Communication Skills Training for Internal Medicine Trainees and Nurse Practitioners
Alison Bays, MD1
Ruth Engelberg, PhD2
Anthony L. Back3
Dee W. Ford4
Lois Downey2
Add other Codetalk faculty authors here
Stuart Alexander5
James Tulsky5
J. Randall Curtis2
Corresponding author:
J. Randall Curtis, MD, MPH
Division of Pulmonary and Critical Care, Box 359762
Harborview Medical Center, University of Washington
Seattle, Washington 98104
Phone: (206) 744-2256; Fax: (206) 744-8584
E-mail: jrc@u.washington.edu
Abstract word count:
Word Count:
1
Department of Medicine, University of Washington, Seattle Washington
2
Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine,
University of Washington, Seattle Washington
3
Seattle Cancer Care Alliance, Division of Medical Oncology, Department of Medicine,
University of Washington; Fred Hutchinson Cancer Research Center, Seattle Washington
4
Medical University of South Carolina, Division of Pulmonary and Critical Care, Department of
Medicine, Charleston South Carolina
5
Duke University, Chapel Hill, North Carolina
Supported by the National Institute of Nursing Research: R01 NR009987.
ABSTRACT
Background: Good communication by physicians with patients and families is rated as an
important component of quality care yet effective training in important communication skills,
such as giving bad news and discussing end-of-life care, have not been fully evaluated. We
designed a randomized trial of internal medicine trainees and nurse practitioner students to
investigate the effect of an experiential communication skills-building workshop, called
CodeTalk, on trainees’ ability to effectively communicate bad news and express empathy. In
this report we describe the effect of CodeTalk on trainees’ communication skills as assessed
with standardized patient interviews before and after the training. We also examined trainee
characteristics that were associated with improvement.
Methods: We recruited nurse practitioner students and internal medicine residents at the
Medical University of South Carolina and the University of Washington. At baseline, trainees
filled out a questionnaire on their characteristics as well as attitudes toward and experiences
with end-of-life care. They then participated in eight workshop sessions over a one month
period. Sessions included skills practice with simulated patients and feedback from
experienced trainers. The first and last sessions were audiotaped sessions between the trainee
and one of two standardized patients, which were coded for specific behaviors that have been
shown to be effective communication tools. Trainees were used as their own controls,
comparing post-intervention to pre-intervention scores. We used linear regression to identify
predictors of change in communication skills.
Results: We identified XXX potentially eligible trainees of whom XXX agreed to participate
(YY%). Of these, 73 (61%) trainees were able to be scheduled for the pre- and post-workshop
standardized patients (XX physicians and YY nurse practitioners). Trainees significantly
improved in 8 of the 11 coded behaviors (p<0.05). Trainee characteristics that were associated
with greater improvement included lower pre-workshop performance, training site, and
increasing year of training. We did not find an association with gender or with attitudes toward
or experience with end-of-life care.
Conclusions: CodeTalk was associated with improvement in trainees’ skills in giving bad news
and expressing empathy. The association between lower baseline performance and greater
improvement could represent a “ceiling effect” on the outcome measures or may reflect
increased value of training for those with lower baseline performance. Later training year
predicted improvement, suggesting that the intervention may be more effective later in training.
INTRODUCTION
Poor communication between clinicians and patients with serious and life-limiting
illnesses, such as cancer, may result psychosocial distress and unnecessary treatment.1 By
contrast, effective clinician-patient communication can result in better emotional health,
improvement in symptoms and pain control, and reduced intensity of treatment at the end of
life.2
Despite the importance of communication, especially in situations of delivering bad news
or discussing end-of-life care, training during medical school and residency is infrequent and
junior trainees often find themselves in the position of giving bad news without supervision. A
survey of residents at two universities in Boston revealed that, although 73% of residents first
delivered bad news as a medical student or intern, 61% of these students had known the patient
for only hours to days, a more senior trainee was available in only 11% of the cases, and an
attending physician was present in only 5% of cases.3 Similarly, training for nurse practitioners,
who are also responsible for conducting these discussions with patients is poor and studies
suggest that nurse practitioners have similar shortcomings in this communication.4
Consensus guidelines for communicating bad news were released in 1995 and included
the importance of assessing the patient’s understanding of the situation and encouraging
patients to express their feelings. 5 These and additional recommendations guiding best
practices for communicating difficult news to patients formed the basis of a workshop,
“Oncotalk”, a four day workshop for medical oncology fellows, The workshop emphasized skills
practice in small groups with simulated patients, using five simulated cancer patients 6-8 This
workshop resulted in significant improvement in communication skills with participants acquiring
a mean of 5.4 skills in their ability to give bad news. It is one of few studies that has
investigated interventions that teach clinicians how to discuss bad news and transitions to
palliative care. 9
We are conducting a randomized trial of an interdisciplinary workshop based on
Oncotalk – which we call Codetalk – targeting internal medicine trainees and nurse practitioner
students. As part of this trial, all trainees randomized to the workshop completed preintervention and post-intervention evaluative encounters with standardized patients in which
participants were asked to give bad news to the patient. The primary objective of this report is
to evaluate improvement in participants’ skills giving bad news and expressing empathy to
patients, as assessed by evaluation of performance with standardized patients. A secondary
objective is to identify factors that predict improvement in giving bad news and expressing
empathy.
