Mobile Learning Resources as a Tool for Improving Clinician's Ability to Break Bad News: A Pre-post Mixed Methods Pilot Study
Phase: NA
Conditions: Education
Sponsor: Imperial College London

 
Study protocol version 2.1 18/03/2019 
1 
 
 
 
 
 
 
 
 
 
 
Mobile learning resources as a tool for improving clinician’s ability 
to break bad news: A pre-post mixed methods pilot study 
 
 
Version 2.1, 18th March 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sponsors: Imperial College London 
Funders: Imperial College London 
Study Coordination Centre: Imperial College London 
IRAS Project ID: 258886 
 
Chief Investigator & Study Management: Dr Gehan Soosaipillai 
Co-investigators: Dr Stephanie Archer and Mr Hutan Ashrafian 
 
For general queries, supply of study documentation, and collection of data, please contact: 
Chief investigator: Dr Gehan Soosaipillai 
Address: Academic Surgical Unit, 10th Floor, QEQM, St Mary’s Hospital, London, W2 1NY 
Tel: 07958 683379  
 
 
 
 
 
 
 
E-mail: gsoosaip@ic.ac.uk  

 
Study protocol version 2.1 18/03/2019 
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CLINICAL QUERIES 
 
Clinical queries should be directed to Dr Gehan Soosaipillai who will direct the query to the 
appropriate person. 
 
 
SPONSOR 
 
Imperial College London acts as the main research Sponsor for the Chief Investigator (CI). For further 
information regarding the sponsorship conditions, please contact: 
 
Ruth Nicholson, Research Governance Manager 
Room 221, Level 2, Medical School Building 
Norfolk Place, 
London W2 1PG 
Tel: 020759 41862 
E-mail: r.nicholson@imperial.ac.uk 
 
 
FUNDER 
 
The CI is funded through a Clinical Research Fellowship at Imperial College London and is not 
receiving any monetary compensation for the work.  
 
 
This protocol describes a pre-post mixed methods pilot study assessing the impact of a mobile 
learning resource on the ability of clinicians to break bad news.  
 
Every care was taken in its drafting, but corrections or amendments may be necessary. This protocol 
will be circulated to investigators in the study. Problems relating to this study should be referred, in 
the first instance, to the CI.  
 
This study will adhere to the principles outlined in the NHS Research Governance Framework for 
Health and Social Care (2nd edition). It will be conducted in compliance with the protocol, the Data 
Protection Act and other regulatory requirements as appropriate.  
 
 

 
Study protocol version 2.1 18/03/2019 
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STUDY SUMMARY 
 
Title Mobile learning resources as a tool for improving clinician’s ability to 
break bad news: A pre-post mixed methods pilot study. 
 
Design All participants granted access to a breaking bad news mobile learning 
resource (VitalTips). 
Baseline and post-intervention questionnaires, pre- and post-intervention 
simulated patient encounters, and post-intervention semi-structured 
interviews. 
 
Objective To assess if a breaking bad news mobile learning resource can improve the 
ability of clinicians to break bad news. 
 
Population/Eligibility 15-20 junior doctors and nurses working within two NHS hospitals trusts 
and one private hospital in England.  
 
Duration January 2019 to August 2019. 
 
 

 
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TABLE OF CONTENTS 
 
1. INTRODUCTION 
6 
1.1 BACKGROUND 
6 
1.2 RATIONALE 
6 
1.3 HYPOTHESIS 
6 
2. STUDY OBJECTIVE 
6 
3. STUDY DESIGN 
7 
3.1 METHODOLOGY & DESIGN 
7 
3.2 STUDY SETTING 
7 
3.3 PARTICIPANTS 
8 
3.4 SAMPLE SELECTION, PERMISSION & INVITATION 
8 
3.4 CONSENT 
9 
3.5 MEASURES 
9 
3.6 DATA HANDLING & CONFIDENTIALITY 
10 
3.7 RISKS 
11 
4. PARTICIPANT ENTRY 
11 
4.1 PRE-REGISTRATION EVALUATION 
11 
4.2 INCLUSION CRITERIA 
11 
4.3 EXCLUSION CRITERIA 
11 
4.4 WITHDRAWAL CRITERIA 
11 
5. ADVERSE EFFECTS 
12 
5.1 DEFINITIONS 
12 
5.2 REPORTING PROCEDURES 
12 
6. ASSESSMENT & FOLLOW-UP 
12 
7. STATISTICS & DATA ANALYSIS 
13 
7.1 SAMPLE SIZE 
13 
7.2 DATA ANALYSIS 
13 
7.3 DATA PROTECTION 
14 
8. REGULATORY ISSUES 
14 
8.1 ETHICS APPROVAL 
14 
8.2 CONSENT 
14 
8.3 CONFIDENTIALITY 
14 
8.4 INDEMNITY 
14 
8.5 SPONSOR 
14 
8.6 FUNDING 
14 
8.7 AUDITS 
15 
9. STUDY MANAGEMENT 
15 
10. PUBLICATION POLICY 
15 
11. REFERENCES 
16 
APPENDICES 
19 
Appendix 1A Invitation email 
19 
Appendix 1B Reminder invitation email 
20 
Appendix 2 Participant information sheet 
21 

 
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Appendix 3 Consent form 
25 
Appendix 4 Baseline questionnaire 
27 
Appendix 5 Post-intervention questionnaire 
32 
Appendix 6A Simulated patient encounter: Participant task sheet template 
38 
Appendix 6B Simulated patient encounter: Participant task sheet example 
39 
Appendix 7A Simulated patient encounter: Character sheet template 
40 
Appendix 7B Simulated patient encounter: Character sheet example 
41 
Appendix 8 Simulated patient encounter: BAS Mark Sheet 
43 
Appendix 9 Semi-structured interview: Topic guide 
47 
 
 
 
 

 
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1. INTRODUCTION 
 
1.1 BACKGROUND 
Open and honest communication is paramount when aiming to provide safe, high quality care (1–4). 
Some conversations can be difficult, such as when breaking bad news (BBN) (5–7). Clinicians cite a 
number of fears when BBN (6), such as causing harm to the patient and or their relatives (8,9), but 
avoiding these difficult conversations may cause undue harm (1,10–13).  
 
Effective communication is a complex two-way process (11,14), and is a teachable core skill (1,6). 
Communication skills training (CST) has been incorporated into health and social care professionals’ 
training curriculums (15,16), reflecting its growing importance. However, as less than 2% of time in 
medical school is devoted to CST (17), there is a need and opportunity to provide adequate and 
appropriate training. Most CST courses are delivered face-to-face, which can be expensive, time-
consuming to facilitate, and difficult to attend (17–20). As such, alternative methods of training need 
to be developed that are flexible, readily accessible and cost-effective (21).  
 
The integration and use of digital technologies in education has increased rapidly in the last decade 
(22) and altered the way we learn and think (23). Digital learning is increasingly used in workplaces, 
classrooms and for continued professional development (22,24–28). Digital learning facilitates 
learning at your own pace and in your own time (18), and removes the constraints of the traditional 
classroom-based learning model (22). Having immediate access to the world wide web, social media, 
blogs and e-mail suits our current culture of learning (27). 
 
A recent study reported that within a London hospital 98.9% of doctors and 95.1% of nurses owned 
a smartphone, and 73.5% and 64.7% owned a tablet device, respectively (29). Medical applications 
were owned by 78.3% doctors and 34.8% nurses, with the majority used for reference and training 
(29). With mobile devices becoming increasingly commonplace in healthcare (29–31), and evidence 
to support the use of digital learning for clinical skills acquisition (28,32,33), this medium of learning 
affords an avenue for CST and BBN training. However, the evidence-base is limited (4), especially 
when considering mobile learning as sub-set of digital learning (34,35).  
 
1.2 RATIONALE 
Digital and mobile learning is at the forefront of healthcare education, but there is little evidence of 
its use for breaking bad news training. This study aims to address this gap in knowledge by assessing 
how mobile learning resources may impact the ability of clinicians to break bad news. 
 
1.3 HYPOTHESIS 
The addition of a breaking bad news mobile learning resource to clinical practice improves the ability 
of junior doctors and nurses to break bad news. 
 
2. STUDY OBJECTIVE 
 
To assess if a breaking bad news mobile learning resource can improve the ability of clinicians to 
break bad news. 
 

 
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3. STUDY DESIGN 
 
3.1 METHODOLOGY & DESIGN 
The study objective will be investigated through a  pre-post mixed methods pilot study (see figure 1). 
 
Potential participants will be sent invitation e-mails (appendix 1A and 1B). Once potential 
participants have read the participant information sheet (PIS) (appendix 2) and given consent 
(appendix 3), they will be asked to complete a baseline questionnaire (appendix 4) to understand 
their demographics, their previous exposure to breaking bad news (through formal or informal 
training) and their engagement with digital resources.  
 
