- Email: [email protected]
The patient’s role in the assessment of students’ communication skills
Nurse Education Today (2009) 29, 405–412
Nurse Education Today www.elsevier.com/nedt
The patient’s role in the assessment of students’ communication skills Christopher S. Davies *, Katherine Lunn Division of Podiatry, University of Huddersfield, Queensgate, Huddersfield, Yorkshire HD1 3DH, United Kingdom Accepted 25 August 2008
KEYWORDS
Summary The central focus of this study was to investigate the effects of the introduction of a new system of formative assessment on students’ perceptions of their communication skills, by recruiting patients to assess the student who provided their treatment on that day .The assessment tool detailed 12 aspects of communication and the patient ‘scored’ the student from 0 (representing very poor skills) to 10 (representing excellence). The patients then handed the completed form at the end of the treatment session to the student. This would then form part of their clinical portfolio for reflection and consideration. A pilot scheme was implemented with the consent of staff, students and patients. Minor adjustments were made to the forms to clarify more precisely the point for assessment. The communication visual analogue scale demonstrated a perceived improvement over the ten-week period 86.4% for the experienced students and 80% for the novoice students. The students who were interviewed all stated that they were comfortable with the patients assessing them and for some it made them feel more confident. Some students were surprised by the marks that the patients gave on some aspects of their communication, particularly pertaining to maintaining eye contact. c 2008 Elsevier Ltd. All rights reserved.
Students’ assessment by patients; Communication skills
Introduction Traditionally the main role of the service user or patient in the clinical teaching milieu has been to * Corresponding author. Tel.: +44 01484 472684; fax: +44 01484 472380. E-mail address: [email protected] (C.S. Davies).
act as a subject for clinical assessment, diagnosis and treatment by students, under the guidance of clinicians, at different stages of the students’ learning cycle. Over time, that role has expanded and has developed where the patients have been encouraged to occupy a range of teaching roles, for example acting as expert patients, where they are best placed to talk about their medical
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.08.018
406 condition and how it affects their lives and their families. More recently their educational role has progressed into the assessment of students. The premise of this paper is to investigate the effects of an expanded role for patients, into becoming assessors of students’ clinical skills thereby promoting an improved tri-partite interaction involving the student, the tutor and the patient, acknowledging their respective roles in the experiential learning of students in any clinical or social setting. Communication skills were chosen as the first area of research as they are core transferable skills, considered to be essential to any setting for clinical practice where there is interaction with patients. This would be achieved through a small scale mixed methods investigation using quantitative and qualitative methods undertaken in one clinical setting, recognising that this scheme could be adapted to a range of Health and Social Care courses.
Aims and objectives The aims were: To investigate the effects of the introduction of a new formative assessment on students’ perceptions of their communication skills. To compare the perceived change in skills of experienced and novice student groups. To investigate the potential for the involvement of service users (patients) and their carers in the assessment of students.
Literature review Collins and Harden (1998) stated that any assessment of clinical competence required the candidate to be observed in consultation with a patient. In any clinical setting, patients have a unique perspective, namely they are the experts on their own condition, living with the signs and symptoms of their presenting complaint they are the ones who provide a narrative of clues to it. Therefore they rely on the practitioner to have the skills and approaches to ask the right questions in an appropriate manner and to be able to summarise, check and interpret the information to facilitate accurate diagnoses of their symptoms, leading to appropriate management strategies. Poor communication is often cited in cases of dispute or claims of negligence. Greco et al. (1998) noted that approximately two-thirds of claims made are the consequence of a breakdown
C.S. Davies, K. Lunn in the communication channels between the therapist and the patient. Newsome and Wright (2000) considered patients to have a unique perspective that allowed them to contribute to the assessment of students’ interpersonal skills. Patients are therefore seen to be an integral part of the education of students in so many more ways than simply being the vehicle through which clinical skills are taught and assimilated. According to Spencer (2004), contact with patients is central to clinical education and it was this acknowledgement that prompted the expansion of research into the development of possible roles that patients may have in the education of students. There is much evidence to show the benefits of asking patients to become involved in the education of students and the use of students playing the roles of simulated patients in assessments of clinical skills. However there is not a lot of research which has investigated the role of real patients in the assessment of students’ skills and this has provided the opportunity and platform for this study. Rider et al. (2006a) investigated communication skills and concluded that they are core clinical skills that can be taught and learned. They should be considered to be essential competences to support and enhance the clinical skills of all health care practitioners. Indeed, Lipkin (1996) recognised that medical interviews are the most commonly performed procedure in clinical medicine, as they precede any form of intervention. Rider and Keefer (2006b) suggested that improvement in health professionals’ interpersonal and communication skills correlated with an improvement in healthcare results. This could have a significance for the effective delivery of health care services. Their paper continued to suggest that over time, the students’ abilities to retain these skills could reduce over the time span of their training period. An explanation for this could be a change in the students’ learning priorities at different stages of their course. One way to improve this situation could be the inclusion of patients at each stage of their course in interactions with students, in formative assessment of a range of skills and abilities, to make the encounter focused. Makoul (2001) reported the findings of a meeting of leaders of major medical education organisations held in 1999. The outcomes facilitated the Kalamazoo consensus statement which concluded that there were seven core communication tasks required of the medical interaction: (1) to establish the doctor-patient relationship; (2) to open the discussion; (3) to gather information; (4) to understand the patient’s perspective; (5) to share
The patient’s role in the assessment of students’ communication skills information; (6) to reach agreement on problems and plans and (7) to provide closure. According to Greco et al. (1998), the adoption of patient-based assessments in training provides two benefits. It gives an opportunity for the immediacy of feedback to the student and it also demonstrates a measure of the effectiveness of the theoretical teaching that supports this part of clinical practice.
