The Journal of Medicine, Law & Public Health Vol 2, No 1.

2022 p79

Effectiveness of Bilingual Multidisciplinary

Simulation-based Training in Improving
Communication and Breaking Bad News Skills
Baraa Tayeb, Jameel Abualenain, Wadeeah Bahaziq, Loui Alsulimani, Abeer Arab, and Abdulaziz Boker

Abstract—Background: Healthcare worker (HCW)- NURSE, simulation education, SPIKES.

patient communication is an essential element of
every patient’s journey, and evidence links good I. I NTRODUCTION
communication with favourable patient experiences
and outcomes. Simulation-based training (SBT) is a Healthcare worker (HCW)-patient communication
promising and effective tool to improve such commu- has been shown to play an integral role in the suc-
nication. cess of therapeutic outcomes in all medical settings.
Aim: To develop a bilingual SBT programme in Multiple studies have shown the potential negative
communication skills for all HCWs in an academic impact of poor patient-centred communication on
tertiary hospital, to improve patient care, experiences clinical outcomes [1-5]. A 2010 review [2] showed
and outcomes. that “...communication has the potential to help
Methods: This was a quasi-experimental design, regulate patients’ emotions, facilitate comprehen-
conducted in 2018 at King Abdulaziz University sion of medical information, and allow for better
(KAU). We designed and delivered a bilingual, identification of patients’ needs, perceptions, and
simulation-based, full-day course for HCWs (both expectations...” and that “... Patients reporting good
clinical and administrative), and measured its im- communication with their doctor are more likely
pact by comparing pre- and post-course test scores, to be satisfied with their care, and especially to
participant feedback, and instructor performance
share pertinent information for accurate diagnosis
satisfaction indices.
of their problems, follow advice, and adhere to the
Results: We trained 318 HCWs over 15 days, using
10 instructors. Post-test scores showed individual and
prescribed treatment...”. It also showed that clini-
overall improvement. The average scores were 26.6% cians tend to overestimate their skills when it comes
(14-40%) for the pre-test and 55.8% (37-70%) for to patient communication [2]. In addition to this
the post-test, with an average improvement of 29% over-estimation, the literature found other barriers
(P<0.005). Participant feedback was 77% positive and to proper HCW-patient communication, including
in favour of more training. The average instructor cultural differences, patient fears, provider anxiety,
performance satisfaction score was 96.2% (92-99%). burden of work, and lack of training.
Conclusion: We demonstrated the positive impact of Simulation-based training (SBT) is a promising
SBT on communication skills for both clinical and training modality that can be utilised to address
administrative HCWs. We also demonstrated the this gap, improving patient communication and
sustainability and scalability of this course. hence clinical outcomes. Hybrid simulation inte-
Index Terms—breaking bad news, communication, grated training in communication and breaking bad
news has resulted in improved providers’ commu-
Baraa Tayeb, Jameel Abualenain, Wadeeah Bahaziq, nication skills, as well as providing an opportunity
Loui Alsulimani, Abeer Arab, Abdulaziz Boker are with King to identify and address individual and system gaps
Abdulaziz University, e-mail: [email protected], e-
[10,11].
mail: [email protected], e-mail:
[email protected], e-mail: [email protected], e- As part of its continuous efforts, the Clinical
mail: [email protected] Skills and Simulation Center (CSSC) at King Ab-
Baraa Tayeb is the corresponding author. dulaziz University (KAU) initiated this project with
DOI:10.52609/jmlph.v2i1.38
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p80

