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QUILT SEMINAR AN APPRAISAL OF COMMUNICATION TEACHING AT POSTGRADUATE LEVEL ACROSS HEALTHCARE CURRICU

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Title: QUILT SEMINAR AN APPRAISAL OF COMMUNICATION TEACHING AT POSTGRADUATE LEVEL ACROSS HEALTHCARE CURRICU


1
QUILT SEMINAR AN APPRAISAL OF COMMUNICATION
TEACHING AT POSTGRADUATE LEVEL ACROSS
HEALTHCARE CURRICULA SRIKANT SARANGI
Cardiff University
Cardiff University, 10 March 2008
2
OUTLINE
  • Introduction Health Communication Research
    Centre (HCRC) and its Remit
  • Patient-centredness and the communicative turn in
    healthcare delivery
  • Rethinking communication going beyond skills
    approach
  • Background to the Project fact finding (mild)
    intervention in a consultative paradigm
  • An overview of work in progress (Phases 1 2)
  • Future agenda?

3
HEALTH COMMUNICATION RESEARCH CENTRE
  • The Health Communication Research Centre (HCRC)
    was established in 1997-98 as an
    interdisciplinary initiative, with a focus on
    Research and Research-led teaching/training in
    healthcare (i) the interactional domain (ii)
    the public domain.
  • www.cardiff.ac.uk/encap/hcrc
  • healthcom_at_cardiff.ac.uk

4
RESEARCH PROJECTS AN OVERVIEW
  • Genetic Counselling Genetic Testing
  • Genetic explanations, health and identity
  • Palliative Care
  • Primary Care Antibiotics prescription
  • NHS DIRECT WALES (websites and telephone triage)
  • HIV/AIDS and Quality of Life
  • Obesity in the media
  • Illness narratives chronic fatigue syndrome
    young people with IBD, Type 1 Diabetes
  • Professional examinations (OSCE, RCGP)
  • Problem-Based Learning in medical curriculum
  • Wales Asylum Seeking and Refugee Doctors (WARD)
    programme

5
HIGHLIGHTS OF HCRC ACTIVITIES
  • Annual Conference on Communication, Medicine and
    Ethics (COMET) since 2003
  • The Cardiff Lecture Series since 2000 (accessible
    via website www.cardiff.ac.uk/encap/hcrc
  • Annual interdisciplinary workshops
  • Annual Summer Schools
  • Regular Health and Discourse Seminars (HEADS)
  • Teaching/supervision input to medical and
    healthcare curricula
  • Pilot projects in neglected areas of healthcare
    communication.
  • Founding Journal Communication Medicine

6
  • CONTRIBUTORS TO FIRST ISSUE
  • Atkinson, P. (Cardiff University)
  • Barrett, R. J. (University of Adelaide)
  • Cicourel, A. V. (University of California, San
    Diego)
  • Frankel, R. M. and Hourigan, N. (Indiana
    University School of Medicine)
  • Hamilton, H. E. (Georgetown University)
  • Hydén, L. and Baggens, C. (Linköping University)
  • Iedema, R., Sorensen, R., Braithwaite, J. and
    Turnbull, E. (University of New South Wales)
  • Körner, H., Hendry, O., and Kippax, S.
  • Li, H.Z., Krysko, M., Desroches, N.G. and Deagle,
    G. (University of Northern British Columbia)
  • Roberts, C. (Kings College London), Sarangi, S.
    (Cardiff University) and Moss, B. (Kings College
    London)
  • DISCUSSION FORUM - Mishler, E. G. (Harvard
    Medical School)

7
  • COMET
  • CHRONOLOGY
  • 2003 Cardiff
  • 2004 Linköping, Sweden
  • 2005 Sydney, Australia
  • 2006 Cardiff
  • 2007 Lugano, Switzerland
  • 2008 Cape Town, S Africa
  • 2009 Cardiff
  • 2010 Boston, USA
  • 2111 Nottingham, UK
  • 2112 Gent, Belgium

Return
8
Return
9
  • PATIENT-CENTREDNESS
  • THE COMMUNICATIVE TURN IN HEALTHCARE DELIVERY

10
PATIENT-CENTREDNESS IN HEALTHCARE DELIVERY
  • EVIDENCE-BASED MEDICINE (the dominant biomedical
    paradigm)
  • NARRATIVE-BASED MEDICINE (cf. ethnomedical
    perspective (Faberga 1975 biopsychosocial
    dimension Engel 1977 cultural hermeneutic
    model Good and Good 1981 voice of the
    lifeworld Mishler 1984)
  • PATIENT-ORIENTED EVIDENCE THAT MATTERS (POEM)
  • MEDICAL HUMANITIES (ethics, philosophy, art,
    literature, language/communication etc.)