Preliminary development of the study Following a series of preliminary discussions with the clinicians, students and representatives of the service users, a successful bid for funding to support the appointment of a research assistant for a 12 month period was made, to develop and implement a scheme whereby patients were approached to assess students. Although this investigation was undertaken in one particular clinical setting, it is anticipated that this initiative could be applied to any courses that provide student involvement with patients and their carers, across the spectrum of Health and Social Care professions. The staff and students of the unit concerned were consulted for their informed consent to cooperate with and agree to take part in the study. The service user representatives were consulted and informed of the details of the proposed study. After consultation, they agreed in principle to proceed on behalf of the patients. At this stage they were involved in the formulation of a range of statements to inform the questionnaire. They were also asked if they felt training for the role was appropriate. In the first instance they did not deem this as being necessary, expressing the feeling that their responses to the interaction would be more spontaneous and less prescribed without training, which may lead participants to provide an engineered score. Collins and Harden (1998) wrote of a ‘continuum’ of patient experience ranging between one end of the spectrum indicated by real patients without training and the other end of the spectrum of simulated patients who are well rehearsed prior to the assessment. They suggested that the major factor that should influence the patient representation within the ‘continuum’ should be the factor being assessed. In this case of formative assessment, the use of real patients with no prior training was considered to be the option of choice. A communication skill assessment tool was developed, adapted from that proposed by Rider et al. (2006a). This detailed 12 statements of communication skills, including, verbal and non-verbal
407
elements, reflecting the areas of the Kalamazoo consensus statement ( Makoul, 2001). Each statement was accompanied by scoring the experience they had from 0 to 10, 10 being the best experience they had had. The statements concerned addressed how students: (1) introduced themselves to the patient; (2) maintained eye contact when talking to the patient; (3) gathered information from the patient; (4) used words that the patient can understand; (5) listened to what the patient has to say; (6) answered the patient’s questions about their treatment; (7) involved the patient in decisions about their treatment; (8) cared about the patient as a person; (9) gave the patient his/her full attention; (10) displayed sensitivity when discussing the patient’s medical history; (11) explained any verbal advice given to the patient and (12) explained any written advice given to the patient. Discussions with the staff team revealed some tension with the format of the form and felt it necessary to include a free text box for their comments to provide a context for the patients’ responses, should they be less than complimentary or too generous.
Selection of patients as assessors According to Cooper and Mira (1998) it should be the patient who assesses (the student) as it is the patient who is the ultimate participant in doctorpatient communication. Wykurz and Kelly (2002) found that patients could be more actively involved in the educational process, particularly where they had the opportunity to teach communication and clinical skills from the perspective of the recipient of information and then give feedback to the students; thereby acting as assessors. They suggested that this series of events provided added benefits for learners, trainers and patients. Recognising that not all patients would feel comfortable in this new role, an information poster (Fig. 1) was sited prominently in the reception waiting area for the patients, or their carers, to read so that when they volunteered or were approached to volunteer there was a source of information available to them. Only those who volunteered or who agreed to take part in the scheme were recruited. Volunteers were reassured that they could withdraw from the scheme at any stage without any effect on their future care. The research assistant prepared a brief introduction to provide information for all the volunteers to explain the study and to confirm what was being asked of them.
408
C.S. Davies, K. Lunn
Become more
Why get
involved!!
involved?
…involving patients in education and assessment.
Patient and public involvement in healthcare and education.
Everyone has experience of using health services and this can be used to help students learn and achieve success in their vocational training. Patients and their family and/or carers can get involved in helping students develop as professionals.
The government and local health trusts are increasing the input that patients have in their treatment and the provision of local services. The university is also starting to involve the public in university life, including interviewing potential students and involvement with assessment.
What are
How can
we doing?
you find out more ?
Running a project for patient and public involvement.
Interested in this project and becoming more involved?
The project is looking into asking patients to assess the communication skills of students, using a tool developed for this purpose. The patients are asked to score the student on a list of twelve key communication skills and the student keeps this assessment in their portfolio for reflection.
Figure 1
Please ask at the Reception for further details
Recruitment poster.
When approached, a small number of people declined to take part for a number of reasons, including some who had not brought their reading glasses, so could not read the questions; some felt confused about their role whilst others just did not feel equipped to take part.
over the 10 week cycle each student was exposed to at least three assessments by patients. Overall, each set of students (novice and experienced) generated approximately 120 responses by patients. This number of students was considered to be a sufficient exposure to enable a meaningful set of data to be generated to achieve the aims of the study.
