More Than Just an Entertainment Show: Identification of Medical Clowns' Communication Skills and Therapeutic Goals.

Medical clowns (MCs) are trained professionals who aim to change the hospital environment through humor. Previous studies focused on their positive impact and began identifying their various skills in specific situations. When placed in pediatrics, MCs face various challenges, including approaching frustrated adolescents who are unwilling to cooperate with their care, dealing with their anxious parents, and communicating in a team in the presence of other health professionals. Research that systematically describes MCs' skills and therapeutic goals in meeting these challenges is limited. This article describes a qualitative, immersion/crystallization study, triangulating between 26 video-recorded simulations and 12 in-depth-semi-structured interviews with MCs. Through an iterative consensus-building process we identified 40 different skills, not limited to humor and entertainment. Four main therapeutic goals emerged: building a relationship, dealing with emotions, enhancing a sense of control, caring, and encouragement, and motivating treatment adherence. Mapping MCs' skills and goals enhances the understanding of MCs' role and actions to illustrate their unique caring practices. This clarification may help other healthcare professionals to recognize their practices and the benefits in involving them in care. Furthermore, other health professionals may apply some of the identified skills when faced with these challenges themselves.

[SIMULATION AS A TRAINING AND ASSESSMENT TOOL FOR COMPETENCY BASED MEDICAL EDUCATION - A REGULATORY CHALLENGE].

INTRODUCTION: Competency Based Medical Education (CBME) is an educational approach that occupies a central place in medical education. Medical education is accountable for the graduates' professional level, ensuring they are skilled and competent in all key areas of their profession. Adopting CBME underscores the importance of simulation-based training. Experiential training provides, among other things: standardization of training, controlled exposure to extreme events and soft skills, such as patient-caregiver communication and teamwork training. Unlike the traditional apprentice approach, accountability reinforces the choice of a preliminary encounter with simulated patients prior to real-life care, as a complimentary tool for improving patient safety. Incorporating a practical exam is self-evident in CBME because of the need to ensure that the examinees are competent to provide unsupervised safe and quality care. Implementation of a national CBME program, likewise, incorporating simulation into national training programs, requires involvement and supervision on health system regulators. In this paper, we describe simulation-based national training programs that to date integrate competency-based training in the various medical sectors. As national programs, they are implemented under the guidance and in cooperation with the regulators. On the one hand, CBME is a new approach and its implementation will require time and the cooperation of many stakeholders. On the other hand, simulation is an existing, well-established training and assessment tool that can be used as an anchor around which you can start building the competency-based training programs.

Expressions of Gratitude and Medical Team Performance.

BACKGROUND AND OBJECTIVES: Exposure to negative social interactions (such as rudeness) has robust adverse implications on medical team performance. However, little is known regarding the effects of positive social interactions. We hypothesized that expressions of gratitude, a prototype of positive social interaction, would enhance medical teams' effectiveness. Our objective was to study the performance of NICU teams after exposure to expressions of gratitude from alternative sources. METHODS: Forty-three NICU teams (comprising 2 physicians and 2 nurses) participated in training workshops of acute care simulations. Teams were randomly assigned to 1 of 4 conditions: (1) maternal gratitude (in which the mother of a preterm infant expressed gratitude to NICU teams, such as the one that treated her child), (2) expert gratitude (in which a physician expert expressed gratitude to teams for participating in the training), (3) combined maternal and expert gratitude, or (4) control (same agents communicated neutral statements). The simulations were evaluated (5-point Likert scale: 1 = failed and 5 = excellent) by independent judges (blind to team exposure) using structured questionnaires. RESULTS: Maternal gratitude positively affected teams' performances (3.9 ± 0.9 vs 3.6 ± 1.0; P = .04), with most of this effect explained by the positive impact of gratitude on team information sharing (4.3 ± 0.8 vs 4.0 ± 0.8; P = .03). Forty percent of the variance in team information sharing was explained by maternal gratitude. Information sharing predicted team performance outcomes, explaining 33% of the variance in diagnostic performance and 41% of the variance in therapeutic performance. CONCLUSIONS: Patient-expressed gratitude significantly enhances medical team performance, with much of this effect explained by enhanced information sharing.

Rudeness and Medical Team Performance.

