The effect of communication skills training on residents' physiological arousal in a breaking bad news simulated task

Recognizing and Responding to Overt Racism Towards Medical Trainees: Using the IRES Tool and Scripted Language

Introduction

Medical educators feel ill equipped to respond to racism directed towards trainees. Available tools for responding to microaggressions rely on clarifying questions or aligning with the aggressor, which may add to the harm experienced by the target. We aimed to provide methods for faculty to recognize and respond to overt racism so that trainees feel supported in the clinical learning environment.

Methods

We created a faculty development workshop with didactic and experiential learning components based on Kolb's theory for program leadership to teach how to respond when racism was directed towards trainees. In the didactic session, we shared the IRES (identify, respond, end, support) tool we created to respond to overt racism. Participants took part in two small-group case-based practice sessions with group debriefing, followed by a postsession survey.

Results

Over 2 years, we held two sessions with a total of 43 faculty participants. Postsession survey response rate was 74% and showed a 1-point Likert-scale median increase (p < .001) in ability to distinguish the strategies for addressing overt racism versus microaggressions, confidence in responding to microaggressions versus overt racism, and ability to debrief learners. The majority of participants noted that scripted language was a valuable tool to promote upstander behavior.

Discussion

Participants appreciated this novel framework for responding to racism directed at trainees in the learning environment. Providing scripted language and being able to practice in a safe environment were particularly important. This training can be adapted to include residents, fellows, and other disciplines.

An Investigation of Patients' and Doctors' Autonomic Nervous System Responses Throughout News-Focused Medical Consultations

Although it is clear that people experience physiological arousal in anticipation of news-focused medical consultations, our knowledge of people's experiences during and throughout these consultations is scarce. We examine interbeat interval responses (IBI) of patients and doctors during real-life medical consultations to understand how the experiences of both parties change throughout these encounters and whether they differ from each other. We also examine how the type of news delivered affects responses. We measured the IBI responses of patients and their oncologists throughout 102 consultations in which providers delivered news (classified as good, bad, or status quo) to patients about a recent computerized tomography scan. We observed two distinct phases of consultations: an initial "news" delivery phase and a subsequent "information" phase. During the news phase, on average, patients' IBI responses rapidly increased-indicating less autonomic arousal over time - whereas doctors' responses did not change over time. In contrast, throughout the information phase, on average, both patients' and doctors' responses remained steady. During the information phase, responses differed based on news type: on average, status quo consultations involved an increase in autonomic arousal, whereas good and bad news consultations involved no changes. Lastly, we observed significant variability in patients' responses during both phases. In sum, on average, patients (but not doctors) experience decreases in autonomic arousal while news is being delivered, suggesting that anticipatory distress regarding these consultations wanes quickly. However, our results also indicate that patients' experiences vary from one another, and future research should focus on factors explaining this variability.

Association between cortisol levels and performance in clinical simulation: a systematic review

OBJECTIVE

To identify how stress measured by salivary cortisol during clinical simulation-based education, or simulation and another teaching method, impacts performance.

METHOD

Systematic review of the association between cortisol and performance in simulations. The following databases were used: PubMed, LIVIVO, Scopus, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS) and Web of Science. Additional searches of gray literature were carried out on Google Scholar and Proquest. The searches took place on March 20, 2023. The risk of bias of randomized clinical trials was assessed using the Cochrane Collaboration Risk of Bias Tool (RoB 2). Inclusion criteria were: simulation studies with salivary cortisol collection and performance evaluation, published in any period in Portuguese, English and Spanish.

RESULTS

11 studies were included which measured stress using salivary cortisol and were analyzed using descriptive synthesis and qualitative analysis.

CONCLUSION

Some studies have shown a relationship between stress and performance, which may be beneficial or harmful to the participant. However, other studies did not show this correlation, which may not have been due to methodological issues.

ACACIAS 1: The physiological and subjective impacts of high fidelity simulation of the breaking of bad news

STUDY OBJECTIVE

Breaking bad news (BN) is difficult and necessitates targeted training. To be effective, training may call for High Fidelity Simulation (HFS). This prospective study was conducted to objectively assess the impact of HFS as a tool conducive to the development of clinical competence in situations involving the delivery of bad news.

