Recuperación en evaluación extraordinaria
UNIDAD 10. El modelado del relieve
Communication skills are a key part of clinical practice. Doctors have to manage
communication with colleagues and patients in a variety of contexts. Some tasks which involve clinical communication, specifically history taking and handover, are dealt with in other chapters, but general communication with colleagues of different professions, with patients and relatives are discussed in this chapter. Also addressed are more challenging areas of communication, such as breaking bad news and dealing with conflict.
14.1 Newcastle Graduates
14.1.1 Expectations of Newcastle primary sample
Prior to starting their F1 placement the sample reported that there had been a strong
emphasis on communication skills teaching throughout their undergraduate course. They felt best prepared with regard to eliciting concerns and expectations within a clinical consultation. Most noted that they felt as well prepared as they could be for the more challenging areas of communication given that they had not practised these in real life situations, and the course had included role play sessions for dealing with breaking bad news and aggressive patients.
"... when you get that first hard question, the first angry patient is going to be a bit of a wake-up as well” (NPS139, first interview, quartile 2)
“I mean there‟s obviously the other bits as well like the real life breaking bad news to people, „cos that‟s not something you could ever practise as a student with real people” (NPS24, first interview, quartile 4)
14.1.2 Experience of Newcastle primary sample
At the end of the first placement, the new F1s saw communication skills as an integral part of being a doctor.
“communication skills I felt fairly prepared for...I had a great teacher at Newcastle but you realise once you get on the wards how important they are” (NPS209, follow-
up, quartile 1)
Communication within teams Asking for help
The large majority of new F1s reported that it had been easy to ask for help when they had needed it. Several respondents reported that it was more difficult to find someone to ask for help when on call at night or during weekends. However the majority of respondents said that they could always find someone to ask for help or advice when needed.
“In the daytime there are a lot of people around so it‟s generally quite easy to find someone that can give you advice or help. At night it‟s more difficult because there‟s only ...the registrar who you need to bleep if you need any help” (NPS18, follow-up,
quartile 4)
“I would say 95% of the time [I managed to find the help needed] the times that you cannot usually are when you are on call...for example, if you are trying to get in touch with other specialties to come and see a patient in the evening or at night ...they are very difficult to get hold of” (NPS22, follow-up, quartile 4)
Overall respondents felt that everyone they approached was helpful, approachable and friendly. Many respondents felt that they had asked very basic or too many questions when they had first started their placement but said that it was better that they were sure for patient
safety reasons. Some talked about being well supported and encouraged in their learning when they asked for help.
“There‟s no-one that sort of reacts badly to being asked stupid questions cos‟ they are all quite happy that you know they understand we‟re still green around the gills”
(NPS24, follow-up, quartile 4)
“Especially at the start, everyone was really kind of...nice...and realising it was all new and that we just needed that little bit of extra help” (NPS139, follow-up, quartile,
2)
Respondents said that it depended upon the situation who they would ask for help but the majority said that they would typically ask F2s, SHOs and Registrars. Some said they would also ask nurses. Some respondents commented that when asking consultants for help they would have liked them to physically see the patient but they did not feel able to make the consultant do this.
“...it‟s mainly the middle grades, ...registrars and the staff grades are the first port of call, the F2s are very good... the other week I really wanted [the consultant] to physically see the patient, so he could make some adjustments and as it was he said „no, it‟s fine you are doing the right things‟ ...once he said that he was kind of hinting I was not going to see him. I think with a consultant it is quite difficult to say, oh physically grab them and say I want you to come and see this patient” (NPS65,
follow-up, quartile 3)
“I would say it‟s been easy to ask for help. Even if my senior SHO wasn‟t here and I needed some help, I could ask someone else and they would take out of their way and try to help me if they could...sometimes they just have a quick look....rather than coming and you want them to see the patient and assess the patient by themselves and make a decision” (NPS182, follow-up, quartile 2)
One new F1 commented that they found it difficult when summarising and asking for help to include all the important information over the telephone.
