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Second Victim -protokollan hyödyt ja käyttöönotto, sen edistäminen

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tiimin johtaminen

tiimin jäsenenä toimiminen

Menetelmänä mm. simulaatiot

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ymmärrys muiden ammatillisista taidoista

moniammatillinen yhteistyö mm. simulaatiot

ratkaise ongelma moniammatillisesti

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Moninaisuuden huomioiminen

DEI-teemat

Monikulttuurisuus potilaissa ja työyhteisössä

Kommunikaation keinot, tulkin ja esim. tekoälykääntäjän kanssa työskentely

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Narratiivisen lääketieteen hyödyntäminen ammatillisessa kasvussa

Työkaluna kirjoittaminen ja reflektio esimerkiksi potilaskohtaamisten, työssä esiintyneiden tilanteiden tai taiteen herättämistä ajatuksista

Teemasta kirjoitettuja katsauksia:

https://bmjopen.bmj.com/content/10/1/e031568

https://www.tandfonline.com/doi/full/10.1080/0142159X.2019.1584274#abstract

Kouluttajana voisi toimia Finlandia-voittaja Jussi Valtonen

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Objectives Narrative medicine (NM) incorporates stories into health sciences paradigms as fundamental aspects of the human experience. The aim of this systematic review is to answer the research question: how effective is the implementation and evaluation of NM programmes in academic medicine and health sciences? We documented objectives, content and evaluation outcomes of NM programming to provide recommendations for future narrative-based education.

Methods We conducted a systematic review of literature published through 2019 using five major databases: PubMed, Embase, PsycINFO, ERIC and MedEdPORTAL. Eligible NM programming included textual analysis/close reading of published literature and creative/reflective writing. Qualifying participants comprised individuals from academic medicine and health sciences disciplines. We reviewed and categorised programme goals, content and evaluation activities to assess participant satisfaction and programme efficacy. Two members of the research team assessed the risk of bias, independently screening records via a two-round, iterative process to reach consensus on eligibility.

Results Of 1569 original citations identified, we selected 55 unique programmes (described in 61 records). In all, 41 (75%) programmes reported a form of evaluation; evaluation methods lacked consistency. Twenty-two programmes used quantitative evaluation (13 well described), and 33 programmes used qualitative evaluation (27 well described). Well-described quantitative evaluations relied on 32 different measures (7 validated) and showed evidence of high participant satisfaction and pre-post improvement in competencies such as relationship-building, empathy, confidence/personal accomplishment, pedagogical skills and clinical skills. An average of 88.3% of participants agreed or strongly agreed that the programme had positive outcomes. Qualitative evaluation identified high participant satisfaction and improvement in competencies such as relationship-building, empathy, perspective-taking/reflection, resilience and burnout detection/mitigation, confidence/personal accomplishment, narrative competence, and ethical inquiry.

Conclusion Evaluation suggests that NM programming leads to high participant satisfaction and positive outcomes across various competencies. We suggest best practices and innovative future directions for programme implementation and evaluation.

Criteria for selecting studies for this review

To be eligible for inclusion in the systematic review, a record had to document NM programming implemented within academic health sciences worldwide. We excluded articles, abstracts, commentary or perspective pieces focused exclusively on NM theory, since an examination of the philosophical and theoretical principles of the NM framework is beyond the scope of this review.

Record eligibility also was contingent on the constituencies to which NM programming was offered. We considered a broad target audience consisting of one or more of the following: 1) graduate medical, dental or health sciences students, including candidates for MD, DMD, PharmD, PhD, MS and MPH degrees; 2) undergraduate or graduate nursing and allied health students; 3) medical, dental, nursing or health sciences trainees, including residents, clinical fellows and research fellows; 4) nurses; 5) allied health professionals; 6) faculty in the medical, dental and health sciences and 7) non-faculty physicians.

A third inclusion criterion involved the educational components of NM training. The history of literature and medicine is grounded in both literary analysis and narrative writing, 9 although some scholars consider reflective/creative writing to be a relatively recent addition to NM programming. 8 Nevertheless, writing is a singularly effective means of fostering reflection. 30 Therefore, we specified that, to be eligible for the systematic review, NM trainings had to include both essential components of NM imbedded in the programmatic core: 1) textual analysis/close reading of published literature (eg, poetry, fiction, creative non-fiction) and 2) creative/reflective writing.

