Nurse Education in Practice xxx (2015) 1e7
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Midwifery education in practice
Teaching midwife students how to break bad news using the cinema: An Italian qualitative study Laura Fieschi, PhD, RM a, *, Barbara Burlon, PhD Student, RM b, Maria Grazia De Marinis c a
School of Midwifery, University of Parma, Italy Doctoral School of Nursing, University of Rome “Tor Vergata”, 00173 Rome, Italy c School of Nursing, Campus Bio-Medico University of Rome, Italy b
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 15 January 2015
Delivering bad news is a difficult task that involves all healthcare professionals, including midwives. The hypothesis is that, in order to learn how to disclose and to discuss bad news, students need a phase of personal reflection, of awareness of their own emotional processes. The use of films in healthcare education can foster this process evoking different emotions concerning suffering and disease, in a “safety zone”. This study examines the effects that a course, which uses reflection as a method of learning and the cinema as a teaching tool, produces on a little group of Italian third-year Midwifery students. From the content analysis (supported by Atlas-Ti® software) of the texts produced by the students after the vision of two entire films, it appears that they correctly identified many elements related to good and poor communication of bad news and that they were able to describe the emotions felt while watching the film, but still revealed a certain difficulty to interpret them. The course helped students to recognize the value of reflection on their emotions to better understand others, to empathize with people who suffer, but also to recognize their difficulties and compete with their own limits. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Midwifery education Bad news Cinema Reflective practice
Introduction The role of midwives in communicating bad news to patients and relatives is important because, being in daily close contact, they may understand how women deal with their condition, know their concerns and desires. Midwives may be more aware of how women adapt to what they are told and may monitor the patients' realization of their condition (Dewar, 2000; Lalor et al., 2007; Warnock et al., 2010). Background Breaking bad news Any information that produces a negative alteration to a person's expectations concerning the present and future could be deemed bad news (Buckman, 1984). Bad news does, of course, have gradations which, to a certain extent, are subjective, dependent on
* Corresponding author. E-mail address: laura.fi[email protected] (L. Fieschi).
an individual's life experiences, personality, spiritual beliefs, philosophical standpoint, perceived social supports, and emotional hardiness (Fallowfield and Jenkins, 2004). The expression ‘breaking bad news’ is usually associated with the moment in which negative medical information is communicated to patients and/or their relatives. During last thirty years many changes have occurred in the healthcare world, the concept of bad news has changed and the communication function is no longer limited to the physician. “Breaking bad news, writes Tiernan (2003) is not just about communicating about diagnosis or recurrence, imparting correct information, discussing the transition from active therapy to palliative care; it is not just about the correct words to use; it is not even just about listening. Communication is about all of these things, but it is about much more. Communication is about the relationship we establish and build with our patients.” Delivering bad news is a difficult and stressful experience that takes place before, during and after bad news is broken (Arber and Gallangher, 2003; Rosenzweig et al., 2008). Discomfort with disclosing bad news may be due to many factors: lack of training, fear of patients' emotional reactions, fear of being blamed for the bad news, fear of one's own emotional reactions, fear of the
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Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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patients' suffering and death, personal fear of illness and death, and uncertainty associated with not being able to provide answers (Buckman, 1984). Institutional barriers such as inadequate amounts of time or not having adequate support from other members of the hospital institution are also reported (Dosanjh et al., 2001). The reluctance to communicate bad news has been recognized for a long time. Rosen and Tesser (1970) coined the term, “MUM effect” for this tendency, shown either by not transmitting the message at all, or by delegating the task to someone else. Moreover, in many reports of adverse obstetric incidents, it often emerged that, due to lack of communication, the woman, her partner and family felt that no-one had listened to them, causing litigation cases (Bick, 2010). Teaching methods Much has been written about the skills which are necessary for the effective delivery of bad news and consensus guidelines have been developed, for example SPIKES (Setting, Perception, Invitation or Information, Knowledge, Empathy, and Summarize or Strategize e Baile et al., 2000), ABCDE (Advance preparation, Build a therapeutic environment/relationship, Communicate well, Deal with patient and family reactions, Encourage and validate emotions e Rabow and McPhee, 1999) and others. The main negative aspect is that guidelines and protocols do not adequately account for the individual's interpretation of the significance or impact of the news. Moreover, although the various guidelines offer practical suggestions, they do not address the emotional aspects of the problem. Before providing students with instructions on how to behave, as sustained by Arber and Gallanger (2003) and Sandars (2009), we believe a phase of personal reflection, of awareness of their own emotional processes is fundamental, because what affects people's lives cannot simply be translated into a list of actions, but must result from the understanding of the complexity of all the elements, the feelings, and the emotions both of the operators and of the patients and their families. Most of the studies in literature use standardized patients to teach how to disclose bad news, but they are very expensive in terms of cost and time (Fallowfield et al., 2003). Furthermore, some authors argue that this pedagogical approach may encourage students to become “simulation doctors” who act out a good relationship to their patients but have no authentic connection with them. They also point out that studying human experience in literature and art enables students to better understand their own experiences and this ultimately helps them improve their ability to relate to patients (Hanna and Fins, 2006). In the same line, in their review Satterfield and Hughes (2007) report that a growing body of literature suggests that attending to emotion and communication skills in medical providers might beneficially impact both patient and provider. Ambuel (2003) highlights the need to reduce learners' discomfort in communicating bad news and Shapiro (2008) affirms that reflective practices and incorporation of medical humanities can help students achieve goals, such as coping with difficult emotions, specifically fear, anxiety, and the desire to distance oneself from decline and death. The main value of reflection is to develop an understanding of both the self and the situation. In order to develop a therapeutic relationship, fundamental when discussing bad news with patients, it may be useful to bring out awareness of strong feelings, recognize and understand personal beliefs and value systems of the people involved. Although communication skills have a cognitive component, they should be taught to healthcare providers through an experiential and not just a didactic method (Rosenzweig et al., 2008). Breaking bad news requires advanced communication skills, which
include interpersonal skills, nurturing reflection, conveying empathy and handling emotions (Rider, 2011). Defined and shared solutions to the problem do not emerge in recent literature. Working in small groups, reflective questioning, role-play, note taking, group discussions, can help students become sensitive to the feelings of others and respond to future difficult encounters with patients who are experiencing profound suffering (Tiernan, 2003). Students are often excluded from the communication of bad news in order to protect patients' intimacy (Harrison and Walling, 2010). Therefore, they have little authentic direct practice experience on which to reflect (Mann et al., 2009). Most of the courses on communication of bad news are addressed to resident or specialized doctors and very few are designed for undergraduate HCP students while no courses at all are envisaged for Midwifery degree courses. Some theoretical articles can be found in literature on the use of reflection as a teaching method in midwifery courses (Phillips et al., 2002; Minter, 2005; Collington and Hunt, 2006), nurse courses (Scanlan et al., 2002; Wilding, 2008) and other HCP courses (Smith, 2011) as well as an exhaustive systematic review (Mann et al., 2009), while there are no articles on teaching communication skills applying the reflective method. Cinema as a teaching tool There is limited tradition of using films in healthcare education, but the experience is positive and has generated considerable enthusiasm for this tool. In their systematic review of cinema in medical education, Darbyshire and Baker (2011) affirm that “The use of cinema in healthcare education has a theoretical basis”. A typical feature of a film is to allow the spectator to experience a different reality and it provides insight into the patients' history and helps understand their point of view. Films are used in healthcare education for their capacity to evoke different emotions and feelings concerning diseases in a zone of safety, they act as a mediator with reality avoiding students' direct involvement, their difficulties and anxieties (Shapiro and Rucker, 2004). The use of films can stimulate students' ability to reflect on their own mental activity and professional actions, putting them in contact with complex situations in protected contexts (Bergonzo et al., 2010; Blasco et al., 2011). Although Alexander and colleagues (2005) explained in their guide how to use films in medical education for all the six areas of competence identified by ACGME in 1999, and the title of one paragraph was “Giving bad news”, we can find only few other examples in literature (Alexander, 2002; Belling, 2006a, 2006b; Saab and Usta, 2006). Movies have been used in order to stimulate reflection (Blasco et al., 2010; Brett-MacLean et al., 2010; Blasco et al., 2011), and to teach ethics, palliative care, pain management, (Carpenter et al., 2008), professionalism, psychiatry and mental health (Hyde and Fife, 2005; Masters, 2005), nursing management (Stringfield, 1999). For more details see the systematic review conducted by Darbyshire and Baker in 2012. The choice whether to show the entire movie or only some clips is determined by learning objectives and time constraints. By allowing time to view an entire movie, a shared experience is created, enhancing the potential for rich classroom discussion and learning. Aim of the study Verify whether a course which uses reflection as a method of learning and the cinema as a teaching tool can foster in students:
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
L. Fieschi et al. / Nurse Education in Practice xxx (2015) 1e7
the ability to observe and to recognize the elements of good/bad communication and the factors which facilitate/hinder such communication. students' knowledge and reflection on their own emotions in situations of delivery of bad news.
