Gender Differences in the Pediatric Neurosurgical Workforce: Professional Practice, Work-Life Balance, and Beyond.

BACKGROUND AND OBJECTIVES: Evidence suggests that female neurosurgeons experience unique challenges in the workplace including lack of academic advancement, challenges with work-life balance, harassment, and discrimination. How these factors influence the gender gap in neurosurgery remains unclear. This analysis investigated gender differences in pediatric neurosurgeons in professional and nonprofessional activities and responsibilities. METHODS: A survey examining professional activities, work-life balance, family dynamics, career satisfaction, and workplace discrimination and harassment was administered to 495 pediatric neurosurgeons. Response rate was 49% (n = 241). RESULTS: One-third of the pediatric neurosurgical workforce is female. There were no gender differences in race/ethnicity, American Board of Neurological Surgery/American Board of Pediatric Neurological Surgery certification rates, or pediatric neurosurgery fellowship completion. No gender differences were found in operative caseload, weekly hours worked, or working after 8 pm or weekends. Women took call more frequently than men (P = .044). Men were more likely to work in academia (P = .004) and have salary subsidization from external sources (P = .026). Women were more likely to anticipate retirement by age 65 years (P = .044), were less happy with call commitments (P = .012), and worked more hours at home while off (P = .050). Women more frequently reported witnessing and experiencing racial discrimination (P = .008; P < .001), sexual harassment (P = .002, P < .001), and feeling less safe at work (P < .001). Men were more likely married (P = .042) with 1 (P = .004) or more children (P = .034). Women reported significantly greater responsibility for child and domestic care (P < .001). There were no gender differences in work-life balance, feeling supported at work, or having enough time to do things outside of work. CONCLUSION: Despite little difference in workload and professional responsibilities, women held more domestic responsibilities and experienced and witnessed more racial and sexual discrimination in the workplace. Surprisingly, there were no reported differences in work-life balance or feeling supported at work between genders. These findings suggest that factors unique to female neurosurgeons may contribute to continued gender disparity in the field.

Oncology Healthcare Professionals' Mental Health during the COVID-19 Pandemic.

The paper begins by reviewing the literature on oncology healthcare professionals' (HCP) mental health. We summarize and present the current data on HCP mental health in order to understand the baseline state of oncology HCPs' mental health status prior to the COVID-19 pandemic. At each juncture, we will discuss the implications of these mental health variables on the personal lives of HCPs, the healthcare system, and patient care. We follow by reviewing the literature on these parameters during the COVID-19 pandemic in order to better understand the impact of COVID-19 on the overall mental health of HCPs working in oncology. By reviewing and summarizing the data before and after the start of the pandemic, we will get a fuller picture of the pre-existing stressors facing oncology HCPs and the added burden caused by pandemic-related stresses. The second part of this review paper will discuss the implications for the oncology workforce and offer recommendations based on the research literature in order to improve the lives of HCPs, and in the process, improve patient care.

"Some things are even worse than telling a child he is going to die": Pediatric oncology healthcare professionals perspectives on communicating with children about cancer and end of life.

INTRODUCTION: This study explored pediatric oncology healthcare professionals' (HCPs) perspectives on direct communication with children with advanced disease about their disease, palliative care, and end-of-life (EOL) communication. METHODS: Forty-six pediatric oncologists, nurses, psychosocial team members, and other HCPs from six hospital centers in Israel participated in semi-structured interviews. The Grounded Theory method was used. Data were analyzed line-by-line with codes and categories developed inductively from participants' narratives. RESULTS: HCPs viewed communication about disease progression and EOL as vital because children were often aware of their prognosis, because lack of communication could lead to emotional distress, and because communication is a prerequisite for shared decision-making. HCPs identified several barriers for communication including HCP barriers (such as emotional strains, lack of training), parental barriers, guardianship law, and language and culture. HCPs also described strategies to promote EOL communication. Direct strategies include tailoring communication, allowing for silence, echoing children's questions, giving information gradually, and answering direct questions honestly. Indirect strategies included encouraging parents to talk to their children and teamwork with colleagues. CONCLUSIONS: Open communication with children who have cancer is essential. Nevertheless, multiple barriers persist. The rising accessibility of online information calls for urgent training of HCPs in communication so that children will not turn to unmediated and potentially misleading information online in the absence of HCP communication. Evidence-based effective communication training modules and emotional support should be offered to HCPs. Knowledge about children's development, age-appropriate communication, and cultural sensitivity should be included in this training.

