Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios.

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

"You Look Young! Are You a Doctor?" A Qualitative Content Analysis of Anesthesiology Resident Responses to Ageism in Clinical Encounters.

BACKGROUND: Healthcare trainees frequently report facing comments from their patients pertaining to their age. Exposure to ageist comments from patients may be related to greater stress and/or burnout in residents and may impact the quality of the resident-patient relationship. However, little empirical work has examined ageism expressed toward anesthesiology residents in clinical care, and therefore not much is known about how residents respond to these comments in practice. This research sought to determine how anesthesiology residents responded to ageist comments. METHODS: Anesthesiology residents (N = 60) engaged in a preoperative interaction with a standardized patient who was instructed to make an ageist comment to the resident. Resident responses were transcribed and coded using qualitative inductive content analysis to identify response themes. RESULTS: The most common resident response to the ageist comment, across gender and resident year, was to state their own experience. Some also described how they were still in training or that they were under supervision. Residents rarely reassured the patient that they would receive good care or identified the patient's anxiety as a cause of the ageist remark. CONCLUSIONS: These results provide a first step in understanding how ageism may be navigated by residents in clinical encounters. The authors discuss potential avenues for future research and education for responding to ageist remarks for both patients and clinicians.

Clinical ethics consultation documentation in the era of open notes.

BACKGROUND: In 2021, federal rules from the 21st Century Cures Act mandated most clinical notes be made available in real-time, online, and free of charge to patients, a practice often referred to as "open notes." This legislation was passed to support medical information transparency and reinforce trust in the clinician-patient relationship; however, it created additional complexities in that relationship and raises questions of what should be included in notes intended to be read by both clinicians and patients. MAIN BODY: Even prior to open notes, how an ethics consultant should document a clinical ethics consultation was widely debated as there can be competing interests, differing moral values, and disagreement about pertinent medical information in any given encounter. Patients can now access documentation of these discussions through online portals which broach sensitive topics related to end-of-life care, autonomy, religious/cultural conflict, veracity, confidentiality, and many others. Clinical ethics consultation notes must be ethically robust, accurate, and helpful for healthcare workers and ethics committee members, but now also sensitive to the needs of patients and family members who can read them in real-time. CONCLUSION: We explore implications of open notes for ethics consultation, review clinical ethics consultation documentation styles, and offer recommendations for documentation in this new era.

Moral Distress Trajectories of Physicians 1 Year after the COVID-19 Outbreak: A Grounded Theory Study.

The COVID-19 pandemic has confronted emergency and critical care physicians with unprecedented ethically challenging situations. The aim of this paper was to explore physicians' experience of moral distress during the pandemic. A qualitative multicenter study was conducted using grounded theory. We recruited 15 emergency and critical care physicians who worked in six hospitals from the Lombardy region of Italy. Semi-structured interviews about their professional experience of moral distress were conducted from November 2020-February 2021 (1 year after the pandemic outbreak). The transcripts were qualitatively analyzed following open, axial, and selective coding. A model of moral distress was generated around the core category of Being a Good Doctor. Several Pandemic Stressors threatened the sense of Being a Good Doctor, causing moral distress. Pandemic Stressors included limited healthcare resources, intensified patient triage, changeable selection criteria, limited therapeutic/clinical knowledge, and patient isolation. Emotions of Moral Distress included powerlessness, frustration/anger, and sadness. Physicians presented different Individual Responses to cope with moral distress, such as avoidance, acquiescence, reinterpretation, and resistance. These Individual Responses generated different Moral Outcomes, such as moral residue, disengagement, or moral integrity. The Working Environment, especially the team and organizational culture, was instrumental in restoring or disrupting moral integrity. In order for physicians to manage moral distress successfully, it was important to use reinterpretation, that is, to find new ways of enacting their own values by reframing morally distressing situations, and to perceive a cooperative and supportive Working Environment.

Aligning Family-Clinician Expectations During Pediatric Surgical Informed Consent: Development and Implementation of an Innovative Communication Skills Workshop.