Following consent, participants will be asked to complete a baseline simulated patient encounter 
(SPE) with a simulated patient (SP) (role-played by a professional actor/patient) to assess their 
baseline ability to break bad news. Participants will be given a task sheet (appendix 6A) with a brief 
history of the SP and what news they need to deliver. The details and history of the SP will be 
documented on a character sheet (appendix 7A) for the professional actor/patient to refer to. The 
SPE will last 15 minutes and it will be video-recorded. The SPEs will be evaluated against a validated 
mark sheet (36) (appendix 8) completed by the SP, the CI (immediately following the SPE) and an 
independent assessor (by watching the video footage).  
 
Following the pre-intervention SPE, access to the mobile learning resource will be granted. The 
mobile learning resource is the freely available VitalTips mobile application, provided by VitalTalk. 
The participants will be expected to spend at least three hours using the VitalTips app, without this 
time impacting on their clinical and academic commitments. As the in-application metrics will not be 
available to the researchers, participants will be asked to self-report their engagement with the 
resource in the post-intervention questionnaire (appendix 5). 
 
Four to six weeks later, all participants will be asked to complete a second videoed SPE, which will be 
marked as described above. The participants will also be asked to complete a post-intervention 
questionnaire to gauge the impact on their clinical practice and their engagement with the mobile 
resources. Each participant will act as their own control when comparing the baseline and post-
intervention SPE scores and questionnaire responses.  
 
Soon after the completion of the questionnaire, the participant will be asked to participate in a 15-
30 minutes semi-structured interview with the researcher. The participant will be asked about their 
general impressions of the mobile learning resource, their use of the resource in and outside of the 
clinical environment, their perception of their ability to break bad news before and after the 
intervention, their perception of their performance in the SPE and any impact on their practice.  
 
3.2 STUDY SETTING 
Participants will be recruited from hospitals within two NHS trusts - Imperial College Healthcare NHS 
Trust and Barts Health NHS Trust, and one private health care site - Bupa Cromwell Hospital. The 
intention is to recruit those working across a range of specialities, where staff frequently break bad 
news (e.g. oncology). 
 
The study is intended to commence in January 2019 (dependant on HRA ethical approval) with final 
recruitment to be at the end of June 2019, to complete the study by August 2019. 
 
 
 

 
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Figure 1: Outline of quasi-randomised controlled trial 
 
 
 
 
3.3 PARTICIPANTS 
Participants will be junior doctors (of any specialty, pre-certificate of completion of training) and 
junior nurses (of any specialty, band 5 to 6), currently working and training within the NHS or a 
private healthcare hospital in England. All participants must be able to communicate and write in 
English. They must be willing to engage with a mobile learning resource as an additional task to their 
clinical role, ensuring their learning does not take time out of their clinical commitments. Potential 
participants will be excluded if they are undergraduates, completed their training or retired.  
 
There will be no coercion or pressure to participate. There will be no monetary reward for 
participation. Participants may use the SPE as a work-based assessment to be completed by the CI 
upon request.  
 
3.4 SAMPLE SELECTION, PERMISSION & INVITATION 
Recruitment of potential participants will utilise a number of methods. As the sample population will 
be those currently training and working within the hospital setting, the CI has the opportunity to 
present the study to doctors and nurses in training in their grand-rounds, trainee teaching sessions 
and department meetings. Having established contacts with the medical and nursing postgraduate 
training leads, the CI aims to disseminate e-mail invitations (see appendix 1A) to potential 
participants through the training leads. Once potential participants have been identified, a snowball 
approach will be used to identify further potential participants through peer word-of-mouth and 
recommendation. Finally, e-mail invitations will be disseminated through the CI and co-investigator’s 
personal contacts, and through contacts of those working within the Department of Surgery and 
Cancer. Potential participants will be given up to two weeks to decide if they want to participate, 
with a reminder sent after one week (appendix 1B). 

 
Study protocol version 2.1 18/03/2019 
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Potential participants will be sent a participant information sheet (PIS) (appendix 2) attached to the 
invitation e-mail. The number of potential participants who have been e-mailed will be tallied by the 
CI on an Excel spreadsheet to compare the number of those who have been approached as potential 
participants to those who become study participants. Each potential participant will be referenced 
by a participant ID number for confidentiality purposes. 
 
3.4 CONSENT 
Respondents to the invitation will be given the opportunity to read a paper-copy of the PIS and 
provide written consent (appendix 3) to join the study. Consent will be gained by the CI at a time 
that is convenient to the potential participant. Participants will be randomised once consent is 
signed and the baseline questionnaire is completed. 
 
3.5 MEASURES 
Questionnaires 
Once consent is gained, the participants will complete a baseline (pre-intervention) questionnaire 
(appendix 4) reporting their demographics, previous exposure to breaking bad news training and 
their engagement with mobile learning resources. The questionnaires will be printed and available 
for completion following consent. If participants would rather have more time to complete the 
questionnaire, an electronic version will be sent via e-mail for them to complete and return within 
two weeks.   
 
The post-intervention questionnaire (appendix 5) will be offered at the time of the second SPE (four 
to six weeks following randomisation). If any participants wish to not attend the SPE, the post-
intervention questionnaire will still be offered to them. Participants will be given two weeks to 
complete and return the questionnaire. 
 
The questionnaires utilise a five-point Likert scale (37,38) ranking of the user’s confidence and 
agreeability with statements. Some statements have a white space to write comments. The 
questionnaires are novel to this study and were developed using principles of Kirkpatrick’s Model of 
Learning Evaluation (39), the Theory of Planned Behaviour (40) and the Technology Acceptance 
Model (41), whilst also drawing on the most important curricula competencies derived from the 
content analysis of a sample of medical and nursing curricula followed by an expert consensus 
(unpublished work by CI). 
 
Simulated patient encounters 
SPEs allow assessments of skills in a safe and controlled environment, without impacting patient 
care (42). Participants will be asked to complete two SPEs – the first at baseline, and the second four 
to six weeks post-intervention. The CI will send dates for the candidates to choose the best time for 
the SPE. The participants will have to ensure the time taken for the assessments are outside their 
clinical commitments or they have adequate clinical cover if they are participating during work 
hours. Those working within the same department will be encouraged to participate on the same 
day to avoid discussion within the group of participants who have and have not completed the SPE. 
The SPEs will be arranged within the hospital premises where the participants work or within the 
premises of the Academic Surgical Unit at Imperial College London.  
 
Prior to the start of the SPE, the participant will be given a participant task sheet to read, which 
summarises the task (appendix 6A and an example in appendix 6B). They will be reminded that their 
personal performance scores will remain confidential (not distributed beyond the CI and his co-
investigators). They will be offered the opportunity to have the consultation documented as a work-
based assessment for their portfolio. 

 
Study protocol version 2.1 18/03/2019 
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The participant will be given 15 minutes to conduct a consultation with a SP where they have to 
break bad news. The SP will be role-played by a professional actor/patient known to Clinical Skills 
team within the Department of Surgery and Cancer, from a bank of professional actors/patients who 
have experience in communication skills training and have previously been trained to participate in 
SPEs. The actor/patient will be compensated for their time according to their agreement with the 
department. A short introduction to their character and how they may respond to questions and 
ques will be provided (appendix 7A and an example in appendix 7B). Task and character sheets are 
adapted from templates provided by MockOSCE (43). Separate scenarios will be used at baseline 
and post-intervention. The previously validated Breaking bad news Assessment Schedule (BAS) (36) 
will be used as the mark sheet (appendix 8) to quantify participant interaction with the SP. The BAS 
has been shown to have high internal consistency (Cronbach’s alpha score of 0.93) and the inter-
rater reliability was within the moderate to good range (weighted kappa values 0.4510, 0.6817 and 
0.6114) (36). The mark-sheet will be completed by the SP and the CI at the time of the SPE. The 
encounter will be video-recorded so that it can be viewed by the independent assessor at a later 
date to complete the mark sheet. Therefore, three separate assessor scores will be used when 
calculating the overall performance score of each participant. 
 
Following the completion of the SPE, the participant will be reminded not to discuss the scenario 
with other members of their department who have not yet completed the consultation. Following 
the completion of the second SPE and the post-intervention questionnaire, the participants will have 
no further commitments to the study. 
 
Semi-structured interviews 
To greater understand the participant’s ability to break bad news following their use of the learning 
resource, they will be asked to participate in semi-structured interviews soon after the completion 
of the post-intervention questionnaire. During the interview, they will be asked about their ability to 
break bad news, how the learning may have impacted their clinical practice, their perception of their 
performance in the SPEs, and how they interacted with the learning resource in practice. 
 
