Teaching communication skills

CLIENT RELATIONS

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Teaching communication skills GOOD communication makes for a more effective and contented veterinary surgeon, nurse, receptionist and practice manager, and the entire practice can benefit from improved communication skills. In this article, Liz Mossop and Carol Gray describe the Calgary-Cambridge guide, a consultation tool used to teach communication skills in veterinary schools. It lists the simple steps and techniques required for practitioners to communicate effectively with their clients, which ultimately results in a better outcome for patients and better business for the practice.

LIZ MOSSOP AND CAROL GRAY Students putting their newly taught communication skills into practice

Liz Mossop graduated from Edinburgh in 2000 and spent six years in mixed/equine practice before joining the new School of Veterinary Medicine and Science at the University of Nottingham. She still works part time in equine practice and holds an MSc in clinical education.

Carol Gray graduated from Glasgow in 1982, and after 15 years in practice moved to academia. She has been lecturing in communication skills at Liverpool university since 2003, and has been involved in the National Unit for the Advancement of Veterinary Communication Skills since then. She is also programme director for the Liverpool veterinary degree.

In Practice (2008) 30, 340-343

IT MAY seem somewhat strange that, up until a few years ago, communication skills were given very little time within the undergraduate veterinary degree. Being a new graduate is stressful enough in itself, but having the tools to communicate effectively with your boss, clients and nurses can often remove one contributory element. The teaching of communication skills is now discussed in a twiceyearly meeting of representatives from the vet schools, the RCVS, several nursing colleges and the Veterinary Defence Society. This group is known as NUVACS – the National Unit for the Advancement of Veterinary Communication Skills. NUVACS has played an essential role in implementing communication skills teaching within all veterinary curricula in the UK and Dublin, and continues to meet to share ideas, training and research. A report is sent to the heads of the veterinary schools on an annual basis informing them of the developments in communication skills teaching within the curricula. The aim of this article is to update readers (who may not have taken part in communication skills training during their own career) on how communication skills, and particularly consultation skills, are being taught within all the veterinary schools in the UK and Dublin. It is useful to see how new graduates are being trained to help understand how the veterinary schools are trying to improve these vital skills. 340

INTRODUCING A CONSULTATION TOOL

In 2002, a group of veterinary educators, practitioners, medical educators and other interested parties met to discuss the adaptation of a consultation tool widely used in medicine to make it suitable for veterinary surgeons, and indeed nurses, involved in consultations. This tool, called the Calgary-Cambridge guide (Silverman and others 2004), lists a series of simple steps and techniques for the clinician to use in order to communicate most effectively with clients. Gold standard

The Calgary-Cambridge guide has been adopted as the gold standard, and is now used to teach all veterinary students (and many student veterinary nurses) how to carry out a consultation (Radford and others 2006). The guide is often introduced at an early stage in the curriculum, and the various steps fit well with the development of student knowledge. For example, students in their early years are able to begin by learning how to introduce themselves, open a consultation and gather information, before they need to have any clinical knowledge. Once the clinical knowledge is in place, they can progress to explaining and planning information, thus completing the process. Introducing communication skills early in a curriculum and then expanding on their

teaching means they are considered as important by the students as the more obvious clinical skills. This training has also been shown to produce a statistically significant improvement in students’ skills, leading to a better outcome for clients (Latham and Morris 2007). Although produced with small animal consultations in mind, much of the detail is also applicable to equine and large animal consultations.

CALGARY-CAMBRIDGE GUIDE

At first glance, the CalgaryCambridge guide to the veterinary consultation may seem rather extensive. In reality, it comprises a series of just seven steps, providing a simple way to consider the consultation. These are discussed below and illustrated in the diagram on page 341. Preparation

Most preparation is obvious, such as updating yourself with any available clinical notes, checking the table is clean and preparing any necessary equipment. However, there are other ways in which preparation can be useful. For example, you may need to prepare yourself by anticipating any possible issues with a particular client. A small amount of reflection at this stage is useful when considering a client you have met before – did you have any issues last time with communicating with this client, In Practice

