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Abstract
Objective This study aimed to investigate healthcare professionals’ (HCPs’) experiences with the simulation-based Four Habits Model (4HM) course programme and evaluate how they perceived the 4HM’s immediate and persistent significance for practice within the intermediate care (IC) context.
Design A qualitative approach was combined with a survey design, structured within an exploratory sequential framework consisting of two phases: (1) focus group interviews with HCPs who had completed the course 2–4 weeks postcourse (n=11), and (2) a detailed questionnaire completed 4 months postcourse (n=14).
Setting and intervention IC serves as a bridge in the patient pathway from hospital to home providing community-based rehabilitation. The 4HM is a well-established framework for improving clinical communication in healthcare. However, it has never been tested in IC. We conducted two 4HM courses in April 2023 at an IC institution in Norway’s capital.
Participants The study involved clinical HCPs (n=15) working in IC, participating in the 4HM courses, and consisted of seven nursing assistants, five nurses and three therapists.
Results The HCPs experienced the 4HM course to be important and useful for practice in the IC context. They perceived that the easy-to-use framework could be applied in many patient–HCP interactions, had the potential to frame the ‘what matters to you’ question and increase satisfaction among patients and relatives. The survey conducted after 4 months disclosed that participants believed they had acquired and applied new communication skills.
Conclusion The 4HM provided a structured framework for interactions in the IC context, enhancing professionalism and streamlining daily tasks. Overall, the model fostered patient participation through improved communication skills. The findings could assist stakeholders, HCPs and IC service managers in developing educational programmes for HCPs to enhance communication skills and improve the quality of care for older patients in transitional care.
- Patient Participation
- MEDICAL EDUCATION & TRAINING
- REHABILITATION MEDICINE
- Health Services
- Community-Based Participatory Research
- Decision Making
Data availability statement
As the data collection approval for the main study states the data to be available only to the researchers, data and materials collected for this manuscript will not be shared.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Patient Participation
- MEDICAL EDUCATION & TRAINING
- REHABILITATION MEDICINE
- Health Services
- Community-Based Participatory Research
- Decision Making
STRENGTHS AND LIMITATIONS OF THIS STUDY
Conducting focus group interviews with healthcare professionals (HCPs) following the Four Habits Model (4HM) course programme captured the participants' immediate experiences with the simulation-based training and the 4HM in intermediate care (IC).
The findings from the qualitative phase were then further evaluated through a detailed questionnaire after 4 months to measure the self-perceived persistent significance of the 4HM course, thereby providing deeper insight into the initial findings.
Both 4HM courses were conducted by certified instructors with prior experience as physiotherapists in the IC context, ensuring instruction that was not only relevant and credible but also enriched with valuable professional insights.
Our study centres on the subjective perceptions of HCPs without including the viewpoints of patients, presenting a limitation as the perceived benefits reported by trained HCPs might not accurately mirror genuine improvements in communication skills.
While we have faith in the credibility of our qualitative results, we caution against generalising the survey study’s results due to the limited sample size.
Introduction
Good communication among healthcare professionals (HCPs), older patients and their relatives is essential for promoting patient participation and ensuring high-quality transitional care.1 Studies underscore that communication skills significantly impact patient satisfaction,2 complaint rates,3 treatment adherence4 and healthcare utilisation.5 Moreover, good communication can positively influence patient-reported outcomes, such as self-reported quality of life, pain management and physiological indicators like blood pressure and blood sugar levels.6 7
Intermediate care (IC) services play a crucial role in facilitating the transition of older individuals between care settings, typically offering short-term rehabilitation within municipal institutions.8 Despite patients’ right to participate in healthcare decision-making,9 patients and their relatives often feel marginalised during their journey from hospital to home through IC.10 This marginalisation is mainly attributed to a breakdown in communication among patients, their families and HCPs.11 12
Training HCPs’ communication skills can contribute to ensure high-quality patient care.11 Simulation training, which simulates real-life patient–staff interactions, through activities such as role-playing, has been identified as an effective method for enhancing these skills.12 Interprofessional simulation shows promise in improving patient participation in transitional care.13 Patient participation in IC can be defined as a dynamic process that emphasises a rehabilitative philosophy of establishing trustful relationships, facilitating mutual information exchange and engagement in rehabilitation activities within flexible organisational structures.14 However, the fast-paced environments of IC, characterised by frequent patient turnover, place significant pressure on HCPs’ communication abilities.15
Patients are often discharged early from hospitals, sometimes in a poor condition, while HCPs in IC may not be fully prepared. Moreover, patients with frailty, chronic conditions and cognitive decline present additional challenges in understanding their perspective and making joint decisions. Furthermore, the hierarchical organisational structure, where the municipal case manager holds administrative authority, can restrict HCPs' autonomy in communication, leading to potential misunderstandings. A prestudy by our team highlighted communication skills among HCPs as a research priority to promote patient participation.