Search methods for identification of studies

We consulted the Boston University School of Medicine Assistant Director of Library and Information Management Education to design a search strategy for the systematic review. Our information sources included five major databases: PubMed, Embase, PsycINFO, ERIC and MedEdPORTAL. PubMed-an online repository of the US National Library of Medicine, National Institutes of Health-is home to over 29 million citations in the realm of biomedical literature. Likewise, Embase indexes significant biomedical literature from across the globe. PsycINFO, the expansive database of the American Psychological Association, focuses on up-to-date behavioural and social science research. ERIC represents the US Department of Education's Institute of Education Sciences online research library. MedEdPORTAL is a database of programme curricula provided by the Association of American Medical Colleges. Strategies were optimised for each database to make the best use of that resource's specific controlled vocabulary or preferred search syntax, and we chose our search terms carefully in order to strike the optimal balance between sensitivity and precision. This is a best practice endorsed by and documented in the Cochrane Handbook for Systematic Reviews for Interventions. 31 The databases were searched in their entirety through October 2019. A table documenting our electronic search strategy is presented in online supplemental digital appendix 1.

Data collection and analysis

We assessed the records identified during the literature search using a two-round, iterative process to reach consensus on eligibility ( figure 1), 32 independently screening the 1569 record abstracts after the removal of duplicates. If an abstract was unavailable, the article text was consulted when possible. To be considered eligible, records had to meet all inclusion criteria. Based on the first round of screening, 164 records qualified for full-text assessment.

During the second screening stage, we read the full texts of records, identifying a further 109 records to exclude due to our discovering on full-text review that they did not meet our established eligibility criteria ( figure 1). Following the full-text screening, 61 records qualified for review. 15 22 33-89 However, we discovered that several qualifying records addressed identical NM programming efforts at the same institution: that is, 12 records 15 22 41 42 44-48 52 70 84 represented 6 programmes. We considered programmes represented by more than one publication type together, thus resulting in 55 unique NM programmes being included in the systematic review.

We performed the data collection independently, analysing the 55 eligible programmes to identify significant information and classifying relevant data for assessing the overall effectiveness of NM in academic medical and health sciences centres. We then cross-checked our results for reliability. Initially, we extracted verbatim data according to date(s) of publication; institution type; geographic location; participant information; programme goals, scope and activities; evaluation methods ( table 1); well-described evaluation outcomes ( table 2, online supplemental digital appendix 2) and evaluation competencies ( figure 2). We coded and synthesised the verbatim data regarding programme context, design, goals and evaluation according to broad themes ( online supplemental digital appendix 3).

Since we were particularly interested in identifying the outcomes, as well as the curricular content and goals of NM education, we paid special attention to categorising evaluation methodology used for assessing programme evaluations. We assessed the quality of reporting for all 55 programmes included in the systematic review, classifying programmes according to whether or not they were evaluated, and then differentiating the evaluated programmes according to evaluation design and method. Fourteen (25.5%) programmes did not report any evaluation methods. For the remaining 41 (74.5%) programmes, we systematically approached the assessment of programme evaluations according to specific criteria which were applied to all studies in order to ascertain whether the reporting of evaluation methods was adequately or inadequately described.

Quantitative evaluations were deemed 'well described' if they reported the evaluation questions or measures used and the results (including the N) to the extent that our study team could interpret the acquisition of NM-related competencies and/or professional growth among programme participants. Qualitative evaluations were deemed 'well described' if they reported the method used to collect qualitative data (eg, content analysis, focus group, open-ended survey) and analysed data from which our study team could interpret whether programme participants had acquired specific NM-related competencies and/or achieved professional growth. Programmes were deemed as 'not well described' if they did not include full details regarding evaluation methods to identify whether the evaluation was conducted in a systematic way.

We stratified programme evaluation based on the type of methods used (qualitative vs quantitative), the thoroughness of the description of the evaluation, including whether the methods and analysis strategy were discussed, and results reported. In regard to evaluation design, programmes were categorised as: 1) cross-sectional, including all programmes with postprogramme evaluation without a comparator; 2) case-control, using a post-test comparing control and treatment groups; 3) controlled or uncontrolled pre-post test, including all programmes that included both a pretest and a post-test and 4) randomised step-wedge design, including all programmes that used a step-wedge design to examine programme impact on participants randomised to participate at different time points. We were open to including other evaluation designs, but only the four designs discussed here emerged from our analysis of the NM programme included in the systematic review.