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Moreover, this study aims at assessing students' feedback on the course.
obstetrics, the different modes of communication are well represented and the factors influencing them are still relevant today. On the second day we projected the film “Wit”. It is a sad movie, with a strong emotional impact, hard to see but instructive, able to move and make people think (Chart 2). The events are narrated in the first person and this draws attention to the point of view of the protagonist. The objective of the vision of Wit was to stimulate students' awareness and reflection on their own emotions.
Ethical considerations
Data collection
Some ethical issues including informed consent, privacy and exposure to stressful situations were taken into account. The participants chose to attend the elective course and to give their personal opinions and interpretations of the movies as part of the educational method of the course. They were informed orally and by a written letter that their answers would be used also for research purposes before they gave their consent. They had the freedom to leave out answers they wished to omit. Students' texts were identified by a progressive number. All information gathered from the participants was treated as confidential and no individual was identified in any written report. First author (L.F.) conducted the course as the researcher, and second author (B.B.), coordinator of the Degree Course, participated as a facilitator. It was made clear to all participants that only the researchers and the course supervisor would have access to their written answers also in order to evaluate the students' educational needs. During and after the course the presence of a tutor was available in case some students were upset or needed emotional support. The researcher paid attention to possible signs of emotional distress in the participants during the course.
At the end of the projection of “So Close to Life” students were asked to give their personal written account on the different communication approaches the film presented. For the film Wit we asked the students to answer four questions, based on the promptings of Sandars (2009), to investigate the awareness of their emotional reactions:
Materials and methods In spring 2012 we organized the elective course “Discussing bad news at the cinema” for third year undergraduate Midwifery students attending an Italian University. The group was composed of 9 female students, mean age 23.88 (DS 2.77). The course “Discussing bad news at the cinema” consisted of two morning sessions each lasting 4.30 h. During each morning session we showed an entire film which presented cases of communication of bad news in obstetrics; after watching the film, students were given time to write down their reflections and their emotions; a debriefing session concluded the course. We chose to show the entire film in order to give students a clear picture of the context, the patient's life and to place students in the situation of identifying themselves with the various characters. On the first day we presented “So Close to Life” (US title: “Brink of Life” Chart 1). The vision of this film aimed at stimulating students to observe and describe the different ways of communicating and discussing bad news, considering both the positive and negative aspects of the different approaches. Although it is a very old film it was chosen because it tells stories that specifically relate to
1) How do you feel and what emotions did you feel during the movie “Wit”? 2) Can you explain the meaning of these emotions? 3) Do you remember other situations in your life when you experienced the same emotions? 4) How do you think these emotions can affect you and others? An anonymous satisfaction questionnaire with 9 open-ended questions was administered to students at the end of the course. The students' papers were faithfully copied out and handled with the support of Atlas-Ti® software. A qualitative narrative methodology was used to interpret the findings. We conducted an inductive content analysis of the students' freely written papers and of their answers to the questions concerning their emotions. This process includes open coding on short passages of the selected texts, creating categories and identifying the emerging issues (Graneheim and Lundman, 2003). The students' texts were then analyzed by two independent researchers. The division into categories and the creation of codes was effected by the two researchers separately and only later in a confrontation session did they agree on the main themes which had come up. The analysis of the students' free texts concerning the film. So Close to Life included three phases (open coding, creating categories and themes) whereas the answers on the film Wit were grouped into categories. Finally, we analyzed the responses to the satisfaction questionnaire in order to evaluate the interest and usefulness perceived by students who attended the “Breaking Bad News Course”. Findings So Close to Life The analysis of the students' papers revealed four themes concerning good and bad communication:
Chart 1. So Close to Life.
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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Chart 2. Wit.
The attention to people's needs First, students observed the need for patients to receive answers “The patient wanted to know, to understand” (St.7) and provide comfort: “each of these women needed help, support, a shoulder to cry on, someone to open their hearts to, as well as their fears, their broken dreams, their vanished hopes which are all inevitably connected to their pregnancy” (St.4) This implies knowing about the personal lives of the patients: “it is necessary first of all to know who the person before me really is” (St.5) and to pay particular attention to her emotional and psychological problems: “… the patient realized she was afraid of coping with her condition …” (St.3). Comfort and support can also be obtained when patients share their experiences: “Also the friendly relationship which was established between woman and woman: sharing a room and becoming a reciprocal support was also very helpful” (St.6).
A welcoming attitude The students underlined that some elements gave a positive connotation to the communication with patients, in particular silence: “… she remained close to her and listened to her pour out her grief but, at the same time, she understood when it was time to remain silent. In certain circumstances that silence is worth more than a thousand words” (St.2) and listening: “the women could let out their voice, they were free to communicate and express their worries, certainties, difficulties and decisions. No decision was imposed on them, but by listening and communicating, they had the feeling they could reach the solution” (St.8); empathy: “She remained nearby in case they needed her and tried to identify herself in the difficult situation of the person before her” (St.1), and this also came out through gestures:“… the compassionate ward sister caressed the patients' faces, tucked in their blankets, sat beside them and was empathetic …” “even small gestures, an act of affection, helping a person to brush her hair, a smile, can mean a lot when there is suffering” (St.7); abstaining from judging:“… she did not judge them in words or in the expressions of her face or in her gestures” (St.9) and with respect: “I was particularly impressed by how respectful she was of the patients' needs” (St.9).
A disdainful attitude The behavior which gave a negative connotation to communication was expressed when the medical staff behaved with indifference, as if the patient is unworthy of notice:
“The doctors seemed to wish to avoid any real contact with the patients. They did not stop to talk with the patients, they even avoided eye-contact, they simply ignored them and gave them a quick, vague, unfeeling answer without any sympathy whenever a patient asked them a question” (St.8) or they expressed indifference and insensibility: “the doctor's attitude, when he sat on the patient's bed after visiting her, showed his personal detachment and his complete lack of concern which was also evident in the expression of his face, the tone of his voice when he asked questions to the patient(St.2); I noticed the excessive 'coldness' of some nurses coming into the room to accomplish their duties behaving as if they were working at an 'assembly line' without revealing any 'sympathy' in their care”(St.7).
The attitude of openness/closure Communicative relations were facilitated or blocked by attitudes of openness or closure. Sensibility and the attention to the patient were among the elements of openness underlined by the students: “A particular sensibility in the manner professional duties were performed, trying to understand the physical, but also the psychological needs of the patient”(St.3). The students pointed out various factors among the elements of closure such as for instance: 'the uncompassionate attitude' of the health professionals which was evident also in their rigid manners and in their fear of becoming emotionally involved: “the rigidity of the doctors was certainly due to the organizational constraints of a huge hospital, but also to the wish of not exposing oneself and becoming 'fond' of the patient, her family, friends and the people around her” (St.9) and also the interference of the personal life of the health professional: “… unfortunately her personal life seems to have a great influence on the manner of communicating. And does not leave any space to the patient who does not feel free to express herself” (St.8). The students highlighted “the particular role of the midwife who, owing to the peculiarity of her profession, could start with the patient a relation of confidence and support which requires a great deal of sensibility” (St.9) and “might represent a salvation for these women in suffering”( … ) One of the students (St.6) underlined the difficulty to compare the present and the period in which the film is set which refers to assistance models and relations between professionals and patients which date back to fifty years ago, because the cultural background is too different.
