Effective communication with families is an integral part of quality neonatal patient care. The World Health Organization and the National Academy of Medicine have recognized the need for and importance of formal communication skills training.1,2 In 2002, the Accreditation Council for Graduate Medical Education (ACGME) recognized communication skills training as a core competency for neonatal-perinatal medicine (NPM) fellows.3 However, due to a paucity of formally trained faculty, cost of simulation-based training, and time constraints, most neonatology fellowship programs do not have formal communication skills curricula.4,5 In a 2009 national survey, 75% of graduating NPM fellows reported no role-play or simulation-based communication training during their fellowship, yet >90% led family meetings regarding goals of care.6 Many physicians learn “on-the-job" without a formal curriculum, explicit role modeling, or simulation-based training, which leads to variable levels of communication skills expertise that do not reliably improve with time and experience.7 Additionally, physicians self-assess their communication skills with low accuracy.8,9 Those who receive formal communication skills training are more likely to engage in difficult conversations and report these experiences as rewarding.10 Conversely, insufficient communication skills training can contribute to burnout.11

Lack of formal communication skills training is highlighted in studies that show that pediatric and neonatal intensivists dominate family meetings.12,13 Much of the dialogue is dedicated to medical information and statistics, with little attention paid to psychosocial questions and family values, even though empathetic statements, question-asking, and emotional talk are associated with parent satisfaction and clinician-family alliance.14 Good communication with the neonatal intensive care unit (NICU) team is central to families’ emotional well-being during and after their infant's NICU admission.15 Positive communication experiences are associated with higher family visitation rates and more frequent skin-to-skin care.16 In contrast, negative communication experiences can lead to post-traumatic stress disorder (PTSD) in parents following NICU discharge, and studies show that approximately half of mothers and one third of fathers in the NICU meet criteria for PTSD.17,18

Effective communication in neonatal care requires skill and practice and can be challenging to achieve. During shared decision-making, clinicians must convey complex medical information in lay terms, respond to emotion, and elicit family beliefs and values. Much like procedural skills (e.g., endotracheal intubation), communication is a skill that can be learned and improved with practice, and competency can be objectively assessed. However, in neonatology in general, communication skills are not held to the same standard as technical skills. Since the late 1990s, experiential learning with role-play has been the standard for communication training. Simulation allows health care professionals to practice communication skills and receive immediate and direct feedback in a safe learning environment. Simulation-based communication skills training changes health professionals’ behavior during serious illness communication encounters, and studies demonstrate the benefits of simulation for communication training.7,19, 20, 21

Most communication skills studies in neonatology focus on antenatal counseling. Simulation studies highlight challenges encountered when conducting difficult conversations and inconsistencies when conveying antenatal information. A simulation-based study of obstetricians and neonatologists counseling a Standardized Patient (SP, trained actor) pregnant with a fetus at the border of viability found inconsistencies in quoted survival rates, likelihood of survival without impairment, risk of long-term disability, and in the use and interpretation of terms such as “intact survival” between and within the two physician groups.22 Rehearsal simulation and debriefing immediately before actual antenatal consultations can improve trainees’ communication techniques, including building rapport and displaying empathy.23 Other studies have similarly demonstrated the benefits of simulation for improving communication during antenatal counseling conversations.24,25

Although physicians are trained to share death and survival statistics with families during antenatal counseling, these outcomes may or may not be relevant to families’ antenatal decision-making.26 For example, survival with disability may be acceptable to some families. In addition, family perception of suffering, quality of life, and being a ‘good parent’ can influence decisions about resuscitation at birth. A simulation-based study of antenatal counseling showed that, in general, physicians dominate conversations and mostly deliver medical information while rarely eliciting family values or asking the family psychosocial questions.25 However, families report that empathy, kindness, and trust have the most positive impact on their well-being and satisfaction with care.27,28

Simulation has also been used to target effective communication during other types of difficult conversations in the NICU. Bowen et al. conducted a randomized control trial to assess the impact of simulation-based training on neonatal nurse practitioner (NNP) communication during difficult conversations.21 NNPs randomized to simulation-based communication practice with SPs prior to assessment of their communication skills asked significantly more open-ended questions (p=0.047) and achieved significantly higher scores on empathy ratings (p=0.015) when compared to the control group, who did not receive simulation-based practice prior to their communication skills assessment.

