Testing health care professionals' communication skills: the usefulness of highly emotional standardized role-playing sessions with simulators

Information Needs Expressed During Patient-Oriented Oncology Consultations: Quantity, Variation, and Barriers

High-quality oncology consultation includes patient-oriented communication tailored to patients' individualized needs. Common methods used in studies to increase question-asking are prompt lists and coaching pre-consultations. However, our patients were encouraged to ask questions by the physician during their visit. We aimed to estimate the quantity, nature, and variation of their questions when they were invited to ask by their oncologist. During radiotherapy consultations from 2012 to 2016, patient's questions were deliberately elicited and physician-transcribed. We derived mean and median number of questions per patient, variance by patient factors, and a taxonomy of subjects using thematic analysis. Three hundred ninety-six patients asked 2386 questions, median asked per patient = 6 (interquartile range = 4). We found significant variance with age (mean = 6.9 questions for < 60 years, 5.4 for ≥ 70 years) p = 0.018, insurance type (mean = 4.7 for Medicaid, 7.2 for private insurance) p = 0.0004, and tumor site (mean number of questions: skin = 4.6, lymphoma = 5.2, lung = 5.8, breast = 6.1, prostate = 6.3, rectum = 6.7 head and neck = 6.9, brain = 7.0, bladder = 7.2, anus = 8.8, others = 5.8) p = 0.0440. Of the diverse set of 57 topics, the commonest were 1. logistics, 2. radiotherapy details, 3. side effects, 4. diagnosis, and 5. stage and prognosis. Only 17 topics were asked by more > 10% of patients and 40 topics were asked by < 10% of patients. With median of 6 questions, it is practicable to routinely elicit and address individualized information needs. Potential barriers may be older and underinsured patients. The wide variety of topics, often pertaining to individuals' case, suggests that cancer clinicians should take time-out during consultation to elicit patients' questions to accomplish best-practice communication.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

Treat patient, not just the disease: holistic needs assessment for haematological cancer patients

Haematological malignancies can have devastating effects on the patients' physical, emotional, psycho-sexual, educational and economic health. With the improvement of therapies patients with these malignancies are living longer, however significant proportion these patient show poor quality of life (QoL) due to various physical and psychological consequences of the disease and the treatments. Health-related QoL (HRQoL) is multi-dimensional and temporal, relating to a state of functional, physical, psychological and social/family well-being. Compared with the general population, HRQoL of these patients is worse in most dimensions. However without routine holistic need assessment (HNA), clinicians are unlikely to identify patients with clinically significant distress. Surviving cancer is a chronic life-altering condition with several factors negatively affecting their QoL, such as psychological problems, including depression and excessive fear of recurrence, as well as social aspects, such as unemployment and social isolation. These need to be adequately understood and addressed in the healthcare of long-term survivors of haematological cancer. Applying a holistic approach to patient care has many benefits and yet, only around 25% of cancer survivors in the UK receive a holistic needs assessment. The efforts of the last decade have established the importance of ensuring access to psychosocial services for haematological cancer survivors. We need to determine the most effective practices and how best to deliver them across diverse settings. Distress, like haematological cancer, is not a single entity, and one treatment does not fit all. Psychosocialoncology needs to increase its research in comparative effectiveness.

Communication about uncertainty and hope: A randomized controlled trial assessing the efficacy of a communication skills training program for physicians caring for cancer patients

Background

Although previous studies have reported the efficacy of communication skills training (CST) programs, specific training addressing communication about uncertainty and hope in oncology has not yet been studied. This paper describes the study protocol of a randomized controlled trial assessing the efficacy of a CST program aimed at improving physician ability to communicate about uncertainty and hope in encounters with cancer patients.

Methods/design

Physician participants will be randomly assigned in groups (n = 3/group) to a 30-h CST program (experimental group) or to a waiting list (control group). The training program will include learner-centered, skills-focused, practice-oriented techniques. Training efficacy is assessed in the context of an encounter with a simulated advanced stage cancer patient at baseline and after the CST for the experimental group, and after four months for the waiting-list group. Efficacy assessments will include communicational, psychological and physiological measures. Group-by-time effects will be analyzed using a generalized estimating equation (GEE). A power analysis indicated that a sample size of 60 (30 experimental and 30 control) participants will be sufficient to detect effects.

Discussion

The current study will aid in the development of effective CST programs to improve physician ability to communicate about uncertainty and hope in encounters with cancer patients.

Trial registration

US Clinical Trials Register NCT02836197.

Evaluating holistic needs assessment in outpatient cancer care--a randomised controlled trial: the study protocol

INTRODUCTION

People living with and beyond cancer are vulnerable to a number of physical, functional and psychological issues. Undertaking a holistic needs assessment (HNA) is one way to support a structured discussion of patients' needs within a clinical consultation. However, there is little evidence on how HNA impacts on the dynamics of the clinical consultation. This study aims to establish (1) how HNA affects the type of conversation that goes on during a clinical consultation and (2) how these putative changes impact on shared decision-making and self-efficacy.

METHODS AND ANALYSIS

The study is hosted by 10 outpatient oncology clinics in the West of Scotland and South West England. Participants are patients with a diagnosis of head and neck, breast, urological, gynaecological and colorectal cancer who have received treatment for their cancer. Patients are randomised to an intervention or control group. The control group entails standard care--routine consultation between the patient and clinician. In the intervention group, the patient completes a holistic needs assessment prior to consultation. The completed assessment is then given to the clinician where it informs a discussion based on the patient's needs and concerns as identified by them. The primary outcome measure is patient participation, as determined by dialogue ratio (DR) and preponderance of initiative (PI) within the consultation. The secondary outcome measures are shared decision-making and self-efficacy. It is hypothesised that HNA will be associated with greater patient participation within the consultation, and that shared decision-making and feelings of self-efficacy will increase as a function of the intervention.

