Evidence Based Practice Formative Assignment
Communication Skills Training and Patient Satisfaction in Oncology Nursing
Introduction
Communication, often undervalued as the mere transmission of information, is in fact a multifactorial experience between two or more parties with the aim of sharing thoughts, feelings, experiences, words, gestures and emotions via spoken content, affective components and non-verbal behaviours (Stiefel and Bourquin, 2016; NIH – National Cancer Institute, 2018).
It has long been recognised that good communication skills are fundamental to effective healthcare practice and the impact of good patient-clinician communication is now widely documented including its role in achieving important clinical outcomes, ensuring patient satisfaction and providing the highest quality care possible (Department of Health, 2000).
Effective communication allows participants to establish trust and rapport; encourages open and honest exchange of information; creates a safe space for the delivery of bad news and provides the clinician with an opportunity to elicit and address patients’ fear, concerns and emotion (Robert, Cox and Reintgen, 1994; Buckman, 2002). The impact of clinical encounters, underpinned by effective communication, include greater patient understanding of care, better treatment adherence, improved clinical outcomes and reduced stress and anxiety in patients (Epstein, Street and Bethesda, 2007; Fallowfield, Lipkin and Hall, 1998).
As a cancer diagnosis is often associated with a marked increase in stress and anxiety (Lancastle, Brain and Phelps, 2011), complex co-morbidities (Sarfati et al, 2016), significant symptom burden and a minefield of treatment options, a clinician’s ability to maintain effective lines of communication becomes increasingly important. Furthermore, in Oncology nursing, as key roles in cancer care include supporting patients with their wider holistic needs and acting as an advocate, transmitting patient preferences to multi-disciplinary teams, the ability to communicate effectively plays an even more central role (Wilkinson, 1999).
With this in mind, one would assume that communication skills development would be high on the educational agenda in nursing development. Sadly, many nurses acknowledge insufficient provision of training in communication skills throughout their careers, which impacts their practice and ability to provide high quality care (Fallowfield, Saul and Gilligan, 2001). Effective communication skills do not always come naturally, and evidence suggests that these skills do not reliably improve with experience alone (Cantwell, 1997). As such, over the last 30 years, significant resources have been poured into developing reliable and effective methods of improving communication skills with the outcomes of several studies suggesting that communication skills can be both taught and learnt.
Prominent research in this area include the work of Fallowfield, Maguire, Faulkner, Langewitz and Wilkinson (Moore et al, 2004). Training programmes, using a variety of methodological approaches have seen positive impacts on various elements of communication and nursing practice.
Of the various techniques used to improve communication skills – including classroom based didactic training, coaching and mentoring (Miles et al , 2014) and embedded in-situ training – the only technique currently supported by RCT evidence is classroom-based training using simulated patients. Due to the strong evidential support for this approach it has been widely adopted by health educators across the UK with the National Cancer Action Team (NCAT) making the course mandatory for core members of Multi-Disciplinary Teams (MDT) (Department of Health, 2011; Rabiee and Bibila, 2012).
Research Question
Is simulated-patient based communication skills training an effective method of
improving patient satisfaction in relation to communication in Oncology nursing?
Rationale for Research Question
Although it is often argued that the use of actors in a classroom-based setting lowers the fidelity/ecological validity of the communication scenario – when compared to in-situ training or scenarios involving real patients – the ethical implications are significantly reduced. Furthermore, despite emerging evidence suggesting contextualised, embedded training, using covert observation, may result in greater retention of skills over time the costs and resources required for implementation are often too high. It is for this reason that this work will investigate the efficacy of simulated-patient based communication skills training models for use in future nursing communication skills training
Literature Search
Inclusion Criteria:
Population
- Registered nurses’ band 5-7
- Nurses working in a primarily clinical role
- Staff working in secondary care/hospital setting
Intervention/Exposure
- Training models that include actors/simulated patients/scenarios
Outcomes
- Improved satisfaction – either self, patient or educator rated
Exclusion Criteria:
Population
- Primary care nurses
- Non-nursing professionals (unless multidisciplinary courses with nurses included)
- Un-registered nursing staff such as students or nursing assistants
- Senior nurses working in primarily non-clinical roles (nursing management)
- Gender specific articles
Intervention/Exposure
- Didactic only training
- In-situ training/working with a real patient
Duration of training removed from exclusion criteria as made the search too narrow, duration is now to become a sub-topic for investigation.
