Analysis of enacted difficult conversations in neonatal intensive care

Simulation for communication training in neonatology

Communication skills training is a core competency for neonatal-perinatal medicine (NPM) fellows, yet many neonatology fellowship programs do not have formal communication skills curricula. Since the late 1990s, experiential learning that includes role-play and simulation has become the standard for communication training. NPM fellows who receive simulation-based communication skills training report greater comfort with difficult conversations in the NICU. Most communication skills studies in neonatology focus on antenatal counseling, with some studies regarding family meetings and end of life conversations. Published examples for simulation-based communication skills curricula exist, with ideas for adapting them to meet the needs of local resources.

Defining Neonatal Serious Illness: Perspectives of Nurses and Social Workers

Objectives: To explore (1) how neonatal nurses (NN) and social workers (SW) define serious illness and (2) how physician, nurse, and SW perceptions of serious illness differ. Design: Prospective survey study. Setting/Subjects: Members of the National Association of Neonatal Nurses or the National Association of Perinatal Social Workers. Measurements: We circulated a modified version of a previously developed survey. Participants were given a list of definition components and asked to rank components by importance and to suggest modifications. Results: Eighty-eight percent of participants agreed with our definition of neonatal serious illness. NN and SW differ in important ways in their views of neonatal serious illness when compared with physicians and parents. Conclusions: Our definition of neonatal serious illness has broad acceptability and may be useful for clinical care and research. Future work should prospectively identify patients with neonatal serious illness and establish the usefulness of our definition in real time.

Decision making at extreme prematurity: Innovation in clinician education

Decision-making at extreme prematurity remains ethically and practically challenging and can result in parental and clinician distress. It is vital that clinicians learn the necessary skills integral to counseling and decision-making with families in these situations. A pedagogical approach to teaching counseling should incorporate adult learning theory, emphasize multidisciplinary team in-situ simulation that links to counseling clinicians' daily practice, and includes critical reflection, debriefing, and program assessment. Multiple educational strategies that train clinicians in advanced communication and decision-making offer promising results to optimize antenatal counseling and shared decision-making for families facing possible delivery at extreme prematurity. Continued process evaluation and innovation in these educational domains are needed while also assessing the effect on patient-centered outcomes.

How to hold an effective NICU family meeting: capturing parent perspectives to build a more robust framework

OBJECTIVE

To record the content and parental perceptions of family meetings in a Neonatal Intensive Care Unit (NICU) to improve existing frameworks for facilitating these meetings.

STUDY DESIGN

A prospective, mixed-methods study. NICU family meetings were audio-recorded, transcribed, and analyzed by an iteratively derived coding framework until thematic saturation. We used descriptive statistics of parental post-meeting assessments.

RESULTS

Qualitative analysis of 21 meetings identified both Communication Facilitators and Barriers. Facilitators included use of visual-aids and participation of social workers to clarify information for parents. Barriers included staff rarely eliciting parental comprehension (3 meetings) or concerns (5) before providing new information, resulting in 39% of parents reporting they didn't ask questions they wanted to ask. In 33% of meetings an important participant was absent.

CONCLUSIONS

This novel qualitative and quantitative dataset of NICU family meetings highlights areas for improving communication. Attention to these components may improve parental perceptions of family meetings.

A simulation based difficult conversations intervention for neonatal intensive care unit nurse practitioners: A randomized controlled trial

Background

Neonatal nurse practitioners are often the front line providers in discussing unexpected news with parents. This study seeks to evaluate whether a simulation based Difficult Conversations Workshop for neonatal nurse practitioners leads to improved skills in conducting difficult conversations.

Methods

We performed a randomized controlled study of a simulation based Difficult Conversations Workshop for neonatal nurse practitioners (n = 13) in a regional level IV neonatal intensive care unit to test the hypothesis that this intervention would improve communication skills. A simulated test conversation was performed after the workshop by the intervention group and before the workshop by the control group. Two independent blinded content experts scored each conversation using a quantitative communication skills performance checklist and by assigning an empathy score. Standard statistical analysis was performed.

