Breaking Bad News in obstetrics: a randomized trial of simulation followed by debriefing or lecture

Interventions Used to Improve Communication Competencies in Surgical Residencies: A Systematic Review

OBJECTIVE

To explore which educational interventions have been used to address communication skill in surgical residents.

DESIGN

Systematic review.

RESULTS

Several interventions have been used to improve communication skill in residency, including simulation, standardized patients, and didactic teaching. These interventions vary widely, yet the majority of interventions tend to result in improvement in resident communication skill.

CONCLUSIONS

Communication is an essential skill for surgical trainees to learn. Integration of communication-focused educational interventions can lead to improved skill development in surgical residents.

[Fetal death: Expert consensus from the College of French Gynecologists and Obstetricians]

Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient's wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it's the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.

Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study

Background

There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved.

Objectives

To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement.

Design

A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases.

Setting

National recruitment (study phases 1 and 3); three English maternity services (study phase 2).

Participants

We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families.

Results

The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced.

Limitations

Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups.

Conclusions

We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research.

Study registration

This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (NIHR award ref: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.

A Cross-Sectional Survey of Healthcare Professionals' Knowledge, Attitude and Current Behaviours towards Female Fertility Preservation Services within the UK

(1) Background: This study aims to establish the knowledge, attitudes and current behaviours towards female fertility preservation (FP) services amongst healthcare professionals (HCPs) in the UK. (2) Methods: An online survey was advertised publicly on the social media platform Instagram between 25 February 2021 and 11 March 2021. (3) Results: In total, 415 participants fulfilled the inclusion criteria and completed the survey. The majority of HCPs discussed FP techniques either never 39.5% (n = 164), once a year 20.7% (n = 86) or once a month 17.8% (n = 74). The majority rated their knowledge of each type of FP method as 'very poor' or 'poor' and strongly disagreed 14.2% (n = 59) or disagreed 42.2% (n = 175) with the statement they 'felt confident to counsel a patient on FP'. The majority either agreed 37.8% (n = 157) or strongly agreed 22.2% (n = 92) that it was their responsibility to discuss FP and 38.1% (n = 158) agreed or strongly agreed 19.5% (n = 81) they considered the desire for future fertility when planning treatment. The majority 87.2% (n = 362) had not experienced formal training on FP. (4) Conclusions: Discrepancies in knowledge remain regarding techniques of FP, referral pathways, awareness of facilities offering services and existing educational resources. Many HCPs recognise the importance of FP and their responsibility to initiate discussions. The knowledge that FP may not delay the treatment of cancer has also improved; however, training in FP is scarce.

Interdisciplinary Simulation Courses to Train Residents on Communication of Unexpected Complications from Perioperative Care: A Randomized Comparison of Within-Event (Microdebriefing) and Postscenario Debriefing

INTRODUCTION

Training to disclose bad news in a pluridisciplinary format facilitates communication and improves learning. There are many different debriefing methods described in the literature. The aim of this study was to compare and evaluate the value of final debriefing and microdebriefing with interruptions of the scenario in a simulation program about communication in unexpected complications from perioperative care.

METHODS

We conducted a prospective, randomized, single center study between October 2018 and July 2019 in a simulation center. Three scenarios were related to patient or family disclosure of complications which had occurred during gynecologic surgery by a dyad involving 2 residents (a gynecology and an anesthesia resident). All sessions involved 6 residents (3 gynecologist and 3 anesthesiologist). The main outcome measure was the immediate residents' self-assessment of the impact of the course on their medical practice immediately after the session.

RESULTS

We performed 15 simulation sessions including 80 residents. Thirty-nine residents were included in final debriefing group and 41 in micro-debriefing group. There was no significant difference on the impact for medical practice between groups (9.3/10 in the micro-debriefing group versus 9.2 in the final debriefing group (p = 0.53)). The overall satisfaction was high in the 2 group (9.1/10 in the 2 groups).

