Embedding an Education Intervention about Shared Decision Making into an RCT: Ensuring competency and fidelity.

Objective: To describe the outcomes of training nephrology clinicians and clinical research participants, to use the Best Case/Worst Case Communication intervention, for discussions about dialysis initiation for patients with life-limiting illness, during a randomized clinical trial to ensure competency, fidelity to the intervention, and adherence to study protocols and the intervention throughout the trial. Methods: We enrolled 68 nephrologists at ten study sites and randomized them to receive training or wait-list control. We collected copies of completed graphic aids (component of the intervention), used with study-enrolled patients, to measure fidelity and adherence. Results: We trained 34 of 36 nephrologists to competence and 27 completed the entire program. We received 60 graphic aids for study-enrolled patients for a 73% return rate in the intervention arm. The intervention fidelity score for the graphic aid reflected completion of all elements throughout the study. Conclusion: We successfully taught the Best Case/Worst Case Communication intervention to clinicians as research participants within a randomized clinical trial. Innovation: Decisions about dialysis are an opportunity to discuss prognosis and uncertainty in relation to consideration of prolonged life supporting therapy. Our study reveals a strategy to evaluate adherence to a communication intervention in real time during a clinical study.

Balancing Act: Acute and Contextual Vestibular Sensations of Cranial Electrotherapy Stimulation Using Survey and Sensor Outcomes in a Non-Clinical Sample.

Cranial electrotherapy stimulation (CES) delivers low-intensity electrical currents to the brain to treat anxiety, depression, and pain. Though CES is considered safe and cost-effective, little is known about side effects emerging across different contexts. Our objective was to investigate how varying physical and cognitive demands impact the frequency and intensity of CES vestibular sensations in a sample of healthy young adults. We used a 2 (stimulation: sham, active) × 2 (physical demand: static sway, dynamic sit-to-stand) × 2 (cognitive demand: single-task remain silent, dual-task count backward) repeated measures design. Vestibular sensations were measured with surveys and wearable sensors capturing balance changes. Active stimulation did not influence reported vestibular sensations. Instead, high physical demand predicted more sensation reports. High cognitive demand, but not active stimulation, predicted postural sway unsteadiness. Significant effects of active stimulation on balance were observed only during the dynamic sit-to-stand transitions. In summary, CES induces vestibular sensations only for a specific outcome under certain circumstances. Our findings imply that consumers can safely maximize the benefits of CES while ensuring they are taking steps to minimize any potential side effects by considering their context and circumstances.

Longitudinal Relations among Identity Distinctiveness, Continuity, and Integration among Dutch Adolescents.

Identity distinctiveness, continuity, and coherence are all components of adolescents' identity development, but their longitudinal relations have rarely been examined. Data were analyzed on these three constructs collected over three years from 349 Dutch adolescents (Mage = 14.7, SDage = 0.7, 215 [61.6%] girls and 133 [38.1%] boys). A cross-lagged panel model of the three constructs showed that stability was relatively high for distinctiveness and continuity, whereas coherence was less stable. Distinctiveness and continuity were correlated positively within time, but cross-lagged associations were mostly not significant: Only distinctiveness and coherence negatively predicted each other across waves. Results suggest that distinctiveness, continuity, and coherence may be interrelated, but may not drive the development of each other.

The Five Cs of Positive Youth Development: Configurations of Thriving in Four U.S. Adolescent Samples.

Positive youth development (PYD) models are widespread, but the empirical evidence for them is primarily nomothetic (i.e., investigations of universal patterns). Contemporary developmental theory suggests that concepts and processes within PYD models should also be explored with respect to specificity. This study demonstrates how the Five Cs Model, a predominant PYD model, can be advanced using group-differential methods. Secondary data from four studies of adolescents were used to test: (1) Whether there were subgroups who varied in their patterns of scores across the Five Cs, and (2) Whether subgroups also varied in Contribution behaviors. Unexpectedly, the four data sets used could not be combined, yielding an opportunity to discuss consistencies and inconsistencies in findings across the four data sets through contextual and sample differences. Findings demonstrate how understanding specificity in theorized concepts and processes in PYD models can complement studies of universal patterns, which are both necessary to advance PYD research and practice.

Measuring Positive Development among College Students in the United States: Investigating Cross-Sectional and Longitudinal Measurement Invariance across Different Racial Groups.

