Giulia Lamiani

An interdisciplinary, family-focused approach to relational learning in neonatal intensive care.

Objective:The aim of this study is to show the efficacy of the Program to Enhance Relational and Communication Skills–Neonatal Intensive Care Unit (PERCS-NICU).Study Design:In this study, 74 practitioners attended workshops and completed baseline, post-training and follow-up questionnaires.Result:On yes/no questions, 93 to 100% reported improved preparation, communication skills and confidence post-training and follow-up. A total of 94 and 83% improved their ability to establish relationships, and 76 and 83% reported reduced anxiety post-training and follow-up, respectively. On Likert items, 59 and 64% improved preparation, 45 and 60% improved communication skills and confidence, 25 and 53% decreased anxiety and 16 and 32% improved relationships post-training and follow-up, respectively. Qualitative themes included integrating new communication and relational abilities, honoring the family perspective, appreciating interdisciplinary collaboration, personal/human connection and valuing the learning. In total, 93% applied skills learned, three-quarters transformed practice and 100% recommended PERCS-NICU.Conclusion:After PERCS-NICU, clinicians improved preparation, communication and relational abilities, confidence and reduced anxiety when holding difficult neonatal conversations.

Assessment of Communication Skills and Self-Appraisal in the Simulated Environment: Feasibility of Multirater Feedback with Gap Analysis

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

When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates

Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. This review describes the publication trend on moral distress and explores its relationships with other constructs. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy). Findings revealed that moral distress negatively affects clinicians’ wellbeing and job retention. Further studies should investigate protective psychological factors to develop preventive interventions.

Assumptions and blind spots in patient-centredness: action research between American and Italian health care professionals

Objective  To examine how patient‐centredness is understood and enacted in an American (US) and an Italian group of health care professionals.

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

Background: The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians’ preparedness to engage in difficult conversations. Aim: To describe the implementation of PERCS in an Italian hospital and assess the programs efficacy. Methods: The Italian PERCS program featured 4-h experiential workshops enrolling 10–15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. Results: 146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patients perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. Conclusion: PERCS proved culturally adaptable to the Italian context and effective in improving participants’ sense of preparation, communication skills, and confidence.

How Italian students learn to become physicians: A qualitative study of the hidden curriculum

Background: A great deal of what medical students learn in terms of behaviors, values, and attitudes related to their profession is conveyed by the hidden curriculum. Aim: To explore the messages conveyed by the hidden curriculum as perceived by third-year students of the Milan School of Medicine, Italy, following their first clinical internship. Method: Three group interviews were conducted. Students were asked to reflect on values, attitudes, and implicit rules they noticed during their internship experiences. Verbatim transcripts of the group interviews were analyzed through content analysis using Nvivo8. Results: Of the 81 students, 57 (70%) participated in the group interviews. Six themes were identified within the hidden curriculum: Physicians reassure and protect patients; power differential between physicians and patients; variable respect for patients; disease-centered medicine; respect for hierarchies; and delegation of patients’ emotional needs to nurses. Conclusions: Our findings suggest that the hidden curriculum has a strong cultural component. In our students’ experience, the hidden curriculum conveyed a paternalistic model of physician–patient relationships. Some of the messages conveyed by the actual hidden curriculum may compromise the standards formally taught in medical schools about doctor–patient relationships. Organizational culture change and student empowerment could be fostered to counteract the negative effects of the hidden curriculum.

What would you do if this were your child?: practitioners' responses during enacted conversations in the United States

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

Applying a deliberation model to the analysis of consultations in haemophilia: Implications for doctor-patient communication

OBJECTIVE Literature highlights the importance of communication in order to achieve patients adherence. However, the specific dialogical components likely to favor patient adherence are not clear. In this study, the deliberation dialogue model was applied as an ideal model of optimal deliberation to real physician-patient consultations in the field of hemophilia in order to identify misalignments with the model and possible improvements in physician-patient communication. METHODS By applying the deliberation model, we analyzed a corpus of 30 check-up consultations in hemophilia. RESULTS Of 30 consultations, 24 (80%) contained 43 deliberation dialogues. Twenty-two (51%) deliberation dialogues were complete (e.g., included an opening stage with a clear statement of the problem, an argumentation stage in which both physician and patient participated, and a closing stage with an explicit patient commitment), whereas 21 (49%) deliberations were incomplete. These featured: Lack of/partial argumentation stage; Lack of closing stage; Lack of/partial argumentation stage and lack of closing stage. CONCLUSIONS The deliberation model can be applied to empirical data and allows to identify causes for suboptimal realizations of deliberation. PRACTICE IMPLICATIONS Once a problem is acknowledged, attention could be paid to engage hemophilic patients in the argumentation stages and elicit their explicit commitment.

