Adaptation and validation of the Brazilian version of the Measure of Moral Distress for Healthcare Professionals (MMD-HP BR) in the context of palliative care.

BACKGROUND: The Measure of Moral Distress for Health Care Professionals (MMD-HP) scale corresponds to the update of the globally recognized Moral Distress Scale-Revised (MDS-R). Its purpose is to measure moral distress, which is a type of suffering caused in a professional prevented from acting according to one's moral convictions due to external or internal barriers. Thus, this study has the objective to translate, culturally adapt, and validate the Brazilian version of the MMD-HP BR in the context of Palliative Care (PC). METHODS: The study had the following steps: translation, cross-cultural adaptation and validation. The MMD-HP BR is composed of 27 Likert-rated items for frequency and intensity of moral distress. In total, 332 health professionals who work in PC participated in the study, 10 in the pre-test stage, and 322 in the validation stage. RESULTS: It was possible to identify six factors, which together explain 64.75% of the model variation. The reliability of Cronbach's alpha was 0.942. In addition, the score was higher in those who are considering or have already left their positions due to moral distress, compared to those who do not or have never had such an intention. CONCLUSIONS: MMD-HP BR is a reliable and valid instrument to assess moral distress in the PC context. It is suggested that the scale be standardized in other healthcare contexts, such as clinical settings. In addition, further research on moral distress is encouraged to identify and reduce the phenomenon and its consequences.

Espiritualidade no ensino em saúde: scoping review / Spirituality in health education: scoping review / Espiritualidad en la educación para la salud: revisión del alcance

Revisão de escopo com objetivo de mapear produções científicas sobre a espiritualidade no ensino em saúde. Utilizou-se o acrônimo População Conceito Contexto (PCC) - População para estudantes das graduações de saúde, Conceito para espiritualidade e religião e Contexto para ensino da saúde. Este estudo foi estruturado pelo PRISMA-Scr. Foram incluídos os artigos publicados em português, espanhol e inglês, de janeiro de 2010 a setembro 2020. Inicialmente identificou-se 798 artigos, dos quais 12 foram incluídos na revisão. Os principais resultados revelam um aumento das publicações entre 2013 e 2019 e apontam que dos 12 artigos incluídos no estudo, oito contêm propostas metodológicas de educação em saúde e espiritualidade, com busca por metodologias e estruturas mais apropriadas do ponto de vista pedagógico. Conclui-se que trazer a espiritualidade aos estudantes da saúde possibilita a autorreflexão e a capacitação do próprio docente.

Scoping review to map scientific productions on spirituality in health education. The acronym Population Concept Context (PCC) - Population for undergraduate health students, Concept for spirituality and religion, and Context for health teaching. This study was directed by PRISMA-Scr and included articles published in Portuguese, Spanish, and English from January 2010 to September 2020. The initial search identified 798 articles of which 12 were included in the review. The main results reveal an increase in publications between 2010 e 2019 and indicate that among the 12 articles included in the study, eight contain methodological proposals for health education and spirituality, with a search for more appropriate methodologies and structures from a pedagogical point of view. It is concluded that bringing spirituality to health students allows self-reflection and training for the professors themselves.

Revisión del alcance para mapear producciones científicas sobre la espiritualidad en la educación para la salud. Se utilizó el acrónimo Poblacion Concept Contexto (PCC) - Población para estudiantes de pregrado en salud, Concepto para espiritualidad y religión y Contexto para enseñanza en salud y fue estructurado por PRISMA-Scr. Se incluyeron artículos publicados en portugués, español e inglés desde enero de 2010 hasta septiembre de 2020. Se identificaron inicialmente 798 artículos, de los cuales 12 fueron incluidos en la revisión. Los principales resultados revelan un aumento de publicaciones entre 2013 y 2019. Los principales resultados indican que de los 12 artículos incluidos en el estudio, ocho contienen propuestas metodológicas para la educación en salud y espiritualidad, con una búsqueda de metodologías y estructuras más adecuadas desde el punto de vista pedagógico. Se concluye que acercar la espiritualidad a los estudiantes de salud permite la autorreflexión y la formación de los propios profesores.

