Teaching (remotely) to communicate (remotely) with relatives of patients during lockdown due to the COVID-19 pandemic

Abstract

Aim

In 2020, due to the pandemic, the lack of specific knowledge on breaking bad news over the phone became apparent. This study aims at assessing the differences, or lack thereof, in satisfaction reported by participants in the different formats of a course in telephone communication for breaking bad news to families of patients, developed based on the previous experience of a team dedicated to this task during the peak of the pandemic.

Methods

Four courses were delivered, two in a fully streamed format and two in a blended format, part pre-recorded, part streamed. There were 41 attendants, mostly doctors, but also nurses, social workers, occupational therapists, and administrative staff who deal with families. Subsequently, a survey was conducted to assess the degree of satisfaction of the participants.

Results

Both formats scored very positively, with small advantages for the fully streamed format, mainly due to the difference in interaction activities.

Conclusions

The main conclusion is the need for these courses, which are demanded by the professionals themselves, without forgetting the benefit obtained from interprofessional education that enriches interaction and learning.

Innovation

The inclusion of administrative staff allows for a global vision of care for family members, which improves it.

Highlights

• •Training in communication and specifically in breaking bad news is a demand from healthcare professionals.
• •Interprofessional education fits better the needs that patients and families have in relationship with the medical team.
• •Today’s technological solutions allow for more flexible and cost-effective courses for the healthcare community.
• •Peer role-playing is an activity that fits perfectly into the training of communication skills.
• •Training based on shared experience generates trust and attention.

1. Introduction

On 14 March 2020, a state of alert was declared in Spain due to the COVID-19 pandemic, which led to the lockdown of the population to their homes [1]. In the meantime, the situation in hospitals was worsening to the point of reaching truly desperate situations, with the creation of hospitalization places for COVID patients that completely exceeded the previous capacity of the hospitals. This situation occurred in almost all countries [2].

Sick people were isolated and their relatives not only could not visit them but also could not physically go to the hospitals where their loved ones were located, so health professionals had to contact these families remotely, usually by phone [3]. This type of communication served to provide information on the clinical condition of the patient, but also to accompany the families who were going through this difficult situation [4].

Too often the kind of news that had to be conveyed was not good, but rather fatal.

Breaking bad news is something that every doctor has gone through or will go through in the course of his or her professional career, but such communication is usually done face-to-face and often in front of a person whom he or she knows beforehand. In fact, before the pandemic, it was considered bad practice to break bad news unless it was in person "Unless it is absolutely unavoidable, an interview about bad news should be carried out in person and not over the telephone" [5]. But during those first weeks of confinement, when it was necessary to improvise in order to deal with an avalanche of sick people, there was no alternative but to use the telephone to inform their families. This was not an easy task, not only because of the workload and the congestion of the system [6], but also because of the health professionals’ lack of training in specific skills for communicating bad news, especially when it had to be done over the telephone [7].

In the wake of this situation, small guides began to appear with recommendations on how to break bad news [8,9,10] although it was already known that there was a lack of training on how to make such calls [11].

Subsequently, all kinds of experiences have been published [12] since this extreme situation has been approached in many different ways. In some cases, specialised teams were set up to communicate with family members [3,13]. In others, simply no importance was given to providing this communication, which led to problems for the medical teams, as the overload of work prevented them from communicating with relatives in an adequate manner.

One cannot lose sight of the fact that the way in which information was provided about patients, together with the impossibility of saying goodbye to those who ended up dying alone, has had and continues to have serious consequences on the mental health of the relatives of these patients, leading to a greater demand for medical care and with it a greater stress on health systems already suffering from a lack of resources and overexploitation of existing ones [14,15].

Given the above situation, the need to provide training in the communication of bad news became evident. In response to this, the present study was carried out in a tertiary hospital in the province of Barcelona, Spain, where during the first peak of hospitalizations and deaths a Family Support Team (FST) was formed to inform relatives of patients admitted for COVID by telephone, which operated during March and April 2020 [16]. Stemming from this collaboration between the doctors responsible for the treatment of patients admitted for COVID-19 and the FST, the Pneumology Department made a request to the FST members to share their experiences and lessons learnt with the professionals that still had to communicate with isolated patients or their families.

Thus, the possibility was raised of holding training courses that had to be very specific and also of very limited duration, as the participating professionals still dealt with heavy workloads, and had to be taught remotely owing to the preventive measures implemented in the hospital environment.

