Second Conversation Project

9th September 2019

Junior doctors describe a need for greater support and training in end of life care (EoLC) communication skills. The Second Conversation project was designed by a multi-professional steering group as a workplace based training intervention for junior doctors to improve their skills and confidence in undertaking EoLC conversations. Qualitative interviews were carried out with 11 junior doctors and five senior doctors across two sites who took part in, or facilitated, a ‘second conversation’.

This is a three-step training intervention that involves 1) observation – the junior doctor observes an EoLC conversation between a senior doctor and patient/caregiver; 2) direct experience – the junior doctor undertakes a follow-up second conversation with the patient/caregiver; and 3) reflection – the junior doctor discusses and reflects on the experience with a senior colleague.

Interviews were analysed using framework analysis and findings informed iterative changes to the intervention and its implementation using ‘Plan, Do, Study, Act’ cycles. Benefits that were identified included the flexibility of the intervention and its positive impact on the confidence and skills of junior doctors. The Second Conversation was felt to be of most value to newly qualified doctors and worked well on wards where length of stay was longer and EoLC conversations frequently happen. Further evaluation and exploration of patient and caregiver experiences is required.

High-quality end of life care (EoLC) discussions allow patients to make informed decisions about their care, set goals and priorities, and prepare for their death. Conversely, poorly handled conversations around EoLC are a common source of complaints and can cause unnecessary distress. The British Medical Association report into EoLC reveals a clear desire among doctors for greater support and training in this area.  This is particularly pertinent to junior doctors working in the acute setting, who have previously reported that they do not always feel adequately prepared or supported to undertake EoLC conversations with patients and families. The literature highlights a feeling among junior doctors of ‘being left’ to care for dying patients and draws attention to concerns they have voiced around making a sensitive situation worse as a result of their inexperience.

‘Learning by observation’ and ‘learning by doing’ have been shown to be effective methods to improve confidence and competence in EoLC communication skills, but isolated educational interventions often lack sustainability and reach. We hypothesised that an EoLC communication skills training intervention that can be embedded in everyday clinical practice would be more sustainable than other interventions, such as simulation or role play, that are traditionally used in both undergraduate and postgraduate training. 

The primary aim of this project was to develop a workplace-based training intervention that would give junior doctors the opportunity to practice and refine their EoLC communication skills.

The secondary aims were to:

  • explore how the intervention is implemented in practice
  • explore the views of junior doctors (participants) and senior doctors (facilitators) regarding the intervention
  • identify the drivers and barriers to embedding the intervention in practice and use these insights to support improved implementation.

 

The Second Conversation was viewed as an acceptable training intervention by both junior and senior doctors. It appears to be of most value to foundation doctors, and works well on wards where patient stay is longer and where EoLC conversations happen frequently. The major advantage of the Second Conversation is that it offers real-life experience and it can be used flexibly in the ward environment. Like many other work place based teaching and assessment methods, junior and senior doctors often find it difficult to make time for these opportunities, alongside their demanding clinical roles. However, it ties in with best practice, which advocates that EoLC conversations should be a continuous process and not a standalone event. Furthermore, if the benefit to patients and caregivers can be confirmed on further evaluation then there would be a strong argument to make the Second Conversation part of routine practice.

Future work

The next phase of this work involves evaluating the impact of the changes made in this first phase of implementation by recording the adoption and spread of the intervention at existing and new clinical sites. A larger qualitative interview study is also currently underway to further explore the experiences of the Second Conversation in more depth from the perspective of patients, caregivers, senior and junior doctors.

Mathew R, Weil A, Sleeman KE, Bristowe K, Shukla P, Schiff R, Flanders L, Leonard P, Minton O, Wakefield D, St John K, Carey I. The Second Conversation project: -Improving training in end of life care communication among junior doctors. Future Healthc J. 2019;6(2):129-36. 10.7861/futurehosp.6-2-129.