Difficult conversations in healthcare: the Italian program to enhance relational and communication skills

Communicating difficult news is a pivotal component of clinical practice. The way this communication occurs influences patients’ and families’ experience of care and bereavement process. Yet, clinicians are poorly trained to manage the emotional and ethical aspects of this task. Since 2002, the Program to Enhance Relational and Communication Skills (PERCS) at Children’s Hospital Boston has offered simulation-based workshops to promote relational skills and self-reflection for PICU and NICU clinicians (1). In collaboration with the Children’s Hospital Boston, the Italian PERCS was launched in 2008 at San Paolo Hospital, University of Milan (2). The aim of this study was to evaluate the efficacy of this program in Italy. Methods Two Italian PERCS programs were developed; one focused on difficult conversations in adult ICU (PERCS-ICU) and another focused on communication with dialyzed adult patients (PERCS-dialysis). The workshops lasted 4 hours, enrolled 10-13 interdisciplinary participants, and were geared around the enactment and debriefing of a case scenario. Participants volunteered to meet with patients/family members portrayed by actors in enacted conversations. The conversations were videotaped in a separate room and showed simultaneously on close-circuit television to the group. After each conversation, participants rejoined the group and had the opportunity to discuss and receive feedback from other participants, actors, and facilitators. Unlike other programs which use standardized patients, the actors were encouraged to improvise responses based on the approach that the individual practitioner had taken. This enabled the conversations to be particularly realistic and to unfold differently each time they were enacted. Participants rated the realism and usefulness of the case scenario on 5-point Likert scales. Participants also rated their sense of preparation, communication and relational skills, confidence, and anxiety before and after the workshop. Wilcoxon test was used to detect differences in pre/post ratings. Results Three PERCS-ICU and 2 PERCS-dialysis programs were offered. A total of 61 clinicians participated (20 physicians, 29 nurses, 7 psychologists, 2 chaplains, 2 social workers, 1 lawyer), and 24 are on a waiting list. The scenarios were perceived as very realistic (m=4.6, SD=.502) and useful (m=4.4, SD=.695). Participants reported an improvement in their sense of preparedness (P=.000), confidence (P=.001), and communication skills (P=.004). All of the participants (100%) reported that they would recommend the workshop to other colleagues in their position. Discussion and Conclusions The PERCS learning paradigm based on the use of realistic enactments and interdisciplinary learning, was demonstrated to be logistically adaptable to the Italian healthcare system. Participants perceived the case scenarios as realistic and reported better preparation, improved communication skills, and greater confidence.