iCAMIRA Facilitator's Resource Manual · scenario is divided into two separate video clips: one where the nurse engages effectively with the patient, which facilitates decreased patient

Facilitated Discussion Program

Facilitator Guide

Table of Contents

Facilitator Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Program Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Equipment, Resources & Planning . . . . . . . . . . . . . . . . . . 6

Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Facilitator Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Facilitator Instructions . . . . . . . . . . . . . . . . . . . . . . . . . 7

Program Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

DVD Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Scenario 1: Rose Hatfield . . . . . . . . . . . . . . . . . . . . . . 10

Rose Clip 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Rose Clip 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Scenario 2: Phil Archer . . . . . . . . . . . . . . . . . . . . . . . . 15

Phil Clip 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Phil Clip 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Scenario 3: Amanda Cooper . . . . . . . . . . . . . . . . . . . . 20

Amanda Clip 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Amanda Clip 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Scenario Summary Points . . . . . . . . . . . . . . . . . . . . . . 24

1© 2010, Mount Sinai Hospital, Toronto, Canada

Facilitator Welcome

Welcome to the Facilitator Guide for the Facilitated Discussion Program. This guide has been prepared to assist you in the delivery of the program. It outlines the purpose of the training, provides a description, the learning objectives for participants, and outlines detailed steps on how to organize the program.

This guide should be used in partnership with the Introduction Guide. All of the facilitator resources and participant handouts can be found in the Resources section of the manual.


Introduction Guide

iCAMIRA Facilitator’s Resource Manual

2 © 2010, Mount Sinai Hospital, Toronto, Canada

Program Overview

Figure 1: Overview of the Education Program

PurposeThis training program provides participants with an opportunity to view and discuss patient scenarios as they pertain to illness related patient anxiety and to practice using the Observer Rating Scale for Patient Anxiety. A clinical leader/content expert or team of individuals leads the program and facilitates the discussion.

DescriptionThe program is designed to be 2 hours in length. It consists of a brief introduction/overview and viewing three patient scenarios on a DVD. The facilitator leads the participants through scoring of the anxiety tool and a series of reflective questions. An explanation of the scoring and discussion points for the reflective questions is provided later on in this guide.

A DVD containing the scenarios is included in the manual. The scenarios were filmed using Standardized Patients (SPs) for both the patient and healthcare professional roles and are generic medical/surgical patient scenarios.

Simulation WorkshopProgram

FacilitatedDiscussion Program

EvaluationAnxietyAssessment

Independent Learner

Program

OrganizationalReadiness

eLearningModule


Program Planning8 Weeks prior to the program

� Determine the date, time and location for the program

� Determine your minimum and maximum registration

� Book rooms and AV equipment

� Prepare the promotional materials and registration process

� Promote the program

� Provide the eLearning module instructions to registered participants

4 Weeks prior to the program

� Send promotional reminders about the facilitated discussion program

� Send reminders about the eLearning module to registered participants

2 Weeks prior to the program

� Print the facilitator resources, including :

– Case Scenarios with Scoring Legends

� Print the participant handouts, including :

– iCAMIRA Participant Evaluation Form

– Observer Rating Scale for Patient Anxiety (3 per participant)

– Reflective Questions Worksheets

� Confirm the eLearning module completion by the participants and send a reminder email to those who have not yet completed the module

� Order the catering for the program (optional); consider the dietary needs of participants

Learning ObjectivesThe learning objectives for the Facilitated Discussion Program are:

1. Recognize symptoms of low, moderate and high anxiety through use of the standardized assessment tool.

2. Describe various verbal and non-verbal communication techniques for engaging patients.

3. Discuss interventions that help manage patient anxiety.


1 - Case Scenarios with Scoring Legend

2 - iCAMIRA Participant Evaluation Form

5 - Observer Rating Scale for Patient Anxiety

6 - Reflective Questions Worksheets



3 Days to 1 week prior to the program

� Send an email reminder to participants and provide instructions and directions to the program location

� If registration does not meet minimum numbers, cancel room bookings, catering, SPs and send a cancellation email to registered participants and managers

1 Day prior to the program

� Confirm the catering order (retain contact information and a copy of the catering order in case of additional inquiries)

