Theme
8AA Communication skills
INSTITUTION
University of Edinburgh - United Kingdom
NHS Lothian - Medical Education Directorate - Edinburgh - United Kingdom
Evaluation of our FY Simulation course has shown that juniors appreciate the opportunity to “break bad news” in a safe environment. In this previous work 56% of FY1s reported “Breaking Bad News” as a key learning point with 24% of our FYs stating that they would use tips given in this training in their future clinical practice (Crichton et al, 2015). This can still be an emotionally challenging experience. In previous simulation work 71.4% felt that a scenario involving a difficult conversation was useful. Despite communication skills workshops as undergraduates some still struggle with this necessary skill.
Simulation has been widely used as a modality for teaching breaking bad news (Bowyer et al, 2010, Tobler et al, 2014) but placing this within a simulated ward round environment with multiple distractors present has, to our knowledge, not been described.
Our plan was to investigate a difficult conversation taking place on a Simulated Ward Round using a mixed methods approach.
Simulated Ward Rounds were run for Year 5 undergraduates in March 2015 –each round was repeated following a structured debrief. The round included a patient who was planned for discharge but whose ultrasound report is suggests the presence of a possible malignancy. The senior in charge of the ward round has left to go to a clinic by this point and the “patient” pushes the student role playing as an FY1 to tell them the scan result. All interactions on the ward round were recorded digitally with prior consent obtained.
An observer checklist was designed (see attached) based on our own university document Clinical Communication in the Consultation (Boyd & Allan, revised 2008) which is based on the Calgary-Cambridge Interview Guide (Silverman et al, 2005).
Other scoring systems have been produced eg modified BAS (mBAS) described by Miller et al and global BAS (glBAS) These rating scales were evaluated by Schildmann et al in 2012 and the Jefferson Scale of Empathy (Hojat et al, 2001) but on studying these were not felt to be practicable in our own context.
All digital recordings were viewed with particular attention being paid to certain sections involving release of the scan report and whether the results were discussed with the patient in question. Any audible parts of this conversation were transcribed for qualitative analysis.
Groups of about 10 students were allocated roles either as Foundation Year (FY) Doctors, a ward clerk or as one of four patients. In a few larger groups some students were assigned the role of observer. The students who role played the patients were given a brief written background which highlighted the particular learning challenge the patient presented e.g. alcohol withdrawal, distress over losing an item, waiting to be discharged, as well as specific medical challenges e.g. allergies.
The patient this work concerns is a 19 year old first year medical student who was admitted with lymphadenopathy, presumed to be glandular fever. The simulated ward round was led by a member of faculty acting as Consultant and other faculty members role played a charge nurse and/or staff nurse. Student nurses participated in some rounds. Realistic clinical documentation was provided for each of the patients e.g. medication and observation charts and those role playing FYs were expected to undertake relevant tasks such as documenting in the notes, arranging discharge and appropriate investigations and prescribing medication.
After each simulated ward round a structured debrief was undertaken with the aim of promoting discussion and highlighting learning points. The debrief centred around exploring the challenges that the ward round presented and ways of managing these challenges in the future. This was led by medical educators experienced in reflective debriefing in simulation based clinical education. Following this debrief the simulated ward round was undertaken a second time with the participants being assigned to different roles. Each session lasted 90 minutes, including the ward round and debriefs.
Bowyer, M.D., Hanson, J.L., Pimental, E.A., Flanagan, A.K., Rawn, L.M., Rizzo, A.G., Ritter, E.M. & Lopreiato, J.O. (2010) Teaching Breaking Bad News Using Mixed Reality Simulation Journal of Surgical Research 159:1pp 462 467
Crichton, F., Thethy, I. & Skinner, J. (2015) Breaking Bad News: Are FYs needing to be taught? Presented as a poster, Scottish Clinical Skills Network Meeting, Easterbrook Hall, Dumfries, April 2015.
Hojat, M., Mangione, S. & Nasca, T.J. et al (2001) The Jefferson scale of empathy: development and preliminary psychometric data. Educ Psychol Meas. 61:349–65.
Miller, S.J., Hope, T. & Talbot, D.C. (1999) The development of a structured rating schedule (the BAS) to assess skills in breaking bad news. Brit J Cancer 80:792–800.
Schildmann, J., Kupfer, S., Burchardi, N.& Vollman, J. (2012) Teaching and evaluating breaking bad news: A pre-post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters. Patient Education and Counselling 86;210-219.
