Conscious sedation in critically ill patients is associated with stressors perception lower than assessed by caregivers.

BACKGROUND: In ICU, the stay is frequently a stressful experience. Caregivers may help to understand patients' perceptions; however, their reliability is uncertain. Despite the recent recommendations of lighter sedation targets, little is known about the impact of "conscious sedation" on ICU patients memories. Purpose of this prospective, observational study is to analyze the stress perception in consciously-sedated ICU-patients, comparing it to caregivers and staff members. METHODS: Twenty-nine high-risk ICU-patients treated with awake/cooperative sedation were enrolled. Before discharge, patients received a validated questionnaire for ICU stressors evaluation, also administered to their main caregiver (N.=29), to caregivers of other ICU patients not enrolled in the study (N.=33) and to staff members (ICU nurses, attending physicians, residents, medical students, N.=56). RESULTS: Total stress score was: patients 141±41, patient relatives 210±63, other relatives: 202±73, ICU staff: 232±44, P<0.001. Among patients, older age (P=0.031), longer ICU-stay (P=0.018) and awake-sedation (P=0.022) were associated with lower stress; sex and illness severity had no effect; mechanical ventilation length (P=0.021) and agitation (P=0.029) were associated with higher stress. Nurses tended to overestimate stressors more than attending physicians and trainees. Within staff members, age (P=0.021) and years of experience (P=0.069) were positively associated with overestimation. CONCLUSIONS: Conscious sedation is associated with stress perception lower than stress assessed by caregivers: relatives and staff members tend to overestimate ICU patient stress, more so with increasing age or expertise. A number of stressors underestimated by staff and families could be target of specific interventions to ameliorate quality of life during ICU stay.

Neurological assessment with validated tools in general ICU: multicenter, randomized, before and after, pragmatic study to evaluate the effectiveness of an e-learning platform for continuous medical education.

BACKGROUND: International guidelines recommend systematic assessment of pain, agitation/sedation and delirium with validated scales for all ICU patients. However, these evaluations are often not done. We have created an e-learning training platform for the continuous medical education, and assessed its efficacy in increasing the use of validated tools by all medical and nursing staff of the participating ICUs during their daily practice. METHODS: Multicenter, randomized, before and after study. The eight participating centers were randomized in two groups, and received training at different times. The use of validated tools (Verbal Numeric Rating or Behavioral Pain Scale for pain; Richmond Agitation-Sedation Scale for agitation; Confusion Assessment Method for the ICU for delirium) was evaluated from clinical data recorded in medical charts during a week, with follow-up up to six months after the training. All the operators were invited to complete a questionnaire, at baseline and after the training. RESULTS: Among the 374 nurses and physicians involved, 140 (37.4%) completed at least one of the three courses. The assessment of pain (38.1 vs. 92.9%, P<0.01) and delirium (0 vs. 78.6%, P<0.01) using validated tools significantly increased after training. Observation in the follow-up showed further improvement in delirium monitoring, with no signs of extinction for pain and sedation/agitation measurements. CONCLUSIONS: This e-learning program shows encouraging effectiveness, and the increase in the use of validated tools for neurological monitoring in critically ill patients lasts over time.

Do occupational therapists' communication behaviours change with experience?

BACKGROUND: An increasing amount of literature has studied changes in communication skills in medical and nursing undergraduate students. AIM: To evaluate whether occupational therapists' communication behaviours change with experience. MATERIAL AND METHODS: A total of 45 participants (second-year OT students, final-year OT students, professional OTs) were enrolled and met three simulated clients. The role plays were video-recorded and analysed through OT-RIAS (Occupational Therapy-Roter Interaction Analysis System). Chi-square tests were used to analyse the statistical differences between groups for the OT-RIAS categories. RESULTS: Process represented 30.74% of communication for second-year students, 33.69% for final year students, and 35.58% for professional OTs; Occupational therapy ranged from 30.41% in the second-year students to 32.54% in the undergraduates and 37.04% in the professional OTs; Medical increased from 18.66% to 34.33% of the final-year students and 47.01% of the professional therapists. Personal and Psychosocial slightly decreased through experience. Emotional decreased gradually: 39.8% in the second-year students, 29.54% in final-year students, and 30.66% in professional OTs. CONCLUSION: During training in occupational therapy the communication skills changed, assuming a more technical shape, increasing control and content-related OT communication. Nevertheless, the therapists' communication behaviours showed the endurance of attention to the client's point of view.

