Teaching and evaluating breaking bad news: A pre–post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters

doi:10.1016/j.pec.2011.04.022

Patient Education and Counseling

Volume 86, Issue 2, February 2012, Pages 210-219

https://doi.org/10.1016/j.pec.2011.04.022 Get rights and content

Abstract

Objective

To investigate changes of different domains of breaking bad news (bbn) competences after a teaching module for medical students, and to collage the results generated by different approaches of evaluation.

Methods

Rating of medical student–SP interactions by means of a global rating scale and a detailed checklist used by SPs and independent raters.

Results

Students improved their breaking bad news competency. However, the changes vary between the different domains of bbn competency. In addition, results generated by different evaluation instruments differ.

Conclusion

This study serves as a stimulus for further research on the training of specific elements of bbn and different approaches of evaluating bbn competency.

Practice implications

In light of the different facets of bbn competency, it is important to set priorities regarding the teaching aims and to provide a consistent approach.

Introduction

Breaking bad news is a frequent and at the same time challenging task for physicians in most clinical specialities [1], [2], [3]. Various study groups have published guidance on the professional handling of this difficult communication situation over the last few years [4], [5] and teaching courses on breaking bad news have been implemented as part of the undergraduate and postgraduate curricula in North America and several European countries [3], [6], [7]. There is evidence that small group teaching interventions which incorporate experiential methods (i.e. role play, standardised patients) and principles of a learner-centred approach improve course participants’ perceived self-efficacy [8], [9] and observable communication skills [10], [11], [12].

The methods which have been used to measure breaking bad news competency differ with respect to the type of the instruments (e.g. detailed checklist, global rating scales) and the raters (e.g. standardised patients, independent raters) [3], [13]. The different possible approaches towards the measurement of communication skills have been discussed not only with respect to feasibility and reliability of assessment but also regarding possible implications for the validity of results gained by the use of different instruments and/or raters [14], [15]. A more detailed analysis of empirical studies on the evaluation of breaking bad news interventions further indicates that there is variation regarding the different communication competences relevant for breaking bad news which have been shown to improve following a teaching intervention [12], [16], [17], [18], [19], [20].

There is a scarcity of empirical research in which different approaches to assess breaking bad news competences have been systematically compared [21], [22]. On the basis of the methodical discussions about differing approaches towards the assessment of breaking bad news competency and for the purpose of the identification of an appropriate and feasible evaluation strategy with respect to our own teaching courses, an evaluation study was designed in which different types of instruments (detailed checklist and global rating scale) were used by the same raters, and different raters (independent raters and standardised patients) used the same measurement instrument (global rating scale) to assess the possible effects of a breaking bad news intervention (see Fig. 1a).

The aims of this research were as follows:

1.
To investigate possible changes regarding the different communication competencies of medical students relevant for breaking bad news before and after a teaching module on breaking bad news.
2.
To compare the results generated by different approaches to measure communication skills.

The results of this study will be discussed with a focus on their implications for an appropriate and consistent design of the teaching and the evaluation of breaking bad news competency.

Section snippets

Teaching course, participants and study protocol

The teaching course on breaking bad news evaluated in this study is one of several special study modules in the field of medical humanities which are offered to third-year medical students at the Friedrich-Alexander-University Erlangen-Nuremberg. At the time of this study there was no other communication skill training using simulated patients as part of the medical curriculum. On this basis the teaching of breaking bad news in this course also covered some basic aspects of communication

Results

Thirty-seven medical students (27 female, 10 male) took part in the teaching sessions. All 74 videotaped medical interactions of SPs and third-year medical students were included for analysis. Both groups taking part in the two courses of similar content were comparable regarding the characteristics of participants and their performance before and after the course.