METHODS
Intervention
CodeTalk is a randomized trial of an interprofessional, experiential workshop designed
to teach end-of-life communication skills to nurse practitioner (NP) students and practitioners
and internal medicine residents and fellows recruited from University of Washington (UW) and
Medical University of South Carolina (MUSC).
Eligible trainees were contacted prior to the start of the academic year by mail or email;
materials included an explanation of the study and a consent form. All internal medicine
residents were eligible for the study. Subspecialty fellows were eligible if they were in the
following fellowships: pulmonary and critical care, oncology, geriatrics, palliative medicine, and
nephrology. Nurse practitioner (NP) students were eligible if they were in training programs, or
were already practitioners, for adult patients with cancer or other chronic life-limiting illnesses;
older adults, and adult primary care patients. Participants were randomly assigned to either the
workshop or the control group, stratified by site, year of training and physician versus nurse.
The control group did not participate in the workshops or the standardized patient evaluations
and are therefore not included in these analyses.
Workshops were composed of eight 4-hour sessions that were led by two trainers, one
of whom was a physician and the other a nurse or nurse practitioner. Sessions included skill
overviews, practice sessions and reflective discussions during which the following topics
addressed: giving bad news, talking about advanced directives, interdisciplinary conflict,
conducting a family conference, goals of care and Do Not Resuscitate (DNR) status, and
transitions to hospice and end-of-life care.9,11 Skills practice was completed with simulated
patients and families who appeared at each session at different points in their illness trajectory.
Simulated patients and family members were actors or actresses trained to portray specific
roles but, in contrast to standardized patients who follow unvarying scripts, they were trained to
alter their reactions in response to differences in trainee communication and with faculty
guidance, allowing trainees to practice new skills, try different approaches, and provide
feedback The simulated patient actors/actresses received training through the University
programs for standardized patients and also received Codetalk-specific training including XXX
hours of training by Codetalk faculty.
Measures
To provide a process evaluation of the workshop’s effectiveness, participants completed
an interview with a standardized, scripted patient at the first and last workshop sessions. We
created two standardized patient scenarios for evaluation and each trainee had a different
scenario for the pre- and post-intervention evaluation with an equal number of trainees seeing
each of the two patient scenarios at pre and post-intervention. Standardized patients were
actors or actresses trained specifically for evaluative purposes, behaving the same way in each
interaction and were trained at both sites through University programs for standardized patients.
In addition, we conducted an additional *** hours of training on the specific scenarios used for
this evaluation.
All standardized patient sessions were recorded digitally and analyzed by trained coders
who assigned scores based on specific communication behaviors. Coders were trained for ***
hours. The coders were blinded to whether or not the encounter occurred prior to or after the
intervention. This methodology was developed previously.9 Fifteen percent of the audiotapes
were assessed for inter-rater reliability with к statistics ranging from 0.65 to1.00.
