A total of 74 health and social care staff (medical, nursing, allied health, risk managers, hospital chaplains and governance staff) from across NHS Scotland participated (Table 2). Of these, 49% were clinical (medical, nursing, allied health) and 51% were nonclinical (risk managers, hospital chaplains and governance staff).
Table 2
Job role
|
Number (%) n = 74
|
Nurse
|
28 (40%)
|
Risk or Governance staff
|
12 (16%)
|
Quality improvement & assurance
|
9 (12%)
|
Child death reviewer/adverse event reviewer
|
8 (11%)
|
Doctor/Consultant
|
5 (7%)
|
Support manager CAMHS
|
4 (5%)
|
Mental health & substance misuse practitioner
|
4 (5%)
|
Healthcare chaplain
|
2 (3%)
|
Pharmacist
|
2 (3%)
|
AHP
|
1 (1%)
|
Patient experience manager
|
1 (1%)
|
Learning disabilities
|
1 (1%)
|
Patient relations
|
1 (1%)
|
Learners’ reaction to training feedback from course evaluation forms
Fifty-nine participants (75%) completed training evaluation forms which asked for details on where the learners accessed the training, feedback on the clarity of the learning aims, the learning technology used and overall satisfaction. The results showed that participants accessed synchronous online training from a variety of venues—workplace, home or a mix—and reported ease of access, appropriate support with technology, reliable connectivity and positive feedback in the use of technology, with high ratings for user satisfaction (Table 3).
Table 3
Learner’s reaction to the training (n = 59)
Participant Role
|
49% clinical (medical, nursing, allied health)
51% non-clinical (risk managers, hospital chaplains and governance staff)
|
Where learning took place
|
34% workplace
34% home
32% mixed setting
|
Confidence in use of technology before training
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98% positive
|
Learning Aims clearly stated
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98% positive
|
Was knowledge of subject matter assessed before, during and after training
|
Before (75%)
During (93%)
After (97%)
|
Assessment of confidence in using TEAMS before training
|
58% positive
34% undecided
8% no
|
Good level of help with technology through programme
|
96% positive
|
Easy to access technology equipment
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98% positive
|
Reliability of connectivity during programme
|
93% positive
|
Technology helped: Communication with other learners, organisers and joint learning with others
|
100% positive
|
Use of technology time-saving way to learn
|
100% positive
|
Overall user satisfaction with training
|
96% positive
|
Thirty-five participants (59%) left additional comments. These were then thematically analysed using NVivo software. Four superordinate themes emerged: enjoyable and interesting course content, new knowledge and skills, use in practice and opportunities to share learning with others (Table 4).
Table 4
Narrative comments from course evaluation forms: learners’ reaction to training:
Super-ordinate theme
|
Indicative quote
|
Enjoyable and interesting content
|
“The programme was engaging and very participatory”..
“The course was pitched just right with lots of interactive material, I especially enjoyed the short films and discussions”
|
New knowledge and skills
|
“The learning aids were very powerful and resulted in reflection on practice/experience”
“I feel it has supported my learning while keeping the activities engaging and interesting throughout.”
|
Use in practice
|
“my confidence and desire to speak with patients has grown massively over the last few weeks”
|
Opportunities to share learning with colleagues
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“I have spoken to many members of my team to explain the benefits of this course and why they should undertake the training in the future if possible. Invaluable training.”
“Would recommend to colleagues”
|
Learning: Pre- and postintervention measures of knowledge and confidence
Participants were asked through pre- and post-training polls to rate their answers to 5 questions before the training and asked the same questions after the training. Participants rated how confident they felt communicating with and including patients and families in adverse event reviews. The participants rated their skills and knowledge about delivering an apology using the 4 Rs (reflection, regret, reason, remedy) and APICCTHS model. These polls were completed only for later training cohorts (n = 42). The results are shown in Figs. 1–5. The results indicate that participants felt more confident including patient and families communicating, crafting, and delivering an apology. Before the training, 12 participants agreed or strongly agreed that they were confident communicating with patients and families, whereas after the training, 36 participants agreed or strongly agreed (Fig. 2). Knowledge and confidence improved in the 4Rs and the APICCTHS model [3]. Only 3 participants felt confident in their knowledge and skills around the 4 Rs before the training, whereas 37 agreed or strongly agreed after the training (Fig. 4).