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Preparation ■ Professional and safe environment ■ Context of the consultation – reflection on past contact

Initiation ■ Greeting and introduction ■ Open question

Gathering information ■ Agenda setting ■ Clarification ■ Summarising and screening

Structure of the consultation

Building the relationship

Physical examination

■ Organisation of thoughts and questions ■ Ensure an even flow to the consultation

■ ■ ■ ■ ■

Explanation and planning Establish client’s starting point Chunk and check Signpost Keep it simple – use of visual aids Informed consent

■ ■ ■ ■

Rapport Active listening Body language Empathy

Closure ■ Safety net ■ Goodbye and thank you

Observation Veterinary Calgary-Cambridge guide to the consultation, highlighting useful techniques. Adapted from Silverman and others (2004), with permission from Radcliffe Publishing.

and, if so, how are you going to deal with them on this occasion? Initiation

Greeting the client is important, and it is stressed to veterinary students that a brief introduction of yourself as the new vet in a practice is very important. The client should always be aware of your particular role within the organisation. Handshakes may be appropriate but eye contact is vital, and a smile will help put the client at ease. Greeting the animal is also essential, and will improve rapport with both the client and their pet. The consultation should then begin with an open question, such as ‘How can I help today?’ or ‘What’s the problem with Susie today?’. An open question invites information from the client, so it is essential not to interrupt the client as they tell the story of their pet’s problem. Gathering information

Once the client has given you an understanding of their pet’s problems, you can then elicit further details from them. In Practice

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■ AGENDA SETTING. You may need to set an agenda if there is a long list of problems – ‘Let’s deal with the cough first, and then we’ll talk about the itchy skin.’ There may be occasions when some items on the agenda may need to be left for a subsequent consultation. ■ CONSIDERING THE CLIENT. An important part of the informationgathering process is that you are not just obtaining a history, but you are

also establishing the ideas and concerns of the client so that you can address these later. This is probably the step that students struggle with most – active listening is difficult when you have a list of closed questions you want answered specifically. However, a series of more open questions can give you exactly the same information in a more effective fashion, without the client feeling like they are going through an

Active listening and body language The ability to listen is one of the most important elements of good communication and one of the most difficult for students to learn. Over-enthusiasm often leads to interruption of the client. Active listening means that although the client is given time to speak, the clinician can use small cues or positive body language to encourage and show engagement. Specifically, this is the ‘hmmm’ and ‘uh-huh’ of the consultation. It is also important to focus on answers to questions you might ask, rather than already forming the next question in your mind and then jumping in with it. Body language can also cause problems with the flow of a consultation. Eye contact is critical, and mirroring your client’s body language appropriately can also help them to feel at ease. Students often get very nervous while practising their communication skills and forget to smile, something we are all guilty of occasionally.

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interrogation! Closed questions can then be used if any information is still missing. ■ CLARIFICATION. You may need to clarify what the client is telling you, especially if the clinical signs they are describing are vague: ‘So, Charlie’s been drinking more water than usual? Could you tell me more about that?’. ■ SUMMARISING AND SCREENING. Summarising is an important technique to confirm what you have been told and check that you have the correct information, particularly in a long or complicated history: ‘So, Cassie has been vomiting for three days and has had diarrhoea for four days, with some blood in it, but she is still eating and drinking and seems bright in herself? Have I got that right?’. It is then appropriate to screen for further information: ‘Is there anything else?’ Throughout the informationgathering process, it is important to avoid jumping to a diagnosis and, of course, you should be building rapport with your client and showing empathy throughout. A few simple words such as ‘I can imagine you must be very worried about that’ can really help to put your client at ease.

