Figure 1
Comfort With Uncertainty (Ilgen model [5]). The key elements in dealing with uncertainty.
Table 1
Demographics of Study Participants.
| Total Number Participants | 34 |
| Female | 20 |
| General Paediatricians | 23 |
| Subspecialists | 11 |
| Emergency department paediatricians | 4 |
| Respiratory paediatricians | 3 |
| Infectious disease | 1 |
| Immunology | 1 |
| Metabolic disease | 1 |
| Palliative care medicine | 1 |
| City Hospital | 22 |
| Rural or Regional Hospital | 12 |
Table 2
Strategies Utilized To Manage Caregiver Comfort With Doctors Reassurance.
| STRATEGY | SUPPORTING QUOTE |
|---|---|
| Relationship Building A strong relationship is a key action in managing caregiver uncertainty that allows healthcare providers to take appropriate actions while ensuring caregivers are comfortable | It’s really important that and it builds that relationship. Even though it’s a 15-to-20 minute consultation, it builds that relationship, it builds confidence, they feel heard. (U14: 9 years; Emergency medicine) |
| Effective Communication Participants referred to observation, active listening, and careful language choice in addition to educating caregivers about red flags and reassuring findings | I feel parental anxiety and the way I interact in my clinic it’s all about communication…. I think you can reassure them if you can effectively communicate what the problem is. (U19: 13 years; Respiratory) |
| Participants felt observation of their history-taking and examination as important in building confidence in their assessment: | they’re very impressed that you’re so thorough with the history and physical exam and communicate it (U17: 4 years; Paediatrics) |
| It’s not just listening, its active listening, …. and that makes them feel reassured that you’re listening to their concerns (U5: 18 years; Paediatrics) |
| It’s quite obvious the words you’re using or the language you’re using or the decision you’re making has got them perturbed (U24: 9 years; Emergency medicine) |
| you find that the parents get a lot out of the patient information leaflets (R23: 19 years; Paediatrics) |
| Empathetic Communication The act of attentive engagement and demonstrating you have heard what they said: | I think, if, if, if the concerns are heard and they’re listened to properly and you communicate everything back to them, I would, in my opinion, I think, 95% of them, or above would accept that, and, and are reasonable and don’t have any, any issues. And I think, not only does it make the consultation better, I think the child’s quality of life potentially is better the quality of life of the parents, the anxiety of the parents is better that they understand it, they’re not worried”. (U18: 6 years: Paediatrics) |
| Walking Them Through the Observed Findings Logically walking the caregiver through the relevant findings in the history and physical examination was highlighted as important: | I think this is one of the most important things to be honest, communication, communication, communication is very important. And then you have to be confident yourself you have to show to the parents look, child is asymptomatic exam is perfect and soft murmurs are common in children. So I think yeah, communication very important to the parents. (U14: 9 years; Emergency medicine) |
| Combining Communication Skills Strategies Specific combinations of strategies include introducing yourself, sitting at the same level, establishing eye contact, taking your time not rushing the consultation and being thorough: | Well, it begins at the start to the consultation and it is walking into the room introducing yourself establishing a good rapport with child and parent and essentially, going through as you should do your structure for this scenario in a very thorough fashion. And the family need to feel that that is done in a thorough fashion. So cannot be rushed or felt to be rushed. I will even how I sit with them as opposed to stand in the room. There’s a psychological importance to that…… if you sit with the family, they perceive the clinical interaction as being much longer than if you stand and your eye-line is at least at level or below the person and not above and domineering and, and being honest with you then the language you use is tailored to their, you know, level of education and literacy with respect to medical terms…. I will often say the same thing, a couple of different ways, if I sense that there is a lack of understanding. And I will often ask the family to repeat back to me, what their understanding of what’s happened, (U24: 9 years; Emergency medicine) |
| Honesty Participants mentioned that the relationship between the provider and the patient or caregiver is of paramount importance. This relationship is built on honesty. Participants indicated that honesty fosters trust, a crucial element in any relationship, but particularly so in healthcare where decisions can have significant consequences. A healthcare provider with 18 years of experience in Paediatrics shares their perspective on this matter: | Being honest is really important for trust. I think there needs to be trust between us. They need to feel that you’re being straight with them. And I think if they feel you’re hiding something from them or that you know something they don’t, that wrecks the relationship because if you’re trying to say to them, we’re happy if they trust you, then they’ll take that information on board, and they’ll say, Okay, if you’re happy and we trust you, then that’s fine. Whereas if you don’t have their trust, then things may linger on and then when other decisions come up, not in this context, but in any context, then you’re at nothing, because they need to trust you when difficult decisions might come up then. (U5: 18 years; Paediatrics) |
| Leaving the Door Open Participants were very transparent with caregivers highlighting that there can be situations where the child’s status may change. Rather than exacerbating the caregivers anxiety, this strategy aimed to leave the door open and reassure the parent that if there was any change or deterioration in their child, they could immediately return for further assessment. This safety net provided the caregivers with significant reassurance and helped quell discomfort with uncertainty they may have experienced. Some participants referenced this as a recurring strategy to reassure parents, sometimes even telephoning parents to check on their child: | I think for me in emergency medicine for instance the febrile child is a scenario which I will be hugely familiar, with head injuries and other things. And we have terminology called safety netting and safety netting is being very open with the families and saying, “I have examined your child, I understood what’s happened, and this is what’s going on from my perspective, this is the diagnosis, however, I appreciate that I am viewing your child at a point in time. And should any of the following things happen, this gives you absolute licence to return to me, and we’ll take it from there essentially”, always saying that I do not expect that to happen, but it’s better that you know about this, than not know about us. “And, and I use that in a huge amount of scenarios…and it’s, I’ve never known it not to work for me. (U24: 9 years; Emergency medicine) There is nothing in it to be concerned about. But leaving the door open that if there are things, explaining to her that if something changes that clearly you’re more than happy to see her again. (U5: 18 years; Paediatrics) If the parent is extremely anxious, I would give regular phone calls so then knowing when their next appointment is when I go to re-evaluate is really helpful. And having the same person see again so not having them see the registrar or SHO, they come back to me, and then knowing that they can contact us between appointments, and not waiting for them to ring with a symptom, giving them a kind of a regular follow up so they know you’re going to have a follow up so that they’re not getting anxious about what’s going to happen. (R21: 20 years; Respiratory) |
Figure 2
Key components underlying doctor comfort with uncertainty (CWU), interaction with patient/caregiver comfort with doctor reassurance (CDR) and strategies to manage patient/caregiver CDR.