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Sarin YK, Banerjee C. Ethical Considerations in Pediatric Surgery. J Indian Assoc Pediatr Surg 2024; 29:93-97. [PMID: 38616841 PMCID: PMC11014172 DOI: 10.4103/jiaps.jiaps_223_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/27/2023] [Accepted: 12/27/2023] [Indexed: 04/16/2024] Open
Abstract
Pediatric surgeons need to learn to give as much importance to the ethical approach as they have been giving to the systemic methodology in their clinical approach all along. The law of the land and the governmental rules also need to be kept in mind before deciding the final solution. They need to always put medical problems in the background of ethical context, reach a few solutions keeping in mind the available resources, and apply the best solution in the interest of their pediatric patients.
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Affiliation(s)
- Yogesh Kumar Sarin
- Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India
| | - Chandrima Banerjee
- Department of Anesthesiology and Critical Care, Altnagelvin Area Hospital, Western Health Social Care Trust, Londonderry, Northern Ireland, UK
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2
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Fraser J, Goold I, Akindolie O, Linney M. External second opinions: building trust between health professionals and families. Arch Dis Child 2024; 109:83-87. [PMID: 37290932 DOI: 10.1136/archdischild-2023-325481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/28/2023] [Indexed: 06/10/2023]
Abstract
In medicine, external second opinions are frequently sought to inform decisions around a patient's proposed course of treatment. However, they are also sought in more challenging circumstances such as when disagreement arises between the healthcare team and the family, or during complex end-of-life discussions in critically ill children. When done well, external second opinions can help build trust and reduce conflict. However, when done poorly they may antagonise relationships and thwart attempts to bring about consensus. While principles of good medical practice should always be followed, the actual second opinion process itself remains essentially unregulated in all its forms. In this review, we set out what a standardised and transparent second opinion process should look like and recommend key recommendations for healthcare Trusts, Commissioners and professional bodies to support good practice.
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Affiliation(s)
- James Fraser
- Bristol Royal Hospital for Children Paediatric Intensive Care Unit, Bristol, Bristol, UK
| | - Imogen Goold
- St Anne's College, University of Oxford, Oxford, Oxfordshire, UK
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3
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Neefjes V. Can mediation avoid litigation in conflicts about medical treatment for children? An analysis of previous litigation in England and Wales. Arch Dis Child 2023; 108:715-718. [PMID: 37365005 DOI: 10.1136/archdischild-2022-325033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/30/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE To investigate the reasons why parents disagree with their clinicians in cases reaching the court and to estimate the number of cases in which mediation might have avoided litigation. DESIGN Analysis of 83 published cases regarding medical treatment decisions for children initiated either by an NHS Trust or Local Authority between 1990 and 1 July 2022. RESULTS The analysis found that the main areas of contention are different value judgements, different interpretations of observable events such as the health of the child, their quality of life or burden of treatment and relational issues (ie, loss of trust). More than half of the cases are estimated not to have been preventable by mediation because either no conflict existed (n=13) or the parental decision was based on strongly held, mostly faith-based, views unlikely to be open for discussion (n=31). CONCLUSION The potential of mediation to avoid future litigation may be more limited than hoped for.
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Affiliation(s)
- Veronica Neefjes
- Department of Law, School of Social Sciences, Centre for Social Ethics and Policy, University of Manchester, Manchester, UK
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4
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Bell CE, Dittborn M, Brierley J. What is the impact of high-profile end-of-life disputes on paediatric intensive care trainees? Arch Dis Child 2023; 108:719-724. [PMID: 37365006 DOI: 10.1136/archdischild-2022-325048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/30/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION This study explores UK paediatric intensive care (PIC) trainees' thoughts and feelings about high-profile end-of-life cases recently featured in the press and social media and the impact on their career intentions. METHODS Semi-structured interviews were conducted with nine PIC-GRID trainees (April to August 2021). Interview transcripts were analysed using thematic analysis. RESULTS Six main themes were identified: (1) All participants wished to do what was best for the child, feeling conflicted if this meant disagreeing with parents. (2) Interviewees felt unprepared and expressed deep concern about the effect of high-profile cases on their future career; all had reconsidered their training in PIC due to concerns about future high-profile end-of-life disputes, despite this all were still in training. (3) Specific training on the ethical and legal nuances of such cases is required, alongside targeted communication skills. (4).All cases are unique. (5) All had purposefully minimised their social media presence. (6) Working in a supportive environment is crucial, underscoring the importance of clear and unified team communication. CONCLUSION UK PIC trainees feel unprepared and anxious about future high-profile cases. A parallel can be drawn to child protection improvements following significant educational investment after government reports into preventable child abuse deaths. Models for supporting trainees and establishing formal PIC training are required to improve trainees' confidence and skills in managing high-profile cases. Further research with other professional groups, the families involved and other stakeholders would provide a more rounded picture.