Students taking a history from a client, played by a medical actor

You may have been examining the pet during the information-gathering process. This can be fine, as long as you can still keep eye contact with your client and they are happy and able to restrain their animal while answering your questions, but there is no doubt that it is too much in many situations! Ideally, the physical examination happens after the animal’s history has been obtained. Additionally, of course, communication with the client about what you are doing or finding is essential. Students are often taught to talk through the examination process so that they and the client are clear about what is happening. Don’t forget to thank the client if they have to help you out by restraining the animal in some way; praising the animal for good behaviour is another way to build rapport.

explanation of a clinical condition or diagnostic work-up, it is useful to establish your client’s level of knowledge. Clients are often very well informed, but this is also a chance to eliminate any misconceptions: ‘Have you any experience of this condition?’. ■ CHUNK AND CHECK. Short pieces of information should be given one at a time and the client’s understanding checked, before moving on to the next item. This is called ‘chunk and check’, and the checking needs to be carried out carefully so that it is not patronising. ‘Have I explained myself properly?’ is better than ‘Do you understand?’. Compliance is ■ SIGNPOST. increased by signposting information for the client. This means listing pieces of information, so that they know there are several steps to what is going to happen: ‘There are three things we’d like to do to improve Henry: we’d like to change his diet, give him some tablets and also some liquid medicine.’ ■ KEEP IT SIMPLE. Visual aids can be useful during the explanation stage, and information to take away in a leaflet is a good way for the client to recap at home. Jargon should be avoided, and students often struggle with this as they find it difficult to distinguish between what they understand and a client’s understanding.

Explanation

Planning process

After obtaining the history and performing the examination, it is the clinician’s turn to explain what has been found and make sure the client understands what is going to happen next. ■ ESTABLISH THE CLIENT’S STARTING POINT. Before beginning a long

The planning process will often merge with the explanation step, and students are taught to involve the client with the former, making sure they are happy with the plan for their animal’s care (chunk and check can be used again). Making

Physical examination

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decisions together, rather than just telling the client what to do, dramatically increases compliance. Consent may need to be obtained from the client at this stage – students are taught about informed consent and the importance of explaining exactly what is going to happen during a particular procedure and how much it may cost. Closure

Any good consultation can be ruined by a poor or rushed ending. ‘Safety netting’ is one of the most important parts of a consultation. While you are closing the consultation, make sure that the client is aware of possible changes or complications to their animal’s treatment plan, and what to do if something untoward arises. Ensure they know about follow-up appointments to make or phone calls to expect. Say goodbye and thank you to both client and animal! Empathy, rapport and observation

Running throughout the consultation should be a degree of empathy. As already mentioned, there are some useful phrases to let your client know that you empathise with what they are dealing with, for example, ‘I can imagine you are really worried about this lameness, especially with the eventing season starting so soon.’ The building of rapport can be more of a long-term process. It is much easier to build a relationship with a client you see regularly or with lots of different animals. Students are advised to keep this simple initially – often just asking how they are or apologising for the wait is a simple way to help build In Practice

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rapport with a client and put them at ease. Observation of both the client and animal is also important throughout the entire consultation.

USING THE GUIDE WITH STUDENTS

Clearly, there is no point in delivering this guidance to the students in a didactic lecture – they need to try it out and practise the techniques. This is where medical actors (simulated clients) are vital. Medical acting has become a highly specialised area and the actors are excellent at not just delivering the scenario consistently to a stream of students, but also giving the students constructive feedback (Radford and others 2003). They will do this either in or out of character. The students are taught in small groups of six to eight in most of the schools, with a NUVACS-trained facilitator to guide the process. One simulator plays several roles, or simulators will rotate between groups to vary scenarios (Gray and others 2006). Peers also contribute to constructive feedback, and video is also employed for selfassessment purposes. Scenarios

A well-written scenario is essential to allow students to get the most out

The NUVACS website A full version of the veterinary Calgary-Cambridge guide is available on the NUVACS’ website, www.nuvacs.co.uk, as well as contact details for the group’s veterinary school representatives. Scenarios for both vets and nurses can also be accessed, which contain instructions for both the simulated clients and the facilitator, as well as information for students. Learning outcomes are also provided. A discussion forum has recently been added that allows educators and practitioners to discuss issues or ask questions relating to communication skills training. The NUVACS group is always happy to give ideas to any practice or group wishing to improve its communication skills.