Search Terms
| Patient or Population or Problem
|
Intervention or Exposure | Comparison or Control (if applicable) | Outcomes or Effects |
| Oncology Nursing | Simulated-patient based communication | N/A | Improving |
| Oncology
Cancer Nurs* RGN Matron* Sister* Senior Nurse* Ward Nurse* VNS Staff Nurse* Registred Nurse* Nursing Practitioner Nurse Specialist Clinical Nurse Specialist |
Simulated
Role-Play Simulation Scenario Patient Based Communication Nontechnical Course Training Programme Education
|
Improving
Patient Satisfaction Feedback Effect*
|
Rationale for Databases Searched
| Cochrane Library, PubMed, CINAHL, TRIP and Scopus were all included in the search strategy as all are widely known expert sources of gold standard, peer reviewed, information including systematic reviews (completed to extremely high objective standards) RCT’s and other data of reputable source. All databases have an extensive collection of articles relating specifically to the subject matter of healthcare, nursing and health education making them suitable for the research question.
Additionally, Cochrane, PubMed, CIHNAL and Scopus are intelligently designed databases which allow for efficient searching of articles. It is possible to set up an account with each, enabling advanced searching to apply a systematic and structured search methodology using Boolean operators as well as being able to save your search history. Also, as a student with a login via a paying institution, an extensive number of full text papers are available through Cochrane, PubMed, CIHNAL and Scopus. For these reasons all core bibliographical databases were included in the search strategy. |
Web of Knowledge (Science & Social Science)
Attempts were made to access this useful resource however it was not possible as access required an institutional login and UoH was not registered.
ASSIA (Social Sciences)
Attempts were made to access ASSIA though were unsuccessful as access required an institutional login and UoH are no longer registered – as such the database was excluded
ChildData
Database was excluded as research question pertains to adults only
HMIC (DoH, Kings Fund, Nuffield Institute)
Delivered by OVID the HMIC database describes itself as ‘Bringing together the bibliographic database of two UK health and social care management organizations: The Department of Health’s Library and Information Services (DH-Data) and King’s Fund Information and Library Service. This Health Management and Policy Database, from The Healthcare Management Information Consortium (HMIC), is an invaluable source of information for health care administrators and managers.’
As the research question proposed forms part of a review of healthcare management and education processes, it was viewed that the database was highly likely to yield relevant sources of information. Unfortunately, a search using a simple collection of key terms yielded no suitable results, so was excluded.
Pedro (physiotherapy)
This database was excluded as the research question relates only to nursing professionals.
PsycINFO
This database, despite being focused on behavioural and social science research, seemed relevant to the research question, the results found from a preliminary search were largely concerned with behavioural/psych therapies rather than training of staff, therefore it was excluded.
Social Care Online
This database was not included for the same reason as with Psych INFO; no relevant data were available.
ERIC (Education database)
ERIC’s information resources include journal articles, reports, conference papers and other materials which are indexed though a formal review process. As such ERIC is considered a primary database for the analysis of educational research and so considered a necessary inclusion in the search strategy. Searching was completed via institutional login providing access a significantly higher number of resources. Searching however was not as straightforward as with those outlined above as did not have advanced searching tools.
British Education index
A highly regarding database provided by EBSCOhost, BEI provides data on educational policy and administration, evaluation and assessment, technology and special educational needs. Unfortunately, it was not possible to access this database using the institutional EBSCOhost channels via Studynet or other channels, so it was excluded.
Education Research complete
While using EBSCOhost for CIHNAL searching and attempts to access BEI the ERC database was discovered. Offering similar advanced searches and an extensive educational research dataset similar to BEI this database was included in the search strategy.
International Education Research Database
A preliminary search of this education database found no results relating to nursing education/communication skills, so was excluded.
National Institute of Health Research NIHR – Portfolio database
http://public.ukcrn.org.uk/search/ – website expired
Now found at https://www.ukctg.nihr.ac.uk/ – No results
As a national research organisation NIHR is as regarded as highly as Cochrane and PubMed for quality, peer reviewed, information relating to healthcare and the medical sciences. A search using basic search terms however yielded no results, so was excluded.