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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Wit The emotions which emerged during the film were divided into two categories: emotions with a positive value and emotions with a negative value according to the model suggested by Scherer (2005) and by Sacharin et al. (2012). “NEGATIVE EMOTIONS” emerged in the answers to the first question. Among the recurring terms we found anguish, impotence, sadness, pain, void, a sense of emptiness facing the inexorable progression of the pathology which led the main character to her “unavoidable destiny” (St.2) despite all the treatments received and the improvements in the medical field. Also the term “FEAR” appeared: fear of the future, of death, of suffering and also “the fear of not being able to do anything to alleviate the suffering of others” (St.7). The students also underlined the patient's other feelings of 'solitude' “seeing her impassivity and solitude” (St.2) “I am very sad, I felt deep emotion at seeing her scared, curled up alone in that bed” (St.7) and “no hope”: “I think there has never been a moment of real hope” (St.2). Another category is represented by the difficulty of “THE ACCEPTANCE OF THE PATHOLOGY AND DEATH”. One of the students wrote that she experienced together with the main character the passage that led to the acceptance of the pathology: “At first almost 'detachment' which gradually turned into compassion, understanding and eventually a sort of “sweet” sadness. As if, together with her, I too, were accepting her death” (St.8). Feelings of “ANGER” came up against the behavior of the doctors, their lack of sympathy and compassion: “patients are not treated as persons but as clinical cases” (St.9) “doctors never showed a gesture of humanity towards her” (St.5) and they treated the protagonist as “a lifeless, plastic doll without feelings to experiment on” (St.5).
The meaning of the emotions for the students After describing their emotions, the students were asked to explain their meaning. A certain DIFFICULTY to do so emerged: one of the students was unable to answer the question; three of them said: “It is hard to explain them” (St.3). Some other students succeeded in interpreting their emotions bringing up again the issue of the “ACCEPTANCE OF THE PATHOLOGY AND OF DEATH” and the feeling of “FEAR”: “fear to look into death's face” (St.1), “fear of death and of being helpless before it”, “fear of losing the people we love, of being unable to alleviate their suffering” (St.7) and they reported their wish to escape and/or avoid these situations. The sensation of “no hope” accounted for the feeling of sadness: “Sadness comes from the fact that, from the very beginning of the film, we understood that this woman was doomed, that above all she had no hope” (St.2), sadness is also due to the fact that “we realized that, in spite of all the research that is being made, there is no real cure against some situations” (St.3).
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In the answers to the third question “Do you remember other situations in your life when you experienced the same emotions?” the term “DIFFICULTY” reappeared: Almost all the students did not give an answer although they, directly or indirectly, had to deal with suffering, pain, death: “I feel I am not ready to deal with this subject” (St.2), “after two or three years it is still difficult for me to speak about this subject” (St.5), “I wouldn't speak about this” (St.3,6). Only one student gave an answer including, besides “FEAR”, also “POSITIVE EMOTIONS”: “… thinking about my life, the people I love suffering with me, near me, awakens in me feelings of sadness, of love, of deep intimacy with the people who are suffering” (St.7). Answering the fourth question “How do you think these emotions can affect you and others?”, the students recognized, on the one hand, the importance of “REFLECTING” on their emotions for their own sake “in order to fortify oneself”, but also to understand ourselves better and what really matters” (St.3) and that “being able to 'participate' in other people''s suffering, represents a help not only for them, but also for ourselves” (St.4), on the other hand it also can be important for their work, for the patients, “to understand their suffering and their anger better” (St.5). They also underlined how useful it can be to support the patients' family. Reflection on emotions, according to the students, also fosters greater “SENSIBILITY” towards the patients and this leads to the understanding of the importance of little gestures, for instance of sitting next to terminal patients, to understand the purpose of silence “silence can go beyond words, it can make the patient feel surrounded by a loving and compassionate presence”; “gradually words lost importance and what really mattered was the person, the gestures, humanizing the pathology” (St.8). Students underlined the importance of keeping the level of “OPENNESS” as high as possible as well as the level of attention, of sympathy, of non-verbal communication, of closeness, offering a spark of hope, of spiritual strength. Students found it useful to reflect on 'VALUES0 as a “reminder that the dignity of every single person is a value which must be respected” (St.2). However, also the fear of being too sensible was expressed, the “fear of becoming petrified” (St.1), of feeling inadequate before so much suffering. The debriefing phase which was intended to relieve the atmosphere and to mitigate the students' emotions, ultimately turned out to offer many interesting issues of debate. It offered the opportunity to express doubts concerning daily acts, the limited amount of time available due to the quantity of tasks which need to be performed, the difficulty to collaborate in harmony with all the members of the staff, the risk of getting used to a routine type of assistance which might make lose sight of the subject and might make end up by treating the patient as an object rather than as a Person. Questionnaire The answers to the questionnaire were submitted to a descriptive analysis from which it emerged that the students:
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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would recommend all their colleagues to take part in this course, to debate, stop to reflect, to share emotions, because it stimulates thoughts and ideas expressed different opinions about the usefulness of the film “So Close to Life”: it is outdated vs. it still has a lot to say and teach as it “shows different ways of communicating”, whereas “Wit” “places the patient's real emotions and difficulties in the foreground”, “it involves and conveys emotions”, “it does not offer solutions, but issues of debate” thought that the vision of the entire film rather than clips is useful in order to “contextualize, follow the plot and the evolution of the characters, to know them and to be able to make more precise considerations” in some answers suggested that the choice of showing short clips of the film would make them run the risk of expressing “guided” opinions. also suggested other teaching methods: by direct experience, meetings with experienced doctors/midwives and the example of a tutor. recognized the importance of dedicating time to writing down their reflections immediately after watching the film “first impressions are more authentic and spontaneous” and the importance of the debriefing phase where they could share their experiences, ask questions, express their concerns, opinions and compare different points of view. believed that in order to make the course more useful it would be advisable to involve other professionals, to establish contacts with other universities, to have a greater amount of time which would allow the vision of more films, more frequent sessions, more structured discussion spaces. Discussion In compliance with the first aim of the study (assess the capacity to observe and recognize the different modes of communication and discussion of bad news through the vision of the film So Close to Life) it was possible to see that the students were able to identify many elements concerning the communication of bad news. They succeeded in identifying the PATIENTS' MAIN NEEDS and they were also able to suggest possible responses. Many adequate communication elements are present in the theme WELCOMING ATTITUDE. Inadequate communication features are described in DISDAINFUL ATTITUDE. The factors which block or foster good communication are clearly expressed in the theme OPENNESS/ CLOSURE. The students were attending the final year of their degree course. Therefore, they were already well acquainted with the themes which the film vision might have reinforced. Whether this method might be able to replace a traditional lesson on learning communicative techniques or whether the two methods might be integrated remains an open question. As far as the second aim is concerned (stimulate students' knowledge and reflection on their own emotions in reaction to situations of communication of bad news), the vision of the film Wit gave rise to very strong emotions as it touched the fundamental issue that is the ACCEPTANCE OF THE PATHOLOGY, of suffering and of death. Fear is the most recurring feeling which appears in all the answers to the four questions. Even the impossibility to answer the
