Advanced Communication Skills Training for specialty trainees - Excellent communication skills are a core requirement for clinicians in all specialties. The particular issues around communication in cancer care led to the introduction of a national advanced communication skills course (Connected). This was mandatory for all senior professionals working as part of cancer MDTs from 2007 and the courses (at first 3 days, later 2 days) were fully funded as was nationally accredited facilitator training. The courses became a mandatory curriculum requirement for trainees in core cancer specialities – oncology and palliative care – and highly recommended for many surgical and medical specialities.
In April 2013, with the ending of the National Cancer Action Team and Local Cancer Networks, all funding was withdrawn. Cornwall Hospice Care coordinated a number of courses locally with remaining funds over the following year but no further funding was identified. The recommendation for training remained a part of the curriculum for trainees in core cancer related specialties but the trainees were only able to access courses from private providers at high cost - £500-1000 for a 2 day course.
This application was submitted to pilot a one day course aimed specifically at the needs of senior trainees. By providing the course in a single day, augmented by pre course reading, costs could be significantly reduced. The key elements of the course: review of theory, simulated practice using trained actors and facilitators and realistic and relevant scenarios, were all retained. Initially the proposal was for a course for 8 trainees at a cost of £2400 total or £300 per head.
This application was accepted but in view of the lack of national funding and chaotic and costly provision the Cancer Peer Review recommendations about types of course approved for training were reviewed and relaxed. This allowed us to redesign the course and accommodate 12 trainees, reducing the cost to £200 per head.
The course was structured around the key elements of the Connected course as detailed above but rather than run an individual simulated consultation scenario for each participant which would have limited practical numbers to 8 trainees, we would use pre course questionnaires to design scenarios relevant to groups of trainees and give multiple trainees the chance to participate in each scenario.
We advertised the course and prioritised applications on the basis of :
a) whether completion of a course was a mandatory curriculum requirement for the trainee
b) seniority in training (and therefore limited opportunities to access other courses)
c) order of application
Once trainees had been offered a place they were sent a questionnaire electronically asking for them to identify key areas of difficult communication both in their current work and that they could foresee as a consultant; and also asking them to score their confidence in aspects of difficult communication using a modified version of the Connected evaluation tool (see evaluation below)
On the basis of the trainees’ responses, scenarios were devised that would be relevant to as many trainees as possible. The scenario outlines are included as appendix 2. The scenarios were devised and refined by the facilitators and then discussed with the very experienced actors.
Twenty applications were received for the course and prioritised using the criteria above. Applications from speciality grade, locum and consultant doctors were refused on the basis that this was an innovation funded course for trainees only. Twelve trainees were offered places, one subsequently was unable to attend and his place offered to a trainee who had been able to act as reserve as he was able to remain available on the day. One trainee failed to attend on the day.
The eventual make up of the group was
6 ST trainees in clinical oncology
2 ST trainees in palliative medicine
3 ST trainees in radiology
1 ST trainee in care of the elderly
3 trainees were at ST3, 4 at ST4, 3 at ST5 and 2 at ST6
The course was delivered in the Knowledge Spa at RCHT on 21/11/14 with two facilitators and two actors, all Connected trained and accredited. The participants were sent pre course reading which all had completed. The trainees participated enthusiastically throughout and the course ran to time.
We chose to use both pre and post course confidence questionnaires and evaluation forms based closely on those used on the Connected course as we had considerable data from running these courses and would therefore be able to compare the outcomes of the one day course against the standardised two day courses. These questionnaires ask the participant to self-evaluate their confidence against seven key aspects of communication (structuring, building rapport, responding to cues, integrating agendas, active listening, giving complex information and closing) and seven types of difficult consultation (distressed patient, withdrawn patient, anxious patient, bad news, anger, multiple agendas and challenging a colleague). The results are discussed below. All forms were completed and returned by trainees. The actors and facilitators also gave feedback.
Course planning and preparation (consultant time) £ 236.91
Course delivery: £2,160.96
The course was evaluated using matched pre and post course questionnaires as described above. The trainees were asked if the course met their expectations and whether they would recommend the course to a colleague. They were also asked for comments.
