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

Language to Support Dignity for Children With Advanced Cancer and Their Families

BACKGROUND AND OBJECTIVES

Conversations about dignity are fundamental to person-centered care in pediatrics, yet practical language strategies to promote and support dignity remain understudied. To address this gap, we aimed to identify and characterize language used by pediatric oncologists to recognize and affirm dignity across advancing illness.

METHODS

In this longitudinal prospective study, we audio-recorded serial disease reevaluation encounters between pediatric oncologists, children with cancer, and families across 24 months or until the child's death. Using a hybrid deductive-inductive qualitative approach, we defined dignity language a priori on the basis of existing descriptions of dignity in the literature and then conducted a content analysis to refine the definition specific to pediatric cancer care before coding serial medical encounters. Thematic frequencies were reported by using descriptive statistics.

RESULTS

A total of 91 discussions at timepoints of disease progression were audio-recorded for 36 patients and their families. No dignity language was identified in nearly half (45%) of "bad news" encounters, and the time spent by the oncologist engaging in dignity language represented a minority (<7%) of overall recorded dialogue. Within coded dialogue, we characterized 3 key themes upholding dignity language (empowerment, autonomy, respect).

CONCLUSIONS

Opportunities exist to improve dignity communication in childhood cancer, and the authors propose a conceptual model ("Lend an EAR") to guide dignity-based communication in pediatric cancer. Future research should emphasize patient and parent perspectives on language to support dignity for children with advanced cancer, with stakeholder-driven refinement of the Lend an EAR model before integration and testing in communication skills training programs.

Development of an integrated milestone assessment tool across multiple early-adopter programs for breaking bad news: a pilot project

BACKGROUND

The transition of the Accreditation Council for Graduate Medical Education (ACGME) to milestone assessment creates opportunities for collaboration and shared assessments across graduate medical programs. Breaking bad news is an essential communication skill that is a common milestone across almost every medical specialty. The purpose of this study was to develop and pilot an integrated milestone assessment (IMA) tool for breaking bad news using ACGME milestone criteria and to compare the IMA tool with the existing SPIKES protocol.

METHODS

The IMA tool was created using sub-anchors in professionalism and interpersonal communication skills that are applicable to every specialty and to the ability to break bad news. Two cases of breaking bad news, designed to be "easy" and "intermediate" in difficulty, were used to assess basic skills in breaking bad news in first-year medical residents from six residency specialties. Eight standardized patients were trained to portray the cases in sessions held in November 2013 and May 2014. Standardized patients completed an assessment checklist to evaluate each resident's performance in breaking bad news based on their use of the SPIKES protocol and IMA tool. Residents answered post-encounter questions about their training and comfort in breaking bad news. The association between SPIKES and IMA scores was investigated by simple linear regression models and Spearman rank correlations.

RESULTS

There were 136 eligible medical residents: 108 (79.4%) participated in the first session and 97 (71.3%) participated in the second session, with 96 (70.6%) residents participating in both sessions. Overall, we were able to identify residents that performed at both extremes of the assessment criteria using the integrated milestone assessment (IMA) and the SPIKES protocol. Interestingly, residents rated themselves below "comfortable" on average.

CONCLUSION

We developed an integrated milestone assessment (IMA) that was better than the SPIKES protocol at assessing the skill of breaking bad news. This collaborative assessment tool can be used as supplement tool in the era of milestone transformation. We aim assess our tool in other specialties and institutions, as well as assess other shared milestones across specialties.

Delivering Serious News in Pediatric Cardiology-A Pilot Program

Pediatric cardiology fellows receive limited training on delivering serious news. This is a teachable skill through simulation-based communication. While studies have shown the use of communication courses in pediatrics, there have been none in pediatric cardiology. Pediatric cardiologists recognize the importance of good communication and desire further development of these skills. Based on an internal needs assessment, three cases were developed; fetal hypoplastic left heart syndrome, teenager with new hypertrophic cardiomyopathy, and young-adult with Fontan failure. A 4-h simulation course using evidence-based methods to teach delivering serious news was designed, consisting of a didactic session, case demonstration and small group case-based encounters with simulated patients. Trainees completed standardized pre/post-course surveys to assess perception of skill and preparedness. Paired survey responses were compared. Six pediatric cardiology fellows participated. Only 33% had received formal training in delivering serious news and 17% in techniques of responding to patient's emotions. The proportion of participants who felt good about their ability to deliver serious news and deal with a family's emotions increased from 0 to 83%. The proportion of participants who felt prepared to provide serious news about a patient's illness increased from 17 to 67%. Given the small number of participants, results were not statistically significant. All participants felt that the course was valuable in improving communication skills. A formal communication course increased perception of skill and preparedness among trainees. We provide an evidence-based framework and clinical cases for delivering serious news in pediatric cardiology, which is generalizable to other training programs.

