An Intensive, Simulation-Based Communication Course for Pediatric Critical Care Medicine Fellows

Effective communication in pediatric palliative care: Evaluation of two educational videos

OBJECTIVES

In pediatric palliative care, effective communication is one of the most important skills. However, physicians often lack proper training. This study examines how to enhance medical students' ability to deliver a life-limiting diagnosis to parents. For this, we evaluated the effectiveness of two educational videos.

METHODS

We randomly assigned 114 medical students to two intervention groups and one control group. The intervention consisted of two different educational videos. We used self-assessment instruments and objective measures. Group-specific differences were analyzed using (repeated measures) Analysis of Variance, accounting for the effects of covariates, and t-tests.

RESULTS

Analysis of self-assessed communication skills identified a positive effect of the 'time x group' interaction (F (2) = 3.25, p = 0.042, np2= 0.055), indicating a statistically significant increase in both intervention groups. A positive effect of both videos on performance was observed for one item.

CONCLUSION

An acting or animated video can have a small but significant impact on self-assessed communication skills and objectively assessed behaviour for medical students with varying levels of experience in delivering bad news to parents.

PRACTICE IMPLICATIONS

Further research is required to investigate the long-term impact of educational videos on the communication behaviour of providers interacting with parents.

Describing the Impact of Physician End-of-Life Communication Training on Simulated Stress Using a Novel Stress Marker

IntroductionEmpathetic end-of-life (EOL) communication is important for high quality pediatric patient and family outcomes. Trainees may have limited exposure and training in caring for patients at EOL which may impact communication-related stress. This study had 2 aims: (1) describe pediatric resident physician EOL exposure and training (2) measure objective and subjective stress during simulated critical communication encounters and the impact of prior communication training/exposures on stress responses.MethodsWe performed a prospective, pilot observational cohort study measuring physician exposure to caring for patients/families at EOL and simulated communication stress. Simulated stress was measured subjectively using the state-trait anxiety inventory (STAI) and objectively using heart rate variability (HRV) during a communication training intervention.Results85.7% (18/21) of residents reported seldom/never caring for patients at EOL and universally felt ill-prepared to provide care. Subjective and objective stress increased when directly communicating with the simulated parent/patient actor compared to baseline in all HRV domains. Residents with limited exposure to patients/families at EOL had a smaller stress response than those who cared for a substantial number.ConclusionsPediatric residents report limited opportunities to communicate with patients/families at EOL, which may impact stress responses when communicating life-altering news to families. Simulated communication encounters can be designed to evoke subjective and objective stress which can be measured using novel technology and may help address limited EOL opportunities.

Delivering Serious News in Pediatric Cardiology-A Pilot Program

Pediatric cardiology fellows receive limited training on delivering serious news. This is a teachable skill through simulation-based communication. While studies have shown the use of communication courses in pediatrics, there have been none in pediatric cardiology. Pediatric cardiologists recognize the importance of good communication and desire further development of these skills. Based on an internal needs assessment, three cases were developed; fetal hypoplastic left heart syndrome, teenager with new hypertrophic cardiomyopathy, and young-adult with Fontan failure. A 4-h simulation course using evidence-based methods to teach delivering serious news was designed, consisting of a didactic session, case demonstration and small group case-based encounters with simulated patients. Trainees completed standardized pre/post-course surveys to assess perception of skill and preparedness. Paired survey responses were compared. Six pediatric cardiology fellows participated. Only 33% had received formal training in delivering serious news and 17% in techniques of responding to patient's emotions. The proportion of participants who felt good about their ability to deliver serious news and deal with a family's emotions increased from 0 to 83%. The proportion of participants who felt prepared to provide serious news about a patient's illness increased from 17 to 67%. Given the small number of participants, results were not statistically significant. All participants felt that the course was valuable in improving communication skills. A formal communication course increased perception of skill and preparedness among trainees. We provide an evidence-based framework and clinical cases for delivering serious news in pediatric cardiology, which is generalizable to other training programs.

Successful Development and Implementation of Communication Skills Simulation Training Within Pediatric Hematology-oncology Fellowship Education

Difficult discussions with patients and families are a primary component of pediatric oncology care. We report our experience in the development and implementation of a longitudinal simulation-based Communication Skills Curriculum within a pediatric hematology-oncology fellowship training program. A 6-session simulation curriculum was created for fellows to practice difficult oncology related discussions with a standardized patient (SP). This program was implemented in 2017 and continues presently. Throughout fellowship training the scenarios progress in content and scope. Each simulation was observed and recorded, and written and verbal feedback was provided. The Gap-Kalamazoo Communication Skills Assessment Form was used to assess communication skills in each session. A total of 15 fellows (100% of possible participants) have participated in this curriculum to date. Across all domains of communication skills assessed, the ratings given by the physician evaluators and self-evaluations improved over the course of the scenarios completed throughout fellowship training. This type of simulation-based communication skills curriculum within a pediatric hematology-oncology fellowship training program is feasible to implement. This training is useful to fellows beyond training in improving communication skills, which has the potential to directly benefit the future patients they care for.

Study protocol for a multicenter randomized controlled trial on simulation-based communication training for pediatric cardiology trainees (SIMUL-CHD)

BACKGROUND

Effective physician-patient communication is crucial to compassionate healthcare, particularly when conveying life-altering diagnoses such as those associated with congenital heart diseases. Despite its importance, medical practitioners often face challenges in communicating effectively. Because of these gaps, we aim to introduce a simulation-based training protocol to improve pediatric cardiology trainee's communication skills. This study will be conducted in collaboration with associations supporting caregivers of children with congenital heart disease. It strives to demonstrate how specific training programs can efficiently foster humanistic, patient-centered care in standard medical practice.

METHODS

This multicenter, open-label randomized controlled trial will be conducted in pediatric cardiac units and simulation centers of across 10 universities in France. The study population comprises pediatric cardiologists in training (including pediatric cardiac fellows or specialist assistants). The SIMUL-CHD intervention will consist of simulation-based training with standardized patients, focusing on improving communication skills for pediatric cardiology trainees during diagnostic counselling. Patients and caregivers have been recruited from a National Patient Association named "Petit Cœur de Beurre". The primary outcome is the quality of physicians' communication skills. The evaluation committee, which will review video recordings of the sessions, will be blinded to which participants received simulation-based training (group of interest) and which received theory-based training (control group). Secondary outcomes are the effect of SIMUL-CHD on empathy and anxiety levels in young pediatric cardiologists. Baseline scores pre and post-intervention will be compared, and skill improvement resulting from the intervention measured.

DISCUSSION

Simulation-based training has proven efficacy in teaching technical skills in various scenarios however its application to communication skills in pediatric cardiology remains unexplored. The involvement of experienced parents provides a unique perspective, incorporating their profound understanding of the emotional challenges and specific hurdles faced by families dealing with congenital heart disease.

TRIAL REGISTRATION

This trial is registered with the OSF registry (registered https://osf.io/ed78q ).

Simulation-based education for teaching aggression management skills to healthcare providers in acute healthcare settings: A systematic review

BACKGROUND

Behavioural emergencies involving aggression in acute care hospitals are increasing globally. Acute care staff are often not trained or confident in their prevention or management. Of available training options simulation-based education is superior for clinical medical education and is gaining acceptance for teaching clinical aggression management skills.

OBJECTIVE

The aim of this study was to conduct a systematic review of the effectiveness of simulation-based education for teaching aggression management skills for health professionals working in acute healthcare settings.