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Affiliation(s)
- Clare Emily Bell
- Stoke Manderville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Mariana Dittborn
- Paediatric Bioethics Centre, Great Ormond Street Hospital For Children NHS Trust, London, UK
| | - Joe Brierley
- Paediatric Bioethics Centre, Great Ormond Street Hospital For Children NHS Trust, London, UK
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5
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Sinclair J, Palokas M. Conflict resolution in a pediatric inpatient unit: a best practice implementation project. JBI Evid Implement 2023; 21:138-145. [PMID: 36775817 DOI: 10.1097/xeb.0000000000000364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
OBJECTIVES The aim of this project was to promote evidence-based practices regarding conflict resolution in the hospital setting on a pediatric inpatient unit. INTRODUCTION Conflict is an inevitable reality in healthcare organizations. Evidence suggests that to facilitate constructive conflict resolution among staff, organizational-level education, as well as formal policies and procedures are both necessary. METHODS A baseline audit on conflict resolution utilizing the JBI Practical Application of Clinical Evidence System program was undertaken and involved 34 nurses and two nursing assistants. The implementation project used a three-phase approach, with audits and feedback for the evaluation of compliance with best practices. Following baseline audits, an intervention, including conflict resolution education, was implemented, and recommendations to update the current policy and procedure were communicated to unit leadership. Then a postimplementation audit was undertaken. RESULTS Postimplementation audits revealed improvements in compliance across all seven audit criteria. The greatest improvement was for audit criterion 4, having a structured formal process for remediation if conflict occurs, and criterion 7, having a follow-up of agreed solutions occur, which garnered 75 and 83% improvements, respectively. CONCLUSION For all seven audit criteria, compliance improved from 24% at baseline to 71% after the implementation of an educational module regarding conflict resolution strategies, tools, and best practices and a recommendation to update the existing policy to include the use of a conflict resolution documentation tool. Recommendations for the next steps include making educational materials and visual reminders about conflict resolution strategies readily available and easily accessible to staff.
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Affiliation(s)
- Jessica Sinclair
- School of Nursing, University of Mississippi Medical Center
- Mississippi Centre for Evidence-Based Practice: A JBI Centre of Excellence, Jackson, Mississippi, USA
| | - Michelle Palokas
- School of Nursing, University of Mississippi Medical Center
- Mississippi Centre for Evidence-Based Practice: A JBI Centre of Excellence, Jackson, Mississippi, USA
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6
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Miles F, Barclay S, Menson E, Shepherd T, Webster L. Boldly going… Introducing conflict management training to Starship Children's Hospital. J Paediatr Child Health 2023; 59:424-426. [PMID: 36728113 DOI: 10.1111/jpc.16347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/19/2023] [Indexed: 02/03/2023]
Abstract
Conflict between health professionals and whānau (families) in paediatric hospitals is common and leads to significant distress for families and staff. The likelihood of challenges and conflict around communication and critical medical decision-making is increased where there are cultural and social complexities. Training staff to recognise and manage conflict as early as possible improves patient/whānau outcomes and staff well-being. This article describes an ongoing collaboration between Starship Children's Hospital in Auckland New Zealand (NZ) and the UK Medical Mediation Foundation (MMF) focused on educating staff in the early recognition and management of conflict using mediation skills. An evidence-based training programme and structured ongoing supervision of a small group of champions has enabled this training to be embedded into Starship clinical practice. The collaboration has included careful consideration of the New Zealand setting, ensuring that the content of the programme specifically addresses our unique cultural and social context. Mediation skills are an important step in ensuring that our patients and whānau feel heard, acknowledged, and respected, and contribute to the Starship Child Health's strategic priority of eliminating inequity and addressing institutional bias.