CONCLUSION

This study is the first one to compare two debriefing methods in case of breaking bad news simulation. No difference between the 2 techniques was found concerning the students' feelings and short and long-term improvement of their communication skills.

Delivering bad or difficult news. An innovative simulation-based education approach to prepare interdisciplinary fellowships

BACKGROUND

There is limited data on the effectiveness of training interventions to improve the delivery of bad news.

METHODS

This preliminary research included pre-post assessments and an open-ended survey to evaluate the effectiveness and perceived value of training on delivering bad news for 26 first- and second-year fellows from five adult and pediatric fellowship programs.

RESULTS

There was a significant increase in faculty assessment scores (34.5 vs. 41.0, respectively, Z = -3.661, p < 0.001) and Standardized Patient (SP) assessment scores (37.5 vs .44.5, respectively, Z = -2.244, p = 0.025). Fellows valued having a standard framework to aid in the delivery of bad news; receiving targeted feedback and having the opportunity to apply their skills in a subsequent case.

CONCLUSIONS

A one-hour, four-phase lesson plan that includes an individualized training approach and simulation do-overs can be effective and valuable for preparing fellows to deliver bad news.

Physicians' Self-Perceived Competence on Breaking Bad News to Parents of Children with Neurodisabilities

Delivering difficult news to parents of children with neurodisabilities, often involving new diagnoses, prognosis changes, or declines in function or health, presents a complex task. Our aim was to assess physicians' self-perceived competence in breaking bad news (BBN) within this context. An online survey was administered to neuropediatricians and developmental and rehabilitation pediatricians in Switzerland. Among 247 invited physicians, 62 (25.1%) responded (age of 51 ± 11 years; M/F ratio of 2:3). They rated their BBN competence at 7.5 ± 1.6 out of 10. Factors significantly associated with self-perceived competence in uni- and multivariate analyses included years of professional experience (≤10 years: 6.2 ± 1.8; >10 years: 8.2 ± 0.8), and region of pregraduate training (Switzerland: 7.3 ± 1.6; European Union: 8.3 ± 0.9). The respondents highlighted the positive roles of professional and personal experience, quality relationships with families, and empathy in BBN. In summary, physicians generally expressed a sense of competence in delivering difficult news to parents of children with neurodisabilities. They underscored the significance of life experiences and certain individual qualities in their effectiveness. These findings provide valuable insights into enhancing professional training and support in this crucial yet underexplored aspect of medical practice.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence

BACKGROUND

Open Disclosure (OD) is open and timely communication about harmful events arising from health care with those affected. It is an entitlement of service-users and an aspect of their recovery, as well as an important dimension of service safety improvement. Recently, OD in maternity care in the English National Health Service has become a pressing public issue, with policymakers promoting multiple interventions to manage the financial and reputational costs of communication failures. There is limited research to understand how OD works and its effects in different contexts.

METHODS

Realist literature screening, data extraction, and retroductive theorisation involving two advisory stakeholder groups. Data relevant to families, clinicians, and services were mapped to theorise the relationships between contexts, mechanisms, and outcomes. From these maps, key aspects for successful OD were identified.

RESULTS

After realist quality appraisal, 38 documents were included in the synthesis (22 academic, 2 training guidance, and 14 policy report). 135 explanatory accounts were identified from the included documents (with n = 41 relevant to families; n = 37 relevant to staff; and n = 37 relevant to services). These were theorised as five key mechanism sets: (a) meaningful acknowledgement of harm, (b) opportunity for family involvement in reviews and investigations, (c) possibilities for families and staff to make sense of what happened, (d) specialist skills and psychological safety of clinicians, and (e) families and staff knowing that improvements are happening. Three key contextual factors were identified: (a) the configuration of the incident (how and when identified and classified as more or less severe); (b) national or state drivers, such as polices, regulations, and schemes, designed to promote OD; and (c) the organisational context within which these these drivers are recieived and negotiated.