Working with senior doctors
Overall respondents felt that it was easy to communicate with senior doctors, with several commenting that they were approachable, friendly and supportive. Although some new F1s commented that while they generally found it easy to communicate with senior doctors this was always not the case, which was perceived to be related to the personality of the
individual senior doctors.
“…it‟s a mixed bag, I mean some of them are brilliant and …I‟ve bounced ideas off and one or two of them have been supportive…whereas one or two of them don‟t want to know about what you‟ve got to say to them…” (NPS224, follow-up, quartile
1)
“…well it depends on the person, sometimes with your own consultant it can be fairly difficult [with the] consultants‟ attitude or management…” (NPS106, follow-up,
quartile 3)
Two respondents made comments relating to visibility of the senior doctors and this seemed to have an impact on whether doctors were approachable or not.
“…because they don‟t do ward rounds and things. They‟re very rarely actually on the ward ...because all the registrars do the ward rounds…It‟s quite hard to approach someone who doesn‟t have a clue who you are” (NPS93, follow-up, quartile 3) “…they are all very approachable if they‟ve got time but you know when they are busy they are not around, you know a lot of them do work in other hospitals…”
Working with nurses
The large majority of new F1s reported that overall they found communicating and working with nurses easy. Several said that they found the nurses to be helpful and approachable.
“…nurses are easy to communicate with…they‟re very open and approachable”
(NPS8, follow-up, quartile 4)
“…they are very approachable and they will ask you for advice and vice versa”
(NPS93, follow-up, quartile 3)
“I would say that most of the nurses I‟ve been working with are quite easy [to communicate with]…I‟m quite comfortable to communicate information to them and they take into account what I have said and also would tell me if there was anything to do” (NPS182, follow-up, quartile 2)
Respondents commented that communication had become easier the further into their placement they were and the more they understood the role of the nurses.
“I think at first I was getting the hang of exactly what the extent of their role was. Some nurses are more senior and so they take on a greater role and that sort of thing…I found it difficult to ask them to do things for me…you get used to it and actually you start to realise that they are expecting you to and that makes it easier”
(NPS22, follow-up, quartile 4)
“I think in the initial stage I think the nurses were a bit bossy…just kind of wanting to let us know what they will do and what they won‟t” (NPS108, follow-up, quartile 3)
Some respondents felt that once they had built up a relationship with the nurses,
communication was easier, whereas some respondents reported that they had felt like they needed to earn the respect of the nurses and sisters in particular.
“…most of the nurses are absolutely lovely especially now that they‟ve got to know us and we know them” (NPS108, follow-up, quartile 3)
“I think at the start they [nurses] like to test you …you have to prove your mettle kind of thing...with the sisters in particular it was very much you had to prove that you were worthy enough for her to respect you…I think if you are generally an outgoing person and you‟re nice to them and you don‟t treat them like rubbish” (NPS139,
follow-up, quartile 2)
“..I think the sister of the ward initially... it was almost like I had to prove myself…I think she was quite wary of new F1s…” (NPS143, follow-up, quartile 2)
However, some respondents reported that the nurses would question their authority or they were working toward different goals and this caused friction in some cases or frustration.
