THE UNIVERSITY of MANCHESTER Breaking Bad News: The Importance of Collaborative Working Dr Ann...

THE UNIVERSITY

of MANCHESTER

Breaking Bad News: The Importance of Collaborative Working

Dr Ann WakefieldDr Ann WakefieldUniversity of ManchesterUniversity of Manchester

School of Nursing, Midwifery & Health Visiting

Background

According to many researchers medical schools still do not adequately prepare doctors for clinical practice

(Barr 1996, 1998, 2002, Rolfe & Sanson-Fisher 2002)

Nursing too has faced similar accusations in response to criticisms that nurses were neither ‘Fit for Purpose’ nor ‘Fit to Practice’

(UKCC 2001).


What needs to happen? Essentially medical and nursing curricula

need to be radically overhauled

This is not an easy task given that curricula are frequently embedded within a department’s educational ethos


Why Change?

Despite a reluctance to break with tradition, research is starting to highlight the mutual benefits of collaborative working for both patients and students

(Parsell et al 1998, Tucker et al. 2000, Cooper et al 2001, Horne & Medley 2001, Tucker et al. 2001, Wakefield et al. 2001, Wee et al 2001, Geller et al 2002, Glen & Leiba 2002, Leipzig et al 2002, Reeves et al 2002,)


What is the purpose of this change?

Change needs to produce a new generation of practitioner one that is flexible and adaptable enough to respond to innovations and new directions in health care

(Francis & Humpherys 1999, Department of Health 2000a, 2000b, 2001, Barr 2002, Glen & Leiba 2002)


Why is Breaking Bad News an Important Area for Fostering

Collaborative Working?

One of the major reasons collaboration is important arises because the need to break distressing news to patients is a form of work that both nurses and doctors find difficult to accomplish

(Back 1999)


Why is Braking Bad News Difficult?

Because those responsible for imparting the news Because those responsible for imparting the news are forced to confront the certainty their own death are forced to confront the certainty their own death each time they engage in such an activity each time they engage in such an activity

(Sudnow 1967, Wakefield 2000))

And because feelings of apprehension and inadequacy often remain hidden as nurses and indeed doctors are expected to carry on with their work unfettered

(Doka 1989, Wakefield 2000)


How Can Distress be Minimised?

By encouraging nurses and doctors to engage in mutually supportive practices

Fostering reciprocal support via the use of interprofessional teaching and learning


What is Interprofessional Learning?

The term interprofessional learning, is defined as a programme of education enabling two or more professions to learn with, from and about each other to facilitate collaborative practice

(CAIPE 1997: 19)


The Study Recounted Here Aimed to:

• Encourage medical and nursing students to break bad news as part of an integrative and interactive team

• Examine whether interprofessional teaching and learning strategies improved team working

• Analyse to what extent interprofessional learning enhanced the students’ skills in breaking bad news and engendered greater understanding of each other’s professional role


Participants

11 BNurs (Hons) students took part in both sessions

11 BNurs (Hons) students took part in one session

***********

4 MB ChB students took part in both sessions

8 MB ChB students took part in one session


Data Collection

Data collection involved four phases Pre-course preparation

Informed consent and pre-course evaluation

Interprofessional learning activity

Post-course evaluation.


Pre-course Preparation

Facilitator training was provided to give the teaching staff an opportunity to learn how to give feedback to students using the SPIKES model (Baile et al 2000)

Each letter in the word SPIKES represents a specific type of action the practitioner should instigate during the interaction


SPIKES

S = Setting up the interview

P = Patients Perceptions

I = Invitation to ascertain how much the person wants to know

K = Knowledge and information giving

E = Emotion management

S = Strategy and Summary summarising the key points

(Taken from Baile et al. 2000 and reproduced by kind permission of AlphaMed Press)


Other Preparatory Considerations

Staff also learned to work with simulated patients

There was also an opportunity to practice giving feedback using the following pointers


Additional Feedback Pointers

• Clarifying the facts – précising what happened during the scenario, what was said, and how people reacted

• Positive comments on what took place – detailing what went well and why

• Outlining other options or strategies – detailing how the situation could have been handled differently


Pre-course evaluation

At the outset students were invited to a briefing, outlining the goals, format and expectations of the study

Participants were also told that nursing and medical undergraduates would be working together in small interprofessional teams


Data Collection Tools

On the day of the first teaching session, students completed two short questionnaires• a 7-point Likert scale exploring the student’s

confidence and comfort in dealing with breaking bad news, angry relatives and conflict situations

• an open-ended questionnaire exploring how the students felt about working both in interprofessional groups, and with simulated patients


Interprofessional Learning Breaking Bad News Pilot Project

During the study, students were divided into 5 groups of 4 or 6 individuals supported by 2 facilitators

Learning took place over 2 sessions

Students were required to role-play breaking bad news using simulated patients

After the role-play students shared their ideas about the outcome of the interaction allowing transfer of key knowledge and skills between the two professional groups


Post-course evaluation

At the end of the study, students were asked to rate their confidence and comfort levels for a second time

In addition, they were asked to state how they felt about interprofessional learning and outline what it felt like working with simulated patients

This second set of questionnaires adopted the same format as those administered during the pre-course evaluation


