Jeffrey Silver Humanism in Healthcare Research Roundup – August 2022

The Jeffrey Silver Humanism in Healthcare Research Roundup features summaries of recently published studies on humanism in healthcare. To receive email notification of new studies once per month, enter your information here and select “Jeffrey Silver Research Roundup” from the checkboxes at the bottom. See previous posts in this series.

Spirituality in serious illness and health Balboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK. JAMA. 2022 Jul 12;328(2):184-197. doi: 10.1001/jama.2022.11086. PMID: 35819420. Dr. Karen Steinhauser has been a Gold Foundation grantee.
Spiritually can be conceptualized as “the way persons seek and experience ultimate meaning, purpose, and transcendence,” according to Dr. Tracey Balboni and colleagues, who note that while attention to spirituality is a component of person-centered care, the role of spirituality in serious illness and health has not been systematically assessed. To explore this, they conducted two systematic reviews of literature, one for serious illness and another for health outcomes, and presented these data to two multidisciplinary Delphi panels to generate evidence statements. Regarding the care of patients with serious illnesses, from 8,946 records, they identified 371 articles that met their inclusion criteria. Eight evidence statements were generated and ranked by perceived order of priority. The top 3 implications included (1) incorporating spiritual care, (2) incorporating spiritual care education into the training of interdisciplinary teams, and (3) including specialty practitioners of specialty care. Regarding health outcomes, out of 6,485 identified articles, 215 met their inclusion criteria. The Delphi panel review identified eight evidence statements and ranked the top 3 as follows: (1) incorporate patient-centered and evidence-based approaches regarding associations of spiritual community with improved patient and population health outcomes; (2) increase awareness among health professionals of evidence for protective health associations of spiritual community; and (3) recognize spirituality as a social factor associated with health in research, community assessments, and program implementation. The authors concluded by noting that these results provide a basis for further exploration of how spirituality impacts serious illness and health outcomes.

Perceived organizational effectiveness, moral injury, and moral resilience among nurses during the COVID-19 pandemic: Secondary analysis Rushton CH, Nelson KE, Antonsdottir I, Hanson GC, Boyce D. Nurs Manage. 2022 Jul 1;53(7):12-22. doi: 10.1097/ PMID: 35776417; PMCID: PMC9245532. Free full text Dr. Cynda Hylton Rushton has been a Gold Foundation grantee and participated in a Gold Human InSight Webinar.
Among many nurses, the ongoing COVID-19 pandemic has led to significant moral injury (MI), “a profound threat or violation of one’s moral foundation and conscience, which occurs in response to severe personal, collective, organizational, or leadership transgressions or betrayals.”  This has led to degradation of well-being, with many nurses reconsidering or leaving the profession entirely. Organizational effectiveness has been speculated to offset this moral injury, but to what degree is uncertain. Dr. Cynda Rushton and colleagues examined this in June through November 2020 through a cross-sectional survey of 344 nurses within the Johns Hopkins Clinical Research Network. In addition to demographic information, investigators collected data on moral resilience (MR), moral injury (MI), and organizational effectiveness (OE). MR was measured through a shortened version of the Rushton Moral Resilience Scale, MI was measured through the Moral Injury System Scale-Healthcare Professionals, and OE was measured by 10 items developed by subject matter experts for this project. Nearly 4 in 10 nurses surveyed had clinically significant moral injury scores. The researchers then developed a multiple regression model to identify correlations. Through this model, they identified factors predicting moral injury: lower moral resilience, perception of lower organizational effectiveness, and less than 10 years in the profession. Because organizational effectiveness can modulate moral injury, improving organizational effectiveness through improving communication and support should be considered a priority. Crucially, investigators found that nurses who provided COVID-19 care had perceptions of poorer organizational effectiveness. Toward that end, the authors concluded by noting the importance of “dismantling disempowering structures and patterns of betrayal” for the well-being of nurses.

