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Neefjes V. Can mediation avoid litigation in conflicts about medical treatment for children? An analysis of previous litigation in England and Wales. Arch Dis Child 2023; 108:715-718. [PMID: 37365005 DOI: 10.1136/archdischild-2022-325033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/30/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE To investigate the reasons why parents disagree with their clinicians in cases reaching the court and to estimate the number of cases in which mediation might have avoided litigation. DESIGN Analysis of 83 published cases regarding medical treatment decisions for children initiated either by an NHS Trust or Local Authority between 1990 and 1 July 2022. RESULTS The analysis found that the main areas of contention are different value judgements, different interpretations of observable events such as the health of the child, their quality of life or burden of treatment and relational issues (ie, loss of trust). More than half of the cases are estimated not to have been preventable by mediation because either no conflict existed (n=13) or the parental decision was based on strongly held, mostly faith-based, views unlikely to be open for discussion (n=31). CONCLUSION The potential of mediation to avoid future litigation may be more limited than hoped for.
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Affiliation(s)
- Veronica Neefjes
- Department of Law, School of Social Sciences, Centre for Social Ethics and Policy, University of Manchester, Manchester, UK
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2
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Miles F, Barclay S, Menson E, Shepherd T, Webster L. Boldly going… Introducing conflict management training to Starship Children's Hospital. J Paediatr Child Health 2023; 59:424-426. [PMID: 36728113 DOI: 10.1111/jpc.16347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/19/2023] [Indexed: 02/03/2023]
Abstract
Conflict between health professionals and whānau (families) in paediatric hospitals is common and leads to significant distress for families and staff. The likelihood of challenges and conflict around communication and critical medical decision-making is increased where there are cultural and social complexities. Training staff to recognise and manage conflict as early as possible improves patient/whānau outcomes and staff well-being. This article describes an ongoing collaboration between Starship Children's Hospital in Auckland New Zealand (NZ) and the UK Medical Mediation Foundation (MMF) focused on educating staff in the early recognition and management of conflict using mediation skills. An evidence-based training programme and structured ongoing supervision of a small group of champions has enabled this training to be embedded into Starship clinical practice. The collaboration has included careful consideration of the New Zealand setting, ensuring that the content of the programme specifically addresses our unique cultural and social context. Mediation skills are an important step in ensuring that our patients and whānau feel heard, acknowledged, and respected, and contribute to the Starship Child Health's strategic priority of eliminating inequity and addressing institutional bias.
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Affiliation(s)
- Fiona Miles
- Paediatric Intensivist, PICU, Starship Children's Hospital, Auckland, New Zealand
| | - Sarah Barclay
- Medical Mediation Foundation, Director Evelina Resolution Project, London, United Kingdom
| | - Esse Menson
- Mediator and Trainer, Medical Mediation Foundation, London, United Kingdom
| | - Toni Shepherd
- Starship Māori Health Director, Starship Children's Hospital, Auckland, New Zealand
| | - Louise Webster
- Child and Adolescent Psychiatrist, Paediatric Consult Liaison Team, Starship Children's Hospital, Auckland, New Zealand
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3
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Shiao YC, Shen RN, Chen WW, Liu YP, Shih CL, Wang CC. Programme of triple-I mediator education (TIME) to improve medical disputes in clinical settings in Taiwan: a Delphi study. BMJ Open 2022; 12:e058880. [PMID: 36028268 PMCID: PMC9422892 DOI: 10.1136/bmjopen-2021-058880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To establish a training programme to cultivate trainee mediation skills through time investment, skill incorporation and formation of in-house mediation services. DESIGN A four-round consensus conference was conducted by a number of seasoned experts selected in the manner of purposive sampling to determine core competences and relevant curricula through the modified Delphi process. SETTING Responses collected from enrolled experts through four rounds of the Delphi process from 11 November 2018 to 17 May 2019. PARTICIPANTS Onboard seasoned mediators with different specialties. OUTCOME MEASURES Items with a median rating of 4 or more on a Likert scale of 1-7 points and 70% or more in agreement were identified as core competence and curricula. RESULTS Eleven enrolled experts reached the consensus about the training syllabus based on the 4-round agreement with four pillars of core competence, including 'knowledge base of law', 'internalisation of the denotative and connotative meanings of care', 'effective, smooth and timely communication' and 'conflict resolution'. To grasp the dynamics and diversity of medical disputes on target, it is necessary to have sufficient knowledge and skills. We arrange our course in the order of teaching materials with pure didactics in the former two and with mixed contents comprising lectures and field exercises in the rest two. CONCLUSIONS The sample developed a syllabus to train apprentices to take intermediate responses to medical disputes through the skills of conflict resolution and establishment of effective communication to improve the relationship between patients/relatives and medical staff, as a result of eventually reducing the conversion rate from dispute into litigation or alternative pathway. Policy-makers in healthcare and top management in healthcare institutions can use this syllabus to guide their future education and training programme.