In addition to tracking overall evaluation strategies, we used grounded analysis to analyse the extracted data. Hence, programme goals did not necessarily map neatly onto actual outcomes. We recorded the well-described evaluation of specific NM-related competencies according to the following thematic groupings: participant satisfaction, relationship-building, empathy, perspective-taking and reflection, resilience and burnout detection/mitigation, confidence/personal accomplishment, narrative competence, ethical inquiry, pedagogical skills, clinical skills, relevance to work, institutional impact and cultural competence. Attentive listening practices were included in the relationship building and narrative competence thematic groupings.

Patient and public involvement statement

No patients were involved in this study.

Descriptive statistics

Table 1 summarises the descriptive statistics of all 55 programmes included in our review. The programmes included in our review were documented and disseminated through a variety of media, including articles (n=36), abstracts (n=18), MedEdPORTAL curricula (n=4), unpublished theses (n=2) and a book chapter (n=1). Publication dates were from 2005 to 2019, with the median year of publication being 2016.

NM programming efforts reported in the literature were concentrated in relatively high-resource settings. The bulk of trainings occurred in North America (n=46, 83.7%), followed by Europe (n=5, 9.0%), Asia (n=3, 5.5%) and South America (n=1, 1.8%). See online supplemental digital appendix 4 for a map of NM programme locations.

NM programme participants and size varied. Programming was offered for medical students (n=23, 41.8%), resident and fellow clinical trainees (n=22, 40.0%), faculty and non-faculty physicians (n=17, 30.9%), nurses and nursing students (n=9, 16.4%), other staff (n=9, 16.4%) and other students (n=2, 3.6%). Some programmes were open to more than one of the above constituencies. Number of participants ranged from 5 to 350 individuals (median 26.5; IQR 12-47.25); for 15 programmes, participant constituency and/or participant numbers were not provided.

The number of sessions offered by NM programme was highly heterogeneous, running the gamut from a single workshop or seminar to as many as 40 half-hour sessions offered over the course of a year. 52 The median number of sessions offered was 5 (IQR 3-11.5). The number of hours of programming offered was similarly highly variable, ranging from 1 to 60, with 8 being the median (IQR 3-17).

NM programmes specified one or several educational objectives related to both narrative and clinical/medical skills. We grouped programmatic goals involving narrative skills into several categories, including the cultivation of reflection (n=23, 41.8%); empathy (n=22, 40.0%); communication, attentive listening and narrative competence (n=20, 36.4%); resilience and burnout detection and/or reduction (n=9, 16.4%); cultural competence (n=3, 5.5%); wellness (n=3, 5.5%); writing (n=3, 5.5%) and narrative skills for pedagogy (n=2, 3.6%). Programmatic goals related to clinical/medical skills sought to employ NM to foster clinical competence (n=13, 23.6%); enhanced sense of professionalism and vocation (n=13, 23.6%) and successful medical team functioning (n=9, 16.4%).

In order to achieve the stated programming goals, NM curricula relied on a combination of activities, including engaging with literary readings and writing reflectively (n=55, 100%); group discussion (n=46, 83.6%); sharing and/or workshopping participants' writing as a group (n=29, 52.7%) and other narrative-based exercises (n=18, 32.7%), such as conducting patients' interviews and writing patients' stories, creating portfolios, participating in an online forum and even presenting a play.

NM programme evaluation

The reporting of NM programme evaluations varied across programme and publication types. Fourteen (25.5%) programmes did not report any evaluation activities. For programme reporting quantitative evaluations, we identified 13 as well described and 9 that reported some quantitative methods but were not thoroughly described. As mentioned previously, programmes were deemed as 'not well described' if they did not include full details regarding evaluation methods. See table 2 for explanations for programmes deemed as well described; incomplete quantitative and qualitative programme evaluations are recorded in online supplemental digital appendix 5. For programmes reporting qualitative evaluations, we identified 27 as well described and 6 that were not described thoroughly. Only six NM programmes were deemed as having both quantitative and qualitative evaluation methods that were well described. 49 51 52 55 77 84 85

Evaluation designs varied across NM programmes and included the use of cross-sectional designs, case-control designs, pre-post designs and randomised step-wedge designs. Of the evaluations we identified as well described, 31 evaluations used a cross-sectional design with a post-test only. Of the evaluations using a cross-sectional design, most had only an immediate post-test (n=29), one had an immediate post-test and a long-term post-test (1.5 years later) 33 and one had a long-term post-test only (1.5 years). 90 One evaluation did not report the timing of the post-test. 52 One evaluation used a case-control design where participants were randomised into the treatment condition or the control condition. 87 Of the seven evaluations that used a pre-post design, six did a pre-test and immediate post-test, and one did a pre-test and long-term post-test (1 year). 22 70 One evaluation used a randomised step-wedge design in which participants were randomised into two groups, and the groups participated in the programme at different times. 41 42 Post-tests of programme participants were compared with pre-tests of those who had not yet participated in the programme.

