PREPARATION FOR PRACTICE
LEARNING HOW TO COMMUNICATE AND MANAGE
SITUATIONS AS A FOUNDATION DOCTOR, WITH
PATIENTS, RELATIVES AND COLLEAGUES.
A COMMUNICATION TEACHING SESSION FOR
YEAR 5 MEDICAL STUDENTS
Original author: C Chew-Graham
Revisions: Mark Perry on behalf of the Communication Education team and
others June 2012
Please send any suggestions for changes to:
communication. admin@manchester.ac.uk
1
CONTENTS and SCENARIO / CASE SUMMARY
LIST
pages
Introduction, ILOs, outline, materials
Session 1
Session 2
Case 1. Shift Handover using SBAR: student worksheets –
copies for all
Case 2: Apology and Negotiate Admission
student instructions
SP role
Case 3: Telephone Negotiation with colleague
Doctor instructions
Radiographer instructions
Case 4A: Emergency Handover
student instructions F1 task
Nurse task (4 copies of EACH for students)
3-4
5-9
10-11
12
Case 4B: Adverse Event
student instructions
SP role
Case 5: Breaking Bad News and Informed Consent (stent)
student instructions
SP role
LUNCH
Case 6: Confidentiality and Relatives
student instructions
SP role
Case 7 DNAR discussion
Case 8: Breaking Bad News – Death
student instructions
SP role
Case 9: Team handling of Complaint / Coroner discussion
student instructions
SP role
Case 10: SELF CARE Discussion – see also session plan
Resource Sheet for tutors and students
SBAR handout
12-14
15
16
17
18
19
20
21-22
23
24
25
26
27
28
29
30
31
32
33
34
2
Introduction:
In the two-session Year 5 Foundation Dr course (usually done in one full day), the tutor should meet
specific learning objectives (below and listed in the session plan) while also attending to additional
needs. The day follows a patient journey. It should consolidate students’ communication, and
introduce new aspects needed as a foundation trainee.
Each session should be time-tabled over 3 hours 15 minutes
Changes for 2012-13 (shown in bold)
Since students should now get more practice Breaking Bad News in Cancer elsewhere, case 3 (am)
We introduce 2 scenarios on Handover and Students should have prepared for SBAR discussion. So
the day now opens with a Shift handover (was in afternoon 2011-12), before we meet an irritated
patient whose investigation has not been pre-booked. Later Case 4 is on emergency Handover using
SBAR (see student handouts p34) and exploring drug concordance and managing adverse events
(resource sheet p33). We introduce an Adverse event in order to initiate discussion on ‘Open
Disclosure’ in a less threatening way. It is more important to consider how we can learn from and
prevent such events in an often unfriendly or ‘blame’ culture than to focus on labels like ‘error’.
There are minor changes to the story timing.
Intended learning outcomes:
Specific Intended Learning Outcomes for year 5 Clinical Communication teaching are:
 Learning to communicate as a Foundation Dr with patients, carers, colleagues
 Developing personal management skills in clinical work
 Development of telephone skills
 Preventing and managing adverse events / ‘critical incidents’
 Taking appropriate responsibility for adverse events / error within teams
 Ability to give and receive Handover (both planned and emergency)
 Using peer review and self-audit eg. on sensitisation to ‘blame cultures’
These come from the Communication ILOs as follows:
 Y 5.1 demonstrate consultation behaviour that ensures information needed for clinical
decision-making will be obtained whilst respecting the patient's autonomy, dignity and
privacy. [S.2,S.3,S.4,A.5, A.9]
 Y 5.2 demonstrate the ability to communicate under pressure and in emergency situations.
[A.5]
 Y5.3 demonstrate consultation behaviour that ensures the patient and/or a carer is in
concordance with the nature of the problem and the plan to manage it [S.7, A.5]
 Y5.8 demonstrate a commitment to self-analysis and peer review of professional status and
personal communication throughout a medical career [A.1, A.2, A.3, A.4]
 Yr 5.10 demonstrate the attitude, even when under pressure, that all patients have a right to
respect however difficult they are to communicate with. [A.5, A.8,A.9]
There may be outstanding objectives from earlier years which also need to be addressed:
 shared decision-making, explaining risk and negotiating management
 breaking bad news
 coping with personal feelings
3
Course outline
 Lead Tutor: Briefing for Tutors and SPs: To highlight changes and timing.
Lead Tutor: (Introductory plenary – Optional, as may be done in small groups):
Outline the format of the day, following a patient ‘journey’ and objectives (Powerpoint): to
review previous learning and add some team skills, especially on Handover. Describe the
methods - using role-play and simulated patients. Give a reminder of rules of group-work and
feedback. Group forming (up to 10 students per group, with one facilitator). Each group
will have a 10 minute introduction and ice breaker followed by 10 minutes to encourage
students to express their own learning needs. The tutor reviews the learning methods. It is
helpful to list the objectives as ‘tasks’ – (see Page 2 or facilitator’s session plan pages 5-11)
link students to the tasks throughout the day. The issues of confidentiality and safety should
be raised, as well as "house-keeping". Watch out for students’ personal feelings! Discussion
of situations in which students may have experienced difficulties should occur naturally
through the day. Following the feedback after each scenario, all the group tasks should be
covered by discussion. Facilitators should keep the focus on communication, but students
may note ethical issues to explore related learning needs later.

Role play. Attached are the scenarios. 1 – 5 to be covered using an SP ‘patient’ in the morning
session, while a ‘relative’ enters the scene for the afternoon session, scenarios 6 - 10. At this
stage students often value increasing challenge in role play, such as strong emotions from the SP;
this should be negotiated with each student in advance. All scenarios require preparatory
discussion by the group and/or input of resources by the tutor.

Preparation: Tutors to prepare using the resources eg handout on SBAR and DNAR article
(with tutor pack) Please watch the student preparatory material on Handover, a short series of
film clips demonstrating communication, first without SBAR and then when using it,
http://www.institute.nhs.uk/safer_care/safer_care/situation_background_assessment_recommend
ation.html.

Final discussion within each group to review the learning, reflect on issues raised, prioritise
future learning needs and plan how to address them. NB Students may want to attend a
Morbidity / Mortality or Critical Incident review in hospital or GP practice. Foundation Doctors
should now discuss anonymised adverse events in small groups from February to July each
year in all Trusts in the NW Deanery under ‘Lessons Learnt’.
