Difficult Conversations Research Articles

Why Dispute Resolution Practitioners Should Embrace Difficult Conversations

Why Dispute Resolution Practitioners Should Embrace Difficult Conversations

Nurse Faculty: Moving Away from the Script.

In this column, the author shares insights on honoring the wisdom of diverse perspectives by cocreating a teaching-learning journey from a humanbecoming perspective. The author urges nurse educators to move away from the use of scripts in having routine and difficult conversations in nurse education. The film The Sound of Music, a favorite of the author, is used to describe honoring wisdom in diverse perspectives by using dialogue in the art of being with. In this way, nurse educators may cocreate a teaching-learning journey that honors humanuniverse dignity.

When “Nice” Isn’t: Confronting Niceness and Whiteness to Center Equity in Teacher Education

ABSTRACT Niceness is a socialized disposition, particularly amongst white women, that prioritizes comfort and neutrality while preventing resistance against oppressive systems. Given the demographics of teachers and teacher educators, niceness and whiteness are deeply embedded in programs and institutions. As eight white, female teacher educators, we drew on the power of cross-institutional collaboration to form a self-study community of practice with the purpose of interrogating and dismantling the ways niceness and whiteness function in our teaching and teacher institutions and create barriers to centering equity and justice. Findings indicated that collaboration helped us identify how niceness shaped and continues to shape our teaching and teacher identities, particularly how we navigate difficult conversations, think about our roles as teacher educators, and imagine literacy curricula. Findings also indicated that despite efforts to recognize and interrupt niceness and whiteness, our growth was nonlinear, and we find that constant vigilance and reflection is necessary. Implications for the broader field of education include the power of self-study for disrupting niceness and whiteness in teacher education and orienting the community toward action through mutual support and accountability, while also recognizing the ways in which niceness continues to function as a barrier for enacting change for social justice.

INTERPROFESSIONAL TEAM MEMBERS’ PERCEPTIONS OF PALLIATIVE SOCIAL WORKERS’ CONTRIBUTIONS TO PATIENT-CENTERED CARE

Abstract Interprofessional collaborative practice (IPCP) is fundamental to the delivery of high-quality patient-centered care. An IPCP core tenet is that efficient and effective teams are crucial for the delivery of care that achieves patient satisfaction as well as positive patient-level outcomes. Although a growing number of IPCP studies explore how IPCP professionals work collaboratively, the vast majority focus on the interactions of physicians and nurses, few consider other professions or simply lump them into an “other” category. This qualitative study addresses this knowledge gap through the exploration of how hospital palliative care teams utilize the skills of advanced hospice and palliative care certified (APHSW-C) social workers to increase teams’ overall effectiveness. A two-step recruitment process was used to create matched samples of 17 palliative social workers and 24 interprofessional team members (i.e., physicians, nurses, physician assistants, chaplains). Using a constructivist grounded theory approach, semi-structured interviews were conducted, recorded, and transcribed. Analysis revealed six themes surrounding other profession's perceptions of social workers’ contributions: 1) providing continuity during and across admissions, 2) assessing and promoting the patient’s bio-psychosocial needs, 3) offering clinical expertise and support to patients with complex psychosocial needs, 4) allocating time to initiate, process and revisit difficult conversations with patients and families, 5) modulating the pace and intensity of emotionally laden conversations, and 6) supporting team well-being. Findings underscore that interprofessional team members view social workers as playing a significant role in developing, building, and sustaining a therapeutic alliance between the patient and the team.