“…sometimes we have differences…they want to do something quicker but you‟re doing something else…or you‟d want them to do an ECG and they‟d rather they‟d want you to do it or something like that” (NPS66, follow-up, quartile 3)
“I think it‟s a bit frustrating when like they‟re very much sort of keen on what‟s their role and what‟s not and they won‟t do anything outside their role, which can
sometimes be frustrating whilst they‟re on their break” (NPS93, follow-up, quartile 3) “There is this idea of doctors and nurses sort of maybe sometimes working for different goals...I think I‟ve learnt it a little bit more now that I‟ve started working…”
(NPS224, follow-up, quartile 1)
Working with pharmacists
All respondents who had worked with and communicated with pharmacists reported that they found communicating with them very easy, that they were helpful, friendly and approachable. Several respondents commented particularly about being able to ask the pharmacists
“They‟ve all been really helpful and they‟ve been really enthusiastic about you actually asking them. I think they‟re really keen with any queries that you do ask them…” (NPS93, follow-up, quartile 3)
“Brilliant, we‟ve got a brilliant pharmacist so it‟s really easy cos he‟s very easy to chat to” (NPS224, follow-up, quartile 1)
“Sometimes when you send down your scripts for a patient‟s discharge and you‟ll write down the wrong thing or…you‟ll [send down] a controlled drugs prescription instead of a proper one and then they just phone you up and they just try to explain what‟s going on. They‟ve been really nice” (NPS139, follow-up, quartile 2)
Respondents also talked about pharmacists being visible on the ward and the ease of being able to contact them.
“It‟s quite easy really...it‟s perfect to ask a question you know if you‟ve got a question about anything and they‟re around quite a lot, they‟re quite approachable” (NPS9,
follow-up, quartile 4)
“Because they‟ve got pharmacists on the ward…you can just bleep them and they usually ring back within, either ring you back within sort of ten seconds or they come round to the ward and speak to you…which is really good…you can get advice…”
(NPS181, follow-up, quartile 2)
Communicating with patients and relatives
The majority of new F1s said that they found communicating with patients and relatives easy overall with some commenting that they enjoyed this particular part of their job.
“It‟s not something I would highlight as a weakness. I absolutely adore I mean...it‟s the best part of the job. It‟s without a doubt the best part of the job I find it quite easy” (NPS 8, follow-up, quartile 4)
“...I quite enjoyed it, it‟s quite good fun” (NPS224, follow-up, quartile 1)
“I quite enjoy speaking to patients on the whole...” (NPS9, follow-up, quartile 4)
However respondents mentioned several areas where they found communicating with patients and relatives difficult and more challenging, for example: patients who had disabilities or were hard of hearing, patients with cognitive impairments and patients with poor English.
“Well it‟s obviously difficult to communicate with people with a physical disability ...and it‟s difficult to communicate to people whose English isn‟t brilliant,...it‟s quite difficult to understand them” (NPS66, follow-up, quartile 3)
“There have been difficult patients where sort of for all sorts of reasons, then the communication, if they‟re hard of hearing or whatever then there have been difficulties in taking histories...the whole sort of managing the interaction with the patient and making yourself understood” (NPS18, follow-up, quartile 4)
“It‟s more challenging...[with a patient who] maybe has dementia and obviously doesn‟t really understand why they‟re in hospital,...patients who are withdrawing from alcohol ... often they might be hallucinating or very disorientated or perhaps a bit agitated or aggressive” (NPS9, follow-up, quartile 4)
Respondents reported that they had found it challenging working with patients whose English was not their first language as this posed additional problems, having to work through
interpreters or relatives.
“...I had to get a translator and everything and that was...I mean we had teaching on this too but it‟s not as real as would think it would be. And that was just very time consuming” (NPS139, follow-up, quartile 2)
Several respondents reported that the more challenging interactions they experienced were not with patients but with relatives who were aggressive and angry.
“It‟s actually not really communicating with patients, it‟s more so patients‟ relatives...and I think there are certain groups of relatives that have been quite difficult and quite confrontational and accusational [sic] and sort of assume that you‟re not trying your best” (NPS26, follow-up, quartile 4)
F1s often felt frustrated because they felt they were trying to do a good job but this didn‘t always feel appreciated by relatives. They also commented that they felt frustrated when talking to relatives because they didn‘t always have all of the information or all the answers to hand.
“I think relatives are tricky...it‟s not something I‟d appreciated they just always have so many questions about the care and what‟s going on and a lot of them were often quite angry ...I really don‟t know, I just find it quite hard not to get angry...because you are obviously trying your best and a lot of the time it‟s not your fault why things haven‟t happened and just trying to explain why can be quite hard” (NPS93, follow-
up, quartile 3)
Some respondents reported that they had received undergraduate training on this, which had helped.