CONCLUSIONS

This is the first review to theorise how OD works, for whom, in what circumstances, and why. We identify and examine from the secondary data the five key mechanisms for successful OD and the three contextual factors that influence this. The next study stage will use interview and ethnographic data to test, deepen, or overturn our five hypothesised programme theories to explain what is required to strengthen OD in maternity services.

Breaking Bad News in Obstetrics and Gynecology: We Must Talk About It

Breaking bad news is common in obstetrics and gynecology (ob-gyn). However, it is difficult, and few doctors receive training on how to deal with this situation. This narrative review aims to gather, analyze, and synthesize part of the knowledge on the area, focused on Ob-Gyn. Among the 16 selected articles, two are randomized controlled intervention studies, and most studies refer to obstetrics. The results found by us pointed out that simulation, feedback/debriefing, lectures, and protocols could improve doctors' performance in communicating bad news. For patients, the context and how the information is transmitted seem to impact more than the content of the news. Ob-Gyn doctors could benefit from specific protocols and education, given the specialty's particularities. There is a lack of evidence about the most effective way to conduct such training. Finding validated ways to quantify and classify studies' results in the area, which would allow for the objective analysis of outcomes, is one of the biggest challenges concerning this topic.

Communication as a High-Stakes Clinical Skill: "Just-in-Time" Simulation and Vicarious Observational Learning to Promote Patient- and Family-Centered Care and to Improve Trainee Skill

Patient-provider communication is a hallmark of high-quality care and patient safety; however, the pace and increasingly complex challenges that face overextended teams strain even the most dedicated clinicians. The COVID-19 pandemic has further disrupted communication between clinicians and their patients and families. The dependence on phone communication and the physical barriers of protective gear limit nonverbal communication and diminish clinicians' ability to recognize and respond to emotion. Developing new approaches to teach communication skills to trainees who are often responsible for communicating with patients and their families is challenging, especially during a pandemic or other crisis. "Just-in-time" simulation-simulation-based training immediately before an intervention-provides the scaffolding and support trainees need for conducting difficult conversations, and it enhances patients' and families' experiences. Using a realistic scenario, the author illustrates key steps for effectively using just-in-time simulation-based communication training: assessing the learner's understanding of the situation; determining what aspects of the encounter may prove most challenging; providing a script as a cognitive aid; refreshing or teaching a specific skill; preparing learners emotionally through reflection and mental rehearsal; coaching on the approach, pace, and tone for a delivery that conveys empathy and meaning; and providing specific, honest, and curious feedback to close a performance gap. Additionally, the author acknowledges that clinical conditions sometimes require learning by observing rather than doing and has thus provided guidance for making the most of vicarious observational learning: identify potential challenges in the encounter and explicitly connect them to trainee learning goals, explain why a more advanced member of the team is conducting the conversation, ask the trainee to observe and prepare feedback, choose the location carefully, identify everyone's role at the beginning of the conversation, debrief, share reactions, and thank the trainee for their feedback and observations.

Standardized vs peer-played patients for learning how to break bad news in lung cancer: A prospective crossover study

CONTEXT

Residents in respiratory medicine are often confronted with breaking bad news to patients. In communication skill training, a recurring question is whether to use standardized or peer-played patients for simulation METHODS: In this prospective single-center crossover study in pulmonology residents, a range of scenarios were performed during training sessions using standardized or peer-played patients. The aim was to assess whether patient type did alter the quality of the role-play. The residents completed post-scenario questionnaires about the role-play of each scenario, but also pre- and post-session questionnaires about their perception of the effectiveness of both modalities, and pre- and post-testing questionnaires about the psychological impact of the training.

RESULTS

Collectively, 4 scenarios were performed 52 times and evaluated 208 times by 52 residents. The use of standardized patients appeared to improve the quality of the patient role (8.8 ± 1.0 vs. 8.3 ± 1.1; p = 0.001) and the general quality of role-play (8.8 ± 1.0 vs. 8.2 ± 0.9; p = 0.008), without affecting the quality of the physician role played by the resident. There were no significant differences between standardized and peer-played patients regarding learning interest or psychological impact. Regardless of the modality, the training sessions did appear to significantly affect the residents' evaluations of their ability to break bad news to patients (5.7 ± 1.1 vs. 7.4 ± 1.1; p < 10-4).