In previous analysis of five two-day Connected courses the average change in confidence scores was 2 points (on a 10 point scale). The trainees reported a 2.6 point average difference in confidence scores. On both the previously analysed courses and this one, 100% of participants felt the course met their expectations and would recommend it.
This suggests that the outcomes of a tailored one day course are comparable with a standard two day course when measured with the same evaluation tools.
Comments were extremely positive. The trainees felt the small group work on scenarios was the most valuable part of the course. Responses to the group MDT exercise were mixed: some found it useful but several felt it was over complex and ambitious in the limited time. All trainees felt that similar courses should be available more widely and valued a course tailored to their training needs. Three trainees commented that they would struggle to pay £200 for the course and all, unsurprisingly, would prefer that it was free.
The actors and facilitators felt the course compared well to the two day courses but that the group MDT exercise was too complex to do well in the time and that ideally more time should be used for small group scenarios.
The course was delivered to budget as above.
Development since pilot
Since this pilot the facilitators have redesigned a one day course for 10 participants with a greater focus on the small group scenarios and this has been run once successfully in Plymouth and funded by Cancer Services in Plymouth. A half day course for palliative medicine trainees is also planned for April 2015 with limited funding.
We hope to present this work at a national forum for communication skills training.
Doctor Explain Yourself is a project based on a recognition of the importance of high quality explanations in the practice of medicine and psychiatry. As we learn to become doctors and gain further expertise, what fundamentally underpins the quality of our care is the way in which we can share our understanding of concepts with patients and carers in language that they can understand, make sense of and which is empowering.
During the course of our training we may be exposed to only a small number of expert clinicians in practise and therefore see only a limited range of ways in which common explanations are used.
The purpose of Doctor Explain Yourself is to provide an electronic portal through which doctors in training can view video explanations, contribute and upload their own.
Knowledge in medicine should be shared and explanations regarding health should provide belief, relief and understanding. The power dynamic that exists within patient doctor relationships is not a necessity and resources that promote the democratisation of knowledge and understanding in health should be encouraged.
The key development was to develop a website with a linked YouTube channel to upload videos of explanations of common facets of psychiatric practice.
Grant Awarded - £4500.00
The grant contributed to:
- Website design
- Website promotion
- Domain hosting
- Domain maintenance
- Domain updates
- Supported social media
The website has been in development and was launched in Autumn 2015. It is supported by a Facebook account and Twitter feed. The site and domain has:
- 72 active videos
- 400 twitter followers
- >15,000 google+ accesses
- >8000 video views
A three month collaboration was run through Falmouth University graphics department as a student project to investigate the potential for the site and produce a range of graphic options for the further development of the site.
Further avenues for exploration that have begun but are not complete are:
- Use of the site to promote mental health teaching via the University of Exeter Medical School links to Ethiopia. One of the site developers hopes to travel to Ethiopia on a teaching project and to use the site as well as seeking videos related to local practice.
- We wish to explore the link with simulation developments in the South West. The site could provide an excellent host for simulation videos and connections have been made with the South West Peninsula Psychiatry simulation lead to investigate this.
- Ongoing funding is being considered. We are investigating the potential for a partnership between up to four organisations, Cornwall Partnership NHS Foundation Trust, Falmouth University, University of Exeter Medical School and Health Education South West, to apply for a Duchy Charity grant to secure ongoing funding and development of the site.
- Cornwall Foundation Trust are investigating the use of video booths on trust premises to develop a subsidiary site “patient explain yourself”. This would enable patients to share brief videos of aspects of mental health care that they have found helpful and could be shared as an educational, stigma reducing and care enhancing resources.
- We are interested in looking at videos of health professionals working in mental health describing why they chose this career. This could be a useful facet of the promoting recruitment into psychiatry programme.
Innovation funding of £2,050 was used to run the Human Factors Education day on 26th June 2015 at the Musgrove Park Academy.
The schedule consisted of a full day of human factors training for 16 educational supervisors (consultants) within the Trust, from a range of specialties. The aim was to educate attendees in the theory of non-technical skills & assessment using parallels from other high risk industries including aviation.