METHODS

The study protocol was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement, registered (27/02/2020) and published. We included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies involving healthcare professionals in acute hospital settings or trainee health professionals who received simulation-based training on managing patient aggression. Comprehensive searches were conducted in PubMed, Ovid MEDLINE, PsycINFO, CINAHL and The Cochrane Library. Two reviewers independently screened all records, extracted data and assessed risk of bias. The primary outcomes included patient outcomes, quality of care, and adverse effects. Secondary outcomes included workplace resource use, healthcare provider related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. A narrative synthesis of included studies was performed because substantial variation of interventions and outcome measures precluded meta-analyses.

RESULTS

Twenty-five studies were included with 2790 participants, 2585 (93 %) acute care hospital staff and 205 (7 %) undergraduate university students. Twenty-two studies combined simulation-based education with at least one other training modality. Three studies were randomised controlled trials, one was a pilot and feasibility cluster randomised controlled trial, one was a three-group post-test design and twenty were pre-/post-test design. Twenty-four studies were deemed to be high/critical or serious risk of bias. Four studies collected primary outcome data, all using different methods and with inconsistent findings. Twenty-one studies assessed performance in the test situation, seven studies provided objective ratings of performance and eighteen provided self-report data. Twenty-three studies reported objective or subjective improvements in secondary outcomes.

CONCLUSIONS

Acute healthcare staff who completed simulation-based education on managing clinical aggression showed statistically significant improvements in knowledge and self-reported confidence. However, there is a lack of evidence about the magnitude of these improvements and impact on patient outcomes.

REGISTRATION

PROSPERO Registration Number CRD42020151002.

TWEETABLE ABSTRACT

Simulation-based education improved acute healthcare clinician knowledge and confidence in managing aggression.

Healthcare providers' communication experience in the pediatric intensive care unit: a phenomenological study

BACKGROUND

Healthcare providers must effectively communicate with other professionals, multidisciplinary teams, and parents of patients in pediatric intensive care units (PICUs) to improve outcomes in children and satisfaction levels of parents. Few studies have focused on healthcare providers' communication experiences, which are crucial for identifying current problems and suggesting future directions. This phenomenological study was conducted to address this gap.

METHODS

A qualitative study using online and face-to-face interviews was conducted from January to June 2021 by a trained researcher in PICUs of two tertiary hospitals. Participants were five physicians and four registered nurses who worked in the PICUs and had over five years of clinical experience. The interviews were audio recorded with the participant's consent and analyzed by the researchers using Colaizzi's seven-step method.

RESULTS

Healthcare providers' communication experiences revealed four categories: facing communication difficulties in PICUs, communication relying on individual competencies without established communication methods, positive and negative experiences gained through the communication process, and finding the most effective communication approach.

CONCLUSIONS

Without adequate support or a systematic training program, healthcare providers often have to overcome communication challenges on their own. Therefore, support and training programs should be developed to facilitate better communication in the future.

Improving the Procedure of Delivering Serious News: Impact of a Six-Month Curriculum for Second Year Pediatric Residents

Objective: We implemented and studied a novel curriculum that combined role play, didactic education, and the use of a procedure card for asynchronous learning to improve second-year pediatric residents' skills in delivering serious news. Design: Phase 1 established baseline performance with a self-efficacy survey and observed simulation delivering serious news. Phase 2 included directed education of participants with a validated communication skills training framework. During Phase 3, participants were instructed to review the communication procedure card as a just-in-time reference prior to delivering serious news to patients and their families over 6 months. Following this period, participants completed a second self-efficacy survey and engaged in another observed simulation session delivering serious news. Pre and post intervention performance and self-efficacy were compared. Results: A total of 21 out of 26 (81%) participants completed all phases of this study. Participants had a statistically significant increase (p < .001) in self-efficacy scores post-intervention compared to pre-intervention for each of the skills to effectively deliver serious news: assess understanding, communicate news clearly, allow for silence, respond to emotion, and equip for next steps. Additionally, investigator assessments of participants showed an overall statistically significant improvement (p < .001) in all five communication skills post intervention compared to pre intervention. Conclusions: This curriculum resulted in significantly improved self-efficacy and observed ratings of communication skills in second-year pediatric residents over a 6-month period.

Pediatric End-of-Life Simulation Workshop to Clinical Care: Lasting Implications on Clinical Practice

Background

Simulations are an important modality for practicing high-acuity, low-frequency events. We implemented a deliberate practice simulation-based workshop to improve pediatric end-of-life care skills (PECS) competence.

Purpose

To understand pediatric subspecialty fellows' perceptions about influences of a simulation-based workshop on PECS provided at the bedside several months following participation.

Methods

Pediatric subspecialty fellows were recruited to voluntary focus groups during regular educational sessions six months following PECS workshop participation with aims to identify perceptions about their workshop participation and any implication on their clinical practice. Inductive qualitative content analysis of focus group interview data was performed adhering to the Standards for Reporting Qualitative Research.

Results

Ten fellows participated in one of three focus groups. Researchers identified three major themes of fellow experience: burden, safe practice space, and self-efficacy. Fellows described practice implications from workshop participation, including incorporation of specific practices, improved anticipatory guidance, and increased team leader confidence.

Conclusions

Targeted, deliberate simulation-based practice of PECS can help close the gap from learning to practice, contributing to provider self-efficacy and potentially improving clinical care for pediatric patients and families at end of life.

Training perinatal nurses in palliative communication by using scenario-based simulation: A quasi-experimental study

AIM

This study aimed to assess the impact of two educational modules on enhancing the communication confidence, competence and performance of perinatal nurses in the context of palliative care.

BACKGROUND

Concerns have arisen regarding the preparedness of perinatal nurses in delivering palliative care, especially in terms of deficiencies in communication skills and negative attitudes toward making life-support decisions for parents facing neonates with terminal conditions. Bridging this gap necessitates improved perinatal palliative care education for healthcare providers. Research has shown that simulation-based teaching effectively enhances procedural competence, communication skills and confidence among healthcare professionals. However, comprehensive curricula focusing on perinatal palliative communication remain limited.

DESIGN

This study used a quasi-experimental design employing a two-group repeated measure approach. It involved a purposive sample of 79 perinatal nurses from a hospital in northern Taiwan.

METHODS

A palliative communication course specifically designed for registered nurses in perinatal units was developed. Participants were allocated to either the experimental group (Scenario-Based Simulation, SBS) or the control group (traditional didactic lecture). Communication confidence and competence were assessed before and immediately after the course through structured questionnaires. Learning satisfaction was collected post-intervention and participants underwent performance evaluation by standardized parents one week later.

RESULTS

A significant training gap in palliative care exists among nurses in OB/GYN wards, delivery rooms and neonatal critical care units, highlighting the need for continuing education. All 79 participants completed the training course. Following the intervention, nurses in the SBS group (n=39) exhibited significant improvements in self-reported confidence (p <0.05), competence (p <0.01) and performance (p <0.001) in neonatal palliative communication compared with the traditional didactic lecture group (n=40). The SBS group also received higher satisfaction ratings from nurse learners (p <0.001).

CONCLUSIONS

The research findings support scenario-based simulation as a more effective educational approach compared with traditional didactic lectures for enhancing communication confidence and competence. These results were further reinforced by evaluation from standardized patients, highlighting the value of direct feedback in enhancing nurses' performance. Tailoring SBS designs to diverse nursing contexts and incorporating a flipped approach can further enrich the overall learning experience. Given its high effectiveness and positive reception, we recommend integrating this educational module into palliative care training programs for perinatal nurses.