Parental leave policies in residency: A national survey of Internal Medicine program directors Stack SW, Finn KM, Kisielewski M, Law KL, Milne CK, Best JA. Acad Med. 2022 Jul 1;97(7):1021-1028. doi: 10.1097/ACM.0000000000004593. Epub 2022 Jun 23. PMID: 35020617. Dr. Shobha W. Stack and Dr. Jennifer A. Best have been Gold Foundation grantees.
Approximately 20% to 40% of graduate medical education trainees either plan to have children or already have had children during training. Despite this high prevalence, there is little known about parental leave policies during residency. This lack of knowledge may impact well-being of residents and decisions around childbearing. To understand the current state of parental leave policies in Internal Medicine residency programs, Dr. Shobha Stack and colleagues conducted a 38-item survey among the 422 Internal Medicine program directors. They then applied statistical analysis and qualitative content analysis to understand the existence, accessibility, content, barriers to policy implementation, and openness to a national standard. Among the 293 responding programs (which altogether represent almost a 70% response rate), 86% (250) reported a written parental leave policy. 43% of these (97) had program-level policies, which involved issues like scheduling during pregnancy, peer coverage, extension of training duration, and associated pay and benefits. Those that didn’t have program-level policies reported several barriers, including a lack of guidance, a deference to institutional policies, and a desire to retain flexibility. About 60% of program directors (170/282) expressed support for a national standard. These results suggest an unmet need for a national standard for program-level parental leave policies that champion flexibility for programs, protection for resident physicians, and promotion of gender equity.

The impact of Covid-19 on professional identity formation: an international qualitative study of medical students’ reflective entries in a global creative competition Moula Z, Horsburgh J, Scott K, Rozier-Hope T, Kumar S. BMC Med Educ. 2022 Jul 15;22(1):545. doi: 10.1186/s12909-022-03595-1. PMID: 35836173; PMCID: PMC9282904. Free full text
The ongoing COVID-19 pandemic has disrupted medical education in many crucial ways, and, in the process, affected the professional identity formation (PIF) of medical students. To better characterize how the pandemic has altered PIF, Dr. Zoe Moula and colleagues examined 155 visual or literary creative pieces by medical students submitted for Imperial College London’s Global Creative Competition. Each piece was accompanied by a 250-word reflection, which was analyzed thematically by three independent reviewers. They identified five ways the pandemic affected PIF: (1) awareness of social accountability, (2) awareness of the global role of the doctor in addressing health inequities, (3) becoming a member of the wider healthcare community, (4) appreciation of person-centered care, and (5) awareness of personal needs and self-care. These insights aligned with Mezirow’s theory of transformative learning, whereby students reexamined pre-existing assumptions about the roles of doctors and explored new perspectives. The investigators also noted tension between a sense of duty and a sense of well-being. The authors strongly recommend incorporating arts and humanities within the medical curriculum and training to allow students to express complex emotions and experiences. They also advocate for greater recognition that student mental health and well-being “is fundamental to their progression and transition to becoming a doctor.”

Does creative arts therapy improve distressing symptoms in children with cancer? A synthesis of extant literature Raybin JL, Harnke B, Hendricks-Ferguson V. J Pediatr Hematol Oncol Nurs. 2022 Jan-Feb;39(1):60-71. doi: 10.1177/27527530211059432. PMID: 35722867. Ben Harnke has been a Gold Foundation grantee.
Pediatric cancer remains the leading cause of death from disease among children in the United States. Despite treatment advances, children with cancer continue to experience distress from both the cancer and the adverse effects of aggressive treatment. Creative arts therapy (CAT) has been hypothesized to improve the quality of life for these children. Dr. Jennifer Raybin and colleagues investigated this through a systematic review, specifically focusing on whether CAT affects symptoms of pain, nausea, fatigue, anxiety, and mood in children with cancer. From 1,391 eligible articles, the investigative team screened 44 for systematic review, and ultimately included 11 studies. Five studies measured mood and anxiety, followed by four for pain, two for fatigue, and one for nausea. When graded for evidence level, the studies were low (4), low-moderate (3), or moderate (4). The authors concluded that the current state of knowledge is limited and that there are ample opportunities for examining how CAT interventions impact symptoms, particularly for physical ones like pain and nausea.

Forgotten in the crowd: A qualitative study of medical interpreters’ role in medical teams Latif Z, Makuvire T, Feder SL, Crocker J, Quintero Pinzon P, Warraich HJ. J Hosp Med. 2022 Aug 1. doi: 10.1002/jhm.12925. Epub ahead of print. PMID: 35912708.
Professional medical interpretation is a vital service that enables the approximately 25 million Americans with limited English proficiency (LEP) to communicate with health care team members. Yet studies show that interpreters are involved in fewer than 16% of patients with LEP. To explore perspectives regarding interpreters’ role within medical teams, Dr. Zara Latif and colleagues conducted semistructured interviews with 20 interpreters at a single, tertiary care academic medical center in Boston. Interview transcripts then underwent thematic analysis, yielding two major themes: (1) the full spectrum of medical interpreters’ roles (i.e. cultural mediators, and patient advocates), and (2) factors acting as barriers and facilitators of interpretation (barriers to optimal interpretation, factors facilitating interpretation). Based on these results, they then synthesized six best practices: (1) a welcoming sentence, (2) presession, (3) addressing the patient directly, (4) pausing during conversation, (5) teach-back method, and (6) debriefing. The authors conclude by noting future directions, including implementing training programs for clinicians and understanding the impact of professional medical interpretation on patient outcomes.