In addition, it was deemed necessary to make the course interprofessional, to include anybody who might deal with relatives and not just health professionals as, due to the work overload, sometimes information was delivered to relatives by administrative personnel, like those working in the Department of Patient Services or secretaries of the medical departments involved. “Interprofessional Education (IPE) occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care” [17]. In 2010, the WHO Framework on Education and Practice was published, and this boosted this practice, establishing IPE “as a necessary step in preparing a collaborative practice-ready health workforce that works together to deliver the highest quality of care, improve health outcomes, and strengthen health systems” [18]. In the specific case of training on breaking bad news, Cooke [19] found that although the main motivation students of nursing and medicine had for joining the course was learning the content, the IPE aspect of the course was one of the main benefits.

The very demanding situation the health professionals found themselves in during the pandemic resulted in accelerated learning processes that can be explained by Transformative Learning, which is a particular adult learning theory that concerns how adults make meaning of life experiences” [20]. In the context of clinical education, the Transformative Learning Theory is being increasingly used as a framework to understand the way in which health professionals promote new ways of thinking [21]. The key elements are a disorienting dilemma that triggers critical reflection and rational discourse whose end result is a change in both the thinking and the acts of the professional [22]. Undoubtedly, the situation the health professionals went through was a challenge that acted as a disorienting dilemma, and more specifically the difficulties in communication between professionals and patients’ families in a highly complex scenario held a transformative power [23,24].

As In this context and to answer the requests made by the health professionals, training courses were designed entitled "Communicating (even more difficult) bad news" in which different tools and formats were experimented with, in the search for the best option to address to this need.

In these courses, the unique characteristics of telephone communication were stressed and at the time of their development, early in 2020, no scientific literature addressing similar coursework was found, only some protocols or guidelines for ER personnel or, in some cases, to police, firemen or other emergency responders who had to call relatives in case of accidents. Subsequently a large number of papers have been published addressing training of protocols for informing families, in all cases stemming from COVID-19.

The present research centres on assessing the degree of satisfaction reported by participants in the aforementioned courses, comparing the two formats employed, one with live sessions and the other with a mix of live and pre-recorded educational material. To do this, a quantitative analysis of answers to a satisfaction survey has been made, as well as a qualitative analysis of the open questions asked to the participants.

2. Methods

2.1. Course design

The design of the training course ‘Breaking bad news over the telephone in a COVID-19 context’ was a swift process, owing to the pressing and daily growing need for training.

The content and format of the courses was designed by a MD, expert in geriatrics and non-oncological palliative care, trained in clinical communication teaching, and with experience in teaching graduate and post graduate courses in communication and breaking bad news, both presential and online and to different health professionals (doctors, nurses, occupational therapists, social workers, midwives, psychologists…) including interprofessional formats, following the ADDIE model [25].

The ADDIE model consists in Analysing, Designing, Developing, Implementing, and Evaluating an instructional design. The first step was assessing, together with the heads of service and the learners themselves, the educational needs, and the different elements of the training: conditions, values, and outcomes [26]. In each edition of the course, the processes of reflection in action and on action of [27], were constantly employed to suit it to the detected needs. The two training outcomes prioritized, following the Iron Triangle Law [28], were efficiency in order to optimize time, space and personnel and effectiveness, to ensure the participants learned what they had to learn; as regards enjoyability, it was deemed to be not so necessary as all students were highly motivated due to the transformative experience of the pandemic. This is the reason the main focus of the post course survey was the degree of satisfaction, as it was not a main factor in the design of the course.

2.2. Course structure

The content was divided into three clearly differentiated themes:

• •Theme 1: Health communication.
• •Theme 2: Breaking bad news.
• •Theme 3: Communication with families in a COVID context.

The first topic covered concepts related to verbal, non-verbal and paraverbal communication, as well as the different barriers that may exist. Different communication techniques were also discussed, for example, active listening. Once the general concepts had been established, the course went on to study communication in health, the need to carry it out correctly, its difficulties and the objectives pursued.

The second topic focused on how to deliver bad news and for this purpose the Buckman six-step model or SPIKES [29] as one of the most widely accepted models with the most academic support.

To close the course, the third topic focused on communication with families during the pandemic, offering a series of good practices when using the telephone as a means of communication with family members, with a special focus on the three moments that comprise it: the preparation before the call, the call itself and the subsequent moment with the registration and preparation for the next call.

In addition, issues of relevance to a situation such as the one experienced at the time were discussed, namely: the need for support from the institution in which one works, the importance of having an organizational culture that gives due importance to communication throughout the process of caring for patients and relatives, and finally, issues related to the care of healthcare professionals who carry out this type of communication, due to the psychological impact that it entails.