INTRODUCTION: Aligning expectations during the informed consent process before a child's surgery is an important element of good communication that benefits both surgical staff and families. We developed and evaluated a 2-hour pilot interprofessional workshop to improve the communication and relational skills of pediatric surgeons and nurse practitioners. METHODS: Focus groups with families identified key challenges in the process of informed consent. An interprofessional team, including parents whose children had experienced complex surgeries, developed the workshop collaboratively. A realistic simulation with professional actors portraying parents allowed surgical staff to practice communication skills and receive feedback about the parent perspective. Participants completed a postworkshop evaluation to determine whether the workshop met its objectives and whether they would change practice. RESULTS: Five key themes identified for the workshop included customize communication; align expectations; share clinical uncertainty; recognize/attend to emotions; and identify team members. Thirty-five clinicians participated in a workshop, and 89% completed evaluations. Three-quarters reported the learning to be valuable, and 64% were likely to change practice. Eighty-seven percent would recommend the workshop to other colleagues, and 58 to 74% felt more prepared to achieve each of eight specific skills. DISCUSSION: An innovative workshop for pediatric surgical practitioners to align family-clinician expectations can help improve clinician communication skills and comfort with informed consent. Keys to workshop development included involving parents to identify themes and participate as workshop co-faculty; enlisting leadership and recruiting surgical champions; and using pre-existing meetings to ease scheduling challenges of busy practitioners. Booster sessions may facilitate the desired cultural changes.

The Case of Billy Best: 25 Years Later.

Billy Best was diagnosed with Hodgkin lymphoma in 1994 at age 16 and became well-known when he ran away from home to avoid receiving further chemotherapy. His story became national news when, with the support of his adopted parents, he returned home and opted to use complementary and alternative medicine (CAM) instead of standard chemotherapy and radiation for his cancer treatment. Now 25 years since Billy Best entered the public eye, his story is one that is frequently referenced in pediatrics, bioethics, and other related fields. Here, the authors examine the evolution of various features of this case, including treatment of Hodgkin lymphoma, the interplay between medicine and the media, the role of CAM in pediatric care, navigating entrenched disagreements and how best to integrate adolescents into health care decision-making, and the role of narrative in medical practice. The authors explore the unique role of each of these facets of Billy Best's case, describing how each has or has not changed in the quarter century since that time amid the changing landscape of pediatric health care. Ultimately, although many advances have occurred since Billy Best's time, significant work remains. Additional effort will be required in the future to optimize communication, improve treatment toxicities from Hodgkin lymphoma without decreasing survival, integrate the voice and perspective of adolescents into their treatment decisions, and navigate the roles of CAM and the media in pediatric health care.

The impact of visiting the Intensive Care Unit on children's and adolescents' psychological well-being: A systematic review.

OBJECTIVES: The visits of children/adolescents in adult intensive care units are increasingly more common. However, few studies examine the psychological impact of visiting. This systematic review aims to summarise the psychological effects that visiting family members has on children/adolescents. RESEARCH METHODOLOGY: A systematic review of research articles published from 1990 to January 2021 was conducted using PsycInfo, PubMed, and CINAHL. Inclusion/exclusion criteria were applied. Those studies included were evaluated using the Joanna Briggs Institute Critical Appraisal tools. A narrative synthesis of the results was conducted. SETTING: Adult intensive care unit. RESULTS: The review identified five studies (three of which qualitative), involving 141 children/adolescents. Although the experience of visiting was potentially traumatic, it enabled children/adolescents to better understand the reality and to preserve their relationships with family members. The impact of visiting was influenced by individual characteristics (e.g., age, past traumatic experiences) and by organisational characteristics (e.g., facilitated visit or not). Regardless of visitation, most children/adolescents presented anxiety and depression symptoms that need to be addressed. CONCLUSIONS: Child/adolescent visitation seems to have positive effects, provided there is preparation and facilitation. Clinicians should pay attention to individual characteristics and optimise organisational factors (e.g., environment) in order to minimise potentially trauma-inducing aspects.

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

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

Health Care Professionals' Reflections on Their Learning as Spiritual Generalists and Integration Into Practice.

INTRODUCTION: Meeting spiritual needs of patients is an important aspect of quality health care, but continuing professional development and training to provide spiritual care remains inadequate. The purpose was to identify participants' learning from simulation-based spiritual generalist workshops and application to practice. METHODS: Interdisciplinary participants completed self-report demographic questionnaires before the workshops and questionnaires after workshops that listed open-ended take-home learning. Responses were analyzed using qualitative content analysis. A subgroup was surveyed 3 to 9 months after training to examine whether and how participants had incorporated workshop learning into clinical work. RESULTS: Workshop participants 181/211 (85.8%) reported learning in four categories: core values and skills of spiritual generalists, understanding spirituality/religion and its role in health care, interfacing with chaplaincy, and interprofessional teamwork. Of the subsample, 73.5% (25/34) completed surveys 3 to 9 months after training. Of those, 25/25 (100%) reported drawing on what they learned in workshops, and 24/25 (96%) reported making clinical practice changes. DISCUSSION: One-day spiritual generalist simulation-based workshops can improve continuing professional development learning experiences to provide generalist level of spiritual care. Workshops offered valuable learning and resulted in applicable clinical skills across professional roles. At 3 to 9 months after training, participants reported improved spiritual screening, recognition of spiritual distress, and referral to chaplaincy.

