Conflict

Navigating difficult conversations: the role of self- monitoring and reflection-in-action Anita Cheng,1 Kori LaDonna,2 Sayra Cristancho2 & Stella Ng3

CONTEXT Clinicians draw upon experiential knowledge to manoeuvre difficult conversations, using tacit knowledge that is difficult to explicitly teach. Instead, learners are taught to communicate through role-play and checklists, both of which are approaches that may fail during moments of clinical complexity. We know that difficult conversations may provoke anxiety in learners, but we know little about how they learn to navigate them. Without a deeper understanding, we may fail to equip learners with the skills to manoeuvre these conversations in practice.

METHODS Using constructivist grounded theory, we applied the sensitising concepts of self-monitoring and reflection-in-action both to explore the process in which trainees engage to navigate difficult conversations and to expand understanding about these theories. We situated our research in the neonatal intensive care unit (NICU), in which difficult conversations are ubiquitous. Fifteen resident and fellow trainees drew rich pictures about difficult conversations, and shared their drawings and experiences during semi-structured interviews. Interview transcripts were analysed using constant comparative analysis.

RESULTS Participants described how they responded when checklist approaches became ineffective during moments of unexpected uncertainty and complexity. For participants, these indeterminate zones of practice triggered a process of seeing families differently and then pausing to understand problems that arose with the checklist-based approach. Throughout this process, learners actively observed others’ communication approaches, negotiated their roles within difficult conversations, and abandoned the checklist to engage differently with families.

CONCLUSIONS Our findings suggest links between the theories of self-monitoring and reflection-in-action, and describe the engagement of both processes in the context of NICU conversations. Self-monitoring may lead to the realisation of an indeterminate zone of practice, after which trainees may respond through reflection-in-action. We recognise that training programmes may need to teach a checklist-based approach as a starting point. We suggest that trainees also be given purposeful opportunities and support to depart from checklists in order to compassionately and flexibly navigate difficult conversations with families.

Medical Education 2017: 51: 1220–1231

doi: 10.1111/medu.13448

1 Department of Neonatal and Perinatal Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada 2 Center for Education Research & Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada 3 Department of Audiology, St Michael’s Hospital, Toronto, Ontario, Canada

Correspondence: Anita Cheng, Department of Neonatal and Perinatal Medicine, London Health Sciences Centre, Room D4- 200, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada. Tel: 00 1 519 685 8500 ext. 64361; E-mail: [email protected]

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challenging conversations

INTRODUCTION

Expert clinicians typically use and build upon their existing knowledge to improvise during unclear or unexpected practice situations, such as difficult conversations with patients and families.1–3

However, as some of this knowledge is tacit, clinicians’ approaches to communication during uncertain situations are difficult to define, to teach and to assess. For trainees who lack sufficient or appropriate experience, therefore, difficult conversations are uncomfortable and tend to provoke anxiety.4 One context in which difficult conversations abound is the neonatal intensive care unit (NICU), in which parents need to be counselled through painful decisions about life support or the news that their baby will die. The uncertainty, unexpectedness and difficult diagnosis of the infant, compounded by the family’s social and emotional experiences, and the provider’s relationship with the family, all contribute to the complexities of difficult conversations in the NICU.5

We know neither how trainees learn to navigate difficult conversations in the NICU, nor how their experiences shape their learning. Without a deeper understanding of trainees’ experiences of learning to communicate during moments of clinical complexity, we risk failing to effectively equip them to manoeuvre these important conversations in practice.6