PSYCHOMETRIC EVALUATION OF CARS: A BRIEF SCREENING INSTRUMENT FOR DRIVING SAFETY

Abstract Driving is critical to mobility, autonomy, freedom of choice, and engagement for older adults, but many eventually stop driving. While poor health often eventually leads to driving cessation, some drivers do not realize that their driving is impaired. The 4-item CARS instrument of driving safety has been created to serve as a screening tool by health professionals during assessments and routine appointments (Curl, 2014). To assess the construct validity of CARS, data were collected in 2015-2016 by The Knight Alzheimer’s Disease Research Center from cognitively impaired (N=42) and cognitively healthy participants (N=229), as well as “collateral sources” who answered the CARS items about the respondents’ driving. Vision problems and cognitive impairment, both known predictors for driving problems, were correlated with CARS scores. Results indicate that worse eyesight in the right eye is correlated with higher CARS scores (Spearman rho = -.17, p<.01), but not the left eye. Poor eyesight (i.e., less than 20/40 vision) was correlated with higher CARS scores (Spearman rho = .12, p<.05). However, cognitive impairment (very mild/mild dementia vs. healthy cognitive functioning) was not statistically significant. Total CARS scores were moderately correlated for respondents and their collateral sources, r = .32, p<.01. Results indicate that this instrument may be more useful as a tool for initiating difficult conversations about driving safety than for identifying older adults who are at higher risk for negative driving outcomes. Future research is needed to identify additional/alternative items with greater psychometric support.

Difficult conversations — turn dread to joy!

I want to introduce a guide for having difficult conversations at work. Tony Panos, another Partner at Organizational Performance Group (OPG), created this template over the years because the most dreaded management and leadership activity seems to be having a difficult conversation with a colleague. Or anyone!

Right Brain: The Purple Scarf and the Cortical Ribbon.

A patient with probable Creutzfeldt Jakob disease (CJD) who was previously a high-functioning financial analyst remains fiercely independent despite her family's concerns about her safety. As a trainee with limited experience in leading these difficult conversations, this neurology resident describes her experience reconciling the viewpoints of herself, the patient, and her family. She reflects on the ability to reframe this delicate conversation from one of loss of independence in a patient with a rapidly progressive, neurodegenerative condition to one of safety, security, and the care of her family.

Dismantling Myths and Teaching Controversial Issues in Conflict-Affected Societies: Insights From Cyprus

In this short piece we argue that although theoretically in times of war and protracted conflict, it is particularly crucial for teachers to engage with controversial issues, doing so in praxis is fraught with ethical, practical, political, contextual and emotional dilemmas and challenges. Informed by our research on and teaching of the Cyprus conflict (and the associated peacebuilding process) as a controversial issue itself, we posit that merely replacing ‘war education’ with ‘peace education’ can fail at best and be counterproductive or solidify essentialist positions at worst. Instead of focusing primarily on replacing one form of knowledge with another and on developing fixed skillsets as part of peace education manuals, we argue that meaningful engagement with difficult conversations requires new modes of being that can only materialise through long-term processes of self-reflection, affective engagement and enactment of critical pedagogies: here, we focus on three such pedagogies, namely, ‘pedagogies of discomfort’; ‘pedagogies of desecuritisation’ and ‘pedagogies of empathy’.

Paediatric anaesthesiology education: simulation-based 'attending boot camp' for fellows shows feasibility and value in the early years of attendings' careers.

Established simulation-based 'boot camps' utilise adult learning theory to engage and teach technical and non-technical skills to medical graduates transitioning into residency or fellowship. However, the transition from trainee to the attending role has not been well studied. The primary aim of this study was to design and execute a simulation-based educational day, exposing senior trainees in paediatric anaesthesia to commonly encountered challenges and teaching critical technical skills relevant to their new role. Secondary aims included assessment of its value and relevance in early years of graduated fellows' new careers as attendings. An 'attending boot camp' day comprised the following: two crisis simulations, an otolaryngologist-taught cadaver cricothyroidotomy laboratory, and a difficult conversations workshop. There was a debriefing after each section. Data were collected using end-of-day and early-career e-mail surveys for five consecutive fellow cohorts from 2016 to 2020. Forty fellows participated; overall feedback was positive. The end-of-day surveys revealed planned changes in practice for 89% (25/28) of fellows, and 54% (15/28) highlighted communication skills as 'most beneficial'. Early-career follow-up surveys found 96% (23/24) identified increased confidence in skill acquisition because of the day; 79% (19/24) experienced scenarios in real life similar to those simulated. The qualitative analysis revealed four high-value themes: delegation, leadership, clinical skills, and difficult communication. The transition from senior trainee to attending physician remains under-researched. A tailored simulation-based 'attending boot camp' was feasible and valued and may be useful in bridging this transition. Participants identified leadership practice, life-saving technical skills, and difficult communication practice as valuable and relevant in their early careers.