Participants will be read a short introduction prior to the start of the interview (see appendix 9). 
They will be reminded that what they disclose in their interview will remain anonymous. They will be 
informed that the interview will be audio recorded, transcribed and anonymised. A list of topics will 
guide the semi-structured interviews (see appendix 9). The interviews are expected to last 15- 30 
minutes. An audio recording will be made of the interview and the researcher may take field notes 
documenting non-verbal responses and any reflections to be used to adapt the topic guide or study 
direction. 
 
3.6 DATA HANDLING & CONFIDENTIALITY 
Following consent, participants will be referenced by their participant ID number (e.g. MLR001). 
Their e-mail address will be recorded next to their participant ID number, gender, role (i.e. doctor or 
nurse) and training grade, on an Excel spreadsheet for the purpose of contacting participants as the 
study progresses. The participant’s hospital of work will not be recorded. Once their commitment to 
the study has been ended, the e-mail address will be deleted. The Excel spreadsheet will be kept on 
a password protected laptop computer. Non-identifiable data will be backed up with secure storage 
for a period of 10 years for purpose of reference to data requested regarding any research 
published. 
 
Video recordings from the SPEs will be transferred from the recording device to a password 
protected USB stick referenced by the participant ID followed by SPE1 (baseline) or SPE2 (post-
intervention), e.g. MLR001_SPE1. Once the independent reviewer has viewed the video and marked 

 
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the participant, the video file will be destroyed. Audio recordings from the interviews will be 
transcribed by the CI and PageSix Transcription Services (we have a confidentiality agreement in 
place with PageSix). Transcripts will be identified by the participant study number and saved to the 
password protected computer. Once transcripts have been checked for accuracy, the original audio 
files will be destroyed. 
 
Physical files (i.e. consent forms) will be kept in a security locked office in Academic Surgical Unit, 
10th Floor, QEQM, St Mary’s Hospital, London, W2 1NY.  
 
3.7 RISKS 
There are no foreseeable physical harms associated with this research. Some participants and the 
professional actors/patients may become emotional during the SPEs. They will be treated with 
dignity, respect and dealt with sensitively. If participants or professional actors/patients become 
overly distressed during the SPEs, it will be abandoned, and support offered, initially by the CI and if 
required the Occupational Health service for their institution. Alternatively, they will be asked to 
seek support from their General Practitioner.  
 
4. PARTICIPANT ENTRY 
 
4.1 PRE-REGISTRATION EVALUATION 
None.  
 
4.2 INCLUSION CRITERIA 
• 
Working and training within NHS England and Bupa Cromwell Hospital. 
• 
Junior doctor, pre-certificate of completion of training (of any specialty). 
• 
Junior nurse band 5 to 6 (any specialty). 
• 
Over the age of 18. 
• 
Able to communicate and write in English. 
• 
Willing to engage with mobile learning resources as an additional task to their clinical role, 
ensuring their learning does not take time out of their clinical commitments.  
 
4.3 EXCLUSION CRITERIA 
• 
Medical and nursing students. 
• 
Clinicians who have completed their training programmes i.e. medical or nursing consultants, 
matrons. 
• 
Retired clinicians. 
 
4.4 WITHDRAWAL CRITERIA 
Participants can choose to stop participating in the study before or during the study, without giving a 
reason, by informing the CI. The SPEs can be stopped at any time by informing the assessors. 
Following completion of the study, the participant can decide to withdraw from the study up to two 
weeks after without giving a reason by informing the CI. 
 
 
 

 
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5. ADVERSE EFFECTS 
 
5.1 DEFINITIONS   
Adverse Event (AE): any untoward medical occurrence in a patient or clinical study subject.   
 
Serious Adverse Event (SAE): any untoward and unexpected medical occurrence or effect that: 
• 
Results in death. 
• 
Is life-threatening – refers to an event in which the subject was at risk of death at the time of the 
event; it does not refer to an event which hypothetically might have caused death if it were 
more severe. 
• 
Requires hospitalisation, or prolongation of existing inpatient’s hospitalisation. 
• 
Results in persistent or significant disability or incapacity. 
• 
Is a congenital anomaly or birth defect. 
 
Medical judgement should be exercised in deciding whether an AE is serious in other situations. 
Important AEs that are not immediately life-threatening or do not result in death or hospitalisation 
but may jeopardise the subject or may require intervention to prevent one of the other outcomes 
listed in the definition above, should also be considered serious. 
 
5.2 REPORTING PROCEDURES 
All adverse events should be reported. Depending on the nature of the event the reporting 
procedures below should be followed. Any questions concerning adverse event reporting should be 
directed to the CI in the first instance.   
 
Given the nature of this study, it is not anticipated that any AEs or SAEs will occur. 
 
However, any SAEs should be reported to the Imperial College Research Ethics Committee where in 
the opinion of the CI, the event was: 
• 
‘related’, i.e. resulted from the administration of any of the research procedures; and 
• 
‘unexpected’, i.e. an event that is not listed in the protocol as an expected occurrence. 
 
Reports of related and unexpected SAEs should be submitted within 15 days of the CI becoming 
aware of the event, using the NRES SAE form for non-IMP studies.  The CI must also notify the 
Sponsor of all SAEs. 
 
6. ASSESSMENT & FOLLOW-UP 
 
Following the completion of their semi-structured interview, the participant will have no further 
commitments to the study. The study is intended to commence in January 2019 with final 
recruitment to be at the end of June 2019, to complete the study by August 2019. Following this, 
there will be no follow-up of the participants unless they have chosen to receive a summary of the 
results, in which case this will be e-mailed to them. 
 
 
 

 
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7. STATISTICS & DATA ANALYSIS 
 
7.1 SAMPLE SIZE 
Due to the exploratory nature of this educational pilot study, the sample size will be relatively small, 
especially as all participants will be given the intervention and there are no comparator groups. 
Considering that there are two professional groups involved (doctors and nurses) a sample of ten 
participants from each (20 in total) should be sufficient to answer the research question and allow 
for thematic analysis of the post-intervention interview transcripts.  
 
Schildmann et al. and similar studies either did not formally report on or had low attrition rates as 
their interventions were part of the participant’s training (44). This makes it difficult to estimate the 
level of attrition in our study, especially as the intervention is not mandatory for training. However, 
it is estimated that attrition levels will be low as evidenced by similar studies.  
 
7.2 DATA ANALYSIS 
Data will be analysed at Imperial College London. 
 
The SPE will be marked by three assessors: the CI, the SP and an independent assessor. The marks 
are in the form of a numerical scale (appendix 8) for quantitative analysis. The scores will be 
recorded on an Excel spreadsheet against the participant ID. Each participant will act as their own 
control, with their baseline and post-intervention scores being compared. Using IBM® SPSS Statistics 
Software, a paired sample t-test will be used to statistically analyse the results (with p < 0.05 
considered a statistically significant change). 
 
The baseline and post-intervention questionnaires will be analysed by the CI using a combination of 
a spreadsheet for the quantitative elements (converting the Likert scale into a numerical scale), and 
qualitative data management software (i.e. NVivo from QRS International) for the white space 
answers.  
 
The user’s confidence in breaking bad news at baseline and post-intervention will be self-assessed 
on a Likert scale which will be converted to a numerical scale: 
• 
Confidence five-point scale: Not very confident at all (= 0); not very confident (= 1); 
somewhat confident (= 2); very confident (= 3); extremely confident (= 4). 
• 
Agreeability five-point scale: Strongly disagree (= 0); disagree (= 1); neutral (= 2); agree (= 3); 
strongly agree (= 4). 
 
Each participant will act as their own control, with comparisons drawn from their own Likert scale 
ratings from baseline and post-intervention. A paired sample t-test will be used to statistically 
analyse the results as above. 
 
The answers to open ended questions will be transcribed into a Word file and then uploaded onto 
NVivo for thematic analysis. This will be performed by the CI becoming familiar with the content of 
the transcriptions and then thematically coded and analysed. To counter analysis bias, a selection 
will be reviewed and coded by a second researcher, with any disagreement resolved through 
discussion. The second researcher will not have access to personal data and will only view 
anonymised transcripts. 
 
The semi-structured interviews will be transcribed verbatim either by the CI or PageSix Transcription 
Services and analysed by the CI using NVivo (qualitative data management software). Thematic 
analysis will be performed by the CI by becoming familiar with the content of the transcriptions 

 
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followed by thematic coding and analysis. To counter analysis bias, a selection will be reviewed and 
coded by a second researcher, with any disagreement resolved through discussion. The second 
researcher will not have access to personal data and will only view anonymised files. 
 
7.3 DATA PROTECTION 
Participants will have their identifiable data recorded in an Excel spreadsheet on a password 
protected computer and backed up regularly. Each participant will be referenced by their study ID 
number, recorded in this database. Any physical files (i.e. consent forms) will be kept in a security 
locked office in the Academic Surgical Unit, 10th Floor, QEQM, St Mary’s Hospital, London. 
 
