Clinicians navigating moral accountability when discussing parental behaviors in the care of the child in the hospital.

OBJECTIVE: The purpose of this study was to explore how moral accountability is navigated when clinicians talk about parental behaviors to support the health of the hospitalized child. METHODS: We conducted a secondary data analysis of 74 conversations during daily rounds video recorded as part of a randomized controlled trial of an intervention to advance family-centered rounds in one children's hospital. Conversations involving children under the age 18 who were cared for by a pediatric hospitalist service, pulmonary service, or hematology/oncology service were recorded. We used conversation analysis to analyze sequences in which physicians engaged in talk that had implications for parent behavior. RESULTS: Two phenomena were apparent in how physicians and parents navigated moral accountability. First, physicians avoided or delayed parental agency in their references to parent behaviors. Second, parents demonstrated and clinicians reassured parental competence of parents caring for their children. CONCLUSION: Physicians appeared to be oriented toward the potential moral implications of asking about parental behavior. PRACTICE IMPLICATIONS: Avoiding attributions of agency and moral accountability as well as providing reassurance for the parents' competence may be useful for clinicians to maintain a good relationship with the parents of children in their care in the hospital setting.

Shame in patient-health professional encounters: A scoping review.

Shame can arise during patient-health professional encounters when discussing traumatising and stigmatising topics and can contribute to negative patient outcomes. This review aims to summarise what is known regarding shame in patient-health professional encounters. We conducted a scoping review using Levac and colleagues' approach and reported the findings using the PRISMA Extension for Scoping Reviews. We searched four databases (CINAHL, PsychINFO, PubMed and SocINDEX) for empirical studies that involved shame in patient-health professional encounters contextualised by trauma or stigma and were published in English. We categorised what is known regarding shame in empirical studies using inductive content analysis. We also collected stakeholders' perspectives on the review findings through an online survey. Our initial search yielded 3658 articles, of which 37 were included. We summarised the literature into four categories: (1) What health professionals say they do in patient-health professional encounters, (2) What health professionals think patients feel in patient-health professional encounters, (3) Patients' descriptions of their own shame during patient-health professional encounters and (4) Health professionals' descriptions of their own shame during patient-health professional encounters. Shame can arise in a variety of circumstances during patient-health professional encounters. More research is needed to identify what specific communication strategies used by health professionals during patient-health professional encounters contribute to or avoid patient shame.

How Hospitalized Older Adults and Physicians Negotiate Plan-of-Care Decisions during Daily Rounds.

The purpose of this study is to explore how older adults and physicians negotiate the plan of care during daily rounds in the hospital setting. We audio-recorded 40 physician-patient interactions during daily rounds in a small teaching hospital. We analyzed the data using conversation analysis, a qualitative method that examines the turns-of-talk during interactions. We focused the analysis on how physicians introduced the plan of care and how the plan of care was subsequently negotiated with the patient. Physicians often introduced the plan in two different ways that have a persuasive design: leading with evidence and medical expertise or, for sensitive topics in which the plan could be disagreeable, using preplan sequences to delicately introduce the plan of care and assess patient response. Patients negotiated the plan of care by displaying resistance, both passively and actively. Despite patients sharing their evidence for their preferred plan of care in resisting the physician's plan, physicians often closed the negotiation by reorienting to a different aspect of the plan of care.

How Patients and Families Describe Major Medical Treatments: "They are No Longer Living, Just Existing".

