Introduction to the Belgian experience in communication skills training
In the last two decades, communication skills training programmes, designed for healthcare professionals working in cancer care, have been the focus of several research endeavours of our research group based in Belgium. The efficacy of designed programmes has been tested in studies using a controlled design. Studies varied in the type of teaching method, the length of training, and the outcome measures considered. Four programmes will be detailed in this chapter in terms of rationale and results. The conclusion will build upon these experiences to develop recommendations and discuss where we may go from there.
Four training programmes have been tested for their efficacy. The aim of the first randomized, controlled trial was to determine the optimal duration of a training programme in order to ensure long-term training effects and transfer in the clinical practice. The duration of the training programme was chosen according to recommendations made at the time of the development of the programme and according to results of programmes developed previously. A 105-hour communication skills training programme for nurses was, therefore, designed. This amount of time allowed each nurse enough time to test the proposed communication strategies in role plays (Razavi et al. 2002; Delvaux et al. 2004; Canivet et al. 2014).
The second study involved physicians working in cancer care. The aim of this study was to assess the impact on physicians’ communication skills of a 40-hour communication skills training programme, utilizing a two-day basic training programme followed by six three-hour consolidation workshops (Razavi et al. 2003; Delvaux et al. 2005). The duration of the basic training programme was chosen according to results of previous studies that had showed the usefulness of short training programmes designed for physicians. Consolidation workshops were considered in order to further improve the communication skills learned during the basic training programme. It had been suggested that consolidation follow-up sessions may be required to facilitate maintenance of newly acquired skills and transfer into the clinical practice.
The aim of the resident study was to assess the efficacy of the Belgian Interuniversity Curriculum—Communication Skills Training (BIC-CST) (Bragard et al. 2006; Liénard et al. 2010a; Merckaert et al. 2013). The BIC-CST programme included 30 hours of communication skills training and 10 hours of stress management training (Bragard et al. 2006). Residents were chosen because optimal communication skills should be acquired as early as possible during physicians’ curriculum before they become rooted in habits. The main topic addressed in the training was breaking bad news (BBN) in two- and three-person interviews. Physiological arousal was assessed to study residents’ engagement to use newly acquired skills, despite the stressfulness of a BBN task. At that time available studies on BBN emphasized the stressfulness of the BBN task (Hulsman et al. 2010). To our knowledge, no study had investigated physicians’ physiological and psychological arousal responses during BBN and none had investigated the impact of training in this regard.
Finally, the latest study assessed the efficacy of a 38-hour communication skills training programme designed to train an entire multidisciplinary radiotherapy team (Gibon et al. 2013; Merckaert et al. 2015). Training an entire team was chosen in order to promote transfer in the clinical practice. Team members targetted by the training programme were secretaries, nurses, physicians, and physicists. Training was divided in two modules: a 16-hour patient-oriented training was carried out among members of the same discipline—for example, nurses came together to carry out role playing and to practice communication skills that might be called upon in their specific discipline. The training also consisted of 22 hours of interdisciplinary, team-oriented communication skills modules, in which at least one member of each discipline was present. These modules included role playing exercises, designed to improve members’ ability to address situations that may arise during radiotherapy sessions and to improve communication with both colleagues and patients.
Study designs and training techniques
All of the studies used a randomized, pre-post design. The rationale behind the samples included in the successive randomized studies was based on the investigators’ wish to determine the threshold of training programme efficacy, not only as regards improvements in communication skills but also as regards improvements in participants’ attitudes and stress levels, and in patients’ satisfaction. The aim of the different studies was also to assess transfer of learned skills to the clinical practice.
The training programmes developed by our group were based on adult theory for complex learning. They were learner-centred, skills-focused, practice-oriented, and tailored to participants’ needs. Training was organized in small groups of up to 12 participants in the nurse study and was reduced to six participants in the subsequent studies. Organizing training in smaller groups allowed participants to more intensively practice the learned skills in the role plays. Training included a cognitive, a behavioural, and a modelling component.
The cognitive component of learning focused on lectures and hand-outs providing evidence of current needs in healthcare professional communication skills and reasons for these. For example, the 105-hour nurse training programme included 30 hours of theoretical information about basic communication components, psychosocial dimensions associated with cancer diagnosis and treatments, coping with patients’ and their relatives’ uncertainties and distress, detecting psychopathologic reactions, and discussing death and euthanasia. The subsequent studies drastically reduced the amount of theoretical information (max 2 hours) given in order to focus on the behavioural component of learning.
