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Tiroke P et al. SICKO. Development of a … Klin Padiatr 2017; 229: 316–321

Original Article Thieme

SICKO. Development of a Multi-Disciplinary Training-Concept for Paediatric Oncology

SICKO. Entwicklung eines multidisziplinären Trainingskonzeptes für die pädiatrische Onkologie

AuthorsPetra Tiroke, Birte Sänger, Urs Mücke, Lea Berndt, Henrike Wittenbecher, Lorenz Grigull

AffiliationsMedizinische Hochschule Hannover, Pädiatrische Hämatologie und Onkologie, Hannover, Germany

Key wordsmedical education, paediatric oncology, communication, bad news, skills training, patient safety

SchlüsselwörterMedizinische Ausbildung, pädiatrische Hämatologie und Onkologie, Kommunikation, schlechte Nachrichten, Skills/Fertigkeiten, Patienten-Sicherheit

BibliographyDOI https://doi.org/10.1055/s-0043-119290Published online: 18.10.2017Klin Padiatr 2017; 229: 316–321© Georg Thieme Verlag KG Stuttgart · New York ISSN 0300-8630

CorrespondenceProf. Dr. med. Lorenz GrigullMedizinische Hochschule HannoverPädiatrische Hämatologie und OnkologieCarl-Neuberg-Straße 130625 HannoverTel.: + 49/176/1 532 9117, Fax: + 49/511/9 120 grigull.lorenz@mh-hannover.de

ABSTr AcT

Background Treating children with cancer requires multiple different skills. For the healthcare personnel (HCP) in Germany the practice of ongoing training to improve professional skills is almost non-existent. Therefore, we developed a programme called ‘SICKO’ to support HCPs skills and attitudes by means of a multidisciplinary workshop.Methods Following a qualitative analysis, we then designed a modular (3 day) workshop. During day one (8 h) participants learn practical skills, the fundamentals of chemotherapy, and effective communication skills. Workshop day 2 (8 h) includes education regarding the complications of cancer therapy (e. g. tumour-lysis syndrome, delayed methotrexate excretion), and

their management. Topics during day 3 (8 h) include ‘breaking bad news’, conflict management in the team, infusion-related complications and ‘crew resource management’ (CRM).Results 43 nurses and 33 physicians participated between 2013 and 2015. All participants highly recommend the workshop. Par-ticipants felt that knowledge increased significantly after workshops and were more confident regarding challenging communications.Discussion/Conclusions Although long-term effects have not yet been evaluated, ‘SICKO’ offers the opportunity for HCP to train and experience simulated day-to-day challenges in the field of paediatric oncology.

ZUSAMMenfASSUnG

Hintergrund Die Behandlung der Kinder mit maligner Er-krankung erfordert ganz unterschiedliche Fertigkeiten. Für das medizinische Personal (MP = Pflege und ärztlicher Dienst) gibt es in Deutschland praktisch keine Trainingskonzepte zur Verbesse-rung der professionellen Fähigkeiten. Daher entwickelten wir ein Programm („SICKO“ = Sicherheit in der Kinderonkologie), um sowohl Fertigkeiten als auch professionelle Einstellung des MP in einem multidisziplinären Workshop-Konzept zu unterstützen.Methoden Nach einer Bedarfsanalyse entwickelten wir ein modulares Workshop Konzept ( = 3-Tage). Während Tag 1 (= 8 h) lernen die Teilnehmer praktische Fertigkeiten sowie Basis-Infor-mationen zu Chemotherapie und Kommunikation. Workshop Tag 2 (8 h) beinhaltet Komplikation der Chemotherapie (z. B. Paravasate, Tumor-Lyse-Syndrom) und deren Management. Themen von Tag 3 (8 h) sind die Überbringung schlechter Nach-richten, Team-Konflikte, Infusions-assoziierte Probleme und Crew Ressource Management (CRM).Ergebnisse 43 Pflegende und 33 Ärztinnen und Ärzte haben seit 2013 an den Workshops teilgenommen. 100 % empfehlen den Workshop weiter. Es konnte ein signifikanter Wissenszuwachs gemessen werden, Teilnehmer geben an, dass sie sich besser für herausfordernde Kommunikationssituationen gerüstet fühlen.Diskussion/Schlussfolgerung: Auch wenn Langzeit-Ergeb-nisse bislang fehlen, zeigt sich ein günstiger Einfluss des SICKO Workshop Modells für das Training und die Simulation tägli-cher Herausforderungen in der Kinderonkologie.