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Affiliation(s)
- Fiona Miles
- Paediatric Intensivist, PICU, Starship Children's Hospital, Auckland, New Zealand
| | - Sarah Barclay
- Medical Mediation Foundation, Director Evelina Resolution Project, London, United Kingdom
| | - Esse Menson
- Mediator and Trainer, Medical Mediation Foundation, London, United Kingdom
| | - Toni Shepherd
- Starship Māori Health Director, Starship Children's Hospital, Auckland, New Zealand
| | - Louise Webster
- Child and Adolescent Psychiatrist, Paediatric Consult Liaison Team, Starship Children's Hospital, Auckland, New Zealand
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7
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Birchley G, Thomas-Unsworth S, Mellor C, Baquedano M, Ingle S, Fraser J. Factors affecting decision-making in children with complex care needs: a consensus approach to develop best practice in a UK children's hospital. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001589. [PMID: 36645756 PMCID: PMC9528619 DOI: 10.1136/bmjpo-2022-001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Children with complex care needs are a growing proportion of the sick children seen in all healthcare settings in the UK. Complex care needs place demands on parents and professionals who often require many different healthcare teams to work together. Care can be both materially and logistically difficult to manage, causing friction with parents. These difficulties may be reduced if common best practice standards and approaches can be developed in this area. OBJECTIVE To develop a consensus approach to the management of complexity among healthcare professionals, we used a modified Delphi process. The process consisted of a meeting of clinical leaders to develop candidate statements, followed by two survey rounds open to all professionals in a UK children's hospital to measure and establish consensus recommendations. RESULTS Ninety-nine professionals completed both rounds of the survey, 69 statements were agreed. These pertained to seven thematic areas: standardised approaches to communicating with families; processes for interprofessional communication; processes for shared decision-making in the child's best interests; role of the multidisciplinary team; managing professional-parental disagreement and conflict; the role of clinical psychologists; and staff support. Overall, the level of consensus was high, ranging from agreement to strong agreement. CONCLUSIONS These statements provide a consensus basis that can inform standardised approaches to the management of complexity. Such approaches may decrease friction between parents, children and healthcare professionals.
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Affiliation(s)
- Giles Birchley
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | | | - Charlotte Mellor
- Paediatric Palliative Care and Bereavement Support, Bristol Royal Hospital for Children, Bristol, UK
| | - Mai Baquedano
- Translational Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Susanne Ingle
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK.,Paediatric Critical Care Society, London, UK
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8
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Jesmont C, Wood K, O'Brien C, Tse Y. Prevalence and sources of tension in paediatric inpatient care. Arch Dis Child 2021; 106:1238-1239. [PMID: 33727238 DOI: 10.1136/archdischild-2020-321232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Ceit Jesmont
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Katy Wood
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Chris O'Brien
- Paediatric Respiratory Unit, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Yincent Tse
- Department of Paediatric Nephrology, Great North Children's Hospital, Newcastle Upon Tyne, UK .,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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9
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Parsons E, Darlington AS. Parents' perspectives on conflict in paediatric healthcare: a scoping review. Arch Dis Child 2021; 106:981-986. [PMID: 33593741 DOI: 10.1136/archdischild-2020-320975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/01/2021] [Accepted: 01/30/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Conflict in paediatric healthcare is becoming increasingly prevalent, in particular relation to paediatric end of life. This is damaging to patients, families, professionals and healthcare resources. Current research has begun to explore perspectives of healthcare professionals (HCPs), but the parental views on conflict are lacking. OBJECTIVES This scoping review explores parental views on conflict during a child's end of life. In addition, parental views are mapped onto HCPs' views. METHODS A search was completed of the databases CINAHL, PubMed, Web of Science, Embase and Medline between 1997 and 2019, focused on parents of children with involvement with palliative or end-of-life care referring to conflict or disagreements. RESULTS The review found 10 papers that included parental views on conflict. Data on conflict were categorised into the following seven themes: communication breakdown, trust, suffering, different understanding of 'best interest', disagreements over treatment, spirituality and types of decision-making. In particular, parental expertise, perspectives on suffering and ways of making decisions were significant themes. A subset of themes mirror those of HCPs. However, parents identified views of conflict unique to their perspective. CONCLUSIONS Parents identified important themes, in particular their perspective of what constitutes suffering and 'best interest'. In addition, parents highlight the importance of being recognised as an expert.
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Affiliation(s)
- Emily Parsons
- Savannah Neurology, Evelina London Children's Hospital, London, UK .,Health Sciences, University of Southampton, Southampton, UK
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10
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Fahy AS, Mueller C, Fecteau A. Conflict resolution and negotiation in pediatric surgery. Semin Pediatr Surg 2021; 30:151100. [PMID: 34635278 DOI: 10.1016/j.sempedsurg.2021.151100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Conflict is pervasive in pediatric surgery - it is experienced during patient care, in the operating room and between colleagues. The ethical principles of autonomy, beneficience, non-maleficience and justice are firmly anchored in any discourse regarding conflict in the setting of healthcare. The authors review key features of conflict in healthcare including the effect on patient outcomes as well as implications for the ability of the surgeon and the medical team to function appropriately and safely when conflicts arise. Although most pediatric surgery fellowship programs have no formal training in conflict management, much has been written about strategies to teach and utilize techniques of conflict mitigation and negotiation. In this article, the authors discuss common areas of conflict in the medical environment and suggest useful tools for the practicing pediatric surgeon to aid in the resolution of conflict.