ETHICS AND DISSEMINATION

This study has been given a favourable opinion by the West of Scotland Research Ethics Committee and NHS Research & Development. Study findings will be disseminated through peer-reviewed publications and conference attendance.

TRAIL REGISTRATION NUMBER

Clinical Trials.gov NCT02274701.

Effectiveness of the palliative care 'Availability, Current issues and Anticipation' (ACA) communication training programme for general practitioners on patient outcomes: a controlled trial

BACKGROUND

Although communicating effectively with patients receiving palliative care can be difficult, it may contribute to maintaining or enhancing patients' quality of life. Little is known about the effect of training general practitioners in palliative care-specific communication. We hypothesized that palliative care patients of general practitioners exposed to the 'Availability, Current issues and Anticipation' communication training programme would report better outcomes than patients of control general practitioners.

AIM

To evaluate the effectiveness of the Availability, Current issues and Anticipation training programme for general practitioners on patient-reported outcomes.

DESIGN

In a controlled trial, general practitioners followed the Availability, Current issues and Anticipation programme or were part of the control group. Patients receiving palliative care of participating general practitioners completed the Palliative Care Outcome Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative, the Rest & Peace Scale, the Patient Satisfaction Questionnaire-III and the Availability, Current issues and Anticipation Scale, at baseline and 12 months follow-up. We analysed differences between groups using linear mixed models.

TRIAL REGISTRATION

ISRCTN56722368.

SETTING/PARTICIPANTS

General practitioners who attended a 2-year Palliative Care Training Course in the Netherlands.

RESULTS

Questionnaire data were available for 145 patients (89 in intervention and 56 in control group). We found no significant differences over time between the intervention and control groups in any of the five outcome measures. Ceiling effects were observed for the Rest & Peace Scale, Patient Satisfaction Questionnaire-III and Availability, Current issues and Anticipation Scale.

CONCLUSION

General practitioner participation in the Availability, Current issues and Anticipation training programme did not have a measurable effect on any of the outcomes investigated. Patients reported high levels of satisfaction with general practitioner care, regardless of group assignment. Future research might focus on general practitioners without special interest in palliative care.

The impact of the SAGE & THYME foundation level workshop on factors influencing communication skills in health care professionals

INTRODUCTION

The "SAGE & THYME Foundation Level Workshop" delivers evidence-based communication skills training to 30 health care workers in 3 hours. It teaches a structured approach (the SAGE & THYME model) to discuss patient/carer concerns. The aim of this study was to determine whether the workshop had a positive outcome on factors that influence communication skills.

METHODS

The study had a pragmatic, mixed methods design. Workshops were run in an acute hospital. One hundred seventy health care workers completed questionnaires pre- and post-workshop; 141 were sent follow-up questionnaires at 2 weeks and 2 months; and 9 were filmed talking to a simulated patient pre- and post-workshop.

RESULTS

From pre- to post-workshop, there was a significant increase in knowledge (p < 0.001), self-efficacy (p < 0.001), and outcome expectancy (p < 0.001). An expert's rating of behavior with the simulated patient also significantly increased after the training (p = 0.011). Motivation to use the training, and the perceived usefulness of the SAGE & THYME model, were high post-workshop. There was a poor response rate in the follow-up period; hence, the quantitative data are not reported. The qualitative data are described, however, as they give an insight into the impact of the training on staff and their patients.

DISCUSSION

The SAGE & THYME Foundation Level Workshop significantly increases communication skills knowledge, self-efficacy, and outcome expectancy of hospital health care workers who are predominantly white, female, nursing, or nonclinical staff. This suggests that the workshop may have a positive impact on some factors influencing communication skills in this group.

Effectiveness of the ACA (Availability, Current issues and Anticipation) training programme on GP-patient communication in palliative care; a controlled trial

Background

Communicating effectively with palliative care patients has been acknowledged to be somewhat difficult, but little is known about the effect that training general practitioners (GPs) in specific elements of communication in palliative care might have. We hypothesized that GPs exposed to a new training programme in GP-patient communication in palliative care focusing on availability of the GP for the patient, current issues the GP should discuss with the patient and anticipation by the GP of various scenarios (ACA), would discuss more issues and become more skilled in their communication with palliative care patients.

Methods

In this controlled trial among GPs who attended a two-year Palliative Care Peer Group Training Course in the Netherlands only intervention GPs received the ACA training programme. To evaluate the effect of the programme a content analysis (Roter Interaction Analysis System) was performed of one videotaped 15-minute consultation of each GP with a simulated palliative care patient conducted at baseline, and one at 12 months follow-up. Both how the GP communicated with the patient (‘availability’) and the number of current and anticipated issues the GP discussed with the patient were measured quantitatively. We used linear mixed models and logistic regression models to evaluate between-group differences over time.

Results

Sixty-two GPs were assigned to the intervention and 64 to the control group. We found no effect of the ACA training programme on how the GPs communicated with the patient or on the number of issues discussed by GPs with the patient. The total number of issues discussed by the GPs was eight out of 13 before and after the training in both groups.