CONCLUSION

Our results did not point to a superiority of either of these modalities for learning how to break bad news. Both may be used, depending on the local resources.

Teaching residents how to break bad news: piloting a resident-led curriculum and feedback task force as a proof-of-concept study

Background

Breaking bad news (BBN) is a critically important skill set for residents. Limited formal supervision and unpredictable timing of bad news delivery serve as barriers to the exchange of meaningful feedback.

Purpose of study

The goal of this educational innovation was to improve internal medicine residents’ communication skills during challenging BBN encounters. A formal BBN training programme and innovative on-demand task force were part of this two-phase project.

Study design

Internal medicine residents at a large academic medical centre participated in an interactive workshop focused on BBN. Workshop survey results served as a needs assessment for the development of a novel resident-led BBN task force. The task force was created to provide observations at the bedside and feedback after BBN encounters. Training of task force members incorporated video triggers and a feedback checklist. Inter-rater reliability was analysed prior to field testing, which provided data on real-world implementation challenges.

Results

148 residents were trained during the 2-hour communications skills workshop. Based on survey results, 73% (108 of 148) of the residents indicated enhanced confidence in BBN after participation. Field testing of the task force on a hospital ward revealed potential workflow barriers for residents requesting observations and prompted troubleshooting. Solutions were implemented based on field testing results.

Conclusions

A trainee-led BBN task force and communication skills workshop is offered as an innovative model for improving residents’ interpersonal and communication skills in BBN. We believe the model is both sustainable and reproducible. Lessons learnt are offered to aid in implementation in other settings.

Breaking Bad News: A Randomized Trial Assessing Resident Performance After Novel Video Instruction

Introduction Delivering bad news to patients is an essential skill for physicians, which is often developed through patient encounters. Residents in our program participate in objective structured clinical examinations (OSCEs) on an annual basis to evaluate their skills in these scenarios. Our objectives were to develop an educational video and determine if an educational video provided to residents prior to OSCEs would improve performance. Methods Previous OSCEs were reviewed to identify best practices and to create a four-minute video highlighting the "do's and don'ts" of delivering bad news. Residents in two post-graduate year (PGY) classes were randomized to watch the video prior to or after a standardized patient encounter. Three masked reviewers assessed resident empathy, attention, and understanding on 10 five-point Likert scales and assigned a total score (scale: 0-50). Hedges' g was used to assess mean scores and effect size. Results A total of 17 residents participated in the evaluation: nine in the pre-OSCE video group and eight in the control group. Residents randomized to the video prior to the patient encounter had a mean score of 37.01 (SD=3.6). Residents randomized to the control group had a mean score of 35.38 (SD=4.85). Hedges' g was 0.37 (95% CI: -0.59 to 1.33). Conclusion Residents randomized to the video group had a small increase in OSCE performance, which was not statistically significant. The novel video was helpful and addresses the need for a quick pre-assessment educational tool, though interns and graduating medical students may be a more appropriate target audience for instruction.

Improving the way healthcare professionals deliver different news to families during pregnancy or at birth: a qualitative study

AIM

To explore the lived experience of delivering or receiving news about an unborn or newborn child having a condition associated with a learning disability in order to inform the development of a training intervention for healthcare professionals. We refer to this news as different news.

BACKGROUND

How healthcare professionals deliver different news to parents affects the way they adjust to the situation, the wellbeing of their child and their ongoing engagement with services. This is the first study that examined the lived experience of delivering and receiving different news, in order to inform the development of training for healthcare professionals using the Theoretical Domains Framework version 2.

METHOD

We conducted qualitative interviews with a purposive sample of 9 different parents with the lived experience of receiving different news and 12 healthcare professionals who delivered different news. It was through these descriptions of the lived experience that barriers and facilitators to effectively delivering different news were identified to inform the training programme. Data analysis was guided by Theoretical Domains Framework version 2 to identify these barriers and facilitators as well as the content of a training intervention.