BACKGROUND: As more life-sustaining treatments become available, the need to provide patients and families clarity about what these treatments are and what they do is increasing. Little is known about how patients and families conceptualize life support. OBJECTIVE: To explore the discourse that patients and families used to describe major medical treatments in their accounts of treatment decision-making. METHODS: This study is a secondary data analysis of a survey sent to random addresses in Wisconsin regarding experiences with major medical treatment decision-making. This analysis includes the subsample of 366 respondents who specified the type of decision made in the survey's open-ended questions. Inductive content analysis was used to qualitatively analyze the responses to the open-ended questions, with particular attention to how respondents described the treatment in their responses. RESULTS: Respondents' descriptions showed a conceptualization of engaging in major medical treatments as keeping patients alive, whereas discontinuing or choosing not to engage in such treatments would bring about the patient's death. However, respondents recognized the potential adverse consequences of engaging in major medical treatments, such as their capacity to cause pain or result in an undesirable neurologic state. Additionally, respondents described the limitations of such treatment regarding the uncertainty of the treatments providing the desired outcome or their uselessness in situations in which the patient's death would be inevitable. CONCLUSION: Understanding how patients and families make sense of major medical treatments can help clinicians during decision-making conversations.

The Use of Toolkits to Increase Student Engagement in a Virtual Course.

BACKGROUND: Encouraging student-to-student engagement during virtual courses is challenging, yet important for students to learn skills they will need as nurses. METHOD: Toolkit activities were developed as an innovative active learning strategy. Students were provided a toolkit: a bag full of clinical items, images of items, clinical documents, or sample data that corresponded to six different toolkit activities. Students completed the toolkit activities in groups of eight; each member of the group had different items, which required students to engage with other group members to complete the activity. RESULTS: Students completed anonymous surveys at midterm and at the end of semester. Most of the students indicated toolkit assignments promoted engagement of group members (91.6% at midterm and 92.4% at the end of the semester). CONCLUSION: The toolkit activities encouraged student-to-student engagement and provided students with hands-on learning they could apply to the clinical setting. [J Nurs Educ. 2022;61(11):654-656.].

"It Made Me Feel Like I Didn't Know My Own Body": Patient-Provider Relationships, LGBTQ+ Identity, and End-of-Life Discussions.

PURPOSE: LGBTQ+ individuals experience multiple challenges receiving quality care at the end of life, such as lack of confidence in the healthcare system to address their needs and lack of knowledge about advance care planning. Important gaps remain about the needs of LGBTQ+ individuals in the provider-patient relationship and how critical discussions about the end of life occur or do not occur in that relationship. The purpose of this study is to explore patients' narratives of their relationship with their provider and their experiences discussing end-of-life care with their providers, among patients who do and do not identify as LGBTQ+. METHODS: Twenty-nine attendants of an event devoted to LGBTQ+ health, 15 of which identified as LGBTQ+, completed an altered version of the CAHPS® Patient Narrative Elicitation Protocol. We used inductive content analysis to qualitatively analyze the data. RESULTS: Respondents described wanting to be heard, finding safety and trust, and valuing competency in their relationship with their provider. Respondents who identified as LGBTQ+ additionally 1) valued providers who avoided making assumptions, 2) looked for cues of safety to indicate they would be accepted by the provider, and 3) sought providers competent in LGBTQ+ care needs. Few respondents had discussed end-of-life care with their provider, although some assumed that their provider may or may not be able to meet their needs based on aspects of their provider-patient relationship. CONCLUSIONS: Strengthening patient-provider relationships may help improve the care of LGBTQ+ populations, particularly for the end of life.

How hospitalized older adults share concerns during daily rounds.

OBJECTIVE: To explore how hospitalized older adults' concerns are solicited and shared during daily rounds. METHODS: We audio recorded 40 physician-patient conversations during daily rounds in a Veterans Affairs Hospital. We developed codes from the conversation analysis (a qualitative method) for the event sequence analysis (a quantitative method) to calculate the conditional probabilities of physicians soliciting for general concerns leading to patients sharing concerns. We used a mixed-effects Poisson regression to calculate the relationship between number of concerns shared and patient education. RESULTS: Most of the 141 concerns were shared during the assessment questions and discussion of the plan of care, such as concerns about the patient's caregiving responsibilities. The conditional probability was higher when physicians solicited for concerns after the assessment questions (0.56) than during the opening (0.25) or the closing (0.19) of the conversation. The design of the solicitation influenced the probability of patients sharing concerns. The number of concerns shared did not differ by level of education. CONCLUSION: Physicians can provide opportunities for patients to share concerns. PRACTICE IMPLICATIONS: Soliciting for concerns after the assessment questions, asking "what" concerns a patient may have, and asking about caregiving responsibilities may be useful for patients to share their concerns.

