The Simulation Training Analysis For The Communicative Skills Formation In Medical Education

An effectiveness in using “Difficult patient” cases

How effective is the use of simulation training for the formation of students’ communication skills during the training period and immediately after its completion by crossing the “Difficult patient” case station?

An observation of the dynamics of communication skills presented before, during and right after the training

Are there any significant differences in assessing the dynamics of the development of communication skills at different stages of formation?

First stage

That step included writing a station scripts based on the specifics of communicative problems in the healthcare system. We conducted an anonymous survey among patients from various clinics in Kazan. Based on the received information, the most common complaints and claims by patients on the communicative component of therapeutic interaction were “inattention”, “indifference”, “lack of empathy”, which caused patients to appear aggression, anxiety, hypochondria, etc. We developed the “Difficult Patient” set of tasks, which included 12 training stations with the participation of actors (for example, the station “Angry Patient”. The example of the task:

Student Information:

The patient (middle-aged woman) suffers from hypertension for 20 years. In recent years, significant increases in blood pressure are periodically repeated after 1-2 months to 180/100 mm Hg. In this connection, the patient calls an ambulance once every 1-2 months. Refuses hospitalization. At home, she takes drugs from time to time. If blood pressure is "normal", then she does not drink pills, she uses drugs only with an increase in blood pressure.

This afternoon the patient was nervous, quarrelling with a neighbor. After the quarrel, it became bad - a severe headache appeared in the occipital region, “flies” in front of the eyes and she called an ambulance. The dispatcher promised to send the first free brigade in the very near future. However, the patient was waiting an ambulance an hour. Her state of health did not improve. At the time of the arrival of the ambulance crew, the blood pressure level was 190/100 mm Hg, after taking the “capoten”, the blood pressure dropped to 160/90 mm Hg.

Now the patient is located in a single box. During a 20-minute wait, she repeatedly asked the staff with questions and requests for an immediate meeting with a doctor. She repeatedly expressed threats and insults to the medical staff.

Second stage

The second stage was devoted to the development of curatorial documentation for a student playing the role of a doctor (curator student) and checklists of experts and actors, based on the criteria necessary for the formation of competencies in accordance with the Federal State Educational Standard within the framework of the discipline “Medical Psychology”.

Third stage

The third stage included the selection of actors and their preparation, one of the selection criteria was the lack of pedagogical and medical education, in order to avoid distortion of the student’s assessment of the actor. Actors were recruited from among third-year students of the theatre college who were trained at the Department of Psychology of Kazan State Medical University with practicing psychologists, psychotherapists and psychiatrists according to given scenarios. As a part of the adjustment of tasks, one of the stations was tested by teachers of the Department of Medical and General Psychology. The technical component of the educational process was to provide a recorded video of consultation from a box in a play situation, with subsequent analysis if necessary.

3 people had to participate playing each case of the station: a curator student (doctor), an expert student, and an actor (patient). Before the start of the training, a briefing was held with students, during which the main tasks for the corresponding role were identified. The main task of the curator student was to demonstrate communication skills in accordance with the station scenario, in a separate box, imitating a ward or viewing room. The play of a case was broadcasted by means of a video camera to the screen of an expert student who was in a specially equipped computer class, which made it possible to observe the situation and evaluate it in real time. After passing the station, each of the participants was offered to fill in the relevant documentation: the student-curator filled out a curatorial documentation, the expert and actor - check-lists. At the end of each lesson, a briefing was also conducted with an analysis of the main mistakes and questions of students.

Since the training was carried out as a part of the “Medical Psychology” subject, the curatorial documentation included a description of psychological traits of the patient such as temperament, character and personality features, the reasons for the patient’s state and the main communicative techniques aimed at solving the problem of a “Difficult patient”.

An expert checklist other than traditional assessment (done/not done) was included blanc space for an expert’s own opinion for valid communicative turns giving an outside perspective.

An actor checklist was conditionally divided into two parts: compulsory skills (welcoming, selfpresentation etc.) and special skills aimed at overcoming a particular communicative difficulty of the case. Also, an actor could leave an open response feedback to a student.

• The training process was divided into two days: each student was playing 6 times per day being a curator (3 cases) and an expert (3 cases different from the first). In this way all 12 cases were passed by a student during two days.