The behavioural component was based on role plays. Role plays allow participants to practice the suggested skills in a protected environment, where trials are encouraged and errors are experienced. In the 105-hour training programme for nurses, every participant had the opportunity to participate in four role plays. These role plays were videotaped and feedback was delivered from the video recordings (Delvaux et al. 2004). While this type of role-play allows viewing and reviewing the sequence of interactions, it does not allow the participant the opportunity to try the suggested skill(s). Skill trial had to be planned for one of the next role play sessions. In the subsequent studies, role plays with immediate feedback were used. Such role plays allowed participants to immediately test the suggested skills in the ‘protected’ environment of the role-play. Pre-defined role plays were planned in the first sessions in the two physicians’ studies. The next sessions focused on role plays based on clinical problems brought up by the participants. In the team study, all role plays were based on clinical problems brought up by the participants, in order to facilitate transfer of learned skills to participants’ everyday practice. In all studies, participants were asked to play the role of the patient in at least one session. This was done in order to allow them the opportunity to experience the impact of communication skills used by colleagues.
Modelling was achieved through health professionals’ observation of the skills used by their colleagues in the role plays. This allowed them to observe the positive and negative consequences of using specific communication skills for patients and professionals.
The choice of the skills taught was based on results of studies indicating the positive impact of using specific communication skills on patients’ disclosure of concerns. Communication skills promoting patients’ disclosure of concerns are important because they allow healthcare professionals to respond to patients concerns and needs in terms of information and support that can be provided. They are also the basis of a patient-centred communication. Though there are many different definitions, patient-centredness can be defined as healthcare professionals’ behaviours that enable the patient to express his/her perspective on illness, treatment, and health-related behaviour, his/her symptoms, concerns, ideas, and expectations (Levenstein et al. 1986; Smith and Hoppe 1991). Healthcare professionals should use facilitating behaviours—behaviours that aim to elicit the patient’s perspective on illness and treatment, such as assessment skills (open and open-directive questions, assessing, checking, summarizing), information skills (appropriate information), and supportive skills (acknowledging, appropriate reassurance giving, empathy, or educated guesses). They should also avoid inhibiting or blocking behaviours—behaviours that restrain the patient from expressing his or her view, such as leading or multiple questions, premature information, or reassurance (Zandbelt et al. 2007).
Three different approaches have been used for measuring changes in participant communication behaviours: measuring participant-based outcomes, assessing behavioural changes in the use of communication skills both in simulated interviews and in actual patient interviews, and measuring patient-based outcomes.
Participant-based outcomes can be proximal measures directly related to healthcare professionals’ behaviour in the observed consultation (i.e. increased confidence, comfort in interaction, reported use of specific skills) or distal measures concerning the more general functioning of healthcare professionals (e.g. attitudes, burnout, stress, physiological arousal). In terms of participant-based outcomes, we decided in our studies to focus on changes in distal measures. This allowed us to observe the impact of the training programmes on the general functioning of healthcare professionals. In the physician study, we assessed physicians’ ability to detect patients’ distress (Merckaert et al. 2005; Merckaert et al. 2008). Indeed, research suggests that physicians have a limited ability to detect patient distress and often tend to underestimate the level of distress that they experience (Sollner et al. 2001; Cepoiu et al. 2008; Mitchell et al. 2011). In the residents’ study, we investigated the impact of the communication skills training programme on residents’ physiological arousal (measured through changes in heart rate and salivary cortisol levels) in a breaking bad news task (Meunier et al. 2013). Given the complexity and duration of the breaking bad news task, it was considered that heart rate and salivary cortisol changes reflect resident physiological arousal in the context of emotional and cognitive demands of a task and their task engagement. Trained subjects were expected to show an elevated physiological arousal, which is an indicator of their engagement to respond adequately to the task using newly learned communication skills while maintaining step-by-step attention to the task challenges.
The behavioural assessments of communication skills rely on audio or video recordings of medical interviews (whether simulated or actual patient interviews) before and after training, and on the objective coding of behaviours using an interaction analysis system. Our first studies used the Cancer Research Campaign Workshop Evaluation Manual (CRCWEM) (Booth and Maguire 1991), which is an utterance-by-utterance analysis assessment tool. The CRCWEM rates the form, function, content, and emotional level of each utterance from transcripts of audio- or video-recorded consultations. In the physician study, a new coding (coders identified whether the utterance was addressed to the patient, the relative, or to both) was added in order to analyse three-person interviews (Delvaux et al. 2005). Raters were specifically trained to ensure concordance of ratings. Moreover, to ensure a quality control and to avoid rating conflicts, raters were systematically supervised by a rater coordinator. This was done through regular sessions where rating problems were discussed. For the nurses’ study, a new coding system was also used to analyse the simulated interview transcripts in terms of pain management (Canivet et al. 2014). PainComCode (Pain management Communication Coding system), which was specifically developed for this study, includes a total of 12 communication strategies derived from recommendations found in the literature about (i) basic communication skills in oncology, (ii) pain assessment for nursing practice and evidence-based analgesia, and (iii) patient-centred communication. The coding system does not involve coding all the utterances in the interview but focuses on identifying and categorizing utterances dealing with pain management. Behavioural analysis is a time-consuming and cost-intensive process, however, it is required in order to ascertain training effects in an objective, non-self-report fashion.
