Abstract Title
A difficult conversation breaking bad News on a simulated ward round

Authors

Fiona Crichton
Ishwinder Thethy
Janet Skinner

Theme

8AA Communication skills

INSTITUTION

University of Edinburgh - United Kingdom
NHS Lothian - Medical Education Directorate - Edinburgh - United Kingdom

Background

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.

Summary of Work

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.

References

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. 

Summary of Results

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

Conclusion

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. 

Take-home Messages

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

Acknowledgement

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

 

Background

Introducing the Acts!


Patient 1:


Francis Begbie, a 55 year old man or woman (depending on the student!) was admitted yesterday via his GP, after presenting with a cough productive of green sputum and a temperature. Francis has a community-acquired pneumonia, for which he is not on the right antibiotics, which will need to be sorted out on the ward round. He will also need DVT prophylaxis to be prescribed. 

The consultant will not do either of these things unless the foundation doctors point out the omission. The nursing faculty plants will not intervene, but the nursing students, if present, may do.
Patient number 2 may frequently try to interrupt this part of the ward round by leaning over towards bed number one, asking if they can be discharged. Both faculty plant nurses appear exasperated with her, and after the third time of her interrupting the ward round, ask that one of the foundation doctors completes a discharge summary.
The staff nurse is concerned that Francis is tremulous and seems confused, he has been increasingly aggressive this morning, asking for alcohol. On examination of his notes, the junior doctors will see that Francis has a history of alcohol excess, and diazepam and Pabrinex will need to be prescribed.
The nurse in charge is frustrated that Francis has friends who have been trying to supply him with vodka, and this must be documented in the notes. As the ward round addresses the first patient, radiology phone the ward asking to speak to a foundation doctor regarding the reason for a chest x-ray, which was ordered for patient number 4. The foundation doctor will be asked to confirm patient details for patient number 4, whether she is on oxygen, whether she needs a bed or a trolley. Unbeknown to the ward round, patient 4 has just died, and only the staff nurse is aware.

 

Patient 2:

Jo Strachan is a 19 year old male or female, who is desperate to be discharged home, and is becoming impatient. Jo was admitted 2 days ago with glandular fever, and needs to have a discharge script form completed, including medications from pharmacy. The nurse in charge is keen that the patient be discharged prior to the end of the ward round, in order that another patient can use the bed. Jo had a ultrasound scan of the neck requested on admission. She is unaware of the result but wants to be told the results before she/he goes home. The report becomes available after Jo has been seen on the ward round. The report raises the possibility of lymphoma. This news and the requirement for further Ix needs to be communicated. The staff nurse is worried that Jo might make a complaint if her discharge is delayed. At this part of the ward round, a phone call will be made, asking if a foundation doctor can speak with the angry family of patient number 3. The staff nurse will relay the message, asking the FY2 doctor to come to the phone.

 

Patient 3:

Kelly Jones is a 74 year old man or woman admitted yesterday following a fall at home, during which she, or he, sustained bruising to her face. Kelly is frail and is on warfarin following an aortic valve replacement 4 years ago. Her INR is 10; she has been on antibiotics for a recent UTI, which have led to her INR becoming high. She has been admitted to the ward for control of her INR. She has been prescribed vitamin K, but this morning developed a new right-sided hemianopia, and needs an urgent CT scan.        

As the consultant discusses the need for an urgent CT scan, the charge nurse will interrupt the ward round asking that a doctor certify the death of patient number 4. The family is waiting to leave the ward, they have been in attendance all night, and need to go home, but want to have the death certificate before they leave.

The nurse in charge is concerned that her family have been phoning the ward wanting an update (the phone will ring as the team are at the bedside of patient number 2), and the staff nurse is aware of the new right sided hemianopia and will communicate this to one of the foundation doctors on the ward round. Kelly Jones will not communicate her hemianopia unless asked about it, following a prompt from the nurse. The CT scan is urgent, and should be ordered during the ward round.

 

Patient 4 (mannequin):

Thora Hird, an 91 year old Lancastrian lady, is dead. She died peacefully, a few moments ago, as the ward round started, and a foundation doctor is required to examine her to confirm her death. Her notes will show that she was admitted yesterday with a large intracerebral haemorrhage, on a background of chronic hypertension, and the decision was made that she should not be for resuscitation. A red DNAR form has been completed. Thora’s daughter is at her bedside, and needs the foundation doctor to complete a death certificate before she can leave.

