Navigating Communication Challenges in Clinical Practice: A New Approach to Team Education.

BACKGROUND: Cultivating a healthy work environment and upholding patient safety are important priorities in health care. Challenges in workplace communication are common and affect staff well-being and patient outcomes. Previous interventions have focused on organizational issues and work-life balance. OBJECTIVE: To assess the feasibility of monthly interdisciplinary educational rounds that support clinicians' ability to navigate workplace clinical and communication challenges while promoting interprofessional teamwork and self-care. METHODS: The Program to Enhance Relational and Communication Skills rounds are an educational initiative within a large pediatric tertiary care hospital. Participation is voluntary and offered to inter-professional clinicians from 4 critical care units, cardiac catheterization unit, and intermediate care unit. Topics of monthly hour-long sessions are developed collaboratively. Feasibility is assessed by ongoing documentation of attendance. Postintervention questionnaires are used to evaluate the program's value. RESULTS: Between April 2010 and December 2016, a total of 1156 clinicians participated (median, 18 per seminar): 653 nurses (56%), 103 social workers (9%), 102 child life specialists (9%), 32 psychologists (3%), 40 chaplains (3%), 18 physicians (2%), 18 ethicists (2%), and 190 others (16%), including medical interpreters, nursing students, and administrative staff. Ninety-two percent of participants rated their participation as "quite valuable" or "very valuable." Programs of highest interest included child assent, bereavement, social media, and workplace bullying. Evolution into actual clinical practice change remains a challenge for the future. CONCLUSION: Our approach to communication and workplace challenges is relevant, user-friendly, and feasible. Difficult topics are addressed in real time, with clinicians learning interprofessionally.

Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.

BACKGROUND: Despite growing interest in engaging patients and families (P/F) in patient safety education, little is known about how P/F can best contribute. We assessed the feasibility and acceptability of a patient-teacher medical error disclosure and prevention training model. METHODS: We developed an educational intervention bringing together interprofessional clinicians with P/F from hospital advisory councils to discuss error disclosure and prevention. Patient focus groups and orientation sessions informed curriculum and assessment design. A pre-post survey with qualitative and quantitative questions was used to assess P/F and clinician experiences and attitudes about collaborative safety education including participant hopes, fears, perceived value of learning experience and challenges. Responses to open-ended questions were coded according to principles of content analysis. RESULTS: P/F and clinicians hoped to learn about each other's perspectives, communication skills and patient empowerment strategies. Before the intervention, both groups worried about power dynamics dampening effective interaction. Clinicians worried that P/F would learn about their fallibility, while P/F were concerned about clinicians' jargon and defensive posturing. Following workshops, clinicians valued patients' direct feedback, communication strategies for error disclosure and a 'real' learning experience. P/F appreciated clinicians' accountability, and insights into how medical errors affect clinicians. Half of participants found nothing challenging, the remainder clinicians cited emotions and enormity of 'culture change', while P/F commented on medical jargon and desire for more time. Patients and clinicians found the experience valuable. Recommendations about how to develop a patient-teacher programme in patient safety are provided. CONCLUSIONS: An educational paradigm that includes patients as teachers and collaborative learners with clinicians in patient safety is feasible, valued by clinicians and P/F and promising for P/F-centred medical error disclosure and prevention training.

Practicing End-of-Life Conversations: Physician Communication Training Program in Palliative Care.

A Physician Communication Training Program (PCTP) utilizing scripts based on actual family conferences with patients, families, and the health care team was developed at one medical center in the Northeast. The program was designed, adapted, and directed by a palliative care social worker. The primary goal of the program is to help residents and attending physicians build better communication skills in establishing goals of care and in end-of-life planning. The scripts focus on improving physicians' basic skills in conducting family meetings, discussing advance directives, prognosis, brain death, and withdrawal of life support. Excerpts from the scripts utilized in the program are included. Feedback from participants has been positive, with all respondents indicating improvement in their capacity to take part in these challenging conversations.

Radiology trainees' comfort with difficult conversations and attitudes about error disclosure: effect of a communication skills workshop.

