Improving the communications skills of healthcare professionals working with cancer patients
The work of Sussex researcher Lesley Fallowfield and her team led to the development and validation of a comprehensive three-day training programme to improve the communication skills of clinicians working with cancer patients.
This work was the first to show that appropriate training in such skills was enduring and is transferrable into a clinical setting. Key components of the training intervention were embedded into a Department of Health initiative called Connected, which was widely adopted across UK Cancer Networks and beyond. Such training has become mandatory for all consultant oncologists in the UK.
Good communication between healthcare professionals (HCPs) and patients is an important aspect of clinical practice. Poor communication can negatively impact both patients and HCPs. It can lead to anxiety, dissatisfaction, confusion about diagnosis and prognosis, lack of consent and poor treatment adherence among patients, and to stress, burn-out and reduced job satisfaction among clinicians. >
In 2000, the Department of Health’s NHS Cancer Plan reported wide inconsistency in the management of cancer patients that ranged from patients receiving ‘sensitive and thoughtful communication’ and ‘clear information about their disease’ to ‘being left in the dark about their condition and badly informed about their treatment and care’. The NHS Cancer Plan proposed that all hospital consultants working in cancer care should be able to demonstrate competence in communication with patients and that advanced communication-skills training would form part of their continuing professional development. NICE guidelines (2004) subsequently proposed that accredited training courses should be made available for all HCPs working with cancer patients.
Traditionally, medical training has relied heavily on an ‘apprenticeship’ model in which trainees learn by observing senior colleagues and mimicking their behaviours with patients. It was also assumed that communication skills could not be taught and that HCPs would either be intrinsically good or poor communicators. The basis for this attitude has largely been dispelled by the work of pioneers in adult learning theory who demonstrated how appropriate educational interventions could enhance an individual’s communication skills in general (Rogers, Knowles and Friere), and how this could be applied to communication in medicine specifically (Lipkin). This concept of enhancing communication skills for HCPs has been expanded and very practically demonstrated in the work of Lesley Fallowfield, Director of the Sussex Health Outcomes Research and Education in Cancer (SHORE-C). In the 1990s, Fallowfield developed an innovative communications-skills training programme, aimed specifically at doctors and nurses working in cancer medicine, which integrated exercises and activities designed to foster simultaneous skills development, knowledge acquisition and a personal awareness of how these factors impact both clinicians and patients.
Following a move to Sussex in 2001, she and colleagues completed the analysis of, and published, a randomised controlled trial (RCT) that had been conducted in 34 UK cancer centres with 160 oncologists and more than 3,000 patients. The study evaluated the effectiveness of Fallowfield’s three-day training programme and provided clear evidence of the training being transferrable into clinical practice, resulting in positive behavioural changes assessed three months later. Notably, she showed that oncologists used fewer leading questions and more focused and open questions, and demonstrated greater empathy and more appropriate responses to patients’ cues. Subsequent analysis showed longevity of the results, with most benefits still observable at 15 months post-training. As earlier skills became embedded, further skills emerged such as increased ability to summarise information and not interrupt patients.
Professor Fallowfield’s research has achieved major impact by being the first of its kind to demonstrate transfer into a clinical setting and the long-term efficacy of the training. Two systematic reviews have concluded that this research is one of only three adequate evaluations of communication-skills training courses out of more than 50 studies. Her work has also gone some way to helping fulfil the NHS Cancer Plan’s original proposal.
Most prior research in this area relied on pre- or immediate post-course changes in behaviour, changes that were self-evaluated and/or used patient simulators rather than real patients. In contrast, in Fallowfield’s research, behavioural data were obtained through video recordings of consultations with real patients and were reliably coded by independent observers. These measured improvements were reinforced by more favourable clinician self-reported beliefs regarding communication skills and psychosocial attitudes. For example, physicians who had received the training were more likely to agree that considering their patients’ psychosocial concerns alongside their clinical problems was important.
On the strength of results from the RCT, many of the teaching components designed by Fallowfield were incorporated into Connected, a national communication-skills training course for cancer clinicians launched in 2008. Connected used a cascade model in which communication-skills facilitators were initially trained at Cancer Network level to deliver the workshops to HCPs. Completion of this training package and workshops became mandatory for all clinicians working with cancer patients from 2008 onwards. Between 2008 and 2013, more than 16,000 HCPs from 48 UK Cancer Networks participated in Connected. The three-day, learner-centred workshops included role play where trained actors take the part of cancer patients and carers. Participants were provided with feedback on their performance and course evaluation data showed a high level of positive feedback, with 95 per cent of attendees saying the course met their training needs. Fallowfield is acknowledged as one of the authors of the Participant Handbook that accompanies the workshops, and her work is extensively cited as supporting evidence.
This research has also achieved international impact with similar training programmes being implemented in Europe and elsewhere. In Switzerland, communication-skills training for medical oncologists was made compulsory in 2006. In addition, in Australia, a large programme of communication-skills training involving many hundreds of HCPs has been implemented. Fallowfield was directly involved in initial training in both cases.
The original Lancet paper on the RCT showing the efficacy of the training model is highly cited (more than 619 times according to GoogleScholar), and Fallowfield and her team act as advisors/consultants on many projects globally. Another associated strand of research, in collaboration with Dr Valerie Jenkins and colleagues at SHORE-C, concerns clinical treatment trials of cancer therapy. Their research identified that the communication of HCPs with patients was often a major barrier to clinical trial recruitment. In response, they designed a comprehensive educational package to help doctors, nurses and others when communicating about trials. The team now also produce specific patient information DVDs for cancer trials to help explain complex trial issues and are given to patients when consent for trial enrolment is sought. These are also made available on YouTube.
Funding and partnership
SHORE-C has been funded by the National Institute for Health Research (NIHR) and Cancer Research UK among others.
Last updated: 20 February 2015
Research Quality and Impact team
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