«HEALTH PSYCHOLOGY Series Editors: Sheila Payne and Sandra Horn Di an ne Be rr y ion at ce nic cti mu Pra om and h C ory alt The He Health ...»
Model the master This is the classic apprenticeship model which involves observing a ‘master’ or more experienced colleague at work. It was assumed until relatively recently that students can acquire good communication skills by ‘a sort of osmosis’, by watching and modelling the behaviour of others. A weakness of Communication skills training 121 this approach, however, is that it tends to lead to conservatism rather than innovation. The learner is unlikely to end up being more skilled than the master, and may pick up the master’s mistakes and weaknesses.
Directed training This tends to be the traditional didactic, or classroom-based approach, and is often more ‘thinking’ or intellectually based. Its chief weakness is that learning takes place ‘out of context’ and any skills acquired may not be applied in practice and may not be generalized to other appropriate situations.
Doing-based training This ﬁnal approach relies on action as a means of bringing about learning.
The trainee attempts the skill and is given feedback on their performance by the trainer or other observers. The feedback is then used to improve their subsequent performance.
According to Dickson et al. (1997), in most situations, it is best to use a combination of diﬀerent approaches, rather than just a single method. This may, for example, involve one or two initial classroom sessions, followed by the use of the ﬁnal method so that the trainee can learn to apply the skills that have been taught and receive feedback and further guidance while doing so. Maguire et al. (1989) suggested that the key elements in any training package include the learner being given written instructions about the skills to be used, opportunity to practise the skills with real or simulated patients under controlled conditions, and feedback on their performance, preferably by using an audio-or video-taped replay. They should also be able to discuss the observed performance with their trainer to obtain any necessary clariﬁcations. Similarly, Leigh and Reiser (1986) advocated that training will be most successful if skills are taught in situations that mirror the situation in which they will be used in practice. They suggested that training that uses direct supervised contact with patients, in which the student receives good feedback immediately after the interaction, should work best.
Empirical evaluation of communication skills training
A number of researchers and practitioners have proposed that healthcare professionals can be taught to use patient-centred communication skills (e.g. Langewitz et al., 1998). It has also been noted that this approach may be particularly eﬀective when having to interact with diﬃcult people or in diﬃcult circumstances (e.g. Anderson and Sharpe, 1991; Sharpe et al., 1994). In line with this, Forshaw (2002) argued that it is relatively easy to teach professionals to use some very basic rules that will improve 122 Health communication their communications, such as greeting patients by name, explaining the purpose of procedures, using more direct eye contact and thanking patients at the end of a consultation. All of these contribute to positive relationship building and eﬀective interactions.
In a relatively early study, Maguire et al. (1986) found that students who received formal feedback-based training showed signiﬁcant improvements in their communication skills. Speciﬁcally, compared with a control group, the feedback-trained group obtained three times more relevant and accurate information about the patient’s problem, and were given higher ratings by patients. In addition, in follow-up studies, they were found to be more empathic and more self-assured when interviewing patients, and more likely to use an open style of questioning and to show appropriate responding to patient cues.
More recently, Fallowﬁeld and colleagues have carried out a series of studies that have applied, and evaluated the eﬀectiveness of, formal communication skills training. Fallowﬁeld et al. (2002), for example, conducted a study to assess the eﬃcacy of an intensive three-day training course on communication skills, using a randomized control trial. The participants in the study were 160 oncologists, recruited from 34 UK cancer centres. They were given one of four diﬀerent treatments: written feedback alone, course alone, written feedback followed by the course, or no training (the control condition). The course was designed speciﬁcally for oncologists and was based on one used extensively in the USA. The focus was user centred and it incorporated cognitive, aﬀective and behavioural components. It involved participants interacting with trained ‘simulated patients’ and receiving feedback on their performance. At each of two diﬀerent assessment periods, consultations with 6 to 10 consecutive ‘patients’ per doctor were videotaped. A total of nearly 2500 patients participated in the study. The investigators used a mixture of objective and subjective post-training performance measures, with ratings being made by researchers, doctors and patients.
There were additional analyses based on length and content of the interaction. The primary outcomes were objective improvements following the training in key communication skills such as showing empathy, responding appropriately to patient cues and asking appropriate questions. Overall, it was found that course attendance signiﬁcantly improved performance in terms of these primary outcomes, but there was little evidence for the eﬀectiveness of written feedback. There was also evidence that the improvements persisted with time. Fallowﬁeld et al. (2003) conducted a follow-up study and found that 12 to 15 months post-intervention, there was still an enduring eﬀect of communication skills training, with virtually no attrition in improved skill use. There was also evidence for appropriate transfer into the clinic. In addition, some new skills that were not apparent in the initial phase of the study (such as making fewer interruptions and increased use of summarization of information) emerged in the follow-up study.
