High-Fidelity Simulation to Teach Communication Skills: Potentially Difficult Discussions

Stephanie N. Sudikoff, MD Medical Director, SYN:APSE Simulation Center Yale New-Haven Health System Assistant Professor of Pediatrics Pediatric Critical Care Director, Pediatric Simulation Yale University School of Medicine

Many types of discussions

 Between caregiver and patient  Between caregiver and family  Among interdisciplinary care team

Delivery of Bad News

 Manner of delivery has significant impact on patients and family  All caregivers (all levels) report discomfort and lack of sufficient training  Many studies into best pedagogical strategy  Lectures  Small groups/role playing  One on one with standardized patient

Ideal strategy…

 Interactive  Learner centered  Draws on prior experience  Relevant  Allows for timely application  Opportunity for repetitive practice  Opportunity for feedback and reflection

Provides basic steps practice, discuss concerns, receive feedback

Delivery of Bad News: Pediatrics

 Frequently delivering news to parent and family, who are often present at the bedside  In acute care settings, news must often be delivered in the midst of complex patient care

Why simulation?

 Simulation facilitates:  Repetitive practice  Safe environment for practice, reflection, discussion, and feedback  Hybrid model creates realistic situation involving simultaneous patient care and family interaction  Faculty teaching without competing clinical responsibilities/time pressure

Previous Simulation Work

 Gaba “Death Scenario”  Rosenzweig Standardized Patients Choose cases relevant to learners

Overly F, Sudikoff SN, Duffy S, Anderson A, Kobayashi L Teaching Difficult Discussions in Pediatric Emergency Medicine: 1)

Sudden Infant Death

2) Child Abuse with Domestic Violence and 3) Medication Error.

Simulation in Healthcare. Accepted December 2008

Participant Feedback

Survey question Relevance to your training/duties Realism of simulation scenario Realism of simulation environment Quality of simulation debriefing Overall simulation training experience Score Average (SD) 4.9 (0.4) 4.5 (0.7) 4.5 (0.5) 4.8 (0.4) 4.9 (0.4)

Comments

 “The SIDS case is very worthwhile. Traumatizing but worthwhile”  “Great experience- very valuable to try out these situations first at sim center rather than on the floors.”  “Very real, excellent learning experience”

Stages of debriefing

   Reactions  “How did that feel?” Understanding  “What results were produced?” Summary  “How can we extrapolate this information to a larger context?”  Events  Emotions  Empathy  Explanations “The four E’s”

Critical characteristics of an effective debriefing

 Safe for the learner  Confidential and trusting  Respectful  Interactive  Non-threatening  Non-confrontational  Non-judgmental

Debriefing for this case

 Allow sufficient time for reactions stage  Sensitivity to powerful emotional responses  Supportive environment  Allow for reflection on learner performance: use their observations to transition to teaching “best practice” concepts  Consider providing “gold standard” for frame of reference

Disclosure of Medical Errors: The Art (and Science) of Apology

Medical error

  The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim   Serious error Minor error  Near miss  An error that could have caused harm but did not …by chance or timely intervention Most are due to system breakdown vs. individual failure

The Importance



To Err is Human

  U.S. National Institute of Medicine report, 1999 Over 100,000 deaths annually in the U.S.

Hospitals 'more dangerous' than air travel (Reuters, 2005)      If you feel safer in hospital than on a airplane, think again.

The risk of being killed in a hospital in a developed country due to medical error is around one in 300, while the risk of dying in an air accident is one in 10 million , Britain's chief medical officer said on Monday. "Paradoxically, people are more frightened of air travel than they are of healthcare," Liam Donaldson, who also chairs the World Health Organization's (WHO) World Alliance for Patient Safety, told a conference. He argued such a gulf in safety standards was unacceptable - even allowing for the poor condition of many patients entering hospital - and healthcare professionals needed to learn from other sectors on how to make safety a top priority. " Other high-risk industries have systematically improved safety over a period of decades in a way that healthcare has not, the airline industry being the most high-profile example ," Mr Donaldson said.

What we know

   Medical errors occur frequently Agreement exists that errors should be disclosed    Family Staff Risk management Caregivers receive little training

What can we do?

 Simulation as a tool to decrease medical errors    Errors are multi-factorial  “Shed light” on the problems Practice Teamwork and communication

What can we do?

 Simulation as a tool to teach disclosure   Advantages   Includes medical management  Requires focus, multi-tasking Interaction with standardized patient or actor  Practice the words  View on video Disadvantages   Limitations of the simulator Requires “buy in”

Disclosure of Medical Errors

   Video clip Debrief Medical error disclosure    The literature Attitudes How we teach (and learn)

??

What families want to know

What families want to know

     What happened?

Why did it happen?

What are the implications for their loved one?

How can the problem be corrected?

How can future errors be prevented?

Apology

 4 components:     Acknowledgement of the offense Explanation for committing the offense   “There is no excuse for what happened” “We are still trying to find out what happened” Expression of shame, remorse, humility Reparation: making amends

Important factors

   Important to choose who offers the disclosure Timing is important Insincere apology is worse than no apology

General recommendations

      Listen without interrupting Relay full information Use easy-to-understand language Ensure that the parents comprehend the information Give a sincere apology Use nonverbal communication to express concern

General recommendations

      Communicate your commitment to the patient’s safety Convey the patient’s medical status and your expectations Solicit families opinion Use open ended questions Communicate to family members that you understand their concerns Communicate what you plan to do to prevent this in the future

Communication among the interdisciplinary team: The Handoff

High Risk

 One of the most common scenarios in which significant miscommunication can occur  Also high risk for patient deterioration while traveling throughout hospital

Why simulation?

Response to need for process improvement

 Multidisciplinary  “Vetting” and refinement  Implementation

 Well received by entire team  Real opportunity for all members to collaborate to create multidimensional tool  Improved buy in