third question (Do you remember other situations in your life when you experienced the same emotions?) indicates this difficulty, thus giving evidence that the problem of accepting pathologies and death plays a central role in the emotional world of the students. Although a certain difficulty to reason on their emotions appeared, the students recognized the value of the reflective method of the process of introspection and analysis of their emotions both for their own sake, as it allows them to improve the understanding of their own internal world, and also in the interest of others, as it might help them manage difficult professional situations and support people in suffering and those around them. The debriefing periods were positively considered by the students, but they also underlined the need to follow precise guidelines to avoid dispersion and to make the debate more effective. From the questionnaire results it appears the students expressed a positive opinion on the course, which they considered enlightening and repeatable; the same results concerning the introduction of Medical Humanities in education can also be found in literature (Fieschi et al., 2013). The use of films, appreciated by the students, makes it easier to deal with the difficult task of delivering bad news. Students are touched but not directly involved, and they can imagine how they want to be in relation to the patient (Shapiro and Rucker, 2004). Comparing the research design of this study with similar ones it is possible to find many common features (group discussions, written re-elaborations by the students). As far as the results are concerned, Belling (2006a, 2006b) and Shapiro and Rucker (2004) do not report data, but just describe methods and students' comments and reactions, which are very similar to those found in this study. Saab and Usta (2006) do not investigate students' emotions, but report data related to an anonymous evaluation questionnaire: more than 90% of the students found that movie clips adequately illustrated the teaching points (communicating with terminal patients) and affirmed that they had learned from the teaching session. This research suggests that the reflective method applied to watching movies in order to teach bad news communication skills may be as useful in Midwifery degree courses as in medical education. Among the limits of this study, the low number of participating students, the fact they all belonged to the same university and the absence of a comparison between initial and final learning assessment must be taken into account. Moreover, the real impact of educational events would require more complex didactic programs which should also take into consideration short, medium and long term evaluations. However, the matter of learning evaluation is a complex issue: educators, except for the most conservative ones, have long ago learned that the measurement of success in teaching remains an elusive and controversial goal. The method employed must be morally defensible and grounded in shared conceptions of reasonableness (Colt et al., 2011). Some authors argue that a more comprehensive approach to the problem of communication of bad news is to consider it as a multidisciplinary activity which requires the active involvement of a wide range of healthcare professionals working as a team (Fallowfield and Jenkins, 2004; Wakefield et al., 2006). Conclusion This experience allowed the students to observe different communication approaches which are present in the films, to identify the needs of the patients and the responses of the healthcare professionals distinguishing the positive and negative aspects of the attitude and the behavior of the protagonists. Moreover, it allowed them to identify the factors which foster or
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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block a good approach to the communication of bad news, stimulating them to reflect on the importance of establishing with the patient an attentive and compassionate relation as free as possible from prejudices. In order to achieve all this it is necessary to take into account the patients' psychological, cultural features, their family background and their problems. The students recognized the central role of the midwife who, owing to her professional peculiarity, represents the figure in the best position to establish a relation of trust and support with the patients. The course represented a help for the students to identify and describe the feelings the film awoke in them, although a certain difficulty in interpreting them emerged. This awareness led the students to comprehend the importance of reflection on their emotions in order to be able to analyze and understand them. Furthermore students acknowledge that this process can improve their ability to understand others, to have empathy with the people who suffer, to develop their sensibility and, at the same time, to recognize their own difficulties and limits. In order to be effective, the introduction of the reflection method and the vision of films as a didactic means, as in other humanities courses, should be integrated in a context of personal and reflective education. If the culture and environment do not value and legitimize this learning strategy, reflection may not be useful (Mann et al., 2009). Further experiences are necessary to confirm the efficacy of reflection and the vision of films on improving midwives' skills on the communication of bad news. Nevertheless, being aware of the difficulty to assess these learning skills objectively and in particular the effect on patients' wellbeing, we underline the need to keep into consideration the students' emotional life: if we do not succeed in entering the student's affective world, if we are unable to activate emotionally strong educational strategies, the student will acquire notions which in time will be probably forgotten. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Alexander, M., 2002. The doctor: a seminal video for cinemeducation. Fam. Med. 34 (2), 92e94. Alexander, M., Lenahan, P., Pavlov, A., 2005. Cinemeducation: a Comprehensive Guide to Using Film in Medical Education. Radcliffe Publishing, Oxford. Ambuel, B., 2003. Delivering bad news and precepting Student/Resident learners. J. Palliat. Med. 6 (2), 265e266. Arber, A., Gallangher, A., 2003. Breaking bad news rivisited: the push for negotiated disclosure and changing practice implication. Int. J. Palliat. Nurs. 9 (4), 166e172. Baile, W.F., Buckman, R., Lenzi, R., Glober, G., Beale, E.A., Kudelka, A.P., 2000. SPIKES*A six step protocol for delivering bad news: application to the patient with cancer. The Oncologist 5 (4), 302e311. Belling, C., 2006a. The “Bad news scene” as clinical drama Part I: writing scenes. Fam. Med. 38 (6), 390e392. Belling, C., 2006b. The “Bad news scene” as clinical drama part II: viewing scenes. Fam. Med. 38 (7), 474e475. Bergonzo, D., Garrino, L., Martin, B., Dimonte, V., 2010. Il cinema per la formazione medica e infermieristica: analisi della letteratura. Tutor 10, 1e13. Bick, D., 2010. Communication, communication, communication. Midwifery 26 (4), 377e378. Blasco, P.G., Garcia, D.S., de Benedetto, M.A., Moreto, L., Roncoletta, A.F., Troll, T., 2010. Cinema for educating global doctors: from emotions to reflection, approaching the complexity of the human being. Prim. Care 10 (3), 45e47. Blasco, P.G., Blasco, M.G., Levites, M.R., Moreto, G., 2011. Educating through movies: how Hollywood fosters reflection. Creat. Educ. 2 (3), 174e180. Brett-MacLean, P.J., Cave, M.T., Yiu, V., Kelner, D., Ross, D.J., 2010. Film as a means to introduce narrative reflective practice in medicine and dentistry: a beginning story presented in three parts. Reflect. Pract. 11 (4), 499e516. Buckman, R., 1984. Breaking bad news: why is it still so difficult? Br. Med. J. 288, 1597e1599.
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Carpenter, J., Stevenson, B., Carson, E., 2008. Creating a shared experience using movies in nursing education. Nurse Educ. 33 (3), 103e104. Collington, V., Hunt, S.C., 2006. Reflection in midwifery education and practice: an exploratory analysis. Evid. Based Midwifery 4 (3), 76e82. Colt, H., Quadrelli, S., Friedman, L., 2011. The Picture of Health. Oxford University Press. Darbyshire, D., Baker, B., 2011. Cinema in medical education e has it penetrated the mainstream? J. Med. Movies 7 (1), 8e14. Darbyshire, D., Baker, B., 2012. A systematic review and thematic analysis of cinema in medical education. Med. Humanit. 38 (1), 28e33. Dewar, A., 2000. Nurses' experiences in giving bad news to patients with spinal cord injuries. J. Neurosci. Nurs. 32 (6), 324e330. Dosanjh, S., Barnes, J., Bhandari, M., 2001. Barriers to breaking bad news among medical and surgical residents. Med. Educ. 35, 197e205. Fallowfield, L., Jenkins, V., Farewell, V., Solis-Trapala, I., 2003. Enduring impact of communication skills training: results of a 12-month follow-up. Br. J. Cancer 89, 1445e1449. Fallowfield, L., Jenkins, V., 2004. Communicating sad, bad, and difficult news in medicine. Lancet 363, 312e319. Fieschi, L., Matarese, M., Vellone, E., Alvaro, R., De Marinis, M.G., 2013. Medical humanities in healthcare education in Italy: a literature review. Ann. Ist. Super. 49 (1), 56e64. Sanita Graneheim, U.H., Lundman, B., 2003. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24, 105e112. Hanna, M., Fins, J.J., 2006. Power and communication: why simulation training ought to Be complemented by experiential and humanist learning. Acad. Med. 81, 265e270. Harrison, M.E., Walling, A., 2010. What do we know about giving bad news? a review. Clin. Pediatr. 49 (7), 619e627. Hyde, N.B., Fife, E., 2005. Innovative instructional strategy using cinema films in an undergraduate nursing course. J. Assoc. Black Nurs. Fac. 95e97. Lalor, J.C., Devane, D., Begley, C.M., 2007. Unexpected diagnosis of fetal abnormality: women's encounters with caregivers. Birth 34 (1), 80e88. Mann, K., Gordon, J., MacLeod, A., 2009. Reflection and reflective practice in health professions education: a systematic review. Adv. Health Sci. Educ. 14, 595e621. Masters, J.C., 2005. Hollywood in the classroom using feature films to teach. Nurse Educ. 30 (3), 113e116. Minter, A., 2005. Teaching and assessing: reflection upon planning, delivery and evaluation. Br. J. Midwifery 13 (11), 722e725. Phillips, D., Fawns, R., Hayes, B., 2002. From personal reflection to social positioning: the development of a transformational model of professional education in midwifery. Nurs. Inq. 9 (4), 239e249. Rabow, M.W., McPhee, S.J., 1999. Beyond breaking bad news: how to help patients who suffer. West J. Med. 171, 260e263. Rider, E., 2011. Advanced communication strategies for relationship-centered care. Pediatr. Ann. 40 (9), 447e453. Rosen, S., Tesser, A., 1970. On reluctance to communicate undesirable information: the MUM effect. Sociometry 33 (3), 253e263. Rosenzweig, M., Hravnak, M., Magdic, K., Beach, M., Clifton, M., Arnold, R., 2008. Patient communication simulation laboratory for students in an acute care nurse practitioner program. Am. J. Crit. Care 17, 364e372. Saab, B.R., Usta, J., 2006. Communicating with terminal patients: lessons from “Wit” and students. Fam. Med. 38 (1), 18e20. Sacharin, V., Schlegel, K., Scherer, K.R., 2012. Geneva Emotion Wheel Rating Study (Report). University of Geneva, Switzerland (Swiss Center for Affective Sciences). Sandars, J., 2009. The use of reflection in medical education: AMEE guide no. 44. Med. Teach. 