Instructor Resource Manual
Module 3 – Mindful presence
Table of Contents
Lecture content outline
Post-lecture knowledge assessment items
Answer key and rationale for knowledge assessment items
Observation assessment form and scoring rubric
Sample Case
Sample case group debrief questions
Sample case role-play activity
Reflective writing assignment and instructor guide
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Content Outline for Lecture
I.
Introduction to COMFORT
a. COMFORT is an acronym that stands for 7 basic principles designed to be taught in
early palliative care communication, care provided for individuals with a lifethreatening or serious illness
b. The curriculum is based on empirical research in hospice and palliative care,
including observations of interprofessional teams, team meetings, team member
collaboration, and interviews with team members across a range of healthcare
professions.
c. This lecture will provide an overview of module 3 – Mindful presence, and more
specifically how being mindful can contribute to team goals. This module
summarizes advanced-level communication skills.
II.
Objectives
a. We will talk about the history of mindfulness and the concept and identify active
listening skills as a focal point for engaging in mindful practice.
III.
Mindfulness
a. The term “mindfulness” originated in Buddhist philosophy and involves the
recognition of relationships between our emotions and our physical and mental
health.
b. Mindfulness is a state of being attentive and aware.
c. Attentiveness includes being aware of your own cognitive habits.
d. Awareness means that you are sensitive to the context around you and engage in a
flexible state of mind that allows you to be sensitive to new things.
e. In contrast, mindlessness involves recognizing and expecting only predictable
emotional responses from patient/family.
IV.
Mindful Presence
a. Mindful presence involves the clinician’s ability to be nonverbally present for a
patient/family while also being attentive, in the moment, nonjudgmental, and
empathic.
b. Presence includes being able to accept and be unprejudiced and non-judging. This
requires practice and emphasizes personal experience.
V.
Core Attitudes
a. Core attitudes include perception, active listening, getting involved, and creating
space.
b. These are relational qualities that you can practice with your patients/family members
to demonstrate mindfulness
c. Becoming comfortable with being involves being comfortable with silence. Sitting in
silence, working in silence, and sometimes becoming as invisible as possible.
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VI.
Mindful Presence
a. Being rather than doing also means being attentive to patient/family indirect cues of
emotion. Recognizing and acknowledging when a patient/family member is
emotional can be done nonverbally, through the use of space and touch.
b. Attempts to hold back or conceal emotions can actually be opportunities to provide
silent support.
c. Opportunities to be empathic don’t always have to come from words or a care
procedure, they can come from recognition that something else is needed.
VII.
Healing/Compassionate Presence
a. Healing presence requires empathy. Research has shown that patients are four times
more likely to implicitly express emotion (Eide, Frankel, Haaversen, Vaupel,
Graugaard, & Finset, 2004).
b. Listening becomes an essential skill when providing care.
c. Compassionate presence involves responding to the suffering of patient/family by
being present. As a witness to most suffering, the clinician can recognize the human
response to illness (Ferrell & Coyle, 2008).
d. Practicing empathy and using a compassionate voice are both ways to recognize the
human impact of illness.
VIII.
Active Listening
a. Hearing is a physiological process that requires no effort.
b. Listening is a complex process that requires effort to attend, receive, perceive,
organize, interpret, respond, and remember messages (Wood, 2000).
IX.
Five Principles of Effective Listening
a. These five principles can be used with patient/family to show effective listening.
X.
Other Aspects of Listening
a. Silence can be a powerful tool to utilize as a communication strategy (Dahlin, 2000).
b. By being silent, the patient/family is allowed to self-disclosure and engage in a deeper
sense of meaning.
c. For the clinician, being silent means suspending judgment and tolerating uncertainty.
OPTIONAL: Invite two students to come to front of the audience. Instruct them to
introduce themselves. As the instructor, remain silent and allow any natural interaction to
occur. Students will either start talking to fill the silence or sit in silence (in which case a
classmate may say something to fill the silence). Use this exercise to demonstrate how
uncomfortable people are with silence and that silence TAKES WORK. Silence, or the
absence of words, does not mean the absence of effort. It is difficult to sit in silence and
“be with” someone.