Measures that are applicable to assess the positive youth development (PYD) of racially diverse college students are needed. The present study tested if a revised version of the very short form of the PYD measure (PYD-VSF) was applicable to college students from five racial groups in the U. S. (White, Black, Latinx, Asian, and other) across three measurement occasions. Participants were 5,735 college students who completed the PYD-VSF at least once across the three waves of a longitudinal study. Confirmatory factor analyses (CFA) indicated that a first-order Five Cs structure, a higher-order structure, and a bifactor structure all provided good fit to the data. Multi-group CFA across racial groups found that the first-order structure fit the data better than the higher-order and the bifactor models, and it showed configural-, factor loading-, intercept-, and residual-invariance. Longitudinal CFA models of the first-order structure supported configural-, factor loading-, intercept-, and residual-invariance. The revised PYD-VSF measure has shown the potential to assess PYD among college students of diverse racial-ethnic backgrounds.

An item response theory analysis of two frequently used measures of identity development.

Identity development-exploring options and making commitments-is an important process related to human functioning across the lifespan. An accurate understanding of identity development processes requires precise measures, but commonly used questionnaires have not been subject to intensive psychometric analyses. We investigated the psychometric properties of two such measures, the Utrecht Management of Identity Commitments Scale and the Dimensions of Identity Development Scale. Previous analyses have treated the response scales as interval rather than ordinal, which may not be reasonable given the measures' Likert-type response scales. Accordingly, we evaluated their measurement precision by conducting multidimensional item response theory analyses of data from six studies of secondary and postsecondary students in The Netherlands and the United States (total N = 4,844; 36.00% boys/men, 63.07% girls/women; 0.02% nonbinary or missing gender data; 62.39% completed the measure in Dutch, 37.61% in English; 52.66% postsecondary school; 47.34% secondary school; racial, ethnic, and nationality information varied across studies). Graded response models showed that a limited range of the latent attributes was precisely measured, and the quality of items varied considerably. The measures functioned mostly similarly between gender groups, but there was substantial differential item functioning based on school level and language of the measure. We originally sought to create shortened versions, but the shortened versions provided no improvement over the low quality of the longer versions. Our analyses suggest that reflection on what these identity processes entail is needed, to develop new items that address different manifestations of the attributes under consideration. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

I Am Whatever I Say I Am: The Salient Identity Content of U.S. Adolescents.

Research about identity development has focused primarily on researcher-chosen domains or overlooked content entirely. To investigate the content that is salient to adolescents, we analyzed responses to a shortened Twenty Statements Test (ten answers to the question, "Who am I?") from 415 adolescents in the northeastern United States (Mage = 13.59 years; 63.7% girls, about 50% identified as White/European American). Inductive content analysis identified four Content codes (what the participants wrote: Personal, Social categories, Relationships, Self-evaluation) and two Structure codes (how they wrote their statements: Qualifiers and Verb Tense). Content codes appeared in eight patterns, and there were between-group differences in content and patterns. Results expand our understanding of adolescents' identity content and demonstrate its complexity.

Latent profile transition analyses and growth mixture models: A very non-technical guide for researchers in child and adolescent development.

Developmental scientists are often interested in subgroups of people who share commonalities in aspects of development; these subgroups often cannot be captured directly but instead must be inferred from other information. Mixture models can be used in these situations. Two specific types of mixture models, latent profile transition analyses and growth mixture models, are highly relevant to developmental science because they can identify subgroups of people who are similar in their patterns of change. This guide highlights foundational aspects of these two types of models and is intended for readers who have not previously conducted either an LPTA or a GMM, or perhaps no mixture model analyses at all. It includes four primary sections. The first focuses on understanding mixture models conceptually and applying that knowledge to identifying appropriate research questions. The second section addresses data requirements, including planning for data collection or evaluating the suitability of previously collected data, and data preparation. The third section focuses on conducting analyses, with step-by-step instructions and syntax, and the final section discusses presenting the results. I illustrate these concepts and procedures with an example data set and research questions derived from the Five Cs model of positive youth development.

Opportunities to Improve Shared Decision Making in Dialysis Decisions for Older Adults with Life-Limiting Kidney Disease: A Pilot Study.