Difficult encounters with a hemophilic patient: the inner perspective of physicians.

This study aimed at exploring the hematologists' internal representation of a difficult encounter with a hemophilic patient, using a written open format. Narrations were analyzed with Interpretative Phenomenological Analysis. Three main issues were identified, each with sub-issues: (1) Inside the relationship: to tell or not to tell, the balance between a normal life and a deviant medical condition, the guilt; (2) The borders of the professional role: professional values, the "do-it-all" doctor; and (3) The existential confrontation. This study reveals the deep involvement of physicians with their patients, at a professional level and, strongly, at a personal level. The experience of being so deeply involved should be considered in the continuing medical programs for physicians dealing with hemophilia.

Satisfaction for quality of life: a comparison of patient and occupational therapist perspectives.

OBJECTIVE: To verify whether the patient's satisfaction with quality of life (QoL) is similar to or different from the occupational therapist's perception of the patient's satisfaction. MATERIALS AND METHODS: Each patient enrolled was given the Satisfaction Profile (SAT-P) questionnaire to be filled out personally; the same questionnaire, the SAT-P, was given to the respective occupational therapist who was asked to fill it out by evaluating the patient's satisfaction as perceived by the therapist. A descriptive statistic was applied for socio-demographic data to describe the cohort. Differences between patient and therapist answers to the SAT-P were evaluated using a t-test. RESULTS: 12 occupational therapists and 69 patients participated in the study. A significant difference between occupational therapist and patient was found for Factor II (physical functioning) (p = 0.048) and for Factor V (social functioning) (p = 0.011). The comparison of patient and therapist mean scores showed that therapists had a tendency to underestimate patient satisfaction levels for all factors except Factor IV. DISCUSSION: The results showed similarities between the therapist and the patient's view of the patient's satisfaction with QoL, confirming occupational therapy as a client-centred discipline. However, as far as physical functioning is concerned, it is possible that the professional makes an "a priori" judgement, considering the objective clinical data regardless of the patient's subjective experience of his/her illness.

To be or not to be: the patient's view of thrombophilia testing.

INTRODUCTION: The literature on the psychological effects of thrombophilia testing is unclear. Little is known about the complex world of significance subjects construct around the test. OBJECTIVE: The study explored the peculiar network of implicit meanings that may be linked to the experience of being tested. MATERIALS AND METHODS: The research was designed according to Interpretative Phenomenological Analysis (IPA). 19 patients were interviewed. Integral verbatim reports of the interviews were analyzed through an inductive process aimed at gaining a holistic understanding of the narratives. RESULTS: Two main issues were identified, each with sub-issues: (1) the clinical problem: (1.1) unhealthy blood and (1.2) the family issue; (2) the test: (2.1) knowing for the sake of knowing; (2.2) knowing for the sake of doing; (2.3) not knowing. CONCLUSIONS: The thrombophilia test is part of a larger network of meanings, where information about the test and its results seem to be lost. PRACTICE IMPLICATION: The study suggests the importance of paying greater attention to the process of doctor-patient communication at the time of the test. The theme of being informed is important for patients, yet often they are not able to understand or retain the information they receive, increasing the risk of misunderstandings.

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare.

BACKGROUND: The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians' preparedness to engage in difficult conversations. AIM: To describe the implementation of PERCS in an Italian hospital and assess the program's efficacy. METHODS: The Italian PERCS program featured 4-h experiential workshops enrolling 10-15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS: 146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patient's perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. CONCLUSION: PERCS proved culturally adaptable to the Italian context and effective in improving participants' sense of preparation, communication skills, and confidence.