Decisional Conflict During Major Medical Treatment Decision-making: a Survey Study.

BACKGROUND: Both patients and surrogate decision-makers experience decisional conflict when making a major medical treatment decision with life or death implications. The relationship between health literacy and decisional conflict while making a major medical treatment decision is not understood. OBJECTIVE: To identify the prevalence of individuals making major medical treatment decisions for themselves or someone else and to explore the relationships between decisional conflict and circumstances of the decision as well as the decision-maker. DESIGN: Two-phase survey study: in phase 1, we screened for who made a major treatment decision; in phase 2, we asked eligible respondents about their experience making the decision. PARTICIPANTS: Address-based random sample of 4000 Wisconsin residents; 1072 completed phase 1 and 464 completed phase 2. MAIN MEASURES: We asked respondents about types of decisions made, the most difficult decision made, and characteristics of the decision-maker and the decision. We included the Decisional Conflict Scale and four domains of the Health Literacy Questionnaire. Open-ended questions also allowed respondents to describe their experiences. KEY RESULTS: About 43% of respondents reported making a major medical treatment decision. Decisions about major surgery and life support were regarded as the most difficult decisions. Respondents who made the decision for a spouse/partner (ß = 6.65, p = 0.012), parent (ß = 9.27, p < 0.001), or someone else (ß = 10.7, p < 0.001) had higher decisional conflict. Respondents who reported higher ability to actively engage with healthcare providers (ß = - 5.24, p = 0.002) and to understand health information well enough to know what to do (ß = - 6.12, p = 0.001) had lower decisional conflict. CONCLUSIONS: The need to make major treatment decisions is likely to increase and making decisions on someone else's behalf appeared to be especially difficult. Improving communication to encourage patient and family engagement in the decision-making conversation, particularly for individuals with limited health literacy, may be helpful.

"Why Am I Not Taking Medications?" Barriers and Facilitators of Diabetes Medication Adherence Across Different Health Literacy Levels.

Medication adherence is important for diabetes management. Better knowledge of how patient factors relate to medication adherence allows us to develop more tailored interventions. We explore patients' perceptions of the barriers to and facilitators of medication adherence across different levels of health literacy. Semi-structured interviews with 23 participants with type 2 diabetes (T2D) were completed, and direct content analysis identified the facilitators of and the barriers to medication adherence through the lens of the Health Literacy Pathway model. Linking medication-taking to daily routine and focusing on the internal locus of control are imperative approaches to fostering self-efficacy of medication use. Understanding patients' life experiences and clarifying medication misinformation help patients address their concerns with medications. Lowering the cost of medications and simplifying therapy regimens can alleviate participants' perceived barriers to medication-taking. In this study, we explore medication adherence from the experience of people with T2D and can inform tailored interventions to improve medication adherence.

Communication Strategies in a Code Status Conversation.

Despite the emphasis on engaging in shared decision-making for decisions involving life-prolonging interventions, there remains uncertainty about which communication strategies are best to achieve shared decision-making. In this paper, we present the communication strategies used in a code status discussion in a single case audio recorded as part of a research study of how patients and physicians make decisions about the plan of care during daily rounds. When presenting this case at various forums to demonstrate our findings, we found that some clinicians viewed the communication strategies used in the case as an exemplar of shared decision-making, whereas other clinicians viewed them as perpetuating paternalism. Given this polarized reaction, the purpose of this perspective paper is to examine the communication strategies used in the code status discussion and compare those strategies with our current conceptualization of shared decision-making and communication best practices.

Treatment decision making involving patients with dementia in acute care: A scoping review.