Simulation-based communication training has also been shown to increase comfort with relaying difficult news, such as the death of an infant.29 Lechner and colleagues demonstrated that NPM fellows who received simulation-based communication skills training reported higher comfort levels with difficult conversations in the NICU compared to those who received standard (no simulation) communication skills training. Furthermore, simulation-trained fellows demonstrated greater emphasis on brief pauses after delivering bad news, and body positioning, during simulations.30 End-of-life simulation scenarios using SPs has been shown to improve newly graduated pediatric intensive care unit nurses’ confidence in delivering end-of-life care, including their ability to listen to and support families.31

Simulation-based communication training promotes effective team communication. Dadiz et al. implemented simulation-based communication training for health care professionals involved in delivery room care and showed improved post-training communication between obstetric and neonatal teams before actual deliveries, and by the neonatology team with families in the delivery room.32 Other studies have also demonstrated the benefits of simulation-based training for team communication.33,34

Simulation can also reveal important information about the communication contribution of health care professionals during NICU family meetings. Studies of simulated NICU family meetings show that medical teams verbally dominate conversations, and that physicians speak the most and social workers and chaplains speak the least.35 The study also demonstrated that physicians discuss more medical and less psychosocial information than other members of the multidisciplinary health care team. Overall, social workers and chaplains asked more psychosocial questions than did the physicians and nurses, and they were more likely to ask the family about their point of view and understanding. This highlights the importance of including multidisciplinary team members in simulation-based training, to capitalize on each team member's expertise and skills, share the burden of communicating difficult news, and provide psychosocial support to families.

Simulation can help identify and improve implicit racial and socio-economic biases in neonatal care. Edmonds and colleagues utilized simulation with SPs to evaluate the effects of insurance status and maternal race on shared decision-making during periviable antenatal counseling of White and Black mothers by neonatologists and obstetricians.36 Consistent with other studies, physicians highlighted medical information and rarely addressed goals of care. Physician scores for shared decision making were significantly lower when counseling Black, privately insured patients than White privately insured patients, on delivery mode and decision for steroid treatment (p=0.03). Additionally, physicians received lower scores for shared decision making when counseling Black privately insured patients than when counseling Black Medicaid-insured patients for decision to resuscitate (p=0.03), delivery mode (p=0.02) and decision for steroid treatment (p=0.01). This novel study suggests that simulation-based communication training has the potential to identify and address implicit biases in neonatal care.

Simulation can also help identify missed conversation opportunities. Edmonds et al., showed that neonatologists and, less often, obstetricians most often deflected, declined, or ignored the question “Doctor, what would you do?” during simulated encounters for antenatal periviable counseling.37 Although one could argue against sharing ones’ personal preferences, this question could be used as a prompt to elicit family values. This is relevant because, in this study, physicians also readily acknowledged the importance of family values on decision-making but did not engage in eliciting them.

Considering medical advancements in neonatal care, the increasing number of infants and young children with medical complexity, and its effect on the entire family, the need for robust experiential communication skills training and practice for NPM fellows and practicing neonatologists is becoming increasingly evident. Recognizing this need, neonatologists and palliative care physicians have developed and implemented simulation-based communication curricula that use case-based scenarios.25,38,41 Details about case design, facilitator behaviors, and skills evaluation have been shared by multiple authors; these provide blueprints for faculty, simulation staff and SPs who may be familiar with Objective Structured Clinical Exam-type simulation but less familiar with communication skills trainings. Several published curricula offer approaches to training SPs, local community actors, or former NICU parents/families.39 Training in situ (in the actual clinical environment) versus in a simulation center may be important considerations for communication skills training, but to date this has not been formally studied.

Formal communication simulation facilitator training is available. For example, VitalTalk, is an evidence-based simulation curriculum that can be adapted for different pediatric subspecialties.40,41 To optimize facilitator training, courses are centralized and rigorous. Other facilitator options are to collaborate with professionals in medical improvisation for communication training.42

Formally trained faculty, time constraints, and cost can be barriers to simulation-based communication training implementation. When developing a curriculum, planning for sustainability is crucial. Unpublished data from one of the authors, SMB, provides an example. She partnered with other formally trained faculty at her institution, whom of note, were adult palliative medicine clinicians. She also applied for an internal education innovation grant to use as “proof of concept”. Mimicking the institution's Internal Medicine residency curriculum, sessions were 3-4 hours per year and feasible using a virtual platform (crucial during the COVID-19 pandemic). Data on self-efficacy and confidence were collected and the results presented at a local conference. The curriculum was then formally integrated into the NPM fellowship program by partnering with the Division of Neonatology and Department of Pediatrics to cover cost.