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Use of Simulation to Validate Questionnaires on a Sensitive Subject

Hureaux, José MD, PhD; Cartier-Chatron, Ingrid MS; Bourgeois, Hugues MD; Rolland-Lozachmer, Ghislaine PhD; Ingrand, Isabelle MD; Colombat, Philippe MD, PhD; Urban, Thierry MD, PhD

doi: 10.1097/SIH.0000000000000145
Letters to the Editor
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LUNAM Université 40 rue de Rennes, 49000 Angers France johureaux@chu-angers.fr

Centre de coordination en cancérologie Centre Hospitalier Universitaire 4 rue Larrey, 49933 ANGERS Cedex 9 France

Angers PLateforme Hospitalo-Universitaire de Simulation en Santé Centre Hospitalier Universitaire 4 rue Larrey, 49933 ANGERS Cedex 9 France

LUNAM Université 40 rue de Rennes, 49000 Angers France

Centre de coordination en cancérologie Centre Hospitalier Universitaire 4 rue Larrey, 49933 ANGERS Cedex 9 France

Départment d’Onco-hématologie Centre Jean Bernard, 72000 Le Mans France

Faculté des Lettres et Sciences Humaines Victor-Segalen de Brest Université de Bretagne Occidentale 29000 Brest

Pôle Biologie Pharmacie et Santé Publique Centre Hospitalier Universitaire de Poitiers Université de Poitiers, 49000 Poitiers France

Département d’Hématologie de l’Université de Tours, 37044 Tours France

LUNAM Université 40 rue de Rennes, 49000 Angers France

Centre de coordination en cancérologie Centre Hospitalier Universitaire 4 rue Larrey, 49933 ANGERS Cedex 9 France

To the Editor:

Communication between doctors and patients is becoming an increasingly important aspect of medical training.1 Teaching based on simulation allows the subject to acquire relational skills in the context of announcement of bad news in pediatrics2 or oncology.3 Of all of the announcements of bad news, announcement of discontinuation of specific treatment and the end of life in oncology is considered to be one of the most difficult situations by experienced health care personnel.4,5

In the context of a French multicenter study designed to describe the communication of an experienced medical oncologist announcing discontinuation of specific cancer treatments to a patient accompanied by a loved one, we have developed questionnaires designed to evaluate the perception and understanding of this announcement for the physician, the patient, and the loved one. These questionnaires, filled out separately by the physician, the patient, and the loved one after the visit, concern the words remembered, the physician’s attitude, and the understanding of the palliative nature of the situation by the patient and the loved one. They were constructed as “mirror” questionnaires to analyze the patient’s and loved one’s understanding according to the physician’s words and attitudes. In view of the sensitive nature of this information, we decided to use an original methodology based on simulation to test and improve the first version of the questionnaires (provided by researchers) and to validate the final version.

Methodology was based on placing an experienced oncologist in a simulation session with 2 standardized patients. The physician was required to play his or her own role and announce discontinuation of all specific cancer treatment to the “actor” patient. The second actor played the role of the loved one. This experiment was conducted with the approval of the Angers University Hospital Ethics Committee (No. 2013–82). The simulation session started with the physician examining all of the patient’s medical records in an office. When the physician was ready, he or she fetched the patient and the relative from the waiting room. The physician then had 30 minutes to conduct the visit. The simulation session was broadcast to an adjacent room so that it could be observed by the investigators. In each scenario, the physician was asked to explain to the patient that no more validated medical treatment or phase I study was available. The specific issue of end of life was or was not discussed depending on the course of the interview. The simulated visit lasted for 30 minutes and was followed by a debriefing for the physician and the actors. Debriefing was performed in 3 steps: emotional debriefing, analysis, and synthesis. The method adopted for debriefing was that proposed by Rudolph et al.6 This type of debriefing is based on a concept derived from cognitive sciences that observed actions are derived from knowledge, hypotheses, and perceptions of the simulated situation by the participants. In this way, the training personnel (in this case, the study investigators) are able to understand the physician’s intentions and ensure that the questionnaire is suitable to study the situation investigated.

The physician, the “actor” patient, and the “actor” loved one were then asked to separately fill out their specific questionnaire over a period of 15 minutes. The responses to each question were then pooled, allowing a combined and interactive critical analysis of the content and format of each questionnaire by the physician, actors, and researchers.

Major changes were made to the questionnaires during the first 3 sessions. During the following 3 sessions, no major changes were required, and these sessions were used to validate the final form of the questionnaires.

We believe that this methodology enabled us to test, improve, and then validate our questionnaires under conditions very close to their future clinical use. The main value of this procedure was to validate 3 questionnaires on a sensitive subject. This approach avoided inconveniencing and distressing actual patients or loved ones. We believe that this methodology could be useful in many other medical settings to investigate sensitive relational dimensions.

José Hureaux, MD, PhD

LUNAM Université

40 rue de Rennes, 49000 Angers

France

johureaux@chu-angers.fr

Centre de coordination en cancérologie

Centre Hospitalier Universitaire

4 rue Larrey, 49933 ANGERS Cedex 9

France

Angers PLateforme

Hospitalo-Universitaire

de Simulation en Santé

Centre Hospitalier Universitaire

4 rue Larrey, 49933 ANGERS Cedex 9

France

Ingrid Cartier-Chatron, MS

LUNAM Université

40 rue de Rennes, 49000 Angers

France

Centre de coordination en cancérologie

Centre Hospitalier Universitaire

4 rue Larrey, 49933 ANGERS Cedex 9

France

Hugues Bourgeois, MD

Départment d’Onco-hématologie

Centre Jean Bernard, 72000 Le Mans

France

Ghislaine Rolland-Lozachmer, PhD

Faculté des Lettres et Sciences Humaines

Victor-Segalen de Brest

Université de Bretagne Occidentale

29000 Brest

Isabelle Ingrand, MD

Pôle Biologie

Pharmacie et Santé Publique

Centre Hospitalier Universitaire

de Poitiers Université

de Poitiers, 49000 Poitiers

France

Philippe Colombat, MD, PhD

Département d’Hématologie de

l’Université de Tours, 37044 Tours

France

Thierry Urban, MD, PhD

LUNAM Université

40 rue de Rennes, 49000 Angers

France

Centre de coordination en cancérologie

Centre Hospitalier Universitaire

4 rue Larrey, 49933 ANGERS Cedex 9

France

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REFERENCES

1. Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 25: 697–700.
2. Greenberg LW, Ochsenschlager D, O’Donnell R, et al. Communicating bad news: a pediatric department’s evaluation of a simulated intervention. Pediatrics 1999; 103: 1210–1217.
3. Fujimori M, Shirai Y, Asai M, et al. Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: a randomized controlled trial. J Clin Oncol 2014; 32: 2166–2172.
4. Mack JW, Smith TJ. Reasons why physicians do not have discussions about poor prognosis, why it matters, and what can be improved. J Clin Oncol 2012; 30: 2715–2717.
5. Jors K, Seibel K, Bardenheuer H, et al. Education in end-of-life care: what do experienced professionals find important? J Cancer Educ 2015. [Epub 15 Mar 2015].
6. Rudolph JW, Simon R, Dufresne RL, et al. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc 2006; 1: 49–55.
© 2016 Society for Simulation in Healthcare