Transcript More questions than answers - Social Policy and Social

Don’t ask me…..
more questions than answers ?
The challenges and
rewards of communication
skills training for nurses
Outline of session
To identify the common challenges faced by
nurses when communicating with patients and
carers in the modern healthcare system
 To describe a typical pre-registration nurse
curriculum
 To outline the work of post-registration nurse
training in the form of the Advanced
Communication Skills Training Programme
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Nurses and Communication
What do we know?
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Nurses and Midwives comprise the largest staff group in the U.K
National Health Service delivering an estimated 80% of all care.
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“Good communication is one of the most important aspects of
nursing care as it pervades every part of the nurse-patient
relationship”
Heaven & Maguire 1996
Much has been written about the poor quality of many nurses’
communication. Despite attempts to redress this, evidence suggests
that problems in communication remain and that despite its
centrality to the role very little formal pre-registration training
takes place.
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The changing role of the patient
Within present day healthcare there has been
intensification in the expectations of patients and
their carers
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Accompanied by a recognised increase in the
number of complaints and litigation
Patients complaints frequently highlight a perceived
failure in communication or more specifically an
inability to “convey a sense of care” rather than a
lack of clinical competence
The changing role of the patient
Greater emphasis on involving the patient in the
decision making process
 Increased access to information, with the internet
proving to be a powerful tool for many patients,
especially around time of diagnosis
 Nurses have been shown to find communication with
the “expert patient" a particular challenge, which may
lead to a reluctance to engage or avoidance of questions
altogether
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Wilson, Kendall and Brookes, 2006
Its nursing Jim…. but not as
we now know it
The changing role of the nurse
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Multiple NHS reorganisations over the last 30 years aimed at
improving the efficiency and quality of the services provided have
had considerable impact on the role of the nurse
Qualified nurses now spend less time at the bedside, with many of
the traditional nursing roles being performed by health care
assistants
A reduction in junior doctors hours has led to a blurring of roles
between nurses and doctors
Nurses new “technical roles” put further pressure on them in
terms of time to talk
Recent growth of specialist nurses has led to a gradual deskilling of
nurses in even basic communication tasks
The changing role of the nurse
Dissatisfaction with new NHS measures has contributed to nursing staff
often feeling over burdened and unable to deliver quality of care.
How are we equipping the nurses
of the future?
Pre-registration nurse training
Although considerable emphasis has been placed on
teaching communication skills to medical students the
same is not true for pre-registration nurse training
Nurses continue to learn vital communication skills on the
job. This is often problematic and is dependant on the
following:
 Ability to find a good role model
 Awareness of the “necessary” communication skills
 Culture of the clinical setting
Pre-registration nurse training
A recent review of the nurse curriculum at the University of East
Anglia reinforced findings from the wider literature regarding preregistration nurse training
Main findings
Content
 Communication skills training is often implied rather than explicit
 Problem focussed not normal
 No evidence of a clear progression from basic to higher order skills
 Multitude of communication skills models and frameworks being
taught
 Content and amount of teaching remains
branch specific
Pre-registration nurse training
Main findings of review – Process
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Delivered in large groups which neither reflects individual learning style or
the evidence base for small group experiential approach
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Not assessment driven.
Standards laid out by the NMC are very broad and not mapped against
expected competencies at different stages of training
What has post-registration
training got to offer?
Post-registration nurse training
For a number of years we have had clear evidence that
specific communication skill training can lead to an
improvement in the behaviour of experienced doctors
and nurses
Aspergen 1999, Fellowes, Wilkinson & Moore, 2004
A recent multi–centre randomised control trial looking at
the effectiveness of three days communication skills
training for 172 cancer and palliative care nurses makes
a significant contribution to this body of evidence
Wilkinson, Linsell, Perry & Blanchard, 2008
What does this RCT add?
Large study sample with multiple facilitators undertaking the intervention.