PedsTalk: A Pilot Communication Skills Education Course for Pediatric Residents

OBJECTIVE

Communication skills are critical to pediatric practice, but few pediatric residency programs provide formal communication skills education. Pediatric residents often lack confidence in these skills. We hypothesized that a simulation-based communication skills course would improve resident confidence in the skills required for serious illness conversations with patients/families.

METHODS

In collaboration with multidiscipline VitalTalk-trained faculty, we developed PedsTalk, a communication skills course for pediatric residents based on the VitalTalk framework. In PedsTalk, faculty/peers offered real-time coaching during simulation sessions with actors. Resident participants self-rated confidence in 9 communication skills using a 5-point Likert scale before, immediately after, and 4 months after course participation, with course nonparticipants serving as controls. Responses were analyzed by using Friedman tests and Wilcoxon rank tests. Thematic analysis was conducted to identify themes among free-text responses.

RESULTS

Twenty-seven pediatric residents participated in PedsTalk, 11 of whom completed survey assessments at all timepoints. Eleven course nonparticipants served as controls. Over time, participants' confidence in the following communication skills was retained or significantly improved: "difficult conversations" (P < .001), "recognizing emotion" (P < .01), "using silence" (P < .008), "headline statements" (P < .001), eliciting "VALUES" (P < .001), and asking "permission to continue" (P < .001). Over time, controls had significant improvements in confidence in 2 skills: headline statements (P < .014) and eliciting "VALUES" (P < .031).

CONCLUSIONS

PedsTalk is a novel approach to communication skills education in pediatric residency. Participation improved residents' confidence in 6 communication skills, including overall confidence in having difficult conversations. Although confidence in some skills may naturally develop through clinical experiences, PedsTalk further enhances communication skills education among trainees.

Assessing Communication Quality in the Intensive Care Unit

Introduction: Successful shared decision-making for critically ill intensive care unit (ICU) patients requires bidirectional communication. Through observation of ICU conversations, our study aimed to identify communication skill deficiencies in providers who care for patients in the ICU. Methods: This was an observational prospective study performed in a single urban academic medical center (671 beds) from June 2021 through August 2021. Twenty-three providers were recruited from medical and surgical ICU services (56 beds). Thirty-nine surrogate decision makers were identified. Provider skills were assessed using a customized observational tool that examined nonverbal communication, verbal communication, opening the discussion, gathering information, understanding the family's perspective, sharing information, reaching agreements on problems and plans, and providing closure. Results: Thirty-nine conversations were observed for six attending physicians, four fellow physicians, eight resident physicians, two nurse practitioners, and three physician assistants during the coronavirus 19 (COVID19) pandemic. A dedicated critical care provider engaged in 19 observed conversations; 20 discussions occurred with individuals rotating/consulting in the ICU. Communication skill did not depend on experience or area of expertise. Less than half of conversations achieved bidirectional communication proficiency. Scheduled conversations (n = 14) had significantly higher average communication scores than unscheduled encounters (n = 25). Conclusions: Superficial unidirectional communication with decision makers was commonly observed. Providers were less proficient at advanced communication skills needed for shared decision-making. We recommend that providers have more scheduled conversations, which were more productive in achieving bidirectional communication. A targeted simulation curriculum addressing these areas may improve patient, decision maker, and provider satisfaction, while promoting patient-centered care.

Taking the Pulse of the Current State of Simulation

Simulation in health-care professions has grown in the last few decades. We provide an overview of the history of simulation in other fields, the trajectory of simulation in health professions education, and research in medical education, including the learning theories and tools to assess and evaluate simulation programs. We also propose future directions for simulation and research in health professions education.

Prognostic and Goals-of-Care Communication in the PICU: A Systematic Review

OBJECTIVE

Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions.

DATA SOURCES

PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus.

STUDY SELECTION

We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication.

DATA EXTRACTION

Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology.

DATA SYNTHESIS

Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions.

CONCLUSIONS

Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.

iValidate: a communication-based clinical intervention in life-limiting illness

OBJECTIVES

Report the implementation, user evaluation and key outcome measures of an educational intervention-the iValidate educational programme-designed to improve engagement in shared decision-making by health professionals caring for patients with life-limiting illness (LLI).

DESIGN

Prospective, descriptive, cohort study.

PARTICIPANTS

Health professionals working in acute care settings caring for patients with an LLI.

MAIN OUTCOMES MEASURED

Participant evaluation of learning outcomes for communication skills and shared decision-making; demographic data of participants attending education workshops; and documentation of patients with LLI goals of management, including patient values and care decision based on area in acute care and seniority of doctor.

RESULTS

The programme was well accepted by participants. Participant evaluations demonstrated self-reported improved confidence in the areas of patient identification, information gathering to ascertain patient values and shared decision-making. There was strong agreement with the course-enhanced knowledge of core communication skills and advanced skills such as discussing mismatched agendas.

CONCLUSIONS

We described the educational pedagogy, implementation and key outcome measures of the iValidate education programme, an intervention designed to improve person-centred care for patients with an LLI. A targeted education programme could produce cultural and institutional change for vulnerable populations within a healthcare institution. A concurrent research programme suggests effectiveness within the current service and the potential for transferability.

Defining Objective Measures of Physician Stress in Simulated Critical Communication Encounters

This study had three aims: 1) quantify the difference in stress levels between low and high stress roles during simulated critical communication encounters using objective physiologic data (heart rate variability [HRV]) and subjective measures (State-Trait Anxiety Inventory [STAI]), 2) define the relationship between subjective and objective measures of stress, and 3) define the impact of trainee preparedness and reported self-efficacy on stress levels.

Teaching Communication as a Procedure by Utilizing a Mixed-Methods Curriculum: A Pilot Study

Objective

In this study, we aimed to develop and pilot a mixed-methods curriculum among pediatric subspecialty fellows that combined didactics, role-play, and bedside coaching with a procedure card. We hypothesized that this curriculum would improve fellows’ ability to navigate difficult conversations and would be feasible to implement across training programs.

Methods

This study was conducted from 2019 to 2020. Phase 1 focused on establishing baseline performance. Phase 2 involved the education of participants and faculty. During phase 3, participants communicated difficult news to patients and families using the procedure card as a prompt with the aid of faculty coaching. Six months later, participants' performance was re-evaluated and compared with baseline performance.

Results

A total of 10 out of 17 (60%) participants completed the pilot study. Likert self-efficacy results revealed an improvement in the skill of delivering difficult news (3.0 pre-intervention, 4.1 post-intervention, p=0.0001), conducting a family conference (2.5 pre-intervention, 3.6 post-intervention, p=0.0001), and responding to emotions (3.4 pre-intervention, 4.2 post-intervention, p=0.0003). Investigator assessments showed improvement in fellows’ ability to communicate information clearly (2.5 pre-intervention, 3.9 post-intervention, p=0.0001) and demonstrate empathy (2.7 pre-intervention, 3.3 post-intervention, p=0.005).

Conclusions

In this pilot study, coaching at the bedside with a procedure-card prompt was effective at improving specific self-perceived and observed communication skills. Future research is needed to evaluate modifications to this curriculum to enhance its feasibility.

Education in the Pediatric Intensive Care Unit

This article addresses the latest data and ideas related to education in the pediatric intensive care unit, including traditional education methods with newer and technology-based methods. A review of adult learning theory is included with discussions regarding medical decision making and error prevention, bedside teaching, medical simulation, and electronic methods of education.

