Teaching Communication Skills in Mental Health: Inter-professional Learning

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1 1 2 Teaching Communication Skills in Mental Health: Inter-professional Learning Annie Cushing 1 Reader in Clinical Communication Skills Julie Attenborough 2 Senior Lecturer in Mental Health Nursing Authors: Julie Attenborough 2, Ania Korszun 1, Annie Cushing 1, Mary Hanrahan 2, Stephen Abbott 2 CETL 2008 s

2 CASE 1 Assessment & Admission of a Depressed Female Patient. Students: Mental Health Nursing Medical s CETL 2008

3 The DVD consists of four chapters: 1. Psychiatrist assessing the patient; 2. Psychiatrist and the charge nurse discussing admission; 3. Charge nurse meeting the patient and explaining the conditions of the section, close observation, checking safety; 4. Psychiatrist and the charge nurse reviewing the case next day. CETL 2008 s

4 Aims of the DVD and workbook To maximise skills practice time for medical students To develop and encourage reflection skills in mental health nurses To develop understanding and awareness of interprofessional communication in both groups

5 Students volunteers: 1. Complete a brief questionnaire before watching the DVD; 2. Complete a longer questionnaire at the end; 3. Actively discuss the DVD whilst being audio-recorded. s CETL 2008

6 Table 2. Inter-professional working Scale: 1 = strongly disagree; 2 = disagree; 3= neutral; 4 = agree; 5= strongly agree Watching the DVD helped me Q3. understand more about the role of other professions in mental health care Q7. understand more about the role of my own profession in mental health care Q11. understand more about communication between doctors and nurses about patient care Q18. learn more about the importance of communication in effective teamwork in mental health care Average score, nursing students Average score, medical students CETL 2008 s

7 Table 3. Discussion times Chapter 1. Psychiatrist and Patient (Assessment & admission) 2. Psychiatrist and Nurse (Team communication) 3. Nurse and Patient (Safety, care & rights) 4. Psychiatrist and Nurse (Team communication) Nursing students (7) mins (% of whole) Total: 75 mins 33 (44) 16 (21)* 21 (28) 5 (7) Medical students (11) mins (% of whole) Total: 40 mins 23 (57)* 5 (13) 9 (23) 3 (8) *Med students spent more time proportionally than nurse students discussing Ch 1.The reverse is true for Ch 2. CETL 2008 s

8 Emergent Themes from Discussions Similar data: Rapport with the patient Power relationships with the patient Inter-professional working Divergent data: Health professional roles s CETL 2008

9 Emergent themes: Relationship Skills (Nurses) William : but I just thought his style was quite patronising. If that was me in her position I would have, you don t do anything for me, I don t feel any kind of warmth there. Patrick: I don t think he was patronising I think he s got a difficult job to do and I think there s a question you could ask and push people away so I think he got the balance right. But.. maybe it comes over that he s got a technique he s acquired rather than something he s internalised. Pauline: I don t know if, I wouldn t agree that he was patronising - because he was very attentive, he focused on the patient, he also the tone of voice was quite I would say therapeutic. William:I don t necessarily agree but maybe it s just his style for me, no, I didn t really think there was any kind of, I know it must be very difficult with somebody that s so depressed and come in who s suicidal. But, yeah, I suppose there s a fine line to, speaking very slowly and giving her space, I just found him a bit, I didn t really warm to him. Jill: you could see the professional there and he made himself clear so it was OK for me.

10 Emergent theme: Relationship Skills (Medical) FREDA : He spoke in a very soft and gentle voice and he used a lot of silence. He didn t pressure her or anything. But at times I thought he came across a little creepy actually, at the beginning. BILL: I think he was quite good. So if he tries to like, hey, how are you doing? I m that ll be more patronising. JIM: No but I think, kind of like you know when you were saying, Freda, there were long silences there, I thought that was a bit of a negative. Because the silences were so long, sometimes I felt that was his way of trying to get himself recollected to try and win back her trust. FREDA: No, it s giving her chance to say something if she wanted to. I think it s important to have that