Behaviors selected for coding were based on the communication skills presented in the
curriculum and were represented by the acronyms of “SPIKES” and “NURSE”. SPIKES is a sixstep protocol for giving bad news and includes: 1) setting; 2) assessing the patient’s perception
of his or her illness; 3) obtaining an invitation from the patient to disclose information; 4) giving
knowledge and information; 5) addressing emotion with empathic responses; and 6) strategy
and summary of the next steps. 12 Two of these steps, setting and summary, were not part of the
scripted exchange and are not included in these analyses. NURSE is an acronym for verbal
empathic expressions8, 13,14 and includes the following: 1) naming emotion; 2) expressing
understanding of a patient’s feelings or situation; 3) showing respect or praise for a patient’s
behavior; 4) articulating support for the patient; and 5) exploring the patient’s emotional state.
Each behavior shown by the trainee is coded only once.
In addition to the audiotaped interviews, participants completed an on-line questionnaire
prior to the start of the workshop. The questionnaire included items to assess trainees’
experience (n= 6) and attitudes (n18) (Block Arnold) towards palliative and end-of-life care.
Based on a priori hypotheses about experiences that would be expected to contribute to
readiness to learn palliative and end-of-life communication skills, we selected two experience
items (i.e., the number of times the trainee personally delivered bad news (scale X, Y, Z), the
number of times the trainee observed a more experienced clinician discuss end-of-life treatment
options with their patients (scale X, Y Z)). The attitude items were selected using E/CRA
analyses that enabled us to identify a scale that captured trainees’ self-efficacy for providing
palliative and end-of-life care. The items included: 1) there is little that can be done to ease
suffering or grief; 2) it is not possible to tell patients the truth about a terminal prognosis and
maintain hope; 3) depression is normal in patients with terminal illness; 4) talking about death
tends to make patients with terminal illnesses more discouraged; and 5) depression is not
treatable in patients with terminal illness. The response options ranged from “strongly disagree”
(1) to “strongly agree” (4) and we created an average score ranging from V to Z. The
questionnaire included demographic questions (e.g., race, ethnicity years of training/experience,
profession). In addition, residency programs and Schools of Nursing provided information on
residency/school year and sex.
Hypotheses and Analyses
We hypothesized that, after the workshop, trainees would improve in their ability to give
bad news and to express empathy. Trainees pre- and post-workshop code counts on each of
the 11 measured skills were compared using the Wilcoxon signed rank test for paired data.
Additionally, we examined whether trainees’ characteristics, experiences and attitudes
were associated with a change in communication skills after completing the workshop. We
used linear regression with robust estimators to identify predictors of change in communication
skills. We conducted two separate regression models, one with a SPIKES total score and the
other with a NURSE total score. These total scores were a sum of the change scores (post-pre)
for each set of codes. Although the outcome scores were limited in range (SPIKES, -6 to 6;
NURSE, -5 to 5), they were relatively normally distributed. The predictor variables for both
models included trainee characteristics, the two experience with end-of-life care items, and the
average score for trainee attitudes toward end-of-life care. For trainee characteristics, we
included study site (UW, MUSC), professional training (MD, NP), sex and year of training.
Lastly, trainees’ baseline SPIKES or NURSE scores were included in the regression for that
specific score, to examine the influence of pre-workshop performance.
SPSS was used to complete the Wilcoxon signed rank tests and STATA 10.0 to
complete the robust linear regression models. Significance was set at p <=0.05.
RESULTS
We identified and approached a total of XXX potentially eligible trainees of whom XXX
agreed to participate (YY%). Of the consenting trainees, XX were excluded because of
scheduling conflicts; 119 were randomized to the intervention. Of these, 73 (61%) trainees
completed audiotaped interviews from both the pre- and post-workshop sessions. The trainee
characteristics are shown in Table 1.
Table 2 shows the scores of the trainees on the SPIKES and NURSE items before and
after the workshop. Of the 6 skills belonging to the SPIKES framework for giving bad news, four
skills were studied with six coded behaviors and trainees made statistically significant gains in
four of the six coded behaviors: 1) addressing the patient’s understanding of their illness
(perception, p<0.001); 2) requesting permission from the patient before giving bad news
(invitation, p < 0.001); 3) using clear language when giving bad news to ensure that the patient
understood the cancer diagnosis (knowledge, p=0.05); and 4) providing empathic statements
directly following sharing the bad news (emotion, p=0.003). Trainees did not improve
significantly on two “giving bad news” skills: 1) giving the patient time to consider the bad news
(emotion, p = 0.74); and 2) exploring emotions related to receiving bad news (emotion,
p=0.439). Of the five skills represented by the acronym NURSE, trainees improved significantly
on the following four: 1) naming an emotion expressed by the patient (naming, p=0.01); 2)
showing respect for or praising the patient (respecting, p=0.025); 3) reassuring the patient that
the clinician will support them throughout their illness (supporting, p < 0.001) ; and 4) exploring
the patient’s emotion at other times in addition to following the communication of bad news
(exploring, p < 0.001). Trainees did not significantly improve in their ability to express
understanding of an emotion (understanding, p=0.617).