the aim of improving the communication skills of course directors to ensure a standardised delivery
its HCWs. The study includes possibly the highest method.
number of participants out of any study in the lit-
erature; we have not found any previous report that C. Study Participants:
approaches more than tens of participants. Another
unique feature of this study is the fact that we Participants were recruited randomly. Both elec-
used Arabic translation of the tools for breaking bad tronic and written course invitations were distributed
news: SPIKES, NURSE and CUS. SPIKES (Setting within the hospital and made available to all HCWs
up, Perception, Invitation, Knowledge, Emotions, at KAUH. No preferences or exclusion criteria were
Strategy/Summary) is a six-step tool for breaking used; seats were allocated on a first-come, first-
bad news; NURSE (Naming, Understanding, Re- served basis to avoid any biases by pre-selecting
specting, Supporting, Exploring) is a helpful tool for participants. We ensured that the invitations were
addressing patient emotion; and CUS (Concerned, extended to non-clinical as well as clinical HCWs.
Uncomfortable, Safety) is a third tool for helping
to improve communication [7-9]. D. Implementation:
These tools are described in the literature as The course consisted of four phases.
having been used effectively in English and a few
other languages, but our report contains the first Phase A: Introduction and Pre-test (30 minutes):
mention of their use in the Arabic language. In Each course started with an introduction, which
addition, the training of administrative HCWs in included a pre-test. The questions targeted the de-
such a project has not previously been reported in termined objectives of the course. The test was
the literature. reviewed by 10 educators and was piloted on 20
In this study, we sought to develop a bilingual participants to ensure its validity and reliability. It
SBT programme in communication skills (including consisted of 14 multiple choice questions (MCQ)
breaking bad news and difficult communication) for and one short answer question. The MCQs covered
all HCWs at the King Abdulaziz University Hospital routes and modes of communication, verbal and
(KAUH), as part of a continuous effort to improve non-verbal communication, while the short answer
patient care, experiences and outcomes. question was about tools used when breaking bad
news (Appendix 1). Participants were also provided
II. MATERIALS AND M ETHODS with handouts containing learning materials.
A. Study Design:
This is a quasi-experimental design, conducted in Phase B: Didactic sessions (240 minutes):
2018 over a period of five months (April-September) The introduction was followed by four didactic
in the CSSC at KAUH. sessions of 60 minutes each, including breaks (Table
1).
B. Study Tools:
The course was developed by simulation and Phase C: Practice Groups (180 minutes)
education experts working at the CSSC. An interdis- The didactic sessions were followed by two 90-
ciplinary committee of physicians, nurses and edu- minute practice sessions, using advanced illness sce-
cators designed a bilingual, full-day (eight hours) narios pre-written with the consensus of simulation
SBT course for HCWs at KAUH. We recruited experts (Table 2).
10 instructors (simulation experts) from various
disciplines (anaesthesiology, emergency medicine,
paediatrics, quality improvement and education spe- The instructions for scenario implementation
cialists) and backgrounds (physicians, nurses, ad- were:
ministration, management and professional actors). Divide participants into subgroups of three to five.
All instructors received unified training from the In each subgroup, one participant will be assigned
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p81

TABLE I
LIST OF 60-MINUTE DIDACTIC SESSIONS
Session 1 Modes of communication
Session 2 Verbal and non-verbal communication
Session 3 Small group communication
Session 4 Difficult communication and tools used to break bad news in a clinical setting

TABLE II
LIST OF STANDARDISED PATIENT CASE SCENARIOS

Case Sudden death of a family member from severe septic shock.

1
Case Unexpected lifesaving emergent Caesarean section with severe post-partum haemorrhage, requiring vascular
2 ligation and possible hysterectomy.
Case Hospital staff termination of employment due to poor performance.
3
Case Medical error (medication administration error) resulting in severe morbidity.
4
Case Medical error (unnecessary intervention) resulting in complication necessitating invasive treatment.
5
Case A senior requesting fraudulent documentation upon a patient’s death.
6
Case Escalating situation wherein a patient requesting non-emergency services at the Emergency Room becomes
7 increasingly aggravated by delays.
Case A co-worker requesting hospital registration and examination of a family member under a different patient file
8 due to administrative and financial issues.