Preparation and Materials required
Email students with the resource sheet and SBAR:
Dear Student. The F1 day starts with the group work and it is
very important that you prepare for this session. Please watch the materials on SBAR (Situation Background Recommendation
Assessment) especially the Escalation scenarios and Acute handover at the link below. Ensure you know how Escalation and Readback
work. http://www.institute.nhs.uk/safer_care/safer_care.html
One tutor per approx 10 students, an older simulated patient for the morning and a different younger
one as the son / daughter for the afternoon
Room with flipchart/pens
Sticky labels for name badges
Copies of doctor roles/student instructions – pages 12, 13, 15, 16, 17, 18, 19, 21, 23, 26, 27, 29
Resource and SBAR sheet for tutors and students (pages 33 & 34 )DNAR article
Hospital/ DoH consent form (see page 8, case 5)
Copies of SP roles – pages 14, 20, 22, 24, 28, 30
4 Copies of: Both Nurse and F1 roles p 17 and p18 and Handover Practice cases p26 & 27
Evaluation forms
4
Group work SESSION 1
TIME
CASE
TYPE
Start 0
Takes 20
mins
INDIVIDUAL
TASK for
student roleplaying F1
Into groups
GROUP TASK / TUTOR NOTES and
RESOURCES (italicised)
Tutor to ice-break and negotiate individual learning
objectives and connect to listed tasks for the day.
Negotiate how students want to give and receive feedback
– (as long as they are constructive, include positives, are
specific, use detailed description, offer alternatives and
own their feedback). They can use Pendleton’s rules
(positives then do differently), or chronological feedback
or gut reaction.
Remind group of the use of the PAUSE BUTTON – a
positive tool that shows they are really thinking about
what they are doing.
5
Start +20
Takes 20
mins
To introduce
SBAR and
practice a shift
handover
Introduce SBAR – (check that students have looked at
pre-course material). So ask them to explain and for
learning from the NHS institute material and personal
experiences: observations of Team Handover? Use of
printed lists? Systems used?
Pages
The SBAR routine provides
1. structure for the ‘giver’ and a way to escalate urgency.
2. enables the handover ‘recipient’ to mentally check and
then challenge incomplete or unclear details
How? Clarify SBAR (see student Handout p34:
Identify the elements: Situation (Identify self and
patient, location, then immediate problem) –
Background
(relevant
history)
–
Assessment
(observations, signs and any urgent results) –
Recommendation / Readback (Explain what you need be specific about request and time frame; Make
suggestions; Clarify expectations )
Put students into Trios or fours, outline task below
and give out copies of patient data - next two pages
one per student. EXPLAIN CONTEXT: As Giver you
are just ending your shift and have been busy admitting
several patients. You want to agree priorities with your
colleague. Receiver: You have just arrived at hospital
and are coming on to the a.m. shift. You are taking
Handover from your colleague (Then going to clerk new
patients under your Consultant - Case 2) NB BOTH
Giver and Receiver to use SBAR, to clarify they have all
the information that they need. The Receiver should
check Recommendation by using Readback
REPEAT so 2/3 students have practiced and made notes
on peer feedback. REMIND that they will all do more
practice later on.
6
Start +40
takes
30 mins
to negotiate
admission with
Patient
Case 1
SP
pages 12-14
Start +70
to negotiate
with
Takes 20 Radiographer
to appreciate a
mins
colleague’s
Case 2
Role-play perspective
Two
students
pages 15 -16
Tea break
10 mins
Start 100
Takes 30
mins
Case 3
Pair into
F1 and
Nurse
roles
with rest
to
observe
Here and throughout, ask student who is interviewing
to read out the scenario, Give out student script and
GP letter – (NB the latter is also needed in cases 3/4 to
identify causes of an ‘adverse event’). Discuss their
approach and clarify any factual points and problem
solve ahead e.g. What options exist to ensure partner’s
care? Increased nurse visits; social service input – carer;
respite admission to nursing home
Instruct observers: Take notes + After scenario (and
during if they pause) feedback to discuss:
Revision of SPIKES (if appropriate)
Patient’s expectations
Negotiating skills: The student should apologise for
planning deficiencies – (1. the Ultrasound has not been
pre-booked and 2. the patient is unprepared for
admission). Reassure the patient that a package of care
for the partner will be put in place urgently.
The patient will go home to their partner but return
later the same day
Feedback to discuss:
Request for urgent US scan. Use SBAR framework
here, especially to ‘Escalate’.
First try using telephone – start with students seated back
to back. Then see if students suggest Dr standing and
phoning –more assertive. Discuss / try alternative
‘personal’ approach
Related issues: Teamwork; Priorities and resources in
NHS, interpersonal influencing skills, Personal
management skills
Handover
To apply and
understand
SBAR
principles in
Emergency
handover of
patient care to
another team
member
Pages 17-18:
Explain that you are now practicing SBAR in an
emergency: taking and acting on an urgent call from
a nurse
Start by reading out to all the Nurse script to include
SITUATION. Explain students also need to problem
solve the emergency management, so it’s best to do
some of this first!* The scenario could evolve, so fold
the student instructions over. At least start above the line!
Ask the students to work in trios/4’s to practice an
urgent Nurse to F1 Dr ‘back to back’ telephone
‘handover’ of Mr/Mrs Smith, giving each pair the
different role play scripts. Link 1-2 Observers to share
‘nurse’ script – It’s best if ‘F1 Dr(s)’ leave room briefly.
If necessary either party can pause to ask observers for
management advice, get data from ‘below the line’, or
restart to ‘escalate’ the urgency. Observers to make
notes on BOTH parties use of SBAR elements and
7
feedback on Clarity of ‘call’ and repetition, escalation.
Clarity of ‘response’ and checking by Readback. Then
debrief the whole group focusing on communication!
*[Management: treat hypoglycaemia with bolus glucose IV and then
drip (NB patient to stay till morning – negotiate) GCS – students
have more details in their script and can review any of this
themselves later ]
Start 130
takes
40 mins
To do
both
tasks
Case 4 task 1
To explore the
reasons for poor
Adherence to
medication with
the patient
Pages 19 and 20
First explore the likely causes of Hypoglycaemia here:
(missed breakfast, but more important then to query an
excess dose of medication – student notes). So return to
the GP letter: what are potential causes of this adverse
event?
Case 4 task 2
To manage an
‘adverse event’
and discuss how
to learn from
error / ‘open
disclosure’
Discussion 15 mins: Preventing and Managing
Adverse Events
Learning objectives: Developing an understanding that
error is unavoidable – but not easily discussed!
Case 4
SP
Role play with the ‘recovered’ SP, debrief for 25 mins
Debrief the group on understanding the patient’s
reasons for non-adherence, being honest about causes:
Try to reach agreed solutions and explain to patient
how you and the organisation can learn from the
incident. Involve SP later in debrief specifically on the
adverse event, as this is the main focus for this Case.
(see student Resource for details on Concordance)
In working out the causes of this Adverse event, the
immediate problem should have emerged. Root Cause (s)
– these are often multiple as here*: Both Consultant AND
F1 doctor copied a dose of Gliclazide 160mg from the
GP’s letter. This was the prescribed dose, not 40mg (1/2 a
tablet), the dose the patient was actually taking. So both
the GP and administering nurse contributed too.
1. Personal Learning: Consider Prevention: To
include the patient by cross checking data. If the
patient had been asked about the dose and was unclear,
then the F1 could fax the GP. The GP Repeat prescription
record might have revealed the lower level of use.
