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.

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.

"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.

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.

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.

Cancer Patients' Mental Health Distress and Suicidality.

Background: A substantial number of people with cancer endorse suicidality when compared with the general population. Thus, oncology healthcare workers may experience the death of a patient to suicide over their careers. Aims: To explore the impact of patients' mental health distress and suicidality on oncology personnel with a secondary aim of exploring how personnel cope with these types of events. Method: We interviewed 61 healthcare professionals (HCPs) at two cancer centers. The grounded theory method (GT) was used. Results: The impact of patients' mental health distress and suicidal ideation on oncology HCPs included sadness, depression, worry and concern, and feeling emotionally overwhelmed. The impact of patient suicide on HCPs included trauma, guilt, and surprise. Oncology personnel reported a change in practice, including communication style, being attuned to patient cues, and changing the physical environment. Coping strategies included colleague support, seeking professional help, and setting boundaries between their work and home life. Limitations: It is likely that HCPs who participated in the study represent those who are more willing to discuss issues related to suicide. Thus, the impact of patient suicide on healthcare providers may be even more pronounced among the general oncology HCP community. Conclusion: Given the higher risk of suicide among cancer patients, it is necessary to increase awareness about the impact these events may have on HCPs. Professional guidelines can highlight the need for a balance between ensuring the availability of informal support and more formal methods of help.

Mental Health Distress: Oncology Nurses' Strategies and Barriers in Identifying Distress in Patients With Cancer.

BACKGROUND: Oncology nurses have an important role in identifying mental health distress; however, the research to date indicates that oncology nurses often do not accurately detect this distress. OBJECTIVES: The aim of this study is to explore oncology nurses' perspectives on indicators of distress in patients, the strategies they use in identifying these signs of distress, and the barriers they face in recognizing these indicators. METHODS: Twenty oncology nurses were interviewed. The study used the grounded theory method of data collection and analysis. FINDINGS: Nurses relied on a number of emotional and behavioral indicators to assess distress. Nurses reported that indicators of mental health distress often were expressed by patients or their caregivers. Strategies to identify distress were limited, with nurses reporting that their only method was directly asking the patient. Barriers to identifying distress included patients concealing distress, nurses' lack of training, and time constraints.

"Please do not act violently towards the staff": Expressions and causes of anger, violence, and aggression in Israeli cancer patients and their families from the perspective of oncologists.

Expressions of anger within the healthcare context are a common occurrence, particularly in clinical situations where patients can experience emotional distress in the face of illness. The purpose of this study was to examine one aspect of this phenomenon by looking at expressions and causes of anger among Israeli cancer patients and their families from the perspective of oncologists who treat them. Twenty-two Israeli oncologists were interviewed from three oncology centers between March 2013 and June 2014. The grounded theory method was used to collect and analyze the data. Our study revealed that oncologists are exposed to and cope with expressions and acts of anger, aggression, and violence from some of their cancer patients and their families. The causes of this anger include physician blame, unrealistic treatment expectations, perceived errors in communication, and lack of follow up with bereaved families. Our study also revealed that the cultural context affected patient-physician interactions, including anger. This context included a culture that has open interpersonal boundaries and is family-oriented; a multicultural society that includes citizens with different cultural norms and expectations around cancer care; and a strained healthcare system that leaves oncologists limited in time and resources, including limited access to palliative care. Policy implications include reducing oncologist workload by hiring more mental health professionals, having translators available on site to help with language barriers, reducing administrative burdens, and incorporating palliative care widely to help with the psychosocial and physical care of patients and families.

Oncologists' Treatment Responses to Mental Health Distress in Their Cancer Patients.

The objectives of this study were to identify how oncologists respond to mental health distress in their patients, what specific strategies they use in treating this distress, and what barriers they report responding to their patients' emotional distress. Twenty-three oncologists at two cancer centers were interviewed. The grounded theory method of data collection and analysis was used. Oncologists varied in their response to patients' emotional distress. Strategies used in responding to patients' distress included creating supportive relationships and prescribing medications, while barriers included patient reluctance, a lack of protocol on how to respond to patients, limited psychosocial resources, and a lack of time. Developing and adopting clear guidelines to addressing mental health distress among cancer patients is critical in assuring quality care for the whole patient and reduce the risk for poor quality of life and potential disease-related morbidity and mortality.

Oncologists', nurses', and social workers' strategies and barriers to identifying suicide risk in cancer patients.