31, 685e695. Satterfield, J.M., Hughes, E., 2007. Emotion skills training for medical students: a systematic review. Med. Educ. 41, 935e941. Scanlan, J.M., Care, W.D., Udod, S., 2002. Unravelling the unknowns of reflection in classroom teaching. J. Adv. Nurs. 38 (2), 136e143. Scherer, K.R., 2005. What are emotions? and how can they be measured? Soc. Sci. Inf. 44 (4), 695e729. Shapiro, J., Rucker, L., 2004. The don quixote effect: why going to the movies can help develop empathy and Altruism in medical students and residents. Fam. Syst. Health 22 (4), 445e452. Shapiro, J., 2008. Walking a mile in their patients' shoes: empathy and othering in medical students' education. Philos. Ethics Humanit. Med. 3 (10). Open Access. http://www.pehmed.com/content/3/1/10. Smith, E., 2011. Teaching critical reflection. Teach. High. Educ. 16 (2), 211e223. Stringfield, Y., 1999. Teaching nursing management using popular movies. Nurse Educ. 24 (4), 30e36. Tiernan, E., 2003. Communication training for professionals. Support Care Cancer 11, 758e762. Wakefield, A., Cocksedge, S., Boggis, C., 2006. Breaking bad news: qualitative evaluation of an interprofessional learning opportunity. Med. Teach. 28 (1), 53e58. 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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Midwifery education in practice
Teaching midwife students how to break bad news using the cinema: An Italian qualitative study Laura Fieschi, PhD, RM a, *, Barbara Burlon, PhD Student, RM b, Maria Grazia De Marinis c a
School of Midwifery, University of Parma, Italy Doctoral School of Nursing, University of Rome “Tor Vergata”, 00173 Rome, Italy c School of Nursing, Campus Bio-Medico University of Rome, Italy b
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 15 January 2015
Delivering bad news is a difficult task that involves all healthcare professionals, including midwives. The hypothesis is that, in order to learn how to disclose and to discuss bad news, students need a phase of personal reflection, of awareness of their own emotional processes. The use of films in healthcare education can foster this process evoking different emotions concerning suffering and disease, in a “safety zone”. This study examines the effects that a course, which uses reflection as a method of learning and the cinema as a teaching tool, produces on a little group of Italian third-year Midwifery students. From the content analysis (supported by Atlas-Ti® software) of the texts produced by the students after the vision of two entire films, it appears that they correctly identified many elements related to good and poor communication of bad news and that they were able to describe the emotions felt while watching the film, but still revealed a certain difficulty to interpret them. The course helped students to recognize the value of reflection on their emotions to better understand others, to empathize with people who suffer, but also to recognize their difficulties and compete with their own limits. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Midwifery education Bad news Cinema Reflective practice
Introduction The role of midwives in communicating bad news to patients and relatives is important because, being in daily close contact, they may understand how women deal with their condition, know their concerns and desires. Midwives may be more aware of how women adapt to what they are told and may monitor the patients' realization of their condition (Dewar, 2000; Lalor et al., 2007; Warnock et al., 2010). Background Breaking bad news Any information that produces a negative alteration to a person's expectations concerning the present and future could be deemed bad news (Buckman, 1984). Bad news does, of course, have gradations which, to a certain extent, are subjective, dependent on
* Corresponding author. E-mail address: laura.fi[email protected] (L. Fieschi).
an individual's life experiences, personality, spiritual beliefs, philosophical standpoint, perceived social supports, and emotional hardiness (Fallowfield and Jenkins, 2004). The expression ‘breaking bad news’ is usually associated with the moment in which negative medical information is communicated to patients and/or their relatives. During last thirty years many changes have occurred in the healthcare world, the concept of bad news has changed and the communication function is no longer limited to the physician. “Breaking bad news, writes Tiernan (2003) is not just about communicating about diagnosis or recurrence, imparting correct information, discussing the transition from active therapy to palliative care; it is not just about the correct words to use; it is not even just about listening. Communication is about all of these things, but it is about much more. Communication is about the relationship we establish and build with our patients.” Delivering bad news is a difficult and stressful experience that takes place before, during and after bad news is broken (Arber and Gallangher, 2003; Rosenzweig et al., 2008). Discomfort with disclosing bad news may be due to many factors: lack of training, fear of patients' emotional reactions, fear of being blamed for the bad news, fear of one's own emotional reactions, fear of the
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Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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patients' suffering and death, personal fear of illness and death, and uncertainty associated with not being able to provide answers (Buckman, 1984). Institutional barriers such as inadequate amounts of time or not having adequate support from other members of the hospital institution are also reported (Dosanjh et al., 2001). The reluctance to communicate bad news has been recognized for a long time. Rosen and Tesser (1970) coined the term, “MUM effect” for this tendency, shown either by not transmitting the message at all, or by delegating the task to someone else. Moreover, in many reports of adverse obstetric incidents, it often emerged that, due to lack of communication, the woman, her partner and family felt that no-one had listened to them, causing litigation cases (Bick, 2010). Teaching methods Much has been written about the skills which are necessary for the effective delivery of bad news and consensus guidelines have been developed, for example SPIKES (Setting, Perception, Invitation or Information, Knowledge, Empathy, and Summarize or Strategize e Baile et al., 2000), ABCDE (Advance preparation, Build a therapeutic environment/relationship, Communicate well, Deal with patient and family reactions, Encourage and validate emotions e Rabow and McPhee, 1999) and others. The main negative aspect is that guidelines and protocols do not adequately account for the individual's interpretation of the significance or impact of the news. Moreover, although the various guidelines offer practical suggestions, they do not address the emotional aspects of the problem. Before providing students with instructions on how to behave, as sustained by Arber and Gallanger (2003) and Sandars (2009), we believe a phase of personal reflection, of awareness of their own emotional processes is fundamental, because what affects people's lives cannot simply be translated into a list of actions, but must result from the understanding of the complexity of all the elements, the feelings, and the emotions both of the operators and of the patients and their families. Most of the studies in literature use standardized patients to teach how to disclose bad news, but they are very expensive in terms of cost and time (Fallowfield et al., 2003). Furthermore, some authors argue that this pedagogical approach may encourage students to become “simulation doctors” who act out a good relationship to their patients but have no authentic connection with them. They also point out that studying human experience in literature and art enables students to better understand their own experiences and this ultimately helps them improve their ability to relate to patients (Hanna and Fins, 2006). In the same line, in their review Satterfield and Hughes (2007) report that a growing body of literature suggests that attending to emotion and communication skills in medical providers might beneficially impact both patient and provider. Ambuel (2003) highlights the need to reduce learners' discomfort in communicating bad news and Shapiro (2008) affirms that reflective practices and incorporation of medical humanities can help students achieve goals, such as coping with difficult emotions, specifically fear, anxiety, and the desire to distance oneself from decline and death. The main value of reflection is to develop an understanding of both the self and the situation. In order to develop a therapeutic relationship, fundamental when discussing bad news with patients, it may be useful to bring out awareness of strong feelings, recognize and understand personal beliefs and value systems of the people involved. Although communication skills have a cognitive component, they should be taught to healthcare providers through an experiential and not just a didactic method (Rosenzweig et al., 2008). Breaking bad news requires advanced communication skills, which