Difficult conversations are high-stakes interactions, in part because poor physician–patient communication can have devastating emotional effects for patients and families.7 Traditionally, handling difficult conversations has been taught using lectures and role-plays,8,9 as tips for communication etiquette,10 and through stepwise protocols for breaking bad news;11 these skills are typically assessed during objective structured clinical examinations (OSCEs). Not uncommonly, trainees memorise checklists of information and then become reluctant or are ill-prepared to go ‘off script’.9 However, these formulaic approaches fall short5 when real life complexities require improvisation and real-time problem solving,4,9 and they may impact on how patients and families perceive difficult conversations. For instance, a trainee’s performance during an OSCE station does not necessarily correspond with parent satisfaction.12 Specifically, NICU families have indicated that checklist-based approaches can be a barrier to compassionate communication13 and psychosocial support.8

Trainees need additional or alternative approaches to learn how to navigate difficult conversations. As self-monitoring is an important part of self-regulation in practice, it may be a useful skill for helping trainees navigate high-stakes conversations. Self- monitoring is defined as ‘an ability to attend, moment by moment, to our own actions; curiosity to examine the effects of those actions; and willingness to use those observations to improve behaviour and patterns of thinking in the future’.14

Self-monitoring occurs in real time, and is required to recognise errors, limitations and personal emotions, to stimulate problem solving around complexities and to recognise when it is necessary to ask for help.15 Clinicians practise self-monitoring to identify families’ emotional responses and their triggers, to de-escalate intense situations and to begin to restore trust.16 It is through self- monitoring, for example, that, while counselling a family, a clinician may sense that the family does not understand or feels uncomfortable, and that the current conversation is ineffective or harmful. This recognition is a prerequisite for shifting the conversational or counselling approach. Through effective self-monitoring, clinicians can recognise their learning needs and can appropriately pursue professional development to hone their skills.17 In a training culture in which residents are rarely observed directly during their interactions with patients, the ability to self-monitor may become critical.4

Self-monitoring seems to be implied in theories of the reflective practitioner, as self-monitoring echoes descriptions of reflection-in-action, the element of reflective practice in which practitioners engage when ‘thinking on their feet’.14 Through reflection-in- action, ‘the practitioner allows himself to experience surprise, puzzlement, or confusion in a situation which he finds uncertain or unique. He reflects on the phenomenon before him, and on the prior understandings which have been implicit in his behaviour. He carries out an experiment which serves to generate both a new understanding of the phenomenon and a change in the situation.’3

Reflection-in-action tends to occur within indeterminate zones of practice, which Schön3 describes as uncertain, unique, value-conflicted or unstable practice situations that do not lend themselves readily to technical or scientific solutions. Instead, the reflective practitioner engages reflection-in-action to navigate and respond to indeterminate zones of practice.

By this definition, difficult conversations with patients and families are indeterminate zones; to

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How NICU trainees navigate difficult conversations

inform strategies to support communication training, we require a theoretically informed understanding about learners’ experiences of, and reasoning during, difficult conversations. As both self-monitoring and reflection-in-action seem to address the gaps in protocol-driven approaches to communication, they provide useful and complementary theoretical starting points. Therefore, we aimed to use the sensitising concepts of self-monitoring and reflection-in-action both to explore the process in which trainees engage to navigate difficult conversations in the NICU, and to further develop these theories through empirical study.

METHODS

We used constructivist grounded theory (CGT) to explore how trainees navigate difficult conversations in the NICU at one Canadian teaching hospital. Grounded theory is an appropriate and useful methodology for asking how and why questions about complex and poorly understood phenomena.18,19 Constructivist grounded theory is also well suited to expanding and refining extant theory.20

Given the co-construction of data between researchers and participants in grounded theory, an understanding of the background of the research team is essential. The research team consisted of health professions education researchers: AC is a neonatologist; SN is a paediatric audiologist, and SN, KL and SC are PhD researchers with expertise in health professions education research and qualitative research approaches.

Participant recruitment and sampling

We purposefully chose to situate our research in the NICU, in which the negotiating of difficult conversations is a feature of many patient encounters. Using convenience sampling,19 all neonatal fellows and residents completing an NICU rotation at one Canadian academic institution were invited to participate. Information about the study was e-mailed to trainees 1 week prior to their rotations. Without disclosing our sensitising concepts, participants were informed that our aim was to use visual methods and semi-structured interviews to explore their experiences in difficult conversations in the NICU. Eighteen trainees were then re-approached at the start of their rotations and invited to participate. Of these, 15 neonatal

fellows, paediatric and obstetrics residents consented (13 women, two men), two declined and one was unable to complete the study.