Reflective writing in the teaching of communication skills for medical students-A systematic review.

OBJECTIVE: To analyse the use, assessment, and measured outcomes of reflective writing (RW) in teaching communication to medical students. METHODS: Systematic search of seven electronic databases, focused on using RW in teaching communication skills. Three reviewers selected and prepared the synthesis of the studies. The synthesis was based on thematic analysis using Braun and Clarke's approach. RESULTS: We identified 1325 studies, reviewed 101 full-text articles, and included 12 articles in the analysis. The four themes identified showed that RW is not a stand-alone practice. RW is blended with other teaching strategies. Through RW, students identified structural, emotional, and relational aspects and challenges of communication. Only a few studies found a positive correlation between reflective ability and communication skills CONCLUSION: RW can be integrated with various teaching methods, at all stages of learning, to stimulate discussion of interpersonal and intrapersonal topics. Through RW, students explore theirs and their patient's emotions, values, behaviours, and needs identifying challenges and practices relevant to communication. PRACTICE IMPLICATIONS: RW can address different structural, relational, and emotional issues that are relevant to communication learning. Further educational development and high-quality empirical research on the use of RW and unique outcomes are needed to support communication skills learning.

Deepening the teaching and learning of clinical communication: the importance of reflection and feedback in health education / Aprofundando o ensino e aprendizagem de comunicação clínica: a importância da reflexão e do feedback no ensino em saúde

Aims: clinical communication (CC) relates to health professionals' interaction with patients/families. CC is fundamental for the physicians' role. This paper aims to contribute to the discussion about reflection and feedback for meaningful teaching and learning of CC. Methods: the authors provided a short review and conceptual discussion of the history and nature of CC teaching, followed by exploring the role of reflection and feedback in teaching CC. Results: communicating well can be challenging as it requires medical students and professionals to adapt their communication to each patient/family while obtaining all the needed information, conveying trustworthiness, care, and compassion. The teaching of CC to medical students involves deepening the doctor-patient relationship's technical, relational, and emotional elements. CC requires teaching that is flexible and tailored to the participants' needs. Therefore, teaching CC must go beyond asking the appropriate question or applying specific checklist-based behaviours. In teaching CC, it is crucial to give medical students support to discuss personal and institutional barriers and attitudes and explore how to transfer their learning to clinical practice. To that end, reflection should be encouraged to allow students to express difficulties and feelings and enhance their understanding of themselves and others. Within this process, feedback is essential to moving beyond skill-based teaching to reflection-based learning. Conclusion: the move from skills-based learning requires using reflective processes and feedback to allow students to learn about their communication tendencies and needs to become more flexible and attuned to different patient's needs in clinical encounters.

Objetivos: a comunicação clínica (CC) está relacionada à interação entre profissionais de saúde e pacientes ou familiares, sendo fundamental para prática médica. Este artigo tem como objetivo contribuir para a discussão sobre reflexão e feedback no ensino e aprendizagem significativos de CC. Métodos: os autores realizaram uma breve revisão e discussão conceitual da história e da natureza do ensino do CC, seguida pela exploração do papel da reflexão e do feedback no ensino de CC. Resultados: comunicar-se bem pode ser desafiador, pois exige que os estudantes de medicina e profissionais adaptem sua comunicação a cada paciente/família enquanto obtêm todas as informações necessárias, transmitindo confiabilidade, cuidado e compaixão. O ensino do CC para estudantes de medicina envolve o aprofundamento de elementos técnicos, relacionais e emocionais da relação médico-paciente. A CC requer um ensino flexível e adaptado às necessidades dos estudantes. Portanto, ensinar CC deve ir além de fazer a pergunta apropriada ou aplicar comportamentos específicos baseados em listas de verificação. No ensino do CC, é crucial dar aos estudantes de medicina apoio para discutir as barreiras e atitudes pessoais e institucionais e explorar como transferir seu aprendizado para a prática clínica. Para tanto, deve-se estimular a reflexão para permitir que os alunos expressem dificuldades e sentimentos e ampliem sua compreensão de si e dos outros. Nesse processo, o feedback é essencial para ir além do ensino baseado em habilidades para o aprendizado baseado em reflexão. Conclusão: a mudança de uma aprendizagem baseada em habilidades requer o uso de um processo reflexivo e feedback para permitir que os alunos aprendam sobre si, assim como, sobre se tornarem mais flexíveis e sintonizados com as diferentes necessidades do paciente nos encontros clínicos.