include interpersonal skills, nurturing reflection, conveying empathy and handling emotions (Rider, 2011). Defined and shared solutions to the problem do not emerge in recent literature. Working in small groups, reflective questioning, role-play, note taking, group discussions, can help students become sensitive to the feelings of others and respond to future difficult encounters with patients who are experiencing profound suffering (Tiernan, 2003). Students are often excluded from the communication of bad news in order to protect patients' intimacy (Harrison and Walling, 2010). Therefore, they have little authentic direct practice experience on which to reflect (Mann et al., 2009). Most of the courses on communication of bad news are addressed to resident or specialized doctors and very few are designed for undergraduate HCP students while no courses at all are envisaged for Midwifery degree courses. Some theoretical articles can be found in literature on the use of reflection as a teaching method in midwifery courses (Phillips et al., 2002; Minter, 2005; Collington and Hunt, 2006), nurse courses (Scanlan et al., 2002; Wilding, 2008) and other HCP courses (Smith, 2011) as well as an exhaustive systematic review (Mann et al., 2009), while there are no articles on teaching communication skills applying the reflective method. Cinema as a teaching tool There is limited tradition of using films in healthcare education, but the experience is positive and has generated considerable enthusiasm for this tool. In their systematic review of cinema in medical education, Darbyshire and Baker (2011) affirm that “The use of cinema in healthcare education has a theoretical basis”. A typical feature of a film is to allow the spectator to experience a different reality and it provides insight into the patients' history and helps understand their point of view. Films are used in healthcare education for their capacity to evoke different emotions and feelings concerning diseases in a zone of safety, they act as a mediator with reality avoiding students' direct involvement, their difficulties and anxieties (Shapiro and Rucker, 2004). The use of films can stimulate students' ability to reflect on their own mental activity and professional actions, putting them in contact with complex situations in protected contexts (Bergonzo et al., 2010; Blasco et al., 2011). Although Alexander and colleagues (2005) explained in their guide how to use films in medical education for all the six areas of competence identified by ACGME in 1999, and the title of one paragraph was “Giving bad news”, we can find only few other examples in literature (Alexander, 2002; Belling, 2006a, 2006b; Saab and Usta, 2006). Movies have been used in order to stimulate reflection (Blasco et al., 2010; Brett-MacLean et al., 2010; Blasco et al., 2011), and to teach ethics, palliative care, pain management, (Carpenter et al., 2008), professionalism, psychiatry and mental health (Hyde and Fife, 2005; Masters, 2005), nursing management (Stringfield, 1999). For more details see the systematic review conducted by Darbyshire and Baker in 2012. The choice whether to show the entire movie or only some clips is determined by learning objectives and time constraints. By allowing time to view an entire movie, a shared experience is created, enhancing the potential for rich classroom discussion and learning. Aim of the study Verify whether a course which uses reflection as a method of learning and the cinema as a teaching tool can foster in students:
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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the ability to observe and to recognize the elements of good/bad communication and the factors which facilitate/hinder such communication. students' knowledge and reflection on their own emotions in situations of delivery of bad news.
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Moreover, this study aims at assessing students' feedback on the course.
obstetrics, the different modes of communication are well represented and the factors influencing them are still relevant today. On the second day we projected the film “Wit”. It is a sad movie, with a strong emotional impact, hard to see but instructive, able to move and make people think (Chart 2). The events are narrated in the first person and this draws attention to the point of view of the protagonist. The objective of the vision of Wit was to stimulate students' awareness and reflection on their own emotions.
Ethical considerations
Data collection
Some ethical issues including informed consent, privacy and exposure to stressful situations were taken into account. The participants chose to attend the elective course and to give their personal opinions and interpretations of the movies as part of the educational method of the course. They were informed orally and by a written letter that their answers would be used also for research purposes before they gave their consent. They had the freedom to leave out answers they wished to omit. Students' texts were identified by a progressive number. All information gathered from the participants was treated as confidential and no individual was identified in any written report. First author (L.F.) conducted the course as the researcher, and second author (B.B.), coordinator of the Degree Course, participated as a facilitator. It was made clear to all participants that only the researchers and the course supervisor would have access to their written answers also in order to evaluate the students' educational needs. During and after the course the presence of a tutor was available in case some students were upset or needed emotional support. The researcher paid attention to possible signs of emotional distress in the participants during the course.
At the end of the projection of “So Close to Life” students were asked to give their personal written account on the different communication approaches the film presented. For the film Wit we asked the students to answer four questions, based on the promptings of Sandars (2009), to investigate the awareness of their emotional reactions:
Materials and methods In spring 2012 we organized the elective course “Discussing bad news at the cinema” for third year undergraduate Midwifery students attending an Italian University. The group was composed of 9 female students, mean age 23.88 (DS 2.77). The course “Discussing bad news at the cinema” consisted of two morning sessions each lasting 4.30 h. During each morning session we showed an entire film which presented cases of communication of bad news in obstetrics; after watching the film, students were given time to write down their reflections and their emotions; a debriefing session concluded the course. We chose to show the entire film in order to give students a clear picture of the context, the patient's life and to place students in the situation of identifying themselves with the various characters. On the first day we presented “So Close to Life” (US title: “Brink of Life” Chart 1). The vision of this film aimed at stimulating students to observe and describe the different ways of communicating and discussing bad news, considering both the positive and negative aspects of the different approaches. Although it is a very old film it was chosen because it tells stories that specifically relate to
1) How do you feel and what emotions did you feel during the movie “Wit”? 2) Can you explain the meaning of these emotions? 3) Do you remember other situations in your life when you experienced the same emotions? 4) How do you think these emotions can affect you and others? An anonymous satisfaction questionnaire with 9 open-ended questions was administered to students at the end of the course. The students' papers were faithfully copied out and handled with the support of Atlas-Ti® software. A qualitative narrative methodology was used to interpret the findings. We conducted an inductive content analysis of the students' freely written papers and of their answers to the questions concerning their emotions. This process includes open coding on short passages of the selected texts, creating categories and identifying the emerging issues (Graneheim and Lundman, 2003). The students' texts were then analyzed by two independent researchers. The division into categories and the creation of codes was effected by the two researchers separately and only later in a confrontation session did they agree on the main themes which had come up. The analysis of the students' free texts concerning the film. So Close to Life included three phases (open coding, creating categories and themes) whereas the answers on the film Wit were grouped into categories. Finally, we analyzed the responses to the satisfaction questionnaire in order to evaluate the interest and usefulness perceived by students who attended the “Breaking Bad News Course”. Findings So Close to Life The analysis of the students' papers revealed four themes concerning good and bad communication:
Chart 1. So Close to Life.
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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Chart 2. Wit.
The attention to people's needs First, students observed the need for patients to receive answers “The patient wanted to know, to understand” (St.7) and provide comfort: “each of these women needed help, support, a shoulder to cry on, someone to open their hearts to, as well as their fears, their broken dreams, their vanished hopes which are all inevitably connected to their pregnancy” (St.4) This implies knowing about the personal lives of the patients: “it is necessary first of all to know who the person before me really is” (St.5) and to pay particular attention to her emotional and psychological problems: “… the patient realized she was afraid of coping with her condition …” (St.3). Comfort and support can also be obtained when patients share their experiences: “Also the friendly relationship which was established between woman and woman: sharing a room and becoming a reciprocal support was also very helpful” (St.6).