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AbbreviationsBMA bone marrow aspirationCRM crew resource managementHCP healthcare personnelMP medical personnelSICKO safety in childhood cancer (German: Sicherheit in der

Kinderonkologie)TLS tumour lysis syndrome

IntroductionIn 2016, the European Society for Medical Oncology and the Amer-ican Society of Clinical Oncology updated their criteria for a curric-ulum in medical oncology [4]. In this curriculum, communication was defined as a basic competency for oncologists. According to the curriculum, oncologists should have the ability to demonstrate communication tasks such as breaking bad news or dealing with strong emotions [4].

There is a growing body of evidence that recently board-certi-fied physicians and residents lack confidence in their communica-tion skills [7, 9]. This shortcoming is compounded by the fact that oncology is rarely a major topic in most medical education pro-grammes [3].

A recent survey among American paediatric haematology-on-cology fellows addressed the quality of communication skills train-ing during their programmes. In that survey, only 32 % of the re-spondents received communication training, mostly in the form of formal lectures. 23 % of the participants received neither commu-nication skills training nor frequent feedback [7].

The importance of good communication skills is strengthened by data from the US. Here, low physician scores on the clinical skills examination for communication was a predictor for complaints to the medical regulatory boards [12].

Of note, during a typical career in clinical oncology a profession-al will conduct approximately 150000 to 200000 consultations with patients [6]. However, very few oncologists actually receive formal training in communication skills [6].

The quality of these consultations can be enhanced and sus-tained with continuous professional education of health care per-sonnel, which has an additional beneficial effect on complaints by the public against physicians [13]. Besides communication, paedi-atric oncologists and nurses working with childhood cancer pa-tients also require a broad range of knowledge and skills about chemotherapy, infusion-therapy, infections, port-/Hickman-cath-eter management, lumbar puncture and bone marrow aspirations. However, until now there was neither a formal (practical) training programme for (paediatric) oncologists in Germany to master skills such as communication, lumbar puncture or catheter manage-ment, nor a formal (board-) examination to guarantee the quality of these skills.

In addition, formal training for these skills is currently provided inconsistently during medical university and nursing qualification. These deficiencies led us to developing this modular training pro-gram for HCP in Germany with the goal of improving practical skills, enhance the self-confidence of participants and ultimately to im-prove upon long-term patient safety and care.

The aim of this paper is to describe the development of a work-shop program for HCP engaged in paediatric oncology and to out-line the needs of such workshops as identified by a focus group.

Development of SICKOAs an initial step in developing this novel workshop, we conducted a focus group survey among nurses (n = 8) and physicians (n = 8) in the Department of Paediatric Haematology and Oncology at the Hannover Medical University. Main topics in the questionnaire were ‘challenges during on-the-job training’ and ‘important skills and competences of HCP’. The majority of the respondents mentioned ‘lack of time’ as a major deficit during their training. 14 of 16 re-spondents highlighted ‘empathy’ and ‘good communication skills’ to be important for HCP in the field of paediatric oncology. 13 of 16 respondents thought that practical training is the best way to teach/improve communication skills. The most important onco-logical topics according to the respondents of the survey were ‘neu-tropenic fever’, ‘pain management’, and ‘nausea and emesis’.

As handling port-/broviac-/hickman catheters is also an impor-tant and frequent task in this medical specialty, commercially avail-able models were purchased.

Up till now, training models for bone marrow puncture have not been commercially available. Initial testing with different animal bones proved unsuccessful. Eventually, a novel bone marrow model was developed with assistance of the University of Veterinary Medi-cine Hannover (▶fig. 1).

Further, we desired to combine the topics effectively and put them into a didactic-teaching concept that would facilitate long-lasting benefits for the workshop participants. Therefore, multiple different didactic teaching methods were tested until the final com-position of the workshops was established.

Initially, only workshop 1 was held and evaluated. In parallel, the workshops 2 and 3 were developed, tested and subsequently opened for participants. Since June 2016 all three workshops are performed one after another. Hence, the number of participants differs between the three workshops.

Ethical ConsiderationThe operational sequence, purpose, and intention of scientific in-terpretation of the data for this practical examination were pre-sented to the local ethics committee, who deemed a formal ethi-cal approval unnecessary. The study was conducted according to principles of the World Medical Associations’ Declaration of Hel-sinki and Declaration of Geneva.

