Interprofessional Learning to Improve Communication in Challenging Healthcare Conversations: What Clinicians Learn From Each Other

Challenges in teacher-student communication during family medicine residency: A qualitative study

BACKGROUND

Deficiencies in communication among healthcare professionals, recognized by medical educators and healthcare institutions, can negatively impact medical education and clinical practice. Analyzing teacher-resident communication difficulties shed light on this issue and propose practical strategies for its mitigation.

OBJECTIVE

To identify common communication challenges between teacher and residents during Family Medicine residency and to analyze their impact on interactions with peers, the work team, and patients.

DESIGN

Qualitative study, the critical incident technique was used to collect information of interest.

PARTICIPANTS

Seventy teachers, and fifty third-year residents from the Mexican Republic described critical incidents related to their communication experiences during Family Medicine residency.

RESULTS

192 critical incidents were collected (several participants reported more than one incident), comprising 127 reports from teachers, and 65 from residents. Four themes were identified: 1) asymmetric communication, 2) assertive communication, 3) organizational communication, and 4) effective communication. The main challenges identified were abuse of power in communication, lack of communication skills, and the absence of institutional communication channels. These issues significantly impacted learning, work environment, interpersonal relationships, and medical care.

CONCLUSION

This study highlights communication issues within Family Medicine residency in Mexico. The issues detected hindered learning and effective collaboration and negatively impacted the work environment, interpersonal relationships, and the quality of medical care. These findings underscore the urgent need to reorient the medical specialty curriculum towards an approach that includes communication skills.

Psychologists as Pivotal Members of the Pediatric Palliative Care Team

CONTEXT

Pediatric psychologists possess unique expertise to positively impact the care provided to children with serious illness and their families. Despite increasing recognition regarding the value of psychology in palliative care, psychologists are not yet routinely integrated into pediatric palliative care (PPC) teams.

OBJECTIVES

This special paper seeks to demonstrate distinctive contributions psychologists can offer to PPC teams, patients, and families, as well as highlight how psychologists enhance the work of their interdisciplinary PPC colleagues.

METHODS

Existing literature, consensus and policy statements, and recently developed competencies inform and provide evidence for the value of incorporating psychologists into PPC.

RESULTS

As children with serious illness are at risk for mental and physical health symptoms, psychologists' specialized training in evidence-based assessment and intervention allows them to assess areas of concern, create treatment plans, and implement nonpharmacological therapies targeting symptom management and promotion of quality of life. By improving patient and family outcomes, psychology involvement saves money. In addition to clinical care, psychologists are skilled researchers, which can help to advance PPC interdisciplinary research. Lastly, psychologists can play a valuable role in contributing to PPC team education, dynamics, and well-being.

CONCLUSIONS

With strong skills in research, clinical care, education, and advocacy, pediatric psychologists are exceptionally equipped to provide care to children with serious illness and their families. Given their unique contributions, it is critical future efforts are directed towards advocating for the inclusion of psychologists into PPC, with the ultimate goal of improving care for children with serious illness and their families.

What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process

OBJECTIVES

Accurate and timely diagnosis relies on close collaboration between patients/families and clinicians. Just as patients have unique insights into diagnostic breakdowns, positive patient feedback may also generate broader perspectives on what constitutes a "good" diagnostic process (DxP).

METHODS

We evaluated patient/family feedback on "what's going well" as part of an online pre-visit survey designed to engage patients/families in the DxP. Patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) were invited to complete the survey between December 2020 and March 2022. We adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with ≥20 words.

RESULTS

In total, 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Of all participants, 1,578 volunteered positive feedback, ranging from 1-79 words. Qualitative analysis of 272 comments with ≥20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). Compared to primary care, subspecialty comments showed the same overall rankings. Within Relationships, patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). Within Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %).

CONCLUSIONS

Patients/families valued relationships with clinicians above all else in the DxP, emphasizing the importance of supporting clinicians to nurture effective relationships and relationship-centered care in the DxP.

Longitudinal faculty development to improve interprofessional collaboration and practice: a multisite qualitative study at five US academic health centres

OBJECTIVES

Interprofessional (IP) collaboration and effective teamwork remain variable in healthcare organisations. IP bias, assumptions and conflicts limit the capacity of healthcare teams to leverage the expertise of their members to meet growing complexities of patient needs and optimise healthcare outcomes. We aimed to understand how a longitudinal faculty development programme, designed to optimise IP learning, influenced its participants in their IP roles.

DESIGN

In this qualitative study, using a constructivist grounded theory approach, we analysed participants' anonymous narrative responses to open-ended questions about specific knowledge, insights and skills acquired during our IP longitudinal faculty development programme and applications of this learning to teaching and practice.