Overall, the quantitative and qualitative evaluations demonstrated that NM programming can have a variety of positive impacts on healthcare providers, showing evidence for modest gains in a variety of competencies, including relationship-building, empathy, perspective-taking/reflection, resilience and burnout mitigation/detection, confidence/personal accomplishment, narrative competence, ethical inquiry, pedagogical skills and clinical skills ( table 2 and figure 2). In addition to evaluating the impact of the programme on participants, many evaluation strategies focused on evaluating participants' satisfaction with the programme. NM satisfaction scores were reported to be high, with the combined per cent agree or strongly agree to the satisfaction measures as 87.9% (our calculation). However, satisfaction outcomes were not necessarily indicative of subsequent changes in the behaviour or experiences of health sciences professionals who engaged in the programming.

Of quantitative programmes deemed as well described, six reported high satisfaction 49 51 52 63 69 84 89 while modest and positive but not statistically significant impacts were reported on: pedagogical skills (n=2), 38 85 relevance to professional work (n=1), 63 resilience and burnout detection/mitigation (n=1) 22 70 and confidence/increased sense of personal accomplishment (n=2). 22 38 70 Programmes that reported statistically significant programmatic impacts examined increased empathy (n=3), 22 55 70 82 and increased perspective-taking/reflection (n=1). 22 70

Of qualitative programmes deemed as well described, 10 reported high satisfaction, 41 42 44 45 51 52 58 69 71 72 84 85 91 while positive impacts were reported on: relationship-building (n=15), 15 37 39 40 43-46 49 52 65 73 74 77 81 85 90 empathy (n=10), 15 46 49 55 64 73 74 76 77 81 90 perspective-taking/reflection (n=10), 37 39 40 43 52 64 73 76 77 84 85 resilience and burnout detection/mitigation (n=4), 39 50 81 90 narrative competence (n=3), 41 42 44 45 49 confidence/personal accomplishment (n=3), 33 40 74 ethical inquiry (n=2), 49 64 relevance to work (n=1), 33 pedagogical skills (n=1), 37 cultural competence (n=1), 15 46 and institutional impact (n=1). 37

We observed that the stated goals of NM programmes were not always reflective of the reported evaluation outcomes. Programmes identified a variety of goals, but a striking number did not report actual evaluation results (n=14) 34 35 53 54 56 59-62 75 79 80 83 92 or only discussed general participant satisfaction (n=7). 51 58 69 71 72 89 91 We found the evaluation methods and outcomes of many programmes to be insufficiently developed or described.

Recommended best practices and future directions for NM

Limitations

We acknowledge several limitations to our systematic review. Because the scope of this review was focused on the implementation, components and evaluation of NM programmes, as opposed to the theory and philosophy underpinning NM as a conceptual framework for health, we did not extend our search to include humanities-based journals such as Narrative, PMLA and Poetics Today. Furthermore, we did not systematically analyse the philosophical and theoretical orientations of the specific NM programmes surveyed, and it is possible that doing so may have helped to inform our understanding of choices made in terms of programme components and evaluations.

Since the conceptual framework of NM generated in the USA-although the framework is firmly rooted in an older, global tradition of medical and health humanities-to some extent the vocabulary and definitions associated with NM programming tends to reflect a particularly American viewpoint on academic health sciences education. We attempted to render our analysis of the records more globally inclusive by including programmes that did not specifically employ NM language (some refer instead to 'storytelling', 'medical humanities', etc), but still met our stated selection criteria.

Our results are inevitably subject to potential publication bias, since programmes with positive results are more likely to have been submitted and selected for publication. While the NM records made little mention of negative or neutral aspects of NM programming, such factors undoubtedly exist, including institutional funding limitations, faculty unfamiliarity with NM theory and participant time constraints. Furthermore, we noted the stated definition of NM to be inconsistent even within publications/programmes that met our inclusion criteria, a factor which may have led to some lack of consistency within reports of programme objectives, evaluations, and outcomes.