2 ‘A Learning Organisation’: to what extent can we be
‘Open’ and what is ‘open disclosure’? – Transparency
on facts AND Reflection later
 Ask: What further actions are needed to prevent a
repetition of this?
 How will you document this in the notes?
 How do you RESPOND when the nurse suggests
that you complete an Incident (IR 1) form? What
8
if you HAD accidentally written an excessive dose
? (i.e. Your ‘error’). How will you cope and how
can teams manage error? (Personal AND safe
group reflection) Reflect on ‘no blame’ / ‘fair’
blame cultures?
Suggest revisit in review of learning in pm session *
Start 160
Takes 35
mins
Case 5
SP
Ends 195
NB: THE
ROLE NOW
JUMPS
AHEAD IN
TIME!
Bad news has
already been
broken by
consultant, but
the student must
continue the
process
IF your group has completed the Cancer ‘block’
(THEY MAY NOT HAVE YET!) they should be
prepared to maintain Hope / discuss disease
progression (months - not years, stent blockage)
dignity in dying and symptom + pain control
To talk to a
dying patient –
use SPIKES
Remind the student role-player this could be
challenging and to Pause as required
To START a
process of
consent. Explore
benefit/risk of
stent procedure
with patient.
How to begin to obtain consent for ERCP? - BUT stress
That full responsibility to complete this remains with
the Consultant, discuss role of Foundation Dr in team –
emphasise process
page 21=
student role
45 mins
NB: FIRST: The patient asks the ambiguous
question (s): ‘What’s going to happen?’
…How long have I got?
Is it worth it?
Sharing information re stent – see reference and checking
understanding
Resources: Use a hospital or D of Health consent form
+/- patient information leaflets see links p33
Summarise the morning’s learning: go round group
Lunch
9
SESSION 2
TIME
INDIVIDUAL
CASE
TASK
TYPE
for student
role-playing F1
Start 0
Confidentiality
dilemmas: to
respond to
takes
daughter/son’s
40 mins
request for
information
Case 6
SP
page 23
GROUP TASK
Get the group to explore the options here, before running the scenario:
Preparation: What's gone before? How do they judge the relationship?
Can they balance these principles?
Keep disclosures to the minimum necessary; inform patients about
any disclosure or check that they have already received
information about it.
You must be considerate to relatives, carers, partners and others
close to the patient, and be sensitive and responsive in providing
information and support.
If the patient cannot give consent, share information with those close
to the patient who need/want it (unless you suspect patient would
object) Resources: MDU and GMC booklets: [GMC website]
Start 40
Case 7
Student led
takes
20 mins
To discuss
DNAR
Case 7
page 26
Feedback on scenario to discuss: How to limit information given and
use assertive behaviour to stop a cyclical discussion; Dealing with
anger; Strategies to use in difficult situations, and house-keeping (i.e.
self care) afterwards.
DNAR: Do Not Attempt Resuscitation:
Ask a student to lead the discussion and give them the scenario
Student prompts How do you respond to the nurse? How is a
decision reached? What happens on the wards? What are the barriers
to reaching DNAR agreements?
Reflect on their own experiences - terminology: ‘pink forms’! How do
they feel about being part of such decision-making? Can the process
be harmful to patients?
See: Three words that can change a life: "Allow natural death" versus
"do not resuscitate": S S Venneman, P Narnor-Harris, M Perish and M
Hamilton J. Med. Ethics 2008;34;2-6
Consequences of decision; Involvement of patient/relatives; Current
policy/guidelines
Resources: DNAR algorithm at
www.ethics-network.org.uk
(Also good for other issues in this course)
Advance directives:
http://www.ageconcern.org.uk/AgeConcern/is5.asp See also ‘BMJ
Learning’ module – good for tutors!
Highlight the ethical issues raised. Ask students to explore other
scenarios and queries later.
10
Start 60
Takes 30
mins
Case 8
SP
BBN : to inform
daughter/son of
their parent’s
death
page 27
10 mins
Start 90
Takes
30 mins
Case 9
SP
Role-play
Two
students
Start 120
Takes 20
mins
Case 10
Discussion
Start 140
Takes 15
mins
155 mins
Feedback on scenario to discuss:
Reaction to bad news
Dealing with own feelings
Note for scenario 8
*Local policies on reporting post-operative deaths vary. Because this
death might not be "natural" but due to post-operative complications
(eg PE, MI), the Coroner’s officer needs to be informed, but will not
necessarily ask for a post-mortem.
Tea break
The group should discuss responses to complaints.
To manage
anger and
resolve
complaint
To respond to
request for
Death
Certificate +
need for report
to Coroner
page 29
Discussion
about personal
feelings
page 31
Revisit sensitive
topics that have
arisen:
A doctor and a ‘nurse’ then prepare to meet the relative together to
discuss what happened: – saying ‘Sorry’ is not an admission of fault.
Reporting to the Coroner’s officer: How could this best be managed?*
Possibility of post-mortem?
Highlight the use of case as a critical event
Peer review and support
Self-audit
Resources: ‘Deaths Reportable to a Coroner’
Discussion of coping strategies
Teamwork / support
“Burn-out”
Where to seek help
e.g. see morning notes on ‘Blame culture’ - scenario 4 * Blame implies
judgement and looking back - are there better terms? eg. consider
‘contribution’ systems – analysis and looking forward
Also opportunities: see page 4 Students may want to attend a
Morbidity / Mortality or Critical Incident / Adverse Event review. It
may be difficult for students to access sensitive reviews, so they may
learn more by talking to Foundation doctors during Assistantships.
Ending & Evaluation, take away points and one thing to look up?
End
Attend tutor debrief – especially if you have anything to pass on.
Hand in register!
Thank you for tutoring on this session – we hope you have enjoyed it.
Mark Perry and Rosie Illingworth
Communication Team
 Manchester Medical School
11
CASE 1. SHIFT HANDOVER PRACTICE
CONTEXT: As Handover ‘Giver’ you are just ending your shift and have been busy admitting
several patients, you want to agree priorities with your colleague, or ‘Receiver’. Receiver: You have
just arrived at hospital and are coming on to the morning shift. You are taking Handover from your
colleague and then going to clerk new patients under Mr Holmes in the Investigation Unit. You
should make notes and clarify using ‘Readback’. NB BOTH Giver and Receiver should use
SBAR, to check that they have all the information that they need. Task:




The information is initially mixed up for you - as if given by a stressed out and disorganised colleague! So sort the
information on 2 patients in the boxes at the bottom of the page into SBAR order, one patient each (7 mins). The Main
patient for today’s session (Mr or Mrs Smith) is shown here at the top as an Example of using this method, but you will
need to personalise this as a ‘script’ to use it yourself!
Discuss your overview of these three patients and prioritise the order for handover (3 mins).
