Transcript Title

THE UNIVERSITY
of MANCHESTER
Breaking Bad News: The Importance
of Collaborative Working
Dr Ann Wakefield
University of Manchester
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).
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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
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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,)
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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)
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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)
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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)
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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
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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)
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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
learning strategies improved team working
and
• Analyse to what extent interprofessional learning
enhanced the students’ skills in breaking bad news and
engendered greater understanding of each other’s
professional role
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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
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Data Collection
Data collection involved four phases
 Pre-course preparation

Informed consent and pre-course evaluation

Interprofessional learning activity

Post-course evaluation.
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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
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SPIKES

S = Setting up the interview

P = Patients Perceptions

I=

K = Knowledge and information giving

E = Emotion management

S = Strategy and Summary summarising the key points
Invitation to ascertain how much the person wants to know
(Taken from Baile et al. 2000 and reproduced by kind permission of AlphaMed Press)
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Other Preparatory Considerations
Staff
also learned to work with
simulated patients
There
was also an opportunity to
practice giving feedback using the
following pointers
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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
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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
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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
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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
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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
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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)
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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
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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)
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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)
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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)
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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
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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
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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
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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)
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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)
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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
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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
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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)
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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)
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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)
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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
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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
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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
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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
Fax
Email
0161-275-7007
0161-275-7566
[email protected]
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