Best Practices for Notification of Unexpected, Violent, and Traumatic Death: A Scoping Review

BACKGROUND

Death reporting is a delicate task. The ways in which it is carried out can have a significant impact on both the recipient and the notifier, especially in the event of a sudden, violent, and traumatic death. Empathetic, sensitive, and attentive communication with survivors can represent a first opportunity to support the bereavement process. The acquisition of specific skills for the delivery of the death notification is necessary for the professional who carries out the communication to increase self-efficacy, knowledge, and perception of competence in this area.

OBJECTIVE

To map what the literature has produced on the theme of best practices for the notification of unexpected, violent, and traumatic deaths and to provide guidance for the formulation of appropriate best practices and the development of effective educational programs.

METHODS

A review was conducted using the PRISMA Scoping Review extension on English language literature published between 1966 and 2022.

RESULTS

Starting from the initial 3781 titles, 67 articles were selected. From a thematic point of view, the analysis of the contents made it possible to identify five dimensions: (1) general guidelines in relation to various professional figures; (2) specific protocols; (3) guidelines for notifying death to children; (4) guidelines for notification of death by telephone; and (5) recommendations and suggestions for death notification training programs.

DISCUSSION

Death notification is configured as a process, divided into sequential phases. The act of notification constitutes the central phase during which communication is carried out. The communication of death is context-specific; therefore, it should require the creation of specific protocols for the various professions involved in the task, along with targeted theoretical and practical training.

CONCLUSIONS

The importance of defining specific guidelines for the various professionals and standardized programs of theoretical and practical training emerges. The implementation of future sectoral studies will allow evaluations of the effectiveness of these protocols and programs.

Breaking bad news in medical services: a comprehensive systematic review

Objective

This study was performed with the aims of screening the previous studies on breaking bad news in all medical wards.

Methods

Eligible observational studies were selected. The quality of the studies was assessed using the STROBE checklist. The findings were reported using Garrard's table. All the stages of the present study were performed in terms of the PRISMA statement.

Results

Totally, 40 articles were included in the study and 96 items were extracted. The results show that breaking bad news is a recipient-centered process. Respect, empathy, and support were reported. The news presenters are better to use guidelines based on evidence-based findings. It is suggested that the presenter should use simple and understandable content. Moreover, suitable time and space are important to present the news. The results show the importance of paying enough attention to the emotions of the recipient and the need to provide support after breaking bad news.

Conclusion

The recipient must be the center of the programs. It is necessary to pay attention to the characteristics of the news presenter, the news content, and finally the support.Practice Implication: Understand the recipient, trained presenter, and use of the evidence-based results, improve the breaking bad news outcome.

Effect of Experiential Communication Skills Education on Graduate Medical Education Trainees' Communication Behaviors: A Systematic Review

PURPOSE

A better understanding of how communication skills education impacts trainees' communication skills is important for continual improvement in graduate medical education (GME). Guided by the Kirkpatrick Model, this review focused on studies that measured communication skills in either simulated or clinical settings. The aim of this systematic review was to examine the effect of experiential communication skills education on GME trainees' communication behaviors.

METHOD

Five databases were searched for studies published between 2001 and 2021 using terms representing the concepts of medical trainees, communication, training, and skills and/or behaviors. Included studies had an intervention design, focused only on GME trainees as learners, used experiential methods, and had an outcome measure of communication skills behavior that was assessed by a simulated or standardized patient (SP), patient, family member, or outside observer. Studies were examined for differences in outcomes based on study design; simulated versus clinical evaluation setting; outside observer versus SP, patient, or family member evaluator; and length of training.

RESULTS

Seventy-seven studies were ultimately included. Overall, 54 (70%) studies reported some positive findings (i.e., change in behavior). There were 44 (57%) single-group pre-post studies, 13 (17%) nonrandomized control studies, and 20 (26%) randomized control studies. Positive findings were frequent in single-group designs (80%) and were likely in nonrandomized (62%) and randomized (55%) control trials. Positive findings were likely in studies evaluating communication behavior in simulated (67%) and clinical (78%) settings as well as in studies with outside observer (63%) and SP, patient, and family member (64%) evaluators.

CONCLUSIONS

This review demonstrates strong support that experiential communication skills education can impact GME trainees' communication behaviors. Marked heterogeneity in communication trainings and evaluation measures, even among subgroups, did not allow for meta-analysis or comparative efficacy evaluation of different studies. Future studies would benefit from homogeneity in curricular and evaluation measures.

Germany-wide evaluation of residency in neurological intensive care medicine

BACKGROUND

Neurointensive medicine is an important subspecialization of neurology. Its growing importance can be attributed to factors such as demographic change and the establishment of new therapeutic options. Part of the neurological residency in Germany is a six-month rotation on an intensive care unit (ICU), which has not yet been evaluated nationwide. The aim of this study was to evaluate kind and feasibility of neurointensive care training in Germany and to discover particularly successful training concepts.