OBJECTIVE: To identify oncologists', nurses', and social workers' strategies and barriers in identifying suicide risk in cancer patients. METHODS: Sixty-one oncology healthcare professionals (HCPs) at 2 cancer centers were interviewed. We used the grounded theory method (GT) of data collection and analysis. Analysis involved line-by-line coding, and was inductive, with codes and categories emerging from participants' narratives. RESULTS: The majority of oncologists and nurses reported that they had encountered at least 1 patient who had committed suicide during their careers (56% and 55%, respectively) and/or had suicidal ideation (65% and 75%, respectively). Social workers reported having fewer suicides in their practices (22%), but similar rates of suicidal ideation among patients (66%). Strategies to identifying suicide risk included paying attention to patients' verbal indicators, explicit actions, and mental health distress. In addition HCPs reported that mental health disorders and other patient characteristics increased their likelihood to assess suicidality among patients. Reported barriers to identification included patient factors such as patients giving no warning, patients concealing suicidality, and patients failing to come in. HCP barriers to identification included lack of training and awareness, difficulty in differentiating suicidality from mental health distress, lack of time with patients, fear of asking about suicidality, and lack of coping resources to deal with suicidal patients. CONCLUSIONS: HCPs reports of their lack of training and awareness on identifying suicide risk is alarming given the higher risk of suicide among cancer patients. Training programs should incorporate the successful strategies used by HCPs and overcome barriers to identifying suicide risk.

From will to live to will to die: oncologists, nurses, and social workers identification of suicidality in cancer patients.

PURPOSE: The purpose of this research was to examine how oncologists, nurses, and social workers identify suicidality in cancer patients. METHODS: Sixty-one healthcare professionals (23 oncologists, 18 social workers, and 20 nurses) at two academic cancer centers were interviewed using an in-depth interview guide. This was a qualitative study based on grounded theory methodology. Analysis involved line-by-line coding, with categories and themes emerging from participants' narratives. RESULTS: Suicidality in cancer patients exists on a wide spectrum that ranges from an active will to live to an active will to die. Four phases were identified that included: (A) a strong will to live expressed in themes of active treatments, seeking second opinions, overtreatment, and alternative treatments; (B) a decreasing will to live indicated in themes of mental health distress and physical pain and suffering; (C) a readiness to die expressed in themes of mental health distress, previous mental health diagnoses, physical pain, avoiding more suffering, preserving quality of life in old age, nearing end of life, lack of social support, and maintaining a sense of control; and (D) a will to die indicated in themes of euthanasia and active suicidality. CONCLUSIONS: Suicidality in cancer patients exists on a continuum. Cancer patients fluctuate on this spectrum depending on circumstances such as degree of suffering, their personalities and life circumstances, and whether they are nearing the end of life. Results of the study emphasize the need to collect more context specific data on suicidality among cancer patients and the importance of early integration of psychosocial and palliative care in the cancer treatment trajectory.

Grief symptoms and difficult patient loss for oncologists in response to patient death.

OBJECTIVE: The study aimed to explore oncologist's grief symptoms over patient death and to identify why and which losses are particularly challenging when patients die. METHODS: The grounded theory method was used to collect and analyze the data. Twenty-two oncologists were interviewed between March 2013 and June 2014 from three adult oncology centers in the north, center, and south of Israel. Oncologists were at different stages of their careers and varied in their sub-specialties, gender, and personal and professional backgrounds. RESULTS: Grief begun when the patient died, in anticipation of the patient's death, many days after the death, or when the patient received a poor prognosis. The phenomenological experience of grief for oncologists included behavioral, cognitive, physical, and emotional symptoms in response to patient death. Behavioral symptoms included crying and difficulties sleeping. Cognitive symptoms included self-doubt and rumination about the patient and the care the patient had received before death. Physical symptoms included chest pain, fatigue, and general physical discomfort. Emotional symptoms included sadness, anxiety, helplessness, guilt, relief, irritability, and loss. Difficult patient loss was caused by patient-related factors, family-related factors, and disease-related factors. CONCLUSIONS: Patient deaths result in behavioral, cognitive, physical, and emotional symptoms of grief in oncologists. These symptoms become particularly intense in the context of patient, family, and disease-related factors. Educational and supportive interventions for managing grief related to patient death are needed in order to support oncologists in their emotionally and mentally taxing work. Copyright © 2016 John Wiley & Sons, Ltd.

Barriers and facilitators in coping with patient death in clinical oncology.

PURPOSE: The purpose of this study was to explore barriers and facilitators in coping with patient death in the oncology context. METHODS: The grounded theory method was used to collect and analyze the data. Twenty-two oncologists were interviewed between March 2013 and June 2014 from three adult oncology centers. Oncologists were at different stages of their careers and varied in their sub-specialties, gender, and personal and professional backgrounds. RESULTS: The analysis revealed that facilitators to coping with patient death included cognitive, behavioral, relational, professional, and spiritual coping strategies. Behavioral coping strategies included sports, hobbies, entertainment, and taking vacations. Cognitive strategies included accepting and normalizing death and focusing on the positive, and on successes in the practice of oncology. Relational coping strategies included accessing social support from family, friends, and colleagues. Professional coping strategies included focusing on work, withdrawing from patients at end of life, and compartmentalization. Spiritual coping strategies included turning to faith and religious coping. Oncologists also reported a number of challenges and barriers in coping effectively with patient deaths. These included challenges in accessing social support, challenges that were related to gender and expression of emotion, and challenges in maintaining emotional boundaries when patients died. CONCLUSIONS: Oncologists turn to a number of diverse coping strategies in dealing with patient death, but many obstacles to accessing this support were reported. Targeted interventions for managing and coping with grief related to patient death need to be developed to support oncologists in their emotionally difficult work.