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of this form of teaching. Scenarios can involve any species and any problem, and in the early stages will just involve history taking. There may be a particular theme running throughout a case – for example, a client with a preconceived idea or an angry client. Situations are also created specifically to tackle difficult scenarios such as breaking bad news. Assessment

There would be little point in teaching students communication skills unless we were to assess their abilities. This assessment should ideally be given as prominent a position as any other topic during their training. The objective structured clinical examination (OSCE) is a practical, performance-related exam in which students can follow a scenario involving a simulated client with or without an animal. This examination is marked using a series of objective check boxes – the student either does or does not carry out a certain technique or skill – and the final outcome is calculated from these. The assessor can also globally assess the student’s communication skills. OSCEs have been widely adapted throughout medical, veterinary and dental education in undergraduate and postgraduate training as a valid and reliable assessment of all clinical skills, including communication skills (Shumway and Harden 2003, Davis and others 2006). They enable skills to be assessed in a holistic fashion, and allow the assessment of performance rather than knowledge. The skills required to facilitate

these sessions do require practice, although they are a very rewarding way to teach. Several veterinary schools use portfolios to assess communication skills, whereby students have the opportunity to submit evidence in written, verbal or video format to demonstrate their abilities. Importantly, portfolios usually include reflection on these abilities, demonstrating the students’ acceptance of their own strengths and weaknesses, while showing how they are developing as a clinician.

PRACTICE MAKES PERFECT

This brief overview of the CalgaryCambridge guide does not do the tool justice – in reality, it needs to be learned in an experiential manner with a good facilitator and a helpful group of peers. Contrary to what some may believe, the ability to communicate can be taught to students, because communication is more than just an individual’s personality or being nice to clients. It is a series of teachable skills, just like any other clinical skill (Kurtz and others 2005). Although these skills may come more easily to some than others, they can always be improved. There is no reason why this form of learning cannot occur in the practice situation as well as in veterinary schools; many of the techniques may benefit even the most expert of communicators. Effective communication will also increase compliance, leading to a better outcome for the animals, and better business for the practice (Wayner and Heinke 2006).

References DAVIS, M. H., PONNAMPERUMA, G. G., McALEER, S. & DALE, V. H. (2006) The objective structured clinical examination (OSCE) as a determinant of veterinary clinical skills. Journal of Veterinary Medical Education 33, 578-587 GRAY, C. A., BLAXTER, A. C., JOHNSTON, P. A., LATHAM, C. E., MAY, S., PHILLIPS, C. A., TURNBULL, N. & YAMAGISHI, B. (2006) Communication education in veterinary education in the United Kingdom and Ireland: the NUVACS project coupled to progressive individual school endeavors. Journal of Veterinary Medical Education 33, 85-92 KURTZ, S., SILVERMAN, J. & DRAPER, J. (2005) Teaching and Learning Communication Skills in Medicine. Oxford, Radcliffe Publishing LATHAM, C. E. & MORRIS, A. (2007) Effects of formal training in communication skills on the ability of veterinary students to communicate with clients. Veterinary Record 160, 181-186 RADFORD, A., STOCKLEY, P., SILVERMAN, J., TAYLOR, I., TURNER, R. & GRAY, C. (2006) Development, teaching, and evaluation of a consultation structure model for use in veterinary education. Journal of Veterinary Medical Education 33, 38-44 RADFORD, A. D., STOCKLEY, P., TAYLOR, I. R., TURNER, R., GASKELL, C. J., KANEY, S., HUMPHRIS, G. & MAGRATH, C. (2003) Use of simulated clients in training veterinary undergraduates in communication skills. Veterinary Record 152, 422-427 SHUMWAY, J. M. & HARDEN, R. M. (2003) AMEE guide no 25: The assessment of learning outcomes for the competent and reflective physician. Medical Teacher 25, 569-584 SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Skills for Communicating with Patients. Oxford, Radcliffe Publishing WAYNER, C. J. & HEINKE, M. L. (2006) Compliance: crafting quality care. Veterinary Clinics of North America: Small Animal Practice 36, 419-436, vii-viii

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Teaching communication skills Liz Mossop and Carol Gray In Practice 2008 30: 340-343

doi: 10.1136/inpract.30.6.340

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