Data will also be archived as per Imperial College standard operating procedures. Data and all 
appropriate documentation will be stored for a minimum of 10 years after the completion of the 
study, including the follow-up period.   
 
8. REGULATORY ISSUES 
 
8.1 ETHICS APPROVAL 
The Study Coordination Centre has obtained approval from the Health Research Authority (HRA). 
The study must also receive confirmation of capacity and capability from each participating NHS 
Trust before accepting participants into the study or any research activity is carried out. The study 
will be conducted in accordance with the recommendations for physicians involved in research on 
human subjects adopted by the 18th World Medical Assembly, Helsinki 1964 and later revisions. 
 
8.2 CONSENT 
Consent to enter the study must be sought from each participant only after a full explanation has 
been given, a PIS offered and time allowed for consideration. Signed participant consent will be 
obtained. The right of the participant to refuse to participate without giving reasons will be 
respected. All participants are free to withdraw without giving reasons. 
 
8.3 CONFIDENTIALITY 
The CI will preserve the confidentiality of participants taking part in the study to fulfil transparency 
requirements under the General Data Protection Regulation for health and care research. 
 
8.4 INDEMNITY 
Imperial College London holds negligent harm and non-negligent harm insurance policies which 
apply to this study. 
 
8.5 SPONSOR 
Imperial College London will act as the main Sponsor for this study. Delegated responsibilities will be 
assigned to any NHS trusts taking part in this study.   
 
8.6 FUNDING 
The research described in this protocol is primarily conducted by the CI who is funded through a 
Clinical Research Fellowship at Imperial College London.  
 

 
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8.7 AUDITS 
The study may be subject to inspection and audit by Imperial College London under their remit as 
Sponsor and other regulatory bodies to ensure adherence to GCP and the NHS Research Governance 
Framework for Health and Social Care (2nd edition).  
 
9. STUDY MANAGEMENT 
 
The day-to-day management of the study will be co-ordinated through the CI (Dr Gehan Soosaipillai). 
 
10. PUBLICATION POLICY 
 
The results of this research may be submitted for conferences and published in journals. The data 
will also be used for the purposes of a doctoral thesis.  
 
A summary of results will be made available to participants who wish to be informed. 
 
 

 
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11. REFERENCES 
 
1.  
Moore PM, Rivera Mercado S, Grez Artigues M, Lawrie TA. Communication skills training for 
healthcare professionals working with people who have cancer (Review). Cochrane Database 
Syst Rev. 2013;(3).  
2.  
General Medical Council. Good medical practice. General Medical Council publications. 2013.  
3.  
Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour 
for nurses and midwives. Nursing and Midwifery Council publications. 2015.  
4.  
Blackmore A, Kasfiki EV, Purva M. Simulation-based education to improve communication 
skills: A systematic review and identification of current best practice. BMJ Simul Technol 
Enhanc Learn. 2018;4:159–64.  
5.  
Buckman R, Kason Y. How to break bad news: A guide for health-care professionals. 
University of Toronto Press; 1992.  
6.  
Buckman R. Breaking bad news: Why is it still so difficult? Br Med J (Clin Res Ed). 1984 May 
26;288(6430):1597 LP-1599.  
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Gawande A. Being mortal: Illness, medicine and what matters in the end. First edition. New 
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Wright AA. Associations between end-of-life discussions, patient mental health, medical care 
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Karimi S. Do learners’ characteristics matter? An exploration of mobile-learning adoption in 
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Siemens G. Connectivism: A learning theory for the Digital Age. Int J Instr Technol Distance 
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Guo P, Watts K, Wharrad H. An integrative review of the impact of mobile technologies used 
by healthcare professionals to support education and practice. Nurs Open. 2016;3(2):66–78.  
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Miller SJ. Hope T. Talbot D. The development of a structured rating schedule (the BAS) to 
assess skills in breaking bad news. Br J Cancer. 1999;80:792–800.  
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Norman G. Likert scales, levels of measurement and the “laws” of statistics. Adv Heal Sci 
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Sullivan GM, Artino AR. Analyzing and interpreting data from Likert-type Scales. J Grad Med 
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Kirkpatrick DL. Evaluating training programs: The four levels. San Francisco: Berrett-Koehler; 
1994.  
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Francis AJJ, Eccles MP, Johnston M, Walker A, Grimshaw J, Foy R, et al. Constructing 
questionnaires based on the theory of planned behaviour: A manual for health services 
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Davis F. Perceived usefulness, perceived ease of use, and user acceptance of information 
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42.  
Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety 
in healthcare. BMJ Simul Technol Enhanc Learn. 2018;1–8.  
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Mockosce. Mockosce.com templates [Internet]. 2018 [cited 2018 Dec 4]. Available from: 
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Schildmann J, Kupfer S, Burchardi N, Vollmann J. Teaching and evaluating breaking bad news: 
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Wand S, Schildmann J, Burchardi N, Vollmann J. Die Aufklärungsgesprächbewertungsskala 

 
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Patienten über Tumorerkrankungen. Z Arztl Fortbild Qualitatssich. 2007;101(10):645–51.  
 
 

 
Study protocol version 2.1 18/03/2019 
19 
APPENDICES 
 
Appendix 1A Invitation email 
 
Invitation Email (18/03/2019) 
 
Dear [insert name of potential participant], 
 
Invitation to study: Mobile learning resources as a tool for improving clinician’s ability to break bad 
news: A pre-post mixed methods pilot study. 
 
Open and honest communication is important when aiming to provide safe, high quality care. Some 
conversations can be difficult, such as when breaking bad news. Communication skills training are 
usually delivered face-to-face, which can be expensive, time-consuming, and difficult to attend. As 
such, alternative methods of training are needed. Digital learning is at the forefront of healthcare 
education, but there is little evidence of the use of digital learning for breaking bad news training. 
This study aims to address this gap in knowledge by assessing how mobile learning resources may 
impact the ability of clinicians to breaking bad news. 
 
You have been invited to participate in this study as you are a junior doctor/nurse working [delete as 
appropriate] with experience in breaking bad news conversations. 
 
You will be asked to complete baseline and post-intervention (four to six weeks later) questionnaires 
and video recorded simulated patient encounters. You will be given access to the mobile learning 
resource. Following the post-intervention questionnaire, a semi-structured interview will be 
conducted to understand your views on the learning resource and your ability to break bad news.  
 
If you choose to participate, your details will be kept confidential. There is no obligation to 
participate and you can withdraw at any point during or up to two weeks after your participation in 
the study. The results of this study will be used for academic outputs, including a PhD research thesis 
and academic publications. 
  
Please find attached a Participant Information Sheet with more details on the study. You can let me 
know if you would like to participate by replying to this e-mail and we can arrange a time to meet 
and begin the consent process. 
  
Kind regards, 
 
Dr Gehan Soosaipillai 
Clinical Fellow, Department of Surgery and Cancer, Imperial College London 
 
 
 

 
Study protocol version 2.1 18/03/2019 
20 
Appendix 1B Reminder invitation email 
 
Reminder invitation Email (18/03/2019) 
 
Dear [insert name of potential participant], 
 
Invitation to study: Mobile learning resources as a tool for improving clinician’s ability to break bad 
news: A pre-post mixed methods pilot study. 
 
Following on from my email last week, I wanted to remind you about the opportunity to participant 
in this study. 
  
Please find attached a Participant Information Sheet with more details on the study. You can let me 
know if you would like to participate by replying to this e-mail and we can arrange a time to meet 
and begin the consent process. 
  
Kind regards, 
 
Dr Gehan Soosaipillai 
 
 

 
Study protocol version 2.1 18/03/2019 
21 
Appendix 2 Participant information sheet 
 
Participant Information Sheet v2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
(IRAS ID 258886) 
 
Researcher: Dr Gehan Soosaipillai 
Supervisor: Dr Stephanie Archer 
 
You are being invited to take part in a research study. Before you decide, it is important for you to 
understand why the research is being done and what it will involve. Please take time to read the 
following information carefully and discuss it with others if you wish. 
 
Please ask the researcher if there is anything that is not clear or if you would like more information.  
 
What is the purpose the Study? 
Open and honest communication is important when aiming to provide safe, high quality care. Some 
conversations can be difficult, such as when breaking bad news (BBN). Communication skills training 
(CST) has been incorporated into most health and social care professionals’ training curriculums, 
reflecting its growing importance. Most CST courses are delivered face-to-face, which can be 
expensive, time-consuming to facilitate, and difficult to attend. As such, alternative methods of 
training need to be developed that are flexible, readily accessible and cost-effective. Digital learning 
is at the forefront of healthcare education, but there is little evidence of the use of digital learning 
for BBN training. This study aims to address this gap in knowledge by assessing how mobile learning 
resources may impact the ability of clinicians to BBN.  
 