SETTING

Five university-based academic health centres across the USA.

PARTICIPANTS

IP faculty/clinician leaders from at least three different professions completed small group-based faculty development programmes over 9 months (18 sessions). Site leaders selected participants from applicants forecast as future leaders of IP collaboration and education.

INTERVENTIONS

Completion of a longitudinal IP faculty development programme designed to enhance leadership, teamwork, self-knowledge and communication.

RESULTS

A total of 26 programme participants provided 52 narratives for analysis. Relationships and relational learning were the overarching themes. From the underlying themes, we developed a summary of relational competencies identified at each of three learning levels: (1) Intrapersonal (within oneself): reflective capacity/self-awareness, becoming aware of biases, empathy for self and mindfulness. (2) Interpersonal (interacting with others): listening, understanding others' perspectives, appreciation and respect for colleagues and empathy for others. (3) Systems level (interacting within organisation): resilience, conflict engagement, team dynamics and utilisation of colleagues as resources.

CONCLUSIONS

Our faculty development programme for IP faculty leaders at five US academic health centres achieved relational learning with attitudinal changes that can enhance collaboration with others. We observed meaningful changes in participants with decreased biases, increased self-reflection, empathy and understanding of others' perspectives and enhanced IP teamwork.

The Impact of Health and Social Care Professionals' Education on the Quality of Serious Illness Conversations in Nursing Homes: Study Protocol of a Quality Improvement Project

Health and social care professionals (HCPs) who work in nursing homes (NHs) are increasingly required to sustain serious illness conversations about care goals and preferences. Although these conversations may also be challenging for experienced HCPs and the literature recognizes high-quality communication as key to providing patient-centered care, so far, no specific educational program has been developed for the NH setting to improve HCPs' communication skills. Our study aims to test the feasibility and potential effectiveness of an innovative, blended communication skills training program (Teach-to-Communicate) targeting the HCPs who work in NHs. This program includes classroom-based theory, experiential learning, and e-learning, and relies on interdisciplinary contexts and several didactic methods. The study consists of two phases: phase I is the development of written resources that employ focus group discussion involving field experts and external feedback from key stakeholders. Phase II consists of a multicenter, pilot, pre-post study with nested qualitative study. The Teach-to-Communicate training program is expected to enhance the quality of communication in NH and HCPs' confidence in sustaining serious illness conversations, reduce family carers' psycho-emotional burden and improve their satisfaction with the care received, and increase advance care planning documentation. Our protocol will provide insight for future researchers, healthcare providers, and policymakers and pave the way for blended educational approaches in the field of communication skills training.

Dealing with Anxious Patients: A Systematic Review of the Literature on Nonpharmaceutical Interventions to Reduce Anxiety in Patients Undergoing Medical or Dental Procedures

Objectives: State (situational) anxiety can create suboptimal outcomes for patients across a variety of health care specializations. While anxiolytic medications reduce anxiety, problematic side effects can compromise outcomes. These challenges have spurred searches for nonpharmaceutical approaches to alleviate patient anxiety. This systematic literature review, largely following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aimed to determine patterns and effectiveness of interventions across medical health care specialty areas, including dentistry. Methods: A systematic review was conducted, using PubMed, CINAHL, and PsycINFO databases, with search terms related to anxiety, specific interventions, and medical or dental procedures. Hand searching for additional citations was performed on the bibliographies of dissertations, meta-analyses, and systematic reviews that met article inclusion criteria. The search process yielded 48,324 articles and 257 dissertations published in English between 1974 and 2018. Each abstract was evaluated for inclusion by two reviewers, yielding 718 articles that were read and evaluated for outcomes, risk of bias, pretest and post-test, controls and quality, using a Critical Appraisal Skills Programme instrument. Of these, 408 articles, describing 501 experimental trials, were accepted for inclusion in this analysis. Results: A total of 50,343 patients were included in these experiments, with an overall success rate of 71% for reducing patient anxiety. Results are summarized by health care specialty area: surgery, oncology, cardiology, obstetrics/gynecology, dentistry, and pain/trauma, and the following diagnostic testing and intervention areas: imaging, colonoscopy, mechanical ventilation, and other. The largest number of experiments (114) was in the surgery category. The types of interventions included music, education, relaxation, cognitive behavioral therapy (CBT), massage, distraction, hypnosis, acupuncture/acupressure, social support, aromatherapy, nature sounds, natural visual stimuli, special garment, and other. The largest numbers of experiments were done with music (143) and education (130). Discussion: The following interventions were most successful, reducing anxiety in over 70% of experiments: music, CBT, relaxation, massage, acupuncture/acupressure, hypnosis, and natural sounds. Confidence in results is limited by publication bias, small sample sizes, and the lack of placebo controls. Directions for future research are discussed.