The Four Habits Model (4HM)
The 4HM is a widely recognised framework which provides clinicians with the necessary tools and skills for promoting person-centred clinical communication in healthcare. The model consists of four specific habits that serve as guiding principles for thought and behaviour during clinical encounters.16 The first habit, ‘invest in the beginning’, focuses on establishing good contact early, comprehending the patient’s concerns and formulating a consultation plan. The purpose is to gain trust, for example, greeting the patient warmly, showing recognition of the patient, engaging in small talk to help the patient relax, asking open-ended questions and explaining what will happen next. The second habit, ‘eliciting the patient’s perspective’, involves understanding the patient by delving into what truly matters to them. This includes addressing specific requests and exploring how they affect the patient’s life. The third habit, ‘demonstrate empathy’, emphasises being attuned to the patient’s emotions, expressing empathy through both words and non-verbal cues and maintaining awareness of one’s own reactions. The fourth habit, ‘invest in the end’, underscores the importance of delivering personalised information, providing patient education, involving the patient in decision making and meaningfully concluding the consultation to avoid misunderstandings.16
The 4HM has been thoroughly documented and validated for its applicability in interactions with general practitioners and hospital doctors17–20 and among nurses.21 22 Only one nursing study did not observe a significant change in empathy.23 The 4HM has demonstrated its effectiveness in dealing with patients experiencing emotional distress24 and appears promising for family meetings.15 In Norway, the 4HM course programme has been implemented in several hospitals, but it has not been tested in primary care settings, and its importance for practice within IC services has not been explored. The 4HM may have the potential to assist HCPs in communication on admission, enabling them to explore the patient perspective and pose the ‘what matters to you’ question. It could also help them to empathically engage with vulnerable patients and their relatives within a limited timeframe, while also facilitating shared decision-making. The IC services distinguishes itself with a particular emphasis on communication skills, aimed at bridging the transition from acute hospital care to community-based care. Therefore, we need insight into the real-world dynamics of what constitutes empowering clinical encounters, which may help identify strategies to improve the quality of care for older patients in IC.
Aim of the study
The aim of this study was to investigate HCPs’ experiences with the simulation-based 4HM course programme and evaluate how they perceived the 4HM’s immediate and persistent significance for practice within the IC context.
Methods
This study employed a qualitative approach alongside a survey design, structured within an exploratory sequential design comprising two main phases.25 26 In the first phase, we collected qualitative data to gain in-depth insights into HCPs’ experiences with the 4HM course programme and its significance for daily IC practice. The findings from the qualitative phase were then further evaluated through a survey to quantify the self-perceived persistent significance of the 4HM course, thereby providing deeper insight into the initial findings. The data sources in the present study are (1) focus group interviews with HCPs who had participated in the 4HM course programme 2–4 weeks postcourse, and (2) a detailed questionnaire completed 4 months after participating in the 4HM communication course.
