Context: Providing patient care at the end of a patient's life is a humbling and sacred experience for both patient and provider. Without a truthful and meaningful conversation about end-of-life care preferences, the care that is delivered may not be the care that the patient prefers.
bjectives: Determine if there is a relationship between level of training, confidence, and presence of decisional conflict in making an accurate prognosis for 2 standardized cases. Additionally, we evaluated the correctness of the prognosis as measured against survival outcomes for patients with similar diagnoses.
Methods: Decisional conflict was measured with the SURE tool, a validated 4-item tool that has been used in assessing for the presence of decisional conflict.
Results: Following analysis of data, it was found that providers with no decisional conflict were much more likely to be attendings with more than 5 years' experience. Providers were more conflicted overall when confronted with a case with a more grave prognosis. It was determined that providers with a lower level of training were more likely to have decisional conflict.
Conclusions: Provider confidence increases and decisional conflict decreases as one increases their level of training. However, the degree in which the provider is correct in their prognosis does not change as one increases their level of training. These findings have broad implications on patients, providers, and the health-care system.
Background: Project ECHO™ (Extension for Community Healthcare Outcomes) is a form of online interactive teaching, which has gained international traction. This project evaluates the effectiveness of an ECHO-delivered palliative care education program for the South Dublin region of Ireland. Our aim was to measure project success by quantifying gains in staff confidence.
Methods: The educational program consisted of 10 interactive sessions over a five-month period on palliative care topics ranging from pain management to advance care planning. Twenty nursing homes took part in the education program. Of these, a subgroup of six nursing homes were randomly selected for assessment. Likert scale-based questionnaires assessed staff confidence before and after each lecture and assessment was repeated at least six weeks postlecture. Five of the 10 sessions were assessed in this way. Other characteristics such as staff role and years of experience were also collected.
Results: Twenty nursing homes and 353 staff participated in the education sessions. Of the 6 nursing homes chosen for assessment, an average of 42 questionnaires were returned per session (n = 211), representing 83% of attendees at these 6 selected nursing homes. Seventy-seven percent of questionnaires were successfully followed up for six weeks. Average confidence increased by 27% pre- to postlecture (6.4 [SD = 1.4] to 8.1 [SD = 2.1], p < 0.005). Confidence gains persisted at six weeks; 8.1 of 10 (SD = 1.4), with no significant drop-off (-0.01/10, p = 0.95). All staff groups (nursing vs. non-nursing) exhibited equal confidence gains (nursing gain of 27%, non-nursing gain 22%, p = 0.16), and all confidence gains persisted at six weeks.
Conclusion: This interactive, novel, training program significantly improved nursing home staff confidence in managing palliative care situations, and this confidence was sustained at least six weeks after the sessions.
BACKGROUND: Around the world, many paramedics are authorised to withhold or terminate resuscitation. Research indicates this can be a challenging part of their role. Little is known about graduating paramedic student confidence, concerns and learning in this area.
METHODS: An online cross-sectional survey of students nearing completion of a paramedic degree in New Zealand, including piloting of a newly-developed confidence scale.
RESULTS: Seventy-two participants reported varying exposure to termination of resuscitation and patient death. Participants felt most confident providing technical procedurally-based care and least confident with non-technical skills. Participants' greatest concerns included making 'the right call', supporting grieving family, controlling emotions and encountering conflict. Clinical exposure with supportive mentoring, clinical simulation, peer reflection and resolved personal experience with death, were considered most useful for professional development.
CONCLUSIONS: Exposure to termination of resuscitation and management of the scene of a patient death is variable amongst graduating paramedics. Novice paramedics may benefit from opportunities to observe and rehearse non-technical skills including delivering death notification and communicating with bystanders and bereaved family. The Confidence with Resuscitation Decision-Making and Patient Death Scale has favourable psychometric properties and utility as an outcome measure for future research in this area.
OBJECTIVES: Having early discussions with seriously ill patients about their priorities and values can improve their peace of mind and family outcomes during bereavement; however, physicians and medical students report feeling underprepared to hold serious illness conversations. We evaluated the impact of the Serious Illness Care Program clinician training workshop on medical learners' knowledge of comfort and confidence in holding such conversations.
