ABSTRACT
If doctors had a way to improve their patients' healthcare experience, improve service feedback, reduce complaints, increase treatment adherence and reduce non-attendance, while at the same time combatting burnout and compassion fatigue in clinicians and enhancing collaborative working between staff and care teams, and all for zero direct cost, could anyone argue against such an intervention? In this paper, we present the views of the educators and clinicians at Maudsley Learning that training in communication and psychological ‘power skills’ is not only feasible, but crucially important for physicians at all stages of training to improve both patient care and the wellbeing of clinicians themselves. We explore some of the key relevant skills and present examples of high-fidelity simulation training that demonstrate the efficacy of this modality in improving individual skills and confidence as well as inter-team and interdisciplinary working.
Introduction
The past few decades have seen an increased focus on teaching communication and relational skills to medical undergraduates, alongside a recognition of the importance of these aspects in providing effective clinical care.
Furthermore, people with serious mental health conditions are known to face disparities in care and outcomes for physical health conditions, highlighting the need for clinicians to be skilled in providing holistic, sensitive, and accessible care to these complex patients.1 Nonetheless, beyond medical school there is little formal training or mentorship provided at registrar or consultant level.
These skills have the potential to improve patients' healthcare experiences and service outcomes related to complaints, treatment adherence, and non-attendance.2,3 At the same time, empowering individual clinicians and teams with greater confidence in relational skills is one way of enhancing collaborative working and combatting work stress and feelings of helplessness, which contribute to burnout and compassion fatigue.4,5 We are talking about skills that have traditionally (and we believe, inappropriately) been called ‘soft skills’ or ‘communication skills’. We prefer the newer term ‘power skills’, which better represents the diversity of skillsets and potential impact on the clinician–patient relationship, and in turn on the lives of patients and their carers, as well as the teams who look after them. Unfortunately, these skills are widely neglected as part of specialist training and often inadequately taught in medical schools.
We believe that a change in culture and practice is needed throughout all stages of medical training and beyond qualification, to provide a consistent emphasis on power skills as a core competency. We argue that these skills can be learned and improved upon through high-quality training and mentorship in a way that is time and cost-effective for clinical teams, and that the systematic use of power skills across services improves outcomes for both patients and staff. Finally, we present case examples of interventions we have been involved with and some evidence for their efficacy.
Background
In 1960, psychoanalyst Isabel Menzies performed a qualitative study of a hospital nursing team, examining individual and team responses to a challenging work environment. Her seminal report noted that in a system under threat, staff managed their anxiety by avoiding emotional engagement with their patients through detachment, depersonalisation, ritualisation of care, diminution of their own role and skillset, avoidance of decision-making and resistance to change. She concluded that staff anxiety was a cultural problem of the institution, which in turn adversely affected staff's wellbeing and patient care.6
The defence mechanisms highlighted by Menzies are employed even more avidly when faced with patients deemed ‘challenging’ or ‘difficult’, especially where feelings of hopelessness or helplessness is evoked. In response, clinicians may withdraw emotionally and intellectually, providing the minimum required input while the task of engagement falls to other members of the team, or is neglected. At worst, it may interfere with our thinking about complex or risky patients and impair good judgement.7
Sixty-three years on, the situation in the NHS is likely much worse. The 2022 NHS National Staff Survey reported that 44.8% of staff had felt unwell due to work related stress.8 Narrowing this down to doctors, the British Medical Association found that, out of 2,766 doctors surveyed, 49% described their physical and mental wellbeing as low or very low.9
Importantly, the literature also suggests that doctors are also at risk of maladaptive coping mechanisms like self-distraction, denial, self-blame, behavioural disengagement and substance use.10 These behaviours have significant implications for patient care. For example, compassion fatigue, exacerbated by similar factors as burnout, has been linked to more clinical errors and irritability, highlighting the potential impact of poor staff wellbeing on service users.11 Compassion fatigue further impacts physician–patient relationships and communication, reducing the focus on patient-centred care. Hojat et al12 and Del Canale et al13 found a positive association between higher levels of physician empathy and positive patient test outcomes in diabetes, which has been replicated for other conditions.14,15
Training may be one way of overcoming these challenges. A review of interventions to improve physician empathy found statistically significant improvements in empathy scores in studies examining communication skills training and role-playing training.16 Another review found a positive effect of communication training and empathy on patient outcomes and patient-clinician communication in oncology.17 Other types of communication training have demonstrated significant benefits to clinicians' self-efficacy and patient outcomes, including weight loss, reducing blood pressure, and decreasing substance use.18–20
When clinicians have the skills to face (rather than avoid) challenging situations and manage them effectively, they feel more confident in their practice and build better rapport with patients. This can decrease feelings of powerlessness that lead to stress and burnout.21 Examination of human factors (individual, interpersonal, environmental, and organisational) through interdisciplinary learning can help teams to name problems and identify solutions collaboratively, fostering better working relationships and greater empathy for colleagues and patients.22,23
What are ‘power skills’?
Power skills refer to communication techniques, interpersonal skills, and low-level psychological interventions, that are aimed at improving relationships and effectively achieving desired outcomes from interactions. Here we describe some of the core skills that we teach regularly in our cross-disciplinary training.
Therapeutic engagement
Without therapeutic rapport, psychological interventions are ineffective, and patients are less likely to trust us or our recommendations. Problems in the patient-clinician relationship are one of the biggest sources of patient complaints.24
Training in therapeutic engagement starts with the clinician's stance: taking a genuine, non-judgemental, and curious approach to understanding the patient's experience and views and using active listening techniques to communicate openness and interest. Simple validation and normalisation techniques (see Box 1 for a clinical vignette) can be hugely powerful ways to respond to worry or doubt, and pave the way to constructive and collaborative solutions when the therapeutic relationship encounters a roadblock.25
| A woman with cystic fibrosis has been non-adherent with her inhalers. Clinicians have repeatedly told her she is putting her health at risk, but this hasn't changed her behaviour. In clinic today she meets a new consultant who acknowledges how difficult it must be to have to take so much medication all the time. Rather than ‘telling’ her anything, the new consultant takes an empathic and curious stance, demonstrating a genuine interest in understanding the patient's experience. They use open questions to explore how the patient is feeling generally, and about their illness and treatment. They spend time simply validating what she says and actively listening without challenging the patient's subjective narrative. This helps to build trust and rapport, eventually allowing the consultant to direct focus on to specific concerns. They ask the patient if she has any worries about her treatment and if there are any practical obstacles to adherence. This opens up a conversation in which the woman reveals her fears about dying and anger about being sick and reflects that not taking her medication is a way of pretending she's not unwell. The consultant helps her to identify some practical steps she can take to improve adherence and she agrees to a health psychology referral. |
Clinical vignette: validation and normalisation techniques
Emotional distress is a common and understandable part of clinical interactions. When we respond appropriately to our patient's distress, we send the message that we are hearing them, that their feelings are valid, and that we are interested in them as whole humans, not just a physical problem to be solved. This has a real, practical impact on the therapeutic process. If patients feel we are responsive to their emotional needs, they are more likely to trust us and our recommendations. They are more likely to be transparent about their opinions and needs, rather than use covert means to subvert care, such as non-adherence. They are also unlikely to take in information in a state of emotional arousal.26
Most of us are uncomfortable witnessing distress in others and it takes awareness and practice to avoid problematic responses like jumping in to ‘fix’ the problem, giving false reassurance, or just steamrolling through the appointment with no regards to their emotional state. Skilled clinicians are able to sit with distress, allowing silence when needed, and offering simple breathing and grounding interventions to highly aroused or agitated people. They recognise when a person is receptive to information and manage the pace and timing of appointments appropriately.