Student availability
Method Students were exposed to this form of assessment by patients on a rota basis depending on their tutorial programme. Each week a minimum of 24 students were in clinical practice and each student experienced practice in 3 of the four weeks, so
Pilot study A small pilot study was undertaken to rehearse the delivery of patient information, to test the planned
The patient’s role in the assessment of students’ communication skills schedule and the measurement tools. All questions were considered to be appropriate and were considered to be understandable for all patients. The introduction to the study for the patients was adapted to suit the patient groups selected for this scheme.
Final method Phase one – experienced students The assessment tool was first used in October 2006 with verbal explanations given to the volunteer patient assessors, staff and students regarding its purpose, how to complete the form and where to return them. As this was a formative tool, the completed assessment forms were kept by the students in their clinical portfolio to inform them of their performance and to assist them in reflection on their clinical experiences. The students were provided with a Likert scale (Fig. 2), to record their perceptions of their communication skills at two points in the investigation; once at the start of the scheme and again after 10 weeks of the scheme. This linear scale score ranged from 0 to 10, 0 representing their lowest perception score and 10 representing the highest level of perception. Volunteer patient assessors were approached at each clinic for a ten-week period, finishing in December 2006. At this point the students were given another communication skills scale to complete, without reference to their original scale, to observe if their perceptions had changed. Interviews with six experienced students, chosen at random from the cohort number of 44, followed this phase to discuss their thoughts and feelings about having the patients assess them, particularly if they felt that it had been beneficial and a worthwhile exercise.
Phase two – novice students The implementation of the patient assessment process with the novice students began in January 2007. The verbal explanations were given to the volunteer patient assessors, staff and students as to their purpose, how to complete the forms and where to return them. As this was a formative tool, Very poor 0
Excellent 10
Figure 2 Likert scale used to show student’s perception of their communication skills.
409
the completed assessment forms were kept by the students in their clinical portfolio to inform them of their performance and to assist them in reflection on their clinical experiences. At the start of this cycle, the students were given a communication skills scale to mark what level they thought their communication skills were at this stage of the scheme. The patients were approached for a ten-week period, finishing in April and on completion, students were given another communication skills scale to complete without reference to the original scale to interrogate whether their perceptions had changed. Follow-up interviews were undertaken with six novice students, once again chosen at random from the cohort number of 58, to discuss their thoughts and feelings about having the patients assess them.
Results Forty four experienced students (the first 10 weeks) and 58 novice students (the second 10 weeks) agreed to take part in this study. In total over the 20 weeks cycle of the whole investigation, approximately 240 patient responses were received.
Perception scales The pre-test and post-test communication skills perception scales (Likert) were paired for each student and the differences were calculated to measure any perceived change.
Novice students’ responses In the novice student group, 80% of students reported a perceived improvement in their communication skills over the ten-week period
Experienced students’ responses In the experienced student group, 86% reported a perceived improvement in their communication skills over the 10-week period.
Interviews The student interviews were conducted after the separate phases of the study. These provided more detailed information about the perceptions of
410 communication and how it impacted on the students’ clinical practice. The interviewed students of both groups highlighted group work, clinics, and placements as key activities that develop their communication skills. The students from both groups were comfortable with the patients assessing them and that their confidence in communicating with people had increased. This was consistent with the findings reported by Wykurz and Kelly (2002).
Novice students’ interviews (n = 6) Thirty three percent of those interviewed from the novice group stated that they were hesitant at the start of the scheme and did feel slightly uncomfortable. This may be explained as the need for their main priority to be in the development of safe psycho-motor skills at this early stage of their clinical learning. All novice group students stated that it made them realise the importance of good communication skills and highlighted areas of limitation that they can improve, for example better eye contact when talking with patients and providing clearer treatment explanations. The interviews asked the students to score the teaching they had received on interpersonal and communication skills, from very poor to excellent. The novice group rated their teaching of communication skills as good. It should be recorded here that this investigation was undertaken at a time when communication skills teaching had been recently delivered in the curriculum.
Experienced students interviews (n = 6) Eighty three percent of those interviewed from the experienced group said it made them feel more confident in their communication skills and such assessments by patients were seen as non-threatening and non-judgemental. This group highlighted an initial concern about the inclusion of the patient in the development and implementation of their management plan. They highlighted negotiation skills as an area for development. The interviews asked the students to score the teaching they had received on interpersonal and communication skills, from very poor to excellent. The experienced group stated that they thought the teaching they received was adequate but that the formal teaching they had received seemed a long time ago in year one. The students had seem-
C.S. Davies, K. Lunn ingly not considered their experiential learning through practice and interactive placement experiences as part of learning.
Discussion The teaching of communication skills is formally introduced as part of a module in Year one studies. This is maintained through clinical experience as the course progresses over the three years of study. Unlike the suggestion reported by Rider et al. (2006a), communication skills are not permitted to decline over the duration of the course as they are formally assessed by clinical staff in the clinical examinations of each stage, although it is recognised that student’s learning priorities can affect their communication skills. In this case, the novice students’ priority is in the safe and effective development of psycho-motor skills for practice and for the experienced students priority is given to the application of theory to practice in a clinical environment. It was identified early on in the project that there were some concerns raised by staff and novice students, who felt that the patients could feel obliged to give high marks because the students get to see the scores and patients would want to return for further treatment. Conversely, it was also thought that some patients may previously have had a poor experience when in receipt of health care, which could negatively affect how they responded. This resulted in the inclusion of an additional comments box to the assessment form; so that staff could put any essential information down to explain the context of the patient’s comments or scores. Interestingly, no comments were recorded by staff in the text boxes provided. The experienced students were all very positive about their experiences and felt that the assessments were a fair reflection on their performance with a particular patient at a particular time and allowed them to see ways to improve on any specific areas that had been highlighted. This may also have had a more positive effect to alter the way students approach patients and how patients approach students, again this is a feature of the review undertaken by Wykurz and Kelly (2002).