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Affiliation(s)
- Aodhnait S Fahy
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Claudia Mueller
- Pediatric General Surgery, Lucile Packard Children's Hospital Stanford, San Francisco, CA, USA
| | - Annie Fecteau
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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11
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Moynihan KM, Taylor L, Crowe L, Balnaves MC, Irving H, Ozonoff A, Truog RD, Jansen M. Ethical climate in contemporary paediatric intensive care. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106818. [PMID: 33431646 DOI: 10.1136/medethics-2020-106818] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 06/12/2023]
Abstract
Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Taylor
- Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Liz Crowe
- Department of Pediatric Intensive Care, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Mary-Claire Balnaves
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen Irving
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Al Ozonoff
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melanie Jansen
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Pediatric Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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12
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Lyons O, Forbat L, Menson E, Chisholm JC, Pryde K, Conlin S, Felton V, Ingle S, McKenzie C, Ramachandran R, Sayer C, Snowball C, Strachan-Gadsby E, Tisovszky N, Barclay S. Transforming training into practice with the conflict management framework: a mixed methods study. BMJ Paediatr Open 2021; 5:e001088. [PMID: 34926836 PMCID: PMC8628327 DOI: 10.1136/bmjpo-2021-001088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 11/03/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To implement and evaluate the use of the conflict management framework (CMF) in four tertiary UK paediatric services. DESIGN Mixed methods multisite evaluation including prospective pre and post intervention collection of conflict data alongside semistructured interviews. SETTING Eight inpatient or day care wards across four tertiary UK paediatric services. INTERVENTIONS The two-stage CMF was used in daily huddles to prompt the recognition and management of conflict. RESULTS Conflicts were recorded for a total of 67 weeks before and 141 weeks after implementation of the CMF across the four sites. 1000 episodes of conflict involving 324 patients/families across the four sites were recorded. After implementation of the CMF, time spent managing episodes of conflict around the care of a patient was decreased by 24% (p<0.001) (from 73 min to 55 min) and the estimated cost of this staff time decreased by 20% (p<0.02) (from £26 to £21 sterling per episode of conflict). This reduction occurred despite conflict episodes after implementation of the CMF having similar severity to those before implementation. Semistructured interviews highlighted the importance of broad multidisciplinary leadership and training to embed a culture of proactive and collaborative conflict management. CONCLUSIONS The CMF offers an effective adjunct to conflict management training, reducing time spent managing conflict and the associated staff costs.
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Affiliation(s)
- Oscar Lyons
- Nuffield Department of Surgical Sciences, Oxford University, Oxford, UK
| | - Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Julia C Chisholm
- Paediatric Oncology, Royal Marsden Hospital NHS Trust, London, UK
| | - Kate Pryde
- Paediatrics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Susanne Ingle
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | | | | | | | - Carly Snowball
- Children and Young People's Unit, Royal Marsden Hospital NHS Trust, London, UK
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13
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Allen KY, Davis A. The hard talk: Managing conflict in the cardiac intensive care unit. PROGRESS IN PEDIATRIC CARDIOLOGY 2020; 59:101306. [PMID: 33071530 PMCID: PMC7547626 DOI: 10.1016/j.ppedcard.2020.101306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
Conflict between parents and providers is common in the cardiac intensive care setting, particularly in patients with prolonged length of stay. Poor communication is the most commonly cited reason for conflict and is exacerbated when providers and families cannot find common ground and develop mutual trust. It is critically important that healthcare providers learn strategies to better partner with families in order to optimize patient medical and psychosocial outcomes. This requires providers to avoid falling prey to their own implicit (or unconscious) biases, including those towards families labeled as “difficult”. Building a healthy family-provider relationship is part of a healthcare provider's duty to treat, has a measurable effect on patient outcomes, and sets up a foundation for the provider-family dyad to more easily navigate any conflicts that do develop. Once a relationship is built, providers and families can talk through their conflicts. They are more likely to have open and transparent communication and are more able to give each other the benefit of the doubt when navigating difficult situations and/or behaviors, rather than labeling each other as intrinsically “difficult” people. The healthcare team is designed to work together like chess pieces on a chess boardParents supporting critically ill hospitalized children may feel more like metaphorical checkers – isolated and out of place. The everyday stresses of living in the cardiac intensive care unit frequently lead to parent-provider conflict. Conflict occurs on a foundation of previous experiences of both parent and provider; these associated biases contribute to conflict escalation. Avoiding labels and approaching difficult situations with empathy and self-reflection helps arrest the cycle of conflict and build mutual trust.