METHODS: Eligible learners were penultimate- or final-year medical students or first-year residents of generalist programs (Family Medicine, Internal Medicine). Learners participated in a 2.5-hour workshop involving reflection on serious illness discussions, didactic teaching and demonstration of the Serious Illness Conversation Guide (SICG), role play with standardized patients, direct observation, and feedback from experts. Participants completed pre- and post-intervention questionnaires with Likert-type scale and open-ended questions, which were analyzed using paired t tests and qualitative content analysis, respectively.
RESULTS: We enrolled 25 learners. The intervention was associated with an increase in knowledge (P < .001) and self-efficacy (P < .001). All learners reported gaining new skills, with a majority specifically identifying a framework for structuring serious illness conversations in the qualitative analysis (n = 14, 56%). Participants stated the workshops would improve their comfort in holding serious illness conversations (n = 24, 96%), and that it would be valuable to integrate the workshops into their formal curricula (n = 23, 92%).
CONCLUSIONS: Training on the use of the SICG is novel for medical students and first-year residents and associated with the improvement in their knowledge of and perceived capacity to hold serious illness conversations. This study suggests that the integration of SICG training into medical curricula may have educational value.
BACKGROUND: Trisomy 13 and trisomy 18 are common life-limiting conditions associated with major disabilities. Many parents have described conflictual relationships with clinicians, but positive and adverse experiences of families with healthcare providers have not been well described.
AIM: (1) To investigate parental experiences with clinicians and (2) to provide practical recommendations and behaviors clinicians could emulate to avoid conflict.
DESIGN: Participants were asked to describe their best and worse experiences, as well as supportive clinicians they met. The results were analyzed using mixed methods.
SETTING/PARTICIPANTS: Parents of children with trisomy 13 and 18 who were part of online social support networks. A total of 503 invitations were sent, and 332 parents completed the questionnaire about 272 children.
RESULTS: The majority of parents (72%) had met a supportive clinician. When describing clinicians who changed their lives, the overarching theme, present in 88% of answers, was trust. Parents trusted clinicians when they felt he or she cared and valued their child, their family, and made them feel like good parents (69%), had appropriate knowledge (66%), and supported them and gave them realistic hope (42%). Many (42%) parents did not want to make-or be part of-life-and-death decisions. Parents gave specific examples of supportive behaviors that can be adopted by clinicians. Parents also described adverse experiences, generally leading to conflicts and lack of trust.
CONCLUSION: Realistic and compassionate support of parents living with children with trisomy 13 and 18 is possible. Adversarial interactions that lead to distrust and conflicts can be avoided. Many supportive behaviors that inspire trust can be emulated.
BACKGROUND: Equipping midwives and nurses with confidence to provide bereavement care to parents who have experienced a perinatal loss is vital and impacts on the efficacy of the care received by grieving parents. In education and clinical practice environments there are shortages of bereavement care questionnaires specifically designed to measure midwives' and nurses' confidence and psychosocial factors that impact on their confidence to provide bereavement care.
AIM: The purpose of the study was to develop a valid and reliable perinatal bereavement care confidence scale (PBCCS).
METHODS: The PBCCS was developed in 4 phases. Phase 1: Questionnaire development, 44 questions were formulated from the literature. Phase 2: Face and content validation of the PBCCS by an Expert Panel. Phase 3: A pilot study was conducted and included 10 cognitive pre-testing interviews and test-retest reliability assessment with a cohort of 26 midwives. Phase 4: Construct validity was assessed using factor analysis with 277 midwives and nurses. In order to avoid confusion with terminologies, the term midwife was used for both nurses and midwives who provided care to bereaved parents and participated in the study. Internal consistency reliability measurement was assessed with Cronbach's alpha. Ethical approval of the study was obtained from four maternity hospitals in Ireland.
RESULTS: The PBCCS has 43 items. Bereavement care knowledge (15 items, 3 sub-scales). Bereavement care skills (9 items, 2 sub-scales). Self-awareness (8 items, 2 sub-scales). Organisational support (11 items, 2 subscales). The internal consistency reliabilities ranged from 0.753 to 0.871 except for one subscale 0.663.
CONCLUSIONS: The PBCCS is a valid and reliable tool with good psychometric properties which can be used to measure midwives' confidence and the psychosocial factors thatimpact on their confidence to provide bereavement care.