Behaviour: impact on practice
Thematic analysis of the participants’ reflective practice assignments identified four superordinate themes: inspired to improve, empathic presence, use of models and tools, and compassion for patients and families (Table 5).
Theme 1: Inspired to improve service
This theme resonated with many participants who were able to reflect and recognise aspects of the review process and their performance in this process that previously could have gone better. Participants spoke of the need for team cohesion, a safe space and opportunities to share knowledge, practice and skills. Participants’ reflective assignments spoke of being inspired by the training, recognising how the support offered to patients, family and staff could be improved, as outlined in the indicative quotes below.
“…this training has given me a passion for improving how we as a unit involve patients and staff in our adverse event reviews.” Participant 19
“I have found the learning in the compassionate communication course to be invaluable in my clinical role. I have been sharing the knowledge and tools with all my charge nurse team. We have been discussing scenarios and learning further from each other in a safe environment.” Participant 10
Participants spoke of the importance of these improvements extending into other areas of patient care and not just for the review process. The training offered a chance to reconnect with compassion, which some felt had been eroded through work pressures and the COVID-19 pandemic.
“I strongly feel that the skills of compassionate communication should not be restricted to adverse event reviews; it has been most beneficial to me from a wider perspective, acceptance of where I am at, or should I say have been at and where I would like to get back to.” Participant 2
The impact of the training on staff members’ desire to use these skills in their everyday practice and interactions is evident, as they strongly believe that this training should not only be reserved for participation in the adverse event process but also in all areas of patient care. This finding suggested that participants actively engaged in improvements in their wider practice.
“I have learned a huge amount from the compassionate communication skills course that I feel I can take forward to use, not only in adverse event reviews but also in my interactions in general keeping the compassion through difficult and challenging times” Participant 21
Theme 2: Empathetic presence
Many participants reflected on how patients and families might be affected by the process and how difficult this can be for patients and families; this was something they had not given as much thought to prior to the training. The participants' reflections suggest more focus on patients’ and families' expectations, what matters to them, and whether they felt resolution was achieved. Some reflected on how their empathy toward patients and families could make a difference.
“I had not previously given full consideration as to how patients/families could experience further trauma from the SAER process.” Participant 23
“The learning throughout the course has made me think deeply about how me and the team around me approach and conduct conversations with families”. Participant 26
Participants spoke of compassion and empathy at length, reconnecting with this and why it is necessary as part of the review process. This led to the recognition of the emotions involved following adverse events.
“Frustration and anger may represent fear, and remembering how that feels and the sensation of hopelessness should underpin all my conversations”. Participant 15
There appeared to be a sense of surprise throughout many of the accounts that the adverse event review process is not perceived as a compassionate and empathetic process by patients and families. From the reflections presented, participants considered how to actively include and engage with patients and families through the use of compassionate communication and listening to ensure the creation of a safe and empathetic space for the review process to take place. The inclusion of patients and families is not only restorative for them, but also enhanced the learning of staff.
“Learning from adverse events is key to quality of care. To truly learn from them, we need to talk to each other and the patients and families in a way that is considered and empathic.... Patients and families have important information and learning to share” Participant 1
Theme 3: Use of models and tools
Participants spoke at length about making an apology and the way this was put into context in the training. Their reflections suggest increased knowledge and skills in how to initiate and deliver a sincere person-centred apology and the importance of getting this right as part of the process.
“Apologising for errors is restorative for patients and families yet difficult for healthcare workers to do – even if we know it is the right thing. The knowledge of why it is so difficult helps, highlight why developing the skills to reflect and connect is so important.” Participant 27
“…until participating in this course, I had never really considered the importance of that first apology and how it could potentially shape the direction of any future family involvement in the review process and ultimately the success of the review”. Participant 24
Participants reflected on why they had previously been hesitant or unsure about offering an apology, and some linked this to a blame culture or lack of team cohesion within the review. Reflections suggest that training has given participants an understanding of why an apology can be difficult and of the importance of compassion and empathy.