METHODS

This feasibility study was conducted from January to May 2021 and included students in medical oncology and digestive surgery. The subjective and objective impacts of HFS were evaluated by means of a self-administered questionnaire and a wristband, Affect-tag, which recorded several indicators: emotional power (EP), emotional density (DE) and cognitive load (CL) in students undergoing training.

RESULTS

Forty-six (46) students with a median age of 25 years (21-34 years) were included. While the participants were effectively and emotionally involved in the HFS training, they were not completely overwhelmed by their emotions, a possible occurrence in this type of program. After two training programs, the students presented with lower EP (P<0.001) and higher DE (P=0.005), while their CL remained stable (P=0.751). The information given in the self-administered questionnaires and the evaluations by outside professionals (actor, nurse, psychologist…) highlighted improved skills.

CONCLUSION

Taking into account the emotional parameters observed and the questionnaires collected, HFS can be considered as a suitable and effective tool in the breaking of bad news.

From threat to challenge-Improving medical students' stress response and communication skills performance through the combination of stress arousal reappraisal and preparatory worked example-based learning when breaking bad news to simulated patients: study protocol for a randomized controlled trial

BACKGROUND

Breaking bad news (BBN; e.g., delivering a cancer diagnosis) is perceived as one of the most demanding communication tasks in the medical field and associated with high levels of stress. Physicians' increased stress in BBN encounters can negatively impact their communication performance, and in the long term, patient-related health outcomes. Although a growing body of literature acknowledges the stressful nature of BBN, little has been done to address this issue. Therefore, there is a need for appropriate tools to help physicians cope with their stress response, so that they can perform BBN at their best. In the present study, we implement the biopsychosocial model of challenge and threat as theoretical framework. According to this model, the balance between perceived situational demands and perceived coping resources determines whether a stressful performance situation, such as BBN, is experienced as challenge (resources > demands) or threat (resources < demands). Using two interventions, we aim to support medical students in shifting towards challenge-oriented stress responses and improved communication performance: (1) stress arousal reappraisal (SAR), which guides individuals to reinterpret their stress arousal as an adaptive and beneficial response for task performance; (2) worked examples (WE), which demonstrate how to BBN in a step-by-step manner, offering structure and promoting skill acquisition.

METHODS

In a randomized controlled trial with a 2 (SAR vs. control) x 2 (WE vs. control) between-subjects design, we will determine the effects of both interventions on stress response and BBN skills performance in N = 200 third-year medical students during a simulated BBN encounter. To identify students' stress responses, we will assess their perceived coping resources and task demands, record their cardiovascular activity, and measure salivary parameters before, during, and after BBN encounters. Three trained raters will independently score students' BBN skills performances.

DISCUSSION

Findings will provide unique insights into the psychophysiology of medical students who are tasked with BBN. Parameters can be understood more comprehensively from the challenge and threat perspective and linked to performance outcomes. If proven effective, the evaluated interventions could be incorporated into the curriculum of medical students and facilitate BBN skills acquisition.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05037318), September 8, 2021.

Perspectives of Palestinian Healthcare Workers on Factors Affecting the Families' Acceptance of News of Death: A Cross-Sectional Study

Introduction In a healthcare setting, communication is essential for every aspect of care. The ability to break bad news to patients and families is one of the most crucial talents in a medical professional's communication toolkit. This study aims to investigate the factors affecting the family's acceptance of death news in Palestinian medical facilities. Methods A survey was constructed and distributed to participants through Palestinian medical social media groups. Palestinian medical health professionals who had reported at least one death (N=136) were included. Associations and correlations were calculated. P-values of < 0.05 were considered significant. Results We found that death is more likely to be accepted by the family if it's reported by an experienced staff member (p-value= 0.031) or a member who was involved in the cardiopulmonary resuscitation (CPR) of the deceased person (Adjusted odds ratio (AOR) = 19.335, p-value = 0.046). The medical ward staff is also more likely to achieve family acceptance (AOR = 6.857, p-value= 0.020). However, no evidence was found to support the claim that adhering to the SPIKES model increases the likelihood of family acceptance of death news (p-value= 0.102). Death of young people and unexpected death are less likely to be accepted (p-value < 0.05). Conclusion Families are less likely to accept unexpected death or the death of young members. Thus, reporting such deaths (mostly in the emergency department) should be done with greater care. We suggest letting experienced staff members or those who were involved in CPR report the death news in such situations.

