The palliative medicine extended standardized patient scenario: a preliminary report

Training Pediatric Fellows in Palliative Care: A Pilot Comparison of Simulation Training and Didactic Education

BACKGROUND

Pediatric fellows receive little palliative care (PC) education and have few opportunities to practice communication skills.

OBJECTIVE

In this pilot study, we assessed (1) the relative effectiveness of simulation-based versus didactic education, (2) communication skill retention, and (3) effect on PC consultation rates.

DESIGN

Thirty-five pediatric fellows in cardiology, critical care, hematology/oncology, and neonatology at two institutions enrolled: 17 in the intervention (simulation-based) group (single institution) and 18 in the control (didactic education) group (second institution). Intervention group participants participated in a two-day program over three months (three simulations and videotaped PC panel). Control group participants received written education designed to be similar in content and time.

MEASUREMENTS

(1) Self-assessment questionnaires were completed at baseline, post-intervention and three months; mean between-group differences for each outcome measure were assessed. (2) External reviewers rated simulation-group encounters on nine communication domains. Within-group changes over time were assessed. (3) The simulation-based site's PC consultations were compared in the six months pre- and post-intervention.

RESULTS

Compared to the control group, participants in the intervention group improved in self-efficacy (p = 0.003) and perceived adequacy of medical education (p < 0.001), but not knowledge (p = 0.20). Reviewers noted nonsustained improvement in four domains: relationship building (p = 0.01), opening discussion (p = 0.03), gathering information (p = 0.01), and communicating accurate information (p = 0.04). PC consultation rate increased 64%, an improvement when normalized to average daily census (p = 0.04).

CONCLUSIONS

This simulation-based curriculum is an effective method for improving PC comfort, education, and consults. More frequent practice is likely needed to lead to sustained improvements in communication competence.

Palliative and end-of-life care: using a standardized patient family for gerontological nurse practitioner students

This article describes an innovative approach to educating gerontological nurse practitioner students about the needs of patients and their families related to palliative and end-of-life care. By using a standardized patient family and creatively using resources from the End-of-Life Nursing Education Consortium (ELNEC), this author maximized learning experiences for advanced practice students who will care for elderly individuals and their families. The goal of ELNEC is to strengthen nursing education to improve end-of-life care. Principles for developing and implementing a complex standardized patient scenario for graduate nursing students are offered.

Avatar-mediated training in the delivery of bad news in a virtual world

BACKGROUND

Delivering bad news to patients is an essential communication skill for physicians. Educators commonly use standardized patient (SP) encounters to train physicians in the delivery of bad news. It is expensive to use actors, for logistical reasons such as travel and scheduling, and there are limits to the characters and conditions an actor can portray in teaching encounters. Thus we studied the feasibility of creating SP avatars in a virtual world for the task of training medical trainees to deliver bad news. The SP avatars are easily customized for different scenarios and amenable to distance learning.

METHODS

We recruited 10 medical trainees to interact with a standardized female avatar in a three-dimensional simulated clinic, where the trainee was to inform the avatar of her newly diagnosed breast cancer. The trainee evaluated his or her self-efficacy in delivering bad news via an affective competency score (ACS) before and after the encounter. Two palliative care specialists evaluated each trainee's performance using the Bad News Assessment Schedule and the performance ACS.

RESULTS

The self-efficacy ACS scores of the trainees improved overall: before, 20 ± 4, versus after, 24 ± 3, p = 0.001 (maximum score = 30). All participants considered the experience positive and commended the novel approach, although noting that the avatars were not able to portray body language cues.

CONCLUSION

Participants viewed the avatar-mediated training as an excellent approach for learning how to deliver bad news but believed it could not substitute for real patient interactions. However, participant self-efficacy improved, which suggests that avatar-mediated training in a virtual world is a viable educational approach for skill training in delivering bad news.