In order to diminish the costs of behavioural analysis and to avoid interrater reliability issues, our different studies also used different computer content analysis techniques. The nurse study used a computer-assisted content analysis programme called PROTocol ANalyser (PROTAN) (Hogenraad et al. 1995), which allows to count the number of words corresponding to word categories defined by dictionaries. PROTAN was used to tag both patients and nurses emotional words found in the transcripts of audio-recorded simulated and actual patient interviews (Razavi et al. 2002). Moreover, a communication content analysis software, LaComm (Centre de Psycho-Oncologie, Brussels, Belgium; http://www.lacomm.be/) was developed and used in the residents’ and the radiotherapy teams’ study. This software analyses verbal communication (in medicine in general and in oncology/radiotherapy in particular) utterance-by-utterance and identifies turns of speech and the type and content of utterances. LaComm provides counts of turns of speech, utterance types, and content. LaComm was used because it is sensitive to change (Gibon et al. 2016) and avoids interrater reliability problems. A validation study has shown that the sensitivity to change of the LaComm is similar to the sensitivity to change of the Cancer Research Campaign Workshop Evaluation Manual (Booth and Maguire 1991). Finally, as the residents’ study focused on breaking bad news, the three phases of bad news delivery (pre-delivery, delivery, and post-delivery) were tagged and their length was measured (Liénard et al. 2010a; Merckaert et al. 2013).
The third approach involves measuring patient-based outcomes, which can be proximal measures (such as patient perception of physician behaviour or patient satisfaction with the interview) or distal measures (such as compliance with treatment, anxiety, or quality of life). As far as we know, studies have mainly focused on proximal measures and few programmes to date have included patient-based distal measures. In terms of patient-based outcomes, several of our studies focused on proximal measures: patient perception of nurses’ and physicians’ behaviour, and satisfaction with nurses’ and physicians’ behaviour (Razavi et al. 2003; Delvaux et al. 2004; Delvaux et al. 2005; Liénard et al. 2010b; Merckaert et al. 2015). Changes in patients’ anxiety pre-post interview are another proximal measure that has been considered in the physician study (Liénard et al. 2006; Liénard et al. 2008). It should be recalled at this level that interaction analyses are objective observational measures of nurse or physician behaviours, while patient perception of nurse or physician behaviours reflects the effects of those communication skills on patients. The two types of measures are thus complementary, as they allow evaluating the effect of communication skills training programmes at different levels.
Factors associated with learning
Another important issue to be reported here is the identification in one of our studies of a factor that could mitigate the impact of learning. In our physician study, we assessed the predictive value of a participant characteristic on their ability to learn new communication skills. It is widely recognized that educational interventions may be more effective for people with an ‘internal’ locus of control (LOC) (who believe that life outcomes are controlled by their own characteristics or actions) compared to people with an ‘external’ locus of control (who believe that life outcomes are controlled by external forces such as luck, fate, or others). Therefore, we tested the hypothesis that physicians with an ‘internal’ LOC would demonstrate communication skills acquisition to a greater degree than those with an ‘external’ LOC (Libert et al. 2007). As it was expected, learned communication skills are more frequent among physicians with an ‘internal’ LOC compared to the frequency of learned skills among physicians with an ‘external’ LOC, either in two-person or three-person simulated interviews.
In the last two decades, several communication skills training programmes, designed for healthcare professionals working in oncology, have been tested by our research group in Belgium. The main aim of the training programmes described here was to promote the knowledge and use of communication skills to improve patient care. Results of these studies have allowed us to draw some conclusions with regards to training effects and intervention techniques.