Measuring Moral Distress Among Critical Care Clinicians : Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised

Objectives: Moral distress is a common experience among critical care professionals, leading to frustration, withdrawal from patient care, and job abandonment. Most of the studies on moral distress have used the Moral Distress Scale or its revised version (Moral Distress Scale-Revised). However, these scales have never been validated through factor analysis. This article aims to explore the factorial structure of the Moral Distress Scale-Revised and develop a valid and reliable scale through factor analysis. Design: Validation study using a survey design. Setting: Eight medical-surgical ICUs in the north of Italy. Subjects: A total of 184 clinicians (64 physicians, 94 nurses, and 14 residents). Interventions: The Moral Distress Scale-Revised was translated into Italian and administered along with a measure of depression (Beck Depression Inventory-Second Edition) to establish convergent validity. Exploratory factor analysis was conducted to explore the Moral Distress Scale-Revised factorial structure. Items with low (less than or equal to 0.350) or multiple saturations were removed. The resulting model was tested through confirmatory factor analysis. Measurements and Main Results: The Italian Moral Distress Scale-Revised is composed of 14 items referring to four factors: futile care, poor teamwork, deceptive communication, and ethical misconduct. This model accounts for 59% of the total variance and presents a good fit with the data (root mean square error of approximation = 0.06; comparative fit index = 0.95; Tucker-Lewis index = 0.94; weighted root mean square residual = 0.65). The Italian Moral Distress Scale-Revised evinces good reliability (&agr; = 0.81) and moderately correlates with Beck Depression Inventory-Second Edition (r = 0.293; p < 0.001). No significant differences were found in the moral distress total score between physicians and nurses. However, nurses scored higher on futile care than physicians (t = 2.051; p = 0.042), whereas physicians scored higher on deceptive communication than nurses (t = 3.617; p < 0.001). Moral distress was higher for those clinicians considering to give up their position (t = 2.778; p = 0.006). Conclusions: The Italian Moral Distress Scale-Revised is a valid and reliable instrument to assess moral distress among critical care clinicians and develop tailored interventions addressing its different components. Further research could test the generalizability of its factorial structure in other cultures.

Il diabete è per me …: la prospettiva degli operatori sanitari

Obiettivo. Indagare le rappresentazioni e i significati attribuiti al diabete da parte degli operatori sanitari attraverso un approccio etnografico. Metodo. Agli operatori sanitari che partecipavano ad un congresso nazionale sul diabete e stato chiesto di scrivere una narrazione sul tema “Il diabete e per me…”. Le narrazioni sono state analizzate qualitativamente da due ricercatori tramite analisi del contenuto e i dati gestiti tramite un software per la ricerca qualitativa (Nvivo). Risultati. Dei 147 presenti al congresso, sono state analizzate 140 narrazioni: 86 di infermieri, 54 di medici. L’analisi del contenuto ha messo in evidenza 6 tematiche: La malattia, che raccoglie le definizioni biomediche e biopsicosociali del diabete; Il vissuto del paziente, in cui si descrive come il diabete influisce sull’esistenza dei pazienti; Il vissuto dell’operatore, in cui l’operatore svela le sue paure che il diabete colpisca o abbia gia colpito se stesso e i propri famigliari; La relazione operatorepaziente, in cui emerge la centralita dell’educazione del paziente e la fatica di un rapporto a continuo contatto col cronico; Il sistema sociosanitario, comprendente le considerazioni sulla societa come causa del diabete ma su cui il diabete pesa in termini economici ed assistenziali. Conclusioni. I risultati evidenziano una profonda comprensione del vissuto del paziente, soprattutto da parte degli infermieri, fino all’identificazione col paziente. Emerge una dimensione relazionale ed educativa ricca, complessa e problematica sia per gli infermieri che per i medici. Interventi sull’area comunicativo-relazionale e sul vissuto degli operatori potrebbero avere ricadute positive sul lavoro coi pazienti.