Development of a patient-centered communication skills training: A qualitative exploration of nurse managers‘ perspectives

Development of a patient-centered communication skills training: A qualitative exploration of nurse managers‘ perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of a patient-centered communication skills training: A qualitative exploration of nurse managers‘ perspectives Kendra Mielke, Wiebke Frerichs, Katja Cöllen, Anja Lindig, Martin Härter, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5287510/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Communication skills trainings can enhance nursing professionals’ patient-centered communication skills, fostering positive health outcomes for both patients and nursing professionals. Understanding experiences and preferences of the target group is crucial when developing a specific communication skills training. Thus, it is essential to involve not only nurses but also nurse managers in the training development, as they offer a comprehensive overview of communication challenges experienced by nursing staff. Therefore, this study aimed to explore nurse managers’ perspectives on essential content for developing a patient-centered communication skills training. Methods: We conducted semi-structured interviews with nurse managers working at an academic medical center in Germany. Transcripts of audio-recorded interviews were analyzed using Kuckatz’s qualitative content analysis. Results: N = 18 nurse managers from various medical disciplines such as gynecology, psychiatry, pediatrics, and neurology participated in the study. The majority highlighted the importance of enhancing general communication skills and strategies such as showing empathy and applying tailored communication, as well as addressing communication challenges with patients. Fewer participants emphasized the need for training in professional self-awareness, communication with relatives, and culturally sensitive communication. Conclusion: Nurse managers identified crucial aspects for a training to enhance nurses’ patient-centered communication, revealing similar communication challenges across all medical disciplines. Nurse managers communication communication skills training interviews patient-centered care 1. Background Patient-centered communication has been identified as a crucial component of patient-centeredness [1], demonstrating a positive influence on health outcomes for both patients (e.g., higher health-related quality of life) [2] and nurses (e.g., reduced distress, improved self-efficacy) [3,4]. In clinical nursing practice, patient-centered communication can be challenging as various tasks, e.g. supporting patients’ physical and emotional needs, handling administrative tasks, and providing information for relatives often occur simultaneously [5]. Evidence indicates that effective communication contributes to patient safety (e.g., by preventing medication errors attributed to communication failures) and high-quality care [6,7]. Nurse managers (NMs) are responsible for creating a safe and supportive work environment while ensuring patient safety and quality of care [8]. Consequently, NMs should advocate for and facilitate the enhancement of nurses’ communication skills [7]. Moreover, NMs have a responsibility to proactively identify areas requiring improvement within their respective areas and to support nurses through tailored education and training [9,10]. Simultaneously, NMs’ own communication skills directly influence nurses’ job satisfaction, empowerment, and commitment, as they serve as pivotal role models [11]. Few international studies have assessed NMs’ perceptions regarding patient-centered communication of nursing professionals [12,13]. In an US-based qualitative study, NMs in oncology identified inconsistency in communication, inadequate information, and difficulties in interprofessional communication as barriers to effective communication among nurses [12]. Additionally, they found that nurses need to learn how to navigate their role as a translator between physicians, patients, and relatives. They concluded, that specific training on patient-centered communication skills could be beneficial [12]. Sawin et al.[13] investigated NMs’ perspectives on end-of-life communication in pediatric oncology. Interviewed NMs highlighted the importance of creating a positive working climate and supporting nurses’ professional development. The mentioned studies highlighted the importance of post-graduate communication training for nursing professionals. We conducted a focus group study with nurses from various medical disciplines on patient-centered communication. Results showed consistent challenges across disciplines, including dealing with angry or demanding patients and relatives, managing emotions, and providing patient-centered communication despite organizational barriers. These findings highlight the need to enhance nurses' communication skills [14]. One effective method to enhance patient-centered communication in nursing care is through a specific communication skills training (CST) [4,15]. Research indicates participation in a CST can improve self-efficacy and patient-centered communication skills [4,15], and is negatively associated with perceived stress and psychological symptoms such as anxiety and depression [16]. However, current CSTs for nursing professionals in Germany vary in quality and quantity [17], are limited to a specific medical discipline (e.g., oncology), and were developed without consideration of nursing professionals’ and NMs’ needs and preferences [18]. To our knowledge, no studies have specifically investigated NMs’ perspectives from various medical disciplines prior the development of a CST in Germany. Given the importance of assessing the target group’s needs and requirements before developing an intervention [19], the aim of this study was to investigate NMs’ perspective on essential content for a patient-centered CST to facilitate the development of such a training. 2. Method 2.1 Design To develop a patient-centered CST that is tailored to the target groups’ needs, we carried out interviews with a semi-structured interview guideline. For preparing the manuscript, we followed the consolidated criteria for reporting qualitative research (COREQ, see supplementary file 1) [20]. 2.2 Study Setting and Recruitment The present study is part of the KOMPAT study study (German: KOMmunikation in der PATient:innenorientierten Pflege; English: Communication within patient-centered nursing care), which aims to develop and evaluate a patient-centered CST for nursing professionals [21], conducted at University Medical Center Hamburg-Eppendorf (UKE). In September 2021, we informed department managers (DMs) of all 13 departments of the UKE about the KOMPAT study and the present study’s background and objectives. Subsequently, invitation e-mails for n = 9 DMs and n = 84 ward managers (WMs) and deputy ward managers (DWMs) were dispatched between December 2021 and January 2022 (the term NMs includes DMs, WMs, and DWM; for detailed information on job titles, see Table 1 ). Purposive sampling [22] was employed to ensure a diverse sample, encompassing a range of medical disciplines and professional experiences. We concluded data collection when no new content emerged during the interviews (i.e. reaching data saturation) [23]. Table 1 Areas of responsibility and tasks of nurse managers (information based on UKE employees’ reports) Nurse Managers Job title Area of Responsibility Tasks DM - Department manager Superior management and coordination of all wards within one department in the hospital a.o. strategic planning, quality management, staff leadership and training, collaboration with hospital management No involvement in direct nursing care WM - Ward manager Superior management of a ward within the hospital a.o. duty planning, direct staff management, work process organization, acting as a contact person for patients and relatives, cooperation with physicians and other disciplines Depending on ward, little or no involvement in direct nursing care DWM - Deputy ward manager Support and deputize for the ward manager Carrying out management tasks in the absence of the ward manager, support with administrative tasks (e.g., duty planning) Depending on the ward, partial to full involvement in direct nursing care 2.3 Inclusion and/or Exclusion Criteria Participants of the semi-structured interviews needed to hold a management position as DM, WM, or DWM within one of the UKE’s departments. Nursing professionals without a management position were not allowed to participate in the study. 2.4 Data collection Interviews were conducted in January and February 2022. Either KC or KM conducted the interviews. Each interview was audio-recorded. Due to the ongoing COVID-19 pandemic, participants were given the option to be interviewed online via a meeting-platform or in-person at the research team’s department or their own office. Interview appointments were scheduled individually. No prior relationships existed between interviewers and participants. An interview guideline (see Table 2 ) was developed and discussed with researchers experienced in conducting interview studies (AL, MH, IS), as well as pilot-tested with two nurses not affiliated with the UKE. Additionally, we collected demographic data through a brief questionnaire. Participants were not invited to comment or correct the transcript, nor did they receive the results to comment on them. Table 2 . Interview guideline for semi-structured interviews 2.5 Data Analysis For this study, we analysed only responses related to NMs’ perspective on nurses’ needs and requirements regarding the content for a patient-centered CST. Therefore, responses concerning participants’ opinion on organizational aspects of training development were not included in the analysis. Two student assistants transcribed all audio files with the transcription software F4 (version 4.2, dr.dresing & pehl GmbH, Marburg, Germany) by following the transcription rules of Dresing & Pehl [24]. To minimize potential misunderstandings during transcription, one member of the study team (either KC, WF, or KM) thoroughly reviewed all transcripts. During transcription, personal data (e.g. names of colleagues or superiors, patient-related information) was pseudonymized. Data analysis was conducted in accordance with the principles of Kuckatz’s content analysis [25], utilizing MAXQDA software (VERBI GmbH, Berlin, Germany). First, KC and KM developed deductive main categories based on topics known form existing research [12,26,27] and discussed it with WF. KC and KM each double coded 20% of the transcripts (4 out of 17 transcripts) to ensure reliability. The remaining 13 transcripts were allocated between KC and KM for individual coding. When new aspects emerged, KC and KM discussed and incorporated them as inductive main categories. Additionally, inductive sub-categories were created for detailed differentiation within a main category, if necessary, gradually building a preliminary category system. In a final stage, KM applied the preliminary category system to code the entire dataset again, making final adjustments to establish the final category system. Throughout all steps, WF was consulted as needed. 2.6 Rigor and reflexivity All authors have previous experiences in collecting qualitative data through semi-structured interviews as well as evaluating qualitative data applying content analysis. KM is a female health scientist (M.A.), trained physical therapist and a doctoral researcher. WF is a female health scientist (M.Sc.), international physical therapist (B.Sc.), and experienced doctoral researcher. KC is a female psychologist (M.Sc.) and a trained nurse. AL is a female neuro-psychologist (M.Sc.), trained psycho-oncologist, and post-doctoral researcher. MH and IS supervised the trial as principal investigators. MH is a male physician, psychologist, and professor for medical psychology. IS is a female psychologist, and professor for psycho-oncology. 2.7 Ethical Considerations The study was approved by the Local Psychological Ethical Committee of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf (approval number LPEK-0367). We followed the most recent version of the World Medical Association's Helsinki Declaration and applied the rules of ethical scientific conduct. Requirements for data protection were met. Participants were informed about the study objective and data protection and had to give their consent by signing a consent form beforehand. Participation was voluntary. 3. Results 3.1 Sample characteristics Overall, we conducted n = 17 interviews with n = 18 NMs, as two WMs asked to be interviewed together. Of these, n = 7 were DMs, n = 8 were WMs and n = 2 were DWMs. N = 63 WMs and DWMs did not respond to the invitation e-mail. Additionally, n = 10 interested WMs and DWMs agreed to participate, which we declined, as we had already achieved data saturation by interviewing NMs across various medical disciplines and with a broad range of work experience. Two participants preferred face-to-face interviews; all other interviews were conducted web-based. The interviews lasted between 25 and 58 minutes (mean 39 minutes) and were audio-recorded. Most of the 18 participating NMs were female (n = 13) and had over than 10 years of professional experience in nursing care (n = 14). Participants came from diverse medical disciplines, including gynecology, obstetrics, intensive care, psychiatry, pediatrics, cardiology, and neurology. To prevent potential identification, we will not disclose the number of participants from each discipline. For more information, see Table 3 . Table 3 Participants characteristics (n = 18) n (%) Gender Female Male 13 (72%) 5 (28%) Age 50 years 4 (22%) 7 (39%) 3 (17%) 4 (22%) Position Department manager Ward manager Deputy ward manager 7 (39%) 8 (44%) 3 (17%) Professional experience in nursing care 20 years No answer 1 (6%) 2 (11%) 7 (39%) 7 (39%) 1 (7%) 3.2 Participants’ perspective on patient-centered communication skills Six deductive and inductive main categories and respective sub-categories emerged from the content analysis. An overview with respective quotes for each category is provided in Table 4 . Table 4 Main and sub-categories with respective quotes Main category 1: Communication skills and strategies Sub-category 1.1: Knowledge about and application of communication theory “Well, the content probably [should include] general communication theory that we all have already gone through in our vocational training. […] I would definitely include it as a refresher, because these are fundamental theories […].” (Interview DWM 06) Sub-category 1.2: Non-verbal communication “Especially nonverbal communication, when you are under a lot of stress and don’t look up, […] a patient is standing in front of the registration desk and sometimes it is enough to just look up and nod, like ‘I see you’.