� Confirm the equipment and room bookings (retain contact information in case of additional needs)

� Print signs for directions to the program location

� Review the facilitator guide and resources

� Print registration roster

Day of the program

Before the program

� Post the signs for directions to the program

� Set up chairs in the main room in a manner that will support the discussion among participants

� Load the DVD

� Set up the registration/sign in area

� Receive catering

End of the program

� Hand out certificates (if required)

� Remind participants to gather all of their belongings

� Clean up any remaining materials

� Take down signs for directions to the program


Post program

� Email the group of participants if any of their belongings were left behind

� Update your participant tracking system, confirming participants who attended the facilitated discussion and those who did not

� Provide an electronic copy of the confirmed participants to the managers (if required)

� Send out ‘thank yous’ as required

� Write the program summary report (if required); summarize how it went and note any tips or suggestions for running future programs (this is an opportunity to refine the process of planning, implementing and evaluating the facilitated discussion program)




Equipment, Resources & Planning

Equipment � DVD Player

� TV

� Screen

� Presentation room large enough to accommodate all of the participants for the group discussion

� Chairs (1 per participant and facilitator)

� Tables (consider whether your space will allow for a set-up where participants can face each other)

� Box of pens

� Name tags

� Masking tape

� Catering and tables to place the food/beverages (optional)

Facilitator ResourcesA copy of the following resources can be found in the Resources section of this manual.

Planning Resources

f The following resources were developed for the Simulation Workshop Program and can be modified for the Facilitated Discussion Program:

– Checklist for Simulation Workshop

– iCAMIRA Poster

– iCAMIRA Registration (sample email/poster)

– Incomplete eLearning Module (sample email)

– Preparing for the Simulation Workshop (sample email)

Implementation Resources

– Case Scenarios with Scoring Legend

– DVD of Patient Scenarios

– iCAMIRA Participant Evaluation Form

1 - Case Scenarios with Scoring Legend

2 - iCAMIRA Participant Evaluation Form

1 - Checklist for Simulation Workshop

2 - iCAMIRA Poster3 - iCAMIRA Registration4 - Incomplete eLearning

Module5 - Preparing for

Simulation Workshop


– Observer Rating Scale for Patient Anxiety (3 per participant)

– Reflective Questions Worksheet

– Registration/sign in form

Facilitator Instructions

Program Agenda

8:00 – 8:15 am8:15 – 9:50 am9:50 –10:00 am

Introduction/OverviewDVD Scenarios and DiscussionWrap-up and Evaluation

Program Overview Introduction/Overview (15 minutes)

During the introduction and overview, cover the following key points:

� Welcome

� Have the facilitator and participants introduce themselves

� Housekeeping: note the location of the washrooms; ask participants to turn off all personal communication devices

� Ensure that each participant has 3 observer rating scales and the reflective questions worksheets so they can jot notes

� Overview of the workshop:

– The workshop is Part 2 of the illness related patient anxiety course

– The goal is to apply knowledge from eLearning module using generic scenarios that occur in the clinical areas on a regular basis

– The session provides an opportunity for interprofessional discussion and learning

– The session also provides an opportunity to practice using the anxiety tool

– The workshop is experiential and not evaluative

5 - Observer Rating Scale for Patient Anxiety

6 - Reflective Questions Worksheet




Scenarios (90 minutes)

The DVD contains three scenarios. There is one scenario demonstrating low anxiety, one demonstrating moderate anxiety, and one demonstrating high anxiety. Each scenario is divided into two separate video clips: one where the nurse engages effectively with the patient, which facilitates decreased patient anxiety; and one where the nurse does not engage effectively with the patient, which does not decrease patient anxiety.

After each clip, it is recommended that you pause the DVD. This provides an opportunity to review the scoring of the anxiety tool with the participants and reflect on a series of questions that relate to the scenario that has just been viewed.

Detailed points of what you will see and hear once you load the DVD are outlined in the DVD Scenarios section of this guide. Also included is the scoring for the anxiety tool and discussion points for the reflective questions in each scenario.