Background: Lack of awareness about the life-limiting nature of renal failure is a significant barrier to palliative care for older adults with end-stage renal disease. Objective: To train nephrologists to use the best case/worst case (BC/WC) communication tool to improve shared decision making about dialysis initiation for older patients with limited life expectancy. Design: This is a pre-/postinterventional pilot study. Setting/Subjects: There were 16 nephrologists and 30 patients of age 70 years and older with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73 m2 in outpatient nephrology clinics, in Madison, WI. Measurements: Performance of tool elements, content of communication about dialysis, shared decision making, acceptability of the intervention, decisions to pursue dialysis, and palliative care referrals were measured. Results: Fifteen of 16 nephrologists achieved competence performing the BC/WC tool with standardized patients, executing at least 14 of 19 items. Nine nephrologists met with 30 patients who consented to audio record their clinic visit. Before training, clinic visits focused on laboratory results and preparation for dialysis. After training, nephrologists noted that declining kidney function was "bad news," presented dialysis and "no dialysis" as treatment options, and elicited patient preferences. Observer-measured shared decision-making (OPTION 5) scores improved from a median of 20/100 (interquartile range [IQR] 15-35) before training to 58/100 (IQR 55-65). Patients whose nephrologist used the BC/WC tool were less likely to make a decision to initiate dialysis and were more likely to be referred to palliative care. Conclusions: Nephrologists can learn to use the BC/WC tool with older patients to improve shared decision making about dialysis, which may increase access to palliative care.

Bridging Undergraduate and Graduate Medical Education: A Resident-as-Educator Curriculum Embedded in an Internship Preparation Course.

BACKGROUND: Many graduate medical education programs have implemented curricula to develop trainees into the next generation of medical teachers; however, coordination of in-person teaching curricula is challenging due to full trainee schedules. METHODS: To address limited in-person time, we developed a largely asynchronous resident-as-educator curriculum. Our elective curricular activities are embedded within the fourth-year internship preparation course at the University of Wisconsin School of Medicine and Public Health and include trainees from internal medicine, family medicine, and pediatrics. RESULTS: Trainee self-assessment of teaching skills improved after our curriculum, and students evaluated resident sessions favorably. DISCUSSION: Trainees can be effective teachers in an internship preparation course after a brief, asynchronous teaching curriculum. To disseminate our curriculum, we designed a resident-as-educator curriculum website.

How Does Racial Context Matter?: Family Preparation-for-Bias Messages and Racial Coping Reported by Black Youth.

Black families and youth likely consider specific racial discriminatory situations in preparation-for-bias messages and racial coping responses. Our study investigated coping responses embedded in youth-reported Black families' preparation-for-bias messages and youths' proactive coping responses to specific racially discriminatory situations-teachers' negative expectations, store employees' hyper-monitoring and police harassment. Gender and racial discrimination experience differences were considered along with relations between messages and coping. Our investigation was guided by the integrated-developmental, transactional/ecological, intersectionality, and Phenomenological Variant of Ecological Systems Theory theoretical frameworks. We conducted cluster analyses using data from 117 Black youth aged 13-14 to identify situation-specific family messages and youth coping responses. Families' messages and youths' responses varied in content and frequency based on the specific discriminatory situation, which suggests consideration of context.

Critical reflection about socioeconomic inequalities among White young men from poor and working-class backgrounds.

An intersectional approach to human development emphasizes the multiple social categories individuals occupy, some of which confer privilege (e.g., being White) and some of which confer marginalization (e.g., being poor). This approach is needed especially in critical consciousness scholarship, and particularly in regard to understanding whether and how it may manifest among youth who simultaneously experience privileges due to some aspects of their identities and marginalization due to other aspects of their identities. We explored critical reflection (CR) about socioeconomic inequalities through interviews with 31 White young men from low-income and working-class backgrounds who were attending trade colleges in Pennsylvania. Participants were asked about their understandings of the causes of poverty in the United States and potential solutions. Multiple rounds of qualitative analysis were conducted to understand the potential manifestation of CR in responses. Inductive across-case thematic analysis yielded 11 themes describing participants' understandings of poverty. We then conducted case-based analyses to identify the specific attributions about poverty that each participant made (structural, fatalistic, and/or individual), the ways in which these attributions arose in responses, and how the pattern identified related to CR. Eight participants were identified as having some CR or the potential to develop CR, and their responses were explored for references to experiences that may have been related to CR as well as their membership in a privileged racial and gender group, and more marginalized socioeconomic group. Implications for examining and promoting CR in different groups of youth are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Using Implementation Science to Adapt a Training Program to Assist Surgeons with High-Stakes Communication.