Predictors of improvement in giving bad news (SPIKES) and expressing empathy
(NURSE) are shown in Table 3. Of the eight predictors for improvement in the SPIKES skills,
three were significantly associated with improvement after the workshop: trainees improved
more at the University of Washington (p<***); the further along clinicians were in training, the
more they improved (p<***) and a lower baseline score was significantly associated with greater
improvement (p<***). Of the eight variables examined for predicting improvement in skills
represented by the NURSE acronym, only baseline score was significant: a lower the initial
score was associated with the greater improvement (p<***).
DISCUSSION
Codetalk was modeled after Oncotalk and our findings similarly showed that the
workshop was associated with significant improvement in trainees’ ability to give bad news and
explore emotion, as assessed by standardized patient evaluation.9 Similarly, a randomized trial
of a skills-building workshop has also been shown to improve communication skills of
oncologists in clinical practice, as assessed by expert evaluation of videotapes with actual
patients.16 This previous randomized trial showed no significant improvement with personalized
written feedback for oncologists based on videotapes of their encounters with actual patients.
These studies suggest that skills practice in a skills building workshop is effective at improving
clinicians’ communication skills for giving bad news and talking about end-of-life care.
There were three specific skills that did not improve in our study. Two of three tasks –
waiting ten seconds after disclosing bad news and expressing understanding for emotion – were
performed by approximately 80% of trainees prior to the workshop and may not have had
enough room to show improvement. Interestingly the Oncotalk study had the same finding with
oncology fellows.9 The third skill, exploring emotion related to bad news, was performed by a
minority of trainees and did not improve, perhaps because of the difficulty trainees have in
exploring patients’ emotions related to bad news.17
Our secondary goal was to identify predictors of improvement to guide future studies and
we hypothesized that prior experience with end-of-life care would make the workshop more
salient and provide trainees with motivation for learning a new skill.18 However, we found no
association between performance improvement and either the number of times the trained had
delivered bad news nor the number of times trainees had observed a more experienced
clinician present end-of-life options. In addition, we hypothesized that more positive attitudes
towards end-of-life care would be associated with more improvement after the intervention, but
found no significant association. It is possible that these associations exist, but our study was
not powered to identify them. We did find that a lower baseline performance was associated
with more improvement on both the SPIKES and NURSE scales. It is not possible to know
whether this represents a “ceiling” effect for the better performers or whether the workshop was
more effective for those with poorer baseline performance. Future studies will be needed to
fully understand the effect of baseline performance on improvement. Interestingly, higher year
of training was significantly associated with better performance on the SPIKES scale, but not on
the NURSE. This supports the hypothesis that the intervention may be more beneficial to those
further along in their training and also deserves further investigation.
We also identified significant differences in the training site, with trainees at the
University of Washington (UW) experiencing greater improvement than at the Medical University
of South Carolina (MUSC). One of the Oncotalk orginators is at at the University of Washington
(ALB) and it is possible that there was difficulty exporting the workshop to a distant site.
However, there was standardized faculty training at the two sites and, given the small number of
sites, it is impossible to determine the reason for this difference,.
Our study has a number of limitations. First, we used standardized patients to evaluate
clinician skill, which may not approximate a true patient-clinician encounter in either skills,
training, or evaluation. However, practice with standardized patients has been shown to result
in better communication skills than practice with peers19 and standardized patients have been
shown to be a valid assessment of clinical skill.20,21 Second, patient-clinician communication
includes non-verbal communication as well as verbal communication.10 Non-verbal
communication was not fully addressed in this study. However, a recent meta-analysis did not
identify any non-verbal behaviors associated with clinically relevant outcomes or patient
satisfaction measures.22 Third, although effective communication has been shown to improve
patient outcomes, the SPIKES and NURSE paradigms have not yet been shown to have an
effect on patient outcomes. Fourth, since we had no control group for the standardized patient
evaluation, it is possible that the improvements seen were due to experience with the baseline
standardized patient or the simulated patients used in CodeTalk. However, we used a different
standardized patient scenario for each trainee pre- and post-intervention and both of these
scenarios were different from the simulated patient scenarios used in CodeTalk. Finally, this
evaluation is a before-after study and therefore it is not possible to determine that the
intervention caused improvement, only that the conduct of the intervention was associated with
improvement.
