Difficult Conversations Research Articles

ISBAR+ a communication tool to advocate for patients

Introduction Recognising the importance of social determinants of health is a key part of the curriculum for health practitioners. The ability to advocate on behalf of patients is a competency that demonstrates enacting this understanding in practice. Communication frameworks are used to structure difficult conversations in multiple settings, notably handover. There is no commonly accepted communication framework to structure a patient advocacy conversation. Approach We assembled a team with skills in patient advocacy, healthcare communication, community advocacy, education and business negotiation to identify the knowledge, skills and attitudes required and to develop a framework suitable for this purpose. We chose to adapt the ISBAR framework as an existing communication framework commonly used for handover. Outcomes ISBAR+ is a framework that is based on a person-centred approach and ‘integrated negotiation’. ‘Intention and Inquiry’ involves a compassionate understanding of the patient’s position. ‘Situation’ is a succinct framing of the problem. ‘Background’ is the information required for the decision-maker to make a person-centred decision. The next step is ‘alignment’ of the priorities of the patient, practitioner and decision-maker. ‘Response’ is the proposed solution, and ‘+’ (‘plus’) is the actions taken for implementation. Conclusions ISBAR+ provides a framework for conversations advocating on behalf of patients that draws from the literature around advocacy inside and outside health. A communication framework allows the development and evaluation of interventions to teach and promote this critical function to promote person-centred care.

Experiences of Simulated Patients Involved in Difficult Conversations With Undergraduate and Postgraduate Health Professionals.

Simulated patients (SPs) are trained to simulate real patient scenarios for health professionals' education and training. The value of including SPs in simulated scenarios, particularly in relation to difficult and complex conversations, has been studied in various contexts, with a focus on learner experiences and outcomes. What has not been as extensively explored is the impact of difficult and complex conversations on the SPs. The aim of this study was to explore the perspectives, motivations, and experiences of SPs, particularly regarding difficult or complex conversations. A qualitative approach was taken to gather and interpret SP experiences. Open-ended interviews were the primary means of obtaining data. Thematic analysis guided the interpretation of interview data to generate key themes that encapsulated the SP experience. Twelve participants shared their experiences of working as SPs in scenarios that involved difficult or complex conversations. From these data, 4 major themes were determined: Care for Students, Pedagogical Focus, Emotional Regulation, and Organizational Environment. The importance of empathy and safe design and support for simulations was apparent. This study presents insights into the experiences and perspectives of SPs regarding difficult and complex conversations. Participants highlighted the necessity of uniformity in standards of practice in simulation and the need for advocacy for awareness of simulation-based practices.

Stakeholders’ Perspective on the Key Features of Printed Educational Resources to Improve the Quality of Clinical Communication

Social and healthcare professionals often feel ill equipped to effectively engage in difficult conversations with patients, and poor proficiency negatively affects the quality of patient care. Printed educational resources (PERs) that provide guidance on sustaining complex clinical communication may be a source of support if thoughtfully designed. This study aimed to describe the key features of PERs in order to improve the quality of clinical communication according to the perspective of meaningful stakeholders. This was a descriptive secondary analysis of data collected by three remote focus group discussions that involved 15 stakeholders in the context of developing an educational booklet to support professionals in complex communication scenarios. Focus groups were audio-recorded and transcribed verbatim, and an inductive thematic analysis was performed. Three key features of PERs that aim toward quality improvement in clinical communication were identified: (1) having the potential to provide benefits in clinical practice; (2) facilitating, encouraging, and enticing reading; and (3) meeting the need of professionals to improve or update their knowledge. These findings suggest that PERs relevant to professionals’ clinical priorities and learning needs may make their efforts to apply learning in practice more likely and consequently result in improved healthcare quality.