OBJECTIVE: Surgeons often conduct difficult conversations with patients near the end of life, yet surgical education provides little formalized communication training. We developed a communication tool, Best Case/Worst Case, and trained surgeons using a one-on-one resource intensive format that was effective but difficult to scale for widespread dissemination. We aimed to generate an implementation package to teach surgeons using fewer resources without sacrificing fidelity. DESIGN, SETTING, AND PARTICIPANTS: We used the Replicating Effectiveness Programs framework to guide our implementation strategy and tested our intervention with 39 surgical residents at 4 institutions from September 2016 to June 2017. The implementation package consisted of: (1) instructional video, (2) checklist to assess competence, (3) learner manual, and (4) instructor manual. We focused on 3 implementation outcomes: feasibility, fidelity, and acceptability to participants. RESULTS: Attendance rates ranged from 16% to 75%. Site leaders had little difficulty identifying suitable instructors; however, resident recruitment proved challenging. Sixty-nine percent of residents completed the post-training assessment and the mean score was 12.8 (range 8-15) using the 15-point checklist. Across sites, 69% strongly agreed that Best Case/Worst Case is better than how they usually approach high-stakes conversations and 100% felt prepared to use the tool after training. Instructors reported that the training provided residents with the necessary skills to perform the fundamental elements of Best Case/Worst Case. CONCLUSIONS: Using implementation science we demonstrated that a resource intensive communication training intervention can be successfully modified for group-learning and wide-scale dissemination. However, we identified barriers to implementation, including challenges with feasibility and programmatic buy-in that inform not only resident education but also communication skills training more broadly.

Barriers to Goal-concordant Care for Older Patients With Acute Surgical Illness: Communication Patterns Extrinsic to Decision Aids.

OBJECTIVE: We sought to characterize patterns of communication extrinsic to a decision aid that may impede goal-concordant care. BACKGROUND: Decision aids are designed to facilitate difficult clinical decisions by providing better treatment information. However, these interventions may not be sufficient to effectively reveal patient values and promote preference-aligned decisions for seriously ill, older adults. METHODS: We conducted a secondary analysis of 31 decision-making conversations between surgeons and frail, older inpatients with acute surgical problems at a single tertiary care hospital. Conversations occurred before and after surgeons were trained to use a decision aid. We used directed qualitative content analysis to characterize patterns within 3 communication elements: disclosure of prognosis, elicitation of patient preferences, and integration of preferences into a treatment recommendation. RESULTS: First, surgeons missed an opportunity to break bad news. By focusing on the acute surgical problem and need to make a treatment decision, surgeons failed to expose the life-limiting nature of the patient's illness. Second, surgeons asked patients to express preference for a specific treatment without gaining knowledge about the patient's priorities or exploring how patients might value specific health states or disabilities. Third, many surgeons struggled to integrate patients' goals and values to make a treatment recommendation. Instead, they presented options and noted, "It's your decision." CONCLUSIONS: A decision aid alone may be insufficient to facilitate a decision that is truly shared. Attention to elements beyond provision of treatment information has the potential to improve communication and promote goal-concordant care for seriously ill older patients.

Adolescent Athletic Participation Patterns and Self-Perceived Competence: Associations With Later Participation, Depressive Symptoms, and Health.

Physical activity is important for well-being across the life span. However, links between patterns of adolescent activity, competence perceptions, and young adult outcomes are underexplored. We used data from seven waves of the 4-H Study of Positive Youth Development (N = 5,961) to assess patterns of adolescent athletic participation, whether these patterns were associated with self-perceived athletic competence and young adult physical activity, depressive symptoms, and health, and associations between changes in participation across adolescence and young adult outcomes. Competence perceptions were associated with increased participation, and more active adolescents had higher rates of adult athletic activity, with links to better health and fewer depressive symptoms. We discuss results in light of the importance of using person-centered analyses to understand active lifestyles.

Modeling Pathways of Character Development across the First Three Decades of Life: An Application of Integrative Data Analysis Techniques to Understanding the Development of Hopeful Future Expectations.

There were two purposes of the present research: first, to add to scholarship about a key character virtue, hopeful future expectations; and second, to demonstrate a recent innovation in longitudinal methodology that may be especially useful in enhancing the understanding of the developmental course of hopeful future expectations and other character virtues that have been the focus of recent scholarship in youth development. Burgeoning interest in character development has led to a proliferation of short-term, longitudinal studies on character. These data sets are sometimes limited in their ability to model character development trajectories due to low power or relatively brief time spans assessed. However, the integrative data analysis approach allows researchers to pool raw data across studies in order to fit one model to an aggregated data set. The purpose of this article is to demonstrate the promises and challenges of this new tool for modeling character development. We used data from four studies evaluating youth character strengths in different settings to fit latent growth curve models of hopeful future expectations from participants aged 7 through 26 years. We describe the analytic strategy for pooling the data and modeling the growth curves. Implications for future research are discussed in regard to the advantages of integrative data analysis. Finally, we discuss issues researchers should consider when applying these techniques in their own work.

