The primary reason for my stay in Boston was to learn more about the Institute of Professionalism and Ethical Practice (IPEP). This is a fantastic institute that aims to promote relational learning learning for health care professionals that integrates patient and family perspectives, professionalism and the everyday ethics of clinical practice.
They run a great range of educational activities and workshops through their educational outreach forum, the Program to Enhance Relational and Communication Skills (PERCS). Healthcare professionals from all disciplines can attend these sessions, which explore how clinical practice can be improved with a focus on difficult conversations in healthcare. I was lucky enough to attend a couple of these sessions, including one on an area pioneered by IPEP and BCH that I have been particularly interested in, supporting families by the bedside – facilitating parental presence during invasive procedures. This workshop came about as parental presence during invasive procedures was always considered controversial and that caused a lot of concern in medical professionals, with common concerns being that it would affect their abilities to undertake the procedure, teach other staff and make decisions if the parents were present. The IPEP team and hospital clinicians involved implemented formal guidelines and commenced these educational workshops with positive results for both the clinicians involved in the practice and for parents and caregivers. See the article here for more detail! http://www.ncbi.nlm.nih.gov/pubmed/22997205
The workshop was lead by the wonderful Elaine Meyer (whose Tedx talk on being present, not perfect, I would recommend). After some theory and teaching about facilitating parental presence, we then had a discussion what the challenges are of this and what solutions could be.
- Interference and distraction from parents
- Countertransference – parents picking up staff anxiety or stress
- What if a mistake is made.
- Enough space around the patient
- Language barriers
In talking about the solutions to these challenges, we explored trying to anticipate the reaction of the family, whether they might be a risk of any of these. If the family members are interfering or distracting the medical team, it was highlighted how important it is just to be honest with the family and explain that their actions could have an impact on the care of the child and moving the conversation to a safer zone, still in sight of the child but out of the way of those carrying out the care. To prevent any countertransference, a good strategy was to ensure it was clearly communicated who was in the room/area to help staff be mindful of the parental presence and not say anything inappropriate or that might unnecessarily scare the parents. Some good communication tips were also given if it is clear something has been said that does upset or anger the parent, particularly to always acknowledge the issue, for example ‘I can see that what I have said has upset you, what would you like me to explain that might help?’.
One of the points about this was that it does not have to be a nurse or a doctor who is the parent facilitator, it could be someone from any profession, e.g. CLS, a social worker etc so long as either a nurse or a doctor gives a debrief at the end of the procedure. The workshop I attended had a variety of different job roles there and we discussed how each could use their skill set to work with the families in these situations. We then had two simulations with actors playing the parents. The condition of the child was already set with nurses acting out the procedure then we decided as a group what sort of people the parents would be, what jobs they would have, what their relationship was like and how anxious they would be. One person from the group then volunteered for the simulation which we then watched on video. A nurse went for the first simulation then a social worker for the second, then afterwards, we had a group discussion including the actors and talked about how everyone felt, what had worked and what could be improved etc. The simulations were incredibly realistic (the first a post theatre child in lots of pain and requiring breathing support and the second was the intubation of a bronchiolitis baby that required CPR after a failed attempt) and the actors were very convincing and not afraid to be ‘difficult’ parents. For both simulations it was amazing to see how the presence of a facilitator kept everything calm and allowed the parents to be there for their child without impeding the care provided. It was an amazing workshop and I was then lucky enough to see it in practice when shadowing on the PICU (see previous blog post) so it was great to how with interventions like these workshops, the evidence can be turned into good practice.
Another initiative is the PERCS Rounds, which take place regularly on the critical care units and are hour long sessions, open to all interested staff that provide an opportunity for interdisciplinary discussion on how to navigate the more challenging situations in everyday practice. The theme for the round I attended was ‘High Reliability: Making the Leap from Classroom to Clinical Practice’. The whole hospital is currently being trained in high reliabilty, which aims to improve the strength of an organisation through individual actions, providing staff with an error prevention tool kit with the three main themes of 1. Speaking up for safety; 2. Communicating clearly; 3. Pay attention to detail. The PERCS round allowed the staff present a safe and confidential space to discuss how they felt about the implementation of this, how it had helped them in clinical practice and what had happened when challenges had occurred. This is a really good session, allowing different disciplines to talk openly together about issues in practice something I feel is really important to help a team work well together, although the bedside nurses did tell me they really struggled to get to these sessions.
Some new work being carried out by IPEP includes a new research study on aligning family and team expectations during surgical consent. Studies have shown that families have a poor memory or understanding of what the surgeons have told them during consent and that there have been issues where families have not realised the extent of aftercare that would be required post surgery and that there has been confusion. This study will look at what the issues are and create an educational intervention for the surgeons and look at the impact it makes on improving the communication during consent. The IPEP team is also working to put some of their workshops online so they can be accessed around the world. They are being put onto the Open Pediatrics site, with the most recent being on disclosing medical errors. It is definitely worth taking a look at the resources online, they include some very engaging educational tools and can be used towards revalidation.
Take a look at the IPEP website if any of this interests you, there is a comprehensive list of their published research on there!