Learning about America's Racial Issues: Beginning Difficult Conversations through Read‐Alouds

AbstractMultiple racial issues in America have been brought to the forefront by the recent deaths of African Americans, yet many teachers feel unprepared to engage with students around issues of race. Their discomfort is likely because traditional textbooks omitted the experiences of non‐dominant, marginalized groups, thereby denying readers an opportunity for a rich, multifaceted understanding of historical events. Education has also become politicized, resulting in educational gag orders and book bans. This article recommends using read‐alouds with children's literature to begin the complex conversations and learning around America's racial history and how it has led to contemporary situations. Using the book Let the Children March, we provide examples of how to prepare for discussion and instruction that recognizes the varied experiences of diverse Americans and honors their contributions to our democracy.

'I need to understand… so we can decide together': Difficult conversations about alopecia areata.

The management of alopecia areata (AA) in pediatric patients poses unique challenges, particularly regarding treatment discussions and decision making involving both patients and their families. This commentary presents findings from unpublished research on treatment-discontinuation discussions between AA patients and their treating providers, shedding light on the hopes, expectations, and disappointments of individuals with severe AA. The study explored patient and guardian satisfaction with these discussions, emphasizing the importance of addressing psychosocial concerns, facilitating contact with support groups, and demonstrating empathy. The role of dermatologists in conversations about treatment, prognosis, and quality of life is examined, emphasizing the need for honesty, empathy, and realistic expectations. The authors propose a patient-centered approach to initiating and guiding discussions, focusing on understanding the impact of AA on patients and their families and collaboratively deciding on treatment options. The mantra: 'I need to understand how this is affecting all of you, so we can decide together what to do next' is central to this proposed approach. Special considerations for different scenarios are discussed, highlighting the importance of individualized care and effective communication. Overall, the commentary emphasizes the significance of actively listening, acknowledging emotions, and prioritizing patient and family goals to optimize care for pediatric AA patients.

Comprehensive Sexual Health Educational Learning Modules for College Students.

Sexual health education in the United States continues to be a controversial topic of discussion with no federal regulations. Due to this, the sex education students receive before college varies greatly. Our team discovered that no mandatory, comprehensive sexual health education is required for students once they enter the California State University system. At Cal Poly specifically, it was found that students were engaging in risky sexual behaviors. For example, the 2021 American College Health Association-National College Health Assessment III Fall 2021 Data Report revealed that less than half (42.1%) of students reported regularly using condoms during vaginal sex, and a mere 5.1% of students reported barrier method use during oral sex. To fill in the noticed gaps in our students' sexual health education, our team developed a set of 10 comprehensive sexual health educational learning modules. The modules cover topics ranging from condom use and STIs to pleasure, porn literacy, and having difficult conversations with a partner. This anonymous online resource provides students with easy-to-read written material and engaging graphics. Future research will focus on user engagement and the effect of the resource on sexual health best practices across our campus.

Developing online communication training to request donation for vascularized composite allotransplantation (VCA): improving performance to match new US organ donation targets.

Approaching families of dying or newly deceased patients to donate organs requires specialized knowledge and a mastery of relational communication. As the transplantation field has progressed, Donation Professionals (DPs) are also leading conversations with family decision makers (FDMs) about the donation of uncommon anatomical gifts, such as face, hands, genitalia, referred to as Vascularized Composite Allotransplants (VCA) without much training or experience. To address the need for training, we adapted and beta tested an evidenced-based communication training program for donation discussions to VCA requests. The overarching goal of Communicating Effectively about Donation for Vascularized Composite Allotransplantation (CEaD-VCA) is to increase the number of VCA authorizations and to improve the socioemotional outcomes of FDMs. We developed CEaD-VCA, an online, on-demand training program based on the previously tested, evidenced-based communication skills training program designed to train DPs to have conversations about solid organ donation. The training was modified utilizing data from a national telephone survey with DPs and results of 6 focus groups conducted with members of the general public. The survey and focus groups assessed knowledge, attitudes, and barriers to VCA donation. The training was shaped by a partnership with a leading industry partner, the Gift of Life Institute.™ RESULTS: Using the results as a guide, the existing CEaD training program, consisting of interactive eLearning modules, was adapted to include technical information about VCA, foundational communication skills, and two interactive example VCA donation request scenarios to facilitate active learning. Forty-two DPs from two partner Organ Procurement Organizations (OPOs) participated in the beta test of CEaD-VCA. Pre- and post-test surveys assessed the impact of the training. The training was scored highly by DPs in effectiveness and ease of use. This project created a standardized, accessible, and comprehensive training for DPs to communicate about VCA donation. CEaD-VCA is an example of how to develop a communication skills training for difficult conversations utilizing input from stakeholders, guided by communication theory. It also demonstrates how gaps in communication skills during medical education can be filled utilizing advanced online Learning Management Systems. The training specifically addresses new CMS rules concerning OPO performance metrics.

