofessional relationships. Not only were the ERCC workshop and TTT program designed specifically to create this interaction but the interview guide also directly addressed the participants’ experiences regarding it. What could not be anticipated was the enthusiasm that ensued during the discussion. Participants repeatedly spoke to the essential quality of having nurses, physicians, and APPs learn together. The comments ranged from reflecting on general relationship building, to the minimizing of traditional hierarchy, to better appreciating another discipline’s perspective, as well as the creation of a unifying identity.

Collectively, these comments illustrate how orchestrating interprofessional learning has several benefits, particularly fostering respect and strengthening relationships, which ultimately benefit the system (3,5,6,8).

“Professionally, it’s been amazing how usable these skills have been outside of patient interactions. This training has opened up more ways to connect with people.” (PA1)

B2. Transferability of RCC skills

The second theme related to interpersonal relationships is that of transferability. The ERCC workshop skills are taught in the context of the patient–provider relationship. The literature, content, demonstrations, and role-plays all refer specifically to patient care. Trainer participants quickly realized, however, other opportunities where they could apply the skills. The examples were diverse and numerous, with family relationships as the most commonly cited stories, followed by professional relationships. Others emphasized that it is not just families and colleagues who benefit, but that the skills are universally applicable.

C. Themes Reflecting Organizational Impact

The final level of transformation was at the organizational level. The first part of this thematic discourse addressed gaps or limitations with implementation alongside a vision for sustainability. Complementing these ideas was a second theme that noted experiences of immediate impact on the organization (see Table 3).

Table 3.

Interview Themes Reflecting Organizational Impact.

C. Organizational impact	Examples
C1. Sustainability	“What is needed to take place is a true system-wide dissemination across the entire health system, not just physicians and trainees, but nurses, administrators, and all healthcare staff.” (PHY3)
	“How do we make it bigger and soon so as not to lose momentum?” (N2)
	“I think is should be open to all disciplines.” (PHY4)
	“I don’t think it should just be physicians and nurses. I think it should be the housekeepers and the transport people and everyone else in this building.” (N4)
C2. Systems impact	“Now if I need something, I can reach out to them. We don’t do a lot of things where we reach out of our service line. We are trying to break down those silos and do more things together.” (N5)
	“My network has expanded with trusted peers” (N1)
	“I think it’s been helpful to have friends from this training and colleagues that you start to form an interconnected web of contacts.” (PHY4)

“What is needed to take place is a true system-wide dissemination across the entire health system, not just physicians and trainees, but nurses, administrators, and all healthcare staff.” (PHY3)

C1. Commitment to sustainability and eliminating gaps

This theme embraced visionary language and suggestions for expansion of the ERCC program. Although the program was still in its infancy at the time of the interviews, participants had already deeply invested in the work and were committed to its potential. Trainers’ views of the potential, however, were not limited to just physicians and nurses, but rather inclusive of a wide range of health care staff.

Idealism, however, was tempered by the challenging reality of getting physicians to attend the ERCC workshop. Two nurses and 2 physicians expressed versions of the following comment when they said, “I think the weakness that we have, and I think it’s very clear and we all see it, is trying to figure out how to get physicians to the table.” (N2, N3, PHY1, PHY2)

“Now if I need something, I can reach out to them. We don’t do a lot of things where we reach out of our service line. We are trying to break down those silos and do more things together.” (N5)

C2. Systems impact

This final theme captures perceptions of immediate benefits to the system. Trainers’ comments implied that something bigger is happening, preparing the system for an even greater outcome than the desired improvement in patient experience scores. This theme recognizes that strengthening interconnections within the system through shared experiences and skill development creates synergy. Consequently, these strengthened connections lead to new relational pathways for achieving work together.

One of the most poignant examples comes from a nurse trainer who was contacted by a senior physician trainer about an issue between their departments. She recounted that he said, “‘You and I now are friends, let’s talk and tell me what you think of this.’ And it made me feel valued that he came to me about it rather than my boss.” (N5)

Discussion

Regardless of organizational dynamics or structure, caregivers need to work interprofessionally in order to provide health care for patients and families. Alignment of strategy, skills, and values, such as with relationship-centeredness, offers an effective, consistent approach that can guide an organization to successfully improve patient care (2,9).

In this study, 11 staff from a large academic multispecialty practice and university hospital—6 nurses, 1 physician assistant, and 4 physicians—who participated in a one-day ERCC workshop and 5 additional days in a TTT program to prepare them to deliver the workshop in interprofessional pairs to their interprofessional colleagues were interviewed. The ERCC workshop and the TTT program had significant impact on their work lives on 3 levels—intrapersonal, interpersonal, and organizational.

These 3 levels reflect the nature of systems. All systems, especially within health care, are nested inside of other systems, and within those systems, all work is relational. As these trainers report, intrapersonal, interpersonal, and organizational experiences are interdependent and mutually influencing. When one resource is introduced into a system, such as skills training in relationship-centeredness, it has the potential to impact all levels of the system. Here, not only was this intervention facilitated intentionally by bringing professions together, the participants explicitly shared that the ERCC workshop and the TTT program transformed the quality of their work experiences by enhancing skillful communication, strengthening relationships, and improving interprofessional efficacy, thereby benefiting organizational performance and, arguably, the patient experience. Although this study did not specifically address the impact of RCC on patients, multiple other studies have reported improved outcomes regarding team-based care, quality of care, patient safety, cost of care, and patient satisfaction with the introduction of RCC (2,10 –13).