Wrap-up and Evaluation (10 minutes)

� Have the participants complete the workshop evaluation

� Hand out the certificates for participation (if required)

� Remind the participants to gather all their belongings


DVD Scenarios

Note: The SPs in these scenarios are depicting the role of an RN. The focus of the scenarios is not about healthcare professional’s roles and skills. The predominant focus is about communication and therapeutic engagement with the patient, which is applicable and can be generalized to all members of the interprofessional team.

When you load the DVD, you will hear the host narrator say:

“On screen there are two links: Facilitated Discussion and Independent Learner . If you are a facilitator leading a group through the scenarios and discussion, click Facilitated Discussion . If you are working through the scenarios on your own, click Independent Learner .”

Once you have clicked on the Facilitated Discussion link, you will hear the host narrator say:

“Welcome to the Facilitated Discussion version of the iCAMIRA scenarios . Please refer to the Facilitated Discussion section of your facilitator manual .

Press play when you are ready to watch the first scenario .

You can pause the DVD as necessary and you can go back and watch the scenarios as often as you wish .”

There are three patient scenarios included on the DVD:

Scenario 1: Rose HatfieldScenario 2: Phil ArcherScenario 3: Amanda Cooper

Note: Please refer to page 7 of the Independent Learner Program Participant Guide for more detail about how to operate the DVD.


Independent Learner Program



Scenario 1: Rose Hatfield

A reminder that there are 2 video clips per scenario. It is recommended that you pause for scoring of the tool and discussion after each clip. The clip where the nurse engages less effectively is always played first.

You can read the following stem (introduction) to the scenario and/or have the participants read along from the Reflective Questions Worksheets for Facilitated Discussion.

Rose Hatfield is a married woman in her 50s with three daughters. She came to the emergency department 2 days ago with severe abdominal cramping.

Rose is aware of her bowel obstruction, which is being treated. She is on intravenous fluids, has a naso-gastric tube, and is receiving Tylenol extra strength every 4 hours as needed for pain. The team has done an X-ray, an ultrasound and some blood work. The Resident she saw this morning told her that they detect an obstruction in the large intestine, but they are awaiting results of the MRI before they can proceed.

Jill is meeting Rose Hatfield for the first time. As you watch the scenario, observe not only what Jill and Rose are saying, but also observe the non-verbal communication. As you watch, have a copy of the anxiety scale with you and score each of the categories: anxious mood, fears, trouble thinking, tension, and sleep problems. There may be some categories that Jill does not assess. Think of the questions you might ask Rose to obtain all the necessary information.

Rose Clip 1

Facilitator Questions and Points for DiscussionQUESTION:

Based on your scoring of the anxiety assessment tool, is Rose’s anxiety low, moderate or high?

DISCUSSION:

Rose’s anxiety would be assessed as low.

f Rose appears very minimally anxious, so that would score a 0.


f She expresses a slight fear with regards to being ill and perhaps losing her job, so this would be scored as a 1.

f Trouble thinking wasn’t directly assessed, but Rose does not appear to be having any difficulties with this, so would score a 0.

f There is some tension in her face so depending on interpretation would be a 0 or 1.

f She clearly indicates difficulty with sleep so this would score a 2.

f Total score is 3 or 4, which suggests low anxiety.

QUESTIONS:

What strategies does Jill use to engage Rose? Does she... seek information? ... ask open-ended or directive questions? ... use touch and appropriate

personal space?

What do you notice about Jill’s non-verbal communication?

DISCUSSION:

f Jill clearly obtains the information for her assessment by asking questions such as: “How are you sleeping”? “How’s the abdominal pain”? These are considered open-ended questions. This gives Rose the opportunity to respond with a simple yes or no or, if she chooses, go on to elaborate. Although Jill’s focus is clearly on the patient, her facial expression and overall disposition was one of being rushed. As if to say “…I’m here to get the info I need for my assessment, I’ll answer some questions and then I’m moving on.”

QUESTIONS:

How would you describe Rose’s body language? - Is it relaxed or tense? - Does she look worried, anxious, upset?

DISCUSSION:

f Rose’s expression is somewhat strained. She is clearly tense, but not overly anxious.




QUESTION:

What appears to be Rose’s main concern/fear/worry?

DISCUSSION:

f Rose appears to be quite focused on her MRI result and she also has some concern about being in the hospital too long and the implications for her job.

QUESTIONS:

Do you think Jill adequately addressed Rose’s anxiety? Explain why you think so.

