Breaking Bad News: The Importance of Collaborative Working

1. Breaking Bad News: The Importance of Collaborative Working Dr Ann Wakefield University of Manchester

2. 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). School of Nursing, Midwifery & Health Visiting

3. 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 School of Nursing, Midwifery & Health Visiting

4. 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,) School of Nursing, Midwifery & Health Visiting

5. 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) School of Nursing, Midwifery & Health Visiting

6. 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) School of Nursing, Midwifery & Health Visiting

7. Why is Braking Bad News Difficult? • Because those responsible for imparting the news are forced to confront the certainty their own death 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) School of Nursing, Midwifery & Health Visiting

8. 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 School of Nursing, Midwifery & Health Visiting

9. 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) School of Nursing, Midwifery & Health Visiting

10. 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 School of Nursing, Midwifery & Health Visiting

11. 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 School of Nursing, Midwifery & Health Visiting

12. Data Collection Data collection involved four phases • Pre-course preparation • Informed consent and pre-course evaluation • Interprofessional learning activity • Post-course evaluation. School of Nursing, Midwifery & Health Visiting

13. 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 School of Nursing, Midwifery & Health Visiting

14. 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) School of Nursing, Midwifery & Health Visiting

15. Other Preparatory Considerations • Staff also learned to work with simulated patients • There was also an opportunity to practice giving feedback using the following pointers School of Nursing, Midwifery & Health Visiting

16. 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 School of Nursing, Midwifery & Health Visiting

17. 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 School of Nursing, Midwifery & Health Visiting

18. 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 School of Nursing, Midwifery & Health Visiting

19. 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 School of Nursing, Midwifery & Health Visiting

20. 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 School of Nursing, Midwifery & Health Visiting

21. 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) School of Nursing, Midwifery & Health Visiting

22. 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 School of Nursing, Midwifery & Health Visiting

23. 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) School of Nursing, Midwifery & Health Visiting

24. 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) School of Nursing, Midwifery & Health Visiting

25. 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) School of Nursing, Midwifery & Health Visiting

26. 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 School of Nursing, Midwifery & Health Visiting

27. 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 School of Nursing, Midwifery & Health Visiting

28. 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 School of Nursing, Midwifery & Health Visiting

29. 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) School of Nursing, Midwifery & Health Visiting

30. 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) School of Nursing, Midwifery & Health Visiting

31. 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 School of Nursing, Midwifery & Health Visiting

32. 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 School of Nursing, Midwifery & Health Visiting

33. 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) School of Nursing, Midwifery & Health Visiting

34. 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) School of Nursing, Midwifery & Health Visiting

35. 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) School of Nursing, Midwifery & Health Visiting

36. 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 School of Nursing, Midwifery & Health Visiting

37. 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 School of Nursing, Midwifery & Health Visiting

38. 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 School of Nursing, Midwifery & Health Visiting

39. Contact Details The Leader of this project was Dr Ann Wakefield Programme Director MSc Nursing and Midwifery Studies School of Nursing and Midwifery Coupland Building 3 Coupland Street Manchester M13 9PL Tel 0161-275-7007 Fax 0161-275-7566 Email ann.b.wakefield@man.ac.uk School of Nursing, Midwifery & Health Visiting