Results

Randomization occurred as follows: n = 5 to the intervention group, n = 7 to the control group. All participants were analyzed in each group. Participation in the simulation based Difficult Conversations Workshop increases participants’ empathy score (p = 0.015) and the use of communication skills (p = 0.013) in a simulated clinical encounter.

Conclusions

Our study demonstrates that a lecture and simulation based Difficult Conversations Workshop for neonatal nurse practitioners improves objective communication skills and empathy in conducting difficult conversations.

Interprofessional Teamwork During Family Meetings in the Pediatric Cardiac Intensive Care Unit

CONTEXT

Parents of children in the pediatric cardiac intensive care unit (CICU) report inadequate communication and a lack of empathy during conversations with their clinicians.

OBJECTIVE

To assess quantitatively and qualitatively the contributions made by team members of different professions in communicating with parents during family meetings.

METHODS

Prospective observational study. The study was conducted in the pediatric CICU at the Children's Hospital of Philadelphia. Subjects were members of the interprofessional team attending family meetings for patients admitted to the CICU longer than two weeks. We used quantitative conversation attribution and coding to compare durations of attendee contributions and contribution type by professional role. The SCOPE codebook and other quantitative codes drawn from best practices in family meetings were used to measure communication behaviors. A qualitative analysis of nurses' and social workers' contributions was used to identify themes not otherwise captured.

RESULTS

Across 10 meetings, physicians spoke for an average of 78.1% (SD 10.7%) of each meeting, nonphysicians 9.6% (SD 7.8%), and parents 17.4% (SD 12.2%). Parental understanding was assessed an average of 0.2 (SD 0.4) times per meeting. Parents expressed emotion an average of 4.2 times per meeting (SD 7.1), and the clinical team responded empathetically 2.2 times per meeting (SD 4.3). All clinician empathic responses were a minority of their overall contributions. Conversation was almost exclusively between physicians and families until physicians indicated other team members could contribute.

CONCLUSIONS

Coordination of team members' roles in the meetings may improve parental engagement necessary for decision-making and empathic responses that are often missed.

Communication During Pediatric Intensive Care Unit Family Conferences: A Pilot Study of Content, Communication, and Parent Perceptions

While there is a robust literature describing family conferences (FCs) in adult intensive care units (ICUs), less information exists about FCs in pediatric ICUs (PICUs). We conducted a pilot study to describe the focus of discussion, communication patterns of health care team members (HTMs) and parents, and parents' perspectives about clinician communication during PICU FCs. We analyzed data from 22 video- or audiorecorded PICU FCs and post-FC questionnaire responses from 27 parents involved in 18 FCs. We used the Roter Interaction Analysis System (RIAS) to describe FC dialogue content. Our questionnaire included the validated Communication Assessment Tool (CAT). FCs were focused on care planning (n = 5), decision making (n = 6), and updates (n = 11). Most speech came from HTMs (mean 85%; range, 65-94%). Most HTM utterances involved medical information. Most parent utterances involved asking for explanations. The mean overall CAT score was 4.62 (using a 1-5 scale where 5 represents excellent and 1 poor) with a mean of 73.02% "excellent" responses. Update and care-planning FCs had lower CAT scores compared to decision-making FCs. The lowest scoring CAT items were "Involved me in decisions as much as I wanted," "Talked in terms I could understand," and "Gave me as much information as I wanted." These findings suggest that while health care providers spend most of their time during FCs relaying medical information, more attention should be directed at providing information in an understandable manner. More work is needed to improve communication when decision making is not the main focus of the FC.

Parent Satisfaction With Communication Is Associated With Physician's Patient-Centered Communication Patterns During Family Conferences

OBJECTIVES

To evaluate the association between physician's patient-centered communication patterns and parental satisfaction during decision-making family conferences in the PICU.

