INTRODUCTION
Antenatal consultations for families expecting the birth of an extremely preterm infant offer critical opportunities to improve infant outcomes through early coordination and multidisciplinary care planning[1,2]. In scenarios involving complex decision-making, these consultations enable clinicians to share information about potential interventions and outcomes using clear, compassionate communication[1,2]. Antenatal consultation period provide space for families to express preferences, and guide the development of care plans that are ethically grounded, legally supported, and aligned with family values[1-5]. Poor-quality antenatal consultations for families expecting extremely preterm births are associated with uninformed or misaligned clinical decisions, heightened parental distress, and care plans that may not align with the family’s values or preferences[1-5]. Deficiencies in communication and documentation can further compromise continuity of care, ethical standards, and trust between families and the healthcare team[6-13]. Even when no immediate medical decisions are required, antenatal consults play an essential role in building trust, strengthening communication between families and the care team, enhancing coordination of clinical care (e.g., timing of corticosteroids or delivery at a tertiary centre), and emotionally preparing families for the uncertainties ahead. These interactions can reduce anxiety, foster clarity, and improve the overall experience for families during a highly vulnerable time[1,2]. These factors are especially important for populations that have been historically marginalized, such as indigenous families and other disadvantaged groups, who continue to experience systemic bias and historical trauma, which leads to fears and disengagement from healthcare systems. Their voices are often underrepresented or misinterpreted, and failing to intentionally elicit and integrate their perspectives may perpetuate existing disparities and deepen mistrust in perinatal and neonatal care. Early inclusive conversations that acknowledge and honor the values and cultural contexts of all families are an essential component of family-centred care as evidenced by existing data[1,2].
Current literature emphasizes the importance of tailoring medical decisions and care plans to the unique needs and contexts of individual families[14,15]. This person-centred approach requires a deep understanding of the family’s structure, their beliefs, values, understanding of prematurity, and their hopes and worries, collectively known as family context[7,16]. Meaningfully eliciting this contextual information is likely to better equip clinicians to integrate family values into antenatal consults[17]. However, the processes of family values clarification; that is, identifying what matters most to a family-and translating those values into care planning remain challenging in practice[17,18]. Common barriers include ineffective communication, clinician assumptions, reluctance to engage in values clarification because of perceived complexity, emotional burden, and time constraints, implicit clinician bias toward biomedical over values-based discussions, and insufficient training in how to conduct these discussions effectively[7,19-24].
There is increasing recognition of the need for formal communication curricula for trainees, and in neonatology the focus is on difficult conversations, including antenatal consultations[25-27]. Simulation training is standard for communication education across neonatal fellowship programs[28,29], with a need to adapt these for local setting and resources. Existing training programs on advanced communication-such as those focused on breaking bad news and serious illness conversations, do not specifically address how to integrate family values into care planning for neonates based on antenatal consultations[30-33]. To the best of our knowledge, researchers have not described a formal training curriculum to help neonatal care providers develop skills in values clarification and integration during antenatal consults[17]. At our center, although sessions on communication were provided, there was a noted gap in guidance on how to apply communication skills to antenatal consults.
Problem description
Following the updated American College of Obstetrics and Gynecology recommendations endorsing the use of antenatal corticosteroids for pregnancies at risk of periviable delivery between 20 and 22 weeks’ gestation, our neonatal service noted a rise in requests for antenatal consultations in this population[34]. In response, we established a multidisciplinary quality improvement (QI) team in April 2023, which included a neonatologist, nurse practitioner, and clinical nurse specialist to assess current practices and identify areas for improvement. In 2022, we recorded 150 antenatal consultation requests; 88 for anticipated deliveries before 29 weeks’ gestation (extreme preterm). Consults for gestation (20-23 weeks) increased by 25% (n = 16 and 22, in 2021 and 2022 respectively). Among the consults on extreme preterm infants, 73% (n = 64) were non-urgent inpatient consults conducted by neonatal fellows, pediatric hospitalists, or nurse practitioners. The remaining 18% (n = 16) were consults done on outpatients in maternal-fetal medicine clinics by staff neonatologists. Additionally, eight cases (9%) involved brief discussions with pregnant women in active labor, as time constraints did not permit a formal neonatal consultation.