“ (Interview DWM 06) Sub-category 1.3: Appropriate language “[…] I don’t want to hear ‘don’t get scared’ anymore, I am automatically scared if someone says that and that I am afraid. […] And that is missing somehow, the comprehension of nursing staff.” (Interview DWM 04) Sub-category 1.4: Showing Empathy “Well, [..] for me, that is kind of a door opener, you have to have this empathy, […] that is also an important story.” (Interview WM 10) Sub-category 1.5: Building relationship “I have to build a relationship with the patient, my counterpart. That is essential and how I mange that varies, and some people [nurses] fail to do so” (Interview WM 10) Sub-category 1.6: Tailoring Communication “ And to translate, […] that they can translate this well for patients and that they can adapt to different counterparts of course. […] In other areas, there are always difficulties, so you have to repeat a lot and communicate according to the intended audience. I think that is a very, very important topic.” (Interview DM 03) Sub-category 1.7: Conversation structure “ Well, I think it is really about a good entrée [in a conversation]. So, when someone arrives, to pick them up from where they are. […] What is the person’s emotional set-up and what is their actual problem.” (Interview WM 01) Main category 2: Communication challenges with patients Sub-category 2.1: Discrimination based on cultural background and sexual harassment “But we have also received feedback that some nurses with another cultural background have experienced discrimination from patients. And then the question arises how to deal with that in communication.” (Interview DM 12) Sub-category 2.2: Patients with cognitive impairments or physical limitations affecting communication “ But generally challenging patient situations arise when they [patients] are cognitively impairments and either as a result of their illness or their therapy are not so accessible, and yet [one] still have to find a way. […] And in daily work, it often happens that one becomes rather unfriendly and tends to abruptly cut off, which usually does not make the situation any better” (Interview DM 07) Sub-category 2.3: Aggressive or demanding patients “So how can I deal with very demanding behavior form patients, how should I react. Kind of de-escalating communication, I think that is actually really important.” (Interview DM 03) Sub-category 2.4: Patients with serious illness, dying patients “And in our field, this has become more and more important- communication with cancer patients. Meaning, that a different approach is needed, that sensitive topics have to be discussed. Topics that patients may not want to deal with at all.” (Interview WM 11). Main category 3: Professional self-awareness Sub-category 3.1: Establishing professional patient-nurse relationship “ And topics of closeness and distance and also authenticity and then how can I, as a nurse, distance myself or stop a conversation. […] How it is possible on the ward. I think that should definitely be a focus.” (Interview DWM 13). Sub-category 3.2: Self-reflection “ Then also, I think, the topic of mindfulness. How am I here today? […] How can I deal with it? One possibility is: I keep to myself and say nothing or I deal with it openly and admit to myself that today is not my day.” (Interview WM 02) Main category 4: Communication with relatives “Then I think it would be very, very important- as I am convinced that this is an increasingly important resource for us as nursing staff in the context of the treatment team - to involve the relatives.“ (Interview WM 02) Main category 5: Culturally sensitive communication “And probably, you are right; we have to look at the cultural aspects […]. So that would probably also be useful in communication skills training.“ (Interview WM 07) Main category 6: Handling time constrains “I think, communication in stressful situations is a topic that is becoming increasingly important.” (Interview DM 09) Main category 1: Communication skills and strategies Participants stated that expanding knowledge of general communication skills and strategies would be beneficial. Analysis of the data revealed seven sub-categories. Sub-category 1.1: Knowledge about and application of communication theory Participants believed it would be beneficially enhancing nurses’ general communication skills to apply communication models such as nonviolent communication. Additionally, discussing educational skills in general was considered helpful. Sub-category 1.2: Non-verbal communication The significance of nonverbal communication was highlighted. Participants pointed out that even small gestures, such as a nod of the head, can convey empathy and help patients to feel recognized. They found it crucial for nursing professionals to recognize the pivotal role nonverbal communication has in interactions with patients. Sub-category 1.3: Appropriate language Appropriate language was considered relevant to provide patient-centered communication. In participants’ opinion this included addressing patients appropriately, using concise sentences, avoiding technical jargon, and employing culturally sensitive language. Additionally, it was noted that using fear-inducing statements, emphasizing only patients' deficits, or giving patients strict instructions regarding behavior or movements that must be followed or avoided under all circumstances can have an adverse effect on patients. Sub-category 1.4: Showing empathy Participating NMs pointed out the significance of displaying empathy when communicating with patients. It was emphasized that the significance of adopting patients' perspective and thus, the necessity of employing an individualized approach depending on patient’s individual needs should be incorporated in a future CST. Sub-category 1.5: Building relationship Participants stated that building relationship with patients is crucial. They mentioned that strong patient-nurse relationship prevented misunderstandings and facilitates the management of highly emotional situations. Further, employing appreciative communication to build robust relationships and ensure patients feel understood was deemed essential. To foster patients’ trust, skills like taking time, sitting down on the bedside, and active listing were considered advantageous and should be incorporated in a CST. Moreover, NMs mentioned that respecting patients’ needs can enhance satisfaction for both patient and nurse. Participants emphasized the necessity of integrating patients into care processes, particularly when more than one nurse is involved in providing care. Additionally, the importance of permitting emotional and physical closeness within in a professional setting was mentioned. Sub-category 1.6: Tailoring communication Delivering communication tailored to the individual patients’ needs was perceived as essential. This included considering patients’ psychosocial characteristics (e.g., cultural background, age) and providing adapted information accordingly. Other topics mentioned were verifying patients’ understanding, offering clear step-by-step explanations to foster patients‘ self-management, and disseminating information about specific situations (e.g., explaining the necessity of certain treatments or post-operative movement limitations). Sub-category 1.7: Conversation structure Interviewed NMs mentioned that participants of a CST would benefit from acquiring skills in conversation structuring. It was emphasized that the initial phase of a conversation would entail managing conversation initiation as well as selecting an appropriate setting. Participants stated that conversation guidelines could assist nurses in organizing recurrent situations (e.g., medical history inquiries, hospital admissions, and discharges), potentially enhancing the exchange of necessary information. Furthermore, participants highlighted the importance of learning standardized skills for structuring conflict communication and breaking bad news. Additionally, standardizing specific conversations could promote consistency among all parties involved. Main category 2: Communication challenges with patients Participants reported that nurses frequently encounter highly challenging situations with patients. To effectively address these situations, they advocate for nurses’ participation in a CST. The analysis of the data unveiled four sub-categories. Sub-category 2.1: Discrimination based on cultural background and sexual harassment NMs considered it important for nursing professionals to acquire skills to respond professionally yet assertively to instances of discrimination. An example of workplace discrimination was recounted, involving racist comments directed at a medical assistant wearing a headscarf. Another aspect mentioned was that responding to inappropriate patient behavior, including sexual innuendo, poses a significant challenge for nursing professionals and should therefore be incorporated in a CST. Sub-category 2.2: Patients with cognitive impairments or physical limitations affecting communication For participants, communication with cognitively impaired patients or patients with physically limits affection communication abilities presents distinct challenges. It was considered essential that nursing professionals required assistance and training to effectively interact with patients affected by conditions such as dementia or delirium, or with those unable to verbally communicate due to treatment effects (e.g., tracheal intubation). Sub-category 2.3: Aggressive or demanding patients A frequently discussed aspect was the critical role of communication in de-escalating situations involving aggressive or demanding patients. Participants highlighted the importance of effective communication in this context. It was reported that some nurses experienced significant fear due to verbal threats from angry patients. According to participants, many nurses found it challenging to manage dissatisfied and noisy patients. Further challenges arise from dealing with patients who are frequently upset and complain, those who are agitated and demanding, or impatient patients. One participant emphasized the importance of staff being aware of where to obtain support in such situations. Sub-category 2.4: Patients with serious illness, dying patients It was emphasized that communication with patients with serious illnesses as well as communication about dying and death poses significant challenges for nurses and should therefore be included in a CST. Several specific challenges were identified in this context: Finding the right words in such situations, communicating with patients after they have received a bad or life-changing diagnosis, supporting patients following such diagnosis, breaking bad news, and communicating with patients in different stages of their illness (e.g., terminal stage). Other participants highlighted the relevance of understanding the process of dying for effective communication, as well as the necessity of ethical perspectives when communicating about death and dying. Main Category 3: Professional self-awareness Participants emphasized the importance of maintaining personal boundaries and managing emotions. Therefore, this aspect should also be included in CST. During analysis, these aspects were divided into two sub-categories. Sub-category 3.1: Establishing professional patient-nurse relationship Participating NMs identified maintaining emotional balance (e.g., avoiding excessive emotional involvement) as one key element for patient-centered communication. Nurses attending a CST should learn strategies and skills to manage their own emotions effectively. This includes sharing positive emotions (e.g., joy) without compromising professionalism and finding a balance between closeness and distance in patient interactions. Additionally, strategies should be discussed on how not to take patient frustration personally or feel offended, as well as how to be aware of and utilize personal resources to mediate challenging situations. Sub-category 3.2: Self-reflection For participating NMs, self-awareness encompasses nurses recognizing their mental state and personal limits, and learning to establish boundaries accordingly. It was considered crucial for nurses to acknowledge these limits without embarrassment and identify when to consult other professionals (e.g., psychologists) or seek support for themselves (e.g., managing challenging situations). The first step in setting boundaries is learning to recognize and reflect inner conflicts (e.g., difficulties in discussing death and dying due to personal experiences with the death of a family member). Additional aspects mentioned include managing personal insecurity, reflecting on and expressing personal emotions and energy levels. Main category 4: Communication with relatives Participants identified communication with relatives of their patients as an important aspect for a CST. They particularly emphasized the challenges of interacting with demanding relatives (e.g., those who are angry or hot-tempered). Furthermore, they noted the complexities of communicating with relatives from diverse cultural backgrounds, highlighting varying behaviors towards ill family members. The importance of engaging with relatives of patients receiving palliative care was also underscored. One participant indicated that in certain situations (i.e., patient is in a comatose state), verbal communication with patients is no longer possible, thereby positioning relatives as the primary contacts for decision-making. Hence, communication with relatives was perceived as a substantial resource alongside patient communication. Main category 5: Culturally sensitive communication Participants emphasized the importance of addressing language and cultural differences in a CST. NMs noted that increased cultural diversity among patients and nursing professionals sometimes results in communication challenges due to language barriers. As behaviors could be influenced by a person's cultural background, understandings of intimacy and personal boundaries might also arise. According to NMs, this divergence among individuals from various cultural backgrounds could lead to misunderstandings, affecting communication. One participant highlighted the significance of raising awareness of cultural diversity, as it fosters acceptance and tolerance. Main category 6: Handling time constrains Participants emphasized the importance of maintaining professional under time pressure while ensuring empathy. Additionally, it was considered essential to prioritize patient’s needs even in high-stress situations (e.g., avoiding to neglect the patient call bell). Moreover, they highlighted the necessity of allocating time to reseat after stressful events, despite existing time limitations. 