Data generation

During recruitment, participants were informed about the method of data generation, which involved a combination of visual methods and an individual, 60-minute, semi-structured interview that would occur at the end of the rotation. They were told they would be asked to share one or two stories of difficult conversations encountered during the 4-week NICU rotation. We defined a difficult conversation as an encounter with a family during a high-intensity situation that the trainee found challenging or surprising; this included breaking bad news and counselling families about high-stakes decisions.

We used rich pictures to elicit how trainees use self-monitoring to navigate difficult conversations. A rich picture uses symbols, metaphors or diagrams to depict information that may be difficult for participants to put into words.21 Visual methods are useful for addressing some of the limitations of traditional interviews because they enable tacit knowledge to be made explicit and discourage participants from simplifying or omitting key details.22 During recruitment, AC introduced rich pictures to each participant and showed examples of rich pictures from other studies published by members of the research team.23 Participants were instructed that their drawings did not require artistic merit and did not need to report everything that happened during a conversation. Instead, participants were encouraged to draw their perspectives, thought processes and emotions in each encounter. Participants were given sketchbooks and were asked to work on their drawings over the course of their 4-week rotation. They were encouraged to add to their drawings if they developed new insights. Figure 1 shows an example of the kinds of drawing participants created during the study.

At the end of the 4-week rotation, participants shared their drawings and experiences during their individual interviews. Participants were asked to describe the cases they had chosen, the content of their drawings, and why they had chosen to tell these particular stories. They were also asked to elaborate on their thoughts, feelings and decisions during each difficult conversation, including on how the event had impacted them, how they

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thought it had impacted the family, and what they had learned from the experience. All interviews were conducted by AC and were audio-recorded and transcribed verbatim. Six participants chose to tell one story each and nine participants shared two stories each, producing a total of 24 stories of difficult conversations.

Data analysis

Data collection and analysis occurred iteratively; in order to challenge and refine our ongoing analysis,19 questions asked in subsequent interviews were informed by preliminary coding. As the drawings were used for the purpose of eliciting participants’ stories and understandings, they were not aesthetically analysed.24 The interview transcripts were analysed using Charmaz’s constant comparative approach, a coding process with three iterative phases.19 Based on the first four interviews, AC and KL used initial coding to identify preliminary codes, and then developed focused codes by condensing frequently occurring

initial codes into themes. Themes were applied to the next four transcripts to refine and expand the developing analysis. After further team discussion, preliminary categories were iteratively developed and refined through analysis of the entire dataset; true to the iterative nature of constant comparative analysis, we also added additional initial codes at this stage. Theoretical coding then enabled us to more explicitly link categories, and to theoretically conceptualise findings. During analysis, we blended the inductive nature of this theoretical coding with extant theory of self- monitoring and reflection-in-action. The team debriefed at each stage of the analytical process25

to ensure rigor, credibility, originality, resonance and usefulness of the data generated.19 We ceased data collection when data analysis reached theoretical sufficiency; that is, although we recognised that we might learn new information by interviewing additional participants, we determined that the data collected were sufficient to inform our exploratory research questions.20,26

All research procedures were approved by the

Figure 1 Example of a rich picture drawn by a participant describing the weight of bad news placed on the parents in a difficult conversation as the team discussed with them the option of withdrawing life support for their baby

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Health Sciences Research Ethics Board of the University of Western Ontario.