Eighteen qualifying records were abstracts, which by nature provide far less information than articles, curricula, unpublished theses or book chapters. Additionally, we recognise the inevitable complexities and potential pitfalls of synthesising mixed data from educational evaluations that have used varying methodologies. 111 In particular, given our reliance on qualitative analysis when synthesising the data, there is inevitably some element of subjectivity involved in data reporting and interpretation. Although we have made a good faith effort in our work, we do recognise that a degree of subjectivity is inevitable. In a discursive way, our review also raises questions regarding the need for further study on best practices for performing quantitative studies of qualitative endeavours such as NM programming and other social science variables.

Finally, while we have provided discussion regarding ways in which the general thematic schema of NM programme effectiveness may be transferable to future educational efforts, nevertheless we are aware that it is unclear how transferable the results of any specific programme may be, since many dimensions influence the impact of NM programming, including the unique participants, facilitator, curriculum and frequency/duration of sessions. To a great extent, however, this challenge supersedes NM and remains ubiquitous to medical and health sciences education as a whole.

Implications for research

We advise that NM programming best practices and future directions should include the use of robust evaluation mechanisms; inclusion of writing training as an additional learning outcome; and the development and implementation of NM for researchers, burnout-prone providers/contexts, cultural competence trainings and low-resource settings. We hope our systematic review helps to further the integration of narrative-based education into curricula at all levels in academic health sciences with a view towards nurturing resilient, reflective and emotionally intelligent professionals who, in turn, will provide better patient care, health sciences education, research and public health.

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Content and outcomes of narrative medicine programmes: a systematic review of the literature through 2019

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Objectives Narrative medicine (NM) incorporates stories into health sciences paradigms as fundamental aspects of the human experience. The aim of this systematic review is to answer the research question: how effective is the implementation and evaluation of NM programmes in academic medicine and health sciences?

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Lääketieteen etiikka / Eettiset kysymykset lääkärin työssä

Potilaan oikeudet, potilaslähtöisyys

Laki ja priorisointi vs. etiikka

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Mitä on terve kollegiaalisuus?

Miksi tarvitaan lääkäriprofessiota?

Kollegatuki työyhteisössä

Mukana lääkäriprofession ulkopuolinen tarkastelija? Potilasnäkökulman mukaannosto

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Ammatillisuus: Lääkäriys eri elämänvaiheissa ja rooleissa

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Ammatillisuus: Lääkäriys eri elämänvaiheissa ja rooleissa

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Kehittyminen lääkärinä eri elämänvaiheissa + siirtymät niiden välissä

Lääkärin eri roolit, esim. johtajana, kouluttajana, potilaana, omaisena

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Perustason pedagogiset taidot kaikille lääkäreille helposti

opetustaidot

pedagoginen jatkokoulutus

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Osaamisen kehittäminen ja sen johtaminen: yksilö ja työyhteisötaso

Kehityskeskusteluiden tehokas hyödyntäminen

Palautteen antaminen ja vastaanottaminen

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Miten viestin terveysasioista kansantajuisesti ja luotettavasti suurelle yleisölle?

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Terveyden ja hyvinvoinnin edistäminen: Tehokkaat keinot lääkärille

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Terveyden ja hyvinvoinnin edistäminen: Tehokkaat keinot lääkärille

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Riskitekijät ja niihin vaikuttaminen

Vaikeiden asioiden puheeksiotto potilastyössä, valmiit fraasit ja keinot

Milloin keinona resepti, milloin muu (elämäntapa)interventio tehokkaampi -kumpi tehokkaampi?

Vaikutuskeinot myös lääketieteen ulkopuolelta (yhteiskunta, liikunnan saavutettavuus, koululaitos yms)

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Vaikeat viestintätilanteet (lääkäri ja potilas, kollegoiden välillä)

Vuorovaikutuksen vinoumat: saavatko mukavat potilaat ylihoitoa

Tunnetaidot: Haastavan vuorovaikutuksen herättämät tunteet ja niiden kanssa toimiminen

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Lääkäri viestijänä erilaisissa rooleissa

Mediataidot, haastattelut

Miten teet vaikutuksen; tiivisti esittäminen, hissipuhe

Vuorovaikutus eri medioissa, some yms.

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Oma osaaminen ja tiedonhallinta: Itsensä johtaminen ja hyvinvointi

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Oma osaaminen ja tiedonhallinta: Itsensä johtaminen ja hyvinvointi

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-Itsensä johtamisen taidot ja hyvät käytännöt

-Vaikeiden tilanteiden käsittely ja keinot

-Työssä jaksamisen edistäminen