Effectiveness of Bi-lingual Multidisciplinary Simulation-based Training in Improving Communication and Breaking Bad-News Skills

Introduction

Healthcare worker (HCW)-patient communication has been shown to play an integral role in the success of therapeutic outcomes in all medical settings. Multiple studies have shown the potential negative impact of poor patient-centred communication on clinical outcomes [1-5]. A 2010 review [2] showed that “...communication has the potential to help regulate patients’ emotions, facilitate comprehension of medical information, and allow for better identification of patients’ needs, perceptions, and expectations...” and that “... Patients reporting good communication with their doctor are more likely to be satisfied with their care, and especially to share pertinent information for accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment...”. It also showed that clinicians tend to overestimate their skills when it comes to patient communication [2]. In addition to this over-estimation, the literature found other barriers to proper HCW-patient communication, including cultural differences, patient fears, provider anxiety, burden of work, and lack of training. Simulation-based training (SBT) is a promising training modality that can be utilised to address this gap, improving patient communication and hence clinical outcomes. Hybrid simulation integrated training in communication and breaking bad news has resulted in improved providers’ communication skills, as well as providing an opportunity to identify and address individual and system gaps [10,11].

As part of its continuous efforts, the Clinical Skills and Simulation Center (CSSC) at King Abdulaziz University (KAU) initiated this project with the aim of improving the communication skills of its HCWs. The study includes possibly the highest number of participants out of any study in the literature; we have not found any previous report that approaches more than tens of participants. Another unique feature of this study is the fact that we used Arabic translation of the tools for breaking bad news: SPIKES, NURSE and CUS. SPIKES (Setting up, Perception, Invitation, Knowledge, Emotions, Strategy/Summary) is a six-step tool for breaking bad news; NURSE (Naming, Understanding, Respecting, Supporting, Exploring) is a helpful tool for addressing patient emotion; and CUS (Concerned, Uncomfortable, Safety) is a third tool for helping to improve communication [7-9]. These tools are described in the literature as having been used effectively in English and a few other languages, but our report contains the first mention of their use in the Arabic language. In addition, the training of administrative HCWs in such a project has not previously been reported in the literature. In this study, we sought to develop a bilingual SBT programme in communication skills (including breaking bad news and difficult communication) for all HCWs at the King Abdulaziz University Hospital (KAUH), as part of a continuous effort to improve patient care, experiences and outcomes.

Materials and Methods

A. Study Design

This is a quasi-experimental design, conducted in 2018 over a period of five months (April-September) in the CSSC at KAUH. B. Study Tools:

The course was developed by simulation and education experts working at the CSSC. An interdisciplinary committee of physicians, nurses and educators designed a bilingual, full-day (eight hours) SBT course for HCWs at KAUH. We recruited 10 instructors (simulation experts) from various disciplines (anaesthesiology, emergency medicine, paediatrics, quality improvement and education specialists) and backgrounds (physicians, nurses, administration, management and professional actors). All instructors received unified training from the course directors to ensure a standardised delivery method. C. Study Participants:

Participants were recruited randomly. Both electronic and written course invitations were distributed within the hospital and made available to all HCWs at KAUH. No preferences or exclusion criteria were used; seats were allocated on a first-come, first-served basis to avoid any biases by pre-selecting participants. We ensured that the invitations were extended to non-clinical as well as clinical HCWs. D. Implementation: The course consisted of four phases. Phase A: Introduction and Pre-test (30 minutes):

Each course started with an introduction, which included a pre-test. The questions targeted the determined objectives of the course. The test was reviewed by 10 educators and was piloted on 20 participants to ensure its validity and reliability. It consisted of 14 multiple choice questions (MCQ) and one short answer question. The MCQs covered routes and modes of communication, verbal and non-verbal communication, while the short answer question was about tools used when breaking bad news (Appendix 1). Participants were also provided with handouts containing learning materials. Phase B: Didactic sessions (240 minutes): The introduction was followed by four didactic sessions of 60 minutes each, including breaks (Table 1). Phase C: Practice Groups (180 minutes) The didactic sessions were followed by two 90- minute practice sessions, using advanced illness scenarios pre-written with the consensus of simulation experts (Table 2). The instructions for scenario implementation were: Divide participants into subgroups of three to five. In each subgroup, one participant will be assigned Translation of validated communication and tools for breaking bad news, such as SPIKES, NURSE and CUS, into the Arabic language for clinical use