Provider Communication Skill Training

Provider Communication Skill Training

PEP Topic 
Anxiety
Description 

Provider communication skill training is an approach in which the healthcare professional who provides services to the patient is trained to improve communication skills. Improved communication with the patient is proposed to have a positive effect on the patient’s symptoms and outcomes. Improved provider communication skills may improve assessment of the patient and the provider’s ability to facilitate effective communication by the patient, thereby enhancing symptom management. The effect of communication skill training to providers in cancer care has been examined for its effect on patient anxiety and depression and on caregiver strain and burden.

Effectiveness Not Established

Research Evidence Summaries

Fukui, S., Ogawa, K., Ohtsuka, M., & Fukui, N. (2008). A randomized study assessing the efficacy of communication skill training on patients' psychologic distress and coping: Nurses' communication with patients just after being diagnosed with cancer. Cancer, 113, 1462–1470.

doi: 10.1002/cncr.23710
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Study Purpose:

To investigate whether a communication skill training program for nurses would reduce psychological distress and improve coping among patients newly diagnosed with cancer

Intervention Characteristics/Basic Study Process:

The communication skill training (CST) program involved two workshops, one at the start of the study and the other after three months. Workshops lasted six hours and were structured in a six-step approach (SPIKES) involving (1) setting up the interview, (2) assessing the patient’s perception of his or her illness, (3) obtaining a patient invitation to disclose information, (4) giving information and knowledge to the patient, (5) addressing the patient's emotion with empathic responses, and (6) strategy and summary. The program involved a large group meeting on theoretic content followed by small facilitated group work in which nurses worked through various scenarios using the SPIKES steps. Study patients were randomly assigned to be interviewed three times by nurses who attended the CST program (experimental group) or interviewed the same three times by nurses in the control group. Interviews were scheduled on the day of diagnosis, and one week and one month after diagnosis. Study measurements were done at one week after diagnosis (T1), one month after diagnosis (T2), and three months after (T3). Nurses were randomly assigned to either CST or usual care provision.

Sample Characteristics:

  • The study reported on a sample of 89 patients, plus 8 nurse participants.
  • Mean patient age in the experimental group was 61.4 ± 10.8 years; mean patient age in the control group was 60.9 ± 14.3 years.
  • The sample was 56%–61% female and 39%–40% male.
  • Patients had gastric, colorectal, and breast cancers.
  • More than 90% of study patients had surgery, 76%–81% were married, 39%–44% were unemployed, and more than 50% in both groups had stage I disease.
  • Nurse participants had a mean age of 40.8 ± 7.2 years, and mean years of experience as an oncology nurse of 17.2 ± 6.87.
  • Inclusion criteria included patients who were newly diagnosed and informed of cancer in physician consultation, were older than age 18, and had disease that was not advanced and at an operable stage.
  • Patients were excluded if they had a severe psychological problem as assessed by the physician.

Setting:

  • Single site
  • Outpatient setting
  • Japan

Phase of Care and Clinical Applications:

Patients were undergoing the diagnostic phase of care.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Mental Adjustment to Cancer Scale (MAC)

Results:

There was a significant different in HADS depression and total scores over time associated with group (p = 0.03). These scores declined over time in both groups; however, the decline was greater for the experimental group. There was no group interaction or for anxiety. There were no significant changes in any other HADS data. MAC score changes over time showed mixed results. The only consistent directional change in the experimental group, as compared to the control group, was in the area of fatalism, with decline over time in the experimental group and increase over time in the control group (p = 0.04).

Conclusions:

CST appears to have a positive effect on psychological distress and some areas of coping for patients newly diagnosed with cancer.