An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness

BACKGROUND

Large-scale efforts to train clinicians in serious-illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support.

OBJECTIVE

To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness.

METHODS

A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively.

RESULTS

Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training.

CONCLUSIONS

Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.

Content Evidence for Validity of Time-to-Task Initiation: A Novel Measure of Learner Competence

INTRODUCTION

Educators require validated tools to assess learner competency in simulation-based mastery learning. We previously created a simulation to incorporate crisis resource management skills after a needs assessment of our pediatric residency program. We present the development of and content evidence for validity of a task list with time-to-task initiation designed to aid in rapid cycle deliberate practice (RCDP) debriefing and assessment of pediatrics resident learners.

METHODS

Five board-certified pediatricians developed the initial task list with 30 tasks. We used the Delphi technique to seek content evidence for validity of the initial task list using 17 board-certified pediatricians at 7 institutions across the United States. After finalizing the task list, we video recorded 3 pediatric experts performing the tasks in a simulation. We then used the Delphi technique to establish and to attain agreement on time-to-task initiation. We calculated Cronbach α coefficient to measure internal consistency of the expert responses. After finalizing the task list, we divided it into 3 stages with 5 separate cycles per stage to direct the educator in performance of RCDP debriefing.

RESULTS

The group reached 80% agreement after 2 Delphi rounds with a Cronbach α coefficient of 0.95. The resultant list included 25 tasks. The group subsequently achieved 80% agreement on the time-to-task initiation in 2 Delphi rounds.

CONCLUSIONS

We present content evidence for validity of a task list with associated time-to-task initiation for a simulation scenario that incorporates crisis resource management skills and is designed to aid educators in RCDP debriefing. This task list may decrease intereducator inconsistencies in delivery of RCDP for a common pediatric resuscitation scenario.

Education and training methods for healthcare professionals to lead conversations concerning deceased organ donation: An integrative review

OBJECTIVES

To determine which training methods positively influenced healthcare professionals' communication skills and families' deceased organ donation decision-making.

METHODS

An integrative review using systematic methods and narrative synthesis for data analysis. Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (EBSCO), Embase (OVID) and ProQuest Dissertations & Theses Global, were searched between August 1997 and March 2020, retrieving 1019 papers. Included papers (n = 14) were appraised using the Medical Education Research Study Quality Instrument.

RESULTS

Training programmes offered theory, experiential learning, feedback and debriefing including self-reflection, the opportunity to role-play and interact with simulated participants within realistic case scenarios. Programmes reported observed and self-rated improvements in communication learning and confidence. The methodological quality score averaged 13, (72% of maximum); few studies used an experimental design, examined behavioural change or families' perspectives. Weak evidence suggested training could increase organ donation authorisation/consent rates.

CONCLUSIONS

Multiple training strategies are effective in improving interprofessional healthcare professionals' confidence and learning of specialised communication. Methodological limitations restricted the ability to present definitive recommendations and further research is warranted, inclusive of family decision-making experiences.

PRACTICE IMPLICATIONS

Learning of specialised communication skills is enhanced by using multiple training strategies, including role-play and debriefing.

Teaching Empathic Communication to Pediatric Interns: Immediate and 3-Month Impact

OBJECTIVE

Evaluate pediatric intern self-reported preparedness to Deliver Serious News, Express Empathy, and Medical Error Disclosure after a 1-day simulation based-empathic communication training. Additionally, we sought to evaluate self-reported use of communication skills and describe the clinical scenarios in which the skills were used.

METHODS

Pediatric interns completed the survey immediately and 3 months after participating in the communication course.

RESULTS

Self-reported preparedness to Deliver Serious News, Express Empathy, and Medical Error Disclosure all significantly improved. At 3 months, 73.9% of respondents reported using the skills at least weekly and 62% described the clinical scenarios in which they used skills. These descriptions show an ability to use the skills appropriately, and in some cases apply the skills in advanced, more difficult scenarios.

CONCLUSION

A 1 day simulation-based reflective teaching course for pediatric interns is an effective way to teach empathic communication skills. They feel more prepared to deliver serious news, respond with empathy and disclose a medical error. In addition, the interns value the training as a part of their education and report using the skills in appropriate scenarios at 3 months.

Primary Palliative Care Education for Trainees in U.S. Medical Residencies and Fellowships: A Scoping Review

Background: The medical profession increasingly recognizes the growing need to educate nonpalliative physicians in palliative care. Objective: This study aims to provide a scoping review of the primary palliative care (PPC) education currently available to graduate medical trainees in primary and specialty tracks. Design: Studies of PPC interventions in U.S. residency or fellowship programs of all subspecialties published in English and listed on MEDLINE, CINAHL, and EMBASE through January 2020 were included. To meet admission criteria, studies had to describe the content, delivery methods, and evaluation instruments of a PPC educational intervention. Results: Of 233 eligible full texts, 85 studies were included for assessment, of which 66 were novel PPC educational interventions and 19 were standard education. Total number of publications evaluating PPC education increased from 8 (2000-2004) to 36 (2015-2019), across 11 residency and 10 fellowship specialties. Residency specialties representing the majority of publications were emergency medicine, general surgery, internal medicine, and pediatric/medicine-pediatrics. PPC content domains most taught in residencies were communication and symptom management; the primary delivery method was didactics, and the outcome assessed was attitudes. Fellowship specialties representing the majority of publications were pediatric subspecialties, nephrology, and oncology. The PPC content domain most taught in fellowships was communication; the primary delivery method was didactics and the outcome evaluated was attitudes. Conclusions: While PPC education has increased, it remains varied in content, delivery method, and intervention evaluations. Future studies should include more widespread evaluation of behavioral outcomes, longitudinal persistence of use, and clinical impact.

Most Children With Medical Complexity Do Not Receive Care in Well-Functioning Health Care Systems

OBJECTIVES

To describe the access of children with medical complexity (CMC) to well-functioning health care systems. To examine the relationships between medical complexity status and this outcome and its component indicators.

PATIENTS AND METHODS

Secondary analysis of children in the National Survey of Children's Health combined 2016-2017 data set who received care in well-functioning health systems. Secondary outcomes included this measure's component indicators. The χ2 analyses were used to examine associations between child and family characteristics and the primary outcome. Adjusted multivariable logistic regression was used to examine relationships between medical complexity status and primary and secondary outcomes. Using these regression models, we examined the interaction between medical complexity status and household income.

RESULTS

CMC accounted for 1.6% of the weighted sample (n = 1.2 million children). Few CMC (7.6%) received care in a well-functioning health care system. CMC were significantly less likely than children with special health care needs (CSHCN) (odds ratio, 0.3) of meeting criteria for this primary outcome. Attainment rates for secondary outcomes (families feeling like partners in care; receives care within a medical home; received needed health care) were significantly lower among CMC than CSHCN. Family income was significantly associated with likelihood of meeting criteria for primary and secondary outcomes; however, the relationships between medical complexity status and our outcomes did not differ by income level.

CONCLUSIONS

CMC are less likely than other CSHCN to report receiving care in well-functioning health care systems at all income levels. Further efforts are necessary to better adapt current health care systems to meet the unique needs of CMC.