RESULTS

Our findings represent how trainees learned to navigate unexpected complexities during difficult conversations. We describe what indeterminate zones of practice look like in the context of NICU conversations, what trainees experience within these zones, and how they respond. For participants, recognising the limits of an ideal approach triggered a process of seeing differently and pausing to understand the problem, leading them to respond by observing actively, making decisions about negotiating roles, and abandoning the checklist to engage actively. Although trainees varied in level of experience, findings were similar across all training levels.

Encountering indeterminate zones

The difficult conversations that participants described included antenatal consultations, breaking bad news, and discussions about withdrawal of life support. Participants often started with the ideal approaches they had learned during their training, using a rehearsed ‘head-to-toe’ approach for disclosing all required information to parents. They had in mind a practised checklist of medical content, as well as the ideal communication skills required to enact empathy:

‘. . . when breaking bad news. . . you’re supposed to be able to take the time that you need with the family. . . ask questions and allow them to talk a lot.’ (Participant 8)

However, in the face of unexpected complexities, participants quickly realised that although their checklist-based approach was effective for passing an OSCE station, it was inadequate for the layers of complexities encountered during real-world clinical practice. Participants recounted how language barriers and religious differences hindered their ability to communicate effectively; trainees were surprised when parents responded with extreme sadness or anger that seemed out of proportion to trainees’ expectations. For example, one participant was taken aback by a family’s anger based on their religious convictions:

‘When I had given the option of comfort care [non-resuscitation], the mother got very, very upset and she began to yell and say, “How dare

you, what kind of doctor are you, how can you even suggest killing my babies, you want me to kill my babies and not resuscitate them!”’ (Participant 9)

In such moments, trainees realised that their checklist-based approach to communicating ‘properly’ did not meet the nuanced needs of clinical practice.

In the zone: seeing differently

In these indeterminate situations, participants often described a moment at which they were able to see the families differently: that is, they suddenly shifted their perspective or focus, empathised with the family, and gained a deeper understanding of how the family experienced clinical complexity. One participant described being engrossed in resuscitating a baby whose twin had died the previous night. She described herself as in the middle of a chaotic scene, in a loud and busy room with alarms ringing, bright lights, and rapid action around the baby. While working furiously to save the baby, she suddenly shifted her focus away from the acuity of the case to see the baby’s parents sitting in the dark, silently watching everything from across the room:

‘I felt so terrible. They were sitting at the empty incubator where their other son had been just 24 hours before.’

This new insight led the participant to empathise with the parents:

‘. . . a number of emotions. . . being uneasy, being very sad, and being mad. . . why does this have to happen? These parents and this baby have been through enough.’ (Participant 11)

Seeing differently allowed participants to shift their focus beyond their role in a purely medical situation and to appreciate the impact of critical illness on families. Seeing differently was a significant learning moment for participants, as illustrated by one interviewee, who described the courage of parents who had decided to withdraw life support from their child:

‘I learned from them humility, compassion, consideration, and courage.’ (Participant 4)

Another participant told of her admiration for a mother, described initially as subservient to the

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father and reliant on him to translate conversations and make decisions for the baby. She began to see the mother differently when she witnessed the parents reverse roles:

‘The power of a woman who was initially weak. . . she was going to lose her baby. . . then suddenly turns around, seeing the dad, who is now breaking down. And then becomes a person who is rock solid, trying to now manage [comfort] the dad. . . that switch-over was the most significant thing about the situation.’ (Participant 6)

For participants, seeing differently was profoundly impactful in terms of re-humanising their view of medicine.