4HM course programme
The 4HM was originally developed in the USA by Frankel and Stein to enable doctors to integrate communication patterns into their clinical practice.16 The 4HM’s course programme spans 2 full days and includes theoretical plenary sessions and interactive group activities featuring role-playing for each of the four habits, followed by constructive feedback and reflection. While the 4HM course template remained consistent, we customised the educational material for the IC context using an authentic self-produced film, PowerPoint slides and pocket cards. Additionally, all simulations entailed typical IC real-life scenarios identified by the HCPs themselves. This study conducted two 4HM courses in an IC institution with 142 beds across six wards. With funding support, HCPs got time off from work for 2 full days to attend the offsite course without disruptions.
Participants
The participants were HCPs (n=15) participating in the 4HM courses and consisted of seven nursing assistants, five nurses and three therapists (two physical therapists and one occupational therapist). All were women except one and represented four different wards in the IC institution. The participants had a mean age of 43 years (range: 24–58). Their mean experience in healthcare exceeded 12 years.
Data collection
In April 2023, we conducted two separate 4HM courses with seven and eight HCPs. Initially, in December 2022, the first author presented the course programme for the leader group, and collaboratively, we identified suitable wards in the IC institution. The department managers informed their staff and recruited volunteer HCPs to participate. They invited 16 motivated HCPs from four departments, representing a diverse range of disciplines, to serve as opinion leaders within their respective departments, and 15 accepted the invitation. The two courses were facilitated by the first and last authors, both of whom are certified 4HM instructors with previous work experience as physiotherapists in IC. Approximately 2 and 4 weeks after the completion of the 4HM courses, we conducted two focus group interviews. These interviews, facilitated by the second and third authors, involved 11 of the participants (five from Group 1 and six from Group 2) to explore their experiences of the 4HM courses. The focus group interviews explored HCPs' experiences of participating in the 4HM communication course, as well as how they perceived the 4HM’s significance for the IC context. Specifically, the interview guide delved into HCPs’ practical applicability of the 4HM, their understanding of its benefits and its potential to become a standard routine in daily care. Insights were gained regarding the perceived worth of the course, its impact on communication skills, its relevance in clinical practice and its integration into leadership. Discussions about potential implementation strategies were held. For the interview guide, see Kvæl et al.27
After 4 months, 14 of the 15 course participants completed a questionnaire to validate the findings from the qualitative phase and quantify the perceived significance of the 4HM course. This questionnaire comprised two sections: (1) background variables (including profession, age, sex, education and years of experience in IC); and (2) 25 questions, including 3-point or 5-point Likert scales, a scale of 1–10 and three open-ended enquiries. These questions, developed and validated in previous studies,20 21 addressed the self-reported importance of training course components, their practical benefits in clinical settings, perceived self-efficacy in communication skills, perceived changes in communication postcourse and the potential of these courses to positively enhance patient interactions (online supplemental appendix A). It is unclear how long it takes to normalise new behavioural habits, but we chose to examine how they perceived their use of new skills after 4 months. The number of participants was based on the amount of valuable and relevant information the participants could contribute. After conducting two focus groups, 2 and 4 weeks postcourses and a survey after 4 months, we believed we had achieved sufficient information power (data saturation). This was based on the specificity of the research question, the representativeness of the sample, the quality of dialogues and the use of multiple research methods for deeper insights.28
Supplemental material
Data analysis
All interviews were subject to a rigorous thematic analysis following Braun and Clarke’s six-step framework.29 First, the primary author transcribed the interviews verbatim, ensuring accuracy and completeness. While the interviews were conducted by the second and third authors, the first author read and reread the transcripts to become familiar with the content. The initial interpretation of the interviews was then discussed collaboratively by all authors. Using HyperResearch software, the first author systematically coded the transcripts to identify significant patterns and categories. Following Braun and Clarke’s approach to reflexive thematic analysis, it is both common and often desirable for one author to carry out the actual coding process.29 Illustrative examples of the initial coding process are provided in table 1. The codes were then organised into potential themes and subthemes and further discussed among the researcher team, which included reviewing and naming themes to reveal both the surface meaning and the deeper essence of the HCPs’ experiences.