as “delivering the news (doctor)” and one as “receiv- satisfaction. Given the timing of the pre- and post-
ing the news (patient, relative or another doctor)”, tests just before and after the intervention (course),
while the rest of the subgroup actively observes the we can conclude that the intervention is the only
communication process and documents their obser- possible cause of the observed outcome. The pre-
vations. Each assigned participant is given two to test and post-test scores were used as a measure
three minutes to read through their role. When they of the improvement in knowledge that could reflect
are ready, they engage in the role-play for 7 to 10 on employee performance and patient satisfaction in
minutes. When the role-play is finished, 15 minutes future practice. Participant feedback and satisfaction
are allocated for feedback. The debriefing format scores were collected as a supporting measure and
was based on the well-known Plus-Delta method to provide ongoing formative assessment to the
[12], focusing simply on general description, what course instructors, using open-ended questions and
went well (WWW) and things to improve (TTI), Likert’s scale as appropriate.
followed by case conclusion, whereupon another To ensure accuracy and completeness, data were
scenario commenced. collected manually by an independent CSSC em-
ployee, who had no interest in the success of failure
E. Phase D: Wrap-up and evaluation (30 minutes) of the course, without any identifying information
Following the practice session, a summary ses- and in such a way that answers could not be traced
sion was conducted which included the post-test to individual participants. There was no missing
and evaluations. The post-test covered the course data.
contents and the questions were identical to those We conducted a descriptive analysis of the data.
in the pre-test. Data collection, coding and analysis were completed
To measure the impact of the project, we analysed manually, using GraphPad Prism 8. We used mul-
the pre-test and post-test scores, collected feedback tiple measures of dispersion, and cross-tabulations.
comments, and measured instructor performance We presented quantitative data for categorical vari-
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p82

ables as percentages or frequencies, as appropriate. scenario exercises (7 comments), mandating the

To measure the difference between pre-test and course to hospital staff (6 comments), providing cer-
post-test scores, we used a paired t-test with a tificates of completion (1 comment), and providing
significance level of p ≤
<0.05. more video materials (1 comment).
This training course involved minimal ethical Instructor performance satisfaction indices: Ten
risks, with the participants’ privacy and well-being instructors participated in this course. All partici-
assured prior to and throughout the course. Given pants responded to the questionnaire, and the av-
the difficult nature of breaking bad news, partici- erage instructor performance satisfaction score was
pants were offered access to appropriate resources 96.2% (92-99%).
in case of any unanticipated psychological stress.
Ethics committee approval was received for this IV. D ISCUSSION
study from the Unit of Biomedical Ethics at KAU This study has demonstrated the feasibility, sig-
School of Medicine (Reference No. 413-20). Con- nificance and reproducibility of a multidisciplinary
sents were waived during the ethical approval, since SBT programme that focuses on improving HCWs’
no personal or traceable data were collected. communication and breaking bad news skills. The
number of participants in this project is one of the
III. RESULTS most sizable reported in the literature. Furthermore,
The course was repeated a total of 15 times to the best of our knowledge, this project is the
(8 times in the Arabic language and 7 times in first of its kind to include administrative staff, and
English), with a total of 318 participants (ranging the first to translate communication tools such as
from 13-27 participants per course), representing SPIKES, NURSE and CUS [7-9] into the Arabic
10-15% of the total number of KAUH employees. language for clinical practice.
Participants were interdisciplinary; 105 (33%) were Our results demonstrated a positive impact on
female and 213 (67%) male; and they represented all knowledge acquisition after completing the course.
the major clinical (69%) and administrative (31%) These results are aligned with multiple previous re-
hospital departments (Table 3). search protocols [6] that showed the positive impact
of communication training for General Practition-
Pre-test/post-test analysis: All participants com- ers, both on post-training test scores (similarly to
pleted the tests. All of the individual courses, as well our study) and on behaviour during patient inter-
as the overall test results, showed an improvement views [6]. Similar positive impacts were repeatedly
in test scores (figure 1). A paired t-test was used demonstrated when role-play was used with stan-
for analysis where appropriate. The average pre- dardised patients and/or training for clinical students
and post-test scores for the 15 courses were 26.6% [10], trainees [11] and/or clinicians in different
(14-40%) and 55.8% (37-70%) respectively. The specialties, including nurses, social workers and
statistically significant mean differences was 29.20, chaplains.
standard deviation of difference was 17.86, and Recent systematic reviews have not revealed a
standard error of mean of difference was 4.611, single study that investigates the potential effect
with a 95% confidence interval; 19.31 to 39.09, of communication training on non-clinical admin-
correlation coefficient (r) -0.6579 (figure 1). istrative HCWs [13,14]. Our project demonstrated
a positive impact not only on clinical HCWs, but
Participant feedback: Only 35 participants pro- also on administrative HCWs. The integration of
vided the optional written feedback. Overall, 77% of multidisciplinary participants, including non-clinical
the feedback was positive. The 23% negative feed- HCWs, did not impede the learning process; rather,
back was related to centre facilities (5 comments) it was viewed as an advantage to facilitate knowl-
and the provision of better materials (3 comments). edge transfer across disciplines.
Suggestions for improvement included prolonging Translation of validated communication and tools
the course duration (18 comments), increasing the for breaking bad news, such as SPIKES, NURSE
and CUS, into the Arabic language for clinical use
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p83