First of all, it should be underlined that all our programmes were learner-centred, skills-focused, practice-oriented, and tailored to the participants’ needs. In particular, the use of role plays based on clinical cases brought up by the participants, and the use of immediate feedback appears to be acceptable for trainees and effective. These techniques allowed healthcare professionals to receive feedback about their specific communication difficulties and have promoted transfer to the clinical practice. Trainers should choose the more difficult clinical cases brought up by participants and start from there. Trainers should, also, be able to provide rapid and immediate feedback to each participant. Communicating is a behaviour highly rooted in habits and therefore needs a lot of practice in order to really modulate these habits. Providing room for physician to engage in the learning process by limiting the number of participants in a training group is the key. Finally, trainers should be careful to promote role playing. Case discussions are useful but they may often be a way for participants of avoiding to engage in role playing exercises.
Second, it should be noted that all of the programmes led, as expected, to changes in the way participants communicated with patients both in simulated and in actual patient interviews. Changes observed in simulated interviews were in general more numerous than changes in participants’ everyday clinical practice. This difference in terms of changes observed highlights the usefulness of simulated interviews, where a high emotional level may be induced and maintained. The complexity of such simulated tasks allow us to observe a wide range of learned skills. It is not surprising that a training duration effect was found. Our different studies showed, however, that the transfer of some skills—for example, skills addressing relatives’ concerns and needs—remain limited, even after a training programme. Training programmes focusing on patient-centred communication skills acquisition seem to produce little change in more distal participant-based outcomes, such as detection of distress or burnout, or on patient-based outcomes, such as patients’ or their relatives’ anxiety.
Third, one of our training programmes allowed us to study the physiological correlates of residents’ communication skills’ acquisition in the context of a simulated breaking bad news task. After training, the physiological arousal levels of trained residents are high compared to the levels recorded in untrained residents. This higher residents’ physiological arousal—which is associated with higher self-efficacy and satisfaction about their performance in the task, with less stress to communicate and with an improvement in their communication skills—may be an indicator of their engagement in performing the communication task. Centring one’s communication on patients’ concerns and needs certainly implies that healthcare professionals make a conscious choice towards exposing themselves to potential sources of distress (patients’ fears, anxiety, uncertainty, suffering, loss of hope … ). Communication disengagement may certainly be an automatic protective psychological reaction of professionals in this context. This reaction may however also be a source of suffering for professionals, as it may result in less professional satisfaction. Our training programmes focused on helping professionals to learn the skills needed to be able to engage in highly emotional communication tasks. Focusing role plays on problems brought up by the participants allows them to develop self-efficacy and promotes transfer of learned skills to the clinical practice. Facilitators should certainly be aware of the numerous contexts where professionals tend to disengage in order to help them cognitively engage themselves in the communication, while maintaining an appropriate emotional distance in order to avoid being overwhelmed by their patients’ suffering. It should be underlined that the type of engagement in clinical practice may be quite different at the start and at the end of the training. The type of engagement associated with pleasure to communicate and skills mastery later in some clinician career is certainly quite different also. The process underlying learning and transfer to clinical practice includes at least three phases: a knowledge-building phase, where professionals learn to cognitively analyse the phases inherent to highly complex communication tasks such as breaking bad news and develop the skills needed to tackle the different phases; a trial and error phase, where they can practice the skills in the secure context of the role plays; and a continuous self-assessment phase, where they learn to optimally adjust their communication to patient needs and concerns in the context of an interview’s specific agenda. Research is needed to better study the impact of different levels of communication skills acquisition on outcomes such as patient information, satisfaction, relation building, and so on.
Fourth, some results of our communication skills training programmes on patients should be stressed. In all of the studies described in this chapter, changes in trainees’ communication skills were observed and patients interacting with trained professionals reported changes in their perception of these professionals’ communication, or in their satisfaction with their communication skills. These impacts highlight that cancer patients may be able to perceive and appreciate their healthcare professionals’ communication skills. This type of results validates the usefulness of communication skills training programmes for healthcare professionals.
Finally, assessment tools used in our first studies led to solid conclusions about behavioural changes. It should be underlined that the use of interaction-process analyses was cost-intensive. A first way to reduce this cost has been to develop a computer-assisted systems of interaction analyses. Such a system has been developed for French transcripts (Gibon et al. 2016). Another positive impact of such systems could be to provide healthcare professionals with an annotated feedback of their consultation, which may further facilitate their communication skills learning.
The results of our studies confirm the usefulness of communication skills training programmes for healthcare professionals working in cancer care. To be effective, training should include learner-centred, skills-focused, and practice-oriented techniques; be organized in small groups; and be at least 20 hours long. The development of communication skills training programmes designed for nurses and physicians can thus be recommended to all healthcare professionals dealing with cancer patients and their families.
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