Innovative Communication Learning: Combining TED Talks and Reflective Writing for Nursing Students.

BACKGROUND: As educational programs compete with online and open courseware, TED (Technology, Entertainment, and Design) Talks provide meaningful complementary content that can be easily integrated into curricula. PURPOSE: Evaluate an innovative approach to the standard lecture by combining media mixture with reflective writing. METHODS: Undergraduate nursing students were asked to view a TED Talk and write a brief narrative reflection as part of their preparation for a communication class. RESULTS: The video and reflective writing assignment were completed by 23/25 (92%) of students. Qualitative analysis of the reflective writing identified three primary themes: Communication as a Foundational Competency, Importance of Empathy, and Professional Role Development. CONCLUSION: This illustrative talk and narrative exercise provided an interactive learning experience for novice nurses that served as a compelling means to critically reflect on effective health-care communication skills, prior to entry into practice.

Guidelines for the Responsible Use of Deception in Simulation: Ethical and Educational Considerations.

STATEMENT: Many techniques and modifications commonly used by the simulation community have been identified as deceptive. Deception is an important issue addressed by both the newly adopted Healthcare Simulationist Code of Ethics and the American Psychological Association Code of Conduct. Some view these approaches as essential whereas others question their necessity as well as their untoward psychological effects. In an attempt to offer guidance to simulation-based healthcare educators, we explore educational practices commonly identified as deceptive along with their potential benefits and detriments. We then address important decision points and high-risk situations that should be avoided to uphold ethical boundaries and psychological safety among learners. These are subsequently analyzed in light of the Code of Ethics and used to formulate guidelines for educators that are intended to ensure that deception, when necessary, is implemented in as psychologically safe a manner as possible.

Location of Clinician-Family Communication at the End of Life in the Pediatric Intensive Care Unit and Clinician Perception of Communication Quality.

Background: Communication between clinicians and families of dying children in the pediatric intensive care unit (PICU) is critically important for optimal care of the child and the family. Objective: We examined the current state of clinician perspective on communication with families of dying children in the PICU. Design: Prospective case series over a 15-month study period. Setting/Subjects: We surveyed nurses, psychosocial staff, and physicians who cared for dying children in PICUs at five U.S. academic hospitals. Measurements: Clinicians reported on the location of communication, perceived barriers to end-of-life care, and rated the quality of communication (QOC). Results: We collected 565 surveys from 287 clinicians who cared for 169 dying children. Clinicians reported that the majority of communication occurred at the bedside, and less commonly family conferences and rounds. Ten barriers to care were examined and were reported with frequencies of 2%-32%. QOC was rated higher when the majority of conversations occurred during family conferences (p = 0.01) and lower for patients of non-white race (p = 0.03). QOC decreased when 8 of the 10 barriers to care were reported. Conclusions: When a child is dying, clinicians report that communication with the family occurs most frequently at the child's bedside. This has important implications for future ICU communication research as the majority of previous research and education has focused on family care conferences. In addition, findings that QOC is perceived as lower for non-white patients and when clinicians perceive that barriers hindering care are present can help direct future efforts to improve communication in the PICU.

Compassionate and Clinical Behavior of Residents in a Simulated Informed Consent Encounter.

BACKGROUND: Compassionate behavior in clinicians is described as seeking to understand patients' psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery. METHODS: Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion. RESULTS: Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not. CONCLUSIONS: In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

Interprofessional Spiritual Care Training for Geriatric Care Providers.

Background: Despite the importance patients place on religion and spirituality, many patients with advanced diseases report that their religious and spiritual needs are not met by their health care team, and many nonchaplain clinicians feel unprepared to address religious and spiritual issues in their practice. Objectives: The purpose of this study was to assess the efficacy of a one-day workshop on spiritual care for nonchaplain clinicians who provide care to elderly long-term care patients. Methods: Clinician participants (N = 68) were given a pre-survey at the beginning of the workshop, a post-survey at the conclusion of the workshop, and a three-month follow-up survey to evaluate their comfort in engaging in spiritual issues before and after the workshop. An average ability score of 13 items in the survey was calculated as well as an average comfort score, which was an average of three items in the survey. Ability scores and comfort scores were analyzed using a pairwise t-test, comparing pre- versus post-workshop and post- versus three-month scores. Results: Overall average scores for clinicians' self-reported perceived ability in engaging in issues around spirituality with patients and their families increased from before the workshop to the post-workshop and three months later. Participants' self-perceived comfort increased from before the workshop to immediately following the workshop. Discussion: This study suggests that a spiritual care training program targeted toward geriatric clinicians has the potential to provide clinicians with the tools, skills, and support they need to approach basic spiritual care with their patients and family members.