2.3. Course format

Courses were delivered in two different formats:

2.3.1. Fully streamed

The first with three 2-hour sessions corresponding to each of the topics, given by the trainers directly via streaming. This type of course was called Fully Streamed. This format included more interactive activities. All participants undertook at least one role-playing activity, often with a heavy emotional burden. Participation is encouraged by the trainers via questions that lead to debates among all participants.

2.3.2. Blended

The second format consisted of providing theoretical material and a video with the first session previously recorded with a duration of 35 minutes in which the contents of the first topic were briefly addressed. The second session is streamed and opens with a time dedicated to answering doubts and questions about what had been studied in the first session and then continued with the content corresponding to the second topic - the communication of bad news - and an introduction to the third topic - communication in the COVID-19 context - this session lasted 2.5 hours, and the third session was, once again, sent by means of a video previously recorded by the trainers with a duration of 45 minutes, which dealt with the content of the third topic. At the end of the third video, they were asked to complete a short task to consolidate learning. These tasks were submitted via the hospital's educational platform, where the theoretical material and videos were also uploaded.

This course, with a format of one live and two pre-recorded sessions, was called Blended due to its mix of synchronous and asynchronous sessions. In this case, and owing to the shorter time devoted to streaming, a minimal amount of role-playing and debate activities is undertaken

This format was designed to give greater weight to the classical approach or didactic model.

2.4. Course tools

The materials were delivered to the participants via the training portal of the hospital where these courses were held.

For the streaming sessions, the Microsoft Teams platform was used, with participants being advised to use the desktop version in order to keep the chat active at all times.

During the synchronous sessions, and with the aim of increasing participation, role-playing exercises were carried out in which, in pairs, difficult conversations were simulated in a hospital environment using telephone communication, with subsequent reflection by the participants and feedback from the teachers.

In addition, several video clips from both commercial and educational films were used to show examples of communicative situations and their execution.

An online voting tool, Mentimeter, was used to answer questions posed by the trainers, generating further discussion.

2.5. Course editions and participants

Courses were included in the continuous training online platform of the hospital, open to a total of 3705 workers including health professionals, management, and support. The courses were free and voluntary, and a total of 368 people applied, with places awarded by order of registration. 8 pupils were assigned to each of the two Fully Streamed courses and 12 to each Blended course, with the addition of the head of the Pneumology Department, who had requested the creation of the courses. The format of the Blended course allowed a higher number of participants, as it was mostly asynchronous. Of the 41 professionals, most were MD (68%) most of them pulmonologists, but there were also nurses, social workers, occupational therapists, and administrative staff who deal with relatives of patients in their daily work. One of the workers admitted to a Fully Streamed course withdrew from it at the last moment for personal reasons.

In the Fully Streamed courses all participants were women, and in Blended courses there were 60% women and 40% men. The age distribution was as shown in Fig. 1:

Fig. 1.

Age distribution.

All courses were given by the same three trainers who were specifically trained in communication skills, two of whom had been part of the Family Support Team and therefore had experience in telephone communication with relatives of patients admitted with COVID-19.

The courses took place between November 2020 and July 2021.

2.6. Data collection

At the end of the four editions of the courses, a satisfaction survey was sent to the participants by e-mail using the SurveyMonkey platform. Two reminders were sent one week apart, and the survey was closed one month after the first one was sent.

The survey was specifically designed for these courses, following the format employed in other continuous training courses at the hospital where the training was done. Level 1 from Kirkpatrick Evaluation Framework was used, which focuses on participants’ reaction. The Kirkpatrick Evaluation Framework was proposed by Kirkpatrick in 1967 [30] and has since been widely used in all fields including Health Professionals’ training [31].

Using the first level implies evaluating the satisfaction level of the participants and, as Kirkpatrick himself explains, this is especially relevant in Inhouse training, as they are usually free and whose existence does not rest on participants attitudes “and when the reactions are positive, the chances of learning are improved.” [32].

Likert-type scales were used with ratings numbered from 1 to 5, 1 being the worst rating and 5 the best.

The questions were divided into three blocks: one dedicated to the content, one dedicated to the format and execution of the courses and the last one to obtain an overall assessment. In addition, the answers were divided into two groups depending on the course format used, Fully Streamed or Blended

An open-ended question was also added where respondents could add any comments they wished.

The collected data are presented with Tableau Desktop Professional Edition.

3. Results

There were two editions of the Fully Streamed format, with a total of 15 participants divided between the two editions (8 and 7), of which 13, 87%, were women.

The Blended format was also used for two editions with a total of 26 participants of which 50%, were women.