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Affiliation(s)
- Kiona Y Allen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Division of Cardiology & Critical Care Medicine, 225 East Chicago Ave., Chicago, IL 60611, USA
| | - Audra Davis
- The Exeter Group, Managing Partner, 180 North Wabash Ave, Suite 815, Chicago, IL 60601, USA
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14
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Mazzetti G, Guglielmi D, Topa G. Hard Enough to Manage My Emotions: How Hardiness Moderates the Relationship Between Emotional Demands and Exhaustion. Front Psychol 2020; 11:1194. [PMID: 32625138 PMCID: PMC7315777 DOI: 10.3389/fpsyg.2020.01194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/07/2020] [Indexed: 11/13/2022] Open
Abstract
The frequency of conflicts with patients' families is one of the main contributors to the amount of emotional demands that healthcare professionals must tackle to prevent the occurrence of burnout symptoms. On the other hand, research evidence suggests that hardiness could enable healthcare professionals to handle their responsibilities and problems effectively. Based on the health impairment process of the Job Demands-Resources model, the main goal of this study was to delve deeper into the relationship between conflict with patients' families, emotional demands, and exhaustion, as well as to test the buffering role of hardiness. Data were collected from a sample of N = 295 healthcare professionals working in a private hospital in Northern Italy. Most of them were women (78.6%) with a mean age of 40.62 years (SD = 9.50). The mediation of emotional demands within the association between conflict with families and emotional exhaustion and the moderating role of hardiness was tested using a bootstrapping approach. In the current sample, emotional demands mediated the association between conflict with families and exhaustion among healthcare professionals. Moreover, this relationship decreased among individuals with higher levels of hardiness. These findings contribute to the current understanding of the negative impact played by conflict with families on healthcare professionals' psychological well-being. Furthermore, they corroborated the role of hardiness as a personal resource that could prevent the occurrence of burnout symptoms. In addition to manage-and decrease-episodes of conflict with patients and their families, organizations in the healthcare sector should develop interventions aimed at fostering employees' hardiness and, consequently, tackle job demands ingrained in their profession (i.e., emotional demands).
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Affiliation(s)
- Greta Mazzetti
- Department of Education Studies, University of Bologna, Bologna, Italy
| | - Dina Guglielmi
- Department of Education Studies, University of Bologna, Bologna, Italy
| | - Gabriela Topa
- Department of Psychology, Universidad Nacional de Educación a Distancia, Madrid, Spain
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15
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Taylor A. Withdrawal of treatment from critically ill children: legal and ethical issues. Nurs Child Young People 2020; 31:20-24. [PMID: 31486596 DOI: 10.7748/ncyp.2019.e1224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 11/09/2022]
Abstract
Withdrawal of treatment from critically ill children is a contentious and ethically difficult area. The principle of best interests was central to three recent high-profile legal cases and raised questions about how this is demonstrated in healthcare for children whose treatment may be of no benefit to them. This article discusses the legal and ethical aspects of caring for such children. Nurses are important advocates and should balance their obligation to deliver holistic and family-centred care with that of keeping the child as the central focus, particularly with decision-making. In cases of disagreement between families and clinicians, children's voices are particularly vulnerable to being lost. Pre- and post-registration education, research and a higher profile for nurses in multidisciplinary decision-making are suggested as ways to improve the nursing contribution to this important debate.
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Affiliation(s)
- Alison Taylor
- School of Health Sciences, University of Brighton, England
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16
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Cass H, Barclay S, Gerada C, Lumsden DE, Sritharan K. Complexity and challenge in paediatrics: a roadmap for supporting clinical staff and families. Arch Dis Child 2020; 105:109-114. [PMID: 31186292 DOI: 10.1136/archdischild-2018-315818] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/01/2019] [Accepted: 05/17/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Hilary Cass
- Neurosciences Department, Evelina London Children's Hospital, London, UK
| | | | | | - Daniel E Lumsden
- Neurosciences Department, Evelina London Children's Hospital, London, UK.,Dept of Women's and Children's Health, King's College London, London, UK
| | - Kaji Sritharan
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK.,Royal Society of Medicine, London, UK
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17
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Gottardo NG. 'Walking their walk': reducing conflict between families of ill children and the medical profession. Arch Dis Child 2020; 105:87-89. [PMID: 31431435 DOI: 10.1136/archdischild-2019-317387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/24/2019] [Accepted: 07/28/2019] [Indexed: 11/04/2022]
Abstract
In recent years, several high-profile court cases generated headlines across the globe. Notably, they brought conflict between families of seriously ill children and the medical profession to the forefront. These conflicts, especially when the courts become involved, are highly destructive to all parties concerned, as the focus inevitably shifts from the child to the conflict itself. Often, at the heart of conflict, is a lack of effective communication between a patient's family and their health providers. In order to assist health workers in the prevention, recognition and management of conflict in paediatrics, a Conflict Management Framework (CMF) and a set of guidelines endorsed by the Royal College of Paediatrics and Child Health (RCPCH) have been developed. Here, I review recent high-profile court cases to underscore the changing landscape of conflict and the central role that the media (and social media in particular) can play in fuelling and intensifying conflicts. The CMF and RCPCH-endorsed guidelines are discussed in the context of my own experience utilising some of these, as well as implementing other strategies aimed at reducing conflict in a paediatric oncology and haematology unit.