Communication skills training 123 In looking at the eﬀectiveness of diﬀerent training programmes, Cegala and Broz (2003) noted that there is now considerable evidence that the provision of training in communication skills is eﬀective. However, they warned that it needs to be recognized that around 30 per cent of the studies reviewed by them had relied solely, or primarily, on participants’ self-perception or self-evaluation of their communication competence.
Although self-perceptions are often related to actual performance, they should not be used as sole evidence for evaluating the eﬀectiveness of training programmes. Cegala and Broz also noted that very few programmes have assessed the longer-term eﬀects of training. A strength of the Fallowﬁeld et al study, described earlier, is that it used a combination of subjective and objective measures, and that it also included a follow-on assessment phase.
Given the increased recognition of the value of communication skills training, many medical schools now routinely incorporate it into their curricula. Haq et al. (2004) described a programme in the USA (Undergraduate Medical Education for the 21st Century – UME-21) to co-ordinate the skills training that is provided for medical students. In the 12 participating medical schools, curricula themes included conﬂict resolution, delivery of bad news, addressing preferences for end-of-life care, health education, and working eﬀectively with families and with patients from diverse backgrounds. The acquired skills were assessed through structured clinical examinations, focused observation and feedback, and debrieﬁng sessions based on videotapes. Haq et al reported that the results of the formal assessments showed beneﬁcial eﬀects of the skills training in the students. Clearly, however, it is not known whether the acquired skills will be incorporated into routine practice once the students have qualiﬁed.
Communication skills training for patients
Another concern raised by Cegala and Broz (2003) is that there has been relatively little research on the eﬀectiveness of patient- (as opposed to provider-) based training. Most of the studies that have been conducted with patients have centred on providing training on information seeking, provision and veriﬁcation. Cegala and Broz noted that, to date, the impact of training on question-asking has been quite modest, with around half of the studies reporting positive eﬀects. The most positive gains have come from studies that have included a practice component, and/or have tailored the content and training objectives to patient needs (see also Kreuter et al., 2000). Finally, Cegala and Broz pointed out that virtually no research has looked at the training of both providers and patients in order to examine and improve interactive contributions. Similarly, there is still very little known about how individual diﬀerences such as gender, ethnicity and educational background interact with skills training.
124 Health communication As far as patient training is concerned, Post et al. (2002) carried out a review of randomized control trials that had taken place in an outpatient setting between 1975 and 2000, and that had involved teaching patients to communicate with physicians. Patient communication interventions were classiﬁed as being either high, medium or low intensive, depending on the length of the intervention, as well as in terms of the use of personnel and the estimated cost. Thus, for example, a high-intensive intervention might have involved face-to-face training, conducted by a research assistant for 15 minutes before a scheduled appointment. In contrast, a low-intensive intervention might have involved simply giving patients a blank sheet of paper and getting them to write down three questions that they would like to ask the doctor. The results of the review showed that skills training resulted in patient improvement on a variety of outcomes. Positive change variables included improved communication, medical outcomes, functional status and adherence to treatment. Patient communication training changed the nature of the physician–patient interaction, with patients exhibiting and feeling increased control. However, the studies revealed mixed ﬁndings in terms of eﬀects on patient satisfaction. In addition, Post et al noted that, overall, there was a wide variation in the types of study design used, the type of intervention and outcomes, and that this hindered the ability to draw well-founded conclusions.
Harrington et al. (2004) carried out a more recent review of intervention studies that have focused on improving patients’ communications with their doctors. The review covered a total of 20 studies, half of which were randomized control trials. These authors found that, overall, half of the interventions resulted in increased patient participation, with there being a greater increase in requests for clariﬁcation than in question asking. There were signiﬁcant improvements in perceptions of control over health, preferences for taking an active role in healthcare, recall of information, adherence to recommendations, attendance and clinical outcomes. As with the Post et al review, there were relatively few signiﬁcant improvements in patient satisfaction. Clearly, there is much more to be done in this important area.
This ﬁnal chapter has emphasized the importance of healthcare professionals having good communication skills, and has shown that such skills can be explicitly trained. It has also acknowledged the increasing recognition of this by government, the ‘medical establishment’ and others. The chapter then looked at some of the core skills that are needed for eﬀective communication, as well as how best to manage and resolve conﬂict. Finally, we reviewed a number of the empirical studies that have assessed the eﬀects of communication skills training in healthcare professionals and patients. Although there Communication skills training 125 is still much more to do in this important area, the preliminary indications are very positive.
Throughout this book, I have stressed the importance of eﬀective communication in health. We have seen some of the negative outcomes of poor communication, and have discussed a number of the common problem areas. We have also identiﬁed a number of basic and more complex communication skills that contribute to eﬀective (and less eﬀective) interactions with others. In this ﬁnal chapter, we have evaluated evidence to show that the eﬀective use of such skills can be explicitly trained. Hopefully, the increasing recognition, availability and use of such training should result in more eﬀective health communication between the diﬀerent players in the healthcare process in the years to come.
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