TABLE III
PARTICIPANT DEMOGRAPHICS
Participant distribution by specialty
Administrative 99 31.1%
Nurse 94 29.5%
Physician 44 13.8%
Technician 24 7.5%
Dietitian 17 5.3%
Pharmacist 11 3.4%
Specialist 7 2.2%
Security 6 1.8%
Laboratory 6 1.8%
Project & Maintenance 8 2.5%
Nurse Educator 2 0.6%
Attendance by department
Emergency Medicine 77 24.2%
Human Resources 36 11.3%
Anaesthesia & Critical Care 20 6.3%
Nursing Administration 20 6.3%
Outpatient 18 5.6%
CSSC 17 5.3%

would have a great impact, both on Arabic-speaking instructions and materials.

clinicians and on their patients, providing an easier
way to build a therapeutic relationship. Moreover, V. C ONCLUSION
our results demonstrated sustainability and scala- Using structured SBT has a positive impact on
bility to include a larger number of participants. improving communication and breaking bad news
The cost to scale and sustain this project after its skills for all HCWs, including administrative per-
establishment would be minimal, attributed mainly sonnel. SBT has the potential to provide the sustain-
to staff time and availability of space. We mitigated ability and scalability of such programmes. Future
the cost by recruiting and training local instructors studies should continue to examine patient-related
and by using the hospital’s facilities to as a course outcomes and quality improvement indices of hos-
venue. Participant recruitment is a potential obstacle pital systems.
that could be overcome with strong support from
higher leadership.
SOURCE OF FUNDING: No funding was received.
Our project had certain limitations. First, although
we included 318 participants, representing 10-15% CONFLICT OF INTEREST: The authors have no
of all of the hospital’s HCWs, the impact of the conflicts of interest.
training on the overall quality of the hospital’s ETHICAL APPROVAL: ethics committee approval
service was too small without training more HCWs. was received for this paper from the unit of biomedical
Second, as with most SBT, demonstrating the direct ethics at King Abdulaziz University school of medicine
effect on patient outcomes is difficult; a longer pe- (reference no. 413-20). Approval date: august 2020.
riod and a higher number of participants is required
ACKNOWLEDGMENTS: The authors would like to
to determine whether a higher level can be reached acknowledge the KAUH leadership for their invaluable
in Kirkpatrick’s model [15]. A third limitation was support, with special mention to the Vice Dean and
the large number of instructors [10] required for Director of KAUH, Dr. Amro Alhibshi. We would also
the project; on a larger scale this might result in like to recognise the KAU Clinical Skills and
a variation in the quality of course delivery. We Simulation
tried to minimize this latter limitation by focusing
on instructor training and providing unified course
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p84

Center (CSSC) and its working team for their training assistance in this simulation
support and facilitation in running the project, programme. Finally, we extend our sincere
with special mention to Mr. Jamal Alshomran. appreciation to Stacy Brady, RN, and the
Furthermore, we would like to thank Dr. Providence VA Medical Center for their support
Abdullah Bawarith and Ms. Abeer Alhazmi for during the preparation of this manuscript.
from:
https://www.ahrq.gov/hai/tools/ambulatory-s
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The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p85

Figure 1: The average pre-test and post-test scores were 26.6% (14-40%) and 55.8% (37-70%) respectively.