FINDINGS

Receiving different news had a significant impact on parents' emotional and mental wellbeing. They remembered how professionals described their child, the quality of care and emotional support they received. The process had a significant impact on the parent-child relationship and the relationship between the family and healthcare professionals.Delivering different news was challenging for some healthcare professionals due to lack of training. Future training informed by parents' experiences should equip professionals to demonstrate empathy, compassion, provide a balanced description of conditions and make referrals for further care and support. This can minimise the negative psychological impact of the news, maximise psychological wellbeing of families and reduce the burden on primary care services.

Effectiveness of Communication Interventions in Obstetrics-A Systematic Review

(1) Background: Obstetric work requires good communication, which can be trained through interventions targeting healthcare providers and pregnant women/patients. This systematic review aims to aggregate the current state of research on communication interventions in obstetrics. (2) Methods: Using the PICOS scheme, we searched for studies published in peer-reviewed journals in English or German between 2000 and 2020. Out of 7018 results, 71 studies were included and evaluated in this synthesis using the Oxford Level of Evidence Scale. (3) Results: The 63 studies that included a communication component revealed a positive effect on different proximal outcomes (i.e., communication skills). Three studies revealed a beneficial effect of communication trainings on distal performance indicators (i.e., patient safety), but only to a limited extent. Most studies simultaneously examined different groups, however, those addressing healthcare providers were more common than those with students (61 vs. 12). Only nine studies targeted expectant mothers. Overall, the evidence level of studies was low (only 11 RCTs), with 24 studies with an evidence level I-II, 35 with level III, and 10 with level IV. (4) Conclusions: Communication trainings should be more frequently applied to improve communication of staff, students, and pregnant women and their partners, thereby improving patient safety.

Improving Psychological Comfort of Paramedics for Field Termination of Resuscitation through Structured Training

This study examines the impact of a newly developed structured training on Singapore paramedics’ psychological comfort before the implementation of a prehospital termination of resuscitation (TOR) protocol. Following a before and after study design, the paramedics underwent a self-administered questionnaire to assess their psychological comfort level applying the TOR protocol, 22 months before and one month after a 3-h structured training session. The questionnaire addressed five domains: sociocultural attitudes on resuscitation and TOR, multi-tasking, feelings towards resuscitation and TOR, interactions with colleagues and bystanders and informing survivors. Overall psychological comfort total (PCT) scores and domain-specific scores were compared using the paired t-test with higher scores representing greater comfort. Ninety-six of the 345 eligible paramedics responded. There was no statistically significant change in the mean PCT scores at baseline and post-training; however, the “feelings towards resuscitation and TOR” domain improved by 4.77% (95% CI 1.42 to 8.13 and p = 0.006) and the multi-tasking domain worsened by 4.11% (95% CI −7.82 to −0.41 and p = 0.030). While the structured training did not impact on the overall psychological comfort levels, it led to improvements in the feelings of paramedics towards resuscitation and TOR. Challenges remain in improving paramedics’ psychological comfort levels towards TOR.

Communication of bad news in relation with surgery or anesthesia: An interdisciplinary simulation training program

INTRODUCTION

Disclosure of damage related to care is a difficult area of communication due to the physician's feeling of guilt or the fear of liability. The aim of this study was to develop, and to evaluate the impact of an inter-disciplinary simulation program on communication of damage related to care.

METHODS

Residents in gynecology/obstetrics and anesthesiology participated in role-playing scenarios of communication of damage related to care. We assessed verbal, non-verbal communication skills and inter-disciplinary relations with a modified SPIKES protocol and with a video analysis with predefined indicators. We evaluated long-term impact of the training at 3-6 months with combining self-assessment and a video analysis on retained knowledge.