Limitations:

  • The study sample was small, with less than 100 participants.
  • The study sample was purposefully homogeneous in terms of diagnoses, disease stage, and phase of care, and findings may not be applicable to other patient groups.
  • Nurses in the study had extensive years of experience in cancer care. The CST described here may not have similar effects with nurses who are less experienced in general or in oncology care.
  • The authors point out that results may have been influenced by the cultural attitude of Japanese patients and poor support systems that are seen to exist in Japan for newly diagnosed patients. These patients tend to not seek professional assistance, so the magnitude of differences in results may not be the same for other cultural groups in which professional support is more available or acceptable.
  • There was no credible evaluation of actual communications between nurses and patients or between physicians and patients that may have also influenced findings. In addition to study nurses, nurses in charge who had not been trained were always present at physician consultations and were involved in patient support afterward. There is no way to tell if charge nurse interactions were different between groups, changed over time, or were influenced by interaction with CST-trained nurses.

Nursing Implications:

Study findings support the idea that providing information, support, and empathic responses to patients can positively influence patient coping and emotional distress, and suggest that nurse training in communication skills of this nature can be useful. Further research in this area needs to demonstrate actual differences in communications between nurses and patients as a result of such training. It would be useful to see if such training can be beneficial in various groups of nurses based on differences in nursing education level and experience.

Morasso, G., Caruso, A., Belbusti, V., Carucci, T., Chiorri, C., Clavarezza, V., . . . Di Leo, S. (2015). Improving physicians' communication skills and reducing cancer patients' anxiety: A quasi-experimental study. Tumori, 101, 131–137. 

doi: 10.5301/tj.5000230
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Study Purpose:

To determine the effectiveness of a physician-centered communication skills training program on anxiety levels in patients with cancer. A three-phrase, multicenter, quasi-experimental study was used.

Intervention Characteristics/Basic Study Process:

The intervention phase of the study invited physician participants in the treatment group to attend a skills program to improve communications knowledge and strategies. The intent of the communications training was to improve communication with patients with cancer and families. The training sessions, taught by psycho-oncologists, were held at each study center and were scheduled in three-hour sessions for three weeks to total nine hours of training. Each physician participant was emailed relevant scientific papers (two published, one unpublished) five days in advance of each three-hour session. The treatment group physician participants were asked to read the materials in preparation for sharing during the training. Each session included didactic, experiential learning, and group discussion including clinical cases and role play. There was no communications training for physician participants from the control group.

Sample Characteristics:

  • N = 36 physicians (17 in the treatment group and 19 in the control group) and 339 patients (174 in the control group and 165 in the treatment group)    
  • MEAN AGE = physician: 46.64 years (SD = 7.9), range = 38.74–53.64; patient: 61.2 years (SD = 13.61), range = 47.59–74.81
  • MALES: physicians, 47%; patients, 45%; FEMALES: physicians, 53%; patients, 55%
  • KEY DISEASE CHARACTERISTICS: None, intervention was focused on physicians. Patients seen by control and intervention physicians varied widely in age, cancer type and cancer stage/prognosis.
  • OTHER KEY SAMPLE CHARACTERISTICS: Physicians were oncologists, hematologists, with a median of 15 years of professional experience, from northern, central and southern Italy, equally. Nineteen had no prescribed training in physician-centered communication; 17 attended training. There was no difference in pre-consultation anxiety scores between the 339 patients enrolled in the two groups. 

Setting:

  • SITE: Multi-site    
  • SETTING TYPE: Multiple settings  
  • LOCATION: Italian oncology practices

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Pediatrics, elder care, palliative care 

Study Design:

Multi-center, quasi-experimental, three-phase study. Of note, the phases of the study, as described, are not phases as used in North American scientific study. Rather, they are components of the methodology. Specifically, the authors describe phase 1 as recruitment, phase 2 as intervention, and phase 3 is evaluation.

Measurement Instruments/Methods:

  • Physician demographics and professional training
  • Patient demographics and communication documentation (physician self-report)
  • Anxiety in patients was measured by the Psychological Distress Inventory (PDI) and completed before the consultation.
  • STAI-S (State-Trait Anxiety Inventory-State) was completed before and after the consultation.