XI.
How we see others…
a. We judge others based on our experiences and relations.
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b. Martin Buber believed that human life finds its meaningfulness in relationships, all of
which ultimately bring us into relationship with God, the eternal Thou (Littlejohn &
Foss, 2008).
c. In I-It relationships there is no dialogue, only monologue, as other people are treated
as objects to be used and experienced.
d. Mindful presence entails dialogue and the treatment of the other as THOU.
XII.
Seeing Differently
a. Seeing differently is a shift in perception that allows one to notice what has not been
seen before or to appreciate the beauty of the familiar.
b. By taking the perspective of the patient/family, clinicians can see what needs to be
done.
XIII.
Team-based mindful presence
a. With an increasingly complex healthcare system and sicker patients, family members
are often exhausted and emotional during family meetings. Team members need to be
especially attentive to indirect (commonly nonverbal) cues of emotion that reveal
stress and burden.
b. Team members can use silence to afford patient/family time to feel comfortable
disclosing.
c. Compassion fatigue involves the physical and spiritual exhaustion that comes from
compassionate caregiving, particularly in futile care. Clinical situations arise that
make team members aware of their own mortality and spirituality and clinicians are
faced with enacting decisions that do not reflect their own choices or beliefs. Team
members should be aware of the mental health and wellbeing of their team members.
d. Clinicians work in the dysfunction of hospital systems or agencies that sustain a
complex communication climate that leaves little to no time or energy for self-care.
Team meetings are one venue that can be used to address self-care needs. For
example, mindfulness-based activities such as structured reflection can aid in analysis
of one’s own experiences, thoughts, and feelings.
References
Bolton, R. (1979). People Skills. Englewood, NJ: Prentice-Hall In MacPhee, M. (1995) The
family systems approach and pediatric nursing care. Pediatric Nursing, 21, 5, 417-437.
Bruce, A., & Davies, B. (2005). Mindfulness in hospice care: Practicing meditation-in-action.
Qualitative Health Research, 15, 1329-1344.
Dahlin, C.M. (2010). Communication in palliative care: An essential competency for nurses. In
B.R. Ferrell & N. Coyle (Eds.), Oxford Textbook of Palliative Nursing, 3rd ed. (pp. 107133).
Eide, H., Frankel, R., Haaversen, A.C.B., Vaupel, K.A., Graugaard, P.K., & Finset, A. (2004).
Listening for feelings: Identifying and coding empathic and potential empathic
opportunities in medical dialogues. Patient Education and Counseling, 54, 291-297.
Ferrell, B.R., & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing. NY:
Oxford University Press.
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Simon, S.T., Ramsenthaler, C.B., Krischke, N., & Geiss, G. (2009). Core attitudes of
professionals in palliative care: A qualitative study. International Journal of Palliative
Nursing, 15(8), 405-411.
Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and
palliative nursing. New York: Oxford.
Wood, J.T. (2000). Relational Communication: Continuity and Change In Personal
Relationships, 2nd ed. Belmont, CA: Wadsworth.
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Post-Lecture Knowledge Assessment Items
1. Mindfulness involves recognizing:
a) The relationship between emotions and physical/mental health
b) Attractiveness of patient/family members
c) Predictable emotions from the patient/family
d) Who the primary family caregiver is for the patient
2. Which of the following statements is true of active listening?
a) Listening is the same thing as hearing.
b) Active listening and listening involve the same processes.
c) Active listening helps the speaker maintain focus on the problem.
d) Active listeners can help the speaker clarify and understand their thoughts feelings.
3. Buber’s I-IT/I-THOU is integral to the practice of mindful presence in which of the
following ways?
a) Highlights the importance of experience and relations.
b) People are seen as unique in a positive light.
c) Illuminates the human condition to treat others as objects.
d) All of the above.
4. To practice mindful presence you should:
a) Be nonverbally present
b) Be nonjudgmental
c) Be empathic
d) All of the above.