“Apologising is not necessarily accepting responsibility but displaying a compassionate response to the harm that has been experienced. Genuine empathy can be displayed just as much in how the apology is said; this might be what the families remember most, not so much the specific content of words used”. Participant 11
“Apology - sorry isn’t the hardest word. All previous hesitancy has been a misunderstanding that I’m accepting responsibility, I wouldn’t hesitate to apologise outside of work, and I should carry this into work......... I intend to offer immediate and heartfelt apologies at the time of all future events.” Participant 15
Having knowledge of the APICCTHS model [3] and what this might mean in practice was highlighted. Participants spoke about their intentions to use this tool and how it would shape their interactions going forward.
“The APICCTHS, heart of the review component, has dramatically changed my thinking about the review process, and I find myself now having a shift in my perspective of SAERs.”Participant 23
“I feel far more prepared to bring families in on adverse event reviews and how to give them a full and meaningful apology—using both the 4Rs and the APICCTHS model.” Participant 21
Participant 14 gave an open account of their performance in a previous review and shared their reflections on how they would address a similar situation in the future, using training tools to prioritise compassion and the power of the apology.
“On reflection, the most important part of my first encounter highlighted that I did not apologise for the death of her son, nor enquire about how she may be feeling....... having to revisit this during the learning review – I realise I was too focused on getting the facts correct” Participant 14
“The 4Rs had a significant impact on how I conducted my approach going forward with all involved in the review… I utilise the APPICTHS model as a reminder before every staff and family encounter going forward. This model highlighted the importance of showing compassion”.Participant 14
Theme 4 Compassion for patients and families
Being person-centered was a focus in many of the accounts and references to creating a safe and supportive environment for patients and families and for staff. Participants reflected on how they would approach a review process now.
“I now see that the review being person-centred is something that I have direct influence on, and I am now committed to changing how SAERs are undertaken at my site. Participant 23
“This has made me realise that I can’t afford not to be compassionate. I should be doing it for my patients, and I should definitely be doing it for myself” Participant 15
Participants alluded not only to having increased self-awareness of their role in the review process but also to having wider achievements and outcomes of the adverse event review itself and its role in engaging with patients and families.
“Going forward in the review I’m involved in now I ensured that what mattered to them (family) was at the heart of our conversations and I was open about what we learned along the way”Participant 14
The impact of the training allowed participants to consider and adapt their role in the review process to ensure that the patient’s and family's voice was heard. The quote below alludes to how participant 23 recognises that this might assist healing.
“I now see myself very much as an advocate for the patient’s/families’ voice within the review team... It can sometimes feel that we are processing SAER’s for the organisation and it's learning rather than SAER’s being seen as an important part of caring and providing healing for patients/families.…this training has given me a deeper insight into how patients/families experience SAER’s, the negative impact SAER’s can have, and the opportunity I have to make a positive impact for and with patients/families in supporting them to participate in the SAER review process” Participant 23
The findings from the analysis of participants' reflective practice logs suggest that training-inspired improvement and empathic presence, as participants valued the models, tools presented and the interactive nature of the training delivery. This contributed to a drive among participants to embed more compassionate communication into their review process (Table 5).
Table 5
Superordinate themes and subthemes
Superordinate Theme
|
Subtheme
|
Inspired to improve
|
Inspired to improve the process and the experience for staff, patients and their families in SAER service, share knowledge with colleagues and extend this to other areas of patient care
|
Empathetic presence
|
Communication, active listening, compassion, empathy, increased confidence. development of skills in creating an empathetic presence in the review process
|
Use of models and tools
|
Apology, APICCTHS, Reflection, increased knowledge on how to construct, frame and deliver a sincere apology
|
Compassion for patients and families
|
Drive to embed compassionate culture into the process: ensure the structure of the review has a focus on finding resolution and support for all affected
|