Added value of assessing medical students' reflective writings in communication skills training: a longitudinal study in four academic centres.

OBJECTIVES: This study describes the development and implementation of a model to assess students' communication skills highlighting the use of reflective writing. We aimed to evaluate the usefulness of the students' reflections in the assessment of communication skills. DESIGN: Third-year and fourth-year medical students enrolled in an elective course on clinical communication skills development were assessed using different assessment methods. SETTING AND PARTICIPANTS: The communication skills course was offered at four universities (three in Brazil and one in Portugal) and included 69 students. OUTCOME MEASURES: The students were assessed by a Multiple-Choice Questionnaire (MCQ), an objective structured clinical examination (OSCE) and reflective writing narratives. The Cronbach's alpha, dimensionality and the person's correlation were applied to evaluate the reliability of the assessment methods and their correlations. Reflective witting was assessed by applying the Reflection Evaluation for Enhanced Competencies Tool Rubric (Reflect Score (RS)) to measure reflections' depth, and the Thematic Score (TS) to map and grade reflections' themes. RESULTS: The Cronbach alpha for the MCQ, OSCE global score, TS and RS were, respectively, 0.697, 0.633, 0.784 and 0.850. The interobserver correlation for the TS and RS were, respectively, 0.907 and 0.816. The assessment of reflection using the TS was significantly correlated with the MCQ (r=0.412; p=0.019), OSCE (0.439; p=0.012) and RS (0.410; p=0.020). The RS did not correlate with the MCQ and OSCE. CONCLUSIONS: Assessing reflection through mapping the themes and analysing the depth of reflective writing expands the assessment of communication skills. While the assessment of reflective themes is related to the cognitive and behavioural domains of learning, the reflective depth seems to be a specific competence, not correlated with other assessment methods-possibly a metacognitive domain.

The assessment of personality traits and its association with learning communication skills / Avaliação dos traços de personalidade e sua associação com a aprendizagem de habilidades de comunicação

Aims: The aim of this study was to investigate the association between personality traits and attitudes toward learning communication skills in undergraduate medical students. The relation between students' attitudes and personality trait could help us identify those who those who will need more support to develop communication skills, based on their personality traits. Methods: The data was collected data from an intentional and cross-sectional sample composed of 204 students from three Brazilian universities. The students answered questionnaires containing the Communication Skills Attitude Scale (CSAS-BR) and the Big Five Mini-Markers (BFMM) for personality. Data were analyzed using frequency calculations, principal components analysis, and the multiple linear regression model. Results: Seven among 26 items of the original Communication Skills Attitude Scale (CSAS) presented factor loads lower than |0.30| and must be excluded in the CSAS -BR that showed one domain including positive and negative attitudes. The value of Cronbach's alpha of the 19-item scale was 0.894. The BFMM showed similar dimensional results with five domains with Cronbach's alpha values of 0.804 for Extroversion, 0.753 for agreeableness, 0.755 for conscientiousness, 0.780 for neuroticism and 0.668 for openness. There were positive and statically significant linear associations with the CSAS-BR and agreeableness (ß: 0.230, p<0.001), extraversion (ß: 0.150, p=0.030), and openness to experience (ß: 0.190, p=0.010). These personality factors drive social interactions and interpersonal relations, which involve the tendency to be friendly, flexible, and cooperative; to show a willing disposition; and the ability to actively engage with others. Conclusions: Based on the methods applied in this study, the results demonstrated a relation between agreeableness, extraversion and openness to experience with attitudes on communication skills in students from three Brazilian universities. Our results suggest that the evaluation of personality traits can contribute to the recognition of students for whom the establishment of special teaching strategies can improve communication skills.