Simulation of operating room crisis management - hypotension training for pre-clinical students

BACKGROUND

Simulation training is an essential criterion for medical staff. The majority of residents are trained in operating room crisis management (ORCM), but only a few pre-clinical anesthesia undergraduate students are trained. Anesthesia methodology and technology were studied by the anesthesia undergraduate students in theory, but they were not able to practically resolve all clinical problems scientifically and reasonably. Consequently, there is a need to apply their competencies and bring together their technology knowledge practically. The crisis management of operating room emergencies was a method of choice applied and used over time. Here, we designed the scenarios for comprehensive crisis management to train anesthesia undergraduate students. We tried to establish or identify the problems which occurred during attempts to implement these scenarios.

METHODS

Anesthesia undergraduate students initially examined the basic theory, fundamental practice techniques, and case studies before the simulation training program. Subsequently, they participated in comprehensive ORCM training. Training outcomes were evaluated through different viewpoints: understanding the subject, crisis management, nontechnical skills, and a user experience evaluation.

RESULTS

Anesthesia undergraduate students performed significantly better with completion of ORCM, indicated by higher scores in all four tests (P < 0.001), as well as clinical crisis management (P = 0.0016) and nontechnical skills (P = 0.0002). Following the simulation, the students described the experience as helpful in "combining theoretical knowledge with clinical practice", helpful with memorization, and in "promoting understanding of the subject," while "learning clinical logic authentically" and "inspiring learning interests."

CONCLUSIONS

This research indicates that ORCM could be implemented as a useful learning tool for pre-clinical anesthesia undergraduate students. The ORCM could be an excellent training method to help improve students' professional competence in crisis management and nontechnical skills, integrating the knowledge and technology of the field of anesthesiology.

National Divergences in Perinatal Palliative Care Guidelines and Training in Tertiary NICUs

Objectives: Despite established principles of perinatal palliative care (PnPC), implementation into practice has shown inconsistencies. The aim of this study was to assess PnPC services, examine healthcare professionals (HCPs) awareness and availability of PnPC guidelines, and describe HCPs satisfaction with PC and guidelines. Material and Methods: A nationwide survey was conducted in Swiss tertiary NICUs between April-November 2019. Data were examined by descriptive statistics and linear regression models. Results: Overall response rate was 54% (65% physicians; 49% nurses; 72% psychosocial staff). Half of professionals (50%) received education in PC during their medical/nursing school, whereas 36% indicated they obtained further training in PnPC at their center. PnPC guidelines were available in 4/9 centers, with 68% HCPs being aware of the guideline. Professionals who had access to a PnPC team (P = 0.001) or were part of the nursing (P = 0.003) or psychosocial staff (P = 0.001) were more likely aware of having a guideline. Twenty-eight percent indicated being satisfied with PC in their center. Professionals with guideline awareness (P = 0.025), further training (P = 0.001), and access to a PnPC team (P < 0.001) were more likely to be satisfied, whereas HCPs with a nursing background (P < 0.001) were more likely to be dissatisfied. A majority expressed the need for a PnPC guideline (80%) and further PC training (94%). Conclusion: This study reveals lacking PnPC guidelines and divergences regarding onsite opportunities for continued training across Swiss level III NICUs. Extending PnPC guidelines and training services to all centers can help bridge the barriers created by fragmented practice.

Improving Patient- and Family-Centered Communication in Pediatrics: A Review of Simulation-Based Learning

Patient- and family-centered care focuses on relationships among patients, families, and health care providers that are mutually beneficial and improve health care outcomes and provider satisfaction. Building relationships is a key component of the provision of excellent health care and can be taught and enhanced through simulation-based communication skills training. This article reviews the available literature on simulation-based learning as used to improve patient- and family- centered communication in the discipline of pediatrics. In this narrative review, we examine the various methods, theories, and frameworks on which simulation-based learning for communication skills are built with the goal of assisting pediatric providers in using this powerful educational technique. [Pediatr Ann. 2021;50(1):e32-e38.].

Pediatric Critical Care Medicine Fellowship Simulation Use Survey

OBJECTIVES

Simulation-based education is used in the U.S. Pediatric Critical Care Medicine fellowship programs, yet the prevalence and types of simulation used is unknown. A survey was developed to determine the prevalence, the perceived importance, and barriers associated with simulation-based education in these programs.

DESIGN

A 43-item survey instrument was sent to all 66 U.S. Accreditation Council for Graduate Medical Education-accredited Pediatric Critical Care Medicine fellowship programs during the summer of 2018. We defined simulation broadly as "any type of simulation that involved mannequins, task trainers, standardized actors, team training, etc."

SETTING

An online survey was used to obtain information regarding simulation used in Pediatric Critical Care Medicine fellowship programs.

SUBJECTS

All sixty-six U.S. Accreditation Council for Graduate Medical Education-accredited Pediatric Critical Care Medicine fellowship programs were sent a survey request.

MEASUREMENTS AND MAIN RESULTS

Forty-four of the 66 U.S. Accreditation Council for Graduate Medical Education-accredited Pediatric Critical Care Medicine fellowship programs (67%) responded to the survey. Ninety-eight percent of responding programs (n = 43) use simulation-based education in their Pediatric Critical Care Medicine fellowship curriculum. Most programs (56%) have incorporated simulation training into their Pediatric Critical Care Medicine fellowship curriculum in the last 4-10 years (range, <1 to >15 yr, median 4-6 yr). A variety of principles, concepts, and programs were reported as used in their simulation programs. The most commonly reported barriers to Pediatric Critical Care Medicine fellowship simulation-based education were lack of funding (56%) and lack of faculty with simulation experience (56%). The majority of programs (64%; N = 28) think simulation-based education is absolutely necessary to Pediatric Critical Care Medicine fellowship training.

CONCLUSIONS

Nearly, all responding U.S. Accreditation Council for Graduate Medical Education-accredited Pediatric Critical Care Medicine fellowship programs use simulation-based education to train Pediatric Critical Care Medicine fellows with the majority perceiving simulation as absolutely necessary to Pediatric Critical Care Medicine fellow training. The reported types of simulation used in fellow training varied, as did training theories and concepts in the simulation programs. More research is needed to understand how to optimize and perhaps standardize parts of Pediatric Critical Care Medicine fellowship simulation training to improve the impact and outcomes of such training.

Recent Advances in Simulation for Pediatric Critical Care Medicine

PURPOSE OF REVIEW

This review highlights the emerging fields of simulation research by tying innovation into principles of learning and process improvement.

RECENT FINDINGS

Advances have been made in both educational simulation and simulation for quality improvement, allowing this versatile modality to be more broadly applied to healthcare and systems.

SUMMARY

Simulation in pediatric critical care medicine continues to evolve. Although the majority of simulation is focused on learner education, emerging research has broadened to focus on patient- and system-centered outcomes, leading to improvement in the quality of care delivered in the ICU.

Simulation-based education to promote confidence in managing clinical aggression at a paediatric hospital

BACKGROUND

An increasing number of incidents involving aggressive behaviour in acute care hospitals are being witnessed worldwide. Acute care hospital staff are often not trained or confident in managing aggression. Competent management of clinical aggression is important to maintain staff and patient safety. Training programmes for acute care staff are infrequently described in the literature and rarely reported for paediatric staff. Simulation training allows practice of skills without patient risk and may be more effective than traditional teaching formats for aggression management.

AIM AND DESIGN

The aim of this proof of concept study was to develop a simulation-based education session on aggression management for acute care paediatric staff based on best practice principles, to evaluate the acceptability of this training programme and to gain an understanding of the impact of the training on participants' perceived confidence in managing clinical aggression. Two separate simulation exercises were delivered as a 2-h component of a hospital management of clinical aggression (MOCA) training day. Participants completed a written survey immediately prior to, at completion of the simulation-based group training, and at 3-6 months following the simulation training.