Quantitative Findings

The quantitative questionnaires examined nine areas of breaking bad news

Students were asked rate their levels of confidence and comfort across all areas on a scale of 1 (not confident/comfortable) to 7 (very confident/comfortable)


Confidence and Comfort Scales

Getting patients to confide in you/disclose their concerns Working as a doctor/nurse team Trusting the doctor/nurse you are working with to do

things right Talking to dying patients Telling patients they cannot be cured/will die (soon) Talking to relatives Dealing with strong emotions e.g. anger/distress Dealing with a complaint Coping with your own feelings


Confidence Ratings

Across seven of the nine areas of sensitive clinical communication, students’ confidence increased significantly following the course with the level of significance set at 0.05 (SPSS Version 10.1 Wilcoxon)


Confidence

One area where confidence gain was not significant, related to ‘talking to dying patients,’ here 3 nursing students actually felt less confident after the course

Rather than being seen as negative, this was viewed as something positive given that the course could have helped students to realise how difficult breaking bad news can be (Sudnow 1967, Back 1999, Renzenbrink 1998, Morton et al 2000, Wakefield 2000)


Comfort Ratings

Across eight of the nine areas of sensitive clinical communication, students significantly increased their feelings of comfort following the course. The level of significance was again set at 0.05 (SPSS Version 10.1 Wilcoxon)


Comfort

After the study students felt more comfortable but less confident about ‘talking to dying patients’

While they demonstrated increased confidence

they felt less comfortable about ‘trusting the doctor or nurse you are working with to do things right’

Caution needs to be noted here however given small number of students involved


Qualitative Data

In the qualitative questionnaires students were asked to identify factors they felt would:

• enhance their ability to work together in interprofessional teams

• inhibit interprofessional working


Themes Generated by Qualitative Questionnaires

Four important themes were highlighted as being worthy of note namely:

• benefits of working together

• the importance of valuing each other

• working together the operational hazards

• the need to trust


Benefits of Working Together

an advantage of the programme was that by working together medical and nursing students were better able to learn more about each other’s work philosophies, with one nursing student stating :

• that working in interprofessional teams enabled him/her to see to what extent nursing and medical student ‘roles were distinct and where they overlapped’ (NS18)


Mirroring Reality

Students also felt able to mirror real practice. In other words, students were able to ‘get used to working together [as they would] in practice’ (NS4)

According to one of the medical students working together enabled both groups to gain a ‘greater understanding of the multi-disciplinary resources available to health care practitioners, and gain insight into how another profession views the same problem’ (MS2)


The Importance of Valuing Each Other

The students stressed the need to work as a team of equals, thereby emphasising the importance of respecting and valuing the contribution to be made by both professional groups

In contrast to the notion of segregation, by the end of the project, the students were starting to work as collective teams


Working Together the Operational Hazards

One of the factors students highlighted, as being a difficulty for them when working together, was the fact that the two groups had not collaborated before

As far as the nurses were concerned, at the start of the study they felt that the medical students would dominate the sessions


Feeling Dominated

This feeling was reflected in the nurses’ responses suggesting that there might be a

• ‘hierarchy between doctors and nurses’ (NS1, NS21, NS22)

• heightening of the ‘general conflict, which has existed between the groups’ (NS6)

• negative outcome resulting in the nurses ‘feeling inferior’ (NS4, NS3) and ‘threatened’ (NS18)


Will it be Relevant to Us?

Interestingly the medical students were also worried about whether the initiative would work

Though few in number those who attended both sessions were concerned about

• ‘differences in the roles and responsibilities’ between medical and nursing students and queried whether these ‘would clash’ (MS2)

• and whether ‘things that are relevant to me [would] necessarily be relevant to others?’ (MS2)


The Need to Trust

During the study students had to trust each other before they could work together collaboratively and somehow learn to associate with each other more creatively

If individuals are to be able to develop trust, there needs to be a climate in which a sharing of ideas can take place in order that communal expectations and mutual goals can be identified

(Lynn-McHale & Deatrick 2000)


Conclusion

The task of breaking bad news is distressing for both practitioner and recipient (Sudnow 1967, Renzenbrink 1998, Back 1999, Morton et al 2000, Wakefield 2000)

When distressing news is imparted as part of an interdisciplinary process those involved are able to feel more supported and trust their co-workers when engaging in challenging forms of work


The Future

By adopting interprofessional teaching strategies, students are able to

• learn with, from and about each other• delineate professional boundaries and• prevent the emergence of competition and uncertainty

Thus it is important for medical and nursing students to learn in this way to help them collaborate, communicate and respect that each has a vital role to play at the clinical interface


Acknowledgements

I would like to thank the following Learning Teaching and Support Network (LTSN) Health

and Sciences and Practice for funding the project All those students who volunteered to take part in the

study Drs. Simon Cocksedge and Heather Anderson who devised

many of the scenarios and the Quantitative Questionnaires Dr Caroline Boggis and Ms Sam Cooke for all their

support and hard work All the tutors and simulated patients without whom this

project would not have been possible


Contact Details

The Leader of this project was

Dr Ann WakefieldProgramme Director MSc Nursing and Midwifery StudiesSchool of Nursing and Midwifery Coupland Building 3Coupland Street ManchesterM13 9PL

Tel 0161-275-7007Fax 0161-275-7566Email [email protected]

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