Hypothesis
That nurses communication would improve following a three-day
communication skills course (intervention) compared to nurses who
did not undertake the course (control)
Primary outcome measure used was the
Communication skills rating scale coverage score
Wilkinson 1991
Secondary outcomes
Changes in nurses levels of confidence
Patient variables
Changes in levels of anxiety (SAI)
Patients general emotional state (GHQ 12)
Patient satisfaction
(pt satisfaction with communication questionnaire)
Ware et al 2002
RCT Results
RCT reported that the three day communication skills course
is effective in changing nurse behaviour up to 3 months post
course.
Coverage rating
Intervention Pre 11.72
Post 20.22
control
Pre 12.53
Post 13.17 P=0.001
Confidence rating
Confidence levels increased for intervention group but
decreased for control group
Intervention Increase in confidence by 18.6 points
Control decrease by 0.7 points
P=0.001
RCT results
Patient variables
State Anxiety Inventory
No significant difference
Patient satisfaction
Intervention 65.3
Control 61.2
P=0.02
GHQ 12
Intervention 17.4
Control 20.2
P= 0.04
Post-registration nurse training
Development of a National Programme
A number of reports, such a those below, have driven the
DH National Advanced Communication Skills Training
Programme (ACST)
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Health Service Ombudsman Report (1995)
The National Cancer Alliance (1996)
Department of Health Cancer Plan (2000)
NICE Supportive and Palliative Care Cancer Service Guidance (2004)
The Audit Office (2005)
Health Care Commission (2007)
Cancer Reform Strategy (2007)
End of Life strategy (2008)
Description of the National ACST
Programme
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Three days in duration
Delivered in safe environment away from work place
Maximum 10 participants
Bound by agreed ground rules
Based on learner centred agenda
Experiential in approach
Delivered by a pair of facilitators, at least one of whom
is a recognised DH facilitator
Experiences of delivering the ACST
Programme to nurses
Registered Nurses consistently report the following challenges
in relation to communication
 Time
Problems with time seem to be linked with some commonly
held beliefs;
I need to spend time putting the patient at ease, building the
relationship so they will trust me
The longer I spend with the patient the more helpful I am being
There are certain issues it is not appropriate to discuss until
you know the patient really well
I need to cover everything just in case the patient doesn't open
up again
Experiences of delivering the ACST
Programme to nurses
Assessment
It is widely acknowledged that nurse assessment is
fundamental to the delivery of good quality care
Yet pre-course audio and video tapes demonstrated a lack of
structure, depth and consistency with regards to content.
Nurses show a tendency to;
 focus on physical rather than emotional concerns
 to problem solve before eliciting all of the patients concern
The fix it nurse
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Experiences of delivering the ACST
Programme to nurses
Handling strong emotions
Many of the “blocking behaviours” displayed by nurses are
aimed at avoiding the expression of strong emotions
Wilkinson,1991
This avoidance is compounded by the introduction of Zero
Tolerance policies.
Breaking bad/significant news
 Growth of nurses in diagnostic roles
 End of life conversations and
preferred place of care
 Fear of getting it wrong
Experiences of delivering the ACST
Programme to nurses
Denial
When and how to tackle it
Is it adaptive or maladaptive?
Collusion
Who does this information belong to?
Working with colleagues
Blurring of roles and the development of
MDT meetings
Nurses experience of the
Programme
We could all relate to situations everybody brought up,
which made it better for us.We could all take something
away, put it into practice.”
 We’re sort of quite high level nurses and we thought we
were reasonably OK … this course has really made us think
and we’ve learnt a lot from it.”
 “You can’t say to a patient, Oh you’re dying. How was that
for you? Did I handle that? Did I do it alright?”
 “Rather than being ‘taught it,’ because you’ve actually had to
practise it and say it.
It’s much easier to then go back
and utilise it.”
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The way forward
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Harness the momentum created by significant pieces of
work such as the Gold Standards Framework, Liverpool
Care Pathway and End of Life strategy and move the
ACST programme to conditions other than cancer
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Consider the role of communication skills training for
health care assistants and staff working in nursing
homes
Thank you for listening
Any questions