3.3 Prioritization of aspects for a CST After participants shared their insights regarding relevant content for a CST, we asked them to prioritize their top three aspects from all their mentioned aspects. Subsequently, the interviewer summarized all aspects discussed in the respective interview before the NM were asked to prioritize. Out of 18 participants, 14 responded to this question. The aspects most frequently chosen by the interviewed NMs chose were (a) learning how to apply general communication skills and strategies (especially for building relationships, conveying empathy, and providing tailored communication) and (b) dealing with challenging situations, with a focus on de-escalation in situations involving demanding or angry patients and communicating about serious illness, death and dying. Fewer participants prioritized (c) communication with relatives, (d) professional self-awareness, and (e) culturally sensitive communication. Additionally, one NM chose (f) communication when facing time constrains and resulting stress as most relevant. 4. Discussion and Conclusion 4.1 Discussion The present study explored NMs’ perspective on the content of a patient-centered CST. The findings revealed that interviewed NMs identified various aspects to be incorporated in a future CST, indicating NMs’ awareness on the importance of such a training. The training needs identified in this study align with the results of the focus group study with nurses, also conducted by the research team [14]. Both NMs and nurses reported that discussions with demanding or aggressive patients, and communication about serious illness and with dying patients are especially challenging and essential to include in a CST. Both groups emphasized the importance of general communication skills and strategies, communication with relatives, and cultural aspects [14]. While focus group participants identified managing emotions as challenging, they did not prioritize it for a CST. However, NMs emphasized professional self-awareness, indicating they are more likely to focus on nurses’ mental well-being than nurses themselves. Self-awareness is a dynamic and iterative process of reflecting own characteristics, emotions, beliefs, and actions [28]. Literature indicates that enhancing nurses’ self-awareness improves communication skills and self-efficacy, helps recognizing stress and preventing burnout, and fosters relationship building and empathy [29]. Further, a study by Younas et al. [30] suggests that enhancing nurses’ self-awareness may also facilitate the improvement of cultural competencies, sensitizing nurses to the needs of patients with diverse cultural backgrounds. Hence, most CST do not focus on self-awareness [31]. Additionally, comprehensive studies detailing these benefits, particularly from patients’ perspective, remain lacking [29]. The highlighted importance of fostering nurses’ general communication skills and strategies such as showing empathy and applying non-verbal communication are also in line with a focus group study with NMs working in oncology, conducted by Wittenberg-Lyles et al. [12]. Participants of that study emphasized the use of tailored information and appropriate communication about pain and spirituality [12]. Brown & Bylund [32] suggested that breaking down communication into different components facilitates learning and teaching. Hence, a set of communication skills can be employed to achieve a specific communication strategy, contributing to the realization of a communication goal - the planned outcome of a conversation. For instance, the communication strategy “to provide understandable information” contributes to the communication goal “to share bad news in a way patient-centered manner”, achieved through communication skills like “summarizing information” and “checking patient’s understanding”. Another aspect mentioned by participating NMs was the importance of learning more about patient-centered communication in challenging situations. Communication with demanding or aggressive patients as well as relatives was specifically described as highly challenging. Research indicates a direct link between patients’ aggressive communication and nurses’ health outcomes, as well as an indirect through communication satisfaction [33]. Considering this, it becomes even more important to equip nurses with communication skills and strategies to manage aggressive communication, thereby fostering communication satisfaction and mitigating negative health outcomes. Similarly to our interviewed NMs, interviewed pediatric oncology NMs in a previous study, observed a lack of general communication skills, particularly in palliative and end-of-life communication, in early career nurses [13]. They indicated that the current approach is more about learning by doing rather than receiving formal education in communication [13]. To foster nurses’ palliative and end-of-life communication skills, appropriate training is beneficial [34]. 4.2 Strengths and Limitations of the Work The study possesses significant strengths. We successfully recruited NMs from diverse medical diciplines, thus encompassing a broad spectrum of perspectives and experiences. Although NMs are not directly or only occasionally involved in clinical care activities, their supervisory roles afford them a comprehensive overview of the communication challenges in nurses' daily work. Therefore, their insights are broadly applicable and hold considerable value for the development of patient-centered CSTs. Due to the selected methodology, several limitations must be acknowledged. Due to their areas of responsibility, DMs’ and WMs’ perspectives on communication challenges in nursing care are based on previous experiences or second-hand information from their staff, potentially leading to the omission of missing aspects. Additionally, during the interview and after asking openly about requested content for a CST, NMs were provided with a list of aspects from prior CST studies, which may have influenced their responses. Moreover, the study exclusively involved NMs from a single academic medical center, which can potentially limit the applicability of the results to NMs working in other hospitals. 4.3 CONCLUSION This study investigated NMs perspective on the content for the development of a patient-centered CST. The interviewed NMs identified and prioritized various aspects to be included in a future CST, aiding in the developing of such a training. Many of the identified aspects align with findings from international studies on nurses’ communication challenges. Our findings indicate that these challenges are not confined to oncology and intensive care but extend to other medical disciplines such as gynecology, obstetrics, psychiatry, pediatrics, cardiology, and neurology. Additionally, the present results indicate that NMs exhibit a stronger emphasis on nurses’ mental well-being. They acknowledge the importance of patient-centered communication in nursing practice and are prepared to facilitate the enhancement of nurses’ communication skills. 4.4 PRACTICE IMPLICATIONS Engaging a diverse range of relevant stakeholders is crucial to develop an intervention tailored to their specific needs. The involvement of NMs in CST development is vital, given their extensive insight into the communication challenges and needs faced by nurses. Further, nursing professionals from diverse medical disciplines should be offered the opportunity to participate in a CST, as our findings indicate that communication challenges are present across all medical disciplines. The insights garnered from this study, along with results from focus groups with nurses [14], are being included in the development of a patient-centered CST which focuses on applying general communication skills, de-escalation communication, and communication about serious illnesses, death and dying. The CST is currently undergoing evaluation in a randomized controlled trial [21]. Abbreviations AL Anja Lindig COREQ Consolidated criteria for Reporting Qualitative Research CST Communication skills training DM Department manager DWM Deputy ward manager IS Isabelle Scholl KC Katja Cöllen KM Kendra Mielke KOMPAT Communication within patient-centered nursing care MH Martin Härter NM Nurse manager UKE University Medical Center Hamburg-Eppendorf WF Wiebke Frerichs WM Ward manager Declarations Ethics approval and consent to participate The study was approved by the Local Psychological Ethical Committee of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf (approval number LPEK-0367). We followed the most recent version of the World Medical Association's Helsinki Declaration and applied the rules of ethical scientific conduct. Requirements for data protection were met. Participants were informed about the study objective and data protection and had to give their consent by signing a consent form beforehand. Participation was voluntary. Consent for publication Not applicable Availability of data and materials The datasets used and analyzed during the current study are not publicly available due to their close association with participants’ working area, making it difficult to sufficiently anonymize all personal data in all documents. Deidentified data (in German language) that support the findings of this study are available on reasonable request. Investigators who propose to use the data have to provide a methodologically sound proposal directed to the principal investigator of the study (Prof. Dr. Isabelle Scholl). Signing a data use/sharing agreement will be necessary, and data security regulations both in Germany and in the country of the investigator who proposes to use the data must be complied with. Preparing the data set for use by other investigators requires work and is thus linked to available or provided resources. Competing interests KM, AL, and KC declare that they have no competing interests. IS and MH declare that they currently are (MH) or have been (IS) members of the executive board of the International Shared Decision Making Society, which has the mission to foster shared decision making implementation and patient-centeredness. WF is currently an active member of tEACH, the teaching subcommittee of the International Association for Communication in Healthcare (EACH), which has the mission to explore and improve communication in healthcare. MH, WF and IS have no further competing interests. Funding This study is funded by the German health insurance fund DAK-Gesundheit. The funding body was not involved in the design of the study, collection, analysis, and interpretation of data nor in writing the manuscript. Authors' contributions Conceived and designed the study: IS, MH. Performed the interviews: KC, KM. Analyzed the data: KM, KC, WF. Contributed materials/analysis tools: AL, KC, WF, KM. Wrote the paper: KM. Revised and gave final approval to the paper: WF, AL, KC, IS, MH. Acknowledgements We thank our student research assistants and research interns Inga Bosch, Juliane Kampmann and Sarah Severin for helping preparing and conducting the study as well as transcribing the interviews. Declaration of Generative AI and AI-assisted technologies in the writing process During the preparation of this work, the authors used ChatGPT-3.5 in order to improve readability and language of the work. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. References Zill JM, Scholl I, Härter M, Dirmaier J. Which dimensions of patient-centeredness matter? - Results of a web-based expert delphi survey. PLoS One 2015;10:e0141978. https://doi.org/10.1371/journal.pone.0141978. Pozzar RA, Xiong N, Hong F, Wright AA, Goff BA, Underhill-Blazey ML, et al. Perceived patient-centered communication, quality of life, and symptom burden in individuals with ovarian cancer. Gynecol Oncol 2021;163:408–18. https://doi.org/10.1016/j.ygyno.2021.08.007. Sprangers S, Dijkstra K, Romijn-Luijten A. Communication skills training in a nursing home: Effects of a brief intervention on residents and nursing aides. Clin Interv Aging 2015;10:311–9. https://doi.org/10.2147/CIA.S73053. Wolderslund M, Kofoed P-E, Ammentorp J. The effectiveness of a person-centred communication skills training programme for the health care professionals of a large hospital in Denmark. Patient Educ Couns 2021;104:1423–30. https://doi.org/10.1016/j.pec.2020.11.018. Scott PA, Matthews A, Kirwan M. What is nursing in the 21st century and what does the 21st century health system require of nursing? Nurs Philos 2014;15:23–34. https://doi.org/10.1111/nup.12032. Wieke Noviyanti L, Ahsan A, Sudartya TS. Exploring the relationship between nurses’ communication satisfaction and patient safety culture. J Public Health Res 2021;10. https://doi.org/10.4081/jphr.2021.2225. Timmins F. Managers’ duty to maintain good workplace communications skills. Nurs Manage 2011;18:30–4. https://doi.org/10.7748/nm2011.06.18.3.30.c8538. American Organization of Nurse Executives. AONE nurse executive competencies. Nurse Lead 2005;3:15–22. https://doi.org/10.1016/j.mnl.2005.01.001. Kodama Y, Fukahori H. Nurse managers’ attributes to promote change in their wards: a qualitative study. Nurs Open 2017;4:209–17. https://doi.org/10.1002/nop2.87. Elsheikh R, Le Quang L, Nguyen NQT, Van PT, Hung DT, Makram AM, et al. The role of nursing leadership in promoting evidence-based nursing practice. J Prof Nurs 2023;48:93–8. https://doi.org/10.1016/j.profnurs.2023.06.007. Fowler KR, Robbins LK, Lucero A. Nurse manager communication and outcomes for nursing: An integrative review. J Nurs Manag 2021;29:1486–95. https://doi.org/10.1111/jonm.13324. Wittenberg-Lyles E, Goldsmith J, Ferrell B. Oncology nurse communication barriers to patient-centered care. Clin J Oncol Nurs 2013;17:152–8. https://doi.org/10.1188/13.CJON.152-158. Sawin KJ, Montgomery KE, Dupree CY, Haase JE, Phillips CR, Hendricks-Ferguson VL. Oncology nurse managers’ perceptions of palliative care and end-of-life communication. J Pediatr Oncol Nurs 2019;36:178–90. https://doi.org/10.1177/1043454219835448. Mielke K, Frerichs W, Cöllen K, Lindig A, Härter M, Scholl I. Perspective on Patient-centered Communication: A Focus Group Study Investigating the Experiences and Needs of Nursing Professionals. ResearchSquare 2024. https://doi.org/https://doi.org/10.21203/rs.3.rs-4835486/v1. Banerjee SC, Manna R, Coyle N, Penn S, Gallegos TE, Zaider T, et al. The implementation and evaluation of a communication skills training program for oncology nurses. Transl Behav Med 2017;7:615–23. Onan N, Barlas G, Karaca S, Yildirim N, Taskiran O, Sumeli F. The relations between perceived stress, communication skills and psychological symptoms in oncology nurses. J Marmara Health Sci 2015. https://doi.org/10.5455/musbed.20150602021515. Jünger J, Doll A. Nationaler Krebsplan, Handlungsfeld 4 „Stärkung der Patientenorientierung. Umsetzungsempfehlungen zu Ziel 12a ‚Kommunikative Kompetenzen im ärztlichen und pflegerischen Beruf‘ “. [National Cancer Plan, action area 4 „Enhancement of patient-centered care. Implementation recommendations for objective 12a 'Communication competencies in medical and nursing professions’ “]. 2016. Umsetzungsempfehlungen zu Ziel 12a (bundesgesundheitsministerium.de) (accessed August 20, 2024). Klöpfer C, Spieser A, Weis J. Ist - Analyse der Vermittlung kommunikativer Kompetenzen in der ärztlichen und pflegerischen Aus-, Fort- und Weiterbildung. [Status analysis of the integration of communication competencies in medical and nursing undergraduate, graduate, and continuing professional education]. Unpublished manuscript 2012. Fernandez ME, Ruiter RAC, Markham CM, Kok G. Intervention mapping: Theory-and evidence-based health promotion program planning: Perspective and examples. Front Public Health 2019;7. https://doi.org/10.3389/fpubh.2019.00209. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349–57. https://doi.org/10.1093/intqhc/mzm042. Lindig A, Mielke K, Frerichs W, Cöllen K, Kriston L, Härter M, et al. Evaluation of a patient-centered communication skills training for nurses (KOMPAT): study protocol of a randomized controlled trial. BMC Nurs 2024;23:2. https://doi.org/10.1186/s12912-023-01660-8. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health 2015;42:533–44. https://doi.org/10.1007/s10488-013-0528-y. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant 2018;52:1893–907. https://doi.org/10.1007/s11135-017-0574-8. Dresing T, Pehl T. Praxisbuch Interview, Transkription & Analyse. Anleitungen und Regelsysteme für qualitativ Forschende. [Manual for interviewing, transcription, and analysis. Instructions and guidelines for qualitative researchers]. 6th ed. Marburg: Eigenverlag; 2015. Kuckartz U. Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterstützung. [Qualitative content analysis: Methodological approaches, practical applications, and computer-assisted techniques]. 4th ed. Weinheim, Basel: Beltz Juventa; 2018. Aslakson RA, Wyskiel R, Thornton I, Copley C, Shaffer D, Zyra M, et al. Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: A qualitative exploration. J Palliat Med 2012;15:910–5. https://doi.org/10.1089/jpm.2011.0481. Banerjee SC, Manna R, Coyle N, Shen MJ, Pehrson C, Zaider T, et al. Oncology nurses’ communication challenges with patients and families: A qualitative study. Nurse Educ Pract 2016;16:193–201. https://doi.org/10.1016/j.nepr.2015.07.007. Eckroth-Bucher M. Self-awareness. ANS Adv Nurs Sci 2010;33:297–309. https://doi.org/10.1097/ANS.0b013e3181fb2e4c. Rasheed SP, Younas A, Sundus A. Self-awareness in nursing: A scoping review. J Clin Nurs 2019;28:762–74. https://doi.org/10.1111/jocn.14708. Younas A, Rasheed SP, Sundus A, Inayat S. Nurses’ perspectives of self-awareness in nursing practice: A descriptive qualitative study. Nurs Health Sci 2020;22:398–405. https://doi.org/10.1111/nhs.12671. Denniston C, Molloy E, Nestel D, Woodward-Kron R, Keating JL. Learning outcomes for communication skills across the health professions: a systematic literature review and qualitative synthesis. BMJ Open 2017;7:e014570. https://doi.org/10.1136/bmjopen-2016-014570. Brown RF, Bylund CL. Communication skills training: describing a new conceptual model. Acad Med 2008;83:37–44. https://doi.org/10.1097/ACM.0b013e31815c631e. Lam C. The link between patients’ aggressive communication and nurses’ emotional health outcomes. Health Commun 2023;38:1033–40. https://doi.org/10.1080/10410236.2021.1989788. Fuoto A, Turner KM. Palliative Care Nursing Communication. An evaluation of the COMFORT model. J Hosp Palliat Nurs 2019;21:124–30. https://doi.org/10.1097/NJH.0000000000000493. Additional Declarations Competing interest reported. KM, AL, and KC declare that they have no competing interests. IS and MH declare that they currently are (MH) or have been (IS) members of the executive board of the International Shared Decision Making Society, which has the mission to foster shared decision making implementation and patient-centeredness. WF is currently an active member of tEACH, the teaching subcommittee of the Interna-tional Association for Communication in Healthcare (EACH), which has the mission to explore and improve communication in healthcare. MH, WF and IS have no further competing interests. Supplementary Files Supplementaryfile1COREQchecklist.doc Supplementaryfile2Listofaspectsforinterviews.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5287510","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370456730,"identity":"e2f838a3-2e67-443c-9320-758466eae0cb","order_by":0,"name":"Kendra Mielke","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACCRCRwGBhwMDewAxkMhOtRcKAgecAKVoYQFokEojUItnewLrhQYWEMb/kG2ODDwzWcgS1SPMcYLuRcEbCTHJ2jnHiDIZ0Y4Ja5CQS2G4ktknYGNzOMT7Mw3A4sYGgFvkHQC3/JGzsb54xPvyH4XA9QS3SEgxALQ0SZgYSPMbJDAyHEwg6TLInse1GwjEJY4kzacWGPQbphgRtkTh++NjNHzU2hv3thzdL/KiwlidoCwMDI7KxBkRoGAWjYBSMglFAGAAAZIk2coKWVl0AAAAASUVORK5CYII=","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":true,"prefix":"","firstName":"Kendra","middleName":"","lastName":"Mielke","suffix":""},{"id":370456731,"identity":"5a74fae4-0030-4efc-a40d-3623d82c1f14","order_by":1,"name":"Wiebke Frerichs","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Wiebke","middleName":"","lastName":"Frerichs","suffix":""},{"id":370456732,"identity":"2aff765c-4731-4e6f-acc4-ac4ba81f3f09","order_by":2,"name":"Katja Cöllen","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Katja","middleName":"","lastName":"Cöllen","suffix":""},{"id":370456733,"identity":"968d2090-bbdf-40ff-af42-9465edf18b84","order_by":3,"name":"Anja Lindig","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Anja","middleName":"","lastName":"Lindig","suffix":""},{"id":370456734,"identity":"5a04b990-b6e1-4f07-b6e0-5de1e38a3b5b","order_by":4,"name":"Martin Härter","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Härter","suffix":""},{"id":370456735,"identity":"0f133c4e-b71e-414d-9fd9-607a26319cf4","order_by":5,"name":"Isabelle Scholl","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Isabelle","middleName":"","lastName":"Scholl","suffix":""}],"badges":[],"createdAt":"2024-10-18 07:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5287510/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5287510/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74199848,"identity":"7c40a78b-03bd-4afa-9b18-b3ddff1b4c53","added_by":"auto","created_at":"2025-01-20 01:53:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":924107,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5287510/v1/d4ffd376-c550-48d8-920f-c679b92ef5ec.pdf"},{"id":68288720,"identity":"36adce79-34de-4748-bab1-3bc31dba2192","added_by":"auto","created_at":"2024-11-05 16:47:18","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":99840,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1COREQchecklist.doc","url":"https://assets-eu.researchsquare.com/files/rs-5287510/v1/4c6b4a70f121146329923084.doc"},{"id":68288719,"identity":"7cdd9c23-1ac1-4a7a-86b8-39a6bb6ffd56","added_by":"auto","created_at":"2024-11-05 16:47:18","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":29693,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2Listofaspectsforinterviews.docx","url":"https://assets-eu.researchsquare.com/files/rs-5287510/v1/84f765fbb390e587de7174d7.docx"}],"financialInterests":"Competing interest reported. KM, AL, and KC declare that they have no competing interests. IS and MH declare that they currently are (MH) or have been (IS) members of the executive board of the International Shared Decision Making Society, which has the mission to foster shared decision making implementation and patient-centeredness. WF is currently an active member of tEACH, the teaching subcommittee of the Interna-tional Association for Communication in Healthcare (EACH), which has the mission to explore and improve communication in healthcare. MH, WF and IS have no further competing interests.","formattedTitle":"Development of a patient-centered communication skills training: A qualitative exploration of nurse managers‘ perspectives","fulltext":[{"header":"1. Background","content":"\u003cp\u003ePatient-centered communication has been identified as a crucial component of patient-centeredness [1], demonstrating a positive influence on health outcomes for both patients (e.g., higher health-related quality of life) [2] and nurses (e.g., reduced distress, improved self-efficacy) [3,4]. In clinical nursing practice, patient-centered communication can be challenging as various tasks, e.g. supporting patients\u0026rsquo; physical and emotional needs, handling administrative tasks, and providing information for relatives often occur simultaneously [5].\u003c/p\u003e \u003cp\u003eEvidence indicates that effective communication contributes to patient safety (e.g., by preventing medication errors attributed to communication failures) and high-quality care [6,7]. Nurse managers (NMs) are responsible for creating a safe and supportive work environment while ensuring patient safety and quality of care [8]. Consequently, NMs should advocate for and facilitate the enhancement of nurses\u0026rsquo; communication skills [7]. Moreover, NMs have a responsibility to proactively identify areas requiring improvement within their respective areas and to support nurses through tailored education and training [9,10]. Simultaneously, NMs\u0026rsquo; own communication skills directly influence nurses\u0026rsquo; job satisfaction, empowerment, and commitment, as they serve as pivotal role models [11].\u003c/p\u003e \u003cp\u003eFew international studies have assessed NMs\u0026rsquo; perceptions regarding patient-centered communication of nursing professionals [12,13]. In an US-based qualitative study, NMs in oncology identified inconsistency in communication, inadequate information, and difficulties in interprofessional communication as barriers to effective communication among nurses [12]. Additionally, they found that nurses need to learn how to navigate their role as a translator between physicians, patients, and relatives. They concluded, that specific training on patient-centered communication skills could be beneficial [12]. Sawin et al.[13] investigated NMs\u0026rsquo; perspectives on end-of-life communication in pediatric oncology. Interviewed NMs highlighted the importance of creating a positive working climate and supporting nurses\u0026rsquo; professional development. The mentioned studies highlighted the importance of post-graduate communication training for nursing professionals.\u003c/p\u003e \u003cp\u003eWe conducted a focus group study with nurses from various medical disciplines on patient-centered communication. Results showed consistent challenges across disciplines, including dealing with angry or demanding patients and relatives, managing emotions, and providing patient-centered communication despite organizational barriers. These findings highlight the need to enhance nurses' communication skills [14]. One effective method to enhance patient-centered communication in nursing care is through a specific communication skills training (CST) [4,15]. Research indicates participation in a CST can improve self-efficacy and patient-centered communication skills [4,15], and is negatively associated with perceived stress and psychological symptoms such as anxiety and depression [16]. However, current CSTs for nursing professionals in Germany vary in quality and quantity [17], are limited to a specific medical discipline (e.g., oncology), and were developed without consideration of nursing professionals\u0026rsquo; and NMs\u0026rsquo; needs and preferences [18]. To our knowledge, no studies have specifically investigated NMs\u0026rsquo; perspectives from various medical disciplines prior the development of a CST in Germany. Given the importance of assessing the target group\u0026rsquo;s needs and requirements before developing an intervention [19], the aim of this study was to investigate NMs\u0026rsquo; perspective on essential content for a patient-centered CST to facilitate the development of such a training.