Communication skills-based training about medication switch encounters: pharmacy staff and patients' experiences.

Non-medical medication switches can lead to difficult conversations. To support pharmacy staff, a communication training has been developed based on two strategies: 'positive message framing' to emphasize positive elements of the message and 'breaking bad news model' to break the news immediately and address emotions. To assess how patients and trained pharmacy staff experience the application of communication strategies for non-medical medication switch conversations and which are barriers and facilitators for the application. The Kirkpatrick training evaluation model, level 3 'behavior', including barriers and facilitators and 4 'results' was used. Trained pharmacy staff registered switch conversation characteristics and asked patients to complete a questionnaire. Semi-structured interviews with trained pharmacy staff members were conducted. Quantitative data were analyzed descriptively and interview data were analyzed thematically. Of the 39 trained pharmacy staff members, 21 registered characteristics of 71 conversations and 13 were interviewed; 31 patients completed questionnaires. Level 3: trained pharmacy staff self-reported they applied aspects of the strategies, though indicated this was not yet a standard process. Interviewees indicated signs of increased patient contact and job satisfaction. Time, face-to-face conversations and colleague support were facilitators. Level 4: pharmacy staff members were satisfied with most switch conversations (89%), particularly with addressing emotions (74%). Patients were (very) positive (77%) about the communication, particularly about clear explanations about the switch. Pharmacy staff's learned behavior includes being able to apply aspects of the strategies. The training results show first signs of better patient-pharmacy staff relationships and increased job satisfaction.

Raising awareness of anti-fat stigma in healthcare through lived experience education: a continuing professional development pilot study

BackgroundAnti-fat attitudes and weight-based discrimination are prevalent in healthcare settings and among healthcare practitioners and clinical trainees, and can result in immense harm to patients. There is increasing recognition that anti-fat bias in healthcare is a critical issue that must be addressed, but there is a dearth of evidence demonstrating sustained attitude and behavioural change among clinicians, illustrating a need for more innovative educational approaches and rigorous evaluation. We describe the co-design and delivery of a narrative-based continuing professional development curriculum aimed at raising awareness of weight-based bias and stigma.MethodsOur research team of lived experience educators, clinicians and researchers collaboratively developed a series of seven podcast episodes comprised of narrative descriptions of lived experiences with and impacts of weight bias, stigma and discrimination in healthcare settings, as well as a post-podcast workshop to facilitate reflection and discussion between participants. The curriculum was piloted among 20 clinicians practicing at a large urban hospital in Mississauga, Canada. We explored feasibility, acceptability and learning impact by analyzing responses to questionnaires completed following each podcast episode and responses shared during the workshops and follow-up feedback sessions.ResultsWe observed high acceptability and feasibility of the curriculum. Participants experienced the podcast as a practical and convenient learning format and the workshop as a valuable opportunity to collectively debrief and reflect. The learning impact of the curriculum was strong; participants described a range of emotions elicited by the podcasts, engaged in self-reflection, and expressed a desire to modify clinical approaches. Barriers to the application of learnings identified by participants include pervasiveness of the use of body mass index (BMI) as an indicator of risk and a criterion for referral; discomfort with difficult conversations; prevalent biomedical understandings about the association between weight and health; and clinicians’ defensiveness.ConclusionThis pilot study yielded promising findings and demonstrated potential impact on weight bias and stigma among healthcare providers. Necessary next steps include conducting larger scale, rigorous evaluations of the curriculum among broader populations, both health professions trainees and current healthcare providers.