Why have I been invited to take part? 
You have been invited to participate in this study as you are a junior doctor or nurse working in 
England with experience in breaking bad news conversations.  
Do I have to take part? 
It is up to you to decide whether or not to take part. If you do decide to take part, you will be given 
this Participant Information Sheet (PIS) to keep and be asked to sign a consent form. If you decide to 
take part, you are still free to withdraw before or during the study without giving a reason.  
What will happen if I take part? 
We will arrange a time and place that suits you to complete the consent form. Once consent is 
gained, you will be asked to complete a questionnaire on your background and experience in BBN. 
Following this, you will be asked to participate in a simulated patient encounter (SPE) with a 
simulated patient (SP). The SPE will be video recorded. Apart from the SP and the researcher, there 
will be no others in the room. Your performance of BBN will be marked by the researcher, the SP 
and an independent accessor (after watching the video). Your scores are kept confidential within the 
research team and your participation has no impact on your training.  
 
Following the SPE you will be granted access to the mobile learning resource. You are expected to 
spend at least three hours using the resource over a four to six week period. After this, you will be 
asked to complete a second questionnaire with addition questions on your experiences of using the 

 
Study protocol version 2.1 18/03/2019 
22 
mobile resource. Then you will be asked to complete a second video recorded SPE. Your 
performance of BBN will be marked by the researcher, the SP and an independent accessor.  
 
Shortly after the second SPE, you will be asked to participate in a semi-structured interview to gauge 
your perception of your ability to break bad news and how you found using the learning resource. 
The interview will be audio recorded. Following this, your commitments to the study will end. 
 
Is taking part anonymous and confidential? 
Yes. All information which is collected from you during this study will be kept strictly confidential. 
Identifiable participant information will be stored on a password protected computer. All data will 
be anonymised and saved to this computer system. Once the video recordings are viewed by the 
independent assessor, they will be destroyed. Once the audio recordings of the interviews are 
transcribed, and the transcriptions checked for accuracy, the audio files will be destroyed. 
 
Data will be backed up with secure storage for a period of 10 years after the completion of the study 
for purpose of reference to data requested regarding any research published.  
 
What are the possible benefits of taking part in this study? 
The aim of the study is to see if a mobile learning resource can enhance your ability to break bad 
news. If you are in a training role and require work-based assessments to be completed, you can ask 
the researcher to complete a relevant assessment for you following the SPE. 
 
What are the possible risks of taking part in this study? 
There is no foreseen physical harm associated with this study. You may find the SPE upsetting or 
difficult. If you become upset, then the SPE can be abandoned if you wish and support will be 
offered. It is important to remember that this is not an assessment that has any impact on your 
training. 
 
Imperial College London holds insurance policies which apply to this study. If you experience harm 
or injury as a result of taking part in this study, you will be eligible to claim compensation without 
having to prove that Imperial College is at fault. This does not affect your legal rights to seek 
compensation. 
 
If you are harmed due to someone's negligence, then you may have grounds for a legal action. 
Regardless of this, if you wish to complain, or have any concerns about any aspect of the way you 
have been treated during the course of this study then you should immediately inform the 
Investigator (Dr Gehan Soosaipillai). The normal National Health Service mechanisms are also 
available to you. If you are still not satisfied with the response, you may contact the Imperial College, 
Joint Research Compliance Office. 
 
What will happen after this study? 
This study forms part of a PhD research project being undertaken by Dr Gehan Soosaipillai at 
Imperial College London. The research may be presented in academic conferences and/or published 
in academic journals. If you wish, we can send you a summary of the results of the study when they 
are ready. 
 
Can I stop taking part? 
You can decide that you do not want to participate without giving a reason by informing the 
researcher at any time before or during the study. Following completion of the study, you can decide 
to withdraw from the study up to two weeks after without giving a reason. 
 

 
Study protocol version 2.1 18/03/2019 
23 
What if there is a problem? 
We do not expect that this study will cause harm to anyone taking part. However, if you have 
concerns please inform the researcher.  
 
Who has reviewed the study? 
The study has been reviewed and approved by the Health Research Authority (HRA). 
 
Who can answer my questions about this study? 
You can talk to the researcher about any questions or concerns you have about this study: 
Dr Gehan Soosaipillai (e-mail: gsoosaip@ic.ac.uk) 
 
Thank you for taking time to read about this study. A copy of this Participant Information Sheet and 
signed consent form will be given to you to keep. 
 
 
TRANSPARENCY NOTICE 
Imperial College London is the sponsor for this study based in the United Kingdom. We will be using 
information from you in order to undertake this study and will act as the data controller for this 
study. This means that we are responsible for looking after your information and using it properly. 
Imperial College London will keep identifiable information about you for: 
• 
Ten years after the study has finished in relation to data subject consent forms. 
• 
Ten years after the study has completed in relation to primary research data. 
 
Further information on Imperial College London’s retention periods may be found at 
https://www.imperial.ac.uk/media/imperial-college/administration-and-support-services/records-
and-archives/public/RetentionSchedule.pdf.  
 
Your rights to access, change or move your information are limited, as we need to manage your 
information in specific ways in order for the research to be reliable and accurate. If you withdraw 
from the study, we will keep the information about you that we have already obtained. To safeguard 
your rights, we will use the minimum personally-identifiable information possible. You can find out 
more about how we use your information by contacting the CI. 
 
Legal basis 
As a university we use personally-identifiable information to conduct research to improve health, 
care and services. As a publicly-funded organisation, we have to ensure that it is in the public 
interest when we use personally-identifiable information from people who have agreed to take part 
in research.  This means that when you agree to take part in a research study, we will use your data 
in the ways needed to conduct and analyse the research study. 
 
Health and care research should serve the public interest, which means that we have to 
demonstrate that our research serves the interests of society as a whole. We do this by following the 
UK Policy Framework for Health and Social Care Research. 
 
International transfers 
There may be a requirement to transfer information to countries outside the European Economic 
Area (for example, to a research partner). Where this information contains your personal data, 
Imperial College London will ensure that it is transferred in accordance with data protection 
legislation. If the data is transferred to a country which is not subject to a European Commission (EC) 
adequacy decision in respect of its data protection standards, Imperial College London will enter into 

 
Study protocol version 2.1 18/03/2019 
24 
a data sharing agreement with the recipient organisation that incorporates EC approved standard 
contractual clauses that safeguard how your personal data is processed. 
 
Contact us 
If you wish to raise a complaint on how we have handled your personal data or if you want to find 
out more about how we use your information, please contact Imperial College London’s Data 
Protection Officer via e-mail at dpo@imperial.ac.uk, via telephone on 020 7594 3502 and via post at 
Imperial College London, Data Protection Officer, Faculty Building Level 4, London SW7 2AZ. 
If you are not satisfied with our response or believe we are processing your personal data in a way 
that is not lawful you can complain to the Information Commissioner’s Office (ICO). The ICO does 
recommend that you seek to resolve matters with the data controller (us) first before involving the 
regulator. 
 
Imperial College Healthcare NHS Trust/ Barts Health NHS Trust/ Bupa Cromwell Hospital [delete as 
appropriate] will collect information from you for this research study in accordance with our 
instructions. 
 
Imperial College Healthcare NHS Trust/ Barts Health NHS Trust/ Bupa Cromwell Hospital [delete as 
appropriate] will keep your name and contact details [e-mail address] confidential and will not pass 
this information to Imperial College London. Imperial College Healthcare NHS Trust/ Barts Health 
NHS Trust/ Bupa Cromwell Hospital [delete as appropriate] will use this information as needed, to 
contact you about the research study, and make sure that relevant information about the study is 
recorded for your care, and to oversee the quality of the study. Certain individuals from Imperial 
College London and regulatory organisations may look at your research records to check the 
accuracy of the research study. Imperial College London will only receive information without any 
identifying information. The people who analyse the information will not be able to identify you and 
will not be able to find out your name or contact details. 
 
Imperial College Healthcare NHS Trust/ Barts Health NHS Trust/ Bupa Cromwell Hospital [delete as 
appropriate] will keep identifiable information about you from this study for ten years after the study 
has finished. 
 
 

 
Study protocol version 2.1 18/03/2019 
25 
Appendix 3 Consent form 
 
Consent Form v2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
(IRAS ID 258886) 
 
Researcher: Dr Gehan Soosaipillai 
Supervisors: Dr Stephanie Archer 
 
Participant ID: 
 
Instructions for the participant: 
Please read each of the sections below. In the box next to each section, please write your initials to 
show that you agree with what the section says.  
 
 
 
Initials 
1 
I have read and understand the Participant Information Sheet for the above study 
(version 2.1 dated 18/03/2019). 
 
