Jeffrey Silver Humanism in Healthcare Research Roundup – July-August 2023

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.

Clinician Well-Being Assessment and Interventions in Joint Commission-Accredited Hospitals and Federally Qualified Health Centers Longo BA, Schmaltz SP, Williams SC, Shanafelt TD, Sinsky CA, Baker DW. Jt Comm J Qual Patient Saf. 2023 Apr 27:S1553-7250(23)00114-9. doi: 10.1016/j.jcjq.2023.04.007. Epub ahead of print. PMID: 37248109. Dr. Tait Shanafelt has been a Gold Foundation grantee
Clinician well-being is a vital aspect of healthcare that directly influences the quality of patient care, and yet it remains under-investigated in hospitals and Federally Qualified Health Centers (FQHCs). To characterize how clinician well-being is measured and supported, Dr. Beth A. Longo and colleagues conducted a cross-sectional study in 2022 to assess the scope and effectiveness of well-being assessments and interventions in these healthcare environments. 481 organizations responded to the survey, of which 34% acknowledged conducting an organizational well-being assessment at least once over the past three years. 28.7% stated that they have adopted a comprehensive approach to address clinician well-being, and only 10.1% of hospitals and 5.4% of FQHCs had an established senior leadership position responsible for well-being. The authors note this disconnect between reporting interventions to improve clinician well-being and actually measuring clinician well-being and discuss the need for leadership to champion measurement and improvement of clinician well-being.

Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic Piscitello GM, Tyker A, Schenker Y, Arnold RM, Siegler M, Parker WF. Crit Care Med. 2023 Aug 1;51(8):1012-1022. doi: 10.1097/CCM.0000000000005863. Epub 2023 Mar 30. PMID: 36995088. Dr. Robert M. Arnold has been a Gold Foundation grantee
The implementation of unilateral Do Not Resuscitate (UDNR) orders, where the decision to withhold resuscitation is made by a clinician without requiring consent from the patient or surrogate, presents an ethical dilemma, especially during the COVID-19 pandemic. To understand the application of UDNR orders, Dr. Gina M. Piscitello and colleagues conducted a retrospective cohort study of 1,473 ICU patients with a high severity of illness (requiring vasopressors or inotropes agents)  in two Chicago-area hospitals during the first pandemic surge between March 1, 2020, and April 30, 2020. The authors discovered that UDNR orders were used in 3% of the patients. Patients whose primary language was Spanish were 4 times more likely to receive a UNDR order than others and patients whose race was identified as Black were twice as likely. The study adds to literature identifying disparities in care among speakers of languages other than English and is the first to describe this in the setting of UNDR orders. The authors speculate that these disparities may be a result of communication barriers but more research is warranted to definitely identify root causes for these disparities.

Parent Priorities in End-of-Life Care for Children With Cancer Ananth P, Lindsay M, Mun S, McCollum S, Shabanova V, de Oliveira S, Pitafi S, Kirch R, Ma X, Gross CP, Boyden JY, Feudtner C, Wolfe J. JAMA Netw Open. 2023 May 1;6(5):e2313503. doi: 10.1001/jamanetworkopen.2023.13503. PMID: 37184834. Rebecca Kirch and Dr. Chris Feudtner have been Gold Foundation grantees Free full text
Understanding parent priorities in end-of-life care for children with cancer is critical in shaping patient-centered quality measures. To address this, Dr. Prasanna Ananth and colleagues conducted a survey study using a cross-sectional discrete choice experiment (DCE) with maximum difference scaling. The study, conducted from January to June 2021 in the U.S., involved 61 parents who had lost a child to cancer. Nearly all of the bereaved parents were white mothers. The DCE was composed of 21 questions, each presenting a set of 4 quality measures from which participants were asked to select the most and least important. Analysis of data revealed that parents prioritized measures related to their child’s symptoms being treated well, feeling that a child’s needs were heard by the healthcare team, and having a goal-concordant end-of-life experience. In fact, symptom management was 9 times more important to parents than psychosocial support for themselves. The authors recognize the potential limitations due to demographic homogeneity among respondents and small sample size. Nevertheless, this study helps to provide better insight into the priorities of parents whose children have received end-of-life cancer care.

The Mindful Ethical Practice and Resilience Academy: Sustainability of Impact Rushton CH, Swoboda SM, Reimer T, Boyce D, Hanson GC. Am J Crit Care. 2023 May 1;32(3):184-194. doi: 10.4037/ajcc2023236. PMID: 37121900. Dr. Cynda Hylton Rushton has been a Gold Foundation grantee and participated in a Gold Human InSight Webinar
The high-stress environment of critical care nursing often brings forth a number of ethical challenges that may lead to moral distress and burnout, in turn adversely affecting the quality of patient care. To address this, Dr. Cynda Rushton and colleagues developed the Mindful Ethical Practice and Resilience Academy (MEPRA),  an experiential educational program for acute care nurses with six 4-hour sessions. MEPRA utilizes facilitated discussion, role-play, guided mindfulness, reflective practices, case studies, and high-fidelity simulation training to bolster nurses’ skills in mindfulness, resilience, and competency in managing ethical challenges. The study, which ran from 2016 to 2019, involved 245 nurses who completed the 11 measures immediately after, 3 months after, and 6 months after finishing MEPRA program. The researchers found robust improvements in ethical confidence, moral competence, resilience, work engagement, mindfulness, emotional exhaustion, depression, and anger three months after MEPRA. In contrast, depersonalization and turnover intentions were initially reduced but that was not sustained at 6 months. These results suggest that MEPRA can be part of a strategy to help reduce burnout among acute care nurses, especially when “coupled with systemic interventions designed to detect and counter the modifiable patterns in health care organizations that contribute to moral suffering of nurses.”

Transformative experiences at art museums to support flourishing in medicine Tackett S, Eller L, Scharff S, Balhara KS, Stouffer KM, Suchanek M, Clever SL, Yenawine P, Wolffe S, Chisolm MS. Med Educ Online. 2023 Dec;28(1):2202914. doi: 10.1080/10872981.2023.2202914. PMID: 37074677; PMCID: PMC10120547. Dr. Margaret Chisolm has been a Gold Foundation grantee Free full text
Art museums have the potential to provide transformative experiences that can contribute to individual flourishing, particularly among medical professionals who often navigate high-stress environments. To explore this idea, Dr. Sean Tackett and colleagues implemented a hybrid 4-week arts-based elective for clinical medical students and evaluated it using a mixed-methods approach. They enrolled 5 third- and fourth-year medical students in 2022 and engaged in activities such as check-ins, visual thinking strategies discussions, personal responses tours, back-to-back sketching sessions, group poem-writing activities, forest bathing exercises, mask-making experiences, and jazz listening seminars. Pre- and post-evaluation surveys showed increased scores in the Capacity for Wonder and Tolerance for Ambiguity, but not in the Interpersonal Reactivity Index and the Openness to Diversity Scale. The researchers also conducted a thematic analysis of the participants’ reflective writings and identified four themes: (1) Art to connect with oneself, (2) Art to connect with others and their perspectives, (3) Art to foster professional identity formation, and (4) Time to be free of distractions and achieve mindfulness. These themes suggest that the museum-based program fosters personal and professional development among the participants. The authors recognized limitations due to the small sample size and the inherent selection bias of participants who might already be inclined toward appreciating art. Nonetheless, they highlight the potential of such programs in supporting the well-being and flourishing of medical professionals.

Using a Mediator’s Toolbox: Reducing Clinical Conflict by Learning to Reconceive the “Difficult” Patient or Family Fiester A, Stites S. MedEdPORTAL. 2023 Jul 14;19:11324. doi: 10.15766/mep_2374-8265.11324. PMID: 37456671; PMCID: PMC10345165 Free full text
Conflict between physicians and patients or their families is a prevalent issue in healthcare settings. To equip trainees with skills to manage such conflicts, Dr. Autumn Fiester and Dr. Shana Stites introduced a workshop applying mediation techniques to clinical encounters. The study adopted a mixed-methods approach, involving 15 medical students in a 60-minute virtual workshop and 10 clinical fellows in a 90-minute in-person workshop in early 2022. Two specific mediation techniques designed to facilitate the resolution of clinical conflict were presented to the trainees. After interactive discussions on each method, small groups practiced applying the techniques to a sample clinical case. Both cohorts rated the workshop highly (4.6/5.0 and 4.7/5.0). These results can help build a base from which to develop further workshops using the mediator’s toolbox. Future directions could include using simulations, specifically addressing offensive language, or incorporating training on cultural competency or trauma-informed care. Regardless, “evaluations of this workshop suggest that teaching core mediation techniques could provide potential tools for trainees in managing these challenging clinical situations.”

