standardized patient acting class response paper

A

G

C h

w r t fi t c c t t s c u

v d t w t r f a c p t g w t s

a f l p t n d w b

T

S

h 1

ARTICLE IN PRESSG ModelUCC-235; No. of Pages 2 Australian Critical Care xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Australian Critical Care

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a u c c

uest editorial

ourage, brains and heart: Lessons from the Wizard of Oz for difficult ealthcare conversations

Difficult conversations abound in healthcare; they simply go ith the territory. Quintessential challenging conversations often

elate to conveying serious, unexpected news to patients and heir families. On any given day, critical care practitioners can nd themselves engaged in conversations ranging from sharing ragic news to parents of previously healthy children, explaining omplex diagnoses and treatment approaches, addressing compli- ations of invasive treatments, acknowledging uncertainty, raising he spectre of maltreatment, disclosing adverse medical outcomes, o helping families broach decisions related to withdrawal of life upport treatments. Initiating and holding difficult conversations an be a challenging area of practice for clinicians who often feel nprepared, yet learning opportunities are limited.

The first conversation is often the beginning in a cascade of con- ersations, especially when serious illness has been diagnosed. As ifficult as the first conversation might be, subsequent conversa- ions can be even more challenging and dreaded by clinicians, as hen the laboratory results are confirmed, the treatment has failed

o bring about the hoped-for response, or when time has simply un out. Such conversations can be life altering for patients and amilies, and clinicians want to “get it right.” Just when patients nd families need their care providers most, clinicians’ words and onfidence can seemingly fail them. This yoke of perfection and ressure can amplify anxiety and erode confidence amongst prac- itioners. When clinicians try so hard during conversations, their enuineness and gestures of kindness can be diminished. Similarly, hen clinicians hide behind medical jargon or cling to scripts, the

reasured moments of real human connection with patients can be acrificed, at a loss to both.

Even seasoned clinicians who are capable and confident in their reas of expertise can find themselves uncomfortable, at a loss or words, or even reluctant to seek out patients and their fami- ies. Practitioners also worry about their own display of emotions, laguing themselves with second-guessing, self-doubt or admoni- ions to “be professional.” Ironically, practitioners may know what ot to do in these intimate conversations, but not exactly what to o or how to be. The myth prevails that there are some practitioners ho are simply gifted in the art of holding difficult conversations;

y comparison others might feel inadequate or not up to the task.

Please cite this article in press as: Meyer EC. Courage, brains and hear sations. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.03

he Wizard of Oz

In our Program to Enhance Relational and Communication kills (PERCS) workshops at the Institute for Professionalism and

ttp://dx.doi.org/10.1016/j.aucc.2014.03.002 036-7314/© 2014 Australian College of Critical Care Nurses Ltd. Published by Elsevier Au

Ethical Practice1–4 (www.ipepweb.org), we have found the story of the Wizard of Oz to be helpful and uplifting when teaching about communication and relational skills. The Wizard of Oz is a classic, enduring children’s adventure fantasy first published in 1900 by L.F. Baum5 and further popularised by the Metro-Goldwyn-Mayer film in 1939. The story has served as a useful metaphor for nursing, medicine and psychology practice.6–10 By recalling images of the Lion, the Scarecrow, and the Tin Man, practitioners can be reminded of the essential balance of ingredients for difficult healthcare con- versations namely courage, brains and heart. When we present the Wizard of Oz analogy in our workshops, most practitioners nod in affirmation of these enduring principles to guide health- care conversations. The approach offers practitioners an advantage by focusing on generalisable principles rather than specific skills, being easy to recall “just in time,” and promoting communicative and relational engagement.11

As the story goes, Dorothy finds herself lost in the mystical, unfa- miliar Land of Oz, determined to find her way home. She is advised to “follow the yellow brick road” to Emerald City where resides the Wizard of Oz, reputed to have fantastic powers. Along the way, she meets her three trusty companions – Lion, Scarecrow and Tin Man, each with troubles of their own. They join in the journey in search of courage, brains and heart certain that the Wizard can bestow these timeless, fundamental qualities upon them.

Courage

The Lion was fearful and overwhelmed with his own inad- equacy, and in search of courage. Never underestimate the importance of courage, confidence, and leadership ability to con- vene and hold challenging conversations in healthcare. These qualities, in fact, are essential to holding conversations since, without them, the conversations might not occur at all. Even sea- soned practitioners describe feelings of heightened anxiety prior to high-stakes conversations, but with courage they can steady themselves to push past the initial fear, hesitancy, and sense of inadequacy. Courage can be the catalyst to assure that the conver- sations get underway and are not unnecessarily delayed.12 With the Lion’s courage, practitioners can cultivate that ineffable calm, non-anxious presence so fundamental to healing and conducive to

t: Lessons from the Wizard of Oz for difficult healthcare conver- .002

meaningful healthcare conversations. This is not to suggest that all anxiety on the part of practitioners should be eradicated. On the contrary, some anxiety is natural, prepares and primes prac- titioners to give their very best selves, and reflects the gravity of

stralia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

ING ModelA 2 Critic

t p a m a s

B

n d a v c o t t a p i t l f m t a d a m a t t a a u

H

h g h t w c p t e g e f f d t t i r “ f s a t t n

1

1 1

1

1

1

1

1 1

ARTICLEUCC-235; No. of Pages 2 Guest editorial / Australian

he clinical situation and conversations at hand. We encourage ractitioners to recognise their anxieties, and to cultivate strategies nd skills to quell and transform their apprehensions in a positive anner.13 The goal is to move beyond being at the mercy of one’s

nxiety, to be energised, empowered, and focused during conver- ations. And remember, practice makes better.

rains

The Scarecrow, made of straw, was convinced that he did ot have a brain and, consequently, perceived himself at a big isadvantage in a world that values intellect, problem-solving bility, and knowledge. With respect to difficult healthcare con- ersations, patients and families highly value practitioners who an effectively bring to bear and communicate their full range f clinical knowledge, experience, decision-making processes, reatment recommendations, and accumulated wisdom. Ideally, hese conversations involve mutual agenda setting, reciprocity, nd exchange between practitioners and family members, thus romoting partnership and mutual understanding. Well-timed

nformation can be enormously helpful when customised and itrated to the needs and preferences of patients and their fami- ies. In our workshops, practitioners enjoy learning directly from amily faculty members and then practice during realistic enact-

ents with professional actors.1,14 Learners have the opportunity o view themselves on video playback and receive feedback across

range of parameters – word choice, clarity of explanations, use of rawings and educational visual supports, mutual problem-solving nd decision-making, and the ability to adapt information that best eets the needs of families. Learners are encouraged to think cre-

tively about ways to explain procedures and clinical situations hat commonly arise in their practice. For example, one anaes- hesiologist shared her approach to describing intubation as using

tool “like a shoehorn” rather than a blade. Practitioners learn nd practice imparting medical information in a user-friendly and nderstandable manner.

eart

Through a series of unfortunate mishaps, the Tin Woodsman ad managed to amputate most of his limbs and his body had been radually replaced by tin, now long-since rusted. The Tin Man’s eart had been left out and he felt empty and incomplete, unable o experience or express emotions, or so he believed. Practitioners ho bring their heart, compassion, and full humanity to health-

are conversations naturally enrich the therapeutic capacity of their rofessional relationships.15 The willingness and ability of practi- ioners to make space for emotions and to express their genuine motions make the difference between a good practitioner and a reat one.16 The relational learning pedagogy of our workshops ncourages practitioners to take the time to sit down, to listen care- ully for emotional cues and inquire gently, and to acknowledge the ull range and complexity of emotional responses that can surface uring challenging conversations – sadness, anxiety, guilt, frustra- ion, anger. Practitioners are encouraged to adjust the rhythm of hese conversations, calibrating their style to the patient and fam- ly’s emotional needs and expressiveness. By slowing down the ate of speaking, honouring natural pauses, granting silence, and speaking in sentences not paragraphs,” practitioners can create avourable conversational conditions for healthy emotional expres- ion. By recognizing patient’s emotions such as, “I can see that you

Please cite this article in press as: Meyer EC. Courage, brains and hear sations. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.03

re disappointed with the latest test results,” the practitioner effec- ively invites the patient to share his or her emotions, conveys he worthiness of emotional aspects of care, and creates “opportu- ity space” for patients to share according to their wishes. Asking