In the zone: pausing to understand

If the situation was non-emergent, once participants were able to see differently, they paused to understand the nuances of the clinical situation. For example, when disclosing to parents that their baby experienced complications, one participant was caught off guard by the parents’ apathetic demeanour and tried to understand their response. The participant was trying to get a sense of whether the mother had misunderstood or if she was upset either by the news or with the participant:

‘. . .I felt like I didn’t get anything from. . . talking to her, no facial expression whatsoever. . . You need to stop for a second. . . rethink what you’re saying. . .is this the right thing to say?’ (Participant 13)

Similarly, another participant was surprised by intense emotions from the parents after she had disclosed a diagnosis of Down’s syndrome. The participant did not perceive this as a catastrophic diagnosis in comparison with those of other babies in the NICU, who were much sicker. Consequently, she was startled when the parents responded as if the diagnosis was a death sentence. She found herself pausing to understand her surprise not only at the parents’ negative outlook, but also at her emotional response:

‘I wasn’t anticipating that I was also going to be struggling with my feeling sad for the parents, and feeling a bit frustrated as well, that they were so negative about everything.’

After being initially caught off guard by the discrepancy between the parents’ reaction and her own, she paused to understand:

‘. . .made me realise there was a real difference in the way that I was looking at the baby and how the parents were looking at the baby. . . they were really high-achieving people, and they have a lot of expectations for their child which probably had to be put aside, to a great extent.’ (Participant 7)

Pausing enabled the participant to relate more effectively to the parents, rather than invalidating their experience.

Another participant described trying to give parents updates about their baby, but she was interrupted by their many questions that led the conversation to diverge from her plan. She paused and tried to understand the parents, and decided to revisit the conversation later rather than trying to say everything she had planned:

‘So, this was a huge learning point for me. . . being able to understand that this conversation is actually just leading to more anxiety and not going anywhere. I think we need to take a pause and we need to come back to this later.’ (Participant 14)

Although most conversations with parents were conducted independently, there were opportunities for participants to actively observe how more experienced clinicians manoeuvred difficult conversations. Some junior trainees were mainly observers who watched more senior members of the team respond to unexpected complexities in difficult conversations. They did not, however, observe passively; instead, they actively made judgements on a moment-by-moment basis and drew learning points about whether or not they would emulate or discard another clinician’s communication styles and skills. For example, one participant extracted positive communication skills observed in the senior staff member:

‘I was very, very impressed with Dr X who did the consult because she was very empathetic but she was also very honest and frank about it. And she went through it. . . even though mum was a health care provider she broke it down for the rest of the family, outlined exactly what he [the baby] was going to look like and didn’t actually

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pressure mum for an answer because mum was very upset and very torn. She said what she would recommend but then she never pressured the mum and she was very open to any suggestions.’ (Participant 3)

By contrast, another participant described feeling quite traumatised by how a senior team member abruptly broke bad news to a mother, and formed learning points based on what she wished could have happened:

‘. . . she walked into the room and right away said, “Your baby is very sick, he is not going to make it.” And I felt like the bomb was dropped on this family. . . I felt a bit awkward, I wanted to turn back time and say, oh my gosh, I wish I could have asked her and maybe even arranged for a private room because we did this all in the patient room. Just go back into a quiet room and maybe explain a little bit more first. . . It would have been maybe a little bit more appropriate to have both parents there.’ (Participant 5)

One junior participant described how the team had planned that they would either offer, or simply recommend, palliation for a child who was quite ill, and questioned the ethics of the team:

‘There was discussion around whether we should be taking the decision away from the parents because it’s difficult. . . when it’s put on the parents to decide not to resuscitate a child.’

The participant was unsure about whether he felt it was ethical to strongly suggest palliation, despite it being perceived as possibly making the situation easier for the parents, but the power differential made him reluctant to voice his opinion:

‘I drew them [the team] larger because I felt that there was quite a differential. . . as indicated by their sizes between parents and medical team, and I felt a little bit lower as well.’ (Participant 1)

Despite not voicing his concerns, this participant considered how this complexity would affect his future practice.