Factors That Influence Intraoperative Decision-Making among Pediatric Neurosurgeons: A Grounded Theory Study.

INTRODUCTION: Pediatric neurosurgery is a subspecialty of medicine that is responsible for diagnosing, managing, and treating neurological disease in children with the use of surgery. Good intraoperative decision-making is critical to ensuring patient safety, yet almost nothing is known about what factors play a role in intraoperative decisions. As such, the purpose of this paper was to explore the factors that influence intraoperative decisions when pediatric neurosurgeons encounter something unexpected or uncertain during surgery. METHODS: The study utilized the grounded theory method of data collection and analysis. Twenty-six pediatric neurosurgeons from 12 countries around the world were interviewed between June and October 2020 about the factors that go into making intraoperative decisions. Data were analyzed line by line and constant comparison was used to examine relationships within and across codes and categories. RESULTS: Pediatric neurosurgeons reflected on 6 factors while operating in order to come to a decision about how to proceed when they encountered an uncertainty or complication. The study findings resulted in a conceptual model that describes how concrete data including biological and technological factors and contextual data including emotional/relational factors, surgeon factors, and cultural factors influence risk assessment when making an intraoperative decision during surgery. CONCLUSIONS: The findings from this research can be used for training and educating surgeons about intraoperative decision-making processes. Pedagogical modules can be developed that include training sessions on factors that may implicitly and explicitly influence thinking processes during an operation. Surgeons may also benefit from having open discussions with surgical colleagues about the rich, emotional, intellectual scope of the work that they do with all the challenges that these relationships can bring into decision-making in the operating room.

'Every patient is like my child': pediatric neurosurgeons' relational and emotional bonds with their patients and families.

PURPOSE: To explore the relational and emotional components of the surgeon-patient relationship from the perspective of practicing pediatric neurosurgeons in the field. MATERIALS AND METHODS: The study utilized the Grounded Theory Method of data collection and analysis. 26 pediatric neurosurgeons from 12 countries were interviewed using video-conferencing technology. RESULTS: Pediatric neurosurgeons find meaning, joy and pleasure in the relationships they form with their patients and their families, while also experiencing difficult and painful emotions when these patients do not do well. Four themes emerged from the analysis that include having a relational attachment to patients, forming bonds with the parents/caregivers of these patients, dealing with patient suffering, death and complications, and communicating bad news to parents. CONCLUSIONS: Pediatric neurosurgeons develop deep and enduring bonds with their patients and their families. These relationships are an integral part of what brings meaning and joy to their work, and simultaneously, are one of the most significant emotional challenges of their careers. . Training neurosurgical fellows should include pedagogical modules about the relational and emotional dimensions of their work, with a specific and dedicated focus on communicating bad news.

Organizational and individual barriers and facilitators to the integration of pediatric palliative care for children: A grounded theory study.

BACKGROUND: Pediatric palliative care has established benefits for children with cancer and their families. Overcoming organizational and healthcare provider barriers have been demonstrated as central for the provision of palliative care in pediatric oncology. A deeper understanding is needed of the influence of these barriers and the interactions between them, specifically in primary palliative care in hospital settings. AIM: To identify the organizational and healthcare provider barriers to the provision of primary pediatric palliative care. DESIGN: This study utilized the grounded theory method. Semi-structured interviews were conducted and analyzed line by line, using NVivo software. SETTING/PARTICIPANTS: Forty-six pediatric oncologists, nurses, psychosocial team members, and other healthcare providers from six academic hospital centers participated in the research. RESULTS: Organizational and healthcare provider factors were identified, each of which acted as both a barrier and facilitator to the provision of pediatric palliative care. Organizational barriers included lack of resources and management. Facilitators included external resources, resource management, and a palliative care center within the hospital. Individual barriers included attitudes toward palliative care among pediatric oncologists, pediatric oncologists' personalities, and the emotional burden of providing palliative care. Facilitators include dedication and commitment, initiative, and sense of meaning. Provider facilitators for palliative care had a buffering effect on organizational barriers. CONCLUSION: Organizational and healthcare provider factors influence the quality and quantity of palliative care given to children and their families. This finding has implications on interventions structured to promote primary palliative care for children, especially in healthcare systems and situations where resources are limited.