Would you have done anything differently to address Rose’s concerns?

DISCUSSION:

f These are subjective questions and meant to stimulate discussion before launching into the second clip.

Rose Clip 2

Facilitator Questions and Points for DiscussionQUESTION:

Based on your scoring of the anxiety assessment tool in this second clip, is Rose’s anxiety low, moderate or high?

DISCUSSION:

Rose’s anxiety would be assessed as low.

f Rose appears very minimally anxious so that would score a 0.

f In this interaction Rose does express a fear of an outcome of cancer so this would be scored as a 2.

f Trouble thinking wasn’t directly assessed. Rose does not appear to be having any difficulties with thinking so would score a 0.

f There is some tension in her face so depending on interpretation would be a 0 or 1.

f She clearly indicates difficulty with sleep so this would score a 2.

f Total score is 4 or 5, which suggests low anxiety.


A few words about the assessment tool. The scoring is subjective which is why some categories are scored within a range. It’s very likely that your total score will vary with that of your colleagues. It’s okay if everyone doesn’t end up with exactly the same number. What’s important are the low, moderate and high categories. These categories determine the appropriate interventions for decreasing anxiety.

For this particular interaction, you may be wondering why the fears category is a 2 instead of a 3. Looking at the scoring scale, a 2 indicates the symptom is obvious, but does not interfere with function. A score of 3 indicates that the symptom is severe enough to be interfering with the patient’s function. In this interaction, it is clear that Rose’s function is not impaired by her fear.

QUESTIONS:

What strategies did Jill use to engage Rose? Does she... seek information? ... ask open-ended or directive questions?

Compared to the first clip how is her use of touch and personal space?

Is Jill’s non-verbal communication different from the first clip and if so, how?

What did this interaction reveal as Rose’s greatest concern or fear or worry?

What did Jill do differently in this interaction to get that information?

DISCUSSION:

f Jill engages the patient by asking more open-ended questions like, “How are you doing today”? “Is there something else worrying you”? Jill probes a little to get more information about Rose’s focus on the MRI result. She also stands closer to Rose and her tone is a little warmer.

f The other thing Jill does in this clip is communicate a lot of information to Rose. You may be thinking, “what”?!! Jill couldn’t tell Rose anything about her MRI result. It’s true that Jill did not have the actual test result, and even if she did would not be able to convey the result. That’s not part of her scope of practice. It’s okay to say that you don’t know or you don’t have the results. But don’t stop there. Think about all the information that Jill did tell Rose. She told her how long the result might take and that the doctor would be the one to come in and tell her the result, and that once the result was back, a treatment plan would be developed. We sometimes take these things for granted because we live and breathe these routines everyday. Remember however, that for the patient, hospital procedures and routines are unfamiliar, and this often gives rise to fears, anxieties and worries.




f At this point, you may think, “The anxiety tool scoring for the two clips is the same. What’s the difference between the two clips?”

f Rose is the type of patient that healthcare professionals (HCPs) often describe as the “nice or pleasant” patient. She doesn’t want to disturb anyone or rock the boat. On the surface, her main concern is the MRI result.

f Jill’s interaction with Rose in the first clip is, reasonable. In the second clip however, Jill’s tone of voice is noticeably warmer. She provides Rose with a lot of useful information about the test result process and the availability of services that might be helpful. She observes Rose’s pre-occupation with the MRI result. Jill takes this as a cue to ask even more open-ended questions. She probes with the question, “Is there something else worrying you?” Sometimes HCPs are wary of asking such pointed questions. Don’t worry; if the patient finds your question too intrusive or doesn’t want to talk, he or she will let you know…and that in itself is a piece of information!

f All of these things help Jill to build trust and rapport with Rose. That trust provides the opportunity for Rose to divulge more about herself. This gives Jill a much clearer picture of why Rose is so worried about the MRI result.

f Our role as HCPs is not just about assessing anxiety and getting a score to document. Our role is to recognize our patients’ anxiety and to try and manage it. Everything Jill did in the second clip to build trust and rapport helped to decrease Rose’s anxiety. Not convinced…go back and watch Rose’s body language at the end of each of the clips…what do you notice? One more thing…Jill’s interaction in the second clip didn’t take much more time than the first clip and overall provided Rose with a better patient experience.


