Quality in Primary Care Open Access

Keywords

Blended-learning; communication skills; Doc.com; primary care; faculty training; role play; family health strategy

Introduction

Brazil’s national health system is expanding toward universal coverage as a result of the Family Health Strategy (FHS), a community-based approach where interdisciplinary health care teams provide primary care for a geographically defined population. FHS teams are composed of a physician, a nurse, a nurse assistant and four to six full-time community health agents and each team member has defined roles and responsibilities.1 Community health agents are lay members of the community selected and trained to provide care management around where they live. Each agent provides a set of activities in health promotion and basic clinical care. They verify if patients have been taking their medications regularly, help patients to schedule appointments in the healthcare unit, look for risk factors such as smoking and symptoms of common chronic disease and identify warning signs of violence, neglect or drug abuse 1. The access and adherence of the families to the FHS can be strengthened by the patient-centered communication approach once it promotes partnership between the patient and health professionals, offering the opportunity to empower patients to become more active in managing their health.2,3,4 Patient-centered communication approach has been associated with improvement of clinical parameters of chronic diseases.4 The “Project Leonardo” demonstrated the benefits of a collaborative “team” consisting of physicians, care manager nurses and specialists working as “patients partners” to change in a positive way some clinical indicators related to cardiovascular disease such as LDL levels, BMI rating and blood pressure values 4. For this reason, communication skills should be part of the undergraduate medical curriculum and of the healthcare professional team training.4,5 However, instruction in doctor-patient communication skills remains a challenge for many medical schools with some concerns regarding the diversity of faculty specialties and the lack of faculty training in communication skills.5,6 Therefore, faculty should be prepared to teach these abilities.5

Objective

The objective of this study was to evaluate the perception of primary health care faculty about a blended-learning training program.

Methods

All the eight primary care faculty working in FHS in the medical course of the University of Ribeirao Preto (Brazil) (five doctors and three nurses) were invited to participate in a one month training in communication skills using two modules of the DocCom program. The main characteristics of the participants are summarized in Table 1. DocCom is a webbased resource with multi-media features including videos demonstrating the communication skills taught developed by the American Academy of Health Communication in Health Care and Drexel University College of Medicine and two of its modules translated into Portuguese (“Building relationship” and “Gathering Information”) were used for faculty training: 7. In a four-week period from October to November in 2014, the faculty watched both modules individually and subsequently participated in a reflective group discussion about their practice and in a role-play activity in which they rehearsed the main skills used in primary care. During the role-play activity faculty alternated their roles as doctors, nurses, patients and observers and provided feedback to each other. After the role-play the participants expressed their perceptions and opinions about the training by answering a structured questionnaire.

Table 1: Participants characteristics

Results

The main results of this study are summarized in Table 2. Most participants stated that the training resulted in acquisition of new skills (87.5%), that the knowledge acquired could be applied in their working environment (75%) and that the methodology facilitated the training (75%). The general practitioners highlighted the applicability of the inverted cone (starting with open-ended questions and progressing to more specific closed questions) in patient interviews. The nurses pointed out that these skills would be very useful for students and community health agents in the context of home visits.

Table 2: Results of structured questionnaire responses

Discussion

With declining resources and rising costs for attending conferences, there is a need to identify innovative ways for faculty training. The use of the open-access web-based format has been growing rapidly in medical education, especially in low and middle-income countries. In these countries several e-learning programs, tools and modalities have been applied including blended teaching platforms.8 In our study we used two DocCom modules and a role-play activity in which faculty rehearsed the main skills used in primary care. Role-play makes an important contribution in communication skills training, considering the validity of simulation, the deliberate practice, and feedback provided for this tool.9 Peer role-play is relatively easy to put into practice, allows exchange of experiences from both physician and patient perspectives, and leads to a better understanding of what is involved in physician-patient interaction.10 The blended-learning model combines a webbased format with a face-to-face activity and its effectiveness has been proved in terms of improvements of knowledge, clinical skill, attitude, and learner satisfaction.11 In our study we used this strategy for faculty training in communication skills and it was considered suitable for most participants. Furthermore the nurses involved in the pilot study intend to implement communication skills acquired during this training in the context of home visits, what means an improvement of FHS effectiveness. One limitation of this study was the small number of participants but this group included the totality of faculty involved in FHS in our medical course. We suggest similar studies in other institutions to confirm our findings.

Conclusion

These results suggest that the blended-learning model for primary care faculty training in communication skills using DocCom modules followed by role-play is suitable and useful. Furthermore, these skills could be applied during home visits in FHS.

Ethical Approval(S)

This study was conducted according to the Declaration of Helsinki and the project was approved by the Research Ethics Committee of the University of Ribeirao Preto. All participants consent has been obtained and all reasonable steps to maintain patient confidentiality have been taken.

Acknowledgements

Brazil FAIMER Regional Institute

Source of funding

University of Ribeirao Preto

Conflict of interest

There is no conflict of interest for any authors related to this work

References

1. Macinko J, Harris MJ. Brazil´s Family Health Strategy- Delivering Community-based  Primary Care in a Universal Health System. The New England Journal of Medicine 2015; 372:2177-2181.
2. Yaman H, Akdeniz M, HüseyinAvci H, Howe J. Democratising and vitalising family practice by patient-centred medicine. Ment Health Fam Med 2010; 7:193-5.
3. Zolnierek KBH, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009;47:826–834.
4. Ciccone MM, Aquilino A, Cortese F et al. Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes (Project Leonardo). Vasc Health Risk Manag 2010; 6:297-305.
5. van Dalen J. Communication skills in context: trends and perspectives. Patient EducCouns 2013; 92:292-295.
6. Lang F, Everett K, McGowen R, Bennard B. Faculty development in communication skills instruction: insights from a longitudinal program with "real-time feedback". Acad Med 2000:75:1222-8.
7. American Academy on Communication in Healthcare, Drexel University College of Medicine. "DocCom" version 6.1.[updated 2016 April 24]. Available from https://webcampus.drexelmed.edu/doccom/
8. Frehywot, Vovides Y, Talib Z et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 2013: 11: 1-15.
9. Lane C, Rollnick S. The use of simulated patients and role-play in communication skills training: a review of the literature to August 2005. Patient Educ Couns 2007:67:13–20.
10. Yardley-Matwiejczuk KM. Role play: theory and practice. London: Sage, 1997.
11. Park JH,Son JY1, Yoo NJ1, Kim S. A Review on Usage and Effectiveness of e-Learning in Medical Education. Korean J Med Educ 2010:22:91-100.