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Design\u003c/h2\u003e\n \u003cp\u003eTo develop a patient-centered CST that is tailored to the target groups\u0026rsquo; needs, we carried out interviews with a semi-structured interview guideline. For preparing the manuscript, we followed the consolidated criteria for reporting qualitative research (COREQ, see supplementary file 1) [20].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Study Setting and Recruitment\u003c/h2\u003e\n \u003cp\u003eThe present study is part of the KOMPAT study study (German: KOMmunikation in der PATient:innenorientierten Pflege; English: Communication within patient-centered nursing care), which aims to develop and evaluate a patient-centered CST for nursing professionals [21], conducted at University Medical Center Hamburg-Eppendorf (UKE). In September 2021, we informed department managers (DMs) of all 13 departments of the UKE about the KOMPAT study and the present study\u0026rsquo;s background and objectives. Subsequently, invitation e-mails for n\u0026thinsp;=\u0026thinsp;9 DMs and n\u0026thinsp;=\u0026thinsp;84 ward managers (WMs) and deputy ward managers (DWMs) were dispatched between December 2021 and January 2022 (the term NMs includes DMs, WMs, and DWM; for detailed information on job titles, see Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Purposive sampling [22] was employed to ensure a diverse sample, encompassing a range of medical disciplines and professional experiences. We concluded data collection when no new content emerged during the interviews (i.e. reaching data saturation) [23].\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAreas of responsibility and tasks of nurse managers (information based on UKE employees\u0026rsquo; reports)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eNurse Managers\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJob title\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArea of Responsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTasks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDM - Department manager\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuperior management and coordination of all wards within one department in the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ea.o. strategic planning, quality management, staff leadership and training, collaboration with hospital management\u003c/p\u003e\n \u003cp\u003eNo involvement in direct nursing care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWM - Ward manager\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuperior management of a ward within the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ea.o. duty planning, direct staff management, work process organization, acting as a contact person for patients and relatives, cooperation with physicians and other disciplines\u003c/p\u003e\n \u003cp\u003eDepending on ward, little or no involvement in direct nursing care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDWM - Deputy ward manager\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSupport and deputize for the ward manager\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCarrying out management tasks in the absence of the ward manager, support with administrative tasks (e.g., duty planning)\u003c/p\u003e\n \u003cp\u003eDepending on the ward, partial to full involvement in direct nursing care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Inclusion and/or Exclusion Criteria\u003c/h2\u003e\n \u003cp\u003eParticipants of the semi-structured interviews needed to hold a management position as DM, WM, or DWM within one of the UKE\u0026rsquo;s departments. Nursing professionals without a management position were not allowed to participate in the study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Data collection\u003c/h2\u003e\n \u003cp\u003eInterviews were conducted in January and February 2022. Either KC or KM conducted the interviews. Each interview was audio-recorded. Due to the ongoing COVID-19 pandemic, participants were given the option to be interviewed online via a meeting-platform or in-person at the research team\u0026rsquo;s department or their own office. Interview appointments were scheduled individually. No prior relationships existed between interviewers and participants.\u003c/p\u003e\n \u003cp\u003eAn interview guideline (see Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) was developed and discussed with researchers experienced in conducting interview studies (AL, MH, IS), as well as pilot-tested with two nurses not affiliated with the UKE. Additionally, we collected demographic data through a brief questionnaire. Participants were not invited to comment or correct the transcript, nor did they receive the results to comment on them.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eInterview guideline for semi-structured interviews\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003cimg 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\"\u003e\u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Data Analysis\u003c/h2\u003e\n \u003cp\u003eFor this study, we analysed only responses related to NMs\u0026rsquo; perspective on nurses\u0026rsquo; needs and requirements regarding the content for a patient-centered CST. Therefore, responses concerning participants\u0026rsquo; opinion on organizational aspects of training development were not included in the analysis.\u003c/p\u003e\n \u003cp\u003eTwo student assistants transcribed all audio files with the transcription software F4 (version 4.2, dr.dresing \u0026amp; pehl GmbH, Marburg, Germany) by following the transcription rules of Dresing \u0026amp; Pehl [24]. To minimize potential misunderstandings during transcription, one member of the study team (either KC, WF, or KM) thoroughly reviewed all transcripts. During transcription, personal data (e.g. names of colleagues or superiors, patient-related information) was pseudonymized.\u003c/p\u003e\n \u003cp\u003eData analysis was conducted in accordance with the principles of Kuckatz\u0026rsquo;s content analysis [25], utilizing MAXQDA software (VERBI GmbH, Berlin, Germany). First, KC and KM developed deductive main categories based on topics known form existing research [12,26,27] and discussed it with WF. KC and KM each double coded 20% of the transcripts (4 out of 17 transcripts) to ensure reliability. The remaining 13 transcripts were allocated between KC and KM for individual coding. When new aspects emerged, KC and KM discussed and incorporated them as inductive main categories. Additionally, inductive sub-categories were created for detailed differentiation within a main category, if necessary, gradually building a preliminary category system. In a final stage, KM applied the preliminary category system to code the entire dataset again, making final adjustments to establish the final category system. Throughout all steps, WF was consulted as needed.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e2.6 Rigor and reflexivity\u003c/h2\u003e\n \u003cp\u003eAll authors have previous experiences in collecting qualitative data through semi-structured interviews as well as evaluating qualitative data applying content analysis. KM is a female health scientist (M.A.), trained physical therapist and a doctoral researcher. WF is a female health scientist (M.Sc.), international physical therapist (B.Sc.), and experienced doctoral researcher. KC is a female psychologist (M.Sc.) and a trained nurse. AL is a female neuro-psychologist (M.Sc.), trained psycho-oncologist, and post-doctoral researcher. MH and IS supervised the trial as principal investigators. MH is a male physician, psychologist, and professor for medical psychology. IS is a female psychologist, and professor for psycho-oncology.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e2.7 Ethical Considerations\u003c/h2\u003e\n \u003cp\u003eThe study was approved by the Local Psychological Ethical Committee of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf (approval number LPEK-0367). We followed the most recent version of the World Medical Association\u0026apos;s Helsinki Declaration and applied the rules of ethical scientific conduct. Requirements for data protection were met. Participants were informed about the study objective and data protection and had to give their consent by signing a consent form beforehand. Participation was voluntary.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Sample characteristics\u003c/h2\u003e\n \u003cp\u003eOverall, we conducted n\u0026thinsp;=\u0026thinsp;17 interviews with n\u0026thinsp;=\u0026thinsp;18 NMs, as two WMs asked to be interviewed together. Of these, n\u0026thinsp;=\u0026thinsp;7 were DMs, n\u0026thinsp;=\u0026thinsp;8 were WMs and n\u0026thinsp;=\u0026thinsp;2 were DWMs. N\u0026thinsp;=\u0026thinsp;63 WMs and DWMs did not respond to the invitation e-mail. Additionally, n\u0026thinsp;=\u0026thinsp;10 interested WMs and DWMs agreed to participate, which we declined, as we had already achieved data saturation by interviewing NMs across various medical disciplines and with a broad range of work experience. Two participants preferred face-to-face interviews; all other interviews were conducted web-based. The interviews lasted between 25 and 58 minutes (mean 39 minutes) and were audio-recorded. Most of the 18 participating NMs were female (n\u0026thinsp;=\u0026thinsp;13) and had over than 10 years of professional experience in nursing care (n\u0026thinsp;=\u0026thinsp;14). Participants came from diverse medical disciplines, including gynecology, obstetrics, intensive care, psychiatry, pediatrics, cardiology, and neurology. To prevent potential identification, we will not disclose the number of participants from each discipline. For more information, see Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipants characteristics (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e13 (72%)\u003c/p\u003e\n \u003cp\u003e5 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e\u0026lt; 30 years\u003c/p\u003e\n \u003cp\u003e31\u0026ndash;40 years\u003c/p\u003e\n \u003cp\u003e41\u0026ndash;50 years\u003c/p\u003e\n \u003cp\u003e\u0026gt; 50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e4 (22%)\u003c/p\u003e\n \u003cp\u003e7 (39%)\u003c/p\u003e\n \u003cp\u003e3 (17%)\u003c/p\u003e\n \u003cp\u003e4 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosition\u003c/p\u003e\n \u003cp\u003eDepartment manager\u003c/p\u003e\n \u003cp\u003eWard manager\u003c/p\u003e\n \u003cp\u003eDeputy ward manager\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e7 (39%)\u003c/p\u003e\n \u003cp\u003e8 (44%)\u003c/p\u003e\n \u003cp\u003e3 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProfessional experience in nursing care\u003c/p\u003e\n \u003cp\u003e\u0026lt; 5 years\u003c/p\u003e\n \u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e\n \u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e\n \u003cp\u003e\u0026gt; 20 years\u003c/p\u003e\n \u003cp\u003eNo answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003cp\u003e2 (11%)\u003c/p\u003e\n \u003cp\u003e7 (39%)\u003c/p\u003e\n \u003cp\u003e7 (39%)\u003c/p\u003e\n \u003cp\u003e1 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Participants\u0026rsquo; perspective on patient-centered communication skills\u003c/h2\u003e\n \u003cp\u003eSix deductive and inductive main categories and respective sub-categories emerged from the content analysis. An overview with respective quotes for each category is provided in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMain and sub-categories with respective quotes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMain category 1: Communication skills and strategies\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 1.1: Knowledge about and application of communication theory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, the content probably [should include] general communication theory that we all have already gone through in our vocational training. [\u0026hellip;] I would definitely include it as a refresher, because these are fundamental theories [\u0026hellip;].\u0026rdquo;\u003c/em\u003e (Interview DWM 06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 1.2: Non-verbal communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Especially nonverbal communication, when you are under a lot of stress and don\u0026rsquo;t look up, [\u0026hellip;] a patient is standing in front of the registration desk and sometimes it is enough to just look up and nod, like \u0026lsquo;I see you\u0026rsquo;.\u0026ldquo;\u003c/em\u003e (Interview DWM 06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 1.3: Appropriate language\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] I don\u0026rsquo;t want to hear \u0026lsquo;don\u0026rsquo;t get scared\u0026rsquo; anymore, I am automatically scared if someone says that and that I am afraid. [\u0026hellip;] And that is missing somehow, the comprehension of nursing staff.\u0026rdquo;\u003c/em\u003e (Interview DWM 04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 1.4: Showing Empathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, [..] for me, that is kind of a door opener, you have to have this empathy, [\u0026hellip;] that is also an important story.\u0026rdquo;\u003c/em\u003e (Interview WM 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 1.5: Building relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I have to build a relationship with the patient, my counterpart. That is essential and how I mange that varies, and some people [nurses] fail to do so\u0026rdquo;\u003c/em\u003e (Interview WM 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 1.6: Tailoring Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eAnd to translate, [\u0026hellip;] that they can translate this well for patients and that they can adapt to different counterparts of course. [\u0026hellip;] In other areas, there are always difficulties, so you have to repeat a lot and communicate according to the intended audience. I think that is a very, very important topic.