“I think the sort of skills that we, we picked up during medical school was how to deal with people who have difficulty communicating and things like, that‟d been really useful because we‟d been able to apply them...so it‟s not been a complete shock coming across that and having difficulty” (NPS24, follow-up, quartile 4) “...in 5th year we had a day course on managing violence and aggression ...it was exceptionally good ...thinking back I felt like I was able to deal with the situation”
(NPS8, follow-up, quartile 4)
Several respondents commented on coping mechanisms they had adopted to deal with difficult situations, such as taking nurses with them when speaking to relatives, and asking closed questions when using interpreters or translators.
“...the nurses are quite good...that‟s one of the important things I‟ve learnt that like, to take a nurse with you when talking to families and things...just because they often know procedures and they can answer a lot of questions you can‟t. And it‟s nice to have someone to back you up really as well” (NPS93, follow-up, quartile 3)
Breaking bad news
Several new F1s said that they had been accompanied by a nurse when they had had to give bad news or talk to relatives after bad news had been given. They reported that they had found this to be helpful and supportive. Many respondents said that the training they had received in medical school on communication skills and breaking bad news was helpful in these situations but that nothing could prepare them for doing it in real life.
“I would say so [prepared for breaking bad news] I think definitely looking back at the training that we‟ve had and maybe the words to use initially ...I always remember the role- what do you know so far and what do you understand by this and that would help me then to gauge their understanding” (NPS143, follow-up, quartile 2) “...we have had training on how to break bad news but I suppose that was probably in the back of my mind somewhere but it kind of went out the window because I was so flustered” (NPS136, follow-up, quartile 2)
“...breaking bad news ...it‟s something we all thought we‟d done stuff in medical school, but then , when you actually have to do it on someone...you are actually breaking proper bad news it‟s quite hard to do and not get emotionally involved”
14.1.3 Newcastle Triangulation
The triangulating sample felt that the Newcastle graduates were well prepared for communication skills.
“I would like to say that the local graduates…have absolutely excellent communication skills…” (N Undergraduate Tutor 2)
“I think their communication skills are good” (N Educational Supervisor 19)
However, while basic communication skills transfer from medical school teaching to the workplace, there was a feeling that the more complex and advanced communication skills could only be expected to develop over time and through observation of real life situations. As with prescribing, it is perceived by the managers and supervisors that the level of expertise necessary to deal with the complexities and contingencies of real cases can only be developed through experience.
“Immediately dealing with patients, I think they are very good …but I don‟t think they have had the exposure to actually practise those communication skills when the patients aren‟t so well, when distressed relatives are around the place. ...I mean it‟s a distressing time for all doctors to deal with that sort of thing…but I think again, final year medical students of old had a bit more exposure to that” (N Educational
Supervisor 7)
“whilst they are explained about advanced communication, I think the sort of thing of sitting there with a grieving family is something you cannot do until you have seen it…I think dealing with patients‟ emotions and relatives‟ emotions and dealing with stressful situations, no matter how often you have a student sitting with an actor or actress, it does not replace the sort of you know the apparent stress that all of us would be under…” (N Undergraduate Tutor 6)
14.1.4 Summary of ‘Communication skills’ for Newcastle graduates
Medical graduates reported feeling well prepared for communication skills. They also reported that they felt as prepared as they could be for dealing with the more challenging aspects of communication given that they had not yet practised these in real life situations. At follow-up F1s reiterated that communication skills was an area for which they felt they had been well prepared and some reported a considerable amount of job satisfaction from their interactions with patients and their relatives. The majority reported it had been easy to ask for help when they needed it (those they asked were usually the next grades up), although nights and weekends were more difficult as there were fewer staff to ask.
Some reported that summarising all the salient aspects of a patient over the telephone was challenging and some would have preferred senior doctors to see the patient but did not have