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Affiliation(s)
- Yi-Chih Shiao
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center; School of Medicine, National Defense Medical Center, Taipei, Taiwan
- College of Law, National Chengchi University, Taipei, Taiwan
| | | | | | - Yueh-Ping Liu
- Department of Medical Affairs, Ministry of Health and Welfare, Taipei, Taiwan
- Ministry of Health and Welfare, Taipei, Taiwan
| | | | - Chih-Chia Wang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center; School of Medicine, National Defense Medical Center, Taipei, Taiwan
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4
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Fahy AS, Mueller C, Fecteau A. Conflict resolution and negotiation in pediatric surgery. Semin Pediatr Surg 2021; 30:151100. [PMID: 34635278 DOI: 10.1016/j.sempedsurg.2021.151100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Conflict is pervasive in pediatric surgery - it is experienced during patient care, in the operating room and between colleagues. The ethical principles of autonomy, beneficience, non-maleficience and justice are firmly anchored in any discourse regarding conflict in the setting of healthcare. The authors review key features of conflict in healthcare including the effect on patient outcomes as well as implications for the ability of the surgeon and the medical team to function appropriately and safely when conflicts arise. Although most pediatric surgery fellowship programs have no formal training in conflict management, much has been written about strategies to teach and utilize techniques of conflict mitigation and negotiation. In this article, the authors discuss common areas of conflict in the medical environment and suggest useful tools for the practicing pediatric surgeon to aid in the resolution of conflict.
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Affiliation(s)
- Aodhnait S Fahy
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Claudia Mueller
- Pediatric General Surgery, Lucile Packard Children's Hospital Stanford, San Francisco, CA, USA
| | - Annie Fecteau
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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5
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Lyons O, Forbat L, Menson E, Chisholm JC, Pryde K, Conlin S, Felton V, Ingle S, McKenzie C, Ramachandran R, Sayer C, Snowball C, Strachan-Gadsby E, Tisovszky N, Barclay S. Transforming training into practice with the conflict management framework: a mixed methods study. BMJ Paediatr Open 2021; 5:e001088. [PMID: 34926836 PMCID: PMC8628327 DOI: 10.1136/bmjpo-2021-001088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 11/03/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To implement and evaluate the use of the conflict management framework (CMF) in four tertiary UK paediatric services. DESIGN Mixed methods multisite evaluation including prospective pre and post intervention collection of conflict data alongside semistructured interviews. SETTING Eight inpatient or day care wards across four tertiary UK paediatric services. INTERVENTIONS The two-stage CMF was used in daily huddles to prompt the recognition and management of conflict. RESULTS Conflicts were recorded for a total of 67 weeks before and 141 weeks after implementation of the CMF across the four sites. 1000 episodes of conflict involving 324 patients/families across the four sites were recorded. After implementation of the CMF, time spent managing episodes of conflict around the care of a patient was decreased by 24% (p<0.001) (from 73 min to 55 min) and the estimated cost of this staff time decreased by 20% (p<0.02) (from £26 to £21 sterling per episode of conflict). This reduction occurred despite conflict episodes after implementation of the CMF having similar severity to those before implementation. Semistructured interviews highlighted the importance of broad multidisciplinary leadership and training to embed a culture of proactive and collaborative conflict management. CONCLUSIONS The CMF offers an effective adjunct to conflict management training, reducing time spent managing conflict and the associated staff costs.