Our results suggest that CodeTalk was an effective intervention, improving trainees’
skills in giving bad news and expressing empathy as evaluated by standardized patients.
Effective communication is correlated with greater patient satisfaction with healthcare,23
improved patient adherence,24 and improved pain control.2,23 This short intervention could be
incorporated into residency and NP programs as a teaching tool to improve patient-clinician
communication and has the potential to improve patient outcomes in areas other than pain
control. Further studies are needed to assess effects of CodeTalk on patient outcomes.
REFERENCES
1. Thorne SE. Is there a cost to poor communication in cancer care?: A critical review of
the literature. Psychooncology. 2005;14:875-84.
2. Stewart, MA. Effective patient-physician communication and health outcomes: a review.
Can Med Assoc J. 1995;152:1423-1433.
3. Orlander JD, Fincke BG, Hermanns D, Johnson GA. Medical Residents’ First Clearly
Remembered Experiences of Giving Bad News. J Gen Intern Med. 2002;17:825-831.
4. Ferrell BR, Grant M, Virani R. Strengthening nursing education to improve end-of-life
care. Nurs Outlook. 1999;47(6):252-6.
5. Girgis A, Sanson-Fisher RW. Breaking bad news: consensus guidelines for medical
practitioners. J Clin Oncol. 1995;13:2449-2456.
6. Girgis A, Sanson-Fisher RW. Breaking bad news. 1: current best advice for clinicians.
Behav Med. 1998;24:53-59
7. Walsh RA, Girgis A, Sanson-Fisher RW. Breaking bad news. 2: what evidence is
available to guide clinicians? Behav Med. 1998;24:61-72.
8. Campbell EM, Sanson-Fisher RW. Breaking bad news 3: encouraging the adoption of
best practices. Behav Med. 1998;24:73-80.
9. Back, AL, Arnold RM, Baile BF, Fryer-Edwards KA, Alexander SC, Barley GE, Gooley
TA, Tulsky JA. Efficacy of communication skills training for giving bad news and
discussing transitions to palliative care. Arch Intern Med. 2007;167:453-460.
10. Feldman-Stewart D, Brundage MD, Tishelman C; SCRN Communication Team. A
conceptual framework for patient-professional communication: an application to the
cancer context. Pyschooncology. 2005;14(10:801-809.
11. Jackson VA, Back AL. Teaching Communication Skills Using Role-Play: An experiencebased guide for educators. J Palliat Med. 2011;14(6):775-780.
12. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudleka AP. SPIKES: a six-step
protocol for delivering bad news: application to the patient with cancer. Oncologist.
2000;5;302-311.
13. Back AL, Arnold R, Baile W, Tulsky J, Fryer-Edwards K. Approaching difficult
communication tasks in oncology. CA Cancer J Clin. 2005;55:164-177.
14. Smith RC. Patient-Centered Interviewing: An Evidence-Based Method. Philadelphia, Pa:
Lippincott Williams & Wilkins; 2002.
15. Cegala DJ, Marinelli T, Post D. The effects of patient communication skills training on
compliance. Arch Fam Med. 2000;9(1):57-64.
16. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a cancer
research UK communication skills training model for oncologists: a randomized
controlled trial. Lancet. 2002;359(9307):650-6.
17. Taylor S, Harley C, Campbell LJ, Bingham L, Podmore EJ, Newsham AC, Selby PH,
Brown JM, Velikova G. Discussion of emotional and social impact of cancer during
outpatient oncology consultations. Psychooncology. 2011;20(3):242-51.
18. Anderson WG, Williams JE, Bost JE, Barnard D. Exposure to death is associated with
positive attitudes and higher knowledge about end-of-life care in graduating medical
students. J Palliat Med. 2008;11(9)1227-33.