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Affiliation(s)
- Nicholas G Gottardo
- Department of Paediatric and Adolescent Oncology/Haematology, Perth Children's Hospital, Nedlands, Western Australia, Australia .,Brain Tumour Research Programme, Telethon Kids Institute, Nedlands, Western Australia, Australia.,School of Medicine, Pediatrics, The University of Western Australia, Perth, Western Australia, Australia
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18
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Richie M, Josephson SA. Team conflict and the neurologist. Neurol Clin Pract 2019; 10:178-183. [PMID: 32309037 DOI: 10.1212/cpj.0000000000000694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/19/2019] [Indexed: 01/19/2023]
Abstract
Collaboration within a complicated organization is inherently challenging and can be fraught with discord. Recent emphasis on interdisciplinary and collaborative teamwork in neurology has brought this issue to the forefront of daily practice. The health care system can be complex and opaque, and the stakes-human life-are high. Medical team conflict has been associated with decreased subjective effectiveness, less job satisfaction, and increase in errors. As specialists, neurologists are necessarily embedded within a network of providers and must be adept in the understanding and management of conflictual situations. For the practicing neurologist, it is important to understand team conflict dynamics. Here, management strategies are provided that illustrate how individual neurologists can serve as effective leaders who mitigate harmful effects and capitalize on benefits of team conflict on performance.
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Affiliation(s)
- Megan Richie
- Department of Neurology, University of California, San Francisco
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19
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Forbat L, Mnatzaganian G, Barclay S. The Healthcare Conflict Scale: development, validation and reliability testing of a tool for use across clinical settings. J Interprof Care 2019; 33:680-688. [DOI: 10.1080/13561820.2019.1593117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Liz Forbat
- Faculty of Social Science, University of Stirling, Stirling, Scotland
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20
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Forbat L, Barclay S. Reducing healthcare conflict: outcomes from using the conflict management framework. Arch Dis Child 2019; 104:328-332. [PMID: 30154178 DOI: 10.1136/archdischild-2018-315647] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test a new conflict management framework (CMF) to help staff identify and de-escalate conflict between staff and patients/families. DESIGN Before/after study that reports staff quality of life, frequency/severity of conflicts and qualitative interviews on using the framework. Data were collected from May 2017 to September 2017. SETTING A paediatric oncology department day-patient and 23-bed inpatient ward. INTERVENTION A two-stage CMF used by staff during daily handovers to identify and then manage conflict cases with families. RESULTS Staff found the CMFto be helpful in identifying and de-escalating conflicts. The number of conflicts reported decreased by 64% from baseline to follow-up. Communication regarding conflict identification improved. Reports of staff burn-out decreased between the two time-points (n=55 at baseline, n=31 at follow-up; p=0.001). Scores on compassion and secondary traumatic stress did not change. CONCLUSIONS The CMF substantially reduces the incidence of conflicts and is an acceptable approach for staff. Continued use of the framework would require it to be fully integrated into the working of the ward, which would need to include senior medical buy-in. Further refinements to the framework have been made and will be tested in four UK sites in 2018/2019.
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Affiliation(s)
- Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
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21
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Beattie RM. Conflict, candour and reflection. Arch Dis Child 2019; 104:309-310. [PMID: 30352810 DOI: 10.1136/archdischild-2018-316002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/06/2018] [Indexed: 11/03/2022]
Affiliation(s)
- R Mark Beattie
- Paediatric Gastroenterology, Southampton Children's Hospital, University Hospital Southampton, Southampton SO16 6YD, UK
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22
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Martin K, Morton L, Reid J, Feltham A, William Reid J, Jeremy G, McCulloch J. The Me first communication model. Nurs Child Young People 2019; 31:38-47. [PMID: 31468770 DOI: 10.7748/ncyp.2019.e1064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2018] [Indexed: 06/10/2023]
Abstract
This article explores communication and decision-making with children and young people in healthcare. Children and young people report that healthcare professionals are good at explaining and helping them to understand what will happen to them, but that they do not feel involved in decision-making about their care or treatment. To improve communication with children and young people, they need to be involved in decision-making about their care and treatment. In partnership with children, young people and healthcare professionals Common Room Consulting, Great Ormond Street Hospital for Children NHS Foundation Trust and Health Education England have co-produced a communication model, Me first, to support decision-making with children and young people in healthcare. This article introduces the Me first model and explores how it can be applied in clinical practice.
