Don’t ask me…..Don’t ask me…..more questions than more questions than

answers ?answers ?

The challenges and rewards of communication skills training for nurses

Outline of sessionOutline 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

Nurses and CommunicationNurses and CommunicationWhat do we know?What do we know?

Nurses and Midwives comprise the largest staff group in the U.K National Health Service delivering an estimated 80% of all care.

“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.

The changing role of the The changing role of the patientpatient

Within present day healthcare there has been intensification in the expectations of patients and their carers

Accompanied by a recognised increase in the number of complaints and litigationPatients 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 The changing role of the patientpatient

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

Wilson, Kendall and Brookes, 2006

Its nursing Jim…. but not as we now know it

The changing role of the The changing role of the nursenurse

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 The changing role of the nursenurse

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 Pre-registration nurse trainingtraining

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 skillsCulture of the clinical setting

Pre-registration nurse Pre-registration nurse trainingtraining

A recent review of the nurse curriculum at the University of East Anglia reinforced findings from the wider literature regarding pre-registration 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 Pre-registration nurse trainingtraining

Main findings of review – Process Delivered in large groups which neither reflects individual

learning style or the evidence base for small group experiential approach

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 Post-registration nurse trainingtraining

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?What does this RCT add?Large study sample with multiple facilitators undertaking

the intervention.HypothesisThat 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 1991Secondary outcomesChanges in nurses levels of confidence

Patient variablesChanges in levels of anxiety (SAI)Patients general emotional state (GHQ 12)Patient satisfaction (pt satisfaction with communication questionnaire)

Ware et al 2002

RCT ResultsRCT ResultsRCT 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 20.22control Pre 12.53 Post 13.17 P=0.001

Confidence ratingConfidence 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 resultsRCT 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 trainingPost-registration nurse trainingDevelopment of a National Development of a National

ProgrammeProgramme A number of reports, such a those below, have driven the DH National Advanced Communication Skills Training Programme (ACST)

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 Description of the National ACST ProgrammeACST Programme

Three days in durationDelivered in safe environment away from

work placeMaximum 10 participantsBound by agreed ground rulesBased on learner centred agendaExperiential in approachDelivered by a pair of facilitators, at least

one of whom is a recognised DH facilitator

Experiences of delivering the Experiences of delivering the ACST Programme to nursesACST Programme to nurses

Registered Nurses consistently report the following challenges in relation to communication

TimeProblems 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 meThe longer I spend with the patient the more

helpful I am beingThere are certain issues it is not appropriate to

discuss until you know the patient really wellI need to cover everything just in case the patient

doesn't open up again

Experiences of delivering the Experiences of delivering the ACST Programme to nursesACST 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

Experiences of delivering the Experiences of delivering the ACST Programme to nursesACST 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 Experiences of delivering the ACST Programme to nursesACST Programme to nurses

DenialWhen and how to tackle itIs it adaptive or maladaptive?

CollusionWho does this information belong to?

Working with colleaguesBlurring of roles and the development ofMDT meetings

Nurses experience of the Nurses experience of the ProgrammeProgramme

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.”

The way forwardThe way forward

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

Consider the role of communication skills training for health care assistants and staff working in nursing homes

Thank you for listening Any questions