Results:

A significant decrease in anxiety scores was noted; however, it was difficult to ascertain if this is a treatment effect. Evaluation of the two groups indicated by adjusted standardized residuals (ASRs) that physicians more heavily represented some wards than others. Otherwise, there were no differences between the two physician groups. There were significant differences in patient groups based on gender, primary tumor type, and disease stage; interestingly, communication of a cancer diagnosis took place more in the treatment group than in the control group. However, the effect size indicated little evidence for bias of effect estimation. Outpatients who were in consultation with physicians who attended the communications training showed a greater decrease (though not a significant change) in anxiety scores than patients in consultation with physicians in the control group. Higher anxiety at baseline was shown in women, had lower educational levels, and who were in more distress. A lower probability of high anxiety scores was associated with longer time since diagnosis and longer consultation periods. 

Conclusions:

Suggestion of effectiveness of a communication skills training program with reference to patient anxiety levels.  Further research needed.

Limitations:

  • Small sample (less than 100)
  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)
  • Measurement validity/reliability questionable
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: Needing to train physicians, expensive, time constraints. Patients were blinded to physician group allocation. Physician communication performance may be skewed (possible Hawthorne effect) because of tendency to improve on each subsequent patient communication encounter when the evaluation form was completed.
 
 

Nursing Implications:

Implications were difficult to ascertain because the intervention was physician-based. The authors indicated a need to explore if nurse training in communication would be beneficial.  Also discussed was the difference in communication styles between oncologists and oncology nurses and the effect on anxiety.

Systematic Review/Meta-Analysis

Moore, P.M., Rivera Mercado, S., Grez Artigues, M., & Lawrie, T.A. (2013). Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database of Systematic Reviews, 2013(3). 

doi: 10.1002/14651858.CD003751.pub3
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Purpose:

STUDY PURPOSE: To assess the effects of communication skills training for healthcare professionals involved in cancer care
 
TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: CENTRAL, MEDLINE, EMBASE, CINAHL, AMED, SIGLE, PsycINFO, dissertation abstracts, evidence-based medicine reviews
 
KEYWORDS: Detailed search documentation provided in article appendix
 
INCLUSION CRITERIA: Studies that involved communication skills training interventions of any type for all professionals and allied healthcare providers; randomized, controlled trials, or cluster-randomized studies
 
EXCLUSION CRITERIA: Not specified

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 5,472
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Evaluation of risk of bias according to the Cochrane Handbook

Sample Characteristics:

FINAL NUMBER STUDIES INCLUDED = 15 studies with 10 studies in meta-analysis
 
TOTAL PATIENTS INCLUDED IN REVIEW = 1,147 professionals (2,105 patient encounters)
 
KEY SAMPLE CHARACTERISTICS: Only two studies examined effects on anxiety; one study examined effects on depression

Results:

Two studies evaluated patient anxiety using the Spielberger State-Trait Anxiety Inventory. Anxiety declined in both study groups, but the reduction in anxiety was significantly greater in the control group (n = 169, SMD = .4, p = .02). Other results of training explored were sensitivity of communications, display of empathy, patient trust, quality of life, and patient recall of information, distress, and satisfaction. One study showed no impact on patient depression.

Conclusions:

Provider communication skill training was not shown to have a positive effect on patients' level of anxiety or depression. Physician training was more likely to result in communications showing empathy.

Limitations:

Type, duration, and timing of training interventions were very diverse, making the synthesis of findings difficult. Similarly, the timing of study follow-up assessments varied. For the individual outcomes examined, the number of available studies was small.

Nursing Implications:

Communication skill training is likely to improve some communication skills of providers, but evidence regarding any impact of this on patient outcomes is lacking, and long-term effects are unknown. The most effective training method also is unclear. Given the current emphasis on shared decision-making and patient-centered care, the importance of provider communication and information-giving skills is evident. The content of training should be aimed at achieving these aspects and empowering patients. Further research is needed to determine the best approaches to achieve these goals.

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