Pediatric neurosurgeons' philosophical approaches to making intraoperative decisions when encountering an uncertainty or a complication while operating on children.

OBJECTIVE: The objective of this study was to explore approaches to intraoperative decision-making in pediatric neurosurgeons when they encounter unexpected events, uncertainties, or complications while operating on children. METHODS: Twenty-six pediatric neurosurgeons from 12 countries around the world were interviewed using a semistructured interview guide. The grounded theory method of data collection and analysis was used. Analysis involved line-by-line coding and was inductive, with codes and categories emerging from participants' narratives. RESULTS: When asked to discuss the strategies they used to make intraoperative decisions, neurosurgeons reported three distinct approaches that formed a philosophy of practice. This included the theme of professional practice-with the subthemes of preparing for uncertainty, doing no harm, being creative and adaptive, being systematic, and working on teams. The second theme pertained to patient and caregiver practices-with the subthemes of shared decision-making and seeing the whole patient. The third theme involved surgeon practice-with the subthemes of cultivating self-awareness and learning from experience. CONCLUSIONS: Pediatric neurosurgeons have a structured, diverse, and well-thought-out analytical philosophy and practice regarding intraoperative decision-making that encompasses a range of approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment techniques.

Can Good Intraoperative Judgement Be Taught?: Pediatric Neurosurgeons' Pedagogical Approaches to Training Residents on Intraoperative Decision-Making.

OBJECTIVE: To explore how pediatric neurosurgeons train residents in developing intraoperative decision-making judgement. DESIGN: This study used the Grounded Theory Method in its study design. In-depth interviews were conducted with pediatric neurosurgeons about their approaches to training residents in intraoperative decision making. Data was analyzed line-by-line with codes and categories emerging from participants narratives. SETTING & PARTICIPANTS: Twenty-six pediatric neurosurgeons from 12 countries were interviewed using video-conferencing technology. RESULTS: Pediatric Neurosurgeons used a variety of training approaches that included pre-surgery discussions, didactic communication during surgery, post-surgery debriefing, allowing residents to model and observe their own intraoperative behaviors, using case studies to teach, and ongoing mentorship. In addition, they encouraged residents to ask for help when needed and emphasized the importance of empathy as a surgeon. Challenges to training residents included the notion that decision-making could only be learned through personal experience, the trainee's personality, and an over-reliance on algorithms and standardized medicine. CONCLUSIONS: Training neurosurgical residents about intraoperative decision-making appears to be ad-hoc and dependent on both the institution and the availability and willingness of senior surgeons to make this a part of their pedagogy. Surgical departments could use these findings to reflect on their own teaching practices and explore whether they wish to teach these skills more explicitly, and in what ways these skills can be best taught to residents.

How Do Pediatric Neurosurgeons Make Intraoperative Decisions?

OBJECTIVE: The purpose of this research was to explore the processes by which pediatric neurosurgeons make intraoperative decisions when they encounter something unexpected or uncertain while they are operating. METHODS: The study used the grounded theory method of data collection and analysis. Twenty-six pediatric neurosurgeons (PNs) from 12 countries were interviewed about the process by which they make intraoperative decisions. Data were analyzed line by line, and constant comparison was used to examine relationships within and across codes and categories. RESULTS: PNs described a complex process that existed along a spectrum in making intraoperative decisions. Three types of response processes emerged from the analysis: 1) internal processing, with the themes of getting oneself under control and performing control for the surgical team; 2) action processes that included the themes of stabilizing the patient, responding intuitively/automatically when making decisions, and shifting surgical strategies; and 3) analytical processing that involved assessing the situation, consulting with colleagues and the family of the patient when making intraoperative decisions. CONCLUSIONS: The findings from this study contribute novel information on PNs' intraoperative decision making processes and can be used to train resident neurosurgeons about the various components involved in these processes. This research suggests that new models of decision making are needed within the medical and neurosurgical context and inspire a new set of questions about the process by which surgeons make life and death decisions in the operating room.