Nursing students satisfaction and self-confidence with standardized patient palliative care simulation focusing on difficult conversations.

Lack of experience communicating with patients and families at the end of life are key concerns for nursing students. Palliative care simulation using standardized patients (SPs) focusing on difficult conversations may lead to increased self-confidence in providing palliative and end-of-life care in clinical practice. There is currently a paucity of research on SP palliative care simulations in undergraduate nursing education. The objective of this research was to assess 3rd year undergraduate nursing students' levels of satisfaction and self-confidence with palliative and end-of-life care simulations focusing on difficult conversations, as measured by the Student Satisfaction and Self-Confidence in Learning Scale (SSSCLS) and the Simulation Design Scale (SDS). A descriptive post-intervention study. Four palliative care simulation days, consisting of 2 clinical scenarios, were conducted over 4 weeks. The first simulation was an outpatient palliative care clinic scenario, and the second was an inpatient hospital scenario. Nursing students enrolled in a 3rd year nursing palliative care elective (n = 51) at an Australian university were invited to participate. Students who attended simulation days were eligible to participate (n = 31). Immediately post-simulation, students were invited to complete the SSSCLS and the SDS. Fifty-seven surveys were completed (simulation 1, n = 28; simulation 2, n = 29). The data were analyzed using descriptive statistics. Results showed that students had high levels of self-confidence in developing palliative care and communication skills after both simulation experiences and high levels of satisfaction with the SP simulations. The lack of published literature on palliative care and end-of-life SP simulation highlights the need to collect further evidence to support this as an innovative approach to teaching palliative care. SP palliative care simulation focusing on difficult conversations assists in developing students' communication skills and improves satisfaction and self-confidence with palliative and end-of-life care.

Belonging Pedagogy: Revisiting Identity, Culture, and Difference

This study examines belonging pedagogy as an effective, culturally respectful intervention in art education. Art education faculty members at three institutions collaborated and organized virtual workshops to broaden the scope of diversity and promote online community building. Culturally sensitive and inclusive education and pedagogy of belonging are presented as conceptual backgrounds, combined with a constant comparative method through which outcomes of the study are analyzed. By incorporating personal narratives into K–16 educational practices, students can revisit their racial and cultural differences and sense of belonging in the classroom context. They can make real-world connections through art by being vulnerable and open to difficult conversations, sharing individual stories, making art collaboratively, and personalizing the social and cultural contexts of society. This approach can be applied to both teacher education and K–12 classrooms to create a safe space for students to reflect on their identities and cultures and build a sense of belonging.

Opening the Door: Rethinking "Difficult Conversations" about Living and Dying with Dementia.

This essay looks closely at metaphors and other figures of speech that often feature in how Americans talk about dementia, becoming part of cultural narratives: shared stories that convey ideas and values, and also worries and fears. It uses approaches from literary studies to analyze how cultural narratives about dementia may surface in conversations with family members or health care professionals. This essay also draws on research on a notable social effect of legalizing medical aid in dying: patients may find it easier to bring up a range of concerns, regardless of whether they have any interest in hastening their own death. The essay proposes that health care professionals rethink an idea prominent within their own culture: that conversations about the end of a person's life are inherently difficult. This framing may make it hard for people facing dementia to bring up their concerns about what lies ahead. We suggest a different way to think about these conversations, using the metaphor of "opening the door" to represent inviting a patient to bring up issues of deepest concern.

An Interactive Allyship and Privilege Workshop for Trainees in Medicine.