Objetivos: Este estudo teve como objetivo determinar se se existe uma associação entre traços de personalidade e atitudes quanto à aprendizagem de habilidades de comunicação em estudantes de medicina. A relação entre as atitudes dos alunos e o traço de personalidade pode nos ajudar a identificar aqueles que necessitarão maior apoio para desenvolver habilidades de comunicação, a partir da identificação inicial do traço de personalidade. Métodos: Os dados foram coletados em uma amostra intencional em um corte transversal composta por 204 estudantes de três universidades brasileiras. Os alunos responderam a questionários contendo a Communication Skills Attitude Scale (CSAS-BR) e o Big Five Mini-Markers (BFMM) para personalidade. Os dados foram analisados usando cálculos de frequência, análise de componentes principais e o modelo de regressão linear múltipla. Resultados: Sete dos 26 itens do Communication Skills Attitude Scale (escala original - CSAS) apresentaram cargas fatoriais inferiores a |0.30|e foram excluídos no CSAS-BR, que mostrou um domínio contendo atitudes positivas e negativas. O valor do alfa de Cronbach na escala de 19 itens foi 0,894. O BFMM mostrou resultados dimensionais semelhantes com cinco domínios com valores alfa de Cronbach de 0,804 para extroversão, 0,753 para amabilidade, 0,755 para conscienciosidade, 0,780 para neuroticismo e 0,668 para abertura. Houve associações lineares positivas e estatisticamente significativas do CSAS-BR com amabilidade (ß: 0,230, p <0,001), extroversão (ß: 0,150, p = 0,030) e abertura à experiência (ß: 0,190, p = 0,010). Esses fatores de personalidade promovem interações sociais e relações interpessoais com tendência de serem amigáveis, flexíveis e cooperativas; bem como estarem disponíveis; e com capacidade de se envolver ativamente com as outras pessoas. Conclusões: Este estudo, com a metodologia empregada, mostrou que traços amabilidade, extroversão e abertura à experiência estiveram associados com habilidades de comunicação em acadêmicos de três universidades brasileiras. Os resultados sugerem que a avaliação dos traços de personalidade possa contribuir para o reconhecimento de alunos para os quais o estabelecimento de estratégias especiais de ensino possa melhorar as habilidades de comunicação.

Clinical communication skills and professionalism education are required from the beginning of medical training - a point of view of family physicians.

BACKGROUND: The Brazilian undergraduate medical course is six years long. As in other countries, a medical residency is not obligatory to practice as a doctor. In this context, this paper aims to clarify what and when competencies in communication and professionalism should be addressed, shedding light on the role of university, residency and post-residency programmes. METHODS: Brazilian family physicians with diverse levels of medical training answered a questionnaire designed to seek a consensus on the competencies that should be taught (key competencies) and when students should achieve them during their medical training. The data were analysed using descriptive statistics and correlation tests. RESULTS: A total of seventy-four physicians participated; nearly all participants suggested that the students should achieve communication and professionalism competencies during undergraduate study (twenty out of thirty competencies - 66.7%) or during residency (seven out of thirty competencies - 23.33%). When competencies were analysed in domains, the results were that clinical communication skills and professionalism competencies should be achieved during undergraduate medical education, and interpersonal communication and leadership skills should be reached during postgraduate study. CONCLUSION: The authors propose that attainment of clinical communication skills and professionalism competencies should be required for undergraduate students. The foundation for Leadership and Interpersonal Abilities should be particularly formed at an undergraduate level and, furthermore, mastered by immersion in the future workplace and medical responsibilities in residency.