The survey consisted in 12 likert-type questions and a final open question in which participants were encouraged to comment on any aspect of the course.

The survey was answered by 27 people, 65.9% of the participants, although one did not complete it, 17 doctors, 3 nurses, 3 social workers, 3 administrative staff and one occupational therapist.

Most respondents were women, 20 in total and 7 men. The ages of the participants ranged from 28 for the youngest to 63 for the oldest, with a median age of 40. See Fig. 2.

Fig. 2.

Ages of respondents.

3.1. Quantitative results

The results from the likert-type questions obtained are presented below, differentiating the two course formats: Fully Streamed and Blended, by blocks: content, format, and implementation and, finally, overall satisfaction with the courses.

In terms of content, although practically all the responses are positive, they are better in the Fully Streamed version, especially in the questions that refer to issues more closely linked to live activities such as simulation or interaction between participants. See Fig. 3.

Fig. 3.

Content rating.

With regard to the questions on the format and delivery of the course, very positive values are also obtained. These are shown in Fig. 4.

Fig. 4.

Assessment of implementation.

In this case, a greater dispersion is observed in the responses of the participants in the Fully Streamed courses, apparently the need to be connected at specific times and for an extended period of time is valued negatively by some participants, as this was necessary in the three sessions that made up the course. On the other hand, in the Blended courses, one person rated the use of Microsoft Teams and the format negatively.

Finally, questions were asked about the assessment of the course as a whole. As can be seen in Fig. 5, the rating in both formats of the course was very satisfactory, although again, it is better in the version with the three live sessions. This is most marked in the ‘It was interesting’ question.

Fig. 5.

Overall assessment of the course.

Likert answers are ordinal, so a non-parametric test has been used. The answers from both groups were subjected to a Mann-Whitney U test which resulted in that only three of the questions showed statistically significative differences. As has been mentioned, these questions were ‘Role-playing activity’, ‘Interaction among participants’ and ‘It was interesting’. See Annex Mann-Whitney test.

3.2. Qualitative results

In addition, some comments were collected from the students, most of whom stressed the need to receive this type of training and that, whenever possible, it should be carried out face-to-face, with increased emphasis during internships. These comments are included below:

"I think that as far as the pandemic allows, these courses should be face-to-face, as the dialogue and interaction is greater.

"It's a pity that the course cannot be attended in person".

"The only thing I would like to highlight is the need for face-to-face practice in order to empathize and interact more with colleagues".

Overall, although the differences are minimal, a higher percentage of favourable responses were obtained in the Fully Streamed courses.

4. Discussion and conclusion

4.1. Discussion

Firstly, the training presented here is a consequence of the request made by experienced professionals, which is explained by the fact that during the pandemic most health workers faced situations they had not dealt with before, leaving them feeling unprepared in certain aspects related to the communication of bad news, especially when it is necessary to do so by telephone [33].

Communication has become increasingly important in the educational programs of health professionals and this has resulted in different models of training in communication skills in the field of health care [34,35,36]. There is also evidence in the scientific literature of an overestimation of communication skills on the part of the most experienced professionals [7]. This has been explained as an increase in confidence that is mistaken for competence [37]. Nevertheless, there are also studies that speak of some of those professionals being aware of a lack of training in this area [38,39]. Although both statements are contradictory, one cannot lose sight of the fact that both perceptions are worrying if one takes into account that these professionals are in charge of training students and residents in daily practice [40].

Therefore, the fact that the training arose from the demand expressed by professionals with many years of experience is linked to the pandemic situation, since from a theoretical point of view, it acted as a trigger and produced what is called in Transformative Learning Theory [41] a disorientating dilemma: they were supposed to have the necessary communication skills but the prevailing conditions meant that they encountered unforeseen difficulties and asked for help.

It must be noticed that the teachers of the course were members of the FST which communicated with family members during the worst of the pandemic, so the future students witnessed first-hand both their learning processes and the effort and dedication they put into this task. This in turn made the students place a great degree of trust in the teachers’ knowledge and experience in the subject.

These two reasons: that it was requested and that it was given by professionals with proven experience, made possible that the degree of satisfaction with the training offered was exceptionally high.

Secondly, although interprofessional training (IPE), that involve practicing health professionals from different disciplines, has been recommended by the [42] for several decades now, it is not common to find training courses in the field of health care. Examples of joint training of doctors and nurses can be found [43]. In some very specific cases with other types of professionals, but most often IPE is limited to undergraduate students [44,45]. Also, there are some experiences of interprofessional training dedicated to palliative care teams which are perhaps the closest reference to the experience reported in the present study [46,47].