The following databases were also excluded as non-relevant to the research question:
- o National Research Register Archive (NHS Funded Research 2000-2007)
- o metaRegister of Controlled Trials (UK)
- o (http://www.controlled-trials.com/mrct/) – link broken
- o Research Register for Social (http://www.researchregister.org.uk)
- o OpenGrey (grey literature)
- o Bandolier
- o now found at – http://www.bandolier.org.uk/ – no results
US National Library of Medicine Database of Clinical Trials (http://www.clinicaltrials.gov/)
As a government archive of current and completed research, this database is considered an excellent source of alternative literature outside of the standard core bibliography information databases. It was not possible to use the full complete collection of search terms used in other databases but a few searches using more simple/common search terms yielded a few results (see below).
Biomed Central
Searching on Biomed Central, using a complex Boolean search, gave 175340 results. As the database had no filtering or limitation options I was unable to reduce the number of hits to a manageable amount of papers, so results were excluded from the search.
Guidelines sites e.g. NICE
Almost all clinical practice is now directed by NICE guidelines. A preliminary scoping exercise indicated that the NICE database included information on educational guidelines for health professionals. For this reason, the database was included in the strategy. A complex search using Boolean operators gave no results however a simpler search, using the terms outlined below, gave a more manageable number of results to work with.
Search Restrictions/limits per database searched
| Cochrane Library
Cochrane searching yielded an effective number of studies so only the restriction ‘Human studies’ was applied (as the research question pertained only to this subject group). |
| Pubmed
Pubmed searching using boolean operators resulted in numerous hit so a number of filters/limitations were applied, and the total number of papers was added together. These included – Cancer speciality – Consumer and communication strategies – Effective practice and health systems
Before including this strategy, the topics of papers were examined for relevance. Papers and subsequently the limitation were found to be suitable for the research question. Application of filters provided a more manageable number of papers to work with that were more specific to the subject area. |
CINAHL
A search of CIHNAL provided a good number of hits. No limitations were applied as none of
the options available were suitable (time/subject limitations).
TRIP (Turning Research into Practice)
Searching using TRIP database resulted in an unmanageable 35,857 results. Unfortunately, without TRIP pro I was unable to restrict the search to access a more suitable number of papers. This seems extremely unfortunate as several papers which were examined for relevance were found highly relevant to the subject matter. The university information manager for biosciences and health was contacted with the hope of securing a login for TRIP pro. I feel this database would be extremely useful to my final submission. No university login was accessible so a less systematic search, using only key search terms, was later employed to ensure the database did not go unused.
Scopus
Like TRIP Scopus yielded an extensive number of results; however, it also provided a good collection of limitation/restrictions. The following were applied with subsequent results:
– Nursing
– Open access
– Humans/human studies
ERIC (Education database)
Only 12 papers were found using the ERIC database so there was no need to apply any further search restrictions.
Education Research complete
Similar to ERIC, a smaller number of papers (51) were discovered during searches of the ERC database. It would be preferable to reduce his number further by applying search limitation but, like CIHNAL, none of the limitation options were suitable for the research question.
US National Library of Medicine Database of Clinical Trials (http://www.clinicaltrials.gov/)
A few papers were found on the clinical trials website using the search restriction ‘completed trials’. This was necessary to ensure results included outcomes as to the effects of communication skills training.
Guidelines sites e.g. NICE
Several papers were found using the NICE dataset (using modified search terms). I would have liked to reduce the total further; however, the only limitations available were ‘document type’ and ‘date’, neither of which were useful restrictions to apply for the research question.
The results of the literature search are presented in the Appendix. Boolean operators have been combined according to the concepts of the research question.