A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case.

Importance: Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. Objective: To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Design, Setting, and Participants: Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. Interventions: A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. Main Outcomes and Measures: We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. Results: The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. Conclusions and Relevance: Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.

"Best Case/Worst Case": Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems.

CONTEXT: Older adults often have surgery in the months preceding death, which can initiate postoperative treatments inconsistent with end-of-life values. "Best Case/Worst Case" (BC/WC) is a communication tool designed to promote goal-concordant care during discussions about high-risk surgery. OBJECTIVE: The objective of this study was to evaluate a structured training program designed to teach surgeons how to use BC/WC. METHODS: Twenty-five surgeons from one tertiary care hospital completed a two-hour training session followed by individual coaching. We audio-recorded surgeons using BC/WC with standardized patients and 20 hospitalized patients. Hospitalized patients and their families participated in an open-ended interview 30 to 120 days after enrollment. We used a checklist of 11 BC/WC elements to measure tool fidelity and surgeons completed the Practitioner Opinion Survey to measure acceptability of the tool. We used qualitative analysis to evaluate variability in tool content and to characterize patient and family perceptions of the tool. RESULTS: Surgeons completed a median of 10 of 11 BC/WC elements with both standardized and hospitalized patients (range 5-11). We found moderate variability in presentation of treatment options and description of outcomes. Three months after training, 79% of surgeons reported BC/WC is better than their usual approach and 71% endorsed active use of BC/WC in clinical practice. Patients and families found that BC/WC established expectations, provided clarity, and facilitated deliberation. CONCLUSIONS: Surgeons can learn to use BC/WC with older patients considering acute high-risk surgical interventions. Surgeons, patients, and family members endorse BC/WC as a strategy to support complex decision making.

A Quantitative Study of Triggered Palliative Care Consultation for Hospitalized Patients With Advanced Cancer.

CONTEXT: Unplanned cancer-related hospital admissions often herald entry into the final phase of life. Hospitalized patients with advanced cancer have a high symptom burden and a short life expectancy, which may warrant palliative care intervention. OBJECTIVES: To identify the impact of implementing triggered palliative care consultation (TPCC) as part of standard care for patients admitted to the solid-tumor oncology service with advanced cancer. METHODS: We conducted a prospective, sequential, three-cohort study to evaluate TPCC feasibility and impact using patient-reported outcomes, electronic medical records to identify resource utilization, and surveys of oncologists' perspectives on TPCC. RESULTS: Sixty-five patients were evaluated before TPCC implementation (Cohort 1). Seventy patients (Cohort 2) were evaluated after initiation of TPCC, and 68 patients (Cohort 3) were evaluated after modifications based on implementation barriers identified in Cohort 2. The percentage of patients correctly identifying their cancer as incurable increased from 65% in Cohort 1 to 94% in Cohorts 2 and 3. TPCC had minimal impact on hospice utilization, cost of care, survival, patient-reported symptoms, and patient satisfaction, likely because of the limited nature of the intervention. Implementation was challenging, with only 60% of patients in Cohort 2 and 62% in Cohort 3 receiving TPCC. Overall, the intervention was viewed favorably by 74% of oncologists. CONCLUSION: Although TPCC was viewed favorably, implementation was logistically challenging because of short stays, high-acuity symptoms, and individual provider resistance. TPCC improved patients' understanding of their cancer. This population demonstrates high palliative care needs, warranting further research into how best to deliver care.

Special issue introduction: Thriving across the adolescent years: a view of the issues.

Framed within a relational developmental systems model, the 4-H Study of positive youth development (PYD) explored the bases and implications of thriving across much of the second decade of life. This special issue pertains to information derived from the recently completed eight waves of the 4-H Study of PYD, and presents findings about the relations between individual and contextual variables that are involved in the thriving process. This introduction briefly reviews the historical background and the theoretical frame for the 4-H Study and describes its general methodology. We provide an overview of the articles in this special issue and discuss the ways in which the articles elucidate different facets of the thriving process. In addition, we discuss the implications of this research for future scholarship and for applications aimed at improving the life chances of diverse adolescents.