2 
I have had the opportunity to think about the information and to ask questions 
about it if I want to. If I have asked questions, I am happy with the way my 
questions have been answered. 
 
3 
I understand what will happen in the study. 
 
 
4 
I understand that my answers to the questionnaires and interview questions, and 
the simulated patient encounter marks will be recorded and saved on the 
researcher’s computer.  
 
5 
I understand that the video recordings from the simulated patient encounter will 
be transferred from the recording device to a USB drive, and once it has been 
viewed by the independent assessor, the file will be destroyed. 
 
6 
I understand that what I say in the interview will be recorded using a digital voice 
recorder, transcribed and saved on the researcher’s computer, and once the 
transcriptions are checked for accuracy, the file will be destroyed. 
 
7 
I have been informed that anything I write in the questionnaires or say during the 
simulated patient encounters will remain completely anonymous; no identifiable 
information will be used.  
 
8 
I agree that my simulated patient encounter marks and parts of what I say in the 
questionnaires may be used anonymously in the results of this study. 
 
9 
I agree that my simulated patient encounter marks and parts of what I say in the 
questionnaires may be used anonymously in academic conferences or 
publications, and the researcher’s academic thesis. 
 
10 
I understand that I can withdraw my consent to participate at any point before or 
during the interview or within two weeks of the date of participation without 
having to give a reason and without my legal rights being affected. 
 
11 
I agree to take part in this study. 
 
 
 
 
 

 
Study protocol version 2.1 18/03/2019 
26 
If you agree to the above, print your name, your signature and today’s date below. 
 
 
 
________________ 
 
________________ 
 
________________ 
Name of participant  
 
Signature  
 
 
Date 
 
________________________________________________ 
E-mail address 
 
 
 
________________ 
 
________________ 
 
________________ 
Name of researcher  
 
Signature  
 
 
Date 
 
 
If you would like to receive a summary of the results, please tick here:  
 
 
1 copy for participant; 1 copy for researcher.  
 
 

 
Study protocol version 2.1 18/03/2019 
27 
Appendix 4 Baseline questionnaire 
 
Baseline Questionnaire 2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
(IRAS ID 258886) 
 
Participant ID: 
 
Thank you for taking part in this study. Please could you complete this questionnaire? It is likely to 
take 15 minutes to complete. Your answers will be kept confidential.  
 
 
PART A 
 
Demographics 
1. What is your gender? 
 
Male / Female / Other / Rather not say 
  
2. Which age bracket applies to you? 
 
18-24 years old 
25-34 years old 
35-44 years old 
45-54 years old 
55-64 years old 
65+ 
 
3A. What is your role? 
 
Doctor / Nurse  
  
3B. How long have you worked in this role? 
 
_____ years 
 
Breaking bad news  
4. In your role, are you involved in breaking bad news? 
 
Yes / No 
  
4B. If ‘Yes’, in what capacity? 
 
Comment: 
 
  
 
 

 
Study protocol version 2.1 18/03/2019 
28 
4C. If ‘Yes’, how often are you involved in breaking bad news in a week? 
 
Comment: 
 
 
 
 
Training 
5A. Have you received training on breaking bad news at either the undergraduate or postgraduate 
level? 
 
Yes / No 
  
5B. If ‘Yes’, what training did you receive?  
 
Comment: 
 
 
 
 
 
Mobile devices & learning 
6A. Do you own or have access to a smartphone or tablet which you use whilst at work? 
 
Yes / No 
 
6B. If ‘Yes’, do you use the smartphone or tablet at work for learning? 
 
Yes / No 
 
6C. If ‘Yes’, what features or applications on your device(s) do you use for work? 
 
Comment: 
 
 
 
 
7. Have you ever used digital learning resources for breaking bad news training? 
 
Yes / No 
 
Comment: 
 
 
 
 
 
PART B 
 
Breaking bad news competencies 

 
Study protocol version 2.1 18/03/2019 
29 
Please rate your level of confidence regarding the following statements related to breaking bad 
news: 
  
1. Your ability to break bad news well. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
2. Your ability to recognise when to break bad news. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
3. Your ability to break bad news in planned and unexpected settings. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
4. Your ability to be empathetic, honest and sensitive when breaking bad news. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
5. Your ability to prepare for breaking bad news (i.e. setting the environment, having sufficient 
information). 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
6. Your ability to establish the person’s understanding. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  

 
Study protocol version 2.1 18/03/2019 
30 
  
7. Your ability to pick up and respond to verbal and visual cues. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
8. Your ability to recognise the impact of bad news on the person/people you are speaking to. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
9. You know that different people may respond to bad news in different ways. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
10. You know how to provide support for the person you have given the bad news to. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
11. You know when to ask for help when breaking bad news. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
12. You can recognise the impact of breaking bad news on yourself.  
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
13. You can recognise the impact of breaking bad news on your colleagues.  
 

 
Study protocol version 2.1 18/03/2019 
31 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
 
 

 
Study protocol version 2.1 18/03/2019 
32 
Appendix 5 Post-intervention questionnaire 
 
Post-intervention Questionnaire v2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
(IRAS ID 258886) 
 
Participant ID: 
 
Please could you complete this questionnaire? It is likely to take 15 minutes to complete. Your 
answers will be kept confidential. 
 
Since participating in this study, have you had any communication skills or breaking bad news 
training (other than the mobile app if you were in the intervention group)? 
 
Yes / No 
 
If yes, please provide details: 
 
 
 
 
 
PART A 
 
Breaking bad news competencies 
You may recognise the following questions from the baseline questionnaire you completed. Please 
rate your level of confidence regarding the following statements related to breaking bad news: 
  
1. Your ability to break bad news well. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
2. Your ability to recognise when to break bad news. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
3. Your ability to break bad news in planned and unexpected settings. 
 
Not very confident at all  
Not very confident  

 
Study protocol version 2.1 18/03/2019 
33 
Somewhat confident  
Very confident  
Extremely confident  
  
4. Your ability to be empathetic, honest and sensitive when breaking bad news. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
5. Your ability to prepare for breaking bad news (i.e. setting the environment, having sufficient 
information). 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
6. Your ability to establish the person’s understanding. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
7. Your ability to pick up and respond to verbal and visual cues. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
8. Your ability to recognise the impact of bad news on the person/people you are speaking to. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
9. You know that different people may respond to bad news in different ways. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  

 
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Extremely confident  
  
10. You know how to provide support for the person you have given the bad news to. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
11. You know when to ask for help when breaking bad news. 
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
12. You can recognise the impact of breaking bad news on yourself.  
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
13. You can recognise the impact of breaking bad news on your colleagues.  
 
Not very confident at all  
Not very confident  
Somewhat confident  
Very confident  
Extremely confident  
  
 
PART B 
 
Please rate how you feel regarding the following statements: 
   
1. I am more confident in breaking bad news. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
2. I feel more confident in leading breaking bad news conversations. 
 
Strongly disagree  
Disagree 

 
Study protocol version 2.1 18/03/2019 
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Neutral 
Agree 
Strongly agree 
 
3. I am more confident in identifying when I need to break bad news. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
4. I am able to break bad news in my practice earlier than I would have before. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
5. I am better prepared for breaking bad news conversations. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
6. When I break bad news, I feel that I am doing something positive for the person/people I am 
speaking with. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
 
PART C (for those in the interventional group) 
 
1. How long did you spend using the mobile learning resource in total? 
 
<1 hour 
1-2 hours 
2-3 hours 
3-4 hours 
>4 hours 
 
2. How often did you use the mobile resource at work? 
 
Never 

 
Study protocol version 2.1 18/03/2019 
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Once only 
Once a week 
Once a day 
Multiple times a day 
 
3. How often did you use the mobile resource outside of work? 
 
Never 
Once only 
Once a week 
Once a day 
Multiple times a day 
 
4A. Did you use any other mobile learning resources during the last few weeks? 
 
Yes / No 
 
4B. If ‘Yes’, could you specify which one(s) and why? 
 
Comment: 
 
 
 
 
 
PART D (for those in the interventional group) 
 
Having used the mobile learning resource, please rate how you feel regarding the following 
statements: 
 
1. The mobile learning resource was useful for my clinical practice. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
2. It was easy to learn about breaking bad news using the mobile learning resource. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
3. Using the mobile learning resource was time consuming, impacting negatively on the time I spend 
on clinical work. 
 
Strongly disagree  
Disagree 

 
Study protocol version 2.1 18/03/2019 
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Neutral 
Agree 
Strongly agree 
 
4. The mobile learning resource did not teach me anything new. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
5. The learning from the mobile resource has not had an influence on the way I work.  
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
6. A mobile learning resource was a good choice of learning-tool for breaking bad news training. 
 