Rationale for exclusion of literature
- The titles of all 412 papers (found from the systematic search of databases and other sources) were screened
- 374 papers were excluded as the title suggested that the research was not pertinent to the question
- Of the 38 articles remaining, 20 further papers were excluded as screening of abstracts found the content to be irrelevant
- Papers were excluded for the following reasons:
- Training did not include simulated-patients
- CST involved the study of medics only
- Participants were largely non-Cancer Professionals
- Patients involved were largely non-Cancer patients
- Training was focussed on palliative care communication (or other specialist communication)
- The paper looked at the transfer of communication skills only
- Studies were highly unsystematic/poor quality
- The final 18 papers were read thoroughly and the data were assessed for potential to answer research question
- From this, 8 papers were found to possess a sufficient similar PICO as the research question
5 papers (systematic reviews) (Moore et al, 2004; Moore et al 2011; Moore et al 2013; Barth et al, 2010 and Kissane 2012) were excluded as they all evaluated the same papers as another, higher-quality, more recent, Cochrane Review (Moore at al, 2018). Moore et al (2004), Moore et al (2011) and Moore et al (2013) are previous iterations of Moore et al (2018) and therefore excluded.
References
Buckman R (2002) Communications and emotions. BMJ 325 (7366), 672
Cantwell, B.M., Ramirez, A.J. (1997) Doctor-patient communication: a study of junior house officers. Medical Education 31 (1), 17–21.
Epstein, R., Street, R.L., Bethesda, M.D. (2007) Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute, NIH publication. 07–6225.
Fallowfield, L., Lipkin, M., Hall, A. (1998) Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom. Journal of Clinical Oncology. 16 (5), 1961–8.
Lancastle D., Brain K., Phelps C. (2011) Illness representations and distress in women undergoing screening for familial ovarian cancer. Psychology and Health. 26 1659–1677.
Miles L.W., Mabey, L., Leggett, S., Stansfield, K.J (2014) Teaching communication and therapeutic relationship skills to baccalaureate nursing students: a peer mentorship simulation approach. Psychosoc Nurs Ment Health Serv.
52(10),34-41.
Moore, P.M., Wilkinson. S.S.M., Rivera Mercado (2004) Communication skills training for health care professionals working with cancer patients, their families and/or carers (Review). Cochrane Database of Systematic Reviews. 2, 1-20
National Cancer Institute (2018) Communication in Cancer Care (PDQ®)–Health Professional Version. National Institute of Health Publication. Retrieved May, 21, 2019, from
https://www.cancer.gov/about-cancer/coping/adjusting-to-cancer/communication-hp-pdq
Rabiee, F., Bibila S. (2012). Communication in Cancer Care: Evaluating the Connected© 2-day Advanced Communication Skills Training Programme. Report produced for the NHS – NCAT, Connected Programme. Birmingham city University: Birmingham.
Roberts, C.S., Cox, C.E., Reintgen, D.S., et al (1994) Influence of physician communication on newly diagnosed breast patients’ psychologic adjustment and decision-making. Cancer 74 (1), 336-41
Sarfati, D. Koczwara,B., Jackson, C. (2016) The Impact of Comorbidity on Cancer and Its Treatment. CA Cancer J Clin. 66, 337-350.
Stiefel, F., Bourquin, C. (2016) Communication in oncology: now we train – but how well?, Annals of Oncology. 27 (9), 1660–1663
United Kingdom. Department of Health. (2000)The NHS Cancer Plan. London: HMSO.
United Kingdom. Department of Health. (2011) Improving Outcomes: A Strategy for Cancer. London: HMSO.
Wilkinson, S. (1999) Schering plough clinical lecture communication: it makes a difference. Cancer Nursing 22, 17–20.