This interdependence is worth noting by those wishing to introduce communication skills training that can lead to improved patient experience, professional transformation, and broad organizational impact. Although the attempt to target key stakeholders with a specific goal is understandable, a truly valuable professional tool will spread seamlessly to other contexts within the organization and benefit all types of relationships. According to the study participants, not only did the ERCC workshop and the TTT program benefit their communication with patients, they found the skills beneficial for improving the quality of their personal relationships, specifically with colleagues and family, as well.

This wide-ranging influence illuminates that “transformation” of the individual carries with it an implicit impact for the system. In this case, that impact was of a beneficial nature resulting in the strengthening of relationships both within and outside of work. The ERCC workshop and TTT program improved connections among the group of interprofessional trainers; these connections then helped to facilitate work on behalf of the organization, both administratively and in the care of patients. In short, though the ERCC workshop and TTT program are intended to enhance patient experience, they also can benefit the individual trainer and consequently their immediate and extended relational systems.

In terms of practical application, our experiences suggest that interprofessional training has multiple benefits to an organization. Leaders looking to strengthen connections across disciplines to improve patient experience should be assured that this approach potentially can bring diverse parts of their organization into connection with one another. This study suggests that fostering stronger relationships across the organization helps to improve coordination of care through direct and trusting conversations. Such findings support other research showing that high performance relies on participants recognizing, responding to, and mindfully improving their communication, and hence their patterns of relationships, which contribute to larger organizational cultural norms (14,15).

Limitations

This study has several limitations. First, the study was conducted at a single institution with only 11 participants. Although this sample size is appropriate for thematic saturation, it and the single setting limit the generalizability of the results. In addition, participants were exposed to both the ERCC workshop and the TTT program and it was not always clear which was responsible for the reported effects. Finally, the trainers had significantly more exposure to each other and to RCC skills than participants in the one-day ERCC workshop do; further research is needed to determine whether interprofessional benefits accrue to participants in the ERCC workshop; we intend to assess this.

Conclusion

Beyond skills acquisition, interprofessional participants in a RCC training program obtained transformational benefits at the intrapersonal, interpersonal, and organizational levels. Interprofessional training encouraged participants to reflect on their own behavior and how that contributed to organizational dynamics and the patient experience. Participants reported improved interprofessional relations and problem-solving with fellow trainers and colleagues. Those influencing the increase of interprofessional training in health professions schools, as well as in continuing education, should consider it a viable model that potentially benefits individuals, relationships, and the entire organization.

TURN ON THE RECORDER

The numbered questions are the “must ask” questions. The lettered questions are follow-up questions to tease out more talk if needed. You may or may not need to ask them.

Appendix A

Interview Agenda for Trainer Participants: Enhancing Relationship Centered Communication Workshop

Suggested introduction

Thank you for agreeing to meet with me. My name is X and my role is Y. Currently I am serving as an interviewer for this research project. Specifically, I’m here to learn more about your experiences as a participant in the TTT program, as well as your thoughts and experiences about its interprofessional design. Our conversation will be recorded, transcribed, and analyzed according to thematic analysis, identifying people only according to roles. The interview should take about 45 minutes and if there are any questions you’d prefer not to answer, or would like to stop the interview at any time, please just let me know. What questions do you have?

Warm-up question

Please state your name and tell me how long you have been at Yale New Haven Hospital.

What roles have you had during that time?

How did you find out about the training opportunity and what were your initial thoughts?

What, if any, expectations did you have?

How were those expectations met or not met?

Thinking of all the other education and professional development activity you’ve completed over the years, how would you compare this opportunity to other experiences?

What was similar or different in terms of content? (Ask for a specific example if needed)

What was similar or different in terms of process? (Ask for a specific example if needed

Describe the training experience in terms of its impact on you professionally and/or personally.

What were key experiences for you during the training?

What, if any, impactful experiences have you had since that you link back to the training?

How has this training impacted you in your current role, if at all?

What do you tell others about the training?

As a trainer, how would you describe your experiences of conducting the workshops?

Were there any key moments or experiences that stood out to you?

What would you want others to know about being a trainer?

Questions Addressing Perception and Impact of Interprofessional Training

Thank you for your answers so far. Now I have some questions specific to the interprofessional nature of the training (some of which may or may not have been touched on already.)

When you were first invited to participate, what were your initial thoughts about it being conducted interprofessionally?

Have your thoughts changed since then? If so, how?

From your perspective, how effective was the workshop with being inclusive and applicable to diverse professions?

What were the strengths?

How could it be improved?

Describe how being trained interprofessionally has impacted you professionally and/or personally.

Were there any key moments or experiences that stemmed from the training being interprofessional?

How has this training impacted your interprofessional relationships, if at all?

How has the interprofessional nature of the training impacted you in your current role, if at all?

What would you tell others about training interprofessionally?

Thank you for your answers. Now I have a question about facilitating the workshops.

4. As a trainer, what is it like to cofacilitate with a trainer who has a different professional role?

Have there been any key moments during workshops when the interprofessional context was highlighted or became an issue (for better or worse) among facilitators or participants?

What happened? How was it addressed?

What would you tell others about co-facilitating interprofessionally?

5. What comments about your experiences with the ERCC program would you like to add that we haven’t addressed?