OBJECTIVES: Rudeness is routinely experienced by medical teams. We sought to explore the impact of rudeness on medical teams' performance and test interventions that might mitigate its negative consequences. METHODS: Thirty-nine NICU teams participated in a training workshop including simulations of acute care of term and preterm newborns. In each workshop, 2 teams were randomly assigned to either an exposure to rudeness (in which the comments of the patient's mother included rude statements completely unrelated to the teams' performance) or control (neutral comments) condition, and 2 additional teams were assigned to rudeness with either a preventative (cognitive bias modification [CBM]) or therapeutic (narrative) intervention. Simulation sessions were evaluated by 2 independent judges, blind to team exposure, who used structured questionnaires to assess team performance. RESULTS: Rudeness had adverse consequences not only on diagnostic and intervention parameters (mean therapeutic score 3.81 ± 0.36 vs 4.31 ± 0.35 in controls, P < .01), but also on team processes (such as information and workload sharing, helping and communication) central to patient care (mean teamwork score 4.04 ± 0.34 vs 4.43 ± 0.37, P < .05). CBM mitigated most of these adverse effects of rudeness, but the postexposure narrative intervention had no significant effect. CONCLUSIONS: Rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety. Interventions focusing on teaching medical professionals to implicitly avoid cognitive distraction such as CBM may offer a means to mitigate the adverse consequences of behaviors that, unfortunately, cannot be prevented.

Applying Judgment Analysis Theory and Methods to Obtain an Insight Into Clinical Judgments: Implementation and Findings With a Simulated Neonatal Intensive Care Unit Setup.

INTRODUCTION: Clinicians who provide acute care are required to quickly identify and judge the illness severity of patients who experience deterioration in their clinical state. Accuracy of judgments can only be tested with respect to a valid reference, but in most health care areas, there is no such score. Judgment analysis theory and methods are presented and proposed as a framework to obtain insight into clinical judgments. A study in a simulated neonatal intensive care unit setup is described to demonstrate the applicability of the proposed methodology. METHODS: Sixteen participants from a neonatal intensive care unit department reviewed 31 clips of simulated cases. The participants were directed to use a 5-point scale to rate their personal interpretation regarding the illness severity of the simulated patient. Judgment analysis techniques were used to identify the judgment capabilities of the participants and to determine factors that influence those capabilities. RESULTS: Most participants interpreted the clinical signs information consistently, but interpretation varied remarkably between clinicians, providing possible explanation to the differences between the clinicians' judgments. Significant correlations were found between the doctors' years of medical experience and attributes of their judgments. CONCLUSIONS: Judgment analysis can be used to obtain insight into clinical judgments and to identify and quantify factors that affect clinicians' judgments. Judgment analysis can promote health care by enhancing clinical assessment teaching, by providing objective and personalized feedback to team members about their judgment performance, and by introducing a unified and objective method to study elements that affect clinical judgments.

Innovative integrative bedside teaching model improves tutors' self-assessments of teaching skills and attitudes.

INTRODUCTION: Patient bedside is the ideal setting for teaching physical examination, medical interviewing, and interpersonal skills. Herein we describe a novel model for bedside teaching (BST) practiced during tutor training workshop and its resulting effect on practitioners' self assessment of teaching skills and perceptions. METHODS: One-day tutor training workshop included theoretical knowledge supplementation regarding tutors' roles as well as implementing practical tools for clinical education, mainly BST model. The model, which emphasizes simultaneous clinical and communication teaching in a stepwise approach, was practiced by consecutive simulations with a gradual escalation of difficulty and adjusted instruction approaches. Pre- and post-workshop-adjusted questionnaires using a Likert scale of 1 to 4 were completed by participants and compared. RESULTS: Analysis was based on 25 out of 48 participants who completed both questionnaires. Significantly improved teaching skills were demonstrated upon workshop completion (mean 3.3, SD 0.5) compared with pre-training (mean 2.6, SD 0.6; p<0.001) with significant increase in most examined parameters. Significantly improved tutor's roles internalization was demonstrated after training completion (mean 3.7, SD 0.3) compared with pre-workshop (mean 3.5 SD 0.5; p=0.002). DISCUSSION: Successful BST involves combination of clinical and communication skills. BST model practiced during the workshop may contribute to improved teaching skills in this challenging environment.