L'entrée en institution d'un sujet exige de ce dernier ainsi que sa famille et ses proches d'accorder un peu de confiance pour se laisser accompagner dans les soins par les soignants. Accorder sa confiance ne se fait pas sans heurts, maladresses, malentendus, conflits qui donnent cependant aux soignants et aux résidents la possibilité de trouver des points d'aménagements, des stratégies à mettre en oeuvre où chacun trouverait sa place. Passer par le conflit permet de dialectiser et d'envisager une issue, une résolution. Cependant nous sommes au coeur d'une époque où le conflit n'est parfois qu'apparence, un bruit sourd, réduit à des positions univoques, des certitudes exprimées qui empêchent la dialectique, même inconfortable, de s'installer.
Nous ne sommes pas épargnés par la rencontre de ce phénomène dans nos EHPAD et au travers de ces deux exemples cliniques, il s'agit de rendre compte du barrage fait au conflit.
Plus que le conflit, ce qui peut être problématique, voire destructeur, c'est son mode de résolution et surtout le cadre dans lequel celui-ci se déroule. Si l'environnement est dédié à la défiance, le conflit peut être problématique. En revanche, si c'est la confiance qui prédomine alors les différents interactants savent qu'il se situe dans un cadre bienveillant et, dès lors, si les arguments échangés sont bien à discuter, ils ne portent pas en eux de charge délétère.
BACKGROUND: Advance care planning (ACP) is an essential skill for clinicians, yet trainees feel inadequately prepared to conduct ACP discussions. Optimal teaching methods and timing are unknown.
AIM: We designed a curricular intervention to expose second-year medical students to the process of ACP, aiming to improve their ACP knowledge and confidence.
DESIGN: The intervention consisted of a case-based workshop facilitated by a physician experienced in ACP ("facilitated ACP workshop"), which was added to an existing multifaceted ACP curriculum (longitudinal senior mentor program including multiple visits with a volunteer older adult, completion of an electronic ACP learning module and reflective writing exercise). The control group received the existing ACP curriculum only, while the intervention group received the existing curriculum plus the facilitated ACP workshop. Both groups completed an ACP knowledge assessment and confidence survey at the conclusion of the curriculum.
SETTING/PARTICIPANTS: Two consecutive classes of second year medical students, single academic hospital.
RESULTS: No statistically significant differences in ACP knowledge or confidence were seen post-intervention. Overall confidence with ACP tasks remained relatively low despite a multifaceted ACP curriculum.
CONCLUSIONS: Future studies should investigate longitudinal, experiential ACP learning, and seek to optimize ACP teaching strategies and timing.
Despite the frequency, complexity, and intensity of communication that occurs between nurses, patients, and families, palliative care nurses often struggle with end-of-life communication. The primary goal of this quality improvement project was to increase nurse confidence and satisfaction engaging in end-of-life communication following the implementation of the COMFORT model; the secondary goal was to improve patient-family satisfaction with care provided in the palliative care unit. Fourteen palliative care nurses attended a 4-hour course to learn the tenets of the COMFORT model and practice through role-play exercises. A repeated-measures design was used to measure nurse confidence and satisfaction precourse, postcourse, and 3 months postcourse. A between-subjects pre-post design was used to compare family satisfaction survey scores in the 3-month period before versus the 3 months after implementation. Analysis revealed a statistically significant increase in all measures of nurse confidence and satisfaction from precourse to postcourse and from precourse to 3 months postcourse. There was no statistical difference between the family satisfaction survey scores before versus after training, although survey results were generally high at baseline and most respondents rated palliative services with the best possible response. This project demonstrates that COMFORT model training increased confidence and satisfaction of palliative care nurses engaged in end-of-life communication and demonstrates potential for use in other clinical areas that do not specialize in end-of-life nursing (eg, critical care) but find themselves in need of the communications skills to address end-of-life care.
The purpose of this project was to explore how registered community nurses experienced providing holistic end-of-life care and how having a structured end-of-life care pathway plan would help develop their knowledge and skills, particularly in respect of communication and their ability and confidence in providing evidence-based compassionate care. For some practitioners there exists a lack of confidence surrounding end of life care, which can result in nurses' reluctance to become involved and avoid engaging in those 'difficult conversations'. Following implementation, early reviews from practice suggest that incorporating the 19 steps of the plan into the delivery of community-based care at end of life has enhanced practice and patient experience.
Background: Research found that low levels of professional confidence and personal comfort among neonatal clinicians regarding palliative care may indicate a lack of competence and hesitancy to offer neonatal palliative care services.
Purpose: This study evaluated the factors associated with the confidence and comfort levels of neonatal clinicians providing neonatal palliative care.
Methods: A cross-sectional survey and questionnaire were used to investigate the confidence and comfort levels of neonatal clinicians regarding neonatal palliative care.