A randomized controlled trial assessing behavioral, cognitive, emotional and physiological changes resulting from a communication skills training in physicians caring for cancer patients

OBJECTIVE

This randomized study assesses behavioral, cognitive, emotional and physiological changes resulting from a communication skills training (CST) for physicians caring for cancer patients.

METHODS

Medical specialists (N = 90) were randomly assigned in groups to complete a manualized 30-h CST or to a waiting list. Assessments included behavioral (communication skills), cognitive (self-efficacy, sense of mastery), emotional (perceived stress) and physiological (heart rate) measures. Assessments were made at baseline (both groups), after CST program (training group), and four months after (waiting list group). All assessments were conducted before, during, and after a complex communication task with an advanced-stage cancer simulated patient (SP).

RESULTS

Trained physicians had higher levels of communication skills (from RR=1.32; p = .003 to RR=41.33; p < .001), self-efficacy (F=9.3; p = .003), sense of mastery (F=167.9; p < .001) and heart rate during the SP encounter (from F=7.4; p = .008 to F=4; p = .050) and same levels of perceived stress (F=3.1; p = .080).

CONCLUSION

A learner-centered, skills-focused and practice-oriented manualized 30-h CST induced multilevel changes indicating physician engagement in a learning process.

PRACTICE IMPLICATIONS

Trainers should consider the CST multilevel benefits (behavioral, cognitive, emotional and physiological) before, during and after a complex communication simulated task as an innovative way to assess the efficacy of a communication skills learning process.

Early career clinicians euthanize more dogs with nontraumatic hemoabdomen but not gastric dilatation and volvulus than more experienced clinicians

OBJECTIVE

To determine if clinician experience influenced the euthanasia rate in 2 common surgical emergencies.

ANIMALS

142 dogs with nontraumatic hemoabdomen (NTH) due to suspected ruptured splenic mass and 99 dogs with gastric dilatation-volvulus (GDV) where the owner either elected surgery or euthanasia.

PROCEDURES

Medical records were reviewed for dogs that had either NTH or GDV. For each patient, the owner's decision to pursue euthanasia versus surgery was recorded. The primary clinician was categorized as an intern, defined as a clinician with < 12 months experience, or a non-intern, defined as a clinician with more than 12 months experience. The euthanasia rates were compared used a Fisher exact, and the 95% CI was calculated for the risk of euthanasia if the primary clinician was an intern compared with a non-intern. If a difference was identified, subgroups comparing time of day, referral status, age, Hct, total solids, lactate, and heart rate were evaluated using a t test with a Bonferroni correction for the continuous variables and a Fisher exact for categorical variables.

RESULTS

For dogs with NTH, the euthanasia rate for cases primarily managed by non-interns (52%) was significantly lower than that of interns (76%; P = .005). The relative risk of euthanasia associated with NTH when the case was treated by an intern was 1.44 with a 95% CI of 1.1229 to 1.8567. For 99 dogs with GDV, the rate of euthanasia was not different between interns and non-interns.

CLINICAL RELEVANCE

The euthanasia rate for dogs with NTH may be impacted by the level of experience of the clinician. Support of new clinicians during challenging conversations should be provided.

Communicating With Breast Imaging Patients During the COVID-19 Pandemic: Impact on Patient Care and Physician Wellness

OBJECTIVE

Assess the impact of COVID-19 on patient-breast radiologist interactions and evaluate the relationship between safety measure-constrained communication and physician wellbeing.

METHODS

A 41-question survey on the perceived effect of COVID-19 on patient care was distributed from June 2020 to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Non-radiologists and international members were excluded. Anxiety and psychological distress scores were calculated. A multivariable logistic model was used to identify demographic and mental health factors associated with responses.

RESULTS

Five hundred twenty-five surveys met inclusion criteria (23% response rate). Diminished ability to fulfill patients' emotional needs was reported by 46% (221/479), a response associated with younger age (OR, 0.8 per decade; P < 0.01), higher anxiety (OR, 2.3; P < 0.01), and higher psychological distress (OR, 2.2; P = 0.04). Personal protective equipment made patient communication more difficult for 88% (422/478), a response associated with younger age (OR, 0.8 per decade; P = 0.008), female gender (OR, 1.9; P < 0.01), and greater anxiety (OR, 2.6; P = 0.001). The inability to provide the same level of care as prior to COVID-19 was reported by 37% (177/481) and was associated with greater anxiety (OR, 3.4; P < 0.001) and psychological distress (OR, 1.7; P = 0.03).