Problem-solving and challenging interactions
Patients and clinicians may face various obstacles to care, of both a practical and psychological nature. For patients dealing with chronic or life-threatening illness, feelings of helplessness or hopelessness can make it difficult to engage with medical care. Comorbid mental health conditions such as depression and anxiety are far more common in people with chronic physical illnesses27,28 and present further challenges to engagement through low motivation, avoidance, and inaction. With communication and relational skills training, doctors can draw on a range of simple techniques to improve engagement through collaborative problem solving with patients and carers with demonstrable positive outcomes25; see Box 2 for a clinical vignette.
| Patricia's stay in hospital was prolonged by C difficile; this resolved but Patricia was left feeling depressed and hopeless. Staff became frustrated by her refusal to engage with physiotherapy and self-care. As a result, some staff showed irritation in their interactions with her. Others became avoidant, providing necessary care but trying not to engage with her emotionally at all. Patricia picked up on this and started to tell clinicians that she knew they were angry with her and that she felt bad that she was letting them down. After hearing the team's frustrations in morning handover, a junior doctor sat down with Patricia and asked about how she was feeling, using a non-judgemental and validating approach. She expressed guilt about her ‘failure’ and shame and fears about being incontinent. When Patricia became distressed or ruminating, the doctor showed her grounding techniques to reduce emotional arousal. When she was calm, they used simple motivational interviewing skills to help Patricia to identify very small, achievable goals. Later, they met with the physiotherapist to agree a plan. The team were shown how to use grounding techniques to help Patricia manage anxiety as she worked towards rehabilitation goals. |
Clinical vignette: improving improve engagement through collaborative problem solving
Reflective practice
Reflective practice can be both a purposeful activity as well as embedded in team culture. While probably not a skill that can be ‘taught’ as such, reflection is a set of individual behaviours and team processes that may be modelled, encouraged, and evolved through learning experiences and effective leadership.29
For clinical teams, reflective practice groups are an opportunity to come together to share challenging aspects of their work. Facilitators help to keep focus on the emotional and interpersonal subjective experience, rather than concrete practicalities of the work. Discussing difficult cases like Patricia's (Box 2) allows teams to reflect on their own emotional and behavioural reactions, which are validated by hearing similar experiences from others. This has the effect of making something explicit and shared that was previously implicit and individual. During groups, teams may generate solutions or alternative approaches to challenges that weren't considered previously and highlights the capacity for joined-up thinking to facilitate change and growth. Ideally, by modelling reflective practice in groups, the benefits extend to other areas of team working, such as multidisciplinary meetings and supervisions.30
Reflective practice requires substantial commitment and support to implement sustainably, however we believe that a culture of reflective practice is the best context in which to use the power skills discussed in this paper. Thus, reflection is an intrinsic part of the skills training we provide, as describe below.29,31,32
Simulation training for teaching power skills
At Maudsley Learning, we have used high-fidelity simulation training for over a decade to teach power skills, cultivate interprofessional learning, and encourage a holistic approach to patients that challenges the unhelpful mind-body dichotomy. Below, we discuss one example from perinatal care; however, we have similar findings for simulation training in paediatrics, oncology and older adult medicine.33,34
Simulation is an experiential form of education where learners interact with high fidelity representations of patients (simulated patients), within an environment that feels and looks clinical in nature. This allows for a psychologically safe experience for learners to practice both technical and non-technical skills, whilst other learners observe. Afterwards, there is a facilitated group debrief where human factors and technical skills are examined, encouraging both learning and reflection.35,36
Simulation initially began in the aviation industry and has a growing evidence base for use in medical and mental health education. Compared with medical settings, in mental health simulation there is less clarity regarding which skills are technical or non-technical; indeed, communication skills, therapeutic relationship building, collaborative working, and engagement are key technical skills needed by clinicians when working with patients in any speciality.37
The Maudsley Learning Perinatal Mental Health simulation course is an interprofessional course aimed at improving skills and confidence in recognising and assessing mental health disorders common in the perinatal period and performing risk assessment. There is also an emphasis on human factors such as working more efficiently with colleagues across multidisciplinary teams, and between primary, secondary and social care. Learners take part in six scenarios focusing on common perinatal presentations, such as postnatal depression, obsessive compulsive disorder, postnatal psychosis, and drug/alcohol use. One or two participants enter each scenario, with the remaining participants actively observing. After each scenario there is a 40-minute debrief using the ‘Maudsley Debrief’ model, adapted from the Diamond debrief.38
This course has been run regularly and data from 240 clinicians were analysed by Maudsley Learning.39 Learners completed a pre- and post-course questionnaire including the Human Factors Skills for Healthcare Instrument (HFSHI).40 This is designed to measure self-efficacy of the individual in their social and cognitive skills within healthcare. Additionally, learners completed a course-specific questionnaire related to the learning objectives.