OBJECTIVE: To summarize the evidence regarding the factors and processes of treatment decision making involving a person with dementia (PWD) in the acute care setting. METHODS: We conducted a scoping review, searching 4 databases (PubMed, CINAHL, Web of Science, & PsychINfo) for articles that contained primary data from a quantitative or qualitative study involving treatment decision making in the acute care setting for PWD and were published in English. We categorized the factors and processes of decision making identified in each article using inductive content analysis. We also consulted with healthcare practitioners to receive stakeholder input on our findings. RESULTS: Our search initially revealed 12,478 articles, of which 28 were included in the review. We identified 5 categories of factors that influence the decision-making process: knowing the patient, culture and systems, role clarity, appropriateness of palliative care in dementia, and caregiver need for support. CONCLUSION: Our findings highlight the complexities of the decision-making process and the importance of attending to the needs of the caregiver, healthcare practitioners, and the patient. PRACTICE IMPLICATIONS: It is important to address beliefs of involving palliative care for a PWD and the role of each healthcare discipline.

A psychometric study of the decisional conflict scale in surrogate decision makers.

OBJECTIVE: To assess the psychometric properties of the 16-item Decisional Conflict Scale (DCS) in surrogate decision makers. METHODS: With a sample of 472 surrogates from intensive care units in five academic medical centers across the United States, we performed the analysis in five phases to 1) model the congeneric structure with confirmatory factor analysis and assess 2) internal consistency reliability, 3) the unidimensional or global assessment, 4) factorial invariance across surrogate gender, and 5) individual item influence on the domains. RESULTS: The congeneric model fit the data, with all factor loadings (0.577-0.955) statistically significant at p < 0.05. All subdomains had acceptable internal consistency (0.751-0.981). The bifactor model supported the sub-domains or the global construct as appropriate measurement models. The DCS demonstrated invariance for use across surrogate genders. The most difficult item for surrogates to complete was "This decision is easy for me to make" [MNSQ Infit/Outfit: 2.37/3.27] and the easiest item was "I have enough advice to make a choice" [0.70/0.67]. CONCLUSIONS: Overall, the DCS demonstrated good fit, and can be considered a valid and reliable tool to use with the surrogate population. PRACTICE IMPLICATIONS: Measuring surrogate decisional conflict could be especially useful to determine how to improve the decision-making process.

Combining conversation analysis and event sequencing to study health communication.

Good communication is essential in patient-centered care. The purpose of this paper is to describe conversation analysis and event sequencing and explain how integrating these methods strengthened the analysis in a study of communication between clinicians and surrogate decision makers in an intensive care unit. Conversation analysis was first used to determine how clinicians introduced the need for decision-making regarding life-sustaining treatment and how surrogate decision makers responded. Event sequence analysis then was used to determine the transitional probability (probability of one event leading to another in the interaction) that a given type of clinician introduction would lead to surrogate resistance or alignment. Conversation analysis provides a detailed analysis of the interaction between participants in a conversation. When combined with a quantitative analysis of the patterns of communication in an interaction, these data add information on the communication strategies that produce positive outcomes. Researchers can apply this mixed-methods approach to identify beneficial conversational practices and design interventions to improve health communication.

Conflict in the intensive care unit: Nursing advocacy and surgical agency.

BACKGROUND: Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy-a responsibility to support the patient's best interest; surgeons have a sense of agency-a responsibility to keep the patient alive. OBJECTIVES: The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as "advocates" and "agents," and (2) apply these findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit. RESEARCH DESIGN: Articles, books, and professional documents were explored to obtain descriptions of nurses' and surgeons' responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations: No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases. FINDINGS: Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient's outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery. DISCUSSION: These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other's responsibilities. CONCLUSION: Interventions that improve understanding of each profession's responsibilities may be helpful to reduce intra-team conflict in the intensive care unit.

Use of Simulation in Multimodal Researcher Training for Observational Studies.