Example of the coding process
The 25-item questionnaire was analysed with descriptive statistics, including frequencies and medians, using the software Statistical Package for the Social Sciences, V.29. Two questions offered open-answer options, allowing respondents to provide details about how and why their communication might have changed. An extra question allowed them to provide any additional feedback. Due to the small number of participants and the limited responses to the open-ended questions, we were unable to perform any formal analysis and reporting. Nonetheless, the skills and communication changes identified are reflected in the survey findings and discussed in the context of the more detailed qualitative analysis.
Patient and public involvement
Informed by a prestudy conducted through the James Lind Alliance process, patients, relatives, HCPs and researchers collaboratively identified and prioritised key evidence gaps. These insights directly shaped our research questions, outcome measures and study design. A reference group of stakeholders actively engaged throughout the process, providing input and contributing to the dissemination of results. Currently, the Nursing Home Agency in Oslo is expanding the 4HM course programme across all IC establishments, demonstrating ongoing stakeholder involvement in our research and its continued impact.
Results
The qualitative analysis resulted in three themes as illustrated in table 2: (1) adding a sense of professionalism to the IC context, (2) a guide to structure interactions and save time in daily work and (3) promoting patient participation through improved communication.
The process of thematic analysis
Adding a sense of professionalism to the IC context
The first theme captures the experiences of HCPs, suggesting that the 4HM communication skills are trainable and can be sustained through the simulation of authentic practice scenarios from the IC context.
The participants evaluated the 4HM course as highly relevant and in line with the values of the IC and its rehabilitative philosophy. They found both communication as a topic and simulation as a method to be pertinent and instructive. The course participants recognised that communication could be improved through self-awareness.
In an environment with a high patient turnover, everything often feels rushed. However, I came to the realisation that taking just a few moments to sit down and establish a connection can make a significant difference. This insight was a wake-up call for me. I found the course to be highly beneficial, as it highlighted the importance of communication. There is always room for improvement and awareness in this area. (No 7, nurse)
The course participants highlighted the importance of participating in the 2-day off-site communication course, perceiving it as a form of recognition and an investment in their development as HCPs. They viewed this initiative as a commitment to promote empowering and suitable communication practices within the IC context. One participant emphasised the value of the 4HM approach:
I know the four habits are commonly applied in hospitals and similar professional environments. It’s quite fascinating that we are also incorporating these practices. It adds a sense of professionalism to our work. Personally, I feel more equipped and prepared, like I have an extra tool in my toolkit. (No 1, nursing assistant)
Furthermore, interdisciplinary simulation through role-playing, regarded as an active learning approach, was considered the most effective and valuable method of learning by the participants. However, it was acknowledged that simulation could be intimidating, underscoring the need for a safe learning environment with proficient and skilled instructors. Importantly, HCPs found it advantageous to create the practice scenarios themselves, as it enabled them to explore different communication techniques during training and when observing their colleagues. One participant shared their perspective:
Having such an interactive course, where you have to role-play in front of others, can be somewhat intimidating. But I personally feel that it results in enhanced learning. The habits we've covered seem easier to remember when they're simulated, rather than just heard or theorised. (No 9, therapist)
Overall, the 4HM communication course programme was deemed highly relevant for the IC context by the course participants, as it placed patient participation on the agenda in a professional and authentic manner.
A guide to structure interactions and save time in daily work
The second theme encompasses the participants’ experiences of the 4HM’s role in promoting empowering clinical encounters and establishing authentic patient and relative involvement.
The HCPs viewed the 4HM as a tool for creating a logical and consistent link to the various aspects of the participants' daily work situations, making the habits more understandable. According to the course participants, the 4HM’s structured format made it easy to memorise, and the habits were seen as a mental guide for organising clinical interactions.