5. Core attitudes associated with practicing mindful presence include:
a) Active listening and strictly guided patient/family meetings with a set agenda
b) Perception, active listening, getting involved, and creating space
c) Creating space for patient/family by meeting in a large conference room
d) Getting involved with patient/family by self-disclosing about yourself
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ANSWER KEY - Post-Lecture Knowledge Assessment Items
1. Answer: A
Rationale:
Mindfulness describes an aspect of Buddhism that has been in existence more than 2,500 years
and involves recognizing the relationships between our emotions and our physical and mental
health. It involves being aware of every moment of experience.
2. Answer: D
Rationale: Hearing is a purely physiological activity requiring no effort; listening, on the other
hand, is far more complex and effortful. Listening is defined as: “a complex process of
attending to, receiving, perceiving, organizing, interpreting, responding, and remembering
messages” (Wood, 2000, p. 68).
3. Answer: D
Rationale: Buber believed that human life finds its meaningfulness in relationships, all of which
ultimately bring us into relationship with God, the eternal Thou. Our experience of the world
consists of two aspects: the aspect of experience, perceived by I-It, and the aspect of relation,
perceived by I-Thou. I-Thou relationships stress the mutual, holistic existence of two beings that
meet one another authentically—it is characterized by dialogue, mutuality, and exchange.
4. Answer: D
Rationale: Mindful presence, while its roots are from Buddhist concepts of mindfulness, involves
being nonverbally present for a patient/family while also being attentive, in the moment,
nonjudgmental, and empathic.
5. Answer: B
Rationale: Mindfulness includes personal characteristics of authenticity, personal presence,
honesty and truthfulness, and openness. Being personally present requires non-acting,
appreciating the other in his being. Perception, active listening, getting involved, and creating
space are key relational competencies.
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The COMFORT Communication Assessment Scale
Module 3 - Mindful Presence
Student:_______________________
Element
Unacceptable
(1)
Poor
(2)
Acceptable
(3)
Good
(4)
Engages the
patient/family
using mindful
communication
Avoids
understanding
patient/family
situation during
interaction
Recognizes patient/family
situation during interaction
while pursuing additional
agendas.
Demonstrates
awareness of
patient/family situation
and communicates
accordingly
Focuses acute awareness of
the situation, by being ‘in
the moment’ through
focusing attention to
present moment and the
task at hand
Comforts
patient/family
using mindful
presence
Avoids mindful
presence as a form
of comfort
Attends to patient/family
situation while pursuing
additional agendas.
Demonstrates
awareness of
patient/family situation
through comforting
nonverbal behaviors
Focuses on being
nonverbally present,
attentive, in the moment,
nonjudgmental, and
empathic, for the
patient/family in times of
need
Engages
patient/family
through physical
and psychological
presence
Avoids close
proximity and
listening
Includes physical or
psychological attentiveness
with patient/family
Demonstrates physical
and psychological
attentiveness with
patient/family
Focuses on appropriate
physical proximity as well
as psychological presence
by listening, demonstrating
empathy, suspending
judgment, and offering
acceptance
Communication
through silence
Fails to remain
silent when
patient/family need
to process difficult
information
Achieves some appropriate
silences while the
patient/family conveys
feelings and needs
Listening without
interruption while the
patient/family convey
feelings and needs
Expresses a deep listening
and suspension of judgment
consistently throughout the
interaction
Narrative clinical
practice
No pursuit of
patient/family
illness journey
Recognition of privacy
boundaries for
patient/family
Inquires about
patient/family privacy
boundaries
Demonstrate
communication skills of
active listening, presence,
and bearing witness to learn
patients’ illness journeys
and encourage illness
narrative disclosures
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Comments to be filled out by students following a recorded encounter:
1. Regarding mindful presence communication skills, what did you think went well?
2. Regarding mindful presence communication with this patient/ family member role play, what, if anything,
would you do differently?
3. What are the barriers and pathways you see in practicing mindful presence communicating with this team?
4. Any other observations or comments about this particular encounter?
NOTE: Feel free to refer to M-Mindful Presence of COMFORT when reflecting on which tasks you accomplished, as well as the
way in which you accomplished them.