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Affiliation(s)
- Oscar Lyons
- Nuffield Department of Surgical Sciences, Oxford University, Oxford, UK
| | - Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Julia C Chisholm
- Paediatric Oncology, Royal Marsden Hospital NHS Trust, London, UK
| | - Kate Pryde
- Paediatrics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Susanne Ingle
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | | | | | | | - Carly Snowball
- Children and Young People's Unit, Royal Marsden Hospital NHS Trust, London, UK
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6
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Allen KY, Davis A. The hard talk: Managing conflict in the cardiac intensive care unit. PROGRESS IN PEDIATRIC CARDIOLOGY 2020; 59:101306. [PMID: 33071530 PMCID: PMC7547626 DOI: 10.1016/j.ppedcard.2020.101306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
Conflict between parents and providers is common in the cardiac intensive care setting, particularly in patients with prolonged length of stay. Poor communication is the most commonly cited reason for conflict and is exacerbated when providers and families cannot find common ground and develop mutual trust. It is critically important that healthcare providers learn strategies to better partner with families in order to optimize patient medical and psychosocial outcomes. This requires providers to avoid falling prey to their own implicit (or unconscious) biases, including those towards families labeled as “difficult”. Building a healthy family-provider relationship is part of a healthcare provider's duty to treat, has a measurable effect on patient outcomes, and sets up a foundation for the provider-family dyad to more easily navigate any conflicts that do develop. Once a relationship is built, providers and families can talk through their conflicts. They are more likely to have open and transparent communication and are more able to give each other the benefit of the doubt when navigating difficult situations and/or behaviors, rather than labeling each other as intrinsically “difficult” people. The healthcare team is designed to work together like chess pieces on a chess boardParents supporting critically ill hospitalized children may feel more like metaphorical checkers – isolated and out of place. The everyday stresses of living in the cardiac intensive care unit frequently lead to parent-provider conflict. Conflict occurs on a foundation of previous experiences of both parent and provider; these associated biases contribute to conflict escalation. Avoiding labels and approaching difficult situations with empathy and self-reflection helps arrest the cycle of conflict and build mutual trust.
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Affiliation(s)
- Kiona Y Allen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Division of Cardiology & Critical Care Medicine, 225 East Chicago Ave., Chicago, IL 60611, USA
| | - Audra Davis
- The Exeter Group, Managing Partner, 180 North Wabash Ave, Suite 815, Chicago, IL 60601, USA
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7
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Johal HK, Danbury C. Conflict before the courtroom: challenging cognitive biases in critical decision-making. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106177. [PMID: 32631970 PMCID: PMC8639943 DOI: 10.1136/medethics-2020-106177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 05/31/2023]
Abstract
Conflict is an important consideration in the intensive care unit (ICU). In this setting, conflict most commonly occurs over the 'best interests' of the incapacitated adult patient; for instance, when families seek aggressive life-sustaining treatments, which are thought by the medical team to be potentially inappropriate. Indeed, indecision on futility of treatment and the initiation of end-of-life discussions are recognised to be among the greatest challenges of working in the ICU, leading to emotional and psychological 'burnout' in ICU teams. When these disagreements occur, they may be within the clinical team or among those close to the patient, or between the clinical team and those close to the patient. It is, therefore, crucial to have a theoretical understanding of decision-making itself, as unpicking misalignments in the family's and clinical team's decision-making processes may offer strategies to resolve conflict. Here, we relate Kahneman and Tversky's work on cognitive biases and behavioural economics to the ICU environment, arguing that these biases could partly explain disparities in the decision-making processes for the two conflicting parties. We suggest that through the establishment of common ground, challenging of cognitive biases and formulation of mutually agreeable solutions, mediation may offer a pragmatic and cost-effective solution to conflict resolution. The litigation process is intrinsically adversarial and strains the doctor-patient-relative relationship. Thus an alternative external party should be considered, however mediation is not frequently used and more research is needed into its effectiveness in resolving conflicts in the ICU.