DESIGN

Single-site, cross-sectional study.

SETTING

Forty-four-bed PICUs in a free-standing children's hospital.

PARTICIPANTS

Sixty-seven English-speaking parents of 39 children who participated in an audiorecorded family conference with 11 critical care attending physicians.

MEASUREMENTS AND MAIN RESULTS

Thirty-nine family conferences were audiorecorded. Sixty-seven of 77 (92%) eligible parents were enrolled. The conference recordings were coded using the Roter Interaction Analysis System and a Roter Interaction Analysis System-based patient-centeredness score, which quantitatively evaluates the conversations for physician verbal dominance and discussion of psychosocial elements, such as a family's goals and preferences. Higher patient-centeredness scores reflect higher proportionate dialogue focused on psychosocial, lifestyle, and socioemotional topics relative to medically focused talk. Parents completed satisfaction surveys within 24 hours of the conference. Conferences averaged 45 minutes in length (SD, 19 min), during which the medical team contributed 73% of the dialogue compared with parental contribution of 27%. Physicians dominated the medical team, contributing 89% of the team contribution to the dialogue. The majority of physician speech was medically focused (79%). A patient-centeredness score more than 0.75 predicted parental satisfaction (β = 12.05; p < 0.0001), controlling for the length of conference, child severity of illness, parent race, and socioeconomic status. Parent satisfaction was negatively influenced by severity of illness of the patient (β = -4.34; p = 0.0003), controlling for previously mentioned factors in the model.

CONCLUSIONS

Parent-physician interactions with more patient-centered elements, such as increased proportions of empathetic statements, question asking, and emotional talk, positively influence parent satisfaction despite the child's severity of illness.

Teaching and assessing ethics in the newborn ICU

Ethics and professionalism education has become increasingly recognized as important and incorporated into graduate medical education. However, such education has remained largely unstructured and understudied in neonatology. Neonatal-perinatal fellowship training programs have generally grappled with how best to teach and assess ethics and professionalism knowledge, skills, and behavior in clinical practice, particularly in light of accreditation requirements, milestones, and competencies. This article reviews currently available teaching methods, pedagogy, and resources in medical ethics, professionalism, and communication, as well as assessment strategies and tools, to help medical educators and practicing clinicians ensure trainees achieve and maintain competency. The need for consensus and future research in these domains is also highlighted.

Teaching professionalism in graduate medical education: What is the role of simulation?

BACKGROUND

We systematically reviewed the literature concerning simulation-based teaching and assessment of the Accreditation Council for Graduate Medical Education professionalism competencies to elucidate best practices and facilitate further research.

METHODS

A systematic review of English literature for "professionalism" and "simulation(s)" yielded 697 abstracts. Two independent raters chose abstracts that (1) focused on graduate medical education, (2) described the simulation method, and (3) used simulation to train or assess professionalism. Fifty abstracts met the criteria, and seven were excluded for lack of relevant information. The raters, 6 professionals with medical education, simulation, and clinical experience, discussed 5 of these articles as a group; they calibrated coding and applied further refinements, resulting in a final, iteratively developed evaluation form. The raters then divided into 2 teams to read and assess the remaining articles. Overall, 15 articles were eliminated, and 28 articles underwent final analysis.

RESULTS

Papers addressed a heterogeneous range of professionalism content via multiple methods. Common specialties represented were surgery (46.4%), pediatrics (17.9%), and emergency medicine (14.3%). Sixteen articles (57%) referenced a professionalism framework; 14 (50%) incorporated an assessment tool; and 17 (60.7%) reported debriefing participants, though in limited detail. Twenty-three (82.1%) articles evaluated programs, mostly using subjective trainee reports.

CONCLUSION

Despite early innovation, reporting of simulation-based professionalism training and assessment is nonstandardized in methods and terminology and lacks the details required for replication. We offer minimum standards for reporting of future professionalism-focused simulation training and assessment as well as a basic framework for better mapping proper simulation methods to the targeted domain of professionalism.