CONCLUSION

The majority of breast radiologists reported that COVID-19 has had a negative impact on patient care. This perception was more likely among younger radiologists and those with higher levels of anxiety and psychological distress.

Stress level experienced by participants in realistic simulation: a systematic review

OBJECTIVES

to identify the available evidence regarding stress levels experienced by participants in education based on a realistic simulation.

METHODS

systematic review that included randomized clinic trials on electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Latin-American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus, and Web of Science. The additional search was performed on Google Scholar and OpenGrey. All searches occurred on September 24, 2020. The methodologic quality of the results was evaluated by the Cochrane Collaboration Risk of Bias Tool.

RESULTS

eighteen studies were included, which evaluated the participants' stress using physiologic, self-reported measures, or the combination of both. Stress as experienced in a high level in simulated scenarios.

CONCLUSIONS

evidence of the study included in this systematic review suggest that stress is experienced in a high level in simulated scenarios.

Notification of Unexpected, Violent and Traumatic Death: A Systematic Review

Background: The way the death of a person is communicated can have a profound impact on the bereavement process. The words and expressions that are used to give the tragic news, the characteristics of who communicates it, the physical setting in which the notification is given, the means used (e.g., in person, via phone call, etc.) are just some of the factors that can influence the way survivors face one of the most difficult moments in their lives. Aim: To review the literature on the topic of death notification to verify the state of the art related to this important procedure. Methods: A systematic review was conducted with PRISMA criteria on English-written materials produced from 1966 to 2019. Results: Out of the initial 3,166 titles considered, 60 articles were extracted for this review. A content analysis has revealed four main areas of interest: (1) protocols and guidelines; (2) emotional reactions of recipients and notifiers; (3) professional figures involved in the notification process; and, (4) types of death. Discussion: The communication of death represents a complex and stressful experience not only for those who receive it but also for those who give it. Alongside the acquisition of a necessary technique and execution methods, the process should involve the selection of notifiers based on personality characteristics and communication styles. Conclusion: Indications for the need of better training and protocols sensitive to different circumstances emerge. Adequate preparation can positively influence the quality of communication and the effects it produces, both on recipients and notifiers. In vocational training, more space should be devoted to this demanding task.

Learning how to break bad news from worked examples: Does the presentation format matter when hints are embedded? Results from randomised and blinded field trials

OBJECTIVES

Video-based worked examples enable medical students to successfully prepare for breaking-bad-news (BBN) encounters with simulated patients (SPs). This is especially true when examples include hints that signal important content. This paper investigates whether the beneficial effect of hints only applies to video-based worked examples or also text-based examples.

METHODS

One-hundred-and-forty-seven fourth-year medical students attending a BBN training participated in either of two equally scaffolded, randomised field trials. Prior to encountering SPs, the students worked through an e-learning module introducing the SPIKES protocol for delivering bad news; it contained the same worked example presented to either of four groups as text or video, with or without additional hints denoting the SPIKES steps being implemented.

RESULTS

Only a main effect of 'hints' was revealed, implying that students in the hints groups delivered the news to an SP significantly more appropriately than those in the without-hints groups.

CONCLUSIONS

Independent of their presentation format, worked examples with hints best foster students' BBN skills learning.

PRACTICE IMPLICATIONS

In addition to video, text-based worked examples can effectively prepare students for BBN simulations if hints are included. This offers an affordable alternative to video examples, as text examples can be generated with less effort.