Then act as Giver for your patient, one group member to act as Receiver and the other as Observer of BOTH Drs in the
SBAR handover. Rotate till 2 or 3 have had practice in one role . ( 5 mins each with feedback)
Situation
Background
Assessment
Recommendation
1. Mrs / Mr Smith: A 64 year old with Obstructive Jaundice –
awaiting admission for tests
Nurse in MIU has just called you to report
1. That an urgent Ultrasound that should have been booked for
today via Outpatients has not been pre-booked 2. That the patient
is upset about this.
Patient may self -discharge
Please come within 30 minutes. See patient, book US for today
if possible.
Priority 1 PATIENT:
Situation
Background
Assessment
Recommendation
Priority 2 PATIENT:
Situation
Background
Assessment
Recommendation
Priority 3 PATIENT:
Situation
Background
Assessment
Recommendation
2. Lisa Ball woman 75, In ward 11 No previous history of DVT
or FH
3. James Prentice male 70 year old
Attend now to assess
Investigations: fbc, U+E normal.
18 hours post op. Transurethral prostatectomy.
5 days post op. defunctioning colostomy for Diverticular abscess.
On ward 7.
Check results within next hour.
No PMH of note.
Patient noted swollen tender left calf this am. Immobile prior to
admission.
Had uncomplicated TURP under spinal yesterday.
If D-dimer test is positive, Medical registrar requests urgent
Normal blood loss in catheter bag – no clots.
LMW Heparin Enoxaparin (Clexane).
Seen by on call Medical team 1 hour ago, no shock or pyrexia.
Physical signs ?DVT L calf.
Nurse has just paged you reporting BP dropped from 110/80 P90 to BP 90/60 - P100. Apyrexial.
Blood pressure has dropped in past 2 hours ?Cause
You await result of D-dimer (done 10 mins ago)
12
Case 2 INSTRUCTIONS TO STUDENT
You are a Foundation Dr. It is Wednesday morning. You are on the Investigation unit (“5-day
ward”) where patients attend for planned investigations.
Mr(s) Smith was seen by your Consultant, Mr Holmes last week and this admission booked.
Attached is the referral letter from the GP to Mr Holmes.
Your Consultant (Mr Holmes) has written the following in the records:
2/52 history of jaundice, itch, pale stools. ?weight loss.
PMH Type 2 Diabetes 1year, on medication 9 months
SH non-smoker
DH: Gliclazide as per GP letter, Gaviscon
o/e jaundiced, thin,
Abdo Tender epigastrium, No mass, No LKKS
? GS ? Ca
Needs Investigation ASAP – Admit PIU
Your task:
To arrange for the patient to be admitted to the Unit and to stay for 2-3 days for investigations.
The patient gave a history in outpatients last week and you would normally confirm this by further
‘clerking’. You can defer this at present.
Your priority is to address any concerns this patient has now, apologising that investigations have
not yet been pre-booked.
13
Dr G Platt
The Health Centre
New Street
Manchester
M14 3PQ
URGENT APPOINTMENT PLEASE
Dear Mr Holmes,
re:
J Smith
I would be grateful if you would see this 64 year old who has developed jaundice. This was noted 10
days ago, and following today’s consultation with him/her I felt that an urgent referral to you was
appropriate.
The jaundice has been accompanied by anorexia and itching as well as pale stools.
On examination I feel there is evidence of weight loss and I wondered if I could feel an epigastric
mass. I feel urgent investigation is required.
Mr(s) Smith’s wife/husband has severe rheumatoid arthritis and is housebound.
The couple have a son and daughter who live down South. The neighbours, I believe, are quite
helpful, and our District Nurse visits weekly.
I have told the patient that (s)he will need some tests. No questions were forthcoming from Mr(s)
Smith, but I believe (s)he may know something is amiss. (S)he is a very stoical person, having had to
care for his/her spouse for many years. The patient has Type 2 Diabetes, diagnosed one year ago and
now controlled on Gliclazide 160mg am. Many thanks for seeing him/her so quickly
Yours sincerely
Dr G Platt
REPEAT PRESCRIPTION:
Drug
Monthly quantity
Dose
Gliclazide tablets
Gaviscon
2 a.m. (160mg) with food.
10mls pc and at night prn
80mg
56
500mls
14
Simulated Patient Script
Patient’s name John/Joan Smith
Setting
Investigation Unit
Wednesday am
Course
Session
Case
Age
Sex
Other info
Yr 5
1
2
64
M/F
You are 64 years old and live with your wife/husband who has severe Rheumatoid arthritis and is
housebound.
Situation Since you retired you have devoted yourself to looking after your spouse who has RA.
He/she is housebound and relies on you for help with very basic activities of daily living. Your
neighbours often pop in and offer to do bits of shopping and gardening (although you like to potter in
the garden). The District Nurse visits weekly to check your spouse's pressure areas and has a chat.
Your son lives in London and your daughter lives in Cornwall and you don't see them much. While
speaking on the phone frequently, you do not / will NOT discuss your medical problems. Apart
from Diabetes, diagnosed a year ago and for which you take ½ a tablet with breakfast in the
morning, you have always been well (NB NEW See Case 4 The doctor wanted you to take a
higher dose, but you are afraid to admit that you have not increased it! Do NOT disclose this
here.)
Now You are in the Investigation Unit (“5-day ward”). You have seen a nurse who has said a
doctor is going to come and talk with you and you are waiting to see what happens next.
Past You noticed your skin was yellow about 2 weeks ago. You also noticed your stools were pale
and wouldn't flush away. Your skin has been itchy for about a week. You went to see your GP who
was concerned because you said you may have lost some weight over the last couple of months. He
said you should come to the hospital and phoned up for an appointment whilst you were with him.
Last week you attended the outpatient clinic and saw Mr Holmes. He seemed concerned about your
symptoms and said he would get you seen in the “Day Unit” as soon as possible. His secretary
phoned you yesterday to ask you to come today at 10am. A neighbour is looking after your spouse.
You assume you will be going home this afternoon.
You want to ensure you don't have to stay in hospital overnight as you couldn't possibly leave your
wife/husband. Now: You are waiting to be told what will happen next. A nurse has told you that
your scan has not been booked for today.
Role Player Task
Think about how hard it would be for this person to come into hospital.
You are quite worried about your symptoms. You are annoyed that the tests have not already
been arranged and are adamant that no-one will force you to stay overnight in hospital until you can
be certain that your spouse will be OK. If the doctor listens to your concerns and is empathic then
you can negotiate a way through this and how to sort out things at home. eg. Go home and come
back later. If the doctor is dismissive, doesn’t listen or if he/she tries to bully you, then be a stubborn
mule! For the NEXT scenario you now come BACK on Wednesday evening
15
CASE 2
INSTRUCTIONS TO DOCTOR
You are a Foundation Dr. Mr/Mrs Smith has been admitted this morning to the Investigation Unit for
investigation of obstructive jaundice. It is Thursday lunchtime.
You have sent off blood to the lab and need to arrange an urgent abdominal Ultrasound scan. You
would really like to get all the tests done today so that Mr/Mrs Smith can go home to care for their
partner, who has severe RA and is, you believe, housebound.
Task: To arrange the Ultrasound scan, for today if possible.
To arrange the appointment by telephone with the Radiographer
Ask your colleagues for suggestions and try different approaches.
How can you use SBAR to ‘escalate’ your request?
16
CASE 2 INSTRUCTIONS TO RADIOGRAPHER
It is Thursday lunchtime. The Foundation Dr phones you to ask for an urgent scan. There are no
routine Ultrasound scan appointments until next Monday.
You don’t really see why this scan is so urgent.
Feel free to improvise from your own experience. Don’t be a push-over. Do they really make out a
case for an urgent scan?
How can you use SBAR to check the urgency of this request? Can you reach a clear agreement?
If you don’t feel convinced, how would you react if the doctor comes down?
17
CASE 4A
INSTRUCTIONS TO STUDENTS: F1 Doctor roles
One day later (Friday 12 MIDDAY)
You are a Foundation Dr. You know Mr(s) Smith (who has Type 2 Diabetes on tablets) is on the
ward this morning having just had an urgent CT for suspected Ca. Head of Pancreas (Ultrasound
yesterday required clarification).
You are just clerking another patient on a nearby ward and should be free in 10 minutes
A nurse pages you TO CALL THE WARD
You will need to use the SBAR system to ‘Receive’, READBACK - Check and Respond to the
Nurse’s Recommendation.
What do you do? If necessary, PAUSE and discuss with your Observer.
Based on YOUR clarification of the nurse’s SBAR report on Mr(s) Smith make your own
ASSESSMENT and RECOMMENDATION back to the ‘Nurse’
FOLD HERE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Background Data that you may require: PAUSE if you are uncertain about the management of
Hypoglycaemia and clarify with the ‘Observer’
1. A BM stick shows glucose 2.0 mmol/l.
2. Some nurses may be able to site a Venflon and administer IV Glucose, IM Glucagon also offers a
short term solution, but you would need to check the patient’s response in 5- 10 minutes
3. GCS – You might want more detail of changes in the patient’s conscious level:
Glasgow Coma Scale: 8 / 15 BUT 7/15 later IF management is delayed for Dr to arrive: Best Responses to mild pain in
3 domains: Motor / Verbal / Eyes. So patient may withdraw arm 4/6; Moan – no words 2/5; Eyes open if Called 2/4
initially, or after a delay as a response to Pain 1/4 or Not at all 0/4
18
CASE 4A
INSTRUCTIONS TO STUDENTS: ‘NURSE’ roles
One day later (Friday 12 MIDDAY)
You are a Ward Sister / Charge Nurse:
SITUATION You note that the patient has become progressively pale, sweaty and confused,
worsening over 15mins… and is now becoming less responsive.
BACKGROUND Mr(s) Smith who has Type 2 Diabetes on tablets, returned to the ward 30 minutes
ago after having had an urgent CT for suspected Ca. Head of Pancreas (Ultrasound yesterday
required clarification). Mr(s) Smith is not yet aware of the diagnosis. You recall that the patient
was anxious before the CT and did not eat, but she was still given her tablets.
PAUSE in setting scene for whole group: Ask all – what is likely cause?
ASSESSMENT (DO NOT READ OUT YET!) Decreasing conscious level. Apyrexial, but pale
and sweaty. P120. BP100/60.
A BM stick shows glucose 2.0 mmol/l.
You have just paged the F1 Doctor and the phone is now ringing.
Task for yourself in role and observers: What do you do? RECOMMENDATION: Think of
both Nurse and Doctor roles here. You will now need to use the SBAR system to:
Make a RECOMMENDATION to the F1 Doctor. If the Doctor does not appreciate the
urgency, ESCALATE both your concern and request. Then to CHECK on the F1’s response
and if needed CLARIFY their recommendation
BOTTOM 1/2 PAGE: Further Background Data here and below that you may require: PAUSE if
you are uncertain about the management and clarify with the ‘Observers’
NB: No qualified nurse is available to site a Venflon and administer IV Glucose (some can do so)
IM Glucagon also offers a short term solution, but you would need to check the patient’s response in
5-10 minutes *(If detail is requested Glasgow Coma Scale: ‘GCS 8’: Responses to mild pain:
Motor - withdraws arm / Verbal - moans / Eyes open – when called. See below for more detail )
FOLD HERE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
SITUATION: Identify self and patient: I am Nurse X on X Ward, calling about Mr(s) Smith.
He/she is HYPOGLYCAEMIC!!! BM stick shows Glucose is only 2mmol/l
He/she has become pale, sweaty and increasingly confused over 15 mins.
BACKGROUND Mr(s) Smith aged 64, has Type 2 Diabetes on tablets, returned to the ward 30
minutes ago after an urgent CT for suspected Ca. Head of Pancreas. The patient did not eat this
morning but I have checked: (S)/He was still given Gliclazide tablets.
ASSESSMENT: Decreasing conscious level*. Apyrexial, but pale and sweaty. P120. BP100/60
IMPORTANT: BM stick shows Glucose is only 2mmol/l
RECOMMENDATION: The patient needs URGENT! i.v Glucose. Come now to site Venflon
GCS: Glasgow Coma Scale: 8 / 15 BUT 7/15 later IF management is delayed for Dr to arrive: Best Responses to mild
pain in 3 domains: Motor / Verbal / Eyes. So patient may withdraw arm 4/6; Moan – no words 2/5; Eyes open if Called
2/4 initially, or after a delay as a response to Pain 1/4 or Not at all 0/4
19
CASE 4B INSTRUCTIONS TO STUDENTS: Doctor role
Task 1
You are the same FY1 from case 3
The patient responds to your management (i.v. glucose) and an hour later you decide to explore the
reasons for the hypoglycaemia with patient over a cup of sweet tea.
How do you approach this? You recall that you were busy on Wednesday evening and wrote up the
patient’s drug chart using the details on the GP letter.
Consider the root causes of this patient’s hypoglycaemia with your group. Look beyond the
immediate ‘cause’
You may also need to PAUSE during the role play to discuss this further with the group
Task now: Decide how to explore and then resolve this with the patient. He/she can go home
tomorrow (Saturday am) if there are no further episodes, but should return for the scan results in 2
days (Sunday night/Monday morning for Mr Holmes’s ward round)
Clues – DO NOT READ THESE OUT yet unless the group really needs prompts!
 A missed meal alone would not often cause hypoglycaemia for a patient on a normal dose of
Gliclazide
 Given the recent weight loss, the patient now requires a minimum dose of Gliclazide 40mg
till readmission.
Task 2
GROUP: Later the ward sister (who has been supportive) recommends filling in an Incident form.
How are adverse events handled at your Hospital site? e.g. at Salford Royal this is done
electronically through the site intranet. When is there anonymity?
Discuss your feelings about ‘adverse events’. How would these differ if you HAD accidentally
written an excessive dose ? (i.e. Your ‘error’). How will you cope as an individual and how
can teams manage error? What is ‘open disclosure’?