A biopsychosocial approach to death, dying, and bereavement: a course on end-of-life education for medical students.

Background: Despite the inevitable nature of death and dying, the conversations surrounding this subject are still uncomfortable for many physicians and medical students. Methods: A six-week humanities-based course, "A Biopsychosocial Approach to Death, Dying, & Bereavement," at Cooper Medical School of Rowan University, United States, which covers definitions of death and dying, the process of dying, ethical dilemmas, and new concepts of the grieving process. Through development of a curriculum using various academic and medical literature and resources, we sought to bring attention to the necessity of having a medical education curriculum on death and dying to prepare medical students for the difficult conversations and patient experiences that lie ahead of them. Qualitative data in the form of surveys and reflection papers submitted by students and quantitative data (Likert scores on course satisfaction) were collected and analyzed both pre- and post-course. Results: 90.7% (49/54) of the respondents answered that they agree or strongly agree with the statement that this selective course was useful in the student's medical education experience. The top three qualitative themes brought up the most in reflection papers (n=54) were:the utility and instruction of the course (21 times), the importance of hospice and palliative care (20 times), avoidance around topics of death (15 times). Conclusions : Medical students are often not prepared to cope with the realities of patient loss and of caring for the patient and their families throughout the dying process. We created this course to familiarize medical students with an aspect of the medical experience that is frequently neglected in traditional medical curricula. We learned that integrating such a course can help educate medical students facilitate important conversations, teach them to act with kindness and dignity in a physician-patient setting, and enhance their personal understanding of death and dying.

Evaluation of a simulation-based learning activity for communicating about at-risk opioid behaviors in a community pharmacy setting

IntroductionThe purpose of our study was to evaluate a learning activity that included an objective structured learning examination (OSLE) focused on identifying and communicating at-risk opioid behaviors in a community pharmacy setting through student perceptions and OSLE performance. MethodsThe activity included a didactic lecture and an OSLE with two opioid use patient cases. Third-year pharmacy students' communication skills were evaluated using faculty-created rubrics. A voluntary, anonymous pre-/post-survey evaluated students' skills confidence and OSLE satisfaction. Responses were analyzed using independent t-tests. An inductive conventional content analysis identified the impact on students' perceptions and future behaviors from post-simulation reflections. ResultsOne hundred forty-three and 111 students completed the pre- and post-surveys, respectively. Students self-reported confidence in their ability to identify red flags and assess at-risk opioid behaviors, counsel on opioid risk behaviors, refuse opioid prescription fills, and respond to patients' nonverbal responses, all significantly improved pre-to-post. Students reported the OSLE was beneficial to their learning. The mean overall OSLE score was 34.2 out of 45 points (SD ± 6.21). Identified student reflection themes included: importance of patient-centered care, pharmacists' role in patients with at-risk opioid behaviors, recognition of judgement against patients taking opioids, and importance of communication and empathy as strategies to mitigate conflict. ConclusionsImplementing a new learning activity focused on communication regarding at-risk opioid behaviors allowed students to engage in difficult conversations with standardized patients in a safe simulation environment. Students demonstrated competent skills, increased their self-reported confidence, and were highly satisfied with the learning activity.