Conclusion

The ACA training programme did not influence how the GPs communicated with the simulated palliative care patient or the number of issues discussed by the GPs in this trial. Further research should evaluate whether this training programme is effective for GPs who do not have a special interest in palliative care and whether studies using outcomes at patient level can provide more insight into the effectiveness of the ACA training programme.

Trial registration

Current Controlled Trials ISRCTN56722368

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is an updated version of a review that was originally published in the Cochrane Database of Systematic Reviews in 2004, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses have been proposed and are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether CST is effective in improving the communication skills of HCPs involved in cancer care, and in improving patient health status and satisfaction.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2012, MEDLINE, EMBASE, PsycInfo and CINAHL to February 2012. The original search was conducted in November 2001. In addition, we handsearched the reference lists of relevant articles and relevant conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In this updated version, we limited our criteria to RCTs evaluating 'CST' compared with 'no CST' or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real and/or simulated patients with cancer, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects model and, for continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 15 RCTs (42 records), conducted mainly in outpatient settings. Eleven studies compared CST with no CST intervention, three studies compared the effect of a follow-up CST intervention after initial CST training, and one study compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists (six studies), residents (one study) other doctors (one study), nurses (six studies) and a mixed team of HCPs (one study). Overall, 1147 HCPs participated (536 doctors, 522 nurses and 80 mixed HCPs).Ten studies contributed data to the meta-analyses. HCPs in the CST group were statistically significantly more likely to use open questions in the post-intervention interviews than the control group (five studies, 679 participant interviews; P = 0.04, I² = 65%) and more likely to show empathy towards patients (six studies, 727 participant interviews; P = 0.004, I² = 0%); we considered this evidence to be of moderate and high quality, respectively. Doctors and nurses did not perform statistically significantly differently for any HCP outcomes.There were no statistically significant differences in the other HCP communication skills except for the subgroup of participant interviews with simulated patients, where the intervention group was significantly less likely to present 'facts only' compared with the control group (four studies, 344 participant interviews; P = 0.01, I² = 70%).There were no significant differences between the groups with regard to outcomes assessing HCP 'burnout', patient satisfaction or patient perception of the HCPs communication skills. Patients in the control group experienced a greater reduction in mean anxiety scores in a meta-analyses of two studies (169 participant interviews; P = 0.02; I² = 8%); we considered this evidence to be of a very low quality.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving some types of HCP communication skills related to information gathering and supportive skills. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', patients' mental or physical health, and patient satisfaction.

Patient-provider communication data: linking process and outcomes in oncology care

OVERVIEW

Patient-provider communication is vital to quality patient care in oncology settings and impacts health outcomes. Newer communication datasets contain patient symptom reports, real-time audiofiles of visits, coded communication data, and visit outcomes. The purpose of this paper is to: (1) review the complex communication processes during patient-provider interaction during oncology care; (2) describe methods of gathering and coding communication data; (3) suggest logical approaches to analyses; and (4) describe one new dataset that allows linking of patient symptoms and communication processes with visit outcomes.

CHALLENGES

Patient-provider communication research is complex due to numerous issues, including human subjects' concerns, methods of data collection, numerous coding schemes, and varying analytic techniques.

DATA COLLECTION AND CODING

Coding of communication data is determined by the research question(s) and variables of interest. Subsequent coding and timestamping the behaviors provides categorical data and determines the interval between and patterns of behaviors.

ANALYTIC APPROACHES

Sequential analyses move from descriptive statistics to explanatory analyses to direct analyses and conditional probabilities. In the final stage, explanatory modeling is used to predict outcomes from communication elements. Examples of patient and provider communication in the ambulatory oncology setting are provided from the new Electronic Self Report Assessment-Cancer II dataset.

SUMMARY

More complex communication data sets provide opportunities to link elements of patient-provider communication with visit outcomes. Given more complex datasets, a step-wise approach is necessary to analyze and identify predictive variables. Sequential analyses move from descriptive results to predictive models with communication data, creating links between patient symptoms and concerns, real-time audiotaped communication, and visit outcomes. The results of these analyses will be useful in developing evidence-based interventions to enhance communication and improve psychosocial outcomes in oncology settings.

Perceived barriers and facilitators for general practitioner-patient communication in palliative care: a systematic review

While effective general practitioner (GP)-patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP-patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP-patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs' lack of availability, and patients' and GPs' ambivalence to discuss 'bad prognosis'. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators.

Facilitators and barriers for GP-patient communication in palliative care: a qualitative study among GPs, patients, and end-of-life consultants

BACKGROUND

Effective communication is considered to be essential for the delivery of high-quality care. Communication in palliative care may be particularly difficult, and there is still no accepted set of communication skills for GPs in providing palliative care.

AIM

To obtain detailed information on facilitators and barriers for GP-patient communication in palliative care, with the aim to develop training programmes that enable GPs to improve their palliative care communication skills.

DESIGN OF STUDY

Qualitative study with focus groups, interviews, and questionnaires.

SETTING

GPs with patients receiving palliative care at home, and end-of-life consultants in the Netherlands.

METHOD

GP (n = 20) focus groups discussing facilitators and barriers, palliative care patient (n = 6) interviews regarding facilitators, and end-of-life consultant (n = 22) questionnaires concerning barriers.

RESULTS

Facilitators reported by both GPs and patients were accessibility, taking time, commitment, and listening carefully. GPs emphasise respect, while patients want GPs to behave in a friendly way, and to take the initiative to discuss end-of-life issues. Barriers reported by both GPs and end-of-life consultants were: difficulty in dealing with former doctors' delay and strong demands from patients' relatives. GPs report difficulty in dealing with strong emotions and troublesome doctor-patient relationships, while consultants report insufficient clarification of patients' problems, promises that could not be kept, helplessness, too close involvement, and insufficient anticipation of various scenarios.