PURPOSE: The aim of this study was to assess the effect of communication skills training on radiology trainees' (1) comfort with communicating directly with patients and family members about unexpected or difficult diagnoses ("bad news"), radiologic errors, and radiation risks and (2) attitudes about disclosing radiologic errors directly to patients and their families. METHODS: One hundred nine radiology trainees from 16 US programs were asked to complete questionnaires immediately before and after attending an institutional review board-exempted, full-day communication workshop. Questionnaires assessed (1) comfort communicating with patients and their families generally and about bad news, radiologic errors, and radiation risks specifically; (2) attitudes and behavioral intent regarding a hypothetical vignette involving a radiologic error; and (3) desire for additional communication training. RESULTS: All trainees completed the questionnaires. After completing the workshop, more trainees reported comfort communicating with patients about bad news, errors, and radiation risks (pre vs post, 44% vs 73%, 25% vs 44%, and 34% vs 58%, respectively, P < .001 for all). More also agreed that the radiologist in the error vignette should discuss the error with the patient (pre vs post, 84% vs 95%; P = .002) and apologize (pre vs post, 78% vs 94%; P < .001). After participation, fewer trainees reported unwillingness to disclose the error despite medicolegal concerns (pre vs post, 39 vs 15%; P < .001). Despite high baseline comfort (92%) and low stress (14%) talking with patients in general, most respondents after participation desired additional communication training on error disclosure (83%), general communication (56%), and radiation risks (80%). CONCLUSIONS: This program provides effective communication training for radiology trainees. Many trainees desire more such programs.

Relational learning and interprofessional practice: transforming health education for the 21st century.

Theories and traditions emphasizing the centrality of caring have guided the evolution of the healthcare professions. In contemporary practice, creating a therapeutic context in which healing can occur relies not just on the caring dispositions of individual clinicians, but also on the collective relational capacities of interprofessional healthcare teams. This article describes the intersection and complementarity of relational and interprofessional learning approaches to health education, provides exemplars of shared learning models and discusses the benefits and obstacles to integrating relational and interprofessional philosophies into real world practice.

Sturdy for common things: cultivating moral sensemaking on the front lines of practice.

This essay argues that the field of bioethics should concern itself especially with the process of making moral sense that unfolds among clinicians, patients and family members during common but high-stakes conversations occurring on the front lines of practice. The essay outlines the parameters of a bioethics grounded in the moral experience of patients, families and practitioners. It challenges ethicists, educators, and clinician leaders to commit themselves to advocating and developing creative approaches to learning that will cultivate the moral sensibilities of frontline clinicians in this critically important domain of practice.

Uncovering and validating clinicians' experiential knowledge when facing difficult conversations: a cross-cultural perspective.

OBJECTIVE: To explore clinicians' experiential knowledge when conducting difficult conversations; and to verify if experiential knowledge is culturally based. METHOD: Data were collected in Italy and the United States during the Program to Enhance Relational and Communication Skills (PERCS) workshops. At the beginning of each workshop, during a whiteboard exercise, clinicians shared the strategies they had found helpful in difficult conversations. The strategies were analyzed in each country through content analysis. Upon completion of this primary analysis, the themes identified within each country were synthesized into second-order themes by means of aggregated concept analysis. RESULTS: We conducted 14 Italian and 12 American PERCS-workshops enrolling a total of 304 clinicians. The suggestions that were similar across both countries were related to: organizational aspects and setting preparation; communication and relational skillfulness; clinician mindfulness; interpersonal qualities and sensibilities; and teamwork and care coordination. Additionally, US participants identified attention to cultural differences as a helpful strategy. CONCLUSION: Clinicians can access relational strategies, tied to their experience, that are typically unrecognized in medical education. The whiteboard exercise is an effective teaching tool to uncover and validate already-existing relational knowledge. PRACTICE IMPLICATIONS: Communication training programs can foster clinicians' sense of preparation by building upon their already-existing knowledge.

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare.

BACKGROUND: The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians' preparedness to engage in difficult conversations. AIM: To describe the implementation of PERCS in an Italian hospital and assess the program's efficacy. METHODS: The Italian PERCS program featured 4-h experiential workshops enrolling 10-15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS: 146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patient's perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. CONCLUSION: PERCS proved culturally adaptable to the Italian context and effective in improving participants' sense of preparation, communication skills, and confidence.

Learning that leads to action: impact and characteristics of a professional education approach to improve the care of critically ill children and their families.