How Italian students learn to become physicians: a qualitative study of the hidden curriculum.

BACKGROUND: A great deal of what medical students learn in terms of behaviors, values, and attitudes related to their profession is conveyed by the hidden curriculum. AIM: To explore the messages conveyed by the hidden curriculum as perceived by third-year students of the Milan School of Medicine, Italy, following their first clinical internship. METHOD: Three group interviews were conducted. Students were asked to reflect on values, attitudes, and implicit rules they noticed during their internship experiences. Verbatim transcripts of the group interviews were analyzed through content analysis using Nvivo8. RESULTS: Of the 81 students, 57 (70%) participated in the group interviews. Six themes were identified within the hidden curriculum: Physicians reassure and protect patients; power differential between physicians and patients; variable respect for patients; disease-centered medicine; respect for hierarchies; and delegation of patients' emotional needs to nurses. CONCLUSIONS: Our findings suggest that the hidden curriculum has a strong cultural component. In our students' experience, the hidden curriculum conveyed a paternalistic model of physician-patient relationships. Some of the messages conveyed by the actual hidden curriculum may compromise the standards formally taught in medical schools about doctor-patient relationships. Organizational culture change and student empowerment could be fostered to counteract the negative effects of the hidden curriculum.

[Between science and suffering: difficult conversations in healthcare]. / Tra scienza e sofferenza: le conversazioni difficili in sanità.

INTRODUCTION: This article describes the adaptation and implementation of the Program to Enhance Relational and Communication Skills (PERCS) in Italy. PERCS was originally developed at Children's Hospital Boston and aims to enhance clinicians' preparedness to engage in difficult conversations with patients/families. DESCRIPTION: After a period of collaboration by the first author with the Children's Hospital Boston, PERCS was launched at San Paolo Hospital, Milan, in 2008. To date, over 80 participants have voluntarily attended the program. The program features monthly 4-hour workshops geared around the enactment of a case scenario by trained actors and participants. Each workshop enrolls 10-13 interdisciplinary participants. After each enactment, participants receive feedback by actors, other participants and facilitators on the challenging junctures of the conversation. Pedagogical principles include: creating safety for learning; emphasizing moral and relational dimensions of care; suspending hierarchy among participants; valuing self-reflection; honoring multiple perspectives; and offering continuity of the educational offering. CONCLUSIONS: Implementing PERCS in Italy has demonstrated that it is possible to culturally adapt learning opportunities that embrace the relational and ethical experience of learners. The positive response of participants affirms that relational learning is meaningful and needed.

[Efficacy of an emotional-based psycho-educational strategy for patients suffering from type 2 diabetes. An almost experimental pilot study]. / Efficacia di un intervento psicoeducativo a matrice emotiva per pazienti affetti da diabete di tipo 2. Uno studio pilota quasi sperimentale.

The authors discuss the creation of a psycho-educational course based on emotions in a group of diabetes type 2 patients. Its effects were assessed : biologically, by measuring blood sugar levels and body weight; cognitively, by behavioral tests; psycho-emotionally, by Moreno's Social Atom test that evaluates the patient's personal life in the light of his/her pathological conditions. 12 subjects were studied (10 patients and 2 spouses). Results showed: significant improvement in life-style; a marginal improvement of weight and level of coping with the illness; a non-significant improvement in blood sugar levels. The study showed that one particularly important aspect regards the role of nurses within the multidisciplinary team conducting the study.

An exploratory study on the Italian patients' preferences regarding how they would like to be told about their cancer.