I believe adopting the 4HM has helped me bring more structure into my approach. Now, I have a clear plan outlining what I aim to achieve following a conversation. (No 7, nurse)
Additionally, the 4HM framework received praise for its practical application in formulating the ‘what matters to you?’ question, thus promoting genuine patient participation. One participant articulated this sentiment:
Previously, we’ve been presented with the ‘What matters to you?’ approach without any proper framework. But now we’re attempting to structure it better. This means I need to invest more time initially to establish a connection. I cannot simply walk in and ask, ‘What matters to you?’ (No 2, nursing assistant)
The course participants emphasised the importance of engaging both patients and relatives in the ongoing plan and the significance of explicitly inquiring about any additional concerns before concluding. This practice was noted to save time in clinical interactions. One participant highlighted the impact of this approach:
I’ve observed that when we fail to enquire, ‘Is there anything else on your mind?’ before leaving, patients frequently call out, resulting in multiple return trips to their room. It appears that we spend more time making these additional visits than we would simply by asking the initial question. (No 3, nursing assistant)
A potential challenge to communication was identified concerning interactions with individuals with dementia or agitated relatives who may have misconceptions about the service’s expertise. However, some participants appreciated the value of empathic phrasing, a skill learnt in the course, as a beneficial technique when communicating with upset relatives. One participant emphasised the significance of empathetic communication:
Indeed, it’s beneficial to engage with relatives using empathetic phrases throughout the conversation, ensuring they feel heard and that we're one step ahead. Expressions like “Yes, we hear you”, “Yes, it was good you called”, and “I understand the frustration” make a difference. These are the types of phrases we've learned - emphasising empathy and active listening formulations. (No 8, nurse)
Overall, all course participants reported integrating aspects of the four habits into their daily routines. For instance, they became more conscientious about making initial contact and dedicating time to have seated interactions with patients. They gained a heightened awareness of the value of using open-ended questions to explore the patient’s perspective and became more at ease when addressing challenging emotions.
Promoting patient participation through improved communication
The third theme encompasses the participants’ experiences regarding the transformative potential of the 4HM framework in establishing a cohesive approach to clinical interactions. It highlights the framework’s capacity to enhance communication and thereby foster greater patient participation, ultimately improving the quality of care provided.
The HCPs discussed the extensive applicability and adaptability of the 4HM course programme across diverse clinical scenarios, considering the varied patient demographics, resource availability and the unique healthcare needs within the IC setting. They underscored how empowering communication could prevent misunderstandings. It is well known that the IC context involves a complex patient group as well as a busy daily clinical schedule. Given the transient nature of IC stays, there is a high patient turnover. The participants acknowledged that this could occasionally pose challenges in communication. One participant reflected on these challenges:
As HCPs in IC, we lack control over the admission and discharge of patients. Therefore, it can be challenging to completely align with the patient’s perspective, especially when we have carefully developed a plan and ensured their needs were addressed, only to see them abruptly discharged by the district. (No. 10, therapist)
Despite these challenges, the course participants shared a collective belief in the pivotal role of empowering communication with patients and relatives to uphold high service quality. They recognised that strong communication could enhance patient and relative satisfaction, but also act as a proactive measure against potential complaints. One participant highlighted the impact of improved communication:
We often spend a lot of time fixing issues due to poor communication, which could have been easily avoided with these 4HM techniques. Misunderstandings can lead to unnecessary clean-up jobs. Improved communication awareness among us professionals could be very beneficial for our work, patients, and their families. I believe it’s one of our most important tools. (No. 11, therapist)
The participants stressed the importance of inclusivity and accessibility of the 4HM course for all staff members, rather than restricting it for a selected few. They advocated that comprehensive training should be extended to everyone working in the service, fostering a unified understanding of empowering work practices and collaborative approaches across various levels of care. One participant reflected on the value of expanding the course’s reach:
I've actually thought a lot about what we learned when communicating with relatives and patients. So, I think this course was so good that more people could benefit from it to establish a shared understanding. Furthermore, I believe it’s essential for those of us who have taken the course to serve as role models for our fellow colleagues. (No 4, nursing assistant)
Overall, the participants reported that the 4HM should be firmly anchored by leadership and continuously nurtured to be fully embedded into IC. In practice, this involves regular discussions, reflective sessions and collaborative practice of communication techniques.
Survey findings
Of the 14 course participants answering the survey, 11 assessed the 4HM course as either ‘relevant’ or ‘highly relevant’. None of the course participants perceived the 4HM course as ‘not relevant’. Among the four habits, ‘Habit 3: demonstrate empathy’ received the highest relevance scores (see figure 1).