11
SETTING THE HEALTH COMMUNICATION SCENE
  • Communication as the beneficiary of
    patient-centredness.
  • Highlighting of communication issues in the
    reform of undergraduate medical training, based
    on General Medical Councils (2002) Tomorrows
    Doctors.
  • Striving for a balance between core and non-core
    training (including Interpersonal Communication
    Skills) also in Continuing Professional
    Development (see Good Medical Practice, GMC
    2001).
  • Parallel developments via Royal Colleges and
    other regulatory bodies.

12
COMMUNICATION IN HEALTHCARE AGENDA
  • Recognition of communication failure leading to
    complaints/litigation
  • Medical uncertainties about new illnesses
    demanding new forms of communication
  • Increased level of patient access to health
    information (the lay expert, especially in the
    context of chronic illnesses).

13
THE COMMUNICATIVE RELATIONSHIP BETWEEN
PROFESSIONAL CLIENT THE CONUNDRUM
  • Good Professional Good Communicator?

CLIENT TYPES
Good Communicator Good Professional??
14
COMMUNICATION SKILLS FOR AGAINST
  • Patient-centred communication skills unveiled
    ideology or ecological practice?
  • Artificial separation of consulting skills and
    communication skills in professional literature
    and teaching/training.
  • Patient-centred models are measured, for example,
    by the number of open questions asked, levels of
    explanation offered on the assumption that
    patients and healthcare providers share the same
    communicative resources.

15
QUESTIONING THE RELEVANCE OF COMMUNICATION SKILLS
  • Patients resistance or dispreference Patients
    are primarily concerned with professionals
    technical expertise rather than their
    communication skills. (Burkitt Wright et al 2004)
  • Recent critique A triumph of evangelism over
    common sense! There is not much evidence that
    communication skills training makes a difference.
    (Williams and Lau 2004)
  • Attempt to throw the Communication Baby with the
    bath water!
  • Communication/Discourse studies as an invisible
    discipline.

16
COMMUNICATION IS MORE THAN A SET OF DIY SKILLS
  • Communication is not a PILL Limitations of
    recipe-style training in A-to-Z of communication
    skills which treats symptoms rather than causes
    one-sided view of communication where the patient
    remains absent potential for de-skilling.
  • Communicative Competence is not a driving licence
    that one passes for lifeneed for ongoing
    appraisal to reflect on new challenges.
  • Communicative Fallacy Models of medical
    interaction analysis work with a notion of
    form-function equivalence (e.g., open questions
    patient-centredness) and thus ignore context
    sensitivity and the indexical dimension of
    language use.

17
A BROADER VIEW OF COMMUNICATION
  • Communication is more than information transfer
    from sender to receiver via a transparent medium,
    channel.
  • Language form does not determine function.
  • There is no one-to-one correspondence between
    language form and function.
  • Meaning is context dependent.
  • Communication is jointly accomplished moving
    away from a speaker/sender bias.

18
PROFESSIONAL PRACTICE AS EXPERT SYSTEM
  • Possible relationship between professional
    theories and interaction theories (Peräkylä et al
    2005)
  • Different healthcare sites will prioritise
    different interactional features based upon their
    diagnostic and treatment regimes.
  • Professionals knowledge of interaction is more
    sophisticated than what textbooks and training
    programmes suggest.
  • Interaction is an essential component of the
    healthcare expert system. (Sarangi 2005, in
    press)

19
COMMUNICATION IS A REPERTOIRE OF VARIABLES
  • C Code (linguistic, visual, non-verbal etc.)
  • O Orderliness
  • M Message
  • M Mediation
  • U Understanding
  • N Narrative Style Structure
  • I Inferencing Intentionality
  • C Context (micro- and macro-levels)
  • A Audience, Addressee
  • T Tone (feeling, evaluation, key etc.)
  • I Identity Role
  • O Objective/Goal
  • N Norms (social, cultural, interpersonal)
  • (Sarangi 2004)