20
Simulated Patient Script
Patient’s name John/Joan Smith
Setting
Medical ward
(Investigation
Unit)
Course
Session
Case
Yr 5
1
4B
Age
Sex
Other info
64
M/F
Two days later, Friday late morning
Since you were reluctantly admitted on Wednesday, you have had an ultrasound scan on your tummy
yesterday and another type of ‘scan’ this morning (one where you had to lie still and go into a big
tunnel). The Dr has said (s)he will come to see you when the scan results are back with clearer
picture of the problem. You are unsure when this will be, but you are keen to go home in the
meantime.
This morning you were so worried about the scans that you did not eat any breakfast. The nurse still
gave you 2 tablets as she has done each morning since you were admitted. You presumed that these
tablets are for your diabetes even though they were a different shape from your usual tablets. You are
beginning to suspect there is something seriously wrong.
.
When you returned from your scan this morning, you suddenly felt unsteady, muddled, sweaty and
sick. This lasted for a few minutes and then you suddenly slumped. When you came round, you
looked at a watch and realized that it was an hour later, and you had little memory of the last hour!
It is now an hour AFTER treatment and the doctor has come to talk to you about what has just
happened over a cup of sweet tea. He/she will explain that your blood sugar had become very low
and will want to explore the reasons why.
Information to be given if asked:
 When your diabetes was discovered, the GP prescribed Gliclazide 40mg (half an 80mg
tablet) and warned you that this medication COULD cause unpleasant side effects and so
must always be taken with food in the morning,
 After 6 months of taking the medication along with a low sugar/fat diet to reduce your
weight, the GP told you that your blood sugar was still too high and increased your dose of
Gliclazide to a full 80mg tablet.
 3 months following that, the dose was doubled again to 160mg (2 tablets)
 HOWEVER - you never took more than the original prescribed dose of 40mg of Gliclazide
as it made you constipated. You did not tell the GP the dose you were taking because, a) he
might not approve and b) it seemed trivial compared with other worries. Please offer your
account tentatively, to allow students to explore the causes. If the group is slow you can say
‘these tablets here are different – mine have a line down the middle’. Even add ’..so they
can be split in half’.
21
Role Player Task:
 to explore with you how you came to have a hypoglycaemic ( Blood sugar too low) incident
 to establish reasons why patients make their own decisions re medication levels
 to understand the dangers of assuming that patients are taking the medication as
prescribed/recommended by their GP. In this situation you have been taking 4 times your
usual dose for the last 2 days!! This is what has caused your attack and it is important that the
students discover this.
You can agree a solution: the prescription will be reduced with the GP being informed. NB You will
then realize that you have contributed to the attack, but it is important to say that ‘I don’t want the
same mistake to affect others in future.’ You may also want reassurance that you have not caused
yourself any long term damage.
Feedback:
Has the doctor explored and explained the problem in an honest manner? Do you know what dose to
take now?
The Learning Objectives here are the problem solving the causes and honesty with you, NOT details
of treatment. Your role is in the discussion that follows this incident, so the tutor should bring you
back in - as if you are now recovered at the bedside. There would still be a tube (IV line) in your
forearm.
22
CASE 5 INSTRUCTIONS TO STUDENT
Tuesday late morning: The CT scan was finally reported on by Monday morning. You are one
of two Foundation Drs working with Mr Holmes and you need your lunch break! You know from
the ward round yesterday morning that (s)he has Ca head of pancreas with liver metastases and is
awaiting stenting, which is a palliative procedure. Mr Holmes stayed after the ward round to ‘break
the news’
Mr Holmes has decided that ERCP is indicated to insert a stent under IV sedation. The operating list
is in 2 days time. After the last ward round you did a quick Medline search finding 2 review papers
on palliation of jaundice in malignancy. These indicate that Teflon stents have a 90% success rate,
most being successfully placed at the first procedure. They relieve symptoms, but will only remain
patent for 3 to 6 months.1
You now need to explain why this procedure is indicated and begin the preparation for consent.
Your Consultant will finish the consent process on his rounds tomorrow.
Tasks:
To explore and respond to the concerns the patient has. Remember SPIKES. You may want to
brainstorm symptom control in advanced or terminal cancer with your group. PAUSE during the
roleplay as required.
Then to begin a consent process for a palliative procedure and
To explain the need for the procedure and check the patient understands
1
F.J.Brescia; Palliative Care in Pancreatic Cancer. Cancer Control, Jan/Feb 2004, 11, no.1 pp. 39-45.
23
Simulated Patient Script
Patient’s name John/Joan Smith
Setting
Investigation Unit
NB NOTE
initial BBN
has been
covered
Day 6
Tuesday late
morning:
Course
Session
Case
Yr 5
1
5
Age
64
Sex
Other info
M/F
DAY 6 CASE 5
It’s Tuesday lunchtime – not that you feel like eating anything.
You came back in on Sunday night when you were happier with your partner’s care and to go
through all the results of the tests with Mr Holmes on his Monday morning ward round. It seems that
you have a cancer in the pancreas which they can't remove - as it is also in the liver.
You also saw Mr Holmes later yesterday and he offered an operation in three days to get rid of the
jaundice, which would be something – as the itch is really upsetting. You were told this would be
fully discussed with you, but he seemed busy. You feel that no-one cares about you.
Last night, whilst you were lying awake, it sunk in that you are dying.
Now
You would like to know how long you've got - Mr Holmes wouldn't tell you. Why?
Role Player Task
You have realised that you are going to die.
You are concerned that it will be unpleasant, painful, that you will lose control of your bladder,
bowels etc. This thought upsets you.
You need to know more about this proposed operation to get rid of the itch. Is it worth having done?
24
CASE 6
INSTRUCTIONS TO STUDENT
It is now 2 days later and 8 days since the patient was admitted.
You are a Foundation Dr on a surgical ward. You are trying to get your notes written up from
yesterday’s ward round. Mr(s) Smith (you may recall him from the last session) has just been
brought up to the ward from theatre following ERCP and remains drowsy from the sedation. You
see from the operation note that a stent has been inserted to relieve the jaundice. Your consultant has
written that the "outlook is poor".
The staff nurse informs you that Mr(s) Smith’s son / daughter is here and wishes to have a word with
you.
Task:
To address the concerns of Mr(s) Smith’s relative.
To end the interaction satisfactorily.
25
Simulated Patient Script
Name in role
Setting
Paul or Paula Smith
Quiet room off main ward
Course
Yr 5
Session
2
Case
6
Patient’s name
John or Joan Smith, parent age 64
Age yours! 30s
Sex
M/F
You You are Mr John/ Mrs. Joan Smith's son/daughter. You live and work in London and have a
very busy life. Your partner works in the City.