RESULTS

We included 80 residents in 15 sessions of simulation. Satisfaction regarding the simulation training was high (9.1/10 [8.9-9.3]). The part of the SPIKES protocol "setting up the interview" was the more difficult to apply. Empathic attitude was adopted 80 % of the time in the two scenarios with a life-threatening complication but was less common in the anesthetic one (broken tooth). The residents found interdisciplinary disclosure helpful due to support from the other resident. Immediately after the session, residents reported an important improvement in communication skills and that the session would significantly change their practice. At 3-6 months, reports were still largely positive but less than on immediate evaluation.

CONCLUSION

Residents did not master the most important communication skills. The interdisciplinary method to breaking bad news was felt useful.

National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse's role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women's Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.

Announcing fetal pathology: Challenges encountered by physicians and potential role of simulation in training for breaking bad news

BACKGROUND

Informing couples about the diagnosis of severe fetal pathologies is part of the daily routine in fetal medicine. This situation is usually complex and can put untrained professionals in an uncomfortable position. The aim of this study was to assess the perception of health care professionals when faced with the need to announce a fetal pathology in order to target their training gaps in this domain.

MATERIALS AND METHODS

A questionnaire was created and disseminated on a national level among physicians practicing or collaborating with the multidisciplinary centers of prenatal diagnosis in France. The questionnaire focused on the difficulties encountered by practitioners when announcing fetal pathologies, and their potential interest in simulation sessions regarding the delivery of bad news.

RESULTS

193 participants filled the questionnaire. 65 % report not receiving any theoretical courses in this field during their initial training, 49 % admit feeling uncomfortable when a fetal anomaly needs to be announced, 79.5 % think that role-play could help them, 87.5 % believe that training sessions in communication skills would help improve their methods and 73.1 % support teaching the delivery of bad news by simulation sessions.

CONCLUSION

This survey illustrates the significance of announcing a fetal pathology for fetal medicine professionals. Many of them report not being properly trained to cope with this situation and would like to improve with a more practical way of teaching. Simulation would be the ideal educational tool to meet this demand.

[Training simulation during the announcement of fetal malformation discovered on screening ultrasound: Results of a pilot study]

OBJECTIVES

Breaking bad news (BBN) to a pregnant woman with fetal abnormalities (FA) on ultrasound (US) examination is a challenge. Announcement technique influences patient reaction. Physicians receive little training in BBN. The simulation and using a BBN protocol as the English SPIKES protocol which guides the announcement consultation according to 6 steps (Setting Up, Perception, Invitation, Knowledge, Emotions and Empathy, Strategy and Summary) can be used for this teaching. The objective was to assess feasibility simulation scenarii of BBN for FA discovered during US and to evaluate the usefulness of SPIKES protocol in this situation.

METHODS

Two scenarios have been created combining US simulator (US Mentor, Symbionix®) with simulated patient (SP). Scenarii objectives were to diagnose FA and break it to SP. Checklist derived from SPIKES was fulfilled by two investigators thanks to video recording, the SP and every participant (residents, physicians, fetal medicine specialists [FMS]). Participants filled out survey about the usefulness of this exercise too.

RESULTS

Nine physicians (3 residents, 4 physicians, 2 FMS) produced 18 scenarii. Seventy-eight percent of physicians thought simulation was like real situation of BBN during US examination. Majority of participant (88%) found that this simulation training could help them to increase their ability to BBN and that it can be used to teach residents (89%) or physicians (100%). FMS had better SPIKES checklist than physicians (P<0,05).

CONCLUSION

Simulation scenario of BBN for FA discovered during US is feasible by combining US simulator and SP. SPIKES protocol can be useful but a validated checklist should be created.