Appendix
Results of Search Strategy
| # | Keyword/Search Term(s) | PubMed | Cochrane | CINAHL | TRIP | Scopus | ERIC | ERC | Total | |
| 1 | Oncology | 3822514 | 132932 | 342,775 | 1,008,236 | 6,105,110 | 171 | 60,820 | 11472558
|
|
| 2 | Cancer | 3352241 | 55692 | 42,383 | 183,937 | 2,557, 509 | 2,441 | 5,597 |
3642291
|
|
| 3 | Nurs* | 265523 | 13477 | 440,682 | 132,425 | 868,806 | 8,176 | 73,135 | 1802224
|
|
| 4 | RGN | 958 | 13 | 105 | 203 | 5836 | 3 | 179 | 7297
|
|
| 5 | RN | 23470 | 3489 | 13,341 | 24,067 | 153,166 | 856 | 20,266 | 238655
|
|
| 6 | Matron* | 429 | 5 | 814 | 208 | 4621 | 13 | 1,852 | 7734 | |
| 7 | Sister* | 40877 | 224 | 3,730 | 8,886 | 182,118 | 1,507 | 126,796 |
|
|
| 8 | Senior Nurse* | 111496 | 18 | 555 | 313 | 2,426 | 16 | 129 |
|
|
| 9 | Ward Nurse* | 431 | 63 | 49 | 252 | 1,318 | 4 | 59 |
|
|
| 10 | CNS | 2321 | 3882 | 334 | 134,896 | 609,782 | 193 | 4,247 |
|
|
| 11 | Staff Nurse* | 557 | 107 | 9,631 | 687 | 13,122 | 102 | 660 |
|
|
| 12 | Registered Nurse* | 3611 | 328 | 36,994 | 2,888 | 39,218 | 938 | 2,953 |
|
|
| 13 | Nursing Practitioner | 27 | 1 | 38 | 1,414 | 432 | 18 | 17 |
|
|
| 14 | Nurse Specialist | 3693 | 306 | 2,760 | 1,414 | 18,558 | 225 | 565 |
|
|
| 15 | Clinical Nurse Specialist | 2669 | 139 | 1,942 | 722 | 15,195 | 65 | 459 |
|
|
| 16 | 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 | 55000 | 60000 | 40000 | 200000 | 190000 | 10000 | 130000 | 230000 | |
| 17 | Simulated | 133010 | 5409 | 14,564 | 102,890 | 1,39,779 | 5,815 | 20,193 |
|
|
| 18 | Role-Play | 521129 | 11020 | 74,728 | 5,379 | 11,491 | 7,070 | 13,173 |
|
|
| 19 | Simulation | 351472 | 7905 | 41,532 | 102,890 | 6,106,560 | 23,495 | 53,289 |
|
|
| 20 | Scenario | 46677 | 3050 | 18,805 | 37,488 | 976,547 | 7,327 | 84,140 |
|
|
| 21 | Patient-based | 503 | 87 | 1,615 | 687 | 13,122 | 102 | 660 |
|
|
| 22 | Communication | 519516 | 14,056 | 156,448 | 588,976 | 10,552,260 | 156,990 | 489,728 |
|
|
| 23 | Nontechnical | 695 | 12,056 | 231 | 576 | 7,065 | 961 | 4,142 |
|
|
| 24 | Course | 530480 | 47145 | 97,436 | 188,219 | 2,930,073 | 189,410 | 673,485 |
|
|
| 25 | Training | 1605419 | 6185 | 176,583 | 435,671 | 2,190,073 | 191,436 | 578,512 |
|
|
| 26 | Programme | 116024 | 80587 | 412,557 | 64,781 | 6,886,268 | 20,297 | 1,292,660 |
|
|
| 27 | Education | 1376294 | 59470 | 581,119 | 465,566 | 4,775,941 | 20,297 | 2,017,390 | 9296077 | |
| 28 | 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 | 550000 | 65000 | 600000 | 600000 | 5000000 | 200000 | 30000000 | 10000000 | |
| 29 | Improving | 563950 | 62404 | 294,578 | 238,445 | 926,192 | 18,017 | 174,799 |
|
|
| 30 | Patient | 1605419 | 6184 | 176,583 | 435,671 | 2,190,073 | 191,436 | 578,512 |
|
|
| 31 | Satisfaction | 185973 | 36046 | 115,549 | 75,957 | 876,074 | 36,277 | 115,267 |
|
|
| 32 | Feedback | 3352241 | 55692 | 42,383 | 183,937 | 2,557, 509 | 2,441 | 5,597 | 3642291 | |
| 33 | Effec* | 3063653 | 431171 | 1,010,127 | 1,866,474 | 26,229,506 | 185,163 | 631,086 |
|
|
| 34 | 29 OR 30 OR 31 OR 32 OR 33 | 57000 | 44000 | 1111111 | 2000000 | 3000000 | 200000 | 700000 | 70000 | |
| 35 | 16 AND 28 AND 34 | 10000 | 12000 | 10000 | 20000 | 9000 | 150 | 6000 | 8397 | |
| 36 | 35 WITH LIMITS APPLIED | 100 | 500 | 200 | 300 | 800 | 60 | 50 | 579 |