METHODS

In a preliminary study, ten residents and ten instructors were interviewed. Using content analysis, two questionnaires were created, which contained questions about specific teaching methods as well as individual satisfaction. The questionnaires were sent to 187 neurological clinics in Germany, and residents and instructors were asked to participate in the study. The data analysis was performed using SPSS and content analysis for the free-text data.

RESULTS

Seventy of the 187 clinics contacted did not offer ICU-rotation. At 59,8% (n = 70) of the remaining hospitals, a total of 154 participants (84 residents, 70 educators) could be recruited. General satisfaction with the neurointensive medical training is high in both groups (residents: 3.34 ± 0.54; instructors: 3.79 ± 0.41, evaluated on the basis of a Likert scale from 1 = "not satisfied" to 5 = "fully satisfied"). Specific teaching methods (e.g. simulation trainings, feedback sessions) are perceived as very useful by residents, but rarely take place. Instructors are interested in educational opportunities such as didactic courses.

CONCLUSION

This study provides an overview of the ICU-rotation as part of the five-year neurological residency. Neurointensive care rotations usually take place at maximum care hospitals and last at least seven months. Despite frequent time and personnel restrictions, motivation of trainers and residents is high. Nevertheless, teaching methods as simulation training and educational opportunities for instructors must be expanded.

Communication skills training for medical residents: Enhancing a psychosocial approach of patient care

OBJECTIVES

One of the issues that has increasingly become relevant to medical practice is the ability to communicate well with patients. Better communication results in better care for the patient, as well as greater satisfaction for the physician. For this reason, the aim of this study was to assess the efficacy of a communication skills training program for medical residents (MR).

METHOD

Eighty-six MR underwent a 6-month training program in three phases: a 12-h theory and practice workshop, a period of real practice, and a 4-h workshop in which the most challenging scenarios were role played with an actress. In each phase (T0, T1, and T2), participants' beliefs about their competence in caring for patients' psychosocial aspects and their self-confidence in communication skills were assessed.

RESULTS

No differences were found between T0 and T1 in participants' beliefs of self-competence in psychosocial care. However, this competence significantly improved after completion of the entire program. Only 7 of the 12 areas explored in communication skills significantly improved between T0 and T1. However, after T2 completion, significant improvements were observed in all 12 areas.

SIGNIFICANCE OF RESULTS

The research results highlight the usefulness and importance of training young doctors to foster their psychosocial approach to patient care and improve their confidence in their own communication skills. The results also show the appropriateness of the structure of the training: the key features of the programme were the follow-up of the participants in three phases over 6 months, and a focus on the needs of the residents and the resolution of difficult clinical cases, with the support of an actress. Therefore, the training presented in this study may become a guide for other trainings in other contexts with similar objectives.

Are emotional intelligence and compassion associated with nursing safety and quality care? A cross-sectional investigation in pediatric settings

PURPOSE

To assess and compare the perceptions of emotional intelligence, compassion, and safety and quality care held by parents of hospitalized children and nurses, and to examine the association between emotional intelligence, compassion, and safety and quality care among nurses.

DESIGN AND METHODS

This cross-sectional study comprised 80 parents whose children were hospitalized for at least three days, and 71 nurses who treated these children. The data were collected during April-June 2018 using a self-administered questionnaire addressing socio-demographic characteristics, safety and quality care in the ward, emotional intelligence, and compassion. A hierarchical multiple regression model was used to assess whether emotional intelligence and compassion could be associated with safety and quality care among pediatric nurses.

RESULTS

Parents considered the safety and quality care in the ward to be significantly (p = .003) higher (M = 4.23 ± 0.61) than did nurses (M = 3.97 ± 0.46). Compassion had a significant positive effect on safety and quality of care (β = 0.260; p = .041), while seniority in nursing had a significant negative effect on safety and quality care (β = -0.289;p = .021). Null effect was found between emotional intelligence and safety and quality care.

CONCLUSION

Compassionate care should be targeted to improve the safety and quality of nursing care delivered to children and their parents.

PRACTICE IMPLICATIONS

Nurse ward managers should promote procedures and guidelines concerning safety and quality care processes among older nurses. Specifically, we recommend nurse ward managers to leverage the results and dedicate efforts to continue to provide compassionate care in pediatric settings as an integral part of safety and quality care.

Evaluating communication with parents in paediatric patient encounters: a systematic review protocol

INTRODUCTION

Breaking bad news and dealing with difficult patient encounters is a skill that medical residents must learn during their curriculum. Many different tools are available to measure communication quality, but their development and validation processes are often missing. In this paper, we present the protocol of a systematic review aiming to identify the validated tools for measuring communication skills or communication effectiveness with parents in a paediatrics setting in general, including for difficult patient encounters.