A welcoming attitude The students underlined that some elements gave a positive connotation to the communication with patients, in particular silence: “… she remained close to her and listened to her pour out her grief but, at the same time, she understood when it was time to remain silent. In certain circumstances that silence is worth more than a thousand words” (St.2) and listening: “the women could let out their voice, they were free to communicate and express their worries, certainties, difficulties and decisions. No decision was imposed on them, but by listening and communicating, they had the feeling they could reach the solution” (St.8); empathy: “She remained nearby in case they needed her and tried to identify herself in the difficult situation of the person before her” (St.1), and this also came out through gestures:“… the compassionate ward sister caressed the patients' faces, tucked in their blankets, sat beside them and was empathetic …” “even small gestures, an act of affection, helping a person to brush her hair, a smile, can mean a lot when there is suffering” (St.7); abstaining from judging:“… she did not judge them in words or in the expressions of her face or in her gestures” (St.9) and with respect: “I was particularly impressed by how respectful she was of the patients' needs” (St.9).
A disdainful attitude The behavior which gave a negative connotation to communication was expressed when the medical staff behaved with indifference, as if the patient is unworthy of notice:
“The doctors seemed to wish to avoid any real contact with the patients. They did not stop to talk with the patients, they even avoided eye-contact, they simply ignored them and gave them a quick, vague, unfeeling answer without any sympathy whenever a patient asked them a question” (St.8) or they expressed indifference and insensibility: “the doctor's attitude, when he sat on the patient's bed after visiting her, showed his personal detachment and his complete lack of concern which was also evident in the expression of his face, the tone of his voice when he asked questions to the patient(St.2); I noticed the excessive 'coldness' of some nurses coming into the room to accomplish their duties behaving as if they were working at an 'assembly line' without revealing any 'sympathy' in their care”(St.7).
The attitude of openness/closure Communicative relations were facilitated or blocked by attitudes of openness or closure. Sensibility and the attention to the patient were among the elements of openness underlined by the students: “A particular sensibility in the manner professional duties were performed, trying to understand the physical, but also the psychological needs of the patient”(St.3). The students pointed out various factors among the elements of closure such as for instance: 'the uncompassionate attitude' of the health professionals which was evident also in their rigid manners and in their fear of becoming emotionally involved: “the rigidity of the doctors was certainly due to the organizational constraints of a huge hospital, but also to the wish of not exposing oneself and becoming 'fond' of the patient, her family, friends and the people around her” (St.9) and also the interference of the personal life of the health professional: “… unfortunately her personal life seems to have a great influence on the manner of communicating. And does not leave any space to the patient who does not feel free to express herself” (St.8). The students highlighted “the particular role of the midwife who, owing to the peculiarity of her profession, could start with the patient a relation of confidence and support which requires a great deal of sensibility” (St.9) and “might represent a salvation for these women in suffering”( … ) One of the students (St.6) underlined the difficulty to compare the present and the period in which the film is set which refers to assistance models and relations between professionals and patients which date back to fifty years ago, because the cultural background is too different.
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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Wit The emotions which emerged during the film were divided into two categories: emotions with a positive value and emotions with a negative value according to the model suggested by Scherer (2005) and by Sacharin et al. (2012). “NEGATIVE EMOTIONS” emerged in the answers to the first question. Among the recurring terms we found anguish, impotence, sadness, pain, void, a sense of emptiness facing the inexorable progression of the pathology which led the main character to her “unavoidable destiny” (St.2) despite all the treatments received and the improvements in the medical field. Also the term “FEAR” appeared: fear of the future, of death, of suffering and also “the fear of not being able to do anything to alleviate the suffering of others” (St.7). The students also underlined the patient's other feelings of 'solitude' “seeing her impassivity and solitude” (St.2) “I am very sad, I felt deep emotion at seeing her scared, curled up alone in that bed” (St.7) and “no hope”: “I think there has never been a moment of real hope” (St.2). Another category is represented by the difficulty of “THE ACCEPTANCE OF THE PATHOLOGY AND DEATH”. One of the students wrote that she experienced together with the main character the passage that led to the acceptance of the pathology: “At first almost 'detachment' which gradually turned into compassion, understanding and eventually a sort of “sweet” sadness. As if, together with her, I too, were accepting her death” (St.8). Feelings of “ANGER” came up against the behavior of the doctors, their lack of sympathy and compassion: “patients are not treated as persons but as clinical cases” (St.9) “doctors never showed a gesture of humanity towards her” (St.5) and they treated the protagonist as “a lifeless, plastic doll without feelings to experiment on” (St.5).
The meaning of the emotions for the students After describing their emotions, the students were asked to explain their meaning. A certain DIFFICULTY to do so emerged: one of the students was unable to answer the question; three of them said: “It is hard to explain them” (St.3). Some other students succeeded in interpreting their emotions bringing up again the issue of the “ACCEPTANCE OF THE PATHOLOGY AND OF DEATH” and the feeling of “FEAR”: “fear to look into death's face” (St.1), “fear of death and of being helpless before it”, “fear of losing the people we love, of being unable to alleviate their suffering” (St.7) and they reported their wish to escape and/or avoid these situations. The sensation of “no hope” accounted for the feeling of sadness: “Sadness comes from the fact that, from the very beginning of the film, we understood that this woman was doomed, that above all she had no hope” (St.2), sadness is also due to the fact that “we realized that, in spite of all the research that is being made, there is no real cure against some situations” (St.3).
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In the answers to the third question “Do you remember other situations in your life when you experienced the same emotions?” the term “DIFFICULTY” reappeared: Almost all the students did not give an answer although they, directly or indirectly, had to deal with suffering, pain, death: “I feel I am not ready to deal with this subject” (St.2), “after two or three years it is still difficult for me to speak about this subject” (St.5), “I wouldn't speak about this” (St.3,6). Only one student gave an answer including, besides “FEAR”, also “POSITIVE EMOTIONS”: “… thinking about my life, the people I love suffering with me, near me, awakens in me feelings of sadness, of love, of deep intimacy with the people who are suffering” (St.7). Answering the fourth question “How do you think these emotions can affect you and others?”, the students recognized, on the one hand, the importance of “REFLECTING” on their emotions for their own sake “in order to fortify oneself”, but also to understand ourselves better and what really matters” (St.3) and that “being able to 'participate' in other people''s suffering, represents a help not only for them, but also for ourselves” (St.4), on the other hand it also can be important for their work, for the patients, “to understand their suffering and their anger better” (St.5). They also underlined how useful it can be to support the patients' family. Reflection on emotions, according to the students, also fosters greater “SENSIBILITY” towards the patients and this leads to the understanding of the importance of little gestures, for instance of sitting next to terminal patients, to understand the purpose of silence “silence can go beyond words, it can make the patient feel surrounded by a loving and compassionate presence”; “gradually words lost importance and what really mattered was the person, the gestures, humanizing the pathology” (St.8). Students underlined the importance of keeping the level of “OPENNESS” as high as possible as well as the level of attention, of sympathy, of non-verbal communication, of closeness, offering a spark of hope, of spiritual strength. Students found it useful to reflect on 'VALUES0 as a “reminder that the dignity of every single person is a value which must be respected” (St.2). However, also the fear of being too sensible was expressed, the “fear of becoming petrified” (St.1), of feeling inadequate before so much suffering. The debriefing phase which was intended to relieve the atmosphere and to mitigate the students' emotions, ultimately turned out to offer many interesting issues of debate. It offered the opportunity to express doubts concerning daily acts, the limited amount of time available due to the quantity of tasks which need to be performed, the difficulty to collaborate in harmony with all the members of the staff, the risk of getting used to a routine type of assistance which might make lose sight of the subject and might make end up by treating the patient as an object rather than as a Person. Questionnaire The answers to the questionnaire were submitted to a descriptive analysis from which it emerged that the students:
