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Original article
peer-reviewed

## Using Immersive Simulation to Engage Pediatric Residents in Difficult Conversations and the Disclosure of Patient Safety Events

### Abstract

#### Background

Full disclosure of patient safety events (PSE) is desired by patients and their families, is required by the Joint Commission and many state laws, and is vital to improving patient outcomes. A key barrier to consistent disclosure of patient safety events is a self-reported lack of proper training. Physicians must be trained to recognize when a PSE has occurred and effectively carry out disclosure, all while caring for a patient who is actively experiencing the consequences of an unintended outcome. Immersive simulation provides the opportunity to practice this complex skill.

#### Objective

To develop and evaluate a simulation-based workshop for pediatric residents on the disclosure of patient safety events.

#### Methods

A workshop in PSE disclosure was developed according to literature review, expert consultation, and feedback from hospital administration. The three-hour workshop included a simulated PSE with a subsequent standardized debriefing, interactive didactic session, and additional simulation-based hands-on practice in disclosure. Participants completed an anonymous survey at one-week and three-months post workshop, assessing workshop satisfaction, subsequent clinical experience, and perceived change to their practice.

### Discussion

This small, single-center study found that all study participants reported increased confidence and preparedness in their ability to lead the initial disclosure conversation after completing the workshop. In addition to reporting that they were more likely to engage their attending physician, risk management, and patient relations in the disclosure conversation, the workshop was shown to be relevant to actual clinical practice given that nine (one-third of) study participants reported involvement in the disclosure of a PSE in the three months after participation. All nine felt that the workshop content helped them with this experience. More notably, four of those nine study participants reported disclosing to the patient/family themselves. While the sample size is small, these data are encouraging and suggest a sustained impact that focused, immersive, and simulation-based educational sessions can have on trainees.

This curriculum addresses an educational need within pediatric training and supports prior literature on barriers to disclosure to the pediatric patient. A prior study on pediatrician attitudes toward disclosure found that most believed that PSE could be disclosed to developmentally appropriate pediatric patients (mean age 12 years) and believe that physicians and parents should jointly decide whether to disclose to pediatric patients [20]. However, they also believe that the training programs in disclosure should include formal instruction on disclosure and offer the opportunity to both practice these skills and receive feedback [7].

The release of the Institute of Medicine (IOM) report “To Err Is Human” was a key driver for the development and implementation of initiatives, policies, programs, and laws to address medical safety [21]. While some organizations have opted to use dedicated disclosure teams, many physicians and professional groups believe that all health care practitioners should receive training, education, and practice with this complex skill. In fact, a recent statement from the American Academy of Pediatrics Committee on Medical Liability and Risk Management states that full disclosure of PSE is an ethical obligation for pediatricians [3]. As the patient’s advocate, the physician plays a key role in the disclosure of a PSE, providing the patient and family with an explanation of what happened and the assurance that steps are being taken to prevent a similar occurrence in the future. A successful training session in error disclosure must stimulate individual reflection, group discussion, and provide a framework for clinicians and educators to approach this challenging discussion. The overarching goal of our workshop is to prepare pediatric residents to handle disclosing a PSE in the immediate setting, to deal with a patient and/or parent’s emotional reaction, to respond to questions regarding how the error occurred, to recognize their own emotions when discussing medical errors, and to provide them with the skills to help them carry out these conversations for the remainder of their residency and in their future careers.

Simulation-based training is uniquely suited for this type of training in that it offers participants an opportunity to push past the boundaries of their comfort, make mistakes in a safe learning environment, and receive corrective feedback for future practice [15]. A simulation-based workshop in disclosure of PSE provides physicians with the opportunity for hands-on practice of this complex skill. One main barrier is the cost of simulation training, which may be prohibitive to the sustainability of an immersive simulation-based training program in the absence of high level institutional commitment and support. However, cost-effectiveness in medical education often cannot be linked to actual outcomes but rather is tied to improved patient safety and intangible long-term societal benefits. Additionally, the disclosure training cost may not reflect its value given that the failure to disclose PSE promptly and properly can disrupt patient-clinician relationships, thereby increasing the chance of malpractice lawsuits [8]. The possibility of even one lawsuit avoided due to good communication may make an investment into a resource-intensive training program worthwhile.

There are a number of limitations to our study. This workshop was implemented at a single center, and participants surveyed may be influenced by local or institutional beliefs and therefore results may not be generalizable to other institutions. In addition, we only enrolled second-year pediatric residents and cannot directly comment how physicians at other levels of training or practice or other health care providers would benefit from such training programs. A principal critique of studies involving an educational intervention is that an improvement in participant confidence is expected and therefore not a noteworthy result; however, in this case we are teaching a psychosocial skill rather than a psychomotor one, and we do believe that improved learner confidence is a more powerful indicator of training success. Additionally, the fact that pediatrics residents participated – and even led – the error disclosure conversation following their participation in our workshop speaks to this. One final limitation is that although our study shows promise as an effective, interactive method for teaching error disclosure to trainees, it is relatively expensive and may not be affordable to all institutions. However, we believe that the traditional lecture format incompletely addresses learner needs in this emotionally and psychologically complex task; we suggest partnering with local experts in medical education to develop a multimodal training curriculum in disclosure, taking into account local resources in order to maximize educational efficacy for your learners.

Our study suggests that while hands-on practice is critical, the faculty and simulation resources needed for implementation of such workshops may not be sustainable long-term. Future training curricula should integrate didactic presentations with ample opportunity for hands-on practice of this critical communication skill. Future work on this subject should explore the long-term retention of skills by participants, impact on clinical practice, and implementation of similar curricula to include other health care providers.

### Conclusions

Health care providers need to be equipped to manage the immediate aftermath of a patient safety event. This small, single-center study found that immersive simulation is uniquely suited for teaching the difficult conversation skills required for disclosure of patient safety events. Hands-on practice is vital to becoming facile with this complex skill. Through our innovative workshop, providers gain practical knowledge, experience, and confidence in disclosure. In addition, the workshop was shown to be helpful in actual clinical practice, which may offset its cost. The sustainability of a comprehensive immersive training curriculum in disclosure ultimately requires institutional commitment to support clinicians in best practices related to patient safety and communication.

### References

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Original article
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### Author Information

###### Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Ann & Robert H. Lurie Children's Hospital of Chicago Institutional Review Board issued approval 2013-15438. The Office of Research Integrity and Compliance, (ORIC), Institutional Review Board has reviewed the above-named study and has determined that it is exempt from IRB review. The above IRB number has been assigned to this study for tracking purposes only. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Original article
peer-reviewed