Breaking Bad News: A Study on Formal Training in a High-Risk Obstetrics Setting

Background: Breaking bad news is a frequent task in high-risk obstetrics clinics. Few studies have examined the role of training in improving such a difficult medical task. Aim: To evaluate the influence of a training program on the participants' perceptions of bad news communication at a high-risk obstetrics center. Design: This prospective study was conducted at the Department of Obstetrics/Gynecology, Hospital das Clinicas, from March 2016 to May 2017. Setting/Participants: Maternal-fetal health specialists were invited to complete an institutional questionnaire based on the SPIKES protocol for communicating bad news before and after training. The training consisted of theoretical lectures and small group practice using role play. The questionnaire responses were compared using nonparametric tests to evaluate the differences in physicians' perceptions at the two timepoints. The questionnaire items were evaluated individually and in groups following the communication steps of the SPIKES protocol. Results: In total, 110 physicians were invited to participate. Ninety completed the pretraining questionnaire and 40 answered the post-training questionnaire. After training, there were significant improvements in knowing how to prepare the environment before delivering bad news (p = 0.010), feeling able to transmit bad news (p < 0.001), and to discuss the prognosis (p = 0.026), feeling capable of discussing ending the pregnancy (p = 0.003), and end-of-life issues (p = 0.007) and feeling confident about answering difficult questions (p = 0.004). The comparison of the grouped responses following the steps of the SPIKES protocol showed significant differences for "knowledge" (p < 0.001), "emotions," (p = 0.004) and "strategy and summary" (p = 0.002). Conclusion: The implementation of institutional training in breaking bad news changed the perception of the physicians in the communication setting.

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

Background

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

Methods

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

Results

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

Conclusions

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

Qualitative Assessment of Bad News Delivery Practices during Miscarriage Diagnosis

Miscarriage is one of the most common pregnancy complications health care providers discuss with patients. Previous research suggests that women's distress is compounded by ineffective communication with providers, who are usually not trained to deliver bad news using patient-centered dialogue. The purpose of this study was to use a patient-centered approach to examine women's experiences with and perspectives of communication during a miscarriage to assist in the development of communication training tools for health care providers. During focus groups, 22 women who had experienced miscarriage discussed video-recorded standardized patient-provider interactions and recalled communication during their own miscarriages. Results of a pragmatic iterative analysis of the transcripts suggest training techniques and communication behaviors that should guide education for providers to deliver the diagnosis of and treatment options for early pregnancy loss, such as demonstrating empathy, creating space for processing, checking for understanding, and avoiding medical jargon and emotionally charged language.

Non-technical skills: a review of training and evaluation in urology

PURPOSE

With non-technical skills (NTS) deficits being recognised as a major cause for error in surgery, there is an increasing interest in their training and evaluation. A growing number of training courses are emerging and some NTS curricula have also been created. Many different training methods are described in the literature but there is still uncertainty with regards to their optimum combination within a curriculum.

METHODS

A literature review of the electronic database Medline was performed. All articles published before December 2018 were screened by abstract and included if deemed relevant by the author. The included articles' reference lists were also screened for further relevant studies.

RESULTS

Simulation training is accepted as the most effective way to train NTS. Within simulation training, it is shown that the 'igloo' full immersion/distributed simulation environment is appropriate for teaching NTS in urological scenarios where a designated operating room or space is not available. The use of multiple settings, for example wards and clinics as well as the operating room, is advantageous, as is training in an interprofessional team. Classroom teaching also plays a role in NTS training as an adjunct to simulation, with evidence that it improves some parameters of NTS. All levels, including qualified surgeons, benefit from NTS training; however, adaptation to both trainee level and specialty is important. Although less time consuming, training juniors and seniors together mainly benefits juniors, and training NTS at the same time as technical skills detracts from the quality of teaching. Debriefing is an important part of training and should be well structured; there are many debriefing models in existence, allowing for choice of method based on examiner preference and participant demographic. Furthermore, examiners should be well briefed in their task and trained in NTS assessment.