Conclusions Recognising that the clinical tutor can not be in the presence of each student all of the time in the clinical setting and that the patient would be,
The patient’s role in the assessment of students’ communication skills the enhanced patient role in the assessment of students’ communication skills can be seen to compliment the role of the clinical teacher, providing that appropriate information and adjustment for all stakeholders was made available. It is important to remember that the patient is the ultimate participant in communication, in the giving and receiving of information. Students found this formative assessment nonthreatening and non-judgemental and thought it provided them with real-life feedback rather than simply re-iterating theoretical principles to a clinical tutor, mirroring the value-added effect reported by Wykurz and Kelly (2002). As practitioners from any of the Health and Social Care professional groups, it is important to develop excellent communication skills to enable the provision of appropriate diagnoses and interventions, based on the evidence and information obtained from patients and their carers. All Professional Bodies representing Health and Social Care personnel have very clear expectations of standards of conduct, performance and ethics which include: (a) Maintaining proper and effective communication with patients, carers and other professionals, (b) keeping accurate patient, client and user records and (c) obtain informed consent. As Health and Social Care professionals, it is essential to adhere to these standards and be in control of effective communication skills. The majority of patients who had been approached and all those who took part were very responsive to the task and reported that they had enjoyed having something to contribute whilst receiving treatment. Feedback from individual patients and their carers is considered to be an essential part of practice, particularly when practitioners are liaising with other Health and Social care professionals and training patient groups, teaching colleagues and being taught. Without effective communication skills, the achievement of the best outcomes for patients and therapists can be seriously jeopardised.
Future developments and collaborations It would require more studies fully to investigate the significance of the implementation of this scheme but there appears to be a very strong trend indicating the worth of involving patients in the formative assessment of students’ communication and possibly other transferable skills across the range of Health and Social care courses where students engage with patients in a ‘clinical’ setting.
411
Although this study ceased in July 2007, the outward wave-effect has drawn considerable interest from other groups and has potential for wider application. Currently, collaboration with colleagues in the University is on-going to share good practice, particularly with the Patient and Public Involvement (PPI) initiatives. The questionnaire and Likert scale is being shared with Assessment and Learning in Placement Settings (ALPS)1 as a means of complementing their pilot work, currently being developed in the use of alternative technologies for students in placement. Some early interest has also been expressed by colleagues in local NHS Primary Care Trusts to use the questionnaire for the inhouse training of their staff, where concerns have been identified about their respective staffs’ abilities in aspects of communication, particularly in the giving of ‘bad news’.
Acknowledgements We are grateful for the generous support proffered by Professor. N. Bax, Head of Academic Unit of Medical Education at Sheffield University and Dr. E. Rider, Co-Director of Communication Skills Teaching program at Harvard Medical School, Boston, USA. Their respective assistance facilitated the development of questions and provided a positive motivation for the continuance of the investigation. We are also grateful to the staff, students and patients at the University of Huddersfield for their cooperation and enthusiasm in support of this investigation.
References Collins, J.P., Harden, R.M., 1998. AMEE medical Education Guide No.13: real patients, simulated patients and simulators in clinical examinations. Medical Teacher 20 (6), 508– 521. Cooper, C., Mira, M., 1998. Who should assess medical students’ communication skills: their academic teachers or their patients? Medical Education 32, 419–421.
1
The Assessment of Learning in Placement Settings (ALPS) is a 5-University collaboration including the University of Bradford, University of Leeds (lead), Leeds Metropolitan University, University of Huddersfield and the University of Ripon and St John, York. This is charged with a number of initiatives in developing and supporting student’s learning using a variety of media and interactive technologies.
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Greco, M., Francis, W., Buckley, J., Brownlea, A., McGovern, J., 1998. Real-patient evaluation of communication skills teaching for GP registrars. Family Practice 15, 51–57. Lipkin Jr., M., 1996. Sisyphus or Pegasus? The physicians interviewer in the era of corporatization of care. Annals of Internal Medicine 124, 511–513. Makoul, G., 2001. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Academic Medicine 76 (4), 390–393. Newsome, P.R., Wright, G.H., 2000. Qualitative techniques to investigate how patients evaluate dentists: a pilot study. Community Dentistry and Oral Epidemiology 28, 257–266.
Rider, E.A., Hinrichs, M.M., Lown, B.A., 2006a. A model for communication skills assessment across the undergraduate curriculum. Medical Teacher 28 (5), 127– 134. Rider, E.A., Keefer, C.H., 2006b. Communication skills competencies: definitions and a teaching toolbox. Medical Education 40, 624–629. Spencer, J., 2004. Patients in medical education. The Lancet 363, 1480. Wykurz, G., Kelly, D., 2002. Developing the role of patients as teachers: literature review. British Medical Journal 325, 818–821.