Learning practices of experienced healthcare teams and dyads in acute care settings: a scoping review Walker K, Asoodar M, Rudolph J, Meguerdichian M, Yusaf T, Campbell-Taylor K, van Merriënboer J. BMJ Open. 2022 Jul 25;12(7):e061144. doi: 10.1136/bmjopen-2022-061144. PMID: 35879009. Free full text Dr. Jenny Rudolph has been a Gold Foundation grantee.
Collaboration among teams is vital to maintaining safe and humanistic care, including among “dyads” – pairs of healthcare team members who share responsibilities, such as surgeons and anesthesiologists. To understand the learning practices that enable healthcare dyads and teams to optimize performance, Dr. Katie Walker and colleagues performed a scoping review, ultimately identifying 86 studies that discussed learning practices of experienced healthcare teams. The most common learning practices were structured observation and case scenarios (21%), audio/video analysis and surveys (17%), and pre-briefing/debriefing and checklists (11%). The authors noted limited high-quality data to help guide learning practice. Therefore, they encourage further research grounded in collaborative frameworks to determine best practices.

Patient activation reduces effects of implicit bias on doctor-patient interactions Gainsburg I, Derricks V, Shields C, Fiscella K, Epstein R, Yu V, Griggs J. Proc Natl Acad Sci U S A. 2022 Aug 9;119(32):e2203915119. doi: 10.1073/pnas.2203915119. Epub 2022 Aug 1. PMID: 35914161; PMCID: PMC9371681. Free full text Dr. Ronald Epstein has been a Gold Foundation grantee and is co-founder of Mindful Practice, which collaborates with the Gold Foundation.
Considerable health disparities exist between Black and white patients, including in the treatment of advanced cancers. Previous studies have shown that one major contributor is implicit bias of non-Black clinicians favoring white patients. Patient activation (“i.e., having patients ask questions and advocate for themselves) has been posited as a strategy to promote more equitable clinician-patient interactions. Dr. Izzy Gainsburg and colleagues tested this idea through a randomized field experiment with 181 simulated encounters that included 14 trained standardized patients (SPs) and 96 physicians. First, the investigators obtained data on physician demographics and implicit bias (using the Implicit Association Test [IAT]). They then conducted 181 visits in which SP were either “activated” or “typical” and had SPs and independent coders rate the quality of interactions. Through linear regression, they sought to estimate the effects of SP race and activation on SP and coder ratings of interaction quality. In their sample, they identified that physician implicit bias toward white SPs was reduced when there was greater patient activation. The authors speculate that through patient activation “physicians learn specific information about the SPs, in turn leading them to perceive SPs as individuals rather than solely as representatives of their race (i.e., individuation).” Regardless of the mechanism of this association, the authors note that patient activation may be a potent means to reducing the effects of implicit bias and potentially improve care for Black patients.

Doctor! Did you Google my symptoms? A qualitative study of patient perceptions of doctors’ point-of-care information seeking Tranter I, van Driel ML, Mitchell B. BMJ Open. 2022 Jul 27;12(7):e061090. doi: 10.1136/bmjopen-2022-061090. PMID: 35896298. Free full text
Because of the rapidly accelerating pace of published new medical knowledge, primary care clinicians often feel prompted to access information during the clinical encounter. But how do patients perceive this information-seeking during clinical encounters? Dr. Isaac Tranter and colleagues conducted interviews with 16 Australian patients in six general practice waiting rooms. Using thematic analysis, they identified four dominant themes: (1) the trust a patient has in the doctor before the consultation, (2) whether the doctor is expected to know the answer to a question without searching, (3) whether the doctor added value to the consultation by searching, and (4) the consultation skills used in the process. While clinicians viewed information-seeking as a cognitive skill, patients saw the process as a communication skill. The authors elaborate the implications of this finding: The “process of a clinician ‘earning the right’ to search can be achieved through building rapport and trust, then bringing the patient along on the journey of searching.” While further research is needed to explore this dynamic, the authors conclude by emphasizing openness and transparency regarding the need to search as well as the key ability of doctors to listen and understand the patient’s agenda.

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Bharat Kumar, MD

Humanism in Research Assistant Editor

Updates the staff, databases, and social media about new studies around humanism in healthcare; curates and compiles the monthly Jeffrey Silver Humanism in Healthcare Research Roundup.