Accurate, reliable communication of task-relevant information across shift changes is a core component of handover.¹ Effective and accurate communication in handover is fundamental to facilitate high-quality healthcare.² Ineffective handover can lead to wrong treatment, delays in medical diagnosis, life-threatening adverse events, patient complaints, increased healthcare expenditure, increased hospital length of stay and a range of other effects that impact on the health system.^3–5 One study identified that errors occurred at a consistent rate of 3.5% during the communication of urgent laboratory results via telephone across three hospital locations, with physicians having the highest error rate of 5% when compared with nurses 3.4% and clerical staff 3.5%.⁶

The use of high-fidelity simulation within medical education is gaining an increasing profile as a means by which the clinical practice skills of undergraduates and postgraduates can be acquired and evaluated in a low-risk environment. In their recent report reviewing both undergraduate and postgraduate medical education in the UK the General Medical Council stated: ‘It is increasingly unacceptable for medical students and trainees to practice skills and procedures on patients without prior simulated experience’.¹² Likewise, the UK's Department of Health's 2011 document ‘A framework for technology enhanced learning’ in its first recommendation states ‘As part of a managed learning process and where appropriate, healthcare professionals should learn skills in a simulation environment and using other technologies before undertaking them in supervised clinical practice’.¹³

All 113 final-year medical students took part in a new curricular development of high-fidelity emergency medicine simulation in a purpose built high-fidelity simulator using a METi Human Patient Simulator mannequin in the ASSET Centre located within our medical school. Twelve scenarios based on real-life cases were designed by faculty, and students had access to the types of scenarios electronically beforehand. During a variety of clinical scenarios a senior intensive care nurse, a member of the simulation team, assisted students. Prior to the simulation the students are given a detailed orientation of the simulator. They are also advised that during all scenarios they may use the telephone to seek the advice of a senior colleague (registrar) on patient management. Participants were briefed to adopt the role of a Junior Doctor (intern, F1) and to refer to themselves with this title during any conversations with the patient, other professionals or senior medical staff. Students were advised during orientation that they would receive feedback from faculty on all aspects of their performance including communication during debrief after each scenario. Faculty observed students from within the control room. If students became distressed during the simulation and wished to withdraw they could indicate this by removing their white coat. Throughout the previous 4 years of the regular curriculum all students received instruction in communication skills including communication via the telephone.

All 114 phone calls were recorded, of these 69 telephone calls were deemed as meeting the criteria for analysis. The results are summarised in table 1. Thirty per cent of students did not positively identify themselves by title and their full name. Thirty-two per cent did not positively identify the recipient of the phone call by confirming their name and title. Twenty-nine per cent of students did not identify their role. Forty-one per cent of students failed to positively identify the patient by name, age and gender (figure 1). Twenty-eight per cent of students did not clearly identify their expectation of their senior colleague (figure 2). Forty-nine per cent of students did not repeat back the recommendations of their senior colleague and 97% of students did not write down and repeat back their supervisors’ recommendations (figure 3).

Our study suggests a significant deficit in 30%, 32% and 29%, respectively, of our sample of final-year medical undergraduates, who did not demonstrate the ability to positively identify themselves, the patient or the recipient during communication via the telephone with a senior colleague. Likewise, 28% were unable to clearly identify the expectation they had of a senior colleague during a telephone consultation. That is whether they were simply informing, requesting advice or requesting that the senior colleague come to attend the patient in the simulation. Of particular concern is the high failure rate of 49% to repeat back instructions and the even higher failure rate of 97% to write down instructions given over the telephone despite receiving instruction with respect to both of these aspects during communications training previously in the curriculum. During debrief after each scenario a specific focus of the feedback process was on performance of communication skills by the students. Students readily identified lapses in appropriate communication in their comments on there performance. Many identified that being nervous and this being their first experience of simulation in this format impacted on their performance. Many also highlighted that this experience highlighted the importance of communication in practice and that would be a ‘take home’ learning point for them. We suggest the deficits highlighted above in the telephone communications reflect the absence of a structured and systematic approach by the medical students. It is our contention that the results reflect their lack of regular practice of these skills and limited assessment of these skills.