Description of SICKOBriefly, the programme consists of a 3-day workshop, with each day lasting 8 h. Workshops are provided for a maximum of 12 partici-pants with 3 tutors. Most topics are to be tackled in groups of 3 to 4 participants, with brief intervening discussions and summaries taking place with the combined groups.

During workshop day 1 (‘Basic training for oncology’) the par-ticipants do role play (experience the arrival of a new family on the ward), receive and provide feedback, perform lumbar punctures

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Original Article Thieme

using a model and learn bone marrow punctures (▶fig. 1). Dress-ing and management of central venous catheters, chemotherapy and communication are additional topics. ▶Table 1 lists the topics for workshop day 1: ‘Basic training for HCP’.

The title for workshop day 2 of the SICKO programme is ‘Com-plications in paediatric oncology and their management’. Topics including tumour lysis syndrome, prolonged methotrexate excre-tion, haemorrhagic cystitis, neutropenic fever, pain and mucositis are addressed during this day. These topics are best trained inter-actively and with a hands-on approach. Therefore, topic related challenges are distributed among small groups of the participants, where they discuss the solution for a given oncological problem before discussing their conclusions in the plenum. Additional top-ics covered during this day of the workshop include: hands-on train-ing in ultrasonography and handling emergency situations (e. g. convulsions, secondary to cerebral venous sinus thrombosis, aller-gic reaction to Asparaginase treatment, extravasation after vincris-tine injection) (▶fig. 2). ▶Table 1 lists the topics for workshop day 2: ‘Complication management in paediatric oncology’.

Workshop day 3 focusses primarily on communication skills, and additionally important aspects of infusion therapy. These topics are tackled in small problem-solving groups using theoretical clin-ical scenarios which include team-conflict management and ‘break-ing bad news’ (▶fig. 2). Crew resource management (CRM) is rel-atively new in the medical field but offers important teamwork skills for HCP, and hence is incorporated into this day of the workshop. ▶Table 1 lists the topics for workshop day 3: ‘Oncology is team-work’.

Results and Evaluation of the SICKO WorkshopsAfter a 2 year phase of developing the programme, a total of 25 work-shops have taken place from January 2015 to date. Participants were recruited whilst contacting all hospitals in an area of 100 km around Hannover with paediatric/paediatric-oncology departments.

▶Table 2 shows the results of the evaluation of the workshop 1–3.

In general, participants described that they very rarely experi-enced professional training. The workshop contents, mixture of theoretical input and different practical tasks were positively high-lighted. In addition, most participants praised the innovative and interdisciplinary concept.

All participating doctors of module 3 presented the topic of break-ing bad news as being outstanding. Nearly two-thirds of the whole group had previously been trained in providing feedback, but their usual work environments all lacked the culture of providing feedback. Prior to undertaking the workshop, none of the participants had pre-viously heard of "crew resource management". The number of partic-ipants during the workshops 2 and 3 are smaller only because these workshops have been started and opened for participants much later than workshop 1. Of note, some participants mentioned the challenge of participating in an off-the job training for three consequent days.

DiscussionIn this project we describe the development and first results of a novel workshop concept for HCP in Germany, where inherent needs for professional behaviour and skills are addressed. In accordance with the needs of the HCP, the workshop focused on selected prac-

a

b

c

▶fig. 1 Production and use of the BM dummy. a Pouring out the mold of the BM dummy b BM dummy in use on workshop day 1 c Aspiration of BM.

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tical skills (e. g. lumbar puncture, bone marrow aspiration, and in-fusion management), complication-management in paediatric on-cology (e. g. fever, convulsions, extravasation, allergic reaction) and communication skills in various scenarios.

Compared to Canada, UK and the US, practical training during the medical (undergraduate) education in Germany is less com-mon. Furthermore, practical exams occur less frequently and are

▶Table 1 Content during workshop days 1–3.