METHODS AND ANALYSIS

We will conduct our systematic review in accordance with the methodology suggested by COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and will report this paper following the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses. We will include the studies in which authors developed and/or validated tools for assessing the quality of communication with families by residents and/or physicians during patient encounters in paediatric settings. Studies assessing communication in telemedicine and studies that use the tool to measure a different outcome than its validation will be excluded. Our search strategy will be developed by a scientific librarian and validated using the Peer Review of Electronic Search Strategy (PRESS) tool. Two reviewers will independently screen the studies for selection, extract data of the ones included and assess their level of risk of bias using the COSMIN Risk of Bias checklist. We will perform a narrative synthesis on the study selection process, the characteristics of studies and study population, the characteristics of tools identified, their process of development and/or validation and their psychometric properties. If sufficient data are available, we will do quantitative analyses for each psychometric property.

ETHICS AND DISSEMINATION

Approval from an ethics committee is not required, as there is no primary data collection. Our findings will be disseminated through a peer-reviewed publication and at local, national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42020151642.

Development and validation of The Breaking Bad News Attitudes Scale

BACKGROUND

Communication of bad news plays a critical role in the physician-patient relationship, and a variety of consensus guidelines have been developed to this purpose, including the SPIKES protocol. However, little is known about physicians' attitudes towards breaking bad news and to be trained to deliver it. This study aimed to develop and validate a self-report questionnaire to assess physicians' attitudes towards principles of the SPIKES protocol and training on them.

METHODS

The Breaking Bad News Attitudes Scale (BBNAS) was administered to 484 pediatricians and 79 medical students, recruited at two scientific conferences and two medical schools in Brazil. The questionnaire structural validity, reliability, and associations with other variables were tested.

RESULTS

The BBNAS showed adequate validity and good reliability, with two factors measuring attitudes towards the SPIKES strategy for braking bad news (α = 0.81) and the possibility to be trained on it (α = 0.77), respectively.

CONCLUSION

The novel questionnaire is a psychometrically sound measure that provides information on physicians' agreement with the SPIKES protocol. The BBNAS can provide useful information for planning training and continuing education programs for clinicians on communication of bad news using the SPIKES as a framework.

Improving Patient- and Family-Centered Communication in Pediatrics: A Review of Simulation-Based Learning

Patient- and family-centered care focuses on relationships among patients, families, and health care providers that are mutually beneficial and improve health care outcomes and provider satisfaction. Building relationships is a key component of the provision of excellent health care and can be taught and enhanced through simulation-based communication skills training. This article reviews the available literature on simulation-based learning as used to improve patient- and family- centered communication in the discipline of pediatrics. In this narrative review, we examine the various methods, theories, and frameworks on which simulation-based learning for communication skills are built with the goal of assisting pediatric providers in using this powerful educational technique. [Pediatr Ann. 2021;50(1):e32-e38.].

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.

Improving communication with parents: the Neonatal Intensive Care Unit Empathy Workshop

OBJECTIVE

To implement an "Empathy Workshop" focused on improving Neonatal Intensive Care Unit (NICU) health care provider communication skills.

METHODS

Staff-led, small group "Empathy Workshops" were conducted over a 2 year period. NICU parents answered a section of the "Picker Institute Parent Experiences of Neonatal Care Survey" in the pre- and post-intervention periods. NICU health care providers completed the "NICU Provider Communication Skills Self-Assessment" at three time points.

RESULTS

Parent survey scores significantly improved in two questions: referring to child by first name (p = 0.02) and being offered emotional support from the staff (p = 0.03) or information on parent support groups (p = 0.03). Fifty-seven NICU providers completed all three self-assessments. Following the workshop, providers were significantly more comfortable with daily communication, discussing end of life issues, managing anxiety around difficult conversations, and handling a combative situation.

CONCLUSIONS

The "Empathy Workshop" successfully enhanced NICU provider communication skills, thereby improving emotional support demonstrated to NICU parents.

Translating Pediatric Hospital Interpreters' Feedback From Difficult Conversations into Improved Communication

BACKGROUND

Medical interpreters are critical mediators in communication with pediatric subjects and families to include participation in difficult conversations.

OBJECTIVE

The objective of this pilot study was to provide suggestions from medical interpreters to palliative care teams as to how to effectively incorporate medical interpreters into end-of-life conversations.

SUBJECTS AND METHOD

Participants included pediatric hospital-based medical interpreters who had interpreted for at least 1 end-of-life conversation in the pediatric hospital setting. A total of 11 surveys were completed by medical interpreters. The study consisted of a written 12-item survey with a follow-up focus group to further explore survey themes.

RESULTS

The translation of cultural contexts, awareness of the mixed messages the family received from health care teams, and the emotional intensity of the interactions were depicted as the most challenging aspects of the medical interpreter's role. Despite these challenges, 9 interpreters reported they would willingly be assigned for interpreting "bad news" conversations if given the opportunity (82%). Medical interpreters recognized their relationship with the family and their helping role for the family as meaningful aspects of interpreting even in difficult conversations. Medical interpreters shared 7 thematic suggestions for improved communication in language-discordant visits: content review, message clarity, advocacy role, cultural understanding, communication dynamics, professionalism, and emotional support.