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Affiliation(s)
| | - Louise Morton
- Healthcare education, Health Education England, England
| | - Joanna Reid
- Non-medical education, Great Ormond Street Hospital for Children NHS Foundation Trust, London, England
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23
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Sinskey JL, Chang JM, Shibata GS, Infosino AJ, Rouine-Rapp K. Applying Conflict Management Strategies to the Pediatric Operating Room. Anesth Analg 2019; 129:1109-1117. [PMID: 30633050 DOI: 10.1213/ane.0000000000003991] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Effective communication is essential in today's health care environment, and poor communication can lead to conflict among health care providers. Differences in cultures and beliefs can further incite conflict among health care team members, families, and patients. Pediatric patient care has a higher potential for conflict because decision-making responsibilities are shared among patients, parents/guardians, and clinicians. It is important to understand the phases and types of conflict because each conflict situation requires a different approach to optimize management. Equally important is an understanding of styles used by individuals to manage conflict. The Thomas-Kilmann Conflict Mode Instrument and the Dutch Test for Conflict Handling are 2 validated tools used to assess conflict management styles. The different styles include competing/forcing, collaborating/problem solving, compromising, avoiding, and yielding/accommodating. A successful physician should be able to identify the phases and types of conflict to use the conflict management approach most suitable for the given conflict.There are several techniques for managing conflict in the pediatric operating room. Acknowledging and managing one's own emotions during conflict is a pivotal first step toward diffusing the situation. Active listening is an important communication skill that improves team dynamics. Aligning the interests of the parties involved in conflict will encourage collaborative problem solving. Cultural competency training can improve communication and conflict management skills. Effective conflict management through formal education of all perioperative team members can lead to improved communication and teamwork and better patient outcomes.
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Affiliation(s)
- Jina L Sinskey
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
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24
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Lantos JD. Best Interest, Harm, God's Will, Parental Discretion, or Utility. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:7-8. [PMID: 30133402 DOI: 10.1080/15265161.2018.1504502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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25
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Coad J, Smith J, Pontin D, Gibson F. Consult, Negotiate, and Involve: Evaluation of an Advanced Communication Skills Program for Health Care Professionals. J Pediatr Oncol Nurs 2018; 35:296-307. [DOI: 10.1177/1043454218765136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Effective communication is central to children, young people, and their families’ experiences of health care. Most patient complaints in developed health care systems result from ineffective communication, including inadequate information provision, not feeling listened to, failure to value patients concerns, and patients not feeling involved in care decisions. Advanced communication skills training is now embedded within cancer care policy in the United Kingdom and now features prominently within cancer education in many countries. Here, we share findings from a research evaluation of an advanced communication skills training program dedicated to health professionals caring for children and young people with cancer. We evaluated participants’ (n = 59) perceptions of the program, impact on their skills, knowledge, competence, and confidence. An appreciative inquiry design was adopted; data included interviews, precourse-postcourse evaluations, e-mail blog survey, and 360-degree reflective work records. The framework approach underpinned data analysis and triangulation of data sets. Key findings highlighted good and poor practice in health professionals’ engagement with children, young people, and their families; the purpose of communicating effectively was not always consistent with collaborative working. Attending a program helped participants expand their knowledge of communication theories and strategies. Participants valued using simulated scenarios to develop their skills and were keen to use their new skills to enhance care delivery. Our emphasis within this evaluation, however, remained on what was communicated, when and how, rather than to what effect. The impact of programs such as these must now be evaluated in terms of patient benefit.
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26
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Balan S, Hassali M, Mak V. Non-regulatory related factors leading to off-label prescribing in children: A concept map. Res Social Adm Pharm 2017; 13:1219-1221. [DOI: 10.1016/j.sapharm.2017.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 05/23/2017] [Indexed: 11/16/2022]
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27
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François K, Lobb E, Barclay S, Forbat L. The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members. PATIENT EDUCATION AND COUNSELING 2017; 100:1459-1465. [PMID: 28268054 DOI: 10.1016/j.pec.2017.02.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/16/2017] [Accepted: 02/20/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Conflict is a significant and recurring problem in healthcare. This study aimed to understand staff and relatives' perspectives on the characteristics of conflict and serious disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care. METHODS Qualitative study of 25 staff and seven bereaved relatives using individual interviews, recruited from a multidisciplinary specialist palliative care setting in Australia. Data were analysed thematically. RESULTS Communication was frequently cited as a cause of conflict. Further, different understandings regarding disease process, syringe drivers and providing nutrition/hydration caused conflict. Staff applied empathy to moderate their responses to conflict. Relatives' reactions to conflict followed a trend of anger/frustration followed by explanations or justifications of the conflict. Relatives identified systemic rather than interpersonal issues as triggering conflict. CONCLUSIONS The data illustrate connections with conflict literature in other clinical areas, but also points of convergence such as the compassion shown by both families and staff, and the identification of systemic rather than always individual causes. PRACTICE IMPLICATIONS Family meetings may fruitfully be applied to prevent and de-escalate conflict. Clinical audits may be useful to identify and provide support to families where there may be unresolved conflict impacting grief process.
