Exploring the Use of the COMFORT Model for Nurse Communication About Social Determinants of Health

Abstract

Background:

There are few curricula available to teach nursing students in communicating about social determinants of health (SDOH), a key aspect of palliative care. The COMFORT model offers a nurse-focused communication framework; however, it has not been used to teach nurse communication about SDOH.

Methods:

Undergraduate nursing students (n = 75) and doctoral nursing students (n = 33) from two academic sites in the United States completed an online communication module based on the COMFORT model. In this secondary data analysis study, researchers analyzed student-written responses to a family caregiver statement for acknowledgment of SDOH and the use of engagement and exploration communication strategies.

Results:

Analysis revealed that all students acknowledged at least one social factor, with economic stability (95%) and community, safety, and social context (19%) domains most mentioned.

Conclusion:

The results of this study demonstrate that the COMFORT model develops student communication attitude and skill about SDOH, expanding their capabilities as future primary palliative care providers. The COMFORT model enhanced student ability to identify and discuss SDOH, preparing them for equitable palliative care.

Background

Communication, relationship, and trust with health care providers are key factors that influence the quality of care among racial and ethnic minority patients,^1,2 a population where the occurrence of health problems and negative health outcomes are likely underestimated and undercounted. ³ Inequities based on race, ethnicity, age, sexual orientation, socioeconomic status, and other factors related to social determinants of health (SDOH) have been identified. ⁴ SDOH factors include environmental conditions that impact health functioning and quality of life risks and are part of the social domain of the Clinical Practice Guidelines for Quality Palliative Care.^5,6 Achieving equity-focused care requires teaching nurses to be curious about patient and family background and to include the distinct needs of patients and families in care planning. ⁷

National recommendations to address health inequities include enhancing professional education to improve clinician communication skills, ⁸ yet few curricula are available to teach nurses how to integrate social context into communication. ⁹ Nurse education currently focuses heavily on task interaction rather than relational interaction, and communication skills are needed in order to ensure referral to palliative care. ¹⁰ The COMFORT model offers a theory-driven, evidence-based, nurse communication curriculum for use across care settings and situations. ¹¹ Based on two decades of palliative and chronic care communication research, ¹² the COMFORT model represents the seven basic principles of palliative care communication: C—Connect, O—Options, M—Making Meaning, F—Family Caregivers, O—Openings, R—Relating, and T—Team. The COMFORT model has theoretical roots in narrative medicine^13,14 and health literacy,^15,16 promoting listening to and asking about patients’ and family members’ stories as a fundamental communication strategy to learn about social, structural, and contextual drivers of health. Although the COMFORT model has been successfully translated into a curriculum, reaching a variety of learners (nursing students, registered nurses, oncology nurses, and advanced practice nurses) across a range of delivery modalities (e.g., online, face-to-face, hybrid, train-the-trainer), the model has never been assessed with undergraduate (e.g., BSN) and graduate (e.g., DNP) nursing students specifically to cultivate conversational skills about social, structural, and contextual drivers of health.

Objective

This project examined whether nurse learners would acknowledge SDOH concerns stated by a family caregiver and how they would communicate about SDOH following exposure to an online communication module based on the COMFORT model.

Methods

A pre-posttest design was used to test an online communication module based on the COMFORT model, including use of the COMFORT smartphone application.^17,18 Participants were undergraduate and graduate nursing students at two different sites in the U.S. recruited by their instructor. Figure 1 provides an overview of the communication module. The module focused on the Connect principle of the COMFORT model, in which learners discover how to (1) seek the patient’s and family’s story about illness, (2) observe how the story is told, and (3) tailor meaningful person-centered messages to engage the story. ¹¹ The module consisted of three units with interactive cases and reflective prompts and was part of a larger study showing the efficacy of the online communication module. ¹⁸

FIG. 1.

COMFORT-based Communication Module Content.

This article presents a secondary data analysis exploring the content of student responses to a case in the module. Students read a statement from a family caregiver, recorded a role-play of the scenario, and then wrote a summary of how they would respond to the caregiver to learn more about the patient’s story. Two coders independently applied directed qualitative content analysis ¹⁹ using the SDOH framework and the communication strategies of acknowledge (recognize SODH factor), engage (recommend future tasks tied to SODH), and explore (propose questions to develop relationship/rapport), reaching consensus through discussion. Study procedures were approved by the Institutional Review Board at the University of Illinois Chicago.