Using online simulation to prepare mental health nursing students for practice

Demand for mental health nursing staff is rising with a drop-in staff of 8% in the last 10 years [1]. Preparing the future NHS healthcare workforce is therefore a vital component of educational delivery for Higher Education Institutions [2]. With funding Health Education England, the aim of this pilot project was to evaluate whether an online simulated learning programme helped students feel more prepared for their final placement in practice before qualifying. 19 final year mental health nursing students participated in a one-day online simulated learning environment programme which focused on difficult conversations and complex communication scenarios, in partnership with an external organisation. It focused on introducing a bespoke context to develop clinically relevant skills, knowledge, and experience, complementing the range of clinical placements opportunities required by the nurses training curriculum. They were then asked to complete the Human Factor Skills for Healthcare Instrument [3]. Participants showed a 7% increase in confidence in Human Factors Skills measured by the Human Factors Skills for Healthcare Instrument from their pre-course (M=93.54) and post-course (M=102.27) scores. Participants also showed a 9% increase in scores in the course specific questions relating to the learning objectives from their pre-course (M=50.86) and post-course (M=57.15) scores. We were unable to conduct paired samples t-tests due to the limited number of participants completing both the pre- and post-evaluation survey. Lastly, 100% of participants responded that they would recommend this course to others. The course is a novel and innovative training method for providing clinical experience to undergraduate nursing students to develop relevant skills and knowledge that complement their placements. The findings demonstrate that participants achieved a variety of learning outcomes including improved confidence in human factors skills and improved confidence across the learning objectives, covering de-escalation skills, working in a multidisciplinary team, identifying mental illness presentation, handover, and referral among other skills. This raft of benefits following training are likely to have a positive impact on interactions with service users or those experiencing mental illness, although further research into this impact would be of great interest. 1. Royal College of Nursing (2022) ‘There is no quick solution to the nurse staffing crisis’. 2. Topal review: NHS (Feb 2019) Preparing the healthcare workforce to deliver the digital future. 3. Reedy G, Lavelle M, Simpson T, Anderson J. Development of the Human Factors Skills for Healthcare Instrument: a valid and reliable tool for assessing interprofessional learning across healthcare practice settings. BMJ Simulation and Technology Enhanced Learning. 2017;3(4):135–141.

Meaningful simulation: service user and academic collaboration supporting physiotherapy students with healthy conversations

Lifestyle factors are a significant cause of mortality and morbidity in England [1]. Physiotherapists are well placed to help people to make healthy lifestyle choices, however junior physiotherapists do not feel well equipped to have these conversations [2]. An innovative teaching session was carried out with physiotherapy students to 1) increase their confidence in addressing lifestyle choices and 2) equip them with communication skills to decrease fear of these difficult conversations. The session was grounded in the theory of motivational interviewing [3]. Teaching staff created role play scenarios. These were reviewed by service users for authenticity. The scenarios included a teenager with cystic fibrosis who was not compliant with chest clearance exercises and a person suffering falls secondary to alcohol misuse. The final scenario involved a discussion about smoking with a person recently diagnosed with a chronic lung condition and their partner. In a face-to-face immersive fishbowl setting, students took part in the scenarios with experienced actors as service users. The session was collaborative, where students could ‘time out’ to seek guidance from their peers. The actors adapted their communication depending on how they felt in the conversation. After each scenario the actors provided feedback from the service user perspective. There was excellent engagement in the session. Students found the final scenario the most challenging as they struggled to gain a rapport with the patient actor due to the partner frequently interrupting. The cohort expressed different ideas of how to manage this situation. Feedback from the actors helped the students to consider the perspective of the partner and how their interference was due to worry. Pre- and post-session data on a five-point Likert scale demonstrated improved knowledge of motivational interviewing and improved confidence to have lifestyle change conversations ( Likert scores to the pre- and post-motivational interviewing simulation training The immersive simulation experience motivated and empowered the physiotherapy students to talk about lifestyle change with service users. The participative forum felt ‘real’ and students left the session better equipped to have lifestyle change conversations with service users. This should help to create future physiotherapists who can help people to live healthy lives. 1. Office for National Statistics. What is happening to life expectancy in England? England: The King’s Fund; 2022. 2. Walkenden S, Walker KM. Perceptions of physiotherapists about their role in health promotion at an acute hospital: a qualitative study. Physiotherapy. 2015;101(2):226–231 3. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care. London: The Guildford Press, 2008.

Communication in the conversation between preceptors and physicians-in-training during simulation: what is not said

ABSTRACT Background: There is an abundance of published communication models, but few explicate how professional conversation may include the communication of some information but exclude the sharing of one’s inner thoughts and feelings. This conceptualization of communication was applied to guide our understanding of how medical learners interact with preceptors at the bedside in a high-fidelity simulation when managing a patient case. Methods: A total of 84 medical learners (42 residents and 42 medical students) participated in a high-fidelity simulation. After they interacted with the patient for about 10 min, a preceptor entered and offered an equivocal or questionable recommendation about diagnosis or treatment. This type of recommendation was designed to trigger a difficult conversation that would create an opportunity for the learners to share facts, thoughts, points of view, and feelings about the patient with the preceptor. The preceptor left the room, and the learners completed their assessment once they made a diagnosis and treatment recommendations. Two raters independently coded the communication between the preceptor and learners by independently watching video recordings. Results: Of the three types of communication styles identified in the model, the majority of learners (n = 56, 66.70%) engaged in a muted conversation where they shared little or no clarification of facts about the patient’s case, their feelings or thoughts, nor did they explore their preceptor’s point of view. Conclusions: Learners may not feel comfortable exploring or expressing thoughts and feelings in front of their preceptors. We recommend that preceptors directly engage learners in conversation.