 

Patient 5


Pat Renton is a 72-year-old man or woman, admitted with a urinary tract infection. Pat has a background of Ischemic heart disease, a long-term catheter, hypertension, congestive cardiac failure and osteoarthritis. Pats main concern is that his / her teeth have gone missing.
Pat has acute on chronic renal failure, and was hyperkalaemic on admission, which was treated. Pat also had an INR of 7.2 on admission, which was also treated. A repeat INR and potassium need to be checked urgently, as neither has been rechecked since treatment was completed, 12 hours ago. Pat normally takes warfarin, ramipril, bisoprolol, furosemide, simvastatin, cocodamol and ibuprofen.

Pat has not had his / her regular medications prescribed on the kardex, which the medical consultant, annoyed by a lack of up to date blood tests, will ask the FY2 doctor to do. Pat is being given oxygen, which has not been prescribed, and the staff nurse will ask the prescriber to write this up, as well as another bag of IV fluids, which have also run out. The medical consultant will demonstrate from the SEWS chart that Pat is septic, and the antibiotics prescribed (ciprofloxacin) will need to be amended, after discussion, the medical consultant will ask for gentamicin to be added. Pat has a penicillin allergy, and is wearing a red band, but the allergy is not documented on the kardex – the nurse in charge will point this out.

The charge nurse is keen that a decision regarding resuscitation is made, but will ask the FY 1 doctor about this, rather than the irritated consultant. The staff nurse will ask an FY 1 doctor to come to the phone to speak with Mark Renton, the patient’s son, who wants to complain about Pats missing teeth. 

Summary of Work

 

Jo Strachan

101093 1234

 

Ultrasound Report Neck -yesterday

 

Clinical Details

19 year old presented with 5 day history of fevers, sore throat and painful swelling of neck ?minimal weight loss over past 6/12 with intermittent sweats. O/E ?anterior cervical chain lymphadenopathy and pain on palpation ? cause

 

 

Report

 

3 enlarged cervical lymph nodes in the anterior chain on the left. These are round, measure between 8-10mm in size with an S/L ratio of > 0.5. The nodes are well defined and contain hypo-echoic areas with surrounding possible areas of haemorrhage which may be suggestive of necrosis. There is some surrounding oedema.

 

Clour doppler shows increased vascular flow in this area.

 

CXR on admission shows a widened mediastinum in keeping with hilar lymphadenopathy.

 

This raises a high degree of suspicion of lymphoma. Suggest further CT Neck/Chest/Abdo/Pelvis with referral ? fine needle aspiration and Haeatology input

 

 

Dr S Ward

Consultant Radiologist 

 

References
Summary of Results

Proforma for Difficult Conversation Analysis

 

Reviewed by

 

Date                            Time                          First / Second round

 

Video quality good enough for analysis             Yes  No           Camera

Audio quality good enough for analysis                        Yes  No           Camera

 

Were scan results made available                                  Yes      No       Time

 

Score 2 for yes, 0 for no or for for unsure/N/A for items below

 

Any attempt made to contact senior                               Yes      No       Unsure

 

Any discussion amongst group about scan results     Yes      No       Unsure

 

Did FY who had initial sight of results have the conversation

(2 for yes, I for no, 0 for unsure for this q)                  Yes      No       Unsure

 

Were scan results communicated to patient                Yes      No       Unsure

 

If no was any attempt made before WR session concluded (don’t score)

                                                                                                Yes      No       Unsure

 

Did they establish pt’s underlying understanding       Yes      No       Unsure

(Eg ask about understanding as to why scan performed, concerns about results)

 

Was language clear and appropriate                              Yes      No       Unsure

 

Did pace of conversation seem appropriate                 Yes      No       Unsure

 

Was reassurance given                                                      Yes      No       Unsure

 

Was cancer / lymphoma / malignancy mentioned     Yes      No       Unsure

(circle word used) Score -2 for yes , +2 for no, 0 for unsure

 

Good eye contact made                                                     Yes      No       Unsure

 

Body posture appropriate                                                            Yes      No       Unsure

(only score yes if appropriate through most of conversation)

 

Was there any physical contact made                            Yes      No       Unsure

If so – what?

 

Any summary made                                                           Yes      No       Unsure

 

Total score                                       (max 26)

Conclusion
Take-home Messages
Acknowledgement
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