Available online at www.sciencedirect.com
Nurse Education Today www.elsevier.com/nedt
The patient’s role in the assessment of students’ communication skills Christopher S. Davies *, Katherine Lunn Division of Podiatry, University of Huddersfield, Queensgate, Huddersfield, Yorkshire HD1 3DH, United Kingdom Accepted 25 August 2008
KEYWORDS
Summary The central focus of this study was to investigate the effects of the introduction of a new system of formative assessment on students’ perceptions of their communication skills, by recruiting patients to assess the student who provided their treatment on that day .The assessment tool detailed 12 aspects of communication and the patient ‘scored’ the student from 0 (representing very poor skills) to 10 (representing excellence). The patients then handed the completed form at the end of the treatment session to the student. This would then form part of their clinical portfolio for reflection and consideration. A pilot scheme was implemented with the consent of staff, students and patients. Minor adjustments were made to the forms to clarify more precisely the point for assessment. The communication visual analogue scale demonstrated a perceived improvement over the ten-week period 86.4% for the experienced students and 80% for the novoice students. The students who were interviewed all stated that they were comfortable with the patients assessing them and for some it made them feel more confident. Some students were surprised by the marks that the patients gave on some aspects of their communication, particularly pertaining to maintaining eye contact. c 2008 Elsevier Ltd. All rights reserved.
Students’ assessment by patients; Communication skills
Introduction Traditionally the main role of the service user or patient in the clinical teaching milieu has been to * Corresponding author. Tel.: +44 01484 472684; fax: +44 01484 472380. E-mail address: [email protected] (C.S. Davies).
act as a subject for clinical assessment, diagnosis and treatment by students, under the guidance of clinicians, at different stages of the students’ learning cycle. Over time, that role has expanded and has developed where the patients have been encouraged to occupy a range of teaching roles, for example acting as expert patients, where they are best placed to talk about their medical
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.08.018
406 condition and how it affects their lives and their families. More recently their educational role has progressed into the assessment of students. The premise of this paper is to investigate the effects of an expanded role for patients, into becoming assessors of students’ clinical skills thereby promoting an improved tri-partite interaction involving the student, the tutor and the patient, acknowledging their respective roles in the experiential learning of students in any clinical or social setting. Communication skills were chosen as the first area of research as they are core transferable skills, considered to be essential to any setting for clinical practice where there is interaction with patients. This would be achieved through a small scale mixed methods investigation using quantitative and qualitative methods undertaken in one clinical setting, recognising that this scheme could be adapted to a range of Health and Social Care courses.
Aims and objectives The aims were: To investigate the effects of the introduction of a new formative assessment on students’ perceptions of their communication skills. To compare the perceived change in skills of experienced and novice student groups. To investigate the potential for the involvement of service users (patients) and their carers in the assessment of students.
Literature review Collins and Harden (1998) stated that any assessment of clinical competence required the candidate to be observed in consultation with a patient. In any clinical setting, patients have a unique perspective, namely they are the experts on their own condition, living with the signs and symptoms of their presenting complaint they are the ones who provide a narrative of clues to it. Therefore they rely on the practitioner to have the skills and approaches to ask the right questions in an appropriate manner and to be able to summarise, check and interpret the information to facilitate accurate diagnoses of their symptoms, leading to appropriate management strategies. Poor communication is often cited in cases of dispute or claims of negligence. Greco et al. (1998) noted that approximately two-thirds of claims made are the consequence of a breakdown
C.S. Davies, K. Lunn in the communication channels between the therapist and the patient. Newsome and Wright (2000) considered patients to have a unique perspective that allowed them to contribute to the assessment of students’ interpersonal skills. Patients are therefore seen to be an integral part of the education of students in so many more ways than simply being the vehicle through which clinical skills are taught and assimilated. According to Spencer (2004), contact with patients is central to clinical education and it was this acknowledgement that prompted the expansion of research into the development of possible roles that patients may have in the education of students. There is much evidence to show the benefits of asking patients to become involved in the education of students and the use of students playing the roles of simulated patients in assessments of clinical skills. However there is not a lot of research which has investigated the role of real patients in the assessment of students’ skills and this has provided the opportunity and platform for this study. Rider et al. (2006a) investigated communication skills and concluded that they are core clinical skills that can be taught and learned. They should be considered to be essential competences to support and enhance the clinical skills of all health care practitioners. Indeed, Lipkin (1996) recognised that medical interviews are the most commonly performed procedure in clinical medicine, as they precede any form of intervention. Rider and Keefer (2006b) suggested that improvement in health professionals’ interpersonal and communication skills correlated with an improvement in healthcare results. This could have a significance for the effective delivery of health care services. Their paper continued to suggest that over time, the students’ abilities to retain these skills could reduce over the time span of their training period. An explanation for this could be a change in the students’ learning priorities at different stages of their course. One way to improve this situation could be the inclusion of patients at each stage of their course in interactions with students, in formative assessment of a range of skills and abilities, to make the encounter focused. Makoul (2001) reported the findings of a meeting of leaders of major medical education organisations held in 1999. The outcomes facilitated the Kalamazoo consensus statement which concluded that there were seven core communication tasks required of the medical interaction: (1) to establish the doctor-patient relationship; (2) to open the discussion; (3) to gather information; (4) to understand the patient’s perspective; (5) to share
The patient’s role in the assessment of students’ communication skills information; (6) to reach agreement on problems and plans and (7) to provide closure. According to Greco et al. (1998), the adoption of patient-based assessments in training provides two benefits. It gives an opportunity for the immediacy of feedback to the student and it also demonstrates a measure of the effectiveness of the theoretical teaching that supports this part of clinical practice.