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Sample Case
After seeing three of their six children die of acute onset illness, the Raters parents, Sue and Don,
are depressed and scared as they face the impending birth of their seventh child in two months.
The most recent death involved their 4-year old daughter Linda. She presented with an ear
infection on one afternoon in the ER and by the next evening demonstrated no brain activity. A
nurse in the ICU suite recommended to the lead pediatrician that they biopsy Linda’s muscle
tissue to determine if this family carries a mitochondrial mutation in all of their children. Linda’s
biopsy was positive for the mutation and her loss of brain function identified as a result of
neuropathy, ataxia, retinitis pigmentosa, and pstosis (NARP) produced by her mitochondrial
disease mutation. A degenerative disorder, Mitochondial disease takes on unique characteristics
in each patient.
With three of their living children, ages 14, 12, and 10, the Raters prepare for the birth a new
daughter who might also be carrying the DNA mutation. With the oversight of a pediatric illness
team in a nearby city, the Raters plan to deliver in the center to be prepared for immunology
intervention upon the birth of the new baby. While meeting their pediatric team in advance of the
baby’s birth, a genetic counselor suggests the three living children be tested for the disorder so
the family can prepare for their lives, as well as allow the children to consider the impact on their
own futures as they age.
Don and Sue are angered by this suggestion and communicate to the counselor as well as the
nurse and physician on the team that they believe the three living children are healthy and do not
want to worry them with the anxiety of biopsies and testing. They determine to not tell the
children about the genetic mutation. While listening to the Raters, the physician expresses that a
biopsy should be taken on the baby once she is born. The Raters, now fully distressed, walk out
of a meeting with the three clinicians.
Concerned by their upbeat and nearly manic behavior during pre-natal planning, the social
worker over the pediatric acute illness unit reaches out to the them on three different occasions to
discuss their feelings about the devastating diagnosis they have recently received. The Rater’s
avoid her phone calls and email, and its seems that all parties involved have no further pathway
to discuss the difficult matters in their midst.
Roter’s Profiles: Sue is quiet and works on part-time on the computer from home. Her
religious background has given her strength as she faced the deaths of three children. She
expressed to her sisters that she wanted another child to fill the void of the ones that had died.
She is dutiful in providing support and care for her family. Sue is still unsure of the diagnosis
her family has been given, and feels hopeful that the disorder can be overcome with good
medical care.
Don is suspect of the medical system that he feels took so long to identify the genetic
mutation in their family. He harbors mistrust. He feels confident that his living children are
not carrying the mutation as they are old older than any of those who have died previously.
Don is the clear head of the household and makes most of the decisions for the family.
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Sample Case Group Debrief Questions
1. Within the interprofessional team, what care is most needed for Don Rater? Sue Rater?
Instructor Guide: The Rater’s have received a tremendous amount of information in a
short time. An investment of clinician presence and their receptiveness to hearing the
Rater’s experience and options first, before trying to guide them in a different decisionmaking process, will have a positive impact on the us vs. them phenomenon that has
developed between the Rater’s and the clinical team. Example:
“We want very much to know what you are going through and thinking about this news”
2. What communication might facilitate the Rater’s processing of this tragic diagnosis in
terms of their psychological and spiritual well being?
Instructor Guide: Remember, deep listening is the practice of being nonverbally present,
and not pre-empting family ideas and concerns with the voice of the Medical World. This
can be very challenging at times when the information we hear from the family is
incorrect, or very emotional. However, allowing the voice of the family to be at the center
serves to develop trust and relationship. Example:
“Sue, what would be helpful to you from a spiritual or religious perspective?”
3. How can a team member provide a mindful presence for Don and Sue Rater? What about
their living children?
Instructor Guide: Remember, eliciting and being present to listen to the experience, pain,
confusion, and story from the patient/family is the most productive way to facilitate
difficult processing of life-changing health news. Asking a simple question and then
being patient through silences and emotion is the most direct path to mindful presence.
Some children and young adults are insulated by parents or guardians from engaging
their own emotions and loss concerning diagnosis, illness, and prognosis. Inviting parents
to include their children is a positive step toward giving them a sense of community in
the loss experience. Example:
“Could we include the kids in our conversation and welcome them to ask questions or
express concerns?”