OBJECTIVE: To determine the impact of an innovative professional educational approach on clinicians' confidence and ability to make institutional improvements in pediatric palliative care. DESIGN: Evaluation to assess impact of educational intervention on participants and participant institutions. SETTING: Retreats lasting 2.5 days. PARTICIPANTS: Physicians, nurses, psychosocial staff, and bereaved parents. INTERVENTION: "Relational learning across boundaries" pedagogy. MAIN OUTCOME MEASURES: Analysis of participant questionnaires (n = 782, response rate of 84%), team leader surveys (n = 72, response rate of 71%), and follow-up interview with subsample (n = 21, response rate of 81%). Outcomes included confidence to act and institutional improvements achieved. RESULTS: Seventy-four percent of team leaders reported significant or moderate improvement in pediatric palliative care after the retreat; only 1% reported no improvement. Ninety-one percent credited the retreat experience as being somewhat or very instrumental to the improvements, which included the establishment of pediatric palliative care and bereavement programs, improvements in interdisciplinary communication, care coordination, clinician-family interaction at the bedside, and educational programs. Participants attributed the impact of the 2.5-day retreat to its key pedagogical features, involvement of family members as equal participants and participation of colleagues from other disciplines and care settings, as well as the ground rules used for the small group seminars. CONCLUSIONS: The intervention was successful in improving clinicians' confidence and catalyzed improvements in pediatric palliative care within participating institutions. Relational learning holds promise for professional learning, especially when the educational goal is tied to enabling a shift in social and ethical norms.

[Between science and suffering: difficult conversations in healthcare]. / Tra scienza e sofferenza: le conversazioni difficili in sanità.

INTRODUCTION: This article describes the adaptation and implementation of the Program to Enhance Relational and Communication Skills (PERCS) in Italy. PERCS was originally developed at Children's Hospital Boston and aims to enhance clinicians' preparedness to engage in difficult conversations with patients/families. DESCRIPTION: After a period of collaboration by the first author with the Children's Hospital Boston, PERCS was launched at San Paolo Hospital, Milan, in 2008. To date, over 80 participants have voluntarily attended the program. The program features monthly 4-hour workshops geared around the enactment of a case scenario by trained actors and participants. Each workshop enrolls 10-13 interdisciplinary participants. After each enactment, participants receive feedback by actors, other participants and facilitators on the challenging junctures of the conversation. Pedagogical principles include: creating safety for learning; emphasizing moral and relational dimensions of care; suspending hierarchy among participants; valuing self-reflection; honoring multiple perspectives; and offering continuity of the educational offering. CONCLUSIONS: Implementing PERCS in Italy has demonstrated that it is possible to culturally adapt learning opportunities that embrace the relational and ethical experience of learners. The positive response of participants affirms that relational learning is meaningful and needed.

Difficult conversations: improving communication skills and relational abilities in health care.

BACKGROUND: Communication skills and relational abilities are essential core competencies that are associated with improved health outcomes, better patient adherence, fewer malpractice claims, and enhanced satisfaction with care. Yet, corresponding educational opportunities are sorely underrepresented and undervalued. OBJECTIVE: To evaluate the impact of an interdisciplinary experiential learning paradigm to improve communication skills and relational abilities of pediatric critical care practitioners. DESIGN: Prepost design, including baseline, immediate follow-up, and 5-month self-report questionnaires. SETTING: Tertiary care pediatric hospital, Children's Hospital Boston. PARTICIPANTS: One hundred six interdisciplinary clinicians with a range of experience levels and clinical specialties. MEASUREMENTS: Participants rated their sense of preparation, communication and relational skills, confidence, and anxiety. Open-ended questions asked participants about lessons learned, aspects of the training they found most helpful, and suggestions to improve the training. MAIN RESULTS: When questions were posed in a yes/no format, participants were nearly unanimous (93% to 98%) that the training had improved their sense of preparation, communication skills, and confidence immediately after and 5 months posttraining. Ninety percent of participants reported improvements in establishing relationships immediately after the training and 84% reported improvements 5 months posttraining. Eighty-two percent reported reduced anxiety immediately after training and 74% experienced reduced anxiety 5 months posttraining. On Likert items, 70% estimated their preparation had improved; 40% to 70% reported improvements in communication skills, confidence and anxiety, and 15% in relationship skills. Four qualitative themes emerged: identifying one's existing competence; integrating new communication skills and relational abilities; appreciating interdisciplinary collaboration; and valuing the learning itself. CONCLUSIONS: A 1-day experiential learning paradigm focused on communication skills and relational abilities was highly valued, clinically useful, and logistically feasible. Participants reported better preparation, improved communication and relational skills, greater confidence, and reduced anxiety. Participants deepened their understanding of family perspectives, recognized valuable existing competencies, and strengthened their commitment to interdisciplinary teamwork.

Assumptions and blind spots in patient-centredness: action research between American and Italian health care professionals.