Family Conferences in the Neonatal ICU: Observation of Communication Dynamics and Contributions

OBJECTIVES

Clinicians in the neonatal ICU must engage in clear and compassionate communication with families. Empirical, observational studies of neonatal ICU family conferences are needed to develop counseling best practices and to train clinicians in key communication skills. We devised a pilot study to record and analyze how interdisciplinary neonatal ICU clinicians and parents navigate difficult conversations during neonatal ICU family conferences.

DESIGN

We prospectively identified and audiotaped a convenience sample of neonatal ICU family conferences about "difficult news." Conversations were analyzed using the Roter interaction analysis system, a quantitative tool for assessing content and quality of patient-provider communication.

SETTING

An urban academic children's medical center with a 45-bed level IV neonatal ICU.

SUBJECTS

Neonatal ICU parents and clinicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed 19 family conferences that included 31 family members and 23 clinicians. The child's mother was included in all conferences, and a second parent, usually the father, was present in 13 conferences. All but one conference included multiple medical team members. On average, physicians contributed 65% of all dialogue, regardless of who else was present. Over half (56%) of this dialogue involved giving medical information; under 5% of clinician dialogue involved asking questions of the family, and families rarely (5% of dialogue) asked questions. Conversations were longer with the presence of nonphysician clinicians, but this did not increase the amount of dialogue about psychosocial information or increase parent dialogue.

CONCLUSIONS

We collected a novel repository of audio-recorded neonatal ICU family meetings that offers insights into discussion content and process. These meetings were heavily focused on biomedical information even when interdisciplinary clinicians were present. Clinicians always talked more than parents, and no one asked many questions. Maximizing the participation of interdisciplinary clinicians in neonatal ICU family meetings may require explicit strategies. Methods to increase family engagement should be targeted.

Ethics and professionalism education during neonatal-perinatal fellowship training in the United States

OBJECTIVE

The objectives of this study were to determine the perceived adequacy of ethics and professionalism education for neonatal-perinatal fellows in the United States, and to measure confidence of fellows and recent graduates when navigating ethical issues.

STUDY DESIGN

Neonatal-Perinatal Fellowship Directors, fellows and recent graduates were surveyed regarding the quality and type of such education during training, and perceived confidence of fellows/graduates in confronting ethical dilemmas.

RESULT

Forty-six of 97 Directors (47%) and 82 of 444 fellows/graduates (18%) completed the surveys. Over 97% of respondents agreed that ethics training is 'important/very important'. Only 63% of Directors and 37% of fellows/graduates rated ethics education as 'excellent/very good' (P=0.004). While 96% of Directors reported teaching of ethics, only 70% of fellows/graduates reported such teaching (P<0.001). Teaching methods and their perceived effectiveness varied widely.

CONCLUSION

Training in ethics and professionalism for fellows is important, yet currently insufficient; a more standardized curriculum may be beneficial to ensure that trainees achieve competency.

"This is a decision you have to make": using simulation to study prenatal counseling

INTRODUCTION

Prenatal decision making during extremely preterm labor is challenging for parents and physicians. Ethical and logistical concerns have limited empirical descriptions of physician counseling behaviors in this setting and constricted opportunities for communication training. This pilot study examines how simulation might be used to engage neonatologists in reflecting on their usual prenatal counseling behaviors.

METHODS

Neonatology physicians counseled a couple (standardized patients) with the female patient having impending delivery at 23 3/7 weeks. Encounters were videotaped. Physicians completed postencounter surveys and debriefing interviews. Mixed-methods analysis explored the outcomes of clinical verisimilitude and counseling behaviors.