Despite growing efforts to increase diversity in recruitment and to teach principles of diversity, equity, and inclusion (DEI), representation of individuals underrepresented in medicine continues to fall short. This demonstrates a need for efforts that target the work environment and culture to increase retention alongside existing recruitment initiatives. We designed this interactive allyship workshop with a focus on building skills necessary for being an ally that has been missing in existing allyship curricula. This workshop was led by multidepartmental faculty with experience in DEI training. Participants engaged in a number of interactive activities to reflect on their own identities and privilege and practiced ways to engage in difficult conversations. Prior to the workshop, participants completed a survey that was repeated at the workshop's completion to evaluate their perspective change and understanding of allyship. We also collected responses to a self-reflective exercise during the workshop. Participants included 68 anesthesia and surgery attendees, 53 of whom (78%) completed the postsurvey. Participants strongly agreed that this workshop was important to the workplace and medical training. Themes from the self-reflective exercises included endorsement of sponsorship and mentorship activities, community support, and advocacy. Interactive skill-building activities are important and effective at helping trainees develop as allies. Long-term follow-up is needed to assess longitudinal knowledge retention and translation into behavioral change to create a more inclusive and supportive work environment.

Pilot Study: Moving Towards a Scalable Intervention for Postgraduate Communication Skills Training.

Communication skills are foundational to the practice of medicine and training to build them is recommended. Serious illness communication skills (SICSs) teaching is inconsistently and sparsely taught in postgraduate training and residents report feeling inadequately trained to have difficult conversations. The authors developed an e-module demonstrating high-yield communication skills from a known evidence-based training program to standardize core SICS teaching and questioned how using it before skills practice impacted comfort and preparedness for residents to complete advance care planning (ACP). Family medicine residents at an academic hospital in Toronto, Canada, completed a novel e-module that replaced a typical didactic-lecture introducing core SICS relevant to ACP conversations. Residents then discussed the skills, followed by practicing them deliberately in a structured role-play simulation with feedback by trained facilitators. Residents completed pre- and post-intervention attitudinal surveys. Residents preferred a combination of learning modalities and welcomed online and virtual teaching methods for learning SICS. Residents reported higher levels of preparedness for engaging in ACP, delivering serious news, and discussing goals of care post-intervention. Residents showed more interest in discussing ACP post-intervention but questioned feasibility for doing so in busy ambulatory clinics. Scalable time-efficient teaching strategies are needed to fill a known education gap. This study demonstrated benefits of incorporating brief e-module learning into residents' preparation for SICS training using deliberate practice simulation training. The online, interactive virtual training improved resident readiness and comfort for ACP, an area often overlooked in medical education. Moreover, it provides an evidence-informed standardized tool for clinician teachers to seamlessly incorporate into their teaching practices.

Interview Completion Protocol

The article raises the question of the necessity to develop clear procedures and regulations for completing interviews that would allow the interviewer, regardless of the type of interview, not only leave a good impression of himself and maintain an empathic relationship, but also not violate the fundamentals of research ethics and maintain high standards of field work. The reader is provided with a protocol for completing an interview, consisting of five requirements, the fulfillment of which guarantees the successful completion of even the most difficult conversation. We are not talking about a set of instructions; rather, basic recommendations and guidelines are presented, guided by which the interviewer will be able to develop his own communicative techniques for completing the interview. The presented protocol is universal and suitable for qualitative and quantitative interviews.

Student Perspectives While Serving Asylum Seekers: A Pilot Study

Background: Medical student-run asylum clinics, which support asylum seekers with medical/psychological evaluations provided by asylum clinics, have significantly expanded in the United States in the last ten years, but minimal data reviews the impact of a program like this on the professional development of providers and students. This study analyzes how student participation impacts cultural competency and professional adeptness. 
 Methods: Fifty-eight CDAC (n=26) and non-CDAC (n=32) participants were surveyed on demographics, comfort, and experiences interacting with asylum populations, as well as philanthropic characteristics of altruism, empathy, and compassion. Data collection and analysis were conducted using Qualtrics, R, and non-parametric testing (Mann Whitney U test, Fisher’s exact test).
 Results: Those who participated in CDAC endorsed greater overall experience interacting with asylum populations (p=0.01), particularly serving refugee populations (p=0.004) and having difficult conversations about physical and mental trauma (p=0.02). CDAC participants also scored higher on select measures of altruism and empathy.
 Conclusion: Participation in service-learning programs is important to medical education and practice, particularly in primary care. CDAC offers a unique learning opportunity for clinicians to gain cultural competency skills while providing vital assistance to marginalized populations, even for those with no prior formal training.