PRESS al Care xxx (2014) xxx–xxx

patients and families to share what they are hoping for and what they are worried about can have profound influence not only on the conversation at hand, but on the relationship as well.17,18

Summary

The Wizard of Oz, the timeless children’s classic, offers practi- tioners a helpful and easily remembered approach to the essential elements for holding difficult healthcare conversations – courage, brains and heart. As the Wizard revealed, these gifts and abili- ties typically lie within each of us, waiting to be discovered, fully realised and balanced. In the context of safe and creative learning experiences, these abilities and related skills can be further culti- vated and refined making for capable and confident practitioners who can whole-heartedly serve their patients and families with distinction.

References

1. Browning DM, Meyer EC, Truog RD, Solomon MZ. Difficult conversations in health care: cultivating relational learning to address the hidden curriculum. Acad Med 2007;82(9):905–13.

2. Meyer EC, Sellers DE, Browning DM, McGuffie K, Solomon MZ, Truog RD. Difficult conversations: improving communication skills and relational abilities in health care. Pediatr Crit Care Med 2009;10(3):352–9.

3. Meyer EC, Brodsky D, Hansen AR, Lamiani G, Sellers DE, Browning DM. An interdisciplinary, family-focused approach to relational learning in neonatal intensive care. J Perinat 2011;31(3):212–9.

4. Lamiani G, Meyer EC, Leone D, Vegni E, Browning DM, Rider EA, et al. Cross- cultural adaptation of an innovative approach to learning about difficult conversations in healthcare. Med Teach 2011;33:e57–64.

5. Baum LF. The wonderful Wizard of Oz. GM Hill; 1900. 6. Baldwin A, Bentley K, Langtree T, Mills J. Achieving graduate outcomes in under-

graduate nursing education: following the yellow brick road. Nurs Educ Pract 2014;14:9–11.

7. Bowles DJ. The Wizard of Oz and medical-surgical nursing. Medsurg Nurs 2013;22(2):75–83.

8. Madger D. The Wizard of Oz: a parable of brief psychotherapy. Can J Psychiatry 1980;25:564–7.

9. Amundson NE. Walking the yellow brick road. J Empl Couns 2006;43:31–8. 0. Bailar JC. The powerful placebo and the Wizard of Oz. NEJM

2001;344(21):1630–2. 1. Howley MC. Come on little lady. Patient Educ Couns 2012;88(2):352–3. 2. Carter BS, Brown JB, Brown S, Meyer EC. Four wishes for Aubrey. J Perinat

2012;32(1):10–4. 3. Lamiani G, Barello S, Browning DM, Vegni E, Meyer EC. Uncovering and validating

clinicians’ experiential knowledge when facing difficult conversations: a cross- cultural perspective. Patient Educ Couns 2012;87:307–12.

4. Browning DM, Comeau M, Kishimoto S, Varrin P, Ward E, Rider EA, et al. Par- ents and interprofessional learning in pediatrics: integrating personhood and practice. J Interprof Care 2011;25(2):152–3.

5. Branch WT, Frankel R, Gracey C, Haidet PM, Weissmann PF, Cantey P, et al. A good doctor and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009;84(1):117–25.

6. Meyer EC, Burns JP, Griffith JL, Truog RD. Parental perspectives on end-of-life care in the pediatric intensive care unit. Crit Care Med 2002;30(1):226–31.

7. Feudtner C. Breadth of hopes. NEJM 2009;361(24):2306–7. 8. Quill TE, Arnold RM, Platt F. I wish things were different: expressing wishes in

response to loss, futility, and unrealistic hopes. Ann Intern Med 2001;135:551–5.

Elaine C. Meyer PhD, RN a,b,∗ a Institute for Professionalism and Ethical Practice,

Boston Children’s Hospital, United States b Harvard Medical School, United States

∗ Correspondence to: Institute for Professionalism and Ethical Practice, Boston Children’s Hospital,

United States. Tel.: +1 617 355 5021; fax: +1 617 730 0739.

E-mail address:

t: Lessons from the Wizard of Oz for difficult healthcare conver- .002

[email protected]

3 March 2014 Available online xxx