Responding to indeterminacy: negotiating roles

Consequent to their active observation, participants found themselves faced with decisions about how to negotiate their role in caring for families. Power differentials often left trainees aware of the tension

between deciding when to step into direct engagement with families and when to step out and defer to a more senior team member. These decisions were not always clear-cut, but they were common in indeterminate zones. One participant recounted how she had been the main person communicating with a family throughout the baby’s hospital stay, but that a more senior person stepped in when the parents needed to be told that their baby would not survive:

‘I was in the background and I wish I could have had more say or [been] part of the discussion because I had been with the family since he was born. . . it might be better if I speak with them because I’m a familiar face.’ (Participant 5)

For other participants, trying to balance the provision of support to families with respect for their privacy created another dilemma about their role. For example, one participant described the process of withdrawing life support for a baby and of hovering just outside the curtain around the incubator and trying to decide whether she should actually be inside with the family as their baby was dying:

‘I really wanted to be with them. . . but I felt that, maybe, I will encroach on their privacy.’ (Participant 4)

Responding to indeterminacy: abandoning the checklist to engage actively

As they tried to navigate these challenges, the complexities of real-world practice triggered participants into reconsidering their initial checklist- based approaches. Participants realised a need to be willing to abandon the checklist, and to tailor their communication based on parents’ preferences and responses:

‘. . .teaching me a lesson in taking the time to really listen, just seeing how scared they were and how emotional mum was. And, just seeing kind of that relief in somebody, just sitting and talking, really taught me how important that time is with your patient, and how I really need to make that effort of seeing just beyond the medical steps. . . being okay to break away from the agenda. I might not get every detail that I want to talk to parents about, but letting them lead.’ (Participant 14)

Another participant regretted persevering with the checklist, and disclosing numerous details about the

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baby’s overwhelming infection and multi-organ failure:

‘We were destroying them but we wouldn’t give up, as if it was so important for us to finish that you keep on going and going and going. . . I know it’s medically important that we tell them all the facts but I think we lose the distinction of doing what is needed and covering the 10 points that we need to cover in such a discussion.’ (Participant 4)

Similarly, one participant described learning to be flexible, rather than adhering to a prescribed method, and instead adapting to each unique family:

‘I usually gauge how the parents respond to me, the way they are asking questions. Some families may ask for very specific details or statistics and things like that, so if they are asking about that then I am more inclined to change my tune and talk more along those lines. For example, we had one family. . . the dad was an engineer and he would focus on all the different numbers on the monitor.’ (Participant 5)

Ultimately, in indeterminate zones, trainees shifted their priorities and values from the provision of medical care and following of communication checklists and protocols, to engaging actively, authentically and humanely with families. For instance, one participant described how she allowed herself to step into sadness with a family who had just been told their child was unlikely to survive:

‘I didn’t hold back any of my sadness, I cried with her.’ (Participant 5)

DISCUSSION

Our findings articulate the indeterminate zones of practice that unfold during difficult conversations with patients and families in the NICU. We also describe the processes trainees use to recognise and respond to difficult conversations. This explication sheds light on the links between theories of self- monitoring and reflective practice. In this discussion, we will expand on the theoretical implications of these two key findings and suggest their educational impact.

Whereas theories of reflective practice exist in order to describe care approaches within indeterminate

zones of practice, indeterminate zones remain abstract and insufficiently theorised.27 Our study provides situated descriptions of indeterminate zones of practice in the real-world clinical setting of difficult conversations with families in the NICU. Participants told stories of the stress imposed by feeling rushed in high-acuity situations, of the unexpected and intense emotional responses of parents, and of decision-making dilemmas created by power differentials. The three factors of stress, unexpected emotional responses and uncertainty about decision-making autonomy may contribute to making a practice situation indeterminate, and may therefore be useful in designing educational activities such as simulation scenarios. Theories of reflective practice tend to describe a moment of surprise, or even a subtler sense of something amiss, leading to reflection-in-action.28 However, not all trainees notice these moments and thus some may continue to push through with an inappropriate application of a checklist-based approach. What is the capacity or skill that allows a trainee to notice indeterminate zones?

