Communication skills training through ‘role play’ in an acute critical care course

Introduction

Effective patient–doctor communication is a key component of patient-centred care, which is one of the six pillars of quality healthcare delivery.^[1] The prevailing attitude is that communication is not important and training in communication is largely lacking. However, structured and effective communication skills training for healthcare providers is the need of the hour in medical education.^[2] Medical trainees in India, though knowledgeable, are not formally trained to achieve competence in communication skills. Therefore, as medical professionals, they feel uncomfortable while facing anxious relatives of patients who are critically ill. Importantly, development of communication skills also includes communication with colleagues, which is vital for the safety of patients and fosters improved working relationships among professionals. Communication skills can be taught and are extremely important for a budding clinician not only for effective management of patients but also for a satisfying career in medicine. The acute critical care course (ACCC) has been developed indigenously to train doctors in technical and nontechnical skills in managing a patient whose condition is deteriorating. Communication skills are taught using role play models. Eighteen such courses have been organized, and 463 residents have been trained during 2014–18. However, only a few courses were organized for interns. The ACCC team believes that interns should be compassionate and competent. Therefore, it is the right level of their medical career for this course to be introduced. It is incumbent upon faculty members in teaching hospitals and medical colleges to be able to teach communication skills as a part of the formal curriculum. The first medical professional who comes in contact with a deteriorating patient often is either an intern or a junior resident, and therefore, they need to be well equipped with necessary communication skills to deal with the situation which may be volatile leading to verbal and even physical violence. The ACCC is an important step towards bridging the ‘know–do gap’, i.e. gap between having knowledge on the one hand and gaining effective technical and nontechnical skills in providing critical care on the other. In December 2018, the ACCC was introduced to interns for the first time at the All India Institute of Medical Sciences (AIIMS), New Delhi after a few modifications, appropriate to their level of clinical experience.

Methods

In December 2018, an e-mail from the Academic Section of the AIIMS, New Delhi and a message on the intern WhatsApp group were sent inviting them to enrol for the ACCC. This course relies on high-quality interaction between students and faculty. The faculty student ratio is 1:4; therefore, we limited the number of candidates to 24. In this course, blended learning activities form the basis of the educational strategy.3 In skill stations, there are face-to-face tasks and discussions and feedback as a part of reflective practice. Quantitative and qualitative data were collected to assess the efficacy of the ACCC. A response was obtained from the candidates 3 weeks after they completed the course to assess whether they were able to make use of this training in their day-to day clinical practice (reliable evidence level 3 of Kirkpatrick).^[4]

In the ACCC, the faculty members role play a vignette of breaking bad news. First an incorrect method is demonstrated. The candidates are asked to reflect and provide their feedback to address the issues in communication by comparing it to the SPIKES model.^[5] After this discussion, faculty members demonstrate the correct approach using high-fidelity simulation, using role play. This emphasizes the point that within a limited time, it is possible to achieve effective communication. The faculty also highlight, using a real-life video recording of a communication episode, a modified version of SPIKES, in the emergency setting. This modified version has been proposed by the authors, which is a brief method of communication best suited for acute settings.

The ACCC uses the ISBAR (I–Introduction, S–Situation, B–Background, A–Assessment, R–Recommendation) technique to teach communication with colleagues. The ISBAR technique was first used by Navy Seals in the USA. It was adapted and popularized by Leonard et al. in 2004.^[6] Since then, it has gained popularity in healthcare systems and is being taught in medical and nursing schools across the globe.^{[7],[8],[9],[10],[11]}

The scenario of communication with a colleague is then role played as a short drama by faculty. A badly done demonstration is shown first, comments and critique are invited from the candidates, and paraphrasing and microteaching skills are used to discuss their comments. A slide presentation is then shown with the correct steps in this type of communication. The correct method is then demonstrated through role model by faculty.

The course also allows the candidates to rehearse and practice communication skills on day 2 of the ACCC during their final assessment on a simulated patient (actor). They are tested on their ability to demonstrate communication with their colleagues over the phone. The faculty and other candidates (using the principles of peer assessment) on moulage station provide constructive feedback for the purpose of learning from five different cases that are real-life situations replayed by acting.