Results

Overall, third-year Bachelor of Science in Nursing students (BSN) (n = 75) and advanced Doctoral of Nursing Practice students (DNP) (n = 33) produced a response to the family caregiver case assignment. The mean age was 27.9 years (range: 19–51 years), 89% were female, and 93% spoke English as a primary language. Students identified as Caucasian (n = 41, 38%), Hispanic/Latino (n = 37, 34%), Asian/Pacific Islander (n = 31, 28%), Black (n = 15, 14%), and Middle Eastern/North African (n = 3, 2%). Three students reported as multiracial, and two students opted not to answer.

All students acknowledged at least one SODH. Table 1 shows a summary of findings.

Table 1.

Student Responses Acknowledging Social Determinants of Health

	Extent (n, %)		Strategy		Examples b
Social determinants of health a	BSN (n = 75)	DNP (n = 33)	Engage	Explore
Economic Stability (Employment, Income, Expenses, Debt, Medical bills, Support)	72, 97%	31, 94%	✓	✓	Has anyone talked to you or your family about financial options or treatment plans? There is [sic] many programs and support services available that can help with treatment costs. (Engage, BSN student) Carlos mentioned his family’s income status, so I would ask about other situations where he felt like his income status was a barrier to health care delivery. Is there anyone else in your life who did not receive appropriate care due to income status? I would ask more about the occupations that his family members engage in to generate income. Has their ability to work been impacted by the Grandfather’s cancer diagnosis? (Explore, BSN student)
Neighborhood and Physical Environment (Housing, Transportation, Safety, Parks, Playgrounds, Walkability, Zip code/Geography)	0, 0%	3, 9%	✓		Carlos needs space to navigate any further socio-economic issues that may come up such as transportation burden or social support. (Engage, DNP student)What was your grandfather like growing up? Did he have any health issues? (Explore, DNP student)
Education (Literacy, Language, Early childhood education, Vocational training, Higher education)	1, 1.3%	2, 6%	✓		I would try to explain things to the best of my ability tailored to his knowledge level and offer to invite other care team members who will be assisting to incorporate their information. Not everyone is fortunate enough to have health insurance or insurance that will cover the costly expenses of cancer treatment. It is important to offer financial and social work resources to make this process a little easier for the patient and his family. (Engage, DNP student)
Food (Food security, Access to healthy options)	1, 1.3%	0, 0%		✓	I would try to get an insight on his grandfather’s life before cancer. For example, how was his diet, was he physically active and did he have any other medical issues? (Explore, BSN student)
Community, Safety, & Social Context (Social integration, Support systems, Community engagement, Stress, Exposure to violence/trauma, Policing/justice policy)	12, 16%	9, 27%	✓	✓	I usually encourage families to be part of support groups, since these usually offer information about resources and also help you feel understood by others that are going through the same circumstances. (Engage, BSN student)In addition to discussing his worries, it’s important to encourage Carlos to share more about his grandfather’s life and experiences. For example, I might ask, “What can you tell me about your grandfather? His life and experiences might help us provide the best care for him. (Explore, DNP student)
Health care System (Health coverage, Provider and pharmacy availability, Access to linguistically/culturally appropriate and respectful care, Quality of care)	3, 4%	5, 15%	✓	✓	Tell me more about your family. Does your Grandfather have any health coverage/insurance? Tell me more about why you feel that your family does not have access to life saving treatment for your grandfather (explore/mindful of immigration status). What happened with your Grandfather’s health to get you to this moment with me today?(Engage, DNP student)To orient the conversation toward his grandfather’s journey, I’d gently prompt him to share more about their experience by adding, “It sounds like this has been tough on everyone in your family, especially with the added financial pressure. If you feel comfortable, I’d love to hear more about what this experience has been like for your grandfather and for you—whatever you’d like to share. (Explore, DNP student)

a

Retrieved from https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/.

b

BSN, Bachelor of Science in Nursing student; DNP, Doctoral of Nursing Practice student.