Results: Research subjects included 154 neonatal clinicians. Clinicians' confidence in providing neonatal palliative care was significantly impacted by age, marital status, years of professional experience (p < 0.05), and prior palliative care training. Comfort levels were significantly impacted by educational degree, marital status, and years of working experience. Clinicians with a supportive workplace reported increases in both professional confidence (r = 0.286, p < 0.001) and personal comfort (r = 0.521, p < 0.001).
Conclusion: Research reveals the importance of neonatal palliative education and suggests further development of interdisciplinary neonatal palliative care teams to improve clinicians' professional confidence and personal comfort.
What is known about the topic? A novel program was implemented to enhance the care provided by paramedics to patients with palliative goals of care. What did this study ask? This study asked about patient experience with the program and the comfort and confidence of paramedics to deliver this care. What did this study find? Patients praised the compassion of paramedics and staying home, and paramedics strongly agreed palliative care should be in their practice. Why does this study matter to clinicians? Knowledge of this program will support similar initiatives and increase access to care and death outside of the hospital setting.
BACKGROUND: Little is understood about the different ways patients complete advance directives (ADs), which is most commonly through lawyers and increasingly using websites.
OBJECTIVE: To understand patients' perspectives on different approaches to facilitating AD completion, the value of legal regulation of ADs, and the use of a web-based platform to create an AD.
DESIGN: Semi-structured interviews with patients.
SETTING/PARTICIPANTS: We purposively sampled 25 patients at least 70 years of age or with a chronic disease from 2 internal medicine clinics.
MEASUREMENTS: Interviews focused on experiences and perspectives creating ADs, including facilitation by lawyers, health-care professionals, and websites. Feedback on a website prototype was also obtained. Responses were analyzed with modified grounded theory until thematic saturation was achieved.
RESULTS: Although a majority of participants with ADs had used lawyers, participants were ambivalent about the benefits of lawyer facilitation. Most valued both the medical perspective of a health-care professional and a lawyer's attention to legal requirements for AD validity. Participants had positive impressions of the web platform, but some were concerned about privacy with online storage. Trust emerged as an overarching theme, and participants valued legal regulation of ADs to ensure document authenticity and delivery of preference-concordant care.
CONCLUSION: Efforts to improve documentation of care planning need to address the disparate methods by which participants complete ADs. Creating options that combine the perceived benefits of a legal approach with greater health professional involvement could appeal to participants. Privacy concerns may limit web use by some patients.
Health care professionals use teach-back to foster adherence to treatment recommendations and to improve safety and quality of care. This improvement project, conducted in one division of a home care agency, used a pretest-posttest design with an interprofessional group of hospice home care clinicians to incorporate teach-back into home visits to evaluate if the use of teach-back enhanced caregiver and patient-provider communication, improved caregivers' confidence in caring for hospice home care patients, and decreased hospitalizations. After the intervention, the teach-back group had zero hospitalizations compared with 2 for the non–teach-back group (0% and 1.97%, respectively), and patient-caregiver “confidence” increased from 58% to 81%, pre to post intervention. In conclusion, teach-back is a cost-effective teaching methodology that can be implemented by any discipline to improve patient-provider communication and patient outcomes.
Au sommaire de ce dossier sur le ressenti et les émotions des soignants dans leur activité professionnelle : "Les soignants et leurs émotions au quotidien" : les soignants doivent, devant leurs émotions, adoptés des stratégies afin d'empêcher les débordements sans, pour autant, être dans l'évitement. "Fatigue compassionnelle et traumatisme vicariant chez les soignants" : le traumatisme vicariant évoque un état de stress post-traumatique chez le soignant confronté au récit traumatique d'un patient. La fatigue compassionnelle se manifeste par une érosion graduelle de l'empathie, de l'optimisme et de la compassion. Ces troubles nécessitent une prise en compte immédiate et adaptée. "Figures de la souffrance et du deuil des soignants" : le travail de verbalisation et de symbolisation est essentiel dans ce contexte. "L'impact des situations difficiles sur les soignants" : il est important de prendre en compte ces émotions et d'identifier les ressources qui peuvent être proposées aux soignants. La solidarité entre soignants et la cohésion d'équipe sont également essentielles. "Des ressources pour soutenir les soignants" : ces ressources sont les temps d'échanges, formels ou non, les réunions d'équipe, les retours d'expérience et l'analyse des pratiques. "A l'écoute de la souffrance du corps soignant". "Les soignants face aux événements douloureux, témoignages". "Rester soignant malgré l'inconcevable.".