OBJECTIVE: To examine how patient-centredness is understood and enacted in an American (US) and an Italian group of health care professionals. METHODS: An action research methodology was used. Two interprofessional groups of US (n = 4) and Italian (n = 5) health care professionals independently wrote a patient-centred dialogue between a doctor and a patient based on the same scenario. The dialogues were then translated and exchanged. Both groups independently commented on the patient-centred aspects of the other's dialogue by completing a written questionnaire. Their respective comments were then shared by international videoconference. The transcript of the videoconference was analysed via content analysis. The participants' opinions about the study were then evaluated. RESULTS: Exploring the patient's illness experience and handling the patient's emotions were identified as core components of patient-centred care by both the US and Italian groups, but were expressed differently in their respective dialogues. Respecting the patient's autonomy was recognised as a component of patient-centred care only by the US group. The Italian group demonstrated a more implicitly paternalistic approach. Participants highlighted the usefulness of one another's feedback to uncover cultural assumptions of patient-centred care and increase self-awareness. CONCLUSIONS: Results suggest that the concept and practice of patient-centred care is variable and may be influenced by culture. The study methodology improved participants' self-awareness of cultural values, and has potential as a cost-effective, experiential educational approach.

Difficult conversations in health care: cultivating relational learning to address the hidden curriculum.

The authors describe the philosophy and pedagogical approach of an innovative educational program, grounded in principles of relational learning and designed to improve the preparedness of health care professionals for engaging in challenging conversations with patients and families. The Program to Enhance Relational and Communication Skills (PERCS) is a project of The Institute for Professionalism and Ethical Practice at Children's Hospital Boston, developed in collaboration with Education Development Center, Inc. The one-day workshop is interdisciplinary in its structure, includes practitioners with varying levels of professional experience, uses trained actors to portray patients and family members, and involves learners in improvised case scenarios. The program responds to several developments in contemporary health care: medical education reform, changing definitions of professional competence, and calls for greater attention to qualities of compassion, trust, and respect in practitioners' relationships with patients and families. The program's pedagogy responds to these developments by creating a safe climate for relational learning, by enacting emotionally challenging and ethically salient case scenarios, and by integrating patient and family perspectives in novel and substantive ways. By creating a curriculum and learning environment that explicitly embraces the moral experience of learners, the program's developers aim to exert a countercultural influence on the dehumanizing effects of the hidden curriculum.

Relational learning in pediatric palliative care: transformative education and the culture of medicine.

The discrepancy between what is taught in formal educational settings and what is learned by practitioners in the informal flow of everyday practice has been called the hidden curriculum. In this article, the authors apply a well-documented range of concerns about the hidden curriculum and the erosion of professionalism to the arena of pediatric palliative care education. The authors propose that educational initiatives must always be grounded in the charged existential space of relationships among children, families,and practitioners, because the learning that matters most occurs within these relationships. The authors present an educational approach, which they call relational learning, and offer some preliminary strategies educators may wish to foster this kind of learning in their own health care organizations.

Sudden traumatic death in children: "we did everything, but your child didn't survive".

When caring for children who become suddenly and catastrophically ill, clinicians must simultaneously attend to a complex and rapidly evolving medical situation, as well as to the equally challenging demands of establishing compassionate relationships with family members and communicating well with colleagues. An 18-month-old toddler was brought to the hospital with severe head injury after being struck by a car. Over a period of hours, her condition evolved from prognostic uncertainty to the diagnosis of brain death and considerations of organ donation. Against this medical backdrop, the clinicians successfully established a trusting relationship with family members by careful attention to their emotional, informational, and care needs as they absorbed the devastating prognosis, took in the results of the brain death examination, and considered the option of organ donation. This case illustrates the importance of interdisciplinary communication, the vital role of social workers and other psychosocial providers with expertise in working with families, and the critical significance of mutual care and support for the clinicians who accompany families through these tragic life events.

The initiative for pediatric palliative care: an interdisciplinary educational approach for healthcare professionals.

There is growing empirical evidence that the U.S. healthcare system fails to meet the needs of children with life-threatening conditions and their families. The confluence of several recent developments has created a critical window of opportunity for improving clinical practice and institutional effectiveness in pediatric palliative care. This article presents an innovative, comprehensive approach to pediatric palliative care education that was developed by the Initiative for Pediatric Palliative Care, a consortium of seven academic children's hospitals, Education Development Center, the National Association of Children's Hospitals and Related Institutions, the New York Academy of Medicine, the Society of Pediatric Nursing, and the Association of Medical School Pediatric Department Chairs. The approach is based on needs assessment research with clinicians and parents and reflects a commitment to culturally respectful, family-centered care of children with life-threatening conditions. The pedagogy combines principles of adult education, includes families as teachers, and integrates affective and cognitive dimensions to enhance learning.