CONCLUSIONS

As experts in cultural dynamics and message transmission, the insights of medical interpreters can improve communication with families.

A Novice Guide to Applications of Simulation in the Pediatric Emergency Department

Healthcare systems and health professions education have gone through radical changes in the past decades. These changes have made it imperative to explore innovative and alternative ways of teaching and training. Simulation-based education has emerged as an effective teaching strategy for both learners and practicing health professionals. Simulation is an educational technique that recreates real-life experiences. Learning occurs through participation in these simulation experiences followed by a period of guided debriefing and reflection. Pediatric emergency medicine, by its very nature, can benefit greatly from a well-designed and thoughtfully implemented simulation program. This review outlines situations where simulation may be used for maximum effectiveness in a pediatric emergency department and provides an overview of the basics of debriefing. A thorough description of each identified use of simulation is beyond the scope of this article.

Effectiveness of Integrating Simulation with Art-Based Teaching Strategies on Oncology Fellows' Performance Regarding Breaking Bad News

The task of breaking bad news (BBN) may be improved by incorporating simulation with art-based teaching methods. The aim of the present study was to assess the effect of an integrating simulation with art-based teaching strategies, on fellows' performance regarding BBN, in Iran. The study was carried out using quasi-experimental methods, interrupted time series. The participants were selected from medical oncology fellows at two teaching hospitals of Tehran University of Medical Sciences (TUMS), Iran. Participants were trained through workshop, followed by engaging participants with different types of art-based teaching methods. In order to assess the effectiveness of the integrating model, fellows' performance was rated by two independent raters (standardized patients (SPs) and faculty members) using the BBN assessment checklist. This assessment tool measured seven different domains of BBN skill. Segmented regression was used to analyze the results of study. Performance of all oncology fellows (n = 19) was assessed for 228 time points during the study, by rating three time points before and three time points after the intervention by two raters. Based on SP ratings, fellows' performance scores in post-training showed significant level changes in three domains of BBN checklist (B = 1.126, F = 3.221, G = 2.241; p < 0.05). Similarly, the significant level change in fellows' score rated by faculty members in post-training was B = 1.091, F = 3.273, G = 1.724; p < 0.05. There was no significant change in trend of fellows' performance after the intervention. Our results showed that using an integrating simulation with art-based teaching strategies may help oncology fellows to improve their communication skills in different facets of BBN performance. Iranian Registry of Clinical Trials ID: IRCT2016011626039N1.

Teaching NICU Fellows How to Relay Difficult News Using a Simulation-Based Curriculum: Does Comfort Lead to Competence?

PROBLEM

Neonatal Intensive Care Unit (NICU) clinicians must frequently relay difficult news to patient families, and the need for formal training for NICU trainees to develop this skill has been established. Although previous studies have shown improved trainee self-efficacy and comfort in handling difficult conversations after formal communication training, it remains unclear whether these interventions lead to improved objectively assessed short-term and long-term performance.

INTERVENTION

A simulation-based intervention emphasizing the SPIKES protocol for delivery of bad news was implemented for 15 fellows in the 3-year Baylor College of Medicine Neonatal-Perinatal Medicine fellowship program in the 2013-2014 academic year. Simulations involved video-recorded encounters between each fellow and a standardized parent (SP) involving communication of difficult news. Each fellow was evaluated before (preintervention), immediately after (postintervention), and 3-4 months after the intervention (follow-up) with an (a) evaluation of video-recorded sessions by two expert raters blinded to the timing of the encounter (blinded rater evaluation [BRE]), (b) Self-Assessment Questionnaire, (c) Content Test evaluating knowledge of taught concepts, and (d) SP evaluation (SPE).

CONTEXT

The 1st- and 2nd/3rd-year fellows participated in the study at separate times in the academic year to accommodate their schedules. First-year fellows had had more prior communication training and less NICU clinical experience than the 2nd/3rd-year fellows at the time of their intervention.

OUTCOME

Although all fellows displayed improved Self-Assessment and Content Test scores at postintervention with retention at the follow-up assessment, the BREs showed no statistically significant improvement in postintervention scores and showed a decline in follow-up scores. First-year fellows had higher BRE postintervention scores than the senior fellows. SPEs showed no difference in scores at all 3 assessment stages.

LESSONS LEARNED

As previously described in the literature, trainee self-efficacy and knowledge may improve in the short term and long term with a simulation-based curriculum in communication of difficult news. However, these results may be inconsistent with those of objective evaluations by expert raters and standardized parents. The impact of the curriculum may be heightened if it reinforces previously learned skills, but the effect may wane over time if not reinforced frequently with additional formal training or in the clinical setting. The results of this study highlight the importance of objective assessments in evaluating the utility of a simulation-based communication curriculum and the need for longitudinal curricula to promote retention of the concepts and skills being taught.