Self-monitoring may be part of the cognitive process by which indeterminate zones of practice are identified in that it leads trainees to realise the problem initially, and then to actively respond by engaging in reflection-in-action.1 We suggest a preliminary model that describes this process; our proposed model resonates with and identifies links between theories of both self-monitoring and reflection-in-action (Fig. 2). Specifically, when faced with an indeterminate zone of practice that rendered their initial idealised approaches inadequate, trainees were triggered to self-monitor. The components of self-monitoring included the initial reactions of seeing differently and pausing to understand the situation. These were then followed by the response to indeterminacy, in which the trainee actively observed senior team members to extrapolate learning points, negotiated roles in engaging with families, and engaged empathically by abandoning the checklist approach.

Reflective practice describes indeterminate zones of practice as the common impetus for reflection-in- action, which is moment-to-moment problem solving in the face of uncertainty. However, theories of reflective practice lack details on how one actually goes about realising indeterminate zones, and what this innovation in uncertainty looks like. Self-monitoring helps to fill this gap because it describes the use of both external and internal cues to continually take in new information and to

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monitor one’s performance. Yet self-monitoring does not focus on valuing different ways of knowing and seeing practice. By contrast, reflective practice, which is rooted in education philosophy, refers to a value shift and provides limited detail about the cognitive processes required to negotiate uncertainty and complexity. This value shift emphasises that practitioners need to move beyond purely technical and scientific ways of knowing and to embrace deeply personal and artistic ways of knowing.1

Our findings contribute to how these theories unfold in practice. For instance, Participant 11’s observation of the contrast between the bright lights and loud alarms and the parents sitting silently in the dark triggered the participant to self-monitor by pausing and reframing the acute situation from the parents’ perspective. In turn, other participants described slowing down, improvising and abandoning the checklist in order to engage more empathetically with families. These findings resonate with a model of expert judgement described by Moulton et al.29 as ‘slowing down when you should’ that describes how one enters into reflection-in-action. Specifically, the model describes a switching from efficient, automatic actions and decision making to more effortful and thoughtful approaches.29 In our study, the external triggers helped trainees to realise the limits of their training and led to a shift away from the rote performance of strategies towards a more adaptive form of

expertise,30 in which trainees drew on their personal experiences and engaged with the family at a more empathetic and holistic level. This shift required trainees to draw not only from technical knowledge sources, but also from experiential and personal knowledge sources, and echoes the epistemological foundation of reflective practice.1

Although self-monitoring and reflection-in-action have primarily been described separately in the literature,31 reflection-in-action has been suggested as part of continuous self-monitoring.32 Our study builds on this by linking reflection-in-action and self-monitoring, and by providing empirical evidence to describe both processes. That is, participants’ experiences suggest that the use of external cues as stimuli resonates with literature on self-monitoring, and reframing through the perspective of the parents resonates with literature on reflection-in-action. In bringing together theories of self-monitoring and reflection-in-action, we were able to construct a rich explanation of how trainees navigate difficult conversations in real time.

Practical implications

Our findings raise the question of whether health professions educators can identify, and possibly teach, this process of realising and responding to uncertain practice situations. Given that self- monitoring may be a key prerequisite to reflection- in-action, we suggest that embracing the techniques

Indeterminant zones of practice

Seeing differently

Pausing to understand

Observing actively

Negotiating roles

Abandoning the checklist

Self-monitoring

Active response to indeterminacy

Initial realisation of indeterminacy

Reflection-in- action

Figure 2 Model for the process of realisation and response to indeterminate zones of practice, linking both self-monitoring and reflection-in-action

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for building mindfulness described in self-monitoring literature14 may also be useful for supporting trainees to engage in reflection- in-action. Although how people can be taught to self-monitor remains unknown, the literature suggests that mindfulness can be fostered by supporting habits that develop attentiveness and curiosity.14