SOCIAL SERVICE DIRECTOR PRIORITIES IN RESOLVING CONFLICTS IN NURSING HOMES

Abstract Social workers in nursing homes serve many critical roles such as assessing for residents’ unmet psychosocial needs, providing support to residents and families at end of life, and resolving conflicts between residents, families, and staff. In their roles, they often need to balance conflicting priorities and determine whose rights or needs should take priority. Little is known about how these conflicts affect the social workers in their jobs. This presentation will report the results of a content analysis of the answers to two open ended questions, “What do you like about your job?” and “What would you change about your job?” in a nationally representative sample of nursing home social service directors. The results illustrate directors’ views of what they value in terms of helping residents, families, and staff navigate change, difficult conversations, and conflicting interests. Social service directors report that their priorities are residents and their families, specifically advocating for resident needs. They also report needing to advocate for the role of social work on the interdisciplinary team. They report that family dynamics are messy, but do not discuss how they prioritize within and between residents, their family members, and nursing home staff. More research is needed to understand the decision making process that social workers employ in decision-making about priorities.

NAVIGATING AGING WHILE CAREGIVING: LONGEVITY PLANNING CONSIDERATIONS FOR CAREGIVERS OF ADULT CHILDREN

Abstract Caregiving is a demanding, complex, and costly role. According to AARP (2020), an increasing population of older adults in the U.S. are providing unpaid care to younger adult family members, with over two million adults in the U.S. providing care for an adult child. Caregivers of adult children experience unique challenges that can affect how they plan for their own longevity, as well as their adult child’s longevity. To further explore the experiences of aging caregivers of adult children, the MIT AgeLab conducted an exploratory, qualitative study based on interviews with participants drawn from the MIT AgeLab’s CareHive panel. Through a series of interviews conducted in June 2022, three key transition points in the lives of caregivers of adult children were identified. These transitions included the discovery that the child has special needs, the child’s transition into legal adulthood, and the aging of the caregiver. The last transition point, focused on the aging of the caregiver, often presents complex implications including balancing one’s own care needs with those of their child; navigating difficult family conversations; and preparing for continuation of care after one’s own eventual death. Leveraging insights from these interviews, this session will explore complexities within each of the three key transition points, using Schlossberg’s Transition Theory as a lens for analysis. The session will also identify resources and support desired by caregivers for support in this transition point, shedding a particular light on important considerations for professionals across multiple sectors and industries.

IMPROVING THE ENGAGEMENT OF RESIDENTS WITH DEMENTIA IN ADVANCE CARE PLANNING DISCUSSIONS IN LONG-TERM CARE

Abstract As part of the Strengthening a Palliative Approach in Long Term Care (SPA-LTC), we have designed and evaluated a number of tools and resources to promote a palliative approach in dementia, including a Canadian version of the Conversation Starter Kit (CSK) booklet. We used participatory action research to design tools for use with care providers based on survey data and interviews. Data was analyzed using thematic analysis and descriptive statistics. We found that residents reported that they engaged in asking more questions to their care provider after completing the CSK booklet. However, care providers stated that they did not feel comfortable addressing questions and concerns raised by residents and their family members. Hence, we co-designed two tools to help build capacity among care providers to support ACP discussions with residents and families, including an e-learning module about ACP discussions for people with dementia and a Conversation Guide. Pilot findings of these tools suggest that staff appreciate the information and tools to enable them to initiate ACP discussions and address difficult conversations. Clearly, residents with dementia and their families need to be supported to engage in ACP discussions early on in their disease trajectory so that residents are afforded the opportunity to voice their values and wishes for end of life care. At the same time, care providers need to have the skills (e.g., listening, probing) and comfort to engage in these discussions to support and help prepare residents and families for important decisions that need to be made later on.

Having the difficult conversations through social work research

Having the difficult conversations through social work research