Introduction
Within the multidisciplinary fertility clinic team, there is a need to train all staff in communication skills in order to facilitate patient satisfaction, treatment compliance and patient retention. The fertility clinic setting is characterised by a lack of control, helplessness and emotional challenges for the patients, which may impact on the staff member’s ability to deliver compassionate care. This may be due to feeling overwhelmed or to a lack of training. Staff support and Continuing Professional Development (CPD) are important to mitigate against potential staff burnout and work dissatisfaction along with a high staff turnover, possibly compromising care and pregnancy rates along the way. This section addresses the type of care to be offered to patients and how this assists clinic staff both professionally and personally.
Clinics work within a multidisciplinary practice. Patients encounter a number of specialists including reception staff, accounting staff, nurses, treatment coordinators, theatre staff, fertility specialists and embryologists. Many clinics are fortunate in that they have trained psychologists or counsellors to provide patient support. However, this is not always the case, notwithstanding the fact that patients may be reluctant to attend counselling or may need immediate feedback from staff members available in that precise moment in time. Burnout has been addressed in health-care professionals dealing with patients in terms of their own ability to deliver potentially bad news and to control their own emotions. They might also have their own ethical or moral codes of behaviour, which make the task more challenging. It is important to provide the team with psychological support and relevant training in communication skills in order to manage patients holistically.
Rationale
Studies state that patients are reluctant to seek psychological support. This highlights the importance of all staff being trained in communication skills (1). Furthermore, over time, patients are more likely to challenge doctors and speak out – hence communication skills are imperative from the ground up. Person-centred therapy is primarily based on the work of Carl Rogers, a humanist, whose theory included warmth, congruence and empathy. This provides the basis for the manner in which patients can be managed effectively and with kindness, without giving solutions or directives. The fertility clinic setting does not always allow communication on all aspects of care, but the compassion and warmth shown by staff members in all patient interactions goes a long way. Person-centred therapy is based on simple, easy-to-follow principles which are transferable to all members of staff. In the fertility clinic context, many individuals deal with patients and it is not easy to deliver bad news or manage the ensuing repercussions. Every patient wants to feel like a person, and not just a number, and this transcends the contact not only with counsellors but with the entire multidisciplinary team.
Caregivers have an ethical responsibility to treat the couple as well as future generations. Caregivers often bear the brunt of this emotionally charged journey and require skills to understand and manage it effectively. The goal of all involved is time to pregnancy. Complaints frequently emerge that staff are not suitably adept at managing the emotional needs of patients. Patients value continuity of care and relationships with familiar staff. They value staff who are sensitive and attentive. This transcends the entire process, from the very first point of contact to the fertility specialist. Patients also appreciate consistency and a reasonable timeframe to discuss their fertility concerns in a holistic manner without fear of judgement. The roles and responsibilities of various staff members need to be clear. In fact, some studies revealed that patients were willing to trade off ongoing pregnancy rates in favour of care, and a large number of patients changed clinics due to a lack of compassion or patient centredness (2). Furthermore, the attitudes of staff impacted on treatment success and satisfaction with care and compliance (3).
Learning that ethical codes of clinics may be different.
Why is person-centred therapy the method of choice? There have been many debates over the years as to whether therapy is an art or a science. Science translates to knowledge of theory and learning whereas art requires softer skills which can be taught to others. This model teaches people to remain supportive, positive and non-judgemental whilst a patient is expressing negative emotions or simply looking for someone to listen to them.
It is acknowledged that fertility clinics sometimes have to deliver bad news to a patient. The patient’s negative emotion might be directed towards the bearer of the bad news and some members of staff might take this personally. Fertility staff must also be sufficiently knowledgeable about the psychosocial care available to effectively address the patients’ needs and refer them to the correct support networks or resources. Given the relative simplicity of person-centred care, this care can be delivered by all staff members within their specific roles, whilst still acknowledging the need for trained mental health professionals such as psychologists, counsellors and/or psychiatrists (4). Person- centred therapy emphasises the attitudes and personal characteristics of the individual, i.e., the particular staff member, and the quality of the relationship between two people, i.e., the patient and the staff member. Person-centred therapy not only benefits patient-staff interactions but also relationships between colleagues as the premises of person-centred therapy are universal. The model is simple, comprising three premises:
- Warmth or unconditional positive regard.
This is the individual’s attitude of acceptance, respect and care. This does not imply that the caregiver agrees with everything the patient says. However, the caregiver has a fundamental belief that all people are born good, and have the potential to self-actualize, given the right environment. This unconditional positive regard allows a patient to express what he or she feels or thinks without fear of being judged. - Congruence is honesty and transparency.
- Empathy is a skill used by trained person-centred caregivers to show understanding of the patients’ emotions.
It involves techniques such as reflecting on the patients’ emotion.
The person-centred approach utilises non-directiveness as a technique. This refers to empowering the patient to make his or her own decision within a non-judgemental environment. This is why person-centred therapy is useful across the entire fertility clinic as even those staff members who do not have answers or whose role excludes giving advice can make use of this model to engage with patients in any setting. The role and responsibility as healers and participant observers in the patient relationship can be challenging. Being a participant observer means you have to remain objective, yet is in a relationship with the patient, you are probably emotionally invested as well.