The targeted review of 41 antenatal consult notes in May 2023 showed the documentation of medical content, including survival rates, long-term prognosis, and neonatal intensive care unit (NICU) processes. However, documentation of family-centred elements such as family context (who makes up the family, what their names, occupations etc.), family values (want intensive life-sustaining therapies vs exploration of treatment options to avoid pain and suffering etc.), religious or cultural beliefs, their hopes, and worries were absent in 80% of cases (n = 33)[7,18]. To assess whether these discussions may have occurred but were not documented, we facilitated a focus group with 11 neonatal fellows. We also conducted individual interviews with six early-career pediatric hospitalists working in our NICU to explore reasons for the lack of documentation (June 2023). Across both groups, providers acknowledged significant gaps in skills and confidence competencies related to eliciting and documenting family values. The major obstacle they found was insufficient formal training in value-centred communication and care planning, despite difficult conversation education already in place. Based on targeted review and interviews, we deconstructed the problem using the cause-and-effect diagram (Supplementary Figure 1). Several participants expressed strong interest in a structured educational approach to developing these competencies.
This project aimed to develop and implement a structured, guided, evidence-informed training curriculum and evaluate its impact on neonatal trainees’ perceived confidence in performing communication tasks in family values elicitation and integration during antenatal neonatal consults.
MATERIALS AND METHODS
Setting
Endorsed by neonatal program leadership, the QI team (neonatologists, fellow, family advisor) partnered with experts in serious illness communication, clinical ethics, curriculum development, implementation, and evaluation to design a training program intended for adoption as a standard practice pending acceptability.
We conducted this observational study between June 2024 and December 2024 at a 60-bed level III perinatal center that manages approximately 70 inborn and out born infants born at less than 29 weeks annually. This included those with surgical conditions. The prospective observational study represents a focused initiative nested within a larger QI project aimed at enhancing the quality and timeliness of antenatal consultations for families expecting extremely preterm deliveries. This project specifically targeted the consistent elicitation of family values and integration of those values into individualized post birth care plans.
Project scope
Antenatal consultations for inpatient pregnant women at less than 29 weeks’ gestation, who are not in imminent labor, and performed by neonatal fellows or hospitalist pediatricians, were considered within scope. Consultations by neonatologists were not included.
Curriculum development process
We applied the six-step approach to curriculum development described by Thomas to guide our process[35]. These include problem identification, needs assessment, defining goals, deciding educational strategies, implementation and evaluation.
Problem identification and needs assessment: Antenatal, neonatal consultation and documentation practices at BC Women’s Hospital before the study
The QI planning team conducted a process mapping exercise to compare current antenatal consultation practices with an envisioned ideal future state. This exercise helped identify existing workflow barriers and potential areas for improvement (Supplementary Figure 2). Building on these insights, the QI team developed a key driver diagram to outline strategic change areas and link them to targeted interventions (Supplementary Figure 3). Our preliminary work suggested that antenatal consultations at our centre primarily emphasized the delivery of medical information related to extreme prematurity-including survival statistics, anticipated interventions, and NICU course expectations. There was no standard consultation template to document medical information. Our neonatal team had a communication tool in place to foster meaningful communication with families, such as the Serious Illness Conversation Guide in Pediatrics[33], although not specific to communication related to extreme preterm birth related antenatal counseling[33]. Critically, documentation of family values, goals, and preferences was frequently absent, as no formal policies or prompts required inclusion of family-centred content. This gap posed potential challenges in understanding the family’s context and values during subsequent consultations, resuscitation pre-huddle, or early NICU admission locally. Such a lack of consistent and accessible information contributed to fragmented communication and hindered the multidisciplinary team’s delivery of empathetic, individualized care[7].
Goals of training curriculum and toolkit creation
To develop a training curriculum designed to equip neonatal fellows and hospitalist pediatricians with the knowledge and skills necessary to: Elicit family values, lead shared decision-making conversations using a structured conversation aid, integrate family preferences into post-birth care plans, and document these discussions effectively. The QI team conducted a targeted literature review of published frameworks, communication guides, and curricular evaluation models related to antenatal consultation and values elicitation, and these findings shaped the adaptation and design of communication tools appropriate to our context.