\u0026rdquo;\u003c/em\u003e (Interview DM 03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 1.7: Conversation structure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eWell, I think it is really about a good entr\u0026eacute;e [in a conversation]. So, when someone arrives, to pick them up from where they are. [\u0026hellip;] What is the person\u0026rsquo;s emotional set-up and what is their actual problem.\u0026rdquo;\u003c/em\u003e (Interview WM 01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain category 2: Communication challenges with patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 2.1: Discrimination based on cultural background and sexual harassment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;But we have also received feedback that some nurses with another cultural background have experienced discrimination from patients. And then the question arises how to deal with that in communication.\u0026rdquo;\u003c/em\u003e (Interview DM 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 2.2: Patients with cognitive impairments or physical limitations affecting communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eBut generally challenging patient situations arise when they [patients] are cognitively impairments and either as a result of their illness or their therapy are not so accessible, and yet [one] still have to find a way. [\u0026hellip;] And in daily work, it often happens that one becomes rather unfriendly and tends to abruptly cut off, which usually does not make the situation any better\u0026rdquo;\u003c/em\u003e (Interview DM 07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 2.3: Aggressive or demanding patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So how can I deal with very demanding behavior form patients, how should I react. Kind of de-escalating communication, I think that is actually really important.\u0026rdquo;\u003c/em\u003e (Interview DM 03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 2.4: Patients with serious illness, dying patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And in our field, this has become more and more important- communication with cancer patients. Meaning, that a different approach is needed, that sensitive topics have to be discussed. Topics that patients may not want to deal with at all.\u0026rdquo;\u003c/em\u003e (Interview WM 11).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain category 3: Professional self-awareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 3.1: Establishing professional patient-nurse relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eAnd topics of closeness and distance and also authenticity and then how can I, as a nurse, distance myself or stop a conversation. [\u0026hellip;] How it is possible on the ward. I think that should definitely be a focus.\u0026rdquo;\u003c/em\u003e (Interview DWM 13).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSub-category 3.2: Self-reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eThen also, I think, the topic of mindfulness. How am I here today? [\u0026hellip;] How can I deal with it? One possibility is: I keep to myself and say nothing or I deal with it openly and admit to myself that today is not my day.\u0026rdquo;\u003c/em\u003e (Interview WM 02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain category 4: Communication with relatives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Then I think it would be very, very important- as I am convinced that this is an increasingly important resource for us as nursing staff in the context of the treatment team - to involve the relatives.\u0026ldquo; (Interview WM 02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain category 5: Culturally sensitive communication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And probably, you are right; we have to look at the cultural aspects [\u0026hellip;]. So that would probably also be useful in communication skills training.\u0026ldquo;\u003c/em\u003e (Interview WM 07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain category 6: Handling time constrains\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think, communication in stressful situations is a topic that is becoming increasingly important.\u0026rdquo;\u003c/em\u003e (Interview DM 09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMain category 1: Communication skills and strategies\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants stated that expanding knowledge of general communication skills and strategies would be beneficial. Analysis of the data revealed seven sub-categories.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category 1.1: Knowledge about and application of communication theory\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants believed it would be beneficially enhancing nurses\u0026rsquo; general communication skills to apply communication models such as nonviolent communication. Additionally, discussing educational skills in general was considered helpful.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 1.2: \u003cem\u003eNon-verbal communication\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThe significance of nonverbal communication was highlighted. Participants pointed out that even small gestures, such as a nod of the head, can convey empathy and help patients to feel recognized. They found it crucial for nursing professionals to recognize the pivotal role nonverbal communication has in interactions with patients.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 1.3: \u003cem\u003eAppropriate language\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAppropriate language was considered relevant to provide patient-centered communication. In participants\u0026rsquo; opinion this included addressing patients appropriately, using concise sentences, avoiding technical jargon, and employing culturally sensitive language. Additionally, it was noted that using fear-inducing statements, emphasizing only patients\u0026apos; deficits, or giving patients strict instructions regarding behavior or movements that must be followed or avoided under all circumstances can have an adverse effect on patients.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 1.4: Showing \u003cem\u003eempathy\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipating NMs pointed out the significance of displaying empathy when communicating with patients. It was emphasized that the significance of adopting patients\u0026apos; perspective and thus, the necessity of employing an individualized approach depending on patient\u0026rsquo;s individual needs should be incorporated in a future CST.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 1.5: \u003cem\u003eBuilding relationship\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants stated that building relationship with patients is crucial. They mentioned that strong patient-nurse relationship prevented misunderstandings and facilitates the management of highly emotional situations. Further, employing appreciative communication to build robust relationships and ensure patients feel understood was deemed essential. To foster patients\u0026rsquo; trust, skills like taking time, sitting down on the bedside, and active listing were considered advantageous and should be incorporated in a CST. Moreover, NMs mentioned that respecting patients\u0026rsquo; needs can enhance satisfaction for both patient and nurse. Participants emphasized the necessity of integrating patients into care processes, particularly when more than one nurse is involved in providing care. Additionally, the importance of permitting emotional and physical closeness within in a professional setting was mentioned.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category 1.6: Tailoring communication\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eDelivering communication tailored to the individual patients\u0026rsquo; needs was perceived as essential. This included considering patients\u0026rsquo; psychosocial characteristics (e.g., cultural background, age) and providing adapted information accordingly. Other topics mentioned were verifying patients\u0026rsquo; understanding, offering clear step-by-step explanations to foster patients\u0026lsquo; self-management, and disseminating information about specific situations (e.g., explaining the necessity of certain treatments or post-operative movement limitations).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category 1.7: Conversation structure\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eInterviewed NMs mentioned that participants of a CST would benefit from acquiring skills in conversation structuring. It was emphasized that the initial phase of a conversation would entail managing conversation initiation as well as selecting an appropriate setting. Participants stated that conversation guidelines could assist nurses in organizing recurrent situations (e.g., medical history inquiries, hospital admissions, and discharges), potentially enhancing the exchange of necessary information. Furthermore, participants highlighted the importance of learning standardized skills for structuring conflict communication and breaking bad news. Additionally, standardizing specific conversations could promote consistency among all parties involved.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMain category 2: Communication challenges with patients\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants reported that nurses frequently encounter highly challenging situations with patients. To effectively address these situations, they advocate for nurses\u0026rsquo; participation in a CST. The analysis of the data unveiled four sub-categories.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 2.1: \u003cem\u003eDiscrimination based on cultural background and sexual harassment\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNMs considered it important for nursing professionals to acquire skills to respond professionally yet assertively to instances of discrimination. An example of workplace discrimination was recounted, involving racist comments directed at a medical assistant wearing a headscarf. Another aspect mentioned was that responding to inappropriate patient behavior, including sexual innuendo, poses a significant challenge for nursing professionals and should therefore be incorporated in a CST.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 2.2: \u003cem\u003ePatients with cognitive impairments or physical limitations affecting communication\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eFor participants, communication with cognitively impaired patients or patients with physically limits affection communication abilities presents distinct challenges. It was considered essential that nursing professionals required assistance and training to effectively interact with patients affected by conditions such as dementia or delirium, or with those unable to verbally communicate due to treatment effects (e.g., tracheal intubation).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 2.3: \u003cem\u003eAggressive or demanding patients\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eA frequently discussed aspect was the critical role of communication in de-escalating situations involving aggressive or demanding patients. Participants highlighted the importance of effective communication in this context. It was reported that some nurses experienced significant fear due to verbal threats from angry patients. According to participants, many nurses found it challenging to manage dissatisfied and noisy patients. Further challenges arise from dealing with patients who are frequently upset and complain, those who are agitated and demanding, or impatient patients. One participant emphasized the importance of staff being aware of where to obtain support in such situations.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category\u003c/em\u003e 2.4: Patients with serious illness, dying patients\u003c/p\u003e\n \u003cp\u003eIt was emphasized that communication with patients with serious illnesses as well as communication about dying and death poses significant challenges for nurses and should therefore be included in a CST. Several specific challenges were identified in this context: Finding the right words in such situations, communicating with patients after they have received a bad or life-changing diagnosis, supporting patients following such diagnosis, breaking bad news, and communicating with patients in different stages of their illness (e.g., terminal stage). Other participants highlighted the relevance of understanding the process of dying for effective communication, as well as the necessity of ethical perspectives when communicating about death and dying.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMain Category 3: Professional self-awareness\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants emphasized the importance of maintaining personal boundaries and managing emotions. Therefore, this aspect should also be included in CST. During analysis, these aspects were divided into two sub-categories.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category 3.1: Establishing professional patient-nurse relationship\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipating NMs identified maintaining emotional balance (e.g., avoiding excessive emotional involvement) as one key element for patient-centered communication. Nurses attending a CST should learn strategies and skills to manage their own emotions effectively. This includes sharing positive emotions (e.g., joy) without compromising professionalism and finding a balance between closeness and distance in patient interactions. Additionally, strategies should be discussed on how not to take patient frustration personally or feel offended, as well as how to be aware of and utilize personal resources to mediate challenging situations.