Breaking Bad News: A Study on Formal Training in a High-Risk Obstetrics Setting

Background: Breaking bad news is a frequent task in high-risk obstetrics clinics. Few studies have examined the role of training in improving such a difficult medical task. Aim: To evaluate the influence of a training program on the participants' perceptions of bad news communication at a high-risk obstetrics center. Design: This prospective study was conducted at the Department of Obstetrics/Gynecology, Hospital das Clinicas, from March 2016 to May 2017. Setting/Participants: Maternal-fetal health specialists were invited to complete an institutional questionnaire based on the SPIKES protocol for communicating bad news before and after training. The training consisted of theoretical lectures and small group practice using role play. The questionnaire responses were compared using nonparametric tests to evaluate the differences in physicians' perceptions at the two timepoints. The questionnaire items were evaluated individually and in groups following the communication steps of the SPIKES protocol. Results: In total, 110 physicians were invited to participate. Ninety completed the pretraining questionnaire and 40 answered the post-training questionnaire. After training, there were significant improvements in knowing how to prepare the environment before delivering bad news (p = 0.010), feeling able to transmit bad news (p < 0.001), and to discuss the prognosis (p = 0.026), feeling capable of discussing ending the pregnancy (p = 0.003), and end-of-life issues (p = 0.007) and feeling confident about answering difficult questions (p = 0.004). The comparison of the grouped responses following the steps of the SPIKES protocol showed significant differences for "knowledge" (p < 0.001), "emotions," (p = 0.004) and "strategy and summary" (p = 0.002). Conclusion: The implementation of institutional training in breaking bad news changed the perception of the physicians in the communication setting.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

Addressing the competency of breaking bad news: What are Canadian general paediatric residency programs currently doing

OBJECTIVE

To describe how breaking bad news (BBN) is currently taught in Canadian general paediatric residency programs and the confidence level of fourth year paediatric residents (Ped-PGY4) in BBN and managing end-of-life-care (EOLC).

METHODS

A prospective, cross-sectional survey of General Paediatric Residency Program Directors (PDs) and Ped-PGY4s was conducted.

RESULTS

When learning to BBN, residents state faculty observation (22/23) and interactive workshops (14/23) are the most helpful, while PDs state interactive workshops (9/16) and deliberate practice (5/16) are ideal. Residents identified a knowledge gap and discomfort with providing anticipatory guidance, and symptom management, including prescribing opioids.

CONCLUSIONS

In the era of competency-based medical education, there is an opportunity to create a standardized national curriculum addressing universal competencies related to BBN and EOLC.

Differential Effects of Physiological Arousal Following Acute Stress on Police Officer Performance in a Simulated Critical Incident

Background: Police officer response in a critical incident is often a life-or-death scenario for the officer, the suspect, and the public. Efficient and accurate decisions are necessary to ensure the safety of all involved. Under these conditions, it is important to understand the effects of physiological arousal in response to acute stress on police officer performance in critical and dangerous incidents. Prior research suggests that physiological arousal following a stressor differentially affects police performance – communication may be impaired, whereas well-rehearsed, tactical behaviors may be resilient.

Objectives: In this study, we examine the differential effects of physiological arousal across three police skill domains: verbal communication, nonverbal communication, and tactical skill.

Methods: A sample of Swedish police cadets (N = 17) participated in a critical incident simulation, which was a reenactment of a real-life incident that had resulted in a police officer death; the simulation included multiple calls, dynamic environments, and surprise threats. An expert rater evaluated the cadets across multiple domains of skill, and physiological arousal was monitored by continuous heart rate monitoring and measures of circulating cortisol and antithrombin taken before and after the incident simulation.

Results: The simulation increased police officer arousal, as reflected in elevated heart rate, but this alone did not predict differences in performance. Greater increase in antithrombin was associated with better general performance, but a specific deficit in verbal communication as compared to tactical performance and nonverbal communication. Change in cortisol was unrelated to the skill assessments.

Conclusions: Police officer performance during a critical incident simulation is affected by physiological arousal. The findings are discussed with implications for police officer decision-making and real-world performance.

Interventions to Improve the Breaking of Bad or Difficult News by Physicians, Medical Students, and Interns/Residents: A Systematic Review and Meta-Analysis

PURPOSE

To assess the effectiveness of news delivery interventions to improve observer-rated skills, physician confidence, and patient-reported depression/anxiety.

METHOD

MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Register of Controlled Trials databases were searched from inception to September 5, 2016 (updated February 2017). Eligible studies included randomized controlled trials (RCTs), non-RCTs, and controlled before-after studies of interventions to improve the communication of bad or difficult news by physicians, medical students, and residents/interns. The EPOC risk of bias tool was used to conduct a risk of bias assessment. Main and secondary meta-analyses examined the effectiveness of the identified interventions for improving observer-rated news delivery skills and improving physician confidence in delivering news and patient-reported depression/anxiety, respectively.