Topics covered included:
- technical frameworks for assessing others.
The aim was to facilitate feedback and development of non-technical skills in educational supervisors and therefore improve the development of these skills in trainees across the Trust.
Structured feedback from the event was largely positive, with constructive feedback suggesting ongoing training in groups rather than didactic lectures.
In August 2014 we were awarded funding to support the purchase of a guamard high fidelity wireless simulation mannequin- Hal Premie. This has been used on a regular basis (we deliver regular neonatal simulation sessions on a monthly basis as well as paediatric sessions also monthly).
This has also been used for the regional training days that we have run in Exeter for the last 4 years “neonatal step up to registrar course.” This course has consistently had fantastic feedback and is one of the outstanding courses in paediatrics in the South West. Without the wireless mannequin it would be very difficult to deliver with the level of fidelity required for the trainees. We have run this course 3 times a year for all ST3 trainees across the southwest. 7 courses have trained more than 40 trainees in the experience of needing to lead a team and the importance of communication and decision making in an emergency situation.
Having a wireless mannequin has added to the ability to deliver more realistic simulation scenarios. Scenarios include moving babies from labour ward to the neonatal unit and a multidisciplinary interdepartmental scenario with a preterm delivery in emergency department. This would have been impossible without the wireless mannequin.
As we move forward with simulation across the south west wireless mannequins are becoming more important in order to aid the fidelity of delivery. I thank the innovation fund for the opportunity of this purchase.
Procurement of specific Quality Improvement Software to facilitate the development of Quality Improvement projects at Derriford Hospital.
After successful application to the Innovation Fund I was able to secure £464 for Quality Improvement Software (QI Macros®) to be installed onto computers at Derriford Hospital.
This Quality Improvement statistical tools package links into Excel and facilitates the formation of statistical process control charts. These charts are crucial for feedback and to help demonstrate if an improvement has occurred as a result of an intervention during a Quality Improvement project.
QI Macros® was installed onto three computers that were accessible by all staff at Derriford hospital and continues to support QI work throughout the trust.
I would personally like to thank Health Education South West for supporting this bid.
A successful grant of £9,576 from the Innovation fund enabled the purchase of simulated ocular surgery training kits for the region. Each kit consisted of Osila anatomical heads, basic phacoemulsification and vitreo-retinal jigs and 360 artificial eyes. The range of tactile synthetic surgical simulation eyes are designed for practice of specific surgical techniques. A kit was purchased for each of the 6 ophthalmic training centres in the Peninsula Deanery.
Learning ophthalmic surgical skills is a challenging and daunting process. The unique intraocular environment plus use of an operating microscope are a challenge to all novice surgeons. Cataract surgery is the most commonly performed operation in the UK yet it is complex, technically demanding with no equivalent training proxy. There is also good evidence that complication rates are higher with trainee surgeons.
Recent advances in simulated ocular training devices, such as those purchased, have now been developed and improved to a degree that is acceptably realistic. These consist of artificial anatomical heads and artificial eyes that can be used with existing operating microscopes and ocular equipment in realistic training scenarios. The artificial eyes can be modified by trainers to simulate uncommon but serious complications that may arise during cataract and other ophthalmic surgery.
The new kits have facilitated training on plastic rather than patients. They have been used in a number of different ways that surpass the previous limitations of porcine eyes and complement the computer virtual simulator (EyeSi) available to trainees in Torbay. Some units have established a dedicated dry-lab station with the artificial head mounted under a microscope.
Trainees will practice specific techniques prior to or after a surgical list or during study sessions. Some trainees will transport the head and some practice eyes to surgical sessions conducted at peripheral hospitals in order to augment training in between ad hoc NHS service provision. Many trainees have set up the artificial head with eyes as an additional ‘case’ on an operating list. Consultant supervisors can set up an uncommon scenario such as ocular trauma with corneal rupture for trainees to practice on.