Paired samples t-tests were conducted comparing the difference between pre- and post-course scores for the course specific questionnaire and the HFSHI. The results demonstrated statistically significant improvements in both the course-specific questionnaire, t(186)=17.942, p < 0.001, as well as in the HuFSHI, t(234)=17.286, p < 0.001, between pre and post course.
Qualitative feedback indicated benefits with regards to multidisciplinary working, sharing opinions and learning from one another, and skills and confidence using verbal and non-verbal communication. The comments also demonstrated thinking about how the learning could be transferred from the course to work settings.39
The importance of the debrief was also mentioned by participants; that it allowed them a space to reflect and learn. Again, participants translated this learning into clinical benefit; explaining how reflection and emotions could be utilised within clinical practice such as allowing space to recognise and discuss difficult feelings, avoiding making assumptions and listening more.
Discussion
Our results help to demonstrate the impact of simulation learning on clinicians' communication skills, interprofessional working, and their ability to reflect and be more emotionally aware, as well as, importantly, how they would practically utilise these skills with patients and colleagues.39
However, these results are limited to pre- and post-course analyses and, despite the promising research surrounding the benefits of interprofessional training, the current literature is limited by a scarcity of longitudinal studies that consider the transfer of training to practice and the long-term impact on patient outcomes and staff workplace wellbeing.
Also, this is not to say that simulation training is the only way to teach power skills or can create systemic change in healthcare teams on its own. One of the authors works in a cancer psychological care team that provides ‘Level 2’ psychological skills41 training to nurse specialists working in oncology. Two days of interactive training is followed by ongoing collaboration in which supervision and support is provided to nurses to implement the skills in their practice through case discussion, resulting in increased use of first-line psychological interventions and higher quality and more appropriate referrals to the psychological care team (unpublished data). This emphasises the need to embed training within routine clinical practice, leadership, and supervision to effect substantial impact.
Measuring the direct impact of any educational intervention in healthcare is challenging, as these are complex interventions in complex systems, with outcomes influenced by a range of confounding variables such as on the job learning, local policy and guidelines, and non-clinician factors impacting patient experience. As such, it is crucial that future work in this area prioritises robust impact measures to support the case for embedding interprofessional training into regular education approaches.
In summary, teaching power skills through immersive learning may improve clinician's abilities in effective communication and psychological interventions. These can be embedded into practice through supervision and reflective practice, and we believe that increased feelings of self-efficacy and confidence in managing patient interactions will improve outcomes for both patients and staff. Prioritising these skills as a core part of undergraduate and specialist training may help to create a future culture in which these skills are more widely utilised and valued, and the mind–body division inherent to medicine is de-emphasised.
Finally, it is clear that we work in a system under increasing threat where the subjective human experience of giving and receiving healthcare can easily be neglected in favour of prioritising performance outcomes. In this environment, organisations and their departments must actively, value, encourage, and support relational aspects of care from the top down, through investing in meaningful training and providing the time and space for clinicians and teams to learn and grow. In the age of strikes and budget cuts, this will become ever more challenging and requires vigilance and advocacy. As senior clinicians, modelling a reflective, compassionate, and person-centred approach to our colleagues and juniors is something we must commit to if we want a different future for our NHS.
Change in participants' course-specific skills and human factors skills scores.
- © Royal College of Physicians 2023. All rights reserved.
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