Jeffrey Silver Humanism in Healthcare Research Roundup – September 2019

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.

Publications from Gold-Affiliated Authors

Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events Gaufberg E, Olmsted MW, Bell SK. J Med Humanit. 2019 Jul 24. Drs. Elizabeth Gaufberg and Sigall Bell are Gold Professors. Dr. Bell is also a Mapping the Landscape grantee, and Dr. Gaufberg was the founding director of the Gold Foundation’s Research Institute, where Molly Olmsted was an intern.
“Third things” are objects, images, or texts that serve as reflective triggers or conversational mediators to help create a safe space for sharing stories and perspectives. They can be used to approach sensitive topics that may otherwise cause emotional harm. Elizabeth Gaufberg and colleagues examined whether visual reflective triggers could serve as “third things” to foster useful dialogue about the emotional impact of harmful events and medical errors. At an Agency for Healthcare Research and Quality conference called “Healing After Harm,” the authors engaged 41 participants in a visual reflective trigger exercise to formulate domains and themes associated with medical injuries. By selecting an image among 200 9×12 cards affixed to the walls and reflecting on their chosen image, participants were able to open up about their experiences, as well as share emotional needs, barriers, and even positive experiences after trauma. The authors noted three major insights: (1) visual reflective triggers uncovered the complex and longitudinal nature of profound emotional and psychosocial harms, (2) harms from medical errors extend beyond the patient to the family and community, and (3) clinician and/or community avoidance of emotions after adverse events has harmful effects on patients and their families. The authors conclude that these visual reflective triggers are powerful catalysts and present opportunities for learning about challenging topics.

The long-term impact of an interprofessional humanistic faculty development programme: a qualitative investigation Tortez LM, Quinlan PS, Makaryus AN, George C, Caruso V, Gilman S, Ricardo A, Fornari A.   J Eval Clin Pract. 2019 Sep 3.
Dr. Alice Fornari is a Gold Foundation grantee and will be speaking at the 2019 Gold Humanism Summit.
Faculty development programs are important components of professional growth among academic clinicians once they have completed formal training, and constitute opportunities for building skills necessary for humanistic care. Leanne Tortez and colleagues examined the long-term impact of one such faculty development program named MAP-IT (Mentoring and Professionalism in Training). During the 10-month longitudinal program, groups of 8-10 individuals participate in monthly 90-minute meetings with a facilitator pair or trio. Humanistic topics are emphasized, including appreciative inquiry, enhancing well-being, and mindfulness and self-care. To evaluate the long-term impact, they utilized semi-structured focus groups from those who had finished the program 1-2 years ago. They found that graduates continued to use these practices and skills in their professional and personal lives. To their surprise, self-care, which was not designed to be an outcome of MAP-IT, emerged as a major theme. Also of note, one of the MAP-IT exercises with the greatest staying power was the participant’s selection of a “third thing.”(See first study listed in this Research Roundup for more about “third things.”) The authors conclude that there is “durability” in humanistic faculty development programs and that they may help to foster cultures of medical education and practice that promote “wellness, community, and social support.”

Reflecting on shared decision making: a reflection-quantification study Free full text Kunneman M, LaVecchia CM, Singh Ospina N, Abu Dabrh AM, Behnken EM, Wilson P, Branda ME, Hargraves IG, Yost KJ, Frankel RM, Montori VM. Health Expect. 2019 Aug 14. Drs. Marleen Kunneman, Megan Branda, Ian Hargraves, Kathleen Yost, Richard Frankel, and Victor Montori are Mapping the Landscape grantees.
Shared decision-making (SDM) refers to the collaborative nature of clinicians and patients in making decisions about health and care. It is considered an important component of healthcare, but assessing it accurately can be difficult. Marleen Kunneman and colleagues developed a reflection-quantification rubric to determine if SDM can better be measured by prompting patients to reflect before they are asked to produce a numeric rating. To do this, they created two modified versions of CollaboRATE, an SDM self-reported instrument, by adding prompts to reflect either on a particular visit or on a particular decision made during a visit. After testing the three versions of this questionnaire on 107 patients, they pursued further modifications to emphasize “stop-and-think” reflection. In this second study, they distributed a second version of the questionnaire to 212 patients. Overall, they found that that the “stop-and-think” emphasis did not significantly alter the ratings. Still, the authors conclude by noting that “other ways to induce a reflective pause” should be considered when studying SDM in these sorts of challenging settings.