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Affiliation(s)
| | - Christopher Danbury
- Adult Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
- School of Law, University of Reading, Reading, UK
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8
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Cass H, Barclay S, Gerada C, Lumsden DE, Sritharan K. Complexity and challenge in paediatrics: a roadmap for supporting clinical staff and families. Arch Dis Child 2020; 105:109-114. [PMID: 31186292 DOI: 10.1136/archdischild-2018-315818] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/01/2019] [Accepted: 05/17/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Hilary Cass
- Neurosciences Department, Evelina London Children's Hospital, London, UK
| | | | | | - Daniel E Lumsden
- Neurosciences Department, Evelina London Children's Hospital, London, UK.,Dept of Women's and Children's Health, King's College London, London, UK
| | - Kaji Sritharan
- Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK.,Royal Society of Medicine, London, UK
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9
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Forbat L, Mnatzaganian G, Barclay S. The Healthcare Conflict Scale: development, validation and reliability testing of a tool for use across clinical settings. J Interprof Care 2019; 33:680-688. [DOI: 10.1080/13561820.2019.1593117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Liz Forbat
- Faculty of Social Science, University of Stirling, Stirling, Scotland
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11
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Forbat L, Barclay S. Reducing healthcare conflict: outcomes from using the conflict management framework. Arch Dis Child 2019; 104:328-332. [PMID: 30154178 DOI: 10.1136/archdischild-2018-315647] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test a new conflict management framework (CMF) to help staff identify and de-escalate conflict between staff and patients/families. DESIGN Before/after study that reports staff quality of life, frequency/severity of conflicts and qualitative interviews on using the framework. Data were collected from May 2017 to September 2017. SETTING A paediatric oncology department day-patient and 23-bed inpatient ward. INTERVENTION A two-stage CMF used by staff during daily handovers to identify and then manage conflict cases with families. RESULTS Staff found the CMFto be helpful in identifying and de-escalating conflicts. The number of conflicts reported decreased by 64% from baseline to follow-up. Communication regarding conflict identification improved. Reports of staff burn-out decreased between the two time-points (n=55 at baseline, n=31 at follow-up; p=0.001). Scores on compassion and secondary traumatic stress did not change. CONCLUSIONS The CMF substantially reduces the incidence of conflicts and is an acceptable approach for staff. Continued use of the framework would require it to be fully integrated into the working of the ward, which would need to include senior medical buy-in. Further refinements to the framework have been made and will be tested in four UK sites in 2018/2019.
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Affiliation(s)
- Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
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12
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Beattie RM. Conflict, candour and reflection. Arch Dis Child 2019; 104:309-310. [PMID: 30352810 DOI: 10.1136/archdischild-2018-316002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/06/2018] [Indexed: 11/03/2022]
Affiliation(s)
- R Mark Beattie
- Paediatric Gastroenterology, Southampton Children's Hospital, University Hospital Southampton, Southampton SO16 6YD, UK
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13
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Huxtable R. Clinic, courtroom or (specialist) committee: in the best interests of the critically Ill child? JOURNAL OF MEDICAL ETHICS 2018; 44:471-475. [PMID: 29880659 DOI: 10.1136/medethics-2017-104706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 06/08/2023]
Abstract
Law's processes are likely always to be needed when particularly intractable conflicts arise in relation to the care of a critically ill child like Charlie Gard. Recourse to law has its merits, but it also imposes costs, and the courts' decisions about the best interests of such children appear to suffer from uncertainty, unpredictability and insufficiency. The insufficiency arises from the courts' apparent reluctance to enter into the ethical dimensions of such cases. Presuming that such reflection is warranted, this article explores alternatives to the courts, and in particular the merits of specialist ethics support services, which appear to be on the rise in the UK. Such specialist services show promise, as they are less formal and adversarial than the courts and they appear capable of offering expert ethical advice. However, further research is needed into such services - and into generalist ethics support services - in order to gauge whether this is indeed a promising development.