Intervention Descriptions in Medical Education: What Can Be Improved? A Systematic Review and Checklist

PURPOSE

Many medical education studies focus on the effectiveness of educational interventions. However, these studies often lack clear, thorough descriptions of interventions that would make the interventions replicable. This systematic review aimed to identify gaps and limitations in the descriptions of educational interventions, using a comprehensive checklist.

METHOD

Based on the literature, the authors developed a checklist of 17 criteria for thorough descriptions of educational interventions in medical education. They searched the Ovid MEDLINE, Embase, and ERIC databases for eligible English-language studies published January 2014-March 2016 that evaluated the effects of educational interventions during classroom teaching in postgraduate medical education. Subsequently, they used this checklist to systematically review the included studies. Descriptions were scored 0 (no information), 1 (unclear/partial information), or 2 (detailed description) for each of the 16 scorable criteria (possible range 0-32).

RESULTS

Among the 105 included studies, the criteria most frequently reported in detail were learning needs (78.1%), content/subject (77.1%), and educational strategies (79.0%). The criteria least frequently reported in detail were incentives (9.5%), environment (5.7%), and planned and unplanned changes (12.4%). No article described all criteria. The mean score was 15.9 (SD 4.1), with a range from 8 (5 studies) to 25 (1 study). The majority (76.2%) of articles scored 11-20.

CONCLUSIONS

Descriptions were frequently missing key information and lacked uniformity. The results suggest a need for a common standard. The authors encourage others to validate, complement, and use their checklist, which could lead to more complete, comparable, and replicable descriptions of educational interventions.

Communication Skills Training for Professionals Working with Adolescent Patients with Cancer Based on Participants' Needs: A Pilot

Purpose: We aimed to pilot and evaluate communication skills training (CST) for health care professionals (HCPs) interacting with adolescent patients with cancer and their parents based on participants' needs. Methods: We developed and piloted a 2-day CST with physicians and nurses in adolescent oncology. The CST's agenda was determined by the critical incidents reported by the participants. Training consisted of experiential learning based on role-play between HCPs and simulated patients and parents. Whenever suited, short lectures were given on specific communication techniques. Skills were self-assessed by questionnaires before, immediately after, and 6 months after training. We compared the proportion of participants who felt confident in 19 predefined areas of difficult communication before and 6 months after training. Responses to open-ended questions were analyzed qualitatively by thematic analysis. Results: Twenty-six physicians and 24 nurses participated in 6 CSTs. The proportion of participants who felt confident increased significantly in 6 of 19 communication items (p < 0.05). Positive feedback outweighed negative in quantity and quality. Predominant themes immediately after training were the training's practical orientation and intensity, and 6 months later, increased self-confidence and applied communication techniques. Participants noted that the effect diminishes with time, and expressed their need for booster trainings. Conclusion: The results of CST tailored to the specific needs of HCPs in adolescent oncology were promising. We suggest that similar training opportunities are implemented elsewhere.

Objective Evaluation of a Simulation Course for Residents in the Pediatric Emergency Medicine Department: Breaking Bad News

INTRODUCTION

Breaking bad news (BBN), especially in the pediatric emergency medicine department, requires significant skill and delicacy due to the acute context of a busy emergency department (ED) and the lack of prior rapport with the patients and families. Pediatric literature on breaking bad news has mostly focused on pediatric oncology and pediatric critical care, with limited literature focused on pediatric emergency medicine. Review of the literature also reveals that most existing studies solely assess the learners' self-ratings of efficacy and comfort, and far fewer studies objectively evaluate learners' actual performance using simulation. Our objectives for this study was to use an objective assessment tool to assess residents' breaking bad news skills, pre- and post-simulation training, specifically in the setting of a pediatric emergency medicine department.

METHODS

34 residents were evaluated on their performance in breaking bad news via videotaped simulation encounters before and after teaching intervention. The "Modified Breaking Bad News Assessment Scale" (mBAS) was used as the assessment tool. A paired t-test analysis was conducted to examine the mean difference in pre- and post-simulation scores in each of the five mBAS domains.

RESULTS

Breaking bad news performance score improves one to two weeks post-intervention, and was statistically significant in three of five domains.

CONCLUSION

Our study shows that breaking bad news is a teachable skill that can be improved by simulated education in the pediatric emergency medicine department. This study demonstrates the utility of simulation course in improving breaking bad news skills in the pediatric emergency medicine department. Future work in developing focused simulation curriculums is important to improve provider communication skills and patient-physician relationships.

Surgery Residents and Family Dynamics: Are Our Trainees Equipped to Handle Patient Care Beyond Disease?