Dealing with Anxious Patients: An Integrative Review of the Literature on Nonpharmaceutical Interventions to Reduce Anxiety in Patients Undergoing Medical or Dental Procedures

Objectives: A previous systematic literature review (SLR) evaluated 501 experiments on reducing patient anxiety across medical and dental environments. This integrative review examines those interventions and explores possible mechanisms leading to relative success or failure within those environments, in the interest of interprofessional education and communication. Methods: Reviewers evaluated 501 experiments testing interventions for reducing patient anxiety in a variety of medical and dental health care settings. Methodology for the SLR, largely following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, is briefly reviewed. Results: A total of 501 experiments (from 408 articles) met review criteria. One hundred and forty-three Music experiments were included, and Music interventions were largely effective, except in the case of colonoscopy. Education is the only intervention that occasionally (5 times of 130 experiments) raised patient anxiety in the face of a procedure; the discussion focuses on the wisdom of assessing patient need for information. Thirty-seven Cognitive Behavioral Therapy (CBT) experiments of various types are included, with a success rate of 89%, with a particularly high rate of success (12 of 12 experiments) in dentistry. Massage has a success rate that is similar to that of CBT, but Massage has been tested in far fewer specialty areas. Relaxation has been tested in every specialty area, except mechanical ventilation, with promising results. Acupuncture and Acupressure have not been widely tested, but their effectiveness rate is 100% when it comes to reducing patient anxiety in various procedural settings. Similarly, experiments show Hypnosis to be successful in 90% of trials. In contrast, Distraction was successful in only 40% of the experiments summarized, although it was more effective in dentistry. A variety of Nature-based Interventions (Aromatherapy, Nature Sounds, and Visual Stimuli) were highly successful across a variety of settings. Discussion: Possible mechanisms are discussed, along with commentary on feasibility. Limitations include publication bias, small sample sizes, and the lack of placebo controls. Future areas of research are pointed out.

Twelve Years of the Italian Program to Enhance Relational and Communication Skills (PERCS)

To describe the experience of the Italian Program to Enhance Relations and Communication Skills (PERCS-Italy) for difficult healthcare conversations. PERCS-Italy has been offered in two different hospitals in Milan since 2008. Each workshop lasts 5 h, enrolls 10–15 interdisciplinary participants, and is organized around simulations and debriefing of two difficult conversations. Before and after the workshops, participants rate their preparation, communication, relational skills, confidence, and anxiety on 5-point Likert scales. Usefulness, quality, and recommendation of the program are also assessed. Descriptive statistics, t-tests, repeated-measures ANOVA, and Chi-square were performed. A total of 72 workshops have been offered, involving 830 interdisciplinary participants. Participants reported improvements in all the dimensions (p < 0.001) without differences across the two hospitals. Nurses and other professionals reported a greater improvement in preparation, communication skills, and confidence, compared to physicians and psychosocial professionals. Usefulness, quality, and recommendation of PERCS programs were highly rated, without differences by discipline. PERCS-Italy proved to be adaptable to different hospital settings, public and private. After the workshops, clinicians reported improvements in self-reported competencies when facing difficult conversations. PERCS-Italy’s sustainability is based on the flexible format combined with a solid learner-centered approach. Future directions include implementation of booster sessions to maintain learning and the assessment of behavioral changes.

"It's Not Just About Getting Along": Exploring Learning Through the Discourse and Practice of Interprofessional Collaboration

PURPOSE

Interprofessional collaboration (IPC) is a necessary competency for all professionals. However, IPC can be fraught with politics leading to variable uptake and execution. The authors set out to understand how trainees come to appreciate the value of the "team" in their learning and to describe the type of learning related to IPC afforded to trainees in a highly collaborative complex care context.

METHOD

The authors conducted 72 hours of observations of pediatric rheumatology settings at a large pediatric hospital across 18 months. They interviewed 10 health professionals and analyzed an archive of texts to ascertain how the field of pediatric rheumatology conceptualizes the role of IPC. They used the concept of governmentality and critical discourse analysis to describe how values of collaboration enabled learning and theories of expertise to understand how learning was enacted and perceived.

RESULTS

Collaboration was perceived to be a product of providing good rheumatological care, which in this case, aligned well with hospital model of IPC. This alignment afforded trainees learning opportunities beyond preparing them to get along with other health professionals. IPC, when role modeled during problem solving, created the conditions for learning "why" collaboration is important for clinical expertise.

CONCLUSIONS

By critically examining the relationship between discourse, practice, and learning, the authors have described how practices that underpin collaboration as a clinical competency are distinct from collaboration as cultural work contributing to civility within teams and across the organization.