20
  • INTRODUCING THE PROJECT
  • PARTICIPATING SCHOOLS/COLLEAGUES

21
PARTICIPATING SCHOOLS
School of Medicine Institute of Medical Genetics
School of Pharmacy
School of Healthcare Studies
School of Medicine Palliative Medicine
School of Nursing Midwifery Studies
ENCAP
22
PARTICIPATING SCHOOLS COLLEAGUES
  • School of English Communication Philosophy
    Professor Srikant Sarangi (Director, HCRC)
  • School of Medicine Institute of Medical
    Genetics Professor Angus Clarke (Director of MSc
    in Genetic Counselling) Dr Clara Gaff (Phase 1)
  • School of Medicine Palliative Medicine (Phase
    1)
  • Dr Anthony Byrne (Director of MSc in Palliative
    Medicine) Professor Ilora Finlay

23
PARTICIPATING SCHOOLS COLLEAGUES
  • School of Nursing Midwifery Studies Dr Annette
    Lankshear (Director of Graduate Programmes) Dr
    Fran Baley (Phase 1) Ms Linda Cooper (Phase 2)
  • School of Healthcare Studies Dr Nikki Phillips
    (Director of MSc in Occupational Therapy,
    Physiotherapy and Radiography) Dr Tina Gambling
    Ms Dinah Sweet Ms Dawn Pickering
  • School of Pharmacy Dr Delyth James (Director of
    MSc in Community Pharmacy) Ms Karen Hodson
    (Director of MSc in Clinical Pharmacy)

24
MODES OF ENGAGEMENT
  • Group Meetings
  • Questionnaire data
  • Joint data session
  • Teaching input
  • Co-supervision
  • Participation in HEADS seminars,
    Interdisciplinary Workshops, Summer Schools
  • Recorded discussions with course directors
  • Targeted data sessions (planned)

25
  • THE SCOPING EXERCISE
  • SO FAR…

26
A CHECK-LIST OF PERSPECTIVES
  • The historical context
  • Role of professional/regulatory bodies
  • The institutional ethos
  • How is communication conceptualised
  • Linkage between postgraduate and undergraduate
    provision
  • Potential for intervention
  • Challenges for implementation
  • Avenues for teaching/training-led collaborative
    research

27
THE HISTORICAL CONTEXT
  • Tracing the origin of communication teaching
    within each strand.
  • Micro-skills training based on different models
    psychoanalysis, Rogerian therapy, cognitive
    behavioural therapy, psychology etc.
  • Patient-centredness as the main trigger for
    foregrounding communication issues
  • In Genetic Counselling, given the complexities
    surrounding genetic disorders with no curative
    outcomes, and the long tradition of non-directive
    counselling, the onus has always been on
    communication issues.

28
THE ROLE OF PROFESSIONAL BODIES
  • The role of Professional bodies such as Royal
    Colleges, GMC, MNC, Department of Health and
    Learned Associations as well as directives
    arising out of government policy in bringing
    about communication teaching. Also
    recommendations from different Inquiries (e.g.,
    Bristol Inquiry).
  • Differential positioning of professional bodies
  • Communicative consequences resulting from changes
    in the professional sphere (e.g. striving towards
    autonomy from taking doctors orders to
    mastering the art of nursing)
  • Levels of communication competencies (e.g. notion
    of advanced communication)

29
INSTITUTIONAL ETHOS
  • Rationale underlying current provision in
    communication teaching. What is
    included/excluded?
  • How does the Cardiff provision compare with
    communication teaching portfolios in other
    comparable institutions?
  • Coverage of oral and written language/communicatio
    n sites of communication such as
    professional-patient encounters,
    multi-professional team work).
  • Perceived fit between the multi-faceted role of
    communication in professional practice and the
    ways in which such communicative trajectories are
    reflected in the curriculum (e.g., current
    developments in professional practice).

30
INSTITUTIONAL ETHOS
  • Needs-based, practice-led and research-informed
    (e.g., Pharmacy)
  • Remaining responsive to what undergraduates bring
    with them in terms of knowledge, skills,
    attitude.
  • Requiring prior exposure to professional practice
    so people make sense of communicative potential
    (e.g., work placement in Genetic Counselling)
  • Flexibility to incorporate new input and design
    new assessments, thus allowing the possibility of
    uptake from the current project.

31
HOW IS COMMUNICATION CONCEPTUALISED?
  • As a skill-set? Confined to oral interaction
    between professionals and clients? Can
    communication skills be taught independent of
    consulting skills? Any evidence that
    communication skills teaching makes a difference?
    If not, is it because how communication is
    reduced to recipe-style skills?
  • From communication nowhere/somewhere to
    communication everywhere.
  • Communication across the curriculum as a response
    to the limitations of recipe-style skills
    training from itemised skills to skills clusters.