Origine : BDSP. Notice produite par APHPDOC R0xltID9. Diffusion soumise à autorisation
Les débats autour de la fin de vie prennent une ampleur démesurée de nos jours, séparant toujours plus les partisans et les opposants du geste euthanasique. Mais que révèle en fait l'une ou l'autre position quant à la posture existentielle que l'on adopte ? Se poser la question, c'est peut-être se détourner de la question essentielle, à savoir que nous sommes très mal à l'aise avec le phénomène de la mort auquel nous ne réfléchissons que de façon précipitée seulement au terme de la vie. D'autre part, ces interrogations masquent une autre problématique qui toucherait davantage à nos choix de société : avons-nous appris à nous accompagner les uns les autres tout au long de notre vie ? C'est-à-dire à partir de la finitude humaine qui se déploie à partir de l'expérience de la mort que la vie prendrait tout son sens.
PURPOSE: To improve the healthcare team's comfort and efficacy with end-of-life conversations at a 474-licensed bed community acute care hospital through training on advance care planning (ACP) and advance directives (ADs).
METHODS: This instructional program utilized training sessions, including pre- and posttests, to demonstrate enhanced knowledge of and confidence in discussing ACP and ADs among healthcare professionals engaging in end-of-life conversations with patients and their families.
RESULTS: There were 138 participants included in the program. A pretest and a posttest were completed by the attendees at the beginning and end of training, respectively. Data indicated improved preparedness for end-of-life conversations following the training sessions.
CONCLUSION: Training specific to ACP and ADs increases confidence with end-of-life conversations. With the proper knowledge and resources, the healthcare staff can foster these difficult conversations. Although the program exceeded expectations, the sample is considered small and more research will be needed.
Background: Perinatal bereavement is traumatic for many parents. Not only is the experience itself emotionally painful, the impact on their lives is made more difficult if midwives are unable to provide appropriate care to the parents.
Aim of the study: To explore within an Irish context, the psychosocial factors that impact on midwives’ confidence to provide bereavement support to parents who have experienced a perinatal loss.
Design: A mixed methods sequential explanatory design was used to complete this two-phased study from August 2013 to July 2014. Ethical approval was granted from Ethics Committees of three maternity hospitals and a University in Ireland. The recruitment process for the survey occurred in August 2013 and July 2014 for the focus groups.
Methods: A series of univariate and multivariate analysis were used to analyze the quantitative data using IBM Statistical Package for the Social Sciences (SPSS; version 20). The qualitative data were analyzed using qualitative content analysis. Steps were taken to ensure data validity and reliability.
Results: The overall meta-inference of this study is that the majority of the midwives did not have adequate levels of confidence to provide bereavement support to grieving parents. The psychosocial factors that impact on midwives’ confidence were identified as the midwives’ awareness of the needs of bereaved parents, their own inner strength and the organizational support they received at their place of work.
Conclusion: Improving midwives’ bereavement support knowledge and skills is essential for promoting their confidence. Midwives also need adequate emotional and practical support from their organizations.
CONTEXT: Racial disparities in rates of hospice use, a marker of quality of end-of-life (EOL) care, have been a long-standing problem. Although distrust has been cited as a main reason for the preference of intensive EOL care among African Americans, the role of trust has not been closely analyzed in predicting EOL care in the context of advance care planning (ACP) outcomes.
OBJECTIVES: The goal of this review was to empirically examine the role of trust in ACP outcomes.
METHODS: For this systematic review, we utilized methods adapted from the GRADE process developed by the Cochrane Collaboration. The research question guiding this review was "What is the quantitative influence of trust in the health care system or health care providers on the ACP process for African Americans?" We searched Medline, Embase, and Web of Science for articles published between 1975 and 2016.
RESULTS: We identified nine quantitative studies that measured and evaluated trust as a predictor or correlate of ACP preferences. Of the studies, eight were observational and one was a pre-post-test study. Three studies were designated as low quality, and six studies were of moderate quality.
CONCLUSION: Distrust has been cited as a central reason for African Americans' tendency to choose life-sustaining treatments over comfort-focused care; however, our findings do not support this hypothesis. The majority of studies found no significant differences in trust between African Americans and their White counterparts. Further, we found that trust was not associated with ACP outcomes in the majority of studies.