11 Emergent themes: (Medical) MATTHEW So therefore, as Dorothy correctly pointed, he had certain questions that to be answered by the patient, and then without pushing the patient he persisted on asking questions. A couple of questions he repeatedly asked. So he was, in a way, a bit pushy, because for the best interest of patient, to decide whether this patient is safe to send home or not. MAHEERA But with those questions, he could have phrased it differently and actually got an answer. JIM How do you phrase it differently? HELGA Yeah, how FREDA I don t think he would have, really. JIM How are you going to phrase it differently? FREDA same effect. JIM Yeah. FREDA I don t know. DOLORES Are we still talking about rapport? FREDA Yeah. DOLORES I think that HELGA Now, I like, one thing is, I know that he asked a lot of questions, the way that I liked it was because he sort of asked an open kind of question and then, when there was no response from that, gave her time and then he went, asked specific questions. I think in this situation, rapport is really difficult. You re not going to get that back from the patient, so using that technique of MATTHEW: I think for the situation, with the patient being so depressed, I think what he achieved was pretty good.

12 Emergent themes; Power relationships with patients Jill:(N) you could see the professional there and he made himself clear who he is at the end when it came to him making decision. So as he said that even though he acknowledges his concerns and the difficulties that she is going through he has a duty of care to admit her on the ward. So I think at that point that relationship, that gap between them, the patient and the doctor was there, I think he knew this even though they re saying that, so it was OK for me. DOLORES (M) And another thing that I found very interesting, it changed once he completed his assessment and decided to section the patient under the Mental Health Act, although not saying, I m going to section you, the phrase he used, I would like to ask you to stay in hospital under the Mental Health Act. So it is still FREDA (M) Giving her the power. DOLORES Giving her the power, although she is being institutionalised and she s being sectioned, still he didn t use that word, I m going to section you. FREDA And when he said, it s my duty, it s my duty to have to do this, kind of like, giving her the power but also saying, look, help me this is what I do.

13 Emergent themes IP working (Nurses) Len: And yeah, the psychiatrist was genuinely interested in what had been happening overnight and when obviously he wasn t around And the way that was communicated was very good I felt, very concise. Patrick: It s essential to care, these things can go wrong. William: Especially if there s, if they have different agendas or there s an ego thing can maybe be quite detrimental to that team idea flowing sort of, you know where there s no undercurrent there of like no I m going to try and undermine you here. there has to be that kind of good honest working relationship and professional thing, egos are not getting in the way, which they probably do in truth. Len: And good communication between the night staff and the day staff as well Dinah: It s good that the charge nurse actually gave him the opinions of the other nurses that worked with her on different shifts, so like establish what she s like at different times of the day...

14 Emergent Theme: IP working (Medical students) Dolores: Its really good they are able to give feedback to each other and kind of realise the increased risk she is so just giving good feedback on what their concerns were is quite good. Freda Knowing what s going on with the patient is so important.

15 Emergent Themes: IP Power relations M: Yeah, there s give and take there isn t there. He s not telling him to do things. M: I suppose, in a way, but he did have the final say I guess at the end of the day the clinical decision has to be, and the clinical responsibility is undertaken by the doctor. N: They both wanted each other s opinions N: It was a joint decision they came to.. N: I d say that s very much, it very much stands up as an ideal. N: Yeah well I m not always fooled by that, because the doctor got what he wanted.

16 Role differences (Nurses).. an example of how psychiatrists come in simply to glean this information and then go at the end, Great it s now the nurses job to come in and to kind of comfort you now. I m making the decision, but you re staying here, and OK, the nurses will be with you now to kind of pick up the pieces. I think it s even just the amount of time that a psychiatrist would spend with somebody, you don t really build up that kind of, or get the chance to. But as a nurse you re there all the time. You see, you were there for breakfast, you re there when they get up, you re there possibly when they go to bed.

17 Q. Identify ways in which the workshop has helped your learning about therapeutic communication in mental health care: Effective communication (NM) The opportunity for group discussion (N) Learning about the role of the nurse (M) Importance of psychiatric assessment (M) CETL 2008 Would like: Additional scenarios (NM) Having a diverse group of students (N) Written materials and role-play (N) s

18 Conclusions & Questions Medical students had shorter discussions Medical students discussed rapport and how to phrase questions in assessment. Nurses had more discussion about roles and value of team communication. Students focus depends on their experience? An additional IP learning session scheduled. s CETL 2008

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