Oncologist conceptualizations of pediatric palliative care: challenges and definitions.

PURPOSE: Pediatric palliative care (PC) is an evolving field and involves a comprehensive approach to care of children with cancer. The goal of this paper was to explore how pediatric oncologists define, interpret, and practice pediatric palliative care in their clinical settings. METHODS: The study used the grounded theory approach to data collection and analysis. Twenty-one pediatric oncologists from six pediatric cancer centers across Israel were interviewed. Data was analyzed using line-by-line coding. RESULTS: The analysis resulted in a four-tiered conceptual model. This model included the following categories: (1) ill-defined concept; (2) philosophies of palliative care; (3) trajectory of palliative care; and (4) palliative care treatment goals. CONCLUSION: The findings illustrate the current conceptualizations of pediatric palliative care among the pediatric oncology community in Israel. The conceptual model documents their understanding of pediatric palliative care as a philosophical approach and the challenges they face in differentiating between palliative care and standard pediatric oncology care. Pediatric palliative care is a highly needed and valued sub-specialty. The findings from this study highlight the importance for its continued development in Israel, as it can reduce the suffering of children and their families. Concurrently, pediatric oncologists need to have more resources and access to explicit knowledge of the conceptual and practical aspects of both primary and specialized pediatric palliative care.

"We are a transit station here": The role of Israeli oncology social workers in responding to mental health distress and suicidality in patients with cancer.

Social workers have a prominent role in responding to cancer patients' mental health needs. Given the risk of mental health distress in cancer patients, and given that social workers are responsible for responding to these needs, the purpose of this study was to explore how social workers describe their role in responding to mental health distress and suicidality in people with cancer. The Grounded Theory method of data collection and analysis was used. Eighteen social workers were recruited and interviewed. Social workers saw themselves and acted as an interprofessional hub for their patients. This approach was based on the values of holistic care, multiple treatment modalities, interpersonal consultation, and continuity of care. From this standpoint, social workers offered their patients (and at times, their families) comprehensive services providing emotional, behavioral and practical support within the hospital setting, but also outside of it in the patient's communities. Consideration should be paid to promote systemic changes to acknowledge and compensate oncology socials workers' invisible labor that includes both emotional carryover and continuous engagement in their role as liaison and intermediaries for their patients.

Prevalence and risk factors for suicidality in cancer patients and oncology healthcare professionals strategies in identifying suicide risk in cancer patients.

PURPOSE OF REVIEW: The aim of this study was to summarize the literature on prevalence and risk factors for suicidality in cancer patients and to document the research on oncology healthcare professionals' strategies in identifying this risk. RECENT FINDINGS: Cancer patients exhibit increased risk of suicidality compared with the general population. Various risk factors have been identified including sociodemographic factors such as poverty, being male and elderly as well as disease-related attributes such as cancer type and stage. The literature on how healthcare professionals identify suicide risk is sparse. Ten articles were found that focused on two main themes. These included information on systematic strategies in identifying suicide risk and factors that affect healthcare professionals' ability to identify risk in their patients. SUMMARY: Although there is an immense amount of literature documenting the problem of suicidality among patients, the research on how healthcare professionals identify and respond to these indications in patients is nearly nonexistent. Cancer centres should implement standardized and systematic screening of cancer patients for suicidality and research on this patient population should collect and report these data. Ongoing training and education for healthcare professionals who work in the oncology setting on how to identify and respond to suicide risk among cancer patients is urgently needed.