Since your parent (the patient) retired they have devoted themselves to looking after your other
parent who has Rheumatoid Arthritis. He/she is housebound and needs help with very basic activities
of daily living. Their neighbours often pop in and offer to do bits of shopping and gardening
(although your parent who is now the patient likes to potter in the garden). The District Nurse visits
weekly to check your housebound parent’s pressure areas and has a chat. You don't see your parents
very much but speak on the phone fairly frequently. Your only sibling (Patricia or Patrick Smith)
lives in Cornwall. Unfortunately, your parents see even less of him/her as they don’t approve of
his/her partner and that has become a barrier between them.
Situation You have travelled up from London to see your sick parent. Before your journey your
housebound parent had rung to say your parent was about to have an operation and now you want to
know what has been done. Your parent at home was a bit vague about why the hospital admission
happened (8 days ago) - something about being jaundiced and then a funny turn in hospital - they
didn't seem to know much. S/he's been able to see his/her spouse only once when s/he came out for
the weekend after that. You hope to drive him/her up the hospital this evening, but only after you’ve
got some information from the doctors. You’ve not been to your parental home yet.
Your housebound parent has been receiving a package of care since your other parent has been in
hospital*. You believe you parent in hospital has just come out of theatre and have asked a nurse if
you can speak to the doctor who's looking after him/her, anticipating you'll see the consultant if this
problem is serious. You’ve not seen your sick parent yet.
Now You have been told to wait in a side room.
Role Player Task - Build up a work and social picture.
You drove up early this morning and are very tired.
You are feeling stressed by the increasing burden of elderly parents who live at a distance from you.
You are concerned about the management of your sick parent so far – why haven’t you been
informed of the diagnosis and prognosis?* Be manipulative – when they explain confidentiality
rules try –‘ I won’t tell anyone – just give me the information.’
What might you be worried about?
Role player feedback:
Handling confrontation/manipulation and handling confidentiality issues. Do they need to stand
firmer with you to stop the discussion going round in circles?
*please check with the group facilitator what contact you have had with the hospital since your
parent's admission (usually none).
26
GROUP SCENARIOS CASE 7
Do Not Attempt Resuscitation - DNAR
TASK FOR FULL GROUP
The nurse caring for Mr/Mrs Smith asks if s/he is for resuscitation.
How do you respond to the nurse?
How is such a decision reached?
What, in practice, happens on the wards? - ask your colleagues to reflect on their experiences.
How do they feel about being part of such decision-making?
What are the barriers to reaching DNAR agreements?
Can the process be harmful to patients?
Have you considered whether the adoption of ‘Allow Natural Death’ (AND) would be acceptable on
wards?
See: Three words that can change a life "Allow natural death" versus "do not resuscitate":
S Venneman, P Narnor-Harris, M Perish and M Hamilton
J. Med. Ethics 2008; 34:2-6
27
CASE 8
INSTRUCTIONS FOR STUDENT
You are a Foundation Dr. Mr/Mrs. Smith, a 64 year old, had palliative surgery for Ca pancreas 3
days ago. You don't really know them or their family, but last night you were told over the telephone
that the patient was vomiting repeatedly and you remember that you did authorise an IM injection of
an anti-emetic using an IT link. The Foundation Dr normally responsible is seeing a patient in A&E.
Mr/Mrs Smith arrested an hour ago. The crash team was called but resuscitation was unsuccessful
and s/he was pronounced dead 45minutes ago. Whilst resus was underway a nurse rang and got hold
of the son/daughter to inform them that things had taken a “turn for the worse” and were told the
son/daughter was coming in to hospital.
Their daughter/son has just arrived onto the ward. You have been asked by the staff nurse to talk to
the relative. Mr/Mrs Smith had told the son/daughter all about the illness and the outlook.
Task:
To inform a relative of their parent’s death.
To manage their reactions and handle strong emotions
28
Simulated Patient Script
Name in role
Setting
Patient’s name
Patient’s age
Paul or Paula Smith
Quiet room off main ward
John/Joan Smith
64years
Course
Session
Case
Age – yours!
Sex
Other info
Yr 5
2
8
30s
M/F
You are …(as in scenario 6).
Situation You travelled up from London 3 days ago to look after your housebound parent whilst
your now ill parent is in hospital. Following that first visit when they wouldn’t tell you anything you
now know about the cancer and the stent. You have seen your parent daily and they have been
able to have a few words with you. You have not been able to bring in your housebound parent
yet, as they’ve had a chest infection. You came to visit hospital last night and s/he looked very
poorly, s/he was yellow and very weak and vomiting repeatedly. You simply sat with your
mother/father and held their hand – they were not up to talking. The ward seemed understaffed and
after you called over a nurse she made a phone call to request an intra-muscular injection to stop the
vomiting. It seemed about an hour later when the nurse gave this hurriedly without any other
apparent discussion or checks. Your parent eventually settled, but on going back to your parents’
house you were concerned about the quality of care.
You had a telephone call from a nurse one hour ago to say that your parent in hospital "had taken a
turn for the worse". You came straight away. On your arrival onto the ward you are ushered into a
sitting room to wait.
Now You remain rather concerned that the medicine your parent had been given last night appeared
to be ordered by phone.
Role Player Task : You wonder what they're going to tell you and what a ‘turn for the worse’
means. Though you saw your parent last night you don’t feel as if you have made your peace with
them yet.
The issue of the injection remains in the background at present but you might mention the long wait
your parent endured just to illustrate your unhappiness with their care. Don’t get angry here – be
upset for your parent and concerned on how you will tell your housebound parent and what the
longer term implications will be for their care. Let them practice BBN using SPIKES. Be emotional
– let’s see how they cope with tears - sobs even.
Feedback BBN and handling emotion
29
CASE 9 INSTRUCTIONS FOR STUDENT
Next day
As the usual Foundation Dr, you have not completed the Death Certificate yet as you know you need
to find the time to contact the Coroner’s office and report the death of Mr/Mrs Smith. You know that
as they died within three days of surgery, the local policy is that you should speak to the Coroner's
officer to report the death.*
Your colleague told you that he/she chose not to mention this yesterday as the relative was in shock
and it seemed inappropriate – it is likely that the Coroner's team accepts the death with out further
question. It might be that they require a post mortem.
You are just about to get yourself into an office to catch up on such admin when Mr/Mrs Smith’s
relative drops in and wants a word. The ward sister spoke to you earlier to say that the relative had
been upset about the standard of nursing care the evening before your patient died, particularly the
delay in giving medication.
The nursing notes record that the on-call doctor was busy in theatre when phoned. But the drug was
prescribed by the doctor on-line. An hour after the injection Mr/Mrs Smith stopped vomiting. The
ward sister has already used the charts to confirm that the correct medication was given.
Task
Prepare for this meeting as a group – Please meet the son / daughter with a ‘nursing colleague’.
Objectives
 To find out facts from other team members and then respond to the relative. Could the drug
be authorized by telephone or instead remotely using online prescription?
To manage anger and a potential complaint
 Explain the need to report to the Coroner with the possibility of post mortem.
Ensure that the relative understands your duty to 'report' the death. You will fax the records and
discus the events. The relative might also wish to speak to the Coroner’s office as an independent
authority, Provided all agree you should then be able to sign the certificate immediately: so 30-60
minutes
* Please note that this rule is not universal and the policy you may use as a resource is just one local
example.
