Palien! Edurution und Counseling, Elsevier Scientific
18 ( I99
Communication and Counseling Skills: Educating Health Professionals Working in Cancer and Palliative Care Ann Faulknera, “Trent Pulliutive
Care Centre, Little
Group, Munchester, (Accepted
Pat Webbb and Peter Maguire’ Common
Lunc, Abbey Lune, Slte~~idd, hHelp the Hospiws
’CRC P.vychologicul Mdicinc
detect them have not been developed [5-71.
is a growing
of the need ,for
health professionals to improve their communicution und counseling skills in cancer andpulliutive cure. A model for teaching groups has been
these skills to multidisciplinury established by Muguire und
Faulkner. Courses are held severul times u yeur subsidized by the UK national churity, Help the Hospices. To further this work, u nutionul training coordinator was appointedfor three yeurs from July 1988, also funded by the charity, to estublish and monitor locully bused courses through the United Kingdom using this same model. Evuluution of the original courses and the development
ed courses is underwuy.
Keywords: Communication; Cancer and palliative care.
Introduction There is a large body of evidence to show that health professionals may neglect patients’ emotional needs in favor of physical care [l-3], often because the skills required to 0738-3991/91/$03.50
1991 Elsevier Scientific
Published and Printed in Ireland
Certainly there has been little emphasis on the teaching of communication skills in health care , for there is an assumption that to communicate is a necessary skill for human survival  and does not need to be taught. This belief equated social and professional communication while ignoring the very skilled approach required in the difficult areas of health care. Teaching counseling skills Help the Hospices has been instrumental in funding workshops to teach communication and counseling skills to health professionals working in cancer and palliative care. The growing demand for these workshops from doctors, nurses, social workers and others demonstrates an awareness of the need to improve skills and practice in cancer and palliative care. These workshops have been described by Maguire and Faulkner [lo]. They follow a pragmatic and highly contextualized apLtd
preach, the format closely following the model of assessment and counseling which is taught in that (i) The program is based on an agenda determined by the participants. This demonstrates the notion of a patient-led agenda, and the need to raise only those items of a professional agenda which the patient has not raised. In the workshops, the professional agenda covers the skills of assessment and consideration of the need for staff support and survival, but these are usually raised by the participants; (ii) Problem areas are prioritized by the participants. This demonstrates that no assumptions should be made on what is important to the patient. (iii) The teaching is made as safe as possible by clear adherence to ground rules which stress permission for time-out, positive feedback followed by constructive suggestion and other rules to demonstrate that patients must be given a safe setting in which to disclose their concerns. (iv) The tutors act as facilitators, looking to the group to generate solutions, and only offering advice if the group is stuck. This demonstrates that counseling is to do with patients generating their own solutions to problems rather than be given (possibly inappropriate) advice. The teaching moves from methods which are safe for the participants to those which involve the exposure of their own strengths and weaknesses. The methods include video discussion where the tutors are seen warts and all, and are happy to be critiqued by students and questioned on their strategies. This is followed by discussion, formal input and role play to practice new skills in problem areas offered by the participants. On the last day of the workshop, time is given to unfinished and survival and a business, support qualitative evaluation. From these national workshops
need for locally based programs. Many participants expressed the wish to set up courses in their own area but realized that they would require further training, support and encouragement before they could begin. The value of supporting such locally based initiatives was in the hope that a cascade effect would result with many more health professionals being encouraged to improve their skills. The project
Help the Hospices agreed to fund a threeyear project on improving the communication skills of health professionals, under the direction of Ann Faulkner in collaboration with Peter Maguire. A research fellow was appointed in July 1988 as the National Training Coordinator with a remit to survey educational needs in cancer and palliative care, and to support those who wished to run locally based courses on communication and counseling. Within the project, the nationally based skills workshops continue and are supplemented with workshops on how to teach communication and counseling skills. These include a general three-day course followed by an intensive course for pairs of teachers who plan to work together to develop a course in their own locality. Most pairs of teachers comprise a doctor/nurse team, as in the original model, but other pairs include social workers with either a doctor or a nurse for a partner. The first year
A survey was conducted to determine the educational needs of all health-care disciplines working in palliative care, a large part of which concentrated on the requirement for skills training in communication and counseling. A self-completion questionnaire was sent to all medical, social work and nursing managers in hospices, home-care teams and
hospital palliative care units in the United Kingdom. An amended questionnaire was sent to designated teachers in this field, or those who have teaching as part of their role. The sample was taken from all entries in the Hospice Information Service Directory produced by St. Christopher’s Hospice in South East London. The aim of the survey was to establish current educational initiatives in palliative care and to demonstrate current and future educational needs. For this project, the data on communication and counseling skills was the most important, but the other data will be used by Help the Hospices and other educational agencies to plan pro-actively for future educational programs. Participants from the national communication skills courses were visited during the first year with the coordinator offering support and encouragement, both to those who wished to develop teaching in their own area, and to others who wished to incorporate the skills learnt into their own clinical practice. The first pairs of teachers were identified who wished to take part in the Cascade project. The second year
The survey results were analysed and reported, showing “the need for training demonstrated in the skills workshop is recognised by many health professionals”. Sixty-nine percent of respondents felt that health professionals are not well equipped to meet patients’ emotional needs, while 78% of teachers felt only partially prepared to teach communication skills. Only 7% considered themselves competent to teach in this area. The most used teaching method was video demonstration with few teachers feeling conlident enough to use role play. Locally based courses have been planned and implemented in several centers, with eleven pairs of teachers involved to date. The courses are based on the original model [lo],