Does Assessment Method Matter in Detecting Mental Health Distress among Ashkenazi and Mizrahi Israeli Women with Breast Cancer?

Authors examined differences in assessment method (structured diagnostic interview versus self-report questionnaire) between ethnic groups in the prevalence of mood and anxiety disorders among women with breast cancer. A convenience sample of 88 Mizrahi (Jews of Middle Eastern/North African descent, n = 42) and Ashkenazi (Jews of European/American descent, n = 46) women with breast cancer from oncology units in three health centers across Israel participated in the study. Participants were within eight months of diagnosis. Participants completed the Hospital Anxiety and Depression Scale (HADS) and a structured diagnostic interview, the Mini-International Neuropsychiatric Interview (MINI). Approximately one-third (31.8 percent, n = 28) of participants were diagnosed with at least one mood or anxiety disorder based on the MINI. Significantly more Mizrahi participants (42.9 percent) were diagnosed with at least one mood or anxiety disorder, compared with their Ashkenazi counterparts (21.7 percent). Mean score on HADS was below the optimal cutoff score (≥13) among all participants, with no significant difference in mean score for emotional distress based on HADS between the two ethnic groups. The findings highlight the role of measurement variance in assessing mental health distress among women with breast cancer in general and among ethnic and racial minorities in particular.

Oncologists, oncology nurses and oncology social workers experiences with suicide: impact on patient care.

OBJECTIVE: To explore how oncology healthcare workers' (HCPs) personal experiences with suicide impacts their practice with cancer patients. DESIGN: The study was designed using Grounded Theory strategies in data collection and analysis. PARTICIPANTS: Eighteen social workers, 23 oncologists, and 20 nurses, participated in the research. METHODS: Themes emerged from systematic line-by-line coding of the interview transcripts. FINDINGS: HCPs reported that personal experiences with suicide: impacted the way they communicated with patients about suicide; made them vigilant about signs of suicidality; and made them aware of specific indicators of this distress. CONCLUSIONS: HCPs drew a direct line between their experiences with suicide to the ways in which they care for their patients. IMPLICATIONS: Increasing HCP awareness of these issues alongside training using evidence-based guidelines for identifying and responding to suicide risk in patients will ensure providing the best quality of care for patients.

The Role of Culture/Ethnicity in Communicating with Cancer Patients About Mental Health Distress and Suicidality.

To explore the role of culture in communicating with cancer patients about mental health distress and suicidality. The Grounded Theory method of data collection and analysis was used. Healthcare professionals (HCPs) reported that language competency was a facilitator while being unable to speak the language or understand the nuances of their patient's communication could be a barrier. HCPs noted that being culturally matched with their patients helped them communicate effectively. HCPs also spoke about religious taboos on suicide as being a barrier to having conversations, either because patients did not feel comfortable discussing these issues, or because they perceived that this was not a topic they could bring up. Some HCPs reported that the culture/ethnicity of their patients had no effect on their ability to communicate effectively with them about mental health distress or suicidality. Advancing effective cross-cultural communication is a challenge faced by HCPs. Raising awareness about communication styles is an important step in addressing communication gaps about mental health and suicide with cancer patients. Training should facilitate skill development to engage in a culturally humble approach to cross-cultural communication including diversity training which encourages asking and actively listening to patients' needs and preferences.

Factors affecting the will to live among elderly jews living in israel.

Objectives: The aim of this qualitative study was to explore factors that influence older persons' will to live (WTL).Methods: Twenty-five Israeli elders were interviewed about what weakens and/or strengthens their WTL. Elements of the grounded theory method guided the data collection and analysis.Results: Our analysis revealed that the elements that pertain to WTL could potentially both increase and decrease the WTL in elders. These factors included social networks, financial security, religious faith, working and volunteering, and honor versus ageism.Conclusions: Five factors represent different aspects of older persons' lives that influence the WTL. The first four themes including Social Networks, Religious Faith, Honor versus Ageism, and Working and Volunteering are consistent with the findings of the study of Blue Zones. Blue Zones are areas characterized by high life expectancy. Israel shares cultural characteristics with the Blue Zones, being a society with traditional collective characteristics stemming from the Jewish tradition. The last theme of financial security is related to the characteristics of Israel as a society in which the social gaps are large and many elderly are pushed to the social margins, and lack financial security. This study points to the unique cultural characteristics of Israel that affect the WTL among elderly Jews and proposes a hypothesis linking Israeli culture to the high life expectancy in Israel.