Surgical trainees are expected to demonstrate family-centered care. However, it is unclear if residents know how to address psychosocial issues of pediatric patients and their families. Our aim was to evaluate surgical trainees’ knowledge of family dynamics. Over a six-month period, trainees (n = 16) were surveyed regarding their comfort and familiarity with the psychosocial aspects of patient care and family dynamics. Residents recorded their comfort level with managing various behaviors using a Likert scale, and indicated which family issues they felt least prepared to handle. Most trainees lacked knowledge of family adjustment phases (50%), relational triangles (78%), developmental stages of families (40%), ambiguous loss (75%), ABCX model of family stress (100%), and the SPIKES model (88%). Excluding anxiety and sadness, almost half of residents felt unprepared for dealing with a variety of challenging behaviors. Finally, trainees were least comfortable with breaking bad news. A Family Dynamics curriculum could potentially increase resident management skills and improve patient care.

Difficult Patient Encounters: Assessing Pediatric Residents' Communication Skills Training Needs

Introduction

Difficult patient encounters (DPEs) are common and can lead to frustration and dissatisfaction among healthcare providers. Pediatric resident physician experiences with DPEs and curricula for enhancing necessary communication skills have not been well described.

Materials and methods

We used a cross-sectional survey research design for our needs assessment on resident experiences with DPEs. Thirty-three pediatric residents completed this anonymous survey. The survey assessed residents’ experiences with and self-efficacy regarding DPEs. Descriptive statistics were used to analyze the quantitative data. Additionally, two authors independently coded free response data to include in the narrative description of the survey results.

Results

These survey results include the views of 92% of the residents in the program (33/36). Residents reported a greater frequency of difficult encounters in the inpatient setting than the outpatient setting. The majority of residents rated their communication skills during DPEs as “fair” or “good” (70%, 23/33). Residents tended to have lower confidence when discussing chronic pain, managing parental insistence on a plan, and breaking bad news. They generally reported higher levels of anxiety for scenarios involving angry patients and families, families insisting on a plan, and when breaking bad news. Residents cited many challenges, including working with angry and demanding families. Additionally, residents described difficulty with managing discordant opinions between the family and the healthcare team regarding the care plan. Residents expressed a preference for learning how to manage challenging patient encounters using clinical experiences. Simulation, discussion, and observation of role models also rated highly as educational methods for increasing skills, while most residents rated lectures as the least important means of training skills for these difficult encounters.

Discussion

We found that pediatric residents experience difficult encounters frequently, especially in the inpatient setting. Individual residents vary in their confidence and anxiety levels with different types of difficult encounters and may benefit from not only general communication skills training, but also from targeted training to equip them for the particular contexts they find most challenging. Residents value interactive structured learning activities, including discussion and simulation. Residents most consistently value the opportunity to lead challenging conversations in the clinical setting, especially when followed by effective debriefing and feedback by trained faculty preceptors.

Conclusions

Next steps include creating a “Difficult Encounters” communication skills curriculum informed by this needs assessment, which aim to enhance patient care as well as increase resident self-efficacy. In addition to the curriculum development for residents, it may be helpful to initiate faculty development on how to supervise resident-led difficult conversations and provide effective debriefing and feedback to promote resident growth.

Breaking Bad News: An Evidence-Based Review of Communication Models for Oncology Nurses

BACKGROUND

A diagnosis of cancer is a stressful, difficult, and life-altering event. Breaking bad news is distressing to patients and families and is often uncomfortable for the nurse delivering it. Evidence-based communication models have been developed and adapted for use in clinical practice to assist nurses with breaking bad news.

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OBJECTIVES

The purpose of this article is to provide an overview on breaking bad news and to review the utility of the SPIKES and PEWTER evidence-based communication models for oncology nurses.
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METHODS

Perceptions of breaking bad news from the nurse and patient perspectives, as well as barriers and consequences to effective communication, will be presented. Clinical examples of possible situations of breaking bad news will demonstrate how to use the SPIKES and PEWTER models of communication when disclosing bad news to patients and their families.
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FINDINGS

By using the evidence-based communication strategies depicted in this article, oncology nurses can support the delivery of bad news and maintain communication with their patients and their patients' families in an effective and productive manner.

Clinical communication skills and professionalism education are required from the beginning of medical training - a point of view of family physicians

BACKGROUND

The Brazilian undergraduate medical course is six years long. As in other countries, a medical residency is not obligatory to practice as a doctor. In this context, this paper aims to clarify what and when competencies in communication and professionalism should be addressed, shedding light on the role of university, residency and post-residency programmes.

METHODS

Brazilian family physicians with diverse levels of medical training answered a questionnaire designed to seek a consensus on the competencies that should be taught (key competencies) and when students should achieve them during their medical training. The data were analysed using descriptive statistics and correlation tests.

RESULTS

A total of seventy-four physicians participated; nearly all participants suggested that the students should achieve communication and professionalism competencies during undergraduate study (twenty out of thirty competencies - 66.7%) or during residency (seven out of thirty competencies - 23.33%). When competencies were analysed in domains, the results were that clinical communication skills and professionalism competencies should be achieved during undergraduate medical education, and interpersonal communication and leadership skills should be reached during postgraduate study.