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Coad J, Smith J, Pontin D, Gibson F. Consult, Negotiate, and Involve: Evaluation of an Advanced Communication Skills Program for Health Care Professionals. J Pediatr Oncol Nurs 2018; 35:296-307. [DOI: 10.1177/1043454218765136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Effective communication is central to children, young people, and their families’ experiences of health care. Most patient complaints in developed health care systems result from ineffective communication, including inadequate information provision, not feeling listened to, failure to value patients concerns, and patients not feeling involved in care decisions. Advanced communication skills training is now embedded within cancer care policy in the United Kingdom and now features prominently within cancer education in many countries. Here, we share findings from a research evaluation of an advanced communication skills training program dedicated to health professionals caring for children and young people with cancer. We evaluated participants’ (n = 59) perceptions of the program, impact on their skills, knowledge, competence, and confidence. An appreciative inquiry design was adopted; data included interviews, precourse-postcourse evaluations, e-mail blog survey, and 360-degree reflective work records. The framework approach underpinned data analysis and triangulation of data sets. Key findings highlighted good and poor practice in health professionals’ engagement with children, young people, and their families; the purpose of communicating effectively was not always consistent with collaborative working. Attending a program helped participants expand their knowledge of communication theories and strategies. Participants valued using simulated scenarios to develop their skills and were keen to use their new skills to enhance care delivery. Our emphasis within this evaluation, however, remained on what was communicated, when and how, rather than to what effect. The impact of programs such as these must now be evaluated in terms of patient benefit.
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15
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François K, Lobb E, Barclay S, Forbat L. The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members. PATIENT EDUCATION AND COUNSELING 2017; 100:1459-1465. [PMID: 28268054 DOI: 10.1016/j.pec.2017.02.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/16/2017] [Accepted: 02/20/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Conflict is a significant and recurring problem in healthcare. This study aimed to understand staff and relatives' perspectives on the characteristics of conflict and serious disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care. METHODS Qualitative study of 25 staff and seven bereaved relatives using individual interviews, recruited from a multidisciplinary specialist palliative care setting in Australia. Data were analysed thematically. RESULTS Communication was frequently cited as a cause of conflict. Further, different understandings regarding disease process, syringe drivers and providing nutrition/hydration caused conflict. Staff applied empathy to moderate their responses to conflict. Relatives' reactions to conflict followed a trend of anger/frustration followed by explanations or justifications of the conflict. Relatives identified systemic rather than interpersonal issues as triggering conflict. CONCLUSIONS The data illustrate connections with conflict literature in other clinical areas, but also points of convergence such as the compassion shown by both families and staff, and the identification of systemic rather than always individual causes. PRACTICE IMPLICATIONS Family meetings may fruitfully be applied to prevent and de-escalate conflict. Clinical audits may be useful to identify and provide support to families where there may be unresolved conflict impacting grief process.
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Affiliation(s)
- Karemah François
- Calvary Centre for Palliative Care Research, Calvary Health Care ACT, Canberra, Australia; School of Health Sciences, Australian Catholic University, Canberra, Australia.
| | - Elizabeth Lobb
- Calvary Health Care Kogarah and Cunningham Centre for Palliative Care, Sydney, Australia; School of Medicine, Univeristy of Notre Dame, Darlinghurst, Australia.
| | - Sarah Barclay
- Medical Mediation Foundation, London, United Kingdom.
| | - Liz Forbat
- Calvary Centre for Palliative Care Research, Calvary Health Care ACT, Canberra, Australia; School of Health Sciences, Australian Catholic University, Canberra, Australia.
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