Strongly disagree  
Disagree 
Neutral 
Agree 
Strongly agree 
 
7. Would you recommend the mobile learning resource to your colleagues? 
Yes / No 
  
8. Do you have any further comments about the mobile learning resource and/or how the 
knowledge you gained has influenced your clinical practice? 
 
Yes / No 
 
Comments: 
 
 
 
 
 
 

 
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Appendix 6A Simulated patient encounter: Participant task sheet template 
 
Participant Task Sheet Template v2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
This is a breaking bad news simulated encounter. Please read the following before you start. If at any 
point, you would like to stop the encounter, please inform the researcher.  
 
Title: Breaking bad news to [insert brief title] 
 
Time allowed: 15 minutes 
 
Location: [Insert location] 
 
You are: [Insert role i.e. Senior house officer, Staff nurse] 
 
Person’s name: [Insert name] 
 
Person’s age: [Insert age] 
 
Person’s gender: Female / Male 
 
Further information: 
 
TASK 
• 
Inform the person of the diagnosis of [insert brief scenario] or Inform the person 
of the results from [insert brief scenario] 
• 
Counsel the person regarding the next steps to be taken 
 
Please note that you are not expected to take a medical history. If you need clarification of anything, 
ask the researcher. 
 
 
 
 

 
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Appendix 6B Simulated patient encounter: Participant task sheet example 
 
Participant Task Sheet Example (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
This is breaking bad news simulated encounter. Please read the following before you start. If at any 
point, you would like to stop the encounter, please inform the researcher.  
 
Title: Breaking bad news to a patient who has an incidental finding on a chest x-ray 
 
Time allowed: 15 minutes 
 
Location: Orthopaedic ward 
 
You are:  Senior house officer / Staff nurse on the Orthopaedic ward 
 
Person’s name: Mrs Ivy Bakewell 
 
Person’s age: 75 years old 
 
Person’s gender: Female 
 
Further information: Mrs Bakewell has been electively admitted the night prior to her right hip 
replacement to control her blood glucose levels. The admitting doctor requested a chest x-ray due to 
Mrs Bakewell having a cough for over a month. The chest x-ray has shown a right upper lobe mass, 
which looks suspicious of a cancer. Mrs Bakewell is curious to know the results of the x-ray and has 
asked to speak to you. You have just started your shift and have not met Mrs Bakewell before. 
 
TASK 
• 
Inform Mrs Bakewell of the results from her chest x-ray including the suspicion of a 
cancer. 
 
Please note that you are not expected to take a medical history. If you need clarification of anything, 
ask the researcher. 
 
 
 
 

 
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Appendix 7A Simulated patient encounter: Character sheet template 
 
Character Sheet Template v2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
This is breaking bad news simulated encounter. Please read the following before you start.  
 
Title: Breaking bad news to [insert brief title] 
 
Time allowed: 15 minutes 
 
Location of consultation: [Insert location] 
 
Your name: [Insert name] 
 
Your age: [Insert age] 
 
Your gender: Female / Male 
 
Your occupation: [Insert occupation] 
 
Clinician's details: [i.e. Senior house officer / Staff nurse] 
 
Role Player Key Information 
Key information                                 insert details here (if relevant)     
Past medical history  
insert details here (if relevant)     
Drug history (including allergies)  
insert details here (if relevant)     
Family history  
insert details here (if relevant)     
Social history  
insert details here (if relevant)     
PFICE: Prior knowledge, feelings, ideas, concerns and expectations 
P - Prior knowledge  
insert details here 
    
F - Feelings  
insert details here 
    
I - Ideas  
insert details here 
    
C - Concerns  
insert details here 
    
E - Expectations  
insert details here 
    
 
 
 
 

 
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Appendix 7B Simulated patient encounter: Character sheet example 
 
Character Sheet Example (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
This is breaking bad news simulated encounter. Please read the following before you start.  
 
Title: Breaking bad news to a patient who has an incidental finding on a chest x-ray 
 
Time allowed: 15 minutes 
 
Location of consultation: Orthopaedic ward, NHS hospital 
 
Your name: Mrs Ivy Bakewell 
 
Your age: 75 years old 
 
Your gender: Female 
 
Your occupation: Retired veterinarian 
 
Clinician's details: Senior house officer / Staff nurse on the Orthopaedic ward 
 
Role Player Key Information 
Key information    
You have been electively admitted the night prior to your right hip 
replacement to control your blood sugar levels. The admitting doctor 
requested a chest x-ray as you told her that you have had a cough for five 
weeks. The doctor told you she would come back and tell you the results of 
the x-ray, and you have waited most of the day but not seen the doctor 
again. You are curious as to the results of the x-ray and want to talk to 
someone on the team looking after you. 
    
Past medical 
history  
Insulin dependent diabetes, which recently has been difficult to control. 
Osteoarthritis affecting your hips and knees. You have been waiting for this 
hip operation for over a year as your mobility has been poor. 
You have never smoked, but your husband did.  
    
Drug history 
(including 
allergies)  
Novorapid insulin 10 units three times a day (with meals) and Lantus Glargine 
insulin 20 units at night, subcutaneous. 
Ramipril 1.25 mg once a day. 
No known drug allergies. 
    
Family history  
Diabetes on the maternal side. Mother possibly had breast cancer, but you 
know little about it. 
    
Social history  
You live alone in a one-bedroom first floor flat.  
Your husband died five years ago. 
You have a lot of friends and family members who visit frequently.  
You enjoy the company of others, reading journals and playing golf. 
    
PFICE: Prior knowledge, feelings, ideas, concerns and expectations 

 
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P - Prior 
knowledge  
You decided not to see your GP, even though you were concerned about the 
cough, as you did not want to bother him, and you knew you would be 
coming for surgery soon. You have been more tired and breathless over the 
last month, but you just felt it was age rather than anything else. You do not 
have any prior knowledge that your symptoms could be due to a cancer. 
    
F - Feelings  
Your husband died of lung cancer. He was a heavy smoker. He had surgery 
followed by radiotherapy and chemotherapy. You cared for him during his 
illness and found it difficult to see him so unwell. You are shocked by the 
news of a possible cancer in the lung.  
Due to the reduced mobility from the osteoarthritis, and as you haven’t 
played golf in months, you have been feeling low in mood. You are optimistic 
that the hip surgery will help you return to your prior level of fitness and 
would be very upset if this was cancelled. 
    
I - Ideas  
You thought only smokers could get lung cancer and you feel relatively well, 
so initially you feel the chest x-ray must be wrong.  
    
C - Concerns  
You are concerned about what this means for your surgery tomorrow – you 
are keen to have the surgery as you want to be well enough to play golf 
again. 
In the long term, you cared for your husband as he became increasingly ill 
with the cancer and the treatment, and you do not want to go through the 
same. 
    
E - Expectations  
You think there must be some mix up with the x-rays. You understand the 
need for further investigations, but you are not keen to go through all the 
treatments your husband did as you do not feel unwell at the moment. 
You are still expecting to have the surgery tomorrow. 
    
 
 
 
 
 

 
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Appendix 8 Simulated patient encounter: BAS Mark Sheet 
 
BAS Mark Sheet v2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
(IRAS ID 258886) 
 
Participant ID: 
 
Title: Breaking bad news to [insert brief title] 
 
Time allowed: 15 minutes 
 
Assessor (select one): Researcher / Simulated patient / Independent marker 
 
Breaking bad news Assessment Schedule (BAS) 
 
When marking please place a circle round the number which reflects the score you wish to give. The 
points adjacent to each question are for guidance only. 
 
A. Setting the scene 
This section looks at whether the participant facilitated an initial rapport before breaking the bad 
news. This can be done by providing an environment which allows private and comfortable 
communication, by the participant introducing him/herself, and by the participant showing an 
interest in the patient as an individual. 
1. 
Did the participant arrange the 
environment? 
 
very well 5 _ 4 _ 3 _ 2 _ 1 poorly 
The participant may have 
• placed the chairs at an angle which allowed eye contact? 
• ensured that the desk was not in-between him/her and 
the patient? 
• prepared for the patient becoming upset, for example by 
placing the tissues so the patient could reach them? 
• taken measures to prevent interruptions? 
2. 
Did the participant use an 
appropriate greeting and 
introduction? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
The participant may have 
• stood up to greet the patient? 
• established the patient’s name? 
• introduced him/herself using his/her own name? 
• given a brief description of his/her occupation? 
• shown the patient where to sit? 
3. 
Did the participant show interest 
in the patient’s current state of 
well-being and personal 
circumstances at the beginning of 
the interview? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
The participant may have 
• used open questions? 
• established recent events for the patient? 
• established the patient’s physical state? 
• asked how the patient felt emotionally? 
• enquired into the patient’s social circumstances? 
• given the patient time to finish their statements? 
B. Breaking the news  
This section specifically focuses on whether the participant was sensitive to this patient’s 
perspective when he/she delivered the news (the establishment of rapport is scored in the above 
section). The amount of information to give each individual patient may vary depending on what 

