International Journal of Healthcare Simulation

Introduction

Professionalism is a multi-dimensional construct, making it challenging to teach and assess desired behaviours [1]. Professional behaviours can erode over time through the challenges of practising medicine including high knowledge standards, emotional labour, unpredictable workplace environments and high-stress interactions [2]. One feature of professional behaviour is good communication, and reports of professionalism lapses from patients or colleagues often note maladaptive communication styles including harsh or demeaning language, emotional outbursts, hostile statements or passive aggression. Poor communication is cited as the underlying cause of medical errors in as many as 80% of events. When an individual is perceived as unpleasant or difficult to communicate with, this contributes to poor information sharing, reduced help-seeking and patient harm [3].

Many healthcare systems have a process for addressing formal grievances by patients or colleagues. However, few interventions exist to allow for practice of desired behaviours in a psychologically safe environment. To support colleagues with formal grievances regarding professionalism lapses, we developed a curriculum that utilizes simulation and debriefing techniques to provide an opportunity to refresh professional communication skills.

Starting with the primary assumption that each of our faculty wants to do their best for patient care, and that they want to avoid maladaptive communication styles, we developed a curriculum to help refresh skills. Rather than treating these communication patterns as personality defects, we sought to treat them as behaviours which may be changed through opportunities for deliberate practice and self-reflection in a psychologically safe encounter [4].

Innovation

To address gaps in faculty development for professional behaviour, we developed a pilot of structured standardized patient (SP) encounters. Faculty with formal grievances and communication concerns were referred for this mandatory encounter by departmental leadership. Seven cases were designed to address various communication behaviours. Two to three cases were selected for each faculty physician based on perceived communication challenges. Example scenarios include a delayed diagnosis due to poor supervision of a novice provider, a condescending consultant and a patient demanding unnecessary diagnostic tests. The SP was trained to play the role of patient or other interprofessional team member (e.g. consultant, trainee, nurse) in a manner meant to evoke stress and challenge the learner. For example, the SP may be rude, dismissive, incompetent or hostile themselves. The learner was tasked with navigating the medical aspects of the case while using professional communication strategies in the context of an interpersonal conflict.

Immediately after the case, the SP and the learner would conduct a private one-to-one debriefing session during which they discussed the conflicts, communication styles and dynamics of the encounter [5]. Prior to the case, the SPs were instructed to use first-person experience to share their reactions and to facilitate learner self-reflection through debriefing using the PEARLS framework [5,6]. After debriefing, the physician completed a new encounter with similar themes. Specific goals of the curriculum are listed in Table 1 [7]. All encounters took place over video conferencing software with only the faculty physician, SP and an SP supervisor that helped advance case slides and take notes for formative feedback. Peers or leadership was intentionally excluded to promote a safe practice environment. Sessions lasted between 30 and 60 minutes.

Table 1.

Specific learning objectives of the professionalism simulation curriculum

Learning objective	Behaviour
Foster a climate of psychological safety	Listen to learn/empathic listening
	Solicit feedback
	Communicate concerns with mutual respect
Conflict resolution and de-escalation	Naming the dynamic
	Stating concerns with respect
	Reflective listening
	Allowing space to speak (not interrupting)
Clear communication	Avoiding passive aggression
	Clearly stating objectives
	Addressing concerns
Non-verbal communication	Open body language
	Avoiding distractors such as cell phone

Evaluation

Learners were informed of the pilot nature of this project and invited to provide feedback via digital forms. To protect learners’ psychological safety, we did not collect any summative feedback about learners except to ask the SP if they felt the learner should repeat the session. Course directors debriefed with the SPs within 1 week of each encounter to address questions, get a sense of how the session went, if it met the intended objectives or needed any future adjustment of case details. This feedback was used to iteratively improve cases.

Specific feedback used to improve the curriculum included normalizing and addressing learners’ defence mechanisms during debriefing, providing additional scripted medical phrases to SPs, development of a pre-case stimulus document and encouraging the SPs to ‘push the learner’s buttons’ with specific trigger phrases or attitudes (e.g. several learners wanted SPs to be ‘less nice’ in their role).

Outcomes

Program feedback ranged from neutral to positive. Some learners reported no meaningful impact on their communication style, while others pointed to specific communication tools that they found helpful. Nobody reported that the curriculum worsened their communication style. Several learners requested additional practice sessions.

The department leadership considered the pilot successful and added a version of the experience as a required component of ‘on-boarding’ new faculty. All physicians hired by our Emergency Department now undergo a practice session on communication and professionalism with an SP.

What’s next?

Additional research would be required to quantify or qualify changes in professionalism behaviour. The cases should be further refined and made accessible to other simulation educators to increase availability of this curriculum. Recorded video pre-briefs for SPs may augment the cases’ portability.