Educators currently employ a range of practical exercises in reflection with the goal of fostering reflective practice.33 It is assumed that practical exercises like writing reflections may encourage trainees to take the time to reflect, especially in busy clinical settings in which trainees may feel that reflection hinders efficiency.34 Embracing uncertainty is historically challenging for trainees,35

and empathy has been shown to decline throughout residency training;36 efforts to encourage acceptance of uncertainty and prioritisation of compassionate care orientations are warranted. Perhaps the process of drawing rich pictures to tell the story of a challenging encounter with parents may represent an interesting pedagogical approach, aligned with theories of narrative and reflective learning.37

Our data suggest a need to balance the teaching of checklist-based approaches with encouraging learners to recognise when the checklist should be abandoned. Some members of our research group have recently discussed the social complexities behind the Surgical Safety Checklist implementation initiatives.38 This narrative review demonstrated the need for more research from a social science perspective to raise awareness of the unintended consequences and risks associated with the use of checklist-based approaches. For instance, in the context of the NICU, protocol-driven approaches may provide useful foundational knowledge, but, when strictly misapplied – that is, when trainees fail to be adaptive – they can also lead to families sensing detachment and a lack of compassion.13 Trainees in our study who were able to see differently seemed to realise they needed to extend beyond the checklist approach of communication and engage in expertise perhaps outside the medical domain, which seemed to empower trainees to self-monitor and to reflect-in- action. Therefore, there may be educational potential in helping trainees to realise that they can and should engage these forms of expertise as needed. This suggestion aligns with bases of reflective practice and with scholarly arguments for an appreciation of non-formulaic, tacitly driven

clinical ‘mindlines’, as opposed to clinical practice guidelines.39,40 This work and ours suggest that educators need to find ways to help trainees feel comfortable in indeterminate zones of practice. Scholars of adaptive expertise have suggested that planning for variability throughout one’s learning may be one way of supporting future ability in novel, challenging situations.30

Limitations

Although we were interested in self-monitoring and reflective practices within the moments of practice (reflection-in-action), we were reliant upon reflection on past action in order to understand these processes. This is a critical challenge that pervades all studies involving the retrospective collection of experiences. On one hand, this is a limitation that might be partially overcome with different methods of data collection, such as ethnographic studies or the ‘think aloud’ method.41

On the other hand, the experience need not be captured in real time if we are not interested in accurate retellings, but, rather, in the impacts of these experiences and in how they become part of the trainee’s repertoire and knowledge moving forward. Future studies should also add the perspectives of clinician-educators and parents involved in difficult conversations. Although our findings may not translate straightforwardly to other settings, the experiences described should resonate and provoke discussions about the nuances of such conversations in other contexts.

CONCLUSIONS

Our study offers empirical data that richly articulate indeterminate zones of practice in difficult conversations with families, using the NICU as the research context. We describe and propose a relationship between self-monitoring and reflection- in-action, linking these existing theories and positioning self-monitoring as a prerequisite for reflection-in-action. This study points to the potential for training programmes to balance checklist-based approaches to communication training with sufficient opportunity and support for appropriate departures from those checklists, in order to provide compassionate care for families.

Contributors: AC designed the study, collected, analysed and interpreted the data, wrote the first draft of the manuscript and critically revised subsequent iterations for

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clarity and intellectual content. KL, SC and SN contributed to data analysis and interpretation, to the intellectual content of the work, and reviewed and revised several iterations of the manuscript. All authors approved the final version of the manuscript and all authors agree to be accountable for all aspects of the work. Acknowledgements: The authors would like to acknowledge Lisa Faden, Center for Education Research & Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada, for reviewing the paper and offering feedback, and the study participants for sharing their experiences. Funding: Financial support for the research, authorship and publication of this article was provided by the Canadian Institutes of Health Sciences and the Royal College of Physicians and Surgeons of Canada. Conflicts of interest: None. Ethical approval: This study was approved by the Health Sciences Research Ethics Board of the University of Western Ontario.

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Received 10 April 2017; editorial comments to author 18 May 2017, accepted for publication 26 July 2017

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