Development of conversation aids
We first reviewed published tools designed to support antenatal consultations by keeping discussions clear, focused, and balanced, particularly in situations involving complex information sharing or decision-making[3,18,33,36]. Rather than creating entirely new instruments, the QI team adapted elements from existing tools that aligned with our centre’s clinical context and workflow.
For scenarios involving decisions about postnatal care, the team reached consensus to structure the conversation aids using the SHARE Approach, a five-step framework for shared decision-making in healthcare[18,33,36,37]. Within this framework, eliciting family values and preferences and integrating them into care decisions is a core component. Accordingly, the conversation aids were designed to explicitly support values clarification prior to discussing care options and reaching shared decisions.
The overarching objective was to develop structured conversation aids that facilitate meaningful, values-based discussions between clinicians and families[38,39]. The aids incorporated prompts intended to support values elicitation, mutual understanding, trust-building, and collaborative care planning aligned with family priorities. To promote consistency and high-quality communication during both training and clinical encounters, the prompts used value-neutral language, such as “What matters most to you in your care right now”?
The layout of each aid was organized to mirror the typical sequence of an antenatal consultation, progressing from understanding the family context to sharing medical information and, when applicable, discussing decisions. Prompts intended for clinician use during the encounter were visually differentiated using italicized grey text to support real-time documentation and reflection, rather than to direct or constrain the content of the conversation[36,40-45]. For each aid, we also specified the intended outcome of the conversation (e.g., shared understanding, values clarification, or a documented shared decision) to guide clinician focus and evaluation.
Following multiple iterative revisions, the QI team reached consensus on three final templates: (1) A pre-consultation medical summary template to standardize the collection of relevant maternal and pregnancy data (Supplementary Table 1); (2) A conversation aid for decision-making contexts, including discussions about neonatal resuscitation or comfort care (Supplementary Table 2); and (3) A conversation aid for non-decision-making contexts focused on information sharing and relationship-building (Supplementary Table 3).
In the final iteration, all conversation aids directed clinicians to begin by exploring the family’s background, including family structure, supports, beliefs, understanding, hopes, and worries, before delivering detailed clinical information[7]. This sequencing was intended to support more responsive and personalized communication. By aligning the tone, depth, and framing of information with the family’s emotional state, prior knowledge, and expressed values, the aids promote values-informed care planning for families confronting the possibility of extreme preterm delivery[42,44].
Implementation strategies
Our clinical intervention was a structured conversation focused on eliciting family values, discussing care options, and supporting shared decision-making. To ensure this intervention occurred reliably, it needed to be paired with clear implementation strategies.
We used two implementation strategies: Development of a clinical guideline and a simulated training workshop. Together, these strategies supported adoption of the conversation aids as part of standard antenatal care and promoted values-informed practice.
The guideline outlined simple step-by-step approach for selecting and using the conversation aids in two clinical contexts: Information sharing only, and information sharing followed by decision-making about post birth care. It defined expectations for eliciting and documenting family values, standardizing follow-up discussions, and consistently integrating family priorities into clinical documentation (Supplementary Figure 4).
The simulated training workshop complemented the guideline by building clinicians’ communication skills through experiential learning. We paired a stepwise approach that aligned with clinicians’ existing workflow with hands-on skill development. This approach aimed to strengthen clinicians’ confidence and consistency in using the tools and to better align antenatal consultations with family values and preferences.
Training workshop design and workshop planning
We planned to build both concepts and practical communication skills, supporting the integration of structured tools and documentation practices into routine clinical care through immersive, experiential learning. The workshop was intentionally designed to target both knowledge and skills across five core communication competency domains; Eliciting family values and preferences, leading individualized decision-making with parents, addressing parental concerns, Documenting family values and preferences under a distinct heading, and Integrating family values and preferences into an actionable care plan. Given this design, we assessed participants’ perceived confidence in performing each of these communication tasks as a pragmatic, learner-centred indicator of gains in applied knowledge and skills. We did not plan to operationalize or test declarative knowledge or observed communication performance, as the primary intent of this evaluation was to assess feasibility, acceptability, and self-reported readiness to apply these competencies. Thus, we used participants’ perceived confidence as a proxy measure for applied knowledge and skills
Inclusion: We invited all neonatal fellows, along with the neonatologist (not part of the QI team) facilitating the fellows’ academic day, to participate in the training workshop. We excluded hospitalist pediatricians and nurse practitioners because of the lack of protected time.
