Communication skills training for healthcare professionals working with people who have cancer
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.
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.
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.
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).
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.
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.
Philippa M Moore, Solange Rivera, Gonzalo A Bravo‐Soto, Camila Olivares, Theresa A Lawrie
Plain language summary
Do courses aimed at improving the way healthcare professionals communicate with people who have cancer impact on their physical and mental health?
What is the aim of this review?- The aim of this Cochrane review was to find out if communication skills training (CST) for healthcare professionals working with people who have cancer has an impact on how healthcare professionals communicate and on the physical and mental health of the patients.- - What types of studies did we include?- We included only randomised trials (RCTs) that evaluated the impact of CST for healthcare professionals (doctors, nurses and other allied health professionals) who work with people with cancer. We included different types of CST and evaluated its impact on healthcare professionals and their patients, through the following reported outcomes: use of open questions, elicited concerns, delivery of appropriate information, empathy demonstration, use of fact contents, healthcare professional 'burnout' and patient anxiety.
What are the main results of the review?- We found 17 RCTs comparing CST with no CST. The studies used encounters with real and simulated patients to measure the communication outcomes. The evidence on whether CST leads to an improvement of the use of open questions is very uncertain. However, we did show that CST probably improves healthcare professional empathy and reduces the likelihood of their giving facts only without individualising their responses to the patient's emotions or offering support. . CST probably does not have an effect on the ability of healthcare professionals to elicit concerns or to give appropriate information.
Evidence suggesting that CST might prevent healthcare professional 'burnout' is of low‐certainty and it is very uncertain whether CST has an effect on patient anxiety.
What do they mean?- CST probably helps healthcare professionals to empathise more with their patients, and probably improves some aspects of their communication skills. These changes might lead to better patient outcomes; however, evidence on the latter is very uncertain and more research is needed.
Philippa M Moore, Solange Rivera, Gonzalo A Bravo‐Soto, Camila Olivares, Theresa A Lawrie
Implications for practice
Communication skills training for healthcare professionals (HCPs) working in cancer care using learner‐centred, experiential education methods by experienced facilitators, can result in improvements of some communication skills, particularly empathy, and can help HCP to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. Whilst improving these communication skills, CST courses should also aim to ensure appropriate eliciting‐concerns and information‐giving skills in HCP participants. It is unclear whether the skills acquired by HCPs are retained in the long term. In addition, it is unclear what type, duration and intensity of CST is most effective, and whether consolidation workshops may improve the impact of CST. CST appears to have little measurable benefit to the mental or physical health, and satisfaction of people with cancer and does not appear to reduce 'burnout' in HCPs.
Implications for research
The original version of this review called for further research and the number of randomised trials has since increased dramatically. However the diversity of studies, particularly in the scales used to measured HCP communication skills, continues to limit the conclusions of this updated review. We recommend that randomised controlled (RCTs) use standard validated scales, and that (limited) core study outcomes (both for HCP outcomes and patient outcomes) are identified and pre‐specified. Several validated scales to measure HCP communication now exist but investigators should ensure that their outcomes permit comparability between studies. It may be preferable to use real patients for measurement of HCP communication in studies of CST interventions to ensure clinically meaningful results. Trials should include clear reporting of trial methods and study outcomes, and data should be reported in full e.g. continuous data as means with standard deviations and the number analysed per outcome.
Other important questions remain unanswered:
- the optimal length of training/course structure;
- the long‐term efficacy of communication skills training;
- the role of e‐learning;
- compulsory rather than voluntary training;
- the role of consolidation courses;
- the role of training both HCPs and patients in communication skills.