Scenario 2: Phil Archer

A reminder that there are 2 video clips per scenario. It is recommended that you pause for scoring of the tool and discussion after each clip. The clip where the nurse engages only minimally is always played first.


Phil Archer is a widowed man of 75 who lives alone in a walk up apartment. He has Type I diabetes, which he does not manage very consistently. He uses the emergency department as his main location for care. He has been a frequent visitor to the hospital for various reasons related to his health over the years.

Phil presented to the emergency department with concerns about his foot 3 days ago. It didn’t hurt so much but it was red and swollen and starting to ooze. His blood glucose levels were very high. He was admitted for tests. His insulin is being titrated and he is receiving intravenous antibiotics. He is eating and can move around but isn’t getting out of bed except to go to the bathroom. The surgical consult team have assessed his foot.

Mary is meeting Phil Archer for the first time. As you watch the scenario, observe not only what Mary and Phil are saying, but also observe the non-verbal communication. As you watch the scenario, have a copy of the anxiety scale with you and score each of the categories: anxious mood, fears, trouble thinking, tension, and sleep problems. There may be some categories that Mary does not assess. Think of the questions you might ask Phil to obtain all the necessary information.




Phil Clip 1

Facilitator Questions and Points for Discussion QUESTION:

Based on your scoring of the anxiety assessment tool, is Phil’s anxiety low, moderate or high?

DISCUSSION:

Using the anxiety assessment tool Phil’s anxiety would be assessed as moderate.

f It’s not clear from this interaction if he has an anxious mood, fears or trouble thinking, so all those components would be scored as 0.

f Phil’s hand ringing and lack of eye contact indicate he is experiencing tension and would be scored as a 2.

f Phil has clearly stated that he has not slept well in hospital. It’s unclear whether this is interfering with Phil’s function and therefore would score a 2.

f Phil’s total score is 4 and therefore a low level of anxiety. Since the assessment has given us no information on the first three categories, we really can’t consider this an accurate reflection of Phil’s level of anxiety.

QUESTIONS:

What strategies does Mary use to engage Phil? Does she... seek information? ... ask open-ended or directive questions?

Describe Mary’s non-verbal communication.

Describe Phil’s non-verbal communication.

DISCUSSION:

f Mary’s tone and facial expression are pleasant. Phil is not making eye contact with Mary and his facial expression appears somewhat put-off or disinterested. Mary seeks information for her assessment by asking questions such as: “How was your sleep last night?” “How’s your foot?” “How are you feeling this morning?” These are open-ended questions.


QUESTION:

Do you have a sense of Phil’s main concern or fear or worry?

DISCUSSION:

f Based on this interaction, it’s very hard to know what Phil’s main worry is.

QUESTION:

Would you have done anything differently in your interaction with Phil?

DISCUSSION:

f Phil is a gentleman who doesn’t open up easily. He’s not a big conversationalist! Because of this, there may be a tendency for HCPs to “write Phil off” and forget about him, thinking that he doesn’t want to engage. The fact that Phil is asking for nurses Margaret or Jackie indicates that he has engaged with staff in the past. This is a cue for Mary.

f Because Phil isn’t a big communicator, he has a lot bottled up and going on in his head. It’s often very hard for this type of patient to answer open-ended questions. They have difficulties focusing on any one problem or concern. So, as HCPs, we need to help focus their thinking. Rather than asking, “How was your sleep last night?”, Mary could ask, “Did you sleep well last night?” Based on Phil’s responses, she could continue to ask more directive questions. This would allow Phil to focus his thinking while at the same time allow for some rapport to develop between Phil and Mary. Another approach would have been for Mary to pick up on Phil’s cue when he responded that he hadn’t been sleeping well in hospital. To ask Phil why he was “having difficulty sleeping”, or “what was interfering with his sleep”, would have helped Mary gain a better understanding of Phil.




Phil Clip 2

Facilitator Questions and Points for Discussion QUESTION:

Based on this interaction, what is your scoring of the anxiety assessment tool for Phil?

