Instructor Resource Manual

Instructor Resource Manual

Instructor Resource Manual

Module 3–Mindful presence

Table of Contents

Lecture content outline2

Post-lecture knowledge assessment items6

Answer key and rationale for knowledge assessment items7

Observation assessment form and scoring rubric8

Sample Case10

Sample case group debrief questions11

Sample case role-play activity12

Reflective writing assignment and instructor guide14
Content Outline for Lecture

  1. Introduction to COMFORT
  2. 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 life-threatening or serious illness
  3. 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.
  4. 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.
  1. Objectives
  2. 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.
  1. Mindfulness
  2. The term “mindfulness” originated in Buddhist philosophy and involves the recognition of relationships between our emotions and our physical and mental health.
  3. Mindfulness is a state of being attentive and aware.
  4. Attentiveness includes being aware of your own cognitive habits.
  5. 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.
  6. In contrast, mindlessness involves recognizing and expecting only predictable emotional responses from patient/family.
  1. Mindful Presence
  2. 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.
  3. Presence includes being able to accept and be unprejudiced and non-judging. This requires practice and emphasizes personal experience.
  1. Core Attitudes
  2. Core attitudes include perception, active listening, getting involved, and creating space.
  3. These are relational qualities that you can practice with your patients/family members to demonstrate mindfulness
  4. Becoming comfortable with being involves being comfortable with silence. Sitting in silence, working in silence, and sometimes becoming as invisible as possible.
  1. Mindful Presence
  2. 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.
  3. Attempts to hold back or conceal emotions can actually be opportunities to provide silent support.
  4. 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.
  1. Healing/Compassionate Presence
  2. 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).
  3. Listening becomes an essential skill when providing care.
  4. 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).
  5. Practicing empathy and using a compassionate voice are both ways to recognize the human impact of illness.
  1. Active Listening
  2. Hearing is a physiological process that requires no effort.
  3. Listening is a complex process that requires effort to attend, receive, perceive, organize, interpret, respond, and remember messages (Wood, 2000).
  1. Five Principles of Effective Listening
  2. These five principles can be used with patient/family to show effective listening.
  1. Other Aspects of Listening
  2. Silence can be a powerful tool to utilize as a communication strategy (Dahlin, 2000).
  3. By being silent, the patient/family is allowed to self-disclosure and engage in a deeper sense of meaning.
  4. 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.

  1. How we see others…
  2. We judge others based on our experiences and relations.
  3. 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).
  4. In I-It relationships there is no dialogue, only monologue, as other people are treated as objects to be used and experienced.
  5. Mindful presence entails dialogue and the treatment of the other as THOU.
  1. Seeing Differently
  2. 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.
  3. By taking the perspective of the patient/family, clinicians can see what needs to be done.
  1. Team-based mindful presence
  2. 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.
  3. Team members can use silence to afford patient/family time to feel comfortable disclosing.
  4. 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.
  5. 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.


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. 107-133).

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.

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.

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

  1. 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.

  1. 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.

  1. To practice mindful presence you should:

a)Be nonverbally present

b)Be nonjudgmental

c)Be empathic

d)All of the above.

  1. 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

ANSWER KEY - Post-Lecture Knowledge Assessment Items

1. Answer: A


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.


The COMFORT Communication Assessment Scale

Module 3 - Mindful Presence


Element / Unacceptable
(1) / Poor
(2) / Acceptable
(3) / Good
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 physicalor 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

Comments to be filled out by students following a recorded encounter:

  1. Regarding mindful presence communication skills, what did you think went well?
  1. Regarding mindful presence communication with this patient/ family member role play, what, if anything, would you do differently?
  1. What are the barriers and pathways you see in practicing mindful presence communicating with this team?
  1. 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.


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.

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 decision-making 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”

  1. 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: