Difficult conversations during the pandemic
RPfT for Newham Hospital and Barts Health Trust
During the first difficult weeks of the coronavirus lockdown here in the UK, most of us spent hours following the latest updates on the news. As the number of fatalities rose, news reports about medical and care staff on the frontline became a daily occurrence. We looked on in growing despair at the impact the virus was having in our hospitals and care homes. How could these doctors, nurses, carers, and support staff cope with the unimaginable stress? And how could the loved ones of those who were alone in the hospital beds, bear the pain of not being able to be at their bedside and to say goodbye in person, if it came to that?
In those first days of lockdown one of RPfT’s Senior Project Managers, Amy Oliver, was approached by Newham University Hospital. Newham had identified an urgent need amongst their clinical staff who were caring for patients seriously ill with Covid-19. Medics were having to deliver the worst news and updates about their patients over the telephone, and they needed support and practical help to do so. Newham wanted us to collaborate with them on this training programme, and the pilot session needed to be rolled out to clinicians the next day.
Amy Oliver led RPfT’s contribution to the design and worked closely with the team at Newham who were in turn led by Helen Parker, Newham’s Medical Lead for Simulation, who is also a Consultant in Emergency Medicine. RPfT already had a working relationship with Barts Health Trust, so we were able to start from a place of trust and mutual understanding.
It is vital to understand that historically medics have been advised not to deliver bad news over the telephone. They are advised to give life changing, difficult or sad messages in person, the reason for this is that the way bad news is delivered can affect the way the receiver responds to and copes with it. However, as we all know, the nature of the virus meant that family and loved ones could not come into hospitals, so all updates about patients, however sensitive, had to be made over the phone.
To give some context, Newham is a very densely populated borough and has been one of the worst affected areas in England due to COVID-19. Latest figures also tell us that over 70% of the population (and staff working at Newham) are from BAME backgrounds. Everyone involved in developing the training was keenly aware of how high the stakes were. There was both the need to write a course that was psychologically safe for the participants, and the importance of ensuring the training was immediate in its effectiveness. The course needed to be flexible enough to be delivered to a wide range of staff, and because of the obvious time constraints they were all under, it needed to be short, impactful, portable, and most importantly – empowering.
The course was delivered in a single hour, in groups of 10 or less and was mostly run as drop-in sessions to allow maximum flexibility for attendance. Some medics would come to a session in the afternoon, knowing they had bad news to deliver that evening. Departments with greatest need, such as critical care and elderly services were also targeted with more formally scheduled sessions to offer support where it was needed most.
During the session, our RPfT facilitator would dial in and would play the role of loved one or next-of-kin to a critically ill patient. The clinicians would take turns simulating making phone calls to deliver updates about the patient at various stages of their journey. As the course was about delivering bad news, there was no easy run in. The first call was to inform the next-of-kin that their loved one was being put on a ventilator, the second was to explain that despite maximal medical intervention the patient continued to deteriorate and was dying, and the final call delivered the news that the loved one had died. The facilitator would give immediate feedback after each interaction and this was followed by a debrief with the whole group to discuss the interaction. Support came from every person in the room, not just the facilitators.
The training session covers sensitive issues that are difficult to address, such as:
- Language choices – For example, the importance of using respectful and thoughtful language and avoiding casual language like “popping in a tube” when discussing intubation, or using euphemisms for death.
- Making room for silence – For example, accepting silences in the conversation as the recipient of the call processes the information that is being delivered.
- Empathy – For example, understanding that it is OK to say you are sorry, including about speaking on the phone and the circumstances surrounding this news.
- Honesty and Authenticity – For example, being able to share the circumstances of the patient’s last moments and knowing their name and the names of those caring for them.
- Ending the conversation – This is often the most difficult part of the process for both the caller and the recipient. Helpful ways to finish the calls included offering to relay a message and promising to call again.
“As one of the facilitators delivering the course,” says Amy Oliver when asked about the process, “the most sensitive challenge was trying to gauge the level of emotion from participants in each session, from the safety of my kitchen table.” Amy went on to recall some of the circumstances the participants on the course found themselves in… Some of the nurses had just come from wrapping bodies, some had lost loved ones or colleagues themselves and some of them simply couldn’t contribute to the training at all and instead spent the hour in tears, processing their grief. All were trying to deliver the highest quality care in the most stressful of circumstances.
Our feedback from the training indicates that it empowers clinicians to deliver upsetting news over the telephone in a way that is most helpful and compassionate for the recipient of the call. Importantly, it also recognises the heavy toll placed on those making the calls. The sessions provide a framework within which the burden these calls place on the clinician can be managed, and offers additional support in the shape of the input they receive from their peers, through being able to discuss the session together. This facilitates ongoing support networks beyond the training sessions.
The Difficult Conversations course has evolved over these last months in line with the changing nature of the pandemic. As we ran the sessions, we gained new insights into the skills required to best conduct the conversations, which we were able to then incorporate into the course. To date, the training has been delivered to multiple departments such as Emergency Medicine, Intensive Care, Paediatric Intensive Care, Oncology and Older People’s Services. It has also been delivered not just in Newham University Hospital, but in Whipps Cross, The Royal London, St Bartholomew’s, and Leicester Royal Infirmary. The training materials have been made available to all NHS Hospitals for their use, and the course can be adapted easily where required.
For us here at RPfT it has certainly been an unusual time – particularly with regards to our work in the corporate sector, much of which was disrupted by the pandemic. We are so grateful that, during this intensely challenging time for our society as a whole, we have had the opportunity to collaborate with Newham University Hospital and Barts Health Trust again and to support the NHS and their incredible staff with their ongoing efforts to manage the challenges COVID-19 has brought.
On reflection now, we’re very proud of Amy for the work she has put into this, and proud of RPfT’s contribution in general. But mostly, we are impressed by the resourcefulness, creativity and quick thinking of the team at Newham Hospital who created the programme. Given what we now understand about COVID-19 and how it impacts different communities, it makes what the team at Newham Hospital achieved during this crisis all the more remarkable and commendable. They acted quickly, whilst under great stress and strain, to put this programme together on behalf of their colleagues in their hour of need. For us, it feels like the most important piece of work we’ve ever had the privilege to be a part of.