These experiences are invaluable in enhancing training and future surgical consistency and quality. Feedback from trainees has been positive with the most junior trainees benefiting the most. By providing identical equipment throughout the region trainees can build on previous skills regardless of their rotation. The simulated ocular surgical equipment directly complements and helps delivery of The Royal College of Ophthalmology training curriculum. Simulated surgery is increasingly forming a part of safe training and we are now amongst the best equipped to offer this.
The purchase of this equipment has benefited and enhanced ophthalmic training in the South West. It will result in better skilled doctors with experience in managing intra-operative complications without having compromised patient safety. Provision of these facilities will result in more competent ophthalmologists able to deliver better care to our patients.
The Innovation Fund bid for North Devon formed part of a wider bid to develop a simulation suite and faculty within the North Devon District Hospital. While the Trust and a local charity funded the build element, Innovations funded equipment totalling £57,305, this included the Sim Junior paediatric model and also the sim view system for recording and debriefing training sessions.
The sim view debriefing system is an advanced tool for capturing and accurately recording simulation activities within our simulation suite. This has benefitted post graduate medical education because it allows learners to fully evaluate their own and others learning experiences through audio and vision playback on a real time event log.
Sim Junior is an interactive manikin of a child approximately 5 to 7 years old. This allows an extension of our current paediatric simulation activities towards older children other than the new born manikin that we currently had. Participants can gain valuable practical experience on acute paediatric situations they would not necessarily have been exposed to.
The new sim suite, manikin and debriefing system has allowed us to incorporate wider participation from the multi profession team which includes the development of technical and non-technical skills for both individuals and teams. As a whole, this project continues to provide further training and education in simulation and human factors for many staff.
In 2013, the Orthopaedic team at the Royal Devon and Exeter Hospital conducted an evaluation of the induction process and continuing education of junior doctors joining the department.
This revealed two particular areas of concern: the difficulty in sourcing reliable resources outlining departmental procedures and policies, and more pressingly, agreed guidance on the management of orthopaedic patients. As a consequence, a smartphone application was created to provide a portable means of delivering educational and departmental material to junior doctors.
The successful Innovation Fund application has allowed us to host the application for download. All existing and new members of staff are registered for the app and encouraged to download it free of charge. Each user is subsequently encouraged to provide feedback to assist in its evolution and to provide further material to enlarge its content.
Since the application went live it has been downloaded 125 times and launched 1116 times. From the original interface that provided details on the principles of acute fracture management and postoperative care, the app’s users have developed the content by provided additional resources. The app now hosts educational information on fractured neck of femur treatment, microbiology guidance and consenting practice. Videos by senior members of staff have been uploaded showing procedural skills such as Fascia Illiaca Block and rehabilitation protocols. The app includes all of our trust protocols and National Orthopaedic standards of care in a portable and easy to use format.
Encouragingly, allied health professionals have been keen to include details of their role in the Orthopaedic patients care. The app now includes physiotherapy and occupational therapy guidelines and the theatre Matrons use the app to educate nursing and auxiliary staff about hip fracture management.
We have received positive local feedback, and are in the process of auditing the impact the app has had on the induction process, availability of educational material and the impact on day-to-day working.
To pilot and evaluate the utility of a virtual 3D anatomical model in supporting the delivery of postgraduate medical education programmes provided by Peninsula Postgraduate Medical Education
We have now commissioned two telemedicine carts – one is based in the Horizon Centre and the other is a mobile unit that can be moved to clinical environments. Both are essentially video conferencing enabled and allow video feeds (from laparoscopic cameras and room view) plus audio. In this way live broadcasts of operations can be transmitted from an operating theatre (or other clinical environment) to a teaching area. The two sites e.g. Surgeon and learners can communicate and in this way operative techniques can be demonstrated and discussed. After test runs Mr Stuart Andrews ran an Upper GI Surgery Course which included the use of this facility (although the theatre video was captured by in-built equipment rather than the cart, but the same principle applies).
Future plans include arthroscopic surgery and potentially endoscopy. We are also keen to look at capturing non-operative learning opportunities e.g. Could be observing human factor interactions or even remote transmission of a simulation session. Although so far we have only linked to the Horizon Centre i.e. On site we can broadcast anywhere that has internet connection so regional / national / international training is possible.