Thirdly, focusing on the satisfaction survey, it can be seen that both Fully Streamed and Blended courses obtained very positive results, with no great differences between the two formats. In terms of content, the biggest differences are in the role-playing activities and interaction between participants, with a greater number of neutral responses in the case of the Blended type, which, because it only had one live session, had fewer opportunities for such activities.

However, in terms of implementation, the greatest satisfaction was observed in this type of course, as it could be followed at a pace more adaptable to the needs of the participants, who only needed to be live online for 2.5 hours on one day, whereas the Fully Streamed type required them to be online for 3 days with a duration of 2 hours.

However, the overall rating results are slightly higher for the Fully Streamed type despite requiring a higher level of time commitment.

The fact that in this type of course the role-playing activity was carried out by all participants is in line with studies that call for the encouragement of experiential learning [48] and with those that show that peer role playing is at least as effective as other types of simulations and, of course, less expensive [49]. In this case, owing to the peculiar pandemic context, the possibility of virtual role playing has been explored [50] and more specifically for training on breaking bad news [51], showcases how virtual training is helpful although face-to-face training is more effective, something that is in line with the comments left in the questionnaire by participants in the courses who say that they would have preferred it if this training could have been done in a face-to-face format.

In any case and bearing in mind that e-learning is here to stay, it is important to remember that flexibility and adaptation of teaching should aim at achieving the deepest and most enduring learning for learners, and thus transform their behaviour and ultimately achieve the final results for patients and their environment, organisations, and society.

The present study does not evaluate the knowledge gained or the implementation of this knowledge. Nor does it aim to study the satisfaction of patients and relatives who communicate with the professionals who attended the course.

This study was carried out with the limitation imposed by the time available to health professionals in the middle of a pandemic, especially taking into account that most of the participants were part of the pneumology service, especially concerned with the treatment of patients with Covid-19, which has led to reduce the desired content and has forced to leave out important issues such as conflict management or emotions, although the need for self-care and psychological support has been referred to.

Sample size is limited by the number or courses scheduled, and the fact that it is a convenience sample, derived from the fact that participants were voluntary and motivated might result in a self-selection bias that influences results. Additionally, the courses were imparted in a single hospital, and where many students were personal acquaintances of the teachers.

4.2. Innovations

The exceptional and innovative aspect of this training has to do with its interprofessional nature, which was not limited to strictly health professionals but also included the participation of administrative staff who, because of their work, also have a relationship with the relatives of admitted patients. And although the doctor is normally responsible for communicating bad news, the rest of the professionals involved, both in the care and in the attention to the patient and their relatives, must be trained so that the treatment is as appropriate as possible and thus minimise the negative consequences of a bad experience, not only for the family [52,53] but also for the professional him/herself [54].

In any situation, patients or their relatives have to deal with administrative staff but, in a pandemic situation and with relatives confined to their homes, these professionals were even more relevant, given that they supported people who had a relative in a serious situation, in the last days or even recently deceased.

The possibility of carrying out simulations playing different roles was an enriching experience for all participants, of use not only in exceptional situations like the pandemic, but also in the day-to-day healthcare environment where good communication with patients and families is a team effort and where all workers in a healthcare facility must work together, understanding the role played by the professionals in areas different from their own.

4.3. Conclusions

The COVID-19 pandemic has strained the healthcare system in many ways and has highlighted the need for regular and structured communication skills training, not only for doctors and nurses but for everyone who deals with patients and families. This deficit existed already, but the pandemic has brought it to the forefront.

Distance learning via technological platforms has proven to be suitable for doctors, nurses, social workers, and other health professionals including administrative staff.

It is advisable that the training be carried out in the most personal way possible with live sessions that allow for greater interaction, both among the students themselves and between them and the teachers.

This study shows the possibility of conducting training courses on how to deliver bad news to senior professionals in a way that can be adapted to the time and presence constraints of the participants, without making it a problem to do it virtually.

Disclosures

This research received no specific funding/grant from any funding agency in the public, commercial or not-for-profit sectors.

The authors have no conflicts of interest to declare.

This study does not require approval by the ethics committee, as it doesn’t use in any way personal or medical data of either patients or their families. Nevertheless, each of the questionnaire participants gave their express permission for their demographic data to be used for this research.

CRediT authorship contribution statement

Ara Ayora: Methodology, Investigation, Writing – original draft. Carme Nogueras: Conceptualization, Writing – original draft. Sonia Jiménez-Panés: Conceptualization, Supervision. Sergi Cortiñas-Rovira: Writing – review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

Mann-Whitney U Test Results