To participate or not participate in unprofessional behavior - Is that the question?

INTRODUCTION: Medical education provides students with abundant learning opportunities, each of which is embodied with messages concerning what is expected from students. This paper analyses students? exposure to instances of unprofessional behavior, investigating whether they judge such behavior to be unprofessional and whether they also participate in unprofessional behavior. METHODS: The survey developed in the Pritzker School of Medicine at the University of Chicago was the basis of this questionnaire that was answered by 276 students from two medical schools in Brazil and Portugal. RESULTS: Unprofessional behavior was observed frequently by students in both universities, and the mean participation rates were similar (26% and 27%). Forty-five percent of students? participation in unprofessional behavior was explained by academic year, prior observation, and judgment. DISCUSSION: The results indicate that once students have observed, participated in or misjudged unprofessional behavior, they tend to participate in and misjudge such behavior. The frequency with which students judged behaviors they had observed or participated in as ?borderline? or unprofessional could mean that they are experiencing moral distress. CONCLUSION: Proper discussion of unprofessional behavior should foster a broad debate to encourage empowered students, faculties, and physicians to co-create a more professional environment for patient care.

OSCE para Competências de Comunicação Clínica e Profissionalismo: Relato de Experiência e Meta-Avaliação / OSCE for Communication Skills and Professionalism: Case Report and Meta-Analysis

RESUMO A comunicação clínica e o profissionalismo estão entre as principais competências médicas e, portanto, devem ter sua avaliação garantida. Nesse contexto, o exame clínico objetivo estruturado (OSCE) tem papel fundamental. Objetivos Descrever as etapas de elaboração de um OSCE, bem como a avaliação da qualidade das estações e a percepção do estudante de Medicina sobre a sua realização. Método O estudo é composto pela realização de um OSCE com quatro estações por 16 estudantes de Medicina e pela análise da qualidade psicométrica e aplicação de um questionário de satisfação. Resultados Para os estudantes, o OSCE é o método que melhor avalia e ensina essas competências, ao passo que os testes de múltipla escolha estão no polo oposto quanto à avaliação. Em relação à qualidade múltipla das estações: duas se apresentaram com boa confiabilidade, uma se tornou satisfatória após adequação e uma se revelou inconsistente. Conclusão Mesmo bem avaliadas pelos estudantes, algumas estações apresentaram falhas. A análise do OSCE é fundamental para sua validade e mensurabilidade, em especial para o OSCE de alta aposta.

ABSTRACT Clinical communication and professionalism are among the primary medical competencies and therefore must have guaranteed assessment. In this context, the objective structured clinical examination (OSCE) plays an important role. Objectives To describe the steps of developing an OSCE, as well as evaluating the quality of the stations and the medical student’s view of the OSCE. Method The study involved an OSCE with four stations performed by 16 medical students, psychometric quality analysis and the application of a user satisfaction questionnaire. Results For the students, the OSCE is the best assessment and teaching method for these skills, whereas multiple choice tests are at the worst form of assessment. Regarding the multiple quality of the stations, two showed good reliability, one became satisfactory following adjustment and one was inconsistent. Conclusion Although highly rated by the students some of the stations were flawed. Analysis of the OSCE is essential for its validity and measurability, especially for high stakes OSCEs.