A ten-year review of the literature on the use of standardized patients in teaching and learning: 1996-2005

BACKGROUND

Although there is a growing body of literature on the educational use of standardized patients (SP) in teaching and learning, there have been no reviews on their value.

OBJECTIVE

To determine whether the educational use of SPs has an effect on the knowledge, skills, and behaviour of learners in the health professions.

METHODS

English-language articles covering the period 1996-2005 were reviewed to address the issue of to what extent has the use of SPs affected the knowledge, skills and performance of learners. Out of 797 abstracts, 69 articles, which met the review criteria, were selected. An adaptation of Kirkpatrick's model was used to classify and analyse the articles.

RESULTS

Most of the learners were students in medicine and nursing. SPs were used mostly to teach communication skills and clinical skills. The study designs were case-control (29%), pre-test/post-test (24.6%), post-test only (26.1%) and qualitative studies (20.3%). METHODOLOGICAL ISSUES: Most of the studies had weak research designs. More rigorous designs with control or comparison groups should be used in future research.

CONCLUSIONS

Most studies reported that the educational use of SPs was valuable. More rigorous studies would support the evidence-based use of SPs in teaching and learning.

Professionalism and communication in the intensive care unit: reliability and validity of a simulated family conference

OBJECTIVE

An Objective Structured Clinical Exam was designed to assess physician's ability to discuss end-of-life (EOL) and disclose iatrogenic complications (DOC) with family members of intensive care unit patients. The study explores reliability and validity based on scores from contrasting rater groups (clinicians, SPs, and examinees).

METHODS

Two 20-minute stations were administered to 17 surgical residents and 2 critical fellows at a university-based training program. The exam was conducted, videotaped, and scored in a standardized setting by 8 clinical raters (MD and RN) and 8 standardized families using separate rating tools (EOL and DOC). Examinees assessed themselves using the same tools. We analyzed the internal consistency, inter-rater agreement, and discriminant validity of both cases using data from each rater group. Cross-rater group comparisons were also made.

RESULTS

The internal consistency reliability correlations were above 0.90 regardless of case or rater group. Within rater groups, raters were within 1 point of agreement (5-pt and 6-pt scales) on 81% of the DOC and between 74% and 79% of the EOL items. Family raters were more favorable than clinical raters in scoring DOC, but not EOL cases. Large raw differences in performance by training level favored more experienced trainees (3rd year residents and fellows). These differences were statistically significant when based on residents own self-ratings, but not when they were based on clinical or family ratings.

DISCUSSION

The Family Conference Objective Structured Clinical Exam is a reliable exam with high content validity. It seems unique in the literature for assessing surgical trainees' ability to discuss "bad news" with family members in intensive care.

Development of the palliative care needs assessment tool (PC-NAT) for use by multi-disciplinary health professionals

Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.

Development and pilot testing of an OSCE for difficult conversations in surgical intensive care

OBJECTIVES

To describe the development and results of an Objective Structured Clinical Exam (OSCE) for leading family conferences in the surgical intensive care unit (SICU).

DESIGN

Pilot demonstration and reliability assessment.

SETTING

General surgery residency program at a major academic teaching hospital.

PARTICIPANTS

PGY-2 and PGY-4 categorical general surgery residents (n=8).

RESULTS

The SICU Family Conference OSCE consists of two 20-minute stations, one requiring residents to lead an end-of-life discussion and the other to disclose an iatrogenic complication. Actual case scenarios and trained actors were used; the examinations were videotaped in a standardized setting. Two professional raters as well as the participating actors assessed each resident performance using rating tools developed for each station and based on guiding principles gleaned from the literature. Resident debriefings and evaluation surveys were also conducted. Resident perception of the OSCE overall was positive. Analysis of the videotapes revealed the need for greater standardization of the actors' roles. The rating tools showed strong internal consistency (0.77-0.85), but inter-rater agreement of scores was generally low (<0.70) within rater groups. Family actors consistently gave residents higher global assessment scores than did the professional raters. Second- and fourth-year residents scored equally well on the examination.