Across the SDOH framework, all but four students (2 BSN, 2 DNP) acknowledged economic stability in their written responses (n = 104, 96%). Students engaged in economic factors by offering to recommend financial resources and by mentioning referrals to social work or case managers. Engagement communication included empathizing by sharing similar status or history and perspective-taking. Exploration communication focused on understanding the history of income, asking who else is involved in care, and asking what treatment options had been presented.

The next most common SDOH acknowledged by students (n = 21, 19%) was community, safety, and social context. Students engaged by offering support and explored by asking about the caregiver’s background. Engagement included offering support groups or other community resources. On the contrary, student responses that explored focused on the character of the patient, occupation, role in the family, coping, and impact on the patient’s life. Exploration also included questions about family, including the caregiver’s hopes and fears and family coping.

The domain of the health care system was acknowledged by eight students (7.4%). Seven students engaged by focusing on health coverage, offering community/federal resources, and relating to difficulties scheduling appointments. Only one DNP student explored by prompting the caregiver to share more about the patient’s and family’s challenges, such as financial strain or emotional toll. Neighborhood and physical environment were only acknowledged by DNP students (8.8%) and focused exclusively on engagement by addressing challenges such as transportation burden, the patient’s health condition growing up, and possible need for assistive devices in the home.

Education was acknowledged by one BSN student (1.3%) and two DNP students (6%). Engaged responses focused on helping the family understand the disease process. Students inquired about what the caregiver understood regarding the patient’s diagnosis and treatment plan. Only one BSN student acknowledged food and explored this factor by trying to get insight on the patient’s life before cancer.

Discussion

This U.S.-based study of an online communication module for undergraduate and graduate nursing students resulted in student acknowledgment of SDOH factors in a family caregiver case study. Students actively engaged in communication about SDOH factors by recommending resources and offering support groups, focusing on health insurance, and helping the family understand the diagnosis or disease process. When exploring SDOH, students learned more about the family context, hopes and fears, and care challenges related to other social drivers. These findings reflect the application of the COMFORT model and support key recommendations for developing an informed workforce with communication skills for primary palliative care. ²⁰

While students’ emphasis on financial stress reflects the salience of economic barriers, these findings may also indicate less comfort addressing education and housing issues. There is a need to develop self-awareness in clinical practice to ease nursing student uncertainty around conversations related to SDOH factors. ²¹ Evaluation and consideration of SDOH factors include the family caregiver’s environment to make sure it is safe and suitable for patient care. ²² Primary palliative nursing supports these care goals with two different communication pathways for nurses; a direct pathway where advanced practice nurses engage in structured, ongoing conversations, and an adaptive pathway where registered nurses engage in structured and unstructured, iterative and ongoing communication. ²³ Simulation has been shown to improve communication with vulnerable populations among nurse practitioner students; ²⁴ however, structured faculty resources and evidence-based exemplars for SDOH implementation in competency-based nursing education are currently lacking. ²⁵

Student acknowledgment of the more obvious categories of SDOH suggests that embedding SDOH domains into case simulations could improve holistic awareness. Student acknowledgment of social, structural, and contextual drivers of health is central to developing student attitudes and skills for delivering palliative care. ²⁶ Best practices for communication with vulnerable patient populations focus on teaching nurses how to create a welcoming environment and should begin upon entry into a nursing program. ²⁷ Providing equitable access to palliative care requires educating nurses about SDOH. ⁷

While immersive learning in nurse education has been effective in teaching SDOH, ²⁸ a concept-based curriculum provides an introduction to SDOH topics that can be integrated into learning activities and incorporated into curricula. ²⁹ Exposure to the COMFORT model can be integrated into the nursing curriculum to create student awareness of the need to communicate about SDOH with vulnerable populations. Future communication curricula should further develop communication strategies that address and revise misconceptions about palliative care and help nursing students prepare to collaborate with health care teams in delivering primary palliative care. Integrating COMFORT-based communication modules in nursing education may advance health equity by preparing nurses to address SDOH in primary palliative care.

Authors’ Contributions

E.W.: Conceptualization, methodology, formal analysis, writing-original draft. H.G.L.: Methodology, formal analysis, writing—original draft. J.V.G.: Conceptualization, methodology, validation, writing—review and editing. C.C.: Data curation; reviewing, and editing. J.M.: Data curation; reviewing, and editing. L.B.: Reviewing and editing.