Relevance perceptions (n=14) of different aspects of the Four Habits Model (4HM) course, scored on a 5-point Likert scale (1=not relevant to 5=very relevant).
Through the survey, the course participants indicated the acquisition of new communication skills (figure 2). Regarding different survey assertions, 12 of 14 course participants agreed that ‘it has been easier to avoid misunderstandings’ after participating in the 4HM course. With regard to the statement ‘the 4HM course programme has complicated my work’, 4 out of 14 participants had not yet successfully incorporated the communication skills into their practice (see figure 2).
Course participants’ (n=14) level of agreement regarding assertions scored on a 5-point Likert scale (1=completely disagree to 5=totally agree).
As depicted in figure 3, the course participants expressed confidence in their ability to complete various tasks after completing the course. The item with the highest top score (median: 9) was ‘make sure that the patient has received answers to their enquiries’. The items ‘exploring intense emotions in a patient, for example, anger’ and ‘conveying bad news to the patient/relatives’ had the lowest scores (median: 7).
Course participants’ assessment of their own competence in completing clinical tasks after 4 months on a scale from 1 (uncertain) to 10 (extremely confident).
The open-ended questions provided respondents with an opportunity to elaborate on how their communication might have changed. They highlighted spending more time initially with patients, prioritising the patient and their family relationships and conducting thorough premeeting patient reviews. They most frequently emphasised seated conversation, eye contact, patience, active listening, awareness of their own body language and more frequent open-ended questions. Many also reported becoming more aware of acknowledging emotions, feeling more comfortable addressing them with patients and relatives, and improving their ability to seize opportunities for empathy during conversations.
Furthermore, the HCPs reported that they were structuring conversations more competently, providing the patient with space to express themselves, being more mindful of their own communication, exploring patient concerns more comprehensively, involving patients and their relatives in the rehabilitation plan, seeking their opinions and enquiring if they had any additional thoughts—all of which could contribute to a sense of security for the patient.To conclude the interaction in a professional and thorough manner, it was essential to ensure that the patient had no remaining questions or concerns before departing. This approach is particularly important in preventing what we know as ‘door-knob syndrome’, where patients raise significant issues or questions at the moment the HCP is about to leave the room.
Finally, 4 months later, all course participants responding to the survey (n=14) reported that they still recalled the four habits and affirmed that they had altered their communication with patients, relatives and other HCPs since the course. The majority believed that consistent practice could enhance communication. The participants partly continued to apply these habits in their daily IC practice. The final question in the survey allowed the participants to provide any additional feedback. Besides describing the course as essential and thought-provoking, there was an emphasis on a potential gap in implementing the 4HM into practice. It was pointed out that more individuals, beyond management, should attend the course to establish a comprehensive understanding of the new approach.
Discussion
To our knowledge, this study is the first to investigate HCPs’ experiences with the simulation-based 4HM course programme and evaluate how they perceived the 4HM’s immediate and persistent significance for practice, particularly in relation to patient participation within the IC context. This discussion focuses on the professionals’ experiences with the simulation-based 4HM course and its implications for practice in this context. Key topics include the relevance of the 4HM course to IC philosophy, the immediate and long-term benefits for communication skills, professional development through simulation, patient care and the trainability of communication skills. Additionally, we will examine aspects such as fidelity, the structured format of the 4HM and challenges in its implementation.