Discussion

This paper presents data of an evaluation study in which the possible effects of a teaching intervention for medical students on breaking bad news were explored by means of different measurement instruments as well as from different rating perspectives (i.e. independent raters vs. standardised patients). Even with a small sample, a comparably weak power statistical analysis showed a significantly improved overall breaking bad news competency following the teaching course. This finding is

Acknowledgements

We would like to thank the two anonymous reviewers very much for their helpful comments on an earlier version of this paper. This work has been supported with a grant of the Stiftung Lehre of the Medical Faculty, Friedrich-Alexander-University Erlangen-Nürnberg. The authors are grateful for the comments of Claudia Kiessling and Heiderose Ortwein on an earlier version of the mBAS and the glBAS. We also would like to thank Sabine Beyer, Ulrich Blanche, Johanna Emmerling, Elisabeth Fischer,

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We report two different peer role-play training courses for breaking bad news (BBN) in Oncology, the classic “in-class” model and the “virtual” peer role-play (VPRP) model developed during the SARS-CoV-2 pandemic.
Each session included 20–25 4th year medical students supervised by two practitioners experienced in oncology. After an ice breaking activity to exchange with students on means to promote hope to patients when BBN, peer role-plays started. Pre-and post-session questionnaires were submitted to evaluate students’ satisfaction, attitudes, and perceptions. Pre-and post-session knowledge test were realized. Each student has participated to only one peer-role play either “in-class” (2018) or VPRP (2020).
In 2018, a total of 222 students received the “in-class” training. In 2020, a total 431 students received the VPRP training. For almost all students it was the first peer role-play training session. Before training, reported level of confidence in BBN was low. After training, students of the VPRP group were highly satisfied regarding quality (realism, organization). Students also reported great interest and perceived benefits. Students who underwent “in-class” training course showed a significantly higher improvement (+1.9 points) of their knowledge scores compared to those who underwent the VPRP training course (+0.7 points) (P-value = 2e–16).
The two methods seem beneficial to improve knowledge skills in BBN although “in-class” training class seem to be more efficient. To our knowledge, this is the first comparison between virtual and in-class peer-role play training for BBN in oncology.
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To assess how successfully the participants accomplished this BBN task, their performances were video-recorded and independently rated by three outcome assessors (Master’s-level psychology students). Assessors used the five-point SPIKES scale [26] and the ‘global Breaking Bad News Assessment Scale’ (glBAS) [31]. Each participant’s final SPIKES and glBAS scores were calculated as grand means based on the assessors’ ratings.
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Only a main effect of ‘hints’ was revealed, implying that students in the hints groups delivered the news to an SP significantly more appropriately than those in the without-hints groups.
Independent of their presentation format, worked examples with hints best foster students’ BBN skills learning.
In addition to video, text-based worked examples can effectively prepare students for BBN simulations if hints are included. This offers an affordable alternative to video examples, as text examples can be generated with less effort.
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The way bad news is conveyed to patients with cancer may affect their comprehension of information, emotional distress, treatment adherence, and health outcomes. Models of communication that are focused on patients’ preferences may result in better treatment outcomes. Available protocols, such as SPIKES and ABCDE, have useful recommendations for health care professionals communicating an oral cancer diagnosis. However, it is important to be attentive to the particular information needs of patients.
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Effective instructional approaches are needed to enable undergraduates to optimally prepare for the limited training time they receive with simulated patients (SPs). This study examines the learning effects of different presentation formats of a worked example on student SP communication.
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¹: Authors contributed equally as first authors to this research.

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Medical EducationTeaching and evaluating breaking bad news: A pre–post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters

Abstract

Objective

Methods

Results

Conclusion

Practice implications

Introduction

Section snippets

Teaching course, participants and study protocol

Results

Discussion

Acknowledgements

Lancet

Patient Educ Couns

Patient Educ Couns

Lancet

Ann Oncol

Eur J Cancer

Ann Oncol

Soc Sci Med

Patient Educ Couns

SPIKES – a six-step protocol for delivering bad news: application to the patient with cancer

Oncologist

Doctors’ stress responses and poor communication performance in simulated bad-news consultations

Acad Med

Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers

Med J Australia

Breaking bad news. 1: current best advice for clinicians

Behav Med

Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness

Cancer

Breaking bad news: qualitative evaluation of an interprofessional learning opportunity

Med Teach

Medical Education
Teaching and evaluating breaking bad news: A pre–post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters