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

1. Don’t ask me…..more questions than answers ? The challenges and rewards of communication skills training for nurses

2. 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

3. Nurses and CommunicationWhat 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.

4. The changing role of the patient 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 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

5. 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 altogetherWilson, Kendall and Brookes, 2006

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

7. The changing role of the nurse 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

8. 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.

9. How are we equipping the nurses of the future?

10. 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

11. Pre-registration nurse training 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

12. Pre-registration nurse training 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

13. What has post-registration training got to offer?

14. 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

15. 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 outcomesChanges in nurses levels of confidencePatient variablesChanges in levels of anxiety (SAI)Patients general emotional state (GHQ 12)Patient satisfaction (pt satisfaction with communication questionnaire)Ware et al 2002

16. 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 20.22control 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

17. 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

18. Post-registration nurse trainingDevelopment of a National Programme • 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)

19. Description of the National ACST Programme • 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

20. 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

21. 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

22. 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 emotionsWilkinson,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

23. 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

24. 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.”

25. The 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

26. Thank you for listening Any questions