Overall, the participants rated the 4HM course as relevant and aligned with the rehabilitative philosophy of IC, as shown in both interviews and most of the postcourse surveys (figure 1) conducted after 4 months. Some perceived engaging in the course as an investment in their professional growth, underscoring a dedication to nurture empowering communication practices. In both interviews and in the survey, a majority of the HCPs reported enhanced communication skills both immediately after the course and at the 4 month mark. This aligns with Jensen et al,17 which showed improved communication skills among hospital doctors’ postcourse. Long-term follow-up studies have also demonstrated the effectiveness of the 4HM, with improved self-efficacy in communication persisting over 3 years.20 Similar findings were observed in nurses, with improvements in communication skills following a 2-day interdisciplinary 4HM course.21 The 4HM has also proven useful as a framework for family meetings in the IC setting15 and in dialogue with caregivers.22
HCPs viewed the course programme as a commitment to promote empowering and suitable communication practices that enhance patient participation within the IC context, adding a sense of professionalism to their practice. The WHO advocates for interprofessional healthcare learning as a strategy to enhance communication in healthcare and address communication challenges, thus enhancing patient safety and overall outcomes.30 31 The 4HM course programme employs interactive activities and group discussions to promote active learning among HCPs. Hence, in addition to enhancing clinical communication skills, it is a pertinent tool for improving interprofessional communication and collaboration. It enables HCPs to work successfully together and guides their communication with patients and relatives in a manner that is respectful and dignified.31 Consequently, the 4HM has the potential to empower HCPs and interdisciplinary practices in the IC setting with high patient turnover.
Furthermore, interdisciplinary simulation through role-playing was considered the most effective and valuable method of learning by the participants. This reiterates that simulation is an exceptionally suitable modality in HCP education, providing a robust and immersive learning experience that mirrors real-world situations and gives participants valuable hands-on training opportunities.32 Initially, simulating real-life communication scenarios was perceived as intimidating, emphasising the importance of a secure learning environment led by proficient instructors. Interestingly, the course participants found navigating these challenging aspects of the simulation to be the source of their most important insights. As they defined the real-life communication scenarios they enacted themselves, they considered the simulation to be highly realistic. The phenomenon of fidelity in simulation refers to how closely a simulation mimics a real event or workplace, encompassing aspects such as physical, psychological and environmental dimensions.33 The 4HM courses employ high-fidelity simulation, providing exceptionally realistic experiences with a high degree of interactivity and realism for HCPs.33 34
Participants found the 4HM’s structured format easy to memorise, viewing the habits as a mental map for organising clinical interactions. In particular, they emphasised the model’s practical application in formulating the ‘what matters to you?’ question, facilitating genuine patient participation. Previous research highlights that framing the ‘what matters to you?’ question competently is important for obtaining authentic patient participation and requires relational and communication skills.35 Using the ‘what matters to you?’ question as part of Habit 2, ‘eliciting the patient perspective’, after establishing trust, understanding the patient’s concerns and formulating a plan, can facilitate authentic patient participation in the final habit.15 This highlights the potential for the 4HM framework to serve as a tool for structuring complex clinical processes in the IC setting.
After 4 months, most participants still reported positive changes in their communication, including initiating seated interactions, using open-ended questions to explore the patient’s perspective, addressing emotions and explicitly enquiring about additional concerns before concluding. Habit 3, ‘demonstrate empathy’, was considered the most relevant in the survey (very relevant=10, relevant=2 and quite relevant=2), contrasting with a previous study that found no significant change in empathy postcourse.23 Eklund and colleagues defined empathy as understanding the person’s perspective, demonstrating compassion, offering emotional support and showing understanding.36
The survey stated that 4 out of 14 participants had not yet successfully incorporated the communication skills into practice. This may be attributed to various factors such as lack of opportunity to practice, difficulty in implementing new techniques, insufficient support and reinforcement within the workplace or a lack of support from leaders or supervisors. In the survey, HCPs rated ‘ensuring that the patient has received answers to their enquiries’ as the most important task (median 9, scale 1–10). Research highlights that addressing concerns early in the consultation is crucial for preventing the ‘door-knob phenomenon’ in which additional important concerns may arise as the interaction concludes.37 Proactively handling concerns early leads to a more positive and timely resolution. This involves approaching the patient with a respectful attitude, honouring their beliefs and values, and upholding their dignity, such as ‘respecting patients’ choices’.36
In the interviews, informants often mentioned HCPs’ busy schedules. The participating HCPs noted a lack of control over patient admission and discharge, making it challenging to truly consider the patient’s perspective. They described engaging in thorough planning and efforts to meet patients’ needs, only to have them abruptly discharged. IC involves a complex patient group and a hectic clinical routine.10 Recognising this, the course participants still adapted the four habits to accommodate individual practice situations in IC. Their adaptability and commitment, despite these constraints, highlight the potential of the 4HM to positively influence patient participation in care within the demanding IC environment.