CONCLUSION

To move forward, studies should combine tried and tested learning techniques into a curriculum covering all training levels, which should then be validated and followed up long term to ensure a positive impact on patient safety.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Using a Standardized Client Encounter in the Veterinary Curriculum to Practice Veterinarian-Employer Discussions about Animal Cruelty Reporting

Animal cruelty is the antithesis of animal welfare. Because veterinarians take an oath to protect animal welfare, they are professionally obligated to report animal cruelty. Several US states have mandatory reporting laws for veterinarians, and both the American Veterinary Medical Association (AVMA) and the American Animal Hospital Association support reporting. Some state veterinary practice acts, such as Arizona's, also require reporting. Despite this, animal cruelty is not always emphasized in veterinary curricula. As a result, not all veterinary students and graduates feel comfortable recognizing signs of animal cruelty and may not be aware of the resources that are available to them when considering reporting. AVMA suggests that practices develop their own protocols for identifying signs that patients may have been victims of cruelty and consulting on cases with senior colleagues with regard to when to report. To enhance student comfort with these conversations, Midwestern University College of Veterinary Medicine developed a standardized client encounter titled "Grizabella's Final Fight." I hope that other colleges of veterinary medicine will adapt this teaching tool to allow students the opportunity to practice discussions surrounding animal cruelty reporting in the context of state-specific legislation that guides their code of professional conduct.

Interventions to Improve the Breaking of Bad or Difficult News by Physicians, Medical Students, and Interns/Residents: A Systematic Review and Meta-Analysis

PURPOSE

To assess the effectiveness of news delivery interventions to improve observer-rated skills, physician confidence, and patient-reported depression/anxiety.

METHOD

MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Register of Controlled Trials databases were searched from inception to September 5, 2016 (updated February 2017). Eligible studies included randomized controlled trials (RCTs), non-RCTs, and controlled before-after studies of interventions to improve the communication of bad or difficult news by physicians, medical students, and residents/interns. The EPOC risk of bias tool was used to conduct a risk of bias assessment. Main and secondary meta-analyses examined the effectiveness of the identified interventions for improving observer-rated news delivery skills and improving physician confidence in delivering news and patient-reported depression/anxiety, respectively.

RESULTS

Seventeen studies were included in the systematic review and meta-analysis, including 19 independent comparisons on 1,322 participants and 9 independent comparisons on 985 participants for the main and secondary (physician confidence) analyses (mean [SD] age = 35 [7] years; 46% male), respectively. Interventions were associated with large, significant improvements in observer-rated news delivery skills (19 comparisons: standardized mean difference [SMD] = 0.74; 95% CI = 0.47-1.01) and moderate, significant improvements in physician confidence (9 comparisons: SMD = 0.60; 95% CI = 0.26-0.95). One study reported intervention effects on patient-reported depression/anxiety. The risk of bias findings did not influence the significance of the results.

CONCLUSIONS

Interventions are effective for improving news delivery and physician confidence. Further research is needed to test the impact of interventions on patient outcomes and determine optimal components and length.

A Novel Approach to Simulation-Based Education for Veterinary Medical Communication Training Over Eight Consecutive Pre-Clinical Quarters

Experiential learning through the use of standardized patients (SPs) is the primary way by which human medical schools teach clinical communication. The profession of veterinary medicine has followed suit in response to new graduates' and their employers' concerns that veterinary interpersonal skills are weak and unsatisfactory. As a result, standardized clients (SCs) are increasingly relied upon as invaluable teaching tools within veterinary curricula to advance relationship-centered care in the context of a clinical scenario. However, there is little to no uniformity in the approach that various colleges of veterinary medicine take when designing simulation-based education (SBE). A further complication is that programs with pre-conceived curricula must now make room for training in clinical communication. Curricular time constraints challenge veterinary colleges to individually decide how best to utilize SCs in what time is available. Because it is a new program, Midwestern University College of Veterinary Medicine (MWU CVM) has had the flexibility and the freedom to prioritize an innovative approach to SBE. The author discusses the SBE that is currently underway at MWU CVM, which incorporates 27 standardized client encounters over eight consecutive pre-clinical quarters. Prior to entering clinical rotations, MWU CVM students are exposed to a variety of simulation formats, species, clients, settings, presenting complaints, and communication tasks. These represent key learning opportunities for students to practice clinical communication, develop self-awareness, and strategize their approach to future clinical experiences.