Cheng Anita, Molinaro Monica, Ott Mary, Cristancho Sayra, LaDonna Kori A
A. Cheng is a neonatologist and assistant professor, Department of Pediatrics, Western University, London, Ontario, Canada; ORCID: https://orcid.org/0000-0002-6787-7275.
M. Molinaro is a banting postdoctoral fellow, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada; ORCID: https://orcid.org/0000-0002-5629-5974.
Acad Med. 2023 Nov 1;98(11S):S65-S71. doi: 10.1097/ACM.0000000000005355. Epub 2023 Jul 28.
Learning to navigate difficult clinical conversations is an essential feature of residency training, yet much of this learning occurs "on the job," often without the formative, multisource feedback trainees need. To generate insight into how on-the-job training influences trainee performance, the perspectives of parents and health care providers (HCPs) who engaged in or observed difficult conversations with Neonatal Intensive Care Unit (NICU) trainees were explored.
The iterative data generation and analysis process was informed by constructivist grounded theory. Parents (n = 14) and HCPs (n = 10) from 2 Canadian NICUs were invited to participate in semistructured interviews informed by rich pictures-a visual elicitation technique useful for exploring complex phenomena like difficult conversations. Themes were identified using the constant comparative approach. The study was conducted between 2018 and 2021.
According to participants, misalignment between parents' and trainees' communication styles, HCPs intervening to protect parents when trainee-led communication went awry, the absence of feedback, and a culture of sole physician responsibility for communication all conspired against trainees trying to develop communication competence in the NICU. Given beliefs that trainees' experiential learning should not trump parents' well-being, some physicians perceived the art of communication was best learned by observing experts. Sometimes, already limited opportunities for trainees to lead conversations were further constricted by perceptions that trainees lacked the interest and motivation to focus on so-called "soft" skills like communication during their training.
Parents and NICU staff described that trainees face multiple barriers against learning to navigate difficult conversations that may set them up to fail. A deeper understanding of the layered challenges trainees face, and the hierarchies and sociocultural norms that interfere with teaching, may be the start of breaking down multiple barriers trainees and their clinician supervisors need to overcome to succeed.
学会应对艰难的临床对话是住院医师培训的一项基本内容，但这种学习大多是在“工作中”进行的，往往缺乏住院医师所需的形成性多源反馈。为了深入了解在职培训如何影响住院医师的表现，本研究探讨了与新生儿重症监护病房（NICU）住院医师进行或观察到艰难对话的家长和医疗服务提供者（HCP）的观点。
迭代的数据生成和分析过程以建构主义扎根理论为指导。邀请了来自加拿大两家新生儿重症监护病房的14名家长和10名医疗服务提供者参与半结构化访谈，访谈以丰富图片为依据——这是一种视觉启发技术，有助于探索艰难对话等复杂现象。采用持续比较法确定主题。该研究于2018年至2021年进行。
据参与者称，家长和住院医师沟通方式的不一致、当住院医师主导的沟通出现问题时医疗服务提供者介入以保护家长、缺乏反馈以及沟通由医生全权负责的文化，都不利于住院医师在新生儿重症监护病房培养沟通能力。鉴于认为住院医师的经验性学习不应凌驾于家长的福祉之上，一些医生认为沟通艺术最好通过观察专家来学习。有时，住院医师主导对话的机会本就有限，但由于认为住院医师在培训期间缺乏专注于沟通等所谓“软”技能的兴趣和动力，这种机会进一步受到限制。
家长和新生儿重症监护病房的工作人员表示，住院医师在学习应对艰难对话时面临多重障碍，这些障碍可能导致他们失败。深入了解住院医师面临的多层次挑战以及干扰教学的等级制度和社会文化规范，可能是打破住院医师及其临床督导员为取得成功需要克服的多重障碍的开端。