CONCLUSIONS

This pilot provided residents with a positive learning experience and valid formative feedback. Case materials developed for each station served their function well. More work in actor and rater training is needed before the examination scores can be reliably used in summative evaluation.

Development of communication skills workshop for oncology advanced practice nursing students

BACKGROUND

Communication skills have not traditionally been included in nursing curriculum. The best educational method to improve health care providers' practice in communication skills is first, introduction of content, followed by continuous skills assessment and mentored feedback.

METHODS

A communication skills workshop using standardized patients (SPs) was planned for oncology nurse practitioner students. A 6-step development plan was used to design, implement, and evaluate the curriculum. Three patient cases using SPs were developed to represent a specific communication skill. SP teaching methodology is relatively new to nursing curriculum. RESULTS. Four methods of evaluation revealed a high level of satisfaction with the course, a high level of communications skills demonstrated during the course, and student need to have more communication content throughout their curriculum. Confidence in communication skills increased following the workshop.

CONCLUSIONS

This methodology has widespread application to other areas of cancer nursing including nurses with less oncology experience and practicing nurses on the oncology units. In addition, there is application throughout nursing curriculum for undergraduate and graduate programs. The content should be presented earlier in the curriculum and then reinforced throughout the remaining courses with clinical follow-up.

The palliative care clinical evaluation exercise (CEX): an experience-based intervention for teaching end-of-life communication skills

PURPOSE

To pilot test the "Palliative Care Clinical Evaluation Exercise (CEX)," a new experience-based intervention to teach communication skills in giving bad news and discussing code status. The intervention allows faculty to observe, evaluate, and give feedback to housestaff in their discussions with patients and families.

METHOD

In 2002-03, the intervention was piloted among 60 first-year residents in the categorical Internal Medicine Residency Programs at the University of Pittsburgh. The authors collected feasibility measurements at the time of intervention, and interns' attitudes were measured before and one week after intervention and at the end of the intern year.

RESULTS

Forty-four residents (73%) completed the intervention. Discussions averaged a total of 49.5 minutes (SD 24.1), divided among 12.7 minutes (SD 7.5) for prediscussion counseling between the resident and faculty observer, 25.6 minutes (SD 16.1) for the resident-patient discussion, and 12.1 minutes (SD 5.7) for postdiscussion feedback. Residents rated the Palliative Care CEX favorably (>3 on a five-point scale) on ease of arranging the exercise, educational value, quality of the experience, effect on their comfort with discussions, importance to their education, and value of preceptor feedback. Self-ratings of communication competence showed improvement one week after the intervention.

CONCLUSIONS

The Palliative Care CEX is feasible and positively valued by residents. The findings from this initial pilot study support the value of further efforts to refine the intervention, to confirm its feasibility in other settings, and to validate its use as an educational and assessment tool.

Education in palliative care

Palliative care education includes the domains of pain and nonpain symptom management, communications skills, ethics and law, psychosocial care, and health systems. Defining key attitudes, knowledge, and skill objectives, and matching these to appropriate learning formats, is essential in educational planning. Abundant educational resource material is available to support classroom and experiential palliative care training.

Learning together: use of simulated patients with nursing and medical students for breaking bad news

This article reports a small research study on the use of simulated patients for teaching medical and nursing students how to break bad news. A total of 34 nursing and medical students undertook the activity in mixed groups. Data obtained from free response questionnaires and a focus group were analysed and independently coded to identify recurrent themes across the data and the two student groups. Students reported that simulated patients gave instant feedback about their performance which they found useful. Students felt that working in doctor-nurse pairs helped them formulate strategies for imparting the bad news and that this made them feel better prepared and less isolated. The article outlines why the use of simulated patients may be valuable and suggests that this form of teaching could be used in other types of communications training. The use of simulated patients appears to have the potential to enhance patient-practitioner and practitioner-practitioner interactions.