Anesthesiology trainees face ethical, practical and relational challenges in obtaining informed consent

BACKGROUND: Categorizing difficulties anesthesiologists have in obtaining informed consent may influence education, performance, and research. This study investigated the trainees' perspectives and educational needs through a qualitative analysis of narratives. METHODS: The Program to Enhance Relational and Communication Skills-Anesthesia used professional actors to teach communication skills and relational abilities associated with informed consent. Before attending the program, participants wrote about a challenging informed consent experience. Narratives were analyzed by two researchers following the principles of grounded theory. The researchers independently read the narratives and marked key words and phrases to identify reoccurring challenges described by anesthesiologists. Through rereading of the narratives and discussion, the two researchers reached consensus on the challenges that arose and calculated their frequency. RESULTS: Analysis of the 39 narratives led to the identification of three types of challenges facing anesthesiologists in obtaining informed consent. Ethical challenges included patient wishes not honored, conflict between patient and family wishes and medical judgment, patient decision-making capacity, and upholding professional standards. Practical challenges included the amount of information to provide, communication barriers, and time limitations. Relational challenges included questions about trainee competence, mistrust associated with previous negative experiences, and misunderstandings between physician and patient or family. CONCLUSIONS: The ethical, practical, and relational challenges in obtaining informed consent colored trainees' views of patient care and affected their interactions with patients. Using participant narratives personalizes education and motivates participants. The richness of narratives may help anesthesiologists to appreciate the qualitative aspects of informed consent

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

Background:\u2003The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians\u2019 preparedness to engage in difficult conversations. Aim:\u2003To describe the implementation of PERCS in an Italian hospital and assess the program's efficacy. Methods:\u2003The Italian PERCS program featured 4-h experiential workshops enrolling 10\u201315 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:\u2003146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p\u2009<\u20090.001) 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:\u2003PERCS proved culturally adaptable to the Italian context and effective in improving participants\u2019 sense of preparation, communication skills, and confidence

&quot;What would you do if this were your child?&quot; : Practitioners&apos; responses during enacted conversations in the United States

OBJECTIVE: To explore how practitioners in the United States respond to the question "What would you do if this were your child?" during realistic enactments with professional actors. DESIGN: Descriptive study of realistic pediatric critical care enactments. SETTING: Pediatric critical care. SUBJECTS: Interprofessional practitioners who enrolled in the Program to Enhance Relational and Communication Skills at Children's Hospital Boston and engaged in realistic simulated enactments. INTERVENTION: During the Program to Enhance Relational and Communication Skills workshops, practitioners met with parent-actors faced with life-support decisions for their 5-yr-old son who had suffered a near-drowning incident. Parent-actors were directed to naturally pose the question, "What would you do if this were your child?" The enactments were videotaped and practitioners' verbal responses to the question were qualitatively analyzed using content analysis. MEASUREMENTS AND MAIN RESULTS: From 2003 to 2008, we offered 20 Program to Enhance Relational and Communication Skills workshops and analyzed 20 realistic enactments during which interprofessional teams engaged in conversations about life-support decisions with parent-actors. In 50% of the meetings, the physician responded to the question, in 25% both the physician and the nurse or social worker, in 20% the nurse, and in 5% the physical therapist. The content of practitioners' responses yielded six themes: acknowledgment; discomfort and/or reluctance; values and decision-making approaches; focus on medical information; emotional and practical support; and personal response and self-disclosure. Eighty percent of practitioners' responses included more than one theme. CONCLUSIONS: Practitioners demonstrated a wide repertoire of responses that varied in their degree of relational engagement and responsiveness. Future research should explore parents' perspectives and preferences regarding such communication to further refine recommendations and educational experiences

Assessment of communication skills and self-appraisal in the simulated environment : feasibility of multirater feedback with gap analysis

INTRODUCTION: Multirater assessment is a powerful means of measuring communication skills. The use of gap analysis to assess self-appraisal is a strength of this technique. On the basis of Kalamazoo Consensus Statement framework and 360-degree assessment models, we developed a multirater instrument with gap analysis, with the goals of examining both communication skills and situational self-appraisal, and assessing the feasibility of the combined approach. METHODS: The multirater communication skills instrument was used to assess Pediatric and Neonatal Intensive Care fellows after participation in seven simulated family meetings. Instrument reliability was determined using Cronbach's Alpha and Factorial Analysis. Correlations between rater groups were examined with Spearman's Rank Coefficient. Gap analyses and rater perceptions of the instruments were analyzed using descriptive statistics. RESULTS: Seven pediatric intensive care unit and neonatal intensive care fellows were each assessed by 11 to 18 raters (108 total assessments). Correlations were identified between disciplinary groups within each encounter. Among the 7 fellows, 30 communication strengths or areas needing improvement and 24 significant gaps were identified, indicating self under-appraisals, 9 (38%) of which overlapped. The instrument was logistically feasible and well received. CONCLUSIONS: Our multirater communication skills instrument with gap analysis proved useful in identifying areas of strength and areas needing improvement, and in highlighting areas of self over- and under-appraisal that require focused feedback. The use of multirater assessment with gap analysis, in a simulated and "safe" environment, may assist in the delivery of feedback to trainees