DISCUSSION:

f Phil’s anxious mood would score a 1.

f He has a fear of losing his foot and fears the implications for his independence, so the fears category would score a 2.

f The trouble thinking category would be scored a 3 because it is interfering with his function: he can’t remember information given to him by the surgeon and he can’t read the newspaper.

f The ringing of his hands and lack of eye contact indicate a score of 2 for the tension category and sleep would score a 1 or 2.

f Total score is 9 or 10 which indicates a moderate level of anxiety.

Notice in this second clip that Phil is not engaged and he may be upset that familiar nurses are not looking after him. Mary is not put off by this. She attempts to connect with Phil by saying, “I’d like to get to know you better.” Mary also tries to find out more about why Phil hasn’t been sleeping by asking, “What’s up?” This conveys to Phil that Mary is interested and helps to develop rapport.

QUESTION:

What do you think Mary accomplishes by moving to the other side of the bed and gently tugging at the bedsheets?

DISCUSSION:

f In moving to the other side of the bed, Mary placed herself directly in Phil’s line of site, tugged at the bedsheet and asked, “Is there something you’re upset or worried about?” When patients are anxious or worried, they are often not aware of their behaviour. Fidgeting and wringing of hands can indicate anxiety. By picking up on that cue, Mary is making Phil aware of his fidgeting and it also conveys to Phil that Mary is paying attention which further develops rapport.


QUESTION:

How does Mary get to Phil’s main fear or worry?

DISCUSSION:

f Mary realizes that she is not getting any information from Phil with open-ended questions and so switches to a more direct line of questioning. “Are you worried about your foot, Phil?” There is a possibility that Phil would have answered, “no” and Mary would then need to ask another question. In this case, Phil’s main fear is about his foot and what that might mean for his independence.

f Mary’s interaction in the first clip was reasonable, but incomplete. Recall that three of the five categories on the anxiety tool were not assessed. Based on the interaction in the second clip, it is clear that spending a bit more time to engage with Phil is very beneficial in getting not only a complete assessment of his level of anxiety, but also a better grasp of Phil’s situation overall. If you can’t recall, view the two clips again and pay attention to Phil visibly relaxing in the second clip as compared to the first clip.

f For patients like Phil, there are two important points to remember: 1. They need more time to open up and engage which means that as a HCP

you may need to return several times to engage in order to develop some rapport

2. Closed or directive type questions will be more effective

f This becomes even more pertinent when the patient is anxious or worried. It may seem counter-intuitive to ask closed or directive type questions because as HCPs we are taught to ask open-ended questions. It’s generally a good rule of thumb to start with open-ended questions, and be prepared to move to directive or more close-ended type questions when the open-ended approach doesn’t work.

f So the next time you encounter a Phil-type patient, don’t dismiss them because of their apparent lack of engagement. There’s often a lot going on for these patients. It just takes a little more time and patience as HCPs to find it out.




Scenario 3: Amanda Cooper

A reminder that there are 2 video clips per scenario. It is recommended that you pause for scoring of the tool and discussion after each clip. The clip where the nurse engages only minimally is always played first.


Amanda Cooper is a married woman in her 40s. She is the mother of five. Yesterday Amanda was shopping when she began to feel weak and her vision went black. She was then brought to the ER where they did a neurological workup and determined that she had a Transient Ischemic Attack (TIA) “mini stroke”.

Amanda has been sick her whole life and is a seasoned consumer of healthcare services. She had rheumatic fever as a child and has been diagnosed with mitral valve stenosis. She is on Coumadin because they told her she has thick blood and she needed it for her heart. The medical team is doing a diagnostic workup including blood work, electrocardiogram and MRI of the head. There is nothing conclusive at this point and the working diagnosis is still a TIA.

Mike is meeting Amanda Cooper for the first time. As you watch the scenario, observe not only what Mike and Amanda are saying, but also observe the non-verbal communication. As you watch the scenario, have a copy of the anxiety scale with you and score each of the categories: anxious mood, fears, trouble thinking, tension, sleep problems. There may be some categories that Mike does not assess. Think of the questions you might ask Amanda to obtain all the necessary information.


Amanda Clip 1

Facilitator Questions and Points for Discussion QUESTION: Based on your scoring of the anxiety assessment tool, is Amanda’s anxiety low, moderate or high?