Narrative medicine workshops for emergency medicine residents: Effects on empathy and burnout Malik Z, Ahn J, Schwartz A, Blackie M. AEM Educ Train. 2023 Jul 20;7(4):e10895. doi: 10.1002/aet2.10895. PMID: 37485471; PMCID: PMC10357272. Dr. Michael Blackie has been a Gold Foundation grantee
Emergency Medicine (EM) resident physicians have some of the highest rates of burnout reported in medicine, in part due to the many emotional challenges they encounter, including navigating conflict and witnessing trauma. Narrative medicine (NM), an educational approach that centers on storytelling and reflection, is one approach that has shown promise in helping to foster well-being. To explore its applicability in EM, Zayir Malik and colleagues conducted a study in which they implemented a series of two NM workshops from June to October 2020. Residents were recruited at two sites, an intervention site and a control site. Residents were surveyed using the Interpersonal Reactivity Index (IRI) and a single-item burnout measure both before and after the two workshops. In total, 76 residents responded, representing 100% of the residents in the intervention group (n=48/48) and 46.7% of the control group (n=28/60). While both groups had worsening burnout over time, those in the intervention group had less severe increases. Empathy did not change. Additionally, 50% of residents in the intervention stated that the workshops should be a standard part of EM residency programs. While the authors note limitations, such as the small sample size and potential response bias (only 48% of residents in the control group responded), they conclude that “exposure to an NM curriculum may be protective against worsening burnout.

What Patients and Caregivers Experience When They Receive Palliative Care: A Study Eliciting Metaphors That Could Shape Public Messaging Back AL, Wax JS, Rossi RD, Shaw K, Grant MS, Zaltman L. J Palliat Med. 2023 Jun;26(6):751-756. doi: 10.1089/jpm.2023.0009. Epub 2023 May 2. PMID: 37126403. Dr. Anthony Back has been a Gold Foundation grantee
Public misconceptions and lack of awareness about palliative care often hinder patients from receiving these beneficial services. To better understand this issue, Dr. Anthony L. Back and colleagues conducted a qualitative study that aimed to understand the “deep metaphors” — the basic and often subconscious frames of reference — associated with palliative care from the perspectives of patients and their caregivers. The researchers used the Zaltman Metaphor Elicitation Technique in 2022 to conduct interviews with 8 patients who had received palliative care and 8 caregivers. Participants voiced that serious illness “took away” a sense of certainty about their lives. Palliative care was able to counter some of this. Four themes emerged from the interview: (1) Validation (feeling connected and heard), (2) Agency (having input and control in your care), (3) Guidance (feeling buoyed by resources and expertise), and (4) Regeneration (becoming a wiser, more experienced version of yourself). Interestingly, participants did not bring up dying or death or “bucket lists” but rather emphasized everyday thoughts and actions that held meaning. The authors noted that these themes can be used in public messaging regarding palliative care in order to reduce misconceptions.

When Did the Empathy Die?: Examining the Correlation Between Length of Medical Training and Level of Empathy Dinoff A, Lynch S, Hameed AS, Koestler J, Ferrando SJ, Klepacz L. Med Sci Educ. 2023 Mar 17;33(2):489-497. doi: 10.1007/s40670-023-01768-1. PMID: 37251206; PMCID: PMC10020755 Free full text
Empathy, “broadly defined as the ability to imagine and understand the thoughts, perspective, and emotions of another,” is a complex multi-dimensional concept that has been shown to improve both patient outcomes and patient and clinician satisfaction. Despite its importance, there is concern about the decline in empathy as medical students progress through their training, as prior studies have revealed. Dr. Adam Dinoff and colleagues conducted a cross-sectional study assessing self-reported empathy among 179 medical students at New York Medical College in August 2020. The participants completed the Jefferson Scale of Empathy-Student Version and were asked to indicate their top choice of specialty. The results showed the mean levels of empathy of the fourth-year medical students were lower than first-year students. Students interested in pediatrics reported higher empathy scores compared to those interested in other specialties. Additionally, those identifying as women were also more likely to have higher empathy levels. However, the authors do acknowledge limitations, such as self-selection bias, since only 179 out of 840 total medical students responded. Regardless, the authors conclude that “medical schools must place a greater effort on teaching and enhancing clinical empathy in students to benefit future patients as well as the well-being of the students throughout their professional careers.”

To receive an email update when next month’s Research Roundup is published, please sign up here and check the box for Research Roundup.



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.