GOAL: Major cross-cultural differences in truth-telling attitudes and practices have been demonstrated. Until recently, in Italy the doctor could conceal both diagnosis and prognosis to seriously ill patients out of beneficence. Signs of change have been reported, but the extent and way patients would be informed is still unknown. The aim of the study was to assess Italian patients' preferences regarding how they would like to be told about their cancer and its treatment. We examined the factor structure of the Measure of Patients' Preferences--Italian version (MPP-It) and whether demographical and medical variables were associated with the dimensions of patients' preferences. MATERIALS AND METHODS: Patients were invited to participate during a visit to the oncology department of the Lecco hospital (Italy) for chemotherapy or follow-up. An Italian version of the MPP-It was administered. Data were analyzed through a factor analysis. MAIN RESULTS: A total of 210 cancer patients agreed to participate. Three main factors were identified: (1) Information (Talking About the Disease). Items in this factor were concerned with the dialogue about the disease and treatment options; (2) Support (The Emotional World of the Patient). These items referred to the supportive and relational aspects of the physician-patient encounter; (3) Care (The Ideal Doctor). These items related to the patients' desires about the doctor's personal attributes. CONCLUSIONS: The first two factors, information and support, were comparable to those of similar American and Asian studies. The study suggests a cross-cultural uniformity among cancer patients who appreciate the informative and clearness of the communication aspects as being primarily important, while also giving high points to relationship aspects. The third factor appears unique to the Italian context.

["Diabetes is for me ...": the health care workers perspective]. / "Il diabete e per me ...": la prospettiva degli operatori sanitari.

AIM: To analyze the representations and meanings of diabetes from the health workers perspective through an ethnographic approach. METHOD: Participants who attended a national conference on diabetes care were asked to write a narrative responding to the question: "For me, diabetes is...". Narratives were qualitatively analyzed by two researchers following the principles of content analysis. Nvivo software was used to organize and code the data. RESULTS: Of the 147 conference participants, 140 narratives were analyzed: 86 written by nurses, 54 by physicians. Six themes emerged: The disease which summarizes the biomedical and biopsychosocial definitions of diabetes; The patient's illness experience, which describes the impact of diabetes on the patients lives; The clinician's experience, where clinicians fear the impact (actual or potential) of diabetes on their families or themselves; The clinician-patient relationship, where the importance of a good patient-clinician relationship and the related emotions are described; and The social and healthcare system, which describes the healthcare system as an aid as well as an obstacle in patients' care. CONCLUSION: Despite some academic description of diabetes, our results showed that health care workers, especially nurses, have a profound comprehension of the patient illness experience that sometimes leads to the identification with patients. The relationship and patient education were described as a complex and challenging area of practice for both professions. Training on relational and emotional skills could improve the patients care.

Assumptions and blind spots in patient-centredness: action research between American and Italian health care professionals.

OBJECTIVE: To examine how patient-centredness is understood and enacted in an American (US) and an Italian group of health care professionals. METHODS: An action research methodology was used. Two interprofessional groups of US (n = 4) and Italian (n = 5) health care professionals independently wrote a patient-centred dialogue between a doctor and a patient based on the same scenario. The dialogues were then translated and exchanged. Both groups independently commented on the patient-centred aspects of the other's dialogue by completing a written questionnaire. Their respective comments were then shared by international videoconference. The transcript of the videoconference was analysed via content analysis. The participants' opinions about the study were then evaluated. RESULTS: Exploring the patient's illness experience and handling the patient's emotions were identified as core components of patient-centred care by both the US and Italian groups, but were expressed differently in their respective dialogues. Respecting the patient's autonomy was recognised as a component of patient-centred care only by the US group. The Italian group demonstrated a more implicitly paternalistic approach. Participants highlighted the usefulness of one another's feedback to uncover cultural assumptions of patient-centred care and increase self-awareness. CONCLUSIONS: Results suggest that the concept and practice of patient-centred care is variable and may be influenced by culture. The study methodology improved participants' self-awareness of cultural values, and has potential as a cost-effective, experiential educational approach.

[When a doctor must treat a collegue]. / Quando un medico cura un medico.