Cultural traits of patient-centeredness : a comparative study between American and Italian clinical consultations

An action research methodology was employed. Participants were drawn, on a voluntary basis, from two interdisciplinary groups of experts in communication at: Children s Hospital, Boston, affiliated with Harvard Medical School, USA and San Paolo Hospital, affiliated with Milan University, Italy. The study included four phases. In the action phase, both groups independently wrote a patient-centered dialogue between a doctor and a patient in response to the same case scenario. The dialogues were then translated and exchanged by e-mail. In the intra-group reflection phase, the groups were asked to comment on each other s dialogue following a semistructured questionnaire. In the inter-group reflection phase, the two groups shared their respective comments regarding the dialogues and the underlying models of patient-centeredness by international conference call. Through discussion, a consensus on similarities and differences on patient-centered concepts and their applications was reached. Written summary of the points generated during the discussion, with extracts of dialogues as examples, were reviewed via e-mail by the two groups and the results were summarized for publication. In the evaluation phase, participants in the American and Italian groups were given a questionnaire to assess which aspects of the cross-cultural learning process had been most valuable for their subsequent clinical work. Discussion/implications for field The results will allow for a deeper understanding of the role of culture in shaping patient-centered concepts and their applicability. Culture-specific traits of patient centeredness as well as its common dimensions across western cultures might be detected. Moreover, the research project will offer the two groups an opportunity to reflect on one of the core concepts that informs their practice and teaching

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 healthcare: the Italian program to enhance relational and communication skills

Communicating difficult news is a pivotal component of clinical practice. The way this communication occurs influences patients\u2019 and families\u2019 experience of care and bereavement process. Yet, clinicians are poorly trained to manage the emotional and ethical aspects of this task. Since 2002, the Program to Enhance Relational and Communication Skills (PERCS) at Children\u2019s Hospital Boston has offered simulation-based workshops to promote relational skills and self-reflection for PICU and NICU clinicians (1). In collaboration with the Children\u2019s Hospital Boston, the Italian PERCS was launched in 2008 at San Paolo Hospital, University of Milan (2). The aim of this study was to evaluate the efficacy of this program in Italy. Methods Two Italian PERCS programs were developed; one focused on difficult conversations in adult ICU (PERCS-ICU) and another focused on communication with dialyzed adult patients (PERCS-dialysis). The workshops lasted 4 hours, enrolled 10-13 interdisciplinary participants, and were geared around the enactment and debriefing of a case scenario. Participants volunteered to meet with patients/family members portrayed by actors in enacted conversations. The conversations were videotaped in a separate room and showed simultaneously on close-circuit television to the group. After each conversation, participants rejoined the group and had the opportunity to discuss and receive feedback from other participants, actors, and facilitators. Unlike other programs which use standardized patients, the actors were encouraged to improvise responses based on the approach that the individual practitioner had taken. This enabled the conversations to be particularly realistic and to unfold differently each time they were enacted. Participants rated the realism and usefulness of the case scenario on 5-point Likert scales. Participants also rated their sense of preparation, communication and relational skills, confidence, and anxiety before and after the workshop. Wilcoxon test was used to detect differences in pre/post ratings. Results Three PERCS-ICU and 2 PERCS-dialysis programs were offered. A total of 61 clinicians participated (20 physicians, 29 nurses, 7 psychologists, 2 chaplains, 2 social workers, 1 lawyer), and 24 are on a waiting list. The scenarios were perceived as very realistic (m=4.6, SD=.502) and useful (m=4.4, SD=.695). Participants reported an improvement in their sense of preparedness (P=.000), confidence (P=.001), and communication skills (P=.004). All of the participants (100%) reported that they would recommend the workshop to other colleagues in their position. Discussion and Conclusions The PERCS learning paradigm based on the use of realistic enactments and interdisciplinary learning, was demonstrated to be logistically adaptable to the Italian healthcare system. Participants perceived the case scenarios as realistic and reported better preparation, improved communication skills, and greater confidence