Topic content MethodModule 1: Basic training for HcPday 1 talk a new family meets the HCP first time role play, feedback

lumbar puncture (LP); bone marrow aspiration (BMA)

participants perform LP/BMA with a dummy model practical task

sterile gloves participants teach colleagues to put on sterile gloves 4-step method of Peyton/legerdemain

chemotherapy important effects/side effects of chemotherapy pantomime

basic skills for communication participants experience the challenge of difficult descriptions tangram puzzle

Module 2: complication management in paediatric oncology

tumour lysis syndrome (TLS) participants have different challenges in the context of TLS role play; feedback

Extravasation participants denominate the correct position for a vincristine injection and subsequently manage a extravasation

role play, simulated patient

Venous sinus thrombosis Participants manage a cerebral convulsion due to venous sinus thrombosis

role play, debriefing

mucositis and pain participants formulate the management for a fictitious patient with severe mucositis

working in small groups, debriefing

neutropenic fever clinical decision making in a fictitious patient with neutropenic fever audience response system

Module 3: Oncology is Teamwork

challenges for the team/communication Inner-team conflicts (body-odour, cherry-picking) small-groups, feedback, role play

breaking bad news Participants give bad news in role play games role play, small groups, video feed-back/analysis

infusion therapy different infusion related challenges small groups, hands-on

crew resource management (CRM) history of CRM is outlined, relevance of CRM for oncology plenum, discussion

a

b

▶fig. 2 Simulation and role playing. a Breaking bad news/role playing/small groups/video feed-back/analysis b Simulation of extravasation/role playing/small groups.

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Original Article Thieme

not standardised. Likewise, continuing professional education with practical aspects is not mandatory.

Störmann and co-workers analysed the results of a cohort (n = 213) of German medical students in their final year to identify areas of deficiency in knowledge/skills. Almost 10 % of the students failed the OSCE. Additionally, 30 % of the students overestimated their performance by 10 % and 18.8 % by 20 % indicating not only a lack of knowledge but also a lack of insight [11]. This OSCE focused on skills including correct physical examination, neurologic and or-thopaedic examination, reading a 12-lead ECG and basic radiology assessment. Although oncology and communication skills were not assessed, it would not be unexpected that these less commonly trained fields would have also fared poorly if they had also been in-cluded in the OSCE.

In the UK, a nationwide survey addressed the issue of prepared-ness whilst caring for cancer patients among newly qualified doc-tors. That study, where interviews and a questionnaire-based sur-vey were included, revealed several key points. First, participants stated that symptom control and communication are regarded as the most important issues for HCP. Second, the subjective prepar-edness varied considerably. 65 % of the newly qualified doctors felt well prepared to break bad news, whereas only 11 % of the respond-ents felt adequately prepared for oncological emergencies [2]. Knowledge in chemotherapy and answering patient’s questions were also listed as important topics. There are no data from Germany. Possibly the percentages are even lower. During the de-velopment of the SICKO program, German HCP were interviewed and similar topics were mentioned and consequently included into this novel concept.

In oncology, HCP regularly face difficult conversations: Day one talks, treatment related side-effect, disease relapse or even end-of life talks are all components of the workload for HCP working with cancer patients. In our workshops we created clinical scenarios to teach various basic skills such as exploring the feelings of the pa-tients/families and self-reflection. An outstanding example for teaching communication skills was provided by Epner and Baile [5]. They designed a curriculum for first-year medical oncology fellows covering a 2-year period. Using a broad variety of methods (e. g. case discussions, reflective writing, and enhanced role-play) they tried to teach key skills for difficult conversations. As opposed to our study, their cohort included only 12 fellows and had no nurses.

Providing information to patients with oncological disease might be a double-edged sword, as some patients do not want to know or are ambivalent [1]. Here the conversation is far beyond delivering information or obtaining informed consent. The oncol-ogists (and the nurse) must first understand the patient’s concerns and then try to shed light in line with the patient’s wishes. In our workshop we addressed this topic in an enhanced role play where parents refused to inform their child about the diagnosis. Accord-ing to our results, this is a typical challenge for HCP in Germany where the professionals feel helpless and lost in the conversation.

Naturally, communication cannot be taught solely within single or 3-day workshops. Surprisingly enough, until recently, commu-nication played only a minor role in medical education in Germany [8]. Using the Delphi approach, a consensus statement for com-munication in medical education in German speaking countries was defined [8]. Beside others, this survey identified two aspects of ▶

Tabl

e 2

Dem

ogra

phic

s and

feed

back

of ‘

SICK

O’-

part

icip

ants

in M

odul

es 1

–3.

part

ici-

pant

s (n

)fe

mal

e ( %

)nu

rse

( %)

age

(med

ian,

ra

nge)

The

one

day

cour

se p

rovi

ded

me

w

ith

know

ledg

e fo

r m

y pr

ofes

sion

? (“

hold

s pe

rfec

tly

true

”)