Based on the survey conducted at the 4-month mark, most of the HCPs reported that they had altered their communication behaviour. The time it takes to normalise new behaviours remains uncertain, however, the research underscores the importance of simple habit formation.38 A study showed that associating one’s behaviour with a daily routine or a specific time is effective for habit formation. Hence, interventions should encourage individuals to repeatedly execute their planned behaviour in response to the intended cue to facilitate habit formation.39 The 4HM, being easy to remember, didactic and linked to specific practice situations through simulation, may have contributed to this transfer value in our study.
Strengths and limitations
This study is robust due to its integration of both qualitative and quantitative methodologies. To our knowledge, this is the first study to explore the 4HM course in the context of IC services. Both courses were conducted by certified instructors with prior experience as physiotherapists in the IC context. To establish trustworthiness, this study adheres to the Standards for Reporting Qualitative Research,40 see checklist in online supplemental appendix B and the Standards for Quality Improvement Reporting Excellence41 (online supplemental appendix C).
Supplemental material
Supplemental material
Nevertheless, the study has several limitations. Our study focuses on the subjective perceptions of HCPs without incorporating the viewpoints of patients. This is a significant limitation because the perceived benefits reported by trained HCPs may not accurately reflect genuine enhancements in communication skills. Furthermore, the involvement of volunteers and committed staff members in the courses may have positively impacted our findings. The researchers’ preconception that efficient clinical communication may improve patient participation might have influenced the analysis.25 Despite participating in the focus group interview and receiving three reminder emails, one participant did not complete the survey 4 months later. The reason for this is unknown. While we have confidence in the trustworthiness of our qualitative results based on established recommendations, we caution against generalising the survey study’s results due to the limited sample size. We recommend future research on a larger scale for comprehensive exploration.
Conclusion
The 4HM provided a structured framework for interactions in the IC context, enhancing professionalism and streamlining daily tasks. The participants appreciated the 4HM’s role in fostering coherence, structuring clinical interactions and framing the 'what matters to you' question. Additionally, they noted its potential to save time, reduce complaints and enhance satisfaction among patients and their relatives. Despite challenges in aligning practice with the patient’s perspectives due to limited control over admissions and discharges, participants observed that the course, through realistic simulation scenarios, improved their communication skills. Overall, the model fostered patient participation through improved communication skills. The participants emphasised the importance of extending the course to all staff members to promote unified communication practices. Survey responses indicated that most participants had acquired and applied new communication skills. These findings have informed stakeholders, HCPs and IC managers in the development of educational programmes that use simulation techniques, such as the 4HM course programme, which is currently being implemented across four settings in the capital of Norway. This scaling-up could potentially elevate care standards for older patients in IC settings.
Data availability statement
As the data collection approval for the main study states the data to be available only to the researchers, data and materials collected for this manuscript will not be shared.
Ethics statements
Patient consent for publication
Ethics approval
All participants provided informed consent after receiving oral and written information about the project. All interviews were recorded as MP3 files and stored on a platform that complies with data protection regulations. The study, approved by the Regional Committees for Medical Research (No. 107392), is registered with the Norwegian Agency for Shared Services in Education and Research (No. 53013).
Acknowledgments
We express gratitude to the participants who took part in the 4HM course programme for generously sharing their experiences and preferences.
References
Footnotes
Contributors LAHK : conceptualisation, methodology, investigation, formal analysis, funding acquisition, writing original draft, project administration (guarantor). AB: methodology, investigation, writing, review and editing. AB: conceptualisation, methodology, investigation, writing, review and editing. CFO: conceptualisation, methodology, investigation, writing, review and editing. We confirm that we have used the artificial intelligence program, Sikt KI-chat (approved by our institution in regard to data privacy), solely for the purpose of editing the English language in our manuscript.
Funding This work was supported by the Dam Foundation.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design or conduct or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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