Preliminary development of the study Following a series of preliminary discussions with the clinicians, students and representatives of the service users, a successful bid for funding to support the appointment of a research assistant for a 12 month period was made, to develop and implement a scheme whereby patients were approached to assess students. Although this investigation was undertaken in one particular clinical setting, it is anticipated that this initiative could be applied to any courses that provide student involvement with patients and their carers, across the spectrum of Health and Social Care professions. The staff and students of the unit concerned were consulted for their informed consent to cooperate with and agree to take part in the study. The service user representatives were consulted and informed of the details of the proposed study. After consultation, they agreed in principle to proceed on behalf of the patients. At this stage they were involved in the formulation of a range of statements to inform the questionnaire. They were also asked if they felt training for the role was appropriate. In the first instance they did not deem this as being necessary, expressing the feeling that their responses to the interaction would be more spontaneous and less prescribed without training, which may lead participants to provide an engineered score. Collins and Harden (1998) wrote of a ‘continuum’ of patient experience ranging between one end of the spectrum indicated by real patients without training and the other end of the spectrum of simulated patients who are well rehearsed prior to the assessment. They suggested that the major factor that should influence the patient representation within the ‘continuum’ should be the factor being assessed. In this case of formative assessment, the use of real patients with no prior training was considered to be the option of choice. A communication skill assessment tool was developed, adapted from that proposed by Rider et al. (2006a). This detailed 12 statements of communication skills, including, verbal and non-verbal
407
elements, reflecting the areas of the Kalamazoo consensus statement ( Makoul, 2001). Each statement was accompanied by scoring the experience they had from 0 to 10, 10 being the best experience they had had. The statements concerned addressed how students: (1) introduced themselves to the patient; (2) maintained eye contact when talking to the patient; (3) gathered information from the patient; (4) used words that the patient can understand; (5) listened to what the patient has to say; (6) answered the patient’s questions about their treatment; (7) involved the patient in decisions about their treatment; (8) cared about the patient as a person; (9) gave the patient his/her full attention; (10) displayed sensitivity when discussing the patient’s medical history; (11) explained any verbal advice given to the patient and (12) explained any written advice given to the patient. Discussions with the staff team revealed some tension with the format of the form and felt it necessary to include a free text box for their comments to provide a context for the patients’ responses, should they be less than complimentary or too generous.
Selection of patients as assessors According to Cooper and Mira (1998) it should be the patient who assesses (the student) as it is the patient who is the ultimate participant in doctorpatient communication. Wykurz and Kelly (2002) found that patients could be more actively involved in the educational process, particularly where they had the opportunity to teach communication and clinical skills from the perspective of the recipient of information and then give feedback to the students; thereby acting as assessors. They suggested that this series of events provided added benefits for learners, trainers and patients. Recognising that not all patients would feel comfortable in this new role, an information poster (Fig. 1) was sited prominently in the reception waiting area for the patients, or their carers, to read so that when they volunteered or were approached to volunteer there was a source of information available to them. Only those who volunteered or who agreed to take part in the scheme were recruited. Volunteers were reassured that they could withdraw from the scheme at any stage without any effect on their future care. The research assistant prepared a brief introduction to provide information for all the volunteers to explain the study and to confirm what was being asked of them.
408
C.S. Davies, K. Lunn
Become more
Why get
involved!!
involved?
…involving patients in education and assessment.
Patient and public involvement in healthcare and education.
Everyone has experience of using health services and this can be used to help students learn and achieve success in their vocational training. Patients and their family and/or carers can get involved in helping students develop as professionals.
The government and local health trusts are increasing the input that patients have in their treatment and the provision of local services. The university is also starting to involve the public in university life, including interviewing potential students and involvement with assessment.
What are
How can
we doing?
you find out more ?
Running a project for patient and public involvement.
Interested in this project and becoming more involved?
The project is looking into asking patients to assess the communication skills of students, using a tool developed for this purpose. The patients are asked to score the student on a list of twelve key communication skills and the student keeps this assessment in their portfolio for reflection.
Figure 1
Please ask at the Reception for further details
Recruitment poster.
When approached, a small number of people declined to take part for a number of reasons, including some who had not brought their reading glasses, so could not read the questions; some felt confused about their role whilst others just did not feel equipped to take part.
over the 10 week cycle each student was exposed to at least three assessments by patients. Overall, each set of students (novice and experienced) generated approximately 120 responses by patients. This number of students was considered to be a sufficient exposure to enable a meaningful set of data to be generated to achieve the aims of the study.