Self-valuation: attending to the most important instrument in the practice of medicine Trockel MT, Hamidi MS, Menon NK, Rowe SG, Dudley JC, Stewart MT, Geisler CZ, Bohman BD, Shanafelt TD.   Mayo Clin Proc. 2019 Sep 18. Dr. Tait Shanafelt is a Mapping the Landscape grantee.
Physician burnout continues to be a growing problem with high levels of occupational stress leading to poorer quality of life among physicians. One component that may help to protect against burnout is self-valuation, a constructive prioritization of personal well-being coupled with a growth-minded perspective. But how much does self-valuation impact well-being? Mickey Trockel and colleagues examined this through cross-sectional survey data from 3,899 physicians who work at 5 academic medical centers. They developed the Clinician Self-valuation Scale composed of 4 items, and compared self-valuation scores to burnout and sleep-related impairment. They identified that increased self-valuation was associated with lower burnout and lower sleep-related impairment, when adjusted for sex and medical specialty. They also found that self-valuation accounts for approximately 27% of variability in physician burnout and that self-valuation seem to be lower and burnout higher among female physicians. The authors use the findings to consider potential interventions, such as cognitive therapy, that may help mitigate burnout and promote well-being.

The Implicit Association Test in health professions education: a meta-narrative review Free full text  Sukhera J, Wodzinski M, Rehman M, Gonzalez CM. Perspect Med Educ. 2019 Sep 18.  Dr. Javeed Sukhera is a Mapping the Landscape grantee. Dr. Cristina Gonzalez was a 2015 Gold Humanism Scholar at the Harvard Macy Institute. Implicit biases are attitudes that are formed through experiences and operate outside an individual’s awareness. Implicit biases often contribute to healthcare disparities and may lead to inequitable treatment, especially to underserved groups. The Implicit Association Test (IAT), an online metric of response time to recognize the strength of these biases, is one widely used tool to help identify these implicit biases. To better understand the utility of the IAT, Javeed Sukhera and colleagues performed a meta-narrative review of 38 articles published between 2003 and 2018. The analysis uncovered two different ways IAT is most often used: (1) to measure implicit bias and assess the impact of educational activities (2) to promote awareness, reflection and discussion. The authors caution that curriculum designers and educators should consider the premise behind the IAT and how it will be used. The authors also note that most of these studies are time-limited or cross-sectional, which limit how strongly these results can be used for evaluation or curricular interventions, especially for sustaining changes for the longer term. Moreover, the authors caution that the IAT is “only one small piece of a larger interconnected set of components” related to identifying and addressing implicit bias.

Other Publications

Teaching empathy to nursing students: a randomised controlled trial  Bas-Sarmiento P, Fernández-Gutiérrez M, Díaz-Rodríguez M; iCARE Team. Nurse Educ Today. 2019 Sep;80:40-51.
Empathy is a touchstone of humanistic healthcare, but can it be acquired as part of health professions education?  This is the question that Pilar Bas-Sarmiento and colleagues sought to explore as part of a randomized control trial of 116 second-year students from two nursing schools in Spain. The investigators designed an intervention consisting of 2-hour= meetings held twice weekly for seven sessions focusing on building empathy. The experimental group received this intervention during the trial, while the control group would only receive it once the trial was completed. They measured outcomes before and after the intervention using standardized measures like the Jefferson Scale of Empathy (JSE), the Consultation and Relational Empathy (CARE) Measure, and a 10-point Likert scale on student perception of learning. They determined that experimental groups had higher post-test scores and that there was increased perception of learning and understanding compared to control groups. The authors noted that certain elements of empathy can be developed through training, but follow-up over longer periods of time and more rigorous studies controlling for other variables are necessary before establishing more definitive conclusions.

Compassion fatigue and compassion satisfaction among multisite multisystem nurses
Kawar LN, Radovich P, Valdez RM, Zuniga S, Rondinelli J. Nurs Adm Q. 2019 Oct/Dec;43(4):358-369.
Compassion fatigue is defined as “emotional exhaustion due to severe and prolonged interaction with clients, use of self and exposure to stress.”  This is a major occupational hazard among inpatient nurses and is associated with burnout. The converse of this is compassion satisfaction, which refers to when “a nurse gains fulfillment through helping clients.” Lina Najib Kawar and colleagues looked at how common these phenomena are among 1,174 nurses from two large Southern California healthcare organizations. They used an online survey composed of the Professional Quality of Life Scale and analyzed items that were most strongly identified with compassion fatigue and compassion satisfaction. They found that more experienced nurses and nurses working the night shift  experienced higher compassion satisfaction, while new graduates, ICU nurses, nurses with a BSN degree, and nurses working 12-hour shifts had higher compassion fatigue scores.  However, there was low variability accounted for by these factors, suggesting that there are other factors, which could include unit culture and management support, that could mitigate the risk of compassion fatigue, and consequently burnout. Overall, these results point to the need for interventions designed for specific specialties and for less-experienced nurses.

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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.