RESULTS

Seventeen studies were included in the systematic review and meta-analysis, including 19 independent comparisons on 1,322 participants and 9 independent comparisons on 985 participants for the main and secondary (physician confidence) analyses (mean [SD] age = 35 [7] years; 46% male), respectively. Interventions were associated with large, significant improvements in observer-rated news delivery skills (19 comparisons: standardized mean difference [SMD] = 0.74; 95% CI = 0.47-1.01) and moderate, significant improvements in physician confidence (9 comparisons: SMD = 0.60; 95% CI = 0.26-0.95). One study reported intervention effects on patient-reported depression/anxiety. The risk of bias findings did not influence the significance of the results.

CONCLUSIONS

Interventions are effective for improving news delivery and physician confidence. Further research is needed to test the impact of interventions on patient outcomes and determine optimal components and length.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

A Review of Selected Studies That Determine the Physical and Chemical Properties of Saliva in the Field of Dental Treatment

Physiological whole saliva is a unique body fluid constantly washing the mucous membranes of the mouth, throat, and larynx. Saliva is a clear, slightly acidic mucinous-serous secretion, composed of various electrolytes, small organic substances, proteins, peptides, and polynucleotides. There are many ways to use saliva as a biological fluid (biofluid). The significant advantages of saliva as a unique diagnostic material are its availability and the noninvasive method of collection. The aim of this review is to emphasize the diagnostic value of saliva as a research material in the configuration of its structure and secretion disorders. The data were obtained using the MEDLINE (PubMed) search engine, as well as an additional manual search. The analysis covered 77 articles selected from a group of 1986 publications and initially qualified for devising. The results were evaluated and checked for the correctness of qualifying in accordance with inclusion and exclusion criteria. The diagnostic use of saliva has attracted the attention of many researchers due to its noninvasive nature and relative simplicity of collection. In addition, it should be noted that the determination of chemical and physical saliva parameters can be effectively performed in the patient's presence in the dental office.

Effect of Simulation on Learner Stress as Measured by Cortisol: An Integrative Review

Simulated learning has become a mainstay in nursing education. Current literature focuses primarily on the development and implementation of simulation, although little is known about the stress that students experience. This integrative review examines studies evaluating learner stress in simulated settings as measured by cortisol. Findings suggest that cortisol is a valid measure of stress in simulation. Evidence is inconclusive on whether elevated stress during simulation promotes performance.

Communication about uncertainty and hope: A randomized controlled trial assessing the efficacy of a communication skills training program for physicians caring for cancer patients

Background

Although previous studies have reported the efficacy of communication skills training (CST) programs, specific training addressing communication about uncertainty and hope in oncology has not yet been studied. This paper describes the study protocol of a randomized controlled trial assessing the efficacy of a CST program aimed at improving physician ability to communicate about uncertainty and hope in encounters with cancer patients.

Methods/design

Physician participants will be randomly assigned in groups (n = 3/group) to a 30-h CST program (experimental group) or to a waiting list (control group). The training program will include learner-centered, skills-focused, practice-oriented techniques. Training efficacy is assessed in the context of an encounter with a simulated advanced stage cancer patient at baseline and after the CST for the experimental group, and after four months for the waiting-list group. Efficacy assessments will include communicational, psychological and physiological measures. Group-by-time effects will be analyzed using a generalized estimating equation (GEE). A power analysis indicated that a sample size of 60 (30 experimental and 30 control) participants will be sufficient to detect effects.

Discussion

The current study will aid in the development of effective CST programs to improve physician ability to communicate about uncertainty and hope in encounters with cancer patients.

Trial registration

US Clinical Trials Register NCT02836197.

Physicians' psychophysiological stress reaction in medical communication of bad news: A critical literature review

INTRODUCTION

Stress is a common phenomenon in medical professions. Breaking bad news (BBN) is reported to be a particularly distressing activity for physicians. Traditionally, the stress experienced by physicians when BBN was assessed exclusively using self-reporting. Only recently, the field of difficult physician-patient communication has used physiological assessments to better understand physicians' stress reactions.