The analysis and the discussion of the first training day results

When analysing the curatorial documentation, conditionally divided into two parts (individual psychological traits and communicative techniques), it could be noted that for the majority of students (67%) assessment of the individual psychological characteristics of the patient was not difficult, however, for more than a half of the students it was difficult to describe how to talk with a patient, what to say and how to react. There were only 12% of students who could find valid communicative techniques for solving the problem that coped with this part of the task (Fig. 01 ).

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As a rule, students offered general recommendations like to “reduce an anxiety”, “psychologist consultation”, which was noted in the actor’s checklist in the form of an unsatisfactory student assessment.

In particular, many students did not achieve the satisfactory result demonstrating skills from the mandatory section: greeting, self-presentation, obtaining informed consent for conversation and physical examination, washing hands. In addition, many actors noted such shortcomings of students' work as a too loud voice, fast pace of speech, improperly chosen posture and distance for communication, and such subjective comments as “strong smell of perfume”, “smell of garlic”, “too long nails”, etc.

From the positive subjective comments could be noted such statements as “a good doctor”, “easy to communicate”, “very convincing”.

The expert’s work at the beginning of the assessment was poorly differentiated: on the first day, most students used only a formalized approach (done/ failed), experts in 93% of cases rated their colleagues as “completed the task”, although the actor’s assessment was unsatisfactory.

Thus, a large number of discrepancies could be noted on the first day of the training - the discrepancy between three types of documentation is quite pronounced. Experts rated the work of colleagues highly (93%), while the actor rated a student as a doctor only in 21.5%, and the number of students who completed the task for the curator (doctor) (by fulfilling the documentation) was 39.5% (Fig. 2 ).

Each student had an opportunity to watch a video of his work. The following data was received, when requesting feedback from students at the end of the first training day: many students were anxious, noted fear and tension before starting work, which they associated with the novelty of the assignment. However, on the first day it was noted the “usefulness” of this format of classes, “the interesting work of the actors”, “the opportunity to observe oneself from the outside”.

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The analysis and the discussion of the second training day results

The results obtained after the second day of class, significantly differed from those on the first day: the percentage of students who completed the task increased significantly (39.5% at the beginning of the first day and 82% at the end of the second), also significantly increased the percentage of students who completed the tasks with the description of communicative techniques (68.5%) (see fig. 1 , 2 ^nd day).

 Significant changes occurred in the student’s assessment of the actor, during the study period, the grade increased from 21.5% to 75%. In addition, the expert’s work was slightly adjusted, a decrease was noted: some students rated their colleagues more critically (from an overvalued 93% to 85%) and offered their own methods of communicative techniques more detailed (Fig. 3 ).

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At the end of the second day of the training, students noted that it was much easier for them to cope with the task. The main evidence of the positive dynamics and effectiveness of that format of classes was an indicator of the consistency of three student assessment parameters, which is illustrated in Figure 3 . The expert assessment was satisfactory in 85% of cases, a satisfactory fulfilling of curatorial documentation was done in 82% of cases, the actors were satisfied with the student in a curator role in 75% of cases. Thus, it can be summarized that there are no significant differences in grades, respectively, the method of forming communication skills has shown some effectiveness.

Communication skills at the first step of training

Many students in practice tried to communicate correctly with patients on an intuitive level, but, in the end, could not implement certain communicative techniques and techniques aimed at solving the problem. This aspect allows us to note the importance of certain psychological and pedagogical skills of a doctor for building communication and, subsequently, teaching the patient constructive behaviour.

Communication skills formation at the last step of training

It is possible to be said that there is a high efficiency of such educational technology as a training station for the formation of students' communication skills. The developed program allows to evaluate several aspects of training: the ability to evaluate the patient’s psychological status, the ability to choose the appropriate communication strategy based on the status, as well as the ability to provide recommendations on the patient’s adaptation in the situation of somatic disease.

• However, it is worth noting that the study showed a certain trend in the effectiveness of the method of developing communication skills by introducing the “Difficult patient” stations for only two days, further research and the expansion of the extra methods of assessment are needed to obtain more objective and accurate data.

• The question remains open about maintaining the acquired knowledge and skills by the student over a longer period of time.