and use the same teaching methods and videotape material . The first course run by any team is supported by a member of the project team, with the teachers given feedback and encouragement on their teaching sessions. An evaluation strategy has been devised to use with course participants to measure, in a simple way, their skills before and after the workshop. This evaluation will be used in all forthcoming courses. The third year
Locally based courses will continue through the third year with an increase in pairs of teachers involved, and with evaluation data to show the impact of the teaching initiatives. All potential teachers will have attended a basic skills workshop, a teaching workshop and finally, an intensive teaching workshop with their planned partner. In this way, the original model [ 10,13,14] should be the basis of the cascade. To date, evaluation of the locally based courses has been subjective, that is the teachers and participants have reported on their impressions. These have been very positive to date, the teachers enjoying the experiences, though finding it demanding, and the participants finding it very useful and stimulating. There has been no difficulty in recruiting participants, and an effort has been made to achieve a balance of both disciplines and work base within the group Conclusions and implications for practice
There is still an expressed need from all health care disciplines working in cancer and palliative care, for communication and counseling skills training. Requests for places on centrally based residential courses and the results of the survey both demonstrate this. Some of this need has been met by the residential courses funded by Help the Hospices. It is hoped that the strategy to develop locally based courses with local teacher teams
will have a positive effect on both patient care and job satisfaction for health professionals. Supervision and support from the project team, funded or subsidized by Help the Hospices, is perceived to be valuable. It also enables data to be collected for subsequent analysis and publication. The objective evaluation strategy for local course participants has not yet been tried and will be reported at the end of the three year project. There now remain some problems to be worked out both in the short and the long term. Supervision of skills at local level is difficult to achieve in practice. While the teaching teams can be supervised during their local courses, participants are also requesting some kind of supervision in their clinical practice. Some of them are encouraged to make tape-recordings of assessment interviews with patients which they can then use in discussion with a supervisor to determine what they did well and how they can improve. This assumes that someone is willing and able to act in the supervisory role. Some of the teachers feel this is an activity they are prepared to take on, while others do not have the time or expertise. Teachers have identified a need to meet together as a group to share ideas and learn new ways to running the courses. It may be possible to do this in the future on a regular basis with members of the project team facilitating the event. Ultimately, most local courses will be incorporated into an education department’s over: all program. Some may continue in isolation where no such education departments exist. Support for this initiative throughout the United Kingdom is good but it remains to be seen how valuable and feasible the local course will be in the future when charity support has been withdrawn. Overall, the desired effect from all these initiatives is that patients and relatives receive better psychological support when they are trying to come to terms with a diagnosis of cancer, or with dying.
Table 1. Practice implications. Group
Undergraduate medical students Undergraduate/learner nurses Trainee social workers
Communication skills should be taught as an integral part of curriculum
Student teachers health care
Course should include methods of teaching interactive skills
All qualified health professionals
Regular update on communication skills essential
If successful at local level, this model of teaching could certainly be introduced in many parts of Europe where there are wellestablished oncology units and a commitment to palliative care. Although the concept of hospices is spreading in some European countries (including those outside the EC but embraced by WHO Europe), in others it is not congruent with the culture or the geography to provide the free-standing hospice buildings that are a well-established feature in’the United Kingdom. However, this is not a problem, providing there is a strategy to give good palliative care to those who require it. This may be through additional education to the primary health care team - community physicians, public health nurses and hospice programs or palliative care teams. The labels will vary from one country to another but the philosophy remains constant. Familiarization with this particular model [lo] would be the first step, followed by an appropriate local strategy for the cascade ef-
feet to occur. There are established systems in cancer education for doctors and nurses in the EC member states. The European School of Oncology (ESO) and others currently provide educational programs on clinical and other subjects for all doctors who have contact with cancer patients or those who are dying. The newly established European College of Oncology Nursing (ECON), the education branch of the well-established European Oncology Nursing Society (EONS), is currently planning its educational programs. There is good collaboration between these two organizations and multidisciplinary courses are the next step in this cooperation. It is clear from conferences and other activities that there is both an enthusiasm and a need for this kind of initiative to run alongside those others being developed by individuals throughout Europe. North America and Australia have also shown an interest. In the former, hospice care as a philosophy is spreading. The management of services differs from Europe because health care is managed in an entirely different way. However, in conversation with doctors and nurses working with those who have cancer or those who are dying, this kind of educaand practice-based skill tional program learning is urgently required by the practitioners. There is no reason why a model such as this could not be just as appropriate and successful, providing a commitment of funding is made to establish it.
Acknowledgment Grateful thanks are expressed funding of this initiative.
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Webb needs Help Help
P. Faulkner A: Report of survey on educational of Health Professionals in Palliative Care. London: the Hospices. 1990. the Hospices: Videotapes - a series of 5 tapes plus
teaching notes. Details and tapes from Prof. A Faulkner. Trent Palliative Care Centre. Little Common Lane. Abbey Lane, Sheffield SI I 9NE. UK. Maguire P. Faulkner A: How to do it ~ Communicate with cancer patients: questions. Br Med J Maguire P. Faulkner with cancer patients: and denial.
In spite of the concerns, there is a real enthusiasm for this initiative and we are now confident that the pilot workshops will show a positive way forward. It may be that future courses for teachers at an advanced level will include essential supervisory skills.
to Help the Hospices
Br Med J 198X: 297: 973--974.
Correspondence to: Ann Faulkner TPCC Little Common Lane Abbey Lane Sheffield Sll
I. Handing bad news and difficult 1988: 297: 907-909. A: How to do it -~ Communicate 2. Handling uncertainty, collusion