STATEMENT: Researchers employing observational studies need to develop a coding scheme that is robust enough to measure behaviors of interest adequately. However, the more intricate the coding scheme, the more difficult it is for observers to code correctly and consistently. The purpose of this article is to describe the use of a simulation suite in a multimodal training approach to accommodate a complex coding structure and achieve observer agreement. The observer training included explanation of codes and technology, coding of simulation video, and observer-trainer hospital practice. The simulation video consisted of hypothetical nurse-patient scenarios filmed in a simulation suite that mimicked the hospital setting. Researchers should consider using simulation suites in their training programs to achieve observer agreement in observational studies of complex behaviors in the ever-changing clinical environment.

Decision proposals in the family conference.

OBJECTIVES: To explore how clinicians make decision proposals about life-sustaining treatments and to determine if certain decision proposals are more likely to lead surrogates to align with or resist the proposal. METHODS: We audio-recorded 36 family conferences between clinicians and surrogates and analyzed the interactions using conversation analysis (a qualitative method) and event sequence analysis (a quantitative method). RESULTS: The transitional probability of a proposal that incorporates the patient's previously described preferences leading to alignment with the proposal was .76. The odds ratio of an aligning response in the presence of this proposal was 8.27 (95% CI 2.21, 30.97). The transitional probability of a proposal that asserts the healthcare team is going to do or not do a treatment leading to resistance was .70. The odds ratio of a resisting response in the presence of this proposal was 8.4 (95% CI 1.83, 38.53). CONCLUSIONS: There is evidence to suggest that incorporating the patient's previously described preferences into a decision proposal leads to surrogates' alignment to those proposals. PRACTICE IMPLICATIONS: These results strengthen the need for clinicians to engage with surrogates in shared decision making to determine the best treatment decision for the patient.

Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery.

OBJECTIVE: To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments. BACKGROUND: During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown. METHODS: We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support. RESULTS: We recorded 43 patients' conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes. CONCLUSIONS: Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

Communicating Delicately: Introducing the Need to Make a Decision About the Use of Life-Sustaining Treatment.

The purpose of this study was to explore how clinicians introduce the need to make a decision about the use of life-sustaining treatment and how surrogates respond to these introductions during family conferences in the intensive care unit. This article focuses on the use of the perspective-display sequence as a way to introduce the decision-making conversation. In the family conferences, the perspective-display sequence involved (a) the clinician's perspective-display invitation of the surrogates' assessment of the patient's wishes, (b) the surrogates' reply or assessment, and (c) the clinician's decision proposal, which often incorporates the surrogates' assessment. Asking about the patient's wishes is a delicate way to ease into the decision-making conversation. By using the perspective-display sequence, clinicians are also participating in shared decision making; their decision proposal is co-constructed with surrogates' understanding of the patient's wishes regarding the treatment.

Virtual collaboration, satisfaction, and trust between nurses in the tele-ICU and ICUs: Results of a multilevel analysis.

PURPOSE: The purpose of the study was to examine how tele-intensive care unit (tele-ICU) nurse characteristics and organizational characteristics influence tele-ICU nurses' trust and satisfaction of monitored bedside ICU nurses, and whether these influences are mediated by communication. MATERIALS AND METHODS: Data of tele-ICU characteristics and characteristics of the ICUs they monitored were collected at 5 tele-ICUs located throughout the country. One hundred ten tele-ICU nurses at those tele-ICUs completed a questionnaire containing items related to their characteristics and their trust, satisfaction, and perceived communication with monitored bedside nurses. We analyzed the data using a hierarchical path model, with communication variables entered as mediators. RESULTS: Many of the tele-ICU nurse characteristics (age, currently or previously worked at the monitored ICU, hours worked per week, and years as a ICU nurse) had statistically significant direct effects on perception of communication timeliness, accuracy, and openness, as well as trust and satisfaction with monitored bedside ICU nurses. Communication openness mediated the relationships of both working at a monitored ICU and being older (≥55) on satisfaction. Communication accuracy mediated the relationships of both a specialized monitored ICU and working at a monitored ICU on trust. CONCLUSIONS: Tele-ICUs and monitored ICUs should work to optimize communication so that trust can be established among the nurses.