Three weeks after the course, the candidates were emailed a questionnaire for feedback. They were asked to return the completed questionnaire.

• Q1. Has anyone in your team noticed a change in your work style since you did the course? Write 1–2 lines.

• Q2. Do you feel any improvement on a scale of 0–10, 0 being no change and 10 being strong impact? Please write number on the dot:

– 2.1 In your ability to assess a sick patient

– 2.2 In your ability to treat a sick patient

– 2.3 In communication with a colleague (senior or same level)

– 2.4 In your confidence in breaking bad news to patient or relatives

The analysis of feedback data required thematic qualitative analysis. The feedback from the interns as their real-life experiences was analysed thematically by using an approach described by Viefers et al.^[12]

Results

We enrolled 24 interns who responded first to the email and WhatsApp message.

Candidate feedback after communication skills training

During the latest ACCC for interns at the AIIMS, New Delhi, we received good feedback. The communication skills training was unique to the ACCC. The candidates enjoyed the course because of using role play for training in human factors such as communication. They would like to have more of that in future courses. This style of teaching was mentioned as ‘interesting and useful without being boring’.

Feedback collection was an evidence for Kirkpatrick highest level return of investment. Three weeks after the course, all 24 interns were emailed a 5-line questionnaire for comments; 15 of them replied after three reminders. We collated qualitative data from emails of 11 interns [Table - 1].

Table 1: Feedback data from 11 interns who described their real-life experiences, 3 weeks after the course

Two different themes emerged as a result of formal written feedback to assess the impact of the ACCC course 3 weeks after the successful completion of the course and from informal feedback.

1. Opportunity to gain human factors skills: The ACCC is an excellent opportunity to get high-quality structured formal training in ‘how to break bad news’ and how to deal with patients and their relatives.
2. Role play is an excellent teaching method: Simulation is an exciting teaching method, it keeps them engrossed and it is valid for patient's day-to-day management. This should be made available to senior residents as well. The technique of enacting drama (role play) is highly effective.

The quantitative data gave an average of 8.3 in response to questions 2.3 and 2.4 on a scale of 0–10 [Table - 2].

Table 2: Quantitative feedback from 15 interns who described their real-life experiences, 3 weeks after the course in response to question 2

Discussion

Role play has been used in medical education with much success. Both students and faculty have described this methodology as interesting and engaging for learning.^{[13],[14],[15],[16]} The time is right to introduce new methodologies of teaching in the Indian medical education system. Communication skill is of utmost importance for young doctors, and it is easy to teach using role play. Training faculty for teaching using this method is the first hurdle. Faculty development is challenging and important. A course such as the ACCC allows participants to learn more than by just listening to lectures. All faculty in this course are trained instructors in one or more of the following courses: Advanced Trauma Life Support, Advanced Cardio-vascular Life Support or Instructor Course led by the ACCC team. Using principles of adult learning during interaction between faculty and candidates also transmits a hidden message. Lively interaction and reflective practice using live feedback are effective education tools. Changing attitudes and behaviour are the main goals of faculty in the ACCC rather than helping students pass the postgraduate entrance examination. These objectives are not formally stated in the curriculum but relate to the culture and ethos of the institution.^[17]

Conclusion

Structured and effective communication skills training programmes should be compulsory for undergraduate and postgraduate trainees and should be a part of faculty development programmes in academic institutions throughout India. Role play based on adult learning principles is effective, it appeals to the learners, breaks the monotony of classroom teaching and encourages interactive learning and active participation. Helping the candidates to apply communication skills in a simulated scenario fostered their understanding and its applicability in day-to-day clinical settings. Hence, simulation is an effective method to teach communication, build psychomotor skills and for training at all levels. The ACCC provides an effective and structured programme for training in communication using adult principles of learning through role play and simulation. Through enthusiastic and interactive teaching, the ACCC transmits a message of compassion among candidates, which will motivate them to change behaviour and attitudes towards patient care.

Conflicts of interest. None declared