Student availability
Method Students were exposed to this form of assessment by patients on a rota basis depending on their tutorial programme. Each week a minimum of 24 students were in clinical practice and each student experienced practice in 3 of the four weeks, so
Pilot study A small pilot study was undertaken to rehearse the delivery of patient information, to test the planned
The patient’s role in the assessment of students’ communication skills schedule and the measurement tools. All questions were considered to be appropriate and were considered to be understandable for all patients. The introduction to the study for the patients was adapted to suit the patient groups selected for this scheme.
Final method Phase one – experienced students The assessment tool was first used in October 2006 with verbal explanations given to the volunteer patient assessors, staff and students regarding its purpose, how to complete the form and where to return them. As this was a formative tool, the completed assessment forms were kept by the students in their clinical portfolio to inform them of their performance and to assist them in reflection on their clinical experiences. The students were provided with a Likert scale (Fig. 2), to record their perceptions of their communication skills at two points in the investigation; once at the start of the scheme and again after 10 weeks of the scheme. This linear scale score ranged from 0 to 10, 0 representing their lowest perception score and 10 representing the highest level of perception. Volunteer patient assessors were approached at each clinic for a ten-week period, finishing in December 2006. At this point the students were given another communication skills scale to complete, without reference to their original scale, to observe if their perceptions had changed. Interviews with six experienced students, chosen at random from the cohort number of 44, followed this phase to discuss their thoughts and feelings about having the patients assess them, particularly if they felt that it had been beneficial and a worthwhile exercise.
Phase two – novice students The implementation of the patient assessment process with the novice students began in January 2007. The verbal explanations were given to the volunteer patient assessors, staff and students as to their purpose, how to complete the forms and where to return them. As this was a formative tool, Very poor 0
Excellent 10
Figure 2 Likert scale used to show student’s perception of their communication skills.
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the completed assessment forms were kept by the students in their clinical portfolio to inform them of their performance and to assist them in reflection on their clinical experiences. At the start of this cycle, the students were given a communication skills scale to mark what level they thought their communication skills were at this stage of the scheme. The patients were approached for a ten-week period, finishing in April and on completion, students were given another communication skills scale to complete without reference to the original scale to interrogate whether their perceptions had changed. Follow-up interviews were undertaken with six novice students, once again chosen at random from the cohort number of 58, to discuss their thoughts and feelings about having the patients assess them.
Results Forty four experienced students (the first 10 weeks) and 58 novice students (the second 10 weeks) agreed to take part in this study. In total over the 20 weeks cycle of the whole investigation, approximately 240 patient responses were received.
Perception scales The pre-test and post-test communication skills perception scales (Likert) were paired for each student and the differences were calculated to measure any perceived change.
Novice students’ responses In the novice student group, 80% of students reported a perceived improvement in their communication skills over the ten-week period
Experienced students’ responses In the experienced student group, 86% reported a perceived improvement in their communication skills over the 10-week period.
Interviews The student interviews were conducted after the separate phases of the study. These provided more detailed information about the perceptions of
410 communication and how it impacted on the students’ clinical practice. The interviewed students of both groups highlighted group work, clinics, and placements as key activities that develop their communication skills. The students from both groups were comfortable with the patients assessing them and that their confidence in communicating with people had increased. This was consistent with the findings reported by Wykurz and Kelly (2002).
Novice students’ interviews (n = 6) Thirty three percent of those interviewed from the novice group stated that they were hesitant at the start of the scheme and did feel slightly uncomfortable. This may be explained as the need for their main priority to be in the development of safe psycho-motor skills at this early stage of their clinical learning. All novice group students stated that it made them realise the importance of good communication skills and highlighted areas of limitation that they can improve, for example better eye contact when talking with patients and providing clearer treatment explanations. The interviews asked the students to score the teaching they had received on interpersonal and communication skills, from very poor to excellent. The novice group rated their teaching of communication skills as good. It should be recorded here that this investigation was undertaken at a time when communication skills teaching had been recently delivered in the curriculum.
Experienced students interviews (n = 6) Eighty three percent of those interviewed from the experienced group said it made them feel more confident in their communication skills and such assessments by patients were seen as non-threatening and non-judgemental. This group highlighted an initial concern about the inclusion of the patient in the development and implementation of their management plan. They highlighted negotiation skills as an area for development. The interviews asked the students to score the teaching they had received on interpersonal and communication skills, from very poor to excellent. The experienced group stated that they thought the teaching they received was adequate but that the formal teaching they had received seemed a long time ago in year one. The students had seem-
C.S. Davies, K. Lunn ingly not considered their experiential learning through practice and interactive placement experiences as part of learning.
Discussion The teaching of communication skills is formally introduced as part of a module in Year one studies. This is maintained through clinical experience as the course progresses over the three years of study. Unlike the suggestion reported by Rider et al. (2006a), communication skills are not permitted to decline over the duration of the course as they are formally assessed by clinical staff in the clinical examinations of each stage, although it is recognised that student’s learning priorities can affect their communication skills. In this case, the novice students’ priority is in the safe and effective development of psycho-motor skills for practice and for the experienced students priority is given to the application of theory to practice in a clinical environment. It was identified early on in the project that there were some concerns raised by staff and novice students, who felt that the patients could feel obliged to give high marks because the students get to see the scores and patients would want to return for further treatment. Conversely, it was also thought that some patients may previously have had a poor experience when in receipt of health care, which could negatively affect how they responded. This resulted in the inclusion of an additional comments box to the assessment form; so that staff could put any essential information down to explain the context of the patient’s comments or scores. Interestingly, no comments were recorded by staff in the text boxes provided. The experienced students were all very positive about their experiences and felt that the assessments were a fair reflection on their performance with a particular patient at a particular time and allowed them to see ways to improve on any specific areas that had been highlighted. This may also have had a more positive effect to alter the way students approach patients and how patients approach students, again this is a feature of the review undertaken by Wykurz and Kelly (2002).
