The half-day workshop

1. The half-day workshop Revised November 2005

2. Aims of the workshop • To enhance the professionals understanding of interpersonal, ethical and communication challenges in clinical practice to ensure women are enabled to make informed choices • To provide the opportunity to discuss and debate in a safe environment challenging issues around informed choice faced by healthcare professionals • To network and share good practice. Revised November 2005

3. Learning outcomes Participants will be able to: • explore professional and ethical issues related to offering informed choice in screening • appreciate the need for ‘self awareness’ surrounding the issue of facilitating informed choice • demonstrate awareness of differing professional perspectives • understand the importance of facilitating informed choice in order to deliver a better service to women • recognise and understand the diversity of individual needs. Revised November 2005

4. Ground rules • Maintain confidentiality of sensitive and personal issues • Respect each other's opinions • Allow each other time to speak • Be non-judgemental • Own the statements you make • Keep to time Revised November 2005

5. Activity 1 Each member of the group is asked to: • identify the challenges faced when offering informed choice to women and then • to share those challenges with the group Revised November 2005

6. The Calgary-Cambridge consultation framework Variety of consultation models available, however the programme has been built around an adaptation of the Calgary-Cambridge framework (Kurtz et al 2003). Rationale: ‘[it]delineates the content and process of medical communication, promoting a comprehensive clinical method that explicitly integrates traditional clinical method with effective communication skills’. (Silverman et al, 2005). Revised November 2005

7. Revised November 2005

8. The framework • Each of the tasks involves achieving a number of objectives • Covers everything the woman and her partner or family need in a focused way • Allows you to agree the next steps with them • Check that they feel able to make an informed choice. Revised November 2005

9. Continuous threads: Building the relationship • Developing rapport to enable the woman (and partner or family member) to feel understood, valued and supported • Establishing trust • Increasing the possibility of achieving the other objectives of the consultation • Enabling supportive counselling Revised November 2005

10. Continuous threads: Providing structure • Enables a flexible but ordered consultation • Helps the woman to understand and be involved in where it is going and why • Encourages the woman to be part of the structuring process • Facilitates her participation and collaboration • Enables accurate information gathering and giving Revised November 2005

11. Stages of the consultation • Initiating the session • Gathering information • Explanation and planning • Closing the session Revised November 2005

12. Activity 2 – Getting the best from the consultation (40 minutes) You are asked to • consider the case study you have been given • debate the question (s) posed (20 minutes) • provide feedback Revised November 2005

13. Case study 1 Lisa • Lisa’s first child, a daughter, had severe developmental dysplasia of both hips that was not detected at either the newborn or 6/8 week physical examination. When she started walking oddly her health visitor told Lisa that ‘a toddler will toddle’ which subsequently delayed Lisa’s daughter’s referral for treatment. • Her second child had an ultrasound of his hips as a diagnostic procedure but Lisa is unsure of the value of attending the 6/8 week physical examination because of her previous experience. • Question: How can you ensure that Lisa is able to make an informed choice about having the 6/8 week physical examination screening? Revised November 2005

14. Case study 2 Karen • Karen’s Down’s syndrome screening tests have estimated that she has a 1:50 risk of having a baby with Down’s syndrome. Karen feels this is an acceptable risk for her, but her partner Paul does not, and wants her to have a diagnostic test. The associated risk of miscarriage means Karen does not want to do this. • Questions: if you strongly agreed with either Karen or Paul how would you prevent your views from affecting the way you handled the situation? What would you do if they asked you for your advice? Revised November 2005

15. Case study 3 Abidah • Abidah is 25 years old and nine weeks pregnant. She moved to the UK from Pakistan a year ago to marry her husband. She doesn’t speak much English and doesn’t know anyone in the UK apart from her husband. When they arrive for her booking–in appointment at the hospital, her husband says that they don’t want any tests. • Question: How could you communicate to Abidah the information she needs to make an informed choice about the antenatal screening choices available to her? Revised November 2005

16. Case study 4 Chanelle • Chanelle is 14 years old and she is pregnant. Her pregnancy was confirmed by her GP, Gulzar, five weeks ago when she was eight weeks pregnant. • Chanelle is an intelligent and mature girl who Gulzar feels is Gillick/Fraser ruling competent and able to make informed decisions for herself. Chanelle told Gulzar she was determined to continue with her pregnancy, but was not ready to tell her parents about it. • Questions: How could you communicate to Chanelle the information she needs to make an informed choice about the antenatal screening choices available to her? What issues would you take into account? Revised November 2005

17. Case study 5 Heather • Heather knows she is a carrier for sickle cell because she got pregnant when she was at school and she had an abortion. Her husband doesn’t know about this. He is fiercely anti-abortion and doesn’t want her to have any tests at all. He says why would they want to have these tests when they know they wouldn’t have a termination, whatever was found. Heather thinks that if they know the baby has sickle cell disorder they could plan for that, it wouldn’t be such a shock. • Questions: How would you explain screening options to the couple? How would you ensure that Heather makes antenatal screening choices that are right for her? Revised November 2005

18. Case Study 6 Mandy • Mandy said that the person who did the scan just sat silently looking at everything and recording the information. She said she found this quite anxiety-making because she didn’t know what was going on. At one stage Mandy asked ‘What does that measure?’ and was told ‘The circumference of the head’ with nothing more forthcoming. At the end Mandy was told ‘I think everything’s fine’. But by this time Mandy didn’t believe it as nothing had been explained. • Questions: Reflect on the communication between the sonographer and Mandy. How could it have been handled better?. Revised November 2005

19. Activity 2 – Closing messages (1) Facts about non-verbal communication: • 7% of the message is verbal (what you actually say) • 38% of the message is vocal (how you say it: tone, intonation etc) • 55% of the message is visual (our body language, eyes, smile, posture etc) Revised November 2005

20. Activity 2 – Closing messages (2) Facts about body language: • It has no words or sentences but communicates your feelings • It sends out messages all the time – especially when you are trying not to! • If your words say one thing and your body another, people will believe your body. Revised November 2005

21. Communication skills: a useful resource • Silverman et al (2005) Skills for communicating with patients • The guide lists 70 individual skills of consulting • You can review the skills and have a language to describe and talk about the skills • You can offer practical advice for enhancement For further information see: www.skillscascade.com Revised November 2005

22. Activity 3 – Ethical dilemma (20 Mins) • There is debate about whether you should give women every last fact about possible outcomes, and about how this would affect their decision making • You are asked to debate the following hypothetical scenario and to consider if it is ethical to withhold certain information • It has been suggested within your unit that information could be displayed in waiting rooms to show prevalence and risk of the disorders for which screening is offered. Revised November 2005

23. Activity 3: Discussion point The following wording has been proposed for the posters • Of every hundred women that screen as high risk for Down’s syndrome, only five babies will actually have the condition. The nationally quoted risk of miscarriage as a result of invasive prenatal diagnosis is 1-2%. • Nationally only around 18% of fetal cardiac defects are detected at the routine 20 week anomaly scan Revised November 2005

24. Activity 4 – Improving care This is the opportunity to revisit the challenges identified in Activity 1. • Consider the challenges that have been discussed or during the workshop. • Need to reach a consensus about the ‘top three’ challenges Revised November 2005

25. Key questions • Please identify the three most useful aspects of the workshop in terms of enhancing the care offered to women. • How might you modify your approach to helping women make an informed choice as a result of exploring the learning material Revised November 2005

26. Revised November 2005