Much research has focused on potential staff burnout in medical settings (5). The healthcare industry and especially the field of infertility, which is often shrouded with uncertainty, challenges staff-patient relationships. Burnout challenges staff retention and is detrimental to patient care. Warmth and compassion are integral to person-centred care. The more you tend towards burnout, the less likely you are to express compassion (6). This is why it is imperative to include professional training in patient-centred therapy as well as support for staff. Job satisfaction nurtures the ability to express compassion. A lack of job satisfaction can lead to compassion fatigue, which is another way of describing burnout. CPD and regular staff support and debriefing, can mitigate against burnout. CPD and regular evaluation of staff practices can help staff discuss their interaction with patients, including the challenges they face and ways to improve. It has been suggested that new staff members be trained in person-centred care from the onset in order to gain competency. The following recommendations are provided for clinics (8):
We would probably describe ourselves as persons of integrity, believing in justice, mutual respect and hard work. These are all values and moral qualities in which we believe. On the other hand, there are ethics which consist of a set of rules that determine how to behave within a specific moral framework, i.e. ethics determine what is acceptable in society while values determine what is important. A code of ethics and morals can be summarised below:
The ethical standards and guidelines implemented in medicine are there to protect the interests of patients, employers and the government that regulates ART. These ethical codes consist of uniform guidelines. Whilst values and morals differ from person to person, ethics are a set of rules according to which people should behave within the workplace. What is moral is not always ethical and vice-versa. The concept of Omerta in the Mafia, where Mafia members have an ethical code of silence, historically used to protect criminals from the police, provides one example. This is deemed ethically correct behaviour for the organisation but can also be viewed as wrong from a moral standpoint. In law, a lawyer who tells the court that his/her client is guilty may be acting out of a moral desire to see justice done, but this is deeply unethical because it violates the attorney-client privilege. In an ideal world, we want compatibility. In reality, we have to find a way to bridge the gap between personal values and ethical standards within an organisation.
Both ethics and values set guidelines for behaviour. We tend to think ethics, morals and values are the same thing. However, the distinct difference is that ethics are codes of conduct which vary across sectors. ART has had a dynamic history. Up to the birth of Louise Brown in 1978 through IVF, this particular sector had limited means to help patients.
Since then, ART has become more readily available and this explosion of knowledge has brought with it a myriad of new challenges ethically, morally, socially and legally. Fertility clinics ethically take into account decisions regarding the futility of ART, the LGBTQ+ population, single parenthood, unmarried couples, donor eggs, sperm and gametes, surrogacy, the number of embryos to be transferred, selective reduction and termination, to mention the most pressing. Ethically, we cannot discriminate. However, individuals within the clinic setting have different viewpoints, different religions, morals and values. It is suggested that these be addressed by a mentor or team leader within the clinic to have peace of mind that one is working within an organisation that has its own ethical code that might not necessarily be compatible with personal morals or values. However, staff need to be trained to prevent personal values from leading to judgmental behaviour towards patients.
Conclusions and recommendations
Patient retention, treatment compliance and patient satisfaction are not only driven by time to pregnancy and success rates. These factors are also determined by the care and compassion offered to patients from all staff members. Training staff in person-centred therapy promotes effective communication, warmth and empathy on a journey fraught with helplessness, disappointment and anxiety. Staff also need to understand their roles and responsibilities in communicating with patients, and person-centred therapy provides a framework in which to empower the patient in a non-directive manner. Furthermore, training in effective communication mitigates against burnout, and staff retention is improved, thus benefitting patients attending a fertility clinic.
Resources
- Boivin, J. (1999), Why are infertile patients not using psychosocial counselling? Human Reproduction, 14 (5), 1384–1391.
- Domar, A.D. (2020), Patient Retention, Nursing Retention: The Importance of Empathic Communication and Nursing Support. Domar, A.D., Sakkas, D., Toth, T.L. (Eds.). Patient-Centred Assisted Reproduction. Cambridge University Press: United Kingdom.
- Gameiro, S., Canavarro, M.C., Boivin, J. (2013), Patient-centred care in infertility health care: direct and indirect associations with wellbeing during treatment. Patient Education and Counselling, 93, 646-654.
- Pedro, J., Canavarro, M.C., Boivin, J., Gameiro, S. (2013), Positive experiences of patient-centred care are associated with intentions to comply with fertility treatment: findings from the validation of the Portuguese version of the PCQ-Infertility tool. Human Reproduction, 28, 2462-2472.
- Gameiro, S., Boivin, J., Domar, A. (2013), Optimal in-vitro fertilization in 2020 should reduce treatment burden and enhance care delivery for patients and staff. Fertil Steril, 100, 302-309.
- Wilkinson, H., Whittington, R., Perry, L., Eames, C. (2017), Examining the relationship between burnout and empathy in healthcare workers: A systematic review. Burnout Research, (6), 18-29. Santana, M.J., Manalani, K., Lu, M. (2018), How to practice person-centred care: A conceptual framework. Health Expert, 21(2), 429-440.