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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would recommend all their colleagues to take part in this course, to debate, stop to reflect, to share emotions, because it stimulates thoughts and ideas expressed different opinions about the usefulness of the film “So Close to Life”: it is outdated vs. it still has a lot to say and teach as it “shows different ways of communicating”, whereas “Wit” “places the patient's real emotions and difficulties in the foreground”, “it involves and conveys emotions”, “it does not offer solutions, but issues of debate” thought that the vision of the entire film rather than clips is useful in order to “contextualize, follow the plot and the evolution of the characters, to know them and to be able to make more precise considerations” in some answers suggested that the choice of showing short clips of the film would make them run the risk of expressing “guided” opinions. also suggested other teaching methods: by direct experience, meetings with experienced doctors/midwives and the example of a tutor. recognized the importance of dedicating time to writing down their reflections immediately after watching the film “first impressions are more authentic and spontaneous” and the importance of the debriefing phase where they could share their experiences, ask questions, express their concerns, opinions and compare different points of view. believed that in order to make the course more useful it would be advisable to involve other professionals, to establish contacts with other universities, to have a greater amount of time which would allow the vision of more films, more frequent sessions, more structured discussion spaces. Discussion In compliance with the first aim of the study (assess the capacity to observe and recognize the different modes of communication and discussion of bad news through the vision of the film So Close to Life) it was possible to see that the students were able to identify many elements concerning the communication of bad news. They succeeded in identifying the PATIENTS' MAIN NEEDS and they were also able to suggest possible responses. Many adequate communication elements are present in the theme WELCOMING ATTITUDE. Inadequate communication features are described in DISDAINFUL ATTITUDE. The factors which block or foster good communication are clearly expressed in the theme OPENNESS/ CLOSURE. The students were attending the final year of their degree course. Therefore, they were already well acquainted with the themes which the film vision might have reinforced. Whether this method might be able to replace a traditional lesson on learning communicative techniques or whether the two methods might be integrated remains an open question. As far as the second aim is concerned (stimulate students' knowledge and reflection on their own emotions in reaction to situations of communication of bad news), the vision of the film Wit gave rise to very strong emotions as it touched the fundamental issue that is the ACCEPTANCE OF THE PATHOLOGY, of suffering and of death. Fear is the most recurring feeling which appears in all the answers to the four questions. Even the impossibility to answer the
third question (Do you remember other situations in your life when you experienced the same emotions?) indicates this difficulty, thus giving evidence that the problem of accepting pathologies and death plays a central role in the emotional world of the students. Although a certain difficulty to reason on their emotions appeared, the students recognized the value of the reflective method of the process of introspection and analysis of their emotions both for their own sake, as it allows them to improve the understanding of their own internal world, and also in the interest of others, as it might help them manage difficult professional situations and support people in suffering and those around them. The debriefing periods were positively considered by the students, but they also underlined the need to follow precise guidelines to avoid dispersion and to make the debate more effective. From the questionnaire results it appears the students expressed a positive opinion on the course, which they considered enlightening and repeatable; the same results concerning the introduction of Medical Humanities in education can also be found in literature (Fieschi et al., 2013). The use of films, appreciated by the students, makes it easier to deal with the difficult task of delivering bad news. Students are touched but not directly involved, and they can imagine how they want to be in relation to the patient (Shapiro and Rucker, 2004). Comparing the research design of this study with similar ones it is possible to find many common features (group discussions, written re-elaborations by the students). As far as the results are concerned, Belling (2006a, 2006b) and Shapiro and Rucker (2004) do not report data, but just describe methods and students' comments and reactions, which are very similar to those found in this study. Saab and Usta (2006) do not investigate students' emotions, but report data related to an anonymous evaluation questionnaire: more than 90% of the students found that movie clips adequately illustrated the teaching points (communicating with terminal patients) and affirmed that they had learned from the teaching session. This research suggests that the reflective method applied to watching movies in order to teach bad news communication skills may be as useful in Midwifery degree courses as in medical education. Among the limits of this study, the low number of participating students, the fact they all belonged to the same university and the absence of a comparison between initial and final learning assessment must be taken into account. Moreover, the real impact of educational events would require more complex didactic programs which should also take into consideration short, medium and long term evaluations. However, the matter of learning evaluation is a complex issue: educators, except for the most conservative ones, have long ago learned that the measurement of success in teaching remains an elusive and controversial goal. The method employed must be morally defensible and grounded in shared conceptions of reasonableness (Colt et al., 2011). Some authors argue that a more comprehensive approach to the problem of communication of bad news is to consider it as a multidisciplinary activity which requires the active involvement of a wide range of healthcare professionals working as a team (Fallowfield and Jenkins, 2004; Wakefield et al., 2006). Conclusion This experience allowed the students to observe different communication approaches which are present in the films, to identify the needs of the patients and the responses of the healthcare professionals distinguishing the positive and negative aspects of the attitude and the behavior of the protagonists. Moreover, it allowed them to identify the factors which foster or
Please cite this article in press as: Fieschi, L., et al., Teaching midwife students how to break bad news using the cinema: An Italian qualitative study, Nurse Education in Practice (2015), http://dx.doi.org/10.1016/j.nepr.2015.01.008
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block a good approach to the communication of bad news, stimulating them to reflect on the importance of establishing with the patient an attentive and compassionate relation as free as possible from prejudices. In order to achieve all this it is necessary to take into account the patients' psychological, cultural features, their family background and their problems. The students recognized the central role of the midwife who, owing to her professional peculiarity, represents the figure in the best position to establish a relation of trust and support with the patients. The course represented a help for the students to identify and describe the feelings the film awoke in them, although a certain difficulty in interpreting them emerged. This awareness led the students to comprehend the importance of reflection on their emotions in order to be able to analyze and understand them. Furthermore students acknowledge that this process can improve their ability to understand others, to have empathy with the people who suffer, to develop their sensibility and, at the same time, to recognize their own difficulties and limits. In order to be effective, the introduction of the reflection method and the vision of films as a didactic means, as in other humanities courses, should be integrated in a context of personal and reflective education. If the culture and environment do not value and legitimize this learning strategy, reflection may not be useful (Mann et al., 2009). Further experiences are necessary to confirm the efficacy of reflection and the vision of films on improving midwives' skills on the communication of bad news. Nevertheless, being aware of the difficulty to assess these learning skills objectively and in particular the effect on patients' wellbeing, we underline the need to keep into consideration the students' emotional life: if we do not succeed in entering the student's affective world, if we are unable to activate emotionally strong educational strategies, the student will acquire notions which in time will be probably forgotten. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Alexander, M., 2002. The doctor: a seminal video for cinemeducation. Fam. Med. 34 (2), 92e94. Alexander, M., Lenahan, P., Pavlov, A., 2005. Cinemeducation: a Comprehensive Guide to Using Film in Medical Education. Radcliffe Publishing, Oxford. Ambuel, B., 2003. Delivering bad news and precepting Student/Resident learners. J. Palliat. Med. 6 (2), 265e266. Arber, A., Gallangher, A., 2003. Breaking bad news rivisited: the push for negotiated disclosure and changing practice implication. Int. J. Palliat. Nurs. 9 (4), 166e172. Baile, W.F., Buckman, R., Lenzi, R., Glober, G., Beale, E.A., Kudelka, A.P., 2000. SPIKES*A six step protocol for delivering bad news: application to the patient with cancer. The Oncologist 5 (4), 302e311. Belling, C., 2006a. The “Bad news scene” as clinical drama Part I: writing scenes. Fam. Med. 38 (6), 390e392. Belling, C., 2006b. The “Bad news scene” as clinical drama part II: viewing scenes. Fam. Med. 38 (7), 474e475. Bergonzo, D., Garrino, L., Martin, B., Dimonte, V., 2010. Il cinema per la formazione medica e infermieristica: analisi della letteratura. Tutor 10, 1e13. Bick, D., 2010. Communication, communication, communication. Midwifery 26 (4), 377e378. Blasco, P.G., Garcia, D.S., de Benedetto, M.A., Moreto, L., Roncoletta, A.F., Troll, T., 2010. Cinema for educating global doctors: from emotions to reflection, approaching the complexity of the human being. Prim. Care 10 (3), 45e47. Blasco, P.G., Blasco, M.G., Levites, M.R., Moreto, G., 2011. Educating through movies: how Hollywood fosters reflection. Creat. Educ. 2 (3), 174e180. Brett-MacLean, P.J., Cave, M.T., Yiu, V., Kelner, D., Ross, D.J., 2010. Film as a means to introduce narrative reflective practice in medicine and dentistry: a beginning story presented in three parts. Reflect. Pract. 11 (4), 499e516. Buckman, R., 1984. Breaking bad news: why is it still so difficult? Br. Med. J. 288, 1597e1599.
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