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSub-category 3.2: Self-reflection\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eFor participating NMs, self-awareness encompasses nurses recognizing their mental state and personal limits, and learning to establish boundaries accordingly. It was considered crucial for nurses to acknowledge these limits without embarrassment and identify when to consult other professionals (e.g., psychologists) or seek support for themselves (e.g., managing challenging situations). The first step in setting boundaries is learning to recognize and reflect inner conflicts (e.g., difficulties in discussing death and dying due to personal experiences with the death of a family member). Additional aspects mentioned include managing personal insecurity, reflecting on and expressing personal emotions and energy levels.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMain category 4: Communication with relatives\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants identified communication with relatives of their patients as an important aspect for a CST. They particularly emphasized the challenges of interacting with demanding relatives (e.g., those who are angry or hot-tempered). Furthermore, they noted the complexities of communicating with relatives from diverse cultural backgrounds, highlighting varying behaviors towards ill family members. The importance of engaging with relatives of patients receiving palliative care was also underscored. One participant indicated that in certain situations (i.e., patient is in a comatose state), verbal communication with patients is no longer possible, thereby positioning relatives as the primary contacts for decision-making. Hence, communication with relatives was perceived as a substantial resource alongside patient communication.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMain category 5: Culturally sensitive communication\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants emphasized the importance of addressing language and cultural differences in a CST. NMs noted that increased cultural diversity among patients and nursing professionals sometimes results in communication challenges due to language barriers. As behaviors could be influenced by a person\u0026apos;s cultural background, understandings of intimacy and personal boundaries might also arise. According to NMs, this divergence among individuals from various cultural backgrounds could lead to misunderstandings, affecting communication. One participant highlighted the significance of raising awareness of cultural diversity, as it fosters acceptance and tolerance.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMain category 6: Handling time constrains\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants emphasized the importance of maintaining professional under time pressure while ensuring empathy. Additionally, it was considered essential to prioritize patient\u0026rsquo;s needs even in high-stress situations (e.g., avoiding to neglect the patient call bell). Moreover, they highlighted the necessity of allocating time to reseat after stressful events, despite existing time limitations.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Prioritization of aspects for a CST\u003c/h2\u003e\n \u003cp\u003eAfter participants shared their insights regarding relevant content for a CST, we asked them to prioritize their top three aspects from all their mentioned aspects. Subsequently, the interviewer summarized all aspects discussed in the respective interview before the NM were asked to prioritize. Out of 18 participants, 14 responded to this question.\u003c/p\u003e\n \u003cp\u003eThe aspects most frequently chosen by the interviewed NMs chose were (a) learning how to apply general communication skills and strategies (especially for building relationships, conveying empathy, and providing tailored communication) and (b) dealing with challenging situations, with a focus on de-escalation in situations involving demanding or angry patients and communicating about serious illness, death and dying. Fewer participants prioritized (c) communication with relatives, (d) professional self-awareness, and (e) culturally sensitive communication. Additionally, one NM chose (f) communication when facing time constrains and resulting stress as most relevant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion and Conclusion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Discussion\u003c/h2\u003e \u003cp\u003eThe present study explored NMs\u0026rsquo; perspective on the content of a patient-centered CST. The findings revealed that interviewed NMs identified various aspects to be incorporated in a future CST, indicating NMs\u0026rsquo; awareness on the importance of such a training.\u003c/p\u003e \u003cp\u003eThe training needs identified in this study align with the results of the focus group study with nurses, also conducted by the research team [14]. Both NMs and nurses reported that discussions with demanding or aggressive patients, and communication about serious illness and with dying patients are especially challenging and essential to include in a CST. Both groups emphasized the importance of general communication skills and strategies, communication with relatives, and cultural aspects [14]. While focus group participants identified managing emotions as challenging, they did not prioritize it for a CST. However, NMs emphasized professional self-awareness, indicating they are more likely to focus on nurses\u0026rsquo; mental well-being than nurses themselves. Self-awareness is a dynamic and iterative process of reflecting own characteristics, emotions, beliefs, and actions [28]. Literature indicates that enhancing nurses\u0026rsquo; self-awareness improves communication skills and self-efficacy, helps recognizing stress and preventing burnout, and fosters relationship building and empathy [29]. Further, a study by Younas et al. [30] suggests that enhancing nurses\u0026rsquo; self-awareness may also facilitate the improvement of cultural competencies, sensitizing nurses to the needs of patients with diverse cultural backgrounds. Hence, most CST do not focus on self-awareness [31]. Additionally, comprehensive studies detailing these benefits, particularly from patients\u0026rsquo; perspective, remain lacking [29]. The highlighted importance of fostering nurses\u0026rsquo; general communication skills and strategies such as showing empathy and applying non-verbal communication are also in line with a focus group study with NMs working in oncology, conducted by Wittenberg-Lyles et al. [12]. Participants of that study emphasized the use of tailored information and appropriate communication about pain and spirituality [12]. Brown \u0026amp; Bylund [32] suggested that breaking down communication into different components facilitates learning and teaching. Hence, a set of communication skills can be employed to achieve a specific communication strategy, contributing to the realization of a communication goal - the planned outcome of a conversation. For instance, the communication strategy \u0026ldquo;to provide understandable information\u0026rdquo; contributes to the communication goal \u0026ldquo;to share bad news in a way patient-centered manner\u0026rdquo;, achieved through communication skills like \u0026ldquo;summarizing information\u0026rdquo; and \u0026ldquo;checking patient\u0026rsquo;s understanding\u0026rdquo;. Another aspect mentioned by participating NMs was the importance of learning more about patient-centered communication in challenging situations. Communication with demanding or aggressive patients as well as relatives was specifically described as highly challenging. Research indicates a direct link between patients\u0026rsquo; aggressive communication and nurses\u0026rsquo; health outcomes, as well as an indirect through communication satisfaction [33]. Considering this, it becomes even more important to equip nurses with communication skills and strategies to manage aggressive communication, thereby fostering communication satisfaction and mitigating negative health outcomes. Similarly to our interviewed NMs, interviewed pediatric oncology NMs in a previous study, observed a lack of general communication skills, particularly in palliative and end-of-life communication, in early career nurses [13]. They indicated that the current approach is more about learning by doing rather than receiving formal education in communication [13]. To foster nurses\u0026rsquo; palliative and end-of-life communication skills, appropriate training is beneficial [34].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Strengths and Limitations of the Work\u003c/h2\u003e \u003cp\u003eThe study possesses significant strengths. We successfully recruited NMs from diverse medical diciplines, thus encompassing a broad spectrum of perspectives and experiences. Although NMs are not directly or only occasionally involved in clinical care activities, their supervisory roles afford them a comprehensive overview of the communication challenges in nurses' daily work. Therefore, their insights are broadly applicable and hold considerable value for the development of patient-centered CSTs.\u003c/p\u003e \u003cp\u003eDue to the selected methodology, several limitations must be acknowledged. Due to their areas of responsibility, DMs\u0026rsquo; and WMs\u0026rsquo; perspectives on communication challenges in nursing care are based on previous experiences or second-hand information from their staff, potentially leading to the omission of missing aspects. Additionally, during the interview and after asking openly about requested content for a CST, NMs were provided with a list of aspects from prior CST studies, which may have influenced their responses. Moreover, the study exclusively involved NMs from a single academic medical center, which can potentially limit the applicability of the results to NMs working in other hospitals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.3 CONCLUSION\u003c/h2\u003e \u003cp\u003eThis study investigated NMs perspective on the content for the development of a patient-centered CST. The interviewed NMs identified and prioritized various aspects to be included in a future CST, aiding in the developing of such a training. Many of the identified aspects align with findings from international studies on nurses\u0026rsquo; communication challenges. Our findings indicate that these challenges are not confined to oncology and intensive care but extend to other medical disciplines such as gynecology, obstetrics, psychiatry, pediatrics, cardiology, and neurology. Additionally, the present results indicate that NMs exhibit a stronger emphasis on nurses\u0026rsquo; mental well-being. They acknowledge the importance of patient-centered communication in nursing practice and are prepared to facilitate the enhancement of nurses\u0026rsquo; communication skills.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.4 PRACTICE IMPLICATIONS\u003c/h2\u003e \u003cp\u003eEngaging a diverse range of relevant stakeholders is crucial to develop an intervention tailored to their specific needs. The involvement of NMs in CST development is vital, given their extensive insight into the communication challenges and needs faced by nurses. Further, nursing professionals from diverse medical disciplines should be offered the opportunity to participate in a CST, as our findings indicate that communication challenges are present across all medical disciplines. The insights garnered from this study, along with results from focus groups with nurses [14], are being included in the development of a patient-centered CST which focuses on applying general communication skills, de-escalation communication, and communication about serious illnesses, death and dying. The CST is currently undergoing evaluation in a randomized controlled trial [21].\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnja Lindig\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated criteria for Reporting Qualitative Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunication skills training\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDepartment manager\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDWM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDeputy ward manager\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIsabelle Scholl\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKatja C\u0026ouml;llen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKendra Mielke\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKOMPAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunication within patient-centered nursing care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMartin H\u0026auml;rter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNurse manager\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUKE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversity Medical Center Hamburg-Eppendorf\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWiebke Frerichs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWard manager\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Local Psychological Ethical Committee of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf\u0026nbsp;(approval number LPEK-0367). We followed the most recent version of the World Medical Association\u0026apos;s Helsinki Declaration and applied the rules of ethical scientific conduct. Requirements for data protection were met. Participants were informed about the study objective and data protection and had to give their consent by signing a consent form beforehand. Participation was voluntary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are not publicly available due to their close association with participants\u0026rsquo; working area, making it difficult to sufficiently anonymize all personal data in all documents. Deidentified data (in German language) that support the findings of this study are available on reasonable request. Investigators who propose to use the data have to provide a methodologically sound proposal directed to the principal investigator of the study (Prof. Dr. Isabelle Scholl). Signing a data use/sharing agreement will be necessary, and data security regulations both in Germany and in the country of the investigator who proposes to use the data must be complied with. Preparing the data set for use by other investigators requires work and is thus linked to available or provided resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKM, AL, and KC declare that they have no competing interests. IS and MH declare that they currently are (MH) or have been (IS) members of the executive board of the International Shared Decision Making Society, which has the mission to foster shared decision making implementation and patient-centeredness. WF is currently an active member of tEACH, the teaching subcommittee of the International Association for Communication in Healthcare (EACH), which has the mission to explore and improve communication in healthcare. MH, WF and IS have no further competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by the German health insurance fund DAK-Gesundheit.