RESULTS

All 10 neonatology physicians found that the simulation was highly realistic and that their behaviors paralleled neonatologist self-report in other studies. Physicians contributed more than 80% of encounter dialogue and mostly focused on biomedical information related to the acute perinatal period. Physicians spent nearly a quarter of each encounter in building relationships and expressing empathy. Most physicians initiated discussion about quality versus quantity of life but infrequently elicited the parents' related goals and values. When medical factors and family preferences were held constant, physicians assumed variable responsibility for making decisions about resuscitation. Most physicians declined parent requests for treatment recommendations, although all of those physicians felt more than 75% certain about what should be done.

CONCLUSIONS

Simulation can reproduce the decisional context of prenatal counseling for extremely premature labor. These results have implications for communication training in any setting where physicians and patients without established relationships must discuss acute diagnoses and make high-stakes medical decisions.

An interdisciplinary, family-focused approach to relational learning in neonatal intensive care

OBJECTIVE

The aim of this study is to show the efficacy of the Program to Enhance Relational and Communication Skills-Neonatal Intensive Care Unit (PERCS-NICU).

STUDY DESIGN

In this study, 74 practitioners attended workshops and completed baseline, post-training and follow-up questionnaires.

RESULT

On yes/no questions, 93 to 100% reported improved preparation, communication skills and confidence post-training and follow-up. A total of 94 and 83% improved their ability to establish relationships, and 76 and 83% reported reduced anxiety post-training and follow-up, respectively. On Likert items, 59 and 64% improved preparation, 45 and 60% improved communication skills and confidence, 25 and 53% decreased anxiety and 16 and 32% improved relationships post-training and follow-up, respectively. Qualitative themes included integrating new communication and relational abilities, honoring the family perspective, appreciating interdisciplinary collaboration, personal/human connection and valuing the learning. In total, 93% applied skills learned, three-quarters transformed practice and 100% recommended PERCS-NICU.

CONCLUSION

After PERCS-NICU, clinicians improved preparation, communication and relational abilities, confidence and reduced anxiety when holding difficult neonatal conversations.

The comprehensive care rounds: facilitating multidisciplinary communication among caregivers of complex patients in the neonatal intensive care unit

Care of the very sick infant can be complicated by extraneous factors that challenge the cohesiveness of the health care team. Chaos results from low levels of professional agreement and certainty about outcomes and manifests in stress and miscommunication among care providers. This milieu is fertile ground for errors of commission and omission. Effective communication and collaboration are recognized as essential for reducing medical errors in such stressful environments. This article describes a multidisciplinary conference, the Comprehensive Care Rounds, at a neonatal intensive care unit of a Magnet-recognized midwestern pediatric hospital. The Comprehensive Care Round provides a forum for open communication among team members and builds on the hospital's efforts at systems approach to developing a culture of safety and quality.

Providing advice to parents for women at acutely high risk of periviable delivery

OBJECTIVE

To better understand preferred approaches that health care professionals could use when caring for parents who are at risk of giving birth to an extremely premature infant.

METHODS

Women who were at high risk of having a periviable birth were recruited from three tertiary care hospitals with level 3 neonatal intensive care units. These women, as well as their partners, physicians, and nurses underwent structured interviews both before and after delivery. Interviews were analyzed for advice that was provided to health care professionals who could be involved in the future counseling of antenatal patients at high risk of periviable delivery.

RESULTS

Forty women, 14 fathers, and 52 health care providers participated in the interview process. Two main themes were identified--namely, the fundamental importance of information provision and support. Nevertheless, although all participants agreed about the importance of these actions, several areas of discordance among participants were noted. Nearly one third of parents emphasized the importance of "hope"; 60% and 45% recommended the provision of supplementary written and Internet materials, respectively. In contrast, most health care providers expressed the importance of "objectivity," and only 15% and 5% thought written or Internet materials, respectively, were desirable, given the concern that supplementary information sources could be misleading.

CONCLUSION

Both patients and providers agree about the centrality of information provision and emotional support for women at risk of periviable delivery. This study not only elucidates preferred approaches and methods by which this information and support could be optimized, but also shows pitfalls that, if not avoided, may impair the relationship between provider and patient.