Cultural competence in a multinational group of sport psychology professionals

Sport psychology scholars and practitioners (SPPs) now recognize the importance of cultural competence (CC). However, only a few SPPs have deliberately centered CC in their practice. The purpose of this study was to understand how SPPs conceptualize and develop CC within their professional practice. Our study is grounded in a critical realist ontology and framed within the consensual qualitative research method (CQR). Using a semi-structured interview guide, we interviewed 25 globally situated SPPs (13 males, 12 females) with three to 40 years of professional experience (17.83, SD = 10.88) residing on four different continents. We constructed seven categories to provide a snapshot of how SPPs conceptualize, develop, and emphasize CC as an ethical and moral obligation to engage in effective professional practice. The participating SPPs described how CC is contextual and encompasses one’s cultural knowledge, awareness, and skills developed from professional and personal cultural interactions and investment in cultural professional development. The SPPs shared how CC plays a relevant role in their sport psychology practice. We also highlighted how culture and CC are frequently conceptualized and experienced from a one-dimensional perspective, overlooking the importance of how cultural identities and modes of being interact within and between SPPs and clients or participants. The implications for individuals and professional bodies are discussed for professional development, training, and effective practice. Lay summary: Cultural competence is an ethical and moral obligation for SPPs to engage in effective professional practice. In this study, a multinational group of SPPs shared how they conceptualize, develop, and implement cultural competence within their professional practice. Applied Implications The development of and deliberate consideration of CC into applied and scholarly practice is an ethical and moral responsibility It is important for SPPs to invest in developing their CC, becoming comfortable with making mistakes, and engaging in difficult conversations. It is important for SPPs to ground their CC development in their own reflections as well as personal and professional cultural encounters.

Common demanding conditions among professional high-level military and sport leaders: a cross-contextual qualitative reflexive thematic analysis

Military and sport have attracted increased research interest separately as two distinctly demanding performance- and leadership-driven contexts. However, cross-contextual psychological research in leadership is lacking. Such research has potential to expose unique cross-fertilising insights into resemblances in leadership challenges among military and sport leaders, transferable to a broader range of contexts. Thus, the current study simultaneously explored high-level military and sport leaders’ real-life experiences of similarities in demanding conditions and their psychological manifestations. Sixteen participants - eight Swedish high-level military leaders and eight Swedish high-level sport leaders, participated in the study. Using a qualitative inductive cross-contextual design enabled in-depth knowledge and transferability. A reflexive thematic analysis (RTA) of sixteen interview transcripts generated four common themes of demanding conditions: (1) Developing organisations: Leading under an extensive workload and responsibility, (2) Managing destructive superiors and subordinates: Standing up for oneself, (3) Taking care of the minds and moods of others: Leading deliberated difficult conversations, and (4) Periods of extreme concentration: Leading critical coordination, decisions, and timing. The findings tie high-level military and sports leaders together into a high-stress and high-stakes leader role invoked to manoeuvre a complex buildup of demanding conditions. Implications are presented. Keywords: High-level leaders, military, sport, demanding conditions.