Workshop details: One week in advance, we gave fellows preparatory materials to encourage reflection and prepare them for participation. These included an overview of the workshop objectives, a rationale for the training based on observed consultation gaps, and three selected reference articles. We conducted the two-hour workshop (Supplementary Table 4) during protected educational time to ensure full participation of neonatal fellows. It combined didactic teaching with interactive components. The didactic portion covered an introduction to the clinical problem, presentation of the conversation aid tools, and a video demonstration of structured communication practices[46]. Two trained faculty took turns to simulate as parent and a doctor doing antenatal consult initially. Two role-playing simulations (Supplementary Tables 5 and 6), lasting 15 minutes each, followed with trainees performing the roles of a parent and doctor[30-32], followed by a structured debrief facilitated by faculty[47]. Finally, we shared the information in the guidelines to support the application of the communication tools.
The simulation scenarios, accompanying role-play guidance, and debriefing questions were all tailored to promote the practice of value clarification and shared decision-making conversations. The curriculum did not address training in: Collecting maternal or obstetric medical data[2], selecting outcome data sources[40,48,49], explaining NICU routines or accessing a link to a virtual NICU tour; or developing electronic medical record-compatible documentation templates. We excluded these components because of time constraints. The needs assessment did not prioritize them for training. One week before the workshop, the QI team reviewed and rehearsed the session content and structure; they also planned a formal post-session debrief to gather feedback and inform refinements.
Endorsement: Workshop implementation was endorsed by the neonatal fellowship program director, the division head, and the lead fellow representative.
Consent: The hospital’s research ethics board reviewed the study and, under Tri-Council Policy Statement Article 2.5[50] approved the project as a QI initiative. The board waived individual informed consent.
Sample size: The sample size was determined by convenience and included all neonatal program fellows who attended the academic day during the study year.
Evaluation
Guided by the Kirkpatrick educational framework[51], we assessed training effectiveness at two levels: Level 1 (reaction): Participants’ engagement, perceived relevance of the content to their clinical roles, and overall satisfaction with the workshop. Level 2 (learning): Gains in participants’ perceived confidence in performing communication tasks. To evaluate these outcomes, participants completed a pre- and post-workshop questionnaire on the day of the session using QR codes that linked to a Qualtrics survey platform. The pre-participation questionnaire included: (1) Five items measuring self-reported confidence in eliciting and integrating family values into a care plan, rated on a 5-point Likert scale (from “Not at all confident” to “Very confident”); and (2) Questions on participant background, including professional role and years of experience conducting antenatal consultations. The post-participation questionnaire repeated the same confidence assessment to evaluate changes attributable to the workshop. It also assessed: Participants’ perceptions of the training content, materials, and delivery; overall experience and satisfaction; suggestions for improvement; intention to change future clinical practice; assessed via Likert scale and open-ended response fields. Likert-scale responses were dichotomized into “confident/very confident” vs all other response categories (neutral, not confident, very not confident). This threshold was chosen to represent a meaningful level of confidence for clinical communication tasks and is consistent with prior educational evaluations that assess readiness for practice. We used Fischer exact test to compare the proportion of participants who rated themselves as “confident” or “very confident” before and after the workshop. We considered a P-value of < 0.05 statistically significant.
DISCUSSION
This study shows that a structured training curriculum designed to help neonatal trainees elicit and integrate family values into antenatal care planning significantly improved their perceived confidence. Our results reflect educational acceptability and perceived learning gains rather than objective communication performance. Participants reported increased ability to develop value-aligned care plans, addressing a critical gap in neonatal training. To our knowledge, this is the first study to incorporate conversation aids, simulation-based role play, and clinician workflow alignment into antenatal consultation training specifically, while also assessing its impact on learner satisfaction and perceived learning outcomes.
Integrating family values into perinatal decision-making-particularly at less than 25 weeks’ gestation has gained importance because of both advancing neonatal care and evolving ethical considerations[9,17,46,52-56]. Improved survival at 22-23 weeks’ gestation is now possible, but with substantial uncertainty around long-term outcomes. This has prompted a shift toward individualized, ethically sound care that focuses not only on clinical prognosis but also on family goals, beliefs, and capacity to cope[17,54,57].