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Affiliation(s)
- Karemah François
- Calvary Centre for Palliative Care Research, Calvary Health Care ACT, Canberra, Australia; School of Health Sciences, Australian Catholic University, Canberra, Australia.
| | - Elizabeth Lobb
- Calvary Health Care Kogarah and Cunningham Centre for Palliative Care, Sydney, Australia; School of Medicine, Univeristy of Notre Dame, Darlinghurst, Australia.
| | - Sarah Barclay
- Medical Mediation Foundation, London, United Kingdom.
| | - Liz Forbat
- Calvary Centre for Palliative Care Research, Calvary Health Care ACT, Canberra, Australia; School of Health Sciences, Australian Catholic University, Canberra, Australia.
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28
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Borrott N, Kinney S, Newall F, Williams A, Cranswick N, Wong I, Manias E. Medication communication between nurses and doctors for paediatric acute care: An ethnographic study. J Clin Nurs 2017; 26:1978-1992. [DOI: 10.1111/jocn.13606] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Narelle Borrott
- Melbourne School of Health Sciences The University of Melbourne Parkville VIC Australia
| | - Sharon Kinney
- Nursing Research The Royal Children's Hospital Melbourne Parkville VIC Australia
- Departments of Nursing and Paediatrics The University of Melbourne Parkville VIC Australia
| | - Fiona Newall
- Nursing Research The Royal Children's Hospital Melbourne Parkville VIC Australia
- Departments of Nursing and Paediatrics The University of Melbourne Parkville VIC Australia
- Murdoch Childrens Research Institute Parkville VIC Australia
- Clinical Haematology Royal Children's Hospital Parkville VIC Australia
| | - Allison Williams
- School of Nursing and Midwifery Monash University Clayton VIC Australia
| | - Noel Cranswick
- Clinical Pharmacology Unit Department of Medicine Royal Children's Hospital Parkville VIC Australia
- Australian Paediatric Pharmacology Research Unit (APPRU) Murdoch Childrens Research Institute & The Royal Children's Hospital Parkville VIC Australia
- The University of Melbourne Parkville VIC Australia
| | - Ian Wong
- School of Pharmacy University College London London UK
| | - Elizabeth Manias
- School of Nursing and Midwifery Faculty of Health Deakin University Burwood VIC Australia
- The Royal Melbourne Hospital The University of Melbourne Parkville VIC Australia
- Melbourne School of Health Sciences The University of Melbourne Burwood VIC Australia
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29
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Forbat L, Simons J, Sayer C, Davies M, Barclay S. Training paediatric healthcare staff in recognising, understanding and managing conflict with patients and families: findings from a survey on immediate and 6-month impact. Arch Dis Child 2017; 102:250-254. [PMID: 27098546 DOI: 10.1136/archdischild-2016-310737] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 03/23/2016] [Accepted: 03/25/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Conflict is a recognised component of healthcare. Disagreements about treatment protocols, treatment aims and poor communication are recognised warning signs. Conflict management strategies can be used to prevent escalation, but are not a routine component of clinical training. OBJECTIVE To report the findings from a novel training intervention, aimed at enabling paediatric staff to identify and understand the warning signs of conflict, and to implement conflict resolution strategies. DESIGN AND SETTING Self-report measures were taken at baseline, immediately after the training and at 6 months. Questionnaires recorded quantitative and qualitative feedback on the experience of training, and the ability to recognise and de-escalate conflict. The training was provided in a tertiary teaching paediatric hospital in England over 18 months, commencing in June 2013. INTERVENTION A 4-h training course on identifying, understanding and managing conflict was provided to staff. RESULTS Baseline data were collected from all 711 staff trained, and 6-month follow-up data were collected for 313 of those staff (44%). The training was successful in equipping staff to recognise and de-escalate conflict. Six months after the training, 57% of respondents had experienced conflict, of whom 91% reported that the training had enabled them to de-escalate the conflict. Learning was retained at 6 months with staff more able than at baseline recognising conflict triggers (Fischer's exact test, p=0.001) and managing conflict situations (Pearson's χ2 test, p=0.001). CONCLUSIONS This training has the potential to reduce substantially the human and economic costs of conflicts for healthcare providers, healthcare staff, patients and relatives.
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Affiliation(s)
- Liz Forbat
- Australian Catholic University and Calvary Health Care, Canberra, Australian Capital Territory, Australia
| | | | - Charlotte Sayer
- Evelina London Children's Hospital, St Thomas' Hospital, London, UK
| | - Megan Davies
- Evelina London Children's Hospital, St Thomas' Hospital, London, UK
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30
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Isaacs D. Anger and aggression in paediatrics. J Paediatr Child Health 2016; 52:689-90. [PMID: 27439629 DOI: 10.1111/jpc.13254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- David Isaacs
- Children's Hospital at Westmead, Sydney, New South Wales, Australia.
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