Diversity in German-speaking medical ethics and humanities

BackgroundBioethics can play an important role in addressing diversity both in and outside of academia, setting precedents for meaningful contributions to public discourse, research, teaching, training, and policy development. However, in order to do so, these conversations also need to reflect on the issue of diversity within the field of bioethics across the globe. This study aims to examine current gender representation and diversity at medical ethics and humanities institutes in Germany, the German-speaking areas of Switzerland, and Austria.MethodsA total of forty-nine medical ethics and humanities institutes from Germany (n=42), the German-speaking areas of Switzerland (n=5), and Austria (n=2) were included in the study. Institutes websites were reviewed in the first week of March 2021 and the details of each staff member listed on the website recorded.ResultsOverall, a total of 964 staff members were identified at the forty-nine German-speaking medical ethics and humanities institutes. Just over half (530/964; 55%) of all staff were female. There were significant differences between gender in some staff positions: 64.6 per cent (31/48) of directors were male (χ2(1)=4.1, P=.04); 62.7 per cent (84/134) of student assistants were female (χ2(1)=8.6, P=.003); and 83.7 per cent (77/92) of administrative staff were female (χ2(1)=41.8, P<.001). There were no significant differences between staff gender for researchers and lecturers, or associated researchers. In addition, 65.5 per cent (19/29) of researchers and lecturers who had a professor title were male, but the difference between genders was not found to be significant. However, significantly more of the researchers and lecturers who had completed a habilitation were male (75.8% (25/33); χ2(1)=8.8, P=.003). When comparing the institute director’s gender presentation with staff gender presentation, it was found that male-led institutes had 53.4 per cent (286/536) female staff overall but had 52.7 per cent (136/258) male researchers and lecturers. However, the difference between genders were not found to be significant. On the other hand, female-led institutes had significantly more female staff overall (59.9% (223/372); χ2(1)=14.7, P<.001) and also significantly more female researchers and lecturers (58.9% (119/202; χ2(1)=6.4, P=.01).ConclusionsThere has been a significant push to address gender diversity in German-speaking academia, and this study finds overall good gender parity in medical ethics and humanities institutes. However, there has not been a similar openness to discussing issues of systemic racism or how other forms of inequality affect academic diversity. Taking diversity seriously requires opening up conversations around intersectionality, including difficult conversations around race and cultural background that have long been taboo in German-speaking countries.

Productive struggle and failing safely: implications for developing adaptive expertise in communication.

Navigating difficult conversations is a complex task that requires flexible and adaptive approaches. Residents developing this skill may initially struggle or fail, and require support. However, this experience may prepare residents for future learning which is essential to adaptive expertise. Limited understanding of how residents learn from failure in the workplace restricts the ability to maximize its potential benefits. The purpose of this study was to explore the role failure plays in learning to navigate difficult conversations during workplace learning. A constructivist grounded theory study was conducted using semi-structured interviews of 13 physicians (subspecialty residents and newly graduated physicians) from a Division of Developmental Paediatrics between 2017 and 2018. The authors used constant comparative analysis to identify themes iteratively. Themes were identified both inductively and deductively using the conceptual framework of adaptive expertise. Through independently leading difficult conversations, physicians were able to recognize that the failure that occurred in these encounters, prompted them to generate new knowledge which led to deeper conceptual understanding, thus supporting development of adaptive expertise. However, participants indicated that staff physicians often protect residents from difficult conversations, which limits their opportunity to receive feedback and engage in learning. Residents participate in difficult conversations that challenge them to go beyond their existing knowledge. Providing residents with opportunity to lead difficult conversations with patients and families while being supported by staff supervisors, allows for struggling through learning, which leads to a deeper conceptual understanding and supports development of adaptive expertise.

The effects of self-viewing in video chat during interpersonal work conversations

Abstract With the growing use of video chat in daily life, it is critical to understand how visual communication channels affect interpersonal relationships. A potentially important feature that distinguishes video chats from face-to-face interactions is the communicators’ ability to see themselves during the interaction. Our purpose was to determine the effects of self-viewing on the process and outcome of a workplace confrontation. A dyadic experiment with two (self-viewing vs. no self-viewing) conditions was conducted using multi-instruments (self-report, physiological arousal, eye-tracking). Results showed that self-viewing reduced self-evaluation, which subsequently reduced solution satisfaction. Self-viewing also impaired one’s ability to assess their partner’s attitude and lowered partner evaluation. Although self-viewing decreased negative emotional expressions, the effect on conversation tone varied depending on the role an individual played. The overall negative impacts of self-viewing ability have significant implications for the appropriate implementation of a computer-mediated channel for enhancing one’s experience when having a difficult conversation.

Difficult Conversations—Turning Dread to Joy!

Difficult Conversations—Turning Dread to Joy!