32
HOW IS COMMUNICATION CONCEPTUALISED?
  • In favour of theme-driven curriculum
    Communication now integral to other modules (e.g.
    diagnostic reasoning, compliance, multi
    agency/multi professional work)
  • This marks a shift in communication as a skill to
    communication as a host of variables (gender,
    power, expertise, difficult patient etc.)
  • The potential disadvantage associated with the
    shift of communication from figure status to
    ground status
  • The risk of taken-for-grantedness in the midst
    of professional concerns
  • How to ensure adequate communication analytic
    input?

33
LINKAGE BEWEEN UG PG PROVISION
  • Progressive calibration of communication
    competencies expected of students at different
    end-points
  • I have done that syndrome
  • Communication is a joking matter possible
    trivialisation when drawing attention to basics
    without content (e.g., nonverbal, dress code
    etc.)
  • The risk of duplication of input, thus making it
    non-cumulative
  • Progressively incorporate complex variables
    client-professional to multi-party encounters to
    multi-professional decision making to managing
    difficult consultations (complex diagnosis,
    ethnic/cultural differences etc.)
  • More integrated, theme-based at PG level

34
  • FUTURE AGENDA?

35
SUMMARY POINTS
  • Healthcare communication is constitutive (not an
    additive layer) of expert knowledge manifest in
    its scientific, clinical and organisational
    dimensions.
  • Healthcare professionals have explicit and tacit
    levels of knowledge about interactional
    complexity in their specific professional
    settings.

36
SUMMARY POINTS
  • Striving towards a balance between check-list
    approach, theoretical approach, experiential
    approach and analytical approach.
  • The analytic processes and outcomes are equally
    complex there is a need to recognise different
    forms of analytic expertise and move towards
    discriminatory expertise, where possible.

37
POTENTIAL INTERVENTION CHALLENGES
  • The success story in MSc Genetic Counselling
    (teaching input and assessment) and its resource
    implications.
  • Signs of change (e.g., MSc programmes in Pharmacy
    Community Pharmacy and Clinic Pharmacy New
    Nursing programme in Advanced Practice to include
    a higher dose of communication).
  • How to implement an integrated, theme-oriented
    approach to communication at the level of
    teaching/assessment (apparent paradox in specific
    Away Days devoted to communication teaching and
    role-play based prescriptive model for purposes
    of learning and assessment).

38
POTENTIAL INTERVENTION CHALLENGES
  • Explore further scenario-based teaching (include
    discourse data simulated or real-life embedding
    professional tasks) layers of context and their
    analytic significance comparative cases of
    good and bad communication when things go
    wrong scenarios and their consequence
    apprentice-expert encounters reflective learning
    potential of self role-plays vs.
    others-in-interaction.
  • From intuitive sense to analytic sensibility
    shift from how to communicate to how to
    analyse communication in effect transform
    teachers clinical experience to communication
    expertise.
  • Targeted data sessions planned as part of
    analytic capacity building in the spirit of
    complementary expertise.

39
POTENTIAL INTERVENTION CHALLENGES
  • How to translate descriptive, analytic insights
    into communication competencies for assessment
    purposes.
  • Reaching beyond already converts
    (communicatively speaking!)
  • Widening access via continued participation in
    summer schools, workshops, HEADS seminars.
  • Develop bibliographies of communication-based
    studies in each area.
  • Maintain a portfolio of co-teaching and
    co-supervision.

40
AVENUES FOR COLLABORATIVE RESEARCH
  • Value of teaching/training led research agenda,
    triggered by professional concerns.
  • Such research will inevitably have impact on
    teaching and professional practice (e.g.,
    Medication Review in Pharmacy).
  • Analytic frameworks already exist which can be
    extended to different sites with minimum effort.
  • Dissemination of findings in journals and at
    conferences (e.g., integrating communication
    skills and counselling skills in genetic
    counselling courses).

41
CHALLENGES FACING THE FUTURE AGENDA
  • Negotiation of curricular space for communication
    (e.g., integration as core skill can lead to
    neglect).
  • Responsiveness of students to new modes of
    teaching communication.
  • Staffing resources SS and training of trainers.
  • Difficulty in sustaining the ongoing programme of
    activities the current inter-school scenario (in
    terms of losers and gainers) and lack of support.
  • Can the barriers (not obstacles) be addressed
    at the university level?
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