CONCLUSION

The authors propose that attainment of clinical communication skills and professionalism competencies should be required for undergraduate students. The foundation for Leadership and Interpersonal Abilities should be particularly formed at an undergraduate level and, furthermore, mastered by immersion in the future workplace and medical responsibilities in residency.

Effect of a simulation-based workshop on breaking bad news for anesthesiology residents: an intervention study

Background

Breaking bad news (BBN) to patients and their relatives is a complex and stressful task. The ideal structure, training methods and assessment instruments best used to teach and assess BBN for anesthesiology residents remain unclear. The purpose of this study is to evaluate the effectiveness of an education intervention for BBN based on immersive experiences with a high fidelity simulator and role-play with standardized patients (SPs). A secondary purpose is to gather validity evidence to support the use of a GRIEV_ING instrument to assess BBN skills.

Methods

The communication skills for BBN of 16 residents were assessed via videotaped SP encounters at baseline and immediately post-intervention. Residents’ perceptions about their ability and comfort for BBN were collected using pre and post workshop surveys.

Results

Posttest scores were significantly higher than the pretest scores for the GRIEV_ING checklist, as well as on the communication global rating. The GRIEV_ING checklist had acceptable inter-rater and internal-consistency reliabilities. Performance was not related to years of training, or previous BBN experience.

Conclusion

Anesthesiology residents’ communication skills when BBN in relation to a critical incident may be improved with educational interventions based on immersive experiences with a high fidelity simulator and role-play with SPs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0374-7) contains supplementary material, which is available to authorized users.

Interactive Palliative and End-of-Life Care Modules for Pediatric Residents

Background. There is a need for increased palliative care training during pediatric residency. Objective. In this pilot study, we created a comprehensive experiential model to teach palliative care skills to pediatric residents. Our Comfort Care Modules (CCMs) address pediatric palliative care (PPC) topics of breaking bad news, dyspnea, anxiety, pain management, and the dying child. We also evaluated a scoring system and gathered qualitative data. Methods. The CCMs are part of the University of California San Diego pediatric residency's second-year curriculum. Comparisons were made for statistical trends between residents exposed to the modules (n = 15) and those not exposed (n = 4). Results. Nineteen of 36 residents (52%) completed surveys to self-rate their preparedness, knowledge, and confidence about PPC before and after the intervention. Resident scores increased in all areas. All improvements reached statistical significance except confidence when breaking bad news. Overall, the resident feedback about the CCMs was positive. Conclusions. This study demonstrates that the CCMs can be performed effectively in an academic setting and can benefit residents' self-perception of preparedness, confidence, and knowledge about pediatric palliative care. In the future, we plan to implement the modules on a larger scale. We encourage their use in interprofessional settings and across institutions.

The feasibility of implementing a communication skills training course in pediatric hematology/oncology fellowship

Communication skills are a competency highlighted by the Accreditation Council on Graduate Medical Education; yet, little is known about the frequency with which trainees receive formal training or what programs are willing to invest. We sought to answer this question and designed a program to address identified barriers. We surveyed pediatric fellowship program directors from all disciplines and, separately, pediatric hematology/oncology fellowship program directors to determine current use of formal communication skills training. At our institution, we piloted a standardized patient (SP)-based communication skills training program for pediatric hematology/oncology fellows. Twenty-seven pediatric hematology/oncology program directors and 44 pediatric program directors participated in the survey, of which 56% and 48%, respectively, reported having an established, formal communication skills training course. Multiple barriers to implementation of a communication skills course were identified, most notably time and cost. In the pilot program, 13 pediatric hematology/oncology fellows have participated, and 9 have completed all 3 years of training. Precourse assessment demonstrated fellows had limited comfort in various areas of communication. Following course completion, there was a significant increase in self-reported comfort and/or skill level in such areas of communication, including discussing a new diagnosis (p =.0004), telling a patient they are going to die (p =.005), discussing recurrent disease (p <.001), communicating a poor prognosis (p =.002), or responding to anger (p ≤.001). We have designed a concise communication skills training program, which addresses identified barriers and can feasibly be implemented in pediatric hematology/oncology fellowship.

Breaking bad news: A communication competency for ophthalmology training programs

As the ophthalmology accreditation system undergoes major changes, training programs must evaluate residents in the 6 core competencies, including appropriately communicating bad news. Although the literature is replete with recommendations for breaking bad news across various non-ophthalmology specialties, no formal training programs exist for ophthalmology. There are many valuable lessons to be learned from our colleagues regarding this important skill. We examine the historic basis for breaking bad news, explore current recommendations among other specialties, and then evaluate a pilot study in breaking bad news for ophthalmology residents. The results of this study are limited by a small number of residents at a single academic center. Future studies from multiple training programs should be conducted to further evaluate the need and efficacy of formal communication skills training in this area, as well as the generalizability of our pilot training program. If validated, this work could serve as a template for future ophthalmology resident training and evaluation in this core competency.