30
Simulated Patient script
Name in role
Paul or Paula
Smith
Setting
Quiet room off
main ward
Patient’s name John/Joan Smith
Patient’s age
64years
Course
Yr 5
Session
2
Case
Age – yours!
Sex
Other info
9
30s
M/F
Next day
You have brought your housebound parent in to the hospital Bereavement Centre You need the
Death Certificate so that you can proceed with the funeral arrangements. You discover that the
Bereavement Centre hasn’t had the signed paper from the doctor yet and so cannot issue the Death
Certificate. You leave your parent
and you nip up to the ward to find the doctor and the Death Certificate. (You will be told that the
Coroner needs to be informed of the death) – become angry that there has been another error that the
hospital is now trying to cover up. You know how important it was for your parent to die at home
and feel they were cheated of that.
You also remain concerned that your parent died so suddenly and wonder if someone made a mistake
during or after the operation. More than this you are upset at the delay in getting the nurse to give an
injection for your parent’s vomiting. You become more concerned that this appeared to be ordered
by phone and even wonder whether the wrong drug was given.
Role Player Task
To collect Death Certificate
To react to information. The Certificate has not yet been signed - another delay. (if they don’t
mention it ask – does this mean a post mortem?)
With all this stuff in the papers about hospitals, the last thing you would normally agree to is a postmortem. But because of your anger and concerns about the quality of care you are ambivalent
about the post mortem.
You want the doctor to be honest and take responsibility for what has happened.
If sensitively handled, you will accept that the doctor has a duty to speak to the Coroner's team.
Feedback
Were you treated sensitively?
Do you understand why the Coroner's team needs to be informed?
Do you feel the staff are being empathetic and open with you? Are they open to considering your
complaint/concerns? Do you receive a satisfactory explanation about the injection?
31
Case 10
Discussion:
Coping with personal feelings: Discussion on normal / abnormal (healthy vs. unhealthy) strategies
Morbidity in the medical profession
Burn-out
Where to seek help
Use of difficult situations as "Significant Events" (critical incidents) Also refer with Tutor to
session plan for further ideas). Use of difficult situations as prompts for peer review, to audit and
stimulate change.
32
PREPARATION FOR PRACTICE: Resource Sheet for Tutors and Students
Prescribing and Concordance Between a third and a half of medicines that are prescribed for long-term conditions are
not used as recommended. (NICE guideline 76 medicines adherence 2009). Definitions: Compliance: the extent to
which a patient’s behaviour matches (adheres to) the prescriber’s recommendation Adherence: the extent to which the
patient’s behaviour matches AGREED recommendations from the prescriber. So this shared planning with patients is to
improve future Concordance: There are many reasons why patients do not adhere to medication plans: What are they?
What have you experienced? How can it be improved?
Britten et al (2000) Misunderstandings in prescribing decisions in general practice: qualitative study BMJ 320;484-488
2000
Glyn E et al (2003) Doing prescribing: how doctors can be more effective, BMJ ;327;864-7).
NICE guidance 76; medicines adherence available from
http://guidance.nice.org.uk/CG76
Consent forms should be available on any ward !
Confidentiality
http://www.gmc-uk.org/guidance/current/library/confidentiality.asp
DNAR agreements
http://www.bma.org.uk/ap.nsf/Content (search resuscitation)
http://www.ethics-network.org.uk/ethical-issues/end-of-life/end-of-life-decisions
Three words that can change a life: "Allow natural death" versus "do not resuscitate": S S Venneman, P Narnor-Harris,
M Perish and M Hamilton
J. Med. Ethics 2008;34;2-6
http://jme.bmj.com/cgi/content/full/34/1/2
Advance directives
http://www.ageconcern.org.uk/AgeConcern/is5.asp
Deaths reportable to the coroner
See as an example (local policies vary slightly)
http://www.manchester.gov.uk/site/scripts/download_info.php?fileID=6145
Patient Safety and Handover
See handout: There are SBAR resources at
http://www.institute.nhs.uk/safer_care/safer_care.html
Guidance on shifts and teamwork: Safe handover Safe patients: BMA Junior Doctors Committee. 2004
www.bma.org.uk/employmentandcontracts/working_arrangements/Handover.jsp
OR http://www.bma.org.uk/images/safehandover_tcm41-20983.pdf
Of general use
www.gmc-uk.org
Self Care for the F1!
Iversen, A., Rushforth, B. & Forrest, K. (2009) How to handle stress and look after your mental health. BMJ, 338, b1368.
33
1 HOW CAN SBAR HELP YOU?
Student resource:
Inadequate verbal and written communication is recognised as being the most common root cause of
serious errors – both clinically and organisationally. There are some fundamental barriers to
communication across different disciplines and levels of staff. These include hierarchy, gender,
ethnic background and differences in communication styles between disciplines and individuals.
Communication is more effective in teams where there are standard communication structures in
place. This is where SBAR can add real value:
• SBAR takes the uncertainty out of important communications. It prevents the use of assumptions,
vagueness or reticence that sometimes occur – particularly when staff are uncomfortable about
making a recommendation due to inexperience or their position in the hierarchy. In short, SBAR
prevents the hit and miss process of ‘hinting and hoping’.
• SBAR helps prevent breakdowns in verbal and written communication by creating a shared mental
model around all patient handovers and situations requiring escalation, or critical exchange of
information.
• SBAR is an effective way of levelling the traditional hierarchy between doctors and other care
givers by building a common language for communicating critical events and reducing
communication barriers between different healthcare professionals.
• SBAR is easy to remember and encourages staff to think and prepare before communicating.
• SBAR can make handovers quicker yet more effective, thereby releasing more time for clinical
care.
How does SBAR work?
SBAR allows staff to communicate assertively and effectively, reducing vagueness and the need for
repetition. The SBAR process consists of four standardised stages or ‘prompts’ that help staff to
anticipate the information needed by colleagues and formulate important communications
with the right level of detail. Situation – Background – Assessment – Recommendation with
Readback
Situation (Identify self and patient, location, then immediate problem / concern)
Background (current problem + relevant history)
Assessment (observations, vital signs and any urgent results. YOUR Diagnosis / concern /
‘hunch’)
Recommendation from the ‘Giver’/ Readback from the Receiver: Explain what you need - be
specific about request and time frame; Make suggestions; Clarify expectations
NB If you are unhappy with the communication, be prepared to Escalate your concern )
Recommended uses and settings for SBAR:
• Urgent or non-urgent communications
• Verbal or written exchanges
• Emails
• Escalation and handove
• Clinical or managerial environments
Training materials to be watched before the session: http://www.institute.nhs.uk/safer_care/safer_care.html
The above extract is adapted from: Safer Care: SBAR NHS Institute for Innovation and Improvement
http://www.institute.nhs.uk/safer_care/safer_care/situation_background_assessment_recommendation.html
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