Strategies and Barriers in Addressing Mental Health and Suicidality in Patients With Cancer.

PURPOSE: To identify how oncology nurses address mental health distress and suicidality in patients, what strategies they employ in treating this distress, and the barriers they face in addressing distress and suicidality in patients with cancer. PARTICIPANTS & SETTING: 20 oncology nurses at two cancer centers in Israel were interviewed. METHODOLOGIC APPROACH: The grounded theory method of data collection and analysis was employed. FINDINGS: Strategies used in addressing patients' mental health distress were being emotionally available, providing practical support, treating physical symptoms, and referring to counseling. Strategies in addressing suicidality were assessing the situation, offering end-of-life or palliative care, treating physical symptoms, and referring for assessment. Barriers to addressing distress were lack of training, stigma, workload or lack of time, and limited availability and accessibility of mental health resources. Barriers in addressing suicidality were lack of knowledge and training, patient reluctance to receive care, and lack of protocol. IMPLICATIONS FOR NURSING: Developing guidelines for addressing and responding to mental health distress and suicidality is essential to improving patients' quality of life and reducing disease-related morbidity and mortality. Reducing mental healthcare stigma for patients is critical.

Oncology health care professionals' perspectives on the causes of mental health distress in cancer patients.

OBJECTIVE: To explore oncologists, social workers, and nurses' perceptions about the causes of their cancer patient's mental health distress. METHODS: The grounded theory (GT) method of data collection and analysis was used. Sixty-one oncology health care professionals were interviewed about what they perceived to be the causes of mental health distress in their patients. Analysis involved line-by-line coding and was inductive, with codes and categories emerging from participants' narratives. RESULTS: Oncology health care professionals were sensitive in their perceptions of their patients' distress. The findings were organized into three categories, namely, disease-related factors, social factors, and existential factors. Disease-related themes included side effects of the disease and treatment, loss of bodily functions, and body image concerns as causing patient's mental health distress. Social-related themes included socio-economic stress, loneliness/lack of social support, and family-related distress. Existential themes included dependence/fear of being a burden, death anxiety, and grief and loss. CONCLUSIONS: Oncology health care professionals were able to name a wide range of causes of mental health distress in their patients. These findings highlight the need to have explicit conversations with patients about their mental status and to explore their understanding of their suffering. A patient-centered approach that values the patient's conceptualization of their problem and their narrative to understanding their illness can improve the patient-provider relationship and facilitate discussions about patient-centered treatments.

Oncology healthcare professionals' perceptions, explanatory models, and moral views on suicidality.

PURPOSE: To explore how oncologists, oncology nurses, and oncology social workers perceive suicidality (suicidal ideation, suicidal acts, and completed suicides) in patients with cancer that they are in contact with. METHODS: The grounded theory method of data collection and analysis was used. Sixty-one oncology healthcare professionals from two university-affiliated cancer centers in Israel were interviewed. RESULTS: The findings resulted in three main categories that included perceptions of suicidality, explanatory models of suicidality, and moral views on suicide. Healthcare professionals considered suicidality in their patients to be a cry for help, a sign of distress, or an attempt at attention seeking. Participants explained suicidality as stemming from a biological disease, from mental illness, as an aberration, or as an impulsive, irrational act. Moral views on suicidality were split among those who were mostly accepting of these patients' actions versus those who rejected it outright. A third group of healthcare professionals expressed ambivalence about suicidality in their patients. CONCLUSIONS: Healthcare professionals vary greatly in their perceptions on suicide. Some view the act as part of a patient's choice and autonomy while others view it negatively. Healthcare providers should receive support in handling patient's suicidality.