\u0026nbsp;The funding body was not involved in the design of the study, collection, analysis, and interpretation of data nor in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceived and designed the study: IS, MH. Performed the interviews: KC, KM. Analyzed the data: KM, KC, WF. Contributed materials/analysis tools: AL, KC, WF, KM. Wrote the paper: KM. Revised and gave final approval to the paper: WF, AL, KC, IS, MH.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank our student research assistants and research interns Inga Bosch, Juliane Kampmann and Sarah Severin for helping preparing and conducting the study as well as transcribing the interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI and AI-assisted technologies in the writing process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work, the authors used ChatGPT-3.5 in order to improve readability and language of the work. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Zill JM, Scholl I, H\u0026auml;rter M, Dirmaier J. Which dimensions of patient-centeredness matter? - Results of a web-based expert delphi survey. PLoS One 2015;10:e0141978. https://doi.org/10.1371/journal.pone.0141978.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Pozzar RA, Xiong N, Hong F, Wright AA, Goff BA, Underhill-Blazey ML, et al. Perceived patient-centered communication, quality of life, and symptom burden in individuals with ovarian cancer. Gynecol Oncol 2021;163:408\u0026ndash;18. https://doi.org/10.1016/j.ygyno.2021.08.007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Sprangers S, Dijkstra K, Romijn-Luijten A. Communication skills training in a nursing home: Effects of a brief intervention on residents and nursing aides. Clin Interv Aging 2015;10:311\u0026ndash;9. https://doi.org/10.2147/CIA.S73053.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Wolderslund M, Kofoed P-E, Ammentorp J. The effectiveness of a person-centred communication skills training programme for the health care professionals of a large hospital in Denmark. Patient Educ Couns 2021;104:1423\u0026ndash;30. https://doi.org/10.1016/j.pec.2020.11.018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Scott PA, Matthews A, Kirwan M. What is nursing in the 21st century and what does the 21st century health system require of nursing? Nurs Philos 2014;15:23\u0026ndash;34. https://doi.org/10.1111/nup.12032.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Wieke Noviyanti L, Ahsan A, Sudartya TS. Exploring the relationship between nurses\u0026rsquo; communication satisfaction and patient safety culture. J Public Health Res 2021;10. https://doi.org/10.4081/jphr.2021.2225.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Timmins F. Managers\u0026rsquo; duty to maintain good workplace communications skills. Nurs Manage 2011;18:30\u0026ndash;4. https://doi.org/10.7748/nm2011.06.18.3.30.c8538.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e American Organization of Nurse Executives. AONE nurse executive competencies. Nurse Lead 2005;3:15\u0026ndash;22. https://doi.org/10.1016/j.mnl.2005.01.001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kodama Y, Fukahori H. Nurse managers\u0026rsquo; attributes to promote change in their wards: a qualitative study. Nurs Open 2017;4:209\u0026ndash;17. https://doi.org/10.1002/nop2.87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Elsheikh R, Le Quang L, Nguyen NQT, Van PT, Hung DT, Makram AM, et al. The role of nursing leadership in promoting evidence-based nursing practice. J Prof Nurs 2023;48:93\u0026ndash;8. https://doi.org/10.1016/j.profnurs.2023.06.007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Fowler KR, Robbins LK, Lucero A. Nurse manager communication and outcomes for nursing: An integrative review. J Nurs Manag 2021;29:1486\u0026ndash;95. https://doi.org/10.1111/jonm.13324.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Wittenberg-Lyles E, Goldsmith J, Ferrell B. Oncology nurse communication barriers to patient-centered care. Clin J Oncol Nurs 2013;17:152\u0026ndash;8. https://doi.org/10.1188/13.CJON.152-158.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Sawin KJ, Montgomery KE, Dupree CY, Haase JE, Phillips CR, Hendricks-Ferguson VL. Oncology nurse managers\u0026rsquo; perceptions of palliative care and end-of-life communication. J Pediatr Oncol Nurs 2019;36:178\u0026ndash;90. https://doi.org/10.1177/1043454219835448.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Mielke K, Frerichs W, C\u0026ouml;llen K, Lindig A, H\u0026auml;rter M, Scholl I. Perspective on Patient-centered Communication: A Focus Group Study Investigating the Experiences and Needs of Nursing Professionals. ResearchSquare 2024. https://doi.org/https://doi.org/10.21203/rs.3.rs-4835486/v1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Banerjee SC, Manna R, Coyle N, Penn S, Gallegos TE, Zaider T, et al. The implementation and evaluation of a communication skills training program for oncology nurses. Transl Behav Med 2017;7:615\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Onan N, Barlas G, Karaca S, Yildirim N, Taskiran O, Sumeli F. The relations between perceived stress, communication skills and psychological symptoms in oncology nurses. J Marmara Health Sci 2015. https://doi.org/10.5455/musbed.20150602021515.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e J\u0026uuml;nger J, Doll A. Nationaler Krebsplan, Handlungsfeld 4 \u0026bdquo;St\u0026auml;rkung der Patientenorientierung. Umsetzungsempfehlungen zu Ziel 12a \u0026sbquo;Kommunikative Kompetenzen im \u0026auml;rztlichen und pflegerischen Beruf\u0026lsquo; \u0026ldquo;. [National Cancer Plan, action area 4 \u0026bdquo;Enhancement of patient-centered care. Implementation recommendations for objective 12a 'Communication competencies in medical and nursing professions\u0026rsquo; \u0026ldquo;]. 2016. Umsetzungsempfehlungen zu Ziel 12a (bundesgesundheitsministerium.de) (accessed August 20, 2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kl\u0026ouml;pfer C, Spieser A, Weis J. Ist - Analyse der Vermittlung kommunikativer Kompetenzen in der \u0026auml;rztlichen und pflegerischen Aus-, Fort- und Weiterbildung. [Status analysis of the integration of communication competencies in medical and nursing undergraduate, graduate, and continuing professional education]. Unpublished manuscript 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Fernandez ME, Ruiter RAC, Markham CM, Kok G. Intervention mapping: Theory-and evidence-based health promotion program planning: Perspective and examples. Front Public Health 2019;7. https://doi.org/10.3389/fpubh.2019.00209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349\u0026ndash;57. https://doi.org/10.1093/intqhc/mzm042.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Lindig A, Mielke K, Frerichs W, C\u0026ouml;llen K, Kriston L, H\u0026auml;rter M, et al. Evaluation of a patient-centered communication skills training for nurses (KOMPAT): study protocol of a randomized controlled trial. BMC Nurs 2024;23:2. https://doi.org/10.1186/s12912-023-01660-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health 2015;42:533\u0026ndash;44. https://doi.org/10.1007/s10488-013-0528-y.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant 2018;52:1893\u0026ndash;907. https://doi.org/10.1007/s11135-017-0574-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Dresing T, Pehl T. Praxisbuch Interview, Transkription \u0026amp; Analyse. Anleitungen und Regelsysteme f\u0026uuml;r qualitativ Forschende. [Manual for interviewing, transcription, and analysis. Instructions and guidelines for qualitative researchers]. 6th ed. Marburg: Eigenverlag; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kuckartz U. Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterst\u0026uuml;tzung. [Qualitative content analysis: Methodological approaches, practical applications, and computer-assisted techniques]. 4th ed. Weinheim, Basel: Beltz Juventa; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Aslakson RA, Wyskiel R, Thornton I, Copley C, Shaffer D, Zyra M, et al. Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: A qualitative exploration. J Palliat Med 2012;15:910\u0026ndash;5. https://doi.org/10.1089/jpm.2011.0481.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Banerjee SC, Manna R, Coyle N, Shen MJ, Pehrson C, Zaider T, et al. Oncology nurses\u0026rsquo; communication challenges with patients and families: A qualitative study. Nurse Educ Pract 2016;16:193\u0026ndash;201. https://doi.org/10.1016/j.nepr.2015.07.007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Eckroth-Bucher M. Self-awareness. ANS Adv Nurs Sci 2010;33:297\u0026ndash;309. https://doi.org/10.1097/ANS.0b013e3181fb2e4c.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Rasheed SP, Younas A, Sundus A. Self-awareness in nursing: A scoping review. J Clin Nurs 2019;28:762\u0026ndash;74. https://doi.org/10.1111/jocn.14708.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Younas A, Rasheed SP, Sundus A, Inayat S. Nurses\u0026rsquo; perspectives of self-awareness in nursing practice: A descriptive qualitative study. Nurs Health Sci 2020;22:398\u0026ndash;405. https://doi.org/10.1111/nhs.12671.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Denniston C, Molloy E, Nestel D, Woodward-Kron R, Keating JL. Learning outcomes for communication skills across the health professions: a systematic literature review and qualitative synthesis. BMJ Open 2017;7:e014570. https://doi.org/10.1136/bmjopen-2016-014570.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Brown RF, Bylund CL. Communication skills training: describing a new conceptual model. Acad Med 2008;83:37\u0026ndash;44. https://doi.org/10.1097/ACM.0b013e31815c631e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Lam C. The link between patients\u0026rsquo; aggressive communication and nurses\u0026rsquo; emotional health outcomes. Health Commun 2023;38:1033\u0026ndash;40. https://doi.org/10.1080/10410236.2021.1989788.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Fuoto A, Turner KM. Palliative Care Nursing Communication. An evaluation of the COMFORT model. J Hosp Palliat Nurs 2019;21:124\u0026ndash;30. https://doi.org/10.1097/NJH.0000000000000493.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Nurse managers, communication, communication skills training, interviews, patient-centered care","lastPublishedDoi":"10.21203/rs.3.rs-5287510/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5287510/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eCommunication skills trainings can enhance nursing professionals’ patient-centered communication skills, fostering positive health outcomes for both patients and nursing professionals. Understanding experiences and preferences of the target group is crucial when developing a specific communication skills training. Thus, it is essential to involve not only nurses but also nurse managers in the training development, as they offer a comprehensive overview of communication challenges experienced by nursing staff. Therefore, this study aimed to explore nurse managers’ perspectives on essential content for developing a patient-centered communication skills training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted semi-structured interviews with nurse managers working at an academic medical center in Germany. Transcripts of audio-recorded interviews were analyzed using Kuckatz’s qualitative content analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e N = 18 nurse managers from various medical disciplines such as gynecology, psychiatry, pediatrics, and neurology participated in the study. The majority highlighted the importance of enhancing general communication skills and strategies such as showing empathy and applying tailored communication, as well as addressing communication challenges with patients. Fewer participants emphasized the need for training in professional self-awareness, communication with relatives, and culturally sensitive communication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eNurse managers identified crucial aspects for a training to enhance nurses’ patient-centered communication, revealing similar communication challenges across all medical disciplines.\u003c/p\u003e","manuscriptTitle":"Development of a patient-centered communication skills training: A qualitative exploration of nurse managers‘ perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-05 16:47:13","doi":"10.21203/rs.3.rs-5287510/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf4a6e04-136f-4923-a698-3f078ee0868f","owner":[],"postedDate":"November 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-01T02:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-05 16:47:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5287510","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5287510","identity":"rs-5287510","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}