FINDINGS

Nine training days were conducted in 2017 for nursing, medical, allied health, education and security staff with a total of 146 participants (83% were acute care nurses). Two thirds (68%) of participants had experienced clinical aggression as part of their routine work, with 51% overall reporting a lack of confidence managing these patients. Immediately following the simulation training, 80% of all participants reported feeling more confident in managing clinical aggression, 47% reported a 1-point increase in confidence, whilst 33% of participants reported a 2- or 3-point increase. At 3-6 months post-training, 66% of respondents (N = 44) reported continued confidence in managing aggression with 100% of participants stating they would recommend simulation training to colleagues.

CONCLUSIONS

Simulation training is an acceptable method of training and shows promise to improve staff-perceived confidence for managing behavioural emergencies in acute paediatric health care settings. In addition, there were potential enduring positive impacts at 3 months after the study. Whilst resource and time intensive, further research assessing the benefits of utilising simulation training in this setting is warranted in order to minimise staff burn-out and improve outcomes for these very vulnerable patients.

Simulation-Based Course Improves Resident Comfort, Knowledge, and Ability to Manage Surgical Intensive Care Unit Patients

BACKGROUND

Simulation-based education can augment residents' skills and knowledge. We assessed the effectiveness of a simulation-based course for surgery interns designed to improve their comfort, knowledge, and ability to manage common surgical critical care (SCC) conditions.

MATERIALS AND METHODS

For 2 y, all first year residents (n = 31) in general surgery, urology, interventional radiology, and the integrated plastics, vascular, and cardiothoracic surgery training programs at our institution participated in a simulation-based course emphasizing evidence-based management of SCC conditions. Precourse and postcourse surveys and multiple-choice tests, as well as summative simulation tests, assessed interns' comfort, knowledge, and ability to manage SCC conditions. Changes in these measures were assessed with Wilcoxon matched-pairs signed rank tests. Factors associated with summative performance were determined by linear regression.

RESULTS

The course consisted of four simulation-based teaching sessions in year 1 and six in year 2. The course taught seven of the 18 core SCC conditions in the Surgical Council on Resident Education general surgery curriculum in year 1 and 10 in year 2. Interns' self-reported comfort, knowledge, and ability to manage each condition taught in the course increased (P < 0.02). Their knowledge of each condition, as assessed by written tests, also increased (P < 0.02). Their summative simulation test performance correlated with the number of course sessions attended (P < 0.03) and status as general surgery residents (P < 0.01).

CONCLUSIONS

A simulation-based SCC training course for surgery interns that emphasizes evidence-based management of SCC conditions improves interns' comfort, knowledge, and ability to manage these conditions.

Pathophysiology for the Pediatric Critical Care Fellow: Three Representative Simulation Cases

INTRODUCTION

During the course of fellowship training, pediatric critical care fellows are expected to develop a broad and in-depth understanding of the pathophysiology of multiple disease processes. The simulation-based pediatric critical care pathophysiology curriculum we present uses scenarios created by pediatric critical care fellows to teach complex pathophysiology.

METHODS

Each of the three representative cases presented covered a specific pathophysiologic process and required participants to acutely manage (1) an 18-year-old patient with altered mental status in the setting of hepatic encephalopathy; (2) an 8-year-old patient with sepsis, coagulopathy, and acute kidney injury; or (3) a 12-year-old patient with status epilepticus. Each case could be conducted in a simulation suite or an acute care unit bed. We assessed learners' knowledge and attitudes at the end of these simulations with a structured debriefing session and via completion of an evaluation form. The simulations were then followed by a 30-minute interactive didactic session on the topic.

RESULTS

Each scenario had six fellow participants who completed evaluations. After completing each of the three case scenarios presented, the majority of participating pediatric critical care fellows indicated that the content was relevant and sufficiently challenging. They also indicated that these simulation scenarios would improve their clinical practice.

DISCUSSION

This fellow-developed simulation curriculum is novel, highlighting the relevance for critical care fellows' understanding of realistic clinical scenarios while promoting advanced management skills with a pathophysiology focus.

Communication Training in Adult and Pediatric Critical Care Medicine. A Systematic Review

Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention (n = 15), cross-sectional survey (n = 5), and instrument validation (n = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention.

Medical simulation utilization among pediatric anesthesiology fellowship programs

BACKGROUND

Simulation-based education is a mainstay in education of pediatric anesthesiology trainees. Despite the known benefits, there is variability in its use and availability among various pediatric anesthesiology fellowship programs.

AIM

The primary aim was to understand the current state of simulation-based education among pediatric anesthesiology fellowship programs and define barriers that impede the development of an effective simulation program.

METHODS

This survey-based, observational study of simulation activities within United States-based pediatric anesthesiology fellowship programs was approved by the Institutional Review Boards (IRB) of the authors' institutions. A 35-question survey was developed in an iterative manner by simulation educators (AA, WW, DY) and a statistician familiar with survey-based research (AN) using research electronic data capture (REDCap) for tool development and data collation. Descriptive and thematic analyses were performed on the quantitative and qualitative responses in the survey, respectively, and were stratified with small, medium, and large fellowship programs.

RESULTS

Forty-five of 60 (75%) fellowship programs responded to the survey. The presence of a dedicated simulation program director and number of simulation instructors was positively associated with the size of program and years in operation. Dedicated simulation support was variable across programs and was usually present within the larger programs. A positive association also existed for educational activities among all programs mostly based on size of program and years in operation. Protected time was the most commonly cited barrier to having a comprehensive and sustainable simulation program. There was general agreement for establishing a standardized and shared curriculum among fellowship programs. Approximately 70% of simulation programs had no formal simulation instructor training requirement.

CONCLUSIONS

Simulation-based curricula are broadly offered by many fellowship programs. Improved collaboration locally, regionally, and nationally may improve educational opportunities for fellowship programs, particularly the small ones. These efforts may begin with the development of a standardized curriculum and formal instructor training programs.

Palliative care for pediatric intensive care patients and families

PURPOSE OF REVIEW

Children with medical or surgical critical illness or injury require skillful attention to physical, emotional, psychological, and spiritual needs, whereas their families need support and guidance in facing life-threatening or life-changing events and gut-wrenching decisions. This article reviews current evidence and best practices for integrating palliative care into the pediatric intensive care unit (PICU), with a focus on surgical patients.

RECENT FINDINGS

Palliative care is best integrated in a tiered approach, with primary palliative care provided by the PICU and surgical providers for all patients and families, including basic symptom management, high-quality communication, and end-of-life care. Secondary and tertiary levels of care involve unit or team-based 'champions' with additional expertise, and subspecialty palliative care teams, respectively. PICU and surgical providers should be able to provide primary palliative care, to identify patients and families for whom a palliative care consult would be helpful, and should be comfortable introducing the concept of palliative care to families.

SUMMARY

This review provides a framework and tools to enable PICU and surgical providers to integrate palliative care best practices into patient and family care.

Pediatric Resident Perception and Participation in End-of-Life Care

BACKGROUND

Despite advances in medical care, pediatric deaths are still an unfortunate reality. Most of these deaths occur within a hospital setting. End-of-life care is an important part of medical care for children with serious illnesses. Despite the importance, pediatric providers report a lack of comfort surrounding end-of-life care.