CONCLUSION

The study findings suggest that the quality of GP-patient communication in palliative care in the Netherlands can be improved. It is recommended that specific communication training programmes for GPs should be developed and evaluated.

Communication skills training and clinicians' defenses in oncology: an exploratory, controlled study

OBJECTIVE

The underlying mechanisms modifying clinician's communication skills by means of communication skills training (CST) remain unknown. Defense mechanisms, defined as psychological processes protecting the individual against emotional stress, may be a mediating factor of skills improvement.

METHODS

Using an adapted version of the Defense Mechanism Rating Scale-Clinician, this study evaluated clinicians' defense mechanisms and their possible modification after CST. Interviews with simulated patients of oncology clinicians (N=57) participating in CST (pre-/post-CST with a 6-month interval) were compared WITH interviews with the same simulated patients of oncology clinicians (N=56) who did not undergo training (T1 and T2 with a 6-month interval).

RESULTS

Results showed (i) a high number (mean=16, SD=6) and variety of defenses triggered by the 15-min interviews, (ii) no evolution difference between groups, and (iii) an increase in mature defenses after CST for clinicians with an initial higher level of defensive functioning.

CONCLUSIONS

This is the first study describing clinicians' defensive functioning; results indicate a possible mediating role of defenses in clinician-patient communication.

Insight on variables leading to burnout in cancer physicians

Although communication skills training programs have been recommended to reduce physicians' burnout, few studies have investigated their efficacy. This study assessed the impact of two training programs on cancer physicians' burnout. Especially, it identified some variables leading to burnout in order to develop effective interventions. Burnout was assessed with the Maslach Burnout Inventory. No statistically significant impact of training programs on burnout was observed. The amount of clinical workload and the overuse of some facilitative communication skills were associated with cancer physicians' burnout. The content of such programs must be redefined to reduce burnout.

Empowerment of disability benefit claimants through an interactive website: design of a randomized controlled trial

BACKGROUND

Individuals claiming a disability benefit after long-term sickness absence, have to undergo medical disability assessments. These assessments, often carried out by specialized physicians, can be complicated by wrong expectations or defensive attitudes of disability benefit claimants. It is hypothesized that empowerment of these claimants will enhance the physician-patient relationship by shifting claimants from a passive role to a more active and constructive role during disability assessments. Furthermore, empowerment of claimants may lead to a more realistic expectation and acceptance of the assessment outcome among claimants and may lead to a more accurate assessment by the physician.

METHODS/DESIGN

In a two-armed randomized controlled trial (RCT), 230 claimants will be randomized to either the intervention or control group. For the intervention group, an interactive website was designed http://www.wiagesprek.nl using an Intervention Mapping procedure. This website was tested during a pilot study among 51 claimants. The final version of the website consists of five interactive modules, in which claimants will be prepared and empowered step-by-step, prior to their upcoming disability assessment. Other website components are a forum, a personal health record, a personal diary, and information on disability assessment procedures, return to work, and coping with disease and work disability. Subjects from the control group will be directed to a website with commonly available information only. Approximately two weeks prior to their disability assessment, disability claimants will be recruited through the Dutch Workers Insurance Authority (UWV). Outcomes will be assessed at five occasions: directly after recruitment (baseline), prior to disability assessment, directly after disability assessment as well as 6 and 16 weeks after the assessment. The study's primary outcome is empowerment, measured with the Vrijbaan questionnaire. Secondary outcomes include claimants' satisfaction, perceived justice, coping strategy, and knowledge. A process evaluation will also be conducted.

DISCUSSION

This study evaluates the effectiveness of an interactive website aimed at empowerment of disability claimants. It is hypothesized that by increasing empowerment, the physician-patient relationship may be enhanced and claimants' satisfaction and perceived justice can be improved. Results are expected in 2010.

TRIAL REGISTRATION

NTR-1414.

Patient Communication Simulation Laboratory for Students in an Acute Care Nurse Practitioner Program

Background Effective communication skills for clinical practice are essential for all advanced practice nurses. However, competence in these skills is not necessarily intuitive. Advanced communication skills should be taught in a way that is similar to the way other psychomotor skills in advanced nursing practice programs are taught.

Objectives To develop a patient communication simulation laboratory for the acute care nurse practitioner program at a major university and to evaluate students’ perceived confidence and communication effectiveness before and immediately as well as 4 months after completion of the laboratory.

Methods The communication simulation laboratory was developed in collaboration with faculty from the schools of nursing and medicine. Students participated in a didactic session and then completed a 2-hour communication simulation in the laboratory. Content and simulation concentrated on breaking “bad news,” empathetic communication, motivational interviewing, and the “angry” patient. Students’ self-reported confidence and perceived skill in communication were measured via a Likert scale before, immediately after, and 4 months after completion of the laboratory simulation. Students also evaluated the experience by responding to open-ended questions.

Results Compared with baseline findings (before the lecture and simulation), students’ confidence in initiating difficult conversations increased significantly both immediately (P&lt;.001) and 4 months after (P=.001) the laboratory simulation. Students’ self-ratings of overall ability to communicate were also significantly greater immediately (P&lt;.001) and 4 months (P=.001) after the simulation. Overall, students rated the laboratory simulation experience highly beneficial.

Conclusions The content and methods used for the simulation improved students’ confidence and perceived skill in communication in potentially difficult acute care situations.

The content and effects of palliative care courses for nurses: A literature review

OBJECTIVES

The present literature review describes the literature (1990-2005) that concerns the effects of courses in palliative care at the pre- and postgraduate levels.

DATA SOURCES

A search was made for literature from the period between 1990 and 2005 using CINAHL, Pubmed and Psychlit, supplemented with a search for relevant systematic reviews from the Cochrane Library.

DESIGN

The research questions were directed on the areas of expertise and skills, the didactical methods, the effects of the courses and the standards to measure these effects.

RESULTS

The studies were all focused on general palliative care. Out of 27 studies 21 reported positive effects for communication, attitude, empathy and pain. Six of these 21 positive trails were studies with good quality designs, whereas 15 had moderate designs. The six studies with a lack of effects was one study with good quality and five studies with moderate quality designs. The effects on patients were described in only a few cases. There was still frequent use of self-constructed rating scales, where data about validity and reliability were lacking or where these aspects were not studied.

CONCLUSIONS

The most successful were integrated courses focused on several themes with a variety of didactical methods.

Factors that influence treatment strategies in advanced colorectal cancer

This review focuses on the factors that now influence our treatment strategies designed to increase the pool of patients with colorectal liver metastases for whom curative treatment may be possible. These strategies include improved preoperative staging techniques, new standards for surgical resection, novel surgical strategies, the application of modern systemic chemotherapy in a neoadjuvant setting, an emerging role for ablative therapies and an emphasis on the collaborative, a reappraisal of staging advanced disease, multidisciplinary management, and defining the role of the patient in managing their disease. It is now clear that an aggressive multi-disciplinary approach to the management of this problem will lead to nearly one third of these patients being considered for treatment that even if not achieving complete cure, offers significant long-term survival.

Preparation for cancer care: Perceptions of newly qualified health care professionals

The present paper is derived from a larger survey which examined the perceptions of recently qualified health care professionals' experience on evidence-based practice, team working and cancer care. This study reports solely on the findings relating to cancer care. The perceptions of recently qualified professionals in relation to their initial educational input on issues such as confidence, anxiety, communication skills and practice in cancer care as well as adequacy of support, professional supervision and use of reflection were gathered using a cross-sectional postal survey design. A total of 50 graduates from each professional category in nursing, occupational therapy, physiotherapy, and social work were sampled yielding a total sample of 200. Eighty-five questionnaires were returned yielding a response rate of 43%. Twenty-eight (33%) respondents stated that they were currently involved in working with people with cancer. These were as follows: 5 nurses, 8 physiotherapists, 9 occupational therapists and 6 social workers. Despite the low response rate, the findings suggest that health care professionals' educational input and experiences of working with people with cancer were overall positive; for example, in the respondents' confidence, communication skills, decrease in anxiety and application of knowledge gained in classroom to professional practice. Moreover, most respondents learnt about caring for cancer patients through practice rather than classroom teaching. A high percentage (i.e. 64%;18) across all groups felt supported when caring for people with cancer and reported receiving professional supervision as well as being able to actively reflect on their practice. The implications for education and practice were discussed particularly as there have been few studies conducted in relation to the specific needs and collaborative learning of these health care professional groups.

Physicians are different when they learn communication skills: influence of the locus of control

PURPOSE

Although it is widely recognised that educational interventions may be more effective for people with an 'internal' Locus of Control (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), no study has yet assessed the influence of physicians' Locus of Control (LOC) on communication skills learning. This study aims to test the hypothesis that, in a communication skills training program, physicians with an 'internal' LOC would demonstrate communication skills acquisition to a greater degree than those with an 'external' LOC.

METHODS

A non-randomised longitudinal intervention study was conducted between January 1999 and April 2001. Sixty-seven volunteer physicians from private and institutional practice in Belgium participated in a learner-centred, skills-focused, practice-oriented communication skills training program. Communication skills changes were assessed in 2 standardised simulated interviews before and after training (one two-person and one three-person interview). Communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. Communication skills changes of the upper and lower third of physicians in respect of their scores on this scale were compared using group by time repeated measures of variance.

RESULTS

In the two-person and three-person interviews, changes in the use of open directive questions were more important among physicians with an "internal" LOC compared with changes observed among physicians with an 'external' LOC (P=0.066 and P=0.004, respectively). In the three-person interview, changes in the use of directive questions, assessing functions and moderate feelings stated explicitly were more important among physicians with an 'internal' LOC compared with changes observed among physicians with an 'external' LOC (P= 0.001; P=0.002 and P=0.011 respectively).

CONCLUSION

This study shows that physicians' LOC is a psychological characteristic that could influence the efficacy of a communication skills training program. This evidence supports the idea that a psychological characteristic such as 'internal' LOC may facilitate communication skills acquisition through physicians' belief that communication with patients may be controlled by physicians themselves.

Current concepts of communication skills training in oncology

Too many patients leave their consultations with insufficient understanding about their diagnosis, prognosis, the need for further diagnostic tests, the management plans, or the therapeutic intent of treatment. This situation is not entirely due to paternalism or a lack of awareness that patients worldwide desire more information, but rather a reflection of the dismal communication skills training that most healthcare professionals receive. There have been many developments aimed at rectifying this situation, but there are still too few publications available demonstrating efficacy. Nevertheless, evidence shows that communication skills can be taught and that if taught well then the impact endures into the clinic. This chapter looks at some of the history of good evidence-based interventions to improve communication and makes a plea for more research-based evidence for improved patient outcomes following training. Unless attention and resources are given to help healthcare professionals in this core clinical skill then we will never be able to help patients and their families take an informed and educated role in their own cancer care.

Psychodynamic aspects of communication skills training: a pilot study

GOALS OF WORK

Communication between patients and oncology clinicians is a key element of cancer care. Emotionally charged consultations may trigger clinicians' defense mechanisms, protecting them from painful emotions. Defense mechanisms, however, may also hamper the recognition of patients' suffering. This pilot study aims to explore clinicians' defense mechanisms observed in communication skills training (CST).

PATIENTS AND METHODS

A verbatim transcription of videotaped interviews with simulated patients were evaluated before (N=10) and after CST (N=10) with the defense mechanism rating scales (DMRS).

MAIN RESULTS

A wide variety of defense mechanisms were observed such as obsessional (e.g. intellectualisation) or disavowal (e.g. denial or projection). Immature defense mechanisms decreased after CST.

CONCLUSIONS

A wide variety of defense mechanisms are operant in oncology clinicians facing challenging interviews with simulated patients. Defense mechanisms may be modified by CST.

Transfer of communication skills training from workshop to workplace: the impact of clinical supervision

OBJECTIVE

Recent studies have recognised that the communication skills learned in the training environment are not always transferred back into the clinical setting. This paper reports a study which investigated the potential of clinical supervision in enhancing the transfer process.

METHODS

A randomised controlled trial was conducted involving 61 clinical nurse specialists. All attended a 3-day communication skills training workshop. Twenty-nine were then randomised to 4 weeks of clinical supervision, aimed at facilitating transfer of newly acquired skills into practice. Assessments, using real and simulated patients, were carried out before the course, immediately after the supervision period and 3 months later. Interviews were rated objectively using the Medical Interview Aural Rating Scale (MIARS) to assess nurses' ability to use key skills, respond to patient cues and identify patient concerns.

RESULTS

Assessments with simulated patients showed that the training programme was extremely effective in changing competence in all three key areas. However, only those who experienced supervision showed any evidence of transfer. Improvements were found in the supervised groups' use of open questions, negotiation and psychological exploration. Whilst neither group facilitated more disclosure of cues or concerns, those in the experimental group responded more effectively to the cues disclosed, reduced their distancing behaviour and increasing their exploration of cues.

CONCLUSIONS

The study has shown that whilst training enhances skills, without intervention, it may have little effect on clinical practice. The potential role of clinical supervision as one way of enhancing the clinical effectiveness of communication skills training programmes has been demonstrated. PRACTISE IMPLICATIONS: This study raises questions about the effectiveness of training programmes which do not incorporate a transfer element, and provides evidence to support the need for clinical supervision for clinical nurse specialist.

Communication skills training in oncology: it works!

While the previous chapter by L. Fallowfield and V. Jenkins focuses on different communication skills training (CST) concepts currently being utilized, this chapter reviews and comments the scientific evidence of the impact of CST on improving communication skills. The aim of this chapter is not to provide a complete review of the evidence-this has already been done in systematic reviews-but to discuss the scientific evidence and reflect on the available results and relevant topics for further investigations.

Physician-patient communication among Southern European cancer physicians: the influence of psychosocial orientation and burnout

Physician-patient communication is a critical factor for comprehensive care in oncology. Although a number of studies have been carried out in Northern Europe and the US on this subject, no data are available in Southern European countries. As a part of a multicenter Southern European Psycho-Oncology study (SEPOS), the present investigation was conducted to examine communication skills and related variables (i.e. psychosocial orientation, and burnout) among 125 physicians from Italy, Portugal, and Spain. The Self-Confidence in Communication Skills (SCCS) scale was given to assess physicians' perception of their communication skills and the Expected Outcome of Communication (EOC) scale was administered to examine the physicians' expectations about the effects of communicating with their patients. Doctors' psychosocial orientation was measured by using the Physician Belief Scale (PBS) and burnout was measured by using the Maslach Burnout Inventory (MBI). Although the physicians reported receiving minimal training in communication during their education, they tended to perceive themselves as skilled in patient communication, apart from some areas (e.g. dealing with denial, managing uncertainty, assessing anxiety and depression, and promoting patient-family openness). Low psychosocial orientation and burnout symptoms (i.e. emotional exhaustion, depersonalization, and poor personal accomplishment in their job) were associated with lower confidence in communication skills and higher expectations of a negative outcome, following physician-patient communication. The results suggest that there is a need for training cancer physicians in communication and for increasing a more definite psychosocially oriented approach in cancer care in Mediterranean countries.

Delivering multiprofessional web-based psychosocial education: the lessons learnt

Psychosocial care is one component of high-quality cancer/palliative care. The development of the internet has revolutionized the way we conduct business, shop, communicate with each other, and seek information. This article reports on the delivery of a web-based 16-week module: 'The management of cancer: psychosocial perspectives'. Twenty-nine students represented by a wide range of members of the multidisciplinary team registered for this module. Electronic-learning programmes are noted for high attrition rates, but, in this delivery, attrition rates and assessment performance were compatible with face-to-face programmes of learning. The delivery of this module indicates that there is scope for helping multiprofessional staff develop their knowledge and skills in psychosocial care.

Does psychological characteristic influence physicians’ communication styles? Impact of physicians’ locus of control on interviews with a cancer patient and a relative

CONTEXT

Physicians' psychological characteristics may influence their communication styles and may thus interfere with patient-centred communication.

OBJECTIVE

Our aim was to test the hypothesis that, in interviews with a cancer patient and a relative, physicians with an "external" locus of control (LOC; who believe that life outcomes are controlled by external forces such as luck, fate or others) have a communication style different from that of physicians with an "internal" LOC (who believe that life outcomes are controlled by their own characteristics or actions).

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

Eighty-one voluntary physicians practising in the field of oncology were recorded while performing an actual and a simulated interview with a cancer patient and a relative.

MAIN OUTCOME MEASURES

Physicians' communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. The communication skills of the upper and lower quartiles of physicians in respect of their scores on this scale were compared using Student's t test.

RESULTS

In actual interviews, physicians with an "external" LOC talked more to the relative (P=0.017) and used more utterances with an assessment function (P=0.010) than physicians with an "internal" LOC. In simulated interviews, physicians with an "external" LOC used less utterances that give premature information (P=0.031) and used more utterances with a supportive function, such as empathy and reassurance (P=0.029), than physicians with an "internal" LOC.

CONCLUSION

These results provide evidence that physicians' LOC can influence their communication styles. Physicians' awareness of this influence constitutes a step towards a tailoring of their communication skills to every patient's and relative's concerns and needs and thus towards a patient-centred communication.

Physicians' communication with a cancer patient and a relative: a randomized study assessing the efficacy of consolidation workshops

BACKGROUND

Although patients with cancer are often accompanied by a relative during medical interviews, to the authors' knowledge little is known regarding the efficacy of communication skills training programs on physicians' communication skills in this context. The objective of the current study was to assess the efficacy of 6 consolidation workshops, 3 hours in length, that were conducted after a 2.5-day basic training program.

METHODS

After attending the basic training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual interviews that were recorded on an audio tape at baseline, after consolidation workshops for the consolidation-workshops group, and 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' perceptions of and satisfaction with physicians' communication performance were assessed using a 15-item questionnaire.

RESULTS

Sixty-two physicians completed the training program. Compared with physicians who participated to the basic training program, when addressing the patient, physicians who were randomized to the consolidation workshops used more open, open directive, and screening questions (P = 0.011 in simulated patient interviews and P = 0.005 in actual patient interviews) and elicited and clarified psychologic concerns more often (P = 0.006 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the relative, physicians who were randomized to the consolidation workshops gave less premature information (P = 0.032 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the patient and the relative simultaneously, physicians who were randomized to the consolidation workshops used more empathy, educated guesses, alerting to reality, confronting, negotiating, and summarizing (P = 0.003 in simulated patient interviews and P = 0.024 in actual patient interviews). Patients, but not relatives, who interacted with physicians in the consolidation-workshops group were more satisfied globally with the interviews (P = 0.022).

CONCLUSIONS

Six 3-hour consolidation workshops resulted in improved communication skills addressed to patients and to relatives. The current results showed that the transfer of skills addressing relatives' concerns remained limited and that consolidation workshops should focus even more systematically on the practice of three-person interviews.

Developing communication competency in the context of cancer: a critical interpretive analysis of provider training programs

We conducted a critical interpretive analysis of 47 studies from the Cochrane Review of the communications training literature to capture the empirical indicators used to judge provider communication competency and to describe how the indicators were characterized in the context of a cancer care system. Of the 47 studies reviewed, few showed any resemblance to recommendations from two international consensus conferences of experts in the communication research field. Some of the challenges in moving forward with cancer-related communication skills involve deciding what we want people to learn, providing learning across various experiences, identifying learning models, and finding alternate ways of motivating people to learn. Once core competencies are clearly articulated, we can determine the best approaches for developing cancer-specific training programs.

Observation of nurse-patient interaction in oncology: review of assessment instruments

The aim of this review is to identify assessment instruments that can be used for analyzing sequences and can be applied to research into nurse-patient communication in cancer care. A systematic search of the literature revealed a variety of methods and instruments applicable to studies recording nurse-patient interaction. The studies that were qualitative in nature offered valuable information on observational research in general, on procedures relating to informed consent and observational arrangements in nursing practice. The quantitative studies provided an insight into the content and structure of the interaction by describing communication concepts or by frequency counts of previously determined behaviours. Systematic research into interaction sequences was not found. However, some of the quantitative instruments identified could be adapted for this purpose. The complexity and time-consuming nature of observational research highlight the need for efficiency. For instance a combination of quantitative and qualitative instruments could be considered.

Communication skills training for health care professionals working with cancer patients, their families and/or carers

BACKGROUND

Research suggests communication skills do not reliably improve with experience. Considerable effort is dedicated to courses improving communication skills for health professionals. Evaluation of such courses is important to enable evidence-based teaching and practice.

OBJECTIVES

To assess whether communication skills training is effective in changing health professionals' behaviour in cancer care with regard to communication/interaction with patients.

SEARCH STRATEGY

We searched CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to November 2001), EMBASE (1980 to November 2001), PsycInfo (1887 to November 2001), CINAHL (1982 to November 2001), AMED (1985 - October 2001), Dissertation Abstracts International (1861 to March 2002) and EBM Reviews (1991 to March/April 2001). Reference lists of relevant articles were searched. Three further studies were detected in November 2003.

SELECTION CRITERIA

Randomized controlled trials or controlled before and after studies of communication skills training in cancer health professionals, measuring changes in behaviour/skills using objective and validated scales.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials and extracted data.