METHOD

This paper's goals are to (a) review current knowledge about the physicians' psychophysiological stress reactions in BBN situations, (b) discuss methodological aspects of these studies and (c) suggest directions for future research.

RESULTS

The seven studies identified all used scenarios with simulated patients but were heterogeneous with regard to other methodological aspects, such as the psychophysiological parameters, time points and durations assessed, comparative settings, and operationalisation of the communication scenarios. Despite this heterogeneity, all the papers reported increases in psychological and/or physiological activation when breaking bad news in comparison to control conditions, such as history taking or breaking good news.

CONCLUSION

Taken together, the studies reviewed support the hypothesis that BBN is a psychophysiologically arousing and stressful task for medical professionals. However, much remains to be done. We suggest several future directions to advance the field. These include (a) expanding and refining the conceptual framework, (b) extending assessments to include more diverse physiological parameters, (c) exploring the modulatory effects of physicians' personal characteristics (e.g. level of experience), (d) comparing simulated and real-life physician-patient encounters and (e) combining physiological assessment with a discourse analysis of physician-patient communication.

Take the HEAT: A pilot study on improving communication with angry families

OBJECTIVE

Our objective was to evaluate the utility of an educational program consisting of a workshop based on the Take the HEAT communication strategy, designed specifically for addressing patients who are angry, using a novel tool to evaluate residents' skills in employing this method.

METHODS

33 first-year pediatric and internal medicine-pediatrics residents participated in the study. The workshop presented the Take the HEAT (Hear, Empathize, Apologize, Take action) strategy of communication. Communication skills were assessed through standardized patient encounters at baseline and post-workshop. Encounters were scored using a novel assessment tool.

RESULTS

After the workshop, residents' Take the HEAT communication improved from baseline total average score 23.15 to total average score 25.36 (Z=-3.428, p<0.001). At baseline, empathy skills were the lowest. Intraclass Correlation Coefficient demonstrated substantial agreement (0.60 and 0.61) among raters using the tool.

CONCLUSION

First-year pediatric trainees' communication with angry families improved with education focused on the Take the HEAT strategy. Poor performance by residents in demonstrating empathy should be explored further.

PRACTICE IMPLICATIONS

This study demonstrates the utility of a brief communications curriculum aimed at improving pediatric residents' ability to communicate with angry families.

Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention

OBJECTIVE

Patients and physicians identify communication of bad news as a skill in need of improvement. Our objectives were to measure change in performance of first-year pediatric residents in the delivery of bad news after an educational intervention and to measure if changes in performance were sustained over time.

METHODS

Communication skills of 29 residents were assessed via videotaped standardized patient (SP) encounters at 3 time points: baseline, immediately post-intervention, and 3 months post-intervention. Educational intervention used was the previously published "GRIEV_ING Death Notification Protocol."

RESULTS

The intraclass correlation coefficient demonstrated substantial inter-rater agreement with the assessment tool. Performance scores significantly improved from baseline to immediate post-intervention. Performance at 3 months post-intervention showed no change in two subscales and small improvement in one subscale.

CONCLUSIONS

We concluded that breaking bad news is a complex and teachable skill that can be developed in pediatric residents. Improvement was sustained over time, indicating the utility of this educational intervention.

PRACTICE IMPLICATIONS

This study brings attention to the need for improved communication training, and the feasibility of an education intervention in a large training program. Further work in development of comprehensive communication curricula is necessary in pediatric graduate medical education programs.

[Breaking bad news in oncology: the Belgian experience]

Breaking bad news is a complex and frequent clinical task for physicians working in oncology. It can have a negative impact on patients and their relatives who are often present during breaking bad news consultations. Many factors influence how the delivery of bad news will be experienced especially the communication skills used by physicians. A three-phase process (post-delivery phase, delivery phase, pre-delivery phase) has been developed to help physician to handle this task more effectively. Communication skills and specific breaking bad news training programs are both necessary and effective. A recent study conducted in Belgium has shown their impact on the time allocated to each of the three phases of this process, on the communication skills used, on the inclusion of the relative in the consultation and on physicians' physiological arousal. These results underscore the importance of promoting intensive communication skills and breaking bad news training programs for health care professionals.