 
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the patient already knows. Individual patients may vary in the amount of information they wish to 
receive during this interview, and in the rate at which they assimilate the news. 
4. 
Before breaking the news, did the 
participant check what this 
patient knew already? 
 
carefully 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• ask the patient what he/she believed was the nature of 
their problem? 
• enquire into what the patient thought the purpose of this 
meeting was? 
• check if the patient had thoughts about the possible 
outcomes from this consultation? 
• ensure that he/she understood the patient’s perspective 
at this stage of the interview? 
5. 
Before breaking the news, did the 
participant introduce it with 
sensitivity? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• gently alert the patient to the fact that what followed was 
going to be important, before using any specific terms? 
• take the lead from the patient as to whether to speak or 
listen after introducing the news? 
6. 
When delivering the news did the 
participant allow the patient to 
decide the detail and language 
used? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• begin by using non-specific lay terminology? 
• respond to the patient’s cues, or ask the patient if he/she 
wanted more detail, before becoming more specific? 
• check that the patient was satisfied with his/her own 
understanding of the terms used? 
7. 
Did the participant allow the 
patient to set the pace for the 
delivery of the news? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• deliver appropriate information when it was asked for? 
• give the news at a rate which gave the patient time to 
think and respond? 
• check that the patient had understood and assimilated 
what had been said before giving more information? 
8. 
Did the participant use an 
appropriate pause after giving the 
news? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• allow the news about the diagnosis and its implications to 
sink in? 
• give the patient time to respond? 
• appropriately break the silence if the pause was too long? 
C. Eliciting concerns 
This section focuses on whether the participant actively attempted to gain a clear idea of the 
personal implications and meaning of the news to this patient, and the concerns that it generated. 
9. 
Did the participant specifically 
invite questions? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
The participant may need to invite questions repeatedly. 
 
10. Did the participant explicitly 
attempt to obtain a complete list 
of the patient’s concerns? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant explore 
• the patient’s feelings and emotions about the news just 
given? 
• the patient’s concerns about treatment? 
• the patient’s concerns about prognosis? 
• the concerns arising from family and relationship issues? 
• the patient’s concerns about the effect on their social 
setting, for example their employment? 

 
Study protocol version 2.1 18/03/2019 
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11. Did the participant explicitly check 
which areas were most important 
to the patient? 
 
carefully 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• ask the patient which issues were important to talk about 
during this meeting? 
• ask in which order the patient wanted to talk about these 
issues? 
D. Information giving 
This section looks at aspects other than giving the news itself. 
12. Did the participant give 
information tailored to the 
patient’s expressed concerns? 
 
entirely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• give information in a manner which related to the 
patient’s expressed concerns? 
• answer the patient’s questions? 
 
13. Did the participant clearly explain 
any information given so that the 
patient understood? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• give information in an ordered and logical manner? 
• use terms appropriate to this patient using plain English 
and avoiding jargon? 
• check that the patient understood, and offer clarification? 
• summarise points for the patient? 
14. Did the participant manage to 
focus on any positive aspects? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• frame treatment options in a positive way? 
• achieve a good balance between explaining benefits and 
side-effects? 
• manage to give correct information about the prognosis 
without extinguishing hope? 
15. Was the content of the interview 
factually accurate? 
 
always 5 _ 4 _ 3 _ 2 _ 1 frequently 
inaccurate 
 
• If all the information given was factually correct this 
should gain full marks. 
• If the participant admitted to uncertainty or lack of 
knowledge this should still allow full marks. 
• Marks should be deducted for incorrect statements, 
undue optimism, premature reassurance, or unjustified 
negativity. 
E. General considerations 
The following points relate to the interview as a whole. 
16. How many of the patient’s 
concerns from the character sheet 
were aired? 
 
All concerns 5 _ 4 _ 3 _ 2 _ 1 none 
at all 
• Depends on number of concerns elicited. 
 
17. How many of the key areas of the 
patient’s concerns were touched 
upon? 
 
all of them 5 _ 4 _ 3 _ 2 _ 1 none at 
all 
 
Each of the following five key areas should be touched upon 
to obtain full marks 
• treatment 
• prognosis 
• feelings and emotions 
• family and relationship issues 
• effect on social circumstances 
18. Were the psychosocial issues 
which the patient flagged up 
during the interview explored? 
 
Did the participant 
• acknowledge: the patient’s feelings and emotions; and the 
effects on family and relationships, and social 
circumstances? 
• allow the patient to talk about these issues? 

 
Study protocol version 2.1 18/03/2019 
46 
fully 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
• ask questions about them? 
• enter into a dialogue? 
19. Did the participant manage to 
appear supportive during the 
interview? 
 
always 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• show warmth? 
• show emotional supportiveness? 
• convey a sense that this really mattered to the 
participant? 
• convey a personal sense of strength and resourcefulness 
that was available to help the patient? 
20. Did the participant use 
appropriate body language during 
the interview? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
 
Did the participant 
• maintain an appropriate level of eye contact? 
• look interested and alert to the patient’s needs? 
• show a competent and caring professional manner? 
 
21. Did the participant avoid 
appearing clumsy during the 
interview? 
 
never clumsy 5 _ 4 _ 3 _ 2 _ 1 often 
clumsy 
 
Did the participant 
• introduce difficult topics gently? 
• deal with painful issues sensitively? 
• show flexibility and sensitivity to the patient’s needs? 
• avoid inappropriately changing the subject? 
• avoid using phrases that were inappropriate? 
22. Did the participant tailor the pace 
of the interview to suit the 
patient? 
 
definitely 5 _ 4 _ 3 _ 2 _ 1 not at all 
Did the participant 
• let the patient speak without interruption? 
• respond to the patient’s cues regarding timing and 
delivery? 
• deliver appropriate information when it was asked for? 
• use pauses where appropriate to give the patient time to 
think and respond? 
• check that the patient had finished with a topic before 
moving on to another? 
23. Did the participant manage the 
time available? 
 
very well 5 _ 4 _ 3 _ 2 _ 1 poorly 
 
Did the participant 
• sensitively make the patient aware of how much time was 
available for discussion? 
• mention the opportunity of further interviews to the 
patient? 
• cover the important issues in this session? 
• make a plan for future action? 
• bring the interview to a conclusion? 
 
 
Notes: 
 
 
 
 
 
 
 
 
 
 
 

 
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Appendix 9 Semi-structured interview: Topic guide 
 
Topic Guide v2.1 (18/03/2019) 
 
Mobile learning resources as a tool for improving clinician’s ability to break bad news:  
A pre-post mixed methods pilot study 
 
(IRAS ID 258886) 
 
Introduction 
 
Researcher: 
“Thank you for participating in this study exploring mobile learning resources as a learning tool for 
breaking bad news.  
 
“You have already completed a baseline questionnaire and simulated patient encounter. Following 
this, you have had access to a mobile learning resource on breaking bad news. Having completed the 
post-intervention questionnaire and simulated patient encounter, the purpose of this interview is to 
delve deeper into your experiences of using the learning resource and breaking bad news.  
 
“Please remember that the interview will be audio recorded, transcribed and anonymised. What you 
disclose in this interview will remain anonymous. During the interview, I will take field notes 
documenting any non-verbal responses and any reflections. If you need to stop the interview at any 
time, let me know.  
 
“Do you have any questions? Are you happy to proceed with the interview?” 
 
Topic guide 
 
• 
How would you compare your ability to BBN now to before joining having the learning 
resource? 
o What do you think your ability to BBN was before having the learning resource? 
o What do you think your ability to BBN is like following the learning resource? 
• 
Do you think you learned something new from participating in the study? 
• 
Do you think the learning has had an impact on your clinical practice? 
 
• 
Do you think the mobile learning resource was a useful tool for BBN?  
o Do you think digital learning resources and/or mobile applications are a valuable 
platform for BBN training? 
o Would you recommend the mobile learning resource or other digital learning 
resources for BBN to your colleagues? 
 
• 
How did you find using the mobile learning resource?  
o What were you first impressions? 
o Was it easy to use? 
o Is there something that you would have liked to have seen within the resource that 
was not available? 
• 
Did you experience any technical difficulties when using the resource?  
o Did these technical difficulties impact your learning? 
 
• 
When did you use the resource?  

 
Study protocol version 2.1 18/03/2019 
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o How often did you use the resource when at work? 
o Did you find the resource helpful in your day to day activities? 
o Did you use the resource before BBN in your practice? 
o How often did you use the resource outside of work? 
 
• 
How do you feel the simulated patient encounters (SPEs) went? 
o How did it make you feel participating in the SPEs? 
o How did you find the two case scenarios? 
o Were they useful to your training? 
 
• 
Is there anything else you would like to add?