The literature about the physician emotional life underlined how to care a collegue generates stress. However this situation is not so much investigated. The aim of this article is to investigate the nature of the relation and of the physician inner life when the doctor meets a patient-doctor, by means of narratives and a qualitative analysis. Having a colleague as patient seems to be very challenging and to evocke struggling feelings difficult to handle with well known stategies.

When talking to the patient is difficult: the physician's perspective.

The aim of the study was to analyze the difficult doctor-patient relationship from a doctor's perspective. A qualitative-interpretative approach was employed to analyze representations of difficult visits collected by means of written narrations. Two main scenarios were identified: (i) a 'personal scenario' in which the doctor had difficulties from a purely personal perspective; and (ii) a 'professional scenario' in which the doctor had difficulties as a professional when the 'other' resists or in facing the 'other' who resists. A further scenario was identified in which problems were generated by the family of the patient. Results suggest that the relation between doctor and patient may be very complex. Difficulties may be internal to the doctor, hence intra-psychic, depending on being both a professional and a human being. Difficulties may also be external between two psychological subjects (labeled as inter-psychic), where interaction of the 'you' and the 'other' becomes a battleground, a wall of opposition, or alternatively a place of experimentation with relationships. Furthermore, external difficulties may also be between more than two persons (labeled as inter-personal), by the possible multiplicity of the 'other'. This happens in particular when the 'other' is represented by the family.

[A very difficult question: a qualitative research from the nurses' perspective]. / Una domanda davvero difficile: una ricerca qualitativa secondo la prospettiva degli infermieri.

UNLABELLED: Aim of this paper is to identify what is a difficult question, according to nurses' perceptions. Since the knowledge on this area is limited, a qualitative method was preferred for a pilot study. METHODS: As part of a training exercise, fifty-one nurses were requested to recall, from their own experience, and to describe, a difficult question asked by a patient, that created problems to the nurse. Data were analysed with hermeneutical-interpretative methodology. RESULTS: Three main conceptual cores were identified: the characteristics of the difficult question; the "after the question"; and the source of the problem experienced. The first core is related to the content of the question but also to the characteristics of the person that formulates it, to the setting, and to the subjective perception of the time window. What happens after the question is related to the nurse's reactions. The third conceptual core is related to the interplay between different possible roles: patient, professional, and human being. The denominator of the three cores has to do with the emotional-relational dimension of the communication. This difficulty may partly be due to the lack of education in the management of the emotions.

Effects of a course on ophthalmologist communication skills: a pilot study.

INTRODUCTION: Although the issue of communication skills is now considered crucial for ophthalmology, no previous research has discussed training in this field. This study aimed to discuss the effects of a 16 hour communication skills course for ophthalmologists. In particular the study assessed the interest of participants with respect to the topic and the efficacy on participants' communication skills, at least in a laboratory setting. MATERIALS AND METHODS: Eleven ophthalmologists participated in the course. Learner satisfaction was evaluated using a questionnaire with a six-point Likert scale. Course efficacy was assessed by a comparison between communicative behaviour of ophthalmologists in videoed role playing before and immediately after attending the course. Videoed consultations were coded using the Patient Centred Score Sheet (PCSS) and the Roter Interaction Analysis System (RIAS). The Wilcoxon signed rank test was used for statistical analysis. FINDINGS: The course obtained high satisfaction in participants (mean score 5.1). In the post test role playing, patient centredness increased significantly (p < 0.01). Furthermore, ophthalmologists improved their competence in using open ended questions (p < 0.02), process categories (e.g. orientation statement) (p < 0.05) and social communication categories (e.g. personal statement) (p < 0.01). DISCUSSION: According to our findings, ophthalmologists did show satisfaction for the course. Results also indicate that the course positively influenced ophthalmologist communication competence, at least in a laboratory setting. After the course, participants became more attentive to patients' psychosocial needs, both in terms of general quality of consultation (patient centredness) and in terms of using specific interpersonal skills. Present results are considered preliminary, and further research is needed with a larger sample and including an evaluation of the effects on ophthalmologists' communication skills in clinical practice.