OBJECTIVE

To assess categorical pediatric residents' perceptions and participation in providing end-of-life care to dying children and their families.

STUDY DESIGN

This is a survey-based, descriptive, mixed-methods study. Survey was sent to categorical pediatric residents at Indiana University School of Medicine in June 2018 to obtain both quantitative and qualitative information on resident perception and participation in end-of-life care. Surveys were sent to 100 residents with a response rate of 68%.

SETTING/PARTICIPANTS

Pediatric residents at Indiana University School of Medicine.

RESULTS

The comfort and participation in end-of-life care are limited in all levels of pediatric training. Residents do not feel comfortable with 19 of 22 questions related to end-of-life care. Only 32% of residents felt their education prepared them to participate in end-of-life care. Almost one-fifth (19.5%) of residents report participating in zero aspect of end-of-life care. Themes discussed by residents include education, experience, communication, social norms, emotions, self-care, comfort, and family.

CONCLUSION

More formalized education and training is needed to increase resident comfort with and participation in end-of-life care. Such future interventions should focus on communication surrounding difficult conversations and providing guidance for families.

Communication Skills and Practices Vary by Clinician Type

OBJECTIVES

Unscheduled admission to the PICU is a stressful experience for families. During the admission process, families communicate with 4 types of clinicians (resident, nurse practitioner, fellow, and attending physician). All clinicians must manage family stress while communicating concise, accurate information. The manner and variability in how different clinicians communicate with families at the time of PICU admission is not yet known.

METHODS

We performed a prospective observational study to evaluate communication patterns of various clinician types, including the length of communication encounters and the number of provider interruptions at the time of admission to the PICU during a 3-month period. All nonscheduled admissions to the PICU were eligible for enrollment. The admission intake was audio recorded and directly observed.

RESULTS

We observed 45 different family-clinician interactions for a total of 19 unique family encounters (48% of eligible admissions). Residents and nurse practitioners spent the most time communicating with families (14.3 and 19 minutes, respectively) compared with fellows (7.3 minutes) and attending physicians (6.6 minutes). Residents were frequently interrupted by pages and phone calls (64% of interactions) and spoke at a higher reading level than all other clinician types (P = .03; 95% confidence interval 74.6-83.9). Qualitatively, residents had more challenges coping with distractions, acknowledging parental emotions, and aligning with parental goals compared with other clinician types.

CONCLUSIONS

Resident trainees spend significantly more time with families and, during this time, are burdened with frequent interruptions. In this stressful communication environment, residents encounter more barriers to communication and may require additional communication skills to manage relaying complex information while simultaneously responding to parental emotions.

Techniques to Communicate Better With Parents During End-of-Life Scenarios in Neonatology

BACKGROUND AND OBJECTIVES

Clinicians are urged to optimize communication with families, generally without empirical practical recommendations. The objective of this study was to identify core behaviors associated with good communication during and after an unsuccessful resuscitation, including parental perspectives.

METHODS

Clinicians from different backgrounds participated in a standardized, videotaped, simulated neonatal resuscitation in the presence of parent actors. The infant remained pulseless; participants communicated with the parent actors before, during, and after discontinuing resuscitation. Twenty-one evaluators with varying expertise (including 6 bereaved parents) viewed the videos. They were asked to score clinician-parent communication and identify the top communicators. In open-ended questions, they were asked to describe 3 aspects that were well done and 3 that were not. Answers to open-ended questions were coded for easily reproducible behaviors. All the videos were then independently reviewed to evaluate whether these behaviors were present.

RESULTS

Thirty-one participants' videos were examined by 21 evaluators (651 evaluations). Parents and actors agreed with clinicians 81% of the time about what constituted optimal communication. Good communicators were more likely to introduce themselves, use the infant's name, acknowledge parental presence, prepare the parents (for the resuscitation, then death), stop resuscitation without asking parents, clearly mention death, provide or enable proximity (clinician-parent, infant-parent, clinician-infant, mother-father), sit down, decrease guilt, permit silence, and have knowledge about procedures after death. Consistently, clinicians who displayed such behaviors had evaluations >9 out of 10 and were all ranked top 10 communicators.

CONCLUSIONS

During a neonatal end-of-life scenario, many simple behaviors, identified by parents and providers, can optimize clinician-parent communication.

Simulation Training in the ICU

Because of an emphasis on patient safety and recognition of the effectiveness of simulation as an educational modality across multiple medical specialties, use of health-care simulation (HCS) for medical education has become more prevalent. In this article, the effectiveness of simulation for areas important to the practice of critical care is reviewed. We examine the evidence base related to domains of procedural mastery, development of communication skills, and interprofessional team performance, with specific examples from the literature in which simulation has been used successfully in these domains in critical care training. We also review the data assessing the value of simulation in other areas highly relevant to critical care practice, including assessment of performance, integration of HCS in decision science, and critical care quality improvement, with attention to the areas of system support and high-risk, low-volume events in contemporary health-care systems. When possible, we report data evaluating effectiveness of HCS in critical care training based on high-level learning outcomes resulting from the training, rather than lower level outcomes such as learner confidence or posttest score immediately after training. Finally, obstacles to the implementation of HCS, such as cost and logistics, are examined and current and future strategies to evaluate best use of simulation in critical care training are discussed.

Addressing the competency of breaking bad news: What are Canadian general paediatric residency programs currently doing

OBJECTIVE

To describe how breaking bad news (BBN) is currently taught in Canadian general paediatric residency programs and the confidence level of fourth year paediatric residents (Ped-PGY4) in BBN and managing end-of-life-care (EOLC).

METHODS

A prospective, cross-sectional survey of General Paediatric Residency Program Directors (PDs) and Ped-PGY4s was conducted.

RESULTS

When learning to BBN, residents state faculty observation (22/23) and interactive workshops (14/23) are the most helpful, while PDs state interactive workshops (9/16) and deliberate practice (5/16) are ideal. Residents identified a knowledge gap and discomfort with providing anticipatory guidance, and symptom management, including prescribing opioids.

CONCLUSIONS

In the era of competency-based medical education, there is an opportunity to create a standardized national curriculum addressing universal competencies related to BBN and EOLC.

Simulation-Based Palliative Care Communication for Pediatric Critical Care Fellows

BACKGROUND

Pediatric palliative care (PPC) education is lacking in pediatric critical care medicine (PCCM) fellowships, despite the desire of many program directors and fellows to expand difficult conversation training. Simulation-based training is an experiential method for practicing challenging communication skills such as breaking bad news, disclosing medical errors, navigating goals of care, and supporting medical decision-making.

METHODS

We describe a simulation-based PPC communication series for PCCM fellows, including presimulation session, simulation session, debriefing, and evaluation methods. From 2011 to 2017, 28 PCCM fellows participated in a biannual half-day simulation session. Each session included 3 scenarios (allowing for participation in up to 18 scenarios over 3 years). Standardized patients portrayed the child's mother. PCCM and interprofessional PPC faculty cofacilitated, evaluated, and debriefed the fellows after each scenario. Fellows were evaluated in 4 communication categories (general skills, breaking bad news, goals of care, and resuscitation) using a 3-point scale. A retrospective descriptive analysis was conducted.

RESULTS

One hundred sixteen evaluations were completed for 18 PCCM fellows. Median scores for general communication items, breaking bad news, and goals of care ranged from 2.0 to 3.0 (interquartile range [IQR]: 0-1) with scores for resuscitation lower at 1.0 (IQR: 1.5-2).