Silverman, J., Kurtz, S. and Draper, J. (2005) Skills for Communicating with Patients. Oxford: Radcliffe Medical Press.
Tobler, K. Grant, E. & Marczinski, C. (2014) Evaluation of the impact of a simulation-enhanced breaking bad news workshop in pediatrics. Simulation in Healthcare Aug;9(4):213-9.
249 out of 269 Year 5 undergraduates took part in the Ward Simulation Exercise held over three weeks in March 2015.
From the proposed 26 sessions digital recording from 4 cameras recording 42 ward rounds with debriefs were available for analysis. This amounted to 126 hours of footage. All footage was reviewed by one investigator (FC). Review of the footage revealed significant problems with analysis of both observed behaviours (wrong camera angles, curtains pulled around beds, and a few where the conversation took place out with the scope of the camera) and with audio analysis (21/42) mainly due to background noise from other participants. Some technical problems were also encountered – for 2 rounds the cameras were not correctly synchronized and for two the footage was not saved.
Footage from the first round of each session was available for 25 rounds in comparison to 17 “repeat” rounds. This can be accounted for the fact that several of the sessions were incorrectly timetabled so less students than were expected attended these sessions, for these we used faculty as patients and only ran the ward round once with a slightly longer debrief on these occasions.
The scan results were made available to the participating “FYs” in the majority of ward rounds –in 3 they were not and in a further 2 it was impossible to identify if this had been done. No contemporaneous records of this were made at the time.
Some groups realized that they really wanted to discuss the scan results with a senior. Quotes from the debriefs included
- "I really wanted a senior"
- "I wouldn't want to make that decision myself"
11/37 actually made an attempt to do so and in a further 12 this could not be established from the recordings, however in 14 they went ahead and spoke to the “patient” without any attempt having been made.
- "as soon as I started I kind of regretted it..I wasn't prepared to go into that situation in the first place"
In 26 sessions the scan result was discussed with at least one other group member and in some cases on more than one occasion before they went to speak to the patient. In only 7 sessions did it appear that the FY took it upon themselves to talk to Jo, the patient, without prior discussion. What was interesting was the fact that on 7 occasions where identities could be verified the scan results were discussed by a different FY than the one who had had initial sight of these results. Chaperones were only used during four sessions, including two ward rounds where the FYs went as a pair to have this conversation.
Jo was told something about his/her scan on 28 ward rounds. The amount of information given varied enormously, partly as a result of time constraints but often as a result of the interaction between Jo and the FY or other staff and the FY (eg prompting by nursing staff).
In the ward rounds where it was possible to listen to this difficult conversation very little attempt was made by our “FYs” to establish Jo’s background understanding, 11/21 jumping straight into their “speech”.
The actual pace of every conversation did seem appropriate for the circumstances and overall the language used was also appropriate. The language used tended to deteriorate into medical jargon when Jo pressed the FYs for more information and in 9 instances the words cancer, lymphoma or malignancy were used. (in a further 2 Jo asked if they had cancer).
In the conversations where behaviours such as body posture and eye contact could be observed the reviewer was satisfied with the findings. Good eye contact occurred in the majority, body posture was more of a problem and it was clear that in a few instances the FY appeared to be very uncomfortable in their situation
Logistical problems resulted in us being unable to quantitatively demonstrate any benefit derived from the first round debrief. We demonstrated that medical students are very good actors and revelled in their “roles” and we believe that acting the part of a patient gives them some insight into a ward round from the patient’s perspective.
There are many definitions of what constitutes “bad news” eg “any information that is not welcome”.¹ The way our round was designed is open to many criticisms eg lack of a private space for this conversation to be held but we are all acutely aware that clinical and space constraints are frequent barriers to the “ideal” environment in clinical work.
Sim Techs are crucial in the design and running of such a complex intervention. Their involvement on a bigger scale may have helped us undertake this work better.
Breaking bad news is never easy but we believe this intervention may help prepare our students by approaching difficult conversations with more confidence
We wish to thank all Year 5 undergraduates who took part in this year’s rounds and to those of last year who consented to their photos being used to illustrate this poster. Thanks also to all Faculty members.
Thanks also to David Cochrane for acting as both a concerned patient and a junior doctor.
For any questions or further information please feel free to contact me
fiona.crichton@ed.ac.uk