19. Schlegel C, Woermann U, Shaha M, Rethans JJ, van der Vleuten C. Effects of
communication training on real practice performance: a role-play module versus a
standardized patient module. J Nurs Educ. 2012;51(1):16-22.
20. van Zanten M, Boulet JR, McKinley D. Using standardized patients to assess the
interpersonal skills of physicians: Six yers’ experience with a high-stakes certification
examination. Health Communication. 2007;22(3):195-200.
21. Weidner AC, Gimpel JR, Boulet JR, Solomon M. Using standardized patients to assess
the communication skills of graduating physicians for the comprehensive osteopathic
medical licensing examination (COMPLEX) level 2-performance evaluation (Level 2-PE).
Teach Learn Med. 2010;22(1):8-15
22. Henry SG, Fuhrel-Forbis A, Rogers MA, Eggly S. Association between nonverbal
communication during clinical interactions and outcomes: A systemic review and metaanalysis. Patient Educ Couns. 2012;86(3):297-315.
23. Smith MY, DuHamel KN, Egert J, Winkel G. Impact of a brief intervention on patient
communication and barriers to pain management: Results from a randomized controlled
trial. Patient Educ Couns. 2010;81(1):79-86.
24. Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to
treatment: a meta-analysis. Med Care. 2009;47(8): 826-34.
Table 2: Communication skill changes – SPIKES and NURSE
Coding
Participant
% (n) Trainees
% (n) Trainees
P value*
Scheme
Behavior Code
with Skill: Pre
with Skill: Post
30.8 (24)
56.4 (44)
< 0.001
1.3 (1)
20.5 (16)
< 0.001
79.5 (62)
91.0 (71)
0.050
Waits at least 10 seconds
after giving bad news
74.4 (58)
84.6 (66)
0.074
Empathic statement
immediately after giving
bad news
41.0 (32)
61.4 (50)
0.003
14.1 (11)
17.9 (14)
0.439
SPIKES
Setting
Not assessed
Perception
Assess patient’s
understanding of their
illness
Invitation
Requests permission from
patient before giving bad
news
Knowledge
Emotion
Wait 10 seconds
Bad News Response
Ask for Emotion
Summary
Uses the word “cancer”
when giving bad news
Explores emotion related
to bad news
Not assessed
NURSE
Naming
Names an emotion
34.6 (27)
52.6 (41)
0.011
Understanding
Expresses understanding
an emotion
83.3 (65)
80.8 (63)
0.617
Respecting
Shows respect or praise
towards the patient
0 (0)
6.4 (5)
0.025
Supporting
Tells patient they will
support him throughout
illness
11.5 (9)
42.3 (33)
<0.001
Exploring
Asks patient to tell them
more about emotion
outside of the bad news
43.6 (34)
69.2 (54)
0.001
Table 3: Multivariate Regression Results for SPIKES and NURSE Behaviors: 8 predictors
SPIKES
β (SE)
p
95% CI
Site (UWMC=0, MUSC= 1)
-0.846 (0.300)
0.006
-1.446,-0.250
MD or NP (MD = 0, NP = 1)
-0.336 (0.441)
0.449
-1.218, 0.545
Year of training
0.319 (0.149)
0.036
0.216, 0.616
Female
-0.050 (0.271)
0.855
-0.591, 0.491
SPIKES baseline score
-0.721 (0.142)
< 0.001
-1.004, -0.440
Experience delivering bad news (a001)
-0.156 (0.166)
0.353
-0.489, 0.177
Observing end-of-life options (a003)
-0.166 (0.167)
0.325
-0.500, 0.168
Attitude scale
0.033 (0.403)
0.934
-0.772, 0.839
Site (UWMC, MUSC)
-0.608 (0.310)
0.054
-1.228, 0.011
MD or NP
0.040 (0.479)
0.933
-0.917, 0.997
Year of training
0.154 (0.136)
0.262
-0.118, 0.427
Female
-0.214 (0.269)
0.429
-0.752, 0.324
NURSE baseline score
-0.785 (0.144)
< 0.001
-1.072, -0.498
Experience delivering bad news (a001)
0.036 (0.124)
0.771
-0.212, 0.284
Observing end-of-life options (a003)
0.055 (0.212)
0.795
-0.368, 0.478
Attitude scale
-0.308 (0.337)
0.363
-0.981, 0.364
NURSE