Wou

ld y

ou s

ay th

at y

ou p

rofit

ed fr

om…

…

(“ho

lds

perf

ectl

y tr

ue”)

favo

urit

e to

pics

part

icip

ants

re

com

men

ding

th

e w

orks

hop

WS1

9585

6332 20

–63

99 %

…LP

: 97

%…

BMA:

98

%…

cent

ral v

enou

s ca

thet

ers:

95

%

BMA

, che

mo-

ther

apy,

co

mm

unic

atio

n

99 %

(1 a

bste

ntio

n)

WS2

5288

6534 22

–63

98 %

…TL

S: 9

8 %

…ha

emor

rhag

ic c

ystit

is: 9

8 %

…ex

trav

asat

ion:

100

%…

dela

yed

MTX

exc

retio

n: 9

8 %

…co

nvul

sion

(Ven

ous

sinu

s th

rom

bosi

s): 9

6 %

…al

lerg

ic re

actio

n to

ASP

: 100

%

extr

avas

atio

n,

alle

rgic

re

actio

n to

ASP

100

%

WS3

4188

8035 22

–58

92 %

…te

am c

onfli

cts:

100

%…

infu

sion

wor

ksho

p: 8

1 %

…br

eaki

ng b

ad n

ews:

94

%…

crew

reso

urce

man

agem

ent:

94

%

brea

king

bad

ne

ws,

inne

r-

team

con

flict

s

100

%

WS

= w

orks

hop,

LP

= lu

mba

r pun

ctur

e, B

MA

= bo

ne m

arro

w a

spira

tion,

TLS

= tu

mou

r lys

is s

yndr

ome,

MTX

= M

etho

trex

ate,

ASP

= A

spar

agin

ase

320

Tiroke P et al. SICKO. Development of a … Klin Padiatr 2017; 229: 316–321

communication (‘Adapts oneself to the patient’s understanding and language’ and ‘Pays attention to non-verbal aspects of com-munication (e. g. gesture, facial expression, posture’) as important educational goals. These points are reflected by a review from Le-vetown and colleagues on communication in paediatrics [10]. The author identified important competencies for health care commu-nication, such as developing a partnership with the patient, review the patient’s preferences for information or establish the patient’s wishes for the role in decision making [10]. During our workshops not all aspects of communication are covered, but the participants are provided with insights, practical experiences and feedback re-garding important aspects of successful communication.

This article has some limitations: first, the workshop was de-signed and held in Germany and as such focuses on the needs of the German health care system. In other countries the responsibil-ities for chemotherapy, lumbar puncture or bone marrow aspira-tion might not lie solely in the hands of the physicians. On the other hand, the concept of practical tasks in the SICKO workshops is not only ‘to learn’, but also ‘to learn how to learn’ and ‘learn how to teach’. Therefore these practical techniques provide the partici-pants with more than just a clinical skill, but rather facilitate a way of thinking.

Second, psychosocial aspects of pediatric oncology (e. g. de-pression and anxiety) are not part of the current workshop concept but represent an integral aspect of taking care of children with can-cer. In the future, these aspects could be part of extra training in the SICKO-concept.

A third limitation is the lack of data on the sustainability of the effects of the programme. As it was the major goal of this project to develop a workshop focusing on oncology this issue has not been addressed yet. However, from 2017 onwards a long-term evalua-tion was commenced and will include staff with and also without training to measure the impact of the training 1 and 2 years after the workshops.

To conclude we designed a workshop for oncological HCP com-bining practical skills with theoretical background. Communica-tion in various scenarios plays a major role. A unique model for the training of BMA was developed for the workshop. Participants eval-uated the quality of the workshops extremely positively indicating a demand for these programs.

AcknowledgementsThis project would not have been realized without the outstanding support of the “Verein für Krebskranke Kinder Hannover e.V. (chair-man: Bärbel Dütemeyer) Marc Dilly and John Rosenthal (University of Veterinary Medicine Hannover) developed the model used for training of bone marrow puncture. Tim Price revised the first draft of the manuscript and gave important advices to improve the text.

Contributor's Statement

study concept & design: P. Tiroke, B. Sänger, L. Grigull; drafting the manuscript: P. Tiroke, U. Mücke, L. Grigull; acquisition and analysis of the data: L. Berndt, H. Wittenbecher, P. Tiroke, B. Sänger.

Conflict of Interest

The authors have no conflict of interest to disclose.

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