Contemporary frameworks for shared decision-making emphasize the ethical imperative to engage families in choosing among medically reasonable care pathways, especially when evidence does not clearly support one option over another[17,54]; Professional guidelines now recommend aligning care with family values in these ethically complex scenarios[2,58,59]. The growing appreciation for diversity in cultural and spiritual perspectives surrounding life, suffering, and intervention further underscores the need for respectful, values-based communication[17,53,54]. Structured conversation templates and guided prompts play a key role in teaching advanced communication. They offer trainees a clear framework for navigating emotionally charged discussions, reduce cognitive load, and encourage the consistent use of person-centred communication strategies. Prompts such as “What matters most to you in your care right now”? guide clinicians in aligning decisions with family goals while fostering empathy and active listening. When embedded in frameworks like the SHARE approach, they help standardize best practices and reinforce reflective learning[36,41,43,45,60].
Simulation and role play are effective methods for improving communication, empathy, and clinical decision-making[30-32]. Well-designed scenarios that mirror real-world challenges, provide clear role expectations, and incorporate structured feedback, help trainees translate communication principles into practice[6,47,61]. Given that shared decision-making often unfolds over multiple consultations, it is essential that training prepares clinicians to build trust and rapport over time. Training programs should incorporate this longitudinal perspective to support skill application beyond the simulation setting[61].
Our findings align with previous studies evaluating advanced communication training, showing high participant satisfaction and statistically significant gains in self-reported knowledge and confidence[31,32,52]. Prior research has employed diverse educational formats, including multi-day workshops, online modules, virtual simulation, and standardized patient encounters, and has consistently reported improvements in participants’ perceived communication competence and empathy. These studies typically involved 10-15 trainees and observed post-intervention gains in self-assessed confidence and communication skills[31,32,62]. However, because the outcome measures varied across studies -ranging from yes/no responses to Likert scale ratings and reporting changes as proportions or score differences-direct comparisons of effectiveness between studies were not possible. To the best of our knowledge, no prior study has explicitly targeted the elicitation of family values or their integration into individualized postnatal care planning during antenatal consultations. None have assessed patient-centred outcomes or provided implementation strategies for translating training into routine clinical practice.
This study’s strengths include its evidence-informed curriculum, alignment with established communication strategies (e.g., conversation aids, decision frameworks), and focus on embedding training into real-world clinical workflows-whether or not a decision-making is involved. We also believe that the conversation aids may serve as effective pre-consultation rehearsal tools to help trainees merge skills when used just prior to real clinical encounters.
Clinicians may routinely use the tools developed through this project to facilitate the elicitation of family context and values in antenatal consultation, supporting the alignment of medical decisions and care plans with each family’s unique circumstances. Training programs may implement the described curriculum to help trainees develop these skills in a safe, simulated setting. Although this study was conducted at a single centre and involved neonatal fellows, the curriculum was designed with transferability in mind. The structured communication templates and scripted prompts are not discipline-specific and can be adapted for other clinician groups, including nurse practitioners, hospitalists, and obstetric providers, by modifying the clinical framing while preserving the communication process. Obstetric providers may use the information-sharing scenarios to prepare families and align expectations prior to neonatal consultation. In settings with limited educational resources or without protected teaching time, the tools may be used independently of simulation through brief case-based discussions, bedside teaching, or integration into routine antenatal workflows. Neonatal programs could adopt our structured approach to assess existing gaps in value-integrated, family-centred care, design targeted improvement strategies and evaluate their impact on clinical practice.
Limitations
Limitations include the single-centre design, small sample size, lack of validated shared decision-making assessment tools[9], and use of unvalidated simulation cases. We measured participants’ self-reported confidence rather than directly assessing knowledge acquisition or observed communication skills. We also did not include standardized actors as parents, nor did we evaluate long-term transfer of skills into clinical practice or patient-centred outcomes.
Next steps
Scaling this curriculum requires a sustainable implementation plan. This might include tiered delivery that offers beginner to advanced levels to accommodate varying experience and incorporating pre-consultation rehearsal using conversation aids. Adaptation of the provided mitigation strategies could support implementation at other centres. As part of our ongoing QI efforts, we plan to track documentation of family context in antenatal consults and assess whether this improves continuity and person-centred care during resuscitation, stabilization, and subsequent NICU admission. We also aim to gather family feedback on the consultation experience.