O conceito de competência: uma análise do discurso docente / The concept of competence: an analysis of the teachers' perspective

As Diretrizes Curriculares Nacionais para o Curso de Medicina de 2001 têm como eixo norteador 28 competências, sem uma definição do conceito de competência utilizado. Na literatura há uma série de definições, sendo esse tema vasto e polêmico. Desse modo, a forma como a competência é compreendida pelo docente terá um impacto direto na formação do aluno. Com a finalidade de clarificar o conceito de competência médica adotado por docentes do curso de Medicina de uma universidade, foi realizada uma pesquisa qualitativa a partir da apresentação e questionamentos frente a um caso clínico comum. Para a síntese, organização e análise desses discursos foi utilizado o método do Discurso do Sujeito Coletivo. Entre os conceitos de competência pode-se notar a aplicabilidade prática dos conhecimentos, das habilidades e atitudes, aliada a uma prática reflexiva e ética. Esta última tem destaque e é um pilar das competências. Atitudes como comprometimento e respeito foram apontadas como essenciais para apresentar competência. As atitudes e a ética têm um papel central na competência do egresso, e estratégias para estimular seu desenvolvimento devem ser um dos focos da formação médica.

The National Curriculum Guidelines for the Medical course of 2001 have 28 core competences, but lack any defined concept of competence used. A number of definitions can be found in literature; this is a vast and controversial subject. Thus, the way in which teachers understand competence will have a direct impact on student education. A qualitative study was conducted among medicine teachers in order to clarify their concept of medical competence, based on the presentation of a common clinical case and related questions. Discourse of the Collective Subject was the method used to organize and analyze these persepctives. The concepts of competence found included the practical applicability of knowledge, skills and attitudes combined with reflective and ethical practice. The latter is given particular merit and can be seen as a pillar of the competences. Attitudes such as commitment and respect were identified as essential for displaying competence. It follows that the attitudes and ethics of graduates are key elements to their competence and encouraging their development should be one of the focuses of medical training.

Currículo de medicina e as competências propostas pelas diretrizes curriculares / The medicine curriculum and competences proposed for curriculum guidelines

A educação médica passa por críticas quanto aos métodos de ensino e conteúdos. O motivo para mudanças está em possibilitar maior eficácia na formação, permitindo aos egressos lidar com problemas da sociedade brasileira. Este artigo objetiva analisar o conteúdo dos Planos de Ação das disciplinas do currículo de um curso de Medicina, tendo como referência o perfil do egresso e as competências/habilidades propostas pelas DCN para o curso de Medicina. Na organização e análise do material,foram utilizadas Análise de Conteúdo e estatística simples para descrição de parte dos resultados. As análises foram feitas por disciplinas, por semestres e por fases do curso. Constatou-se que 23 das 28 competências/habilidades estavam presentes.Do total de 70 disciplinas, oito não faziam referência a qualquer competência presente nas DCN, e as outras 62 faziam menção a pelo menos uma competência. O currículo, em sua grande maioria, está pautado por competências/habilidades, com o desenvolvimento gradual destas durante as fases do curso médico. A APS é o grande eixo, que percorre nove dos 12 semestres do curso, preocupado com as competências técnicas do egresso, sem se ausentar do papel social da universidade, bem como da relação médico-paciente, do cuidado e do trabalho multiprofissional.

Medical education has been the subject of criticisms regarding teaching methods and content. The reason for change is to ensure more efficient training so that graduates are better prepared to deal with problems typical of Brazilian society. This article aims to analyze the content of the action plans for subjects in the curriculum of an undergraduate medicine course, based onthe graduate profile and competences/skills proposed by the National Curriculum Guidelines (DCN) for the medicine course. The material was organized and analyzedthrough the use of content analysis and simple statistics to describe some of the results. The analyses were made per subject, per semester and per stage of the course. It was found that 23 of the 28 competences/skills were present in 62 of 70 subjects. Out ofa total of 70 disciplines,eight did not refer to any competencespecified in the DCN, the other 62 mentioned at least 1 competence.The curriculum is largely based on competences/skills and their gradual development throughout the phases of medical school. Primary Care is a major thrust, covering nine of the 12 semesters; concerned with the technical skills of graduates without ignoringthe social role of the university as well as the doctor-patient relationship, care and multidisciplinary work.