DISCUSSION

This experiential simulation-based PPC communication curriculum taught PCCM fellows valuable palliative communication techniques although revealed growth opportunities within more complex communication tasks. The preparation, methods, and lessons learned for an effective palliative simulation curriculum can be expanded upon by other pediatric training programs, and a more rigorous research program should be added to educational series.

Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty

Background Uncertainty is ubiquitous in medical practice. The Pediatrics Milestones from the Accreditation Council on Graduate Medical Education state that advanced learners should acknowledge and communicate about clinical uncertainty. If uncertainty is not acknowledged, patient care may suffer. There are no described curricula specifically aimed to improve learners' ability to acknowledge and discuss clinical uncertainty. We describe an educational intervention designed to fill this gap. Methods Second-year pediatric residents engaged in a two-phase simulation-based educational intervention designed to improve their ability to communicate about diagnostic uncertainty with patients and caregivers. In each phase, residents engaged in two simulated cases and debriefs. Performance was assessed after each simulated patient encounter using standardized metrics, along with learner perceptions of the experience. Results Residents' skills in communicating with patients and families about diagnostic uncertainty improved after this intervention (mean score post 3.84 vs. 3.28 pre on a five-point Likert scale, p<0.001). Residents rated the experience as relevant, challenging and positive. Conclusions This prospective study suggests that a simulation-based intervention was effective in improving resident physicians' skills in communicating about diagnostic uncertainty with patients and families. Further study is needed to determine how learners perform in real clinical environments.

The National Pediatric Surgery Simulation Program in France: A tool to develop resident training in pediatric surgery

BACKGROUND/PURPOSE

To implement resident curriculum in France based on theoretical teaching and bed side training, the national council known as the "Collège Hospitalier et Universitaire de Chirurgie Pédiatrique" examined the relevance and feasibility of systematically introducing simulation program in the pediatric surgery resident training.

MATERIAL AND METHODS

A national simulation training program was developed and took place in a 2-day session organized in 7 simulation centers in France. The program included technical (laparoscopic/suturing technique on low-fidelity models) and nontechnical (6 scenarios for standardized consultation, and a team work scenario based on errors prevention in the operative room) skills. Evaluation of the program (Likert scale from 1 (bad) to 5 (excellent) and notation on 20 points) concerned trainees and trainers.

RESULTS

40 residents (95% of all pediatric surgery French residents) attended with a ratio of trainees/trainer of ½. The training objectives earned a score of 4.46/5. The pedagogical value of the seminar scored 4.7/5, teaching quality 17.95/20, and the overall seminar score was 17.35/20.

CONCLUSION

This program, unique nationally, was assessed very favorably by the participating residents and by the involved trainers. To our knowledge, it represents the first mandatory national simulation training program included within a surgical training model.

LEVEL OF EVIDENCE

Level IV.

Communication training for inter-specialty clinicians

BACKGROUND

Inter-specialty clinicians often co-lead family conferences for hospitalised patients. Families frequently report receiving different messages from different clinicians. We developed a communication training workshop that crosses disciplines and co-trains clinicians in one setting to create a culture of delivering a unified message.

METHODS

We developed a 2-day paediatric communication skills workshop to teach the skills necessary to conduct a family conference. The workshop was targeted at nurse-practitioners and faculty clinicians representing the different specialties that co-manage children in an intensive care unit. Our primary outcomes were learner self-assessment of skills attainment and workshop satisfaction. We also evaluated the feasibility of recruiting busy clinicians.

RESULTS

Fifteen clinicians, including eight critical care faculty members (80% of eligible participants), three subspecialty faculty members (100% of eligible participants) and four nurse-practitioners (100% of eligible participants), participated. Learners' self-reported confidence improved in all communication metrics assessed. From pre- to post-workshop, confidence increased from 39% to 94% for 'giving bad news' (p < 0.05), from 50% to 83% for 'conducting a family conference' (p < 0.05), and from 39% to 100% for 'eliciting a family's values/preferences (p < 0.05). Every learner rated the workshop as important to their clinical practice and 100% would strongly recommend it to others. All reported the time commitment was not burdensome and 74% would choose this 2-day format over shorter formats. When clinicians learn together, they are more likely to speak the same language when communicating with each other, and ultimately to deliver the same message to families CONCLUSIONS: An inter-specialty communication training workshop for different types of clinician was well received. It is feasible to co-train different types of clinician in a joint session. When clinicians learn together, they are more likely to speak the same language when communicating with each other, and ultimately to deliver the same message to families.

Care for Dying Children and Their Families in the PICU: Promoting Clinician Education, Support, and Resilience

OBJECTIVES

To describe the consequences of workplace stressors on healthcare clinicians in PICU, and strategies for personal well-being, and professional effectiveness in providing high-quality end-of-life care.

DATA SOURCES

Literature review, clinical experience, and expert opinion.

STUDY SELECTION

A sampling of foundational and current evidence was accessed.

DATA SYNTHESIS

Narrative review and experiential reflection.

CONCLUSIONS

The well-being of healthcare clinicians in the PICU influences the day-to-day quality and effectiveness of patient care, team functioning, and the retention of skilled individuals in the PICU workforce. End-of-life care, including decision making, can be complicated. Both are major stressors for PICU staff that can lead to adverse personal and professional consequences. Overresponsiveness to routine stressors may be seen in those with moral distress, and underresponsiveness may be seen in those with compassion fatigue or burnout. Ideally, all healthcare professionals in PICU can rise to the day-to-day workplace challenges-responding in an adaptive, effective manner. Strategies to proactively increase resilience and well-being include self-awareness, self-care, situational awareness, and education to increase confidence and skills for providing end-of-life care. Reactive strategies include case conferences, prebriefings in ongoing preidentified situations, debriefings, and other postevent meetings. Nurturing a culture of practice that acknowledges the emotional impacts of pediatric critical care work and celebrates the shared experiences of families and clinicians to build resilient, effective, and professionally fulfilled healthcare professionals thus enabling the provision of high-quality end-of-life care for children and their families.

Development and Implementation of an End-of-Life Curriculum for Pediatric Residents

Background:

Caring for a child near the end of life (EOL) can be a stressful experience. Resident physicians are often the frontline providers responsible for managing symptoms, communicating difficult information, and pronouncing death, yet they often receive minimal education on EOL care.

Objective:

To develop and implement an EOL curriculum and to study its impact on resident comfort and attitudes surrounding EOL care.

Design:

Kern’s 6-step approach to curriculum development was used as a framework for curriculum design and implementation.

Setting/Participants:

Categorical and combined pediatric residents at a large quaternary care children’s hospital were exposed to the curriculum.

Measurements:

A cross-sectional survey was distributed pre- and postimplementation of the curriculum to evaluate its impact on resident comfort and attitudes surrounding EOL care.

Results:

One-hundred twenty-six (49%) of 258 residents completed the preimplementation survey, and 65 (32%) of 201 residents completed the postimplementation survey. Over 80% of residents reported caring for a dying patient, yet less than half the residents reported receiving prior education on EOL care. Following curriculum implementation, the percentage of residents dissatisfied with their EOL education fell from 36% to 14%, while the percentage of residents satisfied with their education increased from 14% to 29%. The postimplementation survey identified that resident comfort with communication-based topics improved, and they sought additional training in symptom management.

Conclusions:

The implementation of a longitudinal targeted multimodal EOL curriculum improved resident satisfaction with EOL education and highlighted the need for additional EOL education.