Conclusions Recognising that the clinical tutor can not be in the presence of each student all of the time in the clinical setting and that the patient would be,
The patient’s role in the assessment of students’ communication skills the enhanced patient role in the assessment of students’ communication skills can be seen to compliment the role of the clinical teacher, providing that appropriate information and adjustment for all stakeholders was made available. It is important to remember that the patient is the ultimate participant in communication, in the giving and receiving of information. Students found this formative assessment nonthreatening and non-judgemental and thought it provided them with real-life feedback rather than simply re-iterating theoretical principles to a clinical tutor, mirroring the value-added effect reported by Wykurz and Kelly (2002). As practitioners from any of the Health and Social Care professional groups, it is important to develop excellent communication skills to enable the provision of appropriate diagnoses and interventions, based on the evidence and information obtained from patients and their carers. All Professional Bodies representing Health and Social Care personnel have very clear expectations of standards of conduct, performance and ethics which include: (a) Maintaining proper and effective communication with patients, carers and other professionals, (b) keeping accurate patient, client and user records and (c) obtain informed consent. As Health and Social Care professionals, it is essential to adhere to these standards and be in control of effective communication skills. The majority of patients who had been approached and all those who took part were very responsive to the task and reported that they had enjoyed having something to contribute whilst receiving treatment. Feedback from individual patients and their carers is considered to be an essential part of practice, particularly when practitioners are liaising with other Health and Social care professionals and training patient groups, teaching colleagues and being taught. Without effective communication skills, the achievement of the best outcomes for patients and therapists can be seriously jeopardised.
Future developments and collaborations It would require more studies fully to investigate the significance of the implementation of this scheme but there appears to be a very strong trend indicating the worth of involving patients in the formative assessment of students’ communication and possibly other transferable skills across the range of Health and Social care courses where students engage with patients in a ‘clinical’ setting.
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Although this study ceased in July 2007, the outward wave-effect has drawn considerable interest from other groups and has potential for wider application. Currently, collaboration with colleagues in the University is on-going to share good practice, particularly with the Patient and Public Involvement (PPI) initiatives. The questionnaire and Likert scale is being shared with Assessment and Learning in Placement Settings (ALPS)1 as a means of complementing their pilot work, currently being developed in the use of alternative technologies for students in placement. Some early interest has also been expressed by colleagues in local NHS Primary Care Trusts to use the questionnaire for the inhouse training of their staff, where concerns have been identified about their respective staffs’ abilities in aspects of communication, particularly in the giving of ‘bad news’.
Acknowledgements We are grateful for the generous support proffered by Professor. N. Bax, Head of Academic Unit of Medical Education at Sheffield University and Dr. E. Rider, Co-Director of Communication Skills Teaching program at Harvard Medical School, Boston, USA. Their respective assistance facilitated the development of questions and provided a positive motivation for the continuance of the investigation. We are also grateful to the staff, students and patients at the University of Huddersfield for their cooperation and enthusiasm in support of this investigation.
References Collins, J.P., Harden, R.M., 1998. AMEE medical Education Guide No.13: real patients, simulated patients and simulators in clinical examinations. Medical Teacher 20 (6), 508– 521. Cooper, C., Mira, M., 1998. Who should assess medical students’ communication skills: their academic teachers or their patients? Medical Education 32, 419–421.
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The Assessment of Learning in Placement Settings (ALPS) is a 5-University collaboration including the University of Bradford, University of Leeds (lead), Leeds Metropolitan University, University of Huddersfield and the University of Ripon and St John, York. This is charged with a number of initiatives in developing and supporting student’s learning using a variety of media and interactive technologies.
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Greco, M., Francis, W., Buckley, J., Brownlea, A., McGovern, J., 1998. Real-patient evaluation of communication skills teaching for GP registrars. Family Practice 15, 51–57. Lipkin Jr., M., 1996. Sisyphus or Pegasus? The physicians interviewer in the era of corporatization of care. Annals of Internal Medicine 124, 511–513. Makoul, G., 2001. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Academic Medicine 76 (4), 390–393. Newsome, P.R., Wright, G.H., 2000. Qualitative techniques to investigate how patients evaluate dentists: a pilot study. Community Dentistry and Oral Epidemiology 28, 257–266.
Rider, E.A., Hinrichs, M.M., Lown, B.A., 2006a. A model for communication skills assessment across the undergraduate curriculum. Medical Teacher 28 (5), 127– 134. Rider, E.A., Keefer, C.H., 2006b. Communication skills competencies: definitions and a teaching toolbox. Medical Education 40, 624–629. Spencer, J., 2004. Patients in medical education. The Lancet 363, 1480. Wykurz, G., Kelly, D., 2002. Developing the role of patients as teachers: literature review. British Medical Journal 325, 818–821.
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