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A project to promote better communication with patients.

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A local needs assessment of cancer and palliative care services in 2001 in the Forth Valley Acute Operating Division recommended the provision of training in communication skills. Peer reviews in 2001 and 2002 by the Clinical Standards Board for Scotland (now the NHS Quality Improvement for Scotland (NHS QIS)) had also identified this skills gap.


VOL: 102, ISSUE: 19, PAGE NO: 28

Sandra Campbell, PD, BSc, DipPalliative care, RGN, RNT, is Macmillan clinical nurse specialist palliative care and education facilitator for cancer and palliative care, Forth Valley Acute Operating Division, Stirlingshire

A local needs assessment of cancer and palliative care services in 2001 in the Forth Valley Acute Operating Division recommended the provision of training in communication skills. Peer reviews in 2001 and 2002 by the Clinical Standards Board for Scotland (now the NHS Quality Improvement for Scotland (NHS QIS)) had also identified this skills gap.



This need was addressed by providing workshops on communication skills to multiprofessional groups at minimal cost to the organisation.



Communication skills are key within cancer and palliative care. The literature suggests that multidisciplinary teaching of communication skills is both valuable and effective (Farrell et al, 2001).



Fallowfield and Jenkins (2004) found that where guidelines were used or a model of breaking bad news was taught, there was an improvement in communication skills. Baile et al’s (2000) six-step (SPIKES) approach was adopted (Fig 1).



Mueller (2002) believes that adopting this approach can make breaking bad news easier for healthcare professionals. Having a structure to the interaction can save time while maintaining a focus.



Patients are often dissatisfied with the way in which they are given bad news (Mcpherson et al, 2001). This can lead to complaints and an inability to cope with the diagnosis.



The research suggests that training in communication skills should last at least three days (Wilkinson et al, 1999). However, due to restrictions such as time and resources, we decided to offer half-day workshops with an emphasis on breaking bad news and recognising that bad news is any news that negatively alters a person’s view of her or his life (Buckman, 1984).



Edwards and Elwyn (2004) found that when teaching communication skills, addressing practical issues such as time constraints is probably as important as the actual content of the training. We decided to address this issue by allowing participants to set the agenda, asking them at the beginning of each workshop to identify the problems they had faced when breaking bad news.



Fallowfield et al (2002) found that doctors working in oncology encountered difficulties when communicating with patients and their relatives. Often time and experience alone did not help them resolve these issues but attending a communication skills course improved practice (Fallowfield et al, 2002). While patients and their families must be individually assessed before information is imparted, the way in which this information is provided is also crucial to how it will be perceived by them (Kirk et al, 2004).



The project
A year-long pilot project was planned offering a rolling programme of half-day workshops, each of which would be evaluated. The overall aim was to offer multidisciplinary training in effective communication skills with two broad objectives:



- To raise awareness of the need for good communication;



- To acquire and/or improve the skills required to break bad news effectively.



In addition to the knowledge that if patients’ information needs go unmet, psychological problems are more likely to develop (Maguire and Pitceathly, 2003), there were many other significant factors to consider. These were highlighted using a PEST (political, economic, social and technical) analysis (Fig 2) and a SWOT (strengths, weaknesses, opportunities and threats) analysis (Fig 3, p30).



Why undertake the project?



Ultimately, the reason for implementing this project was to improve the quality of care provided to patients with cancer and palliative care needs. By improving the communication skills of as many healthcare professionals as possible, it was hoped that the principles of good communication would be adopted in all aspects of care.



Who would teach and be taught?



Communication skills training was undertaken by six nurses in the cancer and palliative care team and two consultant physicians. They had all previously had training in communication skills.



Despite criticism of the quality of education that is provided by hospitals, as a rule there is no collaboration with other organisations such as universities or colleges, we sought advice from experts at the local hospice who supported us through implementing the project.



A consultant in palliative medicine from the local hospice offered to join our teaching team making a total of nine. To develop those in the group who were less experienced they worked alongside a more experienced member.



Attendance at the workshops was offered to:



- Cancer teams;



- Senior house officers;



- Junior house officers;



- Staff nurses;



- HCAs.



What topics were offered?



Although the emphasis of the workshops was on how to break bad news, the core skills required to communicate effectively were incorporated.



A programme was planned for the first year as a pilot, which would include workshops in:



- Breaking bad news;



- Dealing with difficult situations;



- Dealing with anger and looking after yourself.



How would these be facilitated?



The workshops each had two facilitators. For example, the multidisciplinary cancer teams workshop was facilitated by one nurse and one doctor.



The programme was planned in a generic way and the workshop agenda was set at the beginning as a result of the problems identified by the teams. Ground rules were agreed in an attempt to ensure a safe and supportive environment.



Teaching methods were varied to stimulate learning (Reece and Walker, 1997) and included a technique known as the ‘goldfish bowl’, which is particularly beneficial in teaching communication skills (Jeffrey, 2002). Videos were also used including educational material and clips from television soaps to stimulate discussion.



Each lead clinician was offered a workshop at a time convenient to her or his team to maximise attendance. Despite following the same programme, each team was taught at the correct level for them.



A resource pack including detailed handouts on how to break bad news and a suggested reading list was issued at the end of each workshop.



Where were the sessions?



Local venues at the two hospital sites were used to reduce cost and to encourage attendance. The teams were given the choice of site to maximise convenience and attendance. It was difficult to find suitable venues that created a good learning environment. However, staff appeared to accept the few problems encountered without complaint.



The venues chosen were small, with chairs arranged in a semicircle to encourage group participation. This also helped facilitate the particular teaching methods that were adopted.



When were the sessions?



A timetable was devised and a lead clinician within each cancer team given a month to choose a date and time within that month for the workshop. Once the date and time were known, the venue was booked accordingly. They tended to choose pre-arranged time slots allowed for meetings, which meant that they had already booked the venue for the previously scheduled meeting.



Dates were allocated for the nurse workshops in the three topic areas and a total of six workshops were planned, two on each topic. These were advertised locally through the distribution of fliers.



Dates were also allocated for the junior and senior house officer workshops. Four workshops were planned, two on breaking bad news and two on dealing with difficult situations. These were all timetabled to maximise attendance.



We believe creating a supportive, safe environment for the workshops helped us to develop an openness that in turn allows more constructive teaching. This style of learning follows the theory of Dewey (1958) who believed that all educational processes should originate from the experiences of the students.



The facilitators encouraged reflection on experience with respect for colleagues as paramount. This type of experiential learning stimulates critical thinking and hopefully the questioning of practice (Burnard, 2002).



To date there have been nine workshops, four for cancer teams, two for nurses, one for junior doctors, and two for HCAs with a total of 75 trained healthcare professionals and 35 untrained staff participating. All have been well evaluated with 60 of the 68 trained staff who completed the evaluation form saying that practice would change following attendance at the workshop.



The purpose of this article is to share how we planned this communication skills project. Further evaluation will be ongoing but we believe it to be a practical solution to a very complex problem of attempting to teach effective communication skills to support staff taking into account difficulties in breaking bad news and dealing with complex situations on a daily basis.



This is a useful cost-effective model that meets local needs and can benefit patients by raising awareness of the need for effective communication. As well as the known benefits of teaching a model of how to break bad news, we found that facilitating the team approach in a supportive learning environment has resulted in staff saying that practice will change.



Further evaluation of the project is required but this will be an ongoing process due to the passion and commitment of the group of facilitators.



While we talk of giving realistic hope to our patients, we as healthcare educators must also be realistic about what can be offered and achieved in the real world of the NHS with the constraints of time and resources.



This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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