DISCUSSION:

f Amanda’s anxiety and fears each score a 4. She is completely focused on having a brain tumor and dying.

f Trouble thinking was not clearly assessed, however she is using her laptop which would indicate an ability to concentrate.

f She is not crying or restless, but there is a certain tension in her body so tension could score a 1.

f She does indicate an inability to sleep and so would score at least a 2. It would require a little more probing to get a sense of how much the lack of sleep is contributing to Amanda’s overall anxiety and whether it is interfering with her ability to function.

f Total score is 11 which indicates a high level of anxiety.

QUESTIONS: Amanda is anxious as soon as Mike walks in. What are the signs of her anxiety?What do you observe in Mike’s non-verbal communication?

Mike tells Amanda to calm down. What impact does that have on her anxiety?Does Mike do anything to decrease Amanda’s anxiety?

DISCUSSION:

f With Amanda, it is important to recognize the signs of high anxiety and to try and manage, rather than assess the anxiety. Her level of anxiety is clearly high, as are her fears of a brain tumor and dying.

f Mike’s body language is one of retreating from Amanda and trying to leave the room as quickly as possible. Telling Amanda to “calm down” just inflames the situation, as she does not feel heard or supported. At times, it appears as if Mike is trying to control a bit of a smirk as if to say, “Lady…are you for real?” None of these things help to build rapport with Amanda, nor do they help to decrease her anxiety.




Amanda Clip 2

Facilitator Questions and Points for Discussion QUESTION: Based on your scoring of the anxiety assessment tool, is Amanda’s anxiety low, moderate or high?

DISCUSSION:

Scoring is the same as clip 1.

QUESTIONS: What does Mike say and do to help decrease Amanda’s anxiety?Is the deep-breathing exercise effective with Amanda?

DISCUSSION:

f In this clip, Mike’s body language is conveying that he is going to stay and not run out of the room. He listens and is supportive. He provides reassurance that the team is trying to figure out what is wrong with her and not keeping anything from her in the process. Note Amanda’s response and visible change in presentation when Mike says, “Anyone in your position would be worried.” She is relieved by his normalizing statement, which conveys acknowledgement and support. Similar to the Rose scenario, Amanda has questions that Mike can’t completely answer, yet he provides what information is available. Amanda’s anxiety visibly decreases some more when Mike says, “Now I heard you mention a stroke and a TIA. These are not the same thing…” Listening, understanding and providing some information all build trust with Amanda and help to decrease her anxiety.

f In this instance, the deep-breathing exercise is not very effective. It’s always worth a try as some patients find it very effective. Remember that you can also print out the Information Sheet: Breathing Exercises and Information Sheet: Relaxation Techniques and leave it with your patient. Even a patient as anxious as Amanda might do the exercise on their own after the healthcare professional has left the room.

f Similar to the Rose scenario, you may be saying to yourself, “The anxiety tool scoring for the two clips is the same.” “What’s the difference between the two clips?”

3 - Information Sheet: Breathing Exercises

4 - Information Sheet: Relaxation Techniques


f In the first clip, Mike is challenged by Amanda’s high affect and anxiety. His body language and tone of voice convey to Amanda that she is not being taken seriously and that Mike can’t wait to leave the room. For Amanda, –who is looking for answers and some re-assurance that she’s not dying,- Mike’s interaction does nothing to decrease her anxiety.

f In the second clip, Mike is fully present; not retreating. This is very important in building an initial connection with Amanda. Mike listens and conveys understanding for Amanda’s situation. He provides re-assurance that the team is not avoiding her and provides as much information as he can to allay her fears. As you saw in the second clip, all of these things decreased Amanda’s anxiety.

f The challenge for HCPs is to find a way to tolerate Amanda’s affect. If the HCP just keeps leaving the room (as in the first clip), Amanda’s anxiety will not be addressed and in fact will continue to increase, which will probably lead to her constantly ringing the call bell.

f It’s tempting to label patients like Amanda as histrionic or “over-the-top”. They are often viewed as “difficult or needy”. HCPs need to recognize the patient’s distress and find ways to manage their own discomfort with this high affect. Start by recognizing the patient’s distress. Use your colleagues for support, have a care plan for consistency and be aware of your own triggers.

f Our role as HCPs goes beyond assessing for anxiety and getting a score to document. Our role is to recognize our patient’s anxiety and to try and manage it. Everything Mike did in the second clip to build trust and rapport helped to decrease Amanda’s anxiety. One more thing that bares repeating…Mike’s interaction in the second clip didn’t take a lot more time than the first clip, and overall, provided Amanda with a better patient experience!