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Role Play Activity
Objectives:
1.
2.
3.
4.
Practice identifying mindful presence opportunities.
Identify specific practices of mindful communication.
Engage in role-play activities informed by mindful presence and its communication.
Extend mindful presence module learning for practical communication application
How to Proceed-Introduction & Discussion: (20 minutes)



Review objectives for group activity and facilitate introductions of group members to one
another.
Ask group participants to read case.
Facilitate discussion of caregiver type and indicators.
How to Proceed-Role Play: (20 minutes)
Roles: There are several roles to be played in this case; remaining participants can observe
Facilitator: Keep time (20 minutes MAX for this part of group activity, as divided below):
 5 minutes for role players to read roles and arrange seating for conversation
 10 minutes for role play
 5 minutes for de-brief and discussion.
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Family Meeting Role Play
Situation: Sue and Don have delivered their seventh child. After a complicated C-Section, their
baby daughter Colleen died two hours after birth from what appears to be MELAS
(mitochondrial myopathy, encephalomyopathy, lactic acidosis, and stroke-like symptoms), a
particular mitochondrial myopathy. Sue remains in the recovery room with a deceased baby
Colleen swaddled in her arms wearing a lovely newborn dress, socks, and hat. The pediatric
nurse helped Colleen dress the baby. Don will not enter the room nor allow the 14 year old to
see his baby sister, whom he has requested to hold. Don and his eldest son are in the hallway of
the obstetrics recovery wing.
Present: Don (husband of patient), Joe (son of Don and Sue), Ms. Auld (chaplain), Ms.
Loganbill (obstetrics surgeon and Sue’s doctor), and Mr. Kratz (social worker for obstetrics
floor)
Don: Is not interested in holding his daughter, and wants to protect Joe from seeing his deceased
sister. Don wants to leave the hospital and spend the evening with his children.
Joe: Though he has not shared his knowledge with his parents, Joe has overheard their
discussions about the mitochondrial disorder and has pursued learning about it on the internet.
He is aware of the devastating nature of this diagnosis, is scared for his living siblings, and wants
to hold, kiss, and say goodbye to his baby sister.
Ms. Auld: Having already spent 20 minutes with Sue, Ms. Auld has learned that the family is
not talking about this diagnosis.
Ms. Loganbill: Shattered by losing this newborn, Dr. Loganbill has been crying and emotional,
and wants to express her sympathy to the parents of the lost baby.
Mr. Kratz: Only on the floor for 10 minutes, the Rater’s and the complexity of their loss and
diagnostic news is unknown to him.
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Reflective Writing Activity
During morning rounds for an interprofessional palliative care team, Sally, a physician
fellow, reports on a 42-year old woman with breast cancer who has been referred to the team for
end-of-life care placement. The patient report includes a history of hospitalizations over the last
year, with this latest hospitalization resulting from a fall at home. Sally reports: “It was during
this hospitalization that she learned that the cancer has spread and she is terminal. She has two
children, including an 8 year old son at home.” In typical fashion, Sally continues to provide the
team with an overview report of this patient. When asked by the team leader if Sally has
discussed hospice, advanced care planning, or wishes for her young child with the patient, Sally
reports that she has not. Sally becomes sullen and appears to tear up in the meeting, and falls
silent. Several members of the palliative care team realize that this dying patient is the same age
as Sally, who also has an 8 year old son.
Assignment:
1. As a team member at this meeting, what you would do and how you would react to
Sally’s emotion concerning this patient? What tactic of mindful presence might you
employ to help your team member?
2. Describe how Sally’s inability to talk to this patient reflects the difference between
Buber’s I-IT and I-Thou.
3. What are some of the personal characteristics of the “core attitudes” might you use in
your interactions with Sally?
Instructor Debrief:
Mindfulness is about being aware of others, including patient, family member, and team
members. Perspective-taking is most important. When patient cases become personalized for
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staff, patients become I-thou rather than I-it relationships and influence the way that team
members are able to perform their care duties.
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