MAIN RESULTS

Of 2824 references, 3 trials involving 347 health professionals were included. One provided an intensive 3 day course then assessed oncology doctors interacting with 640 patients; a second provided a modular course then assessed role plays with oncology nurses; the third was modular and assessed outcomes with clinical and simulated interviews and patient questionnaires. In one trial, course attendees used more focused questions (probability < 0.005), focused and open questions (p = 0.005), expressions of empathy (p < 0.005) and appropriate cue responses (p < 0.05) at follow up than non-attendees. No significant differences were found between attendees and non-attendees for leading questions. From baseline to follow up, attendees had significantly different changes in rates of leading questions (p < 0.05), focused questions (p < 0.005), open questions (p < 0.05) and empathy (p = 0.005). The only observed significant difference in the second trial was that trained doctors controlled the follow-up interview more than untrained doctors (p < 0.05). Neither studies found differences in summarising, interrupting and checking. The third trial found trained nurses used more emotional speech than untrained counterparts, particularly regarding anxiety and distress. Patients interviewed by trained nurses used more emotional terms, but no differences emerged in questionnaires.

REVIEWERS' CONCLUSIONS

Training programmes assessed by these trials appear to be effective in improving some areas of cancer care professionals communication skills. It is unknown whether this training would be effective if taught by others, nor the comparative efficacy of these programmes.

Impact of medical specialists' locus of control on communication skills in oncological interviews

Although is it widely recognised that physicians' characteristics could influence their communication styles, no empirical evidence is currently available. No studies are available on the impact of physicians' locus of control (LOC) on their communication skills. LOC is a generalised belief regarding the extent to which life outcomes are controlled by an individual's actions (internal LOC) or by external forces such as luck, fate or other individuals (external LOC). It was hypothesised that physicians with external LOC would take more into account others' concerns than physicians with internal LOC and would consequently use more appropriate assessment, informative and supportive functions. A total of 81 medical specialists were assessed in a simulated interview and a clinical interview. Communication skills were rated according to the Cancer Research Campaign Workshop Evaluation Manual. LOC was assessed using the Rotter I-E scale. Communication skills of the upper and lower quartiles of physicians in respect of their scores on this scale were compared using Student's t-test. Results show that physicians with external LOC give more appropriate information than physicians with internal LOC in simulated interviews (P=0.011) and less premature information than physicians with internal LOC in clinical interviews (P=0.015). This result provides evidence that physicians' LOC can influence their communication styles in oncological interviews and in particular the way they provide information to the patient.

Communicating with patients in cancer care; what areas do nurses find most challenging?

BACKGROUND

Patient communication is a cornerstone of comprehensive oncology nursing care. Oncology nurses, however, do not appear to receive much advanced training in communication skills and many nurses do not feel adequately trained in this area.

METHOD

We designed a 33-item questionnaire to assess nurses' perceived level of difficulty and skill in a variety of common clinical situations where patient communication was a challenge. Three hundred fifty oncology nurses in a major cancer center completed the questionnaire.

RESULTS

Nurses rated areas where they addressed the physical complaints (pain, fatigue, appetite and weight loss) as least challenging and areas in which they were most prepared. Several items ranked as most difficult and where nurses felt they had the least skills had to do with issues related to death and dying, especially requests for euthanasia and patient loss. Advanced practice nurses rated their perceived communications skills more highly in several different areas.

CONCLUSION

The communication challenges faced by oncology nurses require skills that go beyond simple supportive techniques like empathy and listening. Teaching advanced communications skills geared to specific problems identified by nurses may be useful.

Communication skills training for health care professionals working with cancer patients, their families and/or carers

BACKGROUND

Research suggests communication skills do not reliably improve with experience and considerable effort is dedicated to courses improving communication skills for health professionals. The evaluation of such courses is of importance to enable evidence-based teaching and practice.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of health professionals in cancer care with regard to communication/interaction with patients.

SEARCH STRATEGY

We searched CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to November 2001), EMBASE (1980 to November 2001), PsycInfo (1887 to November 2001), CINAHL (1982 to November 2001), AMED (1985 - October 2001), Dissertation Abstracts International (1861 to March 2002) and EBM Reviews (1991 to March/April 2001). Reference lists of relevant articles were searched.

SELECTION CRITERIA

Randomized controlled trials or controlled before and after studies of communication skills training in cancer health professionals, measuring changes in behaviour/skills using objective and validated scales.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Although 2822 references were considered, only two trials involving 232 health professionals were included. One provided an intensive three-day course then assessed oncology doctors interacting with a total of 640 patients; the other provided a modular course then used role plays with oncology nurses for skill assessment. In one trial, course attendees used more focused questions (34% increase, probability < 0.005), focused and open questions (27% increase, p = 0.005), expressions of empathy (69% increase, p < 0.005) and appropriate responses to cues (38% increase, p < 0.05) at follow up than non-attendees. No significant differences were found between attendees and non-attendees in use of leading questions. From baseline to follow up in the same study, attendees had significantly different changes in rates of leading questions (relative risk 0.72, p < 0.05), focused questions (Relative Risk 1.25, p < 0.005), open questions (RR 1.17, p < 0.05) and empathy (RR 1.50, p = 0.005). The only significant difference in observed communication skills in the second trial was that the trained group were more in control of the follow-up interview than the untrained group (p < 0.05). Both studies investigated differences in summarising, interrupting and checking but found none.

REVIEWER'S CONCLUSIONS

The training programmes assessed by these trials appear to be effective in improving cancer care professionals communication skills. It is not known whether the training would be effective if taught by other educators, nor has any trial compared the efficacy of both programmes.