Scenario Summary Points

Now that you have seen and reflected upon all three scenarios, let’s summarize the key points.

1. Engaging your patients and developing rapport helps them feel cared for and will help decrease their anxiety.

2. Engaging your patients and developing rapport improves the patient care experience and gives you more job satisfaction.

3. Recall from the scenarios that it really didn’t take a lot more time to engage and do a good assessment of the patient’s anxiety. Remember that an extra minute can make a big difference in decreasing your patient’s anxiety and actually save you a lot of “responding to call-bell” time in the end.

4. Be aware of “cues” from the patient and don’t be afraid to ask questions rather than trying to guess what the cues mean. The cues may be verbal or non-verbal.

5. Each patient is different. Use the different communication techniques you’ve learned to connect with your patient.

6. The anxiety assessment tool provides you and your colleagues with a common language with which to communicate about patient anxiety. It is a subjective tool, so not everyone will have exactly the same score. What are important are the categories of low, moderate and high. It is these categories that determine the appropriate interventions.


References

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3. Bohachick, P. (1984). Progressive relaxation training in cardiac rehabilitation: Effect on perceptions of challenges, control, competition and collaboration in Ontario’s evolving healthcare system. Healthc Q., 8(3), 36-47.

4. Lawlis, G.F., et al. ( 1985). Reduction of postoperative pain parameters by pre-surgical relaxation instructions for spinal pain patients. Spine, 10(7), 649-651.

5. Frazier, S.K., et al. (2002). Management of anxiety after acute myocardial infarction. Heart and Lung: The Journal of Acute and Critical Care, 31(6), 411-420.

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7. Walker, F.B., et al. (1987). Anxiety and depression among medical and surgical patients nearing hospital discharge. Journal of General Internal Medicine, 2(2):99-101.

8. Simon, E.P., et al. (1995). Delivery of home care services after discharge: what really happens. Health and Social Work, 20(1):5-14.

9. Creed, F., et al. (2002). Depression and anxiety impair health-related quality of life and are associated with increased costs in general medical inpatients. Psychosomatics, 43(4):302-309.

10.Moser, D.K. (2002). Psychosocial factors and their association with clinical outcomes in patients with heart failure: Why clinicians do not seem to care. European Journal of Cardiovascular Nursing, 1(3):183-8.

11. Burman, M.E., et al. (2005). Treatment practices and barriers for depression and anxiety by primary care advanced practice nurses in Wyoming. Journal of the American Academy of Nurse Practitioners, 17(9):370-80.

References



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16.Gaba, D.M. (2004). The future vision of simulation in healthcare. Quality Safe Healthcare, 13 (Suppl 1);i2-i10.

17.Nishisaki, A., et al. (2007). Does patient simulation improve patient safety, self-efficacy, operational performance and patient safety. Anesthesiology Clinics, 25:225-236.

18. Johnson, J.A., et al. (1996). Effectiveness of standardized patient instruction. Journal of Dentistry Education, 60(3):262-66.

19.Estrada, C.A., et al. (1997). Positive affect facilitates integration of information and decreases anchoring in reasoning among physicians, Organizational Behaviour and Human Performance, 72:117–135.

20.Blue, A.V., et al. (1998). The effectiveness of the structured clinical instruction module. American Journal of Surgery, 176(1):67-70.

21.Madan, A.K., et al. (1998). Comparison of simulated patient and didactic methods of teaching HIV risk assessment to medical residents. American Journal of Prevention Medicine, 15(2):114-9.

22.Aspegren, K. (1999). How to get the best physicians? Admission procedure and education must cooperate. Lakartidningen, 96(36):3742-3.

23. Isenberg, S.B., et al